Dedication

This book is dedicated to my wife Despina, for her unfailing love, under-
standing, and full support over the years, and to my two sons, Apostolos
and Harry, with the wish to serve as an inspiration for their future profes-
sional endeavors.

“Give me a place to stand on, and I will move the earth.”

Archimedes (287 BC – 212 BC)

The engraving is from Mechanic’s Magazine

(cover of bound Volume II, Knight & Lacey, London, 1824)
Courtesy of the Annenberg Rare Book & Manuscript Library,
University of Pennsylvania, Philadelphia, USA
For Elsevier
Content Strategist: Alison Taylor
Content Development Specialist: Barbara Simmons/Carole McMurray
Project Manager: Andrew Riley
Designer/Design Direction: Christian Bilbow
Illustration Manager: Karen Giacomucci
Illustrator: Electronic Publishing Services Inc., NYC
Skeletal Anchorage in
Orthodontic Treatment of
Class II Malocclusion
Contemporary applications of orthodontic implants,
miniscrew implants and miniplates
Edited by
MOSCHOS A. PAPADOPOULOS, DDS, DR MED DENT
Professor, Chairman & Program Director
Department of Orthodontics
School of Dentistry
Aristotle University of Thessaloniki
Thessaloniki, Greece

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2015
© 2015 Moschos A. Papadopoulos. Published by Mosby, an imprint of Elsevier Ltd.
No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage
and retrieval system, without permission in writing from the publisher. Details on how to
seek permission, further information about the Publisher’s permissions policies and our
arrangements with organizations such as the Copyright Clearance Center and the Copyright
Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Parts of the text and images in Chapter 9 have been previously published in Papadopoulos
MA, Tarawneh F. The use of miniscrew implants for temporary skeletal anchorage in
orthodontics: a comprehensive review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2007;103:e6–15 as per references.
ISBN 9780723436492
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress

Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices,
or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein.
In using such information or methods they should be mindful of their own safety and the
safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer
of each product to be administered, to verify the recommended dose or formula, the method
and duration of administration, and contraindications. It is the responsibility of practitioners,
relying on their own experience and knowledge of their patients, to make diagnoses, to
determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of
products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.

The
publisher’s
policy is to use
paper manufactured
from sustainable forests

Printed in China
 Foreword

In our millennium we are acutely aware of the many challenges that con- millennium. All the available skeletal anchorage devices are presented and
front us in diverse fields. The field of orthodontics has seen no cataclysmic discussed by experts in the specific areas. The presented results are evi-
events – financial or economic quicksand – but only steady progress based dence based with a combination of internal evidence (individualized clini-
on extensive research around the world. Commercial firms provide the cal expertise and knowledge of the clinicians) and external evidence
armamentarium we need and technical developments have kept pace with (randomized controlled clinical studies, systemic reviews) to conclude on
scientific progress. Long-term evidence-based assessment of treatment what is scientifically recognized therapy.
results is now available. The question as to what we can do and what are
Admittedly, reading this book for the first time may confuse some novice
the borderline situations can be answered in biological, biomechanical and
orthodontic students, but like a sacred text, it must be read again and again.
risk-management terms. There are many roads to Rome: many appliances
The book provides an exact description of techniques, their biomechanical
that can accomplish similar results but only one set of fundamental tissue-
justifications and examples of their potential for correcting orthodontic
related principles.
problems if the technique is handled properly. The criteria for successful
Orthodontics itself has seen a fundamental change (paradigm shift) in treatment are stability, tissue health and esthetic achievement.
direction and treatment emphasis, with greater attention being given to the
The book discusses all aspects of a more efficient use of skeletal anchorage
problem of stationary anchorage without a requirement for patient compli-
devices and also biological and biomechanical considerations, biomaterial
ance. This is achieved by using implants instead of extraoral anchorage.
properties and radiological evaluation. Within the book, all the available
This non-compliance approach enables intraoral extradental stationary
methods are described, such as the Strauman Orthosystem, the Graz
anchorage without the side effect of anchorage loss. The use of stationary
Implant-Supported Pendulum, the Aarhus Anchorage System, the Spider
anchorage with implants has been improved our success in reaching the
Screw anchorage, the Advanced Molar Distalization Appliance, the TopJet
“achievable optimum,” the goal of the treatment.
Distalizer, and many others. Utilizing implants in lingual orthodontics is
Since the introduction of implants in orthodontics, much information has described in two chapters, The book is completed by an in-depth discus-
been generated, mostly disorganized and contradictory with anecdotal case sion of complications and risk management.
presentations. Dr. Papadopoulos has assembled world-class experts from
This unique book makes a deep impression on the reader and shows that
all over the world to cover all aspects of skeletal anchorage using contem-
the nature of orthodontics does not permit a limited narrow view; it
porary application of various orthodontic implants and miniplates. Dr.
deserves understanding of conflicting opinions and evidence.
Papadopoulos is an innovative, enthusiastic pioneer with a holistic approach
in his research.
This book is a comprehensive publication, presenting methods and views Thomas Rakosi, DDS, MD, MSD, PhD
of 96 authors from 20 countries in 52 chapters. It is a unique work in the Professor Emeritus and Former Chairman
orthodontic literature; it is the most extensive compendium of the new Department of Orthodontics, University of Freiburg, Germany

v
Acknowledgements

The editor is most grateful to all colleagues involved in the preparation of Finally, Ms Alison Taylor, Senior Content Strategist, and all other Elsevier
the different chapters included in this book for their excellent scientific staff members are also acknowledged for their excellent cooperation
contributions. during the preparation and publication of this volume. Elsevier Ltd is
acknowledged for the high quality of the published Work.
Dr. Jane Ward, Medical Editorial Consultant, is given particular thanks for
her invaluable input into the rewriting of many of the contributions.

vi
 Preface

Class II malocclusion is considered the most frequent treatment problem skeletal anchorage devices in orthodontics (Sections III and IV, respec-
in orthodontic practice. Conventional treatment approaches require patient tively), the book continuous with sections devoted on the treatment of
cooperation to be effective, while non-compliance approaches used to Class II malocclusion with the various skeletal anchorage devices, such as
avoid the necessity for patient cooperation have a number of side effects. orthodontic implants (Section V), miniplates (Section VI) and miniscrew
Most of these side effects are related to anchorage loss, and therefore, they implants (Section VII). A further section is devoted to the treatment of
can be avoided by the use of skeletal anchorage devices. Class II malocclusion with various temporary anchorage devices (Section
VIII). Finally, the last section discusses the currently available evidence
Anchorage is defined as the resistance to unwanted tooth movements and
related to the clinical efficiency as well as the risk management of the
is considered as a prerequisite for the orthodontic treatment of dental and
skeletal anchorage devices used for orthodontic purposes (Section IX).
skeletal malocclusions. In addition to conventional orthodontic implants,
which have been used for anchorage purposes for some years, miniplates The editor invited colleagues who are experts in specific areas related to
and miniscrew implants have been recently utilized as intraoral extradental orthodontic anchorage to contribute with chapters. Most of the authors have
temporary anchorage devices for the treatment of various orthodontic either developed or introduced sophisticated devices or approaches, or they
problems, including Class II malocclusions. All these modalities may have been actively involved in their clinical evaluation. In total, 96 col-
provide temporary stationary anchorage to support orthodontic movements leagues from 20 different countries participated in this exciting project.
in the desired direction, without the need for patient compliance in anchor-
The detailed discussion by a large number of experts of a variety of issues
age preservation, thus reducing the occurrence of side effects and the total
related to skeletal anchorage may be considered as a breakthrough feature
treatment time.
not previously seen in this form in orthodontic texts. At present, there is
The main remit of this book was to address the clinical use of all the avail- no other book dealing with all possible anchorage reinforcement approaches
able skeletal anchorage devices, including orthodontic implants, mini- (including orthodontic implants, miniplates and miniscrew implants) used
plates and miniscrew implants, that can be utilized to support orthodontic for the treatment of patients with Class II malocclusion.
treatment of patients presenting with Class II malocclusion. The book
It is the hope of the editor that this textbook will provide all the necessary
provides a comprehensive and critical review of the principles and tech-
background information for the better understanding and more efficient
niques as well as emphasizing the scientific evidence available regarding
use of the currently available skeletal anchorage devices to reinforce
the contemporary applications and the clinical efficacy of these treatment
anchorage during orthodontic treatment of patients presenting Class II
modalities.
malocclusion, and that it will be used as a comprehensive reference by
The book is divided into nine sections, starting from an introduction to orthodontic practitioners, undergraduate and postgraduate students, and
orthodontic treatment of Class II malocclusion (Section I) and an introduc- researchers for the clinical management of these patients.
tion to skeletal anchorage in orthodontics (Section II). After a detailed
presentation of the clinical and surgical considerations of the use of Prof. M. A. Papadopoulos

vii
Contributors

YOUSSEF S. AL JABBARI ADITYA CHHIBBER

Associate Professor, Dental Biomaterials Research and Development Resident, Division of Orthodontics, Department of Craniofacial
Chair, College of Dentistry, King Saud University, Riyadh, Saudi Arabia Sciences, School of Dental Medicine, University of Connecticut,
Farmington, CT, USA
GEORGE ANKA
Orthodontist in private practice, Tama-shi, Tokyo, Japan HYERAN CHOO
Director of Craniofacial Orthodontics at The Children’s Hospital of
AYÇA ARMAN ÖZÇIRPICI Philadelphia; Clinical Associate, Department of Orthodontics, University
Associate Professor and Head, Department of Orthodontics, Faculty of of Pennsylvania, Philadelphia, PA, USA
Dentistry, Başkent University, Ankara, Turkey
KYU-RHIM CHUNG
KARLIEN ASSCHERICKX Professor and Chairman, Division of Orthodontics, Ajou University,
Researcher and Lecturer, Vrije Universiteit Brussel, Dental Clinic, School of Medicine, Suwon, South Korea
Department of Orthodontics, Brussels, Belgium; orthodontist in private
practice, Antwerp, Belgium MARIE A. CORNELIS
Assistant Professor, Department of Orthodontics, School of Dentistry,
MUSTAFA B. ATES University of Geneva, Switzerland
Assistant Professor, Department of Orthodontics, Faculty of Dentistry,
Marmara University, Istanbul, Turkey MAURO COZZANI
Professor of Orthodontics and Gnathology, School of Dental Medicine
UGO BACILIERO University of Cagliari, Italy
Director, Department of Maxillofacial Surgery, Regional Hospital of
Vicenza, Vicenza, Italy ADRIANO CRISMANI
Professor and Head, Clinic of Orthodontics, Medical University of
MARTIN BAXMANN Innsbruck, Austria
Visiting Professor, Department of Orthodontics and Pediatric Dentistry,
University of Seville, Seville, Spain: Orthodontist in private practice, MICHEL DALSTRA
Kempen & Geldern, Germany Associate Professor, Department of Orthodontics, School of Dentistry,
University of Aarhus, Denmark
THOMAS BERNHART
Professor, Division of Oral Surgery, Bernhard Gottlieb University Clinic
HUGO DE CLERCK
Adjunct Professor, Department of Orthodontics, School of Dentistry,
of Dentistry, Medical University of Vienna, Austria
University of North Carolina, Chapel Hill, NC, USA; orthodontist in
MICHAEL BERTL private practice, Brussels, Belgium
Lecturer, Division of Orthodontics, Bernhard Gottlieb University Clinic
GLADYS C. DOMINGUEZ
of Dentistry, Medical University of Vienna, Austria
Associate Professor, Department of Orthodontics, Faculty of Dentistry,
LARS BONDEMARK University of Sao Paulo, Brazil
Professor and Head, Department of Orthodontics; Dean, Faculty of GEORGE ELIADES
Odontology, Malmö University, Malmö, Sweden Professor and Director, Department of Biomaterials, School of Dentistry,
S. JAY BOWMAN University of Athens, Greece
Adjunct Associate Professor, Saint Louis University; Instructor, THEODORE ELIADES
University of Michigan; Assistant Clinical Professor, Case Western Professor and Head, Department of Orthodontics and Paediatric
Reserve University; orthodontist in private practice, Portage, Dentistry, Center of Dental Medicine, University of Zurich, Switzerland
Michigan, USA
NEJAT ERVERDI
FRIEDRICH K. BYLOFF Professor, Department of Orthodontics, Faculty of Dentistry, Marmara
Former Clinical Instructor, Department of Orthodontics, School of University, Istanbul, Turkey
Dentistry, University of Geneva, Switzerland; orthodontist in private
practice, Graz, Austria INGALILL FELDMANN
Senior consultant, PhD, Orthodontic Clinic, Public Dental Helth Service,
VITTORIO CACCIAFESTA Gävle and Centre for research and Development, Uppsala University/
Orthodontist in private practice, Milan, Italy County Council of Gävleborg, Gävle, Sweden
LESLIE YEN-PENG CHEN MATTIA FONTANA
Orthodontist in private practice, Taipei, Taiwan Orthodontist in private practice, La Spezia, Italy

viii
 Contributors ix

TADASHI FUJITA BEYZA HANCIOGLU KIRCELLI

Assistant Professor, Department of Orthodontics and Craniofacial Former Associate Professor, Department of Orthodontics, University of
Developmental Biology, Hiroshima University Graduate School of Baskent; orthodontist in private practice, Adana, Turkey
Biomedical Sciences, Hiroshima, Japan
NAZAN KUCUKKELES
NARAYAN H. GANDEDKAR Professor and Head, Department of Orthodontics, Faculty of Dentistry,
Former Assistant Professor, Department of Orthodontics and Dentofacial Marmara University, Istanbul, Turkey
Orthopedics, SDM College of Dental Sciences and Hospital, Dharwad,
India; Dental Officer Specialist and Clinical Researcher, Cleft and KEE-JOON LEE
Craniofacial Dentistry Unit, Division of Plastic, Reconstructive and Associate Professor, Department of Orthodontics, College of Dentistry,
Aesthetic Surgery, K.K. Women’s and Children’s Hospital, Singapore Yonsei University, Seoul, South Korea

COSTANTINO GIAGNORIO GARY LEONARD

Orthodontist in private practice, SanNicandro Garganico (FG), Italy Oral surgeon in private practice, Dublin, Republic of Ireland

BETTINA GLASL SEUNG-MIN LIM

Clinical Professor, Department of Orthodontics, Kangnam Sacred Heart
Orthodontist in private practice, Traben-Trarbach, Germany
Hospital, Hallym University; orthodontist in private practice, Seoul,
ANTONIO GRACCO South Korea
Assistant Professor, Department of Neurosciences, Section of Dentistry,
JAMES CHENG-YI LIN
University of Padua, Italy
Clinical Assistant Professor, School of Dentistry, National Defense
HIDEHARU HIBI Medical University; Consultant Orthodontist, Department of
Associate Professor, Department of Oral and Maxillofacial Surgery, Orthodontics and Craniofacial Dentistry, Chang Gung Memorial
Graduate School of Medicine, Nagoya University, Nagoya, Japan Hospital; private practice of orthodontics and implantology, Taipei,
Taiwan
RYOON-KI HONG
Chairman, Department of Orthodontics, Chong-A Dental Hospital, ERIC JEIN-WEIN LIOU
Seoul; Clinical Professor, Department of Orthodontics, School of Chairman, Faculty of Dentistry, Chang Gung Memorial Hospital;
Dentistry, Seoul National University, Seoul, South Korea Associate Professor, Department of Orthodontics and Craniofacial
Dentistry, Chang Gung Memorial Hospital, Taipei, Taiwan
MASATO KAKU
GUDRUN LÜBBERINK
Assistant Professor, Department of Orthodontics and Craniofacial
Assistant Clinical Professor, Department of Orthodontics, School of
Developmental Biology, Hiroshima University Graduate School of
Dentistry, University of Duesseldorf, Germany
Biomedical Sciences, Hiroshima, Japan
BJÖRN LUDWIG
HANS KÄRCHER Scientific collaborator, Department of Orthodontics, University of
Professor and Head, Department of Maxillo-Facial Surgery, School of Saarland, Homburg/Saar; orthodontist in private practice, Traben-
Dentistry, University of Graz, Austria Trarbach, Germany
HASSAN E. KASSEM CESARE LUZI
Assistant Lecturer, Department of Orthodontics, School of Dentistry, Orthodontist in private practice, Rome, Italy
Alexandria University, Alexandria, Egypt
B. GIULIANO MAINO
BURÇAK KAYA Visiting Professor of Orthodontics at Ferrara University and Insubria
Assistant Professor, Department of Orthodontics, Faculty of Dentistry, University; orthodontist in private practice, Vicenza, Italy
Başkent University, Ankara, Turkey
FRASER MCDONALD
HYEWON KIM Professor and Head, Department of Orthodontics, King’s College
Orthodontist in private practice, Seoul, South Korea London Dental Institute, London, UK
SEONG-HUN KIM BIRTE MELSEN
Associate Professor, Department of Orthodontics, School of Dentistry, Professor and Head, Department of Orthodontics, School of Dentistry,
Kyung Hee University, Seoul, South Korea University of Aarhus, Denmark
TAE-WOO KIM ANNA MENINI
Professor, Department of Orthodontics, School of Dentistry, Seoul Orthodontist in private practice, Monterosso al Mare (SP), Italy
National University, Seoul, South Korea
CAMILLO MOREA
GERO KINZINGER Postdoctoral Researcher, Department of Orthodontics, Faculty of
Professor, Department of Orthodontics, University of Saarland, Dentistry, University of Sao Paulo, Brazil
Homburg/Saar; private practice, Toenisvorst, Germany
 x Contributors

MELIH MOTRO MICHAEL SCHAUSEIL

Assistant Professor, Department of Orthodontics, Faculty of Dentistry, Research Assistant, Department of Orthodontics, School of Dentistry,
Marmara University, Istanbul, Turkey University of Marburg, Germany

RAVINDRA NANDA GIUSEPPE SICILIANI

Professor and Head, Division of Orthodontics, Department of Professor and Head, Department of Orthodontics, School of Dentistry,
Craniofacial Sciences, School of Dental Medicine, University of University of Ferrara, Italy
Connecticut, Farmington, CT, USA
HIROKO SUNAGAWA
CATHERINE NYSSEN-BEHETS Clinical Associate, Department of Orthodontics and Craniofacial
Professor, Pole of Morphology, Institute of Clinical and Experimental Developmental Biology, Hiroshima University Graduate School of
Research, Catholic University of Louvain, Brussels, Belgium Biomedical Sciences, Hiroshima, Japan

JUNJI OHTANI PHILIPPOS SYNODINOS

Assistant Professor, Department of Orthodontics and Craniofacial Orthodontist in private practice, Athens, Greece
Developmental Biology, Hiroshima University Graduate School of
Biomedical Sciences, Hiroshima, Japan KYOTO TAKEMOTO
Orthodontist in private practice, Tokyo, Japan
PAOLO PAGIN
Orthodontist in private practice, Bologna, Italy KAZUO TANNE
Professor and Head, Department of Orthodontics and Craniofacial
MOSCHOS A. PAPADOPOULOS Developmental Biology, Hiroshima University Graduate School of
Professor, Chairman and Program Director, Department of Orthodontics, Biomedical Sciences, Hiroshima, Japan
School of Dentistry, Aristotle University of Thessaloniki, Greece
FADI TARAWNEH
Research Associate, Department of Orthodontics, School of Dentistry,
SPYRIDON N. PAPAGEORGIOU Aristotle University of Thessaloniki, Greece
Resident, Department of Orthodontics; Doctoral fellow, Department of
Oral Technology, School of Dentistry, University of Bonn, Germany HILDE TIMMERMAN
Orthodontist in private practice, Brussels, Belgium
YOUNG-CHEL PARK
President, World Implant Orthodontic Association; Professor, STEPHEN TRACEY
Department of Orthodontics, College of Dentistry, Yonsei University, Orthodontist in private practice, Upland, CA, USA
Seoul, South Korea
SINA UÇKAN
MARCO PASINI Professor, Department of Oral and Maxillofacial Surgery, Faculty of
Orthodontist in private practice, Massa, Italy Dentistry, Başkent University, Ankara, Turkey
ZAFER OZGUR PEKTAS MINORU UEDA
Associate Professor, Department of Orthodontics, University of Baskent, Professor, Department of Oral and Maxillofacial Surgery, Graduate
Department of Oral and Maxillofacial Surgery, Ankara, Turkey School of Medicine, Nagoya University, Nagoya, Japan
BEN PILLER MADHUR UPADHYAY
Scientific collaborator, Department of Orthodontics, The Maurice and Assistant Professor and Program Director (Orthodontic Fellowship
Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Program), Division of Orthodontics, Department of Craniofacial
Israel Sciences, School of Dental Medicine, University of Connecticut,
Farmington, CT, USA
IOANNIS POLYZOIS
Lecturer/Consultant in Periodontology, Dublin Dental University FLAVIO URIBE
Hospital, Trinity College Dublin, Republic of Ireland Associate Professor and Program Director, Division of Orthodontics,
Department of Craniofacial Sciences, School of Dental Medicine,
ROBERT RITUCCI University of Connecticut, Farmington, CT, USA
Orthodontist in private practice, Plymouth, MA, USA
HEINER WEHRBEIN
KIYOSHI SAKAI Professor and Head, Department of Orthodontics, Johannes Gutenberg
Postdoctoral Researcher, Department of Oral and Maxillofacial Surgery,
University Hospital, Mainz, Germany
Graduate School of Medicine, Nagoya University, Nagoya, Japan
BENEDICT WILMES
MASARU SAKAI Professor, Department of Orthodontics, University of Duesseldorf,
Orthodontist in private practice, Nagoya, Japan
Germany
ÇAĞLA ŞAR
Assistant Professor, Department of Orthodontics, Faculty of Dentistry,
Başkent University, Ankara, Turkey
 Contributors xi

HEINZ WINSAUER SPIROS ZINELIS

Orthodontist in private practice, Bregenz, Austria Assistant Professor, Department of Biomaterials, School of
Dentistry, University of Athens, Greece; Dental Biomaterials
SUMIT YADAV Research and Development Chair, King Saud University, Riyadh,
Assistant Professor, Division of Orthodontics, Department of Saudi Arabia
Craniofacial Sciences, School of Dental Medicine, University of
Connecticut, Farmington, CT, USA IOANNIS P. ZOGAKIS
ABBAS R. ZAHER Resident, Department of Orthodontics, School of Dentistry, University
Professor, Department of Orthodontics, School of Dentistry, Alexandria of Jerusalem, Israel
University, Alexandria, Egypt
VASILEIOS F. ZYMPERDIKAS
FRANCESCO ZALLIO Military Dentist, 71st Airmobile Medical Company, 71st Airmobile
Orthodontist in private practice, Sestri Levante (GE), Italy Brigade, Nea Santa, Greece
 Section I: Introduction to orthodontic treatment of Class II malocclusion

Diagnostic considerations and conventional

strategies for treatment of Class II malocclusion
1
Abbas R. Zaher and Hassan E. Kassem

brought forward by surgical procedures.8 There is no evidence that func­

INTRODUCTION
tional appliances increase mandibular growth beyond that which would be
normally achieved.9,10 Growth acceleration does occur, which could be
Treatment of Class II malocclusion in the adolescent period is based on
misinterpreted for true additional growth. However, several studies have
whether there is still growth potential; if so, correction can be attempted
investigated the use of functional appliance treatment to increase mandibu­
by stimulating differential growth of the maxilla and mandible.1,2 This has
lar length in adults11–13 and in growing and adult subjects with a specific
been classically done with headgear or functional appliances.
genetic make-up.14,15
Where there is a mild or moderate Class II malocclusion in an adult, or
an adolescent who is too old for growth modification, camouflage by tooth
movements can be used: (a) moving maxillary molars distally, followed CROWDING
by the entire maxillary arch; (b) extraction of premolars and retraction of
maxillary anterior teeth into the extraction spaces; or (c) a combination of Crowding in either jaw is always a complicating factor in Class II treat­
retraction of the maxillary arch and forward movement of the mandibular ment. In the maxilla, the objective is to retract the maxillary incisors and
arch. Surgical correction is reserved for adults with severe Class II maloc­ reduce overjet. However, space provided by distal movement of molars or
clusion and no further growth potential. premolar extraction is likely to be taken up by resolving the crowding,
Because of individual variation in skeletal, dental and soft tissue mor­ leaving little space for incisor retraction.
phology, treatment plans must be tailored to each patient’s diagnosis, needs In the mandible, treatment aims to maintain the mandibular incisors in
and goals, including treatment approach, appliance design and choice, and their position or to advance them slightly to help to correct the dental
biomechanics. discrepancy in the sagittal plane. There is general agreement that mandibu­
lar incisor advancement should not exceed 2 mm or 3° as beyond this,
reduced stability and periodontal problems can arise.
DIAGNOSTIC CONSIDERATIONS Hence, crowding of more than 4 mm warrants extraction in the mandi­
ble and subsequently in the maxilla. Treatment should be prudent to
From the early 2000s, orthodontic treatment has focused on facial soft resolve crowding without retracting the mandibular incisors, as any inad­
tissue appearance rather than skeletal and dental relations. Facial pro­ vertent retraction necessitates additional retraction of the maxillary inci­
portions can be evaluated clinically using photographs and cephalometric sors, making overjet reduction more difficult to achieve and having effects
radiographs. Accordingly, diagnostic considerations for the Class II patient on facial esthetics.
should focus upon the effect of treatment on the patient’s facial esthetics.
GROWTH POTENTIAL
THE POSITION OF THE UPPER LIP When some growth potential exists, the sensible approach is to attempt
Several cephalometric lines, distances and angles have been proposed to growth modification. Patients in late adolescence with little growth left for
assess the anteroposterior maxillary lip position, of which the E-line is the successful modification can be treated with camouflage tooth movements
most popular.3 The distance of the most prominent point of the upper lip with reasonable facial esthetics unless there is very severe Class II maloc­
to a line dropped from subnasale perpendicular to the Frankfurt horizontal clusion. The remaining vertical growth will offset any further extrusion
is used to assess variation in nose and chin positions and size. The accepted and will reduce the possibility of backward rotation of the mandible, which
norm for males is 4–5 mm and for females 2–3 mm. There is no good would increase facial profile convexity. In adults, camouflage treatment is
predictor of the precise upper lip response to orthodontic treatment4 and difficult because there will be no more vertical facial growth. Excellent
response may vary from 40% to 70% of maxillary incisor movement.5 Any vertical control is essential for adults receiving camouflage treatment. In
lip changes that do occur will be in the direction of movement of the one study, greater molar extrusion occurred in growing patients (4.7 mm)
maxillary anterior teeth.6 A protrusive upper lip can be adjusted by distal than in adults; however, the orginal mandibular plane angle did not change
movement of the maxillary incisors and molars, or by tooth extraction. appreciatively during treatment in the adolescents, while adults failed to
maintain the original angle despite minimal molar extrusion (1.3 mm).16
Recent skeletal anchorage-based treatments have proven very beneficial
THE CHIN in this aspect.
The chin point is an important issue and 85–90% of young patients with
Class II malocclusion who present with mandibular deficiency.7 Various
cephalometric lines have been proposed for spatial evaluation of the chin
OTHER FACTORS
position, including the perpendicular to the Frankfurt horizontal from The significance of the axial inclinations of the posterior teeth is not often
subnasale and the distance from the pogonion (the most prominent point mentioned in the Class II literature. Mesially tipped first molars would
of the soft tissue chin) to the subnasale. If a patient with Class II maloc­ lend themselves more readily to distal tipping, correcting a Class II rela­
clusion presents with a deficient chin, the treatment plan should involve a tion. In contrast, premolars and molars may be tipped distally. In such a
change of chin position. In adults, the chin point can only be consistently case, if a straight wire is used for leveling and alignment, it will move all

1
 2 SECTION I: INTRODUCTION TO ORTHODONTIC TREATMENT OF CLASS II MALOCCLUSION

these teeth forward, thus worsening the Class II condition. Therefore, it Uncommonly, maxillary second molars can be extracted instead of first
can be advised to bond the brackets at an angle in relation to the axis of premolars. Success depends on the third molar eruption path and timing,
these teeth. both of which are not readily predictable for a particular patient. However,
such an approach requires retracting the entire maxillary dentition without
reciprocal protrusion of the incisors.
TREATMENT STRATEGIES

GROWTH MODIFICATION: HEADGEARS Maxillary Posterior Anchorage

AND FUNCTIONAL APPLIANCES
Different strategies have been described for maximizing maxillary poste­
Four randomized controlled trials have clearly shown that headgears and rior anchorage.
functional appliances can successfully be used to correct a Class II dis­
crepancy with no appreciable difference between the two modalities.17–20 Tweed–Merrifield approach
However, the debate centers on how the correction is achieved.
Is the short-term increase in mandibular length achieved with functional This uses J-hook headgears to conserve anchorage by delivering force
appliances clinically significant? Several studies have concluded that it is directly to the anterior segment, sparing the posterior anchor unit. It
unlikely to be of clinical significance21,22 and can be explained by the requires extractions and relies heavily on patient compliance in wearing
observation that the mandible moves downwards rather than forwards as the appliance full-time to ensure efficient tooth movement. In late adoles­
it increases in size.23 cents or adults, compliance will be an issue.
The Herbst appliance and the Mandibular Anterior Repositioning Appli­
ance (MARA) are considered to be the only true fixed functional appli­ Class II elastics and similar non-compliance
ances as they function by dislocating the condyles (believed to increase fixed interarch appliances
mandibular length).1,24 An evaluation of the relative skeletal and dental These use the mandibular arch to balance the maxillary retraction forces.
changes produced by the crown or banded Herbst appliance in growing There are side effects of Class II traction while the use of Class II elastics
patients with Class II division 1 malocclusion concluded that dental still relies on patient compliance.
changes had more correcting effect than skeletal changes.25
The effectiveness of the Herbst appliance compared with a removable Palatal appliances
functional appliance (Twin Block) has been assessed in several studies,
none of which found a significant difference in skeletal, soft tissue or These include transpalatal arches, the Nance holding arch and, less fre­
dental changes as well as in final treatment outcome.26–28 One study did quently, palatal removable retainers.
note that while treatment time was the same with the two approaches,
significantly more appointments were needed for repair of the Herbst Balancing retraction forces against posterior unit
appliance.26 A comparison of the soft tissue effects found that both appli­ Increasing the anchorage value of the posterior segment can be achieved
ances effectively reduced the soft tissue profile convexity but there was by balancing the retraction forces of the anterior segment against the pos­
greater advancement of mandibular soft tissues in the Twin Block group.28 terior anchorage unit, including the maxillary first molars, second molars
The Herbst appliance may have an advantage in terms of increased patient and second premolars.
compliance26 and is also compatible with multibracket therapy, which may
reduce total treatment time in adolescents.
Two-stage space closure

EXTRACTION TREATMENT First the canine is retracted to avoid stressing the anchor unit and then the
canine is added to the posterior segment to increase its anchorage value
The objective of extraction in Class II malocclusion is to compensate the during incisor retraction.
position of the dentition to mask the underlying skeletal discrepancy.
The most popular extraction pattern is the extraction of maxillary first Segmented arch mechanics
premolars to provide space to correct the canine relationship from Class
II to Class I and to correct the incisor overjet. The molars remain in Class Precise differential moments are used to maximize posterior anchorage; in
II intercuspation. Maximum maxillary posterior anchorage is necessary to this case the posterior anchorage is not affected by the friction that is
minimize mesial movement of the maxillary molars and second premolars encountered with sliding mechanics.29
while retracting the anterior segment.
Extraction of mandibular second premolars is considered if there is Classical Begg technique
significant mandibular incisor crowding or labial inclination, in order to Anchorage preservation uses distal tipping of the maxillary anterior
provide space for the retraction of the mandibular canines to align the segment followed by uprighting. The contemporary appliance using this
mandibular incisor. However, in Class II malocclusion, the mandibular technique is the Tip-Edge system.30
canine is already distal to the maxillary canine and so even further retrac­
tion of the maxillary canines is required, stressing maxillary posterior
anchorage even more. In addition, maximum mandibular anterior anchor­ Mandibular Anterior Anchorage
age is necessary to avoid excessive retraction of the mandibular incisors,
To reinforce mandibular anterior anchorage, several strategies have been
which would increase the convexity of the profile.
suggested:
An alternative is to extract two maxillary premolars and one mandibular
incisor. This provides 5–6 mm of space to correct the alignment and axial ■ subdividing the protraction of the posterior segment: the mandibular
inclination of the mandibular incisors; however, it may lead to a residual incisors and canines combined into a single unit to anchor the
excess overjet or a slight Class III canine relation. mesial movement of the posterior teeth one by one
 Diagnostic considerations and conventional strategies for treatment of Class II malocclusion 3

■ balancing the protraction of the mandibular posterior segment orthopedic correction is allowed. Hence, studies reporting posterior posi­
against the maxillary arch using Class II elastics and similar tioning of point A or distal movement of the entire dentition might not
appliances. reflect the use of headgear purely for molar distalization since a growth
■ utilizing differential moments: the segmented arch technique uses an modification effect might be involved. For this reason, studies that apply
asymmetric V-bend to place a large clockwise moment on the headgear forces directly to the first molar are preferred when considering
anterior segment;29 the bidimensional technique uses lingual root the success of headgear use for molar distalization.
torque applied to mandibular incisors and distal root tip to the A study of the use of cervical pull headgear plus implants on the cranio­
mandibular canines to provide stationary anchorage by balancing facial complex compared the effect of adjusting the outer bow of the
the bodily movement of the anterior segment against the forward headgear 20° upwards to 20° downwards relative to the occlusal plane.35
movement of the posterior segment.23 In the first group, only slight distal molar movement occurred, yet the entire
■ utilizing differential tooth movement: the Tip-Edge technique tips maxillary complex moved downwards and backwards relative to the ante­
the posterior teeth followed by uprighting to avoid stressing the rior cranial base. In the second group, more tooth movement was observed,
anterior anchorage.30 particularly a distal tipping to the first molar. Tilting the outer bow upwards
was considered to be appropriate for patients with true maxillary prognath­
ism, while tilting the outer bow downwards may be more suitable for
The Effects of Extraction of Premolars
patients with mesially migrated and/or tipped maxillary first molars.
on Dentofacial Structures
The presence of maxillary second molars is an important consideration
The position of the upper and lower lips after treatment is influenced by in distal molar movement. Maxillary molars move distally more readily
the patient’s pretreatment profile as well as by tooth size–arch length dis­ before the eruption of second molars.18 However, if treatment is initiated
crepancy. A study of patients with Class II malocclusion compared patients before the eruption of the second molar, it is advisable to evaluate the rela­
with extraction of the four first premolars with patients who did not have tive position of the unerupted second molars to the roots of the first molars
extractions.31 The extraction group had more protrusive upper and lower to avoid impactions. An optimal relationship exists when the crowns of
lips relative to the esthetic plane prior to treatment; hence the extraction the second permanent molars have erupted beyond the apical third of the
decision had been influenced by the patient’s pretreatment profile as well roots of the first molars as depicted in periapical radiographs.36
as tooth size–arch length discrepancy. Following treatment, the extraction
group tended to have more retrusive lips, straighter faces and more upright
Non-compliance Maxillary Molar Distalization
incisors compared with the non-extraction group. However, the average
soft tissue and skeletal measurements for both groups were close to the The Pendulum and the Jones Jig appliances were the early non-compliance
corresponding averages from the Iowa normative standards. distalization appliances. These appliances can be classified based on the
Similarly, discriminate analysis scores based on crowding and protru­ source of their intramaxillary anchorage:37
sion were used to create an extraction and a non-extraction group.32 Premo­
■ flexible palatally positioned distalization force systems, e.g. the
lar extraction produced greater reduction in hard and soft tissue protrusion
Pendulum appliance,38 the Keles Slider39 and the Molar Distalizer.40
but long-term follow-up indicated slightly more protrusion in the extrac­
■ flexible buccally positioned distalization force systems, e.g. the
tion group. This was attributed to the greater initial crowding and protru­
Jones Jig,41 Lokar Molar Distalizer,42 Ni-Ti coil springs43 and
sion in the extraction group. This finding refuted the influential belief that
Magneforce.44
premolar extraction frequently causes dished-in profiles.
■ flexible palatally and buccally positioned distalization force systems,
A recent study determined predictive factors for a good long-term
e.g. the Greenfield Molar Distalizer.45
outcome after fixed appliance treatment of Class II division 1 malocclu­
■ rigid palatally positioned distalization force systems, e.g. Veltri
sion. The only treatment variable predictive of a favorable peer assessment
Distalizer.46
rating (PAR) at recall was the extraction pattern.33 The patients who had
■ hybrid appliances with rigid buccal and flexible palatal component,
extraction of either maxillary first premolars or both maxillary first and
e.g. the First Class Appliance.47
mandibular second premolars were more likely to have ideal soft tissue
■ transpalatal arches for molar rotation and/or distalization used as an
outcome as judged by the Holdaway angle. The outcome was less favora­
initial phase in Class II treatment.
ble when the extraction pattern included the first molars and, to a lesser
extent, the mandibular first premolars. Papadopoulos has reviewed the different molar distalization appliances
and their management in Class II malocclusion orthodontic treatment.37
Antonarakis and Kiliaridis have reviewed published data on distal molar
NON-EXTRACTION TREATMENT movement in addition to anchorage loss in premolars and incisors when
using non-compliance intramaxillary appliances with conventional anchor­
Maxillary Molar Distalization
age designs.48 First molars demonstrated a mean of 2.9 mm distal move­
Maxillary molar distalization is an integral part of most non-extraction ment with 5.4° of distal tipping. Incisors showed a mean of 1.8 mm mesial
treatment philosophies for Class II malocclusion.34 Extraoral traction using movement with 3.6° of mesial tipping. Palatal appliances produced less
a facebow headgear is the traditional approach. However, headgear such distal molar tipping (3.6° versus 8.3°) and less mesial incisor tipping (2.9°
as the facebow may be used not only for molar distalization but for growth versus 5°). Friction-free appliances (e.g. pendulum appliances) were asso­
modification as well.23 The two treatment effects are not mutually exclusive ciated with a large amount of distal molar movement and concomitant
and depend to a degree on the intention of treatment. Yet, it is not always substantial tipping when no therapeutic uprighting activation was applied.
possible to discriminate one effect from the other during treatment.
Here the use of the headgear is discussed in the context of strategies to
Fixed Interarch Appliances
move maxillary molars distally to a Class I position in 6 months or less
and to open space in the maxillary arch for the retraction of the remainder Fixed interarch appliances are used in the non-extraction treatment of
teeth of the arch. Once a Class I molar has been achieved, no further Class II malocclusion with retraction of the maxillary teeth and forward
 4 SECTION I: INTRODUCTION TO ORTHODONTIC TREATMENT OF CLASS II MALOCCLUSION

movement of the mandibular teeth. They can be viewed as the fixed alter­ 12. Ruf S, Pancherz H. Herbst/multibracket appliance treatment of Class II, division 1
malocclusions in early and late adulthood: a prospective cephalometric study of con­
native of Class II elastics. A common indication for these appliances is secutively treated subjects. Eur J Orthod 2006;28:352–60.
Class II dental occlusion with retroclined mandibular incisors and deep 13. Pancherz H. The Herbst appliance: a paradigm shift in Class II treatment. World J
overbite.49 Some have claimed that these appliances have an orthopedic Orthod 2005;6(Suppl.):8–10.
14. Purkayastha SK, Rabie AB, Wong R. Treatment of skeletal class II malocclusion in
effect,50,51 while others failed to observe this.52 Proffit et al. have main­ adult patients: Stepwise vs. single-step advancement with the Herbst appliance. World
tained that these “flexible correctors” have little growth effect because they J Orthod 2008;9:233–43.
do not displace the condyles far enough for an orthopedic response.1 15. Chaiyongsirisern A, Rabie AB, Wong RW. Stepwise Herbst advancement versus man­
dibular sagittal split osteotomy: Treatment effects and long-term stability of adult
The fixed interarch appliances are classified into three groups. Class II patients. Angle Orthod 2009;79:1084–94.
1. Extension springs. These are the fixed replica of Class II elastics. 16. McDowell EH, Baker IM. The skeletodental adaptations in deep bite corrections. Am
J Orthod Dentofacial Orthop 1991;100:370–5.
The classic example is the Saif spring (severable adjustable 17. Ghafari J, Shofer FS, Jacobsson-Hunt U, et al. Headgear versus function regulator in
intermaxillary force) but this is no longer commercially available. the early treatment of Class II, division 1 malocclusion: a randomized clinical trial.
2. Curvilinear leaf springs. These springs use a push force rather the Am J Orthod Dentofacial Orthop 1998;113:51–61.
18. Wheeler TT, McGorray SP, Dolce C, et al. Effectiveness of early treatment of Class
more common pull force of Class II elastics, avoiding the II malocclusion. Am J Orthod Dentofacial Orthop 2002;121:9–17.
undesirable extrusion of maxillary anterior and mandibular posterior 19. Tulloch JF, Proffit WR, Phillips C. Outcomes in a 2-phase randomized clinical
teeth, backward rotation of the mandible (worsening the Class II trial of early Class II treatment. Am J Orthod Dentofacial Orthop 2004;125:
657–67.
profile), increase of the anterior face height and excessive gingival 20. O’Brien K, Wright J, Conboy F, et al. Early treatment of Class II, division 1 maloc­
display. The forerunner of this group is the Jasper Jumper,53 which clusion with the Twin-block appliance: a multi-center, randomized, controlled, clinical
is considered the most successful and widely used system. Other trial. Am J Orthod Dentofacial Orthop 2009;135:573–9.
21. Marsico E, Gatto E, Burrascano M, et al. Effectiveness of orthodontic treatment with
examples include the Klapper Superspring II54 and the Forsus functional appliances on mandibular growth in the short term. Am J Orthod Dentofa­
Nitinol Flat Spring.55 cial Orthop 2011;139:24–36.
3. Interarch compression springs. The Eureka Spring was the first 22. Creekmore TD, Radney LJ. Frankel appliance therapy: orthopedic or orthodontic? Am
J Orthod 1993;83:89–108.
system introduced in the market.56 These appliances are the most 23. Gianelly AA, Bednar J, Cociani S, et al. Bidimensional technique theory and practice.
rapidly expanding Class II non-compliance systems because of the Bohemia, NY: GAC International; 2000, pp. 172–81.
promise of fewer breakages, which plagued the Jasper Jumper. The 24. De Vincenzo JP. Treatment options for sagittal corrections in noncompliant patients.
In: Graber TM, Vanarsdall RL, Vig KWL, editors. Orthodontics: current principles
Twin Force,57 Forsus58 and Sabbagh Universal Spring59 followed. and techniques. St Louis, MO: Elsevier-Mosby; 2005.
25. Barnett GA, Higgins DW, Major PW, et al. Immediate skeletal and dental effects of
Papadopoulos gives a more comprehensive review of these appliances.60 the crown- or banded type Herbst appliance on Class II, division 1 malocclusion. Angle
Orthod 2008;78:361–9.
26. O’Brien K, Wright J, Conboy F, et al. Effectiveness of treatment of Class II maloc­
clusion with the Herbst or twin-block appliances: a randomized, controlled trial. Am
CONCLUSIONS J Orthod Dentofacial Orthop 2003;124:128–37.
27. Schaefer AT, McNamara JA Jr, Franchi L, et al. Cephalometric comparison of treat­
The patient with a Class II malocclusion represents a large part of the ment with the Twin-block and stainless steel crown Herbst appliances followed by
fixed appliance therapy. Am J Orthod Dentofacial Orthop 2004;126:7–15.
workload of any orthodontic practice. Generating a problem list and treat­ 28. Baysal A, Uysal T. Soft tissue effect of Twin block and Herbst appliance in patients
ment objectives for such a patient requires careful consideration of a with Class II division 1 retrognathy. Eur J Orthod 2013;35:71–81.
plethora of factors either involving the malocclusion itself or affecting 29. Nanda R, Kuhlberg A, Uribe F. Biomechanics of extraction space closure. In: Nanda
R, editor. Biomechanics and esthetic strategies in clinical orthodontics. St Louis, MO:
treatment outcome. Careful evaluation of the available evidence is crucial Elsevier-Mosby; 2005.
to provide each patient with the most suitable treatment strategy within 30. Parkhouse R. Tip-Edge orthodontics and the Plus bracket. St Louis, MO: Elsevier-
reasonable expectations. Practitioners need to update their knowledge of Mosby; 2009. p. 9–12.
31. Bishara SE, Cummins DM, Jakobsen JR, et al. Dentofacial and soft tissue changes in
new appliances continuously and become familiar with their use. Class II, division 1 cases treated with or without extractions. Am J Orthod Dentofacial
Orthop 1995;107:28–37.
32. Luppapornlap S, Johnson LE. The effects of premolar extraction: a long-term com­
parison of outcomes in “clear-cut” extraction and nonextraction Class II patients.
REFERENCES Angle Orthod 1993;63:257–72.
33. McGuinness NJ, Burden DJ, Hunt OT, et al. Long-term occlusal and soft-tissue profile
1. Proffit WR, Fields HW, Sarver DM. Orthodontic treatment planning: limitations, con­ outcomes after treatment of Class II, division 1 malocclusion with fixed appliances.
troversies and special problems. In: Proffit WR, Fields HW, Sarver DM, editors. Con­ Am J Orthod Dentofacial Orthop 2011;139:362–8.
temporary orthodontics. 4th ed. St. Louis, MO: Elsevier-Mosby; 2007. p. 234–67. 34. Celtin NM, Spena R, Vanarsdall RL Jr. Non extraction treatment. In: Graber TM,
2. Alexander RG. The Alexander discipline: The 20 principles of the Alexander disci­ Vanarsdall RL Jr, Vig KWL, editors. Orthodontics: current principles and techniques.
pline. Hanover Park, IL: Quintessence; 2008. St Louis, MO: Elsevier-Mosby; 2005.
3. Ricketts R. Planning treatment on the basis of the facial pattern and estimate of its 35. Melsen B, Enemark H. Effect of cervical anchorage studied by the implant method.
growth. Angle Orthod 1957;27:14–37. Trans Eur Orthod Soc 1969;45:435–47.
4. Lai J, Ghosh J, Nanda R. Effects of orthodontic therapy on the facial profile in long and 36. Bishara SE. Class II malocclusion: diagnostic and clinical considerations with and
short vertical facial patterns. Am J Orthod Dentofacial Orthop 2000;118:505–13. without treatment. Semin Orthod 2006;12:11–24.
5. Proffit WR, White RP, Sarver DM. Contemporary treatment of dentofacial deformities. 37. Papadopoulos M. Non-compliance distalization: a monograph of the clinical manage­
St Louis, MO: Elsevier-Mosby; 2002. p. 215. ment and effectiveness of a jig assembly in Class II malocclusion orthodontic treat­
6. Kocadereli I. Changes in soft tissue profile after orthodontic treatment with and ment. Thessaloniki, Greece: Phototypotiki Publications; 2005. p. 5–12.
without extractions. Am J Orthod Dentofacial Orthop 2002;118:67–72. 38. Hilgers JJ. The pendulum appliance for Class II non-compliance therapy. J Clin Orthod
7. McNamara JA Jr. Components of Class II malocclusion in children 8–10 years of age. 1992;26:706–14.
Angle Orthod 1981;51:117–210. 39. Keles A, Sayinsu K. A new approach in maxillary molar distalization. Intraoral bodily
8. Talebzadeh N, Porgel MA. Long-term hard and soft tissue relapse after genioplasty. molar distalizer. Am J Orthod Dentofacial Orthop 2000;117:39–48.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:153–6. 40. Keles A. Maxillary unilateral molar distalization with sliding mechanics: a preliminary
9. Papadopoulos MA, Gkiaouris I. A critical evaluation of meta-analyses in orthodontics. investigation. Eur J Orthod 2001;23:507–15.
Am J Orthod Dentofacial Orthop 2007;131:589–99. 41. Jones RD, White JM. Rapid Class II molar correction with an open-coil. J Clin Orthod
10. Huang G. Ask Us – Functional appliances and long term effects on mandibular growth. 1992;10:661–4.
Am J Orthod Dentofacial Orthop 2005;128:271–2. 42. Scott MW. Molar distalization: More ammunition for your operatory. Clin Impressions
11. Ruf S, Pancherz H. Orthognathic surgery and dentofacial orthopedics in adult Class 1996;33:16–27.
II, division 1 treatment: Mandibular sagittal split osteotomy versus Herbst appliance. 43. Gianelly AA, Bednar J, Dietz VS. Japanese NiTi coils used to move molars distally.
Am J Orthod Dentofacial Orthop 2004;126:140–52. Am J Orthod Dentofacial Orthop 1991;99:564–6.
 Diagnostic considerations and conventional strategies for treatment of Class II malocclusion 5

44. Blechman AM, Alexander C. New miniaturized magnets for molar distalization. Clin 52. Cope JB, Buschang PH, Cope DD, et al. Quantitative evaluation of craniofacial changes
Impressions 1995;4:14–19. with Jasper Jumper therapy. Angle Orthod 1994;64:113–22.
45. Greenfield RL. Fixed piston appliance for rapid Class II correction. J Clin Orthod 53. Jasper JJ. The Jasper Jumper: a fixed functional appliance. Sheybogan, WI: American
1995;29:174–83. Orthodontics; 1987.
46. Veltri N, Baldini A. Slow sagittal and bilateral expansion for the treatment of Class II 54. Klapper L. The SUPERspring II: a new appliance for non-compliant Class II patients.
malocclusions. Leone Boll Int 2001;3:5–9. J Clin Orthod 1999;33:50–4.
47. Fortini A, Luopoli M, Parri M. The First Class Appliance for rapid molar distalization. 55. Vogt W. A new fixed interarch device for Class II correction. J Clin Orthod 2003;37:
J Clin Orthod 1999;33:322–8. 36–41.
48. Antonarakis GS, Kiliaridis S. Maxillary molar distalization with noncompliance 56. De Vincenzo JP. The Eureka Spring: a new interarch delivery system. J Clin Orthod
intramaxillary appliances in Class II malocclusion: a systematic review. Angle Orthod 1997;31:454–67.
2008;78:1133–40. 57. Rothenberg J, Campell ES, Nanda R. Class II correction with Twin Force Bite Cor­
49. McSherry PF, Bradley H. Class II correction reducing patient compliance: a review rector. J Clin Orthod 2004;38:232–40.
of the available techniques. J Orthod 2000;27:219–25. 58. Vogt W. The Forsus Fatigue Resistant Device. J Clin Orthod 2006;40:368–77.
50. Weiland FJ, Ingervall B, Bantleon HP, et al. Initial effects of treatment of Class II 59. Sabbagh A. The Sabbagh Universal Spring. In: Papadopoulos M, editor. Orthodontic
malocclusion with the Herren activator, activator-headgear combination and Jasper treatment of the Class II non-compliant patient: current principles and techniques.
Jumper. Am J Orthod Dentofacial Orthop 1997;112:19–27. Edinburgh: Elsevier-Mosby; 2006. p. 203–16.
51. Stucki N, Ingervall B. The use of the Jasper Jumper for the correction of Class II 60. Papadopoulos M. Orthodontic treatment of the Class II non-compliant patient: current
malocclusion in the young permanent dentition. Eur J Orthod 1998;20:271–81. principles and techniques. Edinburgh: Elsevier-Mosby; 2006.
 2 Non-compliance approaches for management of
Class II malocclusion
Moschos A. Papadopoulos

■ the appliances almost always require the use of dental and/or palatal
INTRODUCTION
anchorage, such as fixed appliances, lingual or transpalatal arches or
Class II malocclusion is considered the most frequent problem presenting modified palatal buttons
in the orthodontic practice, affecting 37% of school children in Europe and ■ most appliances use resilient wires, particularly those for molar
occurring in 33% of all orthodontic patients in the USA.1 Class II maloc- distalization, e.g. superelastic nickel–titanium (Ni-Ti) and titanium–
clusion may also involve craniofacial discrepancies, which can be adjusted molybdenum (TMA) alloys.
when patients are adolescent. The usual treatment options in growing All these appliances can be classified into two groups based on their mode
patients include extraoral headgears, functional appliances and full fixed of action and type of anchorage: intermaxillary and intramaxillary.7
appliances with intermaxillary elastics and/or teeth extractions. In adults,
moderate Class II malocclusion can be corrected with fixed appliances in
combination with intermaxillary elastics and/or teeth extractions, and INTERMAXILLARY NON-COMPLIANCE APPLIANCES
severe malocclusion with fixed appliances and orthognathic surgery. While Intermaxillary non-compliance appliances have intermaxillary anchorage
the efficiency of these conventional treatment modalities has improved, and act in both maxilla and mandible in order to advance the mandible to
particularly in growing patients,2 most require patient cooperation in order a more forward position (e.g. the Herbst appliance, the Jasper Jumper, the
to be effective, which is often a major problem.3 Adjustable Bite Corrector and the Eureka Spring). These appliances can
be further classified based on the force system used to advance the
mandible:
THE PROBLEM OF COMPLIANCE
■ rigid
In general, orthodontic appliances interfere with daily life, causing unpleas- ■ flexible
ant sensations and impeding speech. It is difficult to ensure appliance use ■ hybrid of rigid and flexible
by children or adolescents, particularly as treatment can take several years ■ substituting for elastics.
and is likely to occur at a time of complex social and developmental
changes. As orthodontic correction of a malocclusion is an elective treat-
Rigid Intermaxillary Appliances
ment, non-compliance usually has no vital consequences for the patient.3
Reasons for non-compliance do not just relate to the discomfort and In addition to the popular Herbst appliance (Dentaurum, Ispringen,
appearance of wearing for example the headgear; there is also a risk of Germany), several other modifications have been proposed.
injury, such as eye and facial tissue damage,4 and unwanted effects of the
elastic cervical strap on the cervical spine, muscles and skin. Cephalometric The Herbst appliance
evaluations have indicated that extraoral appliances almost always have
The Herbst appliance functions like an artificial joint between the maxilla
skeletal effects in addition to the desired dentoalveolar effects.5 This could
and the mandible (Fig. 2.1). The original design had a bilateral telescopic
be a problem where only molar distalization is needed to gain the appropri-
mechanism attached to orthodontic bands on the maxillary first perma-
ate space for teeth alignment with no restriction of maxillary growth, such
nent molars and on mandibular first premolars (or canines); this main-
as in Class I maloccusion with maxillary crowding. The use of headgears
tained the mandible in a continuous protruded position – a continuous
in Class II caused by maxillary crowding can produce unwanted edge-to-
anterior jumped position. Bands are also usually placed on maxillary first
edge incisor relationships or even anterior crossbite situations.6
premolars and mandibular first permanent molars, while a horseshoe-
Finally, orthodontic treatment in patients with limited compliance can,
type lingual arch is used to connect the premolars with the molars on
among other effects, result in longer treatment times, destruction of the
each dental arch.8
teeth and periodontium, extraction of additional teeth, frustration for the
Each telescopic mechanism has a tube and a plunger, which fit together,
patient and additional stress for clinicians and family.
two pivots and two locking screws.8,9 The pivot for the tube is soldered to
Consequently, much effort has been directed to develop efficient
the maxillary first molar band and the pivot for the plunger to the man-
approaches for the non-compliance patient with Class II malocclusion,
dibular first premolar band. The tubes and plungers are attached to the
particularly when non-extraction protocols have to be utilized.
pivots with locking screws and can easily rotate around their point of
attachment. Special attention should be given to the length of the tube and
the plunger. If the plunger is too short, it may slip out of the tube if the
CHARACTERISTICS AND CLASSIFICATION OF THE patient’s mouth is opened wide and could then jam on the opening of the
NON-COMPLIANCE APPLIANCES tube.10 If the plunger is much longer than the tube, it will extend behind
the tube distally to the maxillary first molar and could wound the buccal
Almost all of the non-compliance appliances used for Class II correction
mucosa.10
have the following characteristics:
The appliance permits large opening and small lateral movements of the
■ forces either to advance the mandible to a more forward position or mandible, mainly because of the loose fit of the tube and plunger at their
to move molars distally are produced by means of fixed auxiliaries, sites of attachment. These lateral movements can be increased by widening
either intra- or intermaxillary the pivot openings of the tubes and plungers.9 If larger lateral movements

6
 Non-compliance approaches for management of Class II malocclusion 7

A B C D

Fig. 2.1 The Herbst appliance (banded Herbst design).

are desired, the Herbst telescope with balls can be utilized, which provides is required for 8–12 months to maintain stable occlusal relationships.10,13,17,22
greater freedom of lateral movements. Class II elastics can also be used.24
There are several design variations depending on how the telescopic The Herbst appliance is indicated for
mechanisms are attached: banded (usual), cast splint,8 stainless steel (SS)
■ non-compliance treatment of Class II skeletal discrepancies, mainly
crowns or acrylic resin splints. In addition to these four basic designs, other
in young patients, to influence mandibular and maxillary growth
variations include space-closing, cantilevered and expansion designs.9,11
efficiently
The anchorage teeth can be stabilized with partial or total anchorage.9
■ patients with a high-angle vertical growth pattern caused by
In maxillary partial anchorage, the bands of the first permanent molars and
increased sagittal condylar growth
first premolars are connected with a half-round (1.5 mm × 0.75 mm)
■ patients with deep anterior overbite
lingual and/or buccal sectional archwire on each side. In the mandible,
■ patients with mandibular midline deviation
the bands of the first premolars are connected with a half-round
■ patients who are mouth breathers, as Herbst does not interfere with
(1.5 mm × 0.75 mm) or a round (1 mm) lingual archwire touching the
breathing
lingual surfaces of the anterior teeth.8,10 When partial anchorage is consid-
■ patients with anterior disk displacement.
ered to be inadequate, the incorporation of supplementary dental units is
advised, thus creating total anchorage.8,10 In maxillary total anchorage, a It is also most suitable for treatment of Class II malocclusion in patients
labial archwire is ligated to brackets on the first premolars, canines and with retrognathic mandibles and retroclined maxillary incisors.10,13 Other
incisors. In addition, a transpalatal arch can be attached on the first molar indications for use of the Herbst appliance are outlined later in the chapter
bands. In mandibular total anchorage, bands are cemented on the first under “Indications and contraindications for non-compliance appliances”,
molars and connected to the lingual archwire, which is extended distally. including its use in obstructive sleep apnea25,26 and as an alternative to
In addition, a premolar-to-premolar labial rectangular archwire attached to orthognathic surgery in young adults.13,20,27
brackets on the anterior teeth can be used.12 When maxillary expansion is The main advantages of the Herbst appliance include:
required, a rapid palatal expansion screw can be soldered to the premolar
■ short and standardized treatment duration
and molar bands or to the cast splint (Fig. 2.1C).8,10 Maxillary expansion
■ lack of reliance on patient compliance to attain the desired
can be accomplished simultaneously10,11,13 or prior to Herbst appliance
treatment
fitment.14 The Herbst appliance can also be used in combination with a
■ easy acceptance by the patient
headgear when banded15 or splinted.16
■ patient tolerance.
The telescopic mechanism exerts a posteriorly directed force on the
maxilla and its dentition and an anterior force on the mandible and its The Herbst appliance is fixed to the teeth and so is functioning 24 hours
dentition.17,18 Mandibular length is increased through stimulation of con- a day and treatment duration is relatively short (6–15 months) rather than
dylar growth and remodeling in the articular fossa, which can be attributed 2–4 years with removable functional appliances. In addition, the distaliz-
to the anterior shift in the position of the mandible.17 The amount of man- ing effect on the maxillary first molars contributes to the avoidance of
dibular protrusion is determined by the length of the tube, which sets extractions in Class II malocclusions with maxillary crowding.28 Other
plunger length. In most cases, the mandible is advanced to an initial edge- advantages include the improvement in the patient’s profile immediately
to-edge incisal position at the start of the treatment, and the dental arches after appliance placement, the maintenance of good oral hygiene, the pos-
are placed in a Class I or overcorrected Class I relationship.13,19–21 In some siblity of simultaneous use of fixed appliances and the ability to modify
cases, a step-by-step advancement procedure is followed (usually by the appliance for various clinical applications.
adding shims over the mandibular plungers) until an edge-to-edge incisal There are also some disadvantages. The main ones are anchorage loss
relationship is established.16 of the maxillary (spaces between the maxillary canines and first premolars)
Treatment with the banded Herbst appliance usually lasts 6–8 and mandibular (proclination of the mandibular incisors) teeth during
months.10,13,22 However, a longer treatment period of 9–15 months may treatment, chewing problems during the first week of the treatment and
give better outcomes.10 soft tissue impingement. There can also be appliance dysfunction.29
Following treatment, a retention phase is required to avoid any relapse Numerous modifications of the Herbst appliance have been proposed,
of the dental relationships from undesirable growth patterns or lip–tongue including Goodman’s Modified Herbst Appliance,30 the upper SS crowns
dysfunction habits.10,22 In patients with mixed dentition and an unstable and lower acrylic resin Herbst design,31 the Mandibular Advancement
cuspal interdigitation,10,17 this phase may last 1 to 2 years or until stable Locking Unit,32 the Magnetic Telescopic Device,33 the Flip-Lock Herbst
occlusal relationships are established when the permanent teeth have Appliance,34 the Hanks Telescoping Herbst Appliance,35 the Ventral Tele-
erupted.23 The retention phase uses removable functional appliances or scope,36 the Universal Bite Jumper,37 the Open-Bite Intrusion Herbst,38 the
positioners. When a second phase with fixed appliances follows, retention Intraoral Snoring Therapy Appliance,36 the Cantilever Bite Jumper,39 the
 8 SECTION I: INTRODUCTION TO ORTHODONTIC TREATMENT OF CLASS II MALOCCLUSION

A B
A B
Fig. 2.3 The Mandibular Protraction appliance. (With permission from
Fig. 2.2 The Ritto appliance. (With permission from Papadopoulos.2) Papadopoulos.2)

Molar-Moving Bite Jumper,40 the Mandibular Advancing Repositioning Fig. 2.4 The Mandibular Anterior
Splint41 and the Mandibular Corrector Appliance.42 Repositioning Appliance. (With
permission from Papadopoulos.2)
The Ritto appliance
The Ritto appliance is a miniaturized telescopic device with simplified
intraoral application and activation (Fig. 2.2).2 It is a one-piece device with
telescopic action that is fabricated in a single form to be used bilaterally,
attached to upper and lower archwires. A steel ball-pin and a lock-controlled
sliding brake are used as fixing components. Two maxillary and two man-
dibular bands and brackets on the mandibular arch can support the appli-
ance adequately. The appliance is activated by sliding the lock around the
mandibular arch distally and fixing it against the appliance. The activation
is performed in two steps, an initial adjustment activation of 2–3 mm and and mesiolingual rotation of the mandibular first molars.44–46 Each maxil-
a subsequent activation of 1–2 mm 1 week later, while further activations lary molar crown also incorporates the same double tube as the mandibular
of 4–5 mm can be performed after 3 weeks. crown. In addition, square tubes (0.062 inch) are soldered to each of the
maxillary crowns, into which slide the corresponding square upper elbows
The Mandibular Protraction appliance (0.060 inch). These upper elbows are inserted in the upper square tubes
while guiding the patient into an advanced forward position, and are hung
The Mandibular Protraction appliance was introduced for the correction vertically. The elbows are tied in by ligatures or elastics after placement
of Class II malocclusion (Fig. 2.3). It has been continuously developed of the device. The buccal position of the upper elbows is controlled by
since its initial introduction and four different types have been torquing them with a simple tool, while their anteroposterior position is
proposed.2,43 controlled by shims. Occlusal rests can be used on the maxillary and
The latest version (MPA IV) consists of a T-tube, a maxillary molar mandibular second molars or premolars. These rests are used in order to
locking pin, a mandibular rod and a rigid mandibular SS archwire with prevent intrusion and tip-back of the maxillary first molars and extrusion
two circular loops distal to the canine.44 The mandibular rod is inserted of the maxillary second molars.46 Brackets on the maxillary second premo-
into the longer section of the T-tube and the molar locking pin is inserted lars should not be used to avoid interfering with the elbow during its
into the smaller section. To place the appliance, the mandibular rod is insertion and removal. The appliance can be combined with maxillary and
inserted into the circular loop of the mandibular archwire; the mandible is mandibular expanders, transpalatal arches, adjustments loops, fixed ortho-
protruded to an edge-to-edge position and the molar locking pin is inserted dontic appliances and maxillary molar distalization appliances.44–46
into the maxillary molar tube from the distal and bent mesial for stabiliza- Before placement of the appliance, the maxillary incisors should be
tion. Thus, the maxillary extremity of the appliance can slide around the aligned, properly torqued and intruded if required so as not to interfere
pin wire. The appliance can also be inserted from the mesial. If activation with mandibular advancement, while the maxillary arch should be wide
is necessary, it can be performed by inserting a piece of Ni-Ti open coil enough to allow the elbows to hang buccally to the mandibular crowns.
spring between the mandibular rod and the telescopic tube.43 The mandible is usually advanced, either in one step or in gradual incre-
ments, into an overcorrected Class I relationship to counteract the expected
The Mandibular Anterior Repositioning Appliance
small relapse usually observed during the post-treatment period.44–46 When
The Mandibular Anterior Repositioning Appliance (MARA; AOA/Pro 4–5 mm of mandibular advancement is required, the mandible is advanced
Orthodontic Appliances, Sturtevant, WI, USA) keeps the mandible in a to an edge-to-edge incisor position. When 8–9 mm correction is needed,
continuous protruded position.44 It can be considered as a fixed Twin Block the advancement is performed in two steps to avoid excessive strain on
because it incorporates two opposing vertical surfaces placed in such a the temporomandibular joint or appliance breakage. The mandible is
way as to keep the mandible in a forward position (Fig. 2.4). advanced initially 4–5 mm and maintained in that position for about 6
The MARA consists of four SS crowns (or rigid bands) attached to the months; it is then advanced in an edge-to-edge position for an additional
first permanent molars. Each mandibular molar crown incorporates a period of 6 months. Alternatively, the advancement can be performed in
double tube soldered on, consisting of a 0.045 inch tube and a gradual increments of 2–3 mm every 8–12 weeks, by adding shims on the
0.022 × 0.028 inch tube for the maxillary and mandibular archwires. A elbows.44–46
0.059 inch arm is also soldered to each mandibular crown, projecting After insertion of the MARA, the patient should be informed that it will
perpendicular to its buccal surface and engaging the elbows on the maxil- take 4–10 days to be comfortable with the new, advanced mandibular posi-
lary molar. For stabilization, the mandibular crowns can be connected tion, during which period some chewing difficulties may occur. If the
through a soldered lingual arch, particularly if no braces are used. A lingual patient is a mouth breather or suffers from bruxism, vertical elastics can be
arch is also recommended to prevent crowding of the second premolars placed during sleeping to keep the mouth closed. The posterior open bite,
 Non-compliance approaches for management of Class II malocclusion 9

which may be observed after appliance placement, is reduced while the Fig. 2.5 The Jasper
posterior teeth erupt normally without interference with the appliance. Jumper.
Treatment duration depends on the severity of the Class II malocclusion
and the patient’s age, but usually lasts 12–15 months.44–46 The patient is
monitored at intervals of 12 to 16 weeks for further adjustments or
reactivations.
After treatment is completed and the dental arches are brought into a
Class I relationship, the appliance is removed and fixed appliances can be
used to further adjust the occlusion. If the mandible is not advanced in an
overcorrected position, Class II elastics can be used for approximately 6
months after appliance removal.

The Functional Mandibular Advancer

The Functional Mandibular Advancer was developed as an alternative to fully engaged mandibular archwires distal to the canine brackets and the
the Herbst appliance for the correction of Class II malocclusions.47 It is a first (or the first and second) premolar bracket is removed. A small plastic
rigid intermaxillary appliance based on the principle of the inclined plane. bead is put on to the archwire to provide an anterior stop, followed by the
It is similar to the MARA but with some fundamental differences. It con- lower end of the jumper; the arch is then ligated in place (Fig. 2.5).48
sists of cast splints, crowns or bands on which the main parts of the appli- However, the most effective method uses an auxiliary tube on the man-
ance, the guide pins and inclined planes, are laser welded buccally. The dibular first molar and sectional archwires (0.017 × 0.025 inch). The distal
bite-jumping mechanism of the appliance is attached at a 60° angle to the end of the sectional archwire, which incorporates an out-set bayonet bent
horizontal, thus actively guiding the mandible in a forward position while mesial to the mandibular molar’s auxiliary tube, is inserted into this tube,
closing, which provides unrestricted mandibular motion and increases while the mesial end is looped over the main archwire between the first
patient adaptation. The anterior shape of the bite-jumping device and the premolar and the canine. Thus, there is no need to remove the premolar
active components of the abutments are designed to allow mandibular brackets and the patient has a greater range of jaw movements.48,49 In
guidance even in partial jaw closure, thus ensuring its effectiveness even patients with mixed dentition, the maxillary attachment is similar to that
in patients with habitual open mouth posture. The appliance is reactivated described above, while the mandibular attachment is achieved through an
by adjusting the threaded insert supports over a length of 2 mm, using archwire extending between the mandibular first molar bands and lateral
guide pins of different widths or by fitting the sliding surfaces of the incisor brackets, thus avoiding the primary canine and molar areas.48
inclined planes with spacers of different thicknesses. Mandibular advance- However, in these patients, a transpalatal arch and a fixed lingual arch must
ment is accomplished using a step-by-step procedure, which provides always be used to prevent undesirable effects.48
better patient adaptation, particularly for adults.47 Prior to appliance placement, heavy rectangular archwires should be
placed in the maxillary and mandibular arches.49 In addition, a lingual arch
can be used in the mandibular arch in order to increase lower anchorage,
Flexible Intermaxillary Appliances
unless extractions are used, and brackets with −5° lingual torque should
The main flexible intermaxillary appliance is the Jasper Jumper. Similar be bonded to the mandibular anterior teeth for the same reason.49 In the
appliances are the Flex Developer, the Adjustable Bite Corrector, the Bite maxillary arch, a transpalatal bar should be used to enhance lateral anchor-
Fixer, the Churro Jumper and the Forsus Nitinol Flat Spring. age. However, when maxillary molar distalization is needed, the use of
transpalatal bars and cinching or tying back the maxillary archwire should
The Jasper Jumper be avoided. The Jasper Jumper can also be combined with rapid palatal
The Jasper Jumper (American Orthodontics, Sheboygan, WI) is a flexible expanders if maxillary expansion is needed.50
intermaxillary appliance introduced to address the restriction of mandibu- The Jasper Jumper exerts a light, continuous force and can deliver
lar lateral movements that occurs with the Herbst appliance.48 It consists functional, bite-jumping, headgear-like forces, activator-like forces,
of a flexible force module, an SS coil spring, enclosed in a polyurethane elastic-like forces or a combination of these.49 When the force module is
cover and attached at both ends to SS endcaps with holes to facilitate straight, it is in passive condition. It is activated when the teeth come into
anchoring (Fig. 2.5).48 The modules differ for the right and left sides and occlusion, thus compressing the spring. A compression of 4 mm can
are supplied in seven lengths, ranging from 26 to 38 mm in 2 mm incre- deliver about 250 g of force. The appliance delivers sagittally directed
ments. Ball-pins, small plastic Teflon friction balls or Lexan beads and forces with a posterior direction to the maxilla and its dentition and recip-
auxiliary sectional archwires are the anchors that are used to attach the rocal anteriorly directed forces on the mandible and its dentition, intrusive
appliance on the maxillary and mandibular fixed appliances. forces on the maxillary posterior teeth and the mandibular anterior teeth,
The appropriate size of Jasper Jumper is determined by guiding the as well as buccal forces on the maxillary arch that tend to expand it.51,52
mandible in centric relation and measuring the distance between the mesial Reactivation of the appliance can take place 2–3 months after initial
of the maxillary first molar headgear tube and the point of insertion to the activation by shortening the ball-pin attached to the maxillary first molar
mandibular arch at the distal of the small plastic beads, adding 12 mm.49 bands or by adding crimpable stops mesial to the ball on the mandibular
The appliance is attached after placement of conventional fixed appli- archwire. Treatment with the Jasper Jumper usually lasts 3–9 months, after
ances and alignment of the teeth in both arches.48 The force module is which the appliance can be left passively in place for 3–4 months for
anchored to the upper headgear tube with a ball-pin passing through the retention, and then finishing procedures can follow.49
upper hole of the Jumper and through the distal end of the headgear tube.
The Flex Developer
Then, the mesial extension of the pin is bent back over the tube to keep it
in position.49 The attachment of the force module to the mandibular arch- The Flex Developer (LPI Ormco, Ludwig Pittermann, Maria Anzbach,
wire can be performed in two ways. In the first, offsets are placed in the Austria) is similar to the Jasper Jumper but is supplied as a kit to be
 10 SECTION I: INTRODUCTION TO ORTHODONTIC TREATMENT OF CLASS II MALOCCLUSION

assembled by the clinician.53 The force module is an elastic minirod made flexible ball-and-socket attachments and a shaft for guiding the spring (Fig.
of polyamide, while additional components include an anterior hooklet 2.7A).54 The appliance is used with full-bracketed maxillary and mandibu-
module, a posterior attachment module, a preformed auxiliary bypass arch, lar dental arches. The open coil spring is attached directly to the upper or
a securing mini-disk and a ball-pin. The anterior locking module is relock- lower archwire with a closed or open ring clamp. The plunger has a
able, thus permitting easy insertion and removal (Fig. 2.6). The appliance 0.002 inch tolerance in the cylinder, and a triple telescopic action allows
is used in combination with conventional fixed appliances and is attached mouth opening to 60 mm, beyond which the appliance is disengaged;
to the headgear tubes of maxillary first molar bands and to a mandibular however, it can be easily reassembled by the patient. The cylinder is con-
bypass arch. nected to the molar tube with a 0.032 inch wire annealed at its anterior
The length of the elastic minirod is determined by measuring the dis- end, and a 0.036 inch ball at the posterior end functioning as a universal
tance between the entrance of the maxillary headgear tube and the labial joint, thus allowing lateral and vertical movements of the cylinder.54
end of the bypass arch using a specially designed gauge. After adjusting The advantages of the Eureka Spring include lack of reliance on patient
the length of the minirod, ensuring that the posterior attachment module compliance, esthetic appearance, resistance to breakage, maintenance of
and the anterior hooklet are parallel, and following placement of the ball- good oral hygiene, prevention of tissue irritation, rapid tooth movement,
pin into the headgear tube from the distal, the patient protrudes the man- optimal force direction, 24-hour continuous force application even when
dible into the desired position and the anterior hooklet is secured on the the mouth is opened up to 20 mm, functional acceptability, easy installa-
bypass archwire.53 To reactivate the appliance, the ball-pin can be short- tion, low cost and minimal inventory requirements.54
ened to the mesial or the bypass arch can be shortened distally, thus
pushing back the sliding arch and bending its end upwards. Alternatively, The Sabbagh Universal Spring
the sliding section of the arch can be shortened by adding an acrylic resin The Sabbagh Universal Spring (Dentaurum, Ispringen, Germany) is
ball at its mesial end. another hybrid appliance; it consists of a telescopic element, a U-loop
The Flex Developer delivers a continuous force of 50–1000 g between anteriorly and a telescope rod with a U-loop posteriorly (Fig. 2.7B).55 The
the maxilla and the mandible, which can be adjusted by thinning the telescopic unit consists of an inner spring over an inner tube, a guide tube
minirod’s diameter; the length of the minirod can also be reduced to allow and a middle telescopic tube. Before insertion of the appliance, alignment,
proper fit of the appliance.53 Lip bumpers, headgears or reversed headgears leveling and decompensation of the dental arches should be completed,
can also be used in combination with the Flex Developer. while brackets with fully engaged SS archwires (i.e. at least 0.016 ×
0.022 inch) in both arches should be used. The appliance is attached to the
Hybrid Appliances maxillary molar headgear tube and to the mandibular archwire. To fit the
appliance, a 0.25 inch ball retainer clasp is placed from the distal through
Among the hybrid intermaxillary appliances that use a combination of the loop in the headgear tube and is bent mesially on the tube. After
rigid and flexible force systems, the Eureka Spring is the most common bending of the tube inwards, the telescopic rod with U-loop is inserted into
for non-compliance Class II orthodontic treatment. Others include the the maxillary fixed telescopic element, and the U-loop is attached to the
Sabbagh Universal Spring, the Forsus Fatigue Resistant Device and the lower SS archwire between the first premolar and the canine bracket.
Twin Force Bite Corrector. The size of the spring can be adjusted by inserting or unscrewing the
inner telescopic tube or by presetting the length of the inner tube with an
The Eureka Spring
activation key. When skeletal effects are required, the spring force should
The Eureka Spring (Eureka Orthodontics, San Luis Obispo, CA, USA) is be minimized, whereas the spring force should be maximized when den-
a hybrid appliance consisting of an open coil spring encased in a plunger, toalveolar effect is mostly needed. The spring can be activated by inserting
or unscrewing the inner telescope tube manually or with an activation key,
by extending or shortening the distal distance of the ball-pin in the head-
gear tube, by inserting activation springs or by placing the U-loop between
the mandibular incisor and canine bracket.55

The Forsus Fatigue Resistant Device

The Forsus Fatigue Resistant Device (3M Unitek, Monrovia, CA, USA)
is a hybrid appliance designed to address the problem of fatigue failure
and consists of a three-piece telescopic spring device. The appliance
Fig. 2.6 The Flex Developer. (With permission from Papadopoulos.2) is attached to the maxillary first molar headgear tube with an L-shaped

A B C

Fig. 2.7 Hybrid appliances. (A) The Eureka Spring. (B) The Sabbagh Universal Spring. (C) The Twin Force Bite Corrector. (With permission from Papadopoulos.2)
 Non-compliance approaches for management of Class II malocclusion 11

ball-pin and to the mandibular archwire through a bypass archwire. The INTRAMAXILLARY NON-COMPLIANCE
appropriate length of the rod is selected to allow full spring compression DISTALIZATION APPLIANCES
without advancing the mandible when advancement is not required. To
simplify the insertion, a direct push rod is incorporated in the device, Intramaxillary non-compliance appliances have intramaxillary or absolute
which permits direct attachment to the mandibular archwire. Ligating the anchorage and act only in the maxilla in order to move molars distally
mandibular canine to the first molar using brackets is advised to avoid (e.g. the Pendulum appliance, the Distal Jet, the Jones Jig, the Sectional
creating space distal to the canine.56 To reactivate the spring, ring bushings Jig assembly, palatal implants and miniscrew implants). These devices can
can be added distal on the stop of the distal rod, thus compressing the also be classified based on the force system used to distalize the maxillary
spring 2–3 mm, or a longer rod can be used to maintain engagement. molars:
Patients should be told not to open their mouth widely because there is a ■ flexible force system positioned palatally or buccally, or both
risk of disengagement. palatally and buccally
■ rigid force system positioned palatally
The Twin Force Bite Corrector ■ hybrid appliances combining a rigid force system buccally and a
flexible one palatally.
The Twin Force Bite Corrector (Ortho Organizers, San Marcos, CA, USA)
is also a hybrid appliance, which is used with conventional full fixed appli-
ances. It consists of dual plungers containing Ni-Ti springs with ball-and-
Appliances with a Flexible Distalization Force System
socket joints in their ends, an anchor wire and an archwire clamp (Fig.
Palatally Positioned
2.7C).57,58 To eliminate the need for a headgear tube, a double lock was
developed. The appliance is attached to the lower archwire between the The Pendulum appliances and the Distal Jet are the most common non-
canine and the first premolar with a ball-and-socket wire clamp and to the compliance appliances that use a flexible molar distalization force system
maxillary molar headgear tube with the anchor wire, which has a ball-and- positioned palatally. Other appliances include the Intraoral Bodily Molar
socket adjustable joint. Before appliance placement, palatal expansion and Distalizer, the Simplified Molar Distalizer, the Keles Slider, Nance Appli-
alignment of the maxillary and mandibular dental arches should be com- ances in conjunction with Ni-Ti open coil springs and the Fast Back
pleted.57,58 Bands with double buccal tubes should also be placed on the Appliance.
maxillary first molars and lingual sheaths in order to facilitate the use of
transpalatal arches. In addition, the mandibular arch should be leveled, the The Pendulum appliance
overbite should be opened and mandibular and maxillary archwires (cross-
The Pendulum appliance consists of a large acrylic resin Nance button that
section 0.017 or 0.018 × 0.025 inch) should be engaged. A lingual lower
covers the mid-portion of the palate for anchorage, and two 0.032 inch
arch can also be used to enhance anchorage. To avoid mandibular incisor
TMA springs (e.g. Ormco, Orange, CA, USA), which are the active ele-
proclination, an elastic chain or a figure-of-eight wire tie can be used from
ments for molar distalization and delivering a light, continuous and
the right to the left molar, cinching back bends at the distal ends of the
pendulum-like force from the midline of the palate to the maxillary molars
archwire.
(Fig. 2.8A).59 The Nance button usually extends from the maxillary first
The appliance exerts a continuous light force of 100–200 g and does
molars anteriorly to just posterior of the lingual papilla and is stabilized
not require reactivation, while it permits lateral movements and a wide
with four retaining wires that extend bilaterally and are bonded as occlusal
range of motion because of its ball joints. After appliance placement, the
rests to the maxillary first and second premolars (or to the first and second
patient should be seen a week later and then monitored once a month.57,58
primary molars).60 Alternatively, the two posterior wires can be soldered
After the desired occlusion has been achieved, the appliance is maintained
to first premolars or first primary molar bands, thus adding to the stability
in place for 2–3 months. On its removal, Class II elastics are used to sta-
of the appliance. Each of the two TMA springs consists of a recurved molar
bilize cuspal interdigitation. Retention appliances can be used to maintain
insertion wire, a small horizontal adjustment loop, a closed helix and a
the mandibular position.
loop for retention in the acrylic resin button.59 These springs are mounted
as close as possible to the center and distal aspects of the Nance button
and when in a passive state they extend posteriorly, almost parallel to the
Appliances Acting as Substitutes for Elastics
midpalatal suture.
Three devices act as substitutes for elastics: the Calibrated Force Module, When activated, each of the springs is inserted into a lingual sheath
the Alpern Class II Closers and the Saif Springs. (0.036 inch) on bands cemented on the maxillary first molars; this produces

A B C D
Fig. 2.8 Pendulum appliances. (A) The basic appliance. (B) The Pendex appliance. (C) The Penguin Pendulum appliance. (D) The K-Pendulum appliance. (With permission
from Papadopoulos.2)
 12 SECTION I: INTRODUCTION TO ORTHODONTIC TREATMENT OF CLASS II MALOCCLUSION

almost 60° of activation and delivers a distalizing force of approximately

230 g, which moves the molars distally and medially.59,61 After the initial
activation of the springs, the patients should be seen, usually every 3–4
weeks, in order to check the spring pressure and to perform appropriate
adjustments if needed. According to Hilgers, approximately 5 mm of distal
molar movement can be achieved in a period of 3–4 months.59
Following the introduction of the Pendulum appliance, a number of
modifications have been presented, such as the Pendex appliance,62,63 the
Penguin Pendulum appliance,64 the K-Pendulum appliance65 and the
Bi-Pendulum and Quad Pendulum appliances (Fig. 2.8).66

The Intraoral Bodily Molar Distalizer

Fig. 2.9 The Keles Slider. (With permission from Papadopoulos.2)
The Intraoral Bodily Molar Distalizer consists of an anchorage unit with
a wide acrylic resin Nance button and an active unit with square-sectioned
TMA distalizing springs (0.032 × 0.032 inch) to achieve improved control period, the patient should be monitored every 4–6 weeks for further
in the transverse plane.67 In addition, bands are placed on the maxillary adjustments.
first molars and premolars, SS retaining wires (0.045 inch) are attached to
the premolar bands and the slot size (0.032 × 0.032 inch) cap palatal The Keles Slider
attachments are welded on the palatal side of the first molar bands. The Keles Slider was developed for unilateral or bilateral molar distaliza-
The springs consist of two sections, the distalizing section that exerts a tion. The design is intended to apply a consistent distal force at the CR of
crown-tipping force and an uprighting section that applies a root-uprighting the first molar, thus producing a more bodily distal molar movement.71 The
force to the first molars.67 In contrast to the Pendulum appliances, the device consists of a Nance button with an anterior bite plane, tubes sol-
springs distalize the maxillary first molars towards the direction in which dered palatally to the maxillary first molars, wire rods (0.036 inch) for
the springs are inactive, exerting a distalizing force of approximately sliding of the first molars, heavy Ni-Ti open coil springs (0.036 inch) and
230 g. The Nance button is very wide, covering the palatal surfaces of the screws to activate the springs (Fig. 2.9).71
incisors as much as possible in order to obtain support from a wider palatal The anchorage unit consists of a wide Nance button to minimize anchor-
tissue and increase anterior anchorage. Thus, it functions as an anterior age loss, including an anterior bite plane to disclude the posterior teeth,
bite plane in order to improve deep bite correction as well as enhance enhance the distal molar movement and correct the anterior deep bite. The
molar distalization by discluding the posterior teeth.67 acrylic resin Nance button is usually stabilized with retaining wires
Class I molar relationships can be accomplished in approximately 7.5 attached to bands on the maxillary first premolars, allowing the second
months. Then, the molars are stabilized for almost 2 months with a con- premolars to drift distally under the influence of the transeptal fibers.71 The
ventional Nance appliance attached to the hinge caps, thus providing easy active unit of the appliance has several parts. Tubes 0.275 inch (1.1 mm)
removal of the appliance for cleaning and if there is soft tissue irritation. in diameter are soldered palatally on the first molar bands, and an SS wire
Following the stabilization period, full fixed appliances are used as the 0.9 mm in length is inserted in the acrylic resin about 5 mm apical to the
second phase of the overall treatment.67 first molar gingival margin, passing through the tube and parallel to the
occlusal plane. A helix is placed at the distal end of the steel rod to control
The Distal Jet the amount of distal molar movement and prevent any disconnection of
The Distal Jet appliance (American Orthodontics, Sheboygan, WI, USA) the tube from the rod. The Ni-Ti coil springs are positioned between the
consists of two bayonet wires inserted in two bilateral tubes embedded in screw on the wire and the tube in full compression, thus producing approx-
a modified acrylic resin Nance button (see Fig. 31.1).68 The Nance button imately 200 g of distalizing force to the molars. To deactivate the appli-
acts as an anchorage unit, while the active part of the appliance consists ance before cementing it, another screw is placed at the distal side of the
of a telescopic unit incorporating two Ni-Ti or SS springs with screw tube. This screw is removed to activate the appliance. After placement of
clamps, sliding through two tubes (internal diameter 0.036 inch) attached the appliance, the patient is monitored once a month and the screws can
bilaterally to the Nance button.68 A wire ending in a bayonet bend is be reactivated if necessary.
inserted in the lingual sheath of the first molar band and the free end is
Nance appliance with coil springs
inserted like a piston into the bilateral tubes.68,69 The telescopic unit and
presumably the line of action of the Distal Jet should be parallel to the A Nance appliance in conjunction with Ni-Ti coil springs can be used for
occlusal plane and located approximately 4–5 mm apical from the maxil- unilateral maxillary molar distalization72 or for bilateral distalization of
lary molar centroid (midpoint on root axis) so that the force produced both first and second molars.73
passes as close as possible to the center of resistance (CR) of the molars.68,69 The appliance for unilateral maxillary molar distalization is a modifica-
In the standard design of the Distal Jet, the Nance button is as large as tion of the traditional Nance holding arch and consists of an active Class
possible to increase stability, extending about 5 mm from the teeth.68 II side, where molar distalization takes place, and an inactive Class I side.
Usually, the Nance button is retained with wires extending bilaterally and The inactive Class I side has an SS wire framework (0.036 inch) ending
soldered to bands on the first premolars, the second premolars or the in an anteriorly projecting arm like that of a Quad helix to resist the hori-
second primary molars. Alternatively, the retaining wires can be bonded zontal moment that can cause distal molar rotation and expansion in the
as occlusal rests to the maxillary first or second premolars.68,70 premolar area. The active Class II side consists also of an arm bend like
To activate the appliance, the screw clamp is moved distally, thus com- the Quad helix with the anterior end soldered to the first premolar band.
pressing the coil spring and creating a distalization force, which is applied An omega loop is soldered to the anterior end of the framework to allow
to the molar band for 3–10.5 months until correction of Class II maloc- distal sliding of the loop when it is opened for activation. A 10 mm long
clusion or a super-Class I relationship has been achieved. During this open coil spring (0.036 inch) is positioned between the omega loop and
 Non-compliance approaches for management of Class II malocclusion 13

Fig. 2.10 The Jones Jig. Lateral (A) and occlusal view (B) of the
appliance after cementation and initial maxillary molar distalization.

A B

the first molar band assembly. A 0.045 inch tube is soldered on the lingual distalizing arches, including the Bimetric Distalizing Arch, the Molar
side of the first molar band and connected to the wire arm with the frame- Distalization Bow, and the Acrylic Distalization Splints.
work moving through the tube, thus allowing sliding of the band assembly.
Following appliance cementing, the omega loop is opened to compress the The Jones Jig
coil spring to a length of 7 mm, which delivers a distalization force of
The Jones Jig (American Orthodontics, Sheboygan, WI, USA) has an
approximately 150 g. The patient is monitored every 2 weeks for further
active unit positioned buccally that consists of active arms or jig assem-
adjustments and reactivations until Class I molar relationship has been
blies incorporating Ni-Ti open coil springs and an anchorage unit consist-
achieved.
ing of a modified Nance button (Fig. 2.10).75
The intra-arch Ni-Ti coil appliance for bilateral distalization of both first
The modified Nance button is stabilized with SS wires (0.036 inch) that
and second molars also has an anchorage unit and an active unit.73 The
extend bilaterally and are soldered to bands on the maxillary first or second
anchorage unit includes a modified Nance appliance and a 0.9 mm lingual
premolars or to primary second molars.75,76 The jig assembly consists of a
archwire soldered to bands on the maxillary second premolars. This lingual
0.036 inch wire that holds the Ni-Ti open coil spring and a sliding eyelet
archwire has two distal pistons that pass through the palatal tubes of the
tube. An additional stabilizing wire is attached along with a hook to the
first molars, which are parallel to the pistons both occlusally and sagittally.
distal portion of the main wire. Thus, the jig assembly includes two arms
The active unit consists of a Ni-Ti coil spring of length 10–14 mm, diam-
in its distal end, which are used to stabilize the appliance.76
eter 0.012 inch and lumen 0.045 inch, which is inserted into the distal
After cementation of the modified Nance appliance, the main arm of the
piston (GAC International, Islandia, NY, USA). The spring is compressed
Jones Jig is inserted into the headgear tube and the stabilizing arm is
to half its length when the tube of the molar band is adapted to the distal
inserted into the archwire slot of the maxillary first molar buccal attach-
piston of the lingual archwire, thus activating the spring and producing an
ment.76 The distal hook is tied with an SS ligature to the hook of the buccal
initial distalization force of approximately 200 g; this reduces to 180 g as
molar tube to further increase stability. The appliance is activated by tying
the molars are distalized. No further activation is required during the dis-
back the sliding hook to the anchor teeth (first or second premolars) with
talization phase of the treatment.
an SS ligature, thus compressing the open coil spring 1–5 mm. The acti-
vated open coil spring can produce approximately 70–75 g of continuous
The Fast Back Appliance distalizing force to the maxillary first molars for 2.5–9 months depending
The Fast Back Appliance (Leone, Florence, Italy) consists of a Nance on the severity of the initial malocclusion. The patient is monitored every
button for anchorage, two palatally positioned sagittal screws and super­ 4–5 weeks for further adjustments and the maxillary molars are shifted
elastic open Memoria coil springs.74 The Nance button is stabilized with distally until a Class I relationship has been achieved.75,76
extension wires soldered on the first premolar bands and includes also the
mesial parts of the screws. Each screw incorporates two wire arms. The The Sectional Jig assembly
mesial one is soldered on the first premolars, while the distal one passes The Sectional Jig assembly is a modification of the Jones Jig consisting
through the palatal first molar tube and incorporates also an open Memoria also of an active and an anchorage unit (Fig. 2.11).76,77 The anchorage unit
coil spring that delivers a distalization force of approximately 200–300 g is a modified Nance button attached with a 0.032 inch SS wire to the
on the maxillary first molars. A self-locking terminal stop with a hole is maxillary second premolar bands. Thus, all teeth mesial to the molars are
added at the distal end of this arm for safety reasons. After the first molars indirectly utilized. Bands with headgear tubes and hooks placed gingivally
are distalized 1.5–2 mm, the screws can be activated to compress the coil are cemented to the first molars. The active unit consists of an active arm
springs, thus maintaining the distalization force. Once the required distali- that is fabricated from a 0.028 inch round SS wire 30–35 mm in length).
zation has been accomplished, the first molars can be maintained in posi- A 3 mm long open loop constructed at a distance of 8 mm from the wire
tion by tying an SS ligature between the molar tubes and the hole of the end divides the wire arm into two sections, a small distal and a larger
self-locking terminal stop. mesial one. A Ni-Ti open coil spring (25–30 mm long, with a wire cross-
section of 0.010 inch and a helix diameter of 0.030 inch) is inserted
Appliances with a Flexible Distalization Force System through the mesial end of the sectional wire. Two sliding tubes are used
Buccally Positioned for positional stabilization of the spring. The distal tube is placed close to
the loop of the sectional wire and stabilizes the coil spring, preventing its
The Jones Jig is one of the most commonly used flexible buccally posi- sliding into the loop. The mesial tube is provided with a hook and is placed
tioned distalization force appliances for non-compliance Class II ortho- close to the mesial end of the sectional wire, which is subsequently bent
dontic treatment. Modifications of the Jones Jig include the Lokar Molar gingivally. This bend prevents the coil spring from sliding away from the
Distalizing Appliance and the Sectional Jig Assembly. These appliances wire and ensures that there is no soft tissue impingement.76,77
use Ni-Ti coil springs in conjunction mainly with Nance buttons, repel- After cementing the modified Nance button and the first maxillary molar
ling magnets and Ni-Ti wires. Other appliances of this type use various bands, the distal end of the Sectional Jig assembly is inserted into the
 14 SECTION I: INTRODUCTION TO ORTHODONTIC TREATMENT OF CLASS II MALOCCLUSION

A B C D

Fig. 2.11 The Sectional Jig assembly. Lateral (A) and occlusal (B) views of the appliance immediately after insertion. Lateral (C) and occlusal (D) views of the appliance
after maxillary molar distalization.

Distalizing Arches, Acrylic Resin Distalization Splints and

the Carriere Distalizer
Several other appliances have been proposed for maxillary molar distaliza-
tion, including
■ distalizing arches, e.g. the Bimetric Distalizing Arch (RMO,
Denver, CO, USA),85 the Multi-Distalizing Arch (Ortho
Organizers, San Marcos, CA, USA), the Molar Distalization
Bow86 and the Korn Lip Bumper (American Orthodontics,
Sheboygan, WI, USA)
■ acrylic resin distalization splints, e.g. the acrylic resin splint with
Fig. 2.12 A magnetic distalization appliance. (With permission from Ni-Ti coils87 and the Removable Molar Distalization Splint88
Papadopoulos.2)
■ the Carriere Distalizer (ClassOne Orthodontics, Lubbock, TX,
USA).89
headgear tube of the first molar band. An SS ligature is then tied between However, almost all of these devices require some form of patient coopera-
the open loop of the active arm and the gingival hook of the molar band, tion either because they are removable or because they have to be used in
thus adding stability to the system and preventing rotation of the sectional conjunction with intermaxillary elastics.
archwire. The spring is activated by ligating the hook of the second
(mesial) sliding tube to the bracket of the second premolar band. Optimal
Appliances with a Double Flexible Distalization Force
activation of the coil spring will deliver 80 g per side. The patient is moni-
System Positioned Both Palatally and Buccally
tored every month for further adjustments and reactivation of the
appliance.76,77 Two appliances have a double flexible distalization force system posi-
tioned both palatally and buccally: the Piston appliance (i.e. the Greenfield
Magnets Used for Molar Distalization Molar Distalizer) and a Nance appliance in conjunction with Ni-Ti open
The development of rare metal permanent magnets has allowed the clinical coil springs and an edgewise appliance.
application of magnetic forces in orthodontics, since there had been specu-
The Piston appliance (Greenfield Molar Distalizer)
lation on the possible biological effects of static magnetic fields on the
mechanism of orthodontic tooth movement.78,79 Blechman was the first to The Piston appliance (Nx Orthodontic Services, Coral Springs, FL, USA)
develop an intraoral magnetic appliance in conjunction with fixed appli- has an active unit positioned both palatally and buccally consisting of
ances and sectional archwires to distalize the maxillary first molars.80 superelastic Ni-Ti open coil springs and an anchorage unit incorporating
Later, the Molar Distalizing System (Medical Magnetics, Ramsey, NJ, an enlarged modified Nance button.90 The modified Nance acrylic resin
USA)81 and a prefabricated magnetic device (Modular Magnetic, New palatal button is stabilized with SS wires (0.040 inch), which are soldered
City, USA) were introduced to distalize maxillary molars.82 to the first premolar bands. The active unit consists of superelastic Ni-Ti
To reinforce anchorage, a modified Nance button is used and stabilized open coil springs (0.055 inch) positioned around the piston assemblies.
to the maxillary first or second premolar bands or maxillary first primary The piston assemblies are fabricated with SS wires (0.030 inch) soldered
molar bands (Fig. 2.12).73,81,83 Bondemark et al. suggested the incorpora- buccally and palatally to the first molar bands and tubes (0.036 inch) sol-
tion of an anterior bite plane to the Nance button to disclude the posterior dered on the maxillary first premolar bands. To activate the appliance,
teeth.84 The active unit consists of a pair of repelling magnets attached to 2 mm ring stops are added to the mesial of the buccal and palatal tubes in
a sectional wire, the surfaces of which are brought into contact to deliver each piston every 6–8 weeks, thus delivering 25 g of distalizing force to
a distalization force. The mesial magnet is mounted so that it can move each piston assembly, and subsequently 50 g of distalization force for each
freely along the sectional wire.83,84 molar. The molars are distalized with a monthly rate of 1 mm.
To activate the appliance, the repelling surfaces of the magnets are
brought into contact by passing a 0.014 inch ligature wire through the loop
Appliances with a Rigid Distalization Force System
on the auxiliary wire and then tying back a washer anterior to the magnets,
Palatally Positioned
producing a continuous distalization force of 200–225 g. As the distance
between the magnets increases to 1–1.5 mm, this force decreases to a The Veltri Distalizer and the New Distalizer are the most common appli-
minimum of 60–100 g, below which the magnets should be reactivated, ances using expansion screws as a rigid distalization force system posi-
approximately every 1–4 weeks.83,84 tioned palatally.
 Non-compliance approaches for management of Class II malocclusion 15

Fig. 2.13 Bilateral maxillary molar distalization with the First Class
Appliance in a patient with permanent dentition (A) and one with
mixed dentition (B).

A B

Veltri Distalizer for bilateral distalization. The anchorage unit of the appliance consists of
a large palatal Nance button having a “butterfly” shape with wires
The Veltri Distalizer (Leone, Florence, Italy) consists of a Veltri sagittal
(0.045 inch) embedded in the acrylic resin. Anteriorly, these extension
expansion screw palatally positioned and incorporating four extension
wires are soldered lingual to the second primary molar or premolar bands;
arms, which are soldered bilaterally to the first and second maxillary molar
posteriorly they are inserted into tubes (0.045 inch) welded to the palatal
bands in a similar way to the Hyrax expansion screw.91 The appliance is
sides of the first molar bands.93,94 The molar tubes act as a guide during
used for maxillary second molar distalization incorporating as anchorage
distalization to enhance bodily tooth movement. Between the solder joint
all the teeth anterior to the second molars, including the first molars. The
on the second primary molar or premolar band and the tube on the molar
appliance is activated by turning the screw half a turn twice every week
band, 10 mm long Ni-Ti open coil springs are positioned in full compres-
until the second molars are completely distalized. Then, distalization of
sion. The continuous force produced by the springs compensates the action
the first molars follows by means of the Ni-Ti coil springs. To reinforce
of the vestibular screws so that the distal molar movement takes place
anchorage during the distalization of the first molars, a palatal bar with
in a “double-track” system, preventing rotations or the development of
Nance button attached to the second molars, full fixed appliances incor-
posterior crossbites.94 The First Class Appliance can be used in patients
porating an archwire with stops mesial to the second premolars and Class
presenting with either permanent (Fig. 2.13A)94 or mixed (Fig. 2.13B)
II elastics can be used. Consequently, some form of patient compliance is
dentition.95
required during this phase of treatment. When the first maxillary molars
are in Class I relationship, the retraction of the anterior teeth can be
initiated. Transpalatal Arches for Molar Rotation
and/or Distalization
The New Distalizer
Transpalatal arches can be an effective adjunct for gaining space in the
The New Distalizer (Leone, Florence, Italy) can be regarded as a modi- maxillary dental arch in terms of molar derotation or distalization. They
fication of the Veltri Distalizer.92 The appliance consists of a Veltri palatal are particularly useful when the need for derotation is the same on both
sagittal screw for bilateral molar distalization that is soldered by means sides of the dental arch. Since the introduction of the transpalatal bar,
of extension arms to bands on the maxillary first molars and second several designs, soldered (fixed) or removable, have become available.
premolars (or second primary molars). A Nance button connected to the These include:
body of the screw by means of two soldered extension wires adds to the
anchorage. The appliance is activated at a rate of two-quarters of a turn ■ prefabricated transpalatal arch for maxillary molar derotation (GAC
every week. When distalization of the maxillary first molars has been International, Islandia, NY, USA)96
accomplished, the screw is blocked and the arms connecting the screw ■ Zachrisson-type transpalatal bar97,98
with the second premolar bands are cut off. Thus, the first molar position ■ Palatal Rotation Arch99
can be maintained and a second phase of treatment with full fixed appli- ■ Nitanium Molar Rotator 2 and Nitanium Palatal Expander 2 (Ortho
ances can follow. Organizers, San Marcos, CA, USA)100
■ 3D (Wilson) Palatal Appliance (RMO, Denver, CO, USA)101
■ TMA transpalatal arch102
Hybrid Appliances ■ Distalix, which is based on the Quad helix appliance, using the four
The only hybrid appliance that uses a combination of a rigid distalization helices as well as a distalization pendulum spring103
force system, which is buccally positioned, and a flexible one, which is ■ Keles transpalatal arch.104
palatally positioned, is the First Class Appliance.

First Class Appliance MODE OF ACTION OF THE NON-COMPLIANCE

The First Class Appliance (Leone, Florence, Italy) consists of a vestibular APPLIANCES
framework, a palatal framework and four bands (Fig. 2.13).93,94 The active
unit of the appliance includes bilateral screws, buccally positioned, and a
INTERMAXILLARY NON-COMPLIANCE APPLIANCES
spring, palatally positioned. On the buccal side of the first molar bands, There are some distinct differences between using intermaxillary non-
10 mm long vestibular screws are soldered occlusally to the single tubes compliance appliances or intermaxillary elastics to correct a Class II
(0.022 × 0.028 inch) in which the base arches can be positioned after malocclusion. Class II elastics are oriented in a posterior–inferior to
molar distalization. The vestibular screws are seated into closed rings that anterior–superior direction, exercising a pulling type force in a forward
are welded to the bands of the second primary molars or the second premo- and upward direction to the mandibular dentition and in a backward and
lars. Each vestibular screw is activated by a quarter turn once per day downward direction to the maxillary dentition (Fig. 2.14A). Analyzing
 16 SECTION I: INTRODUCTION TO ORTHODONTIC TREATMENT OF CLASS II MALOCCLUSION

Fig. 2.14 Biomechanics of mandibular

advancement with intermaxillary Class II
elastics in sagittal view. (A) Original forces.
(B) Horizontal and vertical force components
and moments generated by the elastics.
Although there is a vertical component to the
force, the anteroposterior components are
greater. This pulling configuration on the
maxillary arch results in extrusion and retrusion
of the anterior teeth, while on the mandibular
arch it results in a forward reposition of the
mandible as well as extrusion of the posterior
teeth.

A B

Fig. 2.15 Biomechanics of mandibular

advancement with intermaxillary non-
compliance appliances in sagittal view.
(A) Original forces at treatment start.
(B) Horizontal and vertical force components
and moments generated by the appliance.
Although there is a vertical component to the
force, the anteroposterior components are
greater. This pushing configuration on the
maxillary arch results in distalization and
intrusion of the posterior teeth and retrusion
of the anterior teeth, while on the mandibular
arch it results in a forward reposition of the
mandible as well as in intrusion and
proclination of the anterior teeth.

A B

these forces in their horizontal and vertical components and taking also ■ a forward reposition of the mandible, as well as in intrusion and
into consideration the CR of the maxillary and mandibular dentition, it proclination of the anterior teeth of the mandibular arch.
becomes obvious that this pulling configuration results in Fig. 2.14B: The effect on the proclination of the mandibular anterior teeth is greater
■ retrusion and extrusion of the anterior teeth of the maxillary arch than that seen with the pulling type device (i.e. intermaxillary elastics).
■ a more forward reposition of the mandible, as well as in extrusion There is also a similar tendency as with intermaxillary elastics for a
of the posterior teeth of the mandibular arch. downward tilt of the occlusal plane because of the moments applied
to the maxillary and mandibular dentition. Consequently, intermaxillary
There is also the tendency for a downward tilt of the occlusal plane because non-compliance appliances, such as the Herbst appliance, are not indicated
of the moments applied to the maxillary and mandibular dentition. The in Class II malocclusions with open bite or/and with proclination of the
effect on the proclination of the mandibular anterior teeth is much smaller mandibular anterior teeth.
than that seen with the pushing type device (i.e. intermaxillary non- Based on this analysis, it becomes obvious that the desired effects pro-
compliance appliances), while there is also the same tendency for a down- duced by the use of intermaxillary appliances include:
ward tilt of the occlusal plane because of the similar moments applied to
■ mandibular advancement in a more forward position
the maxillary and mandibular dentition. Therefore, Class II intermaxillary
■ maxillary molar distalization or retrusion of the maxillary dentition.
elastics are not indicated in Class II malocclusions with deep bite and/or
with proclination of the mandibular anterior teeth. However, there are some side effects with this type of appliance,
In contrast, the intermaxillary non-compliance appliances used to including:
advance the mandible are oriented in a posterior–superior to anterior– ■ intrusion
inferior direction. This positioning results in a pushing type of force in a ■ protrusion or proclination of the mandibular anterior teeth.
forward and downward direction to the mandibular dentition and in a
In addition, treatment with the Herbst appliance may induce anchorage
backward and upward direction to the maxillary dentition (Fig. 2.15A).
loss of the maxillary teeth in terms of spacing between the maxillary
Analyzing the applied forces in their horizontal and vertical components
canines and first premolars. These effects may take place in various degrees
and taking into consideration the CR of the maxillary and mandibular
during mandibular advancement using intermaxillary non-compliance
dentition, this pushing configuration results in Fig. 2.15B:
devices in Class II malocclusion. They represent a very important negative
■ distalization and intrusion of the posterior teeth and retrusion of the aspect of their application and must be seriously considered before initiat-
anterior teeth of the maxillary arch ing treatment with these appliances.
 Non-compliance approaches for management of Class II malocclusion 17

Fig. 2.16 Biomechanics of maxillary molar

distalization with cervical headgear in sagittal
view. (A) Original forces along with the
corresponding horizontal and vertical
components, and moments generated by the
appliance at treatment start. (B) Situation after
molar distalization: distal crown tipping and
extrusion can be observed as side effects.

A B

observed (Fig. 2.17Β). In some other distalization appliances, such as the

INTRAMAXILLARY NON-COMPLIANCE Pendulum appliances, the point of force application is located palatally to
DISTALIZATION APPLIANCES the CR of the molars and this leads to a distal rotation of the maxillary
During maxillary molar distalization, either with conventional extraoral molars in almost every case (Fig. 2.17C). This rotation is significantly
headgear or with non-compliance distalization appliances, a number of more pronounced with the Pendulum appliances because the arc type of
unwanted effects always takes place diminishing their clinical effective- movement not only rotates the molars distally but also moves them towards
ness. These side effects of intramaxillary devices may vary with the type the midline, producing a posterior maxillary arch constriction and a cross-
of distalization appliance, but they always accompany molar distalization bite tendency. Distal tipping, distal rotation and extrusion of the molars
and can be posterior (distal molar crown tipping, distal crown rotation and are considered as posterior anchorage loss, since measures have to be taken
occasionally molar extrusion) or anterior (forward movement and procli- to counteract them.
nation of the maxillary anterior teeth) anchorage loss. They result from the Non-compliance distalization appliances usually utilize the first or
biomechanics involved and thus the orthodontist should always consider second premolars for their anchorage and so the reaction forces produced
where the CR of the teeth to be moved is located and the relationship of by the various coil springs are applied indirectly to the anterior dental unit:
this to the point of force application. premolars, canines and incisors. The CR of this dental unit is located
For example, when moving maxillary molars distally with cervical somewhere between the root apices of the premolars; consequently, the
headgears, taking into consideration that in sagittal view the CR is located premolars and canines are moving forward with mesial inclination, the
at the bifurcation of their roots, the point of force application is located incisors are proclined and the overjet is usually increased (Fig. 2.18).
more occlusally and thus the resulting movement will not be a pure bodily These effects are considered as anterior anchorage loss.
distal movement but will have some distal molar crown tipping and extru- These side effects are observed in various degrees when examining the
sion (Fig. 2.16). In addition, in occlusal view, the point of force application clinical efficacy of all non-compliance devices,105 including the Sectional
is located buccally in relation to the CR of the molars (Fig. 2.17A) and so Jig assembly used for simultaneous distalization of maxillary first and
a distal rotation of the molar crowns is also observed. Distal tipping, distal second molars,77 similar devices with Ni-Ti coil springs and the First Class
rotation and extrusion of the molars are considered as anchorage loss, since Appliance.95 However, there is still lack of high-quality evidence-based
additional force systems have to be applied to counteract these unwanted studies investigating not only the appliances and approaches used for non-
side effects. compliance molar distalization but also many other issues related to clini-
There will also be side effects on other areas of the body. Newton’s third cal orthodontics that could impact on the use of these modalities.106
law of motion states that when one body exerts a force on another the After molar distalization has been accomplished using a non-compliance
second body will simultaneously exert a force equal in magnitude and distalization appliance, the appliance is usually removed and the first
opposite in direction to that of the first. As use of headgears will apply molars are retained in position usually by a new modified Nance holding
such a reaction force to the patient’s neck, this can put a strain on the arch for a “stabilization period” of approximately 2 months. This allows
cervical spine and the neck muscles. for a spontaneous distal drift of the first and second premolars through the
Finally, lingual tipping of the maxillary incisors often takes place when pull of the transeptal fibers. Alternatively, a transpalatal arch or a utility
using headgears to distalize maxillary molars; it occurs from pulling of archwire or an archwire with stops mesial to the molar tubes can be used
transeptal fibers (drifting) and from restriction of maxillary growth. The to maintain the position of the maxillary first molars. However, some non-
later effect will, occasionally, be unwanted, for example in Class II maloc- compliance distalization devices, such as the Distal Jet, do not need to be
clusion with maxillary crowding, where space has to be created for teeth removed after molar distalization is accomplished. These appliances can
alignment and there is no need for maxillary growth restriction. be converted to a passive appliance (in other words to a modified Nance
Intramaxillary non-compliance distalization appliances have similar holding arch) to retain the maxillary molars in their new positions. The
problems to those discussed above for cervical headgear: the CR of the conversion steps are usually quite simple.
maxillary molars is at the bifurcation of their roots but the point of force Finally, in order to complete the correction of Class II malocclusion
application is located more occlusally. Hence, the resulting movement is after this stabilization period, a second phase of comprehensive orthodon-
again accompanied by distal molar crown tipping and extrusion (Fig. tic treatment with full fixed appliances should follow, including retraction
2.18). In addition, in occlusal view, the point of force application of many of the anterior teeth and leveling and alignment of the dental arches. A
of these appliances (e.g. the Sectional Jig assembly) is located buccally in variety of methods mechanics is available to complete these tasks, such as
relation to the CR and so distal rotation of the molar crowns is also typical orthodontic biomechanics with preadjusted appliances and Class II
 18 SECTION I: INTRODUCTION TO ORTHODONTIC TREATMENT OF CLASS II MALOCCLUSION

Fig. 2.17 Biomechanics of maxillary molar

distalization in occlusal view. (A) Forces and
moments generated by cervical headgear.
(B) Forces and moments generated by
non-compliance distalization appliances, such
as the Sectional Jig assembly, with a force
system buccally positioned. (C) Forces and
moments generated by non-compliance
distalization appliances, such as the
Pendulum appliance, with a force system
palatally positioned.

A B C

Fig. 2.18 Biomechanics of maxillary molar

distalization with non-compliance
distalization appliances on the sagittal view.
(A) Forces and moments generated by the
appliance at treatment start. (B) Situation
after maxillary molar distalization: distal
crown tipping and extrusion can be observed
as side effects, as well as anchorage loss in
terms of incisor proclination and mesial
movement and inclination of the premolars
and canines.

A B

elastics. However, compliance with elastic wear may be a serious problem to reinforce anchorage both during distalization, in order to avoid mesial
and this can have a negative effect on the posterior anchorage that needs movement and proclination of the anterior teeth serving as a dental anchor-
to be maintained in a maximum state during anterior teeth retraction. age unit, as well as following distalization for the subsequent retraction of
Furthermore, if the patient does not cooperate, the gains from molar dis- the anterior teeth. This anchorage reinforcement can be achieved by skel-
talization may even be jeopardized during this phase, with mesial move- etal anchorage using orthodontic implants, miniplates or miniscrew
ment of the molars that have just been distalized. In these instances, the implants.
combined use of fixed functional appliances, such as the Jasper Jumper,
Sabbagh Spring or Eureka Spring, may support the mesial forces applied
to the maxillary molars. The fixed functional appliances serve in these
INDICATIONS AND CONTRAINDICATIONS FOR
situations much like a cervical headgear, without the need for compliance,
NON-COMPLIANCE APPLIANCES
to support maxillary molar position during active retraction of anterior
teeth.
INTERMAXILLARY NON-COMPLIANCE APPLIANCES
In summary, when non-compliance distalization appliances are used,
three problems mainly occur: Compared with removable functional appliances, the intermaxillary non-
compliance appliances are fixed to the teeth directly or indirectly and are,
■ anchorage loss of the anterior dental unit, in terms of mesial
therefore, able to work 24 hours a day. In addition, the duration of treat-
movement and proclination of the anterior teeth, both taking place
ment is relatively short (6–15 months for the Herbst appliance, 3–4 months
during molar distalization
for the rest), compared with 2–4 years for the removable functional appli-
■ distal tipping of the molars, taking place during molar distalization
ances. This makes these appliances suitable for postpubertal patients while
■ anchorage loss of the posterior dental unit in forward direction that
the Herbst appliance may also be suitable for young adults.
takes place after distalization and during the stage of anterior teeth
The non-compliance intermaxillary appliances used for mandibular
retraction and final alignment of the dental arches.
advancement have similar indications and contraindications. There is,
Consequently, clinically efficient maxillary molar distalization using however, one significant difference. In contrast to the Herbst appliance,
intramaxillary non-compliance distalization devices must provide a bio- almost all of the other non-compliance appliances produce mainly den-
mechanical force system that will not also cause the unwanted distal crown toalveolar effects and they are, therefore, indicated only for the correction
tipping, rotation and extrusion of the maxillary molars. It is also crucial of dentoalveolar Class II molar relationships and not for treatment of Class
 Non-compliance approaches for management of Class II malocclusion 19

II skeletal discrepancies. In moderate or dentoalveolar Class II, full fixed been suggested that the eruption stages of the second molar have a basic
appliances and intermaxillary Class II elastics can be applied but in Class qualitative and quantitative impact on the distalization of the first molars
II skeletal or severe dentoalveolar discrepancies, the Herbst appliance is because a tooth bud may act as a fulcrum on the mesial neighboring tooth.
preferred. When the use of Class II elastics is not indicated or is not effi- It has also been shown that tipping of the first molars is much more pro-
cient, or when there is no patient cooperation, the use of intermaxillary nounced when the second molars are still at the budding stage, and that
non-compliance appliances, such as the Jasper Jumper, the Eureka Spring, tipping of the second molars is greater when a third molar bud is located
the Sabbagh Spring, or the Twin Force Bite Corrector can be used in in the direction of movement.107 For this reason, germectomy of wisdom
combination with the fixed appliances, since they are more easily applied teeth is recommended in order to achieve bodily distalization of both
at this stage of treatment than the Herbst appliance. molars even when the second molars are not banded.
The Herbst appliance is indicated for the non-compliance treatment of Intraoral non-compliance distalization appliances are not solely indi-
Class II skeletal discrepancies, deep anterior overbite and mandibular cated in patients with minimal compliance and can also be useful in
midline deviation, as well as in mouth breathers and in patients with ante- compliant patients, particularly when non-extraction treatment protocols
rior disk displacement. It is also suitable for the treatment of Class II have to be utilized. They can be used, for example, during the early phase
malocclusion in patients with retrognathic mandibles and retroclined max- of permanent dentition in patients with almost completed pre-pubertal
illary incisors. The removable acrylic resin Herbst appliance can be used growth, as well as when the second maxillary molars have already erupted
in patients suffering from obstructive sleep apnea, in order to improve the and treatment with headgears would be difficult, requiring almost 24 hours
clinical symptoms.25,26 a day wear in order to be effective.77
Choosing the correct time to initiate treatment with a Herbst appliance Nevertheless, the use of non-compliance distalization appliances has
is considered critical for success. Treatment before the pubertal peak of some contraindications. These include the crowding or spacing conditions
growth can lead to normal skeletal and soft tissue morphology at a young of the maxillary dental arch and the growth pattern of the craniofacial
age, providing a foundation for normal growth of these structures. However, complex, as well as the anatomical characteristics of the palatal vault.
while this is the most suitable age to initiate treatment, this early approach Severe crowding or spacing in the maxillary dental arch can lead to dis-
requires retention of the treatment device until the eruption of all the per- proportionate anchorage loss of the anterior dental unit. In addition,
manent teeth into a stable cuspal interdigitation, and so the possibility of patients with insufficient seating of the Nance button because of a reduced
occlusal relapse is greater. By initiating treatment in the permanent denti- palatal vault inclination may be unsuitable for molar distalization with
tion at or just after the pubertal growth peak, the increase in condylar these appliances. Further, non-compliance molar distalization is also con-
growth and the shorter retention phase required could lead to a more stable traindicated in patients with vertical growth pattern and the presence of,
occlusion and reduced post-treatment relapse. Herbst treatment can also or a tendency towards, an anterior open bite, because of the extrusive
be effective in patients in late adolescence who still have some residual component of the distal molar movement, as well as in patients with severe
growth.10,13,18,20 It can be used in young adults as an alternative to ortho­ protrusive profiles.
gnathic surgery because it has shown favorable results for intermaxillary Consequently, selecting the right patients for the individual treatment
jaw base relationships and skeletal profile convexity, as well as being of modality is a very important factor for a successful outcome and it is
lower cost and risk for the patient.13,20,27 strongly recommended that this is a major consideration before initiating
The prognosis for Herbst treatment is best in subjects with a brachyfa- a non-compliance maxillary molar distalization.
cial growth pattern and it is contraindicated in autistic children, patients
with severe bruxism,29 vertical growth pattern, skeletal or dental open
bites, and proclined mandibular anterior teeth. Unfavorable growth, unsta- ADVANTAGES AND DISADVANTAGES OF THE
ble occlusal conditions and oral habits that persist after treatment are NON-COMPLIANCE APPLIANCES
potential risk factors for occlusal relapse.9
INTERMAXILLARY NON-COMPLIANCE APPLIANCES
INTRAMAXILLARY NON-COMPLIANCE The main advantages of the intermaxillary non-compliance appliances
DISTALIZATION APPLIANCES include the short and standardized treatment duration, the lack of reliance
Maxillary molar distalization using headgears is typically indicated in on patient compliance to attain the desired treatment effects, the easy
patients presenting with bilateral Class II molar relationships and overjet, acceptance and patient tolerance. In addition, the distalizing effect on the
while the intramaxillary non-compliance distalization devices are indi- maxillary first molars contributes to the avoidance of extractions in Class
cated in young children with mixed dentition, as well as in adolescents or II malocclusions with maxillary crowding. Other advantages include the
adults with permanent dentition and Class II malocclusion presenting improvement in the patient’s profile immediately after appliance place-
minimal cooperation when either a bilateral or a unilateral distalization of ment, the maintenance of good oral hygiene, the simultaneous use of fixed
the maxillary molars is required. Non-compliance distalization is also appliances and the ability to modify the appliances for various clinical
particularly indicated in patients with dentoalveolar Class II malocclusion applications.
or a tendency towards skeletal Class I or Class III relationships. It is also However, there also some disadvantages, such as chewing problems
used when there is crowding in the maxillary arch and space has to be during the first week of treatment, soft tissue impingement, breakage or
created for teeth alignment; here there is a need only for molar distalization distortion of the appliances, bent rods, loose or broken bands, loose brack-
while no restriction of maxillary growth is desirable. ets, and in some cases broken or loose screws.
Whether distalization of first maxillary molars is affected by second
molars is a matter of controversy. Some authors have reported that the
presence and the position of second molars do not influence the amount
INTRAMAXILLARY NON-COMPLIANCE
and the type of maxillary first molar distal movement. In contrast, other
DISTALIZATION APPLIANCES
authors suggest that the presence of second molars increases the duration The main advantages of the intramaxillary non-compliance distalization
of treatment time, produces more tipping and more anchorage loss. It has appliances include producing rapid maxillary molar distalization, requiring
 20 SECTION I: INTRODUCTION TO ORTHODONTIC TREATMENT OF CLASS II MALOCCLUSION

minimal patient cooperation, easy acceptance by patients, requiring 22. Pancherz H. The nature of Class II relapse after Herbst appliance treatment: a
cephalometric long-term investigation. Am J Orthod Dentofacial Orthop 1991;100:
minimal chair-time for reactivations, unilateral or bilateral use, distalizing 220–33.
both first and second molars simultaneously (or in some cases consecu- 23. Pancherz H. The effects, limitations, and long-term dentofacial adaptations to treat-
tively) and creating space for the alignment of the maxillary dental arch ment with the Herbst appliance. Semin Orthod 1997;3:232–43.
24. Eberhard H, Hirschfelder U. Treatment of Class II, division 2 in the late growth
without extractions in dentoalveolar Class II discrepancies (or even in period. J Orofac Orthop 1998;59:352–61.
patients with a tendency for skeletal Class I or Class III relationships) with 25. Bloch KE, Iseli A, Zhang JN, et al. A randomized, controlled crossover trial of two
maxillary crowding. oral appliances for sleep apnea treatment. Am J Respir Crit Care Med 2000;162:
246–51.
However, although these appliances can produce rapid distalization of 26. Shadaba A, Battagel JM, Owa A, et al. Evaluation of the Herbst Mandibular Advance-
the maxillary molars, they present some disadvantages, such as anchorage ment Splint in the management of patients with sleep-related breathing disorders.
loss of the anterior dental unit (in terms of forward movement of the Clin Otolaryngol 2000;25:404–12.
27. Paulsen HU, Thomsen JS, Hougen HP, et al. A histomorphometric and scanning
premolars and canines, incisor proclination and/or increased overjet) and electron microscopy study of human condylar cartilage and bone tissue changes in
distal tipping of the molars. Therefore, the mesial movement and slight relation to age. Clin Orthod Res 1999;2:67–78.
protrusion of the anterior dental anchorage unit during distalization have 28. Rogers MB. Troubleshooting the Herbst appliance. J Clin Orthod 2002;36:268–74.
29. Pancherz H, Anehus-Pancherz M. The headgear effect of the Herbst appliance: a
to be considered seriously when applying these non-compliance approaches cephalometric long-term study. Am J Orthod Dentofacial Orthop 1993;103:510–20.
and, again, selecting the right patients for the treatment modality and 30. Goodman P, McKenna P. Modified Herbst appliance for the mixed dentition. J Clin
careful treatment planning is vital. Anchorage loss of the posterior dental Orthod 1985;19:811–14.
31. Valant JR, Sinclair PM. Treatment effects of the Herbst appliance. Am J Orthod
unit (in terms of mesial movement of the distalized maxillary molars) that Dentofacial Orthop 1989;95:138–47.
takes place during the subsequent phase of the anterior teeth retraction is 32. Schiavoni R, Bonapace C, Grenga V. Modified edgewise-Herbst appliance. J Clin
another major disadvantage that has to be taken also into consideration Orthod 1996;30:681–7.
33. Ritto AK. Tratamento das Classes II divisão 1 com a BielaMagnética. Dissertation
before initiation of treatment. Thesis; 1997.
34. Miller RA. The flip-lock Herbst appliance. J Clin Orthod 1996;30:552–8.
35. Hanks SD. Herbst therapy: trying to get out of the 20th century. Good Pract Newslet-
ter Am Orthod 2003;4:2–4.
REFERENCES 36. Ritto AK. Fixed functional appliances: an updated classification. Orthod CYBERJ 2012
<http://orthocj.com/2001/06/fixed-functional-appliances-a-classification-updated/>;
1. Proffit WR. Contemporary orthodontics. St. Louis, MO: Mosby; 2000. [accessed 27 Ocotober 2013].
2. Papadopoulos MA, editor. Orthodontic treatment for the Class II non-compliant 37. Calvez X. The universal bite jumper. J Clin Orthod 1998;32:493–9.
patient: current principles and techniques. Edinburgh: Elsevier-Mosby; 2006. 38. Dischinger TG. Open-bite intrusion Herbst. AOA Orthod Appliances 2001;5:1–4.
3. Zentner A. The problem of compliance in orthodontics. In: Papadopoulos MA, editor. <www.aoalab.com/learning/publications/aoaVol/ aoaVol5No2.pdf>; [accessed 27
Orthodontic treatment for the Class II non-compliant patient: current principles and Ocotober 2013].
techniques. Edinburgh: Elsevier-Mosby; 2006. p. 3–7. 39. Faulkner J. An interview with Dr. Joe Mayes on the Cantilever Bite Jumper. Orthod
4. Samuels RH, Brezniak N. Orthodontic facebows: Safety issues and current manage- CYBERJ 1997 <http://orthocj.com/archive/issue3/p0000077.htm>; [accessed 27
ment. J Orthod 2002;29:101–7. Ocotober 2013].
5. Papadopoulos MA, Rakosi T. Results of a comparative study of skeletal Class II cases 40. Mayes JH. The molar-moving bite jumper (MMBJ). Clin Impressions 1998;7:16–19.
after activator, headgear and combined headgear-activator treatment. Hell Stomatol 41. Clements RM Jr, Jacobson A. The MARS appliance: report of a case. Am J Orthod
Ann 1990;34:87–96. 1982;82:445–55.
6. Papadopoulos MA. Non-compliance distalization: a monograph on the clinical man- 42. Jones M. Mandibular corrector. J Clin Orthod 1985;19:362–8.
agement and effectiveness of a jig assembly in Class II malocclusion orthodontic 43. Coelho Filho CM. Mandibular protraction appliance IV. J Clin Orthod 2001;35:
treatment. Thessaloniki: Phototypotiki; 2005. 18–24.
7. Papadopoulos MA. Classification of the non-compliance appliances used for 44. Eckhart JE. The MARA Appliance. AOA Orthod Appliances 1997;1:1–2.
Class II correction. In: Papadopoulos MA, editor. Orthodontic treatment for the Class 45. Eckhart JE, White LW. Class II therapy with the Mandibular Anterior Repositioning
II non-compliant patient: current principles and techniques. Edinburgh: Elsevier- Appliance. World J Orthod 2003;4:135–44.
Mosby; 2006. p. 9–17. 46. Eckhart JE. MARA provides effective adult treatment. Clin Impressions 2001;10:
8. Pancherz H. The modern Herbst appliance. In: Graber TM, Rakosi T, Petrovic AG, 16–17.
editors. Dentofacial orthopedics with functional appliances. 2nd ed. St. Louis, MO: 47. Kinzinger G, Ostheimer J, Forster F, et al. Development of a new fixed functional
Mosby-Year Book; 1997. p. 336–66. appliance for treatment of skeletal Class II malocclusion: first report. J Orofac Orthop
9. Pancherz H. The Herbst appliance: its biologic effects and clinical use. Am J Orthod 2002;63:384–99.
1985;87:1–20. 48. McNamara JA Jr, Brudon WL. The Jasper Jumper. In: McNamara JA Jr, Brudon WL,
10. White LW. Current Herbst appliance therapy. J Clin Orthod 1994;28:296–309. editors. Orthodontics and dentofacial orthopedics. Ann Arbor, MI: Needham Press;
11. Rogers MB. Herbst appliance variations. J Clin Orthod 2003;37:156–9. 2001. p. 333–42.
12. Pancherz H, Hansen K. Mandibular anchorage in Herbst treatment. Eur J Orthod 49. Blackwood HO 3rd. Clinical management of the Jasper Jumper. J Clin Orthod
1988;10:149–64. 1991;25:755–60.
13. Pancherz H, Ruf S. The Herbst appliance: research-based updated clinical possibili- 50. Mills CM, McCulloch KJ. Case report: modified use of the Jasper Jumper appliance
ties. World J Orthod 2000;1:17–31. in a skeletal Class II mixed dentition case requiring palatal expansion. Angle Orthod
14. McNamara JA Jr, Brudon WL, Buckhardt DR, et al. The Herbst appliance. In: McNa- 1997;67:277–82.
mara JA Jr, Brudon WL, editors. Orthodontics and dentofacial orthopedics. Ann 51. Covell DA Jr, Trammell DW, Boero RP, et al. A cephalometric study of Class II,
Arbor, MI: Needham Press; 2001. p. 285–318. division 1 malocclusions treated with the Jasper Jumper appliance. Angle Orthod
15. Wieslander L. Intensive treatment of severe Class II malocclusions with a headgear- 1999;69:311–20.
Herbst appliance in the early mixed dentition. Am J Orthod 1984;86:1–13. 52. Stucki N, Ingervall B. The use of the Jasper Jumper for the correction of Class II
16. Hagg U, Du X, Rabie AB. Initial and late treatment effects of headgear-Herbst appli- malocclusion in the young permanent dentition. Eur J Orthod 1998;20:271–81.
ance with mandibular step-by-step advancement. Am J Orthod Dentofacial Orthop 53. Winsauer H. Flex Developer. Adjustable power developer: Variable length and force.
2002;122:477–85. Maria Anzbach, Austria: LPI-Ormco; 2002 <www.flexdeveloper.com>; [accessed 27
17. Pancherz H, Hansen K. Occlusal changes during and after Herbst treatment: a cepha- Ocotober 2013].
lometric investigation. Eur J Orthod 1986;8:215–28. 54. DeVincenzo J. The Eureka Spring: a new interarch force delivery system. J Clin
18. Konik M, Pancherz H, Hansen K. The mechanism of Class II correction in late Herbst Orthod 1997;31:454–67.
treatment. Am J Orthod Dentofacial Orthop 1997;112:87–91. 55. Sabbagh A. The Sabbagh Universal Spring (SUS). In: Papadopoulos MA, editor.
19. Pancherz H, Ruf S, Thomalske-Faubert C. Mandibular articular disk position changes Orthodontic treatment for the Class II non-compliant patient: current principles and
during Herbst treatment: a prospective longitudinal MRI study. Am J Orthod Dento- techniques. Edinburgh: Elsevier-Mosby; 2006. p. 203–16.
facial Orthop 1999;116:207–14. 56. Dionne DG. Clinical trial report: Forsus Fatigue Resistant Device. Orthod Perspect
20. Ruf S, Pancherz H. Dentoskeletal effects and facial profile changes in young adults 2002;IX:11–12.
treated with the Herbst appliance. Angle Orthod 1999;69:239–46. 57. Corbett MC, Molina FG. Twin Force Bite Corrector: light force and patient friendly.
21. O’Brien K, Wright J, Conboy F, et al. Effectiveness of treatment for Class II maloc- Syllabus. San Marcos, CA: Ortho Organizers; 2001.
clusion with the Herbst or twin-block appliances: a randomized controlled trial. Am 58. Uribe F, Rothenberg J, Nanda R. The twin force bite corrector in the correction of
J Orthod Dentofacial Orthop 2003;124:128–37. Class II malocclusion in adolescent patients. In: Papadopoulos MA, editor.
 Non-compliance approaches for management of Class II malocclusion 21

Orthodontic treatment for the Class II non-compliant patient: current principles and 83. Bondemark L. The use of magnets for maxillary molar distalization. In: Papadopou-
techniques. Edinburgh: Elsevier-Mosby; 2006. p. 181–202. los MA, editor. Orthodontic treatment for the Class II non-compliant patient: current
59. Hilgers JJ. The pendulum appliance for Class II noncompliance therapy. J Clin principles and techniques. Edinburgh: Elsevier-Mosby; 2006. p. 297–307.
Orthod 1992;26:706–14. 84. Bondemark L, Kurol J, Bernhold M. Repelling magnets versus superelastic nickel–
60. Hilgers JJ. The pendulum appliance: an update. Clin Impressions 1993;2:15–17. titanium coils in simultaneous distal movement of maxillary first and second molars.
61. Bussick TJ, McNamara JA Jr. Dentoalveolar and skeletal changes associated with Angle Orthod 1994;64:189–98.
the pendulum appliance. Am J Orthod Dentofacial Orthop 2000;117:333–43. 85. Wilson WL. Modular orthodontic systems. Part 2. J Clin Orthod 1978;12:358–75.
62. Byloff FK, Darendeliler MA. Distal molar movement using the pendulum appliance. 86. Jeckel N, Rakosi T. Molar distalization by intra-oral force application. Eur J Orthod
Part 1: clinical and radiological evaluation. Angle Orthod 1997;67:249–60. 1991;3:43–6.
63. Byloff FK, Darendeliler MA, Clar E, et al. Distal molar movement using the pendu- 87. Manhartsberger C. Headgear-free molar distalization. Fortschr Kieferorthop 1994;55:
lum appliance. Part 2: The effects of maxillary molar root uprighting bands. Angle 330–6.
Orthod 1997;67:261–70. 88. Ritto AK. Removable distalization splint. Orthodontic CYBERJ 1997;2.
64. Mayes JH. The Texas Penguin: a new approach to pendulum therapy. AOA Orthod 89. Carrière L. A new Class II distalizer. J Clin Orthod 2004;38:224–31.
Appliances 1999;3:1–2. 90. Greenfield RL. Fixed piston appliance for rapid Class II correction. J Clin Orthod
65. Kinzinger G, Fuhrmann R, Gross U, et al. Modified pendulum appliance including 1995;29:174–83.
distal screw and uprighting activation for noncompliance therapy of Class II maloc- 91. Veltri N, Baldini A. Slow sagittal and bilateral palatal expansion for the treatment of
clusion in children and adolescents. J Orofac Orthop 2000;61:175–90. Class II malocclusions. Leone Boll Int 2001;3:5–9.
66. Kinzinger G, Fritz U, Diedrich P. Bipendulum and quad pendulum for noncompliance 92. Baccetti T, Franchi L. A new appliance for molar distalization. Leone Boll Int
molar distalization in adult patients. J Orofac Orthop 2002;63:154–62. 2000;2:3–7.
67. Keles A, Sayinsu K. A new approach in maxillary molar distalization: Intraoral bodily 93. Fortini A, Lupoli M, Parri M. The First Class Appliance for rapid molar distalization.
molar distalizer. Am J Orthod Dentofacial Orthop 2000;117:39–48. J Clin Orthod 1999;33:322–8.
68. Carano A, Testa M. The distal jet for upper molar distalization. J Clin Orthod 94. Fortini A, Franchi L. The First Class Appliance. In: Papadopoulos MA, editor. Ortho-
1996;30:374–80. dontic treatment for the Class II non-compliant patient: current principles and tech-
69. Carano A, Bowman SJ. Noncompliance Class II treatment with the Distal Jet. niques. Edinburgh: Elsevier-Mosby; 2006. p. 309–29.
In: Papadopoulos MA, editor. Orthodontic treatment for the Class II non-compliant 95. Papadopoulos MA, Melkos A, Athanasiou AE. Noncompliance maxillary molar dis-
patient: current principles and techniques. Edinburgh: Elsevier-Mosby; 2006. talization by means of the First Class Appliance: a randomized controlled trial. Am
p. 249–71. J Orthod Dentofacial Orthop 2010;137:586.
70. Bolla E, Muratore F, Carano A, et al. Evaluation of maxillary molar distalization with 96. Dahlquist A, Gebauer U, Ingervall B. The effect of a transpalatal arch for the cor-
the distal jet: a comparison with other contemporary methods. Angle Orthod rection of first molar rotation. Eur J Orthod 1996;18:257–67.
2002;72:481–94. 97. Gunduz E, Zachrisson BU, Honigl KD, et al. An improved transpalatal bar design.
71. Keles A. The Keles Slider Appliance for bilateral and unilateral maxillary moral Part I. Comparison of moments and forces delivered by two bar designs for sym-
Distalization. In: Papadopoulos MA, editor. Orthodontic treatment for the Class II metrical molar derotation. Angle Orthod 2003;73:239–43.
non-compliant patient: current principles and techniques. Edinburgh: Elsevier- 98. Gunduz E, Crismani AG, Bantleon HP, et al. An improved transpalatal bar design.
Mosby; 2006. p. 273–81. Part II. Clinical upper molar derotation: case report. Angle Orthod 2003;73:244–8.
72. Reiner TJ. Modified Nance appliance for unilateral molar distalization. J Clin Orthod 99. Cooke MS, Wreakes G. Molar derotation with a modified palatal arch: an improved
1992;26:402–4. technique. Br J Orthod 1978;5:201–3.
73. Bondemark L. A comparative analysis of distal maxillary molar movement produced 100. Corbett MC. Slow and continuous maxillary expansion, molar rotation, and molar
by a new lingual intra-arch NiTi coil appliance and a magnetic appliance. Eur J distalization. J Clin Orthod 1997;31:253–63.
Orthod 2000;22:683–95. 101. Young DR. Orthodontic products update. Removable quad helices and transpalatal
74. Lanteri C, Francolini F, Lanteri V. Distalization using the Fast Back. Leone Boll Int arches. Br J Orthod 1997;24:248–56.
2002;4:1–3. 102. Mandurino M, Balducci L. Asymmetric distalization with a TMA transpalatal arch.
75. Jones RD, White MJ. Rapid Class II molar correction with an open-coil jig. J Clin J Clin Orthod 2001;35:174–8.
Orthod 1992;26:661–4. 103. Langlade M. Clinical distalization with the Distalix. World J Orthod 2003;4:
76. Papadopoulos MA. The Jones Jig and modifications. In: Papadopoulos MA, editor. 215–28.
Orthodontic treatment for the Class II non-compliant patient: current principles and 104. Keles A. An effective and precise method for rapid molar derotation: Keles TPA.
techniques. Edinburgh: Elsevier-Mosby; 2006. p. 283–95. In: Papadopoulos MA, editor. Orthodontic treatment for the Class II non-compliant
77. Mavropoulos A, Karamouzos A, Kiliaridis S, et al. Efficiency of non-compliance patient: current principles and techniques. Edinburgh: Elsevier-Mosby; 2006.
simultaneous first and second upper molar distalization: a 3D tooth movement analy- p. 331–7.
sis. Angle Orthod 2005;75:468–75. 105. Papadopoulos MA. Clinical efficacy of the noncompliance appliances used for Class
78. Papadopoulos MA. Clinical applications of magnets in orthodontics. Hell Orthod Rev II orthodontic correction. In: Papadopoulos MA, editor. Orthodontic treatment for
1999;1:31–42. the Class II non-compliant patient: current principles and techniques. Edinburgh:
79. Papadopoulos MA. Biological aspects of the use of permanent magnets and static Elsevier-Mosby; 2006. p. 367–87.
magnetic fields in orthodontics. Hell Orthod Rev 1998;1:145–57. 106. Papadopoulos MA, Gkiaouris I. A critical evaluation of meta-analyses in orthodon-
80. Blechman AM. Magnetic force systems in orthodontics: clinical results of a pilot tics. Am J Orthod Dentofacial Orthop 2007;131:589–99.
study. Am J Orthod 1985;87:201–10. 107. Kinzinger GS, Fritz UB, Sander FG, et al. Efficiency of a pendulum appliance for
81. Gianelly AA, Vaitas AS, Thomas WM. The use of magnets to move molars distally. molar distalization related to second and third molar eruption stage. Am J Orthod
Am J Orthod Dentofacial Orthop 1989;96:161–7. Dentofacial Orthop 2004;125:8–23.
82. Bondemark L, Kurol J, Bernhold M. Repelling magnets versus superelastic nickel–
titanium coils in simultaneous distal movement of maxillary first and second molars.
Angle Orthod 1994;64:189–98.
Section II: Introduction to skeletal anchorage in orthodontics

3 The significance of anchorage in orthodontics

Ingalill Feldmann and Lars Bondemark

occlusal and the much lower orthodontic forces.12 Conventional implants,

INTRODUCTION
however, require space in the dental arch and are most useful when com-
bined orthodontic and prosthodontic treatment is required.13 When patients
Anchorage preparation is decisive in achieving successful orthodontic
have complete dentitions, alternative placements and designs for implant-
treatment. Often anchorage in an orthodontic appliance attempts to dissi-
able devices to reinforce anchorage are needed, and various modifications
pate the reaction forces over as many teeth as possible and thus keep
have been designed. The Orthosystem implant (Institut Straumann, Basel,
pressure in the periodontal ligaments of the anchor teeth to a minimum.1
Switzerland) is one of the most documented (Fig. 3.1).4,14,15 The Orthosys-
Theoretically, anchor values for teeth can be estimated from their root
tem implant is an endosseous titanium screw-type implant with a sand-
surface areas, but this is not always reliable since anchorage capacity is
blasted, large-grit, acid-etched surface; the implant is usually placed in the
also influenced by attachment level, density and structure of the alveolar
palate or the retromolar area (see Figs. 7.2 and 7.3B).
bone, periodontal reactivity, muscular activity, occlusal forces, craniofa-
The Onplant System (Nobel Biocare, Göteborg, Sweden)3 is an
cial morphology and friction within the appliance resulting from tooth
osseointegrated anchorage system that is placed subperiosteally in the
movement.2
palate when vertical bone height is limited (Fig. 3.2). The Onplant is a
Use of an extraoral appliance such as headgear to reinforce anchorage
titanium disc coated with a thin layer of hydroxyapatite to facilitate
is effective in that the reactive forces that normally create anchorage loss
osseointegration (Fig. 3.3). Surgical placement and removal of an
do not affect the dentition. However, these techniques require uncondi-
Onplant involves a larger area of the palate compared with an implant,
tional compliance; consequently, various intraoral appliances have been
and second-stage surgery is required to uncover it. All temporary
developed with minimal compliance demands. The need for maximal
osseointegrated anchorage devices need a healing period, usually 10–12
anchorage control in these intraoral appliances has also led to increased
weeks, although a shorter healing period (e.g. 6 weeks) for palatal
use of implants.
implants is possible.16

ANCHORAGE IN ORTHODONTICS NON-OSSEOINTEGRATED ANCHORAGE SYSTEMS

Ideally, an implanted anchorage device should be easy to insert and
SKELETAL ANCHORAGE remove, be inexpensive and preferably should be insertable by an ortho-
Methods to reinforce anchorage use a selection of devices temporarily dontist. Orthodontic miniscrew implants are derived from maxillofacial
anchored in bone. The devices can be fixed to bone, osseointegrated fixation techniques and rely on mechanical retention for anchorage, but
or non-osseointegrated, and they can be located subperiosteally or their heads are specifically modified to engage orthodontic auxiliaries.5,6
endosteally.3–11 Osseointegration per se requires a healing period of 10–12 weeks, but
When direct skeletal anchorage is used, the forces needed for the desired studies with early loading have indicated that the presence of intermediate
tooth movements are applied directly to the device. This usually requires fibrous tissue does not compromise the clinical stability of the implant
a more detailed biomechanical treatment plan than with indirect skeletal during treatment.6,17 This has led to the use of miniscrew implants, which
anchorage, where the teeth that act as reactive units are indirectly stabi- are easy to insert and remove by the orthodontist, are immediately loadable
lized by the skeletal device via a wire or transpalatal arch. With indirect and are inexpensive compared with osseointegrated orthodontic implants
anchorage, the stability of the anchoring teeth also depends on the rigidity or onplants. The Aarhus Anchorage System,17 the Spider Screw,8 the Abso-
of the connecting units. Anchor Micro Implant7 and the IMTEC Ortho Implant18 are some com-
mercial examples. Their small diameter makes insertion between the roots
of teeth fairly easy (Fig. 3.4); however, a sufficient diameter is more
OSSEOINTEGRATED ANCHORAGE SYSTEMS important than implant length for mechanical interlocking in bone. The
Dental implants are now routinely used for complex prosthetic restora- complications of miniscrew implants are predominately the potential risk
tions. The bone–implant contact is sufficiently stable to withstand the for iatrogenic root lesions and poor soft tissue response.

Fig. 3.1 The Orthosystem implant connected to the

molars via a transpalatal bar (1.2 mm SS).

Fig. 3.2 The Onplant System connected to the molars

via a transpalatal bar (1.3 mm SS).

22
 The significance of anchorage in orthodontics 23

Fig. 3.3 (A) The Onplant disk with a diameter of 7.7 mm; (B) After a
second-stage surgery where the disk is uncovered, an abutment is placed
on top of the Onplant; (C) The suprastructure with a connecting
transpalatal bar in place.

A B B

Fig. 3.4 The Spider Screw miniscrew implant. (A) Placement to

reinforce anchorage during space closure after premolar extractions.
(B) Radiograph showing placement between roots of maxillary first
molar and second premolar.

A B

In 1999, Umemori et al. introduced an orthodontic titanium miniplate CONVENTIONAL ANCHORAGE

system, the Skeletal Anchorage System,9 for stable anchorage with imme-
diate loading. Since then, other designs such as the OrthoAnchor System10 Headgear
(see Fig. 45.2D,E) and the Zygoma Anchorage System11 (see Fig. 22.1) One of the most traditionally used systems to reinforce anchorage is the
have been introduced. The advantage of these plates is that they are located headgear, which also has the advantage of being an active distalizing unit
away from the dentition and do not interfere with tooth movements (Fig. 3.5). Patient compliance is essential and girls are known to cooperate
(see Fig. 22.2C). However, placement of miniplates is far more invasive better than boys.21,25 Several studies comparing skeletal anchorage (both
than placement of miniscrew implants, and infections can occur (see osseointegrated and non-osseointegrated) and headgear for molar anchor-
Chapter 13).19 age during space closure after premolar extractions have found signifi-
cantly larger anchorage loss with headgear.20–23 Patients had a tendency to
cooperate well with headgear during the first phase (leveling/aligning) but
OSSEOINTEGRATED VERSUS NON-
compliance decreased over time21 and some patients do not cooperate at
OSSEOINTEGRATED SYSTEMS
all.21 Consequently, a treatment plan that involves headgear as an anchor-
Several studies have demonstrated that both the osseointegrated Ortho- age unit during the entire treatment must consider the possibility of anchor-
system and Onplant systems are successful and suitable as absolute age loss.
anchorage during space closure after premolar extractions.15,20,21 Recent In clinical trials, there is also the risk of the Hawthorne effect (positive
research has also demonstrated that both mini-implants and miniplates bias), which means that subjects are more compliant because they know
can withstand orthodontic forces and serve as anchorage in situations that they are a part of a trial and real life results may be less good. Con-
where anchorage is crucial.22,23 Failure rates are, however, still higher sequently, headgear cannot be considered as suitable for orthodontic
than with osseointegrated implants and this must be taken into account anchorage purposes where there are maximum needs for reinforced
when comparing studies that do not use an intention-to-treat approach.24 anchorage.
Osseointegrated anchorage systems have the additional advantage of
being stable in all three dimensions. Costs have not been considered in
Transpalatal Bars and Arches
any comparative studies published but are certainly important since
osseointegrated devices are more expensive to purchase and require sur- The transpalatal bar, which theoretically produces anchorage by blocking
gical referrals. However, when treating patients with significant anchor- the maxillary first molars with a stable bar in combination with the pres-
age problems, the secure or absolute anchorage of the osseointegrated sure from the tongue, has been widely used in clinical orthodontics.
device is invaluable and may have benefits in terms of time efficiency for Despite this, surprisingly few studies have examined its anchorage effect.
patients, parents and orthodontists. Osseointegrated implants also require The transpalatal bar is usually passive and so is fabricated as rigidly as
a healing period, which delays application of orthodontic forces and possible. However, transpalatal arches can also be active and less rigid
increases the overall treatment time. (Goshgarian design),26,27 thus enabling tooth movements, for example
At present, there is no published study that compares osseointegrated derotation of teeth, correction of crossbites and torquing of the maxillary
implants with non-osseointegrated miniscrew implants or miniplates. molars (Fig. 3.6).
 24 SECTION II: INTRODUCTION TO SKELETAL ANCHORAGE IN ORTHODONTICS

Fig. 3.5 Headgear anchorage. (A) Occlusal and (B) lateral view of a
headgear with a force of about 400 g and a direction corresponding
to medium pull.

A B

Fig. 3.6 Occlusal view of transpalatal bars. (A) A passive bar. (B) An
active transpalatal arch with Goshgarian design.

A B

A randomized controlled trial (RCT) compared the anchorage capacity Fig. 3.7 Maxillary molar
of a transpalatal bar with osseointegrated skeletal anchorage with the distalization with an
Onplant bar.
Orthosystem implant or the Onplant System. Both the osseointegrated
systems were stable during treatment but the transpalatal bar demonstrated
large anchorage loss along with mesial molar tipping.21 The transpalatal
bar was a passive soldered bar (1.0 cm × 2.0 cm) positioned 2 mm from
the palatal mucosa at the midpalatal surface of the maxillary first molars.
The ratio of anchorage loss to active movement was 0.54 for the total
observation period. Similar results have been presented in studies when
canines were retracted after premolar extractions, but bar designs and
dimensions were all different. Comparison with other studies without
reinforced anchorage on the molars indicates that the transpalatal bar had
some anchoring effects, although substantially less than expected. A ret-
rospective study concluded that a transpalatal arch (Goshgarian design)
had no anchoring effect in anteroposterior direction;28 a finite element anchorage loss in the molar region. Both approaches require anchorage
analysis of stress-related molar response to a transpalatal bar concluded and for both implants may be useful.
that the bar decreased molar rotation, had no effect on molar tipping and Although extraoral devices, such as the headgear, are most commonly
was insufficient as a sagittal anchorage device.29 used to reinforce anchorage in Class II treatment or to distalize the molars
In addition, a study of tongue pressure on the loop of a transpalatal arch to a Class I molar relationship, the problem of patient compliance has led
during deglutition revealed that the pressure was highest if the transpalatal to the development of a number of non-compliance appliances, for example
bar was positioned further back at the level of the second molars and was the Jones Jig, Distal Jet, Pendulum appliances, Keles Slider, repelling
4–6 mm from the palatal mucosa.27 This suggests that an alternative design magnets and compressed coil springs.30–32 These methods, however, have
for the bar might increase its anchorage capacity. side effects that reduce their clinical effectiveness, such as anchorage loss
Based on these studies, the use of transpalatal bars or arches should be in terms of mesial movement and proclination of the maxillary anterior
restricted to situations where there are moderate to minimum needs of teeth. Consequently, skeletal anchorage is considered useful as anchorage
anchorage reinforcement. when molars are distalized (Fig. 3.7).

ANCHORAGE IN CLASS II TREATMENT EVIDENCE-BASED DECISIONS

A Class II malocclusion is commonly corrected by either a non-extraction The RCT is the gold standard study design for evaluation in an evidence-
approach with molar distalization to establish a Class I molar relationship, based approach; this is followed by controlled trials, trials without con-
premolar extraction followed by space closure, with potential risk for trols, case series, case reports and, finally, expert opinions. Randomization
 The significance of anchorage in orthodontics 25

ensures that confounders and both known and unknown determinants of 3

outcome are evenly distributed between groups. Differences in estimated Onplant anchorage
magnitude of treatment effects are common when RCTs are compared with Orthosystem implant anchorage
Headgear
non-randomized prospective studies.33–35 However, the RCT is not appro- Transpalatal bar
2
priate to answer all questions and ethical issues can arise, particularly if

Anchorage Loss (mm)

untreated controls with malocclusions are used over a long period. Con-
sequently, well-designed prospective and retrospective studies can provide
valuable evidence although careful analysis of their results is required. 1
Systematic reviews are helpful tools providing a comprehensive
summary of the available evidence from scientific studies for practitioners.
Often a quality analysis of the methodological soundness of the selected 0
studies is included in the review.36
Evidence-based decision making combines the best available scientific
evidence with clinical experience and can minimize the risk of ineffective
treatment methods and variation in treatment care and outcome. However, –1
patient preferences must be given full consideration, and this is often T0 T1 T2
neglected in comparative studies. Fig. 3.8 Maxillary first molar movements (anchorage loss) from baseline (T0) during
leveling/aligning (T1, mean 8.2 months) and space closure (T2, mean 17.4 months)
after premolar extraction using four different anchorage systems.
EVIDENCE AND ANCHORAGE
To date several studies have been published concerning different anchor- reported significantly less anchorage loss with mini-implants compared
age systems dealing with application, function or effectiveness issues. In with conventional anchorage, such as headgear, transpalatal bars, banding
evaluating results and clinical relevance, a critical approach to the evi- of the second molars and application of differential moments. These
dence is recommended. studies suggest that skeletal anchorage is superior to conventional anchor-
A systematic review37,38 examined orthodontic anchorage systems/ age; however, other factors, such as failure rates, load deflection of the
application for the effectiveness of anchorage and the quality of the evi- connecting units and cost-effectiveness, must be considered when making
dence for conclusions. The review surveyed papers in the Medline data- recommendations.
base and the Cochrane Collaboration Oral Health Group Database of
Clinical Trials for the period from January 1966 to July 2007. The search
ANCHORAGE DURING DISTAL MOVEMENT
identified 751 articles, but retained only 25 as meriting final evaluation;
OF MOLARS
these included RCTs and prospective and retrospective studies with a
control group. Quality assessment used a modification of the method Four RCTs assessed anchorage loss measured at premolars or incisors,
described by Antcak et al.33 and Jadad et al.39 that assessed studies as being which varied between 0.2 mm and 1.6 mm (Table 3.2).32,34,42,43 In two
low, medium or high quality based on a point system. Only RCTs could RCTs,34,42 intraoral appliances were compared with headgear and both
be categorized as high-quality studies according to this system. showed a gain in anchorage in the headgear groups during the observation
Since July 2007, several new articles have been published about anchor- period. The third RCT compared the First Class Appliance with an
age and this systematic review has been updated for the purpose of this untreated control group43 and revealed some forward movement of the
chapter to December 2010, but only to include RCTs. Two main anchorage incisors in the control group although the observation period was short.
situations were investigated in the original articles of the review: (a) As most orthodontic studies are performed on growing patients, anchorage
anchorage of molars during space closure after premolar extractions and loss can also be influenced by growth effects and, therefore, use of matched
(b) anchorage in the incisor/premolar region during molar distalization. control groups becomes essential. The fourth RCT compared a removable
Both are applicable for Class II treatment. Summarized data from the plate with a Jones Jig/Nance appliance and showed no significant differ-
original and updated review resulted in nine RCTs. Five of them evaluated ence in anchorage capacity.32 None of these four studies evaluated any
anchorage loss during space closure after premolar extraction (Table skeletal anchorage.
3.1),20–22,40,41 and four evaluated molar distalization (Table 3.2).32,34,42,43
Conclusions
ANCHORAGE OF MOLARS DURING SPACE CLOSURE The systematic review was based on 1408 papers from 1966 to December
Table 3.1 summarizes the results from the five relevant RCTs.20–22,40,41 Two 2010. Only RCTs were considered for assessment, in total nine studies, all
compared anchorage of molars during leveling/aligning with or without published since 2002, covering the two main anchorage approaches dis-
laceback ligatures and presented conflicting results. Usmani et al.40 dem- cussed above. The main weaknesses were small sample sizes, inadequate
onstrated no difference in anchorage loss of molars during leveling the selection description plus a lack of blinding during measurements. It is
maxillary dental arch with or without laceback ligatures while Irvine clear that there is still a need for well-conducted RCTs with sufficient
et al.41 demonstrated a significant larger anchorage loss when laceback sample sizes in order to provide clear recommendations for anchorage
ligatures were used for leveling the mandibular dental arch. preparation.
Three studies compared skeletal anchorage with conventional anchor-
age (Table 3.1). Benson et al.20 found no significant difference in anchor-
EVIDENCE COMPARING SKELETAL AND
age loss of molars from treatment start to the end of space closure between
CONVENTIONAL ANCHORAGE
Orthosystem implant anchorage and headgear. In contrast, Feldmann and
Bondemark21 found that the Onplant and Orthosystem were significantly While it is generally accepted that osseointegration of implants is
superior to headgear or transpalatal bar (Fig. 3.8). Upadhyay et al.22 sufficiently stable to withstand both occlusal and orthodontic forces, it is
 26 SECTION II: INTRODUCTION TO SKELETAL ANCHORAGE IN ORTHODONTICS

Table 3.1 Randomized controlled trials of anchorage loss during space closure after premolar extractiona
Anchorage loss/active
Study Participants Treatment time Active unit Anchorage unit Outcome movement Conclusions
Usmani et al. 22 girls, 13 boys Unknown I: leveling with Analysis of I: 0.49 mm/0.5 mm No significant
(2002)40 (13.7 ± 1.8 years) laceback upper molar II: 0.5 mm/−0.36 mm difference in
I: 16 ligatures and incisor anchorage loss
II: 19 II: leveling position with or without
without measured on lacebacks
laceback study casts
ligatures before and
after leveling
Irvine et al. 13.7 years 6 months I: leveling with No auxiliary Cephalometric I: 0.75 mm/0.53 mm Significantly
(2004)41 I: 18 girls, 12 laceback anchorage unit analysis of II: −0.08 mm/0.44 mm larger anchorage
boys ligature present molar and loss with
II: 18 girls, 14 II: leveling incisor position lacebacks
boys without before and
laceback after leveling
ligature
Benson et al. I: 18 girls, 7 Unknown Lacebacks and I: midpalatal Cephalometric I: 1.5 mm/2.1 mm No significant
(2007)20 boys (14.8 Ni-Ti closing implant with a analysis of II: 3.0 mm/0.7 mm difference
years) springs transpalatal bar maxillary molar between
II: 20 girls, 6 II: headgear and incisor midpalatal
boys (15.7 position before implant
years) treatment and anchorage and
after space headgear
closure
Feldmann and I: 14 girls, 15 I: 17.1 months I, II: lacebacks I: Onplant Cephalometric I: 0.1 mm/3.9 mm Stable anchorage
Bondemark boys (14.0 II: 16.6 months and tiebacks anchorage analysis of II: −0.1 mm/4.7 mm was provided with
(2008)21 years) III: 17.3 months II: Orthosystem maxillary molar III: 1.2 mm/4.8 mm the Onplant and
II: 15 girls, 15 IV: 18.8 months anchorage and incisor IV: 2.0 mm/3.3 mm Orthosystem
boys (14.6 III: headgear position before implant compared
years) IV: transpalatal bar treatment and with headgear
III: 15 girls, 15 after space and transpalatal
boys (14.0 closure bar
years)
IV: 15 girls, 14
boys (14.4
years)
Upadhyay I: 18 (17.6 I: 8.6 months I,II: Ni-Ti closing I: mini-implants Cephalometric I: −0.78 mm/7.22 mm Mini-implants
et al. (2008)22 years) II: 9.9 months springs II: conventional analysis of II: 3.22 mm/6.33 mm provided absolute
II: 18 (17.3 anchorage maxillary molar anchorage
years) and incisor
position before
and after
space closure

a
All five studies were assessed as high quality.

Table 3.2 Randomized controlled trials of anchorage loss during molar distalizationa
Active unit/ Outcome Anchorage loss/
Study Participants Treatment time anchorage unit measurement active movement Conclusions
Paul et al. 16 girls, 7 boys 6 months I: upper Analysis of upper I: 0.18 mm/1.3 mm No significant difference
(2002)32 I: 12 individuals removable premolar and first II: 0.18 mm/1.17 mm in anchorage loss
(13.5 years) appliance molar position between the two groups
II: 11 individuals II: Jones Jig /Nance measured on study
(14.8 years) appliance casts
Bondemark and I: 10 girls, 10 boys I: 5.2 months I: intraoral Cephalometric analysis I: 1.6 mm/2.2 mm Intraoral appliance more
Karlsson (2005)42 (11.4 years) II: 6.4 months appliance of maxillary first molars II: −0.3 mm/1.0 mm effective to distalize
II: 10 girls, 10 boys II: headgear and incisor position molars but with
(11.5 years) anchorage loss
Papadopoulos I: 7 girls, 8 boys I: 17.2 weeks I: First Class Cephalometric analysis I: 1.6 mm/4.0 mm First Class Appliance
et al. (2010)43 (7.6–10.8 years) II: 22 weeks Appliance of maxillary first molar, II: 0.28 mm/−0.04 mm efficient to distalize
II: 6 girls, 5 boys II: Untreated premolar and incisor molars in mixed
(7.1–11.9 years) control group position; analysis of dentition but associated
upper first molar, with anchorage loss
premolar and incisor
position measured on
study casts
Acar et al. I: 7 girls, 8 boys I,II: 12 weeks I: Pendulum Cephalometric analysis I: 0.33 mm/4.53 mm Anchorage loss with a
(2010)34 (15.0 years) appliance of maxillary first molars II: −1.57 mm/2.23 mm Pendulum appliance
II: 10 girls, 5 boys K-loop and incisor position K-loop combination was
(14.2 years) combination significantly decreased
II: headgear

a
The studies by Paul et al.32 and Acar et al.34 were assessed as medium quality and the other two as high quality.
 The significance of anchorage in orthodontics 27

important to demonstrate that the benefits of skeletal anchorage are made (Orthosystem implant and Onplant) and patients treated with conventional
use of in a clinical situation. There will always be implants that fail to anchorage (headgear or transpalatal bars).50 The conclusion was that there
osseointegrate or become loose later during treatment, and in an intention- were very few significant differences between patients’ perceptions of
to-treat approach these will be presented as anchorage loss. In studies skeletal and conventional anchorage systems. All four anchorage systems
where implants are used as indirect anchorage (e.g. connection via a trans- were connected to the maxillary molars, which were the sites with the
palatal bar), it is also important to remember that success rates depend on second highest levels of pain over time. There was significantly less pain
the rigidity and stability of the bar as well as on implant stability. An in intensity the first 4 days in treatment for the skeletal anchorage groups
vitro study on permanent deformation of transpalatal arches connected compared with the transpalatal bar group, but with no significant differ-
with palatal implants concluded that stainless steel arches with dimensions ence compared with the headgear group. Consequently, skeletal anchorage
from 0.8 mm × 0.8 mm to 1.2 mm × 1.2 mm underwent deformation at a is well accepted by patients in a long time perspective, and can, therefore,
force of 500 cN.44 Moreover, it is important to recognize that deflection of be recommended.
the bar rises in proportion to increased force application and that anchorage
needs should determine bar dimensions.
REFERENCES
Nevertheless, a recent meta-analysis evaluating the clinical effective-
ness of miniscrew implants for anchorage reinforcement compared with 1. Proffit WR, Fields HWJ. Reorganisation of the periodontal and gingival tissues. In:
conventional orthodontic means showed a mean difference in anchorage Proffit WR, Fields HW Jr, Sarver DM, editors. Contemporary Orthodontics. 4th ed.
loss between the implant and conventional groups of 2.4 mm (95% confi- St. Louis, MO: Mosby; 2007. p. 618–19.
2. Ren Y, Maltha JC, Kuijpers-Jagtman AM. Optimum force magnitude for orthodontic
dence interval, 2.9–1.8; p = 0.000), indicating that MIs were more effec- tooth movement: a systematic literature review. Angle Orthod 2003;73:86–92.
tive as anchorage supporting devices since they significantly decreased or 3. Block MS, Hoffman DR. A new device for absolute anchorage for orthodontics.
negated loss of anchorage.45 Am J Orthod Dentofacial Orthop 1995;107:251–8.
4. Wehrbein H, Glatzmaier J, Mundwiller U, et al. The Orthosystem: a new implant
When new methods or techniques are introduced, it is important to system for orthodontic anchorage in the palate. J Orofac Orthop 1996;57:142–53.
compare them with conventional procedures using a clear definition of 5. Kanomi R. Mini-implant for orthodontic anchorage. J Clin Orthod 1997;31:763–7.
ideal anchorage; for example, an ideal anchorage could be described as: 6. Costa A, Raffainl M, Melsen B. Miniscrews as orthodontic anchorage: a preliminary
report. Int J Adult Orthodon Orthognath Surg 1998;13:201–9.
simple to use, providing clinically equivalent or superior results when 7. Kyung HM, Park HS, Bae SM, et al. Development of orthodontic micro-implants for
compared with traditionally anchorage systems, inexpensive and without intraoral anchorage. J Clin Orthod 2003;37:321–8, quiz 314.
the need for patient compliance. 8. Maino BG, Bednar J, Pagin P, et al. The Spider Screw for skeletal anchorage.
J Clin Orthod 2003;37:90–7.
9. Umemori M, Sugawara J, Mitani H, et al. Skeletal anchorage system for open-bite
correction. Am J Orthod Dentofacial Orthop 1999;115:166–74.
PAIN AND DISCOMFORT 10. Chung KR, Kim YS, Linton JL, et al. The miniplate with tube for skeletal anchorage.
J Clin Orthod 2002;36:407–12.
11. De Clerck H, Geerinckx V, Siciliano S. The Zygoma Anchorage System. J Clin Orthod
For all new treatment methods, particularly if surgical procedures are 2002;36:455–9.
involved, it is necessary to explore acceptability to the patients and issues 12. Odman J, Lekholm U, Jemt T, et al. Osseointegrated implants as orthodontic anchor-
age in the treatment of partially edentulous adult patients. Eur J Orthod 1994;
such as pain. Pain has been reported to be patients’ major concern during 16:187–201.
orthodontic treatment, and studies on adults and adolescents reveal that 13. Huang LH, Shotwell JL, Wang HL. Dental implants for orthodontic anchorage. Am J
95% of patients reported pain experiences during such treatment.46 Pain Orthod Dentofacial Orthop 2005;127:713–22.
14. Wehrbein H, Merz BR, Diedrich P, et al. The use of palatal implants for orthodontic
perception is subjective and not merely related to the strength of the pain anchorage. Design and clinical application of the Orthosystem. Clin Oral Implants Res
stimulus, perception being also influenced by emotional, cognitive, envi- 1996;7:410–16.
ronmental, and cultural factors. It has, for example, been shown that ele- 15. Wehrbein H, Feifel H, Diedrich P. Palatal implant anchorage reinforcement of
posterior teeth: a prospective study. Am J Orthod Dentofacial Orthop 1999;116:
vated anxiety levels increase pain reports while high motivation for 678–86.
orthodontic treatment reduces pain reports.47 16. Crismani AG, Bernhart T, Schwarz K, et al. Ninety percent success in palatal implants
One study has examined patients’ experience of surgical placement of loaded 1 week after placement: a clinical evaluation by resonance frequency analysis.
Clin Oral Implants Res 2006;17:445–50.
an Onplant or an Orthosystem implant compared with experiences of 17. Melsen B, Verna C. A rational approach to orthodontic anchorage. Prog Orthod
premolar extraction.48 Since orthodontic treatment often combines these, 1999;1:10–22.
the comparison is particularly valuable. The conclusions in terms of pain 18. Herman RJ, Currier GF, Miyake A. Mini-implant anchorage for maxillary canine
retraction: a pilot study. Am J Orthod Dentofacial Orthop 2006;130:228–35.
intensity were that the Onplant installation was comparable to premolar 19. Kuroda S, Sugawara Y, Deguchi T, et al. Clinical use of miniscrew implants as ortho-
extraction but installation of the Orthosystem implant was better tolerated. dontic anchorage: success rates and postoperative discomfort. Am J Orthod Dentofa-
Indications for the two osseointegrated anchorage systems are the same, cial Orthop 2007;131:9–15.
20. Benson PE, Tinsley D, O’Dwyer JJ, et al. Midpalatal implants vs. headgear for ortho-
and both surgical procedures are simple and take about 10 minutes to dontic anchorage: a randomized clinical trial: cephalometric results. Am J Orthod
perform. One explanation for the higher pain intensity and discomfort Dentofacial Orthop 2007;132:606–15.
reported in the Onplant group is that Onplant installation involves a larger 21. Feldmann I, Bondemark L. Anchorage capacity of osseointegrated and conventional
anchorage systems: a randomized controlled trial. Am J Orthod Dentofacial Orthop
surgical area than the Orthosystem implant. This agrees with a comparative 2008;133:339.
study of surgical placement of miniscrew implants and miniplates, where 22. Upadhyay M, Yadav S, Patil S. Mini-implant anchorage for en-masse retraction of
patients complained more about pain and discomfort after procedures maxillary anterior teeth: a clinical cephalometric study. Am J Orthod Dentofacial
Orthop 2008;134:803–10.
involving mucoperiosteal incision or flap surgery than about procedures 23. Ma J, Wang L, Zhang W, et al. Comparative evaluation of micro-implant and headgear
that did not.19 Overall, the surgical placement of the osseointegrated anchorage used with a pre-adjusted appliance system. Eur J Orthod 2008;30:283–7.
devices was well tolerated by patients.49 24. Wehrbein H, Gollner P. Miniscrews or palatal implants for skeletal anchorage
in the maxilla: comparative aspects for decision making. World J Orthod 2008;9:
It is also important to assess patients’ experience of skeletal anchorage 63–73.
devices throughout the whole treatment period, from baseline to the end 25. Cucalon A 3rd, Smith RJ. Relationship between compliance by adolescent orthodontic
of treatment, and compare it with conventional anchorage systems. In a patients and performance on psychological tests. Angle Orthod 1990;60:107–14.
26. Baldini G, Luder HU. Influence of arch shape on the transverse effects of transpalatal
recent study, perception of pain, discomfort and jaw function impairment arches of the Goshgarian type during application of buccal root torque. Am J Orthod
were compared between patients with osseointegrated anchorage systems 1982;81:202–8.
 28 SECTION II: INTRODUCTION TO SKELETAL ANCHORAGE IN ORTHODONTICS

27. Chiba Y, Motoyoshi M, Namura S. Tongue pressure on loop of transpalatal arch during 40. Usmani T, O’Brien KD, Worthington HV, et al. A randomized clinical trial to compare
deglutition. Am J Orthod Dentofacial Orthop 2003;123:29–34. the effectiveness of canine lacebacks with reference to canine tip. J Orthod 2002;29:
28. Zablocki HL, McNamara JA Jr, Franchi L, et al. Effect of the transpalatal arch during 281–6, discussion 277.
extraction treatment. Am J Orthod Dentofacial Orthop 2008;133:852–60. 41. Irvine R, Power S, McDonald F. The effectiveness of laceback ligatures: a randomized
29. Bobak V, Christiansen RL, Hollister SJ, et al. Stress-related molar responses to the controlled clinical trial. J Orthod 2004;31:303–11, discussion 300.
transpalatal arch: a finite element analysis. Am J Orthod Dentofacial Orthop 42. Bondemark L, Karlsson I. Extraoral vs. intraoral appliance for distal movement
1997;112:512–18. of maxillary first molars: a randomized controlled trial. Angle Orthod 2005;75:
30. Kinzinger GS, Eren M, Diedrich PR. Treatment effects of intraoral appliances with 699–706.
conventional anchorage designs for non-compliance maxillary molar distalization: a 43. Papadopoulos MA, Melkos AB, Athanasiou AE. Noncompliance maxillary molar
literature review. Eur J Orthod 2008;30:558–71. distalization with the first class appliance: a randomized controlled trial. Am J Orthod
31. Patel MP, Janson G, Henriques JF, et al. Comparative distalization effects of Jones Jig Dentofacial Orthop 2010;137:586, discussion 586–7.
and pendulum appliances. Am J Orthod Dentofacial Orthop 2009;135:336–42. 44. Crismani AG, Celar AG, Burstone CJ, et al. Sagittal and vertical load-deflection and
32. Paul LD, O’Brien KD, Mandall NA. Upper removable appliance or Jones Jig for permanent deformation of transpalatal arches connected with palatal implants: an
distalizing first molars? A randomized clinical trial. Orthod Craniofac Res 2002;5: in-vitro study. Am J Orthod Dentofacial Orthop 2007;131:742–52.
238–42. 45. Papadopoulos MA, Papageorgiou SN, Zogakis IP. Clinical effectiveness of orthodontic
33. Antczak AA, Tang J, Chalmers TC. Quality assessment of randomized control trials miniscrew implants: a meta-analysis. J Dent Res 2011;90:969–76.
in dental research. Part I. Methods. J Periodont Res 1986;21:305–14. 46. Krishnan V. Orthodontic pain: from causes to management: a review. Eur J Orthod
34. Acar AG, Gursoy S, Dincer M. Molar distalization with a pendulum appliance K-loop 2007;29:170–9.
combination. Eur J Orthod 2010;32:459–65. 47. Doll GM, Zentner A, Klages U, et al. Relationship between patient discomfort, appli-
35. Chalmers TC, Smith H Jr, Blackburn B, et al. A method for assessing the quality of a ance acceptance and compliance in orthodontic therapy. J Orofac Orthop 2000;61:
randomized control trial. Control Clin Trials 1981;2:31–49. 398–413.
36. Guyatt GH, Sackett DL, Sinclair JC, et al. Users’ guides to the medical literature. IX. 48. Feldmann I, List T, Feldmann H, et al. Pain intensity and discomfort following surgical
A method for grading health care recommendations. Evidence-Based Medicine placement of orthodontic anchoring units and premolar extraction: a randomized
Working Group. JAMA 1995;274:1800–4. controlled trial. Angle Orthod 2007;77:578–85.
37. Feldmann I, Bondemark L. Orthodontic anchorage: a systematic review. Angle Orthod 49. Sandler J, Benson PE, Doyle P, et al. Palatal implants are a good alternative to head-
2006;76:493–501. gear: a randomized trial. Am J Orthod Dentofacial Orthop 2008;133:51–7.
38. Feldmann I. Orthodontic anchorage: evidence-based evaluation of anchorage capacity 50. Feldmann I, List T, Bondemark L. Orthodontic anchoring techniques and its influence
and patients’ perceptions. Swed Dent J Suppl 2007;191:10–86. on pain, discomfort, and jaw function: a randomized controlled trial. Eur J Orthod
39. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized 2012;34:102–8.
clinical trials: is blinding necessary? Control Clin Trials 1996;17:1–12.
 Biological principles and biomechanical
considerations of implants, miniplates and
4
miniscrew implants
Ioannis Polyzois, Gary Leonard and Philippos Synodinos

bony contact and 70% or more bone filling of individual threads in the
INTRODUCTION
cortical passage.
A histological analysis of un-decalcified ground sections of explanted
Early attempts to use implants in dentistry had limited success as the
implants was performed under light microscopy for a large collection of
implant surface became encapsulated in a fibrous layer which prevented
endosseous root-shaped dental implants explanted from humans over a
direct bone–implant contact; as a result, there was a reliance on mechanical
30-year period.7 The implants had all been in clinical function for at least
undercuts to achieve clinical stability. To overcome this problem biologi-
a year and so were surrounded by mature bone and provided a picture of
cally inert materials such as titanium and certain calcium phosphate ceram-
the equilibrium reached at the end of the peri-implant bone healing process.
ics were used, which allowed osseointegration.1
The implants included both SRS and plateau root-shaped (PRS) designs
made of commercially pure titanium and a titanium alloy. A subset had a
hydroxyapatite (HA) spray coating. While both SRS and PRS implants
PRINCIPLES OF OSSEOINTEGRATION showed “maturity and load-bearing anatomical characteristics,” there were
differences in bone structure between the implant designs. Within the
Osseointegration involves the incorporation of a non-reactive foreign mate- cortical bone, the SRS implants showed a narrow (<1 mm) zone of new
rial into the structure of living bone (Fig. 4.1).2 Histological analysis of Haversian bone that continued around the implant perimeter, within the
implants, some of which had been in function for up to 5 years, has shown non-cortical alveolar regions, and was backed by trabecular bone of
a direct bone–implant contact without intervening epithelium or fibrous varying density. This was consistent with the corticalization of cancellous
tissue bone (Fig. 4.1B) and with extensive remodeling of cortical bone at bone around SRS implants.8 In contrast, the PRS implants showed a semi-
the bone–implant interface. Within trabecular bone Brånemark described circular orientated mixed woven-to-Haversian type of bone between the
a “capsule-like” arrangement of bone adjacent to the implant in many plateaus with a centrally located vascular feature within this bone.7 For the
instances. Where the marrow space bordered the surface of the implant, no uncoated titanium PRS implants, the bone extending inside the plateaus
inflammatory cells or other signs of tissue reaction were observed.2 The did not always extend to the central shaft of the implant. Interestingly, this
histology of bone healing around endosseous dental implants is now well deficit was not present with the HA-coated PRS implants, which exhibited
documented from prospective in vivo animal studies.2–4 bone extending into and along the central shaft of the implant. The expla-
Retrospective analysis of explanted dental implants removed for reasons nation offered was that calcium phosphates such as HA are avid protein
other than failure of osseointegration (e.g. implant fracture, psychological absorbers and they may offer a more secure anchorage surface for the
causes, postmortem) have shown a similar picture in humans for the peri-implant blood clot and, as a result, improve osteoconduction.7
mature bone–implant interface. Based on these structural differences between the SRS and PRS peri-
Two studies examined clinically stable machined surface screw root- implant bone, Lemons suggested that bone healing and maturation differs
shaped (SRS) implants explanted from oral and non-oral sites. A retro- for the two types mainly because of variation in the implant fit and shape
spective analysis of 38 SRS implants explanted from 18 patients after within the osteotomy. He also suggested that the combination of different
functioning for 5–90 months showed sound histological evidence of suc- healing and structural characteristics could influence the biomechanical
cessful osseointegration with intimate contact between implant and bone aspects of short- and long-term loading capacities of the implants.7
at an ultrastructural level.5 A histological analysis of 30 machined Another study examined the most dynamic period of peri-implant bone
surface SRS implants that had been in clinical function for at least 1 and healing (first 3 months post-placement) in order to observe if bone healing
up to a maximum of 16 years, retrieved from 17 patients, showed an is significantly different for PRS and SRS implants.9 Development of
average of 84.9% direct bone–implant contact and 81.8% average bone secondary stability was similar for both designs but there was prominent
area in individual threads when measured at the cortical passage.6 The woven bone (callus) in the bone-healing process around PRS implants
authors suggested that “osseointegration” corresponds to 60% or more (Fig. 4.2), which would make these less suitable for early loading.

Fig. 4.1 Photomicrograph of a titanium screw root-shaped implant

in a dog’s mandible after 10 weeks of healing in low (A) and high
(B) magnification. The ground section was surface stained with
toluidine blue.

A B

29
 30 SECTION II: INTRODUCTION TO SKELETAL ANCHORAGE IN ORTHODONTICS

100 In assessing all these ultrastructural studies of the bone–implant interface,

90
it should be taken into consideration that the forces used for specimen
cutting or grinding in slide preparation can affect the surface and make it
80 difficult to determine the true nature of the interface.14
Bone–implant Contact (%)

70

60
BONE-HEALING SEQUENCE OF EVENTS AND TIMESCALE
50

40 The osseointegration of endosseous dental implants involves a complex

mix of both bone modeling (change in shape or size) and bone remodeling
30 (internal turnover or replacement of bone). An understanding of the physi-
20 ological sequence and timescale of these processes is a necessary starting
point in understanding osseointegration.
10

0
3 weeks 5 weeks 8 weeks 12 weeks BONE MODELING
A Time (weeks) Peri-implant bone modeling occurs through both appositional bone forma-
tion and intramembraneous ossification. Appositional bone formation
90 involves the orderly deposition of new lamellar bone directly onto the
80 surface of the old bone lining the osteotomy wall. This occurs at a rela-
tively slow rate of 0.7–1 µm/day.15 In contrast, intramembraneous ossifica-
Bone area fraction occupancy (%)

70
tion gives rise to new bone in a manner similar to bone healing in fractures.
60 Woven bone (callus) forms in the blood clot that fills the gap at the bone–
50 implant interface. The bridging callus of woven bone is formed rapidly, at
30–50 µm/day.15 It is subsequently strengthened by lamellar bone forma-
40
tion on the porous lattice of woven bone. The intermediary mix of woven
30 and lamellar bone is termed composite bone. The process of lamellar
20
compaction ultimately culminates in the complete substitution of compos-
ite bone with load-bearing lamellar bone (bone remodeling). It has been
10 suggested that the less precise bone–implant fit of certain implant designs
0 encourages intramembraneous bone formation due to the larger peri-
3 weeks 5 weeks 8 weeks 12 weeks implant space available for blood clot formation.16
B Time (weeks) Evidence on bone remodeling around an implant has been contradictory.
Fig. 4.2 Comparison of screw root-shaped (red) and plateau root-shaped (blue)
A study in dogs with porous-surfaced intramedullary orthopedic implants
implants after placement: bone-implant contact (A) and bone area fraction indicated that a fracture-healing process was occurring, with rapid cancel-
occupancy (B) over time. (Adapted from Leonard et al., 20099.) lous bone ingrowth that could bridge a bone–implant gap of up to 1 mm.17
However, a study in human knee replacement suggested that bone advanced
appositionally at the bone–implant interface at a rate of 1 µm/day and that
ULTRASTRUCTURAL ANALYSIS bone ingrowth did not occur when the bone was over 50 µm from the
OF PERI-IMPLANT BONE implant surface.18 There is a strong body of animal histological evidence
Use of transmission electron microscopy has allowed a description of the that bone modeling by means of fracture healing (woven bone) occurs
intact bone–implant interface. An “amorphous layer” of ground substance where a blood clot forms in an osseous defect that is protected from
bone–implant adjacent to a stable 10 nm thick titanium oxide layer on the epithelial/fibrous tissue ingrowth. This has also been demonstrated in
implant surface was described 5–90 months after implant placement.5 healing extraction sockets, under membrane-protected bone defects and in
Examination of bone–implant surface in explanted SRS osseointegrated large bone–implant interface gaps in dogs.19,20
implants which had been in function for 1–16 years also showed that, in
areas of direct mineralized bone-titanium contact, mineralized bone
Distance and Contact Osteogenesis
reached close to the implant surface but was separated by a non-calcified
non-cellular amorphous layer.10 This 100–400 nm thick amorphous layer Peri-implant bone modeling has been examined by a number of research-
was further delineated from the mineralized bone by a 50 nm thick ers. Davies has described two different forms of peri-implant bone mod-
electron-dense “lamina limitans.” eling: appositional bone formation and intramembraneous ossification (as
The amorphous layer has been described as an extracellular “cement seen in callus/fracture type healing).11,21 He described the latter as “de
line matrix” consisting of two non-collagenous bone proteins, osteopontin novo” bone formation, which is dependent upon the initial formation of a
and sialoprotein,11 which may reflect a continuous process of interface hematoma in the gap at the initial bone–implant interface. The hematoma
remodeling.12 is soon replaced by a collagen-rich matrix. The subsequent recruitment
Some authors have suggested that the interface zone at HA-coated and migration of osteogenic cells through this matrix he described as
implant surface is unique in demonstrating a continuity of the mineral osteoconduction. Once the migrating osteogenic cells have reached their
phase of forming bone and may form the basis of what has been described desired location, they become stationary osteoblasts and secrete an osteoid
as HA implant–bone bonding.13 However, scanning electron microscopy matrix, which is mineralized to form irregular woven bone.11,21 This com-
indicated that there was a very thin non-mineralized organic bone matrix bination of “osteoconduction” and “de novo” bone formation can culmi-
resembling a reversal line of bone tissue at the implant–bone interface.14 nate in “contact osteogenesis”: the formation of bone directly on to an
 BIOLOGICAL PRINCIPLES AND BIOMECHANICAL CONSIDERATIONS 31

implant surface at a distance from the old parent bone lining the osteotomy Cutting cone Closing cone
wall.11 This theory relies on the assumption that the osteogenic stem cell
migrates to the surface of the implant, differentiates into an osteoblast and
then deposits bone directly on to the implant surface. The layer of new
bone then separates the osteoblast from the implant surface, resulting in a
very intimate bone–implant contact.
Surface modeling has also been described as occurring by means of Reversal Osteoblasts
appositional bone formation.22 This involves the slow and synchronous zone
secretion of more precisely organized lamellar bone on to the surface of
old bone lining the osteotomy wall. It does not involve the migration of
osteogenic cells across a matrix. Instead, an existing population of already Osteoclasts New bone Secondary
differentiated osteoblasts that line the surface of the old bone secretes new formation osteon
bone that encroaches on the implant. As the polarized osteoblasts secrete Fig. 4.3 Schematic representation of the evolution and completion of a secondary
bone matrix from their basal side, they passively recede towards the osteon.
surface of the implant and eventually become trapped between the bone
they are forming and the surface of the implant.22 The authors surmise that granulation tissue. Platelet degranulation results in the conversion of
the only possible outcome for these cells is death, and they use the term fibrinogen to fibrin and in the release of cytokines and growth factors that
“distance osteogenesis” to describe this appositional process, which theo- have a stimulating effect on bone regeneration.11,21,22 Surfaces with a
retically results in a less intimate bone–implant contact.22 greater microtopography have increased fibrinogen adsorption in vitro,27
The terminology has slowly become incorporated into the literature, and higher forces are required to detach fibrin clots in vitro from acid-
with the terms “distance osteogenesis” and “contact osteogenesis” being etched as opposed to machined implant surfaces.22 Consequently, a rough-
used to describe, respectively, appositional bone formation on parent bone ened fibrin–implant interface may have a greater capacity to withstand the
of the osteotomy wall and woven bone formation on the implant surface contractile forces generated by both clot retraction and the migration of
at a distance from the parent bone. Indirect evidence for contact osteogen- osteogenic cells across the transitory matrix, thus enhancing “de novo”
esis is provided by ultrastructural studies of explanted implants showing bone formation.
a cement line matrix directly in contact with the implant surface.5,10 This
would be consistent with an osteoblast depositing bone directly on to the
implant surface and subsequently becoming separated from the implant
BONE REMODELING
surface by the newly formed bone. Remodeling is the turnover or restructuring of previously existing bone by
Since cortical healing relies predominantly on osteonal remodeling, the a coupled process of bone resorption followed by appositional deposition
concept of bone modeling is more relevant to peri-implant bone healing of ordered lamellar bone. Following implant placement, a 1 mm peri-
in trabecular bone, which is capable of de novo bone formation and so implant zone of devitalized bone develops quickly around the implant,
would be better adapted to rapid healing than cortical bone.21 This would particularly in the cortical region, as a result of surgical trauma and pres-
be particularly relevant for Class III and Class IV bone. Modifications of sure necrosis.5 This devitalized interface bone must first be resorbed and
implant design to optimize “de novo” bone formation could enhance then replaced. During this period, there will be a reduction in the primary
implant stability in this environment, particularly since Class III and IV stability of the implant. Interface remodeling is most pronounced during
bone is often associated with insufficient cortex to provide stability.21 the initial bone-healing process following implant insertion. Once the peri-
Two approaches have been used experimentally to facilitate “de novo” implant bone reaches full maturity and the implant persists in function,
bone formation: cutting chambers into the implant to increase the contact- there is a less pronounced but continuous long-term remodeling process
free surface available20 and alteration of the surface design to enhance that maintains a necessary dynamic equilibrium of bone turnover.12
bone–implant bonding through micromechanical retention of the cement The basic multicellular unit for remodeling consists of an ordered col-
lines with the material surface.21 lection of osteoclasts and osteoblasts. Osteoclasts, which are derived from
The latter approach is consistent with the move away from machined monocytes in the bone marrow, resorb bone at the rate of 27–39 µm/day
implant surfaces to macro-roughened (sandblasted and/or acid-etched) and open up a cavity, the cutting-filling cone, of approximately 120–180 µm
ones.4,13,23 Implant surface technology has also progressed to encompass in diameter and 1300 µm in length (Fig. 4.3). When the resorption cavity
surface roughness at an ultrastructural level, as with ion beam-assisted is complete, a reversal occurs and osteoclasts are replaced by osteoblasts
deposition of thin-film HA coatings.24 in a brief quiescent period. Osteoblasts are derived from undifferentiated
In addition to surface topography, surface chemistry has also been perivascular connective tissue cells, the pericytes, which slowly form
assessed as a variable for peri-implant bone modeling. Surface wettability appositional bone at a rate that varies between species (0.7 µm/day for
has been shown to enhance the interaction between the implant surface humans). A central vascular supply within each cutting-filling cone persists
and the implant environment.25 Storage of sandblasted/acid-etched implants after new bone apposition is complete. The resulting secondary osteon, a
in isotonic sodium chloride appeared to protect the titanium surface from concentric lamellar structure, has a scalloped margin with a cement line
carbonates and other atmospheric contaminants and to enhance surface that clearly demarcates new bone from old. Trabecular bone also under-
hydrophilicity and wettability.26 goes remodeling but without the cutting-filling cone seen in cortical bone.
Instead, the basic multicellular unit rests in a hollow, called a Howship
lacuna, on the surface of the trabecular bone within the marrow cavity.
Peri-implant Hematoma
A study of enhanced remodeling at the bone–implant interface and in
The peri-implant blood clot has an important role in stimulating “de novo” peri-implant-supporting bone indicated that remodeling is greatest in the
bone formation. Its formation is affected by implant surface topography. bone adjacent to the bone–implant interface (within 1 mm), and that ele-
Hemorrhage caused by the implantation process results in formation of a vated remodeling (turnover >500% a year) is an ongoing and sustained
fibrin-rich clot that usually lasts only a few days before being replaced by response of bone adjacent to an implant.12 Although this study had several
 32 SECTION II: INTRODUCTION TO SKELETAL ANCHORAGE IN ORTHODONTICS

experimental design weaknesses, including a highly diverse sample and a measure the load-bearing and stress-dissipation properties of dental
low number of specimens in certain groups, this histomorphometric pattern implants in vivo. The development of computer-based finite element anal-
was identical in all specimens. The authors suggested that the ongoing ysis (FEA) modeling has provided a means of analyzing the effects of
process of elevated peri-implant remodeling is necessary to repair local implant external geometry on stress distribution within surrounding bone.39
areas of bone microdamage and fatigue-induced microdamage and, as Such analysis showed that variations in the size and profile of the thread
such, it is essential to the successful maintenance of osseointegration.12 have a profound effect on the magnitude and distribution of stresses in the
surrounding bone.40 In particular, a small ratio of top radius of curvature
to thread depth (sharp edges) should be avoided. This is consistent with
IMPLANT DESIGN retrieval studies that revealed bone defects mainly located at the thread
tips.30,41
Ever since the formal acceptance of Brånemark’s cylindrical threaded It has been suggested that PRS implants provide a more functional load-
design by the American Dental Association in 1986, the SRS endosseous bearing surface for the efficient resistance and distribution of occlusal
implant has become the pre-eminent morphology for endosseous dental loads to the supporting bone.42 An FEA study demonstrated lower com-
implants, with published 10- and 15-year performance data.28,29 pressive stresses around serrated dental implants because of their larger
A large number of other implant designs (endosseous and non- surface areas.43 Stress concentration and distribution properties of SRS and
endosseous) have been employed over the years. Non-endosseous implants, PRS dental implants assessed by FEA have indicated that the enhanced
including subperiosteal, ramus frame and fiber mesh designs, are now stress distribution properties of PRS implants, with their greater surface
largely obsolete. A variety of endosseous designs have been developed area, rendered them more suitable to serve as free-standing implants.44
with widely varying morphologies, including non-root-shaped designs The principle of achieving better biomechanical stress distribution char-
(e.g. the mandibular staple bone plate and the blade-vent implant systems), acteristics through greater surface area has been utilized in the Mark IV
root-shaped designs (e.g. the vented hollow cylinder (basket), the combi- Brånemark SRS implants, which possess an increased thread surface area
nation screw and hollow cylinder, the non-threaded cylinder, the stepped to enhance performance in Class IV bone.8
cylinder) and PRS designs.1,30 With the exception of the PRS design, most
if not all of these systems have been surpassed by endosseous SRS
implants. One problem with the early data on this wide variety of implants ORTHODONTIC USE OF DENTAL IMPLANTS
is that implant survival rates were often quoted as success rates.30,31
Endosseous dental implants were preceded by subperiosteal implants. The use of conventional dental implants has extended from treatment of
These rigid plate-like devices, which were surgically placed on bone partially dentate adults to orthodontic treatments requiring minimal patient
beneath the periosteum, were in common use up to the late 1980s.1 There compliance. Implant-based anchorage allows unidirectional tooth move-
was a clear drop in outcome over longer assessment periods, with a success ment without reciprocal action and it is also effective in treating adults
rate of only 60% after an average follow-up period of 3.3 years in one with absent molars who are not compliant with conventional extraoral
study33 and survival rates at 5, 10 and 15 years of 90%, 60% and 50%, devices.45 Performance of conventional implants as anchorage units for
respectively, in another.32 A comparative review of the literature30 con- orthodontic treatment has been assessed over a number of years and the
cluded that subperiosteal implants had “not survived the scrutiny of time results suggest that they can remain stable when loaded with forces neces-
and could not be recommended for routine clinical usage.” sary for orthodontic tooth movement.45
Despite their reportedly excellent performance as anchorage devices,
conventional implants have a significant diameter and are not always
IMPLANT STABILITY practical if there is a shortage of available bone and space. They also
require several surgical stages, a waiting period of about 3 months for
The precise interference fit between implant and bone is crucial for primary osseointegration before an orthodontic load can be applied and they cannot
stability of the implant, and several studies have shown superior primary be placed in young growing patients. Furthermore, an additional surgical
stability for the SRS dental implant.34,35 As practitioners began to use procedure is required for their removal following orthodontic treatment.
single-staged procedures or immediate loading techniques, thread shape To overcome these limitations, several orthodontic implant designs have
of the implant became of increasing importance. A study of 72 SRS been developed and tested over the years, with encouraging results.
implants placed into rabbit tibias with three different thread designs –
V-shaped, square-shaped and reverse buttress – showed that the square-
thread design had significantly greater bone–implant contact and reverse
TEMPORARY SKELETAL ANCHORAGE DEVICES
torque test strength at 12 weeks.36 Unfortunately, implant stability at inser- Temporary skeletal anchorage devices were introduced as an endosseous
tion was not measured as an assessment of baseline primary stability. form of orthodontic anchorage. Although based on the same principles of
The PRS dental implant has reduced primary stability because its contact structural and functional anchorage, there are substantial differences
fit is only where the outer tips of the fins engage the osteotomy wall.37 between these and conventional implants. Several designs have been intro-
Consequenly, while PRS implants can be immediately temporized, the duced but currently only two are widely used in orthodontic treatment:
temporary PRS restoration must not be subjected to any immediate occlu- miniscrew implants and miniplates. Excluding size, there are three main
sal forces.38 However, there are no published studies providing baseline differences between these skeletal devices and conventional implants:
primary stability values for PRS implants over the initial bone-healing temporary skeletal anchorage devices are loaded prior to osseointegration,
period (1–12 weeks). they are intended to allow removal following completion of orthodontic
treatment, and, finally, the forces applied are light and continuous com-
pared with the high, non-continuous forces that are applied to conventional
STRESS DISTRIBUTION implants. Some concerns have emerged regarding the hard tissue reaction
While SRS implants provide excellent primary stability, their stress distri- to these continuous forces and whether these can affect osseointegration.
bution qualities have been a subject of debate. It is difficult to directly A small number of experimental studies have attempted to answer specific
 BIOLOGICAL PRINCIPLES AND BIOMECHANICAL CONSIDERATIONS 33

questions such as the amount of healing time necessary before loading and 18. Bloebaum RD, Bachus KN, Momberger NG, et al. Mineral apposition rates of human
cancellous bone at the interface of porous coated implants. J Biomed Mat Res
how easily these anchorage systems can be removed following orthodontic 1994;28:537–44.
treatment. 19. Cardaropoli G, Araujo M, Lindhe J. Dynamics of bone tissue formation in tooth
Several animal studies have examined bone remodeling and miniscrew extraction sites: an experimental study in dogs. J Clin Periodontol 2003;30:
809–18.
implant stability in implants with and without immediate loading. In one 20. Berglundh T, Abrahamsson I, Lang K, et al. De novo alveolar bone formation adjacent
study, comparing loading immediately and at 6 or 12 weeks, 50% of to endosseous implants. Clin Oral Implants Res 2003;14:251–62.
implants failed through lack of primary stability. However, the overall 21. Davies JE. Understanding peri-implant endosseous healing. J Dent Edu 2005;67:
932–49.
mean osseointegration at 6 months was 74.48% and there were no signifi- 22. Davies JE, Hosseini MM. Histodynamics of endosseous wound healing. In: Davies
cant differences between the groups. Additionally, the miniscrew implants JE, editor. Bone engineering. Toronto: Em squared; 2000. p. 1–14.
could be easily removed after 6 months of loading, which was advanta- 23. Cochran DL, Schenk RK, Lussi A, et al. Bone response to unloaded and loaded tita-
nium implants with a sandblasted and acid-etched surface: a histometric study in the
geous for orthodontic applications.46 Other studies have shown similar canine mandible. J Biomed Mater Res 1998;40:1–11.
results, with one study suggesting that loading may stimulate bone forma- 24. Coelho PG, Suzuki M. Evaluation of an IBAD thin-film process as an alternative
tion at the interface when loading does not not exceed a certain limit.47 method for surface incorporation of bioceramics on dental implants: a study in dogs.
J Appl Oral Sci 2005;13(1):87–92.
Overall, it appears that immediate loading with light orthodontic forces 25. Kipaldi DV, Lemons JE. Surface energy characterization of unalloyed titanium
does not seem to have an adverse effect on osseointegration for both implants. J Biomed Mater Res 1994;28:1419–25.
miniscrew implants and miniplates.48–50 26. Steinemann SG. Titanium – the material of choice? Periodontol 2000;17:7–21.
27. Park JY, Davies JE. Red blood cell and platelet interactions with titanium implant
surfaces. Clin Oral Implants Res 2000;11:530–9.
28. Brånemark PI, Hansson BO, Adell R, et al. Osseointegrated implants in the treatment
of the edentulous jaw: Experience from a 10-year period. Scand J Plast Reconstr Surg
CONCLUSIONS 1977;11(Suppl. 16):1–132.
29. Adell R, Lekholm U, Rockler B, et al. A 15 year study of osseointegrated implants in
The literature contains few well-controlled studies and the ones reported the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387–416.
30. Albrektsson T, Sennerby L. State of the art in oral implants. J Clin Periodontol
vary greatly in design; the species used; the anchorage devices, with dif- 1991;18:474–81.
ferent lengths and/or diameters; as well as in loading forces. This hetero- 31. Smith DE, Zarb GA. Criteria for success of osseointegrated endosseous implants.
geneity makes it difficult to draw firm conclusions for the best use of J Prosth Dent 1989;62:567–72.
32. Bodine RL, Yanase RT, Bodine A. Forty years of experience with subperiosteal
implants as anchorage devices in humans. implant dentures in 41 edentulous patients. J Prosthet Dent 1996;75:33–44.
33. Mercier P, Cholewa J, Djokovic S. Mandibular subperiosteal implants: retrospective
analysis in light of Harvard consensus. J Can Dent Assoc 1981;47:46–51.
34. Carlsson L, Rostlund T, Albrektsson B, et al. Implant fixation improved by close
REFERENCES fit: cylindrical implant-bone interface studied in rabbits. Acta Orthop Scand 1988;59:
272–5.
1. Balkin BE. Implant dentistry: Historical overview with current perspective. J Dent 35. Gotfredsen K, Nimb L, Hjörting-Hansen E, et al. Histomorphometric and removal
Educ 1988;52:683–5. torque analysis for TiO2-blasted titanium implants: an experimental study on dogs.
2. Brånemark PI, Breine U, Adell R, et al. Intraosseous anchorage of dental prostheses. Clin Oral Implants Res 1992;3:77–84.
I. Experimental studies. Scand J Plast Reconstr Surg 1969;3:81–100. 36. Steigenga J, Al-Shammari K, Misch C, et al. Effects of implant thread geometry on
3. Roberts WE, Smith RK, Zilberman Y, et al. Osseous adaptation to continuous loading percentage of osseointegration and resistance to reverse torque in the tibia of rabbits.
of rigid endosseous implants. Am J Orthod 1984;86:95–111. J Periodontol 2004;75:1233–41.
4. Buser D, Schenk RK, Steinemann S, et al. Influence of surface characteristics on 37. Chess JT. Technique for placement of root form implants of the finned or serrated
bone integration of titanium implants: a histomorphometric study in miniature pigs. type. J Am Dent Assoc 1990;121:414–17.
J Biomed Mater Res 1991;25:889–902. 38. Bicon. Surgical manual: step by step techniques. Boston, MA: Bicon Dental Implants;
5. Albrektsson T, Brånemark PI, Hansson HA, et al. Osseointegrated titanium implants: 2010 <http://www.bicon.com/pdf/Bicon_Surgical.pdf>; [accessed 27 Ocotober 2013].
requirements for ensuring a long-lasting direct bone-to-implant anchorage in man. 39. Bozkaya D, Muftu S, Muftu D. Evaluation of load transfer characteristics of five dif-
Acta Orthop Scand 1981;52:155–70. ferent implants in compact bone at different load levels by finite elements analysis.
6. Albrektsson T, Eriksson AR, Friberg B, et al. Histologic investigations on 33 retrieved J Pros Dent 2004;92:523–30.
Nobelpharma implants. Clin Mat 1993;12:1–9. 40. Hansson S, Werke M. The implant thread as a retention element in cortical bone: the
7. Lemons JE. Biocompatibility of implant materials. In: Proceedings of the 3rd Annual effect of thread size and thread profile: a finite element study. J Biomech 2003;36:
Indiana Conference. Indianapolis: Indiana School of Dentistry, Medical Education 1247–58.
Resource Program; 2002. p. 79–89. 41. Tsuboi N, Tsuboi Y, Sennerby L, et al. Histomorphometric analysis of bone–titanium
8. Sennerby L. Implant integration and stability. In: Palacci P, Ericsson I, editors. Esthetic interface in human retrieved implants. In: Ueda M, editor. Proceedings of the Third
implant dentistry. Berlin: Quintessence; 2001. p. 15–31. International Congress on Tissue Integration in Oral and Maxillofacial Reconstruction.
9. Leonard G, Coehlo P, Polyzois I, et al. A study of the bone healing kinetics of plateau Tokyo: Quintessence; 1996. p. 86–7.
versus screw root design titanium dental implants. Clin Oral Implants Res 42. Morris HF, Ochi S. Survival and stability (PTVs) of six implant designs from place-
2009;20:232–9. ments to 36 months. Ann Periodontol 2000;5:15–21.
10. Sennerby L, Thomsen P, Ericson LE, et al. Structure of the bone–titanium interface in 43. Lin S, Shi S, Le Geros RZ, et al. Three-dimensional finite element analyses of
retrieved clinical dental implants. Clin Oral Implants Res 1991;2:103–11. four designs of a high-strength silicon nitride implant. Implant Dent 2000;9:
11. Davies JE. Mechanisms of endosseous integration. Int J Prosthodont 1998;11:391–401. 53–60.
12. Garetto LP, Chen J, Parr JA, et al. Remodelling dynamics of bone supporting rigidly 44. Rieger MR, Fareed K, Adams WK, et al. Bone stress distribution for three endosseous
fixed titanium implants: a histomorphometric comparison in four species including implants. J Prosthet Dent 1989;61:223–8.
humans. Implant Dent 1995;4:235–43. 45. Janssen KI, Raghoebar M, Vissink A, Sandham A. Skeletal anchorage in orthodontics:
13. Masuda T, Yliheikkilä PK, Felton DA, et al. Generalizations regarding the process and a review of various systems in animal and human studies. Int J Oral Maxillofac
phenomenon of osseointegration. Part 1: In vivo studies. Int J Oral Maxillofac Implants Implants 2008;23:78–88.
1998;13:17–29. 46. van de Vannet B, Sabzevar MM, Wehrbein H, et al. Osseointegration of miniscrews:
14. Piatelli A, Trisi P, Romasco N, et al. Histologic analysis of a screw implant retrieved a histomorphometric evaluation. Eur J Orthod 2007;29:437–42.
from man: influence of early loading and primary stability. J Oral Implantol 47. Büchter A, Wiechmann D, Gaertner C, et al. Load-related bone modelling at the
1993;19:303–6. interface of orthodontic micro-implants. Clin Oral Implants Res 2006;17:714–22.
15. Roberts WE, Garetto LP. Bone physiology and metabolism. In: Misch CE, editor. 48. Luzi C, Calalberta V, Melsen B. Immediate loading of orthodontic mini-implants:
Contemporary implant dentistry. St. Louis, MO: Mosby; 1998. p. 225–39. a histomorphometric evaluation of tissue reaction. Eur J Orthod 2009;31:21–9.
16. Lemons JE. Biomaterials, biomechanics, tissue healing and immediate function dental 49. Woods PW, Buschang PH, Owens SE, et al. The effect of force, timing and location
implants. J Oral Implantol 2004;30:318–24. on bone to implant contact of miniscrew implants. Eur J rthod 2009;31:232–40.
17. Bobyn JD, Pilliar RM, Cameron HU, et al. Osteogenic phenomena across endosteal 50. Cornelis MA, Mahy P, Devogelaer JP, et al. Does orthodontic loading influence bone
bone-implant spaces with porous surfaced intramedullary implants. Acta Orthop Scand mineral density around titanium miniplates? An experimental study in dogs. Orthod
1981;52:145–53. Craniofac Res 2010;13:21–7.
 Biomaterial properties of orthodontic
5 miniscrew implants
Spiros Zinelis, Youssef S. Al Jabbari, Moschos A. Papadopoulos,
Theodore Eliades and George Eliades

INTRODUCTION The great diversity in designs gives rise to variation in primary stability
as assessed by a pullout strength test using artificial bone blocks that simu-
Although miniscrew implants (MIs) have been used in a broad spectrum lated osteoporotic and normal cancellous bone (Fig. 5.2).3 The pullout
of applications, few studies have explored their fundamental material force increased with higher intraosseous surface area with a weak correla-
properties such as strength, structure and design; surface properties; elec- tion (r = 0.54) for the “osteoporotic” block and medium correlation
trochemical behavior; and ion release.1,2 Moreover, the clinical impact of (r = 0.79) for the “normal cancellous bone” block based on re-interpreta-
these properties on pullout strength,3 implant stability4 and nature of the tion of previously published data3 (Fig. 5.2). The variation in statistical
bone–implant interface5 has not been systematically investigated, apart correlation might reflect deviations in linearity or effects of other geometri-
from some published data regarding failure rates of these devices.6–8 This cal features such as thread number or thread face and helix angle, which
chapter reviews current information on the properties of orthodontic MIs were not taken into account. As yet, no mathematical model exists to cor-
discussing their possible clinical implications. relate design parameters with the primary stability of MIs. This is an
interesting field for further developments.

DESIGN PRINCIPLES
MATERIALS
Commercially available contemporary MIs have significant differences in
the design of the retentive head and the intraosseous components (Fig. Orthodontic MIs are mainly manufactured using commercially pure tita-
5.1). Although there is no official standard design, manufacturers have nium (cp-Ti) (graded as I–IV, with decreasing purity towards higher
adopted various concepts in order to avoid clinical complications and grades) and a titanium, aluminum (6%) and vanadium (4%) alloy
achieve specific clinical goals. Some design principles from conventional (Ti-6Al-4V; grade V) (Table 5.1). However, while grade V is the most
dental implants have been retained, for example the need for primary and commonly used form, the corresponding mechanical properties vary, as
secondary stability. Primary stability relates to the implant diameter and they are influenced by the content in trace elements and the thermome-
its intraosseous design,9–11 and secondary stability to the surface chemical chanical history. Ti-6Al-4V is extensively used in aerospace (80% of
composition and roughness of the implant.12,13 Implant design is mainly annual production), medical (orthopedic artificial prostheses, 3%), marine
characterized by the head and thread shapes and associated geometrical and chemical industries because of its tailored properties, which can be
features, such as shaft type, thread face, helix angle and thread depth.3 adjusted by specific mechanical and heat treatments.14 The alloy is sup-
The button-like head with spheroid or hexagonal shape is most common, plied as Ti-6Al-4V or Ti-6Al-4VELI (extra low interstitials). The latter
although bracket-like and hook designs do occur. The head design is contains lower trace element content (O and Fe) and has improved ductil-
intended for the secure attachment of wires and spring coils while ensuring ity, fracture toughness and corrosion resistance. Typically, it is used
the best stress transfer distribution to the bone crest. without aging for maximum toughness.14 The properties of Ti-6Al-4V are
The intraosseous thread design is either conical with a small tapered strongly modified by specific thermal treatments. As an alpha–beta alloy,
end (Dual-Top and AbsoAnchor) or parallel (Spider Screw); there is also
160
a hybrid design with conical and tapered shafts (Vector-TAS) (Fig. 5.1).
10 pcf AbsoAnchor
20 pcf Dual-top
140
Vector
Vecror TAS Tas r = 0.79
120
AbsoAnchor Spider
Spider Screw
screw
Pullout force (Nt)

Dual Top
100

80

60
r = 0.54
40

20
35 40 45 50 55
Surface Area (mm2)
Fig. 5.2 Pullout strength with increasing surface area as measured in artificial bone
blocks made of solid rigid polyurethane foam of 10 and 20 pcf (pounds per cubic
inch) density, simulating osteoporotic and normal cancellous bone, respectively.
2 mm
The pullout force required increased with higher intraosseous surface area with a
weak correlation (r = 0.54) for the 10 pcf block and a medium one (r = 0.79) for
Fig. 5.1 Stereomicroscopic image of contemporary MIs (bar: 2mm). the 20 pcf block. Re-interpretation of published results.3

34
 Biomaterial properties of orthodontic miniscrew implants 35

Table 5.1 Nominal composition and mechanical properties of commercially pure titanium grades I–IV and Ti6-Al4-V alloya
Ultimate
Young Yield tensile Ultimate
modulus strength strength strain
Grade N C H Fe O Ti Al V (GPa) (MPa) (MPa) (%)
I <0.03 <0.1 <0.015 <0.2 <0.18 Bal 102.7 170 240 24
II <0.03 <0.1 <0.015 <0.2 <0.25 Bal 102.7 275 345 20
III <0.05 <0.1 <0.015 <0.2 <0.35 Bal 103.4 380 450 18
IV <0.05 <0.1 <0.015 <0.2 <0.40 Bal 104.1 485 550 25
V (Ti6-Al4-V)b <0.05 <0.1 <0.015 <0.4 <0.20 Bal 5.5~6.75 3.5~4.5 105~116 711~904 856~911 6~36
Ti6-Al4-V-ELI <0.05 <0.08 <0.012 <0.025 <0.13 Bal 5.5~6.75 3.5~4.5 114 795 860 10

Bal, balance; ELI, extra low interstitials.

a
Additional information for small deviations among different standards can be found in the relevant references.14
b
Mechanical properties of Ti-6Al-4V are strongly dependent on previous thermomechanical treatment. The ranges shown in this table correspond to the minimum and
maximum values the alloy can achieve after different thermomechanical treatments.
Source: from Boyer et al. (1994).14

Table 5.2 Elemental composition of orthodontic microscrew implants

(energy dispersive X-ray microanalysis)
Product Atomic %
N O Al P Ti V
AbsoAnchor 11.1 3.9 9.2 ND 73.3 2.4
Dual-Top 12.1 ND 9.0 ND 76.5 2.2
Spider Screw 8.3 4.2 7.5 ND 77.0 2.8
Vector-TAS 2.2 46.1 5.8 0.3 44.5 1.2
Fig. 5.3 A longitudinal 2D reconstruction obtained from a micro-XCT analysis of Thomas 6.9 6.2 8.5 ND 75.8 2.4
an unused MI. The section is free of pores, cracks or other defects. New Anchor Plus 9.9 2.9 9.4 ND 75.2 2.4

it may demonstrate different contents of alpha (hexagonal lattice) and beta

ND, not detected.
(face-centered cubic lattice) phases, with great variations in microstructure
Source: from Alsamak et al. (2012)3 and EDX unpublished data.
dependent on particular thermomechanical treatments. The different
microstructures are classified as lamellar, equiaxial and bimodal (i.e. a
mixture of both). More than seven types of thermomechanical treatments layer of TiO2. Interestingly, Vector-TAS had a much higher O content than
are used to modify the mechanical properties and most are well described the other implants, which might be attributed to its much thicker yellow-
in relevant literature.14 Currently no information exists on the microstruc- colored TiO2 layer. Morphological, compositional and optical surface
ture of MIs. modifications can be performed by various techniques, such as anodic
Apart from the stainless steel (SS) orthodontic MIs, all others are manu- oxidation,17 plasma ion implantation,18 or thermal oxidation.19 However,
factured from cp-Ti grade IV or Ti-6Al-4V alloy.3 It might be postulated the presence of P in this MI, a typical impurity of an anodizing solution,
that Ti-6Al-4V is more appropriate than cp-Ti because of its significantly along with the increased O content, indicates that an anodic oxidation
higher mechanical properties, corrosion resistance and fabricability. The technique was used. The presence of N is sometimes reported as a raw
removal torque of cp-Ti approaches its yield strength during the removal material impurity and, along with C, is considered as a surface contaminant
process,15 which would increase the risk of bulk fracture. Regarding the associated with the manufacturing procedure, storage and/or sterilization.14
internal structure, computerized X ray microtomography (xCT) has shown The presence of these surface contaminants makes the surface less
no internal defects (cracks or pores) in the bulk structure of an unused hydrophilic,20 adversely affecting cell-attachment capacity.21 Surface anal-
commercially available MI (Fig. 5.3),16 findings that were confirmed by ysis with X-ray photoelectron spectroscopy, with a sampling depth of
cross-sectional analysis. approximately 3 nm, provides information on both elemental composition
and the binding state of the elements (Fig. 5.5). Titanium is mainly identi-
fied as TiO2, along with some Ti2O3 and metal Ti. Al and V were not
SURFACE CHARACTERIZATION identified with XPS analysis denoting that MI are fully covered by Ti
oxides as in the case of pure Ti. The presence of C, and traces of Ca, Si
Osseointegration of orthodontic MIs is not a demanding task and so MI and P were considered to be ambient or processing contamination.
surface properties have not attracted great interest. Nonetheless, surface Fig. 5.6 shows the surface texture of the treaded part of MIs as imaged
roughness and composition are the dominant factors for secondary stability in a scanning electron microscope with a backscattered electron detector.
as they influence the postsurgical cellular response. The results for the Miniscrew implants display parallel striations oriented almost vertically to
composition of the near surface region (~1 µm depth) obtained after the longitudinal implant axis, which are attributed to the turning manufac-
energy dispersive X-ray microanalysis (EDX) are summarized in Table turing process. Differences in manufacturing process may explain differ-
5.2, while Fig. 5.4 shows representative ΕDX spectra obtained from MIs. ence in the inclination of these striations among the materials tested. This
The presence of Al and V are indicative of the alloy type, which is prob- is also seen in the three-dimensional images shown in Fig. 5.7. Studies on
ably Ti-6Al-4V, while the presence of O should be attributed to surface several MI threads have disclosed no statistically significant differences in
 36 SECTION II: INTRODUCTION TO SKELETAL ANCHORAGE IN ORTHODONTICS

AbsoAnchor Vector TAS

Ti Ti

O
Ti
Ti AI
O V N V
Ti
Ti AI Ti Ti
N

P
V V

0.60 1.20 1.80 2.40 3.00 3.60 4.20 4.80 5.40 keV 0.60 1.20 1.80 2.40 3.00 3.60 4.20 4.80 5.40 keV
Fig. 5.4 Energy dispersive X-ray microanalysis spectra of two miniscrew implants.

C 1s H2O/OH-
Al kα Ti 2p O 1s
hn = 1486.6 eV Al kα Al kα
hn = 1486.6 eV hn = 1486.6 eV

O 1s
TiO2
O KLL

TiO2/Ti2O3
Intensity (arbitrary units)

Ti 2p
Na KLL

Ca 2p

CC=O/COH
= O/COH
Ti 3s

Ti 2P1/2
Ti 2P3/2
Ti2 O3 Ti
P 2p
Si 2p

Ti 3p

1000 800 600 400 200 0 466 464 462 460 458 456 454 536 534 532 530 528 526
Binding energy (eV) Binding energy (eV) Binding energy (eV)
A B C
Fig. 5.5 X ray photoelectron spectroscopic analysis of AbsoAnchor minisrew implants. (A) Survey scan revealing the presence of Ti and C, N (ambient contamination),
Ca, P and Si (processing contamination). (B,C) High resolution analysis after curve fitting of T12p (B) and O1s (C) peaks, with the corresponding elemental binding states.

Towards head AbsoAnchor SpiderScrew Vector-TAS

Horizontal plane

20 µm 20 µm 20 µm

Fig. 5.6 Backscattered electron images of modern orthodontic miniscrew implants. Pictures were taken between two successive threads (nominal magnification ×1000,
bar = 20 µm). The small black regions of low mean atomic number represent areas of contamination or manufacturing defects.
 Biomaterial properties of orthodontic miniscrew implants 37

um um Fig. 5.7 Representative three-dimensional

AbsoAnchor 1.60 Dual-Top 1.85
profilometric images from the threaded region of
1.50 miniscrew implants taken between two successive
1.00 threads. The orientation is the same as in Figure 5.6.
1.00
The parallel serrations are profound, although with
0.50
0.50 different inclination to the horizontal plane. (Original
0.00 magnification ×41, sampling window,
148.5 148.5 0.00 113.0 µm × 148.5 µm.)
–0.50 –0.50
–1.00 –1.00

–1.50 113.0 um –1.50

113.0 um
–1.74 –1.73

um um
SpiderScrews 2.14 Vector-TAS 1.67

1.50 1.00
1.00
1.50
0.50
148.5 148.5 0.00
0.00
–0.50
–0.50

–1.00 –1.00
113.0 um 113.0 um
–1.59 –1.62

Table 5.3 Results of selected surface roughness parameters for microscrew implants using optical interferometric profilometry3
Product Sa (nm) Sz (µm) Sdr (%) Sds (µm–2) Sci (%)
AbsoAnchor 258 ± 27 3.4 ± 0.5 8.4 ± 0.5 0.02 1.52 ± 0.03
Dual-Top 270 ± 36 3.3 ± 0.1 19.9 ± 1.4 0.02 1.60 ± 0.02
Spider Screw 330 ± 94 3.3 ± 0.4 19.0 ± 3.7 0.02 1.66 ± 0.08
Vector-TAS 286 ± 9 3.0 ± 0.2 30.7 ± 0.7 0.03 1.69 ± 0.02

Sa, Sz, amplitude parameters; Sdr, Sds, hybrid parameters; Sci, functional parameter. Straight lines connect mean values without statistical significant differences.

amplitude parameters (Sa Sz), but significant differences in hybrid (Sdr, Sds) While there are many analytical techniques to define electrochemical
and functional (Sci) parameters (Table 5.3). The Sa and Sz values recorded properties of metallic materials, experimental results cannot be extrapo-
were within the range reported for smooth-machined dental implants, lated directly to the clinical situation, as intraoral corrosion of metallic
requiring a few months for osseointegration.22 However, the high Sdr and biomaterials is not simply based on the contact of the surface with an
Sds values of Vector-TAS are associated with enhanced bone–implant electrolyte, but it is strongly dependent on the oral biofilms developed in
contact, with a beneficial effect on pullout and torque removal strength.13,23 service. Consequently, laboratory results should be considered as indica-
The Sds parameter seems to be associated with the development of a more tive, rather than conclusive, for in vivo electrochemical behavior.
favorable stress pattern at the implant–bone interface, distributing the Generally, cp-Ti and Ti-6Al-4V have high corrosion resistance, but the
stresses over a larger area and thus reducing stress concentration. High presence of Al and V could be problematic in that V has been associated
values of the functional parameter Sci have been shown to exert a positive with cytotoxic effects and adverse tissue reactions and Al may be impli-
effect on pullout strength.24 cated in neurological disorders.25,26 Because of concerns regarding leakage
Although primary and secondary stability are required for the clinical of these ions,27 Ti-6Al-4V has been replaced for orthopedic purposes with
efficacy of orthodontic MIs, osseointegration is considered as a com­ Ti-6Al-7Nb, using Nb instead of V as the beta stabilizer.14 The release of
plication, and thus surface chemistry and morphology must be adjusted ions from Ti-6Al-4V orthodontic MIs has been demonstated in a rabbit
accordingly. model (Fig. 5.8).2 However, the authors postulated that such results might
not be alarming because:
■ the released amounts were very low
ELECTROCHEMICAL PROPERTIES
■ orthodontic MIs have a short service life compared with orthopedic
devices
Placement of any metallic component in the oral cavity gives rise to
■ the surface to body weight ratio is much smaller in rabbits (20 : 3),
concerns about the potential adverse consequences of corrosion and
where the study was carried out, compared with adult humans
ionic release. Apart from the electrochemical properties of metallic materi-
(20 : 70) with four MIs.
als exposed to a biological environment, the presence of dissimilar
metals (a common finding in orthodontic therapy) might trigger galvanic Galvanic corrosion could be a potential problem with MIs as they are
phenomena. placed in the oral cavity along with a variety of dissimilar alloys as part
 38 SECTION II: INTRODUCTION TO SKELETAL ANCHORAGE IN ORTHODONTICS

Ti Al V
12 60 1
Concentration (ppb)

Concentration (ppb)

Concentration (ppb)
11 55 0.8
0.6
10 50
0.4
9 45 0.2
8 40 0
0 2 4 6 8 10 12 0 2 4 6 8 10 12 0 2 4 6 8 10 12
Weeks Weeks Weeks
Fig. 5.8 Concentration of Ti, Al and V in rabbit tissues as a function of time after implantation. The pattern was similar for kidneys, livers and lungs. (From De Morais
et al., 2009.2)

of orthodontic treatment, such as different SS grades and Ti alloys used 12. Larsson C, Thomsen P, Aronsson BO, et al. Bone response to surface-modified tita-
nium implants: studies on the early tissue response to machined and electropolished
for brackets; precious, semiprecious and base brazing alloys used for implants with different oxide thicknesses. Biomaterials 1996;17:605–16.
joining wing and base bracket components; and a variety of SS and Ti 13. Sul YT, Kang BS, Johansson C, et al. The roles of surface chemistry and topography
alloys (Ni-Ti and beta phase alloys) for archwires.28–31 Although galvanic in the strength and rate of osseointegration of titanium implants in bone. J Biomed
Mater Res A 2009;89:942–50.
action requires a minimum difference in electrochemical potential greater 14. Boyer R, Welsch G, Collings EW, editors. Materials properties handbook: titanium
than 0.2 V, it is not possible to predict what the potential difference will alloys. Materials Park, OH: ASM International; 1994.
be in the oral cavity while clear evidence of galvanic coupling is rare in 15. Motoyoshi M, Hirabayashi M, Uemura M, et al. Recommended placement torque
when tightening an orthodontic mini-implant. Clin Oral Implants Res 2006;17:
orthodontic literature.30 However, in vitro studies indicate that Ti and Ti 109–14.
alloys undergo galvanic corrosion when coupled with precious alloys 16. Eliades T, Zinelis S, Papadopoulos MA, et al. Characterization of retrieved orthodontic
(high-Au and low-Au, Ag-alloys, Pd-alloys) and they cause galvanic cor- miniscrew implants. Am J Orthod Dentofacial Orthop 2009;135:10, discussion 10–11.
17. Liu XY, Chu PK, Ding CX. Surface modification of titanium, titanium alloys, and
rosion to Ni-Cr and Co-Cr alloys.32–34 related materials for biomedical applications. Mater Sci Eng R Rep 2004;47:
49–121.
18. Li JL, Sun MR, Ma XX. Structural characterization of titanium oxide layers prepared
by plasma based ion implantation with oxygen on Ti6A14V alloy. Appl Surf Sci
CONCLUSIONS 2006;252:7503–8.
19. Zhu X, Kim KH, Jeong Y. Anodic oxide films containing Ca and P of titanium bio-
The material, the surface composition and the geometrical design of ortho- material. Biomaterials 2001;22:2199–206.
dontic MIs are important factors in their clinical efficacy. Optimization of 20. Serro AP, Saramago B. Influence of sterilization on the mineralization of titanium
implants induced by incubation in various biological model fluids. Biomaterials
their surface chemistry and topography, along with enhancements of their 2003;24:4749–60.
design by modifying geometrical features, may reduce clinical complica- 21. Dohan Ehrenfest DM, Coelho PG, Kang BS, et al. Classification of osseointegrated
tions such as early failure or later displacement of these devices. implant surfaces: materials, chemistry and topography. Trends Biotechnol 2009;28:
198–206.
22. Coelho PG, Granjeiro JM, Romanos GE, et al. Basic research methods and current
trends of dental implant surfaces. J Biomed Mater Res B Appl Biomater 2009;88:
REFERENCES 579–96.
23. Hallgren C, Reimers H, Chakarov D, et al. An in vivo study of bone response to
implants topographically modified by laser micromachining. Biomaterials 2003;24:
1. Morais LS, Serra GG, Muller CA, et al. Titanium alloy mini-implants for orthodontic 701–10.
anchorage: immediate loading and metal ion release. Acta Biomater 2007;3:331–9. 24. Lamolle SF, Monjo M, Lyngstadaas SP, et al. Titanium implant surface modification
2. De Morais LS, Serra GG, Albuquerque Palermo EF, et al. Systemic levels of metallic by cathodic reduction in hydrofluoric acid: surface characterization and in vivo per-
ions released from orthodontic mini-implants. Am J Orthod Dentofacial Orthop formance. J Biomed Mater Res A 2009;88:581–8.
2009;135:522–9. 25. Okazaki Y, Gotoh E, Manabe T, et al. Comparison of metal concentrations in rat tibia
3. Alsamak S, Bitsanis E, Makou M, et al. Morphological and structural characteristics tissues with various metallic implants. Biomaterials 2004;25:5913–20.
of orthodontic mini-implants. J Orofac Orthop 2012;73:58–71. 26. Steinemann SG. Titanium: the material of choice? Periodontol 2000 1998;17:7–21.
4. Gedrange T, Hietschold V, Mai R, et al. An evaluation of resonance frequency analysis 27. Gioka C, Bourauel C, Zinelis S, et al. Titanium orthodontic brackets: structure, com-
for the determination of the primary stability of orthodontic palatal implants: a study position, hardness and ionic release. Dent Mater 2004;20:693–700.
in human cadavers. Clin Oral Implants Res 2005;16:425–31. 28. Eliades T, Zinelis S, Papadopoulos MA, et al. Nickel content of as-received and
5. Buchter A, Wiechmann D, Gaertner C, et al. Load-related bone modelling at the retrieved NiTi and stainless steel archwires: assessing the nickel release hypothesis.
interface of orthodontic micro-implants. Clin Oral Implants Res 2006;17:714–22. Angle Orthod 2004;74:151–4.
6. Chen YJ, Chang HH, Huang CY, et al. A retrospective analysis of the failure rate of 29. Pelsue BM, Zinelis S, Bradley TG, et al. Structure, composition, and mechanical
three different orthodontic skeletal anchorage systems. Clin Oral Implants Res properties of Australian orthodontic wires. Angle Orthod 2009;79:97–101.
2007;18:768–75. 30. Siargos B, Bradley TG, Darabara M, et al. Galvanic corrosion of metal injection
7. Chen Y, Shin HI, Kyung HM. Biomechanical and histological comparison of self- molded (MIM) and conventional brackets with nickel–titanium and copper-nickel–
drilling and self-tapping orthodontic microimplants in dogs. Am J Orthod Dentofacial titanium archwires. Angle Orthod 2007;77:355–60.
Orthop 2008;133:44–50. 31. Zinelis S, Eliades T, Pandis N, et al. Why do nickel–titanium archwires fracture
8. Crismani AG, Bernhart T, Schwarz K, et al. Ninety percent success in palatal implants intraorally? Fractographic analysis and failure mechanism of in-vivo fractured wires.
loaded 1 week after placement: a clinical evaluation by resonance frequency analysis. Am J Orthod Dentofacial Orthop 2007;132:84–9.
Clin Oral Implants Res 2006;17:445–50. 32. Reclaru L, Meyer JM. Study of corrosion between a titanium implant and dental alloys.
9. Kim YK, Kim YJ, Yun PY, et al. Effects of the taper shape, dual-thread, and length J Dent 1994;22:159–68.
on the mechanical properties of mini-implants. Angle Orthod 2009;79:908–14. 33. Grosgogeat B, Reclaru L, Lissac M, et al. Measurement and evaluation of galvanic
10. Wilmes B, Ottenstreuer S, Su YY, et al. Impact of implant design on primary stability corrosion between titanium/Ti6A14V implants and dental alloys by electrochemical
of orthodontic mini-implants. J Orofac Orthop 2008;69:42–50. techniques and auger spectrometry. Biomaterials 1999;20:933–41.
11. Wilmes B, Rademacher C, Olthoff G, et al. Parameters affecting primary stability of 34. Taher NM, Al Jabab AS. Galvanic corrosion behavior of implant suprastructure dental
orthodontic mini-implants. J Orofac Orthop 2006;67:162–74. alloys. Dent Mater 2003;19:54–9.
 Structure and mechanical properties of
orthodontic miniscrew implants 6
Antonio Gracco, Costantino Giagnorio and Giuseppe Siciliani

Each type of head presents distinct clinical advantages and disadvan-

INTRODUCTION
tages.2 A spherical head can only carry one or two coil springs, as their
angle of insertion needs to be fairly acute with respect to the cortical plate,
Miniscrew implants (MIs) are biocompatible, mechanically retentive tem-
and only two-dimensional control of dental movement is possible. A head
porary anchorage devices that can be used in conjunction with osseointe-
with a hook can house more than two coil springs and there is less risk of
grated plates or miniplates.1 They were originally designed for fixing bone
detachment as the MI is inserted at a steep angle. Bracket-like heads have
for orthopedic purposes, but they are now widely employed in orthodontics
a central slot and are small, creating problems for ligating archwires and
providing skeletal anchorage. Their increasing popularity is based on a
for three-dimensional control of tooth movement. A head with a rectangu-
number of advantages over other available anchorage systems:
lar slot can provide optimal housing for archwires and is, therefore, clini-
■ ease of insertion and removal cally the most useful design.
■ versatility in that they can be inserted in many anatomical sites The driver socket can be external, in which the MI head is inserted into
■ possibility of immediate loading the hollow tip of a driver, or internal, in which the tip of a driver is inserted
■ small size so relatively low risk of damaging tooth roots or into the socket on the head of the MI. The internal single or Phillips slots
neurovascular structures near the insertion site allow acute insertion angles and have little risk of disengagement or bone
■ lower costs. stripping.3

IMPLANT STRUCTURE THE NECK

The neck is the portion of the MI between the head and the threaded
There are many types of MIs on the market, each possessing different intraosseous shank (Fig. 6.1). It may vary in length but is usually smooth
design characteristics. However, although structural features may vary, all to prevent tissue irritation, although a rough surface has also been pro-
MIs have a head, neck and shank (Fig. 6.1). posed (see below).4

THE HEAD
THE SHANK
The head is the most coronal portion of the MI and protrudes from the soft
tissues following insertion into bone. The head facilitates the use of a Miniscrew implant shanks are either cylindrical or conical (tapered) and
driver for MI insertion and removal, and its shape depends on whether threaded (Fig. 6.3). The thread transforms a rotational movement of the
direct or indirect anchorage is used, so that anchorage devices can be MI into a roto-translation one, facilitating insertion, and acts as a retention
bonded, ligated or hooked on to the MI (Fig. 6.2).1 mechanism in bone, counteracting the axial and longitudinal forces that
might otherwise cause the implant to work out of the bone.

Fig. 6.1 Basic components of a

miniscrew implant. INTRAOSSEOUS RETENTION

Head Prosthetic implants are intended to be retained in the mouth and so good
osseointegration is a vital factor in their success. By comparison, MIs are
intended to be removed at the end of treatment and so they need to be
stable but have limited osseointegration to facilitate their removal.1 Reten-
tion is provided by mechanical or primary retention derived from the
Neck
interaction between the MI screw threads and the bone itself (Fig. 6.4).
Insertion of the MI also generates controlled compression forces on the
surrounding bone that contribute to the stability of the fixture.5,6 As
osseointegration is not required, loading of orthodontic forces can be
applied immediately following insertion.7
Although immediate loading considerably reduces treatment time, it can
be deleterious from a biomechanical perspective, with issues of tipping or
Shank displacing occurring. In general, tipping is less of a problem with MIs
inserted into thicker cortical bone and in MIs inserted into the maxilla.
Migration of the MI can occur after bone resorption triggered by damage
to the bone during insertion or after secondary remodeling. Primary stabil-
ity is best achieved by ensuring that at least three to four MI threads are
anchored in cortical bone and by achieving optimal bone–screw locking
at the moment of insertion.6,8

39
 40 SECTION II: INTRODUCTION TO SKELETAL ANCHORAGE IN ORTHODONTICS

Fig. 6.2 Miniscrew implant heads. Various head designs (A) and surfaces (B).

Fig. 6.3 Conical (A) and cylindrical Fig. 6.4 Bone-screw locking condition.
(B) miniscrew implant shanks.

A B

Bone–implant contact, a widely used indicator of osseointegration, is

on average 25% in MIs subject to immediate loading and 18.9% in MIs
MINISCREW IMPLANT SUCCESS RATES: BIOLOGICAL
loaded following an appropriate healing period. No association between
AND MECHANICAL CONSIDERATIONS
the length of healing period and MI success rate has been documented.9
The success rate of MIs is currently very high and may reach a mean value
There has been debate as to the degree of loading force that can be
of 93.43%.12 For successful use as a skeletal anchorage, a MI must be able
applied to MIs but it appears that MIs are able to withstand loads of up to
to withstand the forces applied to it without deformation and/or breakage,
500 g, indicating that they are able to function properly in clinical
particularly during insertion and removal. From a physical perspective,
orthodontics.10
MIs are subjected to three phases of mechanical loading:
Because removal of MIs at the end of treatment requires that osseointe-
gration is limited, the vast majority of MIs on the market have a smooth ■ torsion during insertion
intraosseous portion. Even these will see a degree of osseointegration ■ flexion during the period of orthodontic treatment
(~25%) but this still permits their simple removal.11 ■ torsion during removal.
 Structure and mechanical properties of orthodontic miniscrew implants 41

Fig. 6.5 Smooth (left) and rough (right) miniscrew

implant surfaces.

Various factors influence the MI success rate: Although there is a need to achieve sufficient torque, this must be bal-
anced by the fact that excessive placement torque can cause microfractures
■ biological factors: patient health, age, insertion site, occlusion,
and ischemia in the bone surrounding the implant, thereby undermining
skeletal morphology
bone health and increasing the probability of failure. Hence, it is recom-
■ factors linked to operator dexterity/experience
mended that insertion torque be limited to 10 Ncm.17,18 Damage to bone
■ axial inclination of the device
leading to inflammation and bone remodeling is generally limited to 1 mm
■ surgical insertion procedures
of surrounding bone but it can spread further and cause device failure.16
■ structural and design characteristics of the MI: surface, length,
The degree of cortical damage inflicted by cylindrical MIs does not
diameter, neck, platform
differ significantly from that caused by conical MIs of the same diameter,
■ post-implantation factors: orthodontic movements, hygiene,
indicating that diameter, rather than shape, is the determining factor in
smoking.
bony tissue damage.16 The insertion site also must be considered (e.g.
maxilla or mandible, keratinized or non-keratinized mucosa).19 Overheat-
ing of the bone during drilling can occur where a pilot hole is drilled first,
MINISCREW IMPLANT STRUCTURAL with excessive insertion speed and also with prolonged perforation times.
CHARACTERISTICS Overheating is more common with MIs inserted in the generally thicker
Surface Characteristics cortical bone of the mandible.20–22 These considerations, in addition to
analysis of implantation success rates, have led to the conclusion that MIs
The characteristics of the surface of the MI have never been implicated with a diameter greater than 1.4 mm should be used in the mandible.19
in the failure of MIs subject to immediate loading.13 Use of acid etching
on the coronal portion of MIs increases the surface area at the interface,
allowing for very close contact between the bone and the MI (Fig. 6.5). Neck Characteristics
In one study, primary stability was not affected by acid etching but second- The neck is the portion of the MI that connects the head to the threaded
ary stability was improved even without an intervening healing period. intraosseous shank. Various lengths are manufactured to allow for adapta-
Ease of implant removal was not evaluated.14 tion to different thicknesses of mucosa. This prevents the soft tissues from
burying the MI head, an event that would undoubtedly lead to MI failure.
Greater neck thickness confers greater mechanical resistance, a useful
Length
consideration given that this is an area subject to particularly high levels
Although numerous studies have shown better success rates are achieved of mechanical stress. In fact, if the neck is too narrow, MI breakage can
with longer MIs, some authors do not consider this an important factor in easily occur, particularly during the removal procedure.23
MI success.1 In general, the surface of the neck is smooth as this is thought to cause
less damage to soft tissues (see Fig. 10.4).1 However, a MI neck featuring
microgrooves has recently been proposed (Fig. 6.6).4 The authors reported
Diameter
that the connective tissue fibers of the gingiva adhere in a perpendicular
Diameter has clearly been shown to have an influence on implantation fashion to the rough surface of their sandblasted, large-grit, and acid-etched
success.15 The outer diameter is the total diameter to the outer edge of the implant similar to the situation in a natural tooth. In contrast, these fibers
screw, while the internal, or root, diameter is the diameter of the shaft are thought to adhere to a smoother surface in a circular fashion, creating
carrying the screw thread. Manufacturers tend only to give the external a circular peri-implant ligament that runs parallel to the MI surface, which
diameter and so most studies only refer to this. permits epithelial growth and the creation of a pocket capable of harboring
Based on success rates, 1.2 mm can be considered the minimum diam- microorganisms, a possible cause of device failure.24 However, studies
eter required to achieve adequate implantation success. This may be examining the success rates of this MI have not been performed.
because it is more difficult to achieve the optimal placement torque of at
least 5–10 Ncm for good primary stability with narrower MIs.7,15 In terms
Platform
of maximal diameter, microfractures are particularly prevalent when using
MIs with a diameter of 2 mm and so diameters of 1.5 mm and 1.6 mm The platform is a raised area below the head that comes into contact with
represent a satisfactory compromise between MI resistance and cortical soft tissues (Fig. 6.7), serving to compress and protect these tissues from
lesioning.16 the auxiliary devices attached to the MI. The ideal platform should have
 42 SECTION II: INTRODUCTION TO SKELETAL ANCHORAGE IN ORTHODONTICS

Fig. 6.6 Neck of a miniscrew implant Primary stability depends on a number of factors:
featuring microgrooves. (With permission
of Kim et al.4) ■ device features: length, diameter, thread type, thread shape, thread
pitch, thread design, cutting flute, construction material
■ operator/surgical technique-related factors: cortical predrilling
insertion angle
■ patient characteristics: cortical bone thickness.
The following discussion examines the effect of MI design on primary
stability.

DESIGN AND STRUCTURAL CHARACTERISTICS

Length
Length generally refers to the threaded portion of the MI rather than the
entire head-to-tip length and can vary from 4 to 15 mm. An increase in
MI length results in an increase in maximum insertion torque, removal
torque and pullout resistance. In particular, a longer-threaded portion
confers a greater resistance to pullout with axial loads, although it does
not influence the resistance to lateral loads applied at 20 or 40°. However,
primary stability does not increase significantly beyond MI lengths of
5 mm because these greater lengths will be entering medullary bone.
The selection of MI length must also take into account the thickness of
the soft tissues at the insertion site, bearing in mind that the MI must be
supported by 5–6 mm of bone. For example, the palatal mucosa is an
average of 4 mm thick and so a MI of at least 10 mm is required for 6 mm
Platform to be held in bone.
From a strictly biomechanical perspective, the ideal length of a MI is
9 mm, as this is thought to cause less stress on the surrounding bone than
shorter MIs and has less risk of damage to neighboring anatomical struc-
tures than longer MIs.27 From a clinical standpoint, a MI of 4–6 mm can
be inserted into the majority of intraoral sites.28 When choosing a MI,
therefore, it is necessary to strike a balance between the ideal length with
Fig. 6.7 Miniscrew implant platform. respect to the biomechanics and the best clinical option.
Hong et al.29 have designed two MIs to be positioned above the dental
a smooth surface to reduce tissue irritation and to promote healing of the roots, thereby avoiding potentially damaging radicular contact (Fig. 6.8).
insertion wound. The platform should be 1–2 mm thicker than the soft There are two versions: N1, which is cylindrical, has a diameter of 4.1 mm
tissues upon which it is positioned to prevent tissue growth around the and length of 2.6 mm; and N2, which is conical, 2 mm in length and 3 mm
neck of the MI. Direct contact between this structure and the underlying in diameter. The reduced lengths were inspired by a cone beam CT study
anatomical planes is thought to confer greater stability to the device.2 analyzing the cortex above the roots at labial anatomical sites, which
revealed a mean cortical thickness of 2.3 mm. However, N1 required
excessive insertion torques (15.6 Ncm), which could lead to considerable
PRIMARY STABILITY OF MINISCREW IMPLANTS bone damage and so N2 was devised with a reduced diameter and a conical
shape. Mechanical tests performed on the N2 appear to confirm its superior
Primary stability is indispensable for the clinical application of MIs as performance with respect to control MIs in terms of both placement torque
anchorage. Optimal primary stability is particularly important if MIs are and lateral displacement.29
to be subject to immediate loading as stability reduces the potential for
micromovement. This effect favors tissue healing at the insertion site, a
Diameter
necessary condition for long-term stability.6 From a mechanical perspec-
tive, the ultimate goal of MI placement is to create maximum interdigita- The primary stability of a MI is directly proportional to its diameter, as
tion between the bony tissue and the threads of the MI and to generate the forces applied are distributed over a larger surface area when MIs of
controlled compression forces in the bone.6 Both of these properties are larger diameters are used, resulting in a reduction in pressure on the bone
fundamental for achieving primary stability. at the insertion site.30 It is diameter rather than length that is most influ-
There are no good data regarding the acceptable level of micromove- ential with respect to biomechanical yield,31 implantation success32 and
ment that still allows primary stability for osseointegrated devices; pros- resistance to fracture.33 Furthermore, to obtain optimal biomechanical
thetic implants should have a range limited to 50–150 µm upon insertion25 yield from a device, a good relationship between its external and internal
but lower values are more likely for MIs of smaller dimensions. diameters is required.34
Stability deteriorates progressively during the 3 weeks following inser- The external diameter has a large and directly proportional influence on
tion and then increases over the fourth and fifth week;26 the initial decrease placement torque, pullout resistance and removal torque. These properties,
is probably caused by bone remodeling and it is more evident in sites with in turn, affect primary stability, particularly in conical rather than cylindri-
unattached mucosa. cal MIs.35 This latter difference between the MI types is because the tensile
 Structure and mechanical properties of orthodontic miniscrew implants 43

N1 N2

N2 CA

d=4.1mm d=3.0mm
=2.6mm =2.0mm
Cylindrical Tapered

A B

Fig. 6.8 The N1 and N2 miniscrew implants (A) Structural differences. (B) Supraradicular cortical placement of N2 miniscrew implants compared with inter-radicular
traditional commercially available (CA) miniscrew implants. (With permission of Hong et al.29)

resistance corresponds to the cube of the greatest diameter of the MI. The create another pilot hole in the medullary bone to house the entire length
external diameter also influences clinical use because MIs with smaller of the MI. “Threads” in the medullary bone to engage the threads of the
diameters can be positioned in smaller interdental spaces.1 MI were then created with a tapping drill.
Internal diameter has no statistically significant influence on stability, Self-tapping devices rapidly followed and had a blunt tip, a cylindrical
although it has been suggested that a smaller internal diameter allows shank and asymmetrical sharp (cutting) threads. Sometimes there was a
greater thread depth and thus increases the flank overlap area (the area of cutting flute in the terminal part of the threaded portion. The surface of
the bone in contact with the MI threads), leading to larger bony bridges the threads in these MIs is nearly perpendicular to the direction of the
between the threads, particularly near the tip of the MI.36 pullout force, allowing for maximum load transmission. Moreover, some
The external diameter of the MIs must be greater than 1 mm; purchase self-tapping MIs possess a “thread-forming” or “thread-cutting” feature.
varies with diameters ranging from 1 mm to 1.5 mm but appears stable The former compress the surrounding bone during their insertion, forming
for those with diameters of 1.5–2.3 mm in both jaws. A significant loss of threads in the bone by plastic deformation and, therefore, produce no
anchorage has been observed when using MIs with external diameters of osseous debris. The latter cut into bone to form threads as they are inserted,
less than 1.2 mm.2 The ideal external diameter is probably between 1.3 pushing some of the small debris created along the shank to the surface
and 1.5 mm, a compromise between primary stability, mechanical resist- during the implantation procedure. The remainder of the debris is com-
ance and clinical versatility. The mean inter-radicular space is generally pressed between the MI and the surrounding bone.
between 2.5 mm and 3.5 mm, so there is a risk of unwanted root contact Self-tapping devices also require a pilot hole to be made through the
when MIs of diameters greater than 2 mm are used.2 cortical layer and into the spongy bone but only one drill is required and
The space necessary to accommodate a MI and so reduce the risk there is no tapping procedure.41
of damage to neighboring structures can be calculated from the MI The self-drilling implant was designed to be inserted through the mucosa
diameter, its mean displacement (equal to its diameter), the thickness of directly into the bone using a manual driver or handpiece,41 thus avoiding
the periodontal ligament of the adjacent teeth and the inter-radicular dis- any predrilling. Self-drilling devices are similar to bottle-openers in that
tance necessary to house the MI without anatomical damage (average, they are equipped with a cutting tip that is able to perforate the bony cortex
0.25 mm). and a hollow cutting flute on the terminal portion of the thread (Fig.
A success rate of 88.6% has been reported for MIs with a 1.3 mm 6.9A,B). These cut into the bone and facilitate insertion, but also transport
diameter, which is not particularly high but needs to be weighed against the bony debris produced during the procedure to the surface so that it is
the lesser risk of iatrogenic damage.37 Miniscrew implants of even smaller not compressed against the walls of the hole (Fig. 6.9C).42,43
diameter, however, are less resistant to loading perpendicular to their long Although pretapped MIs are more time consuming to insert than the
axis.38 Those with a diameter of less than 1.2 mm tend to possess poor self-drilling versions, they are still used. They should not be used in areas
mechanical resistance and are prone to fracture, particularly in highly where the cortical layer is thin or where the spongy bone is particularly
mineralized tissues.32,39 A reduction in MI diameter of 0.2 mm leads to a sparse (e.g. the midfacial area), as the tapping drill can easily cause strip-
reduction of approximately 50% in the resistance of the device.40 ping, leading to a loss of MI purchase on the bone.42 Moreover, pretapped
The choice of MI diameter may also be influenced by the thickness of MI threads tend not to engage tightly with those created in the bone, and
the cortical layer at the insertion site. In the palate, for example, the use a loss of stability is more likely. Nonetheless, this type of device can be
of MIs with a diameter of at least 1.5 mm is recommended. In the mandi- employed successfully in anatomical areas featuring a thick cortical layer
ble, however, diameters of at least 2 mm are preferable. or when inserted through the spongy bone into the underlying cortical layer
(bicortical implantation).
Self-tapping MIs have a number of advantages over their pretapped
Miniscrew Implant Type
counterparts, including better purchase in thin cortical layers,43 simplified
Miniscrew implants can be pretapped, self-tapping or self-drilling. Early insertion procedures and the consequent need for fewer tools and less
MIs were pretapped and required an initial pilot hole to be drilled through chair-side time. They also decrease the risk of placement torque and bone
the entire thickness of the cortical layer. A suitable bur was then used to damage, and reduce the heat generated during the insertion.
 44 SECTION II: INTRODUCTION TO SKELETAL ANCHORAGE IN ORTHODONTICS

Although the self-drilling systems require only a single-step insertion

procedure, some authors recommend predrilling a pilot hole with a diam-
eter of 0.3 mm and a depth of 2–3 mm at sites with a cortical thickness
2 mm or greater to reduce the risk of damage to the MI tip.1,2 Although
self-drilling MI placement is far less invasive than placement of self-
tapping MIs, the pressure exerted on the bone during perforation of the
cortical layer and the greater placement torque required for insertion
creates more stress on bone and MI, leading to a greater risk of fracture
for both.42,49
Placement of self-drilling MIs requires a high peak insertion torque, the
maximum force of the clockwise movement required for complete inser-
tion of the device, in both the maxilla and mandible. High torques indicate
a greater degree of contact between the MI and bone (in particular the
cortex) and thus a better grip force, resistance to MI failure and stability
A B under orthodontic loads.47 However, the high peak insertion torque with
self-drilling MIs means that care must be taken when they are inserted into
particularly compact bone as this will increase the probability of fracture
during the placement.50
In contrast, the peak removal torque appears to be similar for self-
drilling and self-tapping devices.49
Of the three types of MI, the self-drilling versions appear to possess a
greater primary stability and a superior bone–implant contact, which can
C be considered an indicator of both stability and reduced bone damage.43
Fig. 6.9 (A) Self-tapping miniscrew implant with a round tip. (B) Self-drilling The presence of numerous bony fragments in contact with the threads of
miniscrew implant with a crock-screw tip. (C) Implant insertion/pilot holes in bone. self-drilling MIs can also be interpreted as proof of the lack of damage to
the surrounding bone, as this indicates that the bone is incised rather than
Placement torque is greatly influenced by the diameter of a pilot hole. compressed.43
Although torque increases with a smaller diameter of pilot hole, fracture The self-drilling MIs possess great stability but generate more friction
is more likely with MIs of small diameter.44,45 The ideal pilot hole diameter upon their contact with the bone; they also possess a lower grip capacity
is 0.2–0.5 mm smaller than that of the MI.46 Pretapped systems have the in vitro than self-tapping MIs.43 However, numerous authors maintain that
advantage of a 40% reduction in placement torque compared with self- self-drilling MIs permit a greater degree of contact between the MI and
tapping MIs and they also allow bone debris to be easily removed before the bone, provoke less damage and have a greater success rate than other
device placement. systems.34,41,49,51
The predrilling phase adds time to a procedure and there is a risk of The choice between self-drilling or self-tapping MIs should not be made
excessive perforation and damage to the nerves, roots and tooth buds plus based only on the morphological characteristics of the device; the material
the possibility of drill tip breakage and thermal necrosis of the bone.42 the MI is made of must also be taken into consideration. Indeed,
Whenever a MI is inserted into bone, the Haversian canal system (the commercially pure titanium MIs require a predrilling phase to reduce
supporting structure of the bone) is interrupted, and the tissue responds. subsequent insertion stress on the device, whereas MIs made of titanium
Predrilling can aggravate this type of damage by generating more heat in alloys have been purpose-designed to avoid a need for predrilling (see
the bone. Furthermore, bone fracture and atrophy are more likely with Chapter 5).2
pretapped and self-tapping MIs as they both create a radial displacement Whatever the choice of material, it should be noted that all MIs are
of bone at the MI tip, which can result in compression damage.43 subject to micromovements at loading and during the period of orthodontic
The bone–MI interface is better with self-tapping MIs than with pre- force application. These movements will increase the longer the MI is
tapped MIs: complete contact has been demonstrated in 65.8% of samples subject to orthodontic forces but will not necessarily lead to clinical insta-
of self-tapping MIs compared with a mere 3.7% of pretapped MIs.47 bility or device failure.52
Reduced contact between the bone and the MI translates into less mechani-
cal stability. Moreover, pretapped devices have been shown to create more
Shaft Shape
bone damage and so there is a greater degree of bone remodeling and tissue
formation. At the end of a healing period, greater contact is achieved at Shafts can be conical or cylindrical and the shape has biomechanical and
the bone–MI interface with drill-free insertion than for self-tapping clinical effects. From a biomechanical perspective, conical shafts with
devices. The drilling process for pretapped devices removes the spicules their tapered shape promote increased placement torque,6,41,53,54 particu-
of bone it creates during perforation, creating gaps in the trabecular bone, larly during insertion of the coronal portion of the device, and provide a
whereas self-drilling systems tend to compress these bone fragments into greater surface for interface with the surrounding bone.55 They are also
the trabecular gaps. The disadvantages of self-drilling are the risk of easier to insert into cortical bone and permit better mechanical cohesion
damage to neighboring anatomical structures, overheating of the surround- between the MI threads and the surrounding bony tissue.56 Combined
ing tissues, and loosening of any pilot hole during MI insertion. All may with the progressive compression of the surrounding bone that occurs
lead to a reduction in primary stability. during their insertion, this leads to the greater stability of conical over
The pullout resistance of pretapped and self-tapping MIs is compara- cylindrical MIs.36,57
ble.48 However, some clinicians consider that self-tapping MIs are easier When comparing conical and cylindrical MIs of the same length, the
to grip while others consider there is no significant difference between the maximum insertion torque is generally higher in the former; it increases
two types. with length of the cylindrical MI but remains the same for conical MIs of
 Structure and mechanical properties of orthodontic miniscrew implants 45

increasing shaft length. Cylindrical MIs do not require greater torque with increases between pitches of 0.75 and 1 mm but does not increase between
thicker cortical bone whereas conical MIs do.18,58 pitches of 1 and 1.25 mm.40
Another fundamental characteristic of cylindrical MIs is their improved A smaller pitch (0.5 mm or less) is also thought to decrease the amount
grip on the resistant layer of spongy bone underlying the cortical bone. of bone penetration per turn, thereby reducing the concentration of stress
This is a consequence of the greater diameter of cylindrical MIs and guar- on the bone and creating greater compression on the surrounding tissue.
antees tight contact at the MI–spongy bone interface. In contrast, slight However, it also appears that the pitch has a greater influence on the stabil-
loosening of a conical implant, for any reason, is accompanied by a rela- ity of MIs with a diameter of 2 mm than on the stability of smaller
tively large reduction in grip.59 Aside from loss of purchase, conical MIs versions.
have the added drawback of increased insertion speed.18 When choosing the most appropriate MI, it is important to bear in mind
The shape also influences pullout resistance, with conical MIs being that those with very small pitch are able to engage with very little solid
more resistant to transverse loads at 20 or 40°.41,54 However, the reduced material, particularly in less compact bone. These MIs engage with only
thread depth at the coronal portion of a conical MI would decrease resist- a few fragments of bone, which do not contribute to pullout resistance or
ance to pullout.35 Hence, the pullout resistance of conical MIs is a com- the stability of the device.36
promise between that obtained by compacting the bone and that lost Indeed, a more useful indicator of MI suitability is its thread shape
through decreased thread depth.35 factor, the relationship between the thread depth and pitch. In fact, it is
A conical shaft also increases the removal torque.58 The maximum necessary to increase a MI’s thread shape factor by increasing the pitch
removal torque and torque loss (difference between insertion and removal and reducing the thread depth, or vice versa, to increase its pullout
torque) are greater for conical than for cylindrical MIs.58 resistance.
One undisputed advantage of conical MIs is that they possess a greater
resistance to fatigue and breakage than their cylindrical counterparts.35 Thread Design
This mechanical resistance is thought to derive from their smaller diameter
at the junction between the threaded area and the neck, the region most Miniscrew implant threads come in different shapes, which can influence
susceptible to stress.60 their primary stability.34 The best thread shape in terms of mechanical
By comparison with biomechanical features, several studies have exam- performance appears to be asymmetric and features a leading angle of 45°
ined clinical differences between conical and cylindrical MIs. A study by (Fig. 6.11) at the lower edge of the thread and a trailing angle of 90° at
Kim et al.58 concluded that conical MIs offered no actual clinical benefit the upper edge of the thread. This design is thought to aid insertion and
apart from elevated primary stability, with no significant differences in resistance to removal55 by increasing the pullout resistance.64 The design
bone–implant contact, bone area and success rates. This can be ascribed also provides maximal load transmission, particularly if the thread is
to the fact that conical MIs have 20–30% less surface area than cylindrical attached by means of a “sharp” angle rather than a rounded joint.42
devices,61 and that the greater placement torque required for their insertion Orthopedic studies have found no difference in the pullout force between
is more likely to provoke adverse effects in the surrounding tissues.58 To buttress and disk-shaped threads.65 In contrast, Gracco et al. (unpublished
counteract this, it is advisable to predrill the cortical layer at the insertion data) found that reverse buttress, trapezoidal, rounded reverse buttress and
site. reverse buttress with 75° thread joint shank shapes provide superior pullout
A further study indicated that while primary stability is greater with resistance to those of the buttress design when inserted into a homogene-
conical MIs, after 12 weeks there are no differences in terms of bone– ous support (Fig. 6.12).
implant contact or removal torque.62 However, while the bone–implant A double-threaded conical MI increased the cortical bone–implant
contact of conical MIs is excellent even immediately after insertion, it is contact area and provided a better purchase in terms of greater removal
necessary to allow a healing period of at least 8 weeks to obtain a com- torque when compared with single-threaded conical MIs and single- and
parable level of contact as seen with cylindrical MIs.63 double-threaded cylindrical MIs (Fig. 6.13).66 However, Kim et al.67
showed lower maximum insertion torque for a so-called dual-thread
design, with one series of threads at double the number of thread tips per
Thread Pitch inch than the single-threaded version. In contrast, the double-threaded MI
Miniscrew implant threads come in different shapes and pitches, the pitch proposed by Hong et al. featured two series of threads, each with the same
being the distance between the peaks of two adjacent threads (Fig. 6.10). number of tips per inch as the single-threaded version used as a control
A reduction in pitch and the consequent increase in tips per unit length (Fig. 6.13).66
increase the stability of an implant. Reduced pitch has been shown to
increase resistance to pullout in porous materials,40 although pullout force Cutting Flute
The cutting flute is a helical groove in the apical portion of self-tapping
Fig. 6.10 Miniscrew and self-drilling implants (see Fig. 6.12) to allow the MI to cut into the
implant thread pitch.
Fig. 6.11 Cutting flute
with a 115° trailing angle
(orange), a 90° trailing
angle (red) and a 45°
leading angle (yellow).
 46 SECTION II: INTRODUCTION TO SKELETAL ANCHORAGE IN ORTHODONTICS

The deformation potentials of the two systems are matched and their
combined resistance is increased.

Material
It is also important to consider the material used to construct MIs as this
influences not only the clinical procedures used for their insertion and
removal2,70 but also their mechanical resistance under orthodontic loads.
This topic is covered in detail in Chapter 5.

REFERENCES
1. Papadopoulos MA, Tarawneh F. The use of miniscrew implants for temporary skeletal
anchorage in orthodontics: a comprehensive review. Oral Surg Oral Med Oral Pathol
Oral Radiol 2007;103:e6–15.
2. Lin JCY, Liou EJW, Yeh CL, et al. A comparative evaluation of current orthodontic
miniscrew system. World J Orthod 2007;8:136–44.
Fig. 6.12 Various miniscrew implant thread designs. From left: buttress, reverse 3. Spencer KR, Ferguson JW, Smith AC, et al. Screw head design: an experimental study
buttress with 75° thread joint, rounded reverse buttress, trapezoidal, reverse to assess the influence of design on performance. J Oral Maxillofac Surg 2004;62:
buttress with 90° thread joint. 473–8.
4. Kim TW, Baek SH, Kim JW, et al. Effects of microgrooves on the success rate and soft
tissue adaptation of orthodontic miniscrews. Angle Orthod 2008;78:1057–64.
5. Brettin BT. Bicortical vs monocortical orthodontic skeletal anchorage. Am J Orthod
Dual-threaded Double-threaded Dentofacial Orthop 2008;134:625–35.
6. Cha JY, Kil JK, Yoon TM, et al. Miniscrew stability evaluated with computerized
tomography scanning. Am J Orthod Dentofacial Orthop 2010;137:73–9.
7. Park HS, Jeong SH, Kwon OW. Factors affecting the clinical success of screw
implants used as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2006;130:
18–25.
8. Deguchi T, Nasu M, Murakami K, et al. Quantitative evaluation of cortical bone thick-
ness with computed tomographic scanning for orthodontic implants. Am J Orthod
Dentofacial Orthop 2006;129:721.e7–12.
9. Cheng SJ, Tseng IY, Lee JJ, et al. A prospective study of the risk factors associated
with failure of mini-implants used for orthodontic anchorage. Int J Oral Maxillofac
Implants 2004;19:100–6.
10. Ohashi E, Pecho OE, Moron M, et al. Implant vs screw loading protocols in ortho-
dontics. A systematic review. Angle Orthod 2006;76:721–7.
11. Cornelis MA, Scheffler NR, De Clerck HJ, et al. Systematic review of the experimen-
tal use of temporary skeletal anchorage devices in orthodontics. Am J Orthod Dento-
facial Orthop 2007;131(Suppl. 4):52–8.
12. Antoszewska J, Papadopoulos MA, Park HS, et al. Five-year experience with ortho-
dontic miniscrew implants: a retrospective investigation of factors influencing success
rates. Am J Orthod Dentofacial Orthop 2009;136:158.e1–10.
13. Chaddad K, Ferreira AFH, Geurs N, et al. Influence of surface characteristics on
survival rates of mini-implants. Angle Orthod 2008;78:107–13.
14. Ikeda H, Rossouw PE, Campbell PM, et al. Three-dimensional analysis of peri-bone-
implant contact of rough-surface miniscrew implants. Am J Orthod Dentofacial Orthop
2011;139:e153–63.
15. Wiechmann D, Meyer U, Büchter A. Success rate of mini- and micro-implants used
for orthodontic anchorage: a prospective clinical study. Clin Oral Implants Res
2007;18:263–7.
16. Lee NK, Baek SH. Effects of the diameter and shape of orthodontic mini-implants
on micro-damage to the cortical bone. Am J Orthod Dentofacial Orthop 2010;138:
Fig. 6.13 “Dual-thread” and “double-thread” threads. (With permission of Hong e1–8.
et al.66) 17. Motoyoshi M, Hirabayashi M, Uemura M, et al. Recommended placement torque
when tightening an orthodontic mini-implant. Clin Oral Implants Res 2006;17:
bone and to contain the bone fragments accumulated during the insertion 109–14.
18. Lim SA, Cha JY, Hwang CJ. Insertion torque of orthodontic miniscrews according to
procedure. Some fragments are compressed radially against the bone by changes in shape, diameter and length. Angle Orthod 2008;78:234–40.
the MI tip, and others are brought to the surface by the MI threads. 19. Wu TY, Kuang SH, Wu CH. Factors associated with the stability of mini-implants for
Although the flute aids insertion, it also leads to a loss of local grip of orthodontic anchorage: a study of 414 samples in Taiwan. J Oral Maxillofac Surg
2009;67:1595–9.
approximately 30%. 20. Reingewirtz Y, Szmukler-Moncler S, Semger B. Influence of different parameters on
Orthopedic literature has shown that the cutting capacity of self-tapping bone heating and drilling time in implantology. Clin Oral Res 1997;8:189–97.
implants is also affected by the cutting thread relief, the chamfer position, 21. Sharawy M, Misch CE, Weller N, et al. Heat generation during implant drilling: The
significance of motor speed. J Oral Maxillofac Surg 2002;60:1160–9.
the cutting depth and the incision angle.68,69 The only orthodontic study 22. Brisman DL. The effect of speed, pressure, and time on bone temperature during the
published reported that MIs with a cutting flute had higher placement drilling of implant sites. Int J Oral Maxillofac Implants 1996;11:35–7.
torque and pullout resistance than those without.70 The increased place- 23. Costa A, Pasta G, Bergamaschi G. Intraoral hard and soft tissue depths for temporary
anchorage devices. Semin Orthod 2005;11:10–15.
ment torque is presumably because of the compression of bone fragments 24. Schierano G, Ramieri G, Cortese M, et al. Organization of the connective tissue barrier
against the walls of the insertion chamber, resulting in greater friction and around long-term loaded implant abutments in man. Clin Oral Implants Res
insertion resistance. The increased pullout resistance may be explained by 2002;13:460–4.
25. Szmukler-Moncler S, Salama H, Reingewirtz Y, et al. Timing of loading and effect
the flute interrupting the thread and making it more flexible and thus allow- of micromotion on bone–dental implant interface: review of experimental literature.
ing the overall rigidity of the MI to approach that of the surrounding bone. J Biomed Mater Res 1998;43:192–203.
 Structure and mechanical properties of orthodontic miniscrew implants 47

26. Ure AD, Oliver DR, Kim KB, et al. Stability changes of miniscrew implants over time: 49. Chen Y, Shin HI, Kyung HM. Biomechanical and histological comparison of self-
a pilot resonance frequency analysis. Angle Orthod 2011;81:994–1000. tapping and self-drilling microimplants in dogs. Am J Orthod Dentofacial Orthop
27. Gracco A, Cirignaco A, Cozzani M, et al. Numerical/experimental analysis of the 2008;133:44–50.
stress field around miniscrews for orthodontic anchorage. Eur J Orthod 2009;31: 50. Ellis JA Jr, Laskin DM. Analysis of seating and fracturing torque of bicortical screws.
12–20. J Oral Maxillofac Surg 1994;52:483–7.
28. Costa A, Pasta G, Bergamaschi G. Intraoral hard and soft tissue depths for temporary 51. Kim JW, Ahn SJ, Chang YI. Histomorphometric and mechanical analysis of the drill-
anchorage devices. Semin Orthod 2005;11:10–15. free screw as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2005;128:
29. Hong C, Truong P, Song HN, et al. Mechanical stability assessment of novel ortho- 190–4.
dontic mini-implant designs: Part 2. Angle Orthod 2011;81:1001–9. 52. Wang YC, Liou EJ. Comparison of the loading behavior of self-drilling and predrilled
30. Kim YH, Yang SM, Kim S, et al. Midpalatal miniscrews for orthodontic anchorage: miniscrews throughout orthodontic loading. Am J Orthod Dentofacial Orthop 2008;
factors affecting clinical success. Am J Orthod Dentofacial Orthop 2010;137: 133:38–43.
66–72. 53. Song Y, Cha J, Hwang C. Evaluation of insertion torque and pullout strength of mini-
31. Brown GA, McCarthey T, Bourgeault A, et al. Mechanical performance of standard screws according to different thickness of artificial bone. Korean J Orthod 2007;37:
and cannulated 4.0 mm cancellous bone screws. J Orthop Res 2000;18:307–12. 5–15.
32. Lim JW, Kim WS, Son CY, et al. Three dimensional finite element method for stress 54. Florvaag B, Kneuert P, Lazar F, et al. Biomechanical properties of orthodontic minis-
distribution on the length and diameter of orthodontic miniscrew and cortical bone crews: an in-vitro study. J Orofac Orthop 2010;71:53–67.
thickness. Korean J Orthod 2003;33:11–20. 55. Carano A, Lonardo P, Velo S, et al. Mechanical properties of three different commer-
33. Johansson CB, Han CH, Wennerberg A, et al. A quantitative comparison of machined cially available miniscrews for skeletal anchorage. Prog Orthod 2005;6:82–97.
commercially pure titanium and titanium-aluminium-vanadium implants in rabbit 56. Glauser R, Portmann M, Ruhstaller P, et al. Initial implant stability using different
bone. Int J Oral Maxillofac Implants 1998;13:315–21. implant designs and surgical techniques. A comparative clinical study using insertion
34. Wilmes B, Rademacher C, Olthoff G, et al. Parameters affecting primary stability of torque and resonance frequency analysis. Appl Osseointegr Res 2001;2:6–8.
orthodontic mini-implants. J Orofac Orthop 2006;67:162–74. 57. Abshire BB, McLain RF, Valdevit A, et al. Characteristics of pullout failure in conical
35. Chao CK, Hsu CC, Wang JL, et al. Increasing bending strength and pullout strength and cylindrical pedicle screws after full insertion and back-out. Spine J 2001;1:
and pullout strength in conical pedicle screws: biomechanical tests and finite element 408–14.
analyses. J Spinal Disord Tech 2008;21:130–8. 58. Kim JW, Baek SH, Kim TW, et al. Comparison of stability between cylindrical and
36. Krenn MH, Piotrowski WP, Penzkofer R, et al. Influence of thread design on pedicle conical type mini-implants. Angle Orthod 2008;78:692–8.
screw fixation. Laboratory investigation. J Neurosurg Spine 2008;9:90–5. 59. Lill CA, Schlegel U, Wahl D, et al. Comparison of the in vitro holding strengths of
37. Kuroda S, Sugawara Y, Deguchi T, et al. Clinical use of miniscrew implants as ortho- conical and cylindrical pedicle screws in a fully inserted setting and backed out 180
dontic anchorage: success rates and postoperative discomfort. Am J Orthod Dentofa- degrees. J Spinal Disord 2000;13:259–66.
cial Orthop 2007;131:9–15. 60. Lill CA, Schneider E, Goldhahn J, et al. Mechanical performance of cylindircal and
38. Morarend C, Qian F, Marshall SD, et al. Effect of screw diameter on orthodontic dual core pedicle screw in calf and human vertebrae. Arch Orthop Trauma Surg
skeletal anchorage. Am J Orthod Dentofacial Orthop 2009;136:224–9. 2006;126:686–94.
39. Mah J, Bergstrand F. Temporary anchorage devices: a status report. J Clin Orthod 61. Drago CJ, Del Castillo RA. A retrospective analysis of osseotite NT implants in clini-
2005;39:132–6. cal practice: 1-year follow-up. Int J Periodontics Restorative Dent 2006;26:337–45.
40. De Coster TA, Heetderks DB, Downey DJ, et al. Optimizing bone screw pullout force. 62. Cha JY, Takano-Yamamoto T, Hwang CJ. The effect of miniscrew taper morphology
J Orthop Trauma 1990;4:169–74. on insertion and removal torque in dogs. Int J Oral Maxillofac Implants 2010;25:
41. Mischkowski RA, Kneuertz P, Florvaag B, et al. Biomechanical comparison of four 777–83.
different miniscrew types for skeletal anchorage in the mandibulomaxillary area. Int 63. Yano S, Motoyoshi M, Uemura M, et al. Tapered orthodontic miniscrews induce bone:
J Oral Maxillofac Surg 2008;37:948–54. screw cohesion following immediate loading. Eur J Orthod 2006;28:541–6.
42. Heidemann W, Gerlach K, Gröbel L, et al. Drill free screws: a new form of osteosyn- 64. Tencer AF, Asnis E, Harrington RM, et al. Biomechanics of cannulated and noncan-
thesis screw. J Cranimaxillofac Surg 1998;26:163–8. nulated screws. In: Asnis SE, Kyle RF, editors. Cannulated screw fixation: principles
43. Heidemann W, Terheyden H, Gerlach KL. Analysis of the osseous/metal interface and operative techniques. New York: Springer; 1996. p. 15–40.
of drill free screws and self-tapping screws. J Craniomaxillofac Surg 2001;29: 65. Halsey D, Fleming B, Pope MH, et al. External fixator pin design. Clin Orthop
69–74. 1992;278:305–12.
44. Sakoh J, Wahlmann U, Stender E, et al. Primary stability of a conical implant and a 66. Hong C, Lee H, Webster R, et al. Stability comparison between commercially avail-
hybrid, cylindric screw-type implant in vitro. Int J Oral Maxillofac Implants able mini-implants and a novel design: part 1. Angle Orthod 2011;81:692–9.
2006;21:560–6. 67. Kim YK, Kim YJ, Yun PY, et al. Effects of the taper shape, dual-thread, and length
45. Öktenoğlu BT, Ferrara LA, Andalkar N, et al. Effects of hole preparation on screw on the mechanical properties of mini-implants. Angle Orthod 2009;79:908–14.
pullout resistance and insertional torque: a biomechanical study. J Neurosurgery Spine 68. Yerby S, Scott CC, Evans NJ, et al. Effects of cutting flute design on cortical bone
2001;94:91–6. screw insertion torque and pullout strength. J Orthop Trauma 2001;15:216–21.
46. Chen Y, Kyung HM, Zhao WT, et al. Critical factors for the success of orthodontic 69. Brinley CL, Behrents R, Kim KB, et al. Pitch and longitudinal fluting effects on the
mini-implants: a systematic review. Am J Orthod Dentofacial Orthop 2009;135: primary stability of miniscrew implants. Angle Orthod 2009;79:1156–61.
284–91. 70. Baumgart FW, Cordey J, Morikawa K, et al. AO/ASIF self-tapping screws (STS).
47. Bähr W. Pretapped and self-tapping screws in the human midface. Torque measure- Injury 1993;24:1–7.
ments and bone screw interface. Int J Oral Maxillofac Surg 1990;19:51–3. 71. Carano A, Velo S, Leone P, et al. Clinical applications of the miniscrew anchorage
48. Vangsness CT Jr, Carter DR, Frankel VH. In vitro evaluation of the loosening char- system. J Clin Orthod 2005;19:19–24.
acteristics of self-tapped and non-self-tapped cortical bone screws. Clin Orthop Relat
Res 1981;157:279–86.
Section III: Clinical considerations for the use of skeletal anchorage devices in orthodontics

The use of implants as skeletal anchorage

7 in orthodontics
Karlien Asscherickx

An alternative site for implantation of osseointegrated implants is the

INTRODUCTION
palate. Clear benefits include the facts that the palatal bone is of good
quality and there is no interference with the roots of teeth, and so maxillary
When no ankylosed tooth is present and dental elements lack either quan-
posterior teeth can be easily distalized without interference with the
tity or quality, or when compliance during treatment is unlikely, implants
implant. Design of an implant must be suitable to fit the palatal region,
are an excellent alternative to traditional orthodontic anchorage methods.
which has a decreased bone height compared with the alveolar ridge. The
They have a high success rate and there is a lot of expertise and evidence-
length of the implants is decreased while the diameter can be augmented
based research on their use in dentistry.
since no root interference will occur. This allows an enlarged implant
Skeletal anchorage with implants requires osseointegration, which is
surface in direct contact with bone.
clinically manifest as an absence of mobility. To ensure sufficient resist-
The midline of the palatine bone is of particular anatomic interest. The
ance to continuous loading, such as conventional orthodontic forces, an
vertical height of the bone in the midsagittal area was found to be at least
osseointegration of at least 10% should be present between the implant
2 mm higher than apparent on cephalometric radiographs.6 In the broad
surface and the surrounding bone.1 However, implants also have to be
median suture zone, the bone is relatively dense compared with the more
removed at the end of orthodontic treatment, requiring another minor
paramedian region and consequently this should be the area of choice for
surgical procedure, and ease of removal will also be affected by the degree
the placement of palatal orthodontic implants in adults.
of osseointegration.
In growing adolescents, caution must be taken when inserting the
The major advantages of implants include positional stability, intraoral
implants in the median suture zone as the maxilla is continuously expand-
placement (invisible) and independence from compliance. Furthermore,
ing in the transverse direction during normal growth. This transverse
when inserted in the palate for orthodontic anchorage, one implant
growth results from appositional remodeling of the alveolar processes,
can be sufficient, instead of two miniscrew implants (MIs) or two
leading to the expansion of the dental arches, and growth in the median
miniplates.
palatal suture, leading to expansion of the palate. The second contributes
An implant can be used for different purposes in orthodontics:
more to the development of maxillary width than does the first.7 An
■ orthodontic–prosthetic implant anchorage: the implant is first used average increase of 2.8 mm in maxillary width through median sutural
to provide orthodontic anchorage control, and then it is used to growth at the level of the molars was seen in radiographs between posterior
support a crown or bridgework2 implants for eight boys aged 10–18 years, with the largest increase between
■ pure orthodontic implant anchorage: the implant is used solely for 13 and 15 years.8 On the basis of morphology, the development of the
orthodontic purposes and is removed at the end of treatment3 median suture could be divided into three stages.9 In the first stage, the
■ orthopedic anchorage: skeletal anchorage is used to expand or suture is short, broad and Y-shaped; in the second stage the course is more
move bones in a certain direction, with the implant being removed sinuous, and in the third stage interdigitation is heavy. During adolescence,
at the end of treatment.4 the median palatal suture is in the second stage, and bone availability for
Where implants are removed after they have served orthodontic purposes, implant placement might be limited. The degree of obliteration of the
they are referred to as temporary anchorage devices.2 median palatal suture increases with age but is still very variable. Since
This chapter provides an overview of the different types of implants that orthodontic treatment is most often started during adolescence, it is impor-
can be used for skeletal anchorage in orthodontics, with a special focus tant to know if the insertion of palatal implants in the median suture might
on palatal implants. cause problems either through an influence on normal transverse maxillary
development or through insufficient bone to provide the required osseointe-
gration. An experimental study with dogs has shown that transverse maxil-
lary growth was reduced by the presence of implants and suggested that
IMPLANT TYPES an alternative insertion site should be considered in adolescents.10,11
Several studies have demonstrated that the parasagittal region can
Implants can be placed conventionally in the alveolar ridge or within the provide enough bone support to allow for adequate osseointegration of
palate. An important precondition for successful implant osseointegration palatal implants. In a more recent study, bone height and bone mineral
is a satisfactory bone base, with both bone height and bone mineral density density were assessed at different potential implantation sites for palatal
being factors affecting the success of implant osseointegration. implants.12 The thickest part of the palate was detected at (a) 3.0 mm
The main feature of conventional titanium endosseous dental implants posterior to the incisive foramen and at 6.0 mm distance lateral from the
is osseointegration to provide rigid three-dimensional anchorage control. median line of the palatine bone (paramedian); (b) 6.0 mm posterior to the
The implants can only be inserted in edentulous areas with adequate bone incisive foramen and at 6.0 mm distance paramedian; and (c) 6.0 mm
support. Since the implants behave like ankylosed teeth, they do not erupt posterior to the incisive foramen and at 9.0 mm distance paramedian. Bone
like normal teeth and the vertical development of the alveolar process is mineral density was greatest exactly on the midline at 6 mm, 9 mm and
restricted. Therefore, their indication is limited to partially edentulous and 12 mm posterior to the incisive foramen. Bone mineral density appeared
full-grown patients in order to avoid infra-occlusion of the implant during to correlate negatively with bone height.
the normal eruption of neighbouring teeth in growing patients.5 The indica- The optimal position of a palatal implant will be individual for each
tions are rather limited and they are rarely used for the treatment of Class patient. Analysis of the lateral cephalometric radiograph should be used to
II malocclusion. determine the optimal insertion site and the length of the implant to be

48
 The use of implants as skeletal anchorage in orthodontics 49

grown patient. Another disadvantage is the treatment complexity. Treat-

ment must be coordinated by multiple specialists (including a periodontist
or surgeon, a prosthodontist or restorative dentist, and an orthodontist).2 If
the restorative treatment plan involves a dental implant, it may be benefi-
cial to use the implant itself as anchorage for treating concomitant ortho-
dontic problems.19
Once the implant has been placed and after an appropriate healing
period of 3–4 months, no movement will occur because of osseointegra-
tion. Therefore, the exact position of all teeth after treatment must be
determined in a pretreatment set-up on casts to aid in the precise placement
of implant(s) prior to commencing treatment. This is difficult to do exactly
as tooth movements cannot be predicted with 100% precision and bone
morphology and bone biology vary between patients.20

ONPLANTS
The Onplant System is designed as an implant anchor for insertion in the
midpalatal region.18

Design
The Onplant is a two-stage subperiosteal implant. The device is a titanium
alloy disk (2 mm thick and 10 mm diameter) with a textured side opposing
bone that is coated with a 75 µm layer of hydroxyapatite (see Fig. 3.3).
The side facing soft tissue is smooth titanium alloy with a threaded hole
in the center into which abutments are placed.

Insertion Site and Surgical Procedures

Fig. 7.1 Lateral cephalometric radiograph showing a palatal implant inserted at
the level of the first premolars with a direction perpendicular to the palate. The Onplant is placed subperiosteally on the posterior aspect of the hard
palate with a “tunneling” procedure. A full-thickness mucoperiosteal inci-
sion is made on the anterior aspect of the hard palate and tunnels are
used (Fig. 7.1). As a general rule in adults, the median palatal suture at the reflected posteriorly. These tunnels allow the Onplant to be placed away
level of the first or second premolars is the most stable site for implant from the incision, thus reducing the potential for soft tissue inflammation,
insertion. In addition, short implants should be used. In adolescents, the which can prevent osseointegration. A healing screw is placed, and 10 to
paramedian region (3.0 to 6.0 mm lateral to the midline) at the level of the 12 weeks are allowed for osseointegration. After this healing period, the
first premolars is the area of choice. disk is exposed by a punch technique and a ball-shaped abutment is con-
However, for correction of a Class II, division 2 malocclusion by maxil- nected to which orthodontic devices can be attached. The abutment is
lary molar distalization and torquing of the maxillary anterior teeth, the designed to receive a 1.3 mm wire (see Fig. 3.2).
implant must be inserted even more distally in order to avoid possible root The main problems of this type of implant are that primary stability
contact with the central incisors when they are torqued. often cannot be achieved by mechanical retention and that clinical assess-
Several devices have been developed specifically for the palatal region: ment of integration is not easy.
the BIOS implant system (not commercially available, similar design and To remove the implant, osteotomes are used; removal of a large portion
dimensions as the ITI-Bonefit Screw Implant [Straumann, Waldenburg, of soft tissue is needed and might cause postoperative discomfort for the
Switzerland] but in biodegradable material),13 the Straumann Orthosystem patient.
(Straumann, Basel, Switzerland),14 the Frialit-2 Implant System (Friadent, There is only one study in which the success rates of onplants were
Mannheim, Germany),15 the Midplant system (HDC, Sarcedo, Italy),16 the evaluated.21 A group of 29 children (mean age 14.0 years) each had an
short epithetic implants (Brånemark, Nobel Biocare, Göteborg, Sweden)17 Onplant inserted. Orthodontic treatment comprised extraction of two
and the Onplant System (Nobel Biocare).18 maxillary premolars (in most cases, also two mandibular premolars) fol-
The Onplant System and the Straumann Orthosystem have been studied lowed by fixed appliances in both jaws. The Onplant provided additional
most extensively and, therefore, these types will be described in more indirect anchorage on the maxillary first molars. After the healing period,
detail in this chapter. The descriptions and clinical considerations are more one Onplant was still unstable and was removed. Another two were tilted
or less the same for all implant types that have been developed for palatal (although osseointegrated), and so it was not possible to take impressions
insertion. in order to fabricate the palatal bars. The success rate in this study,
defined by the authors as “suitable to provide stationary anchorage,” was
89.6%.
DENTAL IMPLANTS
While conventional titanium endosseous dental implants have been used
as sources of direct anchorage, there are some disadvantages in their
ORTHOSYSTEM IMPLANTS
use for orthodontic–prosthetic implant anchorage, mainly related to the The Orthosystem implants can be placed in areas of decreased bone height
requirement for an edentulous area with adequate bone support and a fully and so can be used as palatal anchorage.14 The implant may replace
 50 SECTION III: CLINICAL CONSIDERATIONS FOR THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

compliance-dependent extraoral anchoring aids for orthodontics and length. The 4.0 mm diameter implant is a replacement implant that can be
makes bonding and alignment of the mandibular dental arch for the appli- used if primary stability does not establish. The benefit of using longer
cation of Class II elastics unnecessary. (6.0 mm in length) implants was assessed in a study on human cadavers,
which indicated that quality of implantation and bone structure are more
important for stability than the length of the implant.22 When there is any
Design
doubt about the available bone height, shorter implants should be used
The fixture is designed for a one-stage application. The endosseous part (4.0 mm in length).
of the implant is cylindrical, has a self-tapping thread and is made of pure
titanium (Fig. 7.2). It has a diameter of 3.3 or 4.0 mm and a length of 4.0
Insertion Site and Surgical Procedures
or 6.0 mm. The implant has a sandblasted and acid-etched surface because
palatal implants are meant to osseointegrate in bone and the surface treat- The insertion site can be in the median or paramedian palatal region and
ment provides a larger contact area between the implant and the bone. provides anchorage in the maxilla.
There is an abutment above the polished transmucosal neck on which the The insertion procedure (Fig. 7.3) itself is relatively easy and fast when
desired suprastructure is soldered or laser welded. performed by an experienced surgeon.
Which size of implant should be used depends on cephalometric data. Under local anesthesia (palatine nerve on both sides and incisive
Usually, the 3.3 mm diameter implant is used, with 4.0 or 6.0 mm in nerve), the palatal mucosa is removed with the aid of the mucosa tre-
phine and an elevator. The implantation site is marked with a round bur
(diameter 2.3 mm) and the cortical bone is indented. The implant bed is
prepared using the corresponding profile drill. Drilling must be continued
Fig. 7.2 The Straumann Orthosystem
implant with a smooth transmucosal neck
until a complete seat is created, maximally to the stop. To prevent exces-
and a surface-treated endosseous part. sive heat build-up, the speed of rotation should not exceed 750 rpm. The
drills must be sharp and abundant external cooling of the drill with sterile
physiological saline or Ringer’s solution should be provided. The self-
tapping implant is inserted by hand as far as possible and if necessary a
ratchet can be used to tighten the implant into its final position. If there
is no primary stability of the implant, because of an enlarged implanta-
tion bed, the implant bed should be widened with a spiral drill (diameter
3.5 mm) so that a wider implant can be placed (4.0 mm diameter instead
of the standard 3.3 mm).
After implant insertion, a healing cap or a healing screw must be placed
on top of or in the implant (Fig. 7.3D). Postoperative check-ups are sched-
uled after 1 day, 1 week, 1 month and 2 months.
The first weeks after insertion, the patient must be instructed not to “play”
with the implant with the tongue, as this might destabilize the implant and
prevent proper osseointegration. A covering plate can be used for 2 months
after implant placement to prevent tongue pressure on it (Fig. 7.3E).

A B C

Fig. 7.3 Insertion of a palatal implant.

(A) Preparation of implant bed. (B) Insertion of
the palatal implant manually. (C) The implant
inserted. (D) Healing cap placed on the implant
immediately after insertion. (E) A covering
acrylic plate, which can be used to prevent
tongue pressure on the implant during the
healing phase.

D E
 The use of implants as skeletal anchorage in orthodontics 51

Fig. 7.4 Palatal mucosa immediately after implant removal

(A) and 3 months later (B).

A B

A B C D

Fig. 7.5 Impression procedure and construction of the suprastructure. (A) Placement of the transfer coping on the implant. (B) Inserting the analogue in the transfer
coping. (C) The steel coping placed on the analogue on the dental cast. (D) Fabrication of the suprastructure.

The implant should not be cleaned with a toothbrush up until the potentially harmful.22 A possible option is to remove the implant with a
seventh postoperative day, but the mouth should be rinsed three manual torque device by counterclockwise untightening. This is possible
times daily with a chlorhexidine digluconate solution. The implant when implants exhibit a stability of more than −5 periotest units (Periotest
may be cleaned carefully with a toothbrush from the eighth postoperative device; Periotest, Gulden, Germany).23 Fixtures showing stability values
day, and rinsing with chlorhexidine should be continued until day 14 equal to or less than −5 periotest units cannot be removed in this way and
(twice daily). After this, the implant is cleaned during normal tooth removal of the transmucosal part of the implant and sealing of the internal
brushing twice to three times daily using a normal toothbrush. In the screw hole is proposed in order to allow complete “creeping” mucosal
event of soft tissue inflammation around the implant, the mouth should covering of the implant.
be rinsed with chlorhexidine according to medical need. A healing period
of 10 to 12 weeks is most often advocated before orthodontic loading is
Impression Procedure and Construction of Suprastructure
started.
Since no findings on “sleeping orthodontic implants” have been pub- A healing period of 10 to 12 weeks is allowed before an impression is
lished to date, the implant should be retrieved after use. The orthodontic taken. During this time, the implant has sufficient time for osseointegra-
connection is removed and the implant is covered until explantation with tion. Successful implant integration can be concluded if (a) the patient has
a healing cap or a healing screw. Local anesthesia is administered as for no subjective symptoms, (b) there is no inflammation with suppuration
the implantation. Since implants osseointegrate, most often the implant around the implant, (c) there is a high-pitch sound on percussion and (d)
is removed together with the surrounding bone. There are two possible the implant is immobile.
options for reaching bone level with the explantation drill. The transmu- If no healing abutment was placed after implant insertion, mucosa might
cosal cylinder can be exposed by cutting around it with a scalpel (approxi- have grown over the borders of the transmucosal neck, preventing proper
mately 1 mm margin) and then removing the sleeve. Otherwise, the placement of an impression cap. In such a situation, a healing cap might
mucosa can be removed by the drill, set at approximately 400 rpm. Via be placed several days before the impression. This will remove the mucosa
the guiding cylinder, drilling is performed down to bone level while soft from the borders (Fig. 7.3D).
tissue remnants are rinsed away. Explantation proceeds at 400–700 rpm An impression cap or transfer coping is placed in position on the implant
accompanied by continuous cooling with precooled physiological saline (Fig. 7.5A). Then an impression is made and an analogue is placed in the
or Ringer’s solution. The bone should be trephined down to two-thirds of impression cap (Fig. 7.5B). A master cast is fabricated and the steel coping
the implant length. If the implant cannot be removed with extraction is placed on the analogue (Fig. 7.5C). The fabricated suprastructure (Fig.
forceps and gentle rotation, trephining must be continued to the mark cor- 7.5D) is welded or soldered to the steel coping. The steel coping with the
responding to the endosseous implant length. The implant is then removed. suprastructure can be fixed to the implant in the patient’s mouth with a
Simple wound management is indicated after explantation. No flap prepa- small screw.
ration or suturing is necessary. Healing of the palate after removal is There are few studies examining success rates with Orthosystem
uneventful in most patients. After 1 week, the palatal mucosa is usually implants, with values ranging from 90% to 95.4%.24–27 The largest study
closed and the original rugae are restored by 3 months after explantation was a retrospective analysis on prognostic parameters contributing to
(Fig. 7.4). palatal implant failures in which 11 of 239 Orthosystem implants that were
Post-orthodontic evaluation of paramedianly placed fixtures by means used for orthodontic anchorage purposes failed.27 The main conclusions of
of dental scans (General Electric, Milwaukee WI, USA) sometimes reveals the study were that implant losses occurred mainly early in the healing
a close contact between the well-osseointegrated fixture and the nasal phase, and that “surgeon’s experience” is the cornerstone of palatal implant
cavity or the adjacent teeth, making removal by trephine drilling success.
 52 SECTION III: CLINICAL CONSIDERATIONS FOR THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

A B C

Fig. 7.6 Connection of the transpalatal arch (TPA) to the teeth. (A) Sandblasting of TPA and tooth. (B) Etching of the second premolar with phosphoric acid. (C) TPA
bonded to the second premolar.

A B C

Fig. 7.7 Case presentation after extraction of the maxillary second premolars. (A) The transpalatal arch is connected initially to the first molars to reinforce anchorage for
the retraction of the anterior dental segment. (B) After anterior teeth retraction, the arch is connected to the first premolars, to protract the maxillary molars. (C) Lateral
view after treatment. (From Asscherickx et al.,25 with kind permission from Elsevier.)

CLINICAL INDICATIONS FOR PALATAL IMPLANTS

IN CLASS II TREATMENT

For the correction of Class II malocclusion, palatal implants can be used

to provide either direct or indirect anchorage.

INDIRECT ANCHORAGE
A transpalatal arch can be fixed to the implant and to the teeth (usually the
second premolar) to be used as anchorage unit.24 The arch can be attached
to the anchoring teeth by bonding with composite material (Fig. 7.6). Both
the transpalatal arch and the tooth are sandblasted. After etching, the tooth Fig. 7.8 Transpalatal arch connected to upper second premolars to provide
is rinsed and dried, and the adhesive is applied and light cured. With a stationary anchorage for mesial-out rotation and distalization of the maxillary first
flowable composite, the transpalatal arch is attached to the tooth to give a molars. (Courtesy of B. Van de Vannet.)
secure bonding that is both smooth and hygienic.
If the maxillary second premolar is extracted, the transpalatal arch can
DIRECT ANCHORAGE
be connected to the maxillary molars to support retraction of the maxillary
anterior segment. Once the anterior segment is retracted into a neutral Palatal implants can support an implant-anchored distalizer (IAD) in order
occlusion, a new transpalatal arch can be connected to the first premolars to distalize maxillary molars (Fig. 7.9). Once the molars have been distal-
to start mesialization of the molars (Fig. 7.7). This illustrates the versatility ized, the IAD can be made passive to keep the molars secure and stable
of the system. while retracting the premolars, the canines and the frontal dental segment.
If there is no extraction, the implant can be connected with a transpalatal Fig. 7.10 illustrates the use of the IAD for a slight Class II malocclusion
arch to the maxillary second premolars and coils can be used on the with lack of space in the maxillary arch. By using an IAD, treatment can
buccal side to distalize molars (Fig. 7.8). This type of distalization is be started in the maxillary arch only, with an almost invisible appliance.
indicated particularly when molars present an extreme mesial-in rotation Only after distalization of the maxillary posterior teeth fixed appliances
before orthodontic treatment. Once the maxillary molars are distalized are placed on both maxillary and mandibular arches to finish treatment.
into a Class I occlusion, a new transpalatal arch can be connected to the This substantially reduces treatment time with visible appliances, and
first molars to start distalization of the premolars and anterior teeth buccal tipping of the mandibular anterior teeth by Class II elastics can be
retraction. avoided.
 The use of implants as skeletal anchorage in orthodontics 53

A B C D

Fig. 7.9 The implant-anchored distalizer. (A,B) Clinical views. (C) Radiography showing the point of force application very near to the center of resistance of the first
molar and bodily movement. (D) Activation of the transpalatal arch of the implant-anchored distalizer with antirotation bends to prevent mesiopalatal rotation of the first
molars. (Implant-anchored distalizer designed by B. Vande Vannet and J. Aerts.)

A B C D

Fig. 7.10 Case presentation for use of the implant-anchored distalizer. (A) Lateral view before treatment. (B) Occlusal view after installation of the implant-anchored
distalizer. (C,D) Lateral (C) and occlusal (D) views after treatment. (Courtesy of J. Aerts.)

Important in this type of distalization is to make sure that the force score.28 A questionnaire assessment of 85 patients whose orthodontic treat-
application is at the level of resistance of the maxillary molars to ensure ment included the use of a palatal implant showed that most patients got
bodily movement during distalization. The point of force application is used to the implant in about 2 weeks, while 86% of the patients would
very near to the center of resistance of the first molar, which is located at recommend the treatment to others.29 This would suggest that the surgical
the bifurcation of its roots (Fig. 7.9C). steps should not be a good reason for the orthodontist to exclude palatal
Since the distalization force is applied on the palatal side of the center implants from a treatment plan.
of resistance of the molars, mesiopalatal rotation can occur. This side effect Another possible disadvantage of the use of osseointegrated implants
can be prevented by incorporating antirotation bends in the transpalatal is that a healing period is required. If carefully planned, this should not
arch (Fig. 7.9D). However, these bends might slow the distal movement be a problem. If extraction is part of treatment and the implant will
of the molars. support a palatal arch to anchor the posterior teeth, leveling of the teeth
can be accomplished during the healing phase of the implant and the
implant can be loaded when retraction is to be started. With an IAD, the
CONCLUSIONS patient has only a small healing abutment in the oral cavity during the
3 months before initiation of treatment. A randomized clinical trial
Palatal implants specially designed for orthodontic purposes can be of examined immediate loading of palatal implants compared with conven-
great benefit in the treatment of Class II malocclusion. Using these tional loading after a healing period of 12 weeks.25 Immediate loading
implants, stationary anchorage control can be obtained and better oral had equivalent success rates as conventional loading with 4 N after 6
hygiene can be achieved than with classical conventional anchorage means months. However, further follow-up of this group is necessary before a
such as the Nance button. general conclusion can be made that palatal implants can be loaded
A prospective randomized controlled clinical trial compared the anchor- immediately.
age capacity of osseointegrated and conventional anchorage systems.21 The problem of the higher cost cannot easily be solved. Major advan-
Anchorage loss was seen with headgear anchorage and transpalatal bar but tages of the palatal implants are that only one implant is necessary to
both the Onplant and the Orthosystem implant provided stable anchorage. provide sufficient anchorage control on both sides of the maxillary arch
There were more technical problems with the Onplant, resulting in more and that the success rate for palatal implants is relatively high, ranging
failures, and the system required additional surgery to place the abutment. from 90 to 95.4%. This might compensate partially for the high cost. When
The authors concluded that the Orthosystem palatal implant should be the MIs are used in the palate to support an intraoral distalization appliance,
anchorage of choice if maximum anchorage is required but the major usually two MIs are recommended and their success rate is not as high as
disadvantages were the requirement for minor surgery, the need for a that of palatal implants.
healing period and the extra cost. If maximum anchorage is required, anchorage reinforcement by the use
The need for minor surgery means that implants should be inserted by of palatal implants seems to be an ideal approach. The minor surgery
an experienced surgeon, requiring good communication between the needed for insertion (and removal) of the implants is well accepted by the
orthodontist and the surgeon.28 The pain associated with placement of a patients. The healing period needed before loading of the implants with
palatal Orthosystem implant and premolar extraction in adolescent patients orthodontic forces may not be needed but further studies are required to
was assessed using a visual analogue scale, with the latter having a higher support this consideration.
 54 SECTION III: CLINICAL CONSIDERATIONS FOR THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

17. Bernhart T, Freudenthaler J, Dortbudak O, et al. Short epithetic implants for ortho-
REFERENCES dontic anchorage in the paramedian region of the palate. A clinical study. Clin Oral
Implants Res 2001;12:624–31.
1. Roberts WE. Bone tissue interface. J Dent Educ 1988;52:804–9. 18. Block MS, Hoffman DR. A new device for absolute anchorage for orthodontics. Am
2. Kokich VG. Managing complex orthodontic problems: the use of implants for anchor- J Orthod Dentofacial Orthop 1995;107:251–8.
age. Semin Orthod 1996;2:153–60. 19. Heymann G, Tulloch C. Implantable devices as orthodontic anchorage: a review of
3. Mah J, Bergstrand F. Temporary anchorage devices: a status report. J Clin Orthod current treatment modalities. J Esthet Restor Dent 2006;18:68–80.
2005;39:132–6. 20. Smalley WM. Implants for tooth movement: determining implant location and orienta-
4. De Pauw GA, Dermaut L, De Bruyn H, et al. Stability of implants as anchorage for tion. J Esthet Dent 1995;7:62–72.
orthopedic traction. Angle Orthod 1999;69:401–7. 21. Feldmann I, Bondemark L. Anchorage capacity of osseointegrated and conventional
5. Thilander B, Ödman J, Gröndahl K, et al. Osseointegrated implants in adolescents: an anchorage systems: a randomized controlled trial. Am J Orthod Dentofacial Orthop
alternative in replacing missing teeth? Eur J Orthod 1994;16:84–95. 2008;133:339.
6. Wehrbein H, Merz BR, Diedrich P. Palatal bone support for orthodontic implant 22. Gedrange T, Hietschold V, Mai R, et al. An evaluation of resonance frequency analysis
anchorage: a clinical and radiological study. Eur J Orthod 1999;21:65–70. for the determination of primary stability of orthodontic palatal implants: a study in
7. Björk A, Skieller V. Growth in width of the maxilla studied by the implant method. human cadavers. Clin Oral Implants Res 2005;16:425–31.
Scand J Plast Reconstr Surg 1974;8:26–33. 23. Grognard N, van de Vannet B. Aspects in post-orthodontic removal of Orthosystem
8. Björk A, Skieller V. Growth of the maxilla in three dimensions as revealed radiographi- implants. Clin Oral Implants Res 2008;19:1290–4.
cally by the implant method. Br J Orthod 1977;4:53–64. 24. Bantleon HP, Bernhart T, Crismani A, et al. Stable orthodontic anchorage with palatal
9. Melsen B. Palatal growth studied on human autopsy material: a histologic microradio- osseointegrated implants. World J Orthod 2002;3:109–16.
graphic study. Am J Orthod 1975;68:42–54. 25. Crismani AG, Bernhart T, Schwarz K, et al. Ninety percent success in palatal implants
10. Asscherickx K, Hanssens JL, Wehrbein H, et al. Orthodontic anchorage implants loaded 1 week after placement: a clinical evaluation by resonance frequency analysis.
inserted in the median palatal suture and normal transverse maxillary growth in growing Clin Oral Implants Res 2006;17:445–50.
dogs: a biometric and radiographic study. Angle Orthod 2005;75:826–31. 26. Asscherickx K, van de Vannet B, Bottenberg P, et al. Clinical observations and success
11. Asscherickx K, Wehrbein H, Sabzevar MM. Palatal implants in adolescents: a histo- rates of palatal implants. Am J Orthod Dentofacial Orthop 2010;137:114–22.
logical evaluation in beagle dogs. Clin Oral Implants Res 2008;19:657–64. 27. Jung BA, Kunkel M, Göllner P, et al. Prognostic parameters contributing to palatal
12. Lai RF, Zou H, Kong WD, et al. Applied anatomic site study of palatal anchorage implant failures: a long-term survival analysis of 239 patients. Clin Oral Implants Res
implants using cone beam computed tomography. Int J Oral Sci 2010;2:98–104. 2012;23:746–50.
13. Glatzmaier J, Wehrbein H, Diedrich P. Die Entwicklung eines resorbierbaren Implan- 28. Feldmann I, List T, Feldmann H, et al. Pain intensity and discomfort following surgical
tatsystems zur orthodontischen Verankerung. Fortschr Kieferorthop 1995;56:175–81. placement of orthodontic anchoring units and premolar extraction: a randomized
14. Wehrbein H, Glatzmaier J, Mundwiller U, Diedrich P. The Orthosystem: a new implant controlled trial. Angle Orthod 2007;77:578–85.
system for orthodontic anchorage in the palate. J Orofac Orthop 1996;57:142–53. 29. Günduz E, Schneider-Del Savio TT, Kucher G, et al. Acceptance rate of palatal
15. Keles A, Erverdi N, Sezen S. Bodily distalization of molars with absolute anchorage. implants: a questionnaire study. Am J Orthod Dentofacial Orthop 2004;126:623–6.
Angle Orthod 2003;73:471–82.
16. Maino BG, Mura P, Gianelly AA. A retrievable palatal implant for absolute anchorage
in orthodontics. World J Orthod 2002;3:125–34.
 Orthodontic anchorage using a locking plate
and self-drilling miniscrew implants for the
8
posterior maxilla
Hideharu Hibi, Kiyoshi Sakai, Minoru Ueda and Masaru Sakai

anesthesia, two vertical incisions are introduced in the mucogingival junc-

INTRODUCTION
tion of the posterior maxilla, each 3 mm long and approximately 1 cm
Single miniscrew implants are typically used in the alveolus and palate apart (Fig. 8.2A,B). To tunnel these two incisions, the mucosa is suprape-
where bone quality and quantity are adequate to support them since they riosteally undermined with a mucosal elevator (Fig. 8.2C). The longitudi-
are only mechanically retained. However, in order to avoid complications, nal portion of the plate is inserted into the tunnel superiorly through the
the implant must be positioned within the attached mucosa and without lower incision wound and placed on the periosteum (Fig. 8.2D). Based on
any contact with the root surfaces of the underlying teeth. These require- the distance between the plate and the underlying bone, a 4 or 6 mm
ments restrict the location of insertion, inclination and dimensions of the miniscrew is inserted without pilot drilling into the bone through the
miniscrew implants. In contrast, miniplates are associated with fewer loca- opened upper incision wound and screwed and tightened through
tion restrictions, although their insertion requires a more complicated and the miniplate threaded hole (Fig. 8.2E). A second miniscrew is placed into
invasive procedure, as well as higher costs. the adjacent hole in the same manner, thereby providing complete stability
The use of miniplates as anchor devices is, therefore, particularly likely to the plate (Figs 8.3 and 8.4). A bending plier is used to adjust the external
for the treatment of Class II malocclusion when there is need for position- portion of the plate for appropriate orthodontic use (Fig. 8.2G). The
ing in the posterior maxilla, with only a thin bony wall, in order to retract wounds require no suturing and have almost healed after a week, with
the anterior teeth and/or for the treatment of open bite in order to intrude minimal postoperative morbidity. The miniplate can be loaded with ortho-
the maxillary molars. In this challenging environment, skeletally anchored dontic forces immediately after insertion, serving as a temporary ortho-
miniplates using conventional miniscrew systems may become unstable dontic anchorage device (Fig. 8.2H).
over time,1 whereas osteosynthetic systems with locking mechanisms
between the plates and the miniscrews provide more stability.2 This chapter
examines an effective method of using a locking plate and self-drilling INDICATIONS
miniscrew implant (Compact lock 2.0, Synthes Maxillofacial, PA, USA)
Patients undergoing this procedure should generally be healthy and have
for skeletal anchorage in the posterior maxilla.
no intrasinus lesions in the maxilla before placement of the anchorage
device. Radiopaque images should not show thickened mucosal lining or
retained fluid. In general, the anterior area of the infrazygomatic rim pro-
INSERTION TECHNIQUE
vides and represents the most adequate fixation site because its bony wall
This system has self-drilling screws of diameter 2.0 mm and L-shaped is thicker than 1.4 mm, which is regarded as the critical thickness for
miniplates that have five threaded holes, three to be used to secure the miniscrew implant stability.4
miniplate with miniscrew implants to the bone and two to be used for
application of orthodontic forces. The stabilization miniscrew implants can
be locked together with the miniplates via the threaded holes. ADVANTAGES
Prior to insertion, the L-shaped miniplate is bent into a “crank” form,
The advantages of using the current locking osteosynthetic system include:
but it remains straight across its longitudinal portion (Fig. 8.1). Under local
■ higher stability, owing to lower incidence of screw loosening5 and
solid frame construction of the miniplate and miniscrews2
Fig. 8.1 A prebent ■ faster wound healing and resistance to infection, owing to
miniplate and a self- supraperiosteal placement of the plate
drilling screw. (From
■ a wider range of indications for use.
Hibi et al. 20063 with
permission from Elsevier.) Additional advantages of the self-drilling miniscrews used include:
■ less contamination
■ shorter operating time
■ lower risk because a drill-free procedure is required for their
insertion
■ less miniplate movement because of the greater contact achieved
between the miniscrews and the miniplate.6

DISCUSSION

Commercially available skeletal anchoraged miniplates comprise one part

that is specially designed for orthodontic purposes (e.g. hooks or tubes to

55
 56 SECTION III: CLINICAL CONSIDERATIONS FOR THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

A B C D

E F G H
Fig. 8.2 Surgical steps. (A), Anterior area of the infrazygomatic rim adequate for screw fixation (hatch). (B) Two mucosal incisions approximately 3 mm long.
(C) Submucosal tunneling. (D) Longitudinal portion of the plate placed on the periosteum in the submucosal tunnel. (E) Self-drilling screws inserted through the upper
wound. (F) Plate locked with screws and stabilized. (G) External portion of the plate adjusted for orthodontic use with a bending plier. (H) Plate, ready for use as skeletal
anchorage.

Intrasinus lining membrane

Bony wall
Periosteum A B
Mucosa
Fig. 8.3 Skeletal anchorage combining a locking plate and self-drilling screw Fig. 8.4 Final stages of application. (A) The second screw is applied through the
system supraperiosteally applied to the frontal wall of the maxilla. (From Hibi et al. opened upper wound without drilling a pilot hole. (B) The external portion of the
20063 with permission from Elsevier.) plate is adjusted using a bending plier. (From Hibi et al. 20063 with permission
from Elsevier.)

allow application of orthodontic forces), and another conventional osteo-

synthetic part used for fixation on bone. The stability of these systems is The screws, miniplate and bone form a solid frame construction, which
affected by compression forces acting on the miniplate by the bone and results in significantly higher stability.2 This configuration eliminates the
the miniscrew heads, and thus the underlying bony surface under pressure need for a plate adaptation procedure for the bony surface and allows
may resorb over time.5 This resorption impairs miniplate stability and the supraperiosteal plate placement. Periosteal attachment has less postopera-
resulting unstable osteosynthesis may induce an inflammatory response tive morbidity and also preserves bone vascularity, which can facilitate
and promote infection.7 wound healing and infection resistance. Moreover, supraperiosteal appli-
In contrast, the locking miniplate and screw systems have a number of cation of the plate prevents bone apposition over the plate, which is rela-
positive features in addition to a lower incidence of screw loosening. The tively rare but is sometimes observed with traditional plates seated
threaded holes on the miniplates engage and finally stop the miniscrews subperiosteally on the bone. This phenomenon can cause complications,
in a fully seated position, and hence avoid any stripping of the bony hole. such as screw breakage, during removal.8
 ORTHODONTIC ANCHORAGE USING A LOCKING PLATE 57

Fig. 8.5 Plate and screw system applied to the maxillary wall.
(A) Conventional system. (B) Locking plate and self-drilling screw
system. (From Hibi et al. 20063 with permission from Elsevier.)

Periosteum

Plate
Bony wall
Intrasinus
lining membrane
A B

Fig. 8.6 Cone beam CT of membrane with or without the inner bony surface in a similar manner
acquired during to sinus elevation.9 This can facilitate thickening inward and outward over
follow-up, showing a
time (Fig. 8.6).
locking plate and
self-drilling screw applied Although the technique described, with two self-drilling miniscrews and
to the frontal maxillary a locking plate for anchorage, achieves higher and longer-lasting stability,
wall for skeletal the form of the external portion of the miniplate may not be adequate for
anchorage. Note that all possible orthodontic applications. In this sense, specially designed
bone thickening resulted
miniplates for orthodontic purposes may be more effective.
from a screw supporting
the tent of the lining
membrane similar to
maxillary sinus elevation. REFERENCES
(From Hibi et al. 20063
with permission from 1. Cheng SJ, Tseng IY, Lee JJ, et al. A prospective study of the risk factors associated with
Elsevier.) failure of mini-implants used for orthodontic anchorage. Int J Oral Maxillofac Implants
2002;19:100–6.
2. Gutwald R, Schön R, Metzger M, et al. Miniplate osteosynthesis with four different
systems in sheep. Int J Oral Maxillofac Surg 2011;40:94–102.
3. Hibi H, Ueda M, Sakai M, et al. Orthodontic anchorage system using a locking plate
and self-drilling screws. J Oral Maxillofac Surg 2006;64:1173–5.
4. Hibi H, Sakai K, Oda T, et al. Stability of a locking plate and self-drilling screws as
orthodontic skeletal anchorage in the maxilla: a retrospective study. J Oral Maxillofac
The use of self-drilling miniscrews ensures their primary stability and Surg 2010;68:1783–7.
eliminates various problems accompanying initial predrilling of pilot holes 5. Haug RH, Street CC, Goltz M. Does plate adaptation affect stability? A biomechanical
for self-tapping screws, particularly in regions of thin cortical bone (Fig. comparison of locking and nonlocking plates. J Oral Maxillofac Surg 2002;60:
1319–26.
8.5). Predrilling increases operating time, can cause thermal or mechanical 6. Kim JW, Ahn SJ, Chang YI. Histomorphometric and mechanical analyses of the drill-
damage to the bone and results in perforation of the membranous lining free screw as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2005;128:
of the maxillary sinus. Without prior disinfection of the inner membrane 190–4.
7. Ellis E, Graham J. Use of a 2.0-mm locking plate/screw system for mandibular fracture
surface, the returning pilot drill can carry microorganisms and contaminate surgery. J Oral Maxillofac Surg 2002;60:642–5.
the operating field. In contrast, the use of short self-drilling miniscrews 8. Cornelis MA, Scheffler NR, Mahy P, et al. Modified miniplates for temporary skeletal
enables the tips to remain under or within the membrane. If the screw tip anchorage in orthodontics: placement and removal surgeries. J Oral Maxillofac Surg
2008;66:1439–45.
does penetrate the membrane, the inherent one-step procedure minimizes 9. Le Gall MG. Localized sinus elevation and osteocompression with single-stage tapered
the risk of contamination. The self-drilling miniscrews may support a tent dental implants: Technical note. Int J Oral Maxillofac Implants 2004;19:431–7.
 9 Miniscrew implants for temporary skeletal
anchorage in orthodontic treatment
Moschos A. Papadopoulos and Fadi Tarawneh

grated and were difficult to remove after treatment. The second was from
INTRODUCTION
surgical miniscrews used to fix osteosynthesis plates and resulted in the
development of orthodontic MIs, designed for loading shortly after inser-
Anchorage, resistance to unwanted tooth movement, is a prerequisite for
tion and easy removal.
the orthodontic treatment of dental and skeletal malocclusions. Absolute
The first clinical use of miniscrews for absolute anchorage was the
or infinite anchorage is defined as no movement of the anchorage unit
treatment of a patient with a deep overbite using a vitallium bone-screw
(zero anchorage loss) as a consequence of the reaction forces applied to
inserted in the anterior nasal spine.3 A mini-implant specifically made for
move teeth. Such an anchorage can only be obtained by two means, using
orthodontic use was described in 19974 and a screw with a bracket-like
ankylosed teeth or using implants, both relying on bone for their
head in 1998.5 Since then, several types of MIs have been introduced, each
anchorage.
presenting different designs and features.
Currently, there are several skeletal anchorage devices that are used for
orthodontic purposes, for example orthodontic implants, palatal implants
or onplants, zygoma ligatures, zygoma anchors or miniplates, as well as
miniscrews, microscrews or miniscrew implants (MIs). COMPOSITION OF MINISCREW IMPLANTS
Miniscrew implants are small screw-type self-tapping implants, which
in contrast to conventional dental or orthodontic implants have smooth, With the exception of the Orthodontic Mini Implant (Leone, Firenze,
machine-polished surfaces and are designed to be loaded immediately after Italy), which is fabricated from SS, all other systems are manufactured
their insertion and removed easily after treatment (see Fig. 6.1). They carry from pure titanium or titanium alloys (medical type IV or type V titanium
special heads with or without holes to accommodate auxiliaries or wires alloy; see Chapter 5). While both materials are biocompatible, a layer of
for application of orthodontic forces (see Fig. 6.2). connective tissue is usually formed around SS implants while direct bone
The use of MIs to obtain absolute anchorage has become very popular contact and true osteogenesis occurs with pure titanium or titanium
since they provide a non-compliance approach for reinforcing anchorage, alloys.6,7 The rationale for using SS for MIs is that they are less prone to
ease of use and low cost.1 breakage and have less osseointegration than titanium devices. However,
Currently, there are a large number of commercially available MI a study comparing three different MIs, two SS and one titanium, concluded
systems for orthodontic use in the market (Table 9.1). that overall material performance of SS MIs was inferior to titanium MIs
because of their lower yield or tensile strength.7
Removal of MIs is more related to thread design, MI shape and the
TERMINOLOGY drill–screw diameter ratio.7
Titanium alloys are favored over pure titanium because of their higher
Terms such as mini-implant, miniscrew, microimplant and microscrew all strength, excellent corrosion resistance, biocompatibility and favorable
refer to devices with smaller dimensions than conventional dental implants mechanical properties.8,9
and that are removed following treatment; consequently, their use should
not be synonymous with conventional dental or orthodontic implants.
The terms orthodontic implant and mini-implant refer to systems that OSSEOINTEGRATION
require osseointegration in order to be retained in the bone, whereas mini­
screws to self-tapping devices that do not require osseointegration and are Osseointegrated implants are largely used for skeletal anchorage purposes
only mechanically retained.2 Other terms used to describe temporary as they remain stable under orthodontic loading.10 However, they do have
anchorage devices are intraoral or extradental anchorage systems, but the several disadvantages:11
Moyer’s Symposium in 2004 agreed that the term mini-implant should be
■ they cannot be immediately loaded with orthodontic forces since
applied to palatal implants, mini-implants, miniscrews and microscrews.2
several months are needed for proper osseointegration
Nevertheless, the term mini-implant should be restricted to small pros-
■ they require an invasive technique for both insertion and removal,
thetic implants of diameter larger than 2 mm that are osseointegrated and
which should be done by a surgeon
are used to stabilize removable prostheses.
■ there is always need for supraconstruction and laboratory work
The prefixes mini- and micro- are currently used in the literature to
■ they can only be inserted in edentulous areas (or in the palate) with
describe implants or screws of the same dimension without any differentia-
sufficient bone quantity and quality
tion. However, we advocate the use of the term miniscrew implant and
■ they are expensive.
this term is used throughout this textbook.
MIs were introduced in an attempt to avoid some of these problems. Their
osseointegration is less than half that of conventional dental implants.5,12
HISTORICAL DEVELOPMENT A histomorphometric examination of titanium MIs retrieved following
clinical use in alveolar bone found randomly organized osseointegration
Skeletal anchorage concepts in orthodontics developed from two areas. islets on the MI surfaces despite the smooth surface and immediate loading
The first was from osseointegrated dental implants to give orthodontic pattern of these implants, although it was associated with an extended
implants that were smaller but had similar surfaces and so also osseointe- period of retention (>6 months) (Fig. 9.1).13

58
 Miniscrew implants for temporary skeletal anchorage in orthodontic treatment 59

Table 9.1 Commonly used miniscrew implant systems

Product Company Address
Aarhus Anchorage System American 1714 Cambridge Av, Sheboygan, WI, USA (www.americanortho.com)
Orthodontics
AbsoAnchor System Dentos 258 BunJi, Dong-In Dong, Jung-Gu, Taegu, Korea (www.dentos.co.kr)
Ancotek system Tekka ZI de Sacuny, BP 82, 118 Ave Marcel Mérieux, 69530 Brignais, France (www.tekka.eu)
Benefit System PSM Medical Moltkestrasse 41, D-78532 Tuttlingen, Germany (distributed by Mondeal-PSM, North
Solutions America, PO Box 142, 49950 Jefferson St, Indio, CA 92201, USA) (www.psm.ms)
C-Implant Dentium 3105 Korea Trade Tower 159 Samsung-dong, Gangnam-gu, 135–729 Seoul, Korea
(www.implantium.com)
Cizeta Titanium Miniscrew Cizeta Surgical Via Caselle, 76 San Lazzaro di Savena, 40068 Bologna, Italy (www.cizetasurgical.it)
Dual-Top Anchor System Jeil Medical 775–3 Daesung B/D, Daelim 3 Dong Youngdeungpoku, Seoul, Korea
Corporation (www.jeilmed.co.kr); distributed by RMO Inc. PO Box 17085, Denver, CO 80217, USA
(www.rmortho.com)
IMTEC Mini Ortho Implant IMTEC Corporation 2401 N. Commerce, Ardmore, OK 73401, USA (www.imtec.com)
Infinitas Mini Implant System DB Orthodontics Ryefield Way, Silsden, BD20 0EF, UK (www.dborthodontics.co.uk)
Lin/Liou Orthodontic Mini PSM Medical Moltkestrasse 41, D-78532 Tuttlingen, Germany (www.psm.ms); distributed by
Anchorage Screw (LOMAS) Solutions Mondeal-PSM, North America, PO Box 142, 49950 Jefferson St, Indio, CA 92201, USA
Micro Implant Universal Stryker Corporation Stryker Leibinger Micro Implants, 750 Trade Centre Way, Portage, MI 49002, USA
Skeletal Anchorage System (www.stryker.com)
Miniscrew Anchorage System Micerium S.p.a. Via Marconi 83, 16030 Avegno, Italy (www.micerium.it)
(MAS)
OMI – Orthodontic Ancor OsteoMed 3885 Arapaho Rd Addison, TX 75001, USA (www.osteomed.com)
System
Orlus Ortholution 207 Dunchon B/D., 416–1, Seongnae-dong, Gangdong-gu, Seoul 134–844, South Korea
(www.ortholution.com)
Ortho Easy system Forestadent Westliche Karl-Friedrich-Str. 151, 75172 Pforzheim, Germany (www.forestadent.de)
Orthoanchor K1 System Dentsply Sankin Tokyo, Japan (www.dentsply-sankin.com)
Corporation
Orthodontic Mini-implant Ortholution Joongwon-gu, Seongnam-si, 462–725 Kyunggi-do, Korea (www.ortholution.com)
Orthodontic Mini Implant Leone S.p.A. Via P. a Quaracchi 50, 50019 Sesto Fiorentino, Florence, Italy (www.leone.it);
distributed by Leone America, 501 W. Van Buren, Avondale, AZ 85323, USA
Orthodontic screw KLS Martin Group Ludwigstaler Str. 132, 78532 Tuttlingen, Germany www.klsmartin.com)
Spider Screw Anchorage HDC Via dell’Industria 19, 36030 Sarcedo, Italy (www.hdc-italy.com)
System
Temporary Mini Orthodontic Dentaurum Turnstrasse 31, D-75228 Ispringen, Germany (www.dentaurum.de)
Anchorage System (TOMAS)
VectorTAS Ormco 1717 West Collins Ave, Orange, CA 92867, USA (www.ormco.com)

A B

Fig. 9.1 Secondary electron microscopy of miniscrew implants (MIs). (A) Unused MI. (B) Retrieved MI after >6 months inserted in alveolar bone, with integument in the
middle third of threaded area. (C) Higher magnification showing organized osseointegration islets on the surface of the retrieved MI. (From Eliades et al., 200913 with
permission.)
 60 SECTION III: CLINICAL CONSIDERATIONS FOR THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

Table 9.2 Available head designs of the miniscrew implants

Head Indications Coupling elements Advantages Disadvantages
Crossed-slot (bracket) Translation, space closure, Elastic chains. coil springs, Direct/indirect anchorage None
intrusion, extrusion, round/square/rectangular easily achieved; more than one
uprighting wires coupling element can be used;
easy orientation
Single slot (bracket) Translation, space closure, Elastic chains. coil springs, Square/rectangular wires can Orientation of slot important
intrusion, extrusion, round/square/rectangular be used; direct and indirect but could be compensated by
uprighting wires anchorage possible wire bending
Hook Translation, space closure, Elastic chains, coil springs, Coupling elements can be Orientation of hook is crucial;
intrusion round wires easily attached hook can be bent or broken;
indirect anchorage difficult
Button Translation, space closure, Elastic chains, coil springs, Coupling elements can be Indirect anchorage difficult to
intrusion round wires easily attached; orientation achieve
not needed
Hole Translation, space closure, Elastic chains, coil springs, Orientation of hole crucial
intrusion round wires

Since reduced osseointegration is advantageous for removal of MIs after wires; this is mostly used for direct anchorage. With this type of head,
clinical use, most are fabricated with smooth surfaces to achieve good three-dimensional control is not possible since square and rectangular
bone–implant contact but not osseointegration. wires cannot be used. Another disadvantage is the fact that MI heads
The quality and quantity of cortical bone is considered one of the most equipped with holes could be more at risk of fracture during their insertion
important factors for achieving mechanical stabilization and retention of or removal, since this might make the material around the head less rigid
MIs. Although a dense trabecular bone is desirable, cortical bone is more and weaker.
important for primary stability of MIs and this is directly related to its
thickness: the thicker the cortical plate the better the survival rate.14,15
NECK (COLLAR)
The transgingival neck (or collar) connecting the head to the body of
MINISCREW IMPLANT DESIGNS the MI is smooth and intended to form a non-irritant seal to protect
against inflammation and infection of the surrounding soft tissue (see
MIs are designed to provide both direct and indirect anchorage as well as Fig. 6.6).
to decrease tissue irritation. Chapter 6 discusses the significance of the Most common collar shapes are conical (tapering towards the body) or
various components of a MI – head, neck, endosseous body and thread, cylindrical but there are also polyangular collars.8,9 Depending on the
tip – in detail. insertion angle of the MI, pressure areas are formed on the soft tissue in
the area of the collar, which appears to be less in conical collars. The
diameter of collars is for most MIs identical to the threaded body but
HEAD
having the collar wider than the body, as in the top of a conical collar, is
The head of the MIs serves two important purposes; to apply torque to the advantageous in terms of providing a good seal between the MI and soft
thread during insertion and to act as a point for orthodontic force applica- tissue. Ideally, and in order to achieve the best possible seal and hygiene,
tion. Table 9.2 summarizes the different designs currently available, their the diameter of the head should also be smaller or equal to the collar.8,14
indications and coupling methods. The most frequently used shape is the However, most MIs have heads that are larger in width than the collar,
bracket-like design with a single or a double (crossed) slot (e.g. Aarhus which can create areas/undercuts that can be more difficult to clean and
Anchorage System, AbsoAnchor System, Ancotek system, Dual-Top easier for plaque to accumulate. Consequently, systems with MI heads
Anchor System, Ortho-Easy system, Spider Screw, Temporary Mini smaller in diameter than the collars (e.g. Spider Screw, the Ortho-Easy,
Orthodontic Anchorage System) as it can accommodate square and rec- Temporary Mini Orthodontic Anchorage System, AbsoAnchor systems)
tangular wires in its slot plus additional auxiliaries such as elastics and are advantageous. As gingiva width varies between 1 and 4 mm in differ-
ligatures. It can be used for direct and indirect anchorage for uprighting, ent locations in the oral cavity,8,9,16,17 systems that provide a variety of
intrusion, extrusion and mesial and distal translation. The use of rectangu- collars in their inventory are useful. Gingival thickness at the site of inser-
lar wires also allows for three-dimensional control in contrast to round tion should be measured before chosing the MI and this can only be done
wires, thus providing an important advantage over other designs. only after local anesthesia, delaying the selection until just before the
Other MI head shapes, such as the button-like, sphere, double sphere insertion procedure. This necessitates the orthodontist having a large range
and hook (Aarhus Anchorage System, AbsoAnchor System, Dual-Top of available MIs, which could be impractical in clinical practice. Fortu-
Anchor System, IMTEC Mini Ortho Implant, Lin/Liou Orthodontic Mini nately, the most popular sites for MI insertion are covered with 1–2 mm
Anchorage Screw, Miniscrew Anchorage System, Orthoanchor K1 System, gingiva, and MIs with a collar with 2 mm length are usually sufficient
Spider Screw) can be used for mesial and distal translation, space closure apart from for the palatal gingiva, which could reach 3–4 mm and requires
and intrusion, but attachment of square or rectangular wires is not possible a longer collar.8,9,16,17
and indirect anchorage is unattainable or very hard to achieve. Further-
more, correctly orientating the hook-shaped MI during insertion is crucial
for its use.
THREAD
One design has a hole or eyelet through the head (usually 0.6–0.8 mm The body of the MI is a threaded part that is inserted into the bone
in diameter), which can accept tension springs, elastic chains and round (Fig. 9.1A). The body’s primary function is the retention of the MI in the
 Miniscrew implants for temporary skeletal anchorage in orthodontic treatment 61

bone initially after insertion (primary stability) and afterwards during part. In general, it is considered that the longer the MI the higher the
orthodontic force loading (secondary stability), and its shape and design success rate.28,29
can influence the stability of the MI as well as the force (torque) needed Miniscrew implants are usually provided with lengths ranging from 4.0
for insertion and removal. The body can be either conical (e.g. Aarhus to 12.0 mm, although some of them are also available in larger lengths up
Anchorage System, AbsoAnchor System, Miniscrew Anchorage System) to 21 mm. The choice of length is determined by the depth and quality of
or cylindrical (e.g. the Orthodontic Mini Implant) (see Fig. 6.3). The thread bone, the MI angulation, the soft tissue thickness and the adjacent vital
design can be a uniform helix rotating either clockwise or counterclock- structures.26 Based on hard and soft tissue depths in 20 patients, MIs of
wise with fixed helix angles and pitches or it can be a dual-thread design 4–6 mm in length were considered safe in most regions, but individual
formed by two different helixes with different angles and pitches in the patient variations dictate individual evaluation of bone depth before
thread (see Fig. 6.13).18,19 The thread design can influence the bone– surgery.5 Although MIs of 6–8 mm have been recommended by most
implant contact, the stress load of the bone and the insertion and removal authors,5,8,9,30 MIs shorter than 8 mm are more susceptible to failure26,31 and
torque.8,9,18,19 An ideal MI body shape should allow for a high insertion longer MIs with small diameter can be more prone to breakage and bending.
torque that would sustain the MI, but at the same time not damage bone In this regard, longer MIs should also be thicker in diameter, but anatomical
and cause necrosis, and also allow a high enough removal torque to avoid limits restrict the use of very long and thick MIs in clinical practice.
unwanted pullout but at the same time facilitate MI removal without The length of MIs has less effect than diameter on the distribution of
complications. stress, and the majority of the load is borne within the cortical bone.9 The
Conical MI threads have been shown to have an increasing insertion force above which implant length and implant diameter are statistically
torque compared with cylindrical threads, which require less torque, and significant in influencing implant stability was found to be 1 N.21 At low
a more constant torque, throughout the insertion procedure.7,18,19–23 This force (0.5 N), no statistically significant difference in displacement accord-
makes cylindrical MIs more desirable for insertion, minimizing the risk of ing to implant length and implant diameter was observed. However, at
bone necrosis, but their higher removal torque makes them more prone to high force (2.5 N), MIs of 9 mm length displaced significantly less than
fracture. Dual-thread MIs also have a high insertion torque but with a the 7 mm MIs, and the 2 mm wide MIs displaced significantly less than
gentler increase in comparison with conical MIs.18 their 1.5 mm wide counterparts.21 Further, insertion and removal torques
seem to be higher in long MIs.32
The thickness of soft tissue at the insertion site should also be taken
DIAMETER into consideration when choosing the appropriate length of MI. Thick
The diameter of the MIs is a significant factor that may influence (a) the gingival tissue sites demand longer MIs. In general, MI lengths of
possibility of injuring the neighboring roots when inserted inter-radicularly, 6–8 mm are recommended for use in the mandible and of 8–10 mm in
(b) the tendency for breakage, and (c) success/failure rates. Chapter 6 the maxilla. Nonetheless, individual patient variations in soft tissue
discusses in detail the effect of diameter on these issues. Essentially, and cortical bone thickness should be considered prior to insertion of
smaller-diameter MIs have less risk of root contact but a greater risk of any MI.8,9
fracture, while it is more difficult to achieve an optimal placement torque
for good primary stability with narrower MIs. Based on success rates,
1.2 mm can be considered the minimum diameter required to achieve MODE OF INSERTION
adequate implantation success.2,7,24–26 Diameters of 1.5 mm and 1.6 mm
represent a satisfactory compromise. All types of MI are self-tapping/self-cutting. The term self-tapping relates
In clinical practice, however, the use of MIs of larger diameter for inser- to the ability of a screw to create a thread as it advances into the bone.
tion inter-radicularly can be very difficult to accomplish without the risk This is sometimes achieved by having a cutting flute, a groove in the
of injuring adjacent roots, particularly when the roots are close to each thread, that drills away the material to make the hole for the screw.
other. In such circumstances, the choice of insertion site should be recon- Some MIs require a pilot drill before their insertion (non-self-drilling
sidered, which may mean adjusting the force application system and apply- MIs), while others have a fine tip that enables their direct insertion into
ing appropriate orthodontic biomechanics to achieve the required result bone (self-drilling MIs). The diameter of a pilot drill is preferably
for the new chosen site of insertion. This is not an issue for palatal inser- 0.2–0.3 mm thinner than the diameter of the MI thread, otherwise inser-
tion, where larger-diameter MIs can be used, eliminating the risk of both tion torque values are significantly decreased and MI primary stability is
MI fracture and root damage. Careful clinical and radiological examina- reduced.8,33,34 Although the length of the pilot drill is determined by the
tion, preparation and measurement to plan the insertion site and the MI length of the selected MI, deeper holes decrease insertion torque and so
diameter before insertion will minimize the risk of breakage failure. it is recommended that drills with depth markings and depth stops should
Stress distribution within bone is affected by the diameter of MIs. In be used.8,34 Occasionally, a pilot drill is needed even for a self-drilling
cortical bone, the thicker the MI diameter, the more favorable the stress MI; such as in cases where the cortical bone is thicker than 2 mm, as
distribution.9,27 Three-dimensional finite element analysis has shown that dense bone would eventually bend the fine tip of the MI.
a 1.4 mm diameter implant placed in 1.2 mm thick cortical bone can toler- Self-drilling MI systems include the Aarhus Anchorage System, the
ate 150 g of orthodontic forces, while a 1.8 mm diameter implant can AbsoAnchor System, the Dual-Top Anchor System and the Lin/Liou
tolerate 350 g of orthodontic forces.9 Therefore, the planned orthodontic Orthodontic Mini Anchorage Screw, while Spider Screw offers both non-
forces should also be taken into consideration when selecting the appropri- self-drilling and self-drilling MIs.
ate MI diameter. The advantage of the self-drilling over non-self-drilling MIs is the
elimination of the pilot drilling step during insertion, which makes the
whole procedure less invasive, less time consuming and more easily
LENGTH accepted by the patient, particularly to young patients and their parents.
Length generally refers to the threaded portion of the MI rather than the In addition, since the insertion of the self-drilling MIs is less complicated,
entire head-to-tip length but care needs to be taken with catalogues to they can be easily inserted by orthodontists themselves without requiring
check that total length is not given. Here lengths refer to the threaded referral to a surgeon.
 62 SECTION III: CLINICAL CONSIDERATIONS FOR THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

Fig. 9.2 Anchorage. (A) Direct anchorage for the intrusion of a

maxillary central incisor. (B) Indirect anchorage for the mesialization
of a mandibular second molar after first molar extraction.

A B

Table 9.3 Advantages and disadvantages of direct and indirect LOADING

anchorage
Type Advantages Disadvantages
Some authors have suggested a waiting period of 1 to 2 weeks before
loading with orthodontic forces but most agree that, since in contrast to
Direct Simple mechanics Load applied directly to implant
Easy to apply may cause mobility or loss dental implants MIs are mechanically retained in bone sufficiently, they
No dental anchorage loss Should be monitored closely as can sustain immediate light orthodontic loading without compromising
mechanics used are not fail-safe their clinical stability.5,35,36 Only a few studies, mostly on animals, have
Placement site for direct
anchorage not always investigated tissue reaction to immediate loading of MIs; all suggest that
achievable or possible immediate loading with orthodontic forces can be performed without any
Indirect Less load applied to Loss of anchorage in the complications.14,37,38
implant anchorage teeth group is
A finite element analysis found that immediate loading should be limited
Fail-safe mechanics possible
Placement site usually More complicated mechanics and to 50 cN for a 2 mm diameter MI.39 One clinical study of 134 titanium
easy and preferable installment MIs concluded that immediate loading is possible if the applied force is
less than 200 cN,14 which is in agreement with a study showing no associa-
tion between success rates of MIs and the mode of loading.40 This study
concluded that vertical forces seem to be responsible for more failures than
TYPES OF ANCHORAGE horizontal forces.40
The ability of MIs to provide absolute anchorage was shown in a study
Miniscrew implants can provide two different types of anchorage: direct measuring anchorage loss with the use of MIs and conventional molar
and indirect. When used for direct anchorage, MIs directly receive the anchorage for canine retraction.41 A meta-analysis has shown that the use
reactive forces used to move the teeth by acting themselves as an anchor of MIs significantly decreased or negated loss of anchorage, particularly
unit (Fig. 9.2A). In indirect anchorage, MIs are connected through bars or when compared with other conventional orthodontic means such as head-
wires to the teeth of the reactive unit supporting their anchorage (Fig. gears, transpalatal arches or other biomechanical force systems.42
9.2B). However, it is questionable if MIs remain stationary throughout their
Special considerations should be given to the design of the MI head and period of loading. In some patients, MIs were shown to move under ortho-
the placement site for the type of anchorage to be used. Different head dontic loading,43 and it is, therefore, advised to allow 2 mm of safety
designs are more suitable for one type of anchorage over the other, while clearance between the MI and dental roots of the adjacent teeth.
placement site could play a major role in determining the type of anchor-
age. Advantages and disadvantages of direct and indirect anchorage are
summarized in Table 9.3.
COMPLICATIONS

Complications associated with the use of MIs include inflammation, infec-

PROPERTIES OF THE MINISCREW IMPLANTS tion and tissue irritation, injuries to adjacent structures, and failure or
fracture of the MI during insertion or removal.44
Currently available MIs vary in their material, diameter and length of
threaded portion, design of the head, the existence of a collar and the
method of insertion. An ideal MI used for orthodontic anchorage should INFLAMMATION, INFECTION AND TISSUE IRRITATION
present some specific properties and characteristics:
Inflammation and irritation of the tissues around the MI site might occur,
■ fabricated from a biocompatible material although infection is not generally noted (Fig. 9.3). Meticulous oral
■ provided in different diameter and length sizes hygiene maintained around the MI and the use of 0.2% chlorhexidine
■ available in different designs (i.e. button or bracket head) mouth rinses or dental floss dipped in 2% chlorhexidine can help to avoid
■ self-tapping and self-drilling inflammation or infection, or control any that might occur.44 If a patient
■ easily and safely inserted in various sites without complicated and presents with purulence, palor or inflammation, definitive management
invasive approaches with an appropriate antibiotic is indicated.
■ immediately loaded The risk of tissue inflammation is lessened if the MIs are inserted into
■ removed without the need for complicated accessory equipment or keratinized attached gingiva avoiding areas of frenum, muscle tissues and
invasive approaches mobile mucosa (non-attached gingiva).14,26,45 Hypertrophy of mucosa cov-
■ inexpensive (cost beneficial). ering an implant may occur as a complication of placing the MI in
 Miniscrew implants for temporary skeletal anchorage in orthodontic treatment 63

A B C

Fig. 9.3 Inflammation around a miniscrew implant inserted in the palate for the correction of the crossbite of the maxillary left second molar. (A) Immediately after
insertion. (B) Presence of inflammation. (C) After removal of the implant.

non-keratinized gingiva. With such a placement, a healing cap abutment clinical success or failure and many authors define failure in a general way
is recommended at the time of insertion. Alternatively, the mucosa could as a state where a MI is not clinically usable.
be allowed to cover the MI head if there is an attached wire or an auxiliary According to Melsen,52 the insertion angle should be kept stable during
that emerges into the oral cavity passing through the mucosa.44 insertion, and the threaded part should be inserted totally into bone in order
to avoid MI failures.
Orthodontic loading may also affect the success of MIs. The magnitude
INJURIES TO ADJACENT STRUCTURES and direction of force applied to MIs is one of the most important factors
The incidence of root injuries caused by trans-alveolar MIs used for tem- associated with MI failure. Loading with orthodontic forces applied per-
porary intermaxillary fixation of fractured mandibles is very low46 and it pendicular to the long axis of the MIs is preferable;54 the strain obtained
could be assumed that the incidence of root damage using MIs for ortho- by loading a MI perpendicular to its long axis with 50 cN was shown to
dontic anchorage would be even lower as they are inserted after careful lead to loss of primary stability when the cortex is 0.5 mm or smaller.55
planning rather than as an emergency situation. Further, if a MI is used indirectly with a cantilever to a bracket-like head,
Nonetheless, injuring of the adjacent roots, periodontal ligaments, the clinician should avoid the application of moments around the MI long
nerves and blood vessels could occur during MI insertion and is usually axis in a counterclockwise direction since it could unscrew the MI, which
indicated by symptoms such as pain on percussion and mastication, or, in can lead to loosening and failure.54
cases of root injury, sensitivity to hot and cold.47,48 Under such circum- Cortical bone thickness is a significant factor in that greater thickness
stances, the MI should be removed immediately. supports better success rates but can have negative effects through greater
The prognosis of an injured tooth will depend on whether there has chance of MI fractures, overheating and necrosis. A clinical cortical bone
been injury to the pulp. Histological examination of roots of teeth that thickness threshold of 1 mm increased success rate.20
had been damaged by MI placement demonstrated an almost complete A MI diameter below 1.3 mm should be avoided,14,24,25 and longer
repair of the periodontal structures 12 weeks after removal of the MIs.49,50 lengths tended to give higher success rates (see above).28
Only in severe injury with displacement of root fragments ankylosis of Patients with high mandibular plane angles may not be suitable candi-
the lamina dura was noted. External root resorption in response to root dates for MIs because they often have thin cortical bone, while statistically
injury, as well as evidence of inflammatory infiltrate or necrosis in the significant higher success rates have been found in patients with a deep
pulp tissue or on the injured root surfaces, was not found in any of the bite.14,40 Success rates for white patients were found to be higher than for
injured teeth.49,50 Asian patients40 but there was no effect of gender apart from a general
willingness to cooperate with treatment that was better for girls than
boys.20 Some studies have also correlated age with success rates, as failure
FAILURE OF MINISCREW IMPLANTS rates were reportedly higher in adolescents than in adults.26,56
Although it is still not clear what precisely affects the success and failure Placement in attached/keratinized gingiva has been associated with
rates of MIs, some factors have been identified:51 higher success rates of MIs,14,26,40,45 while root proximity has been reported
as a major risk factor for MI failure.57
■ patient-related factors, e.g. sex, gender, malocclusion, oral hygiene
A recent meta-analysis has found that MI failure was not associated with
■ clinician-related factors, e.g. experience, learning curve
patient gender, age and insertion site but was significantly associated with
■ MI-related factors, e.g. length, diameter, thread design
jaw of insertion, insertion torque, cortical bone thickness and root contact.51
■ insertion-related factors, e.g. cortical bone thickness, cortical
No definitive conclusion could be drawn for the other factors discussed
notching, flap surgery, insertion torque, insertion angle
above. However, more MI failures were observed in the posterior region
■ treatment-related factors, e.g. loading time, tooth movement
than the anterior in the maxilla and more failures lingually than buccally
■ outcome-related factors, e.g. inflammation, mobility.
in the mandible. Orthodontic MIs overall presented a modest small mean
A MI can be lost or become loose through various factors such as inflam- failure rate of 13.5%, indicating their usefulness in clinical practice.51
mation (Fig. 9.3), improper placement, inadequate cortical bone at the
chosen site or operator inexperience.47 Based on current evidence, the
quality and quantity of the available bone at the insertion site are consid-
FRACTURE OF MINISCREW IMPLANTS
ered as the most important factors affecting primary stability of MIs. Fracture of MIs may occur during their insertion or their removal if ones
Although most studies have reported success rates of more than 80%,20,28,41,52 of small diameter are employed (<1.2 mm) or if the collar is too narrow
or a failure rate of about 16%,53 there is no consensus about how to define (≤1.3 mm) or is equipped with holes.8,45
 64 SECTION III: CLINICAL CONSIDERATIONS FOR THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

If a MI has to be inserted into high bone density, predrilling should be ■ they can be easily removed
carried out to minimize the risk of fracture. ■ they present reasonable cost relative to other conventional methods
If a MI fractures during insertion, the shaft might need to be removed used for anchorage, while being much cheaper than orthodontic
with a trephine and a new site should be selected for insertion of a fresh implants.
MI. The disadvantages are
■ if no proper attention is given during insertion, damage of the
CLINICAL APPLICATIONS OF MINISCREW IMPLANTS adjacent tissues or root injuries might occur
IN ORTHODONTICS ■ irritation, inflammation of the peri-implant tissues, and consequent
failure of the MI is possible, particularly in patients presenting poor
In general, the various MI systems can be used when dental elements lack oral hygiene
quantity or quality, such as periodontally involved teeth and partial eden- ■ when an oral surgeon is involved for their insertion (mainly when
tulism, as well as when there is a necessity to undertake tooth movements predrilling is required), there is an additional cost and increased
and minimizing or completely neutralizing undesired side effects of the stress to the patient.
reactive forces.58
Melsen suggested using MIs as anchorage for tooth movements that
could not otherwise be achieved, such as in patients with insufficient REFERENCES
number of teeth for the application of conventional anchorage, where the
1. Papadopoulos MA, Tarawneh F. The use of miniscrew implants for temporary skeletal
forces on the reactive unit would generate adverse side effects, in patients anchorage in orthodontics: a comprehensive review. Oral Surg Oral Med Oral Pathol
with a need for asymmetrical tooth movements in all planes of space, and Oral Radiol Endod 2007;103:e6–15.
as an alternative to orthognathic surgery.44 2. Carano A, Melsen B. Implants in orthodontics. Prog Orthod 2005;6:62–9.
3. Creekmore TD, Eklund MK. The possibility of skeletal anchorage. J Clin Orthod
In general, MIs can be used to support anchorage of anterior or posterior 1983;17:266–9.
teeth; for mesialization or distalization of teeth; for intrusion, extrusion 4. Kanomi R. Mini-implant for orthodontic anchorage. J Clin Orthod 1997;31:763–7.
and uprighting; and for palatal expansion and interarch coordination.8,9 5. Costa A, Raffaini M, Melsen B. Miniscrews as orthodontic anchorage: a preliminary
report. Int J Adult Orthodon Orthognath Surg 1998;13:201–9.
More specifically, MIs have been used for the correction of deep or open 6. Christensen FB, Dalstra M, Sejling F, et al. Titanium-alloy enhances bone-pedicle
bite, closure of extraction spaces, correction of a canted occlusal plane, screw fixation: mechanical and histomorphometrical results of titanium-alloy versus
alignment of dental midlines, extrusion of impacted canines, extrusion and stainless steel. Eur Spine J 2000;9:97–103.
7. Carano A, Lonardo P, Velo S, et al. Mechanical properties of three different commer-
uprighting of impacted molars, molar intrusion, maxillary molar distaliza- cially available miniscrews for skeletal anchorage. Prog Orthod 2005;6:82–97.
tion, distalization of mandibular teeth, en masse retraction of anterior teeth, 8. Ludwig B, Baumgaertel S, Bowman J. Mini-implants in orthodontics: Innovative
molar mesialization, maxillary third molar alignment, intermaxillary anchorage concepts. Hanover Park, IL: Quintessence; 2008.
9. Lee J, Kim J, Park Y, et al. Applications of orthodontics mini-implants. Hanover Park,
anchorage for the correction of sagittal discrepancies and for correction of IL: Quintessence; 2008.
vertical skeletal discrepancies that would otherwise demand orthognathic 10. Bantleon HP, Bernhard T, Crismani AG, et al. Stable orthodontic anchorage with
surgery.8,9,37,59–61 palatal osseointegrated implants. World J Orthod 2002;3:109–16.
11. Fritz U, Ehmer A, Diedrich P. Clinical suitability of titanium microscrews for ortho-
dontic anchorage: preliminary experiences. J Orofac Orthop 2004;65:410–18.
12. Vande Vannet B, Sabzevar MM, Wehrbein H, et al. Osseointegration of miniscrews:
CONCLUSIONS a histomorphometric evaluation. Eur J Orthod 2007;29:437–42.
13. Eliades T, Zinelis S, Papadopoulos MA, et al. Characterization of retrieved orthodontic
miniscrew implants. Am J Orthod Dentofacial Orthop 2009;135:10.
In summary, MIs present several advantages and some disadvantages when 14. Miyawaki S, Koyama I, Inoue M, et al. Factors associated with the stability of titanium
used for orthodontic anchorage reinforcement. screws placed in the posterior region for orthodontic anchorage. Am J Orthod Dento-
The advantages are: facial Orthop 2003;124:373–8.
15. Stahl E, Keilig L, Abdelgader I, et al. Numerical analyses of biomechanical behavior
■ their insertion and removal does not require any particular surgical of various orthodontic anchorage implants. J Orofac Orthop 2009;70:115–27.
16. Costa A, Pasta G, Bergamaschi G. Intraoral hard and soft tissue depths for temporary
procedures, in contrast to other means available, such as orthodontic anchorage devices. Semin Orthod 2005;11:10–15.
implants, miniplates and onplants, which require flap surgery 17. Chaimanee P, Suzuki B, Suzuki EY. “Safe zones” for miniscrew implant placement
■ they can be easily inserted chair-side in one appointment, usually by in different dentoskeletal patterns. Angle Orthod 2011;81:397–403.
18. Hong C, Lee H, Webster R, et al. Stability comparison between commercially avail-
the orthodontist him or herself able mini-implants and a novel design. Angle Orthod 2011;81:692–9.
■ there is no need for complicated clinical and laboratory procedures 19. Lim SA, Cha JY, Hwang CJ. Insertion torque of orthodontic miniscrews according to
(fabrication of acrylic resin splints through taking imprints with changes in shape, diameter and length. Angle Orthod 2008;78:234–40.
20. Motoyoshi M, Yoshida T, Ono A, et al. Effect of cortical bone thickness and implant
additional implant copying systems to accurately transfer the placement torque on stability of orthodontic mini-implants. Int J Oral Maxillofac
implant position to the cast models) in order to facilitate safe and Implants 2007;22:779–84.
precise implant insertion 21. Chatzigianni A, Keilig L, Reimann S, et al. Effect of mini-implant length and diameter
on primary stability under loading with two force levels. Eur J Orthod 2011;33:
■ they can be immediate loaded (there is no need for a waiting period 381–7.
for osseointegration, in contrast to orthodontic implants), which 22. Siegele D, Soltesz U. Numerical investigation of the influence of implant shape on
reduces the total treatment time stress distribution in the jaw bone. Int J Oral Maxillofac Implants 1989;4:333–40.
23. Kim JW, Baek SH, Kim TW, et al. Comparison of stability between cylindrical and
■ they offer a great variety of possible locations for insertion, in conical type mini-implants: mechanical and histological properties. Angle Orthod
contrast to conventional dental implants used for orthodontic 2008;78:692–8.
anchorage, which require edentulous areas 24. Wilmes B, Ottenstreuer S, Su YY, et al. Impact of implant design on primary stability
of orthodontic mini-implants. J Orofac Orthop 2008;69:42–50.
■ they provide absolute anchorage, which eliminates any undesirable 25. Wilmes B, Rademacher C, Olthoff G, et al. Parameters affecting primary stability of
effects on the teeth that otherwise would have been normally used orthodontic mini-implants. J Orofac Orthop 2006;67:162–74.
as anchorage 26. Reynders R, Ronchi L, Bipat S. Mini-implants in orthodontics: a systematic review
of the literature. Am J Orthod Dentofacial Orthop 2009;135:564.
■ patient cooperation is limited to maintaining an immaculate oral 27. Gallas MM, Abeleira MT, Fernandez JR, et al. Three-dimensional numerical simula-
hygiene tion of dental implants as orthodontic anchorage. Eur J Orthod 2005;27:12–16.
 Miniscrew implants for temporary skeletal anchorage in orthodontic treatment 65

28. Chen CH, Chang CS, Hsieh CH, et al. The use of microimplants in orthodontic anchor- 46. Fabbroni G, Aabed S, Mizen K, et al. Transalveolar screws and the incidence of dental
age. J Oral Maxillofac Surg 2006;64:1209–13. damage: a prospective study. Int J Oral Maxillofac Surg 2004;33:442–6.
29. Berens A, Wiechmann D, Dempf R. Mini- and micro-screws for temporary skeletal 47. Melsen B, Verna C. Miniscrew implants: The Aarhus Anchorage System. Semin
anchorage in orthodontic therapy. J Orofac Orthop 2006;67:450–8. Orthod 2005;11:24–31.
30. Poggio P, Incorvati C, Velo S, et al. Safe zones: a guide for miniscrew positioning in 48. Maino BG, Mura P, Bednar J. Miniscrew implants: The Spider Screw Anchorage
the maxillary and mandibular arch. Angle Orthod 2006;76:191–7. System. Semin Orthod 2005;11:40–6.
31. Chen Y, Kyung HM, Zhao WT, et al. Critical factors for the success of orthodontic 49. Renjen R, Maganzini AL, Rohrer MD, et al. Root and pulp response after intentional
mini-implants: a systematic review. Am J Orthod Dentofacial Orthop 2009;135: injury from miniscrew placement. Am J Orthod Dentofacial Orthop 2009;136:
284–91. 708–14.
32. Kim YK, Kim YJ, Yun PY, et al. Effects of the taper shape, dual-thread, and length 50. Asscherickx K, Vannet BV, Wehrbein H, et al. Root repair after injury from miniscrew.
on the mechanical properties of mini-implants. Angle Orthod 2009;79:908–14. Clin Oral Implants Res 2005;16:575–8.
33. Uemura M, Motoyoshi M, Yano S, et al. Orthodontic mini-implant stability and the 51. Papageorgiou SN, Zogakis IP, Papadopoulos MA. Failure rates and associated risk
ratio of pilot hole implant diameter. Eur J Orthod 2012;34:52–6. factors of orthodontic miniscrew implants: a meta-analysis. Am J Orthod Dentofacial
34. Baumgaertel S. Predrilling of the implant site: Is it necessary for orthodontic mini- Orthop 2012;142:577–95.
implants? Am J Orthod Dentofacial Orthop 2010;137:825–9. 52. Schätzle M, Männchen R, Zwahlen M, et al. Survival and failure rates of orthodontic
35. Ohashi E, Pecho OE, Moron M, et al. Implant vs. screw loading protocols in ortho- temporary anchorage devices: a systematic review. Clin Oral Implants Res
dontics: a systematic review. Angle Orthod 2006;76:721–7. 2009;20:1351–9.
36. Buchter A, Wiechmann D, Koerdt S, et al. Load-related implant reaction of mini- 53. Wiechmann D, Meyer U, Buchter A. Success rate of mini- and micro-implants used
implants used for orthodontic anchorage. Clin Oral Implants Res 2005;16:473–9. for orthodontic anchorage: a prospective clinical study. Clin Oral Implants Res 2007;
37. Ohnishi H, Yagi T, Yasuda Y, et al. A mini-implant for orthodontic anchorage in a deep 18:263–7.
overbite case. Angle Orthod 2005;75:444–52. 54. Melsen B, Graham J, Baccetti T, et al. Factors contributing to the success or failure
38. Labanauskaite B, Jankauskas G, Vasiliauskas A, et al. Implants for orthodontic anchor- of skeletal anchorage devices: an informal JCO survey. J Clin Orthod 2010;44:
age: meta-analysis. Stomatologija 2005;7:128–32. 714–18.
39. Dalstra M, Cattaneo PM, Melsen B. Load transfer of miniscrews for orthodontic 55. Dalstra M, Cattaneo PM, Melsen B. Load transfer of miniscrews for orthodontic
anchorage. Orthodontology 2004;1:53–62. anchorage. Orthod 2001;1:53–62.
40. Antoszewska J, Papadopoulos MA, Park HS, et al. Five-year experience with ortho- 56. Chen YJ, Chang HH, Huang CY, et al. A retrospective analysis of the failure rate of
dontic miniscrew implants: a retrospective investigation of factors influencing success three different orthodontic skeletal anchorage systems. Clin Oral Implants Res
rates. Am J Orthod Dentofacial Orthop 2009;136:158. 2007;18:768–75.
41. Thiruvenkatachari B, Pavithranand A, Rajasigamani K, et al. Comparison and meas- 57. Kuroda S, Yamada K, Deguchi T, et al. Root proximity is a major factor for screw
urement of the amount of anchorage loss of the molars with and without the use failure in orthodontic anchorage. Am J Orthod Dentofacial Orthop 2007;131:68–73.
of implant anchorage during canine retraction. Am J Orthod Dentofacial Orthop 58. Fortini A, Cacciafesta V, Sfondrini MF, et al. Clinical applications and efficacy of
2006;129:551–4. miniscrews for extra-dental anchorage. Orthodontology 2004;1:87–98.
42. Papadopoulos MA, Papageorgiou SN, Zogakis IP. Clinical effectiveness of orthodontic 59. Papadopoulos MA. Orthodontic treatment of Class II malocclusion with miniscrew
miniscrew implants: a meta-analysis. J Dent Res 2011;90:969–76. implants. Am J Orthod Dentofacial Orthop 2008;134:604.
43. Liou EJ, Pai BC, Lin JC. Do miniscrews remain stationary under orthodontic forces? 60. Lee J, Park HS, Kyung H. Micro-implant anchorage for lingual treatment of a skeletal
Am J Orthod Dentofacial Orthop 2004;126:42–7. class II malocclusion. J Clin Orthod 2001;35:643–7.
44. Melsen B. Mini-implants: Where are we? J Clin Orthod 2005;39:539–47. 61. Bae S, Park H, Kyung H. Clinical application of micro-implant anchorage. J Clin
45. Park Y, Lee SY, Kim DH, et al. Intrusion of posterior teeth using miniscrew implants. Orthod 2002;36:298–302.
Am J Orthod Dentofacial Orthop 2003;123:690–4.
10 Selection of miniscrew implant types,
sizes and insertion sites
Birte Melsen and Michel Dalstra

weeks before loading.12 The different conclusions may reflect differences

INTRODUCTION
in bone quality between the maxilla and the mandible, the latter allowing
This chapter will focus on the different types of miniscrew implants (MIs) more primary stability. An assessment of bone–implant contact in beagle
and the factors that are of significance for their success or failure as identi- dogs supported this by finding no influence of loading time when mandible
fied in different studies: clinical, animal and in vitro. Often, success rates and maxilla results were pooled in a histological and micro-CT study.13
in clinical studies are compared with miniplates rather than among MI A study in mini-pigs used 102 AbsoAnchor (Dentos, Daegu, South
types. A further method, finite element analysis (FEA), allows comparative Korea) and 98 Dual-Top (Jeil Medical, Seoul, South Korea) MIs in eight
assessment of MI designs using computer simulation to examine the effect animals.14 A loading of 100–500 cN was applied and maintained for 72
of design parameters. days, while some of the MIs were kept unloaded as controls. Only loading
over 900 cN led to failure. These results, however, cannot be extrapolated
to the clinical situation in humans since the cortical thickness in mini-pigs
FAILURE RATES exceeds by far that of humans.

CLINICAL STUDIES
The ideal study, the randomized controlled trial, cannot be used to assess IMPLANT DESIGN
MI success for various reasons. Skeletal anchorage is used clinically as an
alternative to conventional treatment and also to perform tooth displace-
IN VITRO STUDIES
ments that cannot be done by another method. So a control group is not The influence of the design of MIs can best be studied by computer simula-
possible. Clinical studies attempting to identify MI factors having an tions or by in vitro studies. In vitro studies allow comparisons of different
impact on failure rate are difficult to analyze as often studies are based on brands, different types of loading and variations in insertion torque. Failure
a small number of MIs and confounded by a high number of variables, of temporary anchorage devices mostly occurs during the first weeks after
such as selection of patients, type of malocclusion and insertion proce- insertion and is, therefore, attributed to insufficient primary stability. The
dure.1 Failure rates may be related more to the type of malocclusion and relationship between insertion torque and primary stability has been
the type of patient selected than the anchorage unit itself.2,3 Age may be a repeatedly demonstrated and so insertion torque is often the parameter
factor as younger patients seem to have a higher failure rate than older chosen to express primary stability. However, cortical bone thickness and
patients.2,4,5 density, and variations in bone quality for animal bone, will have effects
A study of 45 MIs with a diameter of 2 mm reported a success rate of and this makes it difficult to draw clear positive correlations from in vitro
91.1% and ascribed failures to insertion site.6 A retrospective analysis of studies. In addition, in vivo studies often perceive insertion torque values
three systems – MIs, microimplants and miniplates – in 129 patients found as resistance to loading forces.
the lowest failure rate with miniplates but concluded that their related costs A comparison of insertion torque for 12 different MIs used porcine ilium
and need for surgical intervention supported the use of MIs, as microim- bone since its thickness was considered to be comparable to human maxil-
plants presented a slightly higher risk because of increased fracture risk.4 lary and mandibular bone.15 Insertion torque was significantly affected by
A similar sample size of Taiwanese people showed an acceptable failure the design of the 12 different MIs tested: the Orlus (Ortholution, Seoul,
rate and recommended the use of thinner MIs in the maxilla (<1.4 mm) South Korea) and the Aarhus (Medicon eG, Tuttlingen, Germany) had the
and thicker MIs in the mandible (>1.4 mm).7 A larger study, of 905 tem- highest insertion torques. A follow-up study evaluated the effect of bone
porary anchorage devices in 455 patients, showed the lowest failure rate quality and implant site preparation.16 The torque applied to insert the MIs
(6%) for MIs and miniplates, but the “screws,” whether mini- or micro- into resin-embedded porcine iliac crest was significantly correlated with
type, exhibited the lowest inflammation rate.8 the thickness of the compact bone when inserting the Dual-Top MIs. This
correlation was much weaker for TOMAS pins (Dentaurum, Ispringen,
Germany). The results of this study underlined the importance of the
ANIMAL STUDIES
design of the threading.
Beagle dogs have been the preferred animals for many studies. These Five different MIs: FAMI2 (Gebr. Martin, Tuttlingen, Germany), Orlus,
studies rarely identify differences between different MI types, most likely TITAN (Bernhard Förster, Pforzheim, Germany), TOMAS pin and Vec-
because they have focused on other variables such as failure rate.9 torTAS (Ormco, Glendora, CA, USA) were inserted into bovine femoral
Several studies have focused on the tissue reaction associated with the heads in a region where the bone quality was judged to be identical to that
insertion and loading of MIs, using histology and micro-CT to assess of human jaws and both insertion torque and resistance to pullout, axially
bone–implant contact. Insertion of MIs with predrilling in the mandible of and at 20 and 40°, were examined.17 The highest insertion torque after
beagle dogs indicated that longer MIs (10 mm) had a better survival rate predrilling with a cylindrical bur was found with conical MIs, as expected.
than shorter MIs (6 mm),10 that early loading did not have a negative Without predrilling, the cylindrical MI required the highest insertion
impact on the tissue reaction adjacent to the MIs10 and that time of loading torque, while a high number of TOMAS pins fractured during insertion.
did not influence tissue reaction and osseointegration,11 although this last At the pullout tests, the highest forces were found with cylindrical MIs.
study lost 11 out of 20 MIs through lack of primary stability. In contrast, The differences between the MIs were, however, smaller when the pullout
a study in the maxilla of beagle dogs recommended a waiting period of 3 direction was 40° with respect to the long axis. A similar study of five

66
 Selection of miniscrew implant types, sizes and insertion sites 67

120 14
50 MPa
200 MPa
100 12 1000 MPa
Relative stress factor (%)

80 10

Peak strain in the bone (10–3)

60
8

40
6
20
4
0
0.75 1.00 1.25 1.50 1.75 2.00 2.25 2
Diameter (mm)
Fig. 10.1 Stress factor for a constant bending moment depending on diameter of 0
the miniscrew implant. An increase in the diameter from 1 to 2 mm reduces the 0.0 0.5 1.0 1.5 2.0
bending stresses by eight-fold.23 Cortical thickness (mm)
Fig. 10.2 Peak strains in the trabecular bone surrounding a miniscrew implant
depend on the stiffness of the bone (50, 200 and 1000 MPa, corresponding to
different MI types inserted into three different bone types found a signifi- low, medium and high bone density) and the cortical thickness. The colors of the
background correspond to Frost’s mechanostat windows of physiological use
cant positive correlation between insertion and removal torques, with the
(yellow), mild overuse (orange) and excessive overuse (red).23
insertion torque being significantly higher than the removal torque.18 Self-
drilling MIs with a diameter less than 1.3 mm were not suitable for inser-
tion into bone with a density higher than 641 kg/m3 (40 lbs/ft3). This was
corroborated by other studies reporting an increased fracture rate for thin inserting the MIs into a photoelastic material, an epoxy resin, and applying
MIs (Fig. 10.1). various forces to the heads to generate photoelastic fringe patterns in the
Resistance to lateral force was assessed for self-tapping MIs requiring resin related to the local stresses and visible under polarized light. These
predrilling and self-drilling MIs; although the self-tapping MIs could be patterns showed the closest resemblance to the calculated stresses for the
inserted with less torque, both types had the same resistance to lateral FEA where complete osseointegration was assumed. Varying the MI length
forces.19 Similarly, mobility of the Aarhus and the LOMAS (MONDEAL from 7 to 14 mm showed that the maximum stress intensity in surrounding
Medical Systems, Mühlheiman der Donau, Germany) MIs inserted in bone tended to decrease with an increase in MI length up to 11 mm. A MI
bovine bone was the same with a low force, while the Aarhus was more length of 14 mm, surprisingly, displayed the highest stress intensity in the
resistant to a high force.20 The conclusion was that both length and diam- surrounding bone, possibly caused by a more pronounced “wiggling” effect
eter of a MI are of importance.20 of the MI tip because of its longer body length. The authors concluded that
The stability of two connected MIs in bovine bone was compared when a medium length (9–11 mm) yielded the most favorable mechanical condi-
they were linked with a stiff wire or a miniplate; the latter created a larger tions.24 An FEA of 14 different commercially available MIs compared load
resistance to pullout.21 No differences were found between three drill-free transfers with variation in cortical thickness and stiffness of the cancellous
MI systems (the Aarhus MI, the Spider Screw (Ortho Technology, Tampa, bone and with variation in the load angle of the force applied to the head
FL, USA), and the Miniscrew Anchorage System (Micerium, Avegno, of the MI.25 The TOMAS and AbsoAnchor designs yielded the highest
Italy) inserted into rabbit femoral condyles when resonance frequency was stresses and the Aarhus and Dual-Top the lowest, but no details were given
assessed as an indicator of primary stability.22 for the other MI designs nor was any attempt made to explain the results
from the design characteristics of the MIs.
An FEA of 10 commercially available MIs compared the stresses gener-
COMPUTER SIMULATIONS ated in the surrounding bone for various loading modes.26 The intraosseous
Influence of MI designs can be studied by computer simulations of the part of the MI was standardized to the length of the Aarhus design and the
stress distribution and screw-to-bone load transfer. Different designs, vir- native extra-osseous parts were replaced by that of the Aarhus MI using
tually positioned in the same piece of surrounding “bone” and loaded in computer-aided design software (Fig. 10.3A). This way, any confounding
exactly the same way, can be used to neutralize the potential effects of effects from the length itself or the way the external load was applied to
variations in bone structure and quality or insertion procedure. the head were excluded, and any differences in the generated stresses
An examination of the effect of the thickness of the cortical shell and would purely originate from the variations of the MI thread design.
the quality of the underlying cancellous bone following loading of Aarhus The loading modes assumed were axial pullout (Fig. 10.3B), transverse
MIs provided insights to the way loads are transferred from a MI to the flexure and torsional moment. For the pullout mode, the ranking of the
surrounding bone.23 As load transfer primarily takes place in the cortical designs according to the maximum pullout load based on the lowest stress
shell, its thickness is the prime determinant of a MI’s mechanical stability. peaks in the bone was IMTEC (3M IMTEC, Ardmore OK, USA) (100%),
This stability would be seriously compromised by placing a MI in bone Aarhus (84%), AbsoAnchor and MONDEAL (MONDEAL Medical
with less than 0.5 mm cortical thickness and low-density (osteoporotic) Systems) (80%), OASI (Lancer Orthodontics, Vista, CA, USA) (76%),
underlying cancellous bone (Fig. 10.2). A similar model examined the LOMAS (76%), TOMAS (73%), VectorTAS (62%), Miniscrew Anchorage
influence of MI length and various interface conditions between MI and System (59%) and Ace (ACE Surgical Supply, Brockton, MA, USA)
bone (simulating no, partial or complete osseointegration) on load transfer (57%). Similar rankings were found for the other loading modes. The
with the Miniscrew Anchorage System.24 The simulation was validated by results showed, in addition, that parameters such as thread height, pitch
 68 SECTION III: CLINICAL CONSIDERATIONS FOR THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

A B 0 0.1 MPa
Fig. 10.3 Finite element modeling of 10 designs to examine the influence of miniscrew implant (MI) thread on load transfer on the surrounding bone. (A) In order to
exclude confounders such as the length of the intraosseous part and the design of the extra-osseous part, all MI designs were normalized to the Aarhus design, replacing
the native head with that of the Aarhus design and keeping the length of the intraosseous part the same as that of the Aarhus design. (B) The distribution of stress
intensity (von Mises stresses) in the surrounding bone with a vertical pullout force of 100 cN for the 10 designs. Note that the overall load transfer is similar for all designs
and that local differences are limited to the bone at the tip of the MIs, and closely around the threads. Top row (from left to right): Aarhus, AbsoAnchor, Ace, IMTEC and
LOMAS; bottom row: Miniscrew Anchorage System, MONDEAL, OASI, TOMAS and VectorTAS.

length and pitch angle had little or no significant correlation with the stress sections, with root contact increasing the resistance and resulting in higher
peaks in the surrounding bone. The total volume of the intraosseous part torque values. However, one reason for recommending drill-free MIs has
and the inner and outer diameters of the MI were found to have high nega- been that manual insertion is more susceptible to changes in resistance
tive correlations with the stress peaks. This was particularly true for the and, therefore, less risky with respect to root damage.
flexural and torsional loading modes, as those parameters determine the
flexural and torsional stiffness of the MIs. A thinner, and thus a more flex-
ible, design (mechanically dictated by the geometry’s so-called second
INSERTION SITE
moment of inertia) under the same external load would become more
The insertion procedure and insertion site are important parameters for the
deformed, thus enforcing larger deformations on the surrounding bone. In
primary stability of MIs. Sufficient bone thickness is needed for primary
addition, some degree of stress shielding of the bone was observed between
stability and avoidance of root contact is also important for the success of
two consecutive windings of the thread, resulting in medium to high nega-
skeletal anchorage. The risk of root contact is minimized with thinner MIs
tive correlations of the thread’s valley length. In conclusion, the authors
but the risk of fracture and lack of primary stability increases to unaccept-
found that any thread variable that makes the design stiffer, though not
able levels with diameters below 1.3 mm.14,23,29 Ludwig et al.30 recently
necessarily thicker, would have a favorable effect on a MI’s mechanical
published comprehensive anatomical guidelines for insertion of inter-
stability. It should be noted, however, that potentially higher pre-stresses
radicular MIs based on cone beam CT in 70 adolescents and adults of white
in the bone inherent to the insertion of a bulkier MI were not taken into
origin. The inter-radicular site is frequently chosen since it results in
consideration.26
minimum discomfort, and it is possible to perform a wide range of tooth
The influence of the cut of the threading, its angulation and depth, has
movements from this site using the MIs either directly or indirectly. Inter-
not been subjected to detailed studies. One study did examine threading
radicular bone width and cortical thickness at different levels were assessed
of MIs and found that a pitch angle of 7.5° and a flank angle of 12–15°
in sections parallel to the occlusal plane and sections passing through the
improved the primary stability and minimized the damage, thus leading to
contact points to give graphs indicating safe, less safe and dangerous zones.
a low failure rate.27 These values correspond closely to the values of the
However, optimal zones were often unacceptable from a comfort point of
Aarhus MIs (see Fig. 6.10).
view.31 This could be compensated with an anatomically oblique MI inser-
tion. Cortical thickness and insertion torque were positively correlated with
USE OF PREDRILLING primary stability in a clinical study of 76 MIs.32 The best cortical thickness
was found close to the midpalatal suture anteriorly in the palate, which has,
Torque values during predrilling were examined in acrylic resin-embedded therefore, been recommended for palatal insertion of MIs.33
jaws from mini-pigs, using Dual-Top MIs.28 The forces applied to insert The success rate of MIs is also influenced by mucosa levels and failure
the MIs were correlated with the root contact assessed on histological rates increase if MIs are not surrounded by keratinized gingiva.34,35
 Selection of miniscrew implant types, sizes and insertion sites 69

REFERENCES
1. Kalha AS. Is anchorage reinforcement with implants effective in orthodontics? Evid
Based Dent 2008;9:13–14.
2. Moon CH, Park HK, Nam JS, et al. Relationship between vertical skeletal pattern and
success rate of orthodontic mini-implants. Am J Orthod Dentofacial Orthop
2010;138:51–7.
3. Miyawaki S, Koyama I, Inoue M, et al. Factors associated with the stability of titanium
screws placed in the posterior region for orthodontic anchorage. Am J Orthod Dento-
facial Orthop 2003;124:373–8.
4. Chen YJ, Chang HH, Huang CY, et al. A retrospective analysis of the failure rate of
three different orthodontic skeletal anchorage systems. Clin Oral Implants Res
2007;18:768–75.
5. Lee SJ, Ahn SJ, Lee JW, et al. Survival analysis of orthodontic mini-implants. Am J
Orthod Dentofacial Orthop 2010;137:194–9.
6. Tseng YC, Hsieh CH, Chen CH, et al. The application of mini-implants for orthodontic
anchorage. Int J Oral Maxillofac Surg 2006;35:704–7.
1.3 mm 1.5 mm 2.0 mm 7. Wu TY, Kuang SH, Wu CH. Factors associated with the stability of mini-implants for
orthodontic anchorage: a study of 414 samples in Taiwan. J Oral Maxillofac Surg
Fig. 10.4 Different versions of the Aarhus MI with increasing thickness. 2009;67:1595–9.
8. Takaki T, Tamura N, Yamamoto M, et al. Clinical study of temporary anchorage
devices for orthodontic treatment-stability of micro/mini-screws and mini-plates:
Experience with 455 cases. Bull Tokyo Dent Coll 2010;51:151–63.
9. Ohmae M, Saito S, Morohashi T, et al. A clinical and histological evaluation of tita-
nium mini-implants as anchors for orthodontic intrusion in the beagle dog. Am J
Orthod Dentofacial Orthop 2001;119:489–97.
10. Freire JN, Silva NR, Gil JN, et al. Histomorphologic and histomorphometric evalua-
tion of immediately and early loaded mini-implants for orthodontic anchorage. Am J
Orthod Dentofacial Orthop 2007;131:704–9.
11. van de Vannet B, Sabzevar MM, Wehrbein H, et al. Osseointegration of miniscrews:
a histomorphometric evaluation. Eur J Orthod 2007;29:437–42.
12. Zhao L, Xu Z, Yang Z, et al. Orthodontic mini-implant stability in different
healing times before loading: a microscopic computerized tomographic and bio-
mechanical analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;
108:196–202.
13. Cha JY, Lim JK, Song JW, et al. Influence of the length of the loading period
Fig. 10.5 Miniscrew implant with a bracket-like head for the attachment of wires. after placement of orthodontic mini-implants on changes in bone histomorphology:
microcomputed tomographic and histologic analysis. Int J Oral Maxillofac Implants
2009;24:842–9.
14. Büchter A, Wiechmann D, Gaertner C, et al. Load-related bone modelling at
the interface of orthodontic micro-implants. Clin Oral Implants Res 2006;17:
DESIGN OF THE EXTRA-OSSEOUS PART 714–22.
15. Wilmes B, Ottenstreuer S, Su YY, et al. Impact of implant design on primary stability
The extra-osseous part of a MI comprises the neck, the collar and the head of orthodontic mini-implants. J Orofac Orthop 2008;69:42–50.
(see Fig. 6.1). The neck passes through the mucosa and should be smooth 16. Wilmes B, Drescher D. Impact of bone quality, implant type, and implantation site
preparation on insertion torques of mini-implants used for orthodontic anchorage. Int
in order to minimize infection risk; it also needs a slightly larger diameter J Oral Maxillofac Surg 2011;40:697–703.
than the threaded part so it is possible to feel when the neck reaches the 17. Florvaag B, Kneuertz P, Lazar F, et al. Biomechanical properties of orthodontic minis-
bony surface. Overturning beyond this point can lead to loosening as it crews: an in-vitro study. J Orofac Orthop 2010;71:53–67.
18. Chen Y, Kyung HM, Gao L, et al. Mechanical properties of self-drilling orthodontic
can destroy bone adjacent to the threaded part.36 micro-implants with different diameters. Angle Orthod 2010;80:821–7.
To avoid plaque retention, the collar should also be smooth and in addi- 19. Su YY, Wilmes B, Honscheid R, et al. Comparison of self-tapping and self-drilling
tion it should be slightly larger than the head to prevent irritation of the orthodontic mini-implants: an animal study of insertion torque and displacement under
lateral loading. Int J Oral Maxillofac Implants 2009;24:404–11.
mucosa surrounding the MI through the ligatures tied to the MI’s head 20. Chatzigianni A, Keilig L, Reimann S, et al. Effect of mini-implant length and diameter
(Fig. 10.4). on primary stability under loading with two force levels. Eur J Orthod 2011;33:
The design of the head depends on the use of the MI (see Fig. 6.2). If 381–7.
21. Leung MT, Rabie AB, Wong RW. Stability of connected mini-implants and miniplates
only coil springs or elastics are fixed to the MI, a one-point contact is for skeletal anchorage in orthodontics. Eur J Orthod 2008;30:483–9.
sufficient and a hook or a ball can be chosen as a head. If the point of 22. Veltri M, Balleri B, Goracci C, et al. Soft bone primary stability of 3 different minis-
force application needs to be displaced, a bracket-like head is necessary crews for orthodontic anchorage: a resonance frequency investigation. Am J Orthod
Dentofacial Orthop 2009;135:642–8.
(Fig. 10.5). 23. Dalstra M, Cattaneo PM, Melsen B. Load transfer of miniscrews for orthodontic
anchorage. Orthodontics 2004;1:53–62.
24. Gracco A, Cirignaco A, Cozzani M, et al. Numerical/experimental analysis of the
stress field around miniscrews for orthodontic anchorage. Eur J Orthod 2009;31:
CONCLUSIONS 12–20.
25. Stahl E, Keilig L, Abdelgader I, et al. Numerical analyses of biomechanical behavior
The type of MI has only a minor impact on failure rates, which seem to of various orthodontic anchorage implants. J Orofac Orthop 2009;70:115–27.
26. Stavaras F. The effect of geometrical variations of the thread of orthodontic miniscrews
be influenced more by factors relating to the patient (bone quality and on the load transfer mechanism of the surrounding bone. Master Thesis, Aarhus
quantity) and doctor (biomechanics and loading). Nevertheless, when University, Denmark; 2010.
these variables are standardized, there are significant differences in the 27. Ungethüm M, Blomer W, Reichle V. [Experimental study of improved threading of
bone screws.]. Aktuelle Traumatol 1983;13:128–32.
stress generated with different intraosseous designs. An asymmetrically 28. Wilmes B, Su YY, Sadigh L, et al. Pre-drilling force and insertion torques during
cut cylindrical MI seems to be preferential. A bracket-like head (e.g. orthodontic mini-implant insertion in relation to root contact. J Orofac Orthop
Aarhus MIs) offers the advantage of indirect anchorage, the possibility to 2008;69:51–8.
29. Park HS, Jeong SH, Kwon OW. Factors affecting the clinical success of screw
vary the point of force application and of having more points of force implants used as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2006;130:
application for each MI. 18–25.
 70 SECTION III: CLINICAL CONSIDERATIONS FOR THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

30. Ludwig B, Glasl B, Kinzinger GS, et al. Anatomical guidelines for miniscrew inser- 34. Cheng SJ, Tseng IY, Lee JJ, et al. A prospective study of the risk factors associated
tion: vestibular interradicular sites. J Clin Orthod 2011;45:165–73. with failure of mini-implants used for orthodontic anchorage. Int J Oral Maxillofac
31. Poggio PM, Incorvati C, Velo S, et al. “Safe zones”: a guide for miniscrew positioning Implants 2004;19:100–6.
in the maxillary and mandibular arch. Angle Orthod 2006;76:191–7. 35. Chen J, Esterle M, Roberts WE. Mechanical response to functional loading around
32. Motoyoshi M, Yoshida T, Ono A, et al. Effect of cortical bone thickness and implant the threads of retromolar endosseous implants utilized for orthodontic anchorage:
placement torque on stability of orthodontic mini-implants. Int J Oral Maxillofac coordinated histomorphometric and finite element analysis. Int J Oral Maxillofac
Implants 2007;22:779–84. Implants 1999;14:282–9.
33. Kang S, Lee SJ, Ahn SJ, et al. Bone thickness of the palate for orthodontic mini- 36. Wawrzinek C, Sommer T, Fischer-Brandies H. Microdamage in cortical bone due to
implant anchorage in adults. Am J Orthod Dentofacial Orthop 2007;131:S74–81. the overtightening of orthodontic microscrews. J Orofac Orthop 2008;69:121–34.
 Patient expectations, acceptance and
preferences for miniscrew implant treatment
11
Fraser McDonald and Martin Baxmann

INTRODUCTION IDEALLY PAIN-FREE TREATMENT

Patients often associate dentistry with pain; therefore, any way of reducing
The initial use of dental implants for the replacement of missing teeth has discomfort and ensuring patient compliance has to be seen as a benefit.
extended into use for the support of orthodontic treatment in many forms, There is clear evidence that the majority who do not attend the dental
particularly for en masse retraction of teeth, and the development of the surgery are cautious about both their own past experiences and reports of
miniscrew implant (MI). With the growing acceptance that functional others.1
appliances and other orthodontic techniques do not work on all patients,
with a failure rate of around 30% (to such a level that intention-to-treat
statistical evaluation becomes a necessary part of study analysis), there are EFFICIENT TREATMENT
more patients who wish to receive orthodontic treatment that is less The current generation of clients expect delivery of results instantly and
dependent on their own compliance. Equally, the increasing range of com- consistently, have only superficial understanding of how treatment is deliv-
mercial products and numbers of orthodontists chasing a static market can ered and the belief that once treated orthodontic alignment is for life. The
mean that patients are being offered unrealistic treatment approaches. This “downside” of treatment in the form of risks is often neglected and the
chapter considers patients’ expectations, acceptance of treatment require- patients’ full engagement in risk–benefit analysis as part of the informed
ments and preferences. consent process is questionable.

EXPECTATIONS UNOBTRUSIVE TREATMENT

The basis of care delivery has to fit into a patient’s acceptable level of
Expectations relate to all aspects of dental treatment and include: social and professional activity. Procedures that are too obvious in adults
■ convenient timing of treatment can impinge on their confidence in many aspects of their lives, for example
■ minimal time spent in the dental surgery a decline in reaching work targets or in promotion. Consequently, the
■ ideally pain-free treatment search for the invisible brace (ranging from lingual appliances, through
■ efficient treatment tooth-colored fixed apparatus to clear aligners) continues relentlessly and
■ unobtrusive treatment often with commercial interests over-riding patient considerations.2
■ the ability to treat all types of malocclusion
■ economical/affordable care delivery. THE ABILITY TO TREAT ALL TYPES
OF MALOCCLUSION
CONVENIENT TIMING OF TREATMENT Patients anticipate that all malocclusions can be treated regardless of the
causation. The concept of the perfect long-lasting smile seems the focus
Major malocclusions can be treated by “functional” therapy at a stage of of all despite the knowledge that many images seen in publications of all
a patient’s growth and development that will allow some form of modifica- types have been improved by software. In addition, media focus on obscur-
tion of soft and hard tissues. The age of peak growth velocity is clearly ing the aging process can lead to aspirations that are unrealistic in many
ideal, but for many reasons patients still request treatment past this age. and even to psychiatric syndromes of addiction to corrective surgery.
Often this may lead on to complex orthognathic and orthodontic care, but
the provision of implant-supported anchorage offers an interim pathway
of care that could facilitate the management of a significant number of ECONOMICAL/AFFORDABLE CARE DELIVERY
patient problems. In addition to the need for minimizing the time spent on care delivery,
constraining costs is also important for patients. At present, orthodontics
is not associated with convincing evidence of its need in terms of health
MINIMAL TIME SPENT IN THE DENTAL SURGERY
although many individuals report improvement in self-esteem.
With a growing number of young and mature adults seeking orthodontic
care, patients’ concerns for job security and time for maintaining daily life,
there is a need for limiting the time spent in the dental surgery/office. The ACCEPTANCE
problems of long periods of time away from employment (e.g. time
spent in hospital or recuperating following surgery) become increasingly Acceptance of the need to be compliant with treatment can be implicit in
significant as does attending surgery during the working day. Conse- the positive act of arranging follow-up appointments beyond the original
quently, flexible appointment systems with extended opening times for consultation, signing appropriate relevant contracts, particularly when
busy patients or treatment of certain professionals either late at night or financial implications exist, and following instructions offered by a health-
early in the morning are becoming more common but do have a limited care practitioner. Compliance is an issue. For example, even though fluo-
capacity. ride mouthwash is offered free and there is significant positive enforcement,

71
 72 SECTION III: CLINICAL CONSIDERATIONS FOR THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

compliance can be as low as 10%.3 It may be assumed that this is because types in terms of success rate and degree of postoperative discomfort has
there is no instantaneous outcome to bolster compliance. By comparison, been briefly investigated13,24,26 but no study has compared the two methods
orthodontic treatment has an immediate feedback, for example with the from the patient’s perspective.
reduction of an overjet following wear of Class II elastics. There are many dental studies addressing the effectiveness of local
Patient compliance in orthodontics is strongly influenced by issues of anesthetics,27 but none deals with injection techniques for the placement
pain and discomfort. Pain is linked to both unpleasant sensations of actual of MIs. This is particularly surprising because for MI insertion orthodon-
or potential tissue damage and emotional responses and can lead to failure tists utilize anesthetic methods that have an effect only on the superficial
to complete treatment.4–7 A number of procedures in orthodontic treatment soft tissues and periosteum while not anesthetizing either the dental pulp
can cause pain and discomfort, for example during separations, initial of the neighboring teeth or other important structures close by, such as the
archwire changing and bracket/band removal.8–10 inferior mandibular nerve (thus avoiding iatrogenic damage). A prospec-
Pain is reported to lead 1 in every 10 orthodontic patients to fail to finish tive study evaluated two injection techniques for local anesthesia in
treatment.4 Information about pain caused by MIs is scarce,11–13 as few patients requiring skeletal anchorage reinforcement.23 The most important
studies have addressed the postoperative discomfort caused by MIs. result was that it made no difference to the patients whether the orthodon-
Together with assessing treatment efficacy, it is also necessary to examine tist drilled before MI insertion or whether a self-drilling MI was used. In
to what extent patients can tolerate the intended treatment processes.12 both methods, the patients found the pain less unpleasant than the mechan-
Assessment of patient discomfort or pain during treatment can be made ics of insertion – noise from the dental handpiece or pressure from the
with various tools and three have been evaluated14 and proven to be reli- self-drilling MI. As both methods are successful, the orthodontist can
able and suitable, although no one solution is deemed to be optimal: decide which method to use based on the clinical situation or personal
preference.25 However, patient preferences regarding anesthetic injection
■ the visual analogue scale (VAS)
method demonstrate how important it is to respect the patient’s tolerance
■ the numerical rating scale (NRS)
levels concerning treatment as this can differ considerably from the opinion
■ the verbal rating scale (VRS).
of many clinicians. Patients have revealed a significant preference with
The VRS is mostly used to assess pain quality, while the NRS is applied regard to the anesthetic injection method, preferring injections directly into
to measure pain intensity.6,13,15 Both scales provide a discrete form of cat- the area where the MIs were to be inserted. Their reasons for this were the
egorization. In contrast, the VAS uses a continuous or analogue range of shorter period of numbness after treatment and the potentially quicker
values.13,16,17 One of the greatest difficulties when applying the VRS is therapy. Using this method, MIs can be inserted just seconds after the
finding a significant clinical rating classification. A recently published injection, whereas a wait of 3 minutes is necessary using the standard
study has used the NRS to categorize pain and discomfort into five areas.6 infiltration technique. Surprisingly, patients found this delay more impor-
Studies have concentrated on comparing pain during MI treatment with tant than the pain intensity during the injection itself. Pain intensity was
other potentially painful dental treatments, for example tooth extraction,6,12 higher with the injection directly in the MI insertion area than with the
other dental interventions/pathology18,19 or discomfort caused by various standard technique. Interestingly, a prosthetic replacement meant to cover
forms of anchorage equipment.20,21 an implant during the healing phase caused more discomfort than the
Although the use of self-drilling MIs, which can only be introduced by actual surgical procedure.12
manual procedures, and the insertion of MIs after predrilling using a dental Another study focusing on the patient’s pain during insertion procedures
handpiece are both everyday procedures in orthodontic practice,22 exactly compared the soft tissue punch as preparation prior to the actual MI inser-
which method the patient tolerates or prefers has not been well explored. tion (Fig. 11.1) and a “direct” transgingival placement of the implant.6
Similarly, little is known regarding the use of a local anesthetic. A prospec- Patients described the soft tissue punch as significantly more unpleasant,
tive study has examined patient expectations, acceptance and preferences so this is a questionable approach. Obviously it is also of clinical relevance
for two insertion techniques for MIs and two different anesthesia tech- if this technique has an influence on primary stability, and consequently
niques.23 The most important result was that it made no difference to the on the survival rate of the implant. Therefore, a follow-up study is cur-
patients whether the orthodontist drilled before MI insertion or whether a rently being conducted to examine primary stability or survival rate of MIs
self-drilling MI was used. The patients found the noise from the dental placed with either a soft tissue punch or transgingivally. Preliminary
handpiece more unpleasant than the pain, and the pressure from the self- results show no significant differences.
drilling MIs more unpleasant than the pain. If extractions are needed, a dental practitioner or oral surgeon can
perform the premolar extraction but an experienced and specially trained
orthodontist is required to place the MI. It is debatable whether these two
PREFERENCES steps of the insertion stage would benefit the patient if they took place
during one session, even though this requires more complex logistics for
En masse retraction with the help of MIs has proven to be extremely the clinicians.
efficient19,24 and the orthodontist usually selects the treatment plan based During the removal of MIs, patients reported the same preferences as
on the clinical situation, whereby ideal occlusion and function are the described in the insertion study, clearly favoring a manual procedure over
treatment objectives. In general, patients can only influence the treatment a mechanical one.22 The most important finding nevertheless was that pain
through their compliance and degree of cooperation. levels produced by the injection were greater than the pain produced by
The method of delivering MI-based treatment can have significant the removal without anesthesia.
implications for the patients’ perceptions. MIs can be inserted by either
hand-delivered forces or a handpiece method.22 Many clinicians prefer
hand-delivered forces and this mechanism is also least compromising for CONCLUSIONS
the patient’s experience.
There is ample evidence for successful implementation of both self- Although no one of the various rating scales for pain seems to be optimal,
cutting MIs requiring predrilling (i.e. non-self-drilling) and self-drilling the established approach for assessing acute pain involves the analysis of
MIs without a need for predrilling.25 The difference between these two the intensity of discomfort with the VAS, since there are convincing reports
 Patient expectations, acceptance and preferences for miniscrew implant treatment 73

A B
Fig. 11.1 The TOMAS punch. (A) Method of use. (B) A soft tissue punch. (Courtesy of Dentaurum KG, Ispringen, Germany.)

in the scientific literature demonstrating this scale as being quite 7. Bergius M, Kiliaridis S, Berggren U. Pain in orthodontics: a review and discussion of
the literature. J Orofac Orthop 2000;61:125–37.
reliable.15,16 8. Bondemark L, Fredriksson K, Ilros S. Separation effect and perception of pain
A comparison of patient discomfort with regard to manual and mechani- and discomfort from two types of orthodontic separators. World J Orthod 2004;5:
cal insertion methods as well as with regard to the removal of MIs revealed 172–6.
9. Erdinc A, Dincer B. Perception of pain during orthodontic treatment with fixed appli-
significant differences. Patients clearly preferred manual techniques. The ances. Eur J Orthod 2004;26:79–85.
noise associated with the handpiece during these procedures led to more 10. Giannopoulou C, Dudic A, Kiliaridis S. Pain discomfort and cervicular fluid changes
discomfort than the pain itself. Pain intensity varied from moderate to low. induced by orthodontic elastic separators in children. J Pain 2006;7:367–76.
11. Scheffler NR. Patient and provider perceptions of skeletal anchorage in orthodontics.
There were no significant differences in the way patients perceived treat- Am J Orthod Dentofacial Orthop 2006;29:843.
ment with self-drilling as opposed to non-self-drilling MIs. 12. Feldmann I, List T, Feldmann H, et al. Pain intensity and discomfort following surgical
There were also significant differences in patients’ perceptions concern- placement of orthodontic anchoring units and premolar extraction. Angle Orthod
2007;77:578–85.
ing the anesthetic injection techniques when inserting the MIs. A low-dose 13. Lee TCK, McGrath CPJ, Wong RWK, et al. Patients’ perceptions regarding microim-
local anesthetic in the immediate MI insertion area was favored over plant as anchorage in orthodontics. Angle Orthod 2008;78:228–32.
higher doses injected using the standard injection method. During MI 14. Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales.
J Clin Nurs 2005;14:798–804.
removal, the injection itself caused more discomfort than the actual surgery 15. McQuary H, Moore A. An evidence-based resource for pain relief. Oxford: Oxford
with the result that the patients preferred MI removal without anesthesia. University Press; 1998. p. 14–18.
The perceived symptoms were equal to or less intense than expected. 16. Seymour RA, Simpson JM, Charlton JE, et al. An evaluation of length and end-phrase
of visual analogue scales in dental pain. J Pain 1985;21:177–85.
Surgery for MIs seems to be a well-accepted treatment option, with 17. von Bayer CL. Children’s self-reports of pain intensity: scale selection, limitations and
significantly lower pain levels than for tooth extractions. In addition, interpretation. Pain Res Manag 2006;11:157–62.
transgingival placement of MIs was clearly favored by patients, since this 18. Kvam E, Gjerdet NR, Bondevik O. Traumatic ulcers and pain during orthodontic
treatment. Community Dent Oral Epidemiol 1987;15:104–7.
does not need soft tissues to be removed before MI insertion. Since the 19. Versloot J, Verkamp JSJ, Hoogstraten J, et al. Children’s coping with pain during
soft tissue punch does not seem to lead to improved primary stability or dental care. Community Dent Oral Epidemiol 2004;32:456–61.
survival rate, utilization of this technique appears to be of low clinical 20. Cornelis MA, Scheffler NR, Nyssen-Behets C, et al. Patients’ and orthodontists’ per-
ceptions of miniplates used for temporary skeletal anchorage: a prospective study. Am
relevance, particularly as patients did not care for it. J Orthod Dentofacial Orthop 2008;133:18–24.
21. Wehrbein H, Göllner P. Skeletal anchorage in orthodontics: basics and clinical applica-
tion. J Orofac Orthop 2007;68:443–61.
22. Lehnen S, McDonald F, Bourauel C, et al. Expectations, acceptance and preferences
REFERENCES of patients in treatment with orthodontic mini-implants. Part II: Implant removal. J
Orofac Orthop 2011;72:214–22.
1. Liddell A, May B. Some characteristics of regular and irregular attenders for dental 23. Lehnen S, McDonald F, Bourauel C, et al. Patient expectations, acceptance and prefer-
check-ups. Br J Clin Psychol 1984;23:19–26. ences in treatment with orthodontic mini-implants: a randomly controlled study. Part
2. Wright N, Modarai F, Cobourne MT, et al. Do you do Damon? What is the current I: insertion techniques. J Orofac Orthop 2011;72:93–102.
evidence base underlying the philosophy of this appliance system? J Orthod 24. Basha A, Shantaraj R, Mogegowda S. Comparative study between conventional
2011;38:222–30. en-masse retraction (sliding mechanics) and en-masse retraction using orthodontic
3. Alexander SA, Ripa LW. Effects of self-applied topical fluoride preparations in ortho- micro implant. J Oral Implantology 2010;19:128–36.
dontic patients. Angle Orthod 2000;70:424–30. 25. Chen Y, Kyung HM, Zhao WT, et al. Critical factors for the success of orthodontic
4. Patel V. Non-completion of orthodontic treatment: a study of patient and parental mini-implants: a systematic review. Am J Orthod Dentofacial Orthop 2009;135:
factors contributing to discontinuation in the hospital service and specialist practice. 284–91.
Master Thesis, University of Wales, Cardiff; 1989. 26. Kuroda S, Sugawara Y, Deguchi T, et al. Clinical use of miniscrew implants as ortho-
5. Sergl HG, Klages U, Zentner A. Pain and discomfort during orthodontic treatment: dontic anchorage: Success rates and postoperative discomfort. Am J Orthod Dentofa-
causative factors and effects on compliance. Am J Orthod Dentofacial Orthop cial Orthop 2007;131:9–15.
1998;114:684–91. 27. Nakai Y, Milgrom P, Mancl L, et al. Effectiveness of local anesthesia in pediatric
6. Baxmann M, McDonald F, Bourauel C, et al. Expectations, acceptance, and prefer- dental practice. J Am Dent Assoc 2000;131:1699–705.
ences regarding microimplant treatment in orthodontic patients: a randomized con-
trolled trial. Am J Orthod Dentofacial Orthop 2010;138:250, discussion 250–1.
Section IV: Surgical considerations in the use of skeletal anchorage devices in orthodontics

12 Insertion and removal of orthodontic implants

Thomas Bernhart and Adriano Crismani

INTRODUCTION LATERAL CEPHALOMETRIC RADIOGRAPHY

Lateral cephalometric radiography is the basic radiological diagnostic tool
Many patients with dental and skeletal anomalies have fully intact dental on which all subsequent orthodontic treatment is based and so this is the
arches so the alveolar region is not available for implant placement. For primary assessment to make. Postoperative lateral cephalometric radiog-
the maxilla, the median sagittal and paramedian region of the hard palate raphy revealed perforation of the implant into the nose in five patients even
are appropriate sites as they have keratinized mucosa and are accessible though intraoperative probing of the implant bed had not indicated any
surgically (see Chapter 7). There are, however, certain restrictions related perforation.3
to implant geometry. A study in labeled skulls showed that the uppermost bony boundary of
the palate in lateral cephalometric radiographs corresponded mainly to the
structure of the nasal floor, and not to the nasal septum located in a
ORTHODONTIC IMPLANTS INSERTED IN THE PALATE median–sagittal direction. Therefore, vertical bone in the anterior and
median third of the hard palate is at least 2 mm higher than visualized in
Bone quantity in the vertical dimension of the palate and the presence of the lateral cephalometric radiographs, but a safety margin of at least 2 mm
the midpalatal suture can create problems, implying a possible need for to the nasal floor was recommended (Fig. 12.2).3
implants of shorter length (<10 mm) (Fig. 12.1). A recent meta-analysis, The major problem is the transfer of data measured on the cephalometric
however, has indicated that success rate is dependent on implant surface radiograph to the intraoperative site. Wehrbein et al.3 used the incisive
rather than length in the region of the anterior maxilla.1 foramen as the topmost medial boundary of the palate, as depicted on the
The first implant designed for insertion in the palate had reduced length cephalometric radiographs. However, these images are often blurred in this
(down to 4 mm) and a sandblasted and acid-etched surface.2 area; in addition, use of the radiographic information would necessitate a
complete mobilization of the palatal mucosa during surgery. Consequently,
use of a ball-marked splint during lateral cephalometric radiography is
PREOPERATIVE DIAGNOSTICS recommended.

Because of the risk of perforation of the inferior nasal cavity and the need
for a good assessment of bone quantity, radiography is needed in addition DENTAL COMPUTER TOMOGRAPHY
to clinical diagnosis. Since the midpalatal suture may not be fully ossified (closed) even in
adults, restricting the utility of the surrounding area for orthodontic
Fig. 12.1 Histological specimen implants, the paramedian region is an appropriate alternative site (see
showing a palatal implant. Chapter 14).
By using low-dose CT protocols, reduction of radiation dose is achiev-
able without loss of accuracy. For planning orthodontic implants, the usual
dental CT protocol is recommended (thickness of layer, 0.5 mm; integrated
feeding table, 0.5 mm; fast scan mode, 120 kV, 75 mA, 1 s scan, tilt of
cutting plane after the hard palate).
The image data are reformatted in the midsagittal plane on a multiplanar
level and a tangential line can be established along the hard palate on the
oral side (Fig. 12.3A). Perpendicular to the oral tangential line, paracoro-
nal layers are reconstructed at a distance of 3, 6, 9 and 12 mm (Fig.
12.3B,C). In 95% of patients assessed, there was adequate vertical bone
volume for the insertion of a palatal implant of 4 mm in length; 93% had
at least 3 mm of vertical bone volume located 4 mm distal to the incisive
foramen and 3 mm lateral to the median suture of the palate.4 The greatest
amount of bone in the midsagittal plane was observed 6 mm distally from
the incisive foramen. The highest mean value (paramedian) was 7.8 mm
and was observed in the median sagittal “plane 3” at a distance of 3 mm
from the median.

CONE BEAM COMPUTER TOMOGRAPHY

Use of cone beam CT provides three-dimensional images (3D) (Fig. 12.4).
A comparison of the accuracy of cone beam CT and lateral cephalometric
radiography in 18 skulls indicated that the former gave higher vertical bone

74
 Insertion and removal of orthodontic implants 75

A
B
Fig. 12.2 Assessment of bone quantity in the palate. (A) Lateral cephalometric radiograph. (B) Cephalometric tracing of the maxilla. Maximum bone quantity (x) is
marked. The maximum length of the implant should be 2 mm less than x.

0
3
6
9

9 12
6
3

B C
A
Fig. 12.3 CT of the hard palate. (A) Planes 3, 6 and 9 with planned implant insertion positions every 3 mm on the paramedian side. (B) Multiplanar reformation of the
hard palate at the median–sagittal plane. (C) Multiplanar reformation, visualizing the measuring method for distances 0 to 9 mm, 6 mm away from the incisive foramen

Fig. 12.4 Hard palate reconstruction from cone beam CT (green frame, orthoradial reconstruction in the mid-plane; red frame, panoramic reconstruction of the frontal
region).
 76 SECTION IV: SURGICAL CONSIDERATIONS IN THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

heights: mean 8.98 ± 3.4 mm compared with 6.6 ± 3.2 mm.5 In the para- Quantity and quality of bone in the posterior palate corresponded to the
median region, the two approaches were both within the range of the first requirements for palate implant placement.7
premolars in a positive linear relation. It was concluded that lateral cepha- The paramedian region is of particular interest when treating children,
lometric radiographs show a minimum of vertical bone height paramedian because the midpalatal suture will still be developing. Two studies have
and not the maximum in the median sagittal plane.5 Therefore, preopera- examined bone depth in the paramedian region.4,8 Cone beam CT in 183
tive CT or cone beam CT was recommended if lateral cephalometric adolescents aged 10–19 years showed that 93.2% of the boys and 91.9%
evaluation reveals a marginal quantity of bone volume.5 of the girls had sufficient vertical bone volume in the paramedian region
A retrospective clinical cohort indicated that 97.8% (89 out of 91) of to host a 3 mm implant with practically no root interference.8
the patients showed adequate bone volume in lateral cephalometric radio-
graphs. One of the remaining two patients showed inadequate bone volume
(<4 mm) in a further cone beam CT evaluation.6
SURGICAL INSERTION OF ORTHODONTIC
IMPLANTS IN THE PALATE
SUMMARY
The requirements for a good palatal implant are that it should be simple
According to these results, the following diagnostic conclusions may be to handle surgically, it should produce minimal surgical trauma and it
drawn: should be simple to connect to orthodontic appliances. The Straumann
■ a safety margin of at least 2 mm to the nasal floor should be Palatal Implant (Straumann, Basel, Switzerland), a transmucosally inserted
considered in implant planning when using lateral cephalometric implant, fulfills these needs and is recommended for insertion in the
radiographs, thus avoiding possible perforation; a radiological median or paramedian region of the palate. The surgical approach for
marked splint may be helpful implant insertion described below is for this type of implant.
■ CT should only be used if the lateral cephalometric radiograph The Straumann Palatal Implant is a single unit system made of
reveals a bone volume less than 4 mm in the premolar region pure titanium with an endosseous implant part (4.1 and 4.8 mm), a
■ a low-dose protocol is recommended for dental CT. transmucosal smooth neck and a screw-operated abutment (see Fig. 7.2).
The endosseous part has a self-cutting thread with a sandblasted and
acid-etched surface and a length of 4.2 mm. The transmucosal part has a
BONE QUANTITY AND LOCALIZATION high-gloss polished neck.
After assessing local bone quantity, adequate local anesthesia is applied
An analysis of bone quality in the hard palate using histomorphometric to the area of intended implant placement, followed by removal of the
analysis of autopsy material from 22 adults (18–63 years)7 indicated three palatal mucosa with a mucosal punch (Fig. 12.5A) and a periosteal elevator
areas for implant placement: (Fig. 12.5B).
Palatal compact bone is granulated with a round bur (Figure Fig. 12.5C)
■ the anterior part of the medial palate, 7 mm behind the incisive
and the implant bed is prepared with a twist drill (Fig. 12.5D). The initial
foramen in the area of the first premolars
preparation with the round bur prevents sliding of the twist drill. Prepara-
■ the middle part, in the area of the second premolars
tion of the implant site should be done under continuous cooling with
■ the posterior part, in the area of the first molars.
precooled (5°C [41°F] ) physiological saline at a maximum speed of
Age had no influence on bone density. There was adequate bone quality 800 rpm.
in all areas of the medial palate for primary implant stability plus a mean The self-cutting implant is then removed from the blister and inserted
bone depth–volume ratio that was relatively high (>68%).7 in the bone without tilting (Fig. 12.5E).

A B C D

E F G H

Fig. 12.5 Surgical insertion of an orthodontic implant in the palate. (A) Removal of the palatal mucosa with a special punch. (B) Removal of the mucosa with a periosteal
elevator. (C) The round bur as it is marking the implant position. (D) The twist drill preparing the implant bed. (E) Insertion with the special implant insertion device and
the manual torque wrench. The implant is driven to its final position at the high-gloss polished shoulder. (F) Immediately after insertion. (G) Postoperative view subsequent
to insertion of a healing abutment. (H) Peri-implantitis, caused by inadequate hygiene, observed following removal of the orthodontic device.
 Insertion and removal of orthodontic implants 77

Fig. 12.6 Removal of a palatal implant. (A) Using a special guiding

cylinder with a trepan bur. (B) Use of extraction forceps.

A B

The final positioning of the implant may be achieved using a torque tion. Up to 40 Ncm of extraction torque is needed, requiring a mechani-
wrench (Fig. 12.5F). Afterwards, the insertion device is removed and a cal torque wrench.
healing cap is attached manually to the implant to protect the inner threads
(Fig. 12.5G).
For postoperative care (the first 10 days), it is recommended to rinse REFERENCES
several times a day with chlorhexidine digluconate (0.2%), avoiding any
mechanical cleaning. 1. Pommer B, Frantal S, Willer J, et al. Impact of dental implant length on early failure
rates: a meta-analysis of observational studies. J Clin Periodontol 2011;38:856–63.
During the orthodontic loading period, thorough cleaning with a tooth- 2. Wehrbein H, Merz BR, Diedrich P, et al. The use of palatal implants for orthodontic
brush is essential to avoid infections that could lead to peri-implant com- anchorage: design and clinical application of the Orthosystem. Clin Oral Implants Res
plications or implant loss (Fig. 12.5H).9 1996;7:410–16.
3. Wehrbein H, Merz BR, Diedrich P. Palatal bone support for orthodontic implant
anchorage: a clinical and radiological study. Eur J Orthod 1999;21:65–70.
4. Bernhart T, Vollgruber A, Gahleitner A, et al. Alternative to the median region of the
palate for placement of an orthodontic implant. Clin Oral Implants Res
REMOVAL OF ORTHODONTIC IMPLANTS 2000;11:595–601.
5. Jung BA, Wehrbein H, Heuser L, et al. Vertical palatal bone dimensions on lateral
Once treatment is completed, the implant is removed using a special cephalometry and cone-beam computed tomography: Implications for palatal implant
placement. Clin Oral Implants Res 2011;22:664–8.
guiding cylinder with a trepan bur (Fig. 12.6A). The trepan bur has two 6. Jung BA, Harzer W, Wehrbein H, et al. Immediate versus conventional loading of
scales on the outside (6 and 4 mm), for the relative implant length, in palatal implants in humans: a first report of a multicenter RCT. Clin Oral Invest
line with the deep-seated preparation. Again, sufficient cooling is neces- 2011;15:495–502.
7. Wehrbein H. Bone quality in the midpalate for temporary anchorage devices. Clin Oral
sary during surgery. After preparation, the implant is removed with sur- Implants Res 2009;20:45–9.
rounding bone. Extraction forceps and slight rotation may support the 8. King KS, Lam EW, Faulkner MG, et al. Vertical bone volume in the paramedian palate
explantation (Fig. 12.6B) or controlled rotation without mechanical prep- of adolescents: a computed tomography study. Am J Orthod Dentofacial Orthop
2007;132:783–8.
aration can be used. A special adapter aids in gripping the implant, and 9. Männchen R, Schätzle M. Success rate of palatal orthodontic implants: a prospective
the bone–implant contact can be fractured by a counterclockwise rota- longitudinal study. Clin Oral Implants Res 2008;19:665–9.
 13 Insertion and removal of orthodontic miniplates
Ayça Arman Özçırpıcı, Sina Uçkan and Çağla Şar

Titanium miniplates designed for specific orthodontic purposes include

INTRODUCTION
the Skeletal Anchorage System (SAS),5 the Ballard miniplate (Surgitec,
Brussels, Belgium),6 the C-tube (0.036” diameter tube formed by curving
Miniplates offer excellent stability as temporary anchorage devices
the end of the miniplate; Martin, Tuttlingen, Germany)7 and miniplates
and have a wide range of applications including distalization of the
designed for the zygoma, apertura piriformis and symphysis regions
entire dental arch, maxillary protraction and molar intrusion. Conse-
(Tasarım Med, İstanbul, Turkey)4 (Fig. 13.1B–D).
quently, malocclusions that are challenging to treat with conventional
Miniplates and screws are classified based on the diameters of the fixa-
orthodontic mechanics can be managed by the orthodontist with the use
tion miniscrews, such as 1.0, 1.5, 2.0 or 2.3 mm systems. The surface areas
of miniplates.
of 2.0 mm or 2.3 mm screws are considerably larger than that of the
The application and removal of miniplates is more complex and time
1.5 mm screw and they have greater mechanical strength; however, the
consuming than that for palatal implants and miniscrew implants, particu-
risk of root damage increases as the diameter widens. When the diameter
larly since miniplate surgery requires transmucosal access, bone surface
is smaller than 2 mm, mechanical stability of the screw may not be suf-
preparation and insertion of two to four screws per plate. The miniplate
ficient for orthodontic anchorage. Both self-tapping and self-drilling
protocol includes minor surgery for placement and removal by a maxil-
screws can be used for fixation of miniplates.
lofacial surgeon. Despite these drawbacks, there are considerable advan-
The point where the plate arm is exposed or perforates the oral mucosa
tages, including maximal anchorage and safer placement away from the
is called the emergence point of the plate and is one of the most critical
roots of adjacent teeth.1
aspects that has to be taken into consideration during insertion.
Maxillary sites for miniplate fixation are limited to the zygomatic but-
tress1,2 and the apertura piriformis (anterior nasal aperture).3 Maxillary
fractures and Le Fort I osteotomies are also stabilized through these areas ZYGOMATIC ANCHORAGE
by miniplates. The zygomatic region has the thickest cortical bone in the
maxilla.2,4 Miniplates used for skeletal orthodontic anchorage are inserted to the
The mandible has a thicker cortical bone than the maxilla; the outer zygomatic process, apertura piriformis, mandibular symphysis and man-
cortical bone layer of the mandible is strong and thicker at the external dibular oblique ridge (Fig. 13.2), with the zygomatic process most fre-
oblique line and in the symphyseal region and is ideal for miniplate screw quently used.
stability. Anterior, infratemporal and orbital surfaces of the maxilla converge at
Primary stability of the miniplates is essential for absolute anchorage the zygomatic process. Anteriorly, the process merges into the facial
as is secondary stability throughout treatment. Orthodontic forces may be surface of the body of the maxilla. Posteriorly, it is concave and continuous
applied immediately upon insertion and there is no need to wait for with the infratemporal surface. Superiorly, it is roughly serrated for articu-
osseointegration. However, a small waiting period is recommended until lation with the zygomatic bone. Inferiorly, a bony arched ridge, the zygo-
primary soft tissue healing is achieved. maticoalveolar ridge of the jugal crest, separates the facial and infratemporal
surfaces.
TYPES OF MINIPLATES The zygomatic area may be used for molar distalization, posterior en
masse distalization, incisor retraction and en masse retraction in Class II
Because patients vary in anatomy, bone quality and quantity and the malocclusion as well as for molar intrusion in patients with open bite. This
desired orthodontic movement, a range of miniplate sizes is needed. The area may even be used for the correction of Class III malocclusion by
distance from the archwire to the anchorage head should be planned before using Class III elastics.
surgery and the miniplates should be selected accordingly.
Standard miniplates, used in maxillofacial surgery, are also used for
orthodontic anchorage but the emergence area is not rounded and they
SURGICAL TECHNIQUE
have sharp corners (Fig. 13.1A), which can cause delayed wound healing Placement and removal of miniplates is performed under local anesthesia
and more soft tissue irritation. and sedation, although general anesthesia may also be indicated. Following

A B C D

Fig. 13.1 (A) A miniplate used in maxillofacial surgery for fixation of bony segments. (B–D) Different types of miniplates used as skeletal anchorage for orthodontic
purposes.

78
 Insertion and removal of orthodontic miniplates 79

infiltration or posterior superior alveolar block with 4% articaine and most important anatomical structure in this area; generally it is away from
1/100 000 epinephrine (Ultracaine HCl) (Fig. 13.3A), a vertical or hori- the incision region but heavy retraction may cause inflammation at the
zontal incision (depending on the clinician’s preference or anatomy of the orifice of the duct and thus postoperative pain through inadequate drainage
buttress) is made at the buccal vestibule adjacent to the first and second and saliva retention.
molars, 1.5 cm above the coronal gingiva, while maintaining contact with A full-thickness mucoperiosteal flap should be raised and stripped with
the bone (Fig. 13.3B). Buccal muscle attaches to the buccal alveolus of periosteal elevators, exposing the zygomatic process of the maxilla (Fig.
molar teeth but, mostly, a zygomatic incision does not affect, or only mini- 13.3C). A soft tissue retractor is placed as soft tissue tension is very high
mally affects, this muscle. If the incision is made too high, there is a higher at this site and specially designed retractors may be helpful to overcome
risk of bleeding. Stenson’s duct orifice should be identified as this is the this tension (Fig. 13.3D). Plates should be chosen for each patient based
on the anatomy of the buttress area and the emergence point. Plates should
be bent and adapted precisely in all planes to achieve a passive bone–plate
fixation (Fig. 13.3E). Locking systems (special plates that have treads and
hold the screw) may also be used for zygomatic anchorage. The locking
screw has a special double-thread design that allows the threaded screw
head to engage the corresponding threaded plate holes on the miniplate
during insertion.8
At least two miniscrews should be inserted to avoid rotation and to resist
the orthodontic forces applied but three screws are preferred. The insertion
of the miniplate as high as possible accesses a better quality and quantity
of bone but retraction of soft tissues and insertion of the upper screws of
the miniplate are technically more difficult if the insertion is done under
local anesthesia. The first miniscrew should not be completely tightened
so that some rotation is available for adjustment of the plate to an ideal
position. Following insertion of the first miniscrew, the remaining screws
are fixed with a hand driver. Although bone thickness at the zygoma region
is better than in other areas of the maxilla, cortical bone quantity may still
not be sufficient for screw fixation particularly if the maxillary sinus
is highly pneumatized. Zygoma plates are fixed with either 2.0 mm or
2.3 mm diameter screws to increase stability. Surgical closure is performed
Fig. 13.2 Sites for insertion of miniplates for orthodontic anchorage purposes in with 4-0 sutures (Fig. 13.3F). Following surgery, pain killers (acetomi-
the maxilla and the mandible. nophen 500 mg three times a day), chlorhexidine gluconate (mouthwash

A B C

D E F

Fig. 13.3 Miniplate attachment for zygomatic anchorage. (A) Application of infiltration anesthesia. (B) Vertical incision at buccal vestibule adjacent to the first and second
molars, 1.5 cm above the coronal gingiva. (C) Exposure of the zygomatic buttress of the maxilla following elevation of periosteum. (D) A specially designed retractor for
zygomatic region. (E) Adaptation and fixation of the miniplate to the zygomatic buttress with three screws. (F) Closure of the incision with 4-0 sutures.
 80 SECTION IV: SURGICAL CONSIDERATIONS IN THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

three times daily) and amoxicillin trihydrate (500 mg three times a day)
for 4 days are prescribed.
Some problems may be encountered during surgery. The width of
attached gingiva may be too narrow in some patients for the emergence
point to be in attached keratinized gingiva or at least at the mucogingival
junction. If it is at the mobile (non-attached) gingiva, irritation of the sur-
rounding soft tissues, postoperative inflammation and infection can occur,
leading possibly to affect bone and cause loosening of the miniscrews.
Cheek or lip irritation may also occur during orthodontic treatment, which
can be avoided by precise bending of the exposed loop during surgery. If
bending of the loop is attempted postoperatively, the part close to the bone
should be held with one set of pliers while bending is performed with
another set in order to avoid excessive forces on the bone–screw
interface.
Other factors that can lead to loosening of screws are use of rectangular
miniplates, non-homogeneous force distribution along the miniplate, inser-
tion technique, duration of the applied orthodontic force and the patient’s
oral hygiene.
Patients should comply with the instructions regarding maintenance of
immaculate oral hygiene. Miniplates should be cleaned daily to prevent
inflammation. Moderate postoperative facial swelling generally occurs and
may remain a few days after surgery. Applying ice packs every 15 minutes Fig. 13.4 Positioning of a miniplate lateral to the aperture piriformis on an
in the early postoperative period may reduce the edema. anatomical skull model.
There may be moderate levels of discomfort and pain associated with
the placement surgery. An evaluation of pain perception in 15 patients who
had undergone miniplate insertion indicated that patients were concerned
about the surgical procedure before insertion.9 At 7 days after surgery, their thereby exposing the lateral nasal wall of the maxilla on both sides
score on a visual analogue scale (VAS) decreased remarkably. Before (Fig. 13.5A). An appropriate cortical bone area is found for the miniplates,
removal surgery, patients were again anxious as they had experienced pain with particular care to avoid any damage to the erupting canines. Mini-
during the insertion procedure but their VAS score had reduced signifi- plates are shaped according to the underlying anatomical structure and
cantly 24 hours after surgery and 88% stated that they would be prepared fixed in position with two monocortical miniscrews (diameter 1.5–2.0 mm,
to undergo this treatment modality in the future.9 Effective communication length 7 mm) (Fig. 13.5B). The incisions are sutured with 3-0 vicryl,
between patients and doctors can help to address the concerns of patients exposing the third hole of the plate into the oral cavity (Fig. 13.5C). Spe-
with regard to treatment-related pain. cially designed plates are used to avoid any soft tissue problems. If the
Patients should be clearly informed of the pain that they might experi- height of the maxilla is sufficient, insertion of three miniscrews may also
ence during miniplate insertion and removal and of possible complications be possible but insertion and removal of the third screw is usually difficult.
that might occur. Consequently, a third screw is only placed if the stability of the first two
screws is insufficient and the bone-plate interface is not rigid enough.
Drilling is performed bicortically at this area to achieve maximum bone
MINIPLATES ON APERTURA PIRIFORMIS contact and stability. As the total thickness of the bone is limited to a few
millimeters, drills may cause nasal mucosal perforation and bleeding. To
The anterior part of the medial nasal wall is also the lateral wall of the avoid this, a periosteal elevator should be inserted into the gap between
anterior nasal aperture. This structure is a relatively new site for orthodon- the lateral nasal wall and nasal mucosa.
tic anchorage (Fig. 13.4). In addition to Class II elastics, indications for
this site include maxillary protraction using face masks in patients with
Class III malocclusion and intrusion of maxillary incisors in patients with SYMPHYSEAL ANCHORAGE
deep bite.
The apertura piriformis is close to the maxillary midline and growing Miniplates are inserted into the symphysis region to anchor fixed func-
areas; therefore, the incision must be made away from the midline and tional appliances in growing patients with skeletal Class II malocclusion,
incisions and dissections should not be wide. The most important anatomi- and also for Class III elastics and intrusion of mandibular incisors in
cal landmarks are the lateral nasal branch of the facial artery, branches of patients with deep bite.
the infraorbital and angular arteries and the nasalis muscle. However, all The symphysis region is one of the best areas for screw insertion as the
these structures are away from the incision line and the risk of damage is cortical bone is relatively thick and the area can be reached easily (Fig.
unlikely in apertura incision for miniplate insertion. If the canine has not 13.6). Anteriorly, the upper external surface shows an inconstant faint
erupted and is positioned deeply in the maxilla, there is a risk of tooth median ridge, which indicates fusion of the halves of the fetal bone at the
damage as the plate and screws are inserted directly on the canine region. symphysis menti. Inferiorly, this ridge divides to enclose a triangular
mental protuberance; its base is centrally depressed but raised on each side
as a mental tubercle. The mental protuberance and mental tubercles con-
SURGICAL TECHNIQUE
stitute the chin. The mental foramen, from which the mental nerve and
A mucoperiosteal incision is made at the labial vestibule between the vessels emerge, lies below either the interval between the premolar teeth
maxillary lateral incisors and canines and a mucoperiosteal flap is elevated, or the second premolar tooth.
 Insertion and removal of orthodontic miniplates 81

A B C

Fig. 13.5 Miniplate attachment to the apertura piriformis. (A) Mucoperiosteal incisions at the labial vestibule of the maxilla on both sides. (B) Adaptation and fixation of
miniplates, lateral to the aperture piriformis. (C) Sutures exposing the third hole of the miniplate into the oral cavity.

Fig. 13.6 Positioning of a tissues tightly. Medication is prescribed as for zygomatic anchorage.
miniplate on the symphyseal Surface sutures are removed at the sixth postoperative day and orthodontic
region on an anatomical skull
force is applied at the tenth day.
model.

MINIPLATES ON THE RETROMOLAR (ANGULUS) AREA

The retromolar (angulus) area is another site for miniplate insertion (Fig.
13.8). A faint external oblique line ascends backwards from each mental
tubercle and becomes more marked as it continues into the anterior border
of the ramus. The lateral surface of the mandibular ramus is relatively
featureless and bears the external oblique ridge in its lower part. The
anterior border is thicker below where it is continuous with the external
oblique line. Near the second and third molar teeth, the external oblique
line is superimposed upon the buccal plate. The external surface of the
alveolus adjacent to the molar teeth gives attachment to the buccinator. A
SURGICAL TECHNIQUE number of muscles of facial expression are attached to the lateral surface
Following bilateral injection of articaine or lidocaine with 1/100 000 of the mandible.
epinephrine supraperiosteally (infiltrative) to buccal and lingual sites, a Miniplates inserted at this area are used for anchorage to obtain skeletal
1 cm horizontal incision is made transecting the mental muscle at both correction in growing patients with Class II malocclusion using Class II
sides. Care must be taken not to merge the two incisions; there should be elastics and for mandibular molar intrusion in open bite.
a gingival bridge of at least 1 cm between the incisions. This is extremely This area has even better bone quality than the anterior mandible and
important in order to avoid the unpleasant postoperative complication of is an ideal region biomechanically for initial screw stability. Miniplates
lip ptosis, caused by partial loss of function of the mental muscle. This are also inserted to this area following angular fractures or sagittal split
complication is intolerable in growing children. ramus osteotomies in maxillofacial surgery.8 The main disadvantages
Following dissection through the basis of the anterior mandible (Fig. include the requirement for adaptation of the plate and drilling. Since the
13.7A), the plates should be adapted accurately to be passive at the bone area is located posteriorly, insertion of miniscrews and drilling are rela-
surface without interacting with incisor roots, erupting canine or base of tively difficult and miniscrew insertion at 90° to the bone surface may not
the mandible. There are no major anatomical structures in this region; the always be possible. However, angled insertion of the screws does not
frenulum of the lower lip and mental nerve, artery and vein are the most jeopardize the biomechanics as the screw will have a longer length in bone.
apparent. The parasymphyseal incision is anterior to the mental foramen
and so vessel and nerves are generally away from the incision line. After
SURGICAL TECHNIQUE
bending the plates, the emergence point alignment should be made to
perforate the mucosa at the attached gingiva. Otherwise, inflammation and Anesthesia is with buccal infiltration of 1 ml of 4% articaine or lidocaine
screw loosening during the postoperative period can be seen. The plate with 1/100 000 epinephrine; alternatively a nerve block of the inferior
should be bent about 90° at the level of mucosal perforation to avoid pres- alveolar nerve and buccal nerve (branches of the mandibular nerve) can
sure over the soft tissues after screw tightening. be used. Generally, infiltration anesthesia is adequate for painless insertion
Screws, usually 2.0 mm diameter, are inserted to fix the plate in posi- of the plates in young children. A 1.0–1.5 cm anteroposterior incision is
tion; overtightening should be avoided to decrease stresses on cortical made at the buccal sulcus of the mandibular second molar. The incision
bone (Fig. 13.7B). Stability is double-checked and the wounds are closed should not extend through the ascending ramus as damage to the buccal
by 4-0 vicryl resorbable sutures. The mental muscle is sutured first and nerve (sensory branch of the mandibular nerve that innervates the muco-
then the mucosa; this double-layer closure helps the mental muscle to heal periosteum of molar area) is possible. Soft tissues including the periosteum
properly and sustains its function. are dissected and retracted. Plates are adapted and held at the desired posi-
Following suturing of the mucosa, a final suture that turns around the tion before fixing with miniscrews (diameter 2.0 mm). As the bone is thick
neck of the plate helps healing of the most critical area by sealing the soft and dense in this region, overtightening is possible and should be avoided
 82 SECTION IV: SURGICAL CONSIDERATIONS IN THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

A B

Fig. 13.7 Miniplate attachment to the symphysis region. (A) Exposure of the cortical bone
following the dissection of the periosteum at the symphyseal region; (B) Implantation of
miniplates with two miniscrews in the symphyseal region of the mandible. It is crucial to keep the
frenulum labii inferior and mentalic muscle between two miniplates safe.
Fig. 13.8 Positioning of a miniplate on the retromolar region
of an anatomical skull model.

A B C

Fig. 13.9 The procedure for removal of a miniplate. (A) The exposed miniplate. (B) A specially designed screwdriver is used to remove the miniscrews. (C) The incision is
sutured.

in order not to cause necrosis due to pressure. Soft tissues are closed by
ACKNOWLEDGMENTS
4-0 vicryl sutures. Medication is prescribed as for zygomatic anchorage
and the sutures are removed at the sixth postoperative day. The authors wish to thank the faculty of the Department of Anatomy,
School of Medicine, Baskent University, for their valuable contributions.
REMOVAL OF THE MINIPLATES
REFERENCES
Miniplate removal requires a mucoperiosteal incision under local anesthe-
sia to expose the plate and screws (Fig. 13.9A). Although complete 1. Chung KR, Kim YS, Linton J, et al. The miniplate with tube for skeletal anchorage. J
osseointegration of the miniscrews does not occur, there will be some new Clin Orthod 2002;36:407–12.
2. Ding P, Zhou YH, Lin Y, et al. Miniplate implant anchorage for maxillary protraction
bone deposition around the plates and the screws and rotational equipment in Class III malocclusion. Zhonghua Kou Qiang Yi Xue Za Zhi 2007;5:263–7.
may be necessary to remove the bone over the miniscrew head. In contrast, 3. De Clerck H, Geerinckx V, Siciliano S. The zygoma anchorage system. J Clin Orthod
some screws may be loosened and even a small bony defect may occur. 2002;36:455–9.
4. Erverdi N, Usumez S, Solak A. New generation open-bite treatment with zygomatic
Any granulation tissue should be removed by small bone curettes. Screw- anchorage. Angle Orthod 2006;76:519–26.
drivers should be inserted very carefully over the riffle of the miniscrew 5. Sugawara J, Kanzaki R, Takahashi I, et al. Distal movement of maxillary molars in
heads to avoid wear to the heads (Fig. 13.9B). Finally the incision is nongrowing patients with the skeletal anchorage system. Am J Orthod Dentofacial
Orthop 2006;129:723–33.
sutured with 4-0 vicryl (Fig. 13.9C) and the patient is instructed to use 6. De Clerck HJ, Cornelis MA. Biomechanics of skeletal anchorage. Part 2: class II non-
chlorhexidine mouth rinses for 2–3 days after surgery. The soft tissue extraction treatment. J Clin Orthod 2006;40:290–8.
repair is inspected and the sutures removed after 6 days. Recovery is 7. Chung KR, Kim YS, Lee YJ. The miniplate with tube for skeletal anchorage. J Clin
Orthod 2002;36:407–12.
mostly smooth and no scar tissue remains following this period. 8. Oguz Y, Saglam H, Dolanmaz D, et al. Comparison of stability of 2.0 mm standard and
2.0 mm locking miniplate/screws for the fixation of sagittal split ramus osteotomy on
sheep mandibles. Br J Oral Maxillofac Surg 2011;49:135–7.
9. Tseng YC, Chen CM, Wang HC, et al. Pain perception during miniplate-assisted ortho-
dontic therapy. J Med Sci 2010;26:603–8.
CONCLUSIONS

New types of miniplate design with more variability in length or prebent

to fit specific anatomical sites would be advantageous. In addition, the use
of resorbable materials such as poly-L-lactic/polyglycolic acid would
avoid the need for removal surgery.
 Insertion and removal of orthodontic
miniscrew implants
14
Fadi Tarawneh and Moschos A. Papadopoulos

general, buccal cortical bone thickness seems to be greater in the mandible

INTRODUCTION
than in the maxilla, and increases gradually in the apical direction.5,6 Males
In general, insertion of miniscrew implants (MIs) should be as non- and adults have thicker cortical bone than females and adolescents.5,6 A
invasive as possible, in order to reduce postoperative patient discomfort pilot hole is most important for inserting self-drilling MIs in the mandible
and to avoid irritation and inflammation of the peri-implant tissues. The and in an apical location, more specifically between the first and second
insertion procedure for a MI is usually given by the manufacturer; however, mandibular molars.5
certain general issues should be taken into consideration and these are A pilot drill is always necessary for insertion of non-self-drilling MIs.
outlined in this chapter The procedure is performed in a surgical environment and if possible by
an oral surgeon. The soft tissue from the site is either incised or removed
using a soft tissue punch (see Fig. 11.1). Then, the pilot hole is drilled,
PREPARATIONS BEFORE INSERTION usually using a handpiece (see Fig. 18.6D). A speed of 500–1000 rpm is
usually sufficient for cortical bone perforation but should not exceed
ANESTHESIA 1500 rpm.1,2 Copious irrigation and cooling with sterile saline helps to
minimize overheating, which can lead to bone necrosis and implant
Soft tissue anesthesia is usually sufficient for the insertion of MIs and can failure. Cortical bone can be predrilled manually with a sharp drill of
usually be achieved with topical anesthetics, gels or creams; some patients high cutting efficiency to minimize heat production. Pilot drilling is an
may need a small amount of local anesthetic. Block anesthesia is rarely invasive procedure with the potential to introduce microbial contamina-
required and should be avoided as it could mask signs of root contact tion and so it is recommended that the drill is not reinserted into the hole
during insertion, which could lead to root injury.1 once it is made. To avoid fractures and high bone stresses, optimum pre-
drilling diameters should be chosen: the pilot drill must be approximately
SOFT TISSUE PREPARATION 0.2–0.3 mm thinner than the diameter of the MI to be used. Although
drilling a pilot hole makes the procedure more complicated and more
Self-drilling MIs can usually be inserted directly through the gingival time consuming, it provides a fixed path of insertion for the MI, which,
tissue or the mucosa without any need for soft tissue or bone manipulation. in turn, minimizes the risk of injuring adjacent roots or insertions into
In contrast, non-self-drilling MIs are inserted only after removal of the soft the sinus.
tissue covering the insertion site, either through a gingival flap incision or
a soft tissue punch (see Fig. 11.1).1–3
Raising a gingival flap has been associated with pain, discomfort and INSERTION OF MINISCREW IMPLANTS
inflammation that might last up to a week after surgery but use of the
procedure does not influence success rates.4 Use of a flap has been advo- Insertion of implants can be performed either manually with the use of
cated in some circumstances, such as for insertion in the mandibular screwdrivers (Fig. 14.1A) or mechanically with a specially angled hand-
symphysis. When a MI has to be inserted in the frenum area, a frenectomy piece that permits adjustment of torque through altering the speed of the
is suggested to prevent possible mechanical irritation around the implant handpiece (see Fig. 16.5C). For implant insertion, a speed up to 30 rpm is
during function.2 If possible, these areas should be avoided to simplify the usually adequate and should not exceed 60 rpm.1,2 Ratchets are also avail-
soft tissue issues. able that help to work with MIs in different locations (Fig. 14.1B). Some
even provide an adjustable torque control ranging from 5 to 30 Ncm. Once
the desired torque is reached, the ratchet bends preventing further force
PILOT DRILLING application.1
Self-drilling MIs do not require pilot drilling except when they have to be Insertion torque magnitude depends on factors such as bone thickness,
inserted in sites presenting with thick cortical bone where the high force bone quality, size and design of the MI, as well as method and velocity of
required can cause excessive bone compression, which might decrease insertion.1 It is recommended that insertion of MIs should be carried out
secondary stability of MIs or lead to MI fracture during insertion. In at a slow and steady rate, with low and continuous forces so that the load

Fig. 14.1 Manual insertion of a MI using a screwdriver (A) and a

rachet (B).

A B

83
 84 SECTION IV: SURGICAL CONSIDERATIONS IN THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

on both the MI and bone is kept low. Motoyoshi et al.7 have recommended teeth, except in the area of the maxillary sinus, where a more perpendicular
an insertion torque of 5–10 Ncm to avoid bone damage. angulation is favored in order to avoid any damage to the sinus.15 In the
Controlling torque magnitude, particularly for insertion, seems to be mandible, the MIs should be inserted as parallel to the roots as possible if
clinically very significant but is not always easy to achieve, particularly teeth are present, or with a 10–20° angulation.15,16
when using self-drilling MIs inserted manually.1 Insertion torque and
direction is easier to control with non-self-drilling MIs, which require a
pilot hole. The required insertion torque is also lower and so there is less POSSIBLE SITES FOR PLACEMENT
risk of bone compression or MI fracture.8,9 However, both non-self-drilling OF MINISCREW IMPLANTS
and self-drilling MIs show similar resistance to lateral forces.10 There is
still the potential for trauma if the predrilling procedure is not carefully Determination of the best site for placement of a MI is made using radi-
controlled to avoid overheating. ography, casts and clinical examination to assess buccolingual depth and
There is more risk of root injury with self-drilling MIs because of the thickness of the cortical bone, soft tissue characteristics, inter-radicular
increased difficulty in controlling the insertion path. There is also a greater distance, sinus morphology, nerve location, biomechanical considerations
risk of excessive bone compression because of the higher torque values and accessibility.5
needed, particularly when the cortical bone is thicker than 1.5 mm, leading
to loss of secondary stability.8,11 Some reports suggest that self-drilling MIs
MAXILLA
have less mobility and more bone–implant contact than the non-self-
drilling types.1,12 Possible sites for MI placement in the maxilla include the area below the
As a general guideline, self-drilling MIs are favored by most clinicians, nasal spine, the palate (on the median or paramedian area), the infrazygo-
particularly when cortical bone is thin, such as in several sites in the matic crest, the maxillary tuberosities and the alveolar process (both buc-
maxilla, while non-self-drilling MIs are preferable in sites where the corti- cally and palatally between the roots of the teeth) (Fig. 14.2).
cal bone is thick, as in the mandible. Placement recommendations accord- In the maxilla, the more anterior and the more apical the location, the
ing to cortical bone thickness are shown in Table 14.1. safer for insertion of a MI.5,16 The optimal site in the anterior region is
between the roots of the central and the lateral incisor, approximately
6 mm from the cementoenamel junction. Buccally, the optimal sites are
DIRECTION OF MINISCREW IMPLANT INSERTION between the second premolars and the first molars and between the first
Placing MIs perpendicular to the bone surface is not always possible, and second molars (see Fig. 40.1C,D).
particularly when teeth are present and root injury is to be avoided.13 Many Palatally, the best site is between the first and second premolars, since
authors recommend a more oblique insertion rather than perpendicular if it presents the highest cortical bone thickness. The least amount of bone
this achieves better implant–cortical bone contact.14 Inter-radicular space was found to be in the tuberosity and at the wisdom teeth, which was not
increases in an apical direction but so does movable mucosa. If the avail- considered suitable for MI insertion.
able space between two adjacent roots is small, a more oblique direction Within the palate, the paramedian region is considered as the safest site
of insertion seems to be favorable to minimize the risk of root contact.2 for MI placement as it has the greatest amount of ossified tissue in the
In the maxilla, it is recommended to insert MIs at an oblique angle in palate and is away from the roots of neighboring teeth. Alternative to the
an apical direction with an angulation of 30–45° to the long axes of the median region of the palate, the greatest amount of bone support was found
6–9 mm posterior to the incisive foramen and 3–6 mm paramedially;19 a
more recent study showed that orthodontic MIs could be effectively
inserted in palatal areas if placed approximately 3 mm posterior to the
Table 14.1 Placement recommendations according to cortical
incisive foramen and 1–5 mm the paramedian.20
bone thickness
The midpalatal suture has sufficient bony support for implants with a
Cortical bone diameter ranging from 4 to 6 mm (see Fig. 16.5).19,20 However the suture
thickness (mm) Recommendation
is sinuous and interdigitized and may not be fully ossified (closed) even
<0.5 Implant placement not recommended in adults;19,22 consequently, since MIs are provided with a maximum diam-
0.5–1.5 Predrilling not necessary
eter of 2.3 mm, their insertion in the midpalatal suture area should be
1.5–2.5 Predrilling of the cortical plate recommended in
order to decrease compression and unwanted
avoided since there is an increased possibility that a significant part of their
effects to the bone endosseous surface would be within the suture and so not in contact with
bone.

A B
Fig. 14.2 Examples of possible sites for miniscrew implant placement and direction of insertion in the maxilla in frontal (A) and lateral (B) view.
 Insertion and removal of orthodontic miniscrew implants 85

A B

Fig. 14.3 Examples of possible sites for miniscrew implant placement and direction of insertion in the mandible in frontal (A) and lateral (B) view.

A B C

Fig. 14.4 Determination of insertion location for a miniscrew implant using a surgical guide. (A) The surgical guide equipped with several custom-made wire extension
arms in the mouth of the patient. (B,C) Periapical radiographs of the anterior teeth of the same patient depicting the position of the wire extensions for the evaluation of
the quality of the bone, the dimensions of the inter-radicular spaces and the height of the alveolar bone in the possible insertion areas.

MANDIBLE insertion site (Fig. 14.4).15 An adjustable surgical guide, usually fabricated
from wires, silicone and acrylic material, or a stent can be used for place-
Possible sites for the insertion of MIs in the mandible include the symphy- ment of MIs.25,26 Chapters 16–18 contain more details of the use of surgical
sis or parasymphysis, the alveolar process (between the roots of the teeth) guides.
and the retromolar area (Fig. 14.3).15
The safest sites are between the lateral incisor and the canine at 6 mm
from the cementoenamel junction, between the first molar and second
premolars, and between the first and second molars (see Fig. 40.1C,D).5,23 INFECTION CONTROL AFTER INSERTION
However, while adequate bone is located more than halfway down the root
length, this area is likely to be covered by movable mucosa and so there Infection control is vital to avoid peri-implantitis and consequent prema-
is more risk of soft tissue irritation. To overcome this problem, modifica- ture loss and failure of MIs (see Fig. 9.3).1,27 The risk of infection and
tion of the MI head design or placement technique (such as using an inflammation can be reduced by ensuring a sterile environment during MI
oblique insertion direction) may be necessary.23 insertion, placing the implants in attached gingiva and following the
advised insertion procedures. After this, the patient must maintain an
immaculate oral hygiene, similar to that after tooth extraction, but with
SOFT TISSUE CONSIDERATIONS FOR MINISCREW specific instructions on attention to the MI during teeth brushing and how
IMPLANT INSERTION to properly clean the area surrounding the MI as well as the head of the
MI. Antibiotics are not needed, but mouthwashes and disinfectant rinses
Placement within the attached gingiva, where proper soft tissue sealing help the patient to maintain good oral hygiene. The patient must be
can occur, has been associated with fewer soft tissue complications and instructed to avoid manipulating the MI with fingers, tongue or lips, or
failure risks in comparison with placement in the movable mucosa.1,7 with foreign objects such as pens or pencils.
Healing and health of the peri-implant gingival tissues and the status of
the patient’s oral hygiene must be regularly reviewed by the clinician
INTER-RADICULAR SPACE CONSIDERATIONS throughout the time that the MI remains in function.
FOR MINISCREW IMPLANT INSERTION

It is considered that a minimum of 3 mm space is needed for the safe REMOVAL OF MINISCREW IMPLANTS
placement of MIs when they are inserted inter-radicularly.16,23,24
Taking an intraoral radiograph with a surgical guide greatly assists in Usually, the removal of MIs is uncomplicated and easily accomplished in
identification and assessment of a specific inter-radicular region for MI one appointment using the same screwdriver as for the insertion. Local
 86 SECTION IV: SURGICAL CONSIDERATIONS IN THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

5. Fayed MM, Pazera P, Katsaros C. Optimal sites for orthodontic mini-implant place-
ment assessed by cone beam computed tomography. Angle Orthod 2010;80:939–51.
6. Ono A, Motoyoshi M, Shimizu N. Cortical bone thickness in the buccal posterior
region for orthodontic mini-implants. Int J Oral Maxillofac Surg 2008;37:334–40.
7. Motoyoshi M, Hirabayashi M, Uemura M, et al. Recommended placement torque
when tightening an orthodontic mini-implant. Clin Oral Implants Res 2006;17:
109–14.
8. Sowden D, Schmitz JP. AO self-drilling and self-tapping screws in rat calvarial
bone: an ultrastructural study of the implant interface. J Oral Maxillofac Surg 2002;60:
294–9.
9. Wilmes B, Drescher D. Impact of insertion depth and predrilling diameter on primary
stability of orthodontic mini-implants. Angle Orthod 2009;79:609–14.
10. Su YY, Wilmes B, Hönscheid R, et al. Comparison of self-tapping and self-drilling
orthodontic mini-implants: an animal study of insertion torque and displacement under
lateral loading. Int J Oral Maxillofac Implants 2009;24:404–11.
Fig. 14.5 The wound seen immediately after removal of two miniscrew implants 11. Böhm B, Fuhrmann R. Clinical application and histological examination of the FAMI
that were inserted in the paramedian region of the anterior palate. screw for skeletal anchorage: a pilot study. J Orofac Orthop 2006;67:175–85.
12. Kim JW, Ahn SJ, Chang YL. Histomorphometric and mechanical analyses of the drill-
free screw as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2005;128:
190–4.
anesthetic is not usually needed, although it might be used to avoid patient 13. Dalstra M, Cattaneo PM, Melsen B. Load transfer of miniscrews for orthodontic
discomfort or if there is tissue covering the MI. The linking elements of anchorage. Orthodontology 2004;1:53–62.
14. Motoyoshi M, Yoshida T, Ono A, et al. Effect of cortical bone thickness
the orthodontic mechanism are first removed and then the MI is simply and implant placement torque on stability of orthodontic mini-implants. Int J Oral
unscrewed. The resulting small wound requires no special care beyond Maxillofac Implants 2007;22:779–84.
normal dental hygiene and can be gently swabbed with 0.2% chlorhexi- 15. Carano A, Velo S, Leone P, et al. Clinical applications of the Miniscrew Anchorage
System. J Clin Orthod 2005;39:9–24.
dine. The wound left from the removal of a MI is minimal and usually 16. Poggio P, Incorvati C, Velo S, et al. Safe zones: a guide for miniscrew positioning in
closes within a few days (Fig. 14.5). In most cases, healing continues the maxillary and mandibular arch. Angle Orthod 2006;76:191–7.
uneventfully. 17. Bernhart T, Vollgruber A, Gahleitner A, et al. Alternative to the median region of
the palate for placement of an orthodontic implant. Clin Oral Implants Res 2000;11:
If a MI is very tight and cannot be removed at once, it is advised to wait 595–601.
3 to 7 days before retrying as microfractures or bone remodeling at the 18. Moon SH, Park SH, Lim WH, et al. Palatal bone density in adult subjects: Implications
peri-implant surfaces following the initial attempt at removal will lead to for mini-implant placement. Angle Orthod 2010;80:137–44.
19. Henriksen B, Bavitz B, Kelly B, et al. Evaluation of bone thickness in the anterior
loosening of the MI. If during removal the MI fractures flush with the hard palate relative to midsagittal orthodontic implants. Int J Oral Maxillofac Implants
bone, the shaft might need to be removed with a trephine. In such cases, 2003;18:578–81.
referral to an oral surgeon or periodontist might be needed to remove the 20. Gahleitner A, Podesser B, Schick S, et al. Dental CT and orthodontic implants:
Imaging technique and assessment of available bone volume in the hard palate. Eur J
retained fractured part of the MI.2 Radiol 2004;51:257–62.
21. Melsen B. Palatal growth studied on human autopsy material: A histologic microradio-
graphic study. Am J Orthod 1975:68:42–54.
22. Persson M, Thilander B. Palatal closure in man from 15 to 35 years of age. Am J
REFERENCES Orthod 1977;72:42–52.
23. Schnelle MA, Beck FM, Jaynes RM, et al. A radiographic evaluation of the availability
1. Ludwig B, Baumgaertel S, Bowman J. Mini-implants in orthodontics: innovative of bone for placement of miniscrews. Angle Orthod 2004;74:832–7.
anchorage concepts. Hanover Park, IL: Quintessence; 2008. 24. Chaimanee P, Suzuki B, Suzuki EY. “Safe Zones” for miniscrew implant placement
2. Lee J, Kim J, Park Y, et al. Applications of orthodontics mini-implants. Hanover Park, in different dentoskeletal patterns. Angle Orthod 2011;81:397–403.
IL: Quintessence; 2008. 25. Kitai N, Yasuda Y, Takada K. A stent fabricated on a selectively colored stereolitho-
3. Kuroda S, Sugawara Y, Deguchi T, et al. Clinical use of miniscrew implants as ortho- graphic model for placement of orthodontic mini-implants. Int J Adult Orthodon
dontic anchorage: Success rates and postoperative discomfort. Am J Orthod Dentofa- Orthognath Surg 2002;17:264–6.
cial Orthop 2007;131:9–15. 26. Suzuki EY, Buranastidporn B. An adjustable surgical guide for miniscrew placement.
4. Moon CH, Lee DG, Lee HS, et al. Factors associated with the success rate of ortho- J Clin Orthod 2005;39:588–90.
dontic miniscrews placed in the upper and lower posterior buccal region. Angle Orthod 27. Park HS, Jeong SH, Kwon OW. Factors affecting the clinical success of screw implants
2008;78:101–6. used as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2006;130:18–25.
 Selecting a suitable site for miniscrew
implant insertion
15
Antonio Gracco and Giuseppe Siciliani

contra-angle driver. Either could be used for insertion into the zygomatic
INTRODUCTION
crest or the external oblique line.
The choice of site for orthodontic miniscrew implants (MIs) is fundamen-
tal to success for many reasons, including primary stability, protection of
neighboring anatomical structures, biomechanics to apply and patient SOFT TISSUE CHARACTERISTICS
comfort.
Several anatomical sites for the insertion of MIs have been proposed
TISSUE TYPE
(Table 15.1). Factors determining suitability include: The most suitable site for MI insertion is between the clinically invisible
osseous alveolar crest and the clinically evident mucogingival junction
■ ease of access to the insertion site
(Fig. 15.1).1 Attached mucosa guarantees greater MI stability and ensures
■ soft tissue characteristics
a better seal around the MI neck. If a MI is inserted into unattached
■ bony tissue characteristics
gingiva or in the immediate vicinity of a mucosal frenulum, the excessive
■ anatomical characteristics.
mobility of the gingiva can lead to soft tissue irritation, compromising MI
These are discussed in this chapter. stability.1
Adaptation of the tissues around the MI is considered important for
good MI stability. Therefore, in order to prevent capturing of unattached
EASE OF ACCESS TO THE INSERTION SITE mucosa on the MI thread during insertion, a soft tissue punch or diode
laser can be used to remove a portion of the mucosa from the correspond-
Two factors influence ease of access: the position of the orthodontist with ing site (with dimensions approximately equal to the diameter of the MI)
respect to the patient’s head and the use of screwdrivers specific for the prior to MI insertion.
site in question. The MI neck is usually smooth to prevent irritation (see Fig. 6.7) but
The orthodontist requires an unimpeded view of the insertion site, either some carry microgrooves to aid connective tissue adhesion and hamper
directly or via a mirror, without causing discomfort to either patient or epithelial invagination (see Fig. 6.6). Many MIs also have a platform to
practitioner. As a certain amount of force will be required to counteract compress the gingiva and prevent it riding up and covering the head (see
the corresponding one generated during MI insertion, the practitioner’s Fig. 6.7). Provisional use of light-cure composite or winding of an elastic
hand or indeed the whole body may be needed to supplement the resistance around the MI head may also help to prepare the tissues.
provided by the patient.
Most maxillary and mandibular alveolar areas can be reached with
ease using a straight screwdriver of a suitable tip length but some sites, MUCOSAL THICKNESS
such as the median and paramedian palatal, the maxillary tuberosity and MI length is chosen to ensure that it will pass through the thickness of the
the mandibular retromolar areas, can be more easily reached using a mucosa and have sufficient contact with bone for stability. In the maxilla,
the greatest mucosal thickness is generally found on the palatal side of the
premaxilla (mean, 3.38 mm) and on the median area of the hard palate
Table 15.1 Insertion sites for miniscrew implants
(mean, 3.06 mm). In the mandible, the retromolar mucosa tends to be
Areas Sites thickest (mean, 3.02 mm) (Fig. 15.2). The thickness of attached gingiva is
Alveolar areas also influenced by the patient’s gender. In males, the following areas
Maxilla Buccal alveolus feature greater mucosal thickness in both jaws:2
Palatal alveolus
■ between the central and lateral incisors
Alveolar crest
■ between the lateral incisors and canines
Maxillary tuberosity
■ between the canines and first premolars
Mandible Buccal alveolus
■ between the first and second premolars.
Lingual alveolus
Alveolar crest Soft tissue thickness is evaluated by various methods including the
Retromolar area so-called direct methods such as an ultrasonic or a periodontal probe with
Non-alveolar areas an endodontic stopper (the latter employed after local anesthesia).3 Ultra-
Maxilla Hard palate (median and paramedian zones) sound shows greater mucosal thickness at the anterior and premolar areas
Zygomatic crest of the labial side of the maxilla than the corresponding areas of the man-
Mandible External oblique line dible, with the mandibular labial area thicker at the molar region. In
contrast, on the palatal side of the maxilla, the greatest thicknesses are

87
 88 SECTION IV: SURGICAL CONSIDERATIONS IN THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

Fig. 15.1 Reference points for MI insertion. (A) Intraoral points. (B)
Radiographic points. Black dots, points of interproximal contact;
white dashed line, crestal bone; red dashed line, mucogingival
border (in A) and lower wall of maxillary sinus (in B).

A B

Fig. 15.2 Miniscrew of cortical to medullary bone, four types of bone quality can be identified,
implant inserted into the in order of descending compactness:4
retromolar triangle in
order to upright an ■ type I: compact bone consisting predominantly of cortical bone
impacted second molar. ■ type II: bone featuring thick, compact cortex and a dense internal
Note the length of the
network of trabeculae
threaded portion of the
core that penetrates the ■ type III: bone featuring thinner cortex and less dense spongiosa
bone and the quantity of ■ type IV: bone featuring thin cortex and sparsely distributed
soft tissue covering the trabeculae.
miniscrew implant head.
A modified version of this classification, based not only on the ratio of
cortical to medullary bone but also on the macroscopic characteristics of
the bony tissue, was proposed in 1987 by Misch, who identified five dif-
ferent bone densities (D1–D5) (Fig. 15.4).5 The bone densities pertaining
to Misch’s classification can be expressed in Hounsfield units (quantitative
scale for describing radiodensity) (Table 15.2).
Bone quality can be accurately determined by CT; however, expert
surgeons can distinguish D1 and D4 by touch alone.
It seems that bone quality and quantity at the insertion site is linked to
found between the first premolars and the adjacent canines and second
mechanical retention rather than to osteointegration.6 Hence, relative
premolars.
thickness of the cortex becomes an important factor in ensuring primary
stability, with a thickness of at least 1 mm being required. It is considered
that at least 71.2% of the screw length should penetrate alveolar bone,
BONY TISSUE CHARACTERISTICS
particularly in the maxilla, where this percentage may need to be even
higher.7 The MI core should penetrate bone to a depth of at least 5 mm in
TISSUE QUALITY, QUANTITY AND AGE-RELATED
the mandible and 6 mm in the maxilla in order to guarantee stability over
DIFFERENCES
the whole period necessary for dental movements.
The quality of bone refers to its density and thickness, both of which vary Even with adequate bone, secondary stability can be compromised by
with age. the excessive application of forces during MI insertion, which increases
The alveolar process is the part of the maxilla and mandible that forms friction and potentially causes bone trauma. Hence, preparation of the
and supports the dental alveoli. The alveolar walls are lined with compact insertion site by soft tissue punch (see Fig. 11.1) or by flap elevation and
bone, while spongy bone is found in the areas between the cortical walls. predrilling is recommended for thick cortical bone.
The dimensions of these areas are mainly determined by genetics, but they Another means of improving stability is inserting the MI through two
can be influenced also by the functional forces of the dentition. The greater layers of cortical bone, thereby considerably reducing the load on the
part of the interdental septa is filled with spongy bone, but the majority of trabecular layer between them (Fig. 15.5).8
the bone at the labial and palatal surfaces is compact (Fig. 15.3).
The compact bone covering the root surfaces is considerably thicker on
the palatal side than the labial side of the maxilla, whereas in the mandible
MAXILLARY INSERTION SITES
the compact bone at the buccal surface of the incisors and premolars is far Based on these considerations, possible insertion sites in the maxilla
thinner than that at the lingual side. This contrasts with the molar region include:9
of the mandible, where greater compact bone thickness is present at the
■ the buccal sides
labial rather than the lingual surface.7
■ the posterior palatal sides
Bone quality is also affected by conditions such as edentulism. After
■ the median and paramedian palatal areas
tooth loss, the quality of bone in the surrounding area diminishes with
■ the anterior nasal spine and anterior alveolar bone
time. Bone quality is also affected by the presence of muscle insertions,
■ the infrazygomatic crest.
pre- or postedentulous parafunctions, hormone and systemic conditions.
The maxilla and mandible are characterized by anatomical regions of When contemplating insertion into the buccal side of the maxilla, it is
varying degrees of mineralization and cortical thickness; based on the ratio worth bearing in mind that the greatest buccopalatal bone width is found
 Selecting a suitable site for miniscrew implant insertion 89

Fig. 15.3 Axial sections of the maxilla to show bone

thickness and inter-radicular distances. (A,B) Variation in
labial and lingual thickness of cortical bone and in inter-
radicular distances between anterior and posterior teeth in a
section at the cementoenamel junction (A) and halfway up
the root length (B). (C) Section at the central third of the
roots showing the greater inter-radicular distances on the
palatal than the labial side. (D) Section at the apical third of
the roots. Note the appearance of the maxillary sinus, which
invaginates between the roots of the posterior teeth.

A B C D

Fig. 15.4 Areas with different bone densities according to Misch’s

classification on the palatal side of the maxilla (A) and in lateral view
of the craniofacial complex (B).

A B

between the first and second molars, 5 mm from the alveolar crest (Fig.
Table 15.2 Misch’s classification of bone densities
15.6B).9 In contrast, the greatest thickness of cortical bone is located in
Type Bone density Anatomical site
the inter-radicular space between the first and second premolars.10
Compact cortical bone Mandible: symphyseal With regard to posterior palatal insertion, the smallest quantity of bone
featuring little medulla and parasymphyseal (0.2 mm) on both the buccopalatal and mesiodistal planes is at the maxil-
(>1250 HU) regions
lary tuberosity.9
D1
One of the most favorable insertion sites is the area around the median
Bone featuring thick Maxilla: anterior region and paramedian sutures. This area is characterized by type D1 bone. The
cortex and dense Mandible: anterior and width of the palatal cortex decreases incrementally from the anterior to the
internal trabecular posterior regions
D2 structure (850–1250 HU) posterior section. There is a similar trend in total bone depth in the median
area, which decreases proportionally to the distance from the midsagittal
Thin cortex and wide, Maxilla: anterior and plane.11 Consequently, the most favorable palatal sites for MI insertion are
cavernous internal posterior regions
trabecular structure Mandible: posterior
located between 6 and 9 mm posterior to the incisal foramen, and in the
D3 (350–850 HU) region paramedian area between 3 and 6 mm from the midpalatal suture.
The suitability of a paramedian insertion site will need to be based on
Mainly spongy bone Maxilla: posterior region the patient’s age as the palatal suture in growing patients is unlikely to be
with very little cortex
(150–350 HU) completely ossified; consequently, two MIs in the paramedian zone might
D4 be preferable to ensure good primary stability.
Patient age is significant for other reasons: areas with unerupted perma-
D5 Immature bone Immature bone nent teeth should be avoided and bone density is decreased in growing
(<150 HU)
patients. Therefore, in adolescents, insertion areas with more compact
bone are preferred, such as the palate, bearing in mind the necessity to
HU, Hounsfield unit. avoid excessive loading of forces (<100–150 g) because of poor bone
Source: from Misch, 1990.5 quality. It does appear that MI failures are far more common in adolescents
than in adults.6
 90 SECTION IV: SURGICAL CONSIDERATIONS IN THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

Fig. 15.5 Finite element modeling of a miniscrew

implant inserted into bone. (A) Monocortical
anchorage showing the distribution of stresses in the
external cortex at the screw–bone interface. (B) The
effect of bicortical anchorage.

A B

Fig. 15.6 Palatal sites for miniscrew implant (MI) insertion. (A)
Tomographic image of a paramedian sagittal section, showing a MI
inserted into the palate. Note the tip of the implant penetrates the
upper layer of cortical bone, thereby providing bicortical anchorage.
(B) Three-dimensional construction from cone beam CT showing a
MI inserted into the palate between the first and second maxillary
molars.

A B

Cortical bone is significantly thicker in adults in all areas except the the canine and first premolar.9,14 It is also suggested that MIs should be
infrazygomatic crest, between the first and second molars on the buccal inserted 4–6 mm away from the alveolar crest since the cortical bone is
side of the mandible and on the posterior paramedian area of the palate.6,10 significantly thicker in this area (Table 15.3).10,15 Based on bone thickness
The area around the anterior nasal spine and the anterior alveolar bone evaluation, the safest sites for MI insertion in the mandible are the follow-
has bone of D2 type.12 The greatest buccolingual thickness in this area is ing, in order of decreasing stability:9
found between the central and lateral incisors, 6 mm from the cemento­
■ between the first and second molars (all depths)
enamel junction. The greatest mesiodistal thickness is located between the
■ between the first and second premolars (all depths)
two central incisors, 6 mm from the cementoenamel junction.10
■ between the second premolars and first molars, 11 mm from the
Bone thickness of the infrazygomatic crest at the maxillary first molar
alveolar crest
is generally between 5.2 and 8.8 mm, allowing a MI insertion angle of 40
■ between the canines and first premolars, 11 mm from the alveolar
to 75° with respect to the upper occlusal plane. Since 6 mm is considered
crest.
as the minimum thickness of the infrazygomatic crest required to effec-
tively support a MI, the insertion should be performed 14–16 mm above
the maxillary occlusal plane at an angle of 55–70° with respect to this
plane in order to avoid damage to the mesiolabial root of the first molar ANATOMICAL CHARACTERISTICS
(Table 15.3).13
SUFFICIENT SPACE
Consideration of inter-radicular distances when inserting MIs is important
MANDIBULAR INSERTION SITES
in order to avoid damage to teeth roots (Fig. 15.7). The minimum inter-
The bone of the mandible is more compact than that of the maxilla. radicular space required for safe insertion of a temporary anchorage device
Although there are no statistically significant differences between maxilla appears to be 3.3 mm, which corresponds to a 1.3 mm diameter MI leaving
and mandible regarding the total labiolingual bone thickness in the anterior approximately 1 mm on either side as space from the roots of the adjacent
section, differences have been documented in the posterior section. Indeed, teeth.7
in the maxilla, the cortical bone mesial and distal to the inter-radicular In general, the inter-radicular distance increases from the cervical to the
sites of the canines is relatively thin, whereas the thickness in the mandible apical areas of each tooth in both jaws, and the space between the roots is
increases gradually moving away from these sites in both anterior and generally greater in the molar than in the incisor areas (Fig. 15.8A). Con-
posterior directions.15 sequently, the anterior alveolar area, despite its excellent biomechanics and
From all the insertion areas investigated, the greatest thickness of corti- ideal location for intruding the anterior teeth, is a relatively unsuitable
cal bone appears to be at the buccal side of the mandible.6 Cortical bone insertion site because of its smaller inter-radicular space as well as the
thickness in this area depends on both the inter-radicular site considered continual irritation provoked by the labial muscles (Fig. 15.8B).7
for MI insertion and its distance from the alveolar crest. In contrast, adequate inter-radicular distances can be found in the pos-
The greatest thickness of buccal mandibular cortex is found between terior sections of both the maxilla and mandible. In particular, the widest
the first and second molars,9,10 while the smallest bone quantity is between spaces in the mandible are found between the first and second
 Selecting a suitable site for miniscrew implant insertion 91

Table 15.3 Bone thickness in the maxilla and mandible

Maxilla Mandible Source reference
Palatal bone at paramedian site is thicker in anterior than Greater cortical bone thickness in posterior than anterior 6
posterior sites sites
Greatest cortical thickness at infrazygomatic crest Greatest cortical thickness at buccal sides
Small differences in thickness between upper buccal site,
maxillary palate and palatal regions

Greater buccolingual thickness between M1 and M2 Greatest buccolingual and buccal cortical thicknesses 10
Greatest mesiodistal and buccopalatal distances between between M1 and M2
P2 and M1 Greatest mesiodistal buccal distance between P2 and M1
Greatest palatal cortical thickness between central and Greatest mesiodistal lingual distance between P1 and P2
lateral incisors Thickest lingual cortex between canine and P1

No problems with MI insertion Greatest mesiodistal bone thickness between M1 and M2 14

on the labial and lingual sides
Smallest amount of bone in the mesiodistal plane on the
labial side between incisors
Greatest labiolingual bone thickness between M1 and M2
Smallest labiolingual bone thickness between central and
lateral incisors

Greatest buccopalatal bone width between M1 and M2, Safest sites in the mandible are, in decreasing order: 9
5 mm away from the alveolar crest; 0.2 mm bone (a) between M1 and M2 (all depths)
quantity at tuberosity, 11 mm away from the alveolar (b) between P1 and P2 (all depths)
crest (c) between P2 and M1, 11 mm from the alveolar crest
(d) between canines and P1, 11 mm from the alveolar
crest

Thickness of infrazygomatic crest at M1 is 5.2–8.8 mm 13

Buccal cortical thickness increases in the anterior maxillary Greater buccal cortex thickness in the mandible, which 11
sector increases with increasing distance from the alveolar crest

Significant increase in cortical bone thickness beyond 15

4–6 mm from the alveolar crest

MI, Miniscrew implant; M1, first molar; M2, second molar; P1, first premolar; P2, second premolar.

in Class III patients inter-radicular spaces are greater in the mandible

(Table 15.4).19

DISTANCE FROM CRITICAL ANATOMICAL

STRUCTURES
When choosing a site for MI insertion, it is also important to consider the
position of neighboring anatomical structures. In the maxilla, the structures
at risk of insertion damage include the maxillary sinus and the palatine
neurovascular bundle. In the mandible, structures of importance are the
inferior alveolar nerve, the mental foramen and the frenula.
Regarding the maxillary sinus, a perforation of the Schneider membrane
A B of less than 2 mm in diameter is unlikely to become inflamed and will heal
completely over a short period of time upon MI removal. Consequently,
Fig. 15.7 Inter-radicular distances in the maxilla. (A) Root crowding at the canine
and both premolars. Root alignment should be institituted as a precautionary
MIs with diameters of not more than 2 mm should be used in the palatal
measure before miniscrew implant insertion between the two premolars. (B) area of the maxilla.
Miniscrew implant inserted between the premolar roots after orthodontic root The palatine neurovascular bundle (including the palatine artery and
alignment. anterior palatine nerve) exits from the greater palatine foramen, which can
vary widely in position, size and shape but is generally found lateral to
the third molar or between the second and third molar.20 The bundle then
molars.8,16–18 However, because of the abundance of blood vessels on the runs in an anterior direction, between 5 and 15 mm from the gingival
lingual side of the posterior mandible and the possibility of tongue irrita- margin, towards the incisal foramen. Hence, MIs should be placed medial
tion, it is safer to avoid insertion in this area. Both labial and lingual to the nerve and thus mesial to the second molar.12
areas are suitable insertion sites in the maxilla, with the greatest inter- In the mandible, the inferior alveolar nerve could be damaged in MI
radicular space being found between the second premolar and the first insertion.12 and so panoramic radiography is always advisable before any
molar on both sides.9 intervention, although the risk of a lesion is considerably reduced if
Interestingly, the width of the inter-radicular space appears to be the appropriate MI insertion angle is chosen to avoid the root apices.7 MIs
influenced by the skeletal relationships of the patient. In fact, wider spaces should never be positioned in the lingual portion of the mandible because
have been reported in the maxilla of skeletal Class II individuals, whereas of the rich vascularization of this area and significant tongue interference.
 92 SECTION IV: SURGICAL CONSIDERATIONS IN THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

Fig. 15.8 Inter-radicular distances in the mandible. (A) Intraoral

radiography of the posterior section showing the greater inter-
radicular space between the molars than between the second
premolar and first molar. (B) Axial cone beam CT slice taken at the
central third of the mandibular tooth roots. Note the lack of space
between the roots of the lower incisors.

A B

Table 15.4 Inter-radicular widths in the maxilla and mandible

Maxilla Mandible Source (sample)
ID in descending order: between M1 and M2, between the P2 18 (sample size 15; CT)
and M1 and between the P1 and P2
Care needed to avoid the mental foramen for MI insertions
between PMs; a distance of 9 mm from the bony crest is
suggested
Insufficient space for implantation between incisors

Anterior area: greater ID between lateral incisors and canines Anterior region: greater ID between central incisors 10 (sample size 34 maxilla,
Posterior area: greater ID on buccal side between P2 and M1; Posterior region: greater ID, palatal and labial, 66 mandible; CBCT)
on lingual side between P1 and P2 between P2 and M1

Sites with ID >3.1 mm (in descending order): Sites with ID >3.1 mm (in descending order): 9 (sample size 25; CBCT)
(a) between M1 and M2 (a) palatal between M1 and P2, 2–8 mm from crest
(b) between P1 and P2 and between M1 and M2, 2–5 mm from crest
(c) between P2 and M1, 11 mm from the alveolar crest (b) buccal or palatal between P1 and P2 and
(d) between canines and P1, 11 mm from the alveolar crest between canines and P1, both at 5 and 11 mm
from crest
(c) buccal between P2 and M1, at 5 and 8 mm from
crest
Greater ID on both labial and palatal areas
encompassing P2 and M1

ID >3 mm found between PMs, between the Ms and between ID >3 mm found in anterior region 8 mm from the 16 (sample size 30; CT)
P2 and M1, at a distance of 4 mm from the CEJ CEJ and in the posterior region between PMs and
between P2 and M1, 4 mm from the CEJ

ID >3 mm found 11 mm from alveolar crest in all inter- ID >3 mm found between P2 and M1 11 mm from 7 (sample size 25; CT)
radicular spaces and 8 mm from the alveolar crest in all alveolar crest
inter-radicular spaces, except 33–34 and 35–36

Greater ID in area between M1 and M2 at least 5 mm from Greater ID found in area encompassing P2 and M1, 17 (sample size 20; CBCT)
cervical line 6–8 mm from cervical line

CBCT, cone beam computed tomography; ID, inter-radicular distance; CEJ, cementoenamel junction; M1, first molar; M2, second molar; P1, first premolar; P2, second premolar.

The mental foramen usually opens on both sides of the mandible in the implantation site in two dimensions and is subject to varying levels of
space between the first and second premolars, at a relatively deep position distortion in different sections of the stomatognathic system. Periapical
in the fornix. The mucosa in this region is evidently very mobile and could radiographs provide more precise images, but while they are a useful
compromise MI stability, and such a deep position for a MI would be source of information regarding the mesiodistal bone width, they too have
biomechanically unfavorable. the inherent limitations of two-dimensional imaging. Good three-
The frenula are also possible impediments to the mechanical stability dimensional images of high diagnostic value are provided by CT, although
of MIs and are particularly prone to implantation-related inflammation of the radiation dose precludes frequent use. Cone beam CT provides an ideal
the soft tissues. balance between three-dimensional image quality and radiation dose. It
allows precise evaluation of the quantity of bone between roots, of mesio-
distal and labiolingual thickness of bone and also of the thickness of the
PRESURGICAL DIAGNOSIS cortex.9
In addition to their preparatory use, radiographic techniques
Thorough radiographic evaluation of each patient should be carried out using radiopaque pins can simulate implantation and with effective
before initiation of treatment to ensure choice of a good site for MI inser- computer-aided design/manufacturing software can support decision
tion. Panoramic radiography provides very general information about the making.21,22
 Selecting a suitable site for miniscrew implant insertion 93

10. Fayed MM, Pazera P, Katsaros C. Optimal sites for orthodontic mini-implant place-
ACKNOWLEDGMENTS ment assessed by cone beam computed tomography. Angle Orthod 2010;80:939–51.
11. Baumgaertel S, Hans MG. Buccal cortical bone thickness for mini-implant placement.
The authors would like to thank Drs. Claudia Carmen Lombardi, Serena Am J Orthod Dentofacial Orthop 2009;136:230–5.
12. Kravitz ND, Kusnotob B. Risks and complications of orthodontic miniscrews. Am J
Montefrancesco, Antonio D’Ercole and Maria Larosa for their valued Orthod Dentofacial Orthop 2007;131(Suppl.):43–51.
contributions. 13. Liou EJ, Chen PH, Wang YC, et al. A computed tomographic image study on the
thickness of the infrazygomatic crest of the maxilla and its clinical implications for
miniscrew insertion. Am J Orthod Dentofacial Orthop 2007;131:352–6.
14. Hernández LC, Montoto G, Puente RM, et al. “Bone map” for a safe placement of
REFERENCES miniscrews generated by computed tomography. Clin Oral Implants Res 2008;19:
576–81.
15. Lim JE, Lee SJ, Kim YJ, et al. Comparison of cortical bone thickness and root proxim-
1. Ludwig B, Glasl B, Kinzinger GSM, et al. Anatomical guidelines for miniscrew inser- ity at maxillary and mandibular interradicular sites for orthodontic mini-implant place-
tion: Vestibular interradicular sites. J Clin Orthod 2011;45:165–73. ment. Orthod Craniofac Res 2009;12:299–304.
2. Cha BK, Lee YH, Lee NK, et al. Soft tissue thickness for placement of an orthodontic 16. Lee KJ, Joo E, Kim KD, et al. Computed tomographic analysis of tooth-bearing alveo-
miniscrew using an ultrasonic device. Angle Orthod 2008;78:403–8. lar bone for orthodontic miniscrew placement. Am J Orthod Dentofacial Orthop
3. Costa A, Pasta G, Bergamaschi G. Intraoral hard and soft tissue depths for temporary 2009;135:486–94.
anchorage devices. Semin Orthod 2005;11:10–15. 17. Hu KS, Kang MK, Kim TW, et al. Relationships between dental roots and surrounding
4. Lekholm U, Zarb G. Patient selection and preparation. In: Branemark PI, Zarb GA, tissues for orthodontic miniscrew installation. Angle Orthod 2009;79:37–45.
Albrektsson T, editors. Tissue integrated prostheses. Berlin: Quintessence; 1985. 18. Monnerat C, Restle L, Mucha JN. Tomographic mapping of mandibular interradicular
p. 199–210. spaces for placement of orthodontic mini-implants. Am J Orthod Dentofacial Orthop
5. Misch CE. Density of bone: effect on treatment plans, surgical approach, healing and 2009;135:428, discussion 428–9.
progressive bone loading. Int J Oral Implantol 1990;6:23–31. 19. Chaimanee P, Suzuki B, Suzuki EY. “Safe zones” for miniscrew implant placement
6. Farnsworth D, Rossouw PE, Ceen RF, et al. Cortical bone thickness at common in different dentoskeletal patterns. Angle Orthod 2011;81:397–403.
miniscrew implant placement sites. Am J Orthod Dentofacial Orthop 20. Jaffar AA, Hamadah HJ. An analysis of the position of the greater palatine foramen.
2011;139:495–503. J Basic Med Sci 2003;3:24–32.
7. Biavati AS, Tecco S, Migliorati M, et al. Three-dimensional tomographic mapping 21. Ludwig B, Glasl B, Lietz T, et al. Radiological location monitoring in skeletal anchor-
related to primary stability and structural miniscrew characteristics. Orthod Craniofac age: Introduction of a positioning guide. J Orofac Orthop 2008;69:59–65.
Res 2011;14:88–99. 22. Liu H, Liu DX, Wang G, et al. Accuracy of surgical positioning of orthodontic minis-
8. Lombardo L, Gracco A, Zampini F, et al. Optimal palatal configuration for miniscrew crews with a computer-aided design and manufacturing template. Am J Orthod Den-
applications. Angle Orthod 2010;80:145–52. tofacial Orthop 2010;137:728, discussion 728–9.
9. Poggio PM, Incorvati C, Velo S, et al. “Safe zones”: a guide for miniscrew positioning
in the maxillary and mandibular arch. Angle Orthod 2006;76:191–7.
16 Positioning guides for the radiological
evaluation of miniscrew implant insertion sites
Björn Ludwig, Bettina Glasl, Michael Schauseil, Ben Piller and Gero Kinzinger

INTRODUCTION NEWER POSITIONING GUIDES

The X-ray Pin
During preoperative assessment of miniscrew implant (MI) insertion,
radiological and/or positioning devices are frequently used. These devices A common problem with most positioning devices is that the device itself,
improve planning and placement via assessment of the available bone, the or the technique, is complex and not entirely suitable for routine orthodon-
root position of adjacent teeth and the suitable MI dimensions. Positioning tic practice. The X-ray pin is a radiographic auxiliary with a probing func-
guides are intended to transfer information from the implant site, accu- tion that marks the gingiva at the desired MI insertion point, thus eliminating
rately and reproducibly, to the patient’s mouth during MI insertion. the need for laboratory procedures and devices with wires that require
adjustment (Fig. 16.2). It is easy to use for inexperienced practitioners.
The X-ray pin is a very small auxiliary, fabricated from a SS alloy. It
POSITIONING GUIDES has a thickened ball-shaped head and a tapered conical shaft, ending in a
point, for puncturing the gingiva (Fig. 16.2A). The pin is held with a
Early devices were often fabricated in the laboratory and required addi- Weingart plier for positioning in both the maxilla and mandible and
tional time for production and clinical positioning. Some complex systems is particularly useful in sites between the roots of the adjacent teeth
involved the positioning device being attached to a fixed orthodontic appli- (Fig. 16.2C).
ances or coupled to an intraoral radiographic plate holder.1 Other tech- Each pin has a total length of 3.5 mm, which is sufficient for safe reten-
niques involved guiding splints, fabricated on replica models, which were tion in the gingiva.9 The head of the pin has a diameter of 1.6 mm and is
based on reconstructed three-dimensional CT images.2,3 therefore compatible with the diameter of most MIs (Fig. 16.2A,B).
The metric approach used a mock up of the MI insertion point and a Because of their conical shape, the pins can easily be inserted into the
tooth surface point, determined beforehand on a model.4 The distance gingiva in many places (Fig. 16.2C). The pin is designed to perforate the
between the two was measured using a periodontal probe and this meas- gingiva with direct pressure in a single movement. The X-ray pin is reli-
urement was transferred intraorally. able, stable and enables an accurate assessment of the insertion area for

CONVENTIONAL POSITIONING GUIDES

Conventional positioning guides have wire elements that are temporarily
fixed to the teeth (with composite resin or a rim of silicone-impression
material) and adjusted above the planned point of insertion. The basic
shape is a (repeatedly) bent wire, with a circular wire end that tapers off
above the target area5–7 or tapers off to a point8 (Fig. 16.1A). This frame
is adapted to the contours of the alveolar process and the dental arch but
can be fabricated in the laboratory in order to optimize its positional stabil- A B
ity during radiography. The adapted wire elements are set in an acrylic
resin splint, which covers several adjacent teeth, thus maximizing stability Fig. 16.1 A laboratory-fabricated positioning device with a commercially available
wire element (TOMAS-locator, Dentaurum, Ispringen, Germany), incorporating a
and retention. After evaluation of the diagnostic radiograph (Fig. 16.1B), marking hole that corresponds to the MI insertion site. (A) Intraoral photograph
the insertion point is marked with an explorer probe, creating a bleeding after insertion of the device. Note that the acrylic guide is extended to cover
spot.6–8 several teeth. (B) Diagnostic panoramic radiograph.

Fig. 16.2 The X-ray pin. (A) The pin includes a

puncture point, a conical shaft and a ball head (total
length 3.5 mm; working length 2.5 mm, largest
diameter 0.75 mm). (B) Securing of pin with dental
floss. (C) Intraoral application of the pin at the
predetermined point with Weingart plier.

A B C

94
 Positioning guides for the radiological evaluation of miniscrew implant insertion sites 95

A B C D

Fig. 16.3 The use of X-ray pins for inter-radicular insertion of microscrew implants in the mandible. (A) Intraoral photograph showing the positioning of the pin.
(B) Diagnostic panoramic radiograph showing the pin position and the bone availability of the insertion area. (C) Inserted MI. (D) Panoramic radiograph following MI
insertion.

A B C D

Fig. 16.4 The use of X-ray pins for palatal insertion of miniscrew implants (MI). (A) Intraoral photograph showing the positioning of the X-ray pins. (B) Diagnostic lateral
cephalometric radiograph. (C) Intraoral photograph showing MI insertion next to the X-ray pin. (D) Lateral cephalometric radiograph following MI insertion.

safe positioning of MIs. However, this approach does not eliminate the Since the safety of the above procedure is confirmed radiographically,
problems of radiographic image distortion or of choosing the angulation the MI can be inserted securely in the corresponding inter-radicular sites.
during insertion of MIs. Finally, a follow-up radiograph shows the correct insertion of the MI
The use of X-ray pins is a minimally invasive procedure, however, from (Fig. 16.3D).
an infection control standpoint, each device is for single use only.

PALATAL USE OF X-RAY PINS

The Individual Vacuum-formed Splint
Vestibular inter-radicular insertion of MIs has some limitations because of
In some situations, direct positioning of an X-ray pin can be difficult. The the underlying hard and soft tissues (see Chapter 15). The procedure for
use of a vacuum-formed splint, with an incorporated radiopaque tube, is X-ray pins can be easily adapted to the palate if additional diagnostic
an alternative way to assess the MI insertion site radiographically and to information is required prior to MI placement (Fig. 16.4).
provide a precise guide to control the drilling direction for the MI during
its insertion.

CLINICAL APPLICATION OF THE VACUUM-

CLINICAL APPLICATION OF X-RAY PINS FORMED SPLINT

Prior to use, X-ray pins have to be disinfected and sterilized. Attaching A dental impression is taken with alginate or polyvinylsiloxane and a cast
them to dental floss (Fig. 16.2B) and securing them extraorally with an is fabricated. A 2 mm vacuum splint (Track E, Forestadent, Pforzheim,
adhesive tape, is recommended for patient safety. Germany) is fabricated in the laboratory and a 2 mm SS tube is heated and
After determining the MI insertion point, the tissue around the area is inserted into the composite of the splint at the planned MI insertion point.
anesthetized using local infiltration anesthesia, which will also facilitate The splint is transferred to the mouth of the patient (Fig. 16.5A) and a
the insertion of the MI. Initially the area can only be superficially anes- radiograph is taken to evaluate the position of the tube and thus the inser-
thetized and additional local anesthesia will be needed for the insertion of tion position and angulation of the MI (Fig. 16.5B). Following radio-
the MI. Figure 16.3 shows the insertion of the pin and the subsequent graphic assessment, the splint is used as a drilling guide during MI insertion
diagnostic radiograph and MI insertion position. The X-ray pin is stable (Fig. 16.5C). After MI insertion, a final radiograph can be taken to ensure
when positioned and because of its small size and screw-like design, it proper orientation and position of the MI (Fig. 16.5D).
provides a valuable marker for the MI insertion site. After diagnostic
evaluation of the radiographic image, the pin is removed with a slight pull,
marking the insertion site for the MI with a bleeding spot. CONCLUSIONS
If the site chosen is shown to be close to, or in contact with, the roots
of adjacent teeth, an alternative location can be chosen using the bleeding Positioning devices can be useful tools for MI insertion. Those made of wire
spot and the position of the X-ray pin on the radiograph as references. elements require an additional impression appointment, cast construction
 96 SECTION IV: SURGICAL CONSIDERATIONS IN THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

A B C D

Fig. 16.5 The use of vacuum-formed splints for palatal insertion of microscrew implants. (A) Intraoral photograph showing the fabricated vacuum-formed splint along
with the guiding insertion tube applied on the maxillary arch. (B) Diagnostic lateral cephalometric radiograph taken with the splint, showing the radiopaque diagnostic
auxiliary tube indicating the position and the suitable direction for the implant insertion. (C) Intraoral photograph showing the use of the now modified splint as a drilling
guide during implant insertion. (D) Lateral cephalometric radiograph following insertion.

and may cause gingival irritation due to extensive bends and fixing meas-
REFERENCES
ures. In addition, manipulation of the film holder can inadvertently move
the positioning device during periapical radiography. In general, it is diffi- 1. Estelita Cavalcante Barros S, Janson G, Chiqueto K, et al. A three-dimensional
cult to accurately apply the preoperative diagnostic findings using radiologi- radiographic-surgical guide for mini-implant placement. J Clin Orthod 2006;40:
548–54.
cal guides to the designated MI insertion site. A deviation of only 8° from 2. Kim SH, Choi YS, Hwang EH, et al. Surgical positioning of orthodontic mini-implants
the ideal insertion angle can lead to a deviation of more than 1 mm at the with guides fabricated on models replicated with cone-beam computed tomography.
tip of the MI thread.1 Therefore, some clinicians have suggested leaving the Am J Orthod Dentofacial Orthop 2007;131:S82–9.
3. Kitai N, Yasuda S, Takada K. A stent fabricated on a selectively colored stereolitho-
guiding pins used in place for the subsequent predrilling stage.1,2,9 Most graphic model for placement of orthodontic mini-implants. Int J Adult Orthod Orthog-
conventional diagnostic positioning devices provide accurate assessment of nath Surg 2002;17:264–6.
the vertical dimension but are less than perfect in assessing the ideal inser- 4. McGuire MK, Scheyer ET, Gallerano RL. Temporary anchorage devices for tooth
movement: a review and case reports. J Periodontol 2006;77:1613–24.
tion angle. 5. Lietz T. Minischrauben – Aspekte zur Bewertung und Auswahl der verschiedenen
The X-ray pin is a chair-side auxiliary that is diagnostically valuable, Systeme. In: Ludwig B, editor. Mini-Implantate in der Kieferorthopädie: Innovative
clinically efficient and cost effective.10 It avoids all the complexities of Verankerungskonzepte. Berlin: Quintessence; 2007. p. 11–71.
6. Bumann A, Wiemer K, Mah J. Tomas – eine praxisgerechte Lösung zur temporären
wires and fixing associated with conventional guides and allows a precise kieferorthopädischen Verankerung. Kieferorthopädie 2006;20:223–32.
determination of the insertion point, bone quality and vertical bone height. 7. Morea C, Dominguez GC, Wuo A, et al. Surgical guide for optimal positioning of
Repeated diagnostic radiography is rarely necessary. The vacuum-formed mini-implants. J Clin Orthod 2005;39:317–21.
8. Maino BG, Bednar J, Pagin P, et al. The Spider Screw for skeletal anchorage.
splint is a useful alternative when direct positioning of an X-ray pin is J Clin Orthod 2003;37:90–7.
difficult. 9. Suzuki EY, Buranastidporn B. An adjustable surgical guide for miniscrew placement.
There are some limitations with X-ray pins and vacuum-formed splints, J Clin Orthod 2005;39:588–90.
10. Ludwig B, Glasl B, Lietz T, et al. Radiological location monitoring in skeletal anchor-
such as radiographic image distortion and choosing the angulation for MI age: introduction of a positioning guide. J Orofac Orthop 2008;69:59–65.
insertion; therefore, their role in facilitating MI insertion should not be
overestimated.
 Precise miniscrew implant insertion technique
between the roots of maxillary second
17
premolar and first molar (Kim’s stent)
Tae-Woo Kim and Hyewon Kim

INTRODUCTION DIRECTION GUIDE

The direction guide is ligated on to the second premolar bracket and indi-
The space between the roots of the maxillary second premolars and first cates the direction of the MI insertion (Fig. 17.1B). The wire lying on the
molars is the preferred site for miniscrew implant (MI) insertion because occlusal surface is called the occlusal arm and is placed at the midpoint
it is wider than other inter-radicular spaces, particularly after leveling with between the second premolar and the first molar. It passes the contact point
Roth prescription brackets.1 However, even though this is the widest inter- of the two adjacent teeth in close contact and approximates the proximal
radicular space, insertion of MIs here may not always be safe. The most surface. The horizontal angulation of the X-ray beam lies parallel to this
common errors when inserting MIs inter-radicularly are encroachment into occlusal arm. The MI is also inserted parallel to this occlusal arm.
the periodontal ligament, contact with root surfaces or proximity to the
alveolar crest.
There are a number of devices introduced to help in finding a safe MI PREPARATION OF THE PATIENT
insertion site, all with some disadvantages (see Chapter 16). Kim’s stent,
introduced in this chapter, is a guide that can facilitate accurate placement It is recommended that the posterior teeth are leveled up to 0.019 ×
of MIs between roots, it is easy to fabricate in the clinic, and it increases 0.025 inch Ni-Ti (Fig. 17.2) or SS archwire (in 0.022 inch bracket slots).
the success rates of MIs by decreasing the chances of root damage. This is a prerequisite because if there is crowding, the roots may make
contact with the MIs during further leveling or de-crowding procedures.
In addition, after leveling, the regular pattern of root arrangement and
COMPONENTS OF KIM’S STENT inter-radicular distance will provide some consistency in placing the MIs
and will also facilitate in avoiding root contact.
Kim’s stent comprises a positioning gauge and a direction guide
(Fig. 17.1).
FABRICATION OF KIM’S STENT
POSITIONING GAUGE
MATERIAL AND INSTRUMENTS
The positioning gauge is ligated on to the first molar bracket; it has a verti-
The following material and instruments are needed for the fabrication of
cal and a horizontal arm and helps to set the mesiodistal position of the
the Kim’s stent (Figs. 17.3-17.5).
MI. The vertical arm is the vertical portion of the positioning gauge, while
the horizontal arm has five to eight pieces of wire acting as a gauge and ■ Periapical radiograph. Adjacent teeth must not overlap (Fig.
welded at 1 mm intervals (Fig. 17.1A). 17.3A). A panoramic radiograph is not accurate enough and the

Fig. 17.1 Components of Kim’s stent. (A) The

Horizontal arm
positioning gauge, which is ligated into the first
molar bracket. (B) The direction guide, which is
ligated into the second premolar bracket.
Vertical arm
Positioning
gauge Direction
guide

Occlusal arm
A B

Fig. 17.2 Preparation of a patient before inserting a

miniscrew implant (MI) at the maxillary posterior
region. After leveling the posterior teeth with an
archwire, the MI is placed between the roots of the
maxillary second premolar and first molar. This
specific patient shows a wide area of attached
gingiva, and so the MI can be placed in a higher
location.

A B

97
 98 SECTION IV: SURGICAL CONSIDERATIONS IN THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

A B C D

Fig. 17.3 Fabrication of Kim’s stent. (A) Periapical radiograph taken before miniscrew implant insertion making sure that the maxillary right second premolar and first
molar contact points do not overlap. (B) A good-quality model including the vestibular area with the impression taken after removing the archwire. (C,D) Marking on the
study model based on the periapical radiograph. A line is drawn on the model to mark the center of the inter-radicular space (C) and is extended to the occlusal and
palatal surfaces (D) in order to choose the direction of MI insertion.

A B C D

Fig. 17.4 Fabrication of the direction guide. (A) Wire (SS wire 0.022 × 0.028 inch) is inserted into the second premolar bracket, then bent in the occlusal direction at the
pencil mark between the second premolar and first molar. (B) The occlusal arm is bent to contact the proximal area while passing through the center of the contact point
of the two adjacent teeth. The excessive portion is cut to avoid contact with the tongue or the X-ray sensor (or film) and the direction is adjusted, here a little distally to
correspond to the direction of miniscrew implant insertion. (C) The final form of the direction guide. (D) The occlusal arm is bent to follow the direction of the pencil line,
which corresponds to the direction of miniscrew implant insertion and the long axis of the X-ray beam.

A B C D

Fig. 17.5 Fabrication of the positioning gauge. (A) Five to eight pieces of the green Elgiloy wire are welded on to the horizontal arm of the positioning gauge at 1 mm
intervals and the pins are positioned so that the center pin matches the estimated insertion position of the miniscrew implant (red dot); this will be adjusted after taking a
periapical radiograph using the Kim’s stent. The vertical arm is bent to have a position near the contact point of the first premolar and second premolars. (B) The wire is
bent at 90° at the height of the first molar bracket. (C) A bayonet bend is formed at the mesial end of the first molar tube or bracket to act as a stop, providing also
space for the second premolar bracket and the direction guide. (D) Finally, the excessive end is cut and the positioning gauge is ready to be used.

inter-radicular distance is difficult to determine; CT has lower The cast and periapical radiograph are used for a provisional decision on
resolution, higher radiation and higher cost. the position and direction of the MI. With a lead pencil, the corresponding
■ Study model. An impression is taken with the archwire line is drawn on the cast (Fig. 17.3C,D).
removed (Fig. 17.3B). Clear views of the buccal vestibule are
required. If the archwire is not removed and the buccal vestibule
is not duplicated well, it is difficult to precisely manufacture
FABRICATION OF THE DIRECTION GUIDE
Kim’s stent. The direction guide is ligated to the bracket of the tooth mesial to the point
■ Brackets. With 0.022 inch slot. of insertion (i.e. the second premolar; Fig. 17.1B). Figure 17.4 shows the
■ Wires. SS wire 0.0125 × 0.028 inch (Jinsung Industrial, Seoul, steps to fabricate the direction guide.
Korea) and 0.014 inch green Elgiloy wire (Rocky Mountain
Orthodontics, Denver, CO, USA), which is easily welded on to the
0.022 × 0.028 inch SS wire.
FABRICATION OF THE POSITIONING GAUGE
■ Welder device. Five to eight pieces (pins) of the green Elgiloy wire of approximate length
■ Tools. Tweed loop and helix-forming pliers (043-CK, Orthopli, 2–3 mm are welded on to the SS wire (0.0215 × 0.028 inch) at 1 mm
Philadelphia, PA, USA), cutter and marker. intervals. Figure 17.5 shows the steps taken to complete the guide.
 PRECISE MINISCREW IMPLANT INSERTION TECHNIQUE 99

Fig. 17.6 Fixation of Kim’s stent. (A) The direction guide ligated into
the second premolar bracket before fixing the positioning gauge in
place. (B) Occlusal view of the maxillary arch with two Kim’s stents
fixed bilaterally. The direction guides are positioned as planned on
the model.

A B

Fig. 17.7 Periapical radiography. (A) The occlusal arm of the

direction guide and the long axis of the X-ray beam should be
parallel. (B) In this patient, the middle of the second and the third
pins from the vertical arm (arrow) indicates the miniscrew implant
insertion point.

A B

A B C D

Fig. 17.8 Miniscrew implant (MI) insertion. (A) Using an explorer, the position of MI insertion is marked, the mucosal thickness is measured and the quality of the cortical
bone is evaluated. (B) After rotating the screwdriver two or three times, the tip of the MI perforates the cortical bone. With a large mirror, the direction of the MI is
checked and adjusted, and the long axis of the screwdriver is positioned parallel to the occlusal arm of the direction guide. (C) A well-inserted MI between the maxillary
right second premolar and the first molar. The MI is placed as high as possible on the attached gingiva. (D) Periapical radiograph showing a well-inserted MI.

horizontal angle of the X-ray beam are parallel (Fig. 17.7A). In an ideal
MINISCREW IMPLANT INSERTION USING KIM’S STENT
periapical radiograph, the contact point of the second premolar and first
molar is clearly visible, while the crowns do not overlap (Fig. 17.7B). The
ANESTHESIA
insertion position should be at the center of the inter-radicular space
After disinfection of the oral cavity and insertion region, local anesthesia between the second premolar and first molar.
(lidocaine plus epinephrine) is injected, ensuring that only buccal mucosa
is anesthetized.
MINISCREW IMPLANT INSERTION
FIXATION OF KIM’S STENT After disinfection of the oral cavity, the soft tissue is marked with an
The direction guide is ligated on to the second premolar. If required, the explorer, and at the same time the soft tissue thickness and quality of the
occlusal arm is adjusted at this point. Then the positioning gauge is ligated cortical bone are determined (Fig. 17.8A).
after appropriate adjustment. Care should be taken that the gauge of Using a specially designed screwdriver, the MI is inserted in the highest
the horizontal arm does not interfere with the insertion location of the MI. point of the attached gingiva, perpendicular to the gingival surface (Fig.
The gauge should be placed approximately 2 mm above the border of the 17.8B,C). If there is need to insert the MI in an oblique direction, after the
attached gingiva (Fig. 17.6), while the horizontal arm should be well MI has pierced the cortical bone the direction of insertion can be altered,
positioned, almost touching but not impinging on the mucosa. having an angle of approximately 15–30° in relation to the soft tissue
surface. If there is need for a more oblique direction, the use of predrilling
is necessary prior to MI insertion. When viewed from the occlusal surface,
RADIOGRAPHIC EVALUATION the long axis of the screwdriver and the occlusal arm of the direction guide
After fixing the stent on the maxillary arch, a periapical radiograph is should be parallel. Using a large dental mirror from the occlusal surface
performed taking care that the occlusal arm of the direction guide and the may be helpful to determine this direction. Finally, during MI insertion,
 100 SECTION IV: SURGICAL CONSIDERATIONS IN THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

the long axis of the screwdriver should be kept stable without any (Fig. 17.8D). If the position is incorrect, the MI should be removed imme-
jiggling. diately and reinserted in a new position.

EVALUATION OF MINISCREW IMPLANT INSERTION REFERENCE

Immediately after insertion, a further periapical radiograph should be 1. Kim T-W, Kim H. Clinical application of orthodontic mini-implant. Seoul, Korea:
taken to check if the MI is placed in the correct site as initially planned Myung Mun; 2008. p. 44.
 Surgical guides for optimal positioning
of miniscrew implants
18
Camillo Morea, Gladys C. Dominguez and Moschos A. Papadopoulos

■ a sleeve holder, which is inserted in one of the two possible holes of

INTRODUCTION
the apical–coronal angle keeper and retained firmly by a screw.
The biggest challenge for insertion of orthodontic miniscrew implants The mesiodistal position of the sleeve is determined by the line bisecting
(MIs) inter-radicularly in the buccal or palatal area of the alveolar ridge is the two marginal crests, while the coronal–apical direction of the sleeve
to avoid the roots of the neighboring teeth. Availability of adequate bone can be predetermined on the sleeve positioner and can be varied depending
in the interdental septum is one of the key factors for a successful insertion on the anatomical situation of the insertion point. The line is drawn on the
and this is improved by initial leveling and aligning of the teeth (see cast starting from the middle of the marginal crest towards the contact
Chapter 17). In some individuals, such as those with small clinical crowns, point of two neighboring teeth. If this line is extended in an apical direction
there is still not sufficient space for insertion. In these cases, space can be parallel to the long axis of the teeth, it remains between the roots of the
opened with an open coil spring or an alternative location can be chosen. neighboring teeth, avoiding any root contact (Fig. 18.2C). On this imagi-
In all cases where there is a possible risk of root contact or root perfora- nary line, the appropriate fixation point of the sleeve (i.e. the insertion
tion, the precise insertion of MIs using surgical guides (conventional or point of the MI) can be chosen (Fig. 18.2D).
stereolithographic) is suggested to minimize the risks. The sleeve positioner is then inserted into the vertical arm of the paral-
leling device (Fig. 18.2E). The sleeve holder should be parallel to the blade
and attached to the body of the sleeve positioner in such a way that, when
it is inserted in the paralleling device, if a vertical line is traced through
CONVENTIONAL SURGICAL GUIDES
the blade, it hits the center of the sleeve positioner. This allows the scroll-
ing identifier to be moved vertically, thus enabling the sleeve holder to
The principle for constructing a conventional surgical guide1,2 is similar
pass through the predefined MI insertion point. The plaster cast is then
to that used for dental implants, but because the placement of the MI
placed on the table of a paralleling device so that the MI insertion point
must be precise, only non-self-drilling MIs should be used. The aim of
on the septum midline is located parallel to the vertical arm of the device
the surgical guide is to control the bur used for pilot drilling in all three
and perpendicular to the ground (Fig. 18.2F). The inclination of the sleeve
dimensions so that the MI can be inserted precisely into the planned
holder is also adjusted in order to indicate precisely not only the mesio-
position. This is achieved using a metallic sleeve in the body of the sur-
distal (Fig. 18.2G) but also the apical–coronal (Fig. 18.2H) angulation of
gical guide.
the insertion direction of the MI.
Initially, a plaster cast of the dental arch is used to identify the ideal
Once the plaster cast has been oriented towards the sleeve positioner
insertion point based on the mechanics that are going to be used. As
device, the coronal–apical indicator is scrolled downwards until the tip of
described in other chapters, ideally an insertion site in the attached gingiva
the sleeve holder hits the insertion point marked on the plaster model. At
as close as possible to the mucogingival line is chosen but if needed inser-
this point, the blade of the body of the sleeve positioner should bisect the
tion in the alveolar mucosa can be considered. However, in the latter situ-
marginal line. All of the screws of the adjustable parts should be firmly
ation, a miniflap should be elevated before drilling to avoid any tissue
tightened.
being trapped during pilot drilling (see Chapter 14).
After loosening the retention screw and gently retracting the sleeve
Sometimes a vertical depression is visible on the attached gingiva
holder, a metallic sleeve can then be inserted on the tip of the sleeve holder.
between the two neighboring teeth where the clinician is planning to insert
After repositioning the tip of the sleeve holder to the surface of the plaster
the MI. This depression follows the middle of the septum and can be used
cast in contact with the insertion point, the retention screw of the sleeve
as a guide (Fig. 18.1A). When the ideal insertion is selected, it is marked
holder is tightened again. The position and direction of the sleeve now
with a pencil on the plaster cast (Fig. 18.1B).
corresponds to the position and direction of MI insertion. The sleeve is
The sleeve is fixed to the plaster cast with a sleeve positioner (Fig. 18.2),
then fixed to the plaster cast using sticky wax placed around its base and
which is a patented mechanical aid comprising:
the plaster cast is removed from the positioning device.
■ a body incorporating a horizontal blade; the insertion pin is located The extent of the area of teeth and soft tissues that is covered by the
on the upper part of the body for the paralleling device surgical guide is determined by placing utility wax around the area to
■ a scrolling identifier moving in apical–coronal direction to allow ensure the relief of the retentive areas and area for use of orthodontic
adjustment in an apical–coronal inclination appliances such as brackets and tubes (Fig. 18.3).

Fig. 18.1 The interdental septum. (A) A gingival depression indicates

the middle of the interdental septum between the first and second
lower molar. (B) A plaster model on the table of a paralleling device
with the insertion point marked. The septum midline needs to be
oriented perpendicular to the ground.

A B

101
 102 SECTION IV: SURGICAL CONSIDERATIONS IN THE USE OF SKELETAL ANCHORAGE DEVICES IN ORTHODONTICS

A B
C D

E F G H

Fig. 18.2 The sleeve positioner. (A) The components are the body with the blade and the insertion pin for the paralleling device (1), the scrolling apical–coronal level
identifier (2) and the sleeve holder (3). (B) The assembled sleeve positioner ready to be inserted into the paralleling device. (C) The fixation point of the sleeve is set using
a vertical line drawn from the middle of the marginal crest towards the contact point of two neighboring teeth and prolonged in an apical direction parallel to the long
axis of the teeth. (D) The blade and the sleeve holder are constructed to be located on the same vertical line. (E) The sleeve positioner inserted into the vertical arm of the
paralleling device. (F) Positioning of the plaster cast on the paralleling device and adjustment of the sleeve holder in order to correspond to the insertion position of the
miniscrew implant. (G,H) Bur equipped with a sleeve indicating the mesiodistal (G) and the apical–coronal (H) inclination of the insertion direction of the pilot drill.

A B

Fig. 18.3 Delimitation of the surgical guide’s area with wax in occlusal (A) and
lateral (B) view.

Fig. 18.5 Acrylic splint with 2 mm perforations filled with gutta-percha marks used
to capture the cone beam CT images.

A B C D

Fig. 18.4 Surgical guide fitting. (A–C) Checking the guide on the plaster model. (D) Checking the guide in the patient’s mouth prior to surgery.

After delimitation of the surgical guide’s area, the plaster is hydrated in STEREOLITHOGRAPHIC SURGICAL GUIDES
water for 5 minutes and subsequently isolated with Vaseline. Acrylic resin
is deposited into the waxed area and polymerized under pressure. Finally, There are situations where surgical guides as described above are not
the acrylic resin is trimmed and polished and its fitting is checked on the feasible, for example where rotated teeth or pneumatization of the maxil-
plaster cast (Fig. 18.4A–C). lary sinus narrows the insertion path or where multiple MIs are needed.
If the surgical guide fits correctly, it is cleaned in ultrasound detergent In this case, cone beam CT can be used to create a stereolithographic surgi-
and kept in chlorhexidine solution (1%) until its intraoral use. Prior to cal guide.2–4
surgery, the fitting of the surgical guide, as well as the insertion point Initially, plaster models of both arches are obtained and the bite is
and angulation of the sleeve, must be checked again on the patient’s teeth recorded with wax. Using these models, a 5 mm thick occlusal splint is
(Fig. 18.4D). fabricated in the laboratory with acrylic resin. Six perforations, each
 Surgical guides for optimal positioning of miniscrew implants 103

A B

C D

Fig. 18.6 Surgery planning with the stereolithographic approach. (A–C) Simulated surgery for miniscrew implant insertion in transversal (A), panoramic (B) and three-
dimensional (C) views. (D) The prototyped surgical guide used to drill a pilot perforation.

of 2 mm diameter, are created in the splint and filled with gutta-percha The surgical guide is manufactured with a rapid prototyping machine
(Fig. 18.5). Then, the splint is carefully checked in the patient’s mouth to using a stereolithographic approach, and the SS sleeves are inserted and
ensure a firm fit with no movement. fitted perfectly to obtain the planned pilot holes (Fig. 18.6D).
Cone beam CT is used to take an average of 217 thin slices. The protocol Surgical guides manufactured following this approach are useful for the
of acquisition is the same for the maxilla and the mandible (6 cm, 40 seg- insertion of conventional MIs.5 For the insertion of multiple orthodontic
ments, 0.25 high-resolution voxel). If both arches have to be recorded at MIs, two-component MIs (such as the C-implant, where there is a screw
the same time, a slightly different protocol should be used for data acquisi- and a separate abutment), other approaches already described in the litera-
tion (8 cm, 40 segments, 0.25 high-resolution voxel). Two scans are nec- ture can be used.3,4
essary, one of the patient’s maxilla and/or mandible and one of the splint
itself. The first scan is performed with the patient wearing the fabricated
occlusal splint. The patient needs to be positioned with the occlusal plane CONCLUSIONS
parallel to the horizontal plane, and the head has to be stabilized to avoid
any movements during data capture. In addition, the patient must not Each MI system is unique in terms of design, mechanical resistance and
swallow until completion of the scan. The second scan is taken using the the corresponding surgical kit needed for insertion. Each one of these
same acquisition protocol but capturing the splint alone. In order to avoid parameters needs to be taken into consideration before treatment planning.
any density interferences, the splint is positioned on top of a small empty Prototyped surgical guides may be of significant value in ensuring precise
paper box. MI insertion in the desired position, thus improving success rates.
The resulting data are exported in DICOM 3 (digital imaging and com-
munications in medicine; Multi-File) format for segmentation using soft-
ware that generates multiple displays (sagittal, transversal, panoramic and
REFERENCES
three-dimensional). Then, specific software for image analysis and implant
surgery is used with these images for treatment planning: to simulate the 1. Morea C, Dominguez GC, Wuo Ado V, et al. Surgical guide for optimal positioning of
insertion location and angulation for the MIs (Fig. 18.6A–C). Using dif- mini-implants. J Clin Orthod 2005;39:317–21.
ferent simulations, the surgeon can check the position of the MIs in all 2. Suzuki EY, Suzuki B. Accuracy of miniscrew implant placement with a 3-dimensional
surgical guide. J Oral Maxillofac Surg 2008;66:1245–52.
three dimensions. 3. Kim SH, Choi YS, Hwang EH, et al. Surgical positioning of orthodontic mini-implants
After planning and defining the MIs’ insertion points and angulation, with guides fabricated on models replicated with conebeam computed tomography. Am
the file is sent back to a laboratory for fabrication of the corresponding J Orthod Dentofacial Orthop 2007;131:S82–9.
4. Kim SH, Kang JM, Choi B, et al. Clinical application of a stereolithographic surgical
prototyped surgical guide. The surgical guide is designed virtually with guide for simple positioning of orthodontic mini-implants. World J Orthod 2008;9:
computer-aided design software to accurately reproduce the positions and 371–82.
angulations of the MIs as they were defined by the surgeon. The design 5. Morea C, Hayek JE, Oleskovicz C, et al. Chilvarquer I. Precise insertion of orthodontic
mini-screws with a stereolithographic surgical guide based on cone beam computed
process includes also selection of the type of MI and the surgical kit to be tomography data: a pilot study. Int J Oral Maxillofac Implants 2011;26:860–5.
used during surgery.
 Section V: Orthodontic implants for the treatment of Class II malocclusion

19 Overview of orthodontic implants for the

correction of Class II malocclusion
Gero Kinzinger, Heiner Wehrbein, Friedrich K. Byloff and Moschos A. Papadopoulos

almost always observed after non-compliance maxillary molar distaliza-

INTRODUCTION
tion. In addition, the temporary partial coverage of the palate causes oral
hygiene problems. To avoid these problems, anchorage can be provided
Maxillary molar distalization is intended to gain or restore space for the
for example by osseointegrated implants inserted in the palate. This chapter
teeth in the arch. This can be achieved by molar distalization, dental arch
will discuss anchorage designs using orthodontic implants and maxillary
expansion or extraction of teeth. Among others, the following criteria
molar distalization appliances or approaches.
should be considered when assessing available treatment options:
■ the size of the maxillary apical base
■ the functional tongue space
IMPLANTS FOR ORTHODONTIC ANCHORAGE
■ third molar formation
■ potential tooth agenesis
Orthodontic implants of reduced diameter or length inserted in the palate
■ patient’s growth pattern
can serve as absolute or auxiliary types of anchorage modalities, providing
■ patient’s soft tissue profile
either direct or indirect anchorage (see Chapter 3):
■ patient’s oral hygiene and their susceptibility to caries
■ patient’s compliance ■ direct anchorage: the active component is fitted by support elements
■ patient’s perception of esthetics. or special constructions to the implant and applies force directly on
the tooth or group of teeth to be moved during treatment
Intraoral non-compliance distalization appliances allow correction of
■ indirect anchorage: the teeth that act as reactive units are indirectly
Class II malocclusion with a variety of active components delivering the
stabilized by the skeletal device via a transpalatal bar connected to
distalization force (see Chapter 2). Depending on the location of the incor-
the implant
porated force module, they can be classified as appliances with vestibular
■ absolute anchorage: only the orthodontic implant resists the
or palatal force application:
reciprocal forces of the distalization systems
■ vestibular force application: ■ auxiliary anchorage: a number of teeth, or more often other
♦ magnetic modules anchorage modalities (e.g. a modified acrylic resin Nance button),
♦ loaded coil spring systems: Wilson Distalizing Arch, Ni-Ti form part of the anchoring system.
springs, Jones Jig, Lokar Distalizing appliance
■ palatal force application
♦ pendulum appliances DIMENSIONS OF ORTHODONTIC IMPLANTS
♦ loaded coil spring systems: Distal Jet, Keles Slider, First Class
Conventional dental implants have large dimensions and may only be
Appliance.
suitable for orthodontic anchorage in patients who have spaces after
These appliances are anchored on the maxillary anterior teeth, usually by extraction of teeth, where they may provide viable options not only for the
means of bands or occlusal wire rests on the premolars, as well as on the prosthetic rehabilitation of the missing teeth but also to act as absolute
anterior palate by means of modified acrylic resin Nance buttons. However, anchorage for various orthodontic movements including distalization of
this type of anchorage is not always adequate to withstand the reciprocal molars prior to the prosthetic restoration (Fig. 19.1).
forces, and anchorage loss of the anterior teeth, in terms of mesial move- Further, endosseous titanium implants of reduced length inserted in the
ment of the premolars and canines and proclination of the incisors are palate can provide adequate stationary anchorage (see Chapter 7).

A B C D

Fig. 19.1 A dental implant used to support maxillary molar distalization and asymmetrical anterior teeth retraction prior to the final prosthetic restoration. (A) Occlusal
view immediately after insertion of a dental implant with provisional crown for the second premolar to provide orthodontic anchorage control. Push–pull biomechanics
were used (coil spring and elastic chain, respectively) to distalize the molars and move the midline towards the implant simultaneously. (B) In progress occlusal view of the
maxillary arch close to the final result. The space mesial to the second premolar is closed and a distal space has opened. (C) Post-treatment radiograph after molar
distalization. The left canine was retracted as much as possible, almost touching the implant. (D) Post-treatment lateral view following the final restoration of the left
second premolar with the molars in Class I occlusion.

104
 Overview of orthodontic implants for the correction of Class II malocclusion 105

A B C

Fig. 19.2 The Mainz Implant Pendulum (MIP). (A) Occlusal view of the maxillary arch after paramedian insertion of an endosseous palatal implant of reduced length
(Orthosystem) and placement of the MIP for non-compliance maxillary molar distalization. (B) Occlusal view after distalization of the first molars and drifting of the
premolars. (C) Occlusal view following replacement of the MIP with a modified transpalatal bar attached to the molar bands and the palatal implant, providing further
stationary anchorage for the anterior teeth retraction. (From Kinzinger et al., 2005,10 with permission of Springer.)

anterior part of the distal screw is attached directly to the soldered or

INSERTION LOCATION welded cap of the implant by laser welding. The distal part of the screw
In many patients requiring maxillary molar distalization, the most suitable in which the retentive elements of the pendulum springs are located is
area for implant insertion is the palate and the issues of palatal insertion coated with plastic.
are discussed in detail in Chapters 7 and 12. The degree of obliteration of Before insertion of the appliance in the mouth, the arms of the pendulum
the median palatal suture increases with age but is still very variable and springs have to be bent to avoid unwanted effects: (1) uprighting activation
this must be taken into consideration when considering implant position of the springs results in an uprighting of the molar roots and counteracts
in adolescents. the tendency for distal molar crown tipping, which could occur because the
distalization force is applied more occlusally in relation to the center of
resistance of the molars; and (2) a toe-in of the pendulum springs avoids
APPLIANCES FOR NON-COMPLIANCE MAXILLARY undesirable distobuccal rotation of the molars. Regular adjustment of the
MOLAR DISTALIZATION AND IMPLANT-SUPPORTED distal screw allows a larger amount of bodily maxillary molar distaliza-
ANCHORAGE tion.1,2,4,8,9 Since an orthodontic implant is used as anchorage, the reactive
forces are absorbed exclusively by bone and there are no effects on the
The two types of appliances used most frequently for non-compliance anterior dentition in terms of mesial movement and proclination. In addi-
maxillary molar distalization are pendulum appliances and palatal coil tion, since no occlusal wire rests are used to anchor the appliance on the
spring systems (e.g. the Distal Jet), which rely basically on two different teeth, spontaneous distal drifting of the premolars and canines takes place.
biomechanical concepts. Pendulum appliances attempt to achieve maxil- Thus, the severity of the initial malocclusion is reduced and the total time
lary molar distalization by distalizing the maxillary molars along a pen- needed for the retraction of the anterior teeth is less. Following distaliza-
dulum arc. To counteract this pendulum type of movement, certain tion, the appliance is removed and the molars are connected by a new
modifications of the appliance as well as specific preactivations of the fabricated transpalatal bar to the palatal implant, providing for further
pendulum springs are essential.1–4 Uprighting activation at the horizontal stationary anchorage for the retraction of the anterior teeth (Fig. 19.2C).
arm of the pendulum springs is vital to exert an intrusive force and an Thus, anchorage loss of the molars during this stage of treatment is avoided.
uprighting moment on the molars while at the same time it applies a recip-
rocal moment in the opposite direction and an extrusive force on the
anchoring unit.1,4 The anchorage unit should be firm enough to resist this
THE AACHEN IMPLANT PENDULUM
reciprocal distalization force, which can best be achieved using endosseous The Aachen Implant Pendulum (Fig. 19.3) consists of a Quad Pendulum
palatal implants of reduced length5 or subperiosteal osteosynthetic plates anchored solely to an endosseously placed palatal orthodontic implant of
fixed with miniscrews and supported by push-on palatal buttons.6 reduced length (Orthosystem).5 This implant-supported Pendulum appli-
In contrast, in palatal coil spring systems the line of force application ance is an interesting option, particularly for the treatment of adults where
determined by the active components runs almost through the center of the preservation of anchorage is usually very challenging owing to signifi-
resistance of the first molars; since the maxillary molars are forced to move cant periodontal involvement.
on a line parallel to the occlusal plane of the maxillary arch, and no vertical The four pendulum springs allow a sequential distalization of the first
forces and moments are exerted on the anchoring unit, uprighting activa- and second molars, distalizing initially the second molars by applying a
tions are not needed. rather low force. The first molars are not incorporated in the anchoring
The most commonly used non-compliance distalization approaches in system at this stage so that they can drift freely distally under the pull of
combination with stationary anchorage provided by orthodontic implants the transeptal fibers. When the second molars are sufficiently distalized,
are presented below. their pendulum springs are deactivated. This way the second molars are
kept in place, reinforcing the anchorage unit for the subsequent distaliza-
tion of the first molars.
THE MAINZ IMPLANT PENDULUM
The pendulum springs of the Quad Pendulum are removable compo-
The Mainz Implant Pendulum (Fig. 19.2) is a skeletonized K-Pendulum nents, while lingual sheaths originally designed for molar bands are incor-
appliance with a distal screw that is firmly anchored by means of an endos- porated into the acrylic resin button to ensure a firm hold when they are
seously positioned palatal implant of reduced length (Orthosystem, Institut activated and prevent any slippage out of the acrylic resin. By replacing
Straumann, Waldenburg, Switzerland).1,3,5,7 As this is stationary anchorage, these springs with longer ones, it is possible to displace the horizontal and
there is no need for occlusal wire rests for additional dental anchorage or sagittal centers of rotation of molars. Prior to the insertion of the appliance,
for an acrylic resin palatal button, which facilitates maintenance of good uprighting activation and a toe-in have to be performed at the ends of the
oral hygiene of the palatal area, particularly around the implant. The pendulum springs, as described above.
 106 SECTION V: ORTHODONTIC IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C D

Fig. 19.3 The Aachen Implant Pendulum (AIP). (A) Occlusal view of the maxillary arch after median insertion of an endosseous palatal implant of reduced length
(Orthosystem). (B) Occlusal view of the maxillary arch after insertion of the palatal implant and placement of the AIP, initially with two pendulum springs for second molar
distalization. (C) Occlusal view of the maxillary arch after distalization of the second molars. Stabilization of the second molars with “active anchorage” and placement of
one further pendulum spring to distalize the left first molar. (D) Occlusal view of the maxillary arch after removal of the AIP and placement of a transpalatal bar connected
to the first molars to support retraction of the lateral and the anterior teeth.

The modified acrylic resin Nance button serves for the incorporation of 200 g per side. After appliance insertion, there is a 3-month healing period
the sheaths that hold the pendulum springs and is firmly attached to the to allow completion of osseointegration before the palatal implant is
neck of the implant through a clamping cap with an octagonal design to loaded with orthodontic forces. The patient is seen at 1-month intervals
resist rotation. Although the acrylic resin has surface contact with the for regular checks as well as to activate the appliance by compressing the
palatal mucosa, it does not provide any additional anchoring capacity to coil springs using the Gurin locks (3M Unitek, Orthodontic Products,
the system. Consequently it can be very thin and slim to decrease discom- Monrovia, CA, USA), which are attached to the SS wire.
fort for the patient. This system allows the application of a consistent force close to the
Occlusal wire rests on the premolars and canines are not needed. Fol- center of resistance of the first molars, resulting in an almost bodily distal
lowing completion of distalization, supporting the distalized molars with movement of the molars. In addition, because stationary anchorage is used,
a transpalatal bar prevents loss of posterior anchorage (in terms of mesial no anchorage loss of the anterior segment with maxillary incisor proclina-
movement of the molars) during the subsequent stage of Class II treatment tion or increase of the overjet is observed after molar distalization. Fur-
involving the retraction of the anterior teeth (Fig. 19.3D). thermore, since no occlusal rests are used, first and second premolars drift
Compatibility of the Aachen Implant Pendulum with other Pendulum distally during maxillary molar distalization.
appliances is possible in general. All these exclusively implant-supported When molar distalization is completed, the coil springs are removed and
appliances are fitted with only one screw, and, therefore, they can be easily the Gurin locks are tightened and fixed to the mesial side of the molar
removed during treatment by the clinician for reactivations or for ultra- tubes, converting the appliance into a passive anchorage device that can
sound cleaning. be used to reinforce posterior anchorage during the subsequent stage of
anterior teeth retraction with fixed orthodontic appliances.
Either some months before the end of the total orthodontic treatment or
THE IMPLANT-SUPPORTED DISTAL JET during the removal of the fixed orthodontic appliances, the palatal implant
Although some applications of the Distal Jet appliance in conjunction with is easily removed by loosening it with a hollow drill. The implant site heals
palatal implants have been described,11 most uses of the Distal Jet are rapidly, usually within 5 days.
associated with miniscrew implants. These applications are presented in The implant-supported Keles Slider is effective in correcting Class II
detail in Chapters 31 and 32. malocclusion and in resolving maxillary crowding. Maxillary molars are
distalized almost bodily without or with minimal crown tipping and
without loss of anchorage of the anterior teeth. No patient cooperation is
THE IMPLANT-SUPPORTED KELES SLIDER required beyond maintenance of a good oral hygiene.
The implant-supported Keles Slider consists of a modified Keles Slider
appliance (see Fig. 2.9) attached to a stepped screw titanium palatal
IMPLANT-SUPPORTED TRANSPALATAL BAR
implant (diameter, 4.5 mm; length, 8 mm; Frialit-2 Implant System, Fria-
AND COIL SPRINGS
dent, Mannheim, Germany), which is positioned either on the midpalatal
suture or in the paramedian area. This modification eliminates the need to An efficient indirect orthodontic implant anchorage for molar distalization
use palatal soft tissues, first premolars or anterior teeth to support anchor- can be constructed relatively simply in terms of appliance design and
age, thus avoiding the side effects of maxillary molar distalization using without extensive laboratory work. A combined tooth–implant anchoring
the conventional Keles Slider with a Nance button. system can be constructed with a transpalatal bar anchored on a palatal
To construct the appliance, the maxillary first molars are banded, and implant and connected to the first or second premolars. When the Ortho-
tubes (diameter, 0.045 inch; Leone, Firenze, Italy) are soldered on the system implant (length, 4.0 mm; diameter, 3.3 mm) is used, the individu-
palatal side of the first molar bands. A SS wire (diameter, 0.040 inch) is ally manufactured transpalatal bar is attached to the implant by means of
then attached to the palatal implant, positioned approximately 5 mm apical a clamping cap featuring an eccentric slot and a fastening screw. Alterna-
to the gingival margin of the first molars, passing through the tube and tively, the cap and the bar may also be soldered or laser welded. In either
oriented parallel to the occlusal plane. A Ni-Ti open coil spring (length, case, the transpalatal bar is anchored three dimensionally on the palatal
2 cm; diameter, 0.045 inch; thickness, 0.010 inch; Leone) is placed implant and bonded on the palatal surfaces of the first or second premolars
between the lock on the wire and the tube in full compression in order to bilaterally, incorporating these teeth in the anchorage unit. The distaliza-
exercise the appropriate force for molar distalization. The amount of force tion force is provided by open coil springs, which are attached on sectional
generated following full activation of the coil springs is approximately or full archwires positioned vestibularly (Fig. 19.4) or palatally (Fig. 19.5).
 Overview of orthodontic implants for the correction of Class II malocclusion 107

A B C D

Fig. 19.4 Combination of implant-supported transpalatal bar with vestibular mechanics. (A) Occlusal view of the maxillary arch after median insertion of an endosseous
palatal implant of reduced length (Orthosystem). (B) Distalization of the second molars by Nitinol coil springs supported by indirect stationary anchorage. (C) Stabilization
of the distalized second molars with a new transpalatal bar attached to the implant and the second molars, and retraction of the first molars with elastomeric chains.
(D) Distalization of the first premolars and canines. (Parts B,D from Kinzinger et al., 2005,10 with permission of Springer.)

A B C D

Fig. 19.5 Combination of implant-supported transpalatal bar with palatal mechanics. (A) Occlusal view after median insertion of an endosseous palatal implant of
reduced length (Orthosystem). Distalization of the second molars by means of Nitinol coil springs attached to palatal archwires using indirect anchorage. (B) Stabilization
of the distalized second molars with composite interlocking. Distalization of the first molars by open coil springs attached between the second molars and first molars.
(C) Occlusal view of the maxillary arch after placement of a transpalatal bar with the new one connected to the first molars to support retraction of the lateral teeth.
(D) Occlusal view of the maxillary arch during retraction of the anterior teeth. (Parts C,D from Kinzinger et al., 2005,10 with permission of Springer.)

Table 19.1 Appliance designs for non-compliance maxillary molar distalization featuring orthodontic implants, with their specific characteristics
Appliance Design and features Main indications
Mainz Implant Pendulum Stationary anchorage; skeletonized K-Pendulum appliance and endosseous palatal All ages
implant of reduced length
Paramedian/median insertion
No occlusal rests needed
Compatible with various Pendulum appliances
Pendulum appliance can be replaced with a TPA after molar distalization
Aachen Implant Pendulum Stationary anchorage; Quad Pendulum with an endosseous palatal orthodontic Adults
implant of reduced length, supported by a reduced palatal acrylic button
Median insertion
No occlusal rests needed
Compatible with various Pendulum appliances
Pendulum appliance can be replaced with a TPA after molar distalization
Implant-supported Keles Stationary anchorage; modified Keles Slider with endosseous palatal orthodontic All ages
Slider implant
Median/paramedian insertion
No occlusal rests needed
Can be converted into a passive anchorage device after molar distalization
Implant-supported Indirect anchorage; endosseous palatal implant connected to the bar Adults
transpalatal bar with coil Median insertion
springs Transpalatal bar attached (palatally) to first or second premolars bilaterally
Compatible with various loaded spring systems
Original transpalatal bar can be replaced with a new one after molar distalization

When the maxillary second molars are erupted, sequential distalization which has the advantage that no transpalatal bar replacement is needed.
is recommended. Initially, the second molars are distalized while the recip- Finally, the first molars and afterwards the teeth anterior to them can be
rocally acting forces are absorbed by the anchorage unit incorporating the moved distally along the archwires by means of elastomeric chains or
anchoring teeth and the palatal implant. Following distalization of the closed coil springs.
second molars, their position is stabilized with a new transpalatal bar con-
nected again with the palatal implant to reinforce posterior anchorage
during the subsequent phase of the retraction of the anterior teeth. The CONCLUSIONS
initial transpalatal bar is removed and the new one is constructed and
attached to the implant and bonded to the distalized second molars. Alter- Table 19.1 summarizes the appliances designed for use with orthodontic
natively, the second molars may be stabilized by composite interlocking, palatal implants for maxillary molar distalization. Endosseous implants of
 108 SECTION V: ORTHODONTIC IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

reduced length inserted into the anterior region of the hard palate provide
REFERENCES
anchorage that does not result in unwanted mesial proclination of the
anterior teeth, which is evident when conventional non-compliance dis- 1. Kinzinger G, Fuhrmann R, Gross U, et al. Modified pendulum appliance including
talization appliances are used. In particular, the combination of palatal distal screw and uprighting activation for non-compliance therapy of Class II maloc-
clusion in children and adolescents. J Orofac Orthop 2000;61:175–90.
implants with Pendulum appliances can be considered as an alternative 2. Kinzinger GSM, Wehrbein H, Diedrich PR. Molar distalization with a modified pen-
anchorage design that presents several advantages: dulum appliance: in vitro analysis of the force systems and in vivo study in children
and adolescents. Angle Orthod 2005;75:484–93.
■ treatment outcome is not dependent on patient’s cooperation 3. Kinzinger GSM, Diedrich PR. Biomechanics of a modified pendulum appliance: theo-
■ treatment is possible even with a reduced number of teeth (i.e. with retical considerations and in vitro analysis of the force systems. Eur J Orthod 2007;29:
limited dental anchoring capacity of the supporting zone) 1–7.
4. Kinzinger G, Syree C, Fritz U, et al. Molar distalization with different pendulum
■ there is no anchorage loss of the anterior dental unit since the appliances: in vitro registration of orthodontic forces and moments in the initial phase.
anterior teeth are not incorporated in the anchorage unit J Orofac Orthop 2004;65:389–409.
■ spontaneous distal drifting of the premolars and canines takes place 5. Kinzinger G, Wehrbein H, Diedrich P. Pendulum appliances with different anchorage
modalities for non-compliance molar distal movement in adults. Kieferorthopädie
during molar distalization, as well as afterwards, under the pull of 2004;18:11–24.
the transeptal fibers, since there are no occlusal rests on these teeth 6. Byloff FK, Kärcher H, Clar E, et al. An implant to eliminate anchorage loss during
■ following molar distalization, the construction of an “active molar distalization: a case report involving the Graz implant-supported pendulum. Int
J Adult Orthod Orthognath Surg 2000;15:129–37.
anchorage” of the posterior teeth to support anterior teeth retraction 7. Brender D, Thole M, Wehrbein H. Skelettale Verankerung in der Kieferorthopädie.
is possible, but usually the appliances connected to the palatal Freie Zahnarzt 2004;48:22–8.
implants are replaced with newly fabricated transpalatal bars 8. Kinzinger GSM, Fritz UB, Sander FG, et al. Efficiency of a pendulum appliance for
molar distalization related to second and third molar eruption stage. Am J Orthod
connected to molars in order to reinforce posterior anchorage during Dentofacial Orthop 2004;125:8–23.
that stage of treatment. 9. Kinzinger GSM, Gross U, Fritz UB, et al. Anchorage quality of deciduous molars
versus premolars for molar distalization with a pendulum appliance. Am J Orthod
The disadvantages are that insertion and removal of palatal implants are Dentofacial Orthop 2005;127:314–23.
associated with more complicated and invasive surgical procedures and a 10. Kinzinger G, Wehrbein H, Byloff FK, et al. Innovative anchorage alternatives for
molar distalization: an overview. J Orofac Orthop 2005;66:397–413.
higher cost is incurred. 11. Jung BA, Harzer W, Wehrbein H, et al. Immediate versus conventional loading
In conclusion, the use of orthodontic implants in conjunction with of palatal implants in humans: a first report of a multicenter RCT. Clin Oral Invest
intraoral non-compliance maxillary molar distalization approaches is a 2011;15:495–502.
feasible and efficient treatment option that can be applied not only in
children and adolescents but also in adults. For this purpose, the use of
anchorage designs with orthodontic implants of reduced length seems to
be very advantageous compared with use of conventional dental implants.
 The use of the Straumann Orthosystem as
palatal implant in the correction of Class II
20
malocclusion
Adriano Crismani and Michael Bertl

INTRODUCTION CONNECTION TO THE PALATAL IMPLANT

This chapter describes the use of a palatal implant, the Straumann Ortho- Depending on the clinical situation and the orthodontic treatment plan,
system (Institut Straumann, Basel, Switzerland), for treatment of Class II palatal implants may be loaded directly or indirectly in order to achieve
malocclusion.1 maximum anchorage (see Chapters 7 and 19). Connecting procedures for
The implant is a transmucosally placed endosseous titanium screw-type palatal implants have evolved from prosthodontics-derived transfer
implant with a sandblasted, large-grit, acid-etched surface (see Fig. 7.2). impressions involving considerable laboratory input to intraorally bonded
The surface treatment increases implant–bone contact and thus compen- adhesive procedures.
sates for the implant’s reduced length. The implant comprises an endos- The standard procedure for connecting the teeth to be stabilized with a
seous part (length, 4.2 mm; diameter 4.1 or 4.8 mm), a transmucosal neck palatal implant uses an alginate impression to fabricate a study cast. From
(length, 1.8 mm; diameter, 4.8 mm) and a threaded orthodontic abutment this, a custom tray with an occlusal window at the site of the implant (Fig.
(length, 3.5 or 5.5 mm; diameter, 4.8 mm). 20.1) is made at the laboratory and used to create a master cast. The
impression coping is screwed on to the implant through this window, a
silicon impression is taken (Fig. 20.1B) and the master cast with an implant
PALATAL IMPLANTS replica is made at the laboratory. The transpalatal arch (TPA)–palatal
implant connector is fabricated by adapting a 1.2 mm SS wire of spring
Männchen and Schätzle2 proposed a wide range of indications for the hardness to the palate and soldering it to the implant cap (Fig. 20.1C).
utilization of palatal implants based on the favorable combination of Finally, the cap is attached to the implant with a screw and the TPA is
mechanical (cortical) and biochemical (osseointegration) stability (see bonded to the teeth to be stabilized. Although standard and well estab-
Chapter 7). lished, this procedure needs considerable laboratory input and is consid-
Various factors influence the process of osseointegration, including bio- ered quite cost and material intensive.8,9
compatibility, design and surface properties of the implant; the volume, A simpler chair-side procedure with little laboratory input connects the
structural properties and regenerative capabilities of the surrounding bone; TPA with the palatal implant using small connectors that are initially sol-
the surgical techniques of preparing the implant bed and insertion; and the dered to the implant cap and bonded to the TPA. The TPA and connectors
timing of functional loading. The process of osseointegration is described are then removed from the mouth and placed in a plaster support for
in detail in Chapter 4. removal of the composite and soldering the connections.8
The conventional protocol for loading palatal implants suggests a Another innovative adhesive procedure avoids the requirement to solder
healing period of 3 months before applying any orthodontic load for the the small connectors to the TPA, thus replacing the time-consuming steps
maxilla and 6 months for the mandible.3 However, early loading, defined of the approach with a simple bonding technique.9 Initially, the palatal
as the insertion of the restoration (in or out of occlusion) immediately or tubes on the molar bands are opened on the occlusal surfaces with a
a few days after implant placement, has been used successfully by a diamond-studded drill (Fig. 20.2A). A small connector of 0.9 mm SS wire
number of clinicians.4–7 Chapter 4 discusses the evidence for primary and is soldered to the implant cap, which is then placed on the implant and
secondary stability of implants with time of loading. attached with a screw. The wire ends of the small connector should cross
While recent evidence favors early loading protocols for palatal the TPA below and are bent from the distal to the mesial above it, thus
implants, thus shortening overall treatment time, lighter loads or indirect clasping the TPA (Fig. 20.2B). The area where the small connector crosses
loading may be advisable until the onset of secondary stability and the TPA is sandblasted. The TPA is attached to the tubes with 0.010 inch
osseointegration. SS ligatures and secured with orthodontic luting composite in order to

Fig. 20.1 Standard procedure with laboratory and

chair-side stages for attaching to an implant.
(A) Custom tray with occlusal window and
impression coping. (B) Silicon impression with an
implant replica. (C) Master cast with the TPA–palatal
implant connector soldered to the implant cap.

A B C

109
 110 SECTION V: ORTHODONTIC IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Fig. 20.2 Adhesive procedure for attaching to an

implant. (A) The palatal tubes of the molar bands
are opened on the occlusal surfaces. (B) The small
connectors bent around the TPA. (C) Bonding of the
connectors with the TPA.

A B C

Fig. 20.3 Case 1: unilateral distalization.

(A) Pretreatment occlusal intraoral view with the
palatal implant providing indirect anchorage for the
distalization of the right maxillary molars. (B) After
space opening, the right first molar is stabilized with
a new TPA and the second premolar is retracted
with an elastic chain. (C) Retraction of the right first
premolar. (D) Final result.

A B

C D

immobilize it for the next step. Metal primer, sealer and composite are canine was buccally blocked out. Initially, the anterior teeth, including the
applied to the connections and fixed by light curing (Fig. 20.2C). The canines and the teeth in the left quadrant, were left out of treatment. Only
composite-connected component parts resist breakage up to a mean force four teeth in the right quadrant were bonded (0.018 inch slot system) and
of 3323.2 cN and provide absolute stability of the TPA–palatal implant a rectangular (0.016 × 0.022 inch) SS wire was engaged. On the palatal
connection in terms of maximum anchorage at forces up to 408.1 cN.9 side, skeletal anchorage was established using the new adhesive technique
These force levels are well within those typically used in orthodontic treat- with a round SS wire of 1.1 mm, which stabilized the second premolars
ment. In addition, high precision and exact fit are ensured because all the to the palatal implant. Indirect loading of the implant was carried out with
work is carried out intraorally. an open coil spring (Sentalloy yellow) positioned between the second
While all three methods are comparable in terms of effectiveness and premolar and first molar for distalizing the maxillary right first and second
patient comfort, they differ markedly in chair-time and costs. A decision molars, delivering a force of 150 cN (Fig. 20.3A).
should be made on the basis of local availability of laboratory facilities After successful distalization of the maxillary right first and second
and ease of integration with patient workflow. molars and subsequent space opening between the second premolar and
first molar, anchorage was adapted and a new TPA of 1.1 mm SS was
fabricated. By connecting the palatal implant to the right first molar and
CORRECTION OF CLASS II MALOCCLUSION the left second premolar, the right first molar was anchored in the correct
position and the right second premolar was distalized with an elastic chain
Skeletal anchorage techniques have facilitated the decision to opt for a (Fig. 20.3B).
non-extraction treatment, particularly for Class II malocclusion where a Following distalization of the right second premolar, a block consisting
Class I relationship of the canines and molars has to be achieved. Distaliza- of the right first molar and second premolar was established, the remaining
tion of the maxillary teeth is achieved by using palatal implant and a strong maxillary teeth were bonded and anchorage was minimized. Again, the
connecting wire for a rigid osseous anchorage. distalizing force acting on the right first premolar was introduced by
including the blocked-out right canine into the leveling archwire (0.016 inch
Sentalloy blue, 100 cN; GAC) (Fig. 20.3C).9
CASE 1: UNILATERAL DISTALIZATION After 22 months, the fixed appliances and the palatal implant were
removed. At this point the maxillary arch was properly aligned, the right
In this patient, the teeth on the right side of the maxilla were located more canine was properly incorporated into the arch and symmetry was rein-
mesially than the contralaterals. Because of local crowding, the right stated (Fig. 20.3D).
 THE USE OF THE STRAUMANN ORTHOSYSTEM 111

Fig. 20.4 Case 2: bilateral distalization.

(A) Pretreatment occlusal view of the maxilla
of a patient with Class II division 2 malocclusion,
Class II molar relationships and midline deviation.
(B) Maxillary molar distalization using a palatal
implant and cantilever arms to move the point of
force application towards the center of resistance
of the molars. (C) Occlusal view after distalization.
(D) Post-treatment occlusal view of the maxilla.

A B

C D

handling of this skeletal anchorage device. From the biomechanical point

CASE 2: BILATERAL DISTALIZATION
of view, direct and indirect loading types enable controlled tooth move-
ments in different clinical situations.
This patient had a bilateral Class II molar relationship, an increased over-
bite, retroclined maxillary incisors, a mandibular midline deviation of
2 mm to the left and mild crowding in both arches (Fig. 20.4A).
REFERENCES
The maxillary teeth were bonded (0.018 inch slot system) and the arch
leveled. In order to achieve a Class I dentition in this patient, the palatal 1. Wehrbein H, Merz BR, Diedrich P, et al. The use of palatal implants for orthodontic
implant was directly loaded. This means that the distalization force was anchorage. Design and clinical application of the Orthosystem. Clin Oral Implants Res
directly applied between the palatal implant and the first molars, using 1996;7:410–16.
2. Männchen R, Schätzle M. Treatment possibilities of different skeletal anchorage
cantilever arms.10 Bodily tooth movement was achieved by applying systems in view of failures and risk factors. Inf Orthod Kieferorthop 2011;43:
elastic chains (300 cN) between palatal extensions from the implant and 111–22.
cantilever arms attached to the molars’ bands, their endings passing close 3. Ganeles J, Wismeijer D. Early and immediately restored and loaded dental implants
for single-tooth and partial-arch applications. Int J Oral Maxillofac Implants 2004;19:
to the centers of resistance (Fig. 20.4B). 92–102.
By reactivating the force system at each check-up, using new elastic 4. Crismani AG, Bernhart T, Schwarz K, et al. Ninety percent success in palatal implants
chains (150 cN per tooth), the molars were steadily distalized. Success is loaded 1 week after placement: a clinical evaluation by resonance frequency analysis.
Clin Oral Implants Res 2006;17:445–50.
evident in Fig. 20.4C, which shows the increased distance between the 5. Borsos G, Rudzki-Janson I, Stockmann P, et al. Immediate loading of palatal implants
molar cantilever arms and the palatal implant. in still-growing patients: a prospective, comparative, clinical pilot study. J Orofac
At the end of treatment, a Class I molar relationship was achieved, the Orthop 2008;69:297–308.
6. Jackson A, Lemke R, Hatch J, et al. A comparison of stability between delayed versus
overbite was reduced, the crowding resolved and the midlines were cor- immediately loaded orthodontic palatal implants. J Esthet Restor Dent 2008;20:
rected (Fig. 20.4D). 174–84.
7. Gollner P, Jung BA, Kunkel M, et al. Immediate vs. conventional loading of palatal
implants in humans. Clin Oral Implants Res 2009;20:833–7.
8. Crismani AG, Bernhart T, Baier C, et al. Chair-side procedure for connecting trans-
palatal arches with palatal implants. Eur J Orthod 2002;24:337–42.
CONCLUSIONS 9. Crismani AG, Bernhart T, Bantleon HP, et al. An innovative adhesive procedure for
connecting transpalatal arches with palatal implants. Eur J Orthod 2005;27:
The palatal implant is a valuable and reliable tool to support correction of 226–30.
10. Sachdeva RCL, Bantleon HP. Cantilever based orthodontics: biomechanical and clini-
Class II malocclusions. The introduction of the innovative adhesive tech- cal considerations. In: Sachdeva RCL, Bantleon HP, editors. Orthodontics for the next
nique for connecting the palatal implant with the teeth has simplified the millennium. Glendora, CA: Ormco; 1997. p. 269–88.
 Section VI: Miniplates for the treatment of Class II malocclusion

21 Overview of miniplates and zygomatic

anchorage for treatment of Class II malocclusion
Ayça Arman Özçırpıcı, Burçak Kaya and Çağla Şar

downward growth of the maxilla by using extraoral traction during the

INTRODUCTION
growth period. Both require adequate extraoral or intraoral anchorage
mechanics.3 Chapters 1 and 2 cover in detail the various methods available
Miniplates are widely used in maxillofacial surgery as osteosynthesis
for treatment of Class II malocclusion including the various types of
devices for facial fracture repair and for fixation osteotomies. Miniplates
intraoral molar distalization devices, their mode of action and the indica-
used in the orthodontic practice are modified devices with a connection
tions for their use.
bar passing through the attached gingiva. They overcome the disadvan-
The move to use implant-supported intraoral molar distalization systems
tages of miniscrew implants (MIs), such as difficulty in finding a suitable
attempted to avoid issues such as mesialization of maxillary premolars,
site, and can serve as more reliable and long-standing skeletal anchorage
protrusion of maxillary incisors and increase in overjet, which all occur
units that provide excellent stability. The fixation screws of miniplates can
when teeth provide the anchorage. No matter which biomechanical appli-
be placed at various regions of the maxilla and mandible (zygomatic but-
ance configuration is used, all implant-supported molar distalization appli-
tress or aperture piriformis of the maxilla, posterior cortical bone and
ances obtain anchorage from palatal implants, thus allowing molars to be
symphyseal regions of the mandible; see Chapter 13). Miniplates present
distalized without anchorage loss of the premolars and incisors. Neverthe-
however some disadvantages: they are more expensive than MIs, they
less, preventing reciprocal teeth movements is not enough to correct Class
must be placed by a maxillofacial surgeon in an operating room and both
II buccal relationship. The maxillary premolars and canines can only be
placement and removal may cause swelling and discomfort for the patient.1
minimally distalized parallel to molar distalization when using palatal
Minplates have been used for skeletal anchorage for intrusion or distali-
implant-supported molar distalization systems, which results in a need for
zation of molars, in en masse distalization of the entire dental arch, for
a significant amount of premolar distalization in the subsequent phase of
buccal segment distalization, for severe skeletal Class III as an alternative
treatment.4–7
to orthognathic surgery or where anchorage teeth are lacking, and to apply
The use of dentoalveolar MIs with sliding mechanics allowed the seg-
orthopedic forces for treatment in both Class II and Class III cases.
mental distalization of all posterior teeth on rigid archwires: known as
A prospective clinical study evaluated maxillary protraction with mini-
buccal segment distalization. Despite the ability to distalize all maxillary
plates in comparison with conventional face-mask therapy and an untreated
posterior teeth together, the distalization obtained using alveolar MIs is
group.2 Treatment with miniplate anchorage was more effective in a shorter
limited since the MIs are inserted between the roots of the maxillary pos-
period of time, eliminating or reducing the undesired effects of conven-
terior teeth on the buccal or palatal side. This type of MI, which has to be
tional face-mask therapy. Miniplates applied laterally to the apertura piri-
of small diameter and have a relatively small surface in contact with the
formis region could withstand orthopedic forces of 400–500 g, showing a
alveolar bone, is relatively fragile and can only withstand low forces: a
93% success rate. Only 2 out of 30 miniplates had to be replaced by an
maximum of 200 g for a MI of diameter 1.2 mm and length 8 mm.8
additional surgery. This success is important as the face-mask elastics
apply a force vector that can pull miniplate screws out of bone.
Class II malocclusion results from combinations of skeletal and dental
components: facial structure, maxillary and mandibular growth patterns and MINIPLATE ZYGOMA ANCHORAGE
dentoalveolar development. The etiology may include maxillary prognath-
ism, maxillary dental protrusion, mandibular retrognathism, mandibular Zygoma anchors are miniplates placed on the zygomatico-maxillary but-
dental retrusion or any combination of these (see Chapter 1). Accompanying tress and fixed to the bone with two or more miniscrews. Different designs
vertical and transversal problems involving the undereruption or overerup- have been introduced by manufacturers, each with its own clinical advan-
tion of the anterior or posterior teeth, maxillomandibular rotation and maxil- tages. Some miniplates are fabricated in I-, T- or Y-shapes for the zygoma
lary transverse deficiency can also contribute to the severity of the problem. anchor to increase stability, while others have modified head sections,
Differential diagnosis is critical for preparing a problem-based treatment which are exposed to the oral cavity, for better control of orthodontic
plan.3 Miniplates can be valuable tools in Class II treatment as they have forces.9–17 The zygoma anchors offer several advantages, particularly in
the advantages of stability and durability even under high orthopedic forces the treatment of patients having severe maxillary protrusion with accom-
as well as ease of placement at different anatomic locations. panying vertical problems, either open bite or deep bite.
This chapter summarizes the use of miniplate anchorage for the treat- Zygoma plates are positioned at a safe distance from the roots of the
ment of Class II malocclusion. maxillary molars and do not limit the amount of distalization of maxillary
posterior teeth as is the case with alveolar MIs.

TREATMENT OPTIONS
BUCCAL SEGMENT DISTALIZATION
Treatment of Class II malocclusion resulting from maxillary dental protru- The use of zygoma anchors for maxillary buccal segment distalization in
sion is based on retraction of the maxillary dentition either by buccal non-growing patients by Sugawara et al.11 achieved an average of 3.78 mm
segment distalization without extractions or by retraction of the maxillary crown and 3.20 mm root distalization of the molars, which can be consid-
anterior dentition following maxillary premolar extractions. In maxillary ered as an almost bodily translation. Elastic chains were attached from the
prognathism, the treatment protocol is based on inhibiting the sagittal and maxillary first premolar brackets to the hooks of the zygoma anchors, and

112
 Overview of miniplates and zygomatic anchorage for treatment of Class II malocclusion 113

A B A B

Fig. 21.1 Application of the zygoma anchorage system for buccal segment Fig. 21.2 Indirect anchorage reinforcement with zygoma anchors. (A) During
distalization. (A) During distalization. (B) After distalization. canine distalization with a Paul Gjessing spring. (B) After upper maxillary premolar
extraction and canine distalization.
the maxillary buccal segments were distalized using sliding mechanics on
continuous archwires. The authors noted that when a two-stage procedure 50–100 g and the canines moved distally at an average of 1.14 mm per
is used, with the maxillary first molars initially distalized with an intraoral month.10
molar distalization appliance, it is difficult to maintain the distalized posi- Zygoma anchorage has been used for orthodontic treatment in maxillary
tion of the molars during the second stage. Therefore, they considered that first premolar extraction demanding bilateral maximum anchorage.18 A
the distalization obtained with zygoma anchors should be evaluated as true passive SS wire (0.017 × 0.025 inch) was placed starting at the vertical
molar distalization since there is no second stage involving retraction of slot of the fixation unit of the anchor plate and ending at the auxiliary tube
maxillary premolars and anterior teeth that could result in a mesial move- of the maxillary first molar band. This connected the maxillary molars to
ment of the maxillary first molars. the zygoma anchors for reinforced anchorage. The maxillary canines were
In our prospective clinical study sliding mechanics on SS continuous distalized on sectional SS archwires (0.016 × 0.022 inch) with Paul Gjess-
archwires (0.016 × 0.022 inch) were used with anterior bends to achieve ing (PG) springs between the maxillary canines and second premolars (Fig.
maxillary buccal segment distalization (Fig. 21.1A).9 An average of 21.2A). A distalization force of 100–150 g was applied with each activa-
4.5–5 mm distalization of all maxillary premolars and molars (maximum tion of the PG spring, which was reactivated every 4 weeks. An average
7.5 mm distal movement) was obtained (Fig. 21.1B). This was greater than of 5.5 mm canine distalization was obtained with only 0.6 mm anchorage
seen in other implant-supported distalization systems,4–8,11 which could be loss at the molars, the canines moving distally at an average of 1.20 mm
attributed to the dental characteristics of the subjects in our study, as most per month (Fig. 21.2B).18 The advantage of the system described here is
started treatment with a full unit Class II buccal relationship and needed that the zygoma anchors were used as indirect anchorage, which is reported
substantial distalization. One of the biggest advantages of the zygoma to be more stable and less likely to fail.
plates in our experience is that they can be used in the treatment of full
step or even more severe Class II relationship as they allow distalization
of all posterior teeth.9
ANTERIOR SEGMENT OR EN MASSE RETRACTION
The force applied on the zygoma plates in our study9 was approximately Zygoma anchors can also be used as anchorage for the retraction of
twice that achieved with the alveolar MIs in a similar buccal segment maxillary anterior teeth in both extraction and non-extraction treatment of
distalization method (450 g and 200 g, respectively).8 This increased dis- Class II malocclusion. Retraction can be performed smoothly with either
talization force can be achieved because each zygoma anchor is fixed to a two-stage or en masse mechanics using the zygoma anchors as an abso-
the dense bone structure of the zygomatico-maxillary buttress with three lute anchorage unit. As all of the maxillary teeth can be retracted together,
miniscrews of 2.3 mm diameter and 7 mm in length.9 Being able to apply the treatment time can be significantly decreased, which is a major
high distalization forces, similar to those achieved with cervical head- advantage.
gear,11 is an important advantage of zygoma anchors. It gives the option Maxillary incisors were retruded, overjet was decreased and canine
of treating patients with severe maxillary skeletal or dentoalveolar protru- relationship was corrected to Class I using a zygoma anchorage system
sion without maxillary premolar extraction or possibly orthognathic after a maxillary first premolar extraction.19 After canine distalization, the
surgery. patient was instructed to attach intraoral elastics between the zygoma
anchor hooks and crimpable hooks placed mesial to lateral brackets.
Zygoma anchorage has been used for en masse retraction of the maxil-
CANINE DISTALIZATION IN EXTRACTION TREATMENT lary anterior segment to correct excessive overjet and increased lip strain
Zygoma anchors can be used for reinforcing posterior anchorage in extrac- during closure.12 Following extraction of the maxillary first premolars,
tion treatment of Class II where maximum anchorage is required. A zygoma anchors were placed and the maxillary six anterior teeth were
zygoma anchorage system was used for orthodontic treatment in maxillary bonded. An archwire with vertical steps distal to the canine brackets, fol-
first premolar extraction requiring unilateral or bilateral maximum anchor- lowed by loops, was bent. The archwire passed through the buccal vesti-
age.10 The zygoma anchor consisted of an I-shaped miniplate with three bule and entered the head of the zygoma anchors. A retraction force of
screw holes continuing with a round bar and a cylindrical fixation unit at 150 g was applied bilaterally with coil springs attached from the loops to
the end. The specially designed cylindrical fixation unit had a vertical slot the zygoma anchors.
to place an auxiliary wire (0.032 × 0.032 inch maximum size) and a small A similar correction of excessive overjet and increased lip strain during
locking screw inside the cylinder to fix the wire. A unique power arm fitted closure used zygoma anchors for secondary treatment of an adult who had
in the vertical slot of the maxillary canine bracket with a hook at the end already had the maxillary first premolars extracted, so first premolar
of the arm situated at the canine’s center of resistance. Maxillary canines extraction was not a treatment option to gain the appropriate space for
were distalized on continuous archwires using sliding mechanics with anterior teeth retraction.15 The maxillary second molars were distalized on
Ni-Ti closed coil springs attached between the power arms on the canine posterior segmental wires by an open coil spring placed between the
bracket and the zygoma anchors. The distalization force applied was first and second molars. Afterwards, a continuous archwire was placed to
 114 SECTION VI: MINIPLATES FOR THE TREATMENT OF CLASS II MALOCCLUSION

retract all maxillary teeth with sliding mechanics. The authors emphasized The ideal position for exposing zygoma anchors to the oral cavity is the
that the use of zygoma anchors provided absolute anchorage and enabled keratinized gingiva or mucogingival junction, which is clearly higher than
different treatment options that avoided a need for space creation through the maxillary teeth crowns and brackets,20 and so a retrusion force vector
extraction or the use of extraoral anchorage devices such as headgear.15 applied away from the brackets with a long hook will pass above the center
The only treatment alternative would have been orthognathic surgery, of resistance of the teeth and result in mesial or anterior rotation. This kind
which the patient did not want. In our opinion, retraction of the entire of force vector can be an advantage when treating patients with gummy
maxillary arch using zygoma anchors was the best, and possibly the only, smile or deep bite, in which extrusion or retroclination of the maxillary
treatment option for this patient.15 anterior teeth is contraindicated. In contrast, applying the retrusion force
In our study comparing zygoma anchorage with cervical headgear in vector at the same level as the zygoma anchors with a long hook will cause
buccal segment distalization, maxillary buccal segment distalization was the force vector to approach the center of resistance of the teeth, resulting
obtained with the zygoma anchorage system.9 Maxillary premolars and in an almost bodily parallel movement with translation. This parallel force
molars were leveled at the beginning and then distalized segmentally on vector can be preferred in the treatment of patients who do not require
continuous SS archwires (0.016 × 0.022 inch) with a vertical step-up bend vertical tooth movements at the maxillary anterior segment. This was the
at the anterior region. Distalization force was applied on each side with case in our study described above,9 where the neck of the zygoma anchor
Ni-Ti closed coil springs from the zygoma anchors to the crimpable hooks and the crimpable hook were at the same level. No vertical movement or
placed mesial to the first premolar brackets. During this buccal segment tipping was observed at the premolars where the force was applied and
distalization stage, no orthodontic force was applied to the canines and only a minor distal tipping of 5° with no significant vertical movement
incisors. However, at the end of this stage, the maxillary canines, which was perceived at the molars. This was more advantageous than the move-
were initially in Class II relationship or in high vestibule position, moved ment seen with the other implant-supported molar distalization systems.4–7
to Class I relationship. In addition, maxillary incisors were retroclined and The counterclockwise moment force applied to the buccal segment by the
retruded with an average of 2.7 mm, under the pull of the transeptal gin- closed coil springs was thought to be the reason for the unchanged inclina-
gival fibers, and overjet was decreased as a result.9 In the second stage, tion or minor mesial tipping observed at the premolars.9
maxillary anterior teeth did not require any retraction and were only Because of variations in the thickness of the attached gingiva and mor-
leveled, while the distalized posterior teeth were retained in place with phology of the infrazygomatic crest, it is not always possible to expose
ligature wires tied between the zygoma anchors and maxillary first molars. the zygoma anchors through the ideal region.20 The position of the mini-
Based on evidence presented in the literature and our clinical experi- plates on the zygomatic buttress can be changed under these circumstances
ence, we consider that zygoma anchor plates have proven to be stable and but potential complications that must be considered include contact
reliable anchorage units for maxillary anterior retraction. In addition, the between the head of the zygoma anchor and brackets, damage to the buccal
option of en masse maxillary retraction via zygoma anchorage has the fat pad, hypertrophy of the buccal mucosa from irritation and injury to
advantage of shortening treatment time significantly. adjacent teeth roots. In addition, modifying the position of the zygoma
anchor may alter the direction and magnitude of the orthodontic force. The
availability of zygoma plates in variable lengths may help to overcome
CONTROLLING THE VERTICAL COMPONENT OF THE these problems.20
FORCE VECTOR WITH ZYGOMA ANCHORS One design of zygoma anchor was developed to facilitate application
and control of orthodontic force vectors.11 The subperiosteal body portion
With zygoma anchors it is possible to control the vertical component of is a V-shaped titanium miniplate with three miniscrew holes. The trans-
the distalization or retraction force vector. Vertical position of the posterior mucosal arm portion has three possible lengths (short, 6.5 mm; medium,
and anterior teeth can be altered by changing the direction and application 9.5 mm; long, 12.5 mm) to compensate for individual morphological dif-
point of force vectors. The vertical component of the retrusion force vector ferences. The head portion has three continuous hooks to adjust the direc-
applied from the zygoma anchors to the maxillary teeth can be modified tion and application point of orthodontic force vectors. The anchor plate
easily by using crimpable power hooks of different lengths (Fig. 21.3). characteristics can be altered to fit the distance between the implantation
site and the dentition, thus allowing retrusion force vectors with individual
vertical components based on the patient’s needs.11
Zygoma anchors can also be used to control the anteroposterior rotation
Fig. 21.3 The vertical of occlusal and mandibular planes (Fig. 21.4).13 A zygoma anchor with a
component of the
special appliance was designed to impact the maxillary posterior teeth. The
distalization or retraction
force vectors applied appliance consisted of bilateral acrylic resin bite blocks connected by
from the zygoma palatal arches and buccal wire attachments. Coil springs were attached to
anchors can be the buccal wire attachments and extended to the zygoma anchors, creating
controlled by using an intrusive force of 400 g. Because of the impaction of the maxillary
crimpable hooks with
molars, the mandibular plane showed counterclockwise autorotation and
different lengths.
overjet decreased as a result.13 This system has also been used in individu-
als presenting skeletal Class II relationship with increased overjet, anterior
open bite and vertical growth pattern with increased lower anterior facial
height. A 3.6 mm intrusion of the maxillary first molars led to changes in
the cephalometric angles: an increase of 1.8° in SNB, plus a decrease in
ANB of 1.5° and SN-GoGn of 3°. There was a decrease of 2.9 mm in the
lower anterior facial height.14
A patient with a convex profile, increased overjet and open bite was
treated with osteotomy-assisted maxillary posterior impaction with zygoma
anchorage.16 The vertical osteotomy cuts were performed mesial to the first
 Overview of miniplates and zygomatic anchorage for treatment of Class II malocclusion 115

A B C

D E F

Fig. 21.4 A 22-year-old patient with skeletal Class II malocclusion with open bite. (A) Pre-retreatment. (B) The miniplate bent and prepared for zygomatic anchorage after
surgical insertion. (C) Acrylic appliance used for maxillary posterior intrusion with zygoma anchors. (D) An intrusive force of 400 g applied with Ni-Ti closed coil springs
extending from the zygoma anchors to the buccal wire attachments of the appliance. (E) Lateral intraoral view after 16 months of treatment. (F) Lateral intraoral view 5
years later. Advancement genioplasty surgery was also performed after the treatment. (Courtesy of Professor Nejat Erverdi, Department of Orthodontics, Faculty of
Dentistry, Marmara University, Istanbul, Turkey.)

molars and distal to the second molars while the horizontal osteotomy cut ORTHOPEDIC AND SOFT TISSUE CORRECTION
was performed above the apices of the molars on the buccal and palatal WITH ZYGOMA ANCHORS
alveolar bone. An intrusive force of 250 g was applied by coil springs from
the zygoma anchors to the maxillary first and second molar buccal tubes. Palatal implant-supported systems can be used for the dental correction of
At the end of the orthodontic treatment, a 4 mm intrusion of the maxillary Class II malocclusions; however, no skeletal or soft tissue improvements
first and second molars had been achieved. This created a 2° increase in are achieved.4–7 In contrast, maxillary buccal segment distalization with
the SNB angle, a 1° decrease in the ANB angle, a 3° decrease in the zygoma anchorage systems does also allow significant skeletal and soft
SN-MP angle, and 3 mm decrease in the lower anterior facial height.16 tissue correction as the skeletal and soft tissue structures naturally follow
Although MIs can be used as anchorage for en masse retraction, there the dentoalveolar structures, for example a 0.8 mm distal movement of
is a significant correlation between MI failure rate and increased mandibu- point A (position of deepest concavity on anterior profile of maxilla), a
lar plane angle;21 consequently, miniplates may offer a better approach in 1.3° decrease of SNA angle and 0.86 mm upper lip retrusion.9
patients with a high mandibular plane angle. Moreover, the stability and The skeletal and soft tissue improvements obtained with zygoma
durability of MIs under multidirectional forces is less clear at present. By anchorage are only matched by those achieved with use of cervical or
comparison, zygoma anchors can be used efficiently for both the intrusion occipital headgear.
of maxillary molars and the en masse retraction of the maxillary anterior
segment simultaneously in patients with Class II high mandibular plane
angle. A proper occlusion and correction of a convex profile can easily be
achieved with retraction of the maxillary dentition and anterosuperior FUNCTIONAL TREATMENT OF MANDIBULAR
rotation of the mandible at the same time. The system can also be used for RETROGNATHISM WITH MINIPLATE ANCHORAGE
the preprosthetic orthodontic rehabilitation in adults presenting sagittal and
vertical dentofacial discrepancies (Fig. 21.5). Mandibular skeletal retrusion seems to be the major contributing factor
The vertical control mechanism to intrude posterior teeth with mini- in Class II malocclusions and the ideal correction is to alter the amount
plates can be applied at both maxillary and mandibular molar regions.22 and/or direction of growth of the mandible. The main treatment for this
Consequently, miniplate anchorage can be used successfully in patients purpose is functional appliance therapy in growing patients. The hall-
with Class II high-angle vertical growth pattern plus increased mandibular mark of Class II functional appliances is the construction bite, which
plane angles to obtain anterosuperior rotation in the mandible as well as provokes an anterior displacement of the mandible, inducing muscle
to eliminate disto-occlusion with the accompanying convex profile. Hence, stretching with the aim of stimulating condylar growth for supplementary
the effectively applied multidirectional retraction and intrusion biome- lengthening of the mandible.23 Functional appliances, including a range
chanics can be used in severe cases as an alternative to orthognathic of removable (activator, bionator, Twin Block) and fixed (Herbst, Jasper
surgery. Jumper, Forsus) appliances, are used to alter the position of the mandible
 116 SECTION VI: MINIPLATES FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C

D E F

H I

Fig. 21.5 A woman with Class II high mandibular plane angle whose main complaint was that she was unable to close her mouth properly and wrinkles appeared
on her chin when she tried to close her lips. Maxillary molars were extruded before the prosthetic rehabilitation of the previously lower edentulous posterior regions.
(A–C) Pretreatment extraoral (A), intraoral lateral (B) and occlusal (C) views. Note the severe extrusion of the upper right posterior region causing a deviated occlusal
plane and asymmetric smile, plus an inappropriate prosthodontic restoration at the mandibular right region. (D–F) After extraction of upper maxillary right second
premolar and upper maxillary left first premolar, and alignment of the teeth, zygoma anchors and palatal miniscrew implants (MIs) were inserted. Elastic chains from
both miniplates and the palatal MIs were used to obtain posterior intrusion, while Ni-Ti closed coil springs were used for en masse retraction of the anterior segment
simultaneously. (G–I) Extraoral (G), intraoral lateral (H) and occlusal (I) views after 23 months of fixed appliance treatment, which achieved 4 mm maxillary molar
intrusion, 7 mm en masse retraction of the maxillary anterior teeth and 9 mm decrease in overjet. Intrusion of the maxillary molars led to a significant autorotation
of the mandible causing a 4 mm decrease of the lower facial height and a 2° decrease of the ANB angle. Appropriate vertical spaces for the fixed prosthodontic
restorations were also obtained. Afterwards, the patient received advancement genioplasty surgery and prosthodontic restoration for her complete dental
rehabilitation.

in both sagittal and vertical planes. Although functional appliances are the symphyseal region in seven patients (mean age, 13.75 years) and
still considered the best option for treatment of mandibular retrognath- compared the results with those for eight patients who received conven-
ism, it is less clear from the literature as to their efficacy.24,25 A system- tional Jasper Jumper treatment.29 The miniplates were successful through-
atic review found the Herbst to be the most effective functional appliance, out the study period without causing any discomfort or complications,
with a monthly mandibular length increase of 0.28 mm, followed by the but the combination of Jasper Jumper and miniplates did not produce the
Twin Block (0.23 mm), bionator (0.17 mm), activator (0.12 mm) and expected skeletal results and had no significant effect on growth of the
Frankel (0.09 mm).26 It has been claimed that most of the correction with mandible in the sagittal direction. It was suggested that a more rigid
functional appliances is from dentoalveolar changes, with only a small fixed functional appliance such as the Herbst appliance or the Forsus
amount from skeletal effects.27,28 Fatigue Resistant Device symphyseal miniplate anchorage might be more
Skeletal anchorage with MIs might provide a solution to overcome the effective (Fig. 21.6).
undesired dentoalveolar effects of functional appliances and to increase
the amount of mandibular advancement. However, functional fixed appli-
ances exert a heavy force vector and moment that could force MIs out of CONCLUSIONS
bone. Miniplates applied to the posterior region of the mandible might
serve as more stable anchorage sources. Alternatively, four miniplates Miniplates can be used effectively for the treatment of Class II malocclu-
(two at the angulus area and two at the apertura piriformis region) could sion resulting from different maxillomandibular skeletal and dentoalveolar
be used. components. Ideal treatments for different types of discrepancy can be
One study has examined the skeletal and dental effects of the Jasper applied effectively by changing the place, shape and size of the miniplates
Jumper applied between maxillary molar tubes and miniplates inserted in as well as the force application protocol. With their stability and durability,
 Overview of miniplates and zygomatic anchorage for treatment of Class II malocclusion 117

Fig. 21.6 Application of 8. Park H, Lee S, Kwon O. Group distal movement of teeth using microscrew implant
the Forsus Fatigue anchorage. Angle Orthod 2005;75:510–17.
Resistant Device with 9. Kaya B, Arman A, Uckan S, et al. The comparison of zygoma anchorage system with
symphyseal miniplate cervical headgear in buccal segment distalization. Eur J Orthod 2009;31:417–24.
10. De Clerck H, Geerinckx V, Siciliano S. The zygoma anchorage system. J Clin Orthod
anchorage.
2002;36:455–9.
11. Sugawara J, Kanzaki R, Takahashi I, et al. Distal movement of maxillary molars in
non-growing patients with the skeletal anchorage system. Am J Orthod Dentofacial
Orthop 2006;129:723–33.
12. Erverdi N, Acar A. Zygomatic anchorage for en masse retraction in the treatment of
severe Class II division 1. Angle Orthod 2005;75:483–90.
13. Erverdi N, Usumez S, Solak A. New generation open-bite treatment with zygomatic
anchorage. Angle Orthod 2006;76:519–26.
14. Erverdi N, Usumez S, Solak A, et al. Noncompliance open-bite treatment with zygo-
matic anchorage. Angle Orthod 2007;77:86–90.
15. Tanaka E, Nishi-Sasaki A, Hasegawa T, et al. Skeletal anchorage for orthodontic cor-
rection of severe maxillary protrusion after previous orthodontic treatment. Angle
Orthod 2008;78:181–8.
miniplates provide an effective treatment alternative to orthognathic 16. Tuncer C, Ataç MS, Tuncer BB, et al. Osteotomy assisted maxillary posterior impac-
tion with miniplate anchorage. Angle Orthod 2008;78:737–44.
surgery and for severe malocclusion.
17. Veziroglu F, Uckan S, Ozden UA, et al. Stability of zygomatic plate-screw orthodontic
anchorage system: a finite element analysis. Angle Orthod 2008;78:902–7.
18. Cetinsahin A, Dincer M, Arman-Ozcirpici A, et al. Effects of zygoma anchorage
system on canine retraction. Eur J Orthod 2010;32:505–13.
ACKNOWLEDGMENTS 19. Bengi AO, Karacay S, Akin E, et al. Use of zygomatic anchors during rapid canine
distalization: a preliminary case report. Angle Orthod 2006;76:137–47.
The authors wish to thank to Drs. Zahire Sahinoglu, Ipek Coskun, Alev 20. Eroglu T, Kaya B, Cetinsahin A, et al. Success of zygomatic plate-screw anchorage
Yılmaz, Omur Polat-Ozsoy, Bulem Yuzugullu and Neslihan Arhun for system. J Oral Maxillofac Surg 2010;68:602–5.
21. Miyawaki S, Koyama I, Inoue M, et al. Factors associated with the stability of titanium
their valuable contributions. screws placed in the posterior region for orthodontic anchorage. Am J Orthod Dento-
facial Orthop 2003;124:373–8.
22. Sugawara J, Baik UB, Umemori M, et al. Treatment and posttreatment dentoalveolar
changes following intrusion of mandibular molars with application of a skeletal
REFERENCES anchorage system (SAS) for openbite correction. Int J Adult Orthod Orthognath Surg
2002;17:243–53.
1. Cornelis MA, Scheffler NR, Nyssen-Behets C, et al. Patients’ and orthodontists’ per- 23. Moore RN, Igel KA, Boice PA. Vertical and horizontal components of functional
ceptions of miniplates used for temporary skeletal anchorage: a prospective study. Am appliance therapy. Am J Orthod Dentofacial Orthop 1989;96:433–43.
J Orthod Dentofacial Orthop 2008;133:18–24. 24. Toth LR, McNamara JA Jr. Treatment effects produced by the twin-block appliance
2. Şar C, Arman-Ozcirpici A, Uckan S, et al. Comparative evaluation of maxillary pro- and the Fr-2 appliance of Frankel compared with an untreated Class II sample. Am J
traction with or without skeletal anchorage. Am J Orthod Dentofacial Orthop Orthod Dentofacial Orthop 1999;116:597–609.
2011;139:636–49. 25. Ruf S, Baltromejus S, Pancherz H. Effective condylar growth and chin position in
3. Kulbersh R, Pangrazio-Kulbersh V. Treatment of Class II malocclusions. In: English activator treatment: a cephalometric roentgenographic study. Angle Orthod 2001;71:
JD, Peltomaki T, Pham-Litschel K, editors. Mosby’s orthodontic review. St. Louis, 4–11.
MO: Mosby-Elsevier; 2009. p. 152–77. 26. Cozza P, Baccetti T, Franchi L, et al. Mandibular changes produced by functional
4. Mannchen R. A new supra-construction for palatal orthodontic implants. J Clin Orthod appliances in Class II malocclusion: a systematic review. Am J Orthod Dentofacial
1999;33:373–82. Orthop 2006;129:599.
5. Byloff FK, Karcher H, Clar E, et al. An implant to eliminate anchorage loss during 27. Janson GR, Toruno JL, Martins DR, et al. Class II treatment effects of the Frankel
molar distalization: a case report involving the Graz implant-supported pendulum. Int appliance. Eur J Orthod 2003;25:301–9.
J Adult Orthod Orthognath Surg 2000;15:129–37. 28. Konik M, Panherz H, Hansen K. The mechanism of Class II correction in late Herbst
6. Karaman AI, Basciftci FA, Polat O. Unilateral distal molar movement with an implant- treatment. Am J Orthod Dentofacial Orthop 1997;112:87–91.
supported distal jet appliance. Angle Orthod 2002;72:167–74. 29. Gazivekili C. The cephalometric evaluation of Jasper Jumper appliance in conjunction
7. Keles A, Erverdi N, Sezen S. Bodily distalization of molars with absolute anchorage. with skeletal bone anchorage in skeletal Class II cases with mandibular retrognathism.
Angle Orthod 2003;73:471–82. PhD Thesis. Istanbul: Marmara University; 1995.
 22 Distalization of the maxillary arch with
miniplate anchorage
Hugo De Clerck and Hilde Timmerman

region between the holes of the miniplate, it should not exceed 10° and
INTRODUCTION
can only be performed once to avoid any risk of fracture during or after
surgery. The angulation between the miniplate and the neck should not be
Class II malocclusions may reflect maxilla–mandible skeletal disharmony
modified in order to ensure good contact between the lower part of the
with underdevelopment of mandibular growth and/or maxillary excess,
neck and the alveolar bone. The round bar should also not be bent as that
leading to a convex soft tissue profile. Ideally, treatment of Class II maloc-
could lead to its later fracture.
clusions should focus first on improving the skeletal discrepancy using
The device is positioned so that the round connecting bar of the neck
functional appliances while the individual is still growing.1 However,
penetrates the soft tissues exactly at the angle of the L-shaped incision,
dentoalveolar compensations, reducing overjet and the severity of the
2 mm below the mucogingival border. The center of the holes of the mini-
Class II malocclusion, are still the major effect of functional appliances.2,3
plate should be as close as possible to the top of the infrazygomatic crest
In adults, repositioning of the maxilla and mandible can be achieved
oriented parallel to the alveolar bone, with the opening of the hook oriented
with orthognathic surgery, adjusting the position of both in relation to
to the distal. A pilot hole, diameter 1.65 mm, is drilled in the bone through
the cranial base in the three dimensions and improving overall facial
the middle hole of the miniplate using a standard hard steel 1.65 mm
esthetics.
twisted drill (Fig. 22.2D). The fixation screws are seated with a standard
Part of the Class II malocclusion can be treated by dentoalveolar com-
screwdriver. The first screw is not completely fixed to allow some rotation
pensation alone and a variety of methods have been advocated, as described
of the miniplate. The lower hole is drilled and the screw is inserted, fol-
in other chapters of this book. This chapter concentrates on the use of
lowed by the upper one and all are then fixed for a strong and stable
miniplate anchorage,4 which makes it possible to insert the anchor close
retention (Fig. 22.2E).
to the infrazygomatic crest and above the apex of the maxillary first molar.
After rinsing with saline solution, closure is obtained in one plane with
The miniplate can be extended to transfer the point of force application
4-0 resorbable sutures. The mucoperiosteal flap is positioned by the first
close to the fixed appliances (Fig. 22.1). If this extension is an osteosyn-
suture just anterior from the neck of the bone anchor. Additional sutures
thesis plate, oral hygiene at the perforation of the soft tissues can be dif-
are placed until good closure is obtained (Fig. 22.2F).
ficult and local infections sometimes occur. An extension with a round
section facilitates oral hygiene. Major advantages of miniplate anchorage
include the reduced risk of damage to the roots of a tooth during surgery
or by orthodontic movement of neighboring teeth, better quality of the PATIENT INSTRUCTIONS
anchorage and better biomechanics.
Immediately after surgery the fixation units are covered with wax. The
patient replaces the wax after brushing. This protects the cheeks, which
MINIPLATE SURGERY may be irritated by the intraoral extension of the miniplate, particularly
initially when there will be some tissue swelling. Cooling of the area for
Bollard miniplates have three holes and an extension round bar with a 48 hours after surgery is advised and sports should be avoided for 3 days.
fixation hook at its end (Fig. 22.1A). The miniplate is fixed on to the Patients should rinse twice a day with chlorhexidine for 12 days and
infrazygomatic crest by three monocortical osteosynthesis screws with a several times a day with sparkling water. In addition, patients must be
diameter of 2.3 mm; a screw of 7 mm length is inserted through the upper instructed not to touch the extension of the miniplate repeatedly with their
hole and ones of 5 mm through the middle and lower holes. Alternatively, tongues or fingers as this is the main reason for some early loss of stability
self-tapping or self-drilling miniscrew implants (MIs) can be used. of the anchor. Patients should be clearly warned of the risk of loosening
Initially, an L-shaped incision is made with anterior convexity (Fig. the miniplates and even needing further surgery. Continual clinical checks
22.2A) and a posterior-based mucoperiosteal flap is raised for bone expo- for any small mobility of the miniplate can minimize any adverse effects.
sure (Fig. 22.2B). The miniplate is slightly bent to obtain good contact About 10 days after surgery, the patient is given specific instructions on
with cortical bone (Fig. 22.2C). The bending should be limited to the how to clean the soft tissues surrounding the round bar, using a soft

Fig. 22.1 Bollard miniplates. (A) Left and right upper miniplates.
(B) Intraoral view 3 weeks after surgery.

A B

118
 Distalization of the maxillary arch with miniplate anchorage 119

B
A

D
2

Fig. 22.2 Insertion of the Bollard miniplates. (A) The L-shaped incision.
1, The vertical part is ±1 cm mesial from and parallel to the
infrazygomatic crest and up to 2 mm below the mucogingival border; 2,
a horizontal incision 2 mm below and parallel to the mucogingival
E
border. (B) The posterior-based mucoperiosteal flap. (C) Bending of the
miniplate to obtain good contact to the cortical bone. 1, The region for
bending; 2, angulation between the miniplate and the neck, which
should not be modified; 3, contact between the lower part of the neck
and alveolar bone. (D) Drilling the first hole through the middle hole of
the miniplate. (E) Insertion of the fixation screws. (F) Suturing.

conventional toothbrush rather than an electrical one. Orthodontic loading resistance of the canine and so will initially result in distal crown tipping.
should be started no later than 2 to 3 weeks after surgery, with initial Binding of the archwire at the mesial and distal border of the bracket
loading no higher than 100–150 g. Loading can increase progressively generates forces that will upright the root of the canine (Fig. 22.3A).
over the first 3 months but should never exceed 250 g; such high forces Consecutive crown tipping and root uprighting finally results in sliding
are not needed for optimal tooth movement. of the canine bracket along the archwire. Because of the repetitive binding
between the bracket slot and the archwire, friction is generated, which
pulls the archwire posteriorly. The posterior traction on the archwire is
MOLAR DISTALIZATION BIOMECHANICS further amplified by similar friction generated by binding in the brackets
of the premolars and in the molar tubes. All these small distalizing forces
Because of the oblique inclination of the infrazygomatic crest, the fixation are transmitted to the anterior segment and pull the incisors back
unit is usually located in front of the second premolar. An elastic or a (Fig. 22.3B).
closed Ni-Ti coil spring can be placed from the hook directly to the maxil- Where distalization is only needed on one side, a midline deviation
lary canine bracket. The line of force is located below the center of results. During canine crown tipping, the archwire in front of the bracket
 120 SECTION VI: MINIPLATES FOR THE TREATMENT OF CLASS II MALOCCLUSION

CR

Fr
Fa Fr

A Mc B

BA

Fig. 22.3 Distalizing forces. (A) Initial crown tipping during canine distalization. The line of force is located below the center of resistance (CR) of the canine.
(B) Distalizing forces generated in the lateral segment resulting in a posterior traction on the incisors. (C) Crown tipping of the canine tends to extrude the incisors.
(D) A closed coil spring is pushed against the mesial side of the first premolar bracket to act as a rigid sliding jig for posterior movement of the lateral segments.

is pulled down and the archwire behind the bracket is pulled upwards. This Distalization starts only after fixation of a stretched Ni-Ti closed coil
results in some extrusion of the incisors and intrusion of the first premolar spring between the hook on the miniplate and the anterior limit of the
(Fig. 22.3C). closed coil spring, which will be pushed against the bracket of the first
In increased overbite, the maxillary incisors are blocked by the man- premolar. The line of force applied to the mesial border of this bracket is
dibular incisors and cannot move posteriorly together with the canines and located below the center of resistance of the premolar but parallel to the
so space will be created between the canine and the lateral incisor. After archwire. To avoid rotation of the premolars during distalization, a
distalization of the canines into a Class I relationship, the four incisors can 0.010 inch SS ligature should be firmly tied around the distal wings of the
only be distalized in combination with bite-opening mechanics such as a bracket. This provides better control of rotation and reduces friction. A
T-loop arch in the maxillary dentition combined with leveling of the curve round archwire generates less friction than a rectangular wire. The main
of Spee in the mandibular arch. The lack of vertical control of the incisors advantage of using a sliding SS coil spring in front of the maxillary canine
during sliding of the lateral segment will slow down the distalization of is the vertical component of force: a lever is created that generates an
the whole dental arch. This is a consequence of the two-phase biomechan- intrusive force close to the lateral incisors (Fig. 22.4A,B). This vertical
ics: distalization of the lateral segments first followed by retraction of the force alone, applied to the bracket of the incisors at a distance from their
incisors in combination with elimination of the deep bite. center of resistance, would result in incisor proclination. However, binding
A better approach is to use a single phase where lateral and anterior at the bracket–archwire interface in the lateral segments will add a continu-
segments are moved simultaneously. No bracket is bonded on the maxil- ous distalizing force to the incisors. Clinically, this horizontal force is be
lary canines at the start of treatment but the second molars are always to big enough to avoid proclination of the incisors and to maintain contact
be bonded. Crowding in the anterior segment is not corrected during initial with the antagonists. This is very important in order to avoid a spontaneous
leveling to avoid “round tripping” of the incisors. Overlapping or rotation overeruption of the mandibular incisors during bite opening.
of the incisors is maintained and not corrected by the Ni-Ti archwires. Although some extrusion may also occur in the posterior segment, this
However good alignment of all the premolars and first and second molars bite opening in the anterior segment will be more restricted when there is
is required before initiation of distalization. After alignment of the extreme retroclination of the maxillary incisors at the start of treatment.
lateral segments, a round Australian wire is inserted (0.016 inch for a Simultaneous displacement of the lateral and frontal segments results in
0.018 × 0.025 inch bracket slot and and 0.020 inch for a 0.022 × 0.028 inch less increase of arch length, and thus fewer archwire replacements are
slot). Posterior movement of the lateral segments is started by inserting an needed. In fact, at the monthly visits it should be checked if there is still
SS closed coil spring mesial of the bracket of the first premolar to act as sufficient archwire extending behind the second molar tube.
a rigid sliding jig; this has no active inherent force such as that with a When molars are distalized without retraction of the incisors, the total
compressed open coil spring (Fig. 22.3D). arch length increases and the amount of archwire distal to the second molar
 Distalization of the maxillary arch with miniplate anchorage 121

tube can become so short that the sliding movement of the last molar will drift, the canine follows the trajectory with the least resistance, without
be blocked. Blocking will, of course, also result in blocking of the distali- hitting the outer or inner cortical bone plates, and along the labial surface
zation of the complete posterior segment. In order to extend the archwire of the mandibular canine. If a bracket is bonded to the maxillary canine,
distal to the second molar tube without irritating the cheeks, a horizontal the movement will be determined by the shape of the archwire. At each
bend parallel to the occlusal plane is advised; the bended extremity should monthly appointment, some expansion should be added to the archwire in
not be too short. Further irritation may also be caused by sliding of the the canine region. If too much expansion is given, drifting of the canine
archwire to one side. This can be avoided by bending two stops in the will be restricted by contact with the outer cortical plate. If not enough,
archwire mesial to the brackets of both central incisors (Fig. 22.4C,D). the canine will be stopped by occlusal interference with the mandibular
Sometimes, a ligature or chain elastomeric connecting the four incisors is canine. Movement will also be restrained by friction at the bracket–
needed to avoid creation of a medial diastema. archwire interface. The advantage of not bonding the canine is not only a
The maxillary canines partially follow the movement of the first premo- better vertical control of the maxillary incisors but also a smoother distal
lars under the pull of the transeptal fibers, but this only happens when there drift of the canine and a limited amount of rotation.
is no interference with the mandibular canine or by its bracket. Therefore, Rotation always results when a distalizing force is applied to the hook
the lower fixed appliances are only bonded after a nearly Class I occlusion on the canine bracket; this can be avoided by tying the distal wing of the
in the canine region is reached. bracket with an SS ligature to the archwire. However, this will increase
From an occlusal view, the maxillary arch can be divided into three seg- friction. When the first premolar is distalized and no bracket is bonded to
ments, with the canine (middle segment), the only tooth without a bracket. the canine, the canine will move distally under the pull of the transeptal
The lateral segments are pushed back by the sliding closed coil in the rail fibers. Some of these fibers are located at the level of the center of resist-
formed by the labial and palatal cortical plates. This is a movement along ance and will not generate rotation but fibers labial from the center of
a straight line, guided by the walls of the alveolar process but with some resistance will cause a rotation opposite to the rotation generated by the
possibility of labial or palatal crown tipping. The retromolar region has a elastic fibers on the palatal side, thus resulting in distalization with hardly
high potential for remodeling and so the germs of unerupted third molars any rotation.
are not as a rule removed prior to distalization. Because round archwires From a labial view, the force of the fibers is applied far below the center
are used, the front segment is moved posteriorly mainly by retroclination. of resistance of the canine and so distal crown tipping is commonly
This tipping movement is easily obtained because there is little binding observed and root uprighting is needed after a Class I occlusion in the
friction. The light distalizing force generated by sliding of the lateral seg- molar region has been reached. To upright the root of the canine, a bracket
ments will be sufficient to maintain contact with the mandibular incisors is bonded and a Ni-Ti archwire inserted. The resistance against root
during bite opening. The amount of movement of the incisors and the reduc- uprighting will be higher than the resistance against mesial crown tipping.
tion of the overjet will depend on the amount of bite opening. Excessive A laceback from the canine bracket to the miniplate may restrict mesial
retroclination of the incisors will only be corrected by using rectangular crown tipping and help to maintain the Class I relation with the mandibular
archwires in a later stage of treatment after a Class I occlusion is reached. canine (Fig. 22.5A). This laceback should be passive. To avoid rotation of
The most complex movement is made by the canines, which are guided the canine during root uprighting, the distal wing of the bracket should be
between the curved plates of the alveolar process. During this spontaneous firmly tied to the archwire (Fig. 22.5B,C).

A B C D

Fig. 22.4 A continuous light intrusive force results in some bite opening during distalization of the lateral segments. (A,B) Lateral view (A) and after (B) insertion of the
arch wire Sliding of the archwire to one side is avoided by bending two steps between the brackets of the central incisors: without (C) and with fixation (D) of the open
coil spring to the closed coil spring on the archwire.

B C
A

Fig. 22.5 Restriction of mesial crown tipping of the maxillary canine. (A) Laceback from the canine bracket to the miniplate. (B,C) Canine uprighting before (B) and after
(C) application of a passive laceback.
 122 SECTION VI: MINIPLATES FOR THE TREATMENT OF CLASS II MALOCCLUSION

Crowding of the maxillary incisors is not corrected at the start of fixed the canines can be reduced by adding an intrusion auxiliary arch when
appliance therapy. This usually results in proclination of the incisors and there is vertical excess in the front segment. Intrusion auxiliary arches are
an increased overjet. When there is lack of space and overlapping of the usually inserted in an additional molar tube. However, the reaction forces
anterior teeth, all the teeth are bonded but the initial leveling wires are will extrude the molars and tip their crowns to the distal. This can be
only partially inserted into the brackets’ slots. In extreme crowding, as in avoided by inserting the intrusion arch in the tube of the Bollard miniplate.
some Class II, division 2, the archwires are fixed below the lower border Instead of a continuous arch, segmented intrusion arches are easier to
of the incisor brackets (Fig. 22.6). adjust. A SS segmented wire (0.018 × 0.018 inch) is inserted into the tube
To obtain contact with each bracket, some first- and second-order bends of the miniplate. The wire is cut between the lateral incisor and the canine
have to be made in the main archwire so that the intrusion force generated and a small circle is bent (Fig. 22.8A,B). The anterior part of the wire is
by the lever arm of the closed coil spring and the retracting force from pulled down and fixed distal from the lateral incisor to the archwire by
binding in the lateral segments are transferred to the four crowded incisors. means of an SS ligature (Fig. 22.8C). The amount of force is modified by
Distal drift of the canines results in an increased intercanine distance and altering the curvature of the segmented wire and different forces may be
a spontaneous unraveling of the crowded incisors. Only after sufficient used on the left and right where there is a canted occlusal plane. The small
space is available should a light Ni-Ti wire be inserted for the first piece of wire extending behind the tube of the miniplate rarely disturbs
time in the brackets’ slots, aligning the anterior teeth with minimal the patient but can be bent or covered by a drop of a flowable composite
proclination. (Fig. 22.8C). It does facilitate removal if necessary during future
When a sliding coil is used to distalize the maxillary premolars without controls.
bonding the canines, a dual occlusal plane is often created through intru- The transverse dimension of the maxillary arch will be affected by the
sion of the incisors and some extrusion of the premolars (Fig. 22.7). sliding mechanics, and the widths between premolars and between molars
After bonding the maxillary canines and insertion of a straight wire, the will become larger. This can be explained by the direction of traction from
archwire will be flattened again by some intrusion of the premolars, but the sliding hook to the elastic hook on the miniplate (Fig. 22.9). In addition
mainly by extrusion of the incisors. During root uprighting of the maxillary to the sagittal component, there is also a lateral component of force, result-
canines, additional extrusive forces will be applied to the incisors and, ing in some expansion of the premolars.
before leveling the maxillary arch, a choice has to be made as to whether The increase in intercanine width occurs spontaneously without brack-
incisor extrusion is wanted or not, depending on incisor exposure and ets and without forces from the fixed appliance. The distal drift of the
smile esthetics. Without precautions, part of the intrusion obtained in the canines, guided by both cortical plates of the alveolar process, positions
first part of distalizing mechanics will be spontaneously lost. As long as them more posteriorly in the arch, with an increased distance between left
contact with the mandibular incisors is maintained, and once the lower and right center of the alveolar process. This also explains part of the
fixed appliance is bonded, the deepening of the bite will be limited and increase in widths between premolars and between molars.
will not affect the Class I occlusion previously obtained. Furthermore,
simultaneous leveling of the curve of Spee in the mandibular arch will
help to control the overbite. Extrusion of the incisors during uprighting of DISCUSSION

The use of miniplates for direct anchorage as described in this chapter can
support all the treatment required for distalization of the complete maxil-
lary dental arch with little need for patient compliance during treatment
apart from maintenance of oral hygiene. The intraoral tube with a hook,
positioned between the maxillary molar and the second premolar, offers
unique options for adding intrusion or extrusion auxiliaries.
Sliding mechanics have the advantage that all premolars and molars are
A B moved as one unit and that the canine partly follows the movement of the
Fig. 22.6 Frontal (A) and lateral (B) intraoral views showing that the archwire is
premolars, thus creating space for the incisors. The light intrusive and
not inserted in the bracket slot in order to avoid excessive proclination during retraction forces acting continuously on the incisors during distalization
initial alignment. of the lateral segments result in a reduction of the overjet without increase

B C
A
Fig. 22.7 (A) The dual occlusal plane. (B,C) The occlusal plane before (B) and after (C) distalization.
 Distalization of the maxillary arch with miniplate anchorage 123

Fig. 22.8 Segmented

intrusion arch. (A,B)
Before (A) and after
(B) activation. (C) The
intrusion arch fixed to
the archwire between
the lateral incisor and
canine.

A B

Fig. 22.9 The lateral The combination of anteroposterior corrections in the lateral segments
component of force with vertical control in the anterior segment results in an efficient posterior
generated by the open
displacement of the whole maxillary dental arch in one stage. Where no
coil spring.
retraction of the incisors is wanted, the molars, premolars and canines can
be distalized to create extra space for the alignment of crowded incisors
without proclining them. Obtaining a normal sagittal and vertical overbite
of the incisors and a nearly Class I occlusion of the molars within the first
year of treatment leaves more time for finishing and detailing of the occlu-
sion and may improve the final outcome of the orthodontic treatment.
However, more research is needed to find out how the incisor exposure
might change after completion of the fixed appliance therapy and what
tendency there is for relapse.

REFERENCES
of the vertical overbite, and sometimes with a slight bite opening in the
frontal segment. 1. O’Brien K, Macfarlane T, Wright J, et al. Early treatment for Class II malocclusion and
Very few adaptations have to be made to the archwires during the pro- perceived improvements in facial profile. Am J Orthod Dentofacial Orthop
2009;135:580–5.
cedure, which reduces chair-time at the monthly check-ups. As with all 2. AAO. Council on Scientific Affairs (COSA). Functional appliances and long-term
other orthodontic treatment approaches, facial esthetics, incisor exposure effects on mandibular growth. Am J Orthod Dentofacial Orthop 2005;128:271–2.
and smile esthetics should always be taken into consideration. In order to 3. Martin J, Pancherz H. Mandibular incisor position changes in relation to amount of bite
jumping during Herbst/multibracket appliance treatment: a radiographic-cephalometric
avoid over-retraction of the maxillary teeth, some proclination of the study. Am J Orthod Dentofacial Orthop 2009;136:44–51.
mandibular incisors can be used to compensate any mild skeletal dishar- 4. De Clerck H, Geerinckx V, Siciliano S. The Zygoma Anchorage System. J Clin Orthod
mony. This proclination is usually obtained during leveling of the curve 2002;36:455–9.
of Spee and elimination of some initial crowding of the incisors. Class II
elastics should be avoided in order to avoid overproclining the incisors.
 23 Maxillary molar distalization with the Graz
Implant-Supported Pendulum appliance
Friedrich K. Byloff and Hans Kärcher

The removable part of the appliance consists of a resin body similar to

INTRODUCTION
an acrylic resin Nance button. Two cylindrical slots of the acrylic resin
The Graz Implant-Supported Pendulum (GISP) is a Pendulum appliance button are telescoped over the two cylinders of the anchorage miniplate to
with two parts that was developed to distalize maxillary molars in adults.1,2 avoid compression of the mucosa (Fig. 23.1C). After the surgical proce-
A significant characteristic of this device is that the pendulum auxiliary is dure, a healing period of 2 weeks allows any swelling to subside. An
not integrated and is easily removed for reactivation and control of move- impression of the maxillary arch and the palate with the two protruding
ment in all planes of space. cylinders is then taken. The existing maxillary molar bands are also shown
in the impression, so that the distalizing TMA springs (0.032 inch) can be
adapted to the lingual sheaths of the bands. After fabricating the acrylic
DESIGN OF THE GRAZ IMPLANT-SUPPORTED resin Nance button on the cast, the distalizing springs are activated to
PENDULUM generate a force of approximately 250 g per side. Intraorally, this remov-
able pendulum is fitted on the two cylinders (Fig. 23.1C). The two springs,
The GISP has an anchorage part consisting of a surgical miniplate with which are curved at their ends for better three-dimensional molar control,
four miniscrew holes and two cylinders welded at right angles to the center are fitted into the sheaths. The sheaths have a built-in 8° offset for easier
of the miniplate, all made of titanium. This part is directly fixed to the intraoral insertion.
palatal bone via four 5 mm long titanium miniscrew implants (MIs) (Fig. During insertion of the preactivated appliance, the maxillary second
23.1A). The cylinders perforate the palatal mucosa (Fig. 23.1B), which is molars are bonded and a sectional (leveling) archwire is engaged. This
folded back to form a mucoperiosteal flap to expose the bone; alternatively, way both molars can be simultaneously distalized (Fig. 23.1D), which has
they can be tunneled by an incision. In adults, existing maxillary third been shown to be the most efficient approach.
molars are removed during the same surgical session to reduce resistance
to distalization. In this case a general anesthetic is used; otherwise local
IMPROVED DESIGN
anesthesia is sufficient. When there are no maxillary third molars present,
the procedure requires “weakening” of the alveolar bone from the occlusal To avoid invasive surgery, a new design has the miniplate placed directly
with a bur distal to the second molars in order to facilitate distal movement. on to the palatal mucosa and fixed with four 10 mm long locking MIs
Removal of the anchorage attachment during fixed appliance treatment is (TriLock; Medartis, Basel, Switzerland) (Fig. 23.2A,B). The MIs’ heads
completed with two longitudinal tunneling incisions in the mucosa under are sunk into the cavities in the palatal miniplate so that the mucosa is not
local anesthesia. compressed by pressure from the acrylic resin Nance button when the

A B C D

Fig. 23.1 Original design of the Graz Implant-Supported Pendulum appliance. (A) The surgical miniplate and the miniscrew implants. (B) Cylinders perforating the mucosa.
(C) Intraoral occlusal view of the appliance; the removable acrylic button with distalizing springs telescoped over the two cylinders of the miniplate. (D) Sectional archwire
in place during simultaneous distalization of the first and second molars.

A B C D

Fig. 23.2 Improved design of the Graz Implant-Supported Pendulum appliance. (A) The new anchorage miniplate. (B) The miniplate fixed on the palatal mucosa.
(C) Removal of the acrylic button with Weingart pliers and a probe. The probe is inserted into a tunnel at 45° to the occlusal plane and both instruments are pulled gently
down simultaneously. (D) Extraoral reactivation of the distalizing spring.

124
 Maxillary molar distalization with the Graz Implant-Supported Pendulum appliance 125

A B
C
Fig. 23.3 (A) Laboratory-fabricated Graz Implant-Supported Pendulum with pre-reactivated distalizing springs. (B) A specially modified end for the distalizing spring, which
allows molar distal root tipping by the leveling wire. (C) Schematic view of root uprighting using a leveling wire with a modified spring end.

springs are activated. With this system, the hole in the miniplate accom- parents are now able to decide between the classic Pendulum appliance or
modates the MI head in such a way that it is perfectly stabilized. Holes in the implant-anchored GISP. The advantages of the GISP include:
the bone are predrilled under local anesthesia and the MIs inserted using
■ it acts as a counterbalance to mesial movement of premolars
a manual screwdriver. The cylinders in this modified design are smaller:
■ the canines and maxillary incisors are not impinged
7.5 mm in length and 3.6 mm in diameter (Fig. 23.2A). These design
■ spontaneous distal movement of the premolars takes place during
improvements enable the alginate impression for construction of the button
molar distalization
and embedded springs to be made on the insertion day, immediately fol-
■ treatment time is shorter.
lowing surgery.
A small tunnel at about 45° to the occlusal plane is drilled into the In adults, the individual situation will determine the treatment plan. Where
anterior part of the button to allow it to be removed periodically (Fig. there is a third molar in perfect condition and the first or second molar has
23.2C,D). If desired, the removable acrylic resin button can be miniatur- a root canal treatment, a deep filling or crown, the orthodontic decision
ized. This solution offers improved hygiene and gives the tongue more might be to keep the third molar and extract the affected molar. There
space in the palatal vault. would then be no need for molar implant-supported distalization and con-
As with the original GISP, bands are fitted to the maxillary first molars ventional dental anchorage might be possible. If premolars or molars are
prior to surgery, removed and set aside for use when taking the impression to be extracted, reinforcement of anchorage for molar distalization becomes
for the construction of the Nance button. The modified Nance button is necessary. If both maxillary molars are to be moved distally, existing
similar to a Pendulum appliance but without wires bonded to the premo- maxillary third molars are removed. Decisions to extract third molars,
lars. One week should be allowed for healing after which an impression particularly when they are impacted, are generally accepted since they are
is made and the maxillary molar bands are left in the alginate. A simulated often not considered to be valuable teeth.
internal miniplate with cylinders is inserted into the impression and a
plaster cast is fabricated in the laboratory. Once the appliance is made, the
springs are fitted passively to the molar palatal sheaths and then activated ORTHODONTIC PROCEDURE
to exert a force of approximately 250 g per side (Fig. 23.3A). The appli-
ance is inserted into the mouth after the bands have been bonded to the Distalization of first and second molars can sometimes take more than 3
molars; the second molars are bonded and a sectional leveling arch is months before space mesial to the first molar becomes visible. Distal
engaged (Fig. 23.1D). The wire enhances mobilization of the second movement of the premolars under the pull of the transeptal fibers can
molars and we also consider that it improves distal movement of both camouflage space opening for some time, particularly when there is crowd-
molars simultaneously. Patients are seen every 6 to 8 weeks. If necessary, ing at the start of treatment. Initially with the GISP, the first and second
the removable button is pulled off and the springs are reactivated (Fig. molars are distalized individually with an undersized square SS archwire
23.2D). The curved ends of the springs allow the clinician to control verti- and a Ni-Ti push-coil spring. The push-coil spring distalizes the second
cal and rotational movement, as well as tipping throughout treatment.3 molars, while the distalizing spring on the first molars is also activated.
Once the second molars are sufficiently distalized, the force of the push-
coil is reduced until it is barely active. As a result, the TMA spring on the
INDICATIONS first molars becomes dominant and the first molars are moved toward the
second molars, eventually closing the space between them, while the coil
The GISP is mainly indicated when significant distalization of maxillary spring holds the second molars in their distal position.1 This method was
molars is required, either unilaterally or bilaterally. Clinical goals achiev- used to treat a patient who did not return for checks for almost 12 months
able include correction of a dental Class II malocclusion without extraction and we found that the first and second molars distalized simultaneously
of the maxillary premolars, first or second molars. Mandibular advance- with the single activation at the start of treatment (see Case 1). Based on
ment surgery can also be avoided where camouflage treatment is consid- this, we changed to simultaneous distalization as this required the same
ered possible. In general, a final occlusion with a molar and canine Class time with much less effort and clinical time.
I relationship, as provided by nature, is the most harmonious solution that Patients are seen every 6 weeks for an appliance check and, if needed,
can be achieved through the use of the GISP. spring reactivation; the patient also rinses without the removable button
Simplified placement has allowed use of the GISP to be extended from in the mouth. The time required to distalize maxillary molars depends on
adults to adolescents with permanent dentition. Adolescents and their the distance to be covered and on the individual biological response.4
 126 SECTION VI: MINIPLATES FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C D

E F G

Fig. 23.4 Case 1: adolescent with Class II malocclusion. (A,B) Pretreatment. (C) Intraoral photographs after molar distalization
with the Graz Implant-Supported Pendulum appliance (GISP). (D,E) The still slightly activated GISP provides “active anchorage”
during premolar and canine retraction. (F,G) Three years after treatment. (H) Superimposition of the pre- and post-treatment
lateral cephalometric radiographs.

Generally, 8–12 months is likely for correcting a cusp-to-cusp relationship insertion of the internal part of the original GISP. After distalization, the
to a complete molar Class I relationship. During this time, the patient has molars were in an overcorrected Class I relationship (Fig. 23.4C). The first
no other fixed appliances. Fixed appliances are bonded once the molars and second molars were distalized as a unit. During retraction of the
are sufficiently distalized, ideally to a slightly overcorrected Class I rela- premolars and canines with elastic power chains, the GISP provided
tionship. During the leveling and alignment phase with fixed appliances, further “active anchorage” (Fig. 23.4D,E). A clearly visible distalization
the GISP stays in place and the springs are lightly activated to avoid of the maxillary molars was evident.
mesialization of the molars. The force of activation is slightly increased At the end of treatment, the occlusion was corrected to Class I, which
during distalization of the premolars and canines to counteract any mesially remained stable, as shown 3 years after treatment (Fig. 23.4F,G). On the
directed reaction forces (“active anchorage”).1 We consider this to be an superimposition of the pre- and post-treatment radiographs, a 5 mm distal
advantage over other systems that have only passive anchorage (i.e. rigidly movement of the maxillary molars can be seen (Fig. 23.4H). Due to a
holding the molars in their distalized position). Bolton tooth size discrepancy, the crowns of the maxillary lateral incisors
At the end of distalization, the molars should have no distal tip. If the were reconstructed with composite.
first molar has to be uprighted, the sectional archwire between the first and
second molars is removed toward the end of distalization. If fixed appli-
ance therapy begins and there is a molar that is not sufficiently upright,
CASE 2: ADULT WITH CLASS II MALOCCLUSION
but the mesial cusp is in a good Class I relationship, one component of
the curved end of the spring should be cut off (Fig. 23.3B). This way, there
A 25-year-old man sought orthodontic treatment to correct his apparent
will be enough play in the lingual sheath to allow the leveling wire to
Class II occlusion and protruded maxillary anterior teeth (Fig. 23.5A–C).
upright the root without permitting mesialization of the crown (Fig. 23.3C).
As he refused to have combined surgical/orthodontic treatment, it was
Once premolars and canines are positioned in Class I relationship, the
decided to try camouflage treatment by distalizing the maxillary arch with
acrylic resin Nance button is removed to retract the maxillary anterior
the original GISP. The mandibular left molar had been extracted a long
teeth. The internal miniplate is removed under local anesthesia. If neces-
time previously (Fig. 23.5B).
sary, Class II elastics are used as anchorage from the maxillary canines to
Substantial distalization of the maxillary teeth during treatment, particu-
the mandibular second molars. Since patients sometimes postpone the
larly on the left side, could be seen 5 years after treatment (Fig. 23.5D–F).
surgical removal of the miniplate for months, it can be concluded that it
Substantial distal molar movement and uprighting of the maxillary incisors
does not represent a major discomfort.
was achieved, as seen in the superimposition of the radiographs before and
after treatment (Fig. 22.25G). The final profile met the patient expectations
perfectly and was also esthetically acceptable.
CLINICAL PRESENTATIONS

CASE 1: ADOLESCENT WITH CLASS II

MALOCCLUSION DISCUSSION

A 16-year-old boy sought treatment to correct his apparent Class II occlu- When palatal anchorage is used, maxillary molars are distalized before the
sion, dental deep bite and multiple spaces in both arches (Fig. 23.4A,B). fixed appliances are bonded to the teeth. This shortens the time for wearing
The decision was made to distalize the maxillary molars into Class I rela- the fixed appliances significantly, which is a serious consideration for
tionship and to close all spaces. The third molars were removed during the patients.
 Maxillary molar distalization with the Graz Implant-Supported Pendulum appliance 127

A B C

D E F

Fig. 23.5 Case 2: adult with Class II malocclusion. (A–C) Pretreatment. (D–F) Five years after treatment. (G) Superimposition of the pre- and post-treatment lateral
cephalometric radiographs.

With solid palatal anchorage, the first and second premolars can be directed push coils used on the Beneslider do not allow any adjustments
spontaneously distalized along with the molars under the pull of the tran- except for reactivation of the coils.6–8 Despite the volume of the acrylic
septal fibers. If a transpalatal arch is supported by intraosseous MIs, there resin button of the GISP, patients acclimatize to it within about a week,
is some reactive mesial movement of the premolars during molar which is similar to the period needed to get used to a retention plate.
distalization.5–7 Simultaneous premolar distalization with molar movement
has been reported with a palatal implant used as anchorage.8 However,
placement of palatal implants, unlike a miniplate, is dependent on adequate CONCLUSIONS
bone thickness and so radiological examination is required before implant
placement. In addition, palatal implants need at least 3 months of healing The GISP seems to be an absolutely stable palatal anchorage system that
and osseointegration. By comparison, the GISP can be used immediately can be activated without waiting for osseointegration. The removable
after surgical insertion, although 1 week is allowed for mucosal healing. portion is easy to remove and reinsert, which facilitates and simplifies
The area where the internal miniplate of the GISP is placed has been reactivations. During the retraction phase, springs provide further “active
demonstrated to be safe,9,10 thus eliminating the need for pretreatment anchorage,” a function that a rigid anchoring system without springs
radiographic examinations. Further, nasal floor perforations of less than cannot provide. Finally, molars can be moved in all directions of
2 mm tend to heal spontaneously.11 The GISP has no wires attached to the space.
premolars, thus allowing them to migrate distally during molar distaliza-
tion (Fig. 23.4C).
Insertion of the latest version of GISP requires only minor surgery, as REFERENCES
the miniplate is placed directly onto the mucosa and anchored with four
MIs, which provides absolute stability and loosening or loss has never 1. Byloff FK, Kärcher H, Clar E, et al. An implant to eliminate anchorage loss during
molar distalization: a case report involving the Graz implant-supported pendulum.
occurred. By comparison, failure rates as high as 10–30% have been Int J Adult Orthod Orthognath Surg 2000;15:129–37.
reported with other MI anchorage systems.12–15 Surgical protocol, clinician 2. Kärcher H, Byloff FK, Clar E. The Graz implant supported pendulum: a technical
experience, the type of MI and location all play an important role in the note. J Craniomaxillofac Surg 2002;30:87–90.
3. Byloff FK, Darendeliler MA, Clar E, et al. Distal molar movement using the pendulum
failure rates of MIs. Their high failure rate is a clear disadvantage com- appliance. Part 2: the effects of maxillary molar root uprighting bends. Angle Orthod
pared with systems with miniplate anchorage. 1997;67:261–70.
Other designs using metallic plates fixed by MIs to the palatal mucosa 4. Iwasaki L, Haack J, Nickel J, et al. Human tooth movement in response to
continuous stress of low magnitude. Am J Orthod Dentofacial Orthop 2000;117:
have recently been introduced.16–18 These systems, like the GISP, have a 175–83.
solidly fixed miniplate that cannot easily become loose. The GISP has the 5. Gelgor I, Buyukyilmaz T, Karaman A, et al. Intraosseous mini-screw-supported upper
further advantages that the springs can be manipulated to create move- molar distalization. Angle Orthod 2004;74:838–50.
6. Kinzinger G, Gülden N, Yildizhan F, et al. Efficiency of a skeletonized distal jet appli-
ments in all directions (i.e. not only distalization, but also intrusion, rota- ance supported by mini-screw anchorage for noncompliance maxillary molar distaliza-
tion or expansion) and the button with distalizing springs is easily removed tion. Am J Orthod Dentofacial Orthop 2009;136:578–86.
so that activation of the distalizing springs can be made extraorally rather 7. Kinzinger G, Gülden N, Yildizhan F, et al. Anchorage efficacy of palatally-inserted
mini-screws in molar distalization with a periodontally/mini-screw-anchored Distal
than intraorally, as is the case with most other systems. A device with Jet. J Orofac Orthop 2008;69:110–20.
removable pendulum springs on a Straumann Palatal Implant can be 8. Keles A, Erverdi N, Sezen S. Bodily distalization of molars with absolute anchorage.
adjusted extraorally but it seems to be more complicated in handling and Angle Orthod 2003;73:471–82.
9. Schlegel K, Kinner F, Schlegel K. The anatomic basis for palatal implants in ortho-
risks less precise control of the molars due to a looser fit of the springs in dontics. Int J Adult Orthod Orthognath Surg 2002;17:133–9.
their slots.19 10. Gracco A, Luca L, Siciliani G. Molar distalisation with skeletal anchorage. Aust
The GISP allows the clinician to maintain good vertical control of distal Orthod J 2007;23:147–52.
11. Ardekian L, Oved-Peleg E, Mactei E, et al. The clinical significance of sinus mem-
molar movement, which is an advantage compared with the Distal Jet brane perforation during augmentation of the maxillary sinus. J Oral Maxillofac Surg
appliance and its variations, including the Beneslider.20 The distally 2006;64:77–82.
 128 SECTION VI: MINIPLATES FOR THE TREATMENT OF CLASS II MALOCCLUSION

12. Miyawaki S, Koyama I, Inoue M, et al. Factors associated with the stability of titanium 17. Itsuki Y, Imamura E. A new palatal implant with inter-changeable upper units. J Clin
mini-screws placed in the posterior region for orthodontic anchorage. Am J Orthod Orthod 2009;43:318–23.
Dentofacial Orthop 2003;124:373–8. 18. Wilmes B, Drescher D, Nienkemper M. A miniplate system for improved stability of
13. Cheng S, Tseng I, Lee J, et al. A prospective study of the risk factors associated with skeletal anchorage. J Clin Orthod 2009;43:494–501.
failure of mini-implants used for orthodontic anchorage. Int J Oral Maxillofac Implants 19. Giancotti A, Muzzi F, Greco M, et al. Palatal implant-supported distalizing devices:
2004;19:100–6. clinical application of the Straumann Orthosystem. World J Orthod 2002;3:135–9.
14. Fritz U, Ehmer A, Diedrich P. Clinical suitability of titanium microscrews for ortho- 20. Wilmes B, Drescher D. Application and effectiveness of the Beneslider: a device to
dontic anchorage: preliminary experiences. J Orofac Orthop 2004;65:410–18. move molars distally. World J Orthod 2010;11:331–40.
15. Berens A, Wiechmann D, Dempf R. Mini-and micro-mini-screws for temporary skel-
etal anchorage in orthodontic therapy. J Orofac Orthop 2006;67:450–8.
16. Cozzani M, Zallio F, Lombardo L, et al. Efficiency of the distal mini-screw in the
distal movement of maxillary molars. World J Orthod 2010;11:341–5.
 Class II correction with fixed functional devices
using symphyseal bone anchorage
24
Nejat Erverdi, Melih Motro and Nazan Kucukkeles

miniscrews. An antirotation wedge is constructed in order to balance rota-

INTRODUCTION
tion forces. A round bar extension with a slight mesial curve is designed
to carry the point of force application to the level of the canine crown.
The term functional appliance refers to a variety of appliances designed
This round bar can be bent to get the ball ends to the desired position. The
to transmit forces to the dentition and the basal bone in order to alter the
ball ends house round tubes that are parallel to the dental arches and are
function and position of the mandible. Typically this new sagittal and
used to fix functional appliances.
vertical muscular position results in orthodontic and orthopedic changes.
In spite of differences in design, all functional appliances rely on keeping
the mandible in a forward position. The fixed functional appliances all act POSITIONING THE BALL ENDS
in the same way and their clinical consequences are similar.
To position the ball ends, an imaginary line is drawn beginning from the
Approximately 30% of the Class II correction achieved using fixed
cusp tip of the canine and continuing along the root axis; this line repre-
functional appliances is attributed to skeletal response, with 70% to den-
sents the y-axis. Another line connecting the mesial and distal corners of
toalveolar response.1 Dentoalveolar response is characterized by uncon-
the canine crown is drawn to represent the x-axis. The intersection point
trolled and unwanted tipping of the mandibular incisors.2 True treatment
of the axes is the central point. The ball ends are placed 4–5 mm buccally
of the skeletal malocclusion requires correction of the morphogenetic
and centrally in relation to the central point for hygienic purposes. The
pattern. Consequently, condylar adaptation and mandibular skeletal growth
round bar extensions with the ball ends exposed to the oral cavity must
have to be the main goal in functional treatment. Some investigators claim
pass through attached gingiva; peri-implantitis may develop if they pass
that rapid labial tipping of the mandibular incisors, which takes place in
through mobile gingiva.
almost 6 months using functional appliances, limits the time needed to
obtain more skeletal response. It can be assumed that direct protrusive
force application through the mandibular skeletal bone can prevent labial SURGICAL INSERTION OF THE MINIPLATES
tipping of the mandibular incisors and, therefore, pure skeletal response
Under local anesthesia, an incision is made between the premolars along
of the functional treatment can be observed.
a line passing through the mucogingival junction. The mucoperiosteum is
This chapter describes the use of fixed functional appliances with sym-
then released along the incision to the level of the bony chin prominence.
physeal bone anchorage and discusses clinical results with three different
The miniplates are adjusted for symphyseal topography to ensure that the
designs.
ball ends arise through the incision lines in the attached gingiva in the
correct position. The plates are fixed with three 7 mm titanium miniscrews
(2 mm diameter), and the flaps are closed with interrupted 3-0 absorbable
PREPARATION OF THE MAXILLARY DENTITION
polyglycan sutures without any tension (Fig. 24.1). Amoxicillin/clavulanate
Before inserting the symphyseal bone-anchored devices, fixed appliances 1000 mg twice daily is taken for 5 days postoperatively and the sutures
are placed on the maxillary dentition to align and level the teeth. After are removed at 7 days.
leveling, a rectangular (0.017 × 0.025 inch) archwire including a palatal
root torque and a transpalatal arch of 0.9 mm SS wire are applied to the
maxillary teeth. APPLICATION OF FIXED FUNCTIONAL APPLIANCES

JASPER JUMPER
THE MINIPLATE FOR CHIN FIXATION After 7 to 10 days to allow for soft tissue healing, standardized lateral
cephalometric radiographs are taken and the Jasper Jumper is applied
Special titanium alloy (Titanium Alloy Certificate 1210021571000020 01) between the maxillary molar bands to the ball-pins. The correct length for
miniplates to attach to the chin were designed and developed using three- the Jasper is determined by adding 12 mm to the distance between the
dimensional modeling software (Tasarimmed, Istanbul, Turkey) (see mesial end of the molar tube and the distal ball ending. The activation
Fig. 13.1C). protocol is the same as for the conventional method (see Chapter 2). If the
The miniplates are constructed to fit either the left or the right side. The size of the appliance is insufficient for activation, it can be applied between
retentive plate has three holes (diameter, 2.3 mm) suitable for all surgical the mesial (instead of the distal) end of the molar tube and the ball ends.

Fig. 24.1 Surgical application. (A) Miniplates fitted to the chin.

(B) Ball ends of the miniplates rising up through the mucogingival
junction.

A B

129
 130 SECTION VI: MINIPLATES FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C

Fig. 24.2 Attachment of the Jasper Jumper appliance to the miniplate. (A) Routine placement on a model. (B) Placement of the distal portion of the appliance on the
mesial end of the molar tube. (C) Addition of a ball stop for extra activation.

If more activation is needed, ball stops can be placed between the mesial is as above; the sutures are removed after 7 days and the Herbst is applied.
end of the molar tube and the distal end of the Jasper Jumper (Fig. 24.2). Following the adaptation of the appliance, the opening and closing func-
If yet more activation is needed, the mandibular endings of the Jasper tions of the mouth should be checked.
Jumper can be applied distal to the ball ends instead of mesial. The man-
dibular dental arch is not bonded during this stage.
CLINICAL PRESENTATIONS
FORSUS DEVICE
CASE 1: JASPER JUMPER
The same surgical procedure and plates are used as described for the Jasper
Jumper. A 14-year-old boy with Class II, division 1 malocclusion, horizontal (coun-
To determine the correct size of the Forsus device, a special ruler is terclockwise) growth pattern, a convex profile and Class II sagittal skeletal
provided with the manufacturer’s kit. The distal end of the ruler is placed relationships caused by mandibular retrognathism sought treatment.
to the distal part of the headgear tube of the maxillary molar and the mesial Following proper diagnosis and treatment planning, treatment started
part is positioned to the distal part of the ball end of the miniplate. The with rapid maxillary expansion using a fan-type expansion device (Fig.
appliance is applied to the headgear tube as instructed by the manufacturer 24.3A,B). After maxillary expansion was completed, the maxillary dental
with the only difference being that the rod that is supposed to be attached arch was bonded and aligned. Six months later, the SS archwire was placed
to the custom-made miniplates is applied by means of a ball-pin. and cinched behind the first molar tubes (Fig. 24.3C). The expansion appli-
ance was kept in the mouth for retention purposes. After the miniplates
were placed and sutures removed, a Jasper Jumper was applied from the
HERBST
maxillary molar headgear tubes to the ball ends of the miniplates (Fig.
The laboratory procedure for the fabrication of the conventional Herbst 24.3D). After 6 months, a Class I canine and molar relationship was
appliance should be performed very precisely because it does not allow achieved on both sides (Fig. 24.3E). Following Class II correction, the
lateral mandibular movements. When using this protocol (Herbst appli- mandibular teeth were bonded to solve the mild crowding of the mandibu-
ance in conjunction with miniplates), parallelism and precise placement of lar dental arch, and Class II elastics were applied every night to control
the Herbst appliance is crucial to successful treatment. the risk of relapse.
The body of the symphyseal plate for Herbst application has a triangular A Class I dental relationship was achieved on both sides and the overjet
ledge that enhances the stability of the plate against turning forces. and overbite were corrected to the normal values. Significant improvement
However, instead of ball ends, this design has circular heads that are was observed in the facial profile. The occlusal plane presented a clock-
designed to hold the anterior part of the Herbst appliance (see Fig. 13.1D). wise rotation, which resulted in a slight increase of gingival exposure.
Screw and pivots of the Herbst appliance can be easily adapted to this part. Constriction of the mentalis muscle decreased with the overjet correction,
In order to reduce surgery time and increase the accuracy of plate posi- which also improved the patient’s profile.
tioning, three-dimensional models of the symphysis can be used to adapt
the plates in readiness for fixation. Alternatively, and to avoid unnecessary
radiation exposure, plates can be adapted during surgery. CASE 2: FORSUS DEVICE
The surgical procedure for application of the Herbst appliance is a little
different to that described above. Under local anesthesia, the area of bone A 15-year-old boy presented with a Class II, division 2 malocclusion with
is exposed through a horizontal vestibular mucoperiosteal sulcus incision horizontal (counterclockwise) growth pattern before initiation of treatment
flap between the left and right first premolars. The miniplates are posi- (Fig. 24.4A,C).
tioned with the mandible protruded. After releasing the mucoperiosteum, This patient was treated as in Case 1, above, but using a Forsus device.
the Herbst appliance is screwed on the free ends of the miniplates. Plates After leveling and alignment, the SS archwire was placed and cinched back.
are contoured manually with the first screw placed in the middle hole of There was no need for expansion on the maxillary arch and, therefore, a
the plate but not fully tightened. This allows jaw movements to be checked transpalatal arch was placed to control posterior anchorage. The appropri-
and the best position for the plate to be determined. While doing this, care ate length of the Forsus module was attached to the maxillary molar head-
is taken to prevent any lateral movement of the mandible. After achieving gear tubes and on ball ends of the miniplates (Fig. 24.4D). Jasper Jumper
an harmonic position, the two free holes are then drilled (drill diameter, rods were used to adapt the Forsus appliance to the miniplates.
1.5 mm) under saline irrigation; the miniplates are fixed through all three The Class II dental relationship had not improved by much at 8 months
holes and the flaps closed as described above. Antimicrobial prophylaxis (Fig. 24.4E) although some improvement in the convex profile could be
 Class II correction with fixed functional devices using symphyseal bone anchorage 131

A B C

D E

Fig. 24.3 Case 1: Jasper Jumper. (A) Pretreatment view of the occlusion. (B) Pretreatment occlusal view of the maxillary arch. (C) Occlusal view of the maxillary arch 6
months after bonding. The SS archwire and the Fan-type Hyrax appliance still remain in the mouth for retention purposes. (D) Jasper Jumper applied from the maxillary
first molar headgear tubes to the lower ball ends of the chin plates. (E) Six months after fitting the Jasper Jumper and miniplates.

Fig. 24.4 Case 2: Forsus device. (A) Pretreatment profile. (B) Post-treatment profile. (C) Pretreatment lateral
view of the occlusion. (D) Forsus device and miniplates in place. (E) Eight months after initiation of
treatment. (F) Post-treatment lateral view of the occlusion.

A B

C D E F

seen. To finalize treatment, the mandibular dental arch was bonded and A Herbst appliance was used in order to stimulate mandibular
aligned. Treatment continued with conventional Forsus application until growth. Chromium–cobalt cast splints were fabricated for this purpose
Class I molar and canine relationships were achieved (Fig. 24.4B,F). to include the maxillary first and second premolars and first molars, and
a metal bar connecting the sides to each other was constructed 1 mm
away from the palatal mucosa. The pivots of the Herbst appliance
CASE 3: HERBST APPLICATION were soldered to the cast splints. The device was prepared accurately
and attached to the miniplates in the chin area as described above
A 14-year-old girl presented with Class II, division 1 malocclusion, Class (Fig. 24.5D).
II sagittal skeletal relationships and a convex profile caused by mandibular The appliance remained in the mouth for 6 months (Fig. 24.5E) by
retrognathism, as well as a horizontal (counterclockwise) growth pattern which time the molars and canines were in Class I relationships and there
(Fig. 24.5A,C). was a significant improvement in the facial profile. After removal of the
 132 SECTION VI: MINIPLATES FOR THE TREATMENT OF CLASS II MALOCCLUSION

Fig. 24.5 Case 3: Herbst application. (A) Pretreatment profile. (B) Post-treatment profile.
(C) Pretreatment lateral view of the occlusion. (D) Herbst appliance and miniplates in place.
(E) Six months after initiation of treatment. (F) Post-treatment lateral view of the occlusion.

A B

C D E F

appliance, the maxillary and mandibular arches were bonded and the mild The cephalometric measurements in the Jasper Jumper group and the
teeth malalignments were corrected. Following debonding, a significant corresponding statistical evaluation revealed that only changes in the sella-
improvement was evident in the profile and there was a good functional nasion/palatal plane angle were significant (Table 24.1). The evaluations
occlusion (Fig. 24.5B,F). for the other two groups gave similar results.
However, statistically significant dental changes were observed in all
the groups, mainly through alterations to the occlusal plane. More specifi-
DISCUSSION cally, the occlusal plane/sella-nasion and the occlusal plane/palatal plane
angles were increased significantly, while the occlusal plane/mandibular
It is still unclear exactly how much skeletal effect is achieved with func- plane angle was significantly decreased. Similar changes have been
tional appliances whereas the dentoalveolar effects are much more evident; reported with fixed functional appliances with conventional approaches
approximately 30% of the Class II correction achieved using fixed func- rather than skeletal anchorage.5
tional appliances has been attributed to skeletal response with 70% being All these changes resulted in posterior rotation of the mandible, maxil-
dentoalveolar response.1 Fixed functional appliances can create a 1–3 mm lary incisor retroclination and extrusion, maxillary molar intrusion and
change in condylar growth or glenoid fossa remodeling.3,4 The develop- distalization. Consequently, Class I molar relationship and overjet were
ment of functional appliances that direct forces directly to the mandible corrected.
and not through the dental arch is intended to maximize skeletal effects Miniplates fitted to the chin area seem to be suitable for the application
and improvements in soft tissue profile. of fixed functional appliances, except the Herbst. Although no miniplates
While fitting miniplates to the mandibular symphysis is quite easy, the were lost as a result of loading of orthopedic forces in the patients treated
positioning of the miniplate and attachment of the functional appliance with the Jasper Jumper and Forsus, almost 50% of the plates in the Herbst
needs to be very accurate, particularly for the Herbst, which allows little group were lost during the first 6 months of loading. Consequently, treat-
lateral movement of the mandible. ment was only completed for two of the patients in this group. This con-
In groups of patients using the three appliances described above, skeletal firms that this procedure is challenging and not suitable for rigid functional
and dental changes were assessed using lateral cephalometric radiographs appliances such as the Herbst.
obtained before and after treatment. The biggest group of patients (11) was In all the groups, there was a remarkable decrease of overjet and cor-
treated with the Jasper Jumper, with only a few patients in the other two rection of the Class II molar relationship. However, no significant increase
groups. This was insufficient for a statistical evaluation of the Forsus or in mandibular skeletal growth was seen in any patient. There are two pos-
Herbst but did provide some useful insights into what could be achieved sible reasons. First, the treatment period of 6 months may be insufficient
and the treatment period needed. for mandibular skeletal growth to occur. In addition, the changes in maxil-
The 11 patients treated with Jasper Jumpers were seen every 4 weeks lary dentition that took place in a short period of time contributed to the
to check oral hygiene and any problems related to the appliance. Patients quick correction of the dental discrepancy without leaving enough space
found the appliances acceptable for comfort. During treatment, 50% of the for the mandibular skeletal correction. Second, mandibular skeletal growth
Jasper Jumpers broke and were replaced. In addition, the appliances were and condylar adaptation simply do not occur as much as might be expected
renewed every 2 months because of the unpleasant odor from the vinyl with fixed functional treatment regardless of the type of anchorage.
cover. One patient developed peri-implantitis through poor oral hygiene The approach described in this chapter using miniplates on the man-
and the mobile miniplates were removed. Another stopped for personal dibular symphysis can be successfully utilized for the application of fixed
reasons. Treatment of the remaining nine patients continued and treatment functional appliances. However, more clinical studies with large study
was assessed after 6 months of treatment. samples are needed to confirm its clinical effectiveness.
 Class II correction with fixed functional devices using symphyseal bone anchorage 133

Table 24.1 Cephalometric measurements for patients treated with the Jasper Jumper
Measurements (°) Pretreatment (SD) Post-treatment (SD) Difference (SD) p value
SNA 82.29 (2.56) 81.57 (4.69) 0.71 (2.87) 0.492
SNB 75.86 (3.44) 76.00 (3.37) −0.14 (1.22) 0.739
ANB 6.43 (3.31) 5.71 (3.25) 0.71 (2.43) 0.288
SN-Pog 78.14 (4.1) 77.57 (4.12) 0.57 (1.72) 0.458
SN–MP 35.29 (5.47) 35.57 (6.40) −0.29 (2.14) 0.863
SN–PP 7.71 (2.06) 9.29 (2.06) −1.57 (1.51) 0.042*
OP–SN 17.00 (5.03) 22.71 (5.77) −5.71 (4.15) 0.028*
OP–MP 17.71 (3.3) 12.71 (2.75) 5 (3.51) 0.018*
PP–OP 9.86 (3.48) 13.43 (4.76) −3.57 (2.76) 0.027*

A, A point; B, B point; MP, mandibular plane; N, nasion; OP, occlusal plane; Pog, pogonion; PP, palatal plane; SD, standard deviation, SN, sella-nasion.
*p < 0.05.

2. Kucukkeles N, Ilhan I, Orgun A. Treatment efficiency in skeletal Class II patients

ACKNOWLEDGMENTS treated with the Jasper Jumper. Angle Orthod 2007;77:449–56.
3. Marsico E, Gatto E, Burrascano M. Effectiveness of orthodontic treatment with func-
We would like to thank Drs. Gühan Dergin and İmad M. Salih for perform- tional appliances on mandibular growth in the short term. Am J Orthod Dentofacial
Orthop 2011;139:24–36.
ing the surgeries, and Dr. Cem Gazivekili for treatment of patients with 4. Cozza P, Baccetti T, Franchi L, et al. Mandibular changes produced by functional appli-
the Jasper Jumper appliance. ances in Class II malocclusion: a systematic review. Am J Orthod Dentofacial Orthop
2006;129:599.
5. Weiland FJ, Ingervall B, Bantleon HP, et al. Initial effects of Class II malocclusion with
the Herren activator, activator-headgear combination and Jasper Jumper. Am J Orthod
REFERENCES Dentofacial Orthop 1997;112:19–27.

1. Creekmore TD, Radney LJ. Frankel appliance therapy: orthopedic or orthodontic? Am

J Orthod 1983;83:89–108.
 Section VII: Miniscrew implants for the treatment of Class II malocclusion

25 Overview of miniscrew implants in treatment of

Class II malocclusion
Moschos A. Papadopoulos and Vasileios F. Zymperdikas

■ the Beneslider (Chapter 33)

INTRODUCTION
■ the TopJet distalizer (Chapter 34)
Treatment of Class II malocclusion includes in general posterior move- ■ the palatal MI system with interchangeable units: two palatal MIs
ment of the maxillary dentition, anterior movement of the mandibular support a miniplate to which one of three detachable distalizing
dentition or a combination of both; treatment can involve selective extrac- units fits for specific needs (see Chapter 23)
tion of permanent teeth, either two maxillary premolars or two maxillary ■ the dual force distalizer: two palatal MIs anchor an acrylic plate
and two mandibular premolars (see Chapter 1). with arms to which distalizating springs are attached
In contrast to dental or orthodontic implants, miniscrew implants (MIs) ■ the lever arm and MI system
are not osseointegrated but just mechanically retained in bone. They are ■ transpalatal arches (TPAs):
easier to insert, can be used for anchorage without waiting for osseointe-
♦ the MGBM system (Chapter 28)
gration and are removed at the end of treatment. Many types of tooth
♦ the mesially extended TPA and MIs
movement can be achieved using MIs for anchorage,1 such as intrusion or
♦ intraosseous screw and TPA.
uprighting of teeth, correction of open bite or deep bite, maxillary molar The forces needed for orthopedic correction are significantly higher than
distalization and retraction of anterior teeth. those needed for tooth movements and under such forces MIs can fail.
This chapter gives a brief overview of the use of MIs as temporary Consequently, miniplates rather than MIs have been used as anchorage to
anchorage devices for the comprehensive treatment of Class II malocclu- support mandibular advancement (see Chapter 24). However, MIs have
sion. Other chapters in this section cover these systems in more detail. been used for this purpose with the Forsus Fatigue Resistant Device (see
Chapter 46).
A brief description is given here of the non-compliance distalization
NON-COMPLIANCE DISTALIZATION SYSTEMS systems listed above that are not covered in other chapters.
USED WITH MINISCREW IMPLANTS

When MIs are used for the treatment of Class II malocclusion, they are PENDULUM SPRINGS WITH A PALATAL
usually combined with conventional fixed appliances or with non- MINISCREW IMPLANT
compliance intramaxillary distalization systems to support distalization of A modification of the original Pendulum appliance used a single MI (diam-
the maxillary arch. They can also be combined with non-compliance inter- eter, 3.8 mm; length, 9 mm) inserted in the anterior palatal region, laterally
maxillary devices to support mandibular advancement. to the median palatal suture, combined with pendulum springs for molar
When MIs are used as anchorage reinforcement modalities, the provided distalization, thus eliminating the Nance acrylic button (Fig. 25.1).3 A SS
anchorage can be hybrid (both bone-borne and tooth-borne) or pure skel- casting crown is fabricated on the MI to which two pendulum tubes are
etal (bone-borne) anchorage. soldered bilaterally; these are used for the attachment of the TMA distali-
Examples of hybrid anchorage used in maxillary distalization include: zation springs (0.032 inch). The springs attached to lingual sheaths of the
■ the Distal Jet (Chapter 2) and its modifications using MIs for maxillary first molar bands deliver a distalization force of 300 g on both
anchorage such as the skeletonized Distal Jet and the Implant Distal sides. When distalization is completed, the springs are replaced with
Jet 1.2 mm round SS wires, which are soldered between the abutment and the
■ the Pendulum appliance (Chapter 2) and its modification, the MI maxillary molar bands to retain the maxillary first molars in the acquired
supported modified Pendulum appliance. position during the subsequent phase of the distalization of the premolars
and canines and retraction of the anterior teeth.
Examples of pure bone-borne anchorage systems used in maxillary distali-
zation include:
■ the Distal Jet and its modification by Bowman (Chapter 31)
■ the Distal Screw (Chapter 32)
■ the Pendulum B appliance (Chapter 33)
■ the skeletal Pendulum-K appliance (Chapter 35)
■ the bone-anchored Pendulum appliance (Chapter 36)
■ the bone supported Pendulum appliance: similar to the bone-
anchored system but a metallic bearing is placed in the anterior part
of the Nance button, and TMA springs have a double-loop
modification to control molar rotation2
■ combination of MIs with pendulum springs
■ the MI-supported distalization system (Chapter 29) Fig. 25.1 Pendulum springs with a palatal miniscrew implant. (With permission
■ the Advanced Molar Distalization Appliance (Chapter 30) from Oncag et al., 20073.)

134
 Overview of miniscrew implants in treatment of Class II malocclusion 135

A B

Fig. 25.3 The mesially extended transpalatal arch with miniscrew implants.
(A) During active treatment. (B) Seven months after the start of treatment the
device is removed and replaced with a modified transpalatal arch. (With permission
from Kyung et al., 20095.)

Fig. 25.2 The Dual Force Distalizer during maxillary molar distalization. (With
permission from Oberti et al., 2009.4)

THE DUAL FORCE DISTALIZER

The dual force distalizer consists of an acrylic resin plate with four exten-
sion arms and two holes; it is anchored with two MIs inserted in the
midpalatal suture on the anterior palatal region (Fig. 25.2).4 Two arms of A B
SS wires (0.028 inch) extend bilaterally on each side of the maxillary arch,
one toward the buccal zone from the mesial aspect of the premolars and Fig. 25.4 A modified transpalatal arch with an intraosseous screw to support
maxillary molar distalization. (A) The distalization system immediately after
the other toward the palatal zone. Each arm is equipped with two stops
placement in the maxilla. (B) The modified Nance holding arch inserted after molar
and a Ni-Ti open coil spring and is placed into 0.045 inch tubes soldered distalization is accomplished. (With permission from Gelgor et al., 2007.7)
on the vestibular and palatal sides of the first molar bands. The first stop
is located mesially to the molar tube and is used to compress the coil spring
in order to deliver the necessary distalization force of approximately anterior region of the midpalatal suture behind the incisive canal. The
250–300 g, while the second stop is located distally to the molar tube to modified TPA was constructed with a U-bend (which should be in contact
set a limit for the distalization of the first maxillary molar. with the distal surface of the MI neck) and soldered to the maxillary first
The patient is seen every month, and the coil springs are reactivated by or second premolar bands. The TPA was then attached to the neck of the
placing a crimpable stop in the arms mesially to the coil spring. Distaliza- MI. Sectional arches and 0.036 inch Ni-Ti open coil springs were inserted
tion of the maxillary first molars is continued until a super-Class I is buccally on both sides between the brackets of the maxillary first or second
achieved. The appliance is left in place with the vestibular tubes removed premolars and the corresponding first molars, producing a distalization
and fixed appliances are bonded to the maxillary teeth to distalize the force of 250 g to the molars. Patients were seen every 4 weeks for reacti-
premolars and canines also to Class I occlusal relationships, as well as to vation of the coil springs if necessary. After distalization of the maxillary
retract the anterior teeth. molars to a super-Class I relationship, the modified TPA was replaced with
another with two loops bilaterally for possible activations in case of
anchorage loss, and again with a U-bend attached on the MI neck in order
MESIALLY EXTENDED TRANSPALATAL ARCH to provide further skeletal anchorage for the anterior teeth retraction with
WITH MINSCREW IMPLANTS full fixed appliances (Fig. 25.4B). Use of this appliance in 25 patients
A mesially extended TPA (ME-TPA) combined with two MIs can provide resulted in 88% molar distalization and 12% reciprocal anchorage loss of
absolute anchorage for the distalization of the maxillary first and second the maxillary central incisors. The maxillary molar crowns tipped distally
molars simultaneously after extraction of the third molars (Fig. 25.3A).5 by 8.78°; the first premolars tipped mesially by 2.88°; and the maxillary
The MIs are placed in the median region of the midpalatal suture. A cus- incisors proclined by 1° and were moved forward 0.5 mm.6 These changes
tomized MI-supported S-sheath is cemented to the MI heads with flowable were attributed to mesial tipping of the first premolars during molar
composite resin, and a removable sectional wire with two hooks bilaterally distalization, the flexibility of the TPA and inadequate connection
is placed into the sheath. A TPA, extended to the anterior region of the between the TPA and the MI, since there was only a single-point contact
palate and equipped with two soldered hooks, is inserted in the lingual between them.
sheath of the maxillary molar bands. Elastics are used to connect the hooks
of the TPA with the corresponding hooks of the S-sheath, producing as a
consequence a distalization force. After a Class I relationship is accom-
LEVER ARM AND MINISCREW IMPLANT SYSTEM
plished, the ME-TPA is replaced with a modified TPA, which is connected A lever arm and MI-supported system used for the distalization of maxil-
again with the S-sheath in order to maintain the position of the distalized lary molars consisted of two parts.8 The lingual part comprised a conven-
maxillary first molars and support the subsequent anterior teeth retraction tional TPA (0.032 × 0.032 inch SS wire) attached to the palatal sheaths
(Fig. 25.3B). of the maxillary first molar bands and a MI inserted in the posterior
region of the midpalatal suture. The buccal part comprised two lever arms
made of SS wire (0.019 × 0.025 inch) attached to the bracket slots
INTRAOSSEOUS SCREW IN CONJUNCTION (0.032 × 0.032 inch) of the molar bands and two bilaterally positioned
WITH A TRANSPALATAL ARCH MIs, inserted in the inter-radicular space between the second premolars
A modified TPA has also been used with an intraosseous MI to support and the first molars on each side. By applying elastic chain modules
maxillary molar distalization (Fig. 25.4A).6,7 The MI was inserted in the between the MIs and the corresponding lever arms, a distal force of 150 g
 136 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C

Fig. 25.5 Miniscrew implants (MI) to support appliances for maxillary molar distalization. (A) A MI in the anterior region of the midpalatal suture of the hard palate.
(B) MIs buccally in the inter-radicular space between the second premolars and first molars and sliding jigs. (C) MIs in the inter-radicular space between the second
premolars and the first molars. (With permission from Polat-Oszoy, 20089 (A), Young et al., 20071 (B) and Mizrahi and Mizrahi, 200710 (C).)

was applied buccally on each side, while between the midpalatal MI and Furthermore, placement of MIs in the inter-radicular space between the
the TPA a force of 300 g was applied palatally. second premolars and the first molars has also been used to provide indi-
When a super-Class I was achieved, the buccal MIs were removed and rect anchorage for the distalization of first and/or second molars.10 Each
fixed appliances were placed in order to align and level the maxillary teeth, MI was connected with a ligature tie to the canine, first or second premolar
while the TPA and the midpalatal MI remained in position to prevent brackets, or to a hook soldered or bent onto the main archwire (Fig. 25.5C).
relapse of the distal movement. The type of mechanics used depends on the eruption stage of the second
molars. If the second molars are erupted, an open coil spring can be
inserted between the first and second molars. Alternatively, an archwire
MAXILLARY DISTALIZATION WITH MINISCREW incorporating an expansion loop can be used to distalize the second molars.
IMPLANTS IN COMBINATION WITH FIXED APPLIANCES In contrast, if the second molars are not erupted, a coil spring can be
inserted between the second premolars and the first molars, or an expand-
MIs can be used with various configurations in combination with conven- ing arch similar to the one used to distalize the second molars can be used
tional fixed appliances, for to distalize the first molars.
■ maxillary molar distalization alone
■ distalization of the entire maxillary arch, either sequentially (molar
SEQUENTIAL DISTALIZATION OF THE ENTIRE
distalization first and then anterior teeth retraction) or en masse
MAXILLARY ARCH
■ anterior teeth retraction alone (usually after extractions of the
maxillary first premolars). For a sequential distalization, two MIs are usually used and placed bilater-
ally between the roots of the second premolars and the first molars.
For anterior teeth retraction, initial extraction of the first premolars pro-
A two-component MI (C-implant, CIMPLANT, Seoul, Korea) was used
vides the space into which the anterior teeth can be moved under the
with coil springs for the distalization of the maxillary posterior teeth,
influence of MI-anchored systems.
retraction of the maxillary anterior teeth and coordination of both arches
Most clinicians use MIs with conventional fixed appliances for the
for ideal occlusion.11 Initially, the MIs were used with Class III elastics
distalization of the entire maxillary arch, either sequentially or en masse.
and fixed appliances in the lower arch to support uprighting of the man-
dibular molars (Fig. 25.6A). Then, fixed appliances were placed on the
maxillary arch and the MIs were connected by means of Ni-Ti coil springs
MAXILLARY MOLAR DISTALIZATION
to sliding jigs attached on the maxillary first molars, which resulted in
MIs have been placed in various locations to support maxillary molar distalization of the maxillary first and second molars into a Class I relation-
distalization (Fig. 25.5). ship (Fig. 25.6B). This created a space between the maxillary first molars
A MI in the anterior region of the midpalatal suture of the hard palate and second premolars that could be used for the retraction of the teeth
was used to support an acrylic Nance button (Fig. 25.5A).9 The MI was anterior to molars. After molar distalization, the MIs were removed from
embedded in the acrylic plate from which occlusal wires extended to bond between the roots of the second premolars and first molars and reinserted
to the maxillary first premolars bilaterally. After banding of the maxillary between the roots of the maxillary first and second molars. Immediately
first molars and bonding of the first premolars, sectional arches and open after MI relocation, a force of approximately 150 g was applied using
coil springs were inserted between the first premolars and the first molars, Class I elastics connecting the MIs with hooks soldered on the maxillary
delivering a distalization force of approximately 250 g on each side. At archwire mesial to the canines for the retraction of the maxillary anterior
the end of distalization, the initial acrylic plate was removed with a bur to teeth.
expose the MI, and a new Nance acrylic button was fabricated, again over A similar two-step procedure used two MIs inserted bilaterally in the
the MI, to support molar anchorage during anterior teeth retraction.9 maxillary vestibular alveolar bone between the roots of the second premo-
In addition, MIs implanted buccally in the inter-radicular space between lars and first molars (Fig. 25.7).12 After placing rectangular beta-titanium
the maxillary second premolars and first molars have been combined with archwires, each MI was connected through a Ni-Ti coil spring or an elas-
sliding jigs to support molar distalization.1 Each MI was connected through tomeric thread to the corresponding canine for the distalization of the
Ni-Ti coil springs to a sliding jig attached on the maxillary archwire, posterior teeth, delivering a distalization force of approximately 200 g in
applying a distalization force to the maxillary first molars (Fig. 25.5B). each quadrant. The distalization of the posterior teeth created a small space
 Overview of miniscrew implants in treatment of Class II malocclusion 137

A B

Fig. 25.6 Sequential distalization of the entire maxillary arch. (A) Miniscrew
implants (MI) placed bilaterally between the maxillary second premolars and the
first molars and application of Class III elastics from the MIs to soldered hooks
mesial to the canines. (B) Coil springs attached bilaterally to the MIs and to the
sliding jigs (attached on the maxillary first molars) for the distalization of the
maxillary first and second molars into a Class I relationship. (With permission from Fig. 25.9 En masse distalization of the maxillary arch achieved with miniscrew
Chung et al., 2010.11) implants. (With permission from Yamada et al., 2009.14)

stretched elastomeric module connected to the MIs was used to retract the
premolars. Finally, the maxillary canines were also bonded and after align-
ment with a Ni-Ti archwire (0.016 inch) they were retracted as well.

EN MASSE DISTALIZATION OF THE ENTIRE

MAXILLARY ARCH
A B
Methods for en masse distalization of the entire maxillary arch use bilateral
Fig. 25.7 Sequential distalization of the entire maxillary arch. (A) Initial leveling to MIs for anchorage. MIs inserted bilaterally between the roots of the second
gain space for the alignment of the anterior teeth. The distalizing force is applied premolars and first molars were combined with Ni-Ti coil springs or elastic
from the miniscrew implants (MI) to the canines with elastics. (B) En masse chains.14 After bonding and placement of a SS archwire (0.016 × 0.022 inch)
retraction of the anterior teeth. The retraction force is applied from the MIs to the
canines with coil springs. (With permission from Oh et al., 2011.12)
on the maxillary arch, Ni-Ti closed coil springs or elastic chains were
placed from the MIs to hooks attached on the maxillary archwire distal to
the canines on each side, applying a distalization force of approximately
200 g (Fig. 25.9). The direction of the force was upward and backward
and as parallel to the occlusal plane as possible. The molars were distalized
without proclination of the anterior teeth, but this movement was not
bodily since distal tipping also took place.
A similar treatment approach used MIs placed bilaterally in the buccal
alveolar bone of the maxilla, 1 mm distal to vertical lines passing through
A B the contact points of the first and second molars.15 A SS archwire
(0.016 × 0.022 inch) with hooks welded between the canines and the first
Fig. 25.8 Sequential distalization of the entire maxillary arch. (A) Lateral intraoral premolars was placed in the upper arch. The welded hooks were fabricated
view showing the distalization system placed in the maxilla. (B) Progress lateral short to avoid extrusion of the maxillary posterior teeth. Additional labial
view showing premolar retraction after molar distalization and reinsertion of new
miniscrew implants. (With permission from Doshi et al., 2011.13)
crown torque in the anterior region and an accentuated curve of Spee were
given to the arch before placement. Then, power chains were attached
between the MIs and the respective hooks bilaterally, producing a distali-
mesial to the canine in each quadrant. After alignment, the six anterior zation force of 200 g per side.
teeth were tied together and a retraction force applied from the MIs to the A similar system used MIs inserted at the zygoma above the maxillary
canines or to short hooks attached on the archwire between the lateral molars and the results obtained were considered to be a good alternative
incisors and the canines. to conventional distalization with cervical headgears.16 After placement of
An alternative two-step procedure used two MIs inserted bilaterally in SS archwires (0.016 × 0.022 inch) on both arches, two sliding hooks were
the inter-radicular space between the second premolars and first molars cinched with downward orientation between the maxillary lateral incisors
(Fig. 25.8).13 The maxillary first and second premolars and first molars and the canines. Two MIs with gold chains attached to their heads were
were banded and sectional wires with Ni-Ti coil springs extending from inserted bilaterally in the maxillary buttress. The gold chains were con-
the maxillary first premolar to the corresponding first molar were placed nected through power threads to the corresponding sliding hooks, provid-
on each side. Compressed coil springs between the second premolars and ing direct anchorage for anterior teeth retraction.
first molars delivered a continuous distalization force of 240 g per side, Another treatment approach concerning the correction of Class II deep
while a ligature wire was threaded to each MI neck and ligated to the first bite, involves distalization of the maxillary arch with MI anchorage in
premolar bracket. As a result, the MIs provided indirect anchorage for the combination with fixed appliances and bite blocks to increase the vertical
distalization of the molars. When a super-Class I relationship was accom- dimension.17 After bonding and initial aligning of both dental arches, two
plished, the MIs were removed and a second pair of MIs were inserted at MIs were placed bilaterally in the inter-radicular space between the maxil-
an angle of approximately 30° mesial to the first molars. The insertion site lary second premolars and first molars. After 2 months, resin bite blocks
not only permitted retraction of the premolars but also prevented were bonded to the lingual surfaces of the maxillary central incisors, and
the molars from moving mesially. Then the maxillary incisors and premo- later SS wires (0.016 × 0.022 inch) were inserted in both arches along with
lars were bonded and initial alignment was carried out. Subsequently, a crimped hooks (length, 10 mm) attached bilaterally between the lateral
 138 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

and away from the center of resistance of the molars, leading to distal
tipping of the molar crowns.

REFERENCES
1. Young KA, Melrose CA, Harrison JE. Skeletal anchorage systems in orthodontics:
absolute anchorage. A dream or reality? J Orthod 2007;34:101–10.
2. Escobar SA, Tellez PA, Moncada CA, et al. Distalization of maxillary molars with the
bone-supported pendulum: a clinical study. Am J Orthod Dentofacial Orthop 2007;131:
545–9.
Fig. 25.10 Frontal view showing the beta-titanium alloy archwire with hooks and 3. Oncag G, Akyalcin S, Arikan F. The effectiveness of a single osteointegrated implant
torquing bend, the miniscrew implants and the application of coil springs to retract combined with pendulum springs for molar distalization. Am J Orthod Dentofacial
en masse the maxillary dental arch. (With permission from Park et al., 2011.17) Orthop 2007;131:277–84.
4. Oberti G, Villegas C, Ealo M, et al. Maxillary molar distalization with the dual-force
distalizer supported by mini-implants: a clinical study. Am J Orthod Dentofacial
Orthop 2009;135:282.e1–5.
incisors and the canines. The distalization force was applied by Ni-Ti coil 5. Kyung SH, Lee JY, Shin JW, et al. Distalization of the entire maxillary arch in an
springs extending from the MIs to the corresponding hooks (Fig. 25.10). adult. Am J Orthod Dentofacial Orthop2009;135:S123–32.
6. Gelgor IE, Buyukyilmaz T, Karaman AI, Dolanmaz D, Kalayci A. Intraosseous screw-
After 5 months, the maxillary posterior teeth were distalized but the maxil- supported upper molar distalization. Angle Orthod 2004;74:838–50.
lary second molars were extruded and tipped distally, which required these 7. Gelgor IE, Karaman AI, Buyukyilmaz T. Comparison of 2 distalization systems
teeth to be bonded for uprighting during the subsequent final stage of supported by intraosseous screws. Am J Orthod Dentofacial Orthop 2007;131:
161.e1–8.
treatment. 8. Lim SM, Hong RK. Distal movement of maxillary molars using a lever-arm and mini-
Treatment of skeletal gummy smiles in patients with Class II malocclu- implant system. Angle Orthod 2008;78:167–75.
sion is discussed in Chapter 38. 9. Polat-Ozsoy O. The use of intraosseous screw for upper molar distalization: a case
report. Eur J Dent 2008;2:115–21.
10. Mizrahi E, Mizrahi B. Mini-screw implants (temporary anchorage devices): orthodon-
tic and pre-prosthetic applications. J Orthod 2007;34:80–94.
CONCLUSIONS 11. Chung KR, Choo HR, Kim SH, Ngan P. Timely relocation of mini-implants for unin-
terrupted full-arch distalization. Am J Orthod Dentofacial Orthop 2010;138:839–49.
12. Oh YH, Park HS, Kwon TG. Treatment effects of microimplant-aided sliding mechan-
While MIs can be utilized efficiently as temporary anchorage devices in ics on distal retraction of posterior teeth. Am J Orthod Dentofacial Orthop
order to distalize maxillary molars or the entire maxillary dentition, the 2011;139:470–81.
13. Doshi UH, Jamwal RS, Bhad WA. Distalization of molars using two stage mini-
outcome of treatment depends greatly on the biomechanics used for molar implants: a case report. J Orthod 2011;38:55–63.
distalization. When the force vector of the distalization system passes 14. Yamada K, Kuroda S, Deguchi T, Takano-Yamamoto T, Yamashiro T. Distal movement
through or very close to the center of resistance of the molars, pure or of maxillary molars using miniscrew anchorage in the buccal interradicular region.
Angle Orthod 2009;79:78–84.
almost bodily movement of the teeth is produced. Generally, this is mostly 15. Jeon JM, Yu HS, Baik HS, Lee JS. En-masse distalization with miniscrew anchorage
accomplished when the MIs are inserted in the palate, because this allows in Class II nonextraction treatment. J Clin Orthod 2006;40:472–6.
the application of forces parallel to the occlusal plane and close to the 16. Munoz A, Maino G, Lemler J, Kornbluth D. Skeletal anchorage for Class II correction
in a growing patient. J Clin Orthod 2009;43:325–31.
center of resistance of the molars. When MIs are inserted in the buccal 17. Park HS, Kim JY, Kwon TG. Treatment of a Class II deepbite with microimplant
area of the maxilla, the distalization forces are applied more occlusally anchorage. Am J Orthod Dentofacial Orthop 2011;139:397–406.
 Mechanics of Class II malocclusion
compensation with miniscrew
26
implant-supported anchorage
Madhur Upadhyay, Sumit Yadav and Ravindra Nanda

■ distalization of the posterior teeth

INTRODUCTION ■ molar protraction/mesialization.
Class II division 1 malocclusions are described as having labially inclined
maxillary incisors, increased overjet and a vertical overbite, which might
RETRACTION OF THE MAXILLARY ANTERIOR TEETH
vary from a deep overbite to an open bite. In contrast, Class II division 2
malocclusions show excessive lingual inclination of the maxillary central
Treatment for the correction of Class II malocclusions in non-growing
incisors overlapped on the labial by the maxillary lateral incisors. They
patients usually involves selective removal of permanent teeth, with sub-
always show a deep overbite with minimal overjet. There are two broad
sequent dental camouflage to mask the skeletal discrepancy and provide a
approaches for Class II correction: alteration of the skeletal base by surgi-
good facial balance. Extractions can involve two maxillary premolars or
cal or orthopedic means or dental compensation, which involves masking
two maxillary and two mandibular premolars. The extraction of only two
the underlying skeletal discrepancy (if any) by dental movements.
maxillary premolars and anterior teeth retraction is generally indicated
This chapter discusses compensation mechanics using miniscrew
when there is no crowding or cephalometric discrepancy in the mandibular
implant (MI)-supported anchorage. Earlier chapters in this book have
arch. When retracting anterior teeth in a full cusp Class II malocclusion,
covered the general principles of MIs as anchorage and the biomechanics
anchorage control assumes profound importance because maintaining the
involved. Broadly speaking, the following typical dental movements are
posterior segment in place becomes very critical. A loss in molar anchor-
sought:
age can not only compromise correction of the anteroposterior discrepancy
■ distal movement of the maxillary teeth, either stepwise with molar but also affect the overall vertical dimension of the face.1
first followed by rest of the teeth or en masse The preferred location for MI placement is between the roots of the
■ retraction of the maxillary anterior teeth into a premolar extraction second premolars and first molars close to the mucogingival junction. An
space while maintaining the Class II molar relationship SS archwire (0.017 × 0.025 inch) and a force of 150–200 g are considered
■ combination of retraction of the maxillary teeth and forward as optimum conditions for efficient retraction of the maxillary anterior
movement of the lower teeth. teeth.2,3 The biomechanics involved during en masse retraction of the
anterior teeth with MI-assisted anchorage is illustrated in Fig. 26.2. In the
Fig. 26.1 outlines the possible steps required, depending on the individual
second stage after space closure, continuation of the force from the springs,
patient. The following will be discussed in this chapter:
as is sometimes done for en masse distalization, can cause some intrusion
■ retraction of the maxillary anterior teeth while maintaining a Class and distalization of the entire arch. This is primarily because of increased
II molar relationship friction between the archwire and the bracket. Therefore, the thicker the
archwire, the greater the distalizing effect on the entire arch will be.
Class II
(dental compensation)
DISTALIZATION OF THE POSTERIOR TEETH

Sagittal movement of the dentition without extractions is often difficult

Buccal
Overjet and time consuming. Issues of unwanted tooth movements during distali-
occlusion
zation, which have to be corrected in a subsequent stage (“round tripping,”
see Chapter 2), can be avoided if MIs are used for skeletal anchorage.
MI-based anchorage can be lingually from the palate, buccally from the
Procline Retraction of Alter to
mandibular maxillary Class I or Maintain alveolar bone (between the roots), or from the zygomatic buttress.
anterior teeth anterior teeth Class II

MOLAR DISTALIZATION
Protract Fig. 26.3 shows a simple buccal approach to distalize molars individually.
mandibular teeth Maxillary teeth The treatment plan demanded the creation of space by molar distalization
to Class I relation before leveling and aligning the rest of the dentition. A push-coil spring
from the MI inserted between the roots of the first premolar and canine
linked to the molar with an SS wire (0.016 × 0.022 inch) bent passively
Protract to Distalize to from the MI to the auxiliary tube of the molar. Uprighting of the molar
Class II Class I required the center of rotation to be closer to the root apex, leading in
relation relation
principle to greater tip-back of the crown and less root movement. This
Fig. 26.1 Treatment objectives for compensating a dental Class II malocclusion. force system is illustrated in Fig. 26.3C–E.

139
 140 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Fig. 26.2 Biomechanics of en masse retraction

of the anterior teeth with miniscrew implant
anchorage. The force (F) exerted by the bilateral
coil springs has two distinct components: a
larger and predominantly retractive force (r) and CR M
a smaller intrusive force (i). There is also a M i
i
clockwise moment (M) on the anterior segment F
F
as the total force passes below the estimated
center of resistance (CR) of the anterior teeth. r
(A) Initial stage to close the extraction space.
Significant M on the anterior segment causes
tipping of the anterior teeth. (B) After space
closure, the canine is in contact with the
second premolar. The moment is reduced as
the force from the spring is applied closer to
the CR of the entire arch. Note the increase
in the angulation of the total force relative to
the occlusal plane.

A B

Fig. 26.3 Molar distalization for a mesially

tipped maxillary left first molar and to make
space for eruption of an impacted maxillary
left second premolar. (A) Immediately after
miniscrew implant insertion and force application
through a coil spring. (B) After molar
distalization. (C) The force (Fa) applied from the
MI through the push-coil pushes the molar
distally, producing a moment (Mf) because Fa is
not applied at the center of resistance (CR), A B
causing the molar to tip around a point apical
to the CR (approximately). (D) Once molar
distalization is complete and a Class I
relationship is obtained, the molar is included in
the rest of the arch by placing continuous
archwires, resulting in a couple (Mc) at the molar
tube. (E) A couple creates a moment around the
CR; therefore, although there is a moment to
distalize the root, the same moment is also Mf
acting to mesialize the crown of the molar. This
makes it imperative to have a passive distalizing
force (Fp) on the molar too, which will ensure
only root movement. Fa
Mc

Fp

C D

Mc

Fp

E
 Mechanics of Class II malocclusion compensation with miniscrew implant-supported anchorage 141

EN MASSE DISTALIZATION orthodontic mechanotherapy, in addition to preventing extrusion of the

maxillary and mandibular posterior teeth, it is equally important that the
Distalization of the maxillary arch by more than 2–3 mm cannot be maxillary anterior teeth are intruded as they are retracted. This maximizes
achieved using an inter-radicular MI for anchorage. Placement of a MI, or the upward rotation of the mandible as the incisal stop is moved further
miniplate, buccally above the mucogingival junction in the zygomatic up. Without intrusion and control of the axial inclination of the maxillary
bone is a feasible option but the surgery (particularly for miniplates) can anterior teeth, the patient is likely to have a longer face and a more
be more extensive and there are more oral hygiene issues. Placement of downward and backward rotated mandible, exaggerating the Class II
MIs or implants in the palate is also an option (see Chapter 7). The mid- appearance.
palatal suture area seems a particularly good placement site. Some clini-
cians favor the palatal area behind the incisive foramen while others prefer
the paramedian region of the palate as there is more bone support.4–8 One LIMITATIONS OF DISTALIZATION
of the primary advantages of using palatal implants is the application of
One of the limitations encountered in maxillary molar distalization is
force closer to the center of resistance (CR) of the posterior teeth to achieve
associated with the lack of space in the maxillary tuberosity area to move
bodily translation with minimal tipping. In addition, there is no flaring or
teeth distally. Extraction of maxillary third molars can provide sufficient
proclination of the anterior teeth and no mesial movement of the molar
space in the tuberosity area for teeth to move within the alveolar bone.
during retraction of the anterior teeth.
A further limitation can arise if the MI supporting the distalization can
Distalization with MIs helps in efficient control of the vertical dimen-
interfere with adjacent roots. To prevent such interference, MIs should be
sion by preventing the extrusion of the molars, thereby maintaining the
angulated superiorly, to give clearance between the MI and the root apex
mandibular plane angle (Fig. 26.4). A clockwise rotation of the mandibular
in coronal view; alternatively, roots can be tipped apart to create sufficient
plane can worsen the Class II malocclusion and make relapse more likely.
space before insertion of the MI.
The vertical component of the total force can result in binding (or
increase of friction) of the archwire to the brackets or tubes, thereby pre-
venting sliding and resulting in the transmission of the force to the entire
archwire and consequently greater amounts of distalization and intrusion. MOLAR PROTRACTION/MESIALIZATION
Small vertical changes at the posterior teeth can produce profound changes
in the anterior area: 1 mm of intrusion at the posterior teeth can produce Protraction of mandibular molars to correct a Class II molar relationship
3 mm of upward and forward movement at point gnathion and probably is biomechanically one of the most challenging scenarios. The mandibular
more at the chin.9 Such a movement can be a critical factor for the correc- molars are more difficult to move mesially because the mandible is made
tion of Class II relationships, particularly in high-angle relations. The of thick cortical bone connected by coarse trabecular bone, and the molar
occlusogingival position of the MI, or the use of power arms or crimpable roots are extremely wide buccolingually.10 Conventional techniques not
hooks, can also be critical factors in defining the vertical component of only cause mesial tipping of the molars but also lingual tipping of the
the total force. With MIs placed higher up in the vestibule, the vertical anterior teeth, resulting in an increased overjet and worsening of the Class
component of the total force is significantly increased. II profile (Fig. 26.5A). The large root surfaces of molars make their move-
Patients with moderate to severe vertical facial patterns do not always ment uncertain, while simultaneously they can cause unwanted tooth
have an anterior open bite, because often the incisors have been supra- movements, such as lingual tipping of the incisors. Placement of a dental
erupted, compensating for the posterior vertical excess. Therefore, during implant in the retromolar area for absolute anchorage has allowed effective
closure of the space from a missing mandibular first molar.11,12 The dental
implants were strong enough to withstand the reactive forces and thus
produced effective mesial movement of the mandibular molars without
any lingual tipping of the incisors.13,14
Molar protraction usually involves pure forward bodily translation. If
the line of force does not pass through the CR of the molar, there will be
F
a tendency for the molar to tip forward during protraction. This may cause
binding of the molar tube on to the archwire, resulting in bowing of the
archform in the premolar area, which may lead to cessation of protraction
or unwanted side effects on adjacent teeth (Fig. 26.5B). There are several
methods to avoid these side effects during molar protraction with MIs:
■ using thick SS archwire that almost fills the bracket slot:
this reduces play between the molar tube and the archwire
(Fig. 26.6A,D)
■ using a rigid SS power arm or lever arm on the molar: the line
of force from the MI passes through the CR of the molar
(Fig. 26.6B)
■ using regular sliding mechanics by engaging an elastic chain from
the molar tube to the MI directly: after some protraction an
Fig. 26.4 En masse distalization of the entire arch using miniscrew implants (MIs) uprighting spring has to be used to upright the molar (i.e. mesialize
placed in the buccal alveolar bone. A single force (red) is applied bilaterally from the root) and it is important to tie the molar to the MI with a
the anterior segment to the MI. Horizontal and vertical components (in green) of
ligature wire during uprighting to prevent distal movement of the
the force tend to distalize and intrude the teeth. Stiff SS archwires will provide
more effective distalization with fewer side effects than flexible archwires. The crown (Fig. 26.6C,D)
position of the MI will limit the amount of distalization as it could obstruct the ■ using a palatal MI (see Fig. 30.2): force can be applied at the CR of
roots. the molars, ensuring bodily movement with minimal side effects.
 142 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Fig. 26.5 Conventional approach for molar

protraction. (A) Although the anchorage of the
anterior teeth is greater than the molar, the
moments produced (blue) by an elastic chain
(green) from the molar to the anterior segment.
can cause rapid tipping of the anterior teeth. (B) If
this is continued, the archwire can be distorted
(deflected or bent). This can lead to stagnant tooth
movement, poor control over the anterior teeth
and the molar, and bite deepening.
F

A B

A B C

D E

Fig. 26.6 Molar protraction without side effects from archwire distortion. (A) A stiff archwire avoids unwanted bending of the archwire during protraction, thereby
effectively creating a countermoment (red) that prevents mesial tipping of the molar (blue). (B) An appropriately positioned power arm from the molar ensures bodily
movement, as the force application (red) passes though the center of resistance of the molar. (C) Protraction divided into distinct phases; in the first the molar is tipped
forward and subsequently, an uprighting moment (red) can be applied through an uprighting spring. The crown of the molar is prevented from tipping back by tying it to
the MI with a ligature wire (black). (D and E) Clinical example of molar protraction as shown in (C).

8. King KS, Lam EW, Faulkner MG, et al. Vertical bone volume in the paramedian palate
REFERENCES of adolescents: a computed tomography study. Am J Orthod Dentofacial Orthop
2007;132:783–8.
1. Upadhyay M, Yadav S, Nanda R. Vertical dimension control during en masse retraction 9. Kuhn RJ. Control of anterior vertical dimension and proper selection of extraoral
with mini-implant anchorage. Am J Orthod Dentofacial Orthop 2010;138:96–108. anchorage. Angle Orthod 1968;38:340–9.
2. Upadhyay M, Yadav S, Nagaraj K, et al. Treatment effects of mini-implants for 10. Roberts WE. Bone physiology, metabolism, and biomechanics in orthodontic practice.
en-masse retraction of anterior teeth in bialveolar dental protrusion patients: a rand- In: Graber TM, Vanarsdall RL Jr, editors. Orthodontics: current principles and tech-
omized controlled trial. Am J Orthod Dentofacial Orthop 2008;134:18–29. niques. St. Louis, MO: Mosby; 1994. p. 193–257.
3. Upadhyay M, Yadav S, Nagaraj K, et al. Dentoskeletal and soft tissue effects of mini- 11. Nagaraj K, Upadhyay M, Yadav S. Titanium screw anchorage for protraction of man-
implants in Class II, division 1 patients. Angle Orthod 2009;79:240–7. dibular second molars into first molar extraction sites. Am J Orthod Dentofacial Orthop
4. Kim HJ, Yun HS, Park HD, et al. Soft-tissue and cortical-bone thickness at orthodontic 2008;134:583–91.
implant sites. Am J Orthod Dentofacial Orthop 2006;130:177–82. 12. Upadhyay M, Yadav S. Mini-implants for retraction, intrusion and protraction in a
5. Bernhart T, Vollgruber A, Gahleitner A, et al. Alternative to the median region of the Class II, division 1 patient. J Orthod 2007;34:158–67.
palate for placement of an orthodontic implant. Clin Oral Implants Res 2000;11: 13. Roberts WE, Marshall KJ, Mozsary PG. Rigid endosseous implant utilized as anchor-
595–601. age to protract molars and close an atrophic extraction site. Angle Orthod
6. Miyawaki S, Koyama I, Inoue M, et al. Factors associated with the stability of titanium 1990;60:135–52.
screws placed in the posterior region for orthodontic anchorage. Am J Orthod Dento- 14. Roberts WE, Nelson CL, Goodacre CJ. Rigid implant anchorage to close a mandibular
facial Orthop 2003;124:373–8. first molar extraction site. J Clin Orthod 1994;28:693–704.
7. Gracco A, Luca L, Cozzani M, et al. Assessment of palatal bone thickness in adults
with cone beam computerised tomography. Aust Orthod J 2007;23:109–13.
 The Aarhus Anchorage System
Birte Melsen and Cesare Luzi 27

dentition, extraction treatment for alleviation of anterior crowding and the

INTRODUCTION
use of intermaxillary forces in order to advance the mandible (e.g. with
This chapter illustrates the use of the miniscrew implants (MIs) of the the Herbst appliance).
Aarhus Anchorage System to enhance anchorage control in the treatment
of different Class II malocclusions. The MIs can be used as direct or indi-
MOLAR DISTALIZATION
rect anchorage depending on the treatment plan and the patient’s anatomy.1,2
Whenever possible, MIs are inserted through attached gingiva in order to The only real indication for the distalization of the maxillary molars is a
minimize local irritation. Where this is not possible, one solution is to dental Class II or skeletal Class I (or very mild skeletal Class II in a
allow the MI to be covered with a wire or a ligature penetrating the growing individual) malocclusion without mandibular retrusion and asso-
mucosa. If indirect anchorage must be used, a MI with a bracket-like head ciated with crowding of the maxillary arch.
is indicated. The load on the tooth linked to the MI is important as any
lack of rigidity in the connection between the MI and the tooth can lead
to loss of the MI. CASE 1

A 14-year-old girl with good facial proportions presented with concerns

TREATMENT PLANNING about the position of her maxillary canines and their influence on her smile.
The maxillary dental midline was deviated 3 mm to the left; she had a
Treatment planning can occur either through work-up of a three- Class II dental occlusion with severe maxillary crowding and buccally
dimensional visual treatment objective composed of an occlusogram com- displaced maxillary canines (Fig. 27.1AB). Radiography revealed aplasia
bined with the tracing of a cephalometric radiograph or by simulating the of the mandibular third molars and partially impacted maxillary second
desired tooth movements on virtual models. This is the stage where the molars. Extraction of the non-erupted second molars was performed in
clinician will determine the goal of treatment, which is often a compromise order to facilitate molar distalization and allow eruption of the third molars.
between what is possible and what is desirable. Two MIs (thread length, 6.0 mm; diameter, 1.5 mm; Aarhus Mini-Implants,
When using an occlusogram, the orthodontist will have to: American Orthodontics, Sheboygan, WI, USA) were inserted bilaterally
■ define the patient’s symmetry line between the roots of the second premolars and the first molars and tightly
■ indicate the desired movement of the anterior teeth ligated to the brackets of the first premolars with a 0.12 mm SS ligature
■ indicate a tentative transversal dimension of the arch in the premolar to serve as indirect anchorage. A Pendulum appliance was inserted and the
and molar regions posterior beta-titanium springs were activated to achieve first molar dis-
■ choose the anterior arch form. talization as well as to limit the mesial rotation (Fig. 27.1C,D). After 4
months, brackets were bonded on the maxillary incisors and a continuous
This will allow the clinician to: archwire with two open coil springs was placed (bypassing the canines)
■ simulate tooth movements in all planes of space: when combined bilaterally between the first premolars and first molars in order to prevent
with the tracing of the cephalometric radiograph, the movement of any mesial rotation generated by application of the force from the Pendu-
the incisors in three planes in space can be visualized; when using lum springs on the palatal side (Fig. 27.1E,F). After 8 months, no anterior
virtual models instead of occlusal images of the study casts, anchorage loss was registered and the molars were in a super-Class I
three-dimensional simulations of all desired tooth movements can relationship. The MIs were removed and a Nance button replaced the
be performed Pendulum appliance. Treatment was completed with continuous arch
■ define the active and reactive dental units mechanics: an open coil spring was used to provide the space for the buc-
■ evaluate the anchorage requirements. cally blocked-out maxillary left canine and, at the same time, to correct
the upper midline deviation. Intermaxillary elastics were used in the finish-
Independent of the treatment approach planned, it is imperative to deter- ing phase to achieve proper intercuspation. Post-treatment radiography
mine the desired displacement of the individual teeth or group of teeth. showed favorable eruption of the third molars. The result was satisfactory
Only when the necessary tooth movements are defined it is possible to (Fig. 27.1G,H), but it could be argued that the patient could have been
select the correct line of action for the forces. While treatment planning treated with two maxillary premolar extractions, in which case the use of
can to some extent be considered an art, the correct line of action for a MIs would have been superfluous.
specific tooth movement is based on science: the mathematics and an
estimate of the center of resistance of the tooth/teeth based on biological
evidence.
RETRACTION OF THE ANTERIOR SEGMENT
IN A DEGENERATED DENTITION
CLINICAL EXAMPLES OF TEMPORARY ANCHORAGE Many patients present with an increased overjet and overbite as a result
DEVICES FOR CLASS II CORRECTION of spontaneous migration of the anterior teeth, either following loss of
lateral teeth and deepening of the bite or as a consequence of extrusion
The following cases illustrate the use of temporary anchorage devices for and flaring of maxillary incisors and simultaneous crowding in the man-
molar distalization, retraction of the anterior segment in a degenerated dibular arch due to lip pressure. These patients are characterized as Class

143
 144 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C D

E F G H

Fig. 27.1 Case 1: molar distalization for bilateral Class II malocclusion and high labial canines. (A,B) Pretreatment. (C,D) Miniscrew implants and a Pendulum appliance
inserted. (E,F) Fixed appliances inserted on the maxillary dental arch and coil springs between the second premolars and first molars. (G,H) Post-treatment. (Treated by
C. Luzi.)

A B C D

E F G H

Fig. 27.2 Case 2: retraction of the anterior segment. (A,B) Pretreatment. (C,D) Retraction and intrusion of maxillary incisors with a three-piece mechanics. In the
mandibular arch, three-piece mechanics is used for proclination, intrusion and midline correction. (E) During retraction and intrusion of the maxillary front segment against
two mini-implants (one each on either side of the maxilla). (F) Finishing with straight wires. (G) The end of treatment. (H) After prosthetic reconstruction. (Treated by
E. Serra under B. Melsen’s supervision, School of Dentistry, Aarhus University.)

II and can benefit from skeletal anchorage since the lateral teeth cannot be rotated and slightly tipped mesially. The mandibular incisors were retro-
loaded with the reactive force without iatrogenic or side effects. clined and presented with moderate crowding. The patient exhibited
general bone loss but no bleeding at probing, and no pockets more than
4 mm were present.
CASE 2 During the first phase of treatment, the lateral segments were consoli-
dated with a stiff anchorage appliance consisting of an iron-cross of SS
A 49-year-old woman had experienced a gradually increasing overjet, wire (0.030 inch) and bands on the premolars and molars connected by
flaring and spacing of the maxillary incisors, as well as deepening of her SS wire (0.020 inch). In order to increase the occlusal feedback, thereby
bite. She had impingement of the mandibular incisors to the lingual aspect enhancing anchorage, composite teeth were inserted in the edentulous
of the maxillary incisors (Fig. 27.2A,B). The maxillary second premolars spaces and Triad occlusal onlays were placed on the mandibular lateral
and first molars had been extracted previously. The second molars were segments. After bonding, the maxillary incisors were leveled and
 The Aarhus Anchorage System 145

retraction and intrusion were initiated with two curved cantilevers severe osseous defect mesial to the right mandibular second premolar. The
extending from the tube on the molars. In the mandibular arch, the inci- proposed treatment plan involved extraction of two maxillary premolars
sors were intruded and proclined with two cantilevers extending from the to alleviate crowding of the maxillary arch and to maintain the molars in
molars and activated to correct the asymmetrical arch shape (Fig. the initial full Class II relationship. This could only be done with absolute
27.2C,D). Once the spacing between the incisors was closed and the anchorage control during the canine retraction and overjet reduction
deep bite partially corrected, the anchorage unit was slightly loosened phases. Following segmental bonding of the maxillary arch, the second
and the retraction of the maxillary incisors was completed using skeletal maxillary premolars were extracted (as they were considered more com-
anchorage. Two Aarhus MIs were inserted in the apical region mesial to promised than the first premolars from a restorative point of view) and two
the second molar, and the intrusion and retraction was performed using MIs (thread length, 6.0 mm; diameter, 1.3 mm) were inserted bilaterally
50 cN coil springs extending from the MIs to the anterior segment, while on the upper buccal cortex between the roots of the first and second molars
the lateral segments were relieved from the transpalatal arches and (Fig. 27.3C,D). Super­elastic closed coil springs with 50 cN force were
leveled with a continuous arch bypassing the incisal unit of the anterior used bilaterally for the retraction of both canines and first premolars;
teeth (Fig. 27.2E). Finishing of the mandibular arch was carried out with power arms were used to obtain the necessary line of action of the force.
straight wire mechanics (Fig. 27.2F). A transpalatal arch was used for derotation of the second molars, and later
At the end of the orthodontic correction (Fig. 27.2G), the patient was on for the same purpose on the first molars. Once the canine retraction
referred to the prosthodontic department for replacement of the missing was completed, the maxillary incisors and the lower arch were bonded,
teeth with two bridges (Fig. 27.2H). A 4-to-4 retainer was bonded in the leveling and alignment were completed and superelastic closed coil springs
mandibular arch, and once the bridges were inserted the patient received with 50 cN force were used together with sliding mechanics on a continu-
a 2 mm balanced splint to use at night. Careful instructions were given ous SS rectangular posted full-size wire for overjet closure (Fig. 27.3EF).
regarding periodontal control. The reactive forces to the retraction of canines and incisors were loaded
exclusively on the MIs, thus avoiding any possible anchorage loss and
guaranteeing the final proper dental relationships (Fig. 27.3G,H). Follow-
EXTRACTION TREATMENT FOR ALLEVIATING ing treatment, fixed bonded retainers were placed on both arches as per-
ANTERIOR CROWDING manent retention and the patient was sent for periodontal evaluation and
Another approach for a crowded maxillary dental arch without a major a soft tissue graft for the recession present buccally on the maxillary right
component of mandibular retrusion involves extraction of two maxillary premolar. The initial buccal ectopic position outside the buccal cortex did
premolars.3 Maximum maxillary posterior anchorage is necessary to mini- not allow soft tissues to completely follow the orthodontic extrusion of the
mize mesial movement of the maxillary molars and second premolars tooth.
while retracting the anterior segment. Direct anchorage on MIs avoids Panoramic radiography indicated that the osseous defect between the
placing any load to the posterior teeth of the maxillary arch, thus eliminat- mandibular right premolars was still present and the patient was instructed
ing any undesired posterior shifts. to maintain proper hygiene in that area.

CASE 3
INTERMAXILLARY FORCES TO ADVANCE
THE MANDIBLE
A 52-year-old woman was unhappy with the esthetics of her smile and was Intermaxillary non-compliance appliances act in both maxilla and mandi-
not interested in any therapeutic solution that would require maxillofacial ble in order to advance the mandible to a more forward position. (e.g. the
surgery. She had a Class II malocclusion, severe crowding of the maxillary Herbst appliance) (see Chapter 2).4,5 All fixed bite-jumping devices have
arch and mild crowding of the mandibular dental arch (Fig. 27.3A,B). both skeletal and dental effects, with proclination of the mandibular inci-
Radiography revealed the absence of the mandibular third molars and a sors as an unwanted effect (see Fig. 2.15).6,7 Although many attempts have

A B C D

E F G H

Fig. 27.3 Case 3: alleviation of anterior crowding with extractions. (A,B) Pretreatment. (C,D) Insertion of a transpalatal arch and two buccally positioned miniscrew
implants. (E,F) The finishing phase. (G,H) Post-treatment. (Treated by C. Luzi under B. Melsen’s supervision, School of Dentistry, Aarhus University.)
 146 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C D

E F G H

Fig. 27.4 Case 4: intermaxillary temporary anchorage with the Herbst appliance. (A,B) Pretreatment. (C,D) Insertion of a casted Herbst and two buccally positioned
miniscrew implants. (E) Insertion of fixed appliances and leveling and alignment of both dental arches. (F) Herbst appliance removed and the finishing phase.
(G,H) Post-treatment. (Treated by C. Luzi.)

been made to avoid mandibular incisor proclination (cast mandibular received an upper retention plate for night use and a lower bonded fixed
appliances, archwires with torque bends, brackets with selective torques), retainer. The final radiographs depicted improvement of the sagittal skel-
absolute anchorage control cannot be achieved and some amount of den- etal relationships and the final mandibular incisor inclination, which
toalveolar compensation should be always expected.8 increased by 1° (l1/GoMe: 108°) compared with the start of treatment.
Temporary anchorage devices can be used in combination with bite- The use of temporary anchorage devices with Class II traditional devices
jumping appliances to maximize skeletal effects and reduce the side effect such as the Herbst appliance and intermaxillary elastics can be standardized
of incisor proclination. A combination of MIs and a modified Herbst appli- into future treatment protocols for Class II correction. Reducing dentoal-
ance is described below. veolar side effects on the mandibular arch can optimize treatment efficiency
and success through increased skeletal response, enhanced profile improve-
ment and better final dental relationships. Furthermore, it can reduce post-
CASE 4 treatment relapse through solid ideal teeth intercuspation.

A 14-year-old girl presented with a Class II, division I malocclusion with

retrusive chin and a large overjet (Fig. 27.4A,B). Her maxillary dental arch CONCLUSIONS
was asymmetrical with a buccally displaced maxillary left canine and mild
crowding; no space problems were present in the mandibular arch. Lateral In addition to widening the spectrum of clinical orthodontic treatment,
cephalometric radiography revealed skeletal Class II sagittal relationships skeletal anchorage modalities can facilitate treatment, shorten treatment
of the jaws from a retrusive mandible and normal vertical jaw relation- times and avoid side effects. Examples have been given of the use of
ships. The inclination of the mandibular incisors with regard to the man- temporary anchorage devices for direct and indirect anchorage for various
dibular plane (l1/GoMe) was 107°. The treatment plan involved mandibular approaches to Class II malocclusion.
advancement using a modified Herbst appliance. A casted Herbst was
constructed on preformed reinforced bands equipped with two hooks bilat-
erally on the lower mesial part of the casted structure on the buccal side. REFERENCES
Following insertion of the device, two Aarhus MIs (thread length, 6.0 mm;
1. Melsen B. Mini-Implants: where are we? J Clin Orthod 2005;39:539–47.
diameter, 1.5 mm) were inserted bilaterally in the lower buccal cortex 2. Bae SM, Park HS, Kyung HM, et al. Ultimate anchorage control. Texas Dent J
between the roots of the first and the second premolars (Fig. 27.4C,D) and 2002;119:580–91.
tightly ligated with a 0.12 mm SS ligature to the hooks of the Herbst appli- 3. Bryk C, White LW. The geometry of Class II correction with extractions. J Clin Orthod
2001;35:570–9.
ance, thereby using the MIs as indirect anchorage to eliminate or reduce 4. Flores-Mir C, Ayeh A, Goswani A, et al. Skeletal and dental changes in Class II division
proclination of the mandibular incisors. Brackets were bonded on both 1 malocclusions treated with splint-type Herbst appliances: a systematic review. Angle
arches and the teeth were leveled and aligned during the bite-jumping Orthod 2007;77:376–81.
5. Jasper JJ, McNamara JA Jr. The correction of interarch malocclusions using a fixed
months (Fig. 27.4E). Once the Herbst was removed, 9 months after treat- force module. Am J Orthod Dentofacial Orthop 1995;108:641–50.
ment start, full-arch bonding was completed and finishing wires were 6. Barnett GA, Higgins DW, Major PW, et al. Immediate skeletal and dentoalveolar effects
placed together with intermaxillary elastics to consolidate the intercuspa- of the crown- or banded type Herbst appliance on Class II division 1 malocclusion.
Angle Orthod 2008;78:361–9.
tion. The MIs were left in place and used as anchorage for the application 7. Martin J, Pancherz H. Mandibular incisor position changes in relation to amount of bite
of elastics in the mandibular arch (Fig. 27.4F) to prevent relapse and jumping during Herbst/multibracket appliance treatment: a radiographic–cephalometric
maintain a correct forward position of the mandible while the teeth were study. Am J Orthod Dentofacial Orthop 2009;136:44–51.
8. Pancherz H, Ruf S, Erbe C, et al. The mechanism of Class II correction in surgical
settling into the new occlusal relationships. The MIs and the fixed appli- orthodontic treatment of adult Class II, division 1 malocclusions. Angle Orthod 2004;74:
ances were removed 20 months after initiation of treatment. The patient 800–9.
 The Spider Screw anchorage system
B. Giuliano Maino and Paolo Pagin 28

neck of two different heights (long or short) to use with thick or thin soft
INTRODUCTION
tissues (Fig. 28.1).2
Three phases of treatment are identified for monitoring progress, using
This chapter discusses a system for the treatment of Class II malocclusion,
the mandibular arch as reference against which to judge the movements
with and without extractions, that combines sliding mechanics based on
of the maxillary teeth:
the bidimensional technique with miniscrew implants (MIs) as the only
source of anchorage. The bidimensional technique is intended to give ■ phase 1: distalization of the maxillary molars to reach a
stronger torque control through the use of brackets with different horizon- “super-Class I” relationship
tal slot sizes (0.018 × 0.025 inch in the incisors and 0.022 × 0.028 inch in ■ phase 2: distalization of the premolars and canines
the lateral segments). Using a single wire (0.018 × 0.022 inch), a total ■ phase 3: retraction of the incisors.
control of the anterior teeth is obtained while the wire can slide into the
lateral segments (Table 28.1).1
PHASE 1: DISTALIZATION OF THE MOLARS
If the second maxillary molars have not erupted, the first molars are distal-
THE MGBM SYSTEM
ized using sectional mechanics with the SS wire and an open Ni-Ti coil
spring from the first premolar to the first molar. The coil spring is 10 mm
The MGBM system is designed to be used in growing patients as well as
longer than the space between the distal part of the bracket of the first
in adults with varying growth patterns; it is intended to be easy to use, of
premolar and the mesial extremity of the molar band. When the coil is
limited cost and a rapid procedure.
compressed between the first premolar and the first molar, it is activated
This chapter describes its use in distalization of the maxillary molars
by 10 mm. The second premolar is not banded to facilitate the application
with and without extractions and in management of the vertical
of the coil (Fig. 28.2A).
dimension.
The two MIs are inserted on the palatal side between the roots of the
second premolars and the first molars or, if the interproximal space is large,
between the first and the second premolars (Fig. 28.2A). The advantage
DISTALIZATION OF THE MAXILLARY MOLARS
of the latter position is that it allows spontaneous drift of the second
WITHOUT EXTRACTIONS
premolars under the pull of the transeptal fibers. The insertion direction is
The MGBM system comprises an anchorage unit and an active part; The about 30–40° with respect to the inclination of the palatal vault.
anchorage unit is formed by a transpalatal bar bonded to the occlusal The transpalatal bar (0.036 inch SS wire) is bonded on to the occlusal
surfaces of the first premolars and with two long-neck Spider Screw K1 surface of the maxillary first premolars and then connected to the MIs
MIs (Fig. 28.1) (diameter, 1.5 mm; length, 10 mm; HDC, Sarcedo, Italy) through a well-tightened metallic ligature (0.012 inch) (Fig. 28.2B). This
positioned on the palatal side. The active part has two sectional SS wires way, the transpalatal bar prevents loss of anchorage and possible unwanted
(0.016 × 0.022 inch), two Ni-Ti coil springs of 200 g and, if the second rotation, inclination and torsion effects on the premolars. To strengthen
molars are present, two sectional superelastic Ni-Ti (0.018 × 0.025 inch) the anchorage to the palatal bar, acrylic resin can be added in a similar
wires. way to a Nance button so that it rests against the anterior part of the palate
The MIs are self-drilling and self-tapping, thus allowing them to be (Fig. 28.2B).
applied directly. The head has three slots and a transmucosal conical collar/ If the second molar has also emerged, treatment can be accelerated by
integrating the MGBM protocol with the “simultaneous maxillary molar
distalization system” (SUMODIS),3 which has two distinct distalization
components, one activated against the first molar and the other against the
Table 28.1 Characteristics of the brackets used for the second molar (Fig. 28.2C–F). The component activated against the first
bidimensional technique molar has the same SS wire but with a precompressed coil spring posi-
Dimension tioned between the first premolar and the first molar. Before fixing the SS
(inch) Tip (°) Torque (°) Toe-in (°) wire to the bracket of the first premolar, the wire is inserted in the lower
Maxillary arch section of a double sliding tube that is positioned adjacent to the bracket
Central incisors 0.018 × 0.025 5 12 0
Lateral incisors 0.018 × 0.025 9 8 0
Canines 0.022 × 0.028 7 0 0 External rectangular slot
Internal
Internal round hole
Premolars 0.022 × 0.028 0 0 0 rectangular
slot Neck (varies in length)
Molars 0.022 × 0.028 0 0 14
Mandibular arch
Incisors 0.018 × 0.025 0 0 0
Canines 0.022 × 0.028 5 0 0
Premolars 0.022 × 0.028 0 0 0
Molars 0.022 × 0.028 0 0 0
Fig. 28.1 The Spider Screw K1.

147
 148 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Fig. 28.2 Non-extraction treatment of Class

II malocclusion. (A,B) Phase 1 distalization of
the maxillary molars to reach a “super-Class
I” relationship. (A) Positioning of the
miniscrew implants (insertion angle on
right). (B) The complete MGBM system.
(C–F) Phase 1: modification of the MGBM 2 2
protocol with the SUMODIS when the
1 1 Nance button
second molar has emerged. (C) The
(optional)
SUDOMIS system comprises a double sliding
tube and a sectional Ni-Ti wire with stops
(note that the tube on the second molar has
been attached with a distogingival
inclination). (D) The activated SUMODIS
A B
inserted on the maxillary arch. (E) The
complete MGBM system with SUMODIS for
the simultaneous distalization of the
maxillary first and second molars. (F) End of
phase 1, with the maxillary first molars in
super-Class I relationship. (Adapted from
Maino et al., 2007.3)

+6 mm +3 mm
C

E F

of the first premolar. The tube is blocked on one side by the precompressed superelastic coil of 200 g. At the end of phase 1, it is important to obtain
coil and on the other by the bracket of the premolar. The second distal a super-Class I molar relationship (Fig. 28.2F) in order to provide abundant
component is a sectional (0.018 × 0.025 inch) Ni-Ti wire with shape space for the insertion of MIs in phase 2 in a position that will not interfere
memory and excessive length on which a mesial and a distal stop are fixed with the retraction of the second premolar (nor create problems if any
(Fig. 28.2C). It is important that the tube is attached to the second molar small mesial movement of the MI happens).
with a distogingival inclination to counteract the distal crown tipping of
the second molar that could occur because the Ni-Ti wire used to distalize
that molar is not rigid. This is done by fixing a stop corresponding to the
PHASE 2: RETRACTION OF THE PREMOLARS
distal surface of the tube of the second molar and another at the level of
AND CANINES
the distal surface of the bracket of the first premolar; the distance between The transpalatal bar and the MIs in the palate are removed. Two MIs of
these two stops is approximately 9 mm longer than the distance between 1.5 mm diameter (K1, 8/10 mm) are inserted bucally mesial to the first
the mesial part of the tube on the second molar and the distal part of the molars with a perpendicular or oblique direction to the cortical bone (Fig.
double tube inserted on the sectional wire (Fig. 28.2C). This way, when 28.3A). The height of the insertion point in the buccal side is determined
the Ni-Ti wire is inserted into the tube of the second molar and into the by biomechanical factors, whether or not an intrusive movement is needed
upper part of the double sliding tube, it is raised into the buccal fold and for the molars and/or the incisors during the second and third phases of
is automatically activated by 9 mm (Fig. 28.2D). treatment. If intrusion is not needed, the MIs can be inserted low in the
Gradually, the sectional arch assumes its normal horizontal orientation, attached gingiva; if it is necessary, the MIs can be placed at the level of
performing its distalization action at the level of the second molars at the or slightly higher than the mucogingival line. Simultaneously, brackets can
same time as the distalization of the first molars (Fig. 28.2E). In the initial be applied to the entire maxillary arch. It is then possible to pass on to the
phase, a light force is applied to favor stabilization of the MIs. The simul- alignment phase using superelastic Ni-Ti wire (0.016 × 0.022 inch) pro-
taneous distalization is performed with a Ni-Ti wire of 160 g and a vided with stops positioned mesial to the first molars and hooks fixed
 The Spider Screw anchorage system 149

A B

C D

E F
Fig. 28.3 Non-extraction treatment of Class II malocclusion. Phase 2: retraction of the premolars and canines. (A) Miniscrew implants (MIs) inserted after completion of
molar distalization. (B) The alignment phase with Ni-Ti wire, a stop mesial to the first molars, a hook clamped on the archwire mesial to the canines and a metallic ligature
between the MI and the hook. (C) Simultaneous alignment and distalization of the first premolars and canines during the alignment phase. (D) Simultaneous alignment
and distalization of the first premolars and canines using power arms. (E) Simultaneous retraction of the first premolars and canines using direct anchorage. If needed, the
second premolars are retracted using indirect anchorage. (F) Simultaneous retraction of the first premolars and canines using a power arm to retract the first premolar
while minimizing the intrusive force.

mesial to the canines. If the molar has been correctly distalized into a 28.3C). Since the archwire is not rigid, it is possible to have better control
super-Class I relationship, positioning of the stops can be slightly mesial of root inclination by positioning the distalization vector of the force closer
to the first molars, which allows for a certain amount of mesial movement to the center of resistance (CR) of the teeth using power arms inserted in
of the first molar, thus speeding up the alignment phase (Fig. 28.3B). A the vertical slot of the brackets. The length of the power arm does not need
metallic ligature (0.012 inch) is applied from each of the MIs to the hooks to be excessive (6–8 mm) to avoid discomfort for the patient and decreased
clamped to efficiency of tooth movement (Fig. 28.3D).
the archwire. This prevents mesial sliding of the first molars during the Once the alignment is complete, the SS wire (0.016 × 0.022 inch) is
alignment phase, which may result in loss of the Class I relationship inserted with a stop mesial to the first molars and hooks mesial to the
(Fig. 28.3B). canines. The molars are stabilized with a metal ligature (0.012 inch) tight-
During the alignment phase premolars and canines can be moved dis- ened between the MIs and the hooks. After 8 weeks for alignment, during
tally during the alignment phase using light forces of about 50 g (Fig. which the reliability of the MIs is also checked, the forces of each of the
 150 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

E D
Fig. 28.4 Non-extraction treatment of Class II malocclusion. Phase 3 retraction of the incisors. (A) The closed coil spring between the first molar and second premolar
prevents closure of the space between these two teeth. (B) The canines are ligated to the miniscrew implant (MI) with a metallic ligature and the incisors retracted with a
coil spring linking the MIs to the hooks on the archwire. (C) Opening of the bite using an archwire with an exaggerated curve of Spee on the maxillary arch, a reversed
curve on the mandibular arch and vertical elastics between the upper and lower molars. (D) Hooks with power arms clamped on the SS archwire minimize rotation of the
occlusal plane. (E) Two different horizontal slot and a single wire used in Bidimensional Technique to produce a total torque control.

coil springs can be increased to 100–150 g. The simultaneous retraction disadvantages, such as patient discomfort, interference with oral hygiene
of the canines and the first premolars is continued, with forces directed and sometimes a slowing of teeth movement.
from the MI to the teeth applied from the vestibular side (direct anchorage)
(Fig. 28.3E,F). The second premolar is not always retracted as sometimes
it can reach the correct Class I position on its own.
PHASE 3: RETRACTION OF THE INCISORS
If distal movement of the second premolar is required, Class I elastics Phase 3 involves the retraction of the incisors using sliding mechanics. A
using elastic chains attached to the first molars (indirect anchorage) can SS wire (0.018 × 0.022 inch) with hooks distal to the lateral incisors is
be initiated, from the buccal and if necessary also from the palatal side inserted along with a closed coil spring between the second premolar and
(Fig. 28.3E). Because of the stop on the archwire and the metal ligature the first molar to act as a space maintainer, keeping the space between the
between the MI and the hook clamped on the archwire mesial to the canine, teeth constant and preventing possible contact of the mesial root of the
the reaction force is transmitted to the MI and the first molar will remain first molar with the MI (Fig. 28.4A). A new metallic ligature wire
in its position (Fig. 28.3F). To optimize the vertical control of the premo- (0.012 inch) is placed, this time from the MIs to the canines. Then, two
lars, power arms are sometimes used. However, the use of power arms has 300 g Ni-Ti coil springs are positioned, one on each side, from the MIs to
 The Spider Screw anchorage system 151

A B C D

E F G H

Fig. 28.5 A female patient treated with the MGBM system without extractions. (A,B) Pretreatment. (C,D). Phase 1 (distalization of the molars) in buccal view showing the
SUMODIS (C) and occlusal view showing the transpalatal bar connected to the palatal miniscrew implants (MIs) through metallic ligature wires (D). (E) Phase 2:
simultaneous retraction of the premolars and canines with buccally inserted MIs. (F) Phase 3: retraction of the incisors. (G,H) Post-treatment.

the crimped hooks on the archwire, and the en masse retraction of the can be carried out after bonding of both the maxillary and mandibular
incisors begins (Fig. 28.4B). dental arches to retain full control of the extraction space.
Because of the precise fit between the wire and the slot in the brackets Correction of the molars should be carried out before MI insertion in
of the incisors (0.018 × 0.025 inch), it is possible to accomplish the retrac- order to ensure that the MIs will not interfere with the desired mesial
tion of the incisors with full root control (bodily movement). On the other movements of the molars. Once the definitive interarch molar relationship
side, because of the larger dimension of the bracket slot in the lateral is established, treatment can proceed with MI insertion and retraction of
sectors (0.022 × 0.028 inch), the closure of the anterior spaces is accom- the canines and the maxillary incisors.
plished with sliding mechanics. In adults, as well as in patients where the Two MIs are applied directly in the vestibular region, usually in the
root length is greater than average, and whenever it is necessary to increase interproximal space between the maxillary second premolars and the first
the torque control of the anterior teeth, it is possible to use an archwire molars. Anatomically, this usually offers greater space because it frequently
with larger dimensions (e.g. 0.018 × 0.025 inch). corresponds to a concavity of the radicular surface mesial to the first molar.
Many of the patients with Class II malocclusion to be treated without Alternatively, the MIs can be inserted in the interproximal space between
extractions present with a deep bite and so it is necessary to open the bite the maxillary first and second molars. While this location is more efficient
at the same time as retracting the incisors. The bite can be opened by as it provides a longer distance between the MI and the canine during
intrusion of the maxillary or the mandibular incisors, extrusion of the retraction, this longer distance has a greater curvature and so the elastic
molars or a combination of both. chains or coil springs can cause impingements or ulcers of the soft tissues.
To open the bite by intrusion of the incisors, an archwire with an exag- The MIs are usually inserted at the mucogingival junction in a perpen-
gerated curve of Spee is inserted on the maxillary arch, with a reversed dicular direction, thus positioning the head of the MI a sufficient distance
curve on the mandibular arch. Vertical elastics are used between the molars from the orthodontic appliance. This is biomechanically favorable and
of the mandibular and maxillary arches to prevent any intrusion of the allows good oral hygiene. The perpendicular insertion plus the distance of
molars and consequent rotation of the occlusal plane (Fig. 28.4C). the head of the MI with respect to the occlusal plane allows intrusion or
A biomechanical alternative that minimizes rotation of the occlusal extrusion movements of the molars to be carried out with ease, as well as
plane has two hooks with power arms clamped on to the SS archwire. This intrusion of the incisors during retraction, according to the individual need.
ensures that the force line from the MIs to the power arms is closer to the Where there is need to intrude the molars, it is preferable to apply the MIs
CR of the incisors, facilitating their en masse retraction (Fig. 28.4D). It is 1 to 2 mm above the mucogingival line to have more space for maneuvers.
better not to use power arms of excessive length since this might slow Analogous to the description above for the non-extraction procedure, after
down sliding of the wire through increased friction. the alignment phase, the position of the molars is stabilized with a stop
Fig. 28.5 presents in detail a patient treated with the MGBM system mesial to the maxillary first molars on the SS archwire and a metallic liga-
without extractions. ture is applied from each of the MIs to hooks on the archwire.

TREATMENT OF CLASS II MALOCCLUSION PHASE 2

WITH EXTRACTIONS Distalization of the canines is carried out by applying a Class I force (i.e.
using elastic chains) directly from the MIs to the canines (Fig. 28.6A). The
PHASE 1 force applied in this way combined with an exaggerated curve of spee and
Phase 1 comprises extractions and MI insertion. Extraction of the two vertical elastics between the molars develops an intrusive component for
maxillary first premolars is indicated where there is excessive protrusion the maxillary anterior teeth, which is useful for the correction of the
of the maxilla and/or a full Class II molar relationship where it is necessary deep bite that is often seen in most patients with Class II malocclusion
to maintain maximum anchorage at the posterior teeth segment. Extraction (Fig. 28.4C).
 152 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B

Fig. 28.6 Extraction treatment of Class II malocclusion. Phase 2 distalization of the premolars and canines. (A) Distalization of the canines by elastic chain between
the miniscrew implants and the canines. (B,C) Indirect anchorage with a Class I force applied directly from the first molar to the canine (B) and from the palatal side (C).
(D) Direct anchorage with application of forces to the power arm attached in the slot of the canine bracket.

Whenever intrusion of the anterior teeth is not needed, two biomechani- Another strategy to reduce any extrusive component of the incisors is
cal methods can be followed: to use the archwire with an exaggerated curve of Spee with indirect
anchorage via the first molar to the clamped hook on the arch (Fig. 28.7F).
■ indirect anchorage: Class I forces applied directly from the first
Preservation of anchorage is ensured through the use of the SS ligature
molars to the canines from the buccal (Fig. 28.6B) and from the
(0.012 inch) from the MI to the canine. At the discretion of the clinician,
palatal side (Fig. 28.6C)
retraction of the anterior teeth can also be performed using archwires with
■ direct anchorage: application of forces to a power arm attached in
anterior closed loops (Fig. 28.7G).
the slot of the canine bracket to move the point of force application
To reduce treatment time, it may be possible to retract the canines and
on the canine higher, thus minimizing the vertical intrusive
the incisors simultaneously. In this case, we prefer that the canines always
component (Fig. 28.6D).
precede the movement of the incisors by a few millimeters, which allows
them to reach a correct Class I relationship, as well as giving better man-
agement of any eventual Bolton discrepancies (Fig. 28.7H). In patients with
PHASE 3
some growth potential, particularly if differential growth of the mandible
The retraction of the maxillary incisors is commenced once the canines cannot be predicted accurately, an excess of anchorage can sometimes be
have attained a Class I relationship. The canines are blocked with a metal- observed during the closure phase. In this case, the MI can be removed,
lic ligature wire (0.012 inch) to the MIs, and the en masse retraction of preferably after the canines have reached a Class I relationship.
the incisors is performed using sliding mechanics as described above for
the non-extraction procedure, using two coil springs of 300 g from the MIs
to the hooks (Fig. 28.7A). CONTROL OF THE VERTICAL DIMENSION
In deep bite, the procedure for intrusion of the incisors described above
is followed (Fig. 28.7B–D). During this phase, the CR of the maxilla Treatment plans need to be able to take into account variations in skeletal
generally lies superior to or is coincident to the position of the MI,4 and a type and the bite type. In addition, response to therapy is not always as
Class I force from the MIs to the hooks will create rotation of the occlusal predicted and so the orthodontic approach should have versatility. This is
plane, with extrusion and palatal tipping of the incisors plus intrusion and one reason why the MGBM system routinely uses MIs from the palatal
distal tipping of the molars (Fig. 28.7E).5 The intrusive component of the side for the distalization of the molars but from the buccal side for
anterior teeth is needed in most cases to counteract the extrusive effect the retraction of the lateral teeth and of the incisors (see Figs 28.2E
arising from the rotation of the occlusal plane. The precise coupling of the and 28.3A).
full thickness of the SS archwire (0.018 × 0.022 inch) in the bracket slot MIs in vestibular and posterior locations during phase 2 and 3 of treat-
on the incisors (0.018 × 0.025 inch) limits the palatal tipping of the incisor ment also allow the application of conventional direct anchorage biome-
crowns and allows controlled movement of their roots during retraction. chanics, thus avoiding problems from any instability of the MIs.
 The Spider Screw anchorage system 153

A B

E F

G H
Fig. 28.7 Extraction treatment of Class II malocclusion. Phase 3 retraction of the maxillary incisors. (A) Retraction of the maxillary incisors. (B,C) Force vectors generated by
an orthodontic archwire with an exaggerated curve of Spee on the maxilla and a slight reversed curve on the mandible, without (A) and with (B) vertical elastics between
the maxillary and mandibular first molars. (D) Retraction of the maxillary incisors in deep bite with sliding mechanics and direct anchorage. (E) Occlusal plane rotation
around the miniscrew implant during incisor retraction. (F,G) Retraction of the maxillary incisors with sliding mechanics and indirect anchorage (F) and with an archwire
with anterior closed loops (G). (H) Simultaneous retraction of the canines and incisors, with the canine preceding the lateral incisor.
 154 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

OPEN BITE ■ palatal crown torque applied from a rectangular archwire: not very
efficient and rarely effective as a single measure
Excessive vertical dimension is characterized by evident open bite or by ■ MIs in the inter-radicular spaces between the first and second
a tendency to open bite, and one of the most effective systems to control molars on the buccal and palatal sides (Fig. 28.8B): use for severe
open bite is the intrusion of the molars. MIs offer the option of effective open bite or if the intrusion required differs between sides
intrusion of the posterior teeth with good clinical control of the vertical ■ MIs applied on the buccal side and in the palatal vault with or
dimension. without a miniplate (Fig. 28.8C,D).
Various methods can be used for the intrusion of the molars, including
two MIs in vestibular sites in different interproximal spaces, in ascending Two further approaches are useful for treatment of open bite. First, in the
order of difficulty: maxilla, Self-ligating Miniscrews (HDC, Sarcedo, Italy) can be coupled
by wire to a miniplate, thus allowing optimal MI locations to be chosen
■ between the first molars and the second premolars, when the second while providing anchorage through the miniplate (Fig. 28.9). Second,
molars have not yet erupted where there is a need to maximize the counterclockwise rotation of the
■ between the first molars and the second premolars, when the second mandible in order to obtain closure of the bite and/or for esthetic improve-
molars have erupted but there is insufficient space between the two ment, intrusion of the mandibular molars can be carried out using two
molars vestibular MIs and a rigid lingual arch. Orthodontic preparation of the
■ between the first and second molars, which offers the advantage interproximal space between the first and second mandibular molars is
of moving the point of application of the intrusive force more often necessary to allow insertion of MIs, and vestibular crown tipping on
distally, with more evident effects on the anterior part of the the maxillary arch must be controlled. The system includes the applica-
maxilla. tion of a stiff lingual arch (0.032 inch) soldered to the bands of the first
In general, the further the distance of the MI from the occlusal plane, the molars and at sufficient distance from the soft tissues to avoid any tissue
greater the biomechanical efficiency. Therefore, it is better to insert the impingement.
MIs in higher sites.
If MIs are used as anchorage for the intrusion of the molars buccal
tipping of the molar crowns must be controlled, since the applied force DEEP BITE
has a vestibular component with respect to the CR of the molars (Fig. Most Class II malocclusions are characterized by a deep bite, which can
28.8). The following options are available: be managed by:
■ transpalatal bar between the first and/or the second molars (Fig. ■ distalization of the maxillary molars to Class I relationship: most
28.8A): easiest to use, provides symmetrical molar intrusion but the common approach
bar must be solid enough and avoid impinging on the soft tissue of ■ flattening of the curve of Spee, and in particular of the mandibular
the palate arch

A B

Fig. 28.8 Control of the buccal tipping of the molars. (A) Use of a transpalatal bar. (B) Use of miniscrew implants (MIs) in the inter-radicular spaces between the first and
second molars on the buccal and palatal sides. (C,D) Application of MIs and miniplates in the palatal vault to intrude the maxillary molars (C) and second premolars (D).
 The Spider Screw anchorage system 155

Fig. 28.9 The Self-ligating Miniscrew (A) and two types

of miniplate for linkage (B). (HDC, Sarcedo, Italy.)

A B

■ intrusion of the maxillary incisors, degree determined by their the wire carries a crimpable stop before being inserted into the round tube
visibility during speech and smiling of the molar band designed for housing the extraoral traction (see Fig.
■ extrusion of the molars. 28.7D). The amount of extrusion is controlled by making the step-down
equal to the level of extrusion desired.
Intrusion of the maxillary incisors is indicated only where there is a
“gummy” smile or excessive visibility of the maxillary anterior teeth
(>5 mm); otherwise intrusion of the mandibular incisors should be chosen.
REFERENCES
As this may not always completely resolve the problem, it is preferable to
extrude the molars in growing patients with a hypo- or normodivergent 1. Gianelly AA. Bidimensional technique: Theory and practice. New York: GAC Interna-
facial type. The mandibular rotation that follows is compensated by sub- tional; 2000.
sequent condylar growth and so correction of deep bite can be obtained 2. Maino BG, Bednar J, Pagin P, et al. The spider screw for skeletal anchorage. J Clin
Orthod 2003;37:90–7.
without excessive intrusion of the maxillary incisors and without damag- 3. Maino BG, Gianelly AA, Bednar J, et al. MGBM system: new protocol for Class II non
ing the patient’s profile.6,7 extraction treatment without cooperation. Prog Orthod 2007;8:130–43.
The MGBM system with MIs on the vestibular side allows effective 4. Park YC, Lee KJ. Biomechanical principles in miniscrew-driven orthodontics. In:
Nanda R, Uribe FA, editors. Temporary anchorage devices in orthodontics. St Louis,
extrusion of the molars with an auxiliary device. A bend in the archwire MO: Mosby-Elsevier; 2009.
(step-down) is added on the SS archwire between the second premolar and 5. Jung M, Kim T. Biomechanical considerations in treatment with miniscrew anchorage.
the first molar in order to control molar extrusion. A superelastic Ni-Ti Part I: The sagittal plane. J Clin Orthod 2008;42:79–83.
6. Bishara SE, Jakobson JR. Longitudinal changes in three normal facial types. Am J
wire (0.016 × 0.022 inch; 150 g) is inserted across the vertical slot of the Orthod 1985;88:466–502.
Spider Screw (0.018 inch); the rectangular wire must be prepared for entry 7. Sleichter CG. Effects of maxillary bite plane therapy in orthodontics. Am J Orthod
into the vertical slot by reducing its end and rounding it. The free end of 1954;40:450–70.
29 The miniscrew implant-supported
distalization system
Moschos A. Papadopoulos

INTRODUCTION THE ACTIVE UNIT

At the first appointment, bands are positioned on the first maxillary
In addition to osseointegrated orthodontic implants that provide stationary molars while an alginate impression is taken. The bands are transferred
anchorage, miniscrew implants (MIs) have been widely used clinically as to the corresponding cast (Fig. 29.1A) for soldering of headgear tubes
temporary anchorage devices to support orthodontic movements. The minis- (inner diameter, 0.040 inch) palatally to the molar bands. The edge of the
crew implant-supported distalization system (MISDS) was designed for the headgear tube extension opposite to the tube is trimmed prior to solder-
non-extraction treatment of Class II malocclusion in order to distalize maxil- ing to allow better contact with the bands. In order to force molars later
lary molars in an invisible, non-compliant and efficient way.1 on to slide on a line parallel to the dental arch, two pieces of straight
laboratory orthodontic wires (diameter, 0.040 inch) are attached with
THE MINISCREW IMPLANT-SUPPORTED plaster to the palate of the cast to run parallel to the occlusal plane at a
DISTALIZATION SYSTEM distance of 2–3 mm from the mucosa to attach to the headgear tubes.
This ensures that the tube extensions have proper contact with the bands
The MISDS comprises an active and an anchorage unit. The active unit (Fig. 29.1B). The tubes are then soldered to the molar bands using silver
uses apically positioned wire tubes, Ni-Ti open coil springs and stop solder (Fig. 29.1C,D). A horseshoe-type palatal arch is formed from
screws to provide the necessary force for molar distalization (Fig. 29.1F). straight orthodontic wire (0.040 inch) with two symmetrical closed loops
The anchorage unit uses MIs positioned in the paramedian region of the in the anterior region with their centers approximately 6–8 mm apart.
palate for supporting anterior anchorage (in order to resist the anteriorly These loops correspond to the insertion sites for the MIs. This palatal
oriented reciprocal forces produced by the coil springs during the first wire arch is checked on the cast for correct transversal dimension and
phase of molar distalization) and for supporting posterior anchorage during length (Fig. 29.1E).
the second phase of anterior teeth retraction. In contrast to conventional Two stop screws incorporating tubes (inner diameter, 0.040 inch) are
non-compliance devices (e.g. the Distal Jet or Keles Slider), spaces are inserted into the palatal arch from its distal end. The force module consists
created between all the posterior teeth rather than just between the maxil- of two pieces of open Sentalloy coil springs (inner diameter, 0.044 inch;
lary first molars and second premolars. This is because the premolars and approximate length, 15 mm) that are inserted into the palatal arch from its
canines are able to drift distally under the pull of the transeptal fibers distal ends following the insertion of the stop screws. The palatal archwire,
during the first phase of treatment. along with the two stop screws and the two coil springs, is inserted into
The force exerted by the coil springs passes almost through or very close the headgear tubes from their mesial aspects. Two additional stop screws
to the center of resistance of the maxillary molars, thus enabling an almost are inserted on the palatal archwire from its distal ends, which are then
pure bodily molar distal movement with little or no distal molar crown cut off so that the wires extend approximately 6–8 mm to allow distal
tipping. Because the molars are forced to slide on and are guided through movement of the maxillary molars. In order to control maximum distaliza-
the wire-tube system, which is palatally positioned and runs parallel to the tion of the molars, the distal ends of the palatal archwire are bent to form
maxillary occlusal plane, no rotation of these teeth is anticipated during small loops (Fig. 29.1F). This prevents the molars slipping out of the wire
distalization. for any reason.

Fig. 29.1 Fabrication of the appliance. (A) Maxillary

model cast with bands fitted on the first molars.
(B) Positioning of two pieces of straight laboratory
orthodontic wires on the palate through the
headgear tubes. (C,D) Soldering of the tubes with
the molar bands. (E) Positioning of the horseshoe-
type palatal archwire on the maxillary model cast.
(F) The miniscrew implant-supported distalization
A B C system after final adjustment and proper fitting on
the maxillary cast. (F, from Papadopoulos, 2008.1)

D E F

156
 The miniscrew implant-supported distalization system 157

THE ANCHORAGE UNIT Table 29.1 Cephalometric analysis during treatment

Two self-drilling and self-tapping MIs (diameter, 2 mm; length, 8–10 mm; Normal
Aarhus Mini-Implant System, Medicon, Tuttlingen, Germany) are used. Variables values T0 T1 T2
These are inserted paramedian in the anterior region of the palate, 3–9 mm Sagittal relationships
posteriorly to the incisive foramen and 1–6 mm from the midpalatal suture. SNA (°) 81.3 83.6 84.1 83.6
As the MIs will provide anchorage for both phases, the clinician needs to SNB (°) 78.8 77.5 77.4 77.5
ensure that they are positioned so that they will not be in contact with the Facial angle (°) 83.9 88.3 89.7 88.5
dental roots of the anterior teeth during their retraction. An initial clearance ANB (°) 2.5 6.1 6.8 6.1
of 7–10 mm from the roots of the anterior teeth to avoid any contact during Wits appraisal (FOP) (mm) 0 3.9 4.2 4.6
anterior teeth retraction is recommended. NA-APg (°) 3.1 10.4 12.7 10.5
H angle (°) 12.3 21.0 16.9 21.3
Vertical relationships
CLINICAL PROCEDURE SN-SGn (°) 66.0 67.4 68.6 68.3
SN-NL (°) 7.1 5.0 5.4 3.9
The MISDS and the MIs can be inserted at the same appointment. The SN-OcP (FOP) (°) 16.2 15.7 16.6 15.0
device is inserted in the patient’s mouth and the insertion postion for SN-ML (°) 32.3 30.7 31.5 31.3
the MIs is marked. The MIs are inserted using standard methodology. The Ar-Go-Me (°) 126.8 119.5 117.2 116.7
MISDS is cemented on the maxillary molars and then fixed to the MIs SGo : NMe (%) 65.5 66.9 66.7 66.9
with metallic ligatures (0.012 inch). To avoid plaque accumulation, a small Dental relationships
amount of resin is added to each loop of the palatal archwire with the ends 1s-NL (°) 112 114.4 113.7 106.7
of the ligature wires. The MISDS is activated immediately with a light 1i-ML (°) 92.5 104.8 103.5 107.3
load. The stop screws distal to the headgear tubes are screwed approxi- 1s-SN (°) 102 109.5 108.3 102.7
mately 5 mm to their distal aspect in order to prevent sliding of the tubes Lower incisor to A-Pg (mm) 1.4 2.4 1.4 2.5
out of the palatal archwire upon distalization. The patient is seen every 4 Interincisal angle (°) 131.9 115.0 116.7 118.7
weeks for further adjustments and reactivation of the appliance. The first Soft tissue relationships
maxillary molars usually take around 4–8 months to reach a Class I molar Nasolabial angle (°) 110.7 111.6 108.9 102.2
relationship. After molar distalization has been accomplished, the MISDS
is used following a simple modification to support posterior anchorage (i.e.
to retain maxillary molars in position) during the second phase of Class II T0, initiation of treatment; T1, after maxillary molar distalization; T2, after
completion of total orthodontic treatment.
treatement, including retraction of the anterior teeth and leveling and align-
ing the dental arches. This modification can be performed intraorally by
simply removing the coil springs and screwing the stop screws in a posi-
tion having contact with the mesial and distal aspects of each headgear
tube (see Fig. 29.2H). Because this procedure avoids anchorage loss of the towards counterclockwise rotation and an upward inclination of the palatal
posterior dental unit in terms of mesial movement of the maxillary molars, plane. The incisors were protrusive and proclined in relation to the anterior
it is only necessary to distalize the maxillary molars during phase one to cranial base and the mandibular plane. Soft tissue analysis showed a
a formal Class I relationship rather than a super-Class I. Following comple- normal value for the nasolabial angle.
tion of treatment, the resin on the archwire loops is removed and the liga- The patient did not want to wear any extraoral appliances and together
ture wires are cut before removal of the MISDS. The MIs are removed by with her parents requested full retraction of the maxillary anterior teeth
unscrewing the head of the MI. Local anesthesia may be needed only if without performing any extractions.
there is any tissue covering the MI. The treatment objectives were to distalize the first maxillary molars
bilaterally by means of the MISDS in phase one and then, in conjunction
with conventional full fixed orthodontic appliances, to retract and intrude
CASE PRESENTATION the anterior teeth in the second phase. This would improve the interincisal
angle relationship, achieve a stable, functional occlusion through the estab-
An 11-year-old girl was referred for the chief complaint of protruding lishment of a well-intercuspated bilateral Class I canine and molar rela-
anterior teeth. She had a symmetric face, a convex facial pattern with a tionship, and improve lip competence and facial balance.
deep labiomental sulcus and a retruded mandible, a Class II, division 1
malocclusion of between half to three-quarters cusp molar and canine
relationships, increased overjet (10 mm) and overbite (4 mm) and mild
Treatment
crowding of the anterior teeth. The maxillary midline was coincident with Two MIs were inserted and the MISDS was placed as described above.
the facial midline, while the mandibular midline deviated 2 mm to the left. The coil springs were compressed and the MIs loaded at the time of place-
She had permanent dentition with no missing teeth or caries and good oral ment. The patient was instructed to maintain optimal oral hygiene. Cepha-
hygiene (Fig. 29.2A,B). There were no disturbances in mandibular move- lometric radiography confirmed that the MIs had clearance of approximately
ments and she had normal temporomandibular joint function. 7–10 mm from adjacent dental roots.
Alveolar bone and root formation were within the normal limits. Cepha- The patient was monitored every 4 weeks. After 6 months, the first
lometric analysis of the lateral cephalometric radiographs using ViewBox maxillary molars were distalized to a Class I molar relationship (Fig.
version 3.1 (dHal, Athens, Greece) showed a skeletal Class II relationship 29.2C,D). Spaces were created between all the posterior teeth. A further 3
associated with a prognathic maxilla and a slightly retrognathic mandible months was allowed to enable the maximum drifting of the premolars and
(Table 29.1). She had an average growth pattern with a slight tendency canines (Fig. 29.2E,F). However, it did become clear that almost all the
 158 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C D

E F G H

I J K L

M N O P

Fig. 29.2 An 11-year-old girl with Class II malocclusion. (A,B) Immediately after insertion of the miniscrew implant-supported distalization system (MISDS). (C,D) After
molar distalization has been accomplished. Note the initial drifting of the premolars and canines. (E,F) Completion of drifting of the premolars and canines. (G,H) The
MISDS converted to a skeletally anchored horseshoe-type palatal arch and used with a conventional full fixed orthodontic appliance. (I,J) Initial leveling and alignment
completed. (K,L) Insertion of the SS retraction archwire. (M,N) Post-treatment. (O,P) Post-retention. (From Papadopoulos, 2008.1)

drifting took place in the first 6 months and so this second waiting period After 2 months, Ni-Ti archwires (0.016 × 0.016 inch) were used for
was actually not needed. further teeth alignment in both arches (Fig. 29.2I,J), and after a further
A further radiographic evaluation revealed that the MIs were still stable month SS archwires (0.016 × 0.022 inch) were used to finalize the align-
and able to provide the required anchorage from their current position, and ment in both arches and to retract the maxillary canines into a Class I
that there were no injuries to tooth roots. Only minimal non-significant relationship. Two months later (i.e. 14 months after initiation of treat-
cephalometric changes were seen (Table 29.1). ment), the teeth were fully aligned and a new SS retraction archwire
The second phase was commmenced by bonding a preadjusted edgewise formed individually with boot loops was used in the maxillary arch for
appliance with Roth’s prescription and 0.018 inch slot (Mini Master Series en masse retraction and intrusion of the anterior teeth over another 2
metallic and Silkon esthetic brackets; American Orthodontics, Sheboygan, months (Fig. 29.2K,L). The finishing phase used new SS archwires in
WI, USA) and a superelastic Ni-Ti wire (0.012 inch) was inserted for both maxillary and mandibular dental arches for final alignment of the
initial alignment of the teeth. The MISDS was converted simply by pulling teeth and detailing the occlusion.
out the coil springs on both sides and screwing the stop screws into a After 18 months of total treatment time, there was a good posterior
position with contact to the mesial and distal aspects of each headgear intercuspation and a well-functioning and stable occlusion (Fig. 29.2M,N).
tube. This creates a horseshoe-type transpalatal arch to provide the desired The MISDS and MIs were removed and a lingual fixed retainer was
stationary anchorage for anterior teeth retraction and intrusion in conjunc- bonded to the lingual surfaces of the lower anterior teeth extending from
tion with the conventional fixed appliances (Fig. 29.2G,H). In the second canine to canine. Maxillary retention was accomplished by means of a
phase, the MIs were providing indirect anchorage to reinforce the posterior removable acrylic retainer. The patient was instructed to wear the retainers
anchor teeth during anterior retraction. for 24 hours a day for 2 months and then at night only.
 The miniscrew implant-supported distalization system 159

Fig. 29.3 Superimposition of the cephalometric tracings on the

Before Tx anterior cranial base (A) and on the maxillary plane (B), at
After distalization
After Tx treatment start before appliance insertion (black), after active molar
distalization and subsequent drifting of the anterior teeth (red) and
after completion of treatment and removal of all appliances (blue).
(From Papadopoulos, 2008.1)

Before Tx
A B After distalization
After Tx

Two years and five months after the end of active treatment, the occlusal were distalized successfully in both groups but nearly bodily distalization
relationships and the facial appearance of the patient remained stable and was observed only in the MISDS group, whereas significant distal tipping
no relapse was evident (Fig. 29.2O,P). of the molars took place in the BAPA group. In addition, no statistically
significant changes in the sagittal position of the maxilla and mandible,
nor in the position of the maxillary incisors, were found in either group.
Discussion
The treatment results were within the initial treatment goals and both the
CONCLUSIONS
patient and her parents were very pleased with her final facial and dental
appearance (Fig. 29.2M,N) and because no extractions had been needed The case study presented in this chapter illustrates the effectiveness of the
and the girl did not need to wear any extraoral appliances or intermaxillary MISDS for treatment of Class II malocclusion with large overjet and
elastics. overbite. The MISDS was used in the first phase to support anterior
Treatment achieved a bilateral Class I molar and canine relationship anchorage during molar distalization and, in the second phase, to support
with optimal alignment of both maxillary and mandibular teeth, a well- posterior anchorage for retraction and intrusion of the anterior teeth with
intercuspated and stable occlusion and ideal overjet and overbite. The mild conventional full fixed orthodontic appliances.
crowding, the midline deviation and the medial diastema were also cor- Comparisions of lateral cephalometric radiographs confirmed that there
rected (Fig. 29.2M–P). were none of the unwanted effects of forward movement and proclination
Root parallelism was confirmed on the post-treatment panoramic radio- of the anterior teeth, and distal molar crown tipping or rotation, as seen
graph after debonding. Cephalometric analysis of the post-treatment lateral with conventional non-compliance appliances.
cephalometric radiograph after debonding showed maintenance of the Treatment time was about 18 months since drifting of teeth takes place
skeletal Class II relationship as well as the sagittal skeletal position of the in the first 6 months while the molars are being distalized. The MIs
maxilla and mandible (Table 29.1). There were no, or only minimal, changes remained stable despite being loaded with orthodontic forces continuously
in growth pattern and the upward inclination of the palatal plane. The maxil- for the full treatment period.
lary incisors were notably retracted while the mandibular incisors revealed The MIs must be inserted sufficiently far from roots of the adjacent teeth
a slight labial inclination. The interincisal angle was also slightly increased. and safely placed to avoid any contact with the roots of the anterior teeth
Finally, soft tissue analysis showed a decrease of the nasolabial angle. during the second phase of treatment.
Superimposition of the cephalometric tracings shows the changes that The MISDS system has a number of advantages:
occurred during treatment (Fig. 29.3). In total, there was a slight downward
and forward positioning of the mandible due to normal growth (Fig. ■ it does not require patient cooperation
29.3A). After maxillary molar distalization, a pure bodily distal movement ■ it is not visible for the initial 4–6 months during maxillary molar
of the first maxillary molar with a slight extrusion, but without distal distalization
tipping or extrusion, was evident, while no side effects of the “conven- ■ it can be used unilaterally
tional” non-compliance distalization appliances (i.e. forward movement ■ it is simple to adjust for the specific needs of the individual patient
and proclination of the anterior teeth and distal molar crown tipping) were ■ it uses MIs for temporary and stationary anchorage to support both
present (Fig. 29.3B). There was also a minimal distal movement and slight molar distalization and the subsequent anterior teeth retraction
extrusion of the maxillary anterior teeth, which may reflect normal growth ■ molar distalization occurs without distal tipping and/or rotation of
and remodeling of the maxillary alveolar bone. Further, after the comple- molar crowns and without mesial movement and proclination of the
tion of orthodontic treatment, the maxillary anterior teeth were retruded anterior teeth
substantially without anchorage loss of the posterior teeth (i.e. mesial ■ the whole treatment can be provided chair-side.
movement of the maxillary molars) (Fig. 29.3B).
These results were confirmed in a recent clinical trial that compared the REFERENCES
skeletal, dental, and soft tissue effects of the MISDS and the bone-anchored
Pendulum appliance (BAPA) using lateral cephalometric radiographs that 1. Papadopoulos MA. Orthodontic treatment of Class II malocclusion with miniscrew
implants. Am J Orthod Dentofacial Orthop 2008;134:604, discussion 604–5.
were taken on the day of the insertion of the appliances and immediately 2. Şar C, Kaya B, Ozsoy O, et al. Comparison of two implant-supported molar distaliza-
after maxillary molar distalization was acomplished.2 The maxillary molars tion systems. Angle Orthod 2013;83:460–7.
 30 The Advanced Molar Distalization Appliance
Moschos A. Papadopoulos

length, 10–12 mm; outer diameter, 3 mm) and an inner tube (approximate
INTRODUCTION
length, 8–10 mm; outer diameter, 2.3 mm). Compressed Ni-Ti open coil
A number of systems have been developed to use miniscrew implants springs encased in each tubing system deliver a distalization force of
(MIs) as temporary anchorage devices to support orthodontic movements. approximately 300–350 g when fully activated. Two stop screws are incor-
Chapter 29 describes one such system, the miniscrew implant-supported porated in the tubing system, one at the mesial end of the inner tube and
distalization system (MISDS). While this system has many advantages, another at the distal end of the outer tube. Activation or deactivation of
one disadvantage is the laboratory work needed for the fabrication of the the force system takes place by screwing or unscrewing these stop screws.
appliance, and the consequent increased cost of treatment and delay in In addition, an SS extension wire (diameter, 0.9 mm; approximate total
initiating treatment. height, 10 mm) is attached to the external surface of the outer tube. It has
This chapter describes a novel MI-supported device, the Advanced an S-shape to allow height adjustment. The wire has a transpalatal type of
Molar Distalization Appliance (AMDA), that has all the advantages of the ending (similar to a conventional transpalatal arch [TPA]) to facilitate
MISDS but eliminates the need for laboratory work. The AMDA can be insertion of the appliance into the lingual sheaths of conventional ortho-
used for the efficient, invisible, non-compliant bilateral or unilateral dis- dontic bands cemented on the maxillary first molars.
talization of maxillary molars (Fig. 30.1), as well as in conjunction with The single tubing system version used for unilateral maxillary molar
full fixed appliances for the subsequent retraction of the anterior teeth.1 distalization (Fig. 30.1C) has an almost straight palatal archwire with one
anterior loop for the insertion of a single MI, with an additional SS wire
extension (diameter, 0.9 mm) soldered approximately 2 mm distal to the
THE ADVANCED MOLAR DISTALIZATION APPLIANCE anterior loop and bonded to the occlusal surface of the first premolar for
dental anchorage to avoid any rotational movements of the system during
The AMDA (available soon by Dentaurum, Ispringen, Germany) is a unilateral distalization.
prefabricated device anchored to the palate by MIs (Fig. 30.1A),2 and Alternatively, for unilateral molar distalization a conventional AMDA
comprising: relying only on skeletal anchorage can be used. In this case from the two
bilateral tubing systems of AMDA only one is activated (Fig. 30.1B).
■ a tubing system with encased compressed nickel-titanium (Ni-Ti)
open coil springs to provide the necessary distalization force; in the
conventional form this is used on both sides of the dental arch but THE HORSESHOE-TYPE ARCHWIRE
can be activated unilaterally if needed The horseshoe-type SS archwire (diameter, 0.9 mm) is positioned on the
■ conventional orthodontic bands on maxillary first molars equipped palate at a distance of 1–2 mm from the mucosa and runs inside the inner
with lingual sheaths tube of the tubing system (Fig. 30.1). The archwire is positioned approxi-
■ a horseshoe-type palatal archwire mately 10 mm apically to the occlusal surfaces of the maxillary molars,
■ a palatal anchorage unit. thus passing through or very close to their centers of resistance in order
The design of the appliance unit and the use of palatal MIs to provide to facilitate an almost pure bodily molar distalization. Its position parallel
temporary and stationary anchorage for all phases of treatment avoids the to the occlusal plane forces the maxillary molars to slide on it and guides
unwanted problems of conventional non-compliance devices (see Chapter them distally without, or with minimal, rotation. Two symmetrical closed
2) such as molar rotation or distal crown tipping and forward movement loops (or in a later version two movable metallic rings) are attached to the
and proclination of the anterior teeth. In contrast to conventional non- archwire to indicate the insertion sites for the MIs, as well as to secure the
compliance devices, spaces are created between all the posterior teeth appliance onto the MIs.
rather than just between the maxillary first molars and second premolars.
This is because the premolars and canines are able to drift distally under
the pull of the transeptal fibers, which also shortens overall treatment time.
THE ANCHORAGE UNIT
Two self-drilling and self-tapping MIs (suggested diameter 2 mm and
length 8–10 mm) are used to anchor the AMDA and to resist the reciprocal
THE TUBING SYSTEM
forces during molar distalization and anterior teeth retraction. The MIs
The tubing system (Fig. 30.1) runs on a horseshoe-type archwire and should have collars of varying lengths to allow a suitable size to be chosen
consists of two tubes sliding one into the other: an outer tube (approximate for the individual’s width of palatal mucosa. The MIs are placed in the

Fig. 30.1 The Advanced Molar Distalization

Appliance (AMDA). (A) The horseshoe-type palatal
archwire with the tubing systems for bilateral use.
(B) The conventional AMDA for unilateral use relying
only on skeletal anchorage with bilateral tubing
systems of which only one is activated. (C) A single
tubing system for unilateral use using both dental
and skeletal anchorage. (A from Papadopoulos,
2010,1 with permission of Bentham Science.)
A B C

160
 The Advanced Molar Distalization Appliance 161

paramedian region of the palate 3–6 mm from the midpalatal suture and Patients are given clear instructions on how to maintain oral hygiene.
3–6 mm posterior to the incisive foramen. The insertion of the two MIs at They are monitored every 4 weeks for hygiene, for the stability of the MIs,
a distance of 3–6 mm posterior to the incisive foramen provides a safety and for further adjustments and reactivation of the appliance. Reactivation
clearance of approximately 7–10 mm between the MIs and the dental roots occurs by unscrewing the mesial stop screw, moving the anterior part of
of the anterior teeth (depending on the root inclination of these teeth). This the tubing system more distally, thus squeezing the encased coil springs,
avoids contact of the MIs and these teeth during molar distalization, and, and then rescrewing the stop screws in the new position. Any tendency for
more importantly, during anterior teeth retraction. rotation of the maxillary molars can be countered by bending the wire
extensions of the transpalatal archwire extensions welded to the tubing
systems.
A treatment period of 4–8 months is usually needed for distalization of
CLINICAL PROCEDURE the first maxillary molars into a Class I molar relationship.
PHASE ONE: MOLAR DISTALIZATION
PHASE TWO: ANTERIOR TEETH RETRACTION
The AMDA and MIs can be inserted in a single appointment by the ortho-
dontist. Normal full infection control measures similar to those for extrac- The AMDA is easily converted to a passive skeletally anchored horseshoe-
tions should be used, including sterilization of the MI kit. type palatal arch providing indirect anchorage for the posterior teeth
Conventional orthodontic molar bands with lingual sheaths are cemented during a second phase of treatment to retract the anterior teeth and level
on the maxillary first molars. The AMDA is prefabricated and so some and align the dental arches using a full fixed appliance. For this purpose,
individual adjustments are only necessary, which can be carried out either the distal stop screws are tightened to prevent any further molar distal
directly in the patient’s mouth or indirectly on the initial maxillary cast. movement and the mesial stop screws are moved distally and screwed in
The palatal archwire extensions are inserted in the lingual sheaths of the this position again, totally squeezing the coil springs encased in the tubing
molar bands. Once the parallel positioning of the appliance and its width systems. This retains the first maxillary molars in their new positions and
and height have been checked, the mesial stop screws are moved distally allows them to become the anchors to support the subsequent retraction
to fully compress the coil spring encased in the tubing system and the distal of the anterior teeth.
stop screws are screwed in place to stabilize the tubing systems on the In some cases, such as when the first maxillary molars are already
archwire. rotated prior to the initiation of orthodontic treatment and the second
The final length of the palatal archwire is determined by marking its molars are already erupted, rotation of first maxillary molars cannot be
distal ends with a pencil, leaving approximately 8–10 mm extending out totally avoided during the active distalization phase through bend adjust-
of the distal screw. With the appliance removed from the patient’s mouth, ments of the transpalatal archwire extensions of the tubing systems. In
the distal ends are cut off at the mark and a bend or loop is formed on these cases the AMDA and the MIs are removed after retraction of the
each distal end to act as mechanical stop to prevent any distalization of anterior teeth and, since there is no more need to support molar anchorage,
the molars beyond this point and to avoid any tissue irritation. Alterna- a TPA is used until completion of treatment to correct this rotation.
tively or in addition, a small amount of light-cured resin can be added to
the ends to ensure that the molars cannot slip out of the wire. REMOVAL OF THE APPLIANCE
The appliance is then inserted into the patient’s mouth, ensuring that it
is parallel to the occlusal plane and the two symmetrical loops are 3–6 mm The MIs are removed by unscrewing the head of the MI. Local anesthesia
posterior of the incisive foramen. The wire extensions welded on the may be needed if there is any tissue covering the MI. The AMDA is
tubing systems are inserted into the lingual sheaths of the molar bands and removed by cutting the SS ligature wires that secure the transpalatal wire
secured in position with SS ligature wires. extensions to the lingual sheaths of the molar bands. The AMDA can then
MIs with appropriate collar length are inserted through the loops using be removed from the sheaths in the normal way. Debonding of the con-
the normal procedure. The head of the MI should be wider than the diameter ventional fixed orthodontic appliances (bands and brackets) and cleaning
of the loops to provide the appropriate stability to the system. However, in procedures are performed as usual.
some cases, fixing of the AMDA with the MIs through SS ligature wires
(diameter, 0.012 inch) might be necessary, particularly when MIs with
CLINICAL APPLICATIONS
smaller head dimensions are used. In some cases, SS ligature wires of a
smaller diameter (0.012 inch instead of 0.040 inch) might be needed if the The AMDA can be used efficiently for the comprehensive treatment of
chosen MIs have smaller heads. A small portion of light-cure resin can be Class II malocclusion. The following two case studies illustrate its use for
added to cover the top of each implant head plus the endings of the ligature bilateral and unilateral maxillary molar distalization.
wires and the loops of the palatal archwire to avoid plaque accumulation.
The AMDA can be loaded immediately with light orthodontic forces by
unscrewing the distal screws to allow free distal sliding of the posterior CASE 1: BILATERAL MAXILLARY
part of the tubing system and thus distal movement of the maxillary MOLAR DISTALIZATION
molars. The mesial stop screws of the tubing systems (which are already
moved and fixed distally) are not altered and so the compressed coil A 12-year-old girl was referred with a chief complaint of protrusion of the
springs can begin to exercise their distalizing force. Distal movement of upper anterior teeth. She had a symmetric face and a convex facial profile
the maxillary molars can be enhanced through disocclusion of the posterior with protruded lips, a retruded mandible and increased overjet (6 mm) and
teeth using lower acrylic splints with posterior bite blocks or cemented overbite (5 mm). She had permanent dentition, with the second permanent
build-ups. molars erupted, no caries and good oral hygiene. Both maxillary first
Lateral cephalometric radiography can be used to check the installation molars, particularly the left one, were mesially rotated. Occlusal analysis
immediately after placement, at the end of phase one and at a completion revealed a Class II, division 1 malocclusion, with bilateral Class II molar
of treatment. relationships: three-quarters cusp on the right and full cusp on the left. She
 162 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Table 30.1 Cephalometric analysis during treatment

Treatment
Normal Two MIs were placed in the paramedian region of the palate and the
Variables values T0 T1 T2 T3 AMDA fitted; it was activated and correct placement confirmed radio-
Sagittal relationships graphically as described above (Fig. 30.2A,B). Since both first and second
SNA (o) 82.1 84.5 85.8 87.9 84.2 molars had to be moved simultaneously, and in order to enhance distal
SNB (o) 80.2 80.3 78.9 79.7 79.7 movement of these teeth, a removable acrylic splint with posterior bite
Facial angle (o) 85.6 94.7 94.5 91.5 93.4 blocks was also inserted to disocclude the posterior teeth. The patient was
ANB(o) 1.9 4.2 6.9 8.2 4.5 instructed to wear this splint 24 hours a day including meals and to remove
Individual ANB(o) 5.1 6.1 6.9 5.3 it only for cleaning.
NA-APog (o) 0.4 10.2 14.2 16.9 8.6 After 4 months, the splint with bite blocks was removed as the maxillary
H angle (o) 11.3 17.4 10.9 21.7 20.2 molar cusps no longer interfered with the mandibular molar cusps.
Vertical relationships After 7 months, both first and second maxillary molars were distalized
SN-SGn (o) 65.3 64.1 66.2 65.4 65.1 bilaterally and the first maxillary molars had a Class I molar relationship
SN-NL (o) 6.8 4.8 5.7 5.5 4.1 (Fig. 30.2C,D). The maxillary premolars and canines had also drifted to
SN-ML (o) 29.8 32.2 34.8 34.7 33.9 an almost Class I relationship. Further radiographic evaluation confirmed
Ar-Go-Me (o) 124.4 135.8 132.3 137 136.2 that the MIs were stable and would not interfere with retraction of the
SGo : NMe × 100 (%) 68.2 64.5 62.9 63.5 63.7 anterior teeth.
Dental relationships
The second phase was commenced by bonding a preadjusted edgewise
appliance with Roth’s prescription and 0.018 inch slot (Silkon esthetic
1s-NL (o) 112 122.4 115.6 106.9 110.8
1i-ML (o) 92.7 94.5 92.2 95.1 98.7
brackets; American Orthodontics, Sheboygan, WI, USA), and a Ni-Ti
1s-SN (o) 104 117.6 109.9 101.3 106.7
archwire (0.012 inch) was inserted for initial alignment of the teeth (Fig.
Lower incisor to A-Pg 1.2 4.1 2.6 3.8 5.3 30.2E). The AMDA was converted to a horseshoe-type TPA as described
(mm) above (Fig. 30.2F).
Interincisal angle (o) 132.3 117.6 123.1 128.9 120.7 After another month, Ni-Ti wires (0.016 inch) were used for teeth align-
Soft tissue ment in both arches. Two months later, Ni-Ti archwires (0.016 × 0.016 inch)
relationships were placed and elastic chains were also inserted on the maxillary arch in
Nasolabial angle (o) 112 93.2 105.3 99.8 99.7 order to start the en masse retraction of the maxillary anterior teeth. One
month later, SS archwires (0.016 × 0.016 inch) were inserted to further
align both dental arches and for the continuation of the en masse retraction
T0, initiation of treatment; T1, after maxillary molar distalization; T2, after
completion of anterior teeth retraction; T3, immediately after completion of total of the maxillary anterior teeth. After a further month (i.e. 12 months after
orthodontic treatment. initiation of treatment), the retraction of the anterior teeth was completed
(Fig. 30.2G,H).
At that time, a slight increase in mesial rotation of the maxillary first
had spaces in her upper anterior teeth, which were also proclined, and there molars was observed despite adjustment of the transpalatal-type wire
was a mild crowding in the lower anterior teeth. Maxillary midline was extensions of the AMDA during treatment. Therefore, it was decided to
coincident with the facial midline, while the mandibular one deviated remove the AMDA and the MIs and insert a TPA to correct the
2 mm to the left. rotations.
Functional analysis revealed no disturbances of mandibular movements After 3 months, the molar rotation had been corrected and SS archwires
and normal temporomandibular joint function. (0.016 × 0.016 inch) with reverse curves of Spee and asymmetric elastics
The initial panoramic radiograph showed that the third molars were were inserted to fully align the dental arches, correct the midline deviation
present, no teeth were missing and alveolar bone and root formation and further correct the deep bite (Fig. 30.2I,J). Four months later, new SS
were within normal limits. Cephalometric analysis of the lateral cephalo- archwires were used for final alignment of the teeth and detailing the
metric radiographs using ViewBox version 3.1 (dHal, Athens, Greece) occlusion.
showed skeletal Class II relationships associated with a prognathic The fixed appliances were removed 5 months later (i.e. after 24
maxilla and an orthognathic mandible (Table 30.1). Analysis of vertical months of total treatment time), following establishment of a nice posterior
skeletal relationships showed a slight tendency towards a vertical growth intercuspation and a well-functioning and stable occlusion (Fig. 30.2K,L).
pattern with a corresponding clockwise rotation of the mandible and an After debonding, a lingual fixed retainer was bonded to the mandibular
upward inclination of the palatal plane. Analysis of dental relationships anterior teeth extending from canine to canine. Maxillary retention was
revealed protrusive incisors, as well as proclination of the upper and accomplished by means of a removable acrylic retainer. The patient was
lower incisors in relation to the anterior cranial base and the mandibular instructed to wear the retainer 24 hours a day for 2 months and then at
plane, respectively. Finally, soft tissue analysis showed a decreased night only.
nasolabial angle.
The patient did not want to wear any extraoral appliances and
Treatment Results
together with her parents requested orthodontic treatment without any
extractions. The treatment results were within the initial treatment goals and both the
The treatment objectives were to distalize the first maxillary molars patient and her parents were very pleased with her final facial and dental
bilaterally and then to correct overjet and overbite by retracting and intrud- appearance (Fig. 30.2K,L) and because treatment did not involve extraoral
ing the maxillary anterior teeth, to improve the interincisal angle relation- appliances, intermaxillary elastics or extractions. Treatment took 24 months
ship, correct the midline deviation and achieve a stable, functional and achieved a bilateral Class I molar and canine relationship with optimal
occlusion as well as improve lip competence and facial balance. alignment of both maxillary and mandibular teeth, a well-intercuspated and
 The Advanced Molar Distalization Appliance 163

A B C D

E F G H

I J K L

N O

M P

Fig. 30.2 Case 1: unilateral maxillary molar distalization. (A,B) Pretreatment views immediately after insertion of the Advanced Molar Distalization Appliance (AMDA).
(C,D) Molar distalization completed. Note the initial drifting of the premolars and canines. (E,F) Insertion of conventional full fixed orthodontic appliances and conversion
of the AMDA to a skeletally anchored horseshoe-type transpalatal arch. (G,H) Retraction of the maxillary anterior teeth. (I,J) Correction of molar rotation. (K,L) At end of
treatment following removal of the fixed appliances. (M,N) Superimposition of the cephalometric tracings to show changes from before treatment start (black line) to end
of active molar distalization (blue line) on the anterior cranial base (M) and the maxillary plane (N). (O,P) Superimposition of the cephalometric tracings on the maxillary
plane to show changes from after active molar distalization (black line) to retraction of the maxillary anterior teeth (red line) (O) and from after retraction of the maxillary
anterior teeth (blue line) to completion of treatment and removal of all appliances (black line) (P). (A–G from Papadopoulos, 2010,1 with permission of Bentham Science.)

stable occlusion and ideal overjet and overbite. The mild crowding, the retraction of the anterior teeth, the maxillary molars, which served as
midline deviation and the medial diastema were also corrected (Fig. anchors during this phase, remained almost totally stable, while the ante-
30.2K,L). Root parallelism was confirmed radiographically. rior teeth retruded substantially. Skeletal Class II relationships were main-
tained as were the sagittal skeletal positions of the maxilla and mandible
Cephalometric Analysis after Distalization
(Table 30.1). There was a slight increase in vertical growth pattern. The
After distalization, the first maxillary molars were moved almost bodily maxillary incisors were notably retracted, while the mandibular incisors
without distal tipping, while the anterior teeth did not procline at all; had a slight lingual inclination. The interincisal angle was also signifi-
instead they were slightly retruded. Further, during the subsequent cantly increased. There was an increase in nasolabial angle.
 164 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Superimposition of the cephalometric tracings on the anterior cranial Table 30.2 Cephalometric analysis during treatment
base from before treatment start and after active molar distalization (and
Normal
subsequent passive drifting of the anterior teeth; Fig. 30.2M) showed a
Variables values T0 T1 T2
slight downward positioning of the mandible due to movement of maxil-
lary molars into a more distal position, forcing the bite to open. The cor- Sagittal relationships
responding superimposition on the maxillary plane (Fig. 30.2N) showed SNA (o) 82.1 84.3 83.2 83
a pure bodily distal movement of the first maxillary molars with a slight SNB (o) 80.2 80.6 79.7 81.8

extrusion but without distal tipping, as well as slight retrusion and extru- Facial angle (o) 85.6 96 95.4 99.2
ANB(o) 1.9 3.7 3.5 1.2
sion of the anterior teeth.
Individual ANB(o) 4.8 4.4 4.1
Cephalometric Analysis after Anterior Teeth Retraction NA-APog (o) 0.4 5.5 4.1 −0.5
H angle (o) 11.3 17.9 17.4 15.9
A comparison of the situation after the anterior teeth retraction phase with
Vertical relationships
that at the end of molar distalization showed maintenance of the skeletal
SN-SGn (o) 65.3 65.2 65.7 64.2
Class II relationships, while both the maxilla and mandible were moved
SN-NL (o) 6.8 9.4 6.7 4.8
slightly anteriorly (Table 30.1). Vertical growth pattern remained almost
SN-ML (o) 29.8 31.1 31.4 30.1
stable. The maxillary incisors were further retracted, while the mandibular
Ar-Go-Me (o) 124.4 116.6 122.8 123.5
incisors had a slight labial inclination. The interincisal angle was also SGo : NMe X 100 (%) 68.2 65.4 66.7 67.8
significantly increased. Soft tissue analysis showed a decrease in the
Dental relationships
nasolabial angle. Trace comparisons confirmed that the first molars
1s-NL (o) 112 110.3 111.6 116
remained stable in position while the anterior teeth were retracted and
1i-ML (o) 92.7 96 96.7 102.5
slightly extruded (Fig. 30.2O).
1s-SN (o) 104 100.9 104.8 111.3
Lower incisor to 1.2 0.3 0.4 1.8
Cephalometric Analysis at End of Treatment A-Pg (mm)
A comparison of the final result with that before treatment start showed Interincisal angle (o) 132.3 132 127.2 116.1
maintenance of the skeletal Class II relationships as well as of the sagittal Soft tissue relationships
skeletal positions of the maxilla and mandible (Table 30.1). There was a Nasolabial angle (o) 112 101.6 100.5 101.8
slight increase in vertical growth pattern, the maxillary incisors were sig-
nificantly retracted, the mandibular incisors slightly proclined and the
T0, initiation of treatment; T1, after maxillary molar distalization; T2, immediately
interincisal angle was slightly increased. Finally, there was an increase in after completion of total orthodontic treatment.
nasolabial angle.
Superimposition of the cephalometric tracings on the maxillary plane while the interincisal angle was normal. Finally, there was a decreased
after anterior teeth retraction and after completion of treatment revealed nasolabial angle.
that the position of the first molars remained unchanged, while the anterior The patient and his parents wanted a treatment plan that did not involve
teeth were further intruded and slightly retruded (Fig. 30.2P). extraoral appliances or extractions.
The treatment objectives were to distalize the right first maxillary molar
into a Class I relationship, to maintain the Class I relationship of the left
CASE 2: UNILATERAL MAXILLARY first molars and then to correct the crossbite between the right upper and
MOLAR DISTALIZATION lower lateral incisors, the anterior crowding in both arches and the midline
deviation, plus to achieve a stable, functional occlusion by establishing a
A 14-year-old boy was referred with a complaint of a crossbite by the well-intercuspated bilateral Class I molar and canine relationship.
upper right lateral incisor. He had a symmetric face and a slightly convex
facial profile. He had a complete permanent dentition with the second
Treatment
permanent molars already erupted in both arches, good oral hygiene and
no caries. Occlusal analysis revealed a one-half cusp Class II molar rela- Treatment was started with the placement of the single-tube configuration of
tionship on the right and a Class I on the left side. There was a crossbite AMDA (Fig. 30.1C) on the right side of the palate. Skeletal anchorage was
between the right upper and lower lateral incisors, a normal overjet of provided by a single MI inserted through the anterior loop of the AMDA,
6 mm, an overbite of 3 mm and a slight maxillary midline deviation of while additional dental anchorage was provided by bonding the extension
1 mm to the left. In addition, there was 3 mm crowding on the maxillary wire on the occlusal surface of the right maxillary first premolar (Fig.
anterior teeth and a mild crowding on the mandibular anterior teeth. Func- 30.3A,B). The AMDA was activated and correct placement confirmed
tional analysis revealed no disturbances of the mandibular movements and radiographically, as described above. Light-cured resin was applied to the
normal temporomandibular joint function. top of the implant head to avoid plaque accumulation.
The initial panoramic radiograph showed that the third molars were A removable acrylic splint with posterior bite blocks was also inserted
present, and no teeth were missing. Cephalometric analysis of the pretreat- to disocclude the posterior teeth in order to enhance simultaneous distal
ment lateral cephalometric radiograph showed skeletal Class I relation- movement of the first and second molars and to facilitate correction of the
ships associated with a slight prognathic maxilla and an orthognathic crossbite of the right maxillary lateral incisor (Fig. 30.3C). The patient was
mandible (Table 30.2). There was a slight tendency towards a vertical instructed to wear this splint 24 hours a day including meals, and to remove
growth pattern with a corresponding clockwise rotation of the mandible it only for cleaning.
and a downward inclination of the palatal plane. There was also a slight After 3 months, the extension wire bonded on the occlusal surface of
retroclination of the upper incisors in relation to the anterior cranial base the right maxillary first premolar was cut in order to facilitate distal drifting
and proclination of the lower incisors in relation to the mandibular plane, of the right first premolar and canine (Fig. 30.3D). During the following
 The Advanced Molar Distalization Appliance 165

A B C D

E F G H

I J K L

+ +

+
M N +
+

O Q

P
Fig. 30.3 Case 2: unilateral maxillary molar distalization. (A,B) Immediately after insertion of the unilateral Advanced Molar Distalization Appliance (AMDA). (C,D) After
extension wire bonded on the occlusal surface of the first premolar. (E,F) After unilateral molar distalization has been completed. Note the initial drifting of the premolars
and canines and the labial movement of the lateral incisor. (G,H) Insertion of conventional full fixed orthodontic appliance on the maxillary arch and conversion of the
unilateral AMDA to a passive skeletal anchored device. (I,J) Insertion of conventional full fixed orthodontic appliance on the mandibular arch. (K,L) Following removal of
the fixed appliances. (M,N) One year after the removal of the fixed appliances. (O,P) Superimposition of the cephalometric tracings to show changes from before
treatment start (black line) to end of active molar distalization (blue line) on the anterior cranial base (O) and the maxillary plane (P). (Q) Superimposition of the
cephalometric tracings on the maxillary plane before treatment (black line), after molar distalization (blue line) and after completion of treatment (red line).
 166 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

appointments, spontaneous drifting of the right premolars and canines were unaffected on the contralateral side. The crossbite between the upper
could be seen plus spontaneous opening of the space between the right and lower right lateral incisors, the midline deviation and the anterior
maxillary canine and central incisor, proclination of the right lateral incisor crowding were also corrected, while an optimal alignment of both maxil-
and spontaneous correction of the crossbite. lary and mandibular teeth, and a well-intercuspated and stable occlusion
Seven months after start of treatment, the tip of the right maxillary were obtained. Ideal overjet and overbite were also achieved (Fig. 30.3K,L).
lateral incisor was positioned slightly more labially to the tip of the right There was a great improvement in the patient’s smile and facial esthetics.
mandibular lateral incisor and the crossbite had vanished. The cusps of his Root parallelism was confirmed radiographically.
posterior maxillary teeth no longer interfered with those of the mandibular
teeth. The lower splint with the posterior bite blocks was removed. Cephalometric Analysis after Distalization
After a further month, both right first and second maxillary molars were
After distalization, the right first maxillary molar had moved almost bodily
distalized while the first maxillary molars presented a Class I molar rela-
without distal tipping, while the anterior teeth did not procline at all;
tionship on both sides (Fig. 30.3E,F). The maxillary premolars and canines
instead they were very slightly retruded. During the subsequent phase of
had also drifted distally, the space for the right lateral incisor was enlarged
distal movement of the right maxillary canines and premolars, the maxil-
and the spontaneous labial movement and proclination of the lateral incisor
lary molars, which served as anchors, and the anterior teeth remained
was further improved.
almost totally stable.
Further radiographic evaluation confirmed that the MIs were stable and
Skeletal Class I relationships and the sagittal skeletal positions of the
would not interfere with retraction of the anterior teeth.
maxilla and mandible were maintained (Table 30.2). There was a slight
Eight months after start of treatment the molar relationship was Class
decrease of the vertical growth pattern, moving close to average values.
I; distal drifting of the right premolars and canines had occurred and the
The inclination of maxillary incisors was slightly increased towards labial,
anterior crossbite was slightly corrected. A fully bonded preadjusted edge-
while the inclination of the mandibular incisors remained almost unaf-
wise appliance with Roth’s prescription and 0.018 inch slot (Mini Master
fected. The interincisal angle was slightly decreased. There was a slight
Series metallic and Silkon esthetic brackets, American Orthodontics) and
decrease in nasolabial angle.
a Ni-Ti archwire (0.012 inch) was inserted for initial alignment of the teeth
Superimposition of the cephalometric tracings on the anterior cranial
(Fig. 30.3G,H). The AMDA was converted to a passive skeletal anchorage
base from before treatment start and after active molar distalization (Fig.
device as described above.
30.3O) showed a slight downward positioning of the mandible resulting
One month later, a Ni-Ti archwire (0.016 inch) was inserted on the
from the movement of maxillary molars to a more distal position, forcing
maxillary dental arch, and after another month (i.e. 10 months after initia-
the bite to open. The corresponding superimposition on the maxillary plane
tion of treatment) the AMDA and MIs were removed and a Ni-Ti archwire
(Fig. 30.3P) revealed a pure bodily distal movement of the right first maxil-
(0.016 × 0.016 inch) was inserted for further alignment of the maxillary
lary molar without distal tipping, as well as a slight retrusion and extrusion
dental arch.
of the anterior teeth.
Eleven months after treatment start, the lower dental arch was bonded,
a Ni-Ti archwire (0.012 inch) was inserted for initial alignment in the Cephalometric Analysis at End of Treatment
lower arch, and a SS archwire (0.016 × 0.016 inch) was inserted in the
upper arch (Fig. 30.3I,J). At that point, the slight mesial rotation of the A comparison of the final result with that before treatment start showed
right maxillary first molar had been corrected. strengthening of the skeletal Class I relationships, maintenance of the
Two months later, a Ni-Ti archwire (0.016 × 0.016 inch), and after sagittal skeletal position of the maxilla and a slightly more forward posi-
another month a SS archwire (0.016 × 0.016 inch) were used for further tion of the mandible (Table 30.2). There was a further decrease of the
alignment of the lower dental arch. vertical growth pattern towards average. The inclination of maxillary and
Fifteen months after initiation of treatment, SS archwires (0.016 × mandibular incisors was slightly increased towards labial, while the inter-
0.016 inch) with reverse curves of Spee were inserted to fully align both incisal angle was decreased. The nasolabial angle was maintained.
dental arches and detail the occlusion. Superimposition of the cephalometric tracings on the maxillary plane
The fixed appliances were removed 5.5 months later (i.e. 20.5 months after molar distalization and after completion of treatment showed that
from treatment start). The anterior crossbite had been corrected and a good the position of the first molars and the anterior teeth remained unaffected
posterior intercuspation and a well-functioning and stable occlusion had (Fig. 30.3Q).
been established (Fig. 30.3K,L).
After debonding of the fixed appliances, a lingual fixed retainer was
bonded to the mandibular anterior teeth extending from canine to canine.
CONCLUSIONS
Maxillary retention was accomplished with a removable acrylic retainer.
The construction and application of the AMDA is based on careful con-
The patient was instructed to wear the retainer 24 hours a day for 2 months
sideration of the issues related to the use of non-compliance distalization
and then only at night. The patient followed these recommendations and
appliances with orthodontic implants. Features include:
18 months after debonding his occlusal relationships as well as his facial
appearance remained stable with no evident relapse (Fig. 30.3M,N). ■ use of self-drilling and self-tapping MIs to make insertion easier for
the patient and a process that can be carried out by the orthodontist
■ MI dimensions of 2 mm diameter and 8–10 mm length to give ideal
Treatment Results
stability
The treatment results were within the initial treatment goals and both the ■ MIs with varying collar length to allow a choice of length to suit
patient and his parents were very satisfied with his final facial and intraoral the patient’s mucosal thickness
(Fig. 30.3K,L) appearance, particularly because this had been achieved ■ two MIs to provide effective skeletal anchorage
without extraoral appliances or extractions. ■ the paramedial region of the palate (3–6 mm from the midpalatal
Treatment took 20.5 months to achieve a Class I molar and canine rela- suture and 3–6 mm posterior to the incisive foramen) as the safest
tionship on the right side of the maxillary dental arch, while relationships site for MI insertion
 The Advanced Molar Distalization Appliance 167

■ a palatal force system with the line of force application passing as ■ no anchorage loss of the molars is anticipated during anterior teeth
close as possible to the center of resistance of the maxillary molars retraction
■ the open Ni-Ti coil springs encased in the tubing system to reduce ■ can be used bilaterally or unilaterally
issues of plaque accumulation and irritation of the tongue. ■ closed tubing system protects from excessive distalization if the
patient misses an appointment
The AMDA can be used for either bilateral or unilateral maxillary molar
■ the AMDA can be used for a broad spectrum of orthodontic
distalization without the need of extractions, as illustrated in the two cases.
problems requiring maximum anchorage on the maxillary dental
The cephalometric evaluations described above confirm that the AMDA
arch.
achieves the desired tooth movements without the side effects of other
distalization systems, such as anchorage loss and molar tipping. The two There are also some disadvantages:
cases illustrate its effectiveness in bilateral treatment as well as for unilat-
■ it may cause discomfort, especially during swallowing and speech
eral distalization without side effects on the contralateral side.
■ there can be difficulties in maintaining optimal oral hygiene
A unique advantage of the AMDA is that it can be easily converted
■ irritation of the tongue or palatal soft tissues can occur
chair-side to a skeletal anchored horseshoe-type transpalatal arch to
■ bodily movement of the maxillary molars may cause a mandibular
support subsequent treatment with a conventional full fixed orthodontic
downward rotation and thus worsen Class II jaw relationships;
appliances.
therefore, this system should be used with caution in patients with a
The advantages of the AMDA can be summarized as:
vertical growth pattern or open bites.
■ can be used for the complete non-compliance correction of Class II
The AMDA can be used for the efficient, invisible, non-compliant bilateral
malocclusion, initially to distalize the maxillary molars and later to
or unilateral distalization of maxillary molars, as well as in conjunction
retract the anterior teeth
with full fixed appliances for the subsequent retraction of the anterior teeth
■ prefabricated design eliminates complicated laboratory procedures
(i.e. for the comprehensive treatment of Class II malocclusion).
■ insertion is easily carried out in one appointment by the orthodontist
■ activation is initiated immediately after its insertion
■ appliance is invisible during distalization of maxillary molars REFERENCES
■ no side effects of distal molar tipping
■ no anchorage loss of anterior teeth during active distalization 1. Papadopoulos MA. The “Advanced Molar Distalization Appliance”: a novel approach
■ distal drifting of posterior teeth and the incisors during molar to correct Class II malocclusion. Recent Pat Biomed Eng 2010;3:6–15.
2. Papadopoulos MA. German patent 10 2006 033 774; US patent 7,785,102.
distalization, which reduces the total treatment time
■ conversion of the AMDA to a horseshoe-type palatal arch is simply
performed intraorally
 31 The evolution of the Horseshoe Jet
S. Jay Bowman

Reducing the Distal Jet into a ‘horseshoe’ eliminated the acrylic button
INTRODUCTION
(Fig. 31.2A).5 Initially, implants were inserted either anterior to the horse-
The Distal Jet appliance was developed to apply distalizing forces (through shoe framework and luted together with light-cured flowable composite or
a couple) close to the center of resistance of a molar to reduce the degree they were placed posteriorly and tied to the wire with SS ligatures.
of tipping that is an unwanted effect of many devices (see Chapter 2).1 The However, no consideration was given to the issue of MI tipping and so
Distal Jet appliance serves two purposes: molar distalization without patient anchorage was lost unpredictably.5,6
compliance and subsequent conversion to a modified Nance holding arch To prevent mesial loss of anchorage, it became clear that skeletal anchor-
to maintain molar position after distalization. Compared with other devices, age needed to be separated from dental anchorage. Consequently, the appli-
the Distal Jet produces the least amount of molar tipping, minimal extrusion ance was further simplified by eliminating the supporting arms to the
of maxillary teeth and negligible changes in mandibular plane angle, lower premolars, leaving only the horseshoe wire (Fig. 31.2B,C).7–9 There are then
anterior face height, while expanding and rotating if preadjusted.2,3 no reciprocal forces from the coil springs acting on the teeth anterior to the
However, like other idstalizers it still exhibits the issue of anchorage loss. molars. Pure skeletal anchorage is used to push the molars distally and
Once the initial distalization has been achieved, the molars must be main- the rest of the maxillary teeth are left completely unfettered. Any tipping of
tained in their new position or they will move mesially. At this stage, it is the MIs (Fig. 31.2C) is inconsequential apart from the fact that they should
preferable to select methods that are simple, comfortable, versatile, esthetic, not be used as a Björk implant for cephalometric investigations.
hygienic, easy to comply with, cost effective, self-limiting and with few Ideally, a MI should be used in a way that can be tested easily for
undesirable side effects, and yet are predictable, effective and efficient. integrity and easily removed if it fails, with replacement of a new MI at a
The Bowman modification, or Horseshoe Jet (Sybron AOA Laboratory, different location. The final Horseshoe Jet design9,10 can be supported by
Racine, WI, USA) (Fig. 31.1) simplifies the conversion to a holding arch nearly any type of MI, inserted in any number of locations (e.g. anterior
by replacing the original tube-and-piston construction with a more rigid, or palatal alveolus) and connected to the horseshoe wire by luting with
solid tracking; the coil springs are not removed. bonding adhesive or tied with ligature wire. The appliance can be adjusted
fore and after by unlocking the stop screws and moving the wire back and
forth to avoid impinging on the anterior palate or to increase the working
DEVELOPMENT OF THE HORSESHOE JET length for more distalization.

Initial attempts to use minscrew implant (MI) anchorage with the Distal
Jet involved inserting MIs through holes in the acrylic button into the CLINICAL PROCEDURE
anterior palate or placing the MIs between the premolars in the palatal
alveolus and tied them to the supporting arms of the appliance attached to Orthodontic molar bands are seated on the first molars and a pick-up
the premolars.4 impression is taken. Full fixed preadjusted brackets (e.g. Butterfly System;

A B C

Fig. 31.1 Modified Distal Jet. (A) The Bowman modification is a laboratory modification in which the tube-and-piston construction has been replaced with simple tracking
wires for better geometry and rigidity. Bands or bonded occlusal rests and a Nance acrylic button provide anchorage. Mesial locks are slid posteriorly to compress the coil
spring. The appliance is activated every 4–6 weeks for 6–9 months. Distal stop screws are unlocked a quarter turn to initiate the process. (B) The distal stop screws are
tightened at the end of distalization to stop the process. Note: premolars have followed molars as transseptal fibers were stretched. (C) Simple transition to a modified
Nance holding arch required only sectioning the premolar support arms at the acrylic button.

A B C

Fig. 31.2 The Horseshoe Jet appliance. (A) The original design with only skeletal anchorage. The tracking wire is abutted against two miniscrew implants (MIs) inserted in the
anterior palate. (B,C) The simplified Horseshoe Jet and MIs (Note: the premolar supporting arms should not be used) (B); as molars are pushed distally, the premolars follow,
moving past the MIs, which tip mesially (C).

168
 The evolution of the Horseshoe Jet 169

A B C D

Fig. 31.3 The final modified Horseshoe Jet. (A) The appliance attached to miniscrew implants (MIs) between the first molars and second premolars. SS ligatures tie the
MIs to hooks on the anterior part of the tracking wire. The mesial stop screw is moved posteriorly to compress the coil spring and locked into place. (B) The distal stop
screw is unlocked a quarter turn to permit distalization. (C) At the conclusion of distalization, the mesial stop screw is moved back to compress the coil spring and prevent
food impaction. The tracking wire is now held in place by both pairs of arch locks and steel ligation to the MIs. (D) The Horseshoe Jet serves as indirect skeletal anchorage
for retraction of the remaining maxillary teeth with preadjusted appliances.

Fig. 31.4 Treatment of a Class II, division 2

malocclusion. (A) Maxillary Horseshoe Jet inserted
and supported by two miniscrew implants. (B)
Mandibular preadjusted appliance placed. (C) Molar
distalization with pure skeletal anchorage to prevent
A B C unintended anterior anchorage loss. (D) A super-
Class I molar relationship achieved; the premolars
have drifted posteriorly under the influence of the
transseptal fibers. (E) A maxillary preadjusted
appliance is then applied and the Horseshoe Jet is
locked down to serve as indirect skeletal anchorage
for the retraction of remaining maxillary teeth. (F)
The final result.
D E F

American Orthodontics, Sheboygan, WI, USA) are placed on only the Once the molars have been distalized, the distal stop screws are locked
lower arch to initiate leveling and alignment. The plaster cast with bands to prevent further movement (Fig. 31.3C). The Horseshoe Jet is now con-
is sent to the laboratory for fabrication of the Horseshoe Jet. After the verted to MI-supported indirect anchorage for retraction of the rest of the
appliance is constructed, a trial fit is done. maxillary teeth (i.e. acting as transpalatal arch with MI support).
Self-drilling MIs of nearly any head design can be used (e.g. 1.5–2.0 mm
diameter and 6–8 mm length). Insertion of MIs follows a standard proce-
dure: the position of MI insertion is indicated by the small bleeding point CASE EXAMPLES
where local anesthetic is infiltrated. The preferred site is in the palatal
alveolus between the first molar and second premolar and approximately Three examples illustrate the use of the Horseshoe Jet. In the first, the
5–8 mm apical to the gingival margin. As the root of the second premolar appliance is used for a Class II, division 2 malocclusion (Fig. 31.4). In
is typically oriented buccally, this is an ideal insertion site for use with the the second, it is used for a Class II, division 1 subdivision malocclusion
Horseshoe Jet as the premolars will move past the screws. (Fig. 31.5) and in the third it is used in a Class II, division 2 malocclusion
The Horseshoe Jet is then cemented into place and SS ligatures are (Fig. 31.6).
doubled over for added strength and tied tightly from the MIs to hooks on
the anterior part of the tracking wire (Fig. 31.3). The distal stop screws are
unlocked by a one-quarter turn only, just to permit distal movement along
CONCLUSIONS
the tracking wire. Each mesial stop screw is unlocked and moved posteri-
The development of the Horseshoe Jet has addressed many of the con-
orly, compressing the superelastic open coil springs on the wire, and then
cerns regarding molar distalization. Use of pure skeletal anchorage
locked in position (Fig. 31.3). The patient is seen over 5–10 months at
appears to be the only way to avoid unwanted anchorage loss resulting
4-week intervals to reactivate the device (recompress the springs). If the
from reciprocal forces. The simplification of the process with the
tracking wire comes into contact with the tissues of the anterior palate, the
Horseshoe Jet has improved the predictability of molar distalization for
mesial stop screws are loosened, the tracking wire moved posteriorly to
Class II malocclusion. The advantages of the Horseshoe Jet can be sum-
provide clearance and the device religated and reactivated.
marized as:
As the molars are pushed distally, the premolars begin to follow
under the pull of the transseptal fibers (Fig. 31.2C). Since the MIs are ■ one appliance serves two purposes: molar distalization and
inserted at an angle to the alveolus, and because the root of the second subsequent retraction
premolar is angled buccally, there should be no interference. The MI may ■ simple conversion to MI-anchored lingual arch
begin tipping mesially6 and the second premolar may move distally, adja- ■ dual locks to avoid anchorage slippage
cent to the tip of the MI. In most cases, the MI will end up transposed ■ coil springs remain in place
between the second and first premolars at the conclusion of distalization ■ force applied via a couple near tooth center of resistance
(Fig. 31.2C). ■ completely adjustable anteroposteriorly
 170 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Fig. 31.5 An 11-year-old girl with a Class II, division

1 subdivision malocclusion. (A) The Horseshoe Jet
with two miniscrew implants inserted. (B) At
completion of distalization, upper braces and sliding
retraction was initiated with indirect skeletal
anchorage support. (C) Torquing auxiliary inserted to
improve incisor position. Treatment was completed
in 23 months.

A B C

Fig. 31.6 An 11-year-old girl with a Class II, division

2 malocclusion. (A) The Horseshoe Jet is inserted
with miniscrew implants (MIs) at an angle between
the upper first molars and second premolars. (B)
Steel ligatures are tied from the MIs to hooks on the
tracking wire to provide anchorage support for
molar distalization. (C) Upper brackets are added at
completion of distalization. (D) Sliding space
consolidation is supported indirectly by MIs via the A B C
Horseshoe Jet. (E) Space closure complete and the
Horseshoe Jet removed. (F) Final results in 25
months.

D E F

■ pure skeletal anchorage

REFERENCES
■ no anterior dental support
■ no acrylic button needed so more hygienic, less tissue 1. Carano A, Testa M. The Distal Jet for upper molar distalization. J Clin Orthod
impingement 1996;30:374–80.
■ nearly any type of MI can be used 2. Bolla E, Muratore F, Carano A, et al. Evaluation of maxillary molar distalization with
the Distal Jet. Angle Orthod 2002;72:481–94.
■ option for multiple MI insertion sites 3. Ferguson DJ, Carano A, Bowman SJ, et al. A comparison of two maxillary molar
■ no need to remove and reposition MI distalizing appliances with the Distal Jet. World J Orthod 2005;6:382–90.
■ largest inter-radicular sites for MI insertion 4. Velo S, Rotunno E, Cozzani M. The implant Distal Jet. J Clin Orthod 2007;41:
88–93.
■ no root interference 5. Kinzinger GSM, Diedrich PR, Bowman SJ. Upper molar distalization with a
■ no incisive papilla injection miniscrew-supported Distal Jet. J Clin Orthod 2006;40:672–8.
■ fewer issues with tongue playing with MIs and food impaction 6. Liou EJ, Pai BC, Lin JC. Do miniscrews remain stationary under orthodontic forces?
Am J Orthod Dentofacial Orthop 2004;126:42–7.
■ no contra-angle handpiece MI driver needed 7. Bowman SJ. Thinking outside the box with mini-screws. In: McNamara JA Jr, Ribbens
■ direct driver access for insertion KA, editors. Microimplants as temporary anchorage in orthodontics [Craniofacial
■ no concerns with midpalatal suture Growth Series]. Ann Arbor, MI: University of Michigan; 2008. p. 327–90.
8. Ludwig B, Baumgartel S, Bowman SJ, editors. Mini-implants in orthodontics: innova-
■ no analogue impression caps for MIs tive anchorage concepts. Berlin: Quintessence; 2008.
■ appliance not ‘keyed’ or locked to MIs 9. Bowman SJ. Distal Jets refined: Bowman modification and Horseshoe Jet. AOAppli-
■ less MI loss rate in palatal tissues ances 2008;11:1–5.
10. Bowman SJ. Class II combination therapy: molar distalization and fixed functionals.
■ compress springs to distalize uni- or bilaterally In: Nanda R, Kapila S, editors. Current therapy in orthodontics. St. Louis, MO:
■ self-limiting appliance. Elsevier-Mosby; 2009. p. 115–36.
 The Distal Screw: a modified Distal Jet
Mauro Cozzani, Mattia Fontana, Anna Menini, Marco Pasini,
Robert Ritucci and Francesco Zallio
32
The preformed back-end telescopic arms are bent to form a 90° angle,
INTRODUCTION
about 8 mm away from the lingual sheath of the molar band (Fig. 32.3A),
Issues of anchorage loss that are inherent with the original Distal Jet appli- and adjusted so that they will not contact the underlying soft tissues. The
ance can be avoided by using intraosseous instead of dental anchorage arms must extend a few millimeters mesially to the steel plate so that they
with the Distal Screw, a modified Distal Jet. Anchorage is obtained by form a 5° angle with the line passing along the fossae of the posterior teeth
using miniscrew implants (MIs) as temporary anchorage devices. As these (Fig. 32.3B).
MIs are not osseointegrated, they do not guarantee absolute anchorage and A telescopic pipe is cut and positioned on the arms to allow for easy
so the Distal Screw retains the palatal button of the classical anchorage movement without binding. The anterior end of the pipe is bent to ensure
set-up. adequate retention in the Nance button. When the two pipes (on the left
and right sides) are positioned and adapted, they are blocked with wax
(Fig. 32.3C). The acrylic resin button is prepared avoiding any resin block-
ing the holes in the steel plate.
THE DISTAL SCREW
All elements of the appliance are assembled with the spring activation
The main characteristic that differentiates the Distal Screw from the origi- device and a 240 g Ni-Ti coil spring positioned on the tube and a stop
nal Distal Jet is the use of a steel plate with two to five holes that is inserted screw for the coil spring positioned on the arms.
in the Nance button (Fig. 32.1). The holes are large enough to receive the The tubes are inserted on the wire arms and the appliance is checked
MIs and the larger number of holes permits the clinician to choose on the plaster cast. A temporary metallic ligature is used to prevent the
the best insertion site and to replace the MI in a different place in case of two parts from moving apart during cementing in the patient’s mouth
failure. Since bone anchorage is utilized, the premolar anchorage arms of (Fig. 32.3D).
the conventional Distal Jet are not needed.1
A bayonet bend in the arm incorporating the coil spring allows the point
of force application to be closer to the center of resistance of the teeth. CLINICAL APPLICATION
The telescopic arms are parallel to their insertion parts on the first molar
lingual sheaths; this allows the distalization of the maxillary first molars The maxillary molar bands are cemented in place. The appliance is checked
to follow the natural arch form and avoids an excessive increase in inter- in the patient’s mouth to verify its adaptation and stability before being
molar width. fixed in position.
Compared with the Distal Jet, the Distal Screw is less bulky and also Usually, one MI per palatal side is inserted through a guide hole drilled
permits spontaneous premolar distalization under the pull of the transeptal with a handpiece and the MIs are tightened using either a hand-tightened
fibers,2 which can decrease treatment time. screwdriver or a slow-speed handpiece. The appliance is activated by
At the end of the active distalization phase, the appliance can be used cutting the metallic ligatures.
to support anchorage for the distalization of the premolars and canines Once the first maxillary molars have reached their correct position, the
(Fig. 32.2) as well as for bite opening. It cannot be used for anterior teeth appliance can be used to support anchorage for premolar and canine
retraction because the acrylic resin Nance button would impede their retraction. The coil spring is cut and removed, the pipe at the distal
movement. Consequently the Distal Screw must be removed before the end of the arm is brought into position and blocked with the stop screw
retraction of the maxillary incisors. and the telescopic arm is squeezed with Weingart pliers to ensure its
fixation.

CONSTRUCTION OF THE APPLIANCE

Orthodontic bands are fitted on the maxillary first molars and an impres- CASE PRESENTATION
sion is taken with alginate. The impression with the bands positioned in it
is sent to the laboratory for the construction of the appliance. A 12-year-old girl presented with a bilateral dental Class II malocclusion
Plaster casts are prepared with the molar bands positioned. A steel plate in her permanent dentition, protrusive maxillary incisors, deep bite and a
is adapted to the palate vault and blocked out on the cast with some wax. hypodivergent growth pattern (Fig. 32.4A,B; Table 32.1).

Fig. 32.1 Distal Screw

positioned on a plastic model.
Bone anchorage is used and so
the premolar anchorage arms
of the conventional Distal Jet
have been removed.

A B

Fig. 32.2 At the end of the active distalization phase, the Distal Screw can be
used as anchorage for the distalization of the premolars and canines, before
(A) and after (B) distalization.

171
 172 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C D

Fig. 32.3 Construction of the appliance. (A) Telescopic arm is bent to form a 90° angle about 8 mm away from the lingual sheath of the molar band and adapted to
avoid contact with the underlying soft tissues. (B) The arms (yellow line) form a 5° angle with the line passing along the fossae of the posterior teeth (red line). (C) The
two tubes are positioned and adapted and then blocked with wax. (D) The appliance is checked on the cast and a metallic ligature is used to hold the two parts together
during cementing in the patient’s mouth. (Courtesy of Mr Andrea Bertelli.)

A B C D

E F G H

Fig. 32.4 Treatment of bilateral dental Class II malocclusion with the Distal Screw. (A,B) Pretreatment. (C,D) Immediately after completion of maxillary molar distalization.
(E,F) After insertion of fixed appliances. (G,H) After completion of treatment and removal of all appliances.

Table 32.1 Cephalometric analysis during treatment

Variables Normal (mean ± SD) T1 T2
Sagittal skeletal relations
Maxillary position, SNA (°) 82 ± 3.5 76 76
Mandibular position, SNPg (°) 82 ± 3.5 74 74
Sagittal jaw relationship, ANPg (°) 2 ± 2.5 2 2
Vertical skeletal relations
Maxillary inclination, SN/ANS-PNS (°) 8 ± 3.0 11 11.5
Mandibular inclination, SN/Go-Gn (°) 33 ± 2.5 29 27.5
Vertical jaw relation, ANS-PNS/Go-Gn (°) 25 ± 6.0 18 16
Dentobasal relations
Maxillary incisor inclination, +1-ANS-PNS (°) 110 ± 6.0 110 107
Mandibular incisor inclination, −1-Go-Gn (°) 94 ± 7.0 100 100
Mandibular incison compensation, −1-A-Pg (mm) 2 ± 2.0 3 1
Dental relations
Overjet (mm) 3.5 ± 2.5 5.5 4.0
Overbite (mm) 2 ± 2.5 5.0 4.0
Interincisal angle (°) 132 ± 6.0 133 136

T1, before the insertion of the Distal Screw; T2, after removal of all appliances.
 The Distal Screw: a modified Distal Jet 173

A non-extraction treatment plan was considered appropriate using a The Distal Screw has a number of advantages:
Distal Screw for molar distalization together with fixed appliances. The
■ it is a non-compliance method that is generally accepted by patients
Distal Screw was cemented and fixed. Appliances were inserted at the
because it is invisible when they talk or smile
same time in the mandibular arch in order to prepare it for possible anchor-
■ it is less bulky and less time consuming than the Distal Jet
age support with Class II elastics. The distalizing phase to Class I molar
■ it uses skeletal anchorage with MIs in the median and paramedian
relationship took about 12 months. At this point there were spaces between
region of the palate, which is an area that is easily accessible, easy
all posterior maxillary teeth and the maxillary canine had moved distally
to maintain a good oral hygiene and less likely to interfere with
(Fig. 32.4C,D).
vessels, nerves or roots of teeth
The Distal Screw was deactivated and fixed appliances were inserted in
■ it does not require radiographic evaluation for MI placement or
the maxillary arch for alignment and retraction of the anterior teeth (Fig.
surgical guides as the modified Nance button acts as a guide
32.4E,F).
■ treatment time is reduced because there is no anchorage loss of the
At the end of treatment, there was good alignment in both arches and
anterior teeth and the maxillary first and second premolars can drift
molar and canine bilateral Class I relationships had been achieved (Fig.
distally spontaneously
32.4G,H) (Table 32.1). Total treatment time was approximately 30 months.
■ maxillary molars are moved almost bodily with a minimum degree
of crown tipping
■ there is no significant change in the vertical dimension
CONCLUSIONS
■ first premolar and canine retraction, as well as incisor intrusion, can
be accomplished using the skeletonized Nance button as anchorage.
Distalization is more effective prior to the eruption of the maxillary second
molars, and if it is carried out before the mandibular second premolars
have emerged, this allows the leeway space to be exploited. Although REFERENCES
molar distalization is not recommended in patients with increased facial
divergence or skeletal open bite, the Distal Screw can be used because it 1. Carano A, Testa A, Bowan J. The distal jet simplified and updated. J Clin Orthod
2002;36:586–90.
produces an almost bodily movement of the molars with no significant 2. Cozzani M, Zallio F, Lombardo L, et al. Efficiency of the distal screw in the distal
vertical changes. movement of maxillary molars. World J Orthod 2010;11:341–5.
 33 The Beneslider and Pendulum B appliances
Benedict Wilmes

INTRODUCTION

The Beneslider and Pendulum B appliances are designed to take advantage

of direct anchorage using miniscrew implants (MIs) as temporary anchor-
age devices for maxillary molar distalization.1–3 Both are fixed to the top
of the MIs with exchangeable abutments, part of the Benefit system (PSM,
Tuttlingen, Germany) (Fig. 33.1). The Beneslider device is better for
bodily distal movement of the maxillary molars whereas the Pendulum B
seems to be more appropriate when the maxillary molars need to be
uprighted and/or derotated while being distalized.

CLINICAL APPLICATION

One or two Benefit MIs are inserted in the anterior median region of the D
palate near the third palatal rugae using standard techniques. A predrilled E
F
pilot hole may be needed. MI insertion can be carried out using a hand-
piece adapted to a commonly used contra-angle. It is advisable to choose
MIs with a wider diameter for higher stability. Coupling of two MIs in the G
line of force in the sagittal direction will minimize the risk of MI tipping
or failure. If one MI is used, the recommendable dimension is 2.3 × 11 mm;
if two MIs are inserted, the anterior one should be 2.0 × 11 mm and the
posterior 2.0 × 9 mm. C
The Beneslider appliance comprises two activation locks, two open
H
springs and two Benetubes (Fig. 33.2). Bands with lingual sheaths are
bonded to the maxillary molars and Benetubes are inserted in the molar
sheaths. A Beneplate with a 1.1 mm SS wire in place is then adapted to I
the curvature of the palate and connects the MIs with the molars. Depend-
ing on the insertion site and angle of the MIs, the Beneplate body may
need to be bent as well. The Beneplate wire should be parallel to the B A
occlusal plane if the molars have to be distalized horizontally. By changing
the angulation of the Beneplate wire, the molars can be intruded or extruded
during distalization (Fig. 33.3). Fig. 33.1 The Benefit system. A, Miniscrew implant; B, laboratory analogue;
C, impression cap; D, slot abutment; E, standard abutment; F, bracket abutment;
The Beneplate is then connected to the MIs with two fixing screws using G, abutment with a wire in place (1.1 or 0.8 mm); H, Beneplate with a wire in
a small hand driver or a contra-angle. If the Beneslider is based on just place (1.1 or 0.8 mm); I, fixing screw for the Beneplate; J, screwdriver for fixation
one MI, the abutment with a wire in place (Fig. 33.2C) is used instead of of the abutments/Beneplates.

Beneplate
or abutment

Activation lock

Open spring

Benetube
B C
A
Fig. 33.2 (A) The Beneslider comprises two activation locks, two open springs and two Benetubes. (B) Beneplate with two miniscrew implants. (C) Beneplate with one
miniscrew implant. In both, an abutment is used with a 1.1 mm wire.

174
 The Beneslider and Pendulum B appliances 175

Fig. 33.3 Proper guidance of the molars is achieved using a 1.1 mm SS wire through the center of
resistance of the teeth. If the molars have to be distalized horizontally, the Beneplate wire should
be parallel to the occlusal plane. By changing the angulation of the wire, the molars can be
intruded or extruded simultaneously to the distalization process (dashed line, in this case intrusion).

Fig. 33.4 Adaptation of the appliance in the

laboratory. (A) Impression caps are plugged on top
of the miniscrew implants. (B) After taking an silicon
impression, laboratory analogues are plugged into
the impression caps. (C) Plaster cast with molar
bands and laboratory analogues (when extraoral
bending of the Beneslider is preferred).

A B C

the Beneplate. The Beneslider is completed by two open coils and two total treatment time was 14 months (6 months distalization and 8 months
activations locks. Molar distalization force is achieved by pressing of the leveling and retraction of the anterior dentition) (Fig. 33.6G,H).
activation locks against the coil springs. In young adolescents, 240 g
springs are used. If the second molars are fully erupted, 500 g springs are
recommended.
DISCUSSION
Both the Beneslider and the Pendulum B appliance can be bent and
adapted intraorally. To shorten the chair-side time, impressions can be
Both the Beneslider and the Pendulum B are effective appliances for
taken and adaptation of the appliances can be carried out in the laboratory
maxillary molar distalization without any side effects in terms of anchor-
on a plaster cast (Fig. 33.4).
age loss of the anterior dentition.
The distalization effect (approximately 5 mm) achieved with Beneslider
mechanics is adequate when compared with other distalization devices.1
CASE EXAMPLES There is very little first molar tipping, which can be attributed to the fact
that the line of force is near the estimated center of resistance of the molar
THE BENESLIDER and correct guidance is delivered by the SS wire.1
The Benefit MIs were inserted in the anterior palate in the region of the
A 16-year-old boy with a full Class II occlusion and maxillary anterior
midpalatal suture in all patients, including adolescents. The MI insertion
crowding was initially treated with a headgear but he refused to wear it
method provided sufficient stability and did not adversely affect maxillary
sufficiently. In order to avoid extraction of two premolars, molar distaliza-
growth. Use of MIs to support maxillary distalization in 178 patients
tion was performed using a Beneslider. Figure 33.5 outlines the treatment
showed major MI tipping in only seven (a failure rate of 3.9%). The
steps. The treatment time was 10 months for the invisible distalization and
maximum insertion moments of the MIs ranged from 8 to 25 Ncm, which
15 months with brackets in place.
can be regarded as adequate to achieve a sufficient primary stability for
MIs of diameter 2.0 or 2.3 mm.
The question of whether there might be an impairment of transversal
THE PENDULUM B APPLIANCE maxillary growth was investigated by Asscherickx et al.4 using Orthosys-
Pendulum B mechanics are employed if frictionless mechanics is preferred tem implants in beagle dogs. In this case, they saw transversal growth
and/or the molars should be uprighted or derotated simultaneously to the inhibition, although only in one parameter. However, the MIs used in this
distalization. study had a greater diameter plus a rougher surface to stimulate osseointe-
A 39-year-old man with a Class II malocclusion and upper and lower gration. Our clinical observations have not revealed any tendency for
anterior crowding presented for treatment. Four premolars had been reduced transversal growth of the maxilla. If desired, the MIs could be
extracted when he was a child (Fig. 33.6). After 6 months of treatment inserted lateral to the suture. No clinical problems were observed even
with the Pendulum B appliance, the distalization effect was appropriate in when the posterior MI appeared to penetrate the nasal cavity.
this patient (approximately 5 mm) (Fig. 33.6D,E). This was followed by Maxillary molar distalization takes approximately 3 months until dis-
leveling and retraction of the anterior dentition using fixed appliances and talization of the molars is visible. This is partly because there is a simul-
a power chain (Fig. 336F). Panoramic radiography after retraction of the taneous distal migration of the premolars under the pull of the transeptal
anterior dentition confirmed good bodily distalization of the molars. The fibers. Employing indirect anchorage devices (using premolars) leads to
 176 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C D

E F G H

I J

Fig. 33.5 Full Class II occlusion, maxillary anterior crowding and deep bite treated with the Beneslider. (A,B) Pretreatment. (C) Two Benefit miniscrew implants in place.
(D) Beneslider in place with posterior coupling using a headgear tube since Benetubes were not available at the time. (E) After 10 months of follow-up. (F) Situation after
bonding of brackets. Bite opening is achieved by bonding of resin “bite turbos” at the palatal surfaces of the upper central incisors. (G) One month after bonding:
application of an intrusion overlay in the lower arch. (H) Four months after bonding, leveling is finished. Retraction of the anterior dentition with a SS wire
(0.016 × 0.22 inch) and a power chain. The Beneslider is now used for anchorage of the molars. (I,J) Treatment end. (K) Superimposition of cephalometric radiographs
before and after distalization: maxillary molars were distalized approximately 7 mm.

A B C D

E F G H

Fig. 33.6 Class II malocclusion and upper and lower anterior crowding treated with the Pendulum B appliance. (A,B) Pretreatment. (C) To avoid tipping and severe
rotation during distalization, Pendulum mechanics preactivated by uprighting and antirotation bends. (D) Distalization effect after 6 months with the Pendulum B
appliance; many spaces can be seen in the posterior region. (E) Cephalometric radiograph showing the distalization effect (approximately 5 mm) after 6 months of
treatment. (F) After leveling and aligning, the anterior dentition was retracted with a power chain. During this retraction phase, the Pendulum B appliance was reactivated
properly for molar anchorage purposes. (G,H) After debonding.
 The Beneslider and Pendulum B appliances 177

the reverse effect of mesial migration of the premolars (anchorage loss),

REFERENCES
which create spaces between the second premolars and the first molars that
may appear to be the result of distalization of the first molars. 1. Wilmes B, Drescher D. Application and effectiveness of the BENEslider: a device to
move molars distally. World J Orthod 2010;11:331–40.
2. Wilmes B, Drescher D, Nienkemper M. A miniplate system for improved stability of
skeletal anchorage. J Clin Orthod 2009;43:494–501.
CONCLUSIONS 3. Wilmes B, Drescher D. A miniscrew system with interchangeable abutments. J Clin
Orthod 2008;42:574–80.
A MI system with exchangeable abutments offers a variety of different 4. Asscherickx K, Hanssens JL, Wehrbein H, et al. Orthodontic anchorage implants inserted
in the median palatal suture and normal transverse maxillary growth in growing dogs: a
mechanics; for example, either a Beneslider or a Pendulum B can be used biometric and radiographic study. Angle Orthod 2005;75:826–31.
for maxillary molar distalization. If bodily distal movement of maxillary
molars is needed, the Beneslider provides very effective and easy mechan-
ics. If maxillary molars have to be distalized and simultaneously uprighted
or derotated, the Pendulum B is suggested.
 34 The TopJet distalizer
Heinz Winsauer

plunger enables a secure connection to the TPA. This joint provides a hinge
INTRODUCTION
along the axis of the TPA–wire but also some resistance against molar
tipping in the vertical axis. Four circumferential rubber elastics are sequen-
Three molar distalizers using purely bone-borne anchorage via miniscrew
tially wedged into the four available slots during the initial and subsequent
implants (MIs) are currently in use: the Beneslider, with elements of the
activation. The mechanics of molar distalization with the TopJet are sum-
Distal Jet and the Keles Slider (Chapter 33); the miniscrew implant-
marized in Fig. 34.2. For reactivation of the power module, the twin tube
supported distalization system (Chapter 29) and its development, the
is pushed towards the MI’s head to recompress the open coil spring.
Advanced Molar Distalization Appliance (Chapter 30), and the TopJet,
which is connected to a palatal arch and thus offers a friction-free distal-
izing force.1,2 The TopJet was the first “ready-to-use” appliance for molar THE TRANSPALATAL ARCH
distalization.
Seven prefabricated TPAs are available and the size is chosen to corre-
spond to the patient’s maxillary intermolar fossae distance. This can be
THE TOPJET DISTALIZER measured either directly in the patient’s mouth or on a plaster cast. The
U-shaped portions of the TPA can increase the distance between the MI
The TopJet distalizer consists of a distalizing open coil spring power insertion point and section-D of the TPA to provide a minimum distance
module, an adjustment module housed biaxially in a twin tube and a pre- of 14 mm for placement of the TopJet. If this distance is longer, the TopJet
fabricated transpalatal arch (TPA) in seven different sizes (Fig. 34.1). can be elongated as described above. The T-connector embedded in
section-D is kept firm and cannot slide on the TPA. Even in unilateral
molar distalization, a TPA with bilateral U-shaped bends is preferred as
THE POWER MODULE section-E allows easy adjustment of the TPA’s height. The classical
The power module is a cylinder containing an open Ni-Ti coil spring that Goshgarian-type TPAs end with a double-back bend to allow molar torque
extends a plunger. It is connected to the MI in the anterior palate with the for correction of molar inclination. As long as molar torque is not needed,
C-clip at the plunger’s front end. At the power module’s rear end, a para- section-A of the TPA, which is a single wire with retention notches that is
chute safety thread holds the open coil spring compressed during insertion fixed with light-cure resin into the fenestrated lingual sheaths of the molar
by means of a “crimped” golden-colored pearl (Fig. 34.1A). This thread bands, is sufficient to withstand rotation and tipping movements of the
is cut and removed along with the pearl to start distalization. molars during distalization.
The distalizing force of the TopJet is transferred through the TPA to the
connected molar(s). As the force is delivered close to the center of resist-
THE ADJUSTMENT MODULE
ance of the molars and the TPA prevents rotation of the molars, a friction-
The adjustment module comprises a tube with four slots housing an free bodily molar distalization is expected. If the distalizing force is applied
extendable plunger. For individual adjustment in length, this plunger can in the middle between the molars, both molars are distalized equally. Pure
be extended towards the TPA to allow fitment to different sizes of palate. unilateral distalization would require a distalizing force passing through
The T-shaped connector with crimpable wings at the rear end of the the center of resistance of the molar. Since the T-connector is connected

Fig. 34.1 The TopJet molar distalizer. (A) Before Tube slot Adjustment module
activation, the golden pearl and the securing thread Twin tube
keep the open Ni-Ti coil spring compressed. (B) After Screw head
activation, the C-clip is connected to the miniscrew
implant head; the pearl and thread are removed and
the T-connector is attached to the transpalatal arch. T-connector
A B C-clip Open coil spring
power module

A B C D

Fig. 34.2 Distalization mechanics of the TopJet. (A) TopJet in place, securing thread removed and open coil spring still compressed. (B) Coil spring decompressed; twin
tube, adjustment module, transpalatal arch and molars have been moved distally. (C,D) For reactivation, the twin tube is pushed towards the screw head with a fork
probe or a hooklet probe (C) until the next rubber elastic falls into the slot (D) to keep the plunger of the adjustment module in its new, extended position. This
procedure recompresses the coil spring and restarts distalization.

178
 The TopJet distalizer 179

Fig. 34.3 The prefabricated transpalatal arch (TPA) with its sections A–F (before
placement in the palate). Section-A is placed into the Goshgarian lingual sheath;
section-B positions the TopJet in or near the center of resistance of the molar;
section-C elongates the distance between screw head and TPA; section-D attaches
the T-connector to the TPA; section-E allows adjustment of the TPA in height;
section-F is predetermined by the anatomical size of the palate. The individual TPA
length corresponds to the intermolar fossae distance.

Fig. 34.4 The bilateral M4 sites on the transverse line through the palatal cusps of
the first premolars half way to the midpalatal suture.
to the TPA, part of the distalizing force will act on the contralateral molar.
This can be of advantage when slight distalization of the contralateral
molar is desired. In this case, bilateral retention is required for stability
Step 2: Insertion of the Transpalatal Arch
after the end of the distalization in order to prevent relapse. Otherwise, the
contralateral molar will relapse while the extended TopJet keeps the distal- Conventional molar bands equipped with fenestrated lingual sheaths are
ized molar in position. Differing from other appliances, unilateral molar banded on both maxillary first molars. The prefabricated TPA section-A is
distalization with the TopJet needs no more than one MI (see Fig. 34.7 adjusted to fit passively into the lingual sheaths with adequate distance
below). Alternatively, if any contralateral distalization is not required, a from the palatal mucosa. To enable the desired expansion during distaliza-
second MI inserted on the contralateral side may be connected with a liga- tion, the TPA is routinely activated transversally 2–4 mm per side before
ture to the TPA to retain the distance. An elastic chain between the MI and its final insertion. The fenestrated lingual sheaths facilitate the application
TPA will even mesialize molars, if needed, on this side while the buccal of light-cure resin to stabilize the inserted TPA.
teeth are distalized on the other side (push–pull appliance).
Step 3: Insertion of the TopJet
TOPJET VERSIONS The securing thread of the TopJet is unrolled. This thread prevents the
The TopJet has a length of 14 mm, a diameter of 2.4 mm and is a prefab- patient from accidentally swallowing the appliance and also holds the open
ricated compact distalizer. There are three TopJet versions: the TopJet 250 coil spring compressed to ensure that it remains passive during insertion.
and TopJet 360, which produce forces of 250 and 360 cN, respectively, The TopJet is securely held in place with self-locking forceps, and the
and the TopJet plus 8, which is an 8 mm elongated version of the C-clip is moved toward the groove of the MI’s head and clipped on to it
appliance. with Weingart pliers (Fig. 34.5A–C). The piston in the adjustment module
The TopJet 360 is indicated for the en masse distalization of premolars is then extended towards the TPA with a fork probe in order to connect
and second molars. After insertion of the MI, the TopJets 360 or 250 are the piston’s T-connector to section-D of the TPA (Fig. 34.6A). During this
connected to them and fully activated respectively with 360cN or 250cN. extension, one or two elastics fall into the slot(s) of the adjustment mod-
If less force is required, an initial reduction of the distalizing force can be ule’s twin tube (Fig. 34.2D), thus preventing the piston from sliding back
ensured by lifting the stopper elastics that have dropped into the tube slots into the tube. If the piston has been pulled out too far, it can easily be
during the insertion or reactivation process. This is done one at a time, so pushed back by lifting the appropriate elastic. Using pliers (TopJet pliers
that the twin tube can slide backwards while decompressing the coil spring or a modified angle Tweed plier), the upper and lower flaps of the
(Fig. 34.3). The same procedure can be applied if less power is desired in T-connector are closed tightly around the TPA (Fig. 34.6B). Light-cure
the course of treatment with the TopJet 250 or 360 and its actual version resin is used to fill the gaps around the T-connector and the median portion
(see below). The extra-long version (plus 8 mm) is indicated in large of the C-clip. This provides a stable connection in terms of rotation and
maxillae or for distalizing the second molars. angulation at the C-clip and a hinge axis-like joint at the T-connector,
allowing bodily movement of the molars. The MI head and the C-clip are
also covered and secured with light-cure resin, while avoiding any resin
CLINICAL APPLICATION contacting the mucosa. This provides a stable yet reversible connection in
terms of rotation and angulation for the TopJet. Insertion of the MIs and
INSERTION PROCEDURE the TopJet is painless and usually takes less than 20 minutes.
Once the appliance, including the TPA, has been secured, the safety
Step 1: Insertion of the Miniscrew Implants
thread is pulled slightly laterally and cut between the golden pearl and the
The TopJet is anchored with self-drilling MIs (e.g. Dual-Top Jet Screws; power module (Fig. 34.6C). This releases the closed Ni-Ti coil spring and
Jeil Medical, South Korea). A thread length of 7 mm is required, with a the patient should notice a light pressure on the maxillary molars.
smooth neck varying between 3 and 7 mm depending on gingiva thickness.
The MIs are inserted on the transverse line through the palatal cusps of the
first premolars, half way to the midpalatal suture, the so-called M4 site
CLINICAL CONSIDERATIONS
(Fig. 34.4). In order to pass through the palatal mucosa at this position, the If not reactivated, the TopJet can produce a distalization of 5.6 mm. At
MI is initially placed perpendicular to the surface of the bone, somewhat that distance, the force of the open coil spring decreases to 50 cN. However,
medial to the final required position, and inserted for four or five turns. It in order to efficiently distalize the molars, the appliance will need to
is then uprighted over a few turns and is ultimately screwed into the bone be reactivated at intervals. This can be achieved in 2 mm increments
in a strict vertical direction (perpendicular to the occlusal plane) with no (i.e. the distance between two rubber elastics). Using a fork probe or
more than three turns per second until the head is in the desired position. hooklet probe, the twin tube is pulled forward towards the anchorage MI,
 180 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Fig. 34.5 Easy, fast and safe clip-on (A–C) and

clip-off (D–F) of the C-shaped connector.

Clip on
A B C

Clip off
D E F

A B C D

Fig. 34.6 Connecting the TopJet to the transpalatal arch (TPA). (A) The plunger in the adjustment module is extended towards the TPA with a fork probe. When the
T-connector has reached section-D of the TPA, one or two elastics fall into the slots, thus preventing the adjustment plunger from sliding back. (B) The upper and lower
flaps of the T-connector are closed tightly around the TPA with pliers and light-cured resin is used to fill the gaps around the T-connector. This provides a stable hinge
axis-like joint granting bodily movement of the molars. (C) To activate the TopJet, the safety thread is cut between the golden pearl and the power module. (D) If there is
soft tissue irritation, section-E has to be bent slightly downward.

which compresses the open coil spring encased in the power module, REMOVAL OF THE TOPJET
re-establishing the distalization force; when the elastic has fallen into its
recess, the piston within the adjustment module can be locked (Fig. Composite is removed from the MI head and a Weingart plier is placed
34.2CD). If the elastics have been lost, a stop can also be created by between the mesial C-clip extension of the TopJet and the MI head,
slightly compressing the corresponding arch between the slots behind the pushing back the clip without applying any pressure on the MI (Fig.
piston (irreversible stop). In total, a maximum molar distalization of 34.5D–F). The anterior part of the TopJet can then be raised, which breaks
14 mm is possible if all four increments are used to reactivate the the composite cover at the posterior end of the T-connector, and the flaps
appliance. opened to release the TopJet.
A period of 2 to 3 months is required for bodily movement and en masse After the removal of the TopJet, the prefabricated TPA is removed.
distalization of up to three molars per side. During this time, the second Usually, section-A of the TPA extends through the lingual sheath by about
and first premolars start to drift distally under the pull of the transeptal 2 mm. The covering resin is broken away and the ends of the TPA are
fibers. A gap mesial to the first molars will appear. After 3 to 5 months of pushed mesially with the Weingart plier. If this is not possible, the TPA
molar distalization, premolar and canine brackets are used to gain space can be cut with a water-cooled mini-diamond bur while being secured with
in the anterior region. Because the posterior palate becomes narrower and a needle holder, and the remaining segments can be pulled out.
inclines towards inferior, extensive distalization may be accompanied by
palatal soft tissue irritation caused by the TPA. In this case, section-C of
the TPA has to be bent slightly inwards and section-E upwards for immedi- CLINICAL APPLICATIONS
ate relief (Fig. 34.6D). After sufficient distalization, the twin tube is
released backwards by lifting up the appropriate elastic (the stopper elastic) CASE 1: UNILATERAL DISTALIZATION
to deactivate the compressed coil spring. The residual force of 50 cN will
prevent relapse. An 11-year-old boy presented with a low-angle growth pattern, bialveolar
In addition to spontaneous premolar distal movement during molar protrusion of the maxillary and mandibular anterior teeth and normal sagit-
distalization, the premolars can be retracted with segmented arches to tal relationships (ANB, 2°; Wits appraisal, 0 mm). He had unilateral Class
accelerate treatment progress. If further (en masse) retraction of the ante- II of half a premolar width on the right side with an upper midline shift to
rior teeth is required, the necessary retraction force can be counteracted the left of 2 mm, as well as minor crowding of the maxillary incisors (Fig.
either by increasing the distalization force accordingly (reactivation of the 34.7A,B). Treatment plan was a unilateral distalization of the right maxil-
TopJet) or by crimping the plunger at the anterior end of the cylinder to lary teeth to create space, to correct the upper midline and to retrocline the
create a rigid anchorage. maxillary incisors. A MI (length, 12 mm; diameter, 2 mm) was used to
 The TopJet distalizer 181

A B C D

E F G H

Fig. 34.7 Case 1: unilateral distalization. (A,B) Pretreatment. (C) TopJet immediately after insertion. (D) Unilateral space creation after 2.5 months of distalization. (E,F) End
of distalization after 7 months. (G,H) Post-treatment after strict unilateral distalization and orthodontic treatment with two sets of aligners.

A B C D

E F G H

Fig. 34.8 Case 2: bilateral distalization. (A,B) Pretreatment. (C) Insertion of the TopJet distalizers. (D) Creation of space in the premolar region, en masse retraction of the
upper incisors with elastic chains. (E) Insertion of full fixed appliances; TopJet remained in place for further distalization. (F) Further distalization required on the right side,
left side finished. (G,H) Post-treatment.

anchor a TopJet 250 on the right side (Fig. 34.7C). After 10 weeks, a total Extraction of four premolars was suggested but because her parents were
of 3 mm of space between the maxillary right molar, the second and first opposed to extractions, an attempt at bilateral non-compliant distalization
premolar and the canine had been achieved (Fig. 34.7D). Brackets were of the maxillary posterior teeth was agreed. Two MIs and two TopJet 250
bonded on the right maxillary canine and the first and second premolar, and were installed without any other appliances (brackets) (Fig. 34.8C). Seven
these teeth were then distalized with an elastic chain (Fig. 34.7E,F). After months later, both first molars were in a Class I relationship. For overcor-
9.5 months, the MI and the TopJet were removed. The maxillary right first rection, the TopJets stayed in place for another 5 months, and the patient
molar reached an overcorrected Class I relationship (one-third a premolar also wore Class III elastics to distalize the mandibular posterior teeth (Fig.
width), and the upper midline corrected spontaneously. No tipping or rota- 34.8D–F). Finally, the distalizers and the MIs were removed and the treat-
tion of the maxillary right molar occurred during distalization. The rest of ment was finished with fixed appliances and positioners. In order to keep
the teeth of the maxillary and mandibular arch were treated with two sets the vertical dimension, bite ramps were placed on the maxillary incisors.
of aligners (Copyplast, Scheu Dental, Iserlohn, Germany). Overall treat- At completion of treatment, a perfect Class I occlusion and retrusion of
ment time was 22 months (Fig. 34.7G,H). The presence of the third right the incisors with sufficient overbite was achieved (Fig. 34.8G,H). Although
maxillary molar did not prolong treatment time. maxillary third molars were present, pure bodily distalization of first
molars was achieved.

CASE 2: BILATERAL DISTALIZATION

DISCUSSION
A girl aged 11.5 years presented with bilateral Class II malocclusion of
one-half a premolar width, bialveolar protrusion and a vertical growth There are now several prefabricated distalizers available in addition to the
pattern: a classic indication for premolar extractions (Fig. 34.8A,B). TopJet (versions of the Beneslider and the miniscrew implant-supported
 182 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Fig. 34.9 Current version of the TopJet.

A B

distalization system, plus the Advanced Molar Distalization Appliance);

ACTUAL VERSION OF THE TOPJET
all need only some small adjustments of their wire elements either on the
casts or in the patient’s mouth in order to be used directly for molar dis- It has been shown that the rubber elastics tended to accumulate plaque.
talization. They have a number of advantages: For hygienic reasons, these rubber elastics have been replaced in the new
■ partially or completely prefabricated version of the TopJet by a ratchet mechanism with a locking tooth (Fig.
■ use conventional molar bands with standard lingual sheaths 34.9A) and the extendable plunger has been replaced by an extendable
■ can be inserted chair-side in one session grooved plunger. This modification allows easy activation and deactivation
■ can be reactivated stepwise in the clinical setting (Fig. 34.9B).
■ offer the possibility for spontaneous movement (drifting) of the
premolars and canines
■ can be used for anterior tooth retraction. CONCLUSIONS
The TopJet has a number of additional advantages: The TopJet is a prefabricated fixed non-compliance molar distalizer with
■ the unique clip-on/clip-off mechanism enables an easy, secure, fast, a unique and easy clip-on/clip-off mechanism and elegant telescopic
reliable and reversible connection adjustment to fit palate dimensions. Insertion is easy, secure and quick,
■ the telescopic adjustment mechanism enables individual palatal taking a single appointment of 20–30 minutes. The connnection of the
length adaptation using an automatic locking system TopJet to the TPA is reliable and stable, but still easy to disengage. The
■ removal and reinsertion are easy insertion procedure can be carried out by an orthodontic practitioner.
■ the MIs are placed bilaterally (unilateral MI is possible) in the Reactivation of the appliance is easy, fast and safe. The TopJet 360
anterior palate in an area presenting the greatest bone height (360 cN) can even distalize premolars and molars en masse without
■ friction-free bodily molar distalization occurs unwanted effects. These advantages make the TopJet feasible for the eve-
■ the TPA does not permit rotation of the molars during distalization. ryday practice as a time-saving and ready-to-use appliance.
In contrast, the new Beneslider requires anchorage in the midpalatal suture
while the Advanced Molar Distalization Appliance requires more complex
REFERENCES
adjustment at fitting. Both also have some friction during distalization and
some minor rotations can occur, although the latter can be counteracted 1. Winsauer H, Muchitsch P, Winsauer C, et al. The TopJet: a convenient appliance for
by means of adjustable bends on the wire extensions of the tubing system. routine bodily molar distalization. J Clin Orthod 2013;in press.
2. Winsauer H, Vlachojannis J, Winsauer C, et al. Körperliche Distalisation der Molaren-
In general, complications with the TopJet are rare but palatal soft tissue
mitdem TopJet-Konzept. Inf Orthod Kieferorthop 2011;43:197–204.
irritation can occur, particularly at the later stages of distalization, but this 3. Winsauer H, Vlachojannis J. Letter to the editor. Inf Orthod Kieferorthop 2010;42:211.
can be relieved by adjusting section-C and section-E of the TPA. MI loss
is seen in less than 2% of the patients.3
 The skeletal Pendulum-K appliance
Björn Ludwig, Bettina Glasl, Michael Schauseil, Ben Piller and Gero Kinzinger 35

INTRODUCTION or, if there are missing canines or mesial drift of the premolars, behind the
most posterior palatal rugae. The MIs should be no more than 3 mm from
The original Pendulum K appliance required dental anchorage. This intro- the median suture to ensure an area with adequate bone thickness.6-8
duced reactive side effects, predominantly protrusion of the anterior teeth
(see Chapter 2).1-3 The skeletal Pendulum-K appliance incorporates minis-
CHOOSING THE ABUTMENTS
crew implants (MIs) for anchorage and thus avoids these issues. To fabri-
cate the appliance, components were selected due to their compact design Initially, the Pendulum-K appliance was anchored to the MIs through an
and ease of clinical use.4 These prefabricated components are available acrylic resin Nance button. However, this had an issue of maintaining oral
from manufacturers.5 hygiene, so an adapted abutment was developed from the Ortho-Easy
system (Forestadent, Pforzheim, Germany). This would allow direct con-
nection between the MIs and the appliance (Fig. 35.2). Alternatively, the
THE SKELETAL PENDULUM-K APPLIANCE skeletal Pendulum-K can be connected to the Benefit system (PSM Medical
Solutions, Tuttlingen, Germany) (see Fig. 33.6) or any other MI-system
The prefabricated components of the Pendulum-K, which is commercially offering abutments.
known as the Skeletal Frog Appliance (Forestadent, Pforzheim, Germany),
are customized in the laboratory. These components are comprised of a
distalization screw, a SS or TMA preformed transpalatal arch (TPA) TAKING THE ALGINATE IMPRESSION
(0.032 inch) and a hex adjustment key for intraoral activation of the screw After the abutments have been checked in the mouth, any adjustments
in the sagittal direction (Fig. 35.1). The TPA can be removed from the are made to improve attachment to the device. The abutments are then
screw housing and used separately. The appliance is activated at the ante- filled with petrolatum to provide a better fit. The molar bands are
rior end of the screw, allowing the adjustment key to be inserted sagittally selected and the abutments are placed on the MI heads (Fig. 35.2B).
into the hex, thus providing an easy method of activation intraorally during During alginate preparation, the patient holds the abutments in position.
treatment. Prior to the impression, it is suggested to put a dab of alginate on each
abutment.

CLINICAL APPLICATION
LABORATORY FABRICATION PROCEDURE
MINISCREW IMPLANTS
The molar bands and the abutments are embedded in the alginate impres-
The Pendulum-K appliance is supported by two MIs that are placed in the sion and fixed into position. A transfer MI is inserted into each coping,
anterior palate slightly mesial to the line connecting the first premolars, and the impression is poured with high-strength dental stone. This ensures

A B C D E

Fig. 35.1 Components of the skeletal Pendulum-K appliance. (A,B) Two variations of the distalization screw. (C,D) Two variations of the adjustment key for frontal or
lateral activations. (E) Preformed transpalatal arch inserted in the adjusted slot of the screw.

183
 184 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C D

E F G

Fig. 35.2 (A) The miniscrew implants (MIs) in situ. (B) Abutments and molar bands in situ before undertaking the impression. (C) Working model of high-strength dental
stone with an abutment and the molar bands. (D) Finished laboratory work with passive fitting of the transpalatal arch to the molar bands. (E) Finished laboratory work
with distal activation of the transpalatal arch. (F) Toe-in bend of approximately 5–10° to derotate the molars. (G) Uprighting activation of approximately 15–20° to avoid
distal tipping of the molars.

that the two MI heads on the cast correspond to the exact intraoral position
(Fig. 35.2C). The abutments are removed from the impression, fitted over
the MI heads and integrated into the appliance as coupling elements.
Afterwards, the abutments are soldered to the tabs of the distal screw, on
the working cast. The TPA is customized and inserted passively in the
lingual sheaths of the molar bands (Fig. 35.2D).

PREACTIVATING THE PALATAL ARCH

The skeletal Pendulum-K uses TMA wire with the K-Pendulum prescrip-
tion instead of a prefabricated SS arch. Each wire is bent into a double A B C
spring based on the Kinzinger concept (Fig. 35.2D). The end-sections have
Fig. 35.3 (A) A toe-in bend is necessary to derotate the molars during distalization.
to be initially set up with three different bends: (B) Intraoral situation at the end of treatment. (C) Superimposition of the start and
■ a distal activation (about 2N) (Fig. 35.2E) finished 3D-casts.
■ a toe-in bend to produce an antirotation effect (Fig. 35.2F
and 35.3)
■ an upright activation to counteract the tipping moment (Figs 35.2G).

Hence, the skeletal Pendulum-K appliance has the same biomechanical

control as the dental K-Pendulum. The application of the distal force, CLINICAL CONSIDERATIONS
which should be approximately 200 g, can be measured with a Correx
gauge. According to Walde,1,4 activation of the screw every 4–5 weeks (by turning
the screw three to five times) is adequate to achieve a distalization of
1–2 mm per month. A full 360° activation of the screw body opens the
appliance 0.4 mm longitudinally. Alternatively, the appliance can also be
INTRAORAL MOUNTING OF THE APPLIANCE activated with a quarter turn every 3 days by the patient him- or herself
The preactivated appliance is attached to the molars, while the abutments or a carer.
are fixed with glass–ionomer cement or with a ligature wire to the MIs of
the Ortho-Easy system. When the Benefit system is used, the abutments
are screwed. After insertion, the abutments completely cover the MI heads. CASE EXAMPLE
As the appliance has only metallic parts, it is rigid and stable, while the
elimination of an interconnecting Nance button ensures easier maintenance Fig. 35.4 illustrates activation and clinical application of the skeletal
of oral hygiene. Pendulum-K appliance.
 The skeletal Pendulum-K appliance 185

A B C

D E

Fig. 35.4 The skeletal Pendulum-K appliance to treat a patient with Class II molar relationships and ectopic maxillary canines. (A) Pretreatment. (B) Preactivated pendulum
springs on the model cast: toe-in bend, uprighting activation, and additional activation for distalization. (C) Occlusal view immediately following insertion of the
preactivated appliance and its fixation on the miniscrew implants. (D) Occlusal view after 4 months of treatment. (E) Frontal view post treatment.

2. Kinzinger GS, Wehrbein H, Diedrich PR. Molar distalization with a modified pendulum
CONCLUSIONS appliance–in vitro analysis of the force systems and in vivo study in children and
adolescents. Angle Orthod 2005;75:558.
The skeletal Pendulum-K appliance has proven to be an efficient maxillary 3. Kinzinger G, Syree C, Fritz U, et al. Molar distalization with different pendulum appli-
ances: in vitro registration of orthodontic forces and moments in the initial phase.
molar distalization device with significant clinical results. The adaptation J Orofac Orthop 2004;65:389.
from the dentally anchored appliance enables effective molar distalization 4. Walde KC. The simplified molar distalizer. J Clin Orthod 2003;37:616.
and simultaneous leveling and alignment of the maxillary dental arch 5. Ludwig B, Glasl B, Kinzinger GS, et al. The skeletal frog appliance for maxillary molar
distalization. J Clin Orthod 2011;45:77.
without reactive side effects. 6. Lombardo L, Gracco A, Zampini F, et al. Optimal palatal configuration for miniscrew
applications. Angle Orthod 2010;80:145.
7. Ludwig B, Glasl B, Bowman SJ, et al. Anatomical guidelines for miniscrew insertion:
palatal sites. J Clin Orthod 2011;45:433.
REFERENCE 8. Gracco A, Lombardo L, Cozzani M, et al. Quantitative evaluation with CBCT of palatal
bone thickness in growing patients. Prog Orthod 2006;7:164.
1. Kinzinger G, Fuhrmann R, Gross U, et al. Modified pendulum appliance including
distal screw and uprighting activation for non-compliance therapy of Class-II maloc-
clusion in children and adolescents. J Orofac Orthop 2000;61:175.
36 The bone-anchored Pendulum appliance
Beyza Hancıoglu Kircelli and Zafer Ozgur Pektas

Fig. 36.1 The bone-

INTRODUCTION anchored Pendulum
appliance in place.
The original Pendulum appliance had two main parts: the active TMA
springs, delivering a light and continuous distal force to the maxillary first
molars, and a large palatal acrylic resin Nance button that provided anchor­
age through attachment to teeth (see Fig. 2.8). The intramaxillary appli­
ance generated a distal and intrusive force to the maxillary molars and a
reciprocal mesial and extrusive force to the anchoring premolars. The
active TMA springs produced a broad swinging arch or pendulum type of
force from the midpalate to the molars.
The major concern regarding the Pendulum appliance is the anchorage
loss of the anterior teeth in terms of forward movement (see Chapter 2).
With forces applied on the molars, the reactive forces are received by the
anchoring premolars and mucosa of the palatal vault. Therefore, the reac­
tive forces emerging on the anterior anchorage segment create a mesial aerotor under copious irrigation can be used. To facilitate this detachment,
tipping and extrusion of the premolars, and consequently incisor proclina­ it is suggested that the resin plate is made no thicker than 2 mm over the
tion and increase of the overjet. This effect is in contradiction to the goals MI head and the grooves on the top of the MIs are filled with a thin layer
of treatment of Class II malocclusion at most times, particularly where of wax. Alternatively, the Nance button can be fabricated without acrylic
there is already an increased overjet or crowding of the maxillary dental resin coverage of the MIs.4
arch. In order to overcome the problem of anterior anchorage loss, in 2006,
Kircelli et al.1 modified the original Pendulum appliance by using mini­
screw implants (MIs) under the Nance button to create the the bone- CASE PRESENTATION
anchored Pendulum appliance (BAPA). A further modification combined
the pendulum springs with palatal osseointegrated implants.2 A 12-year-old girl was referred with crowding of her teeth (Fig. 36.2). She
had a skeletal Class I relationship (ANB angle, 2.1°) with dental Class II
molar and canine relationships. She had an average growth pattern, with
CLINICAL APPLICATION a Frankfort–mandibular plane angle of 27° and a sella/nasion–mandibular
plane angle of 34°. She had 7 mm crowding in the maxillary arch and mild
The BAPA is a modified Pendulum appliance that is anchored to the palatal crowding in the mandibular arch. The maxillary canines were erupted
bone by MIs, preferably two, which are located under an acrylic resin buccally. The maxillary dental midline was shifted 2 mm to the right side.
Nance button. Pendulum springs of TMA wire (0.032 inch) are fabricated She had a normal overjet and overbite of 3.7 mm and 2.3 mm, respec­
and activated in the same way as with the original Pendulum appliance. tively. Maxillary and mandibular incisor inclinations were within the
Two MIs (diameter, 2.0 mm; fixation screw length, 8 mm; IMF inter­ normal limits. Her profile was well balanced (lower lip to E-plane, 0.9 mm).
maxillary, Stryker, Leibinger, Germany) are inserted in the paramedian The treatment plan was to distalize the first molars in the maxillary arch
region of the anterior median palatal suture, 7–8 mm posterior to the to achieve a Class I molar and canine relationship and to gain space for
incisive foramen and 3–4 mm lateral to the median line (see Fig. 36.2B, the alignment of the maxillary crowding and correction of the midline
below). shift. In the mandibular arch, proximal stripping of the mandibular incisors
After soft tissue healing, impressions and casts are obtained. The MI was planned to gain the appropriate space needed for alignment of the mild
heads are blocked out with wax on the cast, and the appliance is con­ crowding. Since the maxillary and mandibular incisors presented normal
structed according to Hilgers’ descriptions,3 excluding the auxiliary wires inclinations and the profile was well balanced, molar distalization would
for dental anchorage. The appliance is checked in the mouth and the be undertaken using the BAPA (Fig. 36.2C).
springs are activated parallel to the median palatal suture. The acrylic resin Maxillary molar distalization took 7 months to achieve a super-Class I
plate is connected to the MI heads using cold-curing, methyl methacrylate- molar relationship on both sides. In addition, the first and second premolars
free acrylic resin (Ufi Gel hard, Voco, Cuxhaven, Germany). Finally, the drifted distally to a Class I relationship. Because of this spontaneous
activated TMA springs (Ormco Corp, Glendora, CA, USA) are inserted distalization, partial alignment of the maxillary anterior crowding was
into the lingual sheaths on the first molar bands (Fig. 36.1). achieved and even the midline discrepancy was spontaneously corrected
Patients should be instructed carefully on oral hygiene and regular use (Fig. 36.2D,E).
of a mouthwash. The soft tissues are checked at each appointment, when The second phase of treatment used full fixed appliances. During the
the springs can also be reactivated if necessary. uprighting process of the distally tipped molars and premolars, the BAPA
was left in place to reinforce anchorage of the newly distalized molars.
Overall treatment lasted approximately 22 months. After finishing, flat­
REMOVING THE APPLIANCE
tened and dead soft 8-braided wire (Bond-a-Braid, Reliance Orthodontics,
The only difficulty that may be experienced in removing the BAPA is in Itasca, IL, USA) was bonded to each tooth from canine to canine in both
detaching the acrylic resin plate from the MI head. A carbide bur with an maxillary and mandibular arches for retention purposes (Fig. 36.2F,G). In

186
 The bone-anchored Pendulum appliance 187

A B C

D E F G

Fig. 36.2 Treatment of a 12-year-old girl with skeletal Class I relationships with dental Class II molar and canine relationship. (A,B) Pretreatment. (C) The bone-anchored
Pendulum appliance in place. (D,E) After maxillary molar distalization, with distal drift of the premolars along with the first molars to a Class I relationship and the
spontaneous alignment of the canines. (F,G) Post-treatment.

addition, for the first 6 months after debonding, transparent thermoplastic

Table 36.1 Comparison of treatment changes between the bone-
vacuum-molded retainers were recommended to be worn at night.
anchored Pendulum appliance and the conventional Pendulum appliance
Bone anchored Conventional
Variables (mean ± SD) (mean ± SD) p valuea
DISCUSSION
No. in group 22 17
Age of patients 13.6 ± 2.1 13.6 ± 2.0
The BAPA seems to be an effective intraoral maxillary molar distalization (years)
appliance. Kircelli et al.1 reported a mean maxillary first molar distaliza­ Distalization time 6.8 ± 1.7 5.1 ± 0.9 0.010
tion of 6.4 mm in approximately 7 months, with the second and first (months)
premolars drifted distally a mean of 5.4 and 3.8 mm, respectively. This 1st molar (mm) 4.8 ± 1.8 distal mv. 2.7 ± 1.7 distal mv. 0.025
simplifies and shortens treatment. Anterior crowding can be, at least par­ 1st molar (°) 9.1 ± 4.6 distal tip. 5.3 ± 3.8 distal tip. 0.008
tially, corrected spontaneously during molar distalization, with an average 2nd premolar 4.1 ± 2.1 distal mv. 2.3 ± 2.1 mesial mv. 0.000
of 13.9 and 6.2 mm of space gain after molar distalization in the total (mm)
2nd premolar (°) 9.9 ± 5.2 distal tip. 3.8 ± 2.7 mesial tip. 0.000
maxillary dental arch and in the anterior segment, respectively.1 As the
1st incisor (mm) 1.2 ± 1.7 retrusion 0.1 ± 1.7 protrusion 0.035
BAPA is identical to the original Pendulum appliance apart from the
1st incisor (°) 1.7 ± 2.9 0.9 ± 2.4 0.034
method of anchorage, maxillary molar tipping could be expected to occur. retroclination proclination
Studies using MI-supported Pendulum appliances show various degrees
of molar tipping, from 9.1 to 14.4°.1,2,4,5 A systematic review has evaluated
the effectiveness of the distalization of molars with distalizers supported mv, movement; tip, tipping; SD, standard deviation; BAPA, bone-anchored
Pendulum appliance; CPA, conventional Pendulum appliance.
by temporary skeletal anchorage compared with tooth-borne anchorage.6 a
Significance from independent t-test.
Greater molar distal tipping was seen with the devices supported by tem­ Source: from Polat-Ozsoy et al., 2008.5
porary skeletal anchorage, which the authors suggested might be a conse­
quence of the greater pressure exerted on the molars in this method. We
also consider that the increased tipping is linked to the greater amount of Distalization with tipping is significant because some of the space
distalization achieved. This is supported by studies showing more distal created can be lost during molar uprighting when full fixed therapy is initi­
tipping with a greater molar distalization.6,7 This link could have two ated. However, the BAPA can be left in place immediately after distaliza­
causes. First, clinicians may prefer to use devices supported by temporary tion and it will then be able to maintain molar position when a continuous
skeletal anchorage for patients who need more extensive molar distaliza­ archwire is applied to upright the molars. Thus, molar position can be
tion. Second, anchorage loss, through space opening between the diverging maintained when leveling and retracting the first premolars and canines.
molars and the second premolars, in a tooth-supported system may occur This concept of “active anchorage” is helpful to cope with the anchorage
earlier in distalization and so the process would be terminated earlier, thus concerns when distalizing maxillary molars.8 Overcorrection of the molar
limiting the amount of molar tipping. A comparison of the original Pen­ relationships could also be used to support molar anchorage during full
dulum appliance with the BAPA in a group of 39 patients indicated that fixed therapy, particularly if distal tipping exists. In this context, the BAPA
4.8 mm of molar distalization and 9.1° of molar tipping was achieved in can be used to move maxillary molars to a super-Class I relationship to
6.8 months with BAPA therapy, while 2.7 mm of molar distalization and overcome the anchorage loss that takes place during the leveling and
5.3° of molar tipping was evident after 5.1 months of treatment with the anterior teeth retraction phase of treatment.
tooth-anchored appliance (Table 36.1). This supports the idea that the Some skeletal and soft tissue effects have been observed with the BAPA;
greater distal movement of maxillary molars may cause more distal tipping the cant of the palatal plane remained unchanged but the mandibular plane
of their crowns. rotated by 0.98° in a clockwise direction after molar distalization.1
 188 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Clockwise rotation can be attributed to the fact that maxillary molars move treatment of Class II patients presenting with a horizontal or average
distally into the wedge of occlusion as well as to cusp interferences. growth pattern in routine clinical practice. It is particularly useful for
Although clinically insignificant, point A moved anteriorly by 0.6 mm. borderline situations where there is usually a need to extract the maxillary
This might occur through a modeling process with reciprocal forces acting premolars. The major drawback of the appliance is the significant distal
on the anterior plate causing bone apposition at the A-point. Further studies tipping of the molar crowns, which occurs along with molar distalization.
should be conducted to test this hypothesis. No significant differences were In addition, minor mandibular posterior rotation should be taken into
observed regarding the upper and lower lip positions relative to the esthetic account when using the BAPA.
line after molar distalization with the BAPA.1 When deciding an individual treatment plan, it must be considered that
more than half of the amount of the new maxillary position achieved by
intraoral molar distalization will be lost. It is obvious, therefore, that the
COMPREHENSIVE TREATMENT OUTCOMES mandibular growth pattern is very important to maintain the achieved
Cephalometric outcomes following distalization of the maxillary molars Class I molar relationship, and patients who present a vertical growth
using the BAPA have been assessed.9 In the first distalization stage, the pattern may not be good candidates for treatment by intraoral molar dis­
maxillary first molars moved distally 4.6 mm and the second and first talization with the BAPA.
premolars drifted distally 2.9 and 2.2 mm, respectively. At the end of the
comprehensive treatment, statistically significant mesial movement of
the molars (2.8 mm) and the second premolars (1.7 mm) was observed. REFERENCES
The maxillary first molars exhibited significant distal tipping (13.0°)
during the first phase of treatment, but they were effectively uprighted in 1. Kircelli BH, Pektaş ZO, Kircelli C. Maxillary molar distalization with a bone-anchored
pendulum appliance. Angle Orthod 2006;76:650–9.
the second phase with fixed orthodontic appliances. Approximately 61% 2. Oncag G, Seckin O, Dincer B, et al. Osseointegrated implants with pendulum springs
of the molar distalization obtained in the first phase of treatment was lost for maxillary molar distalization: a cephalometric study. Am J Orthod Dentofacial
during the second phase of treatment; however, the Class I molar relation­ Orthop 2007;131:16–26.
3. Hilgers JJ. The pendulum appliance for Class II non-compliance therapy. J Clin Orthod
ship was maintained. The mesial movement detected at the end of the 1992;26:706–14.
comprehensive treatment in this study could not be totally attributed to 4. Escobar SA, Tellez PA, Moncada CA, et al. Distalization of maxillary molars with the
relapse of distalization since continuing eruption of the maxillary molars bone-supported pendulum: a clinical study. Am J Orthod Dentofacial Orthop
2007;131:545–9.
in a forward and downward direction was taking place and this may have 5. Polat-Ozsoy O, Kircelli BH, Arman-Ozcirpici A, et al. Pendulum appliances with 2
contributed to the mesial molar movement.9 anchorage designs: conventional anchorage vs bone anchorage. Am J Orthod Dento­
In patients with growth potential, the mandible outgrows the maxilla facial Orthop 2008;133:339.
6. Fudalej P, Antoszewska J. Are orthodontic distalizers reinforced with the temporary
and thus the mandibular first molars move anteriorly in most patients. skeletal anchorage devices effective? Am J Orthod Dentofacial Orthop 2011;139:
Consequently, despite the mesialization of the maxillary molars, mainte­ 722–9.
nance of the new Class I molar relationship at the end of fixed appliance 7. Antonarakis GS, Kiliaridis S. Maxillary molar distalization with noncompliance
intramaxillary appliances in Class II malocclusion. Angle Orthod 2008;78:1133–40.
therapy is probably achieved by dentoalveolar compensation and contin­ 8. Byloff FK, Kärcher H, Clar E, et al. An implant to eliminate anchorage loss during
ued normal anterior mandibular growth. molar distalization: a case report involving the Graz implant-supported pendulum. Int
J Adult Orthodon Orthognath Surg 2000;15:129–37.
9. Kircelli BH, Pektas ZO, Karan S, et al. Evaluation of the changes associated with
bone-anchored pendulum appliance after the completion of comprehensive orthodon­
CONCLUSIONS tic treatment. Turkish J Orthod 2008;21:13–24.

The BAPA presents an efficient, convenient and cost-effective Pendulum

appliance modification. It is a reasonable choice for non-compliant
 Non-extraction treatment of Class II
malocclusion using miniscrew
37
implant anchorage
George Anka and Moschos A. Papadopoulos

Another issue to be considered is the type of molar distalization approach

INTRODUCTION
needed, sequential or en masse:
Correction of Class II malocclusion with a non-extraction and non- ■ sequential distalization: initially the first and second molars are
compliance protocol may be performed either through maxillary molar distalized, then the premolars and then the anterior teeth
distalization using temporary anchorage devices such as miniscrew ■ en masse distalization: the whole maxillary arch is distalized as one
implants (MIs) and/or through mandibular advancement using intermaxil- rigid block.
lary non-compliance appliances.1
Choice between the approaches relates to the CR of the tooth or teeth to
When planning to treat Class II malocclusion without extractions, an
be distalized. As the force in en masse distalization is always located below
important issue to be considered is how far the patient’s maxillary molars
the CR of the maxillary teeth, the occlusal plane always tips with a clock-
can be distalized. Implantation of MIs is not a problem in adults unless
wise rotation in a downward direction (Fig. 37.1). In contrast, sequential
there is periodontal involvement. However, when fixed intermaxillary
distalization can avoid or minimize this tipping but at the cost of increased
non-compliance appliances are used for mandibular advancement, distali-
treatment time.
zation of maxillary molars is limited.
The final position of the molars and the inclination of the occlusal plane
This chapter discusses two non-extraction and non-compliant approaches
at the end of treatment should be considered and should be based on pre-
for the correction of Class II malocclusion using MIs as temporary anchor-
treatment imaging, with an awareness of what is suitable for that patient in
age devices and intermaxillary non-compliance devices.
terms of occlusal plane manipulation. Factors that need to be considered
include in detail the position of the occlusal plane in relation to the condylar
pathways, the form and health of both condyles, the morphology and cusp
MAXILLARY MOLAR DISTALIZATION
height of the posterior teeth, canine and anterior guidance and the patient’s
When a tooth or a group of teeth needs to be moved, the preferable move- wishes. The presence of third molars (as buds or erupted) may also limit
ment is bodily without tipping. Two factors need to be taken into consid- the amount of maxillary molar distalization, but their removal to facilitate
eration: the center of resistance (CR) of that particular tooth, or group of first molar distalization is controversial. When the second molars have not
teeth, and the location of the MI from which the forces will be applied. In yet fully erupted, distalization of the first molars with a continuous force
the maxilla, as the number of teeth to be moved increases, the CR is (e.g. using elastic chains and MIs) will also push the second molar buds
moving upward and towards the cranial base (Fig. 37.1). This issue of distally. However, this movement is uncontrolled and so their final position
balancing the location of the MI and the force application required has led is uncertain. Routine panoramic radiography is necessary to ensure that
clinicians to favor indirect force application, where the force is applied molar distalization approaches control second or third molar uprighting and
indirectly to the MI using an auxiliary or a hook. eruption in a position that will not cause significant problems in the future.
Several other issues need to be considered. Assuming that the third
molars are absent, the first and second maxillary molars can theoretically
be distalized about 8 to 9 mm, enabling an anterior teeth retraction of
CR
approximately 3–4 mm without any extractions. However, when the max-
illary anterior teeth are moved distally, their roots may touch the palatal
side of the corresponding alveolar bone and this can lead to root resorption.
Root resorption of the central incisors may also take place if their roots
Force direction are positioned too close to the anterior palatine foramen (incisive foramen).
The extent to which any arch length discrepancy can be resolved without
extractions must also be considered, including the degree of pretreatment
protrusion, the specific goals of treatment and whether expansion of the
dental arch is possible in order to gain space. Approximately 16–18 mm
could be provided by distalization. In addition, if a transversal expansion
of 10 mm is possible, the 6 mm gain in arch length will provide an addi-
tional 12 mm, giving a total of 30 mm of space that can be used to resolve
arch length discrepancy without extractions of teeth.2
A realistic treatment plan should depend on the characteristics of each
individual patient while taking into consideration these anatomical issues.

THE TRANSPALATAL ARCH PLUS HOOKS DEVICE

A transpalatal arch (TPA) with hooks soldered or attached to it (TPA-PH
Fig. 37.1 Biomechanics of the en masse distalization of the maxillary arch. device) provides an easy force application system via elastic chains

189
 190 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

(Fig. 37.2). The design and construction of the device depends on the final improve the skeletal discrepancy, the E-line (esthetic line) and thus the
occlusal plane position required. facial appearance. These treatment goals can be achieved through the use
The TPA is fabricated from an SS wire (diameter, 1 mm) and is soldered of intermaxillary non-compliance appliances.
to the bands of the first maxillary molars (Fig. 37.2A). The first molars are The Forsus Fatigue Resistant Device with Direct Push Rod (FFRD-
used to anchor the appliance since these teeth dictate the type of occlusion DPR; 3M Unitek, St. Paul, MN, USA) is a spring type (flexible) jumping
and are of significant importance when maneuvering the dental arch in appliance (see Fig. 37.4D, below). This and other types of flexible inter-
three dimensions (Fig. 37.2B). maxillary non-compliance appliances can provide a gentle way to gradu-
A full-size or close to full-size main archwire with closing loops is ally advance the mandible in a more forward position with more protection
inserted in the bracket slots of the maxillary teeth (e.g. 0.017 × 0.025 inch for the temporomandibular joint than is possible with the rigid appliances,
archwire for 0.018 inch bracket slots) (Fig. 37.2C). Both ends of the arch- which create this advancement instantly.4
wire have additional loops that are essential to control any tipping of the When using intermaxillary non-compliance appliances, it is possible to
second molars that might take place during distalization. In addition, distalize the maxillary molars in addition to the main effect of advancing
omega loops positioned mesial to the first maxillary molars are used to the mandible. However, the applied force system usually produces
control sequential or en masse distalization through linkage to the corre- unwanted labial tipping and proclination of the mandibular incisors. To
sponding attachments of the molar tubes. counteract this effect, it is recommended tthat brackets with negative
Once the treatment plan has been prepared, the exact design of the torque values are used for the mandibular anterior teeth. Alternatively, MIs
TPA-PH and the insertion position for MIs can be decided. implanted in the posterior region of the mandible may be very effective in
preventing this proclination of the anterior mandibular teeth.
Optional Designs
There are three available designs of the TPA-PH device (Fig. 37.2D–F).
DISTALIZATION OF MANDIBULAR MOLARS
The A design is simple and more easily accepted by the patient (Fig.
37.2A,D). It has hooks to facilitate placement of elastics from the MIs to In many Class II patients, there is a certain amount of arch length discrep-
the device. The length of the hooks can be adjusted depending on the ancy that has to be resolved, usually through distalization of all maxillary
biomechanics needed (e.g. bodily distalization, distalization and intrusion and mandibular teeth and/or some expansion of the dental arches.
for open bite (Fig. 37.2G) or distalization and extrusion for deep bite
(Fig. 37.2H).
The B design differs from the A design only in the number and position LINGUAL ARCH PLUS HOOKS DEVICE
of MIs used: the B design uses a single MI positioned on the midline of
Mandibular molars can be distalized using a modified lingual arch in
the palate (Fig. 37.2D,J), while the A design uses two MIs positioned
combination with MIs for indirect force application, the so-called Lingual
inter-radicularly on either side of the palate (Fig. 37.2E).
Arch Plus Hooks (LA-PH) device (Fig. 37.3). This incorporates two can-
With the B design, the force direction cannot be changed and so control
tilevers that are soldered on the buccal surfaces of the mandibular first
and manipulation of the occlusal plane is restricted. Where a differential
molar bands and extend to the area of the first premolars. The mesial ends
force application is needed to distalize the maxillary right and left molars
of these cantilevers are bent to form hooks, which are used to apply the
asymmetrically, the C design is recommended (Fig. 37.2F,I). This design
distalization forces from the MIs. This system facilitates differential force
uses a combination of a miniplate (Beneplate, PSM Medical Solutions,
application in order to control the vertical dimension of the molar move-
Tuttlingen, Germany) and two MIs with caps to secure the miniplate. The
ment depending on the specific needs. Depending on the point of force
miniplate incorporates an extended wire (diameter, 1.1 mm) that is sol-
application, on the hooks or on the distal aspect of these cantilevers, molar
dered at its distal end. Two hooks are bent at both ends of this wire, which
intrusion (Fig. 37.3C) or extrusion (Fig. 37.3D) can take place simultane-
can be positioned in different positions on the palate according to the
ously to the distalization of mandibular molars.
biomechanical needs of the patient.3
The MIs are inserted inter-radicularly on the buccal side of the alveolar
process between the roots of the first molars and second premolars, near
Insertion Position for Miniscrew Implants the mucogingival junction and usually about 8 mm below the cervicogin-
The preferred location for inter-radicular MIs is the alveolar bone area gival line. If there is insufficient space, more space can be created by
between the roots of the maxillary first molars and second premolars, where leveling and aligning the mandibular dental arch, an alternative site can
there is a wide interdental root space. The MIs are inserted, on average, be selected or miniplates can be considered for anchorage. Some women
5–7 mm from the cervicogingival line, although 11 mm distance may be have a high mandible plane angle, which makes inter-radicular implanta-
needed in some patients, depending on the alveolar bone volume and the tion difficult.
position of the maxillary sinus. Occasionally the maxillary sinus extends The system requires that the mandibular first molars are already aligned
too far down to make insertion of MIs feasible. If there is not adequate within the arch, and that left and right molars are parallel to each other.
alveolar bone for the implantation of MIs, the midline of the anterior area Therefore, conventional fixed orthodontic appliances are placed initially
of the palate can be used (Fig. 36.2I,J). In young adults, the midpalatal in order to level and align the mandibular dental arch so that the roots of
suture is not fully ossified and placement in the paramedian region, about the teeth are parallel, sufficient space for MI placement is available and
3–6 mm away from the midpalatal suture, is recommended. left and right first molars are also parallel to each other. The LA-PH device
is bonded with the lingual arch acting as a rigid fixation of the molars,
thus allowing their distalization as a group. Placement of hooks directly
MANDIBULAR ADVANCEMENT USING INTERMAXILLARY on the main archwire to start molar distalization earlier may be an option,
NON-COMPLIANCE APPLIANCES but it should be avoided as it is usually associated with molar tipping.
There are some limitations concerning the extent of molar distalization
In Class II with mandibular deficiency, the treatment of choice is the in the mandible as in the maxilla. The main limitations include the bone
advancement of the mandible to a more forward position in order to of the mandibular ramus and the soft tissues in front of it. The distance of
 Non-extraction treatment of Class II malocclusion using miniscrew implant anchorage 191

A B C

* * *

D E

G
*
*
*

F H

I J

Fig. 37.2 The Transpalatal Arch Plus Hooks device. (A,B) The standard device. (C) The maxillary archwire with closing loops used for molar distalization. (D-F) The three
designs: A design (D) B design (E) and C design (F). (G,H) The Transpalatal Arch Plus Hooks device as it is used for maxillary molar intrusion (G), and maxillary molar
extrusion (H). (I,J) The C design supported by two miniscrew implants (I) and the B design supported a single one on the midpalatal suture (J).
 192 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

* *

A
B

*
*

C D
Fig. 37.3 The Lingual Arch Plus Hooks device. (A) Construction of the device. (B) Placement. (C) Biomechanics in mandibular molar distalization and intrusion.
(D) Biomechanics in mandibular molar distalization and extrusion.

the distal surface of the second molars from the surface of the ramus soft patient had passed his growth peak, intermaxillary non-compliance appli-
tissues increases with age; consequently, mandibular molar distalization is ances could be used to take advantage of the remaining growth of the
less effective in young patients. The use of laser devices to cut the soft mandible. It was, therefore, decided to use the FFRD-DPR in order to
tissues distally to the second molars, particularly in young patients, may advance the mandible to a more forward position, gaining a maximum of
provide some millimeters of space, but this should be performed very 4 mm toward mesial. This would decrease the need for maxillary molar
carefully in order to avoid creation of gingival pockets, which would distalization to a total 11 mm (19 mm less 2 × 4 mm), a distalization of
facilitate food impaction and periodontal inflammation. 6.5 mm per side, which is considered a moderate molar movement.
Expansion of the maxillary dental arch was also planned in order to gain
some additional space to further decrease the need for pure maxillary
CLINICAL EXAMPLES molar distalization. Finally, since the patient presented with a deep bite,
an increase of the vertical dimension by opening the bite would be advan-
Two cases are presented that the treatment approaches described above tageous, and so retraction of the maxillary teeth was planned, with some
have been used: a patient presenting a Class II, division 1 malocclusion extrusion of the maxillary molars.
with maxillary protrusion and a patient with Class II malocclusion, subdi-
vision left.
Treatment Course
Following insertion of conventional fixed appliances, a Hyrax appliance
CASE 1: CLASS II, DIVISION 1 MALOCCLUSION WITH was used to expand the maxilla (Fig. 37.4C). An FFRD-DPR exerting a
MAXILLARY PROTRUSION force of 180 g per side was used for 1 year (Fig. 37.4D). During this
period, a TPA-PH device modification was used, where the elastic chain
A 14-year-old boy presented with a chief complaint of maxillary protru- was used to generate a force to distalize and extrude the molars simultane-
sion, which did not allow proper lip closure. He had a symmetric face and ously (Fig. 37.4E). Two MIs were inserted in the palatal alveolar bone
a convex facial pattern with a deep labiomental sulcus and a retruded between the roots of the first molars and the second premolars and the
mandible. He could only close his lips by straining the orbicularis oris elastic chain was strapped around the anterior omega loop of the TPA,
muscle complex. He had a bilateral Class II molar relationship (Fig. exerting a force of 300 g. On the frontal part of the TPA, a pearl was used
37.4A,B), an overjet of 10 mm and an overbite of 7 mm. He had an arch to provide non-compliant tongue position training, as well as to enable the
length discrepancy of 7 mm in the maxilla and 11 mm in the mandible. patient to position his tongue away from the anterior teeth, which could
The boy showed little interest in maintaining his oral hygiene, which was decrease the distalization capacity of the device. Tongue myofunctional
a reason to have as short as possible treatment time. training was also prescribed but the patient was not cooperative.
Prior to the initiation of treatment, three-dimensional CT was performed The TPA-PH device, the MIs and the fixed appliances were removed
in order to determine the amount of movements needed to correct Class II after 2 years of total treatment time, when a good posterior intercuspation
into Class I molar relationship. The results indicated that the maxillary and a well-functioning and stable occlusion were established (Fig. 37.4F,G).
molars had to be distalized 6 mm on each side, resulting in a total movement Superimposition of the cephalometric tracings before and after treat-
of 12 mm. Together with the 7 mm of arch length discrepancy in the maxil- ment and cephalometric analysis show that the bite was opened after
lary arch, this meant that a total of 19 mm of space was needed in order to treatment, as a result of a clockwise rotation of the occlusal plane as well
correct the Class II relationship. Each molar needed to be distalized approxi- as of the mandible (Fig. 37.4H). This clockwise rotation positioned the
mately 9.5 mm, which is considered very difficult to achieve. Although the mandible further backwards but this was counteracted by the FFRD-DPR,
 Non-extraction treatment of Class II malocclusion using miniscrew implant anchorage 193

A B C D

E F G

Fig. 37.4 Case 1: Class II, division 1 malocclusion with maxillary protrusion. (A,B) Pretreatment. (C) Occlusal view of the maxillary arch following application of fixed
appliances and a Hyrax expansion device. (D) Application of the Forsus Fatigue Resistant Device with Direct Push Rod. (E) Application of the Transpalatal Arch Plus Hooks
device for molar distalization and extrusion. (F,G) Post-treatment. (H) Superimposition of the cephalometric tracings before (black) and after treatment (red) on the
sella–nasion line.

which also advanced the mandible to a more forward position after Table 37.1 Cephalometric evaluation
treatment.
Variables Before treatment After treatment
The maxillary left molar was distalized 2.4 mm and the right 4.6 mm.
This distalization was enough to correct the Class II malocclusion since Facial angle (°) 84.8 86.7
Convexity (°) 0.8 0.9
the remaining discrepancy was corrected through the mandibular advance-
A-B plane (°) −5.1 1.0
ment produced by the FFRD-DPR (Fig. 37.4D) (Table 37.1). In order to
Y-axis (°) 62.9 62.9
avoid relapse of the deep bite under the heavy forces of the masticatory
FH to SN (°) 7.4 6.8
muscles, composite build-ups were bonded on the palatal sides of the
SNA (°) 77.7 80.3
maxillary central incisors (Fig. 37.4E). The size of these build-ups was
SNB (°) 75.7 80.5
kept to minimum in order just to prevent the relapse and not to actively
ANB (°) 2.0 −0.2
intrude the anterior teeth.
N-Pg to SN (°) 77.4 79.9
Nasal floor to SN (°) 7.9 6.2
Treatment Results Nasal floor to FH (°) 0.4 −0.6
ML to SN (°) 29.0 30.2
The extraoral and intraoral treatment results (Fig. 37.4G,H) were good in ML to FH (°) 21.6 23.4
spite of the lack of cooperation from the patient during treatment. The Ramus plane to SN (°) 94.3 94.8
patient and his parents were very satisfied with the treatment outcome. Ramus plane to FH (°) 86.8 88.1
After completion of treatment, a lingual fixed retainer was bonded on Gonial angle (°) 114.7 115.3
the mandible and a maxillary removable clear plastic retainer was given U1 to SN (°) 119.6 105.1
to the patient for retention purposes. Despite instructions, the patient did U1 to FH (°) 127.1 111.9
not attend routine check-ups. L1 to ML (°) 95.7 97.6
Interincisal angle (°) 115.7 127.1
OP-SN (°) 12.8 14.1
CASE 2: CLASS II MALOCCLUSION, OP-FH (°) 5.4 7.4
SUBDIVISION LEFT

A 26-year-old woman presented with a chief complaint of crowding of her crowding of the maxillary anterior teeth, moderate crowding of the man-
anterior teeth and lack of confidence because of her malocclusion. Although dibular anterior teeth and deviation of the mandibular midline to the left
she was charming, she did not like to smile and tried to prevent exposure (Fig. 37.5A–C).
of her anterior teeth. The patient expressed her desire to receive an orthodontic treatment that
She had a Class II malocclusion, subdivision left (a Class I molar rela- would not alter her facial appearance. After discussing some alternatives,
tionship on the right side and a Class II on the left side), moderate to severe including the use of intermaxillary non-compliant devices or the use of
 194 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C

D E F G

H I J

Fig. 37.5 Case 2: Class II malocclusion, subdivision left. (A–C) Pretreatment. (D) The maxillary arch showing the insertion position of the four miniscrew implants (MIs) and
of the modified Transpalatal Arch Plus Hooks device. (E) The maxillary arch showing the bone-borne Hyrax expansion device attached to the MI heads and elastic chains
for distalization of the maxillary molars. (F) Placement of the Lingual Arch Plus Hooks device, insertion of the MIs and the application of elastic chains for distalization of
the mandibular molars. (G) Insertion position of the two MIs for anterior teeth intrusion. (H–J) Post-treatment.

lingual appliances, the following non-extraction treatment approach was premolars in order to correct anterior crowding by distalizing the man-
agreed and executed. dibular molars (Fig. 37.5F). Elastic chains were attached between the MIs
and the hooks of the LA-PH. The force generated was 200 g per side.
Full-size archwires were used during mandibular molar distalization. Dis-
Treatment Course
talization of the mandibular molars was necessary to avoid labial proclina-
Following placement of conventional fixed appliances, a modified TPA-PH tion of the mandibular incisors, resulting in an anterior crossbite and an
device was placed in the maxilla in order to distalize the maxillary molars adverse effect on facial appearance. Because of the slight open bite ten-
(Fig. 37.5D). dency, intrusion of the molars was also performed during distalization,
Expansion of the maxillary arch was necessary to resolve crowding. while myofunctional treatment was also prescribed.
However, because the midpalatal suture was already ossified, it was Some degree of canting of the occlusal plane was detected during the
decided to use a Hyrax appliance (Fig. 37.5E) anchored on four MIs orthodontic treatment when the patient was smiling. The canted occlusal
(two on each side of the palate) (Fig. 37.5D) and not a tooth-borne plane was caused probably by the asymmetric positions of the maxillary
device. The maxillary sinus was positioned downward and very close to and mandibular dental arch. Smile was also affected by the constriction of
the roots of the maxillary teeth, probably a result of chronic maxillary the risorius muscle on the right corner of her mouth, making it asymmetri-
sinusitis, which made MI placement very difficult. Because of the defi- cal. In addition, an asymmetric gummy smile was detected during treat-
cient bony support, it was decided to use the bone-anchored Hyrax ment, since gingival exposure of the right side of her mouth was more
device already in place to apply the distalization forces during the expan- pronounced. To eliminate this problem, myofunctional therapy, facial
sion procedure by incorporating hooks on its distal aspect. Thus, both the massage and training were prescribed, while progressive intrusion of the
expansion and the distalization devices were constructed and inserted in maxillary incisors was also performed. This was done by intrusion of the
such a way as to facilitate both distalization and expansion of the maxil- anterior teeth using anchorage of two MIs in the frontal area of the maxil-
lary dental arch (Fig. 37.5D,E). Two elastic chains were used on each lary alveolar bone between the roots of the lateral incisors and the canines
side of the palate, attached to the hooks of the Hyrax appliance and to (Fig. 37.5G). These measures were successful in correcting both the
the hooks on the anterior part of a TPA-PH, producing a distalization gummy smile and the canted occlusal plane.
force of approximately 250 g per side. An expansion of 8 mm in the area
of the first molars was achieved.
Treatment Results
Following placement of fixed appliances on the mandibular arch and
initial alignment, a standard LA-PH device was used in combination with After 1 year and 8 months of treatment, a bilateral Class I molar and canine
two MIs inserted between the roots of the first molars and the second relationship with optimal alignment of both maxillary and mandibular
 Non-extraction treatment of Class II malocclusion using miniscrew implant anchorage 195

teeth was obtained, plus a well-intercuspated and stable occlusion. Ideal skeletal structures. Therefore, clinicians should remain aware of the limita-
overjet and overbite were also achieved. Anterior crowding of both arches tions of such treatments, as well as of the biological limitations that govern
and midline deviation were also corrected (Fig. 37.5H–J). tooth movements.
The post-treatment extraoral photographs showed no significant change Patients’ expectations of treatment outcomes and treatment times vary
of the patient’s profile, as she had wished. The treatment results achieved and this must be taken also into consideration. While the use of MI-anchored
were within the initial treatment goals and the patient was very satisfied devices can enable complex situations to be treated without extractions
with her final dental and facial appearance, particularly because no extrac- and in a more predictable way, a longer treatment time is usually needed,
tions and no significant soft tissue profile changes were performed. which is sometimes beyond the expectations of patients.
After completion of treatment, the patient rediscovered her confidence Finally, not all Class II patients can or should be treated by non-
and started to smile again without any psychological restrictions. extraction approaches. In some cases, such as in severe Class II malocclu-
sion or with increased arch length discrepancies, extraction of teeth still
remains a treatment option not only to achieve but also to retain an appro-
CONCLUSIONS priate treatment result.

Non-extraction Class II correction can now be performed using intermaxil-

lary non-compliance appliances and MIs even in adults. Further, the com- REFERENCES
bined use of MI-supported treatment and expansion of the maxillary arch
may at least theoretically provide sufficient space to resolve arch length 1. Papadopoulos MA, editor. Orthodontic treatment for the Class II non-compliant patient:
current principles and techniques. Edinburgh: Elsevier-Mosby; 2006.
deficiency. The use of MI-anchored devices can facilitate camouflage 2. Anka G, Aonuma M. TAD (temporary anchorage device) use in distalizing molars.
orthodontic treatment of patients with orthognathic problems, who previ- Tokyo Orthod J 2009;19:169–78.
ously had to be treated surgically. However, it should be noted that, when 3. Wilmes B, Drescher D, Nienkemper M. A miniplate system for improved stability of
skeletal anchorage. J Clin Orthod 2009;43:495–501.
providing a camouflage treatment, only the teeth and the corresponding 4. Anka G. Management of non-compliant Class II, division 1 extraction cases with
alveolar bone are moved in order to restore oral function, esthetics and jumping appliance Forsus DPR: a suggestion of the use of Gurin lock and anterior fixed
self-esteem for the patient; there is no change to modify the underlying bite plate. Ortodontia 2004;9:122–33.
38 Treatment of skeletal origin
gummy smiles with miniscrew
implant-supported biomechanics
James Cheng-Yi Lin, Leslie Yen-Peng Chen, Eric Jein-Wein Liou and S. Jay Bowman

■ Gingival exposure during maximum posed smile (measured from

INTRODUCTION
the gingival margins to the lower border of the upper lip), clinical
Improving the “smile line” is one aspect of esthetic enhancement that may crown lengths and pocket depths of the maxillary anterior teeth,
benefit from orthodontic treatment. The excessive exposure of gingival activity of the elevator muscles of the upper lip, philtrum length,
tissue upon smiling, the gummy smile, may, in fact, be a patient’s chief age, sex, as well as individual craniofacial features must also be
complaint.1 Since gingival display can be caused in a number of ways, considered.
proper diagnosis is critical prior to embarking upon any resolution Wu et al. recommend the following four diagnostic measurements to facil-
(Table 38.1).2–4 Although surgical approaches may be effective for some itate diagnosis.5 With all of these, the patient’s age, sex and personal
etiologies, this is not always acceptable to patients, and this has stimulated preference will be modifying factors that need to be considered.
interest in alternative treatment methods.
■ Amount of maxillary incisor display with the upper lip at
The use of tooth movements supported by miniscrew implant (MI)
rest. This should ideally be 2 mm and is used as a reference to
anchorage has become more refined and widely accepted. This chapter
avoid overintruding the maxillary anterior teeth.
describes an innovative non-orthognathic approach using MI-supported
■ The clinical crown lengths and periodontal pocket depths of the
biomechanics, with or without alveoloplasty (periodontal plastic surgery),
maxillary central incisors. The length of a maxillary central
to resolve the skeletal origin gummy smile in adults.
incisor is typically 9.5–11.2 mm for pleasing tooth proportions.6,7
The pocket depths of healthy incisors should be no more than
3 mm. These measurements are important (1) to determine if the
DIAGNOSIS
excessive gingival display is a result of altered passive eruption
A number of factors need to be considered in the management of skeletal and/or gingival inflammation, (2) to estimate how much maxillary
origin gummy smile.5 anterior intrusion is required, and (3) to determine the optimal
clinical crown lengths and relative gingival margins of the other
■ Skeletal Class II malocclusion and vertical growth pattern, as maxillary anterior teeth by using the maxillary central incisor as a
opposed to skeletal Class III malocclusion or horizontal growth reference.
pattern, is associated with a gummy smile and can be deemed as the ■ The distance between the gingival margins of maxillary anterior
representative facial morphology. teeth and upper lip in the maximum posed smile. More than a
■ Retrusive mandible, excessive anterior maxillary height, labially 2 mm continuous band of gingival exposure during maximum posed
inclined maxillary incisors and upper lip, plus a significant overjet smile may be considered as excessive. This measurement is also
and overbite, are obvious in patients with a gummy smile. The cant important in determining if the gingival display is muscular in
of the palatal plane is not a factor. The actual length of upper lip is origin if the patient exhibits normal clinical crown lengths and
usually the same or longer than normal, but the ratio of upper lip pocket depths of maxillary anterior teeth.
length to anterior maxillary height is often reduced. ■ The distance between the palatal plane and tip of maxillary incisor
edge. The average value of the upper incisor–palatal plane
Table 38.1 Possible etiology and treatment strategies of excess (U1–PP) cephalometric variable is 31.0 ± 2.34 mm. Patients may
gingival display (gummy smile) simply be “long in the tooth” compared with the palatal plane.
Origin Etiology Treatment strategy Commonly, patients with a skeletal origin gummy smile have a combina-
Dental Plaque- or drug-induced Gingivectomy/gingivalplasty tion of the last two criteria. The first two measurements are used to deter-
gingival enlargement Mucogingival surgery
Altered/delayed passive combined with
mine if there are other etiological factors contributing to the excessive
eruption alveoloplasty (re-establish gingival display.
Retroclined maxillary ideal biological width)
incisors Torque control
Skeletal Vertical maxillary excess Orthognathic surgery +
orthodontic treatment
CLINICAL APPROACH
Muscular Hyperactivity of the Lip surgery
elevator muscle of Cartilage spacer/silicone MINISCREW IMPLANTS
upper lip (hypermobile laid; V-Y cheiloplasty;
lip) Botulinum toxin type A The LOMAS orthodontic MI system (Lin/Liou OrthodonticMini Anchor
Short upper lip length injection System, Mondeal Medical Systems, Tuttlingen, Germany) comprises a
(philtrum length) Botulinum toxin; myotomy series of self-tapping and self-drilling titanium alloy MIs (diameters, 1.5,
of the levator labii
superioris muscle 2.0 and 2.3 mm; lengths, 7.0, 9.0, 11.0 and 13.0 mm).8–10 The variety of
Combination Combination etiologies Combination treatment sizes and designs allows flexibility in insertion site and biomechanics. Two
designs of MI head are available: the Hook screw and the Quattro screw.

196
 Treatment of skeletal origin gummy smiles with miniscrew implant-supported biomechanics 197

Table 38.2 Four types of miniscrew implant-supported treatment biomechanics for skeletal origin gummy smile correction
Anterior implant sites
Biomechanics and MI size Posterior implant sites and MI size Force delivery
Type 1 direct anchorage with Interseptum bone between Interseptum bone between upper 5&6 Intrusion–retraction
alveoloplasty (Case 1) upper 1&2 (Hook screw L, (Quattro screw L, 9.0 mm; D, 2.0 mm) forces: coil springs/
9.0 mm; D,1.5 mm) Infrazygomatic crest (Quattro screw L, power chains
Interseptum bone between 9.0–11 mm; D, 2.0 mm)
upper 2&3 (Hook screw L, Alveolar ridge without teeth (Hook/Quattro
9.0 mm; D, 1.5 mm) screw L, 9.0–11 mm; D, 1.5–2.0 mm)
Type 2 indirect anchorage with Interseptum bone between upper 5&6 Intrusion forces:
alveoloplasty (Case 2) (Quattro screw L, 9.0 mm; D, 2.0 mm) segmented level arms
Infrazygomatic crest (Quattro screw L, (0.017 × 0.025” TMA
9.0–11 mm; D, 2.0 mm) wires)
Alveolar ridge without teeth (Hook/Quattro Retraction forces: coil
screw L, 9.0–11 mm; D, 1.5–2.0 mm) springs/power chains
Type 3 indirect anchorage Interseptum bone between upper 5&6 Intrusion forces:
without alveoloplasty (Quattro screw L, 9.0 mm; D, 2.0 mm) segmented level arms
(Case 3) Infrazygomatic crest (Quattro screw L, (0.017 × 0.025” TMA
9.0–11 mm; D, 2.0 mm) wires)
Alveolar ridge without teeth (Hook/Quattro Retraction forces: coil
screw L, 9.0–11 mm; D, 1.5–2.0 mm) springs/power chains
Type 4 direct anchorage Interseptum bone between Interseptum bone between upper 6&7 Intrusion forces: power
without alveoloplasty upper 2&3 (Screw size L, (Screw size L, 8.0 mm; D, 1.6 mm) chains
(Case 4) 6.0 mm; D, 1.6 mm)

D, diameter; L, length; MI, miniscrew implant.

The Hook screw features a simple hook on the top of the MI head, similar CASE 1: DIRECT ANCHORAGE WITH
to a molar hook, for the application of forces (e.g. elastic chain, thread or ALVEOLOPLASTY FOR EXCESS GINGIVAL
coil springs). The Quattro screw has a head with a rectangular slot and an EXPOSURE DURING SMILING
edgewise tube (0.018 × 0.025 inch or 0.022 × 0.028 inch) to permit the
insertion of rectangular segmented wires to utilize indirect anchorage A 26-year-old woman presented with the chief complaint of excess gingi-
while elastic chains or superelastic coil springs can be attached at the same val exposure during smiling (Fig. 38.1A). She exhibited more than 7 mm
time. This allows the MI to serve two purposes. of gingival exposure in her posed smile, along with a convex profile, an
acute nasolabial angle, retrognathic chin, short upper lip and a degree of
lip incompetence. She had a Class II canine and molar relationship, 11 mm
TREATMENT BIOMECHANICS of overjet, a 4 mm overbite and multiple missing teeth (Fig. 38.1D,E). The
The authors have developed four types of MI-supported biomechanics to clinical crown lengths of the maxillary central incisors and other anterior
treat skeletal origin gummy smile (Table 38.2): teeth were all obviously shorter than normal values. The gingival margins
of all maxillary anterior teeth stayed almost at the same level. The pocket
■ type 1: direct MI anchorage with alveoloplasty (e.g. Case 1) depths of the maxillary anterior teeth were between 1.0 and 3.0 mm, with
■ type 2: indirect MI anchorage with alveoloplasty (e.g. Case 2) no gingival inflammation. Cephalometric analysis indicated skeletal Class
■ type 3: indirect MI anchorage without alveoloplasty (e.g. Case 3) II relationships, while the U1–PP distance (39.0 mm) was significantly
■ type 4: direct MI anchorage without alveoloplasty (e.g. Case 4). larger than the norm. It was determined that her excessive gingival display
There are four issues to consider when selecting which type to use in a had both skeletal and dental origin, while any contribution of the muscular
particular clinical situation. system could not be determined.
As part of informed consent, two treatment options were discussed
■ Is there sufficient inter-radicular space to safely insert the MI with the patient. The first option included traditional orthodontic treat-
between the roots of teeth? This is particularly significant when MIs ment in combination with Le Fort I osteotomy to “impact” or shorten the
are to be placed in the anterior alveolus for direct anchorage support height of the maxilla, thereby reducing the gingival display in the posed
of intrusion forces.11 smile. The second option involved no orthognathic surgery but used
■ Will the MIs produce severe irritation of the lip and/or vestibular MI-assisted direct anchorage to produce intrusive forces to the maxillary
mucosa? dentition. This would, in turn, reduce the amount of gingiva exposed
■ Do the clinical crowns of the teeth to be intruded exhibit favorable during smiling. After reviewing the risk–benefits of both options, the
height to width ratio? patient gave her informed consent to the more conservative and less
■ Would any excess and/or irregular bony protuberances above the invasive method.
maxillary anterior teeth be noticed, thereby being indicative of Treatment was initiated with fixed preadjusted appliances to level and
requiring post-orthodontic alveoloplasty? align the dentition. After 5 months, two Quattro MIs (diameter, 2 mm;
length, 7 mm) were inserted into the bilateral alveolar ridges and two
Hook MIs (diameter, 1.5 mm; length, 9 mm) were placed into the alveo-
CASE EXAMPLES lar bone between the maxillary lateral incisors and canines above the
root apices.
The following case examples illustrate the four types of MI-supported Immediately after MI insertion, a retraction force of approximately
biomechanics. 200 g was applied through power chains connected from the bilateral
 198 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Fig. 38.1 Case 1: direct anchorage with

alveoloplasty. (A,D,E) Pretreatment showing excess
gingival exposure during smiling. (F,G) LOMAS
miniscrew implants (MIs) inserted for retraction and
intrusion of the maxillary anterior teeth with power
chains extending from the MIs to hooks on the
upper archwire. (H) Overjet and overbite before
treatment. (I) Intrusion and retraction of the
maxillary anterior teeth at 15 months of treatment.
(B,J,K) Final treatment result. (L) Superimposition of A B C
the pretreatment (black line) and post-treatment
(red line) cephalometric tracings. (C) Post-retention
view. (M) Superimposition of the post-treatment
(red line) and post-retention (black line)
cephalometric tracings.

D E F

G H I J

K L M

posterior MIs to hooks on the upper archwire, positioned between the later- months to resolve the patient’s chief complaints and to achieve the
als and canines. An intrusive force of 50 g was also applied from the “orthognathic-like” treatment effects.4
anterior MIs to the same hooks (Fig. 38.1F,G). The intent was to both After 45 months of post-treatment retention, the facial profile, smile line
intrude and en masse retract the maxillary dentition to correct the Class II and occlusion were favorable despite a slight amount of labial movement
relationship and improve the smile line. of the maxillary incisors (Fig. 38.1C,M).
Fifteen months later, the patient’s original severe gummy smile and
overjet were substantially improved. Unfortunately, the clinical crown
lengths of the maxillary anterior teeth had decreased as the teeth were
intruded or “buried” in the gingiva, which was an unintended (but antici-
CASE 2: INDIRECT ANCHORAGE WITH ALVEOPLASTY
pated) side effect (Fig. 38.1H). In addition, an excess protuberance of
FOR SIMULTANEOUS REDUCTION IN GUMMY SMILE
alveolar bone near the gingival margin was noted both intraorally and in
AND VERTICAL DIMENSION
a lateral cephalometric radiograph (Fig. 38.1I). Because of these iatrogenic A 21-year-old woman did not like her protrusive profile and excess gingi-
changes, alveoloplasty was recommended to eliminate the excess alveolus val display when smiling. She exhibited a convex profile, acute nasolabial
and improve the clinical crown length. Specifically, the gingival margins angle, retrusive chin, short upper lip length and a mentalis strain upon lip
of the maxillary anterior teeth were coordinated with the lower border of closure. More than 3 mm of gingival display was apparent in her posed
the upper lip in her posed smile. smile. She had bilateral Class I canine and molar relationships, mild ante-
After periodontal procedures had taken place, a dramatic esthetic rior bimaxillary crowding without periodontal involvement, and 2 mm
improvement in the patient’s smile was obvious when compared with her overjet and overbite (Fig. 38.2A,D). The clinical crown lengths of her
pretreatment photographs (Fig. 38.1B,J,K). The gingival margins of the maxillary central incisors and of other anterior teeth were normal, but the
maxillary anterior teeth were coordinated with the lower border of the gingival margin of the maxillary right lateral incisor was uneven. The
upper lip in her smile. Her original gummy smile had been corrected probing depths of the periodontal pockets of the maxillary anterior teeth
without undergoing orthognathic surgery. were no more than 3 mm, and the gingiva was healthy. She had skeletal
Superimposition of the cephalometric tracings demonstrated significant Class II relationships, a significantly obtuse mandibular plane, a retro­
retraction and intrusion of the maxillary teeth (Fig. 38.1L), while the U1– gnathic chin and flared mandibular incisors. Both maxillary and mandibu-
PP was reduced from 39.0 to 34.5 mm. Despite substantial tooth move- lar incisors and molars were substantially erupted. The etiology of the
ment, only minor root resorption of the maxillary incisor apices was noted excessive gingival display appeared to be skeletal in origin (U1–PP,
in the post-treatment periapical radiographs. Total treatment time was 20 36.5 mm) (Table 38.3).
 Treatment of skeletal origin gummy smiles with miniscrew implant-supported biomechanics 199

A B C

D E F G

H I J K

L M N O

Fig. 38.2 Case 2: indirect anchorage with alveoloplasty. (A,D) Pretreatment. (E–H) Simultaneous en masse
anterior intrusion/retraction for both arches along with upper posterior intrusion; all supported with miniscrew
implant (MI) anchorage. (I) The mandibular arch following insertion of buccal Quattro and lingual Hook MIs.
(B,J,K,L) Post-treatment. (C,M,N,O) Post retention views. (P) Superimpositions of the pretreatment (black line) and
post-treatment (red line) cephalometric tracings on the anterior cranial base.

The patient was diagnosed with a Class I malocclusion with underlying anchored mechanics to produce “orthognathic-like” treatment effects. At
Class II skeletal relationships, a hyperdivergent long-face pattern, a retro- the conclusion of informed consent, the patient chose the non-surgical
gnathic chin and a gummy smile resulting from vertical maxillary excess. alternative.
The treatment objectives were (1) to improve the gingival display, (2) Indirect MI anchorage mechanics were used in both dental arches for
to improve the facial appearance by maximum retraction of the anterior three reasons: (1) the gummy smile, vertical dimension and mandible
teeth, (3) to reduce the lower anterior facial height, and (4) to permit autorotation could be addressed simultaneously; (2) simultaneous intru-
autorotation of the mandible to improve the chin projection. sion and retraction forces could be applied from the same MIs; (3) increased
Two treatment options were presented to the patient: an orthodontic/ mandibular autorotation was anticipated to improve the retruded chin
orthognathic surgical approach, and a non-surgical approach using MI- position.
 200 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Superimposition of the cephalometric tracings confirmed significant

Table 38.3 Case 2: cephalometric data
retraction and intrusion of the maxillary and mandibular anterior teeth,
Variables Pretreatment Post-treatment
which were accompanied by a significant amount of intrusion of the maxil-
SNA (°) 80 79.5 lary posterior teeth (Fig. 38.2P). The entire maxillary dentition appears to
SNB (°) 72.5 73 have been retracted and intruded, much like that achieved by orthognathic
ANB (°) 7.5 6.5 surgery. The mandibular molars were moved mesially into the extraction
MPA (°) 49 46
sites but without extrusion. The U1–PP improved from 36.5 to 32.5 mm;
U6-PP (mm) 27.5 25.0
U6–PP changed from 27.5 to 25.0 mm, and the mandibular plane decreased
U1-PP (mm) 36.5 32.5
3.0°. The chin projection was improved by the counterclockwise rotation
L6-MP (mm) 39.0 39.0
of the mandible. Thirty-three months after completion of treatment, there
L1-MP (mm) 52.0 50.0
was minimal change in incisor position (Fig. 38.2C,M,N,O).

MP, mandibular plane; PP, palatal plane.

CASE 3: INDIRECT ANCHORAGE WITHOUT
ALVEOLOPLASTY FOR PROTRUSIVE MAXILLARY
Both dental arches were bonded with preadjusted fixed appliances for ANTERIOR TEETH AND A GUMMY SMILE
initial leveling and alignment. Four first premolars were extracted to
A 16-year-old girl presented with chief complaints of protrusive maxillary
provide space to permit retraction of the anterior dentition in order to
anterior teeth and a gummy smile. She had a convex profile, protrusive
reduce bimaxillary protrusion. In addition, all third molars were also
upper lip, recessive chin, lip incompetence and mentalis muscle strain. She
extracted.
also had 6 mm of gingival display in her full smile and the maxillary
Four months later, six MIs were placed in the maxillary arch and two
midline was coincident to her facial midline (Fig. 38.3A).
in the mandibular arch: two Quattro MIs (diameter, 2.0 mm; length, 7 mm)
Her lower dental midline deviated 2 mm to her right side; the molar
bilaterally between the roots of the maxillary second premolars and first
relationship on the right side was Class II and on the left side was Class
molars; two Hook screws (diameter, 1.5 mm; length, 9 mm) in the buccal
I (Fig. 38.3C). The overjet was 6 mm, while the overbite was 3 mm. Both
alveolus between the maxillary first and second molars; two Hook screws
the maxillary and mandibular dental arch forms were ovoid and symmetri-
(diameter, 2.0 mm; length, 7 mm) in the paramedian palatal area (2 mm
cal with mild anterior crowding. The space deficiency was 2.0 mm in the
from the midpalatal suture) near an imaginary midline between the maxil-
maxillary arch and 4.0 mm in the mandibular arch. The clinical crown
lary first and second molars; and two Quattro screws (diameter, 2.0 mm;
lengths of the maxillary central incisors and of the other anterior teeth were
length, 9 mm) in the buccal oblique ridge between the mandibular first and
within the normal range; however, their gingival margins were uneven.
second molars.
The probing depths of periodontal pockets of the maxillary anterior teeth
All MIs were loaded 2 weeks after their insertion. Sectional, intrusive
were between 2.0 and 3.0 mm.
lever arms (0.017 × 0.025 inch TMA wire) were inserted into the rectan-
Panoramic radiography showed the presence of all third molars, a
gular tubes of the Quattro screws in both arches. In addition, Ni-Ti closed
missing mandibular right first molar and mesial tipping of the mandibular
coil springs were attached to the heads of the Quattro MIs and stretched
right second molar. Analysis of the lateral cephalometric radiograph
to hooks on the canines. The combination of forces applied from these MIs
revealed skeletal Class II relationships, an obtuse ANB angle, a steep
was designed to provide simultaneous maxillary en masse anterior retrac-
mandibular plane, a retrognathic mandible and vertical maxillary excess
tion and intrusion.
(U1–PP, 35.6 mm) (Table 38.4). Soft tissue analysis demonstrated an acute
Additional maxillary posterior intrusion was produced by attaching
nasolabial angle and protrusive upper and lower lips.
elastic chains from the Hook screws (between the first and second molars)
The patient was diagnosed with a skeletal Class II mandibular retro­
to the main archwire and also from the palatal Hook screws to the lingual
gnathism with steep mandibular plane, vertical maxillary excess and dental
buttons on the maxillary molars (Fig. 38.2E–H).
Class II, division 1, subdivision malocclusion.
Although significant intrusion of the maxillary posterior teeth and man-
The treatment objectives were (1) to relieve the anterior crowding, (2)
dibular autorotation were noted 15 months after treatment start, chin pro-
to correct the lower dental midline, (3) to achieve Class I molar on the left
jection was still not prominent and more was desired. Consequently, two
and Class II molar on the right side, and (4) to improve lip posture, gummy
Hook MIs (diameter, 1.5 mm; length, 9 mm) were inserted bilaterally,
smile and chin projection.
oriented obliquely into the lingual alveolus between the mandibular first
The treatment plan suggested was a non-surgical approach featuring
and second molars. Immediately after MI placement, lower posterior intru-
closure of the mandibular right edentulous space, as well as extraction of
sion was initiated by attaching power chains from the buccal Quattro MIs
the maxillary first premolars and of the mandibular left first premolar. Both
to the lingual Hook MIs, laid across segments of SS wires (0.016 × 0.022 inch)
direct and indirect anchorage would be derived from MIs. Retraction and
that had been bonded across the occlusal surfaces from the mandibular
intrusion of both dental arches was anticipated along with substantial
first to second molars (Fig. 38.2I).
mandibular autorotation.
After 24 months of treatment, the original skeletal gummy smile was
Quattro screws (diameter, 2.0 mm; length, 9 mm) were inserted into the
substantially improved through the large amount of simultaneous intrusion
infrazygomatic crests of the maxilla and in the oblique ridges of the man-
and retraction of the maxillary anterior teeth. Unfortunately, the clinical
dible to support bimaxillary en masse retraction and intrusion using can-
crown lengths of the maxillary anterior teeth had been decreased and some
tilever arms, Ni-Ti closed coil springs, a transpalatal arch and a lingual
iatrogenic bony protuberances were noticed in the labial alveolus as well
holding arch as follows (Fig. 38.3D–K).
as in lateral cephalometric radiographs. Alveoloplasty was performed to
improve the clinical crown lengths. ■ Low-friction TMA archwires (0.017× 0.025 inch ) with lingual root
Post-treatment photographs (after 28 months of orthodontic treatment) torque for the anterior teeth. Lingual root torque was applied to
revealed a Class I occlusion with normal overbite/overjet, along with reduce lingual tipping of the incisors during retraction. Crimpable
improvement of the patient’s profile and smile (Fig. 38.2B,J,K,L). hooks were attached to the archwire about 3 mm distal to the
 Treatment of skeletal origin gummy smiles with miniscrew implant-supported biomechanics 201

A B

C D E F

G H I J

Fig. 38.3 Case 3: indirect anchorage without alveoloplasty. (A,C) Pretreatment.

(D–K) En masse retraction and intrusion of the molars and incisors in the maxilla
(D–G) and mandible (H–K). (B,L) Post-treatment.

K L

brackets on the maxillary and mandibular canines and superelastic Table 38.4 Case3: cephalometric data
closed coil springs were stretched posteriorly to the MIs.
Variables Pretreatment Post-treatment
■ TMA cantilever arms (0.019 × 0.025 inch) with 110° of tip-back
bends. Removable and adjustable sectional arms were inserted into SNA (°) 80 79
SNB (°) 72 72
one of the tubes in the heads of the Quattro screws and then hooked
ANB (°) 8 5
over the main archwire between the laterals and canines. These
MPA (°) 46 44
arms employed indirect anchorage derived from the MIs to produce
U1-SN (°) 103 94
light intrusive forces on the anterior teeth.
IMPA (°) 97 96
■ Medium force Ni-Ti closed coil springs. Closed coil springs were
U6-PP (mm) 23.7 19.7
attached from the MIs to crimpable hooks on the main archwire to
U1-PP (mm) 35.6 28.1
produce en masse sliding retraction of the anterior teeth. Additional
springs were stretched perpendicularly from the MIs to the archwire
for posterior intrusion. MP, mandibular plane; PP, palatal plane; IMPA, incisor mandibular plane angle.
■ TMA transpalatal and lingual holding arches (0.032 inch). A
transpalatal arch and a lower lingual arch were constructed from
TMA wire featuring double backs for insertion into the lingual After 27 months, the treatment objectives were achieved. More specifi-
sheaths of the first molars. The double-back portions of these cally, the patient’s facial profile, lip posture, gummy smile and chin projec-
removable arches were bent with 6° of mesial angulation and 10° of tion were all improved (Fig. 38.3B,L). The maxillary incisor clinical
buccal root torque to prevent the molars from “rolling out” during crown length and the probing depth of their periodontal pockets were
simultaneous posterior intrusion and en masse retraction. similar before and after treatment. No alveoloplasty was performed. The
 202 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

post-treatment cephalometric analysis demonstrated that U1–PP was of biomechanics not dependent upon patient compliance. Ideally, treatment
reduced from 35.6 to 28.1 mm; U6–PP was improved from 23.7 to would have used Tweed biomechanics of setting anchorage, intruding the
19.7 mm, and the mandibular plane decreased 2.0° (Table 38.4). Cepha- incisors during space closure, controlling vertical dimension and produc-
lometric superimpositions revealed an “orthognathic-like” treatment ing counterclockwise rotation of the occlusal plane anchored by J-hook
effect, including vertical shortening of the entire maxillary dentoalveolar highpull headgear. However, as this patient had already endured the typical
process, substantial maxillary and mandibular anterior retraction and intru- timeframe for a course of orthodontic treatment, she was uninterested in
sion. These changes resembled the effects of LeFort I maxillary impaction complying with headgear, and even oral hygiene was problematic. Conse-
surgery, maxillary and mandibular anterior segmental osteotomy, and quently, it was decided to employ direct anchorage derived from MIs in
counterclockwise rotation of the mandible. both dental arches to support all these planned teeth movements.
A mandibular lingual arch was installed and MIs (diameter, 1.6 mm;
length, 8 mm) were inserted between the mandibular first and second
CASE 4: DIRECT ANCHORAGE WITHOUT molars. Elastic separators were stretched from the first molar tubes to the
ALVEOLOPLASTY FOR SIMULTANEOUS REDUCTION MIs to provide posterior intrusive force (transmitted through a continuous
IN GUMMY SMILE AND VERTICAL DIMENSION rectangular steel archwire) in order to maintain the vertical dimension and
A 12-year-old girl presented after more than 2 years of orthodontic treat- counteract any extrusion resulting from Class II elastics wear.
ment including premolar extractions that had been performed elsewhere. MIs (diameter, 1.6 mm; length, 6 mm) were also inserted between the
She had a mildly convex profile, an acute nasolabial angle, a retrusive chin, roots of the maxillary central and lateral incisors (Fig. 38.4D–F). These
normal upper lip length, lip incompetence and a mentalis strain upon lip were used for direct anchorage support of elastic forces to intrude the
closure. More than 5 mm of gingival display was apparent in her posed maxillary anterior teeth. Retraction and intrusion of the anterior dental
smile. She had bilateral Class I canine and molar relationships; the extrac- segment was accomplished using an asymmetrical TMA T-loop with
tion spaces were still evident, and the maxillary anterior teeth had been accentuated curve of Spee (0.017 × 0.025 inch).13 The combination of
extruded and tipped lingually (Fig. 38.4A,C). The clinical crown lengths these biomechanics was intended to control the vertical dimension and
of the maxillary central incisors and other anterior teeth were normal with occlusal plane. Despite the use of the rectangular wire for retraction, there
no periodontal burdens, despite poor oral hygiene. She had a Class I rela- was no improvement in the incisal angulation. Consequently, an anterior
tionship, an obtuse mandibular plane and a retrognathic chin. The etiology root torquing auxiliary was utilized to facilitate lingual root torque for the
of the excessive gingival display appeared to be skeletal and dental in incisors. Upon removal of her appliances, the patient wore a custom posi-
origin.12 tioner 24 hours a day for 1 week to accentuate “settling” of her occlusion,
Orthodontic treatment focused on the following issues: (1) completion followed by overlay retainers.
of extraction space closure with root parallelism, (2) management of the The resulting elimination of this patient’s chief complaint of gummy
vertical dimension during future facial growth, (3) improvement in the smile without employing a J-hook headgear (Fig. 38.4B,G) was accentu-
overbite/overjet, (4) reduction of the lip incompetency, and (5) application ated by the improvement in her facial profile and lip incompetency, even

A B

C D E

F G H

Fig. 38.4 Case 4: direct anchorage without alveoloplasty. (A,C) Pretreatment (after more than 2 years of orthodontic treatment with premolar extractions performed
elsewhere). (D–F) Insertion of two miniscrew implants (MIs) in the maxillary anterior alveolus and closed loop mechanics, as well as after insertion of two MIs between the
lower molars. (B,G) Post-treatment. (H) Superimposition on the anterior cranial base of the pretreatment (black line) and post-treatment (red line) cephalometric tracings.
 Treatment of skeletal origin gummy smiles with miniscrew implant-supported biomechanics 203

considering the continued facial growth she exhibited during treatment solution for skeletal origin gummy smiles, for a number of reasons ortho­
(Fig. 38.4H). gnathic surgery is not always acceptable for patients. The new non-surgical
alternative proposed here combines MI-anchored orthodontic treatment
and alveoloplasty to simulate an orthognathic-like treatment effect. The
DISCUSSION advantages of this new approach include:
■ avoiding the risks inherent to orthognathic surgery
Although orthognathic surgery was a treatment option to reduce vertical
■ simple and reliable orthodontic biomechanics
maxillary excess and the associated gummy smile for all the patients
■ no substantial discomfort compared with surgery
described in this chapter, all elected to pursue non-surgical approaches.
■ cost effective
This decision was based, at least in part, on concerns that the nasal alar
■ no change in alar base or the midface, which can accompany
base tends to widen with Le Fort I impaction procedures and that jaw
surgery.
surgery carries some risk of serious sequelae, such as excessive hemor-
rhage, infection, loss of tooth vitality, periodontal problems, plus the risks It appears that orthodontists now have a viable option to orthognathic
inherent with anesthesia. In contrast, orthodontic treatment, including the surgery for patients presenting with a gummy smile since more predicta-
insertion of MIs, offered fewer risks and potential side effects. The disad- ble, effective and efficient tooth movements are possible using MI
vantage is that it requires substantially more time for the correction to anchorage.
occur.
Two of the patients required alveoloplasty procedures to eliminate iatro-
genic bony protuberances that were produced by substantial incisor intru- REFERENCES
sion and retraction. The risks associated with these periodontal surgical
procedures are substantially less than those associated with orthognathic 1. Hugh O, Johnston C, Hepper P, et al. The influence of maxillary gingival exposure on
dental attractiveness. Eur J Orthod 2002;24:199–204.
surgery. Two patients did not require alveoloplasty. Individual variations 2. Sarver DM, Proffit WR, Ackerman JL. Diagnosis and treatment planning in orthodon-
of bone physiology may play an important role in deciding whether short tics. In: Graber TM, editor. Orthodontics: current principles and techniques. 3rd ed.
clinical crowns necessitating alveoloplasty will result from these types of St. Louis: Mosby; 2000. p. 65–109.
3. Silberberg N, Goldstein M, Smidt A. Excessive gingival display: etiology,diagnosis,
biomechanics. and treatment modalities. Quintessence Int 2009;40:809–18.
Two of the patients had sufficient inter-radicular space to permit safe 4. Liou EJW, Lin JCY. The appliances, mechanics, and treatment strategies toward
placement of MIs between the roots of the maxillary teeth to provide direct orthognathic-like treatment results. In: Nanda R, editor. Temporary anchorage devices
in orthodontics. St. Louis, MO: Elsevier; 2008. p. 167–97.
anchorage for simple power chains to hooks on the base archwire for both 5. Wu H, Lin J, Zhou L, et al. Classification and craniofacial features of gummy smile
intrusion and retraction. For the other two patients, alternative sites for MI in adolescents. J Craniofac Surg 2010;21:1474–9.
placement were needed (e.g. between the roots of maxillary second premo- 6. Chiche GJ. Proportion, display and length for successful esthetic planning. In: Cohen
M, editor. Interdisciplinary treatment planning, principle, design, implementation.
lars and first molars for Case 2, or in the infrazygomatic crests of the Chicago, Berlin: Quintessence; 2008. p. 1–48.
maxilla for Case 3) to provide indirect anchorage for intrusion using sec- 7. Sarver D. Principles of cosmetic dentistry in orthodontics: Part 1. Shape and propor-
tional mechanics. tionality of anterior teeth. Am J Orthod Dentofacial Orthop 2004;126:749–53.
8. Lin JCY, Liou EJW. A new bone screw for orthodontic anchorage. J Clin Orthod
Although non-surgical correction of skeletal origin gummy smiles 2003;37:676–81.
appears to be quite effective for certain patients, such as the ones described 9. Lin JCY, Liou EJW, Yeh CL. Intrusion of over-erupted maxillary molars with minis-
here, clinicians should be cautious in deciding if a patient would benefit crew anchorage. J Clin Orthod 2006;40:378–83.
10. Liou EJW, Lin JCY. The Lin/Liou Orthodontic Mini Anchor System (LOMAS). In:
from this approach, avoid overly optimistic expectations and carefully Cope JB, editor. OrthoTADs: the clinical guide and atlas. Dallas, TX: Under Dog
evaluate any potential for relapse. In some instances, different retention Media; 2007. p. 213–30.
strategies, such as overcorrection, slow intrusive movement to allow 11. Poggio PM, Incorvati C, Velo S, et al. “Safe zones”: a guide for miniscrew positioning
in the maxillary and mandibular arch. Angle Orthod 2006;76:191–7.
for neuromuscular adaptation, longer retention periods, active retention 12. Lin JCY, Yeh CL, Liou EJW, et al. Treatment of skeletal-origin gummy smiles with
methods, and perhaps some periodontal surgical procedures (intrasulcus miniscrew anchorage. J Clin Orthod 2008;42:285–96.
incision or alveoloplasty), should be employed. 13. Hilgers JJ, Farzin-Nia F. Adjuncts to bioprogressive therapy: the asymmetrical “T”
archwire. J Clin Orthod 1992;26:81–6.
There are also probable limitations to the amount of retraction/intrusion 14. Mimura H. Treatment of severe bimaxillary protrusion with microimplant anchorage:
that is possible. For example, the cortex bone of the incisive canal may be treatment and complications. Aust Orthod J 2008;24:156–63.
the biological boundary for such types of tooth movement and impacting
that bone could result in external apical root resorption.14

CONCLUSIONS

Soft tissue and smile esthetics are often major concerns for patients. While
the surgical–orthodontic approach has often been the only recommended
39 Altering the smile line with miniscrew
implant-supported biomechanics
James Cheng-Yi Lin, Eric Jein-Wein Liou, S. Jay Bowman and George Anka

Two treatment options were offered: (1) traditional orthodontic treat-

INTRODUCTION
ment in combination with Le Fort I osteotomy, including downgrafting, to
Although orthodontics involves more than simply improving patients’ increase maxillary height, and (2) MI-based orthodontic mechanics to
smiles, the esthetic display of teeth is certainly one of the primary motivat- extrude the maxillary dentition (Fig. 39.1H–O). The intent of dental extru-
ing factors for seeking orthodontic treatment. Challenges in using appro- sion was to increase the lower anterior face height and to increase incisor
priately controlled mechanics to improve proper function while producing display during smiling.
favorable esthetics have been enhanced with the availability of miniscrew The patient provided her informed consent to the more conservative
implant (MI) anchorage. This chapter describes the management of the method after the risks and benefits had been discussed.
vertical dimension by either decreasing gingival display via intrusion or
by improving the smile line via extrusion. Treatment Progress
Treatment was initiated using fixed preadjusted appliances (0.022 inch)
for leveling and alignment. After 6 months, the fractured upper left bridge
INCREASING INCISOR DISPLAY was removed and replaced with a temporary resin bridge, which was
constructed with elongated crowns. This “bridge” served as a “bite opener”
Insufficient maxillary incisor display may result from a variety of factors to assist in increasing the patient’s vertical dimension. “Propping open”
(e.g. short face heights, anterior open bites) (Table 39.1).1 If the etiology the bite facilitated the extrusion of the maxillary dentition (except of the
is primarily skeletal in nature, then combined surgical–orthodontic treat- bridge abutments).
ment is often suggested. As an alternative, a successful non-surgical treat- Two weeks later, a thermal Ni-Ti wire (0.016 × 0.022 inch) was inserted
ment to improve smile line used a modified lip bumper, rapid palatal into the edgewise slots of all brackets, except those on the maxillary central
expansion and elastics.2 The case below illustrates the use of MI-supported incisors, where the wire was laid just apical to the gingival tie wings of
biomechanics to provide a non-surgical option. the brackets to initiate sequential extrusion of the maxillary anterior teeth
(Fig. 39.1H,I). To control the reciprocal forces on the lateral incisors
(i.e. anchoring the extrusion of the central incisors), intermaxillary elastics
CASE 1: IMPROVING SMILE LINE ACCOMPANYING (50 g) were hooked from the lateral incisors down to one LOMAS
SHORT FACE HEIGHT Hook MI (diameter, 2 mm; length, 9 mm; Mondeal Medical, Tuttlingen,
Germany), which had been inserted, angled apically, in the mandibular
A 28-year-old woman presented with a chief complaint of insufficient symphysis below the roots of the mandibular central incisors.3
display of the maxillary incisors. She exhibited a straight profile, obtuse At the next visit, the upper wire was positioned apical to the lateral
nasolabial angle, short upper lip length and a mildly prominent chin button. incisor brackets to extrude them (Fig. 39.1J,K). The elastics were also
Less than 20% of the clinical crown length of the maxillary incisors could moved sequentially to the next teeth down the line. The patient was also
be seen in her full smile. Intraoral examination demonstrated a Class I asked to wear “up-and-down” intermaxillary elastics from the maxillary
relationship with favorable periodontal health. However, multiple poste- to mandibular first molars (Fig. 39.1H–O). The intent of the combined
rior teeth were missing and she had a fractured dental bridge (Fig. 39.1A,D). anterior and posterior elastics was to extrude the anterior teeth but also to
Cephalometric analysis revealed that the insufficient incisor display was a counteract the reciprocal intrusive forces on the posterior teeth, thereby
result of maxillary vertical deficiency (Table 39.2). altering the facial profile and improving the smile line.

Table 39.1 Possible etiologies and treatment strategies for insufficient Table 39.2 Case 1: cephalometric data
maxillary incisor display
Variables Pretreatment Post-treatment
Origin Etiology Treatment strategy SNA (°) 84 83.5
Dental Short clinical crown Increase clinical crown length SNB (°) 80.5 78
length using crown, veneer,
ANB (°) 3.5 5.5
periodontal surgery
MPA (°) 27 31
Flared maxillary incisors Orthodontic torque and/or
retraction U1-SN (°) 108 99.5
Skeletal Vertical maxilla Maxillary downgrafting with IMPA (°) 99 99.5
deficiency Le Fort I osteotomy U6-PP (mm) 23.0 25.0
Muscular Hypoactivity of the Smile trainer U1-PP (mm) 27.5 31.0
elevator muscle of the L6-MP (mm) 30.0 32.5
upper lip
L1-MP (mm) 37.0 38.5
Long upper lip length Lip lift surgery
Aging Face lift
Combination Combination etiologies Combination treatments MP, mandibular plane; MPA, mandibular plane angle; PP, palatal plane; SN,
sella-nasion; IMPA, incisor mandibular plane angle.

204
 Altering the smile line with miniscrew implant-supported biomechanics 205

A B C

D E F G

H I J

K L M

Fig. 39.1 Case 1: improving smile line accompanying short face height. (A,D) Pretreatment. (H–O) Biomechanics for sequential extrusion of the maxillary dentition from
anterior to posterior teeth in order to improve the maxillary vertical deficiency and increase anterior dental display. (H,I) A posterior bite block is used to prop open the
anterior bite in order to facilitate extrusion of the anterior teeth. The archwire is initially placed just apical to the central incisors to extrude them. Elastics are worn from
the maxillary lateral incisors to a miniscrew implant (MI) inserted in the mandibular symphysis and also from upper to lower molar. (J,K) The archwire is placed apical to
the canine bracket and then on the first premolar bracket to continue the extrusion process. Elastics are also moved to the next adjacent tooth distal to the one to be
extruded. (L,M) The process of individual tooth extrusion continues to the first molar, then “up-and-down” elastics are worn on every tooth. (N,O) Increasing the extrusion
of the upper incisors and deepening the overbite can be achieved using elastics from the anterior teeth to the MI inserted in the symphysis. (E) To satisfy the patient’s
desire for even more incisor display, the anterior teeth were further extruded using elastics from the canines to the mandibular MI while simultaneously intruding the
mandibular incisors with elastic chains from the same MI. (B,F) Post-treatment after 24 months of treatment. (P) Overall superimposition on sella–nasion line demonstrates
the intended changes: extrusion of the maxillary dentition, increase in lower anterior face height and clockwise rotation of the mandible. (C,G) At 18 months after
treatment completion.
Continued
 206 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

N O

Fig. 39.1, cont’d

After 11 months of treatment, the temporary resin bridge was sectioned from some limited anterior extrusion to close the bite and improve smile
to permit some movement of the abutments. Three months later, the patient esthetics. In other instances, the process of orthodontic leveling and align-
requested an even greater increase of incisor display. In order to achieve ment may inadvertently create or exacerbate an anterior open bite by
this goal, the mandibular anterior teeth were intruded using elastic chains unintended extrusion of posterior teeth: “propping open the bite.”
extended from the MI positioned on the symphysis directly to the lower
archwire, while simultaneously extruding the maxillary incisors with an
additional intermaxillary elastic worn to the same MI (Fig. 39.1L,M,E). CASE 2: OPEN BITE AND POOR SMILE
Twenty months after the start of treatment, the patient’s original insuf-
ficient incisor display had been dramatically improved without ortho­ A woman presented with a chief complaint of an open bite and “upside-
gnathic surgery. Final cephalometric data are shown in Table 39.2. down smile,” which could be improved with simultaneous intrusion of the
After completion of orthodontic treatment, prosthetic replacements for posterior and extrusion of the anterior teeth (Fig. 39.2A,C–E).
the missing teeth were placed (Fig. 39.1F).
Treatment Progress
Treatment Results Two Aarhus MIs (length, 6 mm; American Orthodontics, Sheyboygan, WI,
After 24 months of orthodontic care, there were clear improvements USA) were inserted between the roots of the maxillary first molars and
in facial and smile esthetics: substantial maxillary incisor display was second premolars to provide direct anchorage for intrusion of the posterior
achieved, which answered the patient’s original complaint (Fig. 39.1B,F,P). teeth. Elastic chain was applied from the MI heads and looped around a
Cephalometric superimposition revealed significant positional change rectangular archwire (0.019 × 0.025 inch). A third MI was inserted
of the maxillary dentition, similar to that produced in LeFort I downgraft- between the maxillary central incisors, adjacent to the midline frenum,
ing (Fig. 39.1P). Interestingly enough, the mandibular teeth exhibited with the MI angled apically by 10° (Fig. 39.2F–H).
some extrusion despite the intrusive forces applied from the MI in the The larger helix of a Ulysses extrusion auxiliary spring (American
symphysis. The patient’s chin projection became less prominent as a result Orthodontics) (Fig. 39.2I) was applied over the head of the MI. The spring
of the clockwise rotation of the mandible and the increased lower anterior was activated (i.e. stretched out with the smaller loop of the spring about
facial height. These positive changes appear to be stable 18 months after 5 mm incisal to the main archwire). The archwire was then inserted
the completion of treatment (Fig. 39.1C,G). Nevertheless, the stability of through the lumen of the smaller helix of the auxiliary, thereby compress-
these types of change in the vertical dimension has been a subject of ing the spring between the wire and the MI. The archwire was subse-
debate.4,5 quently tied into the brackets with the spring force to extrude the anterior
The same biomechanics were applied in the following case, which teeth. Light-cured adhesive was placed over the head of the MI to reduce
illustrates further the insertion location of the Hook MI in the any tissue irritation. Simultaneous intrusion of the maxillary posterior
symphysis. teeth and extrusion of the anterior teeth was performed, which closed the
open bite and improved the smile line in 6 months (Fig. 39.2B,J–L).

INCREASING INCISOR DISPLAY IN ANTERIOR OPEN BITE

Treatment Results
Some patients with anterior open bite exhibit also a so-called “reverse Final results, 1 year after completion of treatment, demonstrated favorable
smile line,” which could benefit from not only posterior intrusion but also stability.
 Altering the smile line with miniscrew implant-supported biomechanics 207

Fig. 39.2 Case 2: increasing incisor display for anterior open bite and poor smile. (A,C–E) Pretreatment.
(F–H) Aarhus miniscrew implants (MIs) were inserted between maxillary posterior teeth for intrusion
with direct anchorage using elastic chains around a rectangular archwire. A third MI was placed in the
anterior region and a Ulysses spring was stretched from the MI to the archwire to extrude the anterior
teeth, close the open bite and improve the incisor display and smile line. (I) The Ulysses extrusion
auxiliary spring. (B,J–L) Post-treatment.

A B

C D E

F G H I

J K L

TREATMENT OF DEEP OVERBITE were used to maintain leeway space to avoid extraction or unstable inter-
canine expansion while resolving crowding for a 13-year-old girl with
Altering the smile line in deep bite requires careful diagnosis to ascertain mixed dentition. Sectional square wire segments were bonded into the
if intrusion of anterior teeth is appropriate, as well as to determine the heads of the MIs and into auxiliary tubes on the first molars to support
correct dental arch to address. A knee-jerk reaction to intrude maxillary sequential retraction of the mandibular teeth into the residual leeway space
incisors (e.g. intrusion arch or J-hook headgear) for a patient with a deep (Fig. 39.3B). This same anchorage system then supported Class II elastics
bite, but with long upper lip and minimal incisor display, would certainly to reduce unwanted flaring of mandibular incisors or extrusion of man-
be inappropriate. In some instances, intrusion of hypererupted mandibular dibular molars. The MIs were also employed to intrude the hypererupted
anterior teeth may, in fact, be indicated. A number of examples are given mandibular incisors (using elastic thread from the support wires to the base
of methods to deal with this problem. archwire).
Fig. 39.3A shows a 13-year-old boy with a deep overbite and a favorable Occasionally, simple retraction (with or without intrusion) is the key to
smile line for whom maxillary anterior intrusion was contraindicated. an improved smile line. Figure 39.3C shows a 14-year-old boy with a
A MI was inserted between the mandibular incisors to provide direct moderate bimaxillary protrusion, some lip incompetence and mildly exces-
anchorage for intrusion of the mandibular anterior teeth. A Monkey Hook sive gingival display. MIs were inserted in all four posterior quadrants
(American Orthodontics) was attached to the head of the MI and (between the second premolars and first molars). Direct anchorage was
elastic thread was tied from the hook to the archwire (Fig. 39.3A). Total employed for en masse retraction of both dental arches using elastic chain
treatment required 26 months, but the MI was removed after 8 months of for 9 months (Fig. 39.3C). Improvement in the smile line, gingival display
intrusion. and facial profile were achieved in 18 months.
Indirect anchorage from MIs may also be employed for intrusion of If, however, a gummy smile is the chief complaint, then mechanics
anterior teeth. MIs, inserted between the mandibular laterals and canines, specifically designed to intrude are compulsory (Fig. 39.3D–F).6,7
 208 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C

D E F

Fig. 39.3 Improving smile line for deep overbite. (A) Direct anchorage from a miniscrew implant (MI) inserted between the lower incisors for intrusion of the mandibular
incisors. (B) Indirect anchorage from MIs inserted between the mandibular lateral incisors and the canines to maintain leeway space and to support sequential retraction of
lower teeth into the residual leeway space. The same anchorage supported Class II elastics to reduce unwanted flaring of lower incisors and extrusion of lower molars, as
well as to provide indirect anchorage to intrude the hypererupted lower incisors. (C) Direct MI anchorage in all four quadrants for bimaxillary en masse retraction to
improve smile line, gingival display and facial profile. (D) Direct MI anchorage for the intrusion of maxillary anterior teeth to reduce an asymmetric gummy smile; impacted
canines were exposed and erupted at the same time. (E,F) A “TAD Bite-Opening Spring” auxiliary placed on a MI to intrude the maxillary central incisors to improve the
patient’s smile line.

Fig. 39.3D shows a 13-year-old girl with a gummy smile, moderate over- Class II correction, an en masse retraction of the maxillary dentition is
bite and also palatally impacted canines. Two MIs were inserted between required.
the maxillary central and lateral incisors and used as direct anchorage for
intrusion of the maxillary anterior teeth using elastic thread. Simultane-
CASE 3: DEEP OVERBITE AND CONSIDERABLE
ously, the impacted canines were surgically exposed and Monkey Hooks
GINGIVAL DISPLAY
with elastic chains were used to pull the crowns distally, away from the
roots of the lateral incisors, thereby, tipping the teeth occlusally. Only then
A 24-year-old woman presented with a complaint of considerable gingival
were they moved laterally into the arch form as the smile line was improved.
display. She had a Class II, division 2 with a deep overbite (Fig. 39.4A)
The patient was later referred to a periodontist to further improve her
and upon smiling, the right side risorius muscle contracted more, lifting
dental display.
the right corner of the mouth, warranting myofunctional therapy during
Another option for a gummy smile as the chief complaint is to use a
orthodontics.8
specific auxiliary designed to produce intrusive forces (Fig. 39.3E,F). A
13-year-old girl with concerns about her prominent canines and gum tissue
Treatment Progress
display was treated with a TAD Bite Opening Spring7 (American Ortho-
dontics) placed over the head of a MI that had been inserted between the MIs were inserted between the maxillary lateral incisors and canines to
roots of the maxillary incisors (Fig. 39.3E). An SS ligature was inserted provide direct anchorage support for their intrusion. This area is easily
through the head in the neck of the MI to secure the auxiliary. The arms accessible and the root prominences are often readily identifiable on the
of this auxiliary were lifted incisally and hooked over the archwire to labial alveolus, simplifying the insertion process. Since the canine is at the
produce an intrusive force on the anterior teeth, supported by the MI. corner of the arch form, the insertion angle of the MIs must be oriented
Improvement in the occlusal plane and smile line were achieved without distally to account for the rotation of the ovoid root.
a J-hook headgear and the MI removed at the halfway point of a 2-year A maxillary midline frenectomy was performed at the time of MI inser-
treatment (Fig. 39.3F). tion to release tension on the upper lip, thereby reducing retention of food
debris in the buccal vestibule and permitting improved oral hygiene (Fig.
39.4B). Elastic forces were applied from the MIs directly to the maxillary
GUMMY SMILE CAUSED BY MAXILLARY archwire to intrude the anterior teeth.
ALVEOLAR EXCESS As this patient was likely to respond well to en masse retraction of the
maxillary dentition, a Transpalatal Arch Plus Hooks (TPA-PH) device (see
Gummy smiles are a common complaint of patients, and their correction Chapter 37) and two additional MIs were inserted into the palatal alveolus
may be as simple as the use of a J-hook headgear. However, predictability between the roots of the second premolars and first molars (Fig. 39.4C).
is problematic because of issues of patient cooperation. The option of Elastic chains (replaced monthly) were stretched from the hooks on the
incorporating MI anchorage can improve treatment predictability through TPA-PH to the MIs to produce a distalizing force of about 200 g per side,
avoiding compliance issues and by reducing the side effects of reciprocal transmitted throughout the dental arch using a full-size rectangular arch-
anchorage mechanisms. wire to reduce attendent dental tipping. The TPA-PH device comes in
Some adults with Class II, division 2 malocclusion respond favorably various designs that are suitable for specific patient facial patterns, bone
to mandibular anterior repositioning, and the potential for a positive structures and locations of the sinus (see Chapter 37). In this case, bonded
response is best predicted by the difference between centric occlusion and anterior bite plates10 were added to the construction of the TPA-PH to assist
centric relation.9 Since in adults there is no mandibular growth to support in correcting the overbite.
 Altering the smile line with miniscrew implant-supported biomechanics 209

Fig. 39.4 Case 3: deep overbite and considerable gingival display. (A) Pretreatment. (B) Maxillary midline frenectomy and
insertion of miniscrew implants. (C) Transpalatal Arch Plus Hooks device in place. (D) Post-treatment.

B C D

En masse maxillary retraction and intrusion of the anterior teeth was of the impacted canine and (4) canted occlusal plane (Fig. 39.5B,D). The
continued with the combination of TPA-PH device, anterior bite planes maxillary left canine and the third molars were removed instead of the
and Class II elastics until the centric occlusion/centric relation was deemed originally planned second molars. Consequently, the maxillary left poste-
to be coincident. Completion of treatment required 11 months (Fig. 39.4D). rior segment had to be moved mesially using MI anchorage and associated
Myofunctional therapy also improved the asymmetrical nature of her auxiliaries.
smile. The anterior bite plates were left in place to reduce relapse of the Asymmetric extraction exacerbated the midline deviation. Extraction of
overbite.10 a corresponding premolar on the right side was avoided by intra-arch
mechanics supported with MIs (Fig. 39.5E). MIs were inserted in the
Treatment Results palatal alveolus between the roots of the premolars and connected with
elastic chains to a TPA-PH device (with finger springs) to protract the
Cephalometric superimposition demonstrated some flaring and 2 mm of
upper left posterior dentition and simultaneously retract the right
intrusion of the maxillary and mandibular incisors, improved overbite and
dentition.
overjet, and some distalization without alteration of the mandibular plane.
A short propeller arm auxiliary (American Orthodontics) was connected
to a MI placed in the buccal alveolus between the roots of the maxillary
left premolars, and the sliding hook was fastened with SS ties to the first
IMPROVING A DEVIATED SMILE LINE
premolar bracket (Fig. 39.5F).11,12 The coil spring was compressed between
the MI and the premolar to protract the posterior teeth into the extraction
Patient perceptions of their unattractive teeth may cause them to adopt
site of the ankylosed canine. Elastic chain was also connected from an
asymmetric or unnatural smiles. Both myofunctional therapy and ortho-
extended hook on the first molar band to the same MI anchor for additional
dontic treatment can assist in this problem.
protraction force.
After the left space was closed, a Ulysses extrusion auxiliary spring was
compressed between a MI inserted between the roots of the lateral incisor
CASE 4: A HABITUAL ASYMMETRIC SMILE
and the first premolar and the anterior brackets to close the anterior left
open bite (Fig. 39.5G). In the mandibular arch, minor en masse retraction
A 15-year-old female with Class III malocclusion, featuring substantial
of the dentition to resolve crowding was accomplished using direct anchor-
crowding of the anterior teeth (including an impacted maxillary left
age from MIs inserted between the roots of the mandibular first molars
canine), had assumed a habitual asymmetric smile that had warranted
and second premolars.
myofunctional therapy during her orthodontic care (Fig. 39.5A,D).8 The
original treatment plan included the extraction of maxillary second molars
with an intention to open space to direct the eruption of the impacted Treatment Results
canine.
After 36 months of treatment, significant improvement in dental and smile
esthetics was achieved (Fig. 39.5C,H). Assessments of the pre- and post-
Treatment Progress
treatment cephalometric radiographs showed a mild extrusion of the max-
During initial leveling and alignment, several issues become apparent: illary left posterior dentition. Although substantial improvement in the
(1) an anterior open bite, (2) substantial midline deviation, (3) ankylosis original malocclusion and the unintended iatrogenic effects that occurred
 210 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C

D E F

G H

Fig. 39.5 Case 4: a habitual asymmetric smile. (A,D) Pretreatment. (B) En face during treatment indicating the canted occlusal plane. (E) The maxilla following asymmetric
extraction of the ankylosed canine and insertion of miniscrew implants and the Transpalatal Arch Plus Hooks device. (F) Application of the short “propeller arm” auxiliary.
(G) Application of a Ulysses extrusion auxiliary spring. (C,H) Post-treatment.

during initial leveling were accomplished during 36 months of treatment, 2. Paik CH, Woo YJ, Boyd RL. Non-surgical treatment of an adult skeletal Class III
patient with insufficient incisor display. J Clin Orthod 2005;39:515–21.
some compromises resulted, but the overall esthetic improvement in the 3. Liou EJW, Lin JCY. The Lin/Liou Orthodontic Mini Anchor System (LOMAS). In:
patient’s deviated smile was significant. Cope JB, editor. Ortho TADs: clinical guide and atlas. Dallas, TX: Under Dog Media;
2007. p. 213–30.
4. Kokich VG. Altering vertical dimension in the perio-restorative patient: the orthodon-
tic possibilities. In: Cohen M, editor. Interdisciplinary treatment planning, principle,
DISCUSSION design, implementation. Hanover Park, IL: Quintessence; 2008. p. 49–80.
5. Spear F, Kinzer G. Approaches to vertical dimension. In: Cohen M, editor. Interdisci-
Recently, orthodontists have placed great emphasis on soft tissue and plinary treatment planning, principle, design,implementation. Hanover Park, IL: Quin-
tessence; 2008. p. 249–82.
smile esthetics rather than concentrating purely on tooth alignment and 6. Lin JCY, Yeh CL, Liou EJW, et al. Treatment of skeletal origin gummy smiles with
occlusion. This may be because the appearance of their smile is a major miniscrew anchorage. J Clin Orthod 2008;42:285–96.
concern for patients, even though they may also benefit from an improve- 7. Lin JCY, Liou EJW, Bowman SJ. Simultaneous reduction in vertical dimension and
gummy smile using miniscrew anchorage. J Clin Orthod 2010;44:1–14.
ment in their bite.13,14 Combined surgical–orthodontic options provide sub- 8. Winchell B. Orofacial myofunctional therapy for adult patients. Int J Orofacial Myol
stantial improvements but are not always acceptable to patients. The 1989;15:14–18.
addition of MI anchorage into the orthodontic armamentarium has 9. Dawson P. Evaluation, diagnosis and treatment of occlusal problems. 2nd ed. St. Louis,
MO: Mosby; 1989.
improved the predictability of traditional orthodontic biomechanics and 10. Carano A, Mannarini C, Bowman SJ. Deep bites: correction and retention with per-
has permitted the simulation of some orthognathic effects without surgery. manent bite planes. Ortho Prod 2006;42–5.
These types of improvement, specifically on patient smile lines, have been 11. Ludwig B, Baumgaertel S, Bowman SJ. Mini-implants in orthodontics: innovative
anchorage concepts. London: Quintessence; 2008.
demonstrated in this chapter. 12. Bowman SJ. Thinking outside the box with mini-screws. In: McNamara J Jr, editor.
Microimplants as temporary orthodontic anchorage [Craniofacial Growth Series], vol.
45. Ann Arbor, MI: University of Michigan; 2008. p. 327–90.
13. Bowman SJ. The social six redux: is that really all there is? Ortho Tribune 2007;2:
REFERENCES 11–15.
14. Burrow SJ. Biomechanics and paradigm shift in orthodontic treatment planning. J Clin
1. Sarver DM. The importance of incisor positioning in esthetic smile: the smile arc. Orthod 2009;43:635–44.
Am J Orthod 2001;120:98–111.
 Lingual orthodontics and the use of miniscrew
implants for the management of Class II
40
malocclusion in adults
Kee-Joon Lee and Young-Chel Park

symptoms. Idiopathic condylar resorption, which mainly occurs in young

INTRODUCTION
females in their late teens and early twenties, is considered a major patho-
Classically, orthodontic treatment in adults was considered inappropriate logical sequence that eventually alters the facial morphology into a Class
where there was inadequate space to move teeth into, where movement of II profile with mandibular retrusion and open bite. Although condylar
teeth against occlusal apposition or into occlusal trauma was needed, change is prevalent in many Class II patients with retrusive mandibles, it
where anchorage was inadequate or where the periodontal health, function is not clear whether the Class II morphology is a cause or a result of the
or esthetics of the teeth would not be improved. Nevertheless, ideal occlu- morphological change. There are no clear guidelines for detection or pre-
sion with proper interdigitation is still a treatment goal regardless of a vention of the pathology. Orthodontists are advised to avoid the use of
patient’s age. There are a number of specific issues that need to be taken intermaxillary elastics in these patients in order to minimize or eliminate
into consideration before initiation of orthodontic treatment in adults. possible loading of the joint. Once again, this indicates that the anchorage
The adult will present with a history that may include tooth wear, caries for either incisors or molars should be established within the arch, neces-
and previous prosthesis use. Preventive measures, including space main- sitating the use of MIs.
tenance around peg-shaped or fused incisors, are often impossible in
adults, particularly when mesial migration of the posterior teeth has already
taken up the interdental space adjacent to the target tooth. Even regaining BIOMECHANICAL CONSIDERATIONS
a minor space around a small tooth may demand overall restructuring of
the dentition, including molar distalization. Consequently, making a pro- Class II malocclusion has been shown to be more common than Class III
visional cast is essential to assess the specific type and amount of tooth malocclusion in many ethnic groups.1 Class II means not only a Class II
movement possible at each area and if a radical change in the molar rela- denture relation but also a Class II skeletal/facial pattern, represented by
tion may be indicated. a convex profile, retrusive mandible and protrusive upper lips. Treatment
Adults will also present with variations in alveolar bone thickness. plans should be tailored to the individual patient’s needs but the following
Reduced alveolar bone height is a significant risk factor in orthodontic issues should be taken into account.
treatment in adults as this will alter the center of resistance (CR) of teeth.
Consequently, a force-driven appliance should be selected that can deliver
a precision force system, for example extension of a lever arm. The pos-
ESTHETICS OF APPLIANCE
terior segment may also have some alveolar bone loss, which would Esthetic issues during treatment are significant for the majority of adults,
suggest that reciprocal anchorage within the arch may not be suitable and who prefer lingual or clear appliances over the more highly visible labial
bone-borne temporary anchorage devices may better serve the purpose. (buccal) appliances.2 Although removable clear plastic appliances provide
As bone formation capacity diminishes with age, treatment for the relief esthetics and comfort, as they can be removed for eating and cleaning, the
of crowding in adults should avoid modalities such as incisor flaring or type of tooth movement that can be induced is significantly limited. In
transversal expansion that are regarded as tooth movement against the thin contrast, lingual fixed appliances can overcome these technical limitations,
labial/buccal cortical plate, as these may cause irreversible gingival reces- although they do have difficulties for speech and maintenance of oral
sion or bony dehiscences. The third approach, molar distalization, takes hygiene. So-called lingual treatment does not necessarily mean that all of
place within the alveolar housing and is, therefore, considered a safer way the attachments must be located on the lingual sides of the teeth. Patients
to regain the space in the arch than the other types of tooth movement are mainly concerned about the exposure of the attachments during normal
(Table 40.1). function, such as speech, mastication and smiling. Therefore, esthetics of
Temporomandibular joint disorders are also prevalent in young adults, the maxillary anterior teeth is usually the major concern. Labial/buccal
with clicking, crepitus and limitation of mouth opening as major attachments may be included if these are in areas other than the maxillary
anterior region, and some clear attachments, such as clear plastic buttons,
can also be used. Awareness of this flexibility will expand the scope of
Table 40.1 Effect of tooth movements on esthetics, function lingual orthodontics that can be offered.
and safety
Transverse
Anterior flaring expansion Distalization CONTINUOUS OR SEGMENTAL APPROACHES
Esthetics Poor Not much N/S In most adults with tight occlusions and possibly some degree of alveolar
Function Not much Risky (tipping) N/S bone loss, precision tooth movement without round tripping is an absolute
Safety Risky Very risky high requirement, since a jiggling type of movement can be detrimental. Careful
(tipping, adults)
assessment of the required tooth movement followed by use of the continu-
ous or the segmented approach, depending on the purpose, is advised. If
N/S, Not significant. movement of a specific teeth segment is not desired, additional temporary

211
 212 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

anchorage devices such as MIs can be used to move the target segment Tooth Movements
that has to be moved.
The amount and direction of tooth movement and the arch length discrep-
EXTRUSIVE OR INTRUSIVE MECHANICS ancy should be quantified in each quadrant, with the midline as the refer-
ence line. This allows the amount of either symmetric or asymmetric tooth
Class II intermaxillary elastics tend to extrude both maxillary incisors and movement at each side to be assessed, particularly when the initial occlusal
mandibular molars, contributing to a posteroinferior rotation of the man- relationship is asymmetric. The clinician must also determine whether a
dible and an increase in the vertical dimension. Even without intermaxil- specific tooth/teeth segment has to be moved or not by defining the amount
lary elastics, vertical bowing of a continuous arch often causes extrusion of required movement, sagittal, vertical and transverse, in each quadrant
of the posterior teeth, which, in turn, leads to opening of the mandibular using imaging.
plane and worsens the Class II profile. Therefore, extrusion of a tooth/teeth The type of tooth movement in anterior and posterior segments should
segment is contraindicated in most Class II patients. Careful application also be defined before treatment: tipping, translation, root movement or
of intrusive mechanics is recommended. The use of MIs inserted in the intrusive/extrusive. For example, in the anterior segment, flared incisors
interdental alveolar region is, therefore, justified in that they create intru- may need to be uprighted via controlled tipping, whereas transition from
sive force vectors.3 a Class II to Class I molar relationship may be accomplished mainly
through posterior translation of the maxillary molars or anterior translation
MINISCREW IMPLANTS of the mandibular molars.
The monocortical type of MIs is versatile, economic and less invasive than
other types of bone-borne anchorage devices, such as miniplates, onplants
Incisor Relations
and dental implants.
From a biomechanical standpoint, the force applied using MIs as anchors In skeletal Class II patients, the common approach for anteroposterior
can be characterized as a constant single line of force, moderate in amount dental compensation in the incisor region includes labial flaring of the
and intrusive. This makes MIs very advantageous anchorage modalities in mandibular incisors and/or lingual inclination of the maxillary incisors.5
treating adults with Class II malocclusion. This reflects the adaptation of the dentoalveolar complex within the soft
As lingual appliances are normally attached on the lingual sides of the tissue envelope during growth. In contrast, the decompensation indicated
teeth, both lingual and palatal alveolar areas may be readily used for MI before orthognathic surgery often includes a tipping (uprighting) move-
insertion to allow direct application of forces from the MIs to the arch- ment of the incisors toward an ideal position within the basal bones:
wires. MIs can be effective for both incisor and molar correction in Class lingual tipping of mandibular incisors and labial tipping of maxillary inci-
II patients. sors. However, in order to attempt a successful camouflage treatment with
The main insertion sites for MIs in the maxilla are the buccal and palatal an ideal occlusion and desirable esthetics in spite of the underlying skeletal
interdental alveolar areas (Fig. 40.1A,B).4 It is recommended that longer discrepancy, it is crucial to move not only the crown but also the root of
MIs are used on the palatal side than on the buccal side, for example, 7 mm the tooth, implying the need for translational movement instead of tipping.
on the buccal and at least 8–9 mm on the palatal side (Fig. 40.1B). To The required type of tooth movement is often translation of the maxillary
avoid damage to adjacent roots, sufficient inter-radicular space and bone incisors and uprighting of the mandibular incisors. Hence, removable
thickness needs to be secured. In the maxilla, inter-radicular areas between appliances are not readily indicated for camouflage treatment as they
the second premolars and first molars, and between the first and second cannot move the roots of the teeth. Fixed appliances that can deliver a
molars, are regarded as safe insertion sites (Fig. 40.1C). Placement on the precision force system are better indicated for most patients requiring
lingual side avoids any risk of damage to the major nerves and vessels that camouflage treatment.
run along the palatal side. Extension of a lever arm is easier on the maxil- There are two ways to control incisor movement: by changing the
lary palatal side than on the labial side and will allow control of the type moment-to-force ratio applied to a bracket or by changing the line of force
of tooth movement using the line of force. The midpalate is a reliable by extending lever arms from the main archwire.
insertion site, particularly for lingual appliances. Variable molar and/or Translation of maxillary incisors with a line of force at the palatal side
incisor control is feasible using midpalatal MIs. However, midpalatal MIs of the arch can be easy. The palatal vault is normally deeper than the
will create a vertical force vector, which leads to intrusive movement of labial/buccal vestibule and, therefore, the clinician can extend longer
the target segment. lever arms than on the labial side. Long lever arms may induce transla-
There are fewer suitable sites for MIs in the mandible because of the tion or root movement depending on the position of the line of force
presence of the tongue although both buccal and lingual alveolar inter- relative to the CR of the tooth. Incisors with reduced alveolar bone
radicular areas are available for insertion. Buccal bone thickness and height need longer lever arms since the CR is lowered in relation to the
inter-radicular space in the premolar and molar region are sufficient to alveolar bone height.
maintain the MI in place, but the retromolar area has thick soft tissue
covering dense cortical bone and this can cause difficulties in MI mainte-
nance (Fig. 40.1D). The retromolar area is regarded as a stable MI insertion MOLAR DISTALIZATION IN CLASS II MALOCCLUSION
site during mandibular teeth distalization and uprighting. Precise anteroposterior control of the molars is often indicated in Class II
camouflage treatment. Assuming that the initial molar relation tends to be
Class II, treatment objectives with regard to molar control can be twofold;
PRACTICAL GUIDELINES FOR CLASS II LINGUAL mesial movement of molars into a full cusp Class II position or distaliza-
ORTHODONTICS tion into complete Class I position. The former is mainly indicated where
extractions are used, the latter with no extractions.
TREATMENT GOALS Molar correction can be by single tooth movement (Fig. 40.2A,B) or
Treatment goals should be visualized prior to treatment, in particular from segmental movement (Fig. 40.2C,D). Single tooth control needs precision
the occlusal view. appliance construction when it comes to translation or root movement. In
 LINGUAL ORTHODONTICS AND THE USE OF MINISCREW IMPLANTS 213

Buccal cortex (mm) Palatal cortex (mm) Buccal mucosa (mm) Palatal mucosa (mm)

2 1.5 1 0.5 0 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0 0.5 1 1.5 2 2.5 3 3.5
M1 M1
PM2 PM2

Between PM2 and M1 Between PM2 and M1

2 1.5 1 0.5 0 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5
M2 M2
M1 M1

A Between M1 and M2 B Between M1 and M2

8 mm Mandible
6 mm
4 mm CEJ
2 mm 2 mm
CEJ 4 mm
6 mm
Maxilla 8 mm

3 mm < distance < 4 mm 3 mm < distance < 4 mm

4 mm < distance 4 mm < distance

8 mm
Mandible
6 mm
4 mm CEJ
2 mm 2 mm
CEJ 4 mm
6 mm
Maxilla 8 mm

4 mm < depth < 5 mm 4 mm < depth < 5 mm

5 mm < depth < 6 mm 5 mm < depth < 6 mm
C 6 mm < depth D 6 mm < depth
Fig. 40.1 Insertion sites. (A,B) Maxillary buccal and palatal alveolar area cortical bone thickness (A) and soft tissue thickness (B). (C,D) Available inter-radicular bone in the
maxilla (C) and mandible (D). CEJ, cementoenamel junction. (With permission from Lee et al., 2009.4)

contrast, segmental control of molars can be easy in terms of appliance using continuous archwires, which may reduce the total chair-time by
fabrication when it is combined with inter-radicular MIs. Anteroposteri- eliminating the need for additional appliances.
orly, a long segment can be more resistant to tipping than a single tooth,
which enables distal translation without additional apparatus such as
lever arms.
THE LEVER ARM DESIGN
Segmental distalization using MIs as anchorage is limited by the pos- In a two-dimensional model, lever arms can be extended as an extension
sible contact between the roots and MIs; the maximum amount of move- wire up to or beyond the CR of the target segment (Fig. 40.3A).6 Three-
ment is 2–3 mm, which is sufficient to correct end-to-end Class II molars. dimensional finite element analysis has shown that long lever arms
For more distalization, removal of MIs and reinsertion at nearby inter- extended toward the palatal vault may show elastic deformation to the
radicular sites is recommended. Angulation of the insertion path is recom- distal side according to the force direction, which, in turn, may tip the
mended to secure more clearance between the MI and the roots of the central incisors lingually (Fig. 40.3B).7 In order to secure precision tooth
teeth. Simultaneous segmental or total arch distalization can be possible movement, it is advised that the two lever arms extending from each side
 214 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Fig. 40.2 Molar correction. (A,B) Clinical (A) and schematic

(B) representation of single molar distalization using midpalatal
miniscrew implants (MIs). (C,D) Clinical (C) and schematic
(D) representation of segmental distalization using buccal
alveolar MIs.

A C

CR

B D

0.15198
0.119596
0.087212
CR CR 0.054828
0.022444
0.00994
0.042324
0.074709
0.107093
0.139477
A B

Fig. 40.3 Lever arm design. (A) Two-dimensional model. (B) Occlusal view with application of forces from the miniscrew implants to hooks attached to the lingual
archwire.

are reinforced with rigid connecting wires. The lever arms along the floor displacement of the maxillary right central incisor and a mild Class II
of anterior maxilla should be as long as 20 mm. molar relation on both sides. There was a 3.0 mm arch length discrepancy
in both the maxillary and mandibular arches. Her facial profile was convex,
possibly because of protrusive lips and retrusive chin. Initial cephalometric
FINISHING STAGE analysis revealed moderate Class II pattern (Table 40.2). Considering the
Following segmental correction, continuous archwires are normally used severity of the protrusion, extraction of the first premolars was indicated.
to stabilize the entire arch. Up-and-down vertical elastics can be used short However, the maxillary and mandibular left second premolars had received
term for occlusal seating. However, the use of either Class II or Class III root canal treatment. Consequently, second premolar extraction was con-
elastics for a relatively long period of time for incomplete anteroposterior sidered as more appropriate in order to save the sounder teeth. To be able
correction is not recommended because of their extrusive nature. to retract the eight teeth encompassing the incisors, canines and first
premolars as a unit, firm anchorage preparation was crucial. For this
reason, insertion of the MIs was planned on both the maxillary and man-
CLINICAL APPLICATIONS dibular lingual sides.
To relieve the anterior crowding while ensuring maximum retraction at
Some clinical examples of treatment of adults with Class II malocclusion the same time, the canines and the first premolars were first retracted on
using lingual appliances and MIs are presented and discussed below. round SS wire (0.016 inch) from the MIs (diameter, 1.8 mm; length,
7 mm; tapered body; Orlus 18107, Ortholution, Seoul, Korea) with
elastic chains (Fig. 40.4F,G). The MIs were inserted on the palatal slope
CASE 1: PROTRUSION OF MAXILLARY AND between the maxillary molars. Following partial retraction of the premo-
MANDIBULAR INCISORS lars and canines, brackets were bonded on the incisors for full-arch align-
ment. Retraction of premolars and canines in the mandibular arch was
A 29-year-old woman presented with protrusion of the maxillary and initially accomplished with reciprocal elastic chains engaged on the
mandibular incisors (Fig. 40.4A,C–E). There was prominent labial second molars.
 LINGUAL ORTHODONTICS AND THE USE OF MINISCREW IMPLANTS 215

Fig. 40.4 Case 1: protrusion of maxillary and mandibular incisors. (A,C–E) Pretreatment.
(F,G) The two arches during retraction of the premolars and canines. (H,I) The two arches
during retraction of the upper and lower anterior segments immediately after insertion of a
splinted H-lever arm. (B,J–L) Post-treatment.

A B

C D E

F G H I

J K L

After full alignment, both upper and lower anterior segments were
Table 40.2 Case 1: cephalometric measurements
retracted with a splinted H-lever arm, which was fabricated with 0.8 mm
Variables Before treatment After treatment round SS wire, soldered on the main SS archwire (Fig. 40.4H,I). In the
SNA (°) 86.59 84.79 mandibular arch, the MIs were inserted on the lingual alveolar bone mesial
SNB (°) 79.65 78.69 to the first molars.
ANB (°) 6.94 6.09 Following anterior retraction and detailing, the appliances were removed
Wits appraisal (mm) 0.04 −2.63 (Fig. 40.4B,J–L). The maxillary and mandibular incisors had been moved
Sum (°) 396.40 396.23 8.5 mm and 5.5 mm, respectively. Lateral facial profile was improved
SN-GoMe (°) 36.40 36.23
through a significant lip profile change.
U1 to SN (°) 115.43 99.21
IMPA (°) 103.86 92.63
Upper lip to E-line (mm) 3.73 −2.05 Discussion
Lower lip to E-line (mm) 5.82 −0.73
For this patient, significant displacement of the roots and crowns of the
incisors was indicated in both arches for improvement of the profile.
IMPA, incisor mandibular plane angle. Hence, the incorporation of the rigid lever arm on the main continuous
archwire aimed was intended to achieve this desired tooth movement.
 216 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Extraction of the second instead of the first premolar was another limiting problems with her temporomandibular joint, which had subsided some
factor. In order to secure maximum anchorage for the retraction of both years ago. Associated with this, flattening of the condylar head was noted
the anterior teeth and the premolars, as well as to produce an appropriate in the initial panoramic radiograph. Cephalometric and model analysis
line of force passing through the CR of the incisors, the MIs were placed revealed a severe Class II skeletal pattern, incisor dental compensation
on the lingual alveolar slope in both arches. Subsequently, tooth movement (flared mandibular incisors and uprighted maxillary incisors) and a nega-
was translation of the maxillary incisors and a combination of translation tive overbite of 2 mm with hyperactivity of the mentalis muscle at reposed
and lingual tipping of the mandibular incisors. lip position (Table 40.3). Her major concern was to improve the lateral
profile with invisible braces. However, in spite of the severe skeletal
pattern, she did not want invasive orthognathic surgery procedures. There-
CASE 2: ANTERIOR OPEN BITE AND PROTRUSION fore, orthodontic camouflage treatment was chosen, aiming to induce a
significant profile change without mandibular advancement. The limita-
A 20-year-old woman presented with a chief complaint of anterior open tions of this approach were explained to the patient and informed consent
bite and protrusion (Fig. 40.5A,C–E). In the past, she had suffered from was gained. Considering the compensated incisor relation, maximum

A B

C D E

F G H I

J K L

Fig. 40.5 Case 2: anterior open bite and protrusion. (A,C–E) Pretreatment. (F,G) Premolars have been extracted, a lingual appliance placed in the maxillary arch and
conventional buccal fixed appliances in the mandibular arch. (H) Four months later. (I) Completion of segmental retraction. (B,J–L) Post-treatment.
 LINGUAL ORTHODONTICS AND THE USE OF MINISCREW IMPLANTS 217

Table 40.3 Case 2: cephalometric measurements Table 40.4 Case 3: cephalometric measurements
Variables Before treatment After treatment Variables Before treatment After treatment
SNA (°) 87.14 85.31 SNA (o) 76.68 76.00
SNB (°) 76.96 77.42 SNB (o) 71.45 71.4
ANB (°) 10.18 7.89 ANB (o) 5.24 4.60
Wits appraisal (mm) 1.95 3.88 Wits appraisal (mm) 2.73 0.48
Sum (°) 401.59 400.42 Sum (o) 397.58 396.95
SN-GoMe (°) 41.59 540.42 SN-GoMe (o) 37.58 36.95
U1 to SN (°) 104.44 97.91 U1 to SN (o) 107.19 98.76
IMPA (°) 115.15 96.45 IMPA (o) 106.43 112.55
Upper lip to E-line (mm) 4.42 1.49 Upper lip to E-line (mm) 1.63 1.31
Lower lip to E-line (mm) 7.63 1.64 Lower lip to E-line (mm) 2.41 1.26

IMPA, incisor mandibular plane angle. IMPA, incisor mandibular plane angle.

translation of maxillary incisors was planned, together with controlled lar incisors were proclined and in particular, root shortening of the upper
tipping of the mandibular incisors. incisors and alveolar bone loss in the anterior area were severe. The
To achieve maximum translation of the maxillary incisors, a high line patient refused to receive orthognathic surgery, asking for a less invasive
of force application was needed, which was provided using a cross-arch orthodontic treatment. Considering her maxillary incisors, distalization
lever arm soldered from the main archwire positioned at the deepest palatal of the upper arch by 3.5 mm on both sides was better indicated than
arch to a MI (diameter, 1.8 mm; length, 7 mm; tapered body; Orlus 18107) the extraction of premolars. In order to avoid round tripping of incisors,
inserted in the midpalatal area (Fig. 40.5F,G). the use of tooth- (or/and tissue-) borne intraoral distalizers, such as the
Vertical bowing was noted during retraction, and so the main archwire Distal Jet or the Pendulum, were contraindicated. Instead, a simultane-
was segmented distal to the canines. A high line of force was constantly ous distalization of both molar and incisor segments, i.e. total arch, was
provided for the root movement of incisor segment (Fig. 40.5H). planned.
After further segmental retraction of 8 months, flattening of the occlusal To reduce the friction during alignment, 2D lingual brackets were selec-
plane was observed (Fig. 40.5I). Further space closure was performed on tively bonded on the anterior teeth. After leveling and alignment, the
the segmented arch. anterior 2D brackets were removed, and the total maxillary arch was
After 18 months of active treatment, space closure and detailing were retracted using a modified lever arm, which was composed of a mesh pad
complete (Fig. 40.5B,J–L). Proper incisor and molar relationship was bonded on the anterior segment to avoid any jiggling movement by the
attained through pure translation of the maxillary incisors. Her lateral bracket-wire play and a conventional main archwire inserted into the
profile was improved mainly by retraction of the upper and lower lips and brackets of the posterior teeth (Figure 40.6F,G). The MIs were initially
the relief of soft tissue tension, particularly in the mentalis muscle. inserted on the palatal slope between the molars.
At 1 year following active treatment, the temporomandibular joint did In order to induce a sufficient amount of distalization, alternative
not show any drastic change and the occlusion remained stable. Incisor lingual and buccal MIs were used. After significant distalization was
relation, midline and molar relation were maintained during the short-term achieved, conventional lingual brackets were bonded for finishing
retention phase. (Figure 40.6H,I).
After 27 months of treatment, all appliances were removed (Figure
40.6J-L). The maxillary incisors were retracted 6.0 mm, the maxillary
Discussion
molars were distalized 3.5 mm, the mandibular incisors were flared
In order to overcome the underlying severe Class II skeletal pattern, extru- 2.0 mm, and the patient’s profile was improved (Figure 40.6B).
sion of the teeth was strictly contraindicated in this patient. The midpalatal
MI position in combination with the long lever arm from the incisor brack-
Discussion
ets was, therefore, selected in order to produce the highest line of force
for the intrusive translation of the maxillary incisors. The resulting move- With the limitation of the camouflage treatment understood beforehand,
ment was consequently lingual translation of the maxillary incisors and the patient was satisfied with the result of treatment.
lingual tipping (uprighting) of the mandibular incisors. The labial appli-
ances on the mandibular arch were tolerated well by the patient.
CONCLUSIONS

CASE 3: MAXILLARY ANTERIOR PROTRUSION Based on both esthetic factors during treatment and treatment effects,
lingual appliances may be a very strong option for adults. The greatest
A 37-year-old woman presented with a chief complaint of maxillary strength of the utilization of MIs in lingual orthodontic treatment is the
anterior protrusion (Fig. 40.6Α,C-E). Initial cephalometric and model fact that they can induce arbitrary segmental movement depending on the
analysis showed severe Class II skeletal pattern with end-to-end Class II insertion sites. This versatility enables the orthodontist to attempt lingual
molars on both sides (Table 40.4). Both the maxillary and the mandibu- treatment even in very challenging cases.
 218 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B

C D E

F G H I

J K L

Fig. 40.6 Case 3: maxillary anterior protrusion. Pre- (A) and post-treatment (B) extraoral photographs. (C-E) Pre-treatment intraoral photographs. (F,G) After placement of
a modified lever arm, insertion of the MIs and application of elastic chains for the retraction of the maxillary arch. (H,I) After insertion of buccal MIs and placement of
conventional lingual brackets for finishing. (J-L) Post-treatment intraoral photographs.

4. Lee KJ, Joo E, Kim KD, et al. Computed tomographic analysis of tooth-bearing alveolar
REFERENCES bone for orthodontic miniscrew placement. Am J Orthod Dentofacial Orthop
2009;135:486–94.
1. Tod MA, Taverne AA. Prevalence of malocclusion traits in an Australian adult popula- 5. Kinzinger G, Frye L, Diedrich P. Class II treatment in adults: comparing camouflage
tion. Aust Orthod J 1997;15:16–22. orthodontics, dentofacial orthopedics and orthognathic surgery. A cephalometric study
2. Hohoff A, Wiechmann D, Fillion D, et al. Evaluation of the parameters underlying to evaluate various therapeutic effects. J Orofac Orthop 2009;70:63–91.
the decision by adult patients to opt for lingual therapy: an international comparison. J 6. Park YC, Choy K, Lee JS, et al. Lever-arm mechanics in lingual orthodontics.
Orofac Orthop 2003;64:135–44. J Clin Orthod 2000;34:601–5.
3. Lee KJ, Park YC, Hwang CJ, et al. Displacement pattern of the maxillary arch depend- 7. Kim KH, Lee KJ, Cha JY, et al. Finite element analysis of effectiveness of lever arm
ing on miniscrew position in sliding mechanics. Am J Orthod Dentofacial Orthop in lingual sliding mechanics. Korean J Orthod 2011;41:324–36.
2011;140:224–32.
 Skeletal anchorage in lingual orthodontic
treatment with sliding mechanics
41
Kyoto Takemoto and Moschos A. Papadopoulos

INTRODUCTION CLINICAL APPLICATION

Treatment of Class II malocclusion usually involves maxillary molar dis- For en masse retraction of the maxillary teeth in lingual orthodontic treat-
talization and subsequent retraction of the anterior teeth. This can be ment of Class II malocclusion, strong retraction forces may cause a tip-
performed either without friction (using loop mechanics) or with friction forward of the posterior teeth, and consequently lateral occlusal function
(using sliding mechanics). Table 41.1 compares these approaches as it is may be impaired. The use of MIs for anchorage reinforcement can help to
important for the clinician to understand the advantages and disadvantages avoid these undesirable countermovements of the posterior teeth during
in order to choose an appropriate mechanism for a patient’s treatment. anterior teeth retraction or during closure of extraction sites.
Miniscrew implants (MIs) can provide greater anchorage in the man- MIs can be positioned either inter-radicularly on the palatal side in the
dibular arch than in the maxilla, while posterior anchorage needs to be alveolar bone between the roots of the teeth or in the midpalatal suture.
reinforced in lingual orthodontics, particularly in the maxillary arch.1–3
Various methods of maximum, moderate and minimum anchorage (e.g. INTER-RADICULAR SITES
MIs, transpalatal arches, headgears, Class II elastics) can support loop and
The most common site is inter-radicularly on the palatal side, usually
sliding mechanics in the maxillary dental arch.
between the second premolars and the first molars on both sides of the
This chapter focuses on the management of Class II malocclusion with
maxillary arch (Fig. 41.1A,B), since these regions provide the best bone
lingual orthodontics and application of sliding mechanics combined with
quality and quantity. For MIs in this position, power chains or closed coil
MIs to reinforce posterior anchorage during en masse retraction of the
springs are placed between the MIs and the hooks attached between the
maxillary teeth.
canines and second premolars on the upper archwire, and the maxillary
anterior teeth are retracted en masse with sliding mechanics.
The wire is usually furnished with a gable-bend to maintain the torque
Table 41.1 Advantages and disadvantages of loop of the maxillary anterior teeth. This procedure may induce lingual tipping
and sliding mechanics of the maxillary anterior teeth and deep bite, particularly when the retrac-
Loop mechanics Sliding mechanics tion force is strong. However, the maxillary posterior teeth may intrude
Wire friction + − and, consequently, posterior disocclusion tends to occur (Fig. 41.1B).
Anti-tipping bend + +/− Therefore, this procedure is indicated for the treatment of patients with
Control of retraction force + +/− open bite, particularly when the maxillary anterior teeth are proclined. It
Unilateral extraction cases + +/− is not suitable for patients with deep bite, such as those with Class II,
Bite opening control + − division 2 malocclusion.
Discomfort +/− +
Wire bending − + Midpalatal Suture Sites
The MI is inserted in the midpalatal suture at the level between the second
+, achievable with these mechanics; −, difficult to achieve with these mechanics. premolars and first molars (Fig. 41.1C,D). For MIs in this position, a

Fig. 41.1 En masse retraction of the maxillary

anterior teeth. (A,B) Clinical view (A) and
schematic (B) of inter-radicularly placed
miniscrew implants (MIs). (C,D) Clinical view
(C) and schematic (D) of MI inserted in the
midpalatal suture.

A C

B D

219
 220 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C D

E F G H

I J K L

Fig. 41.2 Case 1: non-extraction treatment for protrusion of maxillary anterior teeth. (A,B) Pretreatment. (C) Insertion of a lingual arch and two inter-radicularly placed
microscrew implants. (D) Nine months later at end of maxillary molar distalization. (E,F) Removal of the lingual arch and insertion of lingual fixed appliances at 10 months
after initiation of treatment. (G,H) Start of the finishing stage at 2 years after initiation of treatment. (I–L) Post-treatment.

closed coil spring or a power chain is placed between the MIs and the
Table 41.2 Case 1: wire sequence followed during treatment
hooks attached between maxillary lateral incisors and canines, and the
Date Maxillary arch Mandibular arch
maxillary anterior teeth are retracted en masse with sliding mechanics.
The MI should be inserted more mesially if a stronger intrusive force Nov 2008 0.012 inch Ni-Ti 0.012 inch Ni-Ti
is desired and more distally if a stronger distalization force is desired. This Jan 2009 0.016 × 0.016 inch Ni-Ti

procedure allows retraction without deepening the bite, since the posterior March 2009 0.0175 × .0.0175 inch TMA
May 2009 0.016 × 0.016 inch SS 0.016 × 0.016 inch Ni-Ti
teeth maintain stability as simultaneous intrusive and retraction forces can
June 2009 0.018 × 0.018 inch SS
be applied. However, because of the application of these additional
Nov 2009 0.0175 × 0175 inch TMA
intrusive forces, it may take additional time for the retraction of the maxil-
Nov 2010 0.0175 × 0.0175 inch TMA
lary anterior teeth. Therefore, this procedure is mainly indicated for
patients presenting with a normal to deep bite, but not for patients with an
open bite.
approach, the maxillary and mandibular dental arches were leveled and
aligned, while the anterior teeth and first premolars were retracted. Ante-
rior teeth retraction was initiated by applying open coil springs between
CASE EXAMPLES
the brackets of the canines and first premolars, while the MIs were con-
nected through wire ligatures to the canine brackets to support anchorage.
CASE 1: NON-EXTRACTION TREATMENT OF Elastic chains were applied between the MIs and hooks attached on the
PROTRUSION OF MAXILLARY ANTERIOR TEETH maxillary archwire between the brackets of the canines and the first premo-
A 21-year-old woman presented with protrusion of her maxillary anterior lars (Fig. 41.2G). Two years after treatment start, short Class II elastics
teeth. She had a Class II, division 1 malocclusion and Class II molar and were used and the finishing stage of treatment was initiated (Fig. 41.2G,H).
canine relationship on both sides, plus Class I skeletal relationships of the The wire sequence used during treatment is presented in Table 41.2.
maxilla and mandible (Fig. 41.2A,B). After a total treatment time of 3 years, the fixed appliances and MIs
Initially, a maxillary lingual arch was bonded on the maxillary first were removed (Fig. 41.2I–L). The final result was a well-functioning
molars and two MIs were inserted inter-radicularly between the maxillary occlusion presenting Class I canine and molar relationships, ideal torque
second premolars and first molars (Fig. 41.2C). Maxillary molar distaliza- of the anterior teeth, as well as ideal overjet and overbite.
tion was initiated by applying elastic chains between the MIs and the
lingual arch as shown in Fig. 41.2C. Molar distalization was completed in
9 months (Fig. 41.2D).
CASE 2: EXTRACTION TREATMENT OF PROTRUSION
The lingual arch was removed and lingual appliances (STb Light
OF MAXILLARY ANTERIOR TEETH
Lingual System, Ormco, Orange, CA, USA) were bonded on both dental A 21-year-old woman presented with maxillary anterior teeth protrusion.
arches (Fig. 41.2E,F). Using this lingual system and the straight wire She had Class I molar relationships on both sides, severe proclination of
 Skeletal anchorage in lingual orthodontic treatment with sliding mechanics 221

Fig. 41.3 Case 2: extraction treatment

for protrusion of maxillary anterior teeth.
(A–C) Pretreatment. (D–F) After extraction
of teeth and insertion of fixed lingual appliances.
(G–I) Leveling stage at 2 months after initiation
of treatment. (J–L) Insertion of two miniscrew
implants between the first and second maxillary
A B C molars at 3 months after initiation of treatment.
(M–O) Retraction of the maxillary first premolars
and anterior teeth at 9 months after treatment start.
(P–R) Post-treatment.

D E F

G H I

J K L

M N O

P Q R

the maxillary anterior teeth and a large overjet (Fig. 41.3A,B). The overjet Three months after initiation of treatment, two MIs were inserted
was partially attributed to the missing mandibular lateral incisors. In addi- inter-radicularly between the first and second maxillary molars to
tion, the maxillary right second primary molar was present but the corre- support the retraction of the maxillary anterior teeth (Fig. 41.3J–L).
sponding second premolar was missing. The mandibular lateral incisors Elastic chains were applied between the MIs and hooks attached
and the maxillary right second premolar were congenitally missing. She on the archwire between the brackets of the canines and first
had Class II skeletal relationships of the maxilla and mandible with a slight premolars.
dolichofacial tendency. Nine months after treatment start, the retraction of the maxillary first
Before initiating treatment, the maxillary right primary second molar premolars and the anterior teeth was completed (Fig. 41.3M–O). Since
and the left second premolar were extracted. Lingual appliances (STb lingual tipping of the maxillary anterior teeth and posterior disocclusion
Light Lingual System) were bonded on both dental arches (Fig. 41.3D–F) had occurred, the maxillary dental arch was leveled again, and final extrac-
for leveling and alignment, which was undertaken using the straight wire tion space closure and finishing was carried out. The wire sequence used
approach (Fig. 41.3G–I). during treatment is presented in Table 41.3.
222 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

The total treatment time was 2.5 years. After completion of treatment,
Table 41.3 Case 2: wire sequence followed during treatment
the fixed lingual appliances and MIs were removed (Fig. 41.3P–R). The
Date Maxillary arch Mandibular arch
final result revealed a good and stable occlusion with Class I canine and
Apr 2008 0.012 inch Ni-Ti 0.012 inch Ni-Ti molar relationships, normal overbite and overjet, and ideal torque of the
June 2008 0.016 × 0.016 inch Ni-Ti 0.016 × 016 inch Ni-Ti anterior teeth.
July 2008 0.016 inch SS
Aug 2008 0.0175 × 0.0175 inch TMA
Dec 2008 0.016 × 0.016 inch Ni-Ti
REFERENCES
Jan 2009 0.0175 × 0.0175 inch TMA
Apr 2009 0.016 × 0.022 inch SS 1. Geron S. Anchorage considerations in lingual orthodontics. Semin Orthod 2006;12:
Aug 2009 0.018 × 0.01 inch TMA 167–77.
Oct 2009 0.018 × 0.01 inch β-Ti 2. Papadopoulos MA, Papageorgiou SN, Zogakis IP. Clinical effectiveness of orthodontic
miniscrew implants: a meta-analysis. J Dent Res 2011;90:969–76.
3. Scuzzo G, Takemoto K. Invisible orthodontics. Current concepts and solutions in
lingual orthodontics. Berlin: Quintessence; 2003.
 Lever arm and miniscrew implant system
for distalization of maxillary molars and
42
anterior teeth retraction
Seung-Min Lim and Ryoon-Ki Hong

INTRODUCTION THE LEVER ARM AND MINISCREW IMPLANT SYSTEM

The lever arm and MI system fulfills these needs. Lingual lever arms can
This chapter will discuss the lever arm and miniscrew implant (MI) system
be easily fabricated and positioned in the maxillary arch to fit the available
for the treatment of Class II malocclusion through distal movement of
width and depth of the palate. Their use facilitates alteration of the point
maxillary molars and anterior teeth retraction.
of force application and consequently of the moment-to-force ratio in a
much easier way than using calibrated springs, since springs cannot be
adjusted independently to produce differential forces and moments.
DISTALIZATION OF MAXILLARY MOLARS For bodily translation of a tooth, two forces are applied at some distance
from the center of resistance (CR) of the tooth. One force at the level of
An ideal force system for distal movement of the maxillary molars in three
the crown and another at the root apex creates a resultant force through
dimensions should have distinct effects in different planes:
the CR and, thus, causes no rotational movement.
■ sagittal plane: produce a bodily distal movement of molars The lever arm and MI system allows adjustment of the distalizing force
without undesired effects of the reciprocal force on the anterior through a buccal and a palatal force system, thus varying the overall line
teeth of force, as shown in Fig. 42.1.1 If the expansion of a posterior tooth is
■ vertical plane: exert intrusion forces simultaneously to distalization needed during distalization, it can be obtained simultaneously using a
without changing the mandibular plane angle (i.e. avoid unintended transpalatal arch (TPA). To prevent hanging down of the palatal cusp of
molar extrusion) the maxillary first molars during expansion, buccal root torque should be
■ transverse plane: provide rotational control of the molars. applied when using the TPA or an adequate intrusive force should be

A B

D
C
Fig. 42.1 The lever arm and miniscrew implant (MI) system. (A) The line of action of the resultant distalizing force passes through the center of resistance (CR) of the
maxillary molars, producing a bodily movement parallel to the occlusal plane. (B) The line of action of the resultant force passes through the CR of the maxillary molars
in a superior direction, producing bodily distal movement along with intrusion. (C) Buccal and palatal forces together facilitate rotation control of the maxillary molars.
(D) Determination of the length of the lever arm and of the position of the MIs using lateral cephalometric radiography. OP, occlusal plane; BLA, buccal lever arm;
PLA, palatal lever arm.

223
 224 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

A B C

D E F

Fig. 42.2 Indirect bonding method. (A,B) Occlusal (A) and lateral (B) views of the transfer trays and lever arms on the cast. (C,D) Intraoral occlusal (C) and lateral (D) views
of the lever arm and miniscrew implant (MI) system immediately after bonding, insertion of one palatal and two buccal miniscrew implants and application of distalizing
forces with elastic chains. (E,F) Intraoral occlusal (E) and lateral (F) views of the same patient after distalization of the maxillary molars.

utilized by altering the height between the midpalatal MI and the TPA.The resultant force passes through the CR of the maxillary molars. If the palatal
lever arm and MI system comprises three MIs (one inserted in the palate vault is deep, the MIs are implanted more occlusally, while if it is shallow,
and two inserted buccally between the roots of the maxillary first molars the MIs are implanted more gingivally.
and second premolars on both sides), two buccally positioned lever arms,
a TPA functioning as a palatal lever arm, bands on first maxillary molars
(and occasionally brackets on second maxillary molars) (Fig. 42.1A–C).
CLINICAL APPLICATION
Forces are applied using elastic chains. CASE 1: SEVERE ANTERIOR CROWDING
AND MAXILLARY PROTRUSION
Appliance Construction
A 27-year-old Korean woman presented with the chief complaint of severe
The maxillary first molars are banded with double combination tubes anterior crowding and maxillary protrusion. She had a convex profile and
(0.022 inch) welded on the buccal side and Burstone lingual brackets Class II molar relationships (Fig. 42.3A,B). There was an arch length
(0.032 × 0.032 inch) on the palatal side. The maxillary second molars discrepancy of 18.5 mm and 12 mm in the maxillary and mandibular
are bonded with 0.022 inch tubes. A TPA fabricated from either TMA dental arches, respectively. Bilateral maxillary posterior dental constric-
(0.032 × 0.032 inch) or SS wire (0.9 mm) is used as the palatal lever tion and slight anterior open bite were also present. Cephalometric analysis
arm. When SS wire is used, the portion engaged in the Burstone lingual revealed Class II skeletal relationships of the maxilla and mandible and a
brackets is ground with a green stone bur. The buccal lever arm is SS dolichofacial growth pattern (Table 42.1).
wire (0.019 × 0.025 inch). The positions of the MI and the buccal and Prior to treatment, the first maxillary premolars and second molars, right
palatal lever arms are determined by evaluating the lateral cephalometric mandibular first premolar and the retained root of the left first molar were
radiograph (Fig. 42.1D) and the maxillary cast. Figure 42.2 shows the extracted (Fig. 42.3D). Two MIs (length, 6 mm) were inserted between
indirect bonding method for the buccal and palatal lever arms. If there is the maxillary first molars and second premolars bilaterally and both maxil-
no need for expansion of the maxillary molars, or if both first and second lary canines were retracted with elastic chains (Fig. 42.3C,D). An addi-
molars need to be intruded, the TPA can be bonded on both the first and tional MI was inserted in the palate and, after 3 months, distalization of
the second molars. the maxillary molars was initiated.
The length of the lever arm is set to place the applied force in the desired Because of the anterior open bite tendency and the hyperdivergent
position with regard to the CR of the molars, which is assessed by thor- growth pattern, the extrusion of maxillary molars that usually takes place
oughly evaluating a lateral cephalometric radiograph (Fig. 42.1D). If the during distalization could lead to a clockwise rotation of the mandible and
height of alveolar bone is low, the CR of the tooth moves toward the root opening of the bite. Consequently, the vertical levels of the MI heads and
apex; therefore, alveolar bone height should be carefully determined. The lever arms on both sides were adjusted to produce an intrusive force in
occlusal plane and facial pattern should be evaluated to decide the type of addition to the distalization force (Fig. 42.3E,F). Using elastic chain
tooth movement needed, for example whether the tooth should be just modules, a force of approximately 150 g was applied on each lever arm
distalized parallel to the occlusal plane or with simultaneous intrusion. on the buccal side and a force of approximately 300 g was applied on the
TPA on the palate (i.e. in total a force of approximately 300 g on each
maxillary molar). In addition, a 0.9 mm SS expanded TPA was used to
Position for Miniscrew Implants
correct bilateral posterior maxillary dental constriction.
The depth of the palatal vault should also be taken into consideration. If After 9 months of treatment, the lever arms and the TPA were removed
it is extremely shallow, bodily movement of maxillary molars is accom- and two additional MIs were inserted on the palate between the roots of
plished by inserting a MI in the midpalatal suture. However, in most the second premolars and first molars (Fig. 42.3G,H). Elastic chains and
patients, the head of the MI is positioned vertically on the root apex level. power hooks were utilized to retract the anterior teeth and treatment was
Therefore, the vertical position of the buccal MIs should be set so the continued for an additional 12 months.
 LEVER ARM AND MINISCREW IMPLANT SYSTEM 225

A B C D

E F G H

I J

K
Fig. 42.3 Case 1: distalization of maxillary molars for severe anterior crowding and maxillary protrusion. (A,B) Pretreatment. (C,D) Placement of buccal fixed appliances
on the lower arch, and insertion of the palatal lever arm and of one palatal and two buccal miniscrew implants (MIs) on the maxilla. The buccal MIs facilitate canine
retraction, while the palatal MI effects distalization of maxillary molars. (E,F) Insertion of the buccal lever arms on the maxillary arch. Adjustment of the vertical level of all
MI heads and lever arms to apply an intrusive force simultaneous to distalization. (G,H) Insertion of two additional MIs on the palate between the roots of the second
premolars and first molars to facilitate anterior teeth retraction. (I,J) Post-treatment. (K,L) Superimposition of the cephalometric tracings before (black) and after (red)
treatment; overall superimposition on the SN line (K) and maxillary superimposition (L).

The fixed appliances were removed 24 months after initiation of treat-

Table 42.1 Case 1: cephalometric measurements
ment. Ideal Class I molar and canine relationships, overbite and overjet
Measurement Pretreatment Post-treatment
were achieved (Fig. 42.3I,J). On the cephalometric superimposition before
Skeletal and after treatment, a 3.0 mm bodily distalization and 1.5 mm intrusion
SNA (°) 81 80 of the maxillary molars were evident, while the mandibular plane angle
SNB (°) 73 73 did not change (Fig. 42.3K,L).
ANB (°) 8 7
FMA (°) 29.5 29.5
NPo-FH (°) 73.5 73.5 ANTERIOR TEETH RETRACTION
Dental
U1to FH (°) 124 105 Temporary anchorage devices seem to be effective for intraoral anchorage
FMIA (°) 55 55.5 reinforcement for en masse retraction of the anterior teeth. However,
Overbite (mm) −1 2 torque control is still a significant issue to be taken into consideration.
Overjet (mm) 8 2.5 The design of a force system for retraction of the anterior teeth is based
Soft tissues on knowledge of the CR of the unit (the six anterior teeth) to be moved.
Upper lip to E-line (mm) 1.5 −2 Based on retraction with sliding mechanics, the CR of the six anterior teeth
Lower lip to E-line (mm) 3 −0.5 has been determined as 77% of the total root length away from the apex,
which is approximately 11–12 mm apical to the incisal edge of the incisors
(6.5–7.5 mm apical to labial brackets position).2,3
FMA, Frankfort-mandibular plane angle; FMIA, Frankfort-mandibular incisor angle. Factors such as wire size, the bracket slot size and the interplay
between bracket slot and archwire are some of the variables affecting the
biomechanical behavior of tooth movement. A three-dimensional finite
element analysis of sliding mechanics showed that a lever arm placed
 226 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

Fig. 42.4 Analysis of anterior teeth retraction.

(A,B) Effects of bracket positioning and point of
force application on tooth movement when FI
bonding on the labial (A) or the lingual (B) surface CR FI FR+I CR
of the maxillary central incisor. When using lingual FR+I
appliances, the resultant force produces a larger
moment, which tips the incisor more lingual than FR
FR
when using conventional labial appliances. (C–E) M1 M2
Line of action of the retraction forces with varying B
A
configurations of the lever arm or miniscrew
implant (MI) position. (C) When the resultant force
vector passes through the CR of the incisors; the
anterior teeth will be retracted bodily and MI
intruded (left), retracted bodily (middle) or MI
retracted bodily and extruded (right). (D) With CR CR CR
simultaneous lingual crown torque of the anterior LA LA LA
MI
teeth where the resultant force vector passes
below the CR of the incisor, the anterior teeth will C
be retracted and intruded (left), retracted (middle)
or retracted and extruded (right). (E) With
simultaneous lingual root torque of the anterior
teeth where the resultant force vector passes
above the CR of the incisors, the anterior teeth MI
will be retracted and intruded (left), retracted CR CR CR
MI
(middle) or retracted and extruded (right). CR, LA
D LA MI LA
center of resistance; FR, retraction force; FI,
intrusion force; FR+I, resultant force; LA, lever arm;
M1 and M2, moments.

MI
MI
CR CR CR
LA LA MI LA
E

mesial to the canine at a height of 5.5 mm apical to the bracket position arm, MIs can be used not only for anchorage reinforcement but also for
produced bodily movement for anterior teeth retraction.4 As the position anterior torque control in lingual orthodontics.
of the lever arm on the archwire was moved from the incisor to the
premolars, the length of the lever arm had to be increased in order to
produce parallel translation: the length should be 4.99 mm apical to the
THE LEVER ARM AND MINISCREW IMPLANT SYSTEM
bracket position when the lever arm was located between the lateral inci- To design the optimal lever arm and MI system for obtaining the desired
sors and the canines and 8.22 mm when located between the canines and force system during retraction with respect to the CR of the anterior
the first premolars.5 If the interplay between the bracket slot and arch- segment, the point of force application and the line of action of the retrac-
wire is increased, the height of the lever arm is also increased in order to tion force are planned using lateral cephalometric radiographs.
produce bodily movement, and vice versa. Therefore, the lever arm Figure 42.4C–E illustrates the overall reaction that can be expected with
should be placed mesial to the canines in order to attain better control of retraction forces in various configurations. Force parallel to the occlusal
the anterior teeth with sliding mechanics. plane and applied through the CR of the anterior teeth will bodily retract
Several other variables affecting the biomechanical behavior of tooth the anterior segment, alone or with simultaneous intrusion or extrusion
movement must be taken into consideration in clinical lingual orthodon- (Fig. 42.4C).
tics, for example anatomic parameters, such as the length and the shape If the length of the lever arm is adjusted so that the line of action of the
of teeth roots, the width of the periodontal ligament, the palatal alveolar retraction force is located below the CR of the anterior teeth, there will be
bone height, the angle of crown inclination and the physical properties of lingual crown torque of the anterior segment (Fig. 42.4D), while if the line
periodontal tissue. of action of the retraction force is located above the CR, there will be
In lingual orthodontics, torque control of anterior teeth during retraction lingual root torque of the anterior segment (Fig. 42.4E).
is more challenging than using labial fixed appliances because of the spe-
cific position of the brackets on the lingual surfaces of the teeth (Fig.
Appliance Construction
42.4A,B). Anterior torque control is achieved either by directly applying
a moment and a force to a lingual bracket or by using lever arm mechanics Because the interplay between the bracket slot and archwire is a very
to obtain the desired line of action of the force with respect to the CR of important factor, affecting the height of the lever arm, clinicians must be
the tooth (Fig. 42.4C–E).6–8 The desired tooth movement is attained by aware of the real slot size and shape of the lingual brackets (Table 42.2).9
adjusting the length of the lever arm and the point of force application. In lingual orthodontics during anterior teeth retraction with sliding
Using lingual appliances allows the lever arm system to be ideally located mechanics using brackets with horizontal slots, there is a tendency of the
because appropriate space is almost always available within the width and archwire to come out of the lingual bracket slot. Consequently, there is a
depth dimensions of the palate. Therefore, in combination with a lever bigger chance of losing control of anterior segment torque if the bracket
 LEVER ARM AND MINISCREW IMPLANT SYSTEM 227

slot walls are divergent. In such a case, a longer lever arm should be used an SS segmented archwire (0.018 × 0.018 inch or 0.019 × 0.019 inch) is
and additional anterior torque should be applied to the archwire. inserted into the vertical slot. This segmented archwire can be used for
Fujita lingual brackets are provided with horizontal and vertical slots additional anterior torque control and can prevent unintentional anterior
(Fig. 42.5). The size of the main horizontal slot is 0.018 × 0.025 inch torque loss, thus allowing shorter lever arms to be used during anterior
and of the vertical slot is 0.019 × 0.019 inch. An SS archwire (0.016 × teeth retraction.10
0.022 inch) is inserted into the horizontal slot as the main archwire, while When the lever arm is located between the lateral incisor and the canine,
its length in the vertical is 2–3 mm shorter than its actual length because
of the inclination of the palatal vault. Therefore, a crimpable hook 7 mm
Table 42.2 Bracket slot size, shape and difference between slot top
in length is recommended to be used as lever arm for controlled tipping
and slot base
during anterior teeth retraction and one of 10 mm in length for bodily
Mean slot size (%) Difference movement. Alternatively, a 7 mm crimpable hook fabricated from SS
Bracket-type from slot segmented archwire (0.019 × 0.019 inch) can be applied for additional
prescription Slot base Slot top Slot shape top to base
lingual root torque. However, when a lever arm of more than 10 mm in
Ormco 7th 13.95 17.23 D 3.28
generation
length is needed for bodily movement, for example with low bone level
STB −0.92 2.58 D 3.5
or requiring lingual root movement, soldering of a 0.9 mm SS wire is
Fujita 6.08 4.33 C −1.75 recommended to prevent deformation.
Stealth 7.61 7.63 P 0.2
In-Ovation L 3.94 5.2 D 1.26 CLINICAL APPLICATION
CASE 2: LIP PROTRUSION AND
D, divergent; C, convergent; P, parallel. ANTERIOR CROWDING

A 33-year-old Korean woman presented with the chief complaint of lip

VS protrusion and anterior crowding. She had a convex profile and Class I
malocclusion (Fig. 42.6A,B). Cephalometric analysis revealed Class II
skeletal relationships of the maxilla and mandible (Table 42.3).
Initially, all four first premolars were extracted and the brackets were
HS bonded indirectly. After 5 months of treatment, both maxillary and man-
dibular teeth were leveled and aligned (Fig. 42.6C,D). During space
closure, bodily movements of maxillary anterior teeth without anchorage
loss were required. Two 9 mm MIs were inserted between the maxillary
first molars and second premolars. A 7 mm crimpable hook (SS wire,
0 mm
0.016 × 0.022 inch) was used as lever arm and positioned distal to the
Fig. 42.5 Anterior Fujita bracket. VS, vertical slot; HS, horizontal slot. canines. An SS wire (0.019 × 0.019 inch) was also placed into the vertical

A B C D

E F

G
H
Fig. 42.6 Case 2: anterior teeth retraction for lip protrusion and anterior crowding. (A,B) Pretreatment. (C) Bonding of lingual appliances on both dental arches.
(D) Insertion of the lever arm and miniscrew implant system for anterior teeth retraction on the maxilla. (E,F) Post-treatment. (G,H) Superimposition of cephalometric
tracings before treatment (black) and before retraction (green) (G), and before retraction (green) and after treatment (red) (H).
 228 SECTION VII: MINISCREW IMPLANTS FOR THE TREATMENT OF CLASS II MALOCCLUSION

After treatment, the convex profile was favorably improved, and crowd-
Table 42.3 Case 3: cephalometric measurements
ing was corrected (Fig. 42.6E,F). Superimpositions of the cephalometric
Before
tracing before and after treatment showed that bodily movement of the
Measurement Pretreatment retraction Post-treatment
maxillary incisors occurred without evidence of loss of anchorage of the
Skeletal posterior teeth (i.e. maxillary molars did not move mesially during retrac-
SNA (°) 86 86 85 tion; Fig. 42.6G,H). In addition, no downward or backward rotation of the
SNB (°) 78 78 78 mandible was evident, and lip protrusion was improved.
ANB (°) 8 8 7
FMA (°) 32 31.5 31.5
NPo-FH (°) 87 86.5 86.5
REFERENCES
Dental
U1 to FH (°) 107 95 93 1. Lim SM, Hong RK. Distal movement of maxillary molars using a lever-arm and
miniscrew implant system. Angle Orthod 2008;78:167–75.
FMIA (°) 45 56 69 2. Sia SS, Koga Y, Yoshida N. Determining the center of resistance of maxillary anterior
Overbite (mm) 3 4.5 3.5 teeth subjected to retraction forces in sliding mechanics: an in vivo study. Angle
Overjet (mm) 4.5 5 3.5 Orthod 2007;77:999–1003.
3. Sia SS, Shibazaki T, Koga Y, et al. Experimental determination of optimal force
Soft tissues system required for control of anterior tooth movement in sliding mechanics.
Upper lip to E-line (mm) 5.5 4.5 0.5 Am J Orthod Dentofacial Orthop 2009;135:36–41.
4. Tominaga JY, Tanaka M, Koga Y, et al. Optimal loading conditions for controlled
Lower lip to E-line (mm) 6.5 5 1
movement of anterior teeth in sliding mechanics. Angle Orthod 2009;79:102–7.
5. Kim TS, Suh JS, Lee MK. Optimum conditions for parallel translation of maxillary
anterior teeth under retraction force determined with the finite element method.
FMA, Frankfort-mandibular plane angle; FMIA, Frankfort-mandibular incisor angle. Am J Orthod Dentofacial Orthop 2010;137:639–47.
6. Bantleon HP. Modified lingual lever arm technique: biomechanical considerations. In:
Nanda R, editor. Biomechanics in clinical orthodontics. Philadelphia, PA: Saunders;
1997. p. 229–45.
slot, with 10° of additional lingual root torque. According to the evaluation 7. Park YC, Choy KC, Lee JS, et al. Lever-arm mechanics in lingual orthodontics.
of the lateral cephalometric radiograph, the upper ending of the lever arm J Clin Orthod 2000;34:601–5.
8. Hong RK, Heo JM, Ha YK. Lever-arm and miniscrew implant system for anterior
was constructed 12 mm away from the incisal edge. After 3 further months, torque control during retraction in lingual orthodontic treatment. Angle Orthod
6 mm MIs were inserted between the mandibular first molars and second 2005;75:129–41.
premolars for anchorage reinforcement and treatment was continued for 9. Lim SM, Hong RK. An evaluation of slot size in lingual orthodontic brackets. Kor J
Lingual Orthod 2012;1:19–23.
an additional 10 months. After a total of 18 months, treatment was 10. Lim SM, Hong RK. The tandem archwire technique in lingual orthodontics. J Clin
completed. Orthod 2013;47:232–40.
 Section VIII: Treatment of Class II malocclusion with different temporary anchorage devices

Molar and group distalization for the correction

of Class II malocclusion using bone anchorage
43
Nazan Kucukkeles, Mustafa B. Ates and Nejat Erverdi

such as loss of anchorage of the anterior teeth in terms of maxillary incisor

INTRODUCTION
proclination and increase of overjet.
Distalization using skeletal anchorage devices allows group movement of
buccal segments without any side effects on the other teeth of the dental
arch or the need for extended treatment in stages to complete the Class II CASE 1: MAXILLARY MOLAR DISTALIZATION WITH
correction (see Chapter 2). THE KELES SLIDER AND MINISCREW IMPLANTS
This chapter describes (1) the initial use of a tooth-based anchorage that
was converted to one using miniscrew implants (MIs) to support the tooth A 15-year-old girl presented with the chief complaint of crowding of her
anchorage, (2) use of palatal implants, (3) use of zygomatic miniplate upper anterior teeth. She had a symmetrical face, incompetent lips, an
anchorage, and (4) use of MIs for maxillary molar distalization. asymmetrical smiling line and a convex profile. She presented a Class II,
division 1 malocclusion with Class I skeletal relationships in conjunction
with a normal to high-angle vertical growth pattern. The lower incisors
MOLAR DISTALIZATION WITH MINISCREW IMPLANTS were proclined. The amount of crowding was 3.05 mm and 2.55 mm in
SUPPORTING THE TOOTH-ANCHORING SYSTEM the maxillary and mandibular arches, respectively (Fig. 43.1A,B). The
treatment plan included a Keles Slider to distalize the upper posterior seg-
Using MIs in the dental arch to support a tooth-anchored system can avoid ments to correct the Class II dental relationships and fixed appliances to
some of the unwanted side effects seen when using tooth anchoring alone, align the arches.

A B C D

E F

G H I J

Fig. 43.1 Case 1: maxillary molar distalization with the Keles Slider and miniscrew
implants (MIs). (A,B) Pretreatment. (C,D) Keles Slider cemented and bonding of
the mandibular arch. (E,F) Insertion of MIs. (G,H) Molar distalization completed.
(I,J) Premolars and canines have been distalized. (K,L) Post-treatment.

K L

229
 230 SECTION VIII: TREATMENT OF CLASS II MALOCCLUSION WITH DIFFERENT TEMPORARY ANCHORAGE DEVICES

Treatment Progress ■ if an area rich in cortical bone is available, as this improves the
primary stability of the implant.
The Keles Slider was cemented to the first premolars and first molars. A
Roth multibracket system with a slot (0.018 × 0.025 inch) was bonded on Palatal bone is widely used as a site for orthodontic implants because of
the lower arch and leveling was started with Ni-Ti archwire (0.014 inch) its favorable cortical bone thickness.8 The midpalatal suture area seems
(Fig. 43.1C,D). Over the next 3 months, spaces developed between the particularly suitable as it has both thin soft tissue and thick cortical bone9
premolars and first molars on both sides, but there was little improvement and so will allow maximum retention (good quality and quantity of bone)
in molar relationship and little molar distalization. Activation of the appli- with least risk of soft tissue inflammation. There are also no anatomical
ances was discontinued, and two MIs (diameter, 1.6 mm; length, 8.0 mm) structures, such as nerves, blood vessels or roots, that can be damaged
were placed between the premolars and ligated with the first premolars to during implant placement.10 The palatal area within 1 mm of the midpala-
control anchorage loss (Fig. 43.1E,F). Activation of the Keles Slider was tal suture presents the thickest bone in the whole palate, with thickness
restarted and maintained for 6 months until a super-Class I molar relation- tending to decrease toward lateral and posterior.11 The best area seems to
ship was achieved on both sides (Fig. 43.1G,H). be at the level of the first and second premolars. The soft tissue of the
The Keles Slider was then removed and a Nance appliance was placed median palate in this area is, on average, 0.45–3.06 mm thick. This, with
to maintain molar position (Fig. 43.1I,J). In addition, the initial MIs were the intrinsic characteristics of the palatal mucosa, guarantees biomechani-
removed and two new MIs were placed mesial to the upper first molars. cal stability for the placement of implants and MIs.10
Using these MIs as anchorage, both premolars and canines were distal- There are some studies reporting results following the use of osseointe-
ized using elastic chains on SS archwire (0.016 inch) (Fig. 43.1I,J). grated palatal implants or onplants as direct or indirect anchorage modali-
Anchorage of posterior teeth was then reinforced by ligating the canines ties during molar distalization.8,12–13 When maxillary molars are distalized
with the MIs during retraction of anterior teeth with a TMA archwire using palatal implants as anchorage, two side effects are commonly
(0.016 × 0.022 inch) with closing loops. Total treatment time was 28 observed, depending on the location of the line of action of the force. First,
months (Fig. 43.1K,L). when the force vector from the sagittal aspect does not pass through the
center of resistance of the maxillary molars, the molar crowns tip mesially
or distally. Second, depending on the location of the distalizing force
Treatment Results (buccal side for mesial-out, lingual side for distal-out) from the occlusal
Placement of MIs in the maxillary buccal inter-radicular space between aspect, the molar crown will rotate mesial-out or distal-in. Preventing this
the second premolars and the first molars at an oblique angle proved useful rotational tendency is usually more difficult because of anatomical con-
for moving the maxillary teeth distally en masse in this patient. Mesial straints. A rigid TPA may help to prevent it.14
movement of anchor teeth did not occur during distalization, and after
molar movement, the premolars and canines were also distalized and the
incisors retracted successfully. This protocol allowed effective non- CASE 2: MAXILLARY MOLAR DISTALIZATION WITH
compliance maxillary molar distalization without side effects. PALATAL IMPLANTS
Use of sandblasted MIs (diameter, 1.8 mm; length, 14.0 mm) in the
anterior palatal region avoided mesial movement of the first premolars A 17-year-old patient presented with the chief complaint of crowding of
when they were used as anchor teeth during molar distalization through her upper teeth. She had a symmetrical face and a balanced profile. She
buccal mechanics.1 Average distal movement of the first molars in this had a Class II molar and canine relationship and severe crowding of the
study was 3.9 mm and there was no anchorage loss. However, there was maxillary anterior teeth (Fig. 43.2A,B). Both upper canines were buccally
8.8° of tipping as well as some distopalatal rotation with the buccal force positioned, the left canine totally out of the arch, while the left lateral
application. incisor was in full crossbite. The upper dental midline was in line with the
If distal tipping occurs alongside molar distalization, some of the space face, but there was a 1.5 mm midline deviation of the mandibular arch to
attained by distalization can be lost during molar uprighting when full the left. Overbite was 1.0 mm and overjet 1.5 mm. She had skeletal Class
fixed therapy is initiated.2,3 Consequently, this should also be considered I relationships and an average vertical growth pattern. The treatment plan
when using molar anchorage during fixed appliance treatment.1 included maxillary molar distalization using palatal implants.

MOLAR DISTALIZATION WITH PALATAL IMPLANTS Treatment Progress

A stepped screw titanium implant (diameter, 4.5 mm; length, 3.8 mm)
While it has been shown that dental implants placed in alveolar bone can
(Frialit-2 Implant System, Synchro Screw Implants, Friadent, Mannheim,
withstand the forces required for orthodontic movements,1,4–6 many patients
Germany) was placed in the anterior palatal region (paramedian to
seeking orthodontic treatment have complete dentitions and, therefore, no
the suture) for anchorage reinforcement. After waiting 3 months for
available alveolar bone sites for implant placement. Consequently, several
osseointegration of the implant, molar distalization was initiated using
studies have looked at alternative sites, such as the hard palate, the man-
mini-expansion screws that were anchored on the palatal implant (Fig.
dibular retromolar area, the inferior border of the zygomatic buttress, the
43.2C,D). The patient was instructed and trained to open the screws
symphysis region and the labial or buccal inter-radicular bone areas.7
twice a week (0.25 mm each turn) and was reviewed every 4 weeks to
Several criteria should be considered when selecting an implant site:
monitor progress. Once a super-Class I molar relationship was achieved,
■ whether the site can support the planned biomechanics required for the device was kept in place for at least 3 months for retention to prevent
indirect or direct anchorage relapse and to allow maxillary premolars to drift distally (Fig. 43.2E–G).
■ if implant placement can be achieved without causing any root, The distalizing screws were then removed and a 1.2 mm SS transpalatal
nerve or artery injury arch was adjusted and inserted into the abutment slot to maintain
■ if a bone site is available that presents adequate depth and molar position (Fig. 43.2G) during the subsequent orthodontic treatment
thickness (Fig. 43.2H,I).
 MOLAR AND GROUP DISTALIZATION 231

A B C D

E F G

Fig. 43.2 Case 2: maxillary molar distalization with palatal implants.

(A,B) Pretreatment. (C,D) Application of mini-expansion screws in conjunction with
the palatal implant. (E–G) Distalization completed. (H,I) Post-treatment.

H I

Treatment Results MOLAR DISTALIZATION WITH

Molar distalization took 6 months and overall treatment time was 20 ZYGOMATIC ANCHORAGE
months. Maxillary first molars moved 4.5 mm distally. Maxillary second
bicuspids followed the first molars through distal drifting. Distal tipping The maxilla is made up of thin cortical bone in its buccal and labial aspects.
of the maxillary molars and retrusion of incisors also occurred. Bone thickness is not more than 2 mm, except in the three buttress areas:
The amount of maxillary molar distalization was similar to that reported (1) the posterior buttress close to the tuber area, (2) the zygomatic buttress
elsewhere: 6.4 mm in 7 months,8 6 mm in 7.8 months,12 3.4–4.5 mm in 6 and (3) the nasal buttress close to the nasal area. All these areas have a
months5 and 5.9 mm in 5 months.13 Although bodily molar distalization thick and solid bony structure, which makes implant placement possible.
had been expected, cephalometric radiographs revealed that the molars The location of the posterior buttress prevents easy access and the nasal
also tipped during treatment. buttress area is not suitable because of its close location to the infraorbital
Distal molar tipping ranging from 4.0° to 15.7° has been reported in foramen and nasal cavity. However, the inferior border of the zygomatico-
many studies using intraoral distalization mechanics without skeletal maxillary buttress is suitable as direct access is easy and it is away from
anchorage.15,16 However, it is also seen in studies using skeletal anchorage5 critical anatomical structures. Because it is close to the maxillary molars,
even when attempts were made to avoid it, for example using coil springs the zygomatic buttress can be used for their anchorage either directly or
or elastic chains along the archwire and an orthodontic titanium miniplate indirectly.
system (Skeletal Anchorage System).6 Although some studies have used a Zygomatic miniplates are easily placed and removed under local
distalization device soldered directly to a steel cap17 or a specially designed anesthesia. They can be used in various clinical situations, such as arch
cap with a rectangular slot to overcome tipping (Oric Cap, Basel, Switzer- expansion, retraction and distalization, as well as for the treatment of open
land), no data are available on the type of molar movement that occurs. bite, without the need for patient cooperation in wearing an appliance.
In the patient described here, the maxillary molars and premolars were However, although they provide new treatment possibilities, careful case
rotated slightly in the distobuccal direction because the force vectors were selection is needed.
applied on the palatal side.18 Although this was not expected from such a
rigid system, it can be attributed to bending of the arms of the device under
the high forces delivered by activation of the expansion screws.19 CASE 3: MAXILLARY MOLAR DISTALIZATION WITH
Retroclination of the incisors was also observed, probably because of the ZYGOMATIC MINIPLATES
pull of the transeptal fibers as the distalization forces acted on the maxillary
arch. This effect was opposite to the effects of other intraoral molar distali- A 15-year-old girl was referred with the chief complaint of protrusion of
zation systems, which result in proclination of the maxillary incisors.2,20,21 the upper incisors. She had a symmetrical face, high smiling line, compe-
However, increases in the overjet (of 1.3 to 4.7 mm) have been noted in tent lips and a convex profile (Fig. 43.3A,B). Clinical examination revealed
studies with conventional intraoral distalization systems,2,15,22 which is not a unilateral Class II canine and molar relationship on the right side and
unexpected as the devices included the incisor segment as anchorage. Class I on the left. The maxillary arch was constricted, while both arches
 232 SECTION VIII: TREATMENT OF CLASS II MALOCCLUSION WITH DIFFERENT TEMPORARY ANCHORAGE DEVICES

A B C D

E F G H

Fig. 43.3 Case 3: maxillary molar distalization with zygomatic miniplates.

(A,B) Pretreatment. (C,D) Application of zygomatic miniplate and distalization
mechanics. (E,F) Maxillary molar distalization completed. (G,H) Application of fixed
appliances in both dental arches. (I,J) Post-treatment.

I J

showed slight crowding of the anterior teeth. The treatment objectives The patient was seen every 4 weeks to monitor progress, while the
included correction of the unilateral Class II molar and canine relationship system was reactivated every 2 months by shifting the sliding lock towards
and improvement of smile esthetics by eliminating the posterior gummy distal or by placing a longer open coil spring. Distalization was completed
smile and dark buccal corridors. The treatment plan involved distalization in approximately 4 months (Fig. 43.3E,F).
of the right maxillary molars using zygomatic anchorage, followed by After completion of distalization, the second premolars had also moved
fixed appliance therapy. distally, partially under the influence of the transeptal fibers. Orthodontic
treatment was continued using fixed appliances for the final alignment of
the arches and detailing of the occlusion, during which time molar position
Treatment Progress
was maintained using wire ligation between the implant and the molar
A zygomatic miniplate (Multi Purpose Implant MPI 1000, Tasarim, Istan- tubes (Fig. 43.3G,H).
bul, Turkey) with a 0.9 mm bar thickness was used as anchorage for
maxillary molar distalization. The upper part of the miniplate was adapted
Treatment Results
to the curve of the zygomatic buttress area, 5 mm mesial to the line passing
from the mesial edge of the first molar tube. The round bar was extended At the end of treatment, a Class I canine and molar relationship was
downwards to the level of the first molar tube and then bent towards mesial achieved on both sides; the maxillary arch was slightly expanded and smile
along the sulcus depth, 3 mm away from the vestibular mucosa to maintain esthetics were improved (Fig. 43.3I,J). Zygomatic miniplates were easily
hygiene in this area (Fig. 43.3C,D). An SS round wire (diameter 1 mm) removed under local anesthesia.
was soldered on to the lower surface of the custom fabricated metal sliding
lock (Dentaurum, Ispringen, Germany), extending towards the archwire to
transfer the point of force application to the level of the archwire. A hori- MOLAR DISTALIZATION WITH MINISCREW IMPLANTS
zontal U-bend was made in the wire to adjust the force vector. A segmental
round tube was soldered to the lower edge of this wire at the same level Recently, MIs have gained wide acceptance for use as stationary anchorage
as the main archwire in order to facilitate compression of an open coil modalities. They have several clinical advantages: minimal anatomical
spring. The metal sliding lock was engaged on the mesial extension of the placement limitations, lower cost and simpler placement with less trau-
zygomatic implant. An SS archwire (0.016 inch) was engaged passing matic surgery. In patients who had MI insertion, 50% did not feel pain at
through the segmental tube, a segmental Ni-Ti open coil spring was placed any time after placement, and most reported minimal discomfort from
on the archwire after the segmental tube, and the archwire was engaged swelling and few speech or chewing difficulties. However, use of MIs does
in the main tube of the molar band. A metal sliding lock was moved in a have several disadvantages and risks: damage can occur to anatomical
distal direction so that sufficient activation of the open coil spring was structures such as dental roots, nerves and blood vessels; a MI can break
obtained and it was then fixed in position. during placement or removal; and failure can occur, mainly through
 MOLAR AND GROUP DISTALIZATION 233

A B C D

E F G

H I
J

Fig. 43.4 Case 4: unilateral maxillary molar distalization with miniscrew implants (MIs). (A,B) Pretreatment. (C,D) Fixed orthodontic appliances inserted. (E) Application of
the MI. (F,G) Molar distalization completed. (H,I) Post-treatment. (J) Cephalometric superimposition of the maxilla before (black) and after (red) treatment shows the
distalization effect.

peri-implant inflammation. Success rates with MIs are reported between arch. The treatment plan included use of a MI to support distalization of
80 and 95%.23 the upper right posterior segment and correction of the Class II dental
Various anatomical sites have been proposed for MI insertion. Placement relationship plus fixed appliances to correct crowding of the maxillary and
into the basal bone below the roots of the teeth prevents root damage but mandibular dental arches and create some space for the peg-shaped right
limits the amount of vertical force vectors that can be applied.24,25 Implant- lateral incisor to enable it to be restored to a normal shape.
ing MIs into alveolar bone between the roots of the posterior teeth increases
the horizontal component of the applied force.26 The inter-radicular spaces
between the roots of the second premolars and those of the first molars in Treatment Progress
the maxillary arch and between the roots of the first molars and those
A Roth multibracket system with a slot (as used in Case 1) was bonded
of the second molars in the mandibular arch are generally now accepted as
first on the maxillary arch and after 2 months to the mandibular teeth.
the best sites for MI placement on the buccal side of the jaws.27
Leveling was started with Ni-Ti archwires (0.014 inch) (Fig. 43.4C,D).
In the maxilla, the greatest amount of bone mesiodistally is on the
Following insertion of SS wire (0.016 inch), a MI (diameter, 1.6 mm;
palatal side between the second premolars and the first molars, while the
length, 7 mm) was placed between the maxillary first and second molars
least amount of bone is in the tuberosity. In addition, the greatest bone
in order to distalize the upper right posterior segment and correct Class
thickness in the buccopalatal dimension is between the first and second
II malocclusion. The MI was positioned 8 mm above the sulcus between
molars, whereas the least is again in the tuberosity.28
the roots. The MI was then tied to the right canine and a distalization
Skeletal anchorage can be obtained directly, where force is transmitted
force of 150 g was provided using a closed coil spring. In order to correct
directly to the implant, or indirectly, where the skeletal anchorage device
the occlusal cant of the mandibular arch, an asymmetric intrusion arch
is connected to the anchor teeth and forces are applied to these teeth and
was tied to the main Ni-Ti archwire (0.016 × 0.016 inch) at the left
to a tooth or group of teeth that have to be moved.14
lateral incisor (Fig. 43.4E). At every appointment, both the closed coil
spring tied to the maxillary right canine and the intrusion utility arch
CASE 4: UNILATERAL MAXILLARY MOLAR were activated. After 6 months, the occlusal cant was corrected and the
DISTALIZATION WITH MINISCREW IMPLANTS intrusion arch was removed and replaced by SS archwire. Because of the
existence of Bolton excess on the anterior region of the mandibular arch,
A 16-year-old boy presented with the chief complaint of crowding of his interproximal stripping of the incisors (approximately 1.5 mm) was
upper anterior teeth. He had a symmetrical face, normal smiling line and undertaken. After distalization of the maxillary right posterior segment, a
a convex profile (Fig. 43.4A,B). He had a Class II, subdivision malocclu- diastema was created between the upper right lateral incisor and canine.
sion and Class I skeletal relationships with an average vertical growth Since the right lateral incisor was peg shaped, a composite restoration
pattern. The lower incisors were proclined and there was a 3.75 mm arch was performed to recreate the normal shape (Fig. 43.4F,G). Total treat-
length discrepancy in the maxillary arch and 1.2 mm in the mandibular ment time was 18 months.
 234 SECTION VIII: TREATMENT OF CLASS II MALOCCLUSION WITH DIFFERENT TEMPORARY ANCHORAGE DEVICES

Treatment Results 4. Karaman AI, Basçiftçi FA, Polat O. Unilateral distal molar movement with an implant-
supported distal jet appliance. Angle Orthod 2001;72:167–74.
After completion of treatment, a Class I canine and molar relationship was 5. Oncag G, Seckin O, Dincer B, et al. Osseointegrated implants with pendulum springs
for maxillary molar distalization: A cephalometric study. Am J Orthod Dentofacial
achieved on both sides, and the smile esthetics were improved (Fig. Orthop 2007;131:16–26.
43.4H,I). The right maxillary molar moved distally approximately 4 mm 6. Sugawara J, Kanzaki R, Takahashi I. Distal movement of maxillary molars in non-
against the MI and slightly extruded during leveling. However, this was growing patients with the skeletal anchorage system. Am J Orthod Dentofacial Orthop
2006;129:723–33.
not a bodily movement since the molar also exhibited 6° of tipping (Fig. 7. Erverdi N, Keleş A, Nanda R. Orthodontic anchorage and skeletal implants. In: Nanda
43.4J). Maxillary incisor position was almost stable. The MI was also R, editor. Biomechanics and esthetic strategies in clinical orthodontics. Missouri:
stable during distalization as well as during the subsequent treatment, Elsevier, Saunders; 2005. p. 278–94.
8. Kircelli BH, Pektas ZO, Kircelli C. Maxillary molar distalization with a bone-anchored
without any complications, and it was removed easily during debonding. pendulum appliance. Angle Orthod 2006;76:650–9.
No root resorption was observed in the post-treatment panoramic 9. Asscherickx K, Vannet BV, Bottenberg P, et al. Clinical observations and success rates
radiograph. of palatal implants. Am J Orthod Dentofacial Orthop 2010;137:114–22.
10. Gracco A, Lombardo L, Cozzani M, et al. Quantitative cone-beam computed tomog-
Placement of MIs in the maxillary buccal inter-radicular spaces between raphy evaluation of palatal bone thickness for orthodontic miniscrew placement. Am
the first and the second molars at an oblique angle proved very useful for J Orthod Dentofacial Orthop 2008;134:361–9.
moving a group of teeth distally in this patient. Molar distal movement 11. Martinelli FL, Luiz RR, Faria M, et al. Anatomic variability in alveolar sites for
skeletal anchorage. Am J Orthod Dentofacial Orthop 2010;138:252.e1–e9.
was achieved without active patient compliance and with no undesirable 12. Escobar SA, Tellez PA, Moncada CA, et al. Distalization of maxillary molars with the
side effects such as incisor proclination, clockwise mandibular rotation or bone-supported pendulum: A clinical study. Am J Orthod Dentofacial Orthop
root resorption. 2007;131:545–9.
13. Oberti G, Villegas C, Ealo M, et al. Maxillary molar distalization with the dual-force
The procedure reported for this patient was slower than other published distalizer supported by mini-implants: A clinical study. Am J Orthod Dentofacial
distalization methods. However, the overall treatment time was similar or Orthop 2009;135:282.e1–e5.
even shorter because all the posterior teeth were retracted simultaneously 14. Uribe FA, Nanda R. Skeletal anchorage based on biomechanics. In: Nanda R, Uribe
FA, editors. Temporary anchorage devices in orthodontics. Missouri: Elsevier, Mosby;
with MI-aided mechanics. The anterior teeth were retracted with conven- 2009. p. 145–63.
tional methods after distalization of the posterior segment, while maintain- 15. Keles A, Sayinsu K. A new approach in maxillary molar distalization: Intraoral bodily
ing the corrected position of the right segment by means of the MI. molar distalizer. Am J Orhod Dentofacial Orthop 2000;117:39–48.
16. Kucukkeles N, Doganay A. Molar distalization with bimetric molar distalization
arches. J Marmara Univ Dent Fac 1994;2:399–403.
17. Giancotti A, Muzzi M, Greco M, et al. Palatal implant-supported distalizing devices:
CONCLUSIONS Clinical application of the Strauman Orthosystem. World J Orthod 2002;3:135–9.
18. Kucukkeles N, Cakirer B, Mowafi M. Cephalometric evaluation of molar distalization
by hyrax screw used in conjunction with a lip bumper. World J Orthod 2006;7:
Use of skeletal anchorage to provide an anchor for distalization forces 261–8.
allows tooth movements to occur without any reciprocal unwanted effects 19. Zimring J, Isaacson R. Forces produced by rapid maxillary expansion. Angle Orthod
1965;35:178–86.
on other teeth of the dental arch. Use of MIs for skeletal anchorage has 20. Byloff FK, Darendeliler MA, Clar E, et al. Distal molar movement using the pendulum
become popular as they are available in many sizes, facilitating their appliance. Part 2: The effects of maxillary molar root uprighting bends. Angle Orthod
application in various areas; they provide stable anchorage for the applica- 1997;67:261–70.
21. Scuzzo G, Pisani F, Takemoto K. Maxillary molar distalization with a modified pen-
tion of orthodontic forces; and are easy to insert. However, the location dulum appliance. J Clin Orthod 1999;33:645–50.
for insertion, as for all anchorage devices, is very important when design- 22. Joseph AA, Butchart CJ. An evaluation of the pendulum distalizing appliance. Semin
ing the treatment plan for distalization, and planning must consider the Orthod 2000;6:129–35.
23. Yamada K, Kuroda S, Deguchi T, et al. Distal movement of maxillary molars using
vertical components of the force vectors among other issues. miniscrew anchorage in the buccal interradicular region. Angle Orthod 2009;79:
78–84.
24. Kanomi R. Mini implant for orthodontic anchorage. J Clin Orthod 1997;31:763–7.
25. Costa A, Raffainl M, Melsen B. Miniscrews as orthodontic anchorage: A preliminary
REFERENCES report. Int J Adult Orthod Orthognath Surg 1998;13:201–9.
26. Park HS. The skeletal cortical anchorage using titanium microscrew implants. Korean
1. Gelgor IE, Buyukyilmaz T, Karaman IE, et al. Intraosseous screw-supported upper J Orthod 1999;26:699–706.
molar distalization. Angle Orthod 2004;74:836–48. 27. Park HS. An anatomical study using CT images for the implantation of micro-implants.
2. Ghosh J, Nanda RS. Evaluation of intraoral maxillary molar distalization technique. Korean J Orthod 2002;32:435–41.
Am J Orthod Dentofacial Orthop 1996;10:639–46. 28. Poggio PM, Incorvati C, Velo S, et al. ‘Safe Zones’: A guide for miniscrew positioning
3. Bolla E, Muratore F, Carano A, et al. Evaluation of maxillary molar distalization with in the maxillary and mandibular arch. Angle Orthod 2006;76:191–7.
the distal jet: A comparison with other contemporary methods. Angle Orthod
2002;72:481–94.
 Treatment of Class II open bite malocclusion
supported by skeletal anchorage
44
Kazuo Tanne, Junji Ohtani, Hiroko Sunagawa, Masato Kaku and Tadashi Fujita

INTRODUCTION TREATMENT OF CLASS II OPEN BITE WITH MINISCREW

IMPLANT-SUPPORTED TREATMENT
Class II open bite morphologically is characterized by large molar height
and subsequent mandibular displacement backward and downward. The It has been shown that molar intrusion is superior to incisor extrusion for
large mandibular plane angle in Class II open bite is regarded as the most open bite treatment in terms of lower incidences of relapse and root resorp-
difficult malocclusion for orthodontic treatment because of the associated tion.4 The treatment biomechanics when using MI anchorage may be
nasopharyngeal respiratory disorders that may have induced it. Nasopha- similar to that when using the MEAW technique; however, the efficiency
ryngeal disorders may lead to Class II open bite by the following of molar intrusion is substantially higher with MI anchorage than with the
sequence.2,3 MEAW technique.
Successful use of MIs and miniplates as anchorage is dependent upon
■ Nasopharyngeal airway obstruction
the clinician’s knowledge of the many factors that may affect their primary
■ Habitual mouth opening and breathing
stability, both host factors (e.g. age, comorbidities, oral hygiene, bone
■ Reduction in masticatory muscle activity, masseter muscle in
quality) and technical factors (e.g. length, diameter of the MI, insertion
particular, with abnormal swallowing and tongue thrusting
technique, torque). Section II discusses in detail the factors for successful
■ Prominent vertical growth of posterior dentoalveolar structures with
use of MIs and miniplates as temporary anchorage devices for orthodontic
large molar height
treatment. The twisting torque used during MI insertion has been shown
■ Backward and downward displacement of the mandible
to be one key determinant for successful implantation. The optimal twist-
■ Onset of Class II open bite with small and/or distally located
ing torque for MI insertion in humans is 5–15 Ncm for the maxilla and
mandible.
6–17 Ncm for the mandible and clinicians are recommended to maintain
Based on this, it could be reasonably assumed that open bite can be cor- MI insertion torques within these optimal ranges. Our group has recently
rected efficiently by molar intrusion and the resultant forward and upward developed an electrical driver (approved by the Japanese Ministry of
rotation of the mandible (in other words, mandibular autorotation). An Health) that facilitates control of rotation direction, speed and twisting
edgewise technique with extraction of teeth does enable correction of open torque (Fig. 44.2). This electrical hand driver is rechargeable, very light
bite through alignment of teeth, movement of the molar teeth into the and easy to use.
extraction site and extrusion of the anterior teeth. However, this anterior
teeth extrusion can lead to substantial root resorption. The multiloop edge-
wise archwire (MEAW) technique1 was developed for distalizing and CASE EXAMPLES
intruding molars for the treatment of open bite (Fig. 44.1) and for treatment
of mandibular prognathism and maxillary protrusion. The cases described below illustrate treatment approaches based on MIs
However, the MEAW technique and the vertical elastics create repetitive (Cases 1 and 2) and a miniplate (Case 3).
intrusion and extrusion forces on the anterior teeth experience, and a
certain amount of anterior teeth extrusion is almost always produced,
CASE 1: AN ADULT WITH OPEN BITE
which could lead to relapse of open bite and root resorption of the anterior
teeth. Consequently, approaches using miniscrew implants (MIs) and mini- A 23-year-old woman presented with open bite with a Class II molar
plates may be an opportune way to obtain the desired results without relationship and large overjet and overbite (7.2 mm and −3.6 mm,
unwanted side effects. respectively; Fig. 44.3A,B). Tooth–jaw discrepancy was prominent, and

O
E E
O
O E
E
O

A
B C D
Fig. 44.1 (A-D) Biomechanics of the MEAW technique for the correction of open bite.

235
 236 SECTION VIII: TREATMENT OF CLASS II MALOCCLUSION WITH DIFFERENT TEMPORARY ANCHORAGE DEVICES

so the maxillary first premolars and mandibular second premolars were of the mandible, directly leading to the correction of the Class II open bite.
extracted. In addition, both maxillary and mandibular incisors experienced a promi-
After initial leveling with fixed appliances, four MIs were placed inter- nent lingual tipping movement, which contributed to the correction of lip
radicularly in the maxilla, two on the buccal side and two on the palatal protrusion.
side (Fig. 44.3C,D). Elastics were used for the intrusion of the maxillary
first and second molars and second premolars. The mandibular molars
were fixed with a lingual arch because the curve of Spee was straight,
CASE 2: A 19-YEAR-OLD WOMAN WITH OPEN BITE
indicating that molars were not extruded.
AND IMPAIRED MASTICATORY FUNCTION
After 8 months of treatment, the overbite was corrected from −3.6 to A 19.5-year-old woman with open bite tendency complained that she had
2.0 mm. At the end of active treatment after 29 months, overjet and over- impaired masticatory function from the reduced occlusal contacts. Four
bite were improved from 7.2 to 2.5 mm and from −3.6 to 2.5 mm, respec- premolars had been extracted previously. Her facial profile was convex,
tively, and a well-functioning occlusion was established (Fig. 44.3E,F). with mentalis muscle overactivity. She had Class II molar relationships
On the superimposition of the cephalometric tracings before and after with 5.5 mm overjet and 0.5 mm overbite (Fig. 44.4A). Functional exami-
treatment, maxillary molar intrusion and subsequent counterclockwise nation showed that the patient had pain on the temporomandibular joints
rotation of the mandible were observed (Fig. 44.3G). These changes con- (TMJ) during chewing and mouth opening. She had skeletal Class II rela-
stitute the principal mechanism for an upward and forward displacement tionships of the jaws (ANB angle, 9.8°) with severe mandibular deficiency
(ANB angle, 66.7°) and a steep mandibular plane angle (37.1°) (Table
44.1). On TMJ radiographs taken by the Schüller method, the condyles
occupied a relatively posterior position on the glenoid fossa (Fig. 44.4E),
implying an anterior displacement of the articular disk. Her diagnosis was
as a skeletal Class II open bite with TMJ problems. The initial treatment
plan, involving surgery, was refused by the patient.
Treatment commenced with bonding of fixed appliances in both arches;
a self-drilling titanium alloy MI (diameter, 1.6 mm; length, 6 mm; Dual-
Top Auto Screw) was inserted into the midpalatal region at the level of
the maxillary first molars in order to intrude the maxillary posterior teeth
(Fig. 44.4B,C). A transpalatal arch was also placed in order to maintain
Rotation direction
the transversal dimension of the maxillary molars. The molars were
intruded using elastic chains attached between the MI and the lingual
sheaths of the first molar bands. Class II elastics were never used during
Rotation speed treatment to avoid extrusion of mandibular posterior teeth. After 1 year of
treatment, intrusion of the maxillary molars was completed. Overjet was
changed from 5.5 to 2.0 mm and overbite from 0.5 to 2.5 mm; the teeth
Maximum twisting torque were well aligned in a good intercuspal position and the TMJ pain had
disappeared. After a 3-year retention period, the occlusion was stable with
Fig. 44.2 The electronic torque controllable hand driver. no symptoms of TMJ problems (Fig. 44.4D). Radiography revealed that

A B C D

E F

G
Fig. 44.3 Orthodontic treatment of Case 1. (A,B) Pre-treatment intraoral photographs. (C,D) Intrusion of the maxillary molars using MIs. (E,F) Post-treatment intraoral
photographs. (G) Superimposition of the cephalometric tracings on the anterior cranial base (SN) before (black line) and after (red line) treatment.
 Treatment of Class II open bite malocclusion supported by skeletal anchorage 237

A B C D

E F

G I

Fig. 44.4 Orthodontic treatment of Case 2. (A) Pretreatment intraoral photograph. (E) Pretreatment TMJ radiograph of the right and left condyle. (B,C) Progress intraoral
photographs during intrusion of maxillary molars using an MI. (D) Post-treatment intraoral photographs. (F) Post-treatment TMJ radiograph of the right and left condyle.
(G-I) Superimpositions of the cephalometric tracings on the anterior cranial base (G), on the maxilla (H), and on the mandible (I) before (black line) and after (red line)
treatment.

mandible rotated in a counterclockwise direction (Fig. 44.4G–I), while the

Table 44.1 Case 2: cephalometric measurements
maxillary incisors experienced a lingual root torque. The ANB angle
Measurements Pre-retreatment Post-treatment
changed from 9.8 to 8.6°, the mandibular plane angle from 37.1 to 35.1°
SNA (°) 76.5 76.5 and the Z-angle from 56.0 to 62.7°, indicating an improvement of the
SNB (°) 66.7 67.8 lateral soft tissue profile (Table 44.1).
ANB (°) 9.8 8.6
FMA (°) 37.1 35.1
FMIA (°) 41.2 44.3 CASE 3: AN ADULT WITH SEVERE OPEN BITE
IMPA (°) 101.6 100.6 AND DIFFICULTY IN LIP CLOSURE
U1-FH (°) 111.8 106.3
A 32-year-old woman with severe open bite complained of difficulty in lip
Z-angle (°) 56.0 62.7
closure, which was caused by the severe maxillary protrusion and the open
Overjet (mm) 5.5 2.0
bite. Although orthognathic surgery was proposed, she requested a con-
Overbite (mm) 0.5 2.5
servative non-surgical treatment plan. She had a convex lateral soft tissue
profile with mentalis muscle overactivity caused by habitual mouth
IMPA, incisor mandibular plane angle; FMA, Frankfort-mandibular plane angle; opening and breathing. She had bilateral Class II molar relationships and
FMIA, Frankfort-mandibular incisor angle.
a severe open bite, with an overjet and overbite of 5.0 mm and −4.0 mm,
respectively (Fig. 44.5A,B). Cephalometric analysis revealed skeletal
after treatment both condyles were shifted significantly to an anterior posi- Class II relationships of the jaws (ANB angle, 11.0°) and a skeletal open
tion, occupying a more central position in the glenoid fossa (Fig. 44.4F). bite with a large mandibular plane angle (39.3°).
The facial profile was slightly changed, with a more relaxed mentalis The treatment plan included molar intrusion and retraction of the ante-
muscle. rior teeth after the extraction of maxillary second premolars with use
Superimposition of the lateral cephalometric tracings before and after of a miniplate placed on the zygomatic bone to provide skeletal anchorage
treatment revealed that the maxillary molars were intruded by 2 mm, the (Fig. 44.5C).
 238 SECTION VIII: TREATMENT OF CLASS II MALOCCLUSION WITH DIFFERENT TEMPORARY ANCHORAGE DEVICES

A B C D E

F G

H I

Fig. 44.5 Orthodontic treatment of Case 3. (A,B) Pre-treatment intraoral photographs. (C) Intraoral photograph depicting the positioning of the zygomatic miniplate.
(D,E) Progress intraoral photographs during intrusion of the molars with miniplates. (F,G) Post-treatment intraoral photographs. (H,I) Post-retention intraoral photographs.
(J-L) Superimpositions of the cephalometric tracings on the anterior cranial base (J), on the maxilla (K), and on the mandible (L) before (black line) and after treatment
(red line).

After insertion of fixed appliances and leveling of both dental arches, bone (Case 3) provided more extensive and efficient tooth movements
intrusion of the first and second molars was initiated using elastic chains than MIs in terms of molar intrusion, molar distalization and retraction
connected to the miniplate. Seven months later, the open bite was corrected of anterior teeth, all of which are essential for the treatment of Class II
(Fig. 44.5D,E). After 2 years of treatment, an acceptable occlusion was open bite.
achieved and retention was initiated with lingual bonded retainers on both These findings suggest that some patients with skeletal open bite, which
dental arches and removable retainers for night wear (Fig. 44.5F,G). The would ideally have been treated by surgical correction, may be treated
occlusion was stable even after 2 years in retention (Fig. 44.5H,I). solely orthodontically. However, more extensive studies are required to
The overall facial balance was improved. Superimposition of the cepha- examine the nature of relapse of molar intrusion and the long-term stability
lometric tracings before and after treatment showed that the maxillary of the results.
molars were intruded by 4.0 mm and a counterclockwise rotation of the
mandible had occurred (Fig. 44.5J–L). The ANB angle changed from 11.0
to 5.2° and the mandibular plane angle from 39.3 to 37.0°. REFERENCES
1. Kim YH. Anterior open bite and its treatment with MEAW. Angle Orthod 1987;57:
290–321.
CONCLUSIONS 2. Tanne K. Association between nasopharyngeal disease and orthodontic treatment. Part
1: the onset of malocclusion resulted from nasorespiratory disturbances. J Orthod Pract
The treatment outcomes described here indicate that MIs are more reliable 2000;16:11–20.
3. Shikata N, Ueda HM, Kato M, et al. Association between nasal respiratory obstruction
and efficient for the treatment of open bite than the MEAW approach, in and vertical mandibular position. J Oral Rehabil 2004;31:957–62.
terms of quick molar intrusion and distalization with less dependence on 4. Chang YI, Moon SC. Cephalometric evaluation of the anterior open bite treatment. Am
patient cooperation. Skeletal anchorage with miniplates on the zygomatic J Orthod Dentofacial Orthop 1999;115:29–37.
 Non-extraction correction of Class II
malocclusion using biocreative therapy
45
Kyu-Rhim Chung, HyeRan Choo and Seong-Hun Kim

miniplates and/or C-palatal miniplates,1 in a manner quite distinct from

INTRODUCTION
the systems that use MIs, focusing on them as the core construct of the
Molar and canine Class II relationships can result from skeletal discrepan- dental movement protocol and supplemented by orthodontic brackets and
cies of a hypoplastic mandible relative to a normal maxilla, a hyperplastic wires.2–4 The C-type OBAs can endure multidirectional heavy orthodontic
maxilla relative to a normal mandible or a combination of hyperplastic and orthopedic forces with better stability, which is essential to moving
maxilla to hypoplastic mandible to varying degrees. In bimaxillary skeletal multiple teeth at the same time and may reduce the total treatment time.
harmony, dental Class II patterns can still occur if the maxillary posterior Higher resistance to heavy forces also effectively reduces the total number
molars drift mesially as a result of early loss or exfoliation of primary of C-type OBAs needed to achieve the orthodontic tooth movement.
teeth. This chapter will discuss two types of C-type OBAs applied for the
If there is minimal anticipated growth, such as in older adolescents and non-extraction correction of Class II malocclusion: the C-implant and the
adults, and the skeletal discrepancy is determined to be within the bounda- C-tube miniplate.
ries of dental camouflage, the malocclusion is usually corrected using
conventional orthodontic biomechanics, which rely on dentoalveolar com-
pensation and on extractions of permanent teeth. However, many individu- C-TYPE ORTHODONTIC BONE ANCHORS
als and parents are extremely resistant to removal of permanent teeth and
are adamant in treating their problems without extractions. There are many different force application options for OBAs in the oral
The use of skeletal anchorage, such as miniscrew implants (MIs) or cavity. For example, molar distalization can be achieved either by placing
miniplates, avoids issues of patient compliance, provides a consistent OBAs in the anterior region and pushing the posterior dentition distally
intraoral anchor unit and allows the desired tooth movements without any (pushing mechanics), or by placing them in the posterior region in such a
untoward movement of peripheral teeth. way that a sliding jig can pull against them to move molars distally (pulling
This chapter describes the clinical applications of the C-type orthodontic mechanics). They can also be placed in the maxillary posterior region in
bone anchors (OBAs), such as the C-implant and C-tube miniplate, includ- conjunction with Class III elastics to the mandibular anterior dentition to
ing immediate relocation procedures for these in the correction of Class II distalize both maxillary and mandibular posterior dentitions (Fig. 45.1). If
malocclusions without extracting permanent teeth. an OBA is placed in the palatal region and rigidly fixed to the lingual
The treatment philosophy follows the fundamental principles of bio- premolar region to establish stationary anchorage, the posterior molar
creative therapy (C-therapy). Biocreative therapy is a novel treatment dentition can also be pushed distally. OBAs can be used to move the
philosophy advocated and clinically applied by K. R. Chung in Korea maxillary posterior dentition distally without losing anchorage when they
since 2001. The objectives are simplified and patient-friendly orthodontic are positioned in the maxillary buccal region. The most commonly recom-
biomechanics using OBAs plus reduced time for orthodontic adjustment mended site for placement when distalizing the posterior dentition is
at each visit. The treatment protocol dictates that conventional fixed ortho- between the maxillary first molars and maxillary second premolars. Con-
dontic appliances are placed only on teeth that need to be moved. Biocrea- sequently, the OBA will need to be relocated once sufficient space has
tive therapy uses C-type OBAs, which include C-implants, C-tube been created since it can obstruct distal movement of premolars.

A B C
Fig. 45.1 The C-implant used for different force application options. (A) Use as direct anchorage in a pulling mechanism. A power chain from the C-implant to the
maxillary first premolar (red) distalizes the entire maxillary posterior segment, while the open coil (blue tube) between the second molar and second premolar creates room
for the first molar. The transpalatal arch (green) bonded to the first premolar prevents buccal flaring of the teeth during distalization. The C-implant concurrently serves as
direct anchorage to support Class III elastics (blue lines) to distalize mandibular posterior segments. (B) Use in direct anchorage for individual tooth distalization of second
molars using open coil spring pushing directly against installed C-implants. (C) Use as indirect anchorage with a transpalatal arch. The open coil spring between the
second molar and second premolar will push the two teeth apart. When the C-implant is anchored to the transpalatal arch bonded to the lingual surfaces of the first
premolars, it will hold these teeth in position and there will be no mesial movement of these teeth. The net space gained will be complete distalization of the second
molar.

239
 240 SECTION VIII: TREATMENT OF CLASS II MALOCCLUSION WITH DIFFERENT TEMPORARY ANCHORAGE DEVICES

A B C D E
Fig. 45.2 C-type orthodontic bone anchors. (A–C) The two separate parts of the C-implant (A,B) and as one piece (C). (D,E) The C-tube miniplate.

Relocation to the distal in the molar region allows the force vector to be better adaptation. The head is then attached and tapped gently to fix it in
changed from a push to a pull system. place. Orthodontic force is immediately applied afterwards.

THE C-IMPLANT THE C-TUBE MINIPLATE

The C-implant is made of titanium grade V alloy (C-implant Co., Seoul, The C-tube miniplate is made of commercially pure titanium (Jin Biomed,
Korea) and has a screw base (diameter, 1.8 mm; lengths, 6.5, 7.5 or Bucheon, Korea) (Fig. 45.2D,E) with its free end rolled to form a tube-
8.5 mm) and head attachment (lengths, 1, 2 or 3 mm) (Fig. 45.2A–C). shaped head with a 0.036 inch lumen to be exposed through the oral
Choice of screw base is determined by bone thickness and of head attach- mucosa in order to engage orthodontic archwires. The anchor part is
ment by gingival thickness. The screw base is inserted into the bone first usually I-shaped and has two to three holes for the insertion of the cor-
and then the head attachment is placed, thereby avoiding any torque frac- responding miniplate anchoring screws. The anchoring screws are self-
ture of the implant neck during insertion and removal. The sandblasted, drilling and self-tapping MIs (diameter, 1.5 mm; length, 4-5 mm). The
large-grit and acid-etched surface induces only partial osseointegration and C-tube miniplates are recommended when there is insufficient inter-
enables easily removal. The C-implant is relatively small in size and can radicular space for C-implant placement or when much heavier forces are
be easily inserted into the inter-radicular areas of the maxilla and mandible, expected to be used in order to control en masse teeth movements.
making it very versatile in a variety of clinical applications.
In complex orthodontic situations, many different directions of force
vector may be needed at once and sequentially. Frequently, this may SEVERE MAXILLARY CROWDING AND MINIMAL
require the insertion of OBAs in many sites, or removal from a site once MANDIBULAR CROWDING
the OBA is in danger of becoming a physical obstruction to additional
tooth movement.5 Buccal OBAs may need to be replaced after distal move- Two cases illustrate the use of C-implants for direct and indirect
ment of a posterior part is accomplished or palatal implants can be used anchorage.
for large amounts of distal movement of teeth.6 How easy it is to take out
an OBA and reinsert it at a different location depends on the degree of
osseointegration that occurs, and whether this osseointegration is sustained CASE 1: C-IMPLANT USED FOR DIRECT
under functional loading. AND INDIRECT ANCHORAGE

A 15-year-old girl presented with a chief complaint of crowding of the

Recommended Protocol for Immediate
maxillary anterior teeth (Fig. 45.3). She had an end-on Class II molar and
Relocation of C-implant
a Class III canine relationship with 2 mm skeletal open bite. The maxillary
After applying local anesthesia, an explorer can be located in the hole on anterior segment showed severe dental crowding while there was minimal
the head component to pull it with a counterclockwise rotational force to crowding in the mandibular arch. A non-extraction treatment plan was
separate the head attachment from the screw base. The screw base is then suggested using dramatic distal and intrusive movements of the maxillary
removed with a counterclockwise rotational force using a manual screw- posterior dentition.
driver provided with the C-implant system. The C-implant is relocated C-implants were placed in the inter-radicular space between the maxil-
either by drilling a pilot hole 1.5 mm in diameter at 1000 rpm to a depth lary second premolars and first molars. The C-implant head attachment
sufficient just to perforate compact bone or by manually inserting a self- incorporated a 0.8 mm diameter hole, which was used as an orthodontic
drilling MI of 1.5 mm in diameter to create a pilot hole. wire slot. The second molars were first distalized by placing an open Ni-Ti
The concavity of the removed C-implant body should be snugly fitted coil spring between the second molar and the second premolar on SS wire
into the screwdriver before being inserted by rotating the screwdriver (0.018 × 0.025 inch), with the premolars ligated by SS wire to the
clockwise with mild pressure. The angle of the C-implant body is directed C-implant head for indirect anchorage to prevent mesial migration of the
parallel to the occlusal plane. Irrigation should be avoided in order to anterior dentition (Fig. 45.3A). The first molars were engaged and distal-
maximize contact between the C-implant and the patient’s own blood for ized in the same manner, while the second molars were held in position
 Non-extraction correction of Class II malocclusion using biocreative therapy 241

A B C

D E F

Fig. 45.3 Case 1: C-implant used for direct and indirect anchorage. (A) C-implant inserted between the maxillary first molar and second premolar for indirect anchorage.
(B) Distalization of molars using the C-implant as both direct and indirect anchorage. (C) Relocation of the C-implant more distally in the same surgical site. (D) Retraction
of premolars using the C-implant as direct anchorage with orthodontic elastic bands. (E) Before debonding. (F) After a further year of retention with the C-implant.

A B C D

Fig. 45.4 Case 2: C-implant used as direct anchorage with auxiliary distalization appliances. (A) Dental Class II end-on molar relationship. (B) Distal movement of molars
using a sliding jig. (C) Relocation of the C-implant. (D) Detailing and finishing of the occlusion after 17 months of C-implant relocation.

with an auxiliary wire and open Ni-Ti coil springs between the second relocation procedure (Fig. 45.4D). It should be noted that a transpalatal
molar and the hole of the C-implant head (Fig. 45.3B). Once molar dis- arch between maxillary premolars is often critical in preventing an
talization had been achieved, the C-implants were carefully removed and unwanted buccal divergence of maxillary premolars during molar distali-
immediately repositioned superodistally but still in the region mesial to zation when OBAs are used as indirect anchors.
the roots of the first molars (Fig. 45.3C). The maxillary premolar segments
were pulled distally against the newly repositioned C-implants with direct
anchorage by connecting them with elastics to the premolar brackets (Fig. MINIMAL MAXILLARY CROWDING AND SEVERE
45.3D). As the premolar segments moved distally, crowding of the anterior MANDIBULAR CROWDING
dentition resolved. Mandibular bands or brackets were unnecessary until
the final stage of the treatment since all the required anchorage was Three cases illustrate the use of C-implants and C-tube miniplates.
obtained by maxillary OBAs. The initially placed C-implants were reused
successfully without failure for 18 months in this immediate relocation
procedure (Fig. 45.3E). Since the maxillary canines were extremely high CASE 3: RELOCATION OF C-IMPLANT WITHIN
at the start of treatment, C-implants were retained in position and con- THE MANDIBLE
nected to the canine brackets (replaced with ceramic brackets for esthetic
reasons) with SS ligatures for an additional year after removal of ortho- A 32-year-old man with a history of orthodontic treatment 15 years previ-
dontic appliances (Fig. 45.3F). ously presented with relapse and expressed concerns about anterior teeth
crowding and the loss of the left mandibular first molar (Fig. 45.5). The
treatment plan included protraction of the left mandibular second molar
CASE 2: C-IMPLANT USED AS DIRECT ANCHORAGE against a unilateral C-implant (Fig. 45.5A).
WITH AUXILIARY DISTALIZATION APPLIANCES Initially, the C-implant was placed immediately distal to the mandibular
left second premolar. A lever arm was positioned on the second molar
Instead of Ni-Ti push-coil springs as in Case 1, a sliding SS wire jig buccal tube and engaged to the C-implant with an elastic chain to have the
(0.018 × 0.025 inch) was used against the C-implant to distalize the maxil- line of protraction force passing closely to the center of resistance of the
lary posterior dentition to a Class I molar relationship (Fig. 45.4A,B). second molar. A lingual attachment was also bonded on the lingual surface
During this approach, the C-implant was repositioned superodistally to of the second molar crown and connected to the C-implant with elastic
further retract the premolars and anterior teeth (Fig. 45.4C). The C-implant chains to prevent rotation of the tooth during mesialization. The C-implant
was continuously used for an additional 17 months by using an immediate was angulated parallel to the long axis of the tooth and raised to the
 242 SECTION VIII: TREATMENT OF CLASS II MALOCCLUSION WITH DIFFERENT TEMPORARY ANCHORAGE DEVICES

A B C

Fig. 45.5 Case 3: relocation of C-implant within the mandible. (A) Initial phase of space closure. The C-implant inserted distal to the second premolar. (B) C-implant
relocated between the premolars. (C) All spaces closed and progressing to the finishing stage 14 months after relocation of the C-implant.

A B C D

Fig. 45.6 Case 4: C-tube miniplates used as direct anchorage with auxiliary distalization appliances. (A) Pretreatment. (B) Distal movement of molars using C-tube
miniplates as direct anchorage and a sliding jig. (C) Multiple sliding jigs simultaneously engaged against the C-tube miniplate using multiple Ni-Ti closed coils.
A transpalatal arch between the maxillary second premolars was installed to prevent unwanted buccal divergence of the midsegment of the maxillary dentition.
(D) Debonding after 27 months of distalization.

occlusal surface to prevent gingival impingement of the power chains.

CASE 5: RELOCATION OF C-IMPLANT FROM BUCCAL
After extensive mesialization of the second molar to the point where it
MAXILLARY BONE TO PALATE
was starting to impinge on the C-implant, the C-implant was removed and
immediately repositioned between the first and second premolar (Fig.
A 28-year-old woman presented with a chief concern of maxillary protru-
45.5B). The lever arm was repositioned flush distal to the second molar
sion. She had Class I molar and Class II canine relationships with crowding
tube and engaged to the C-implant with a longer elastic chain. Final space
of the maxillary and mandibular anterior teeth. Non-extraction correction
closure was achieved and detailing of the occlusion and root parallelism
of crowding was planned by distalizing the maxillary and mandibular
was followed (Fig. 45.5C). The C-implant was maintained successfully for
posterior teeth.
14 months during mesialization of the second and third molars after imme-
Initially, a C-implant was placed on each side between the maxillary
diate relocation.
first molars and second premolars, and Class III elastics were used against
the C-implants to the mandibular canines (direct anchorage) to effectively
upright and distalize the mesially tipped posterior segment (Figs 45.1B
CASE 4: C-TUBE MINIPLATES USED AS DIRECT
and 45.7A,B). The C-implants were also ligated with SS wire to the
ANCHORAGE WITH AUXILIARY DISTALIZATION
premolar region (indirect anchorage) to distalize the maxillary posterior
APPLIANCES
molar teeth (Fig. 45.7B). After sufficient molar distalization, the buccal
C-implants were removed. One of the removed C-implants was immedi-
A 30-year-old man presented with a chief complaint of mandibular anterior
ately relocated to the median palatal suture area (Fig. 45.7C,D) and a
incisor crowding (Fig. 45.6A). A skeletal and dental Class II malocclusion
transpalatal arch of SS wire (diameter, 0.8 mm) was engaged to the palatal
was confirmed and a non-extraction treatment plan was suggested with the
C-implant to fix the molars in position in order to use them as anchorage
intention to distalize the entire maxillary dentition as well as the mandibu-
to retract the maxillary premolars. A solid Class I molar and canine rela-
lar posterior teeth to relieve the mandibular anterior crowding.
tionship with well-intercuspated occlusion and with an ideal overbite and
Two C-tube miniplates were used in the maxillary posterior areas since
overjet was achieved (Fig. 45.7E,F). No orthodontic appliances were used
large force loads were anticipated in order to distalize the maxillary denti-
for the maxillary anterior teeth until the final stage of treatment, minimiz-
tion en masse. Initially, a single sliding jig was used to distalize the maxil-
ing the total time of wearing braces on the front teeth (in line with the
lary second molars (Fig. 45.6B). Soon after, multiple sliding jigs were
principles of biocreative therapy, which discourages unnecessary and
simultaneously engaged against the C-tube miniplates using multiple Ni-Ti
extended use of orthodontic appliances). The C-implant was maintained
closed coils (Fig. 45.6C). A transpalatal arch between the maxillary second
well for an additional 8 months of treatment from the time of its relocation
premolars was immediately installed to prevent an unwanted buccal diver-
to the palate.
gence of the midsegment of the maxillary dentition. Full fixed orthodontic
appliances were placed on both dental arches from the start of treatment,
since the maxillary dentition required full distalization and the mandibular DISCUSSION
dentition required a significant amount of leveling for molar uprighting
and curve of Spee correction. The full maxillary arch was distalized until The design of the C-implant enables good bone–implant contact and stabil-
Class I molar and canine relationships were established, with a total of 27 ity and having the two components avoids issues of fracture of the neck
months of treatment time (Fig. 45.6D). region of the implant during placement and removal.2 The screw base has
 Non-extraction correction of Class II malocclusion using biocreative therapy 243

A B C D

E F

Fig. 45.7 Case 5: relocation of C-implant from buccal maxillary bone to palate. (A) Mandibular molar distalization using Class III elastics from a buccally positioned
C-implant to the mandibular canines on each side. (B) Maxillary molar distalization using the C-implant as indirect anchorage. (C,D) Relocation of C-implant to the palate
to be used as indirect anchorage via a transpalatal arch bonded to the molars. (E,F) Completion of orthodontic treatment 8 months after C-implant relocation.

a blunt pitch and dull apex, effectively reducing the risk of root damage
REFERENCES
compared with many other self-drilling and self-tapping MI systems. The
dual components also give greater flexibility, since there is the option to 1. Chung KR. C-palatal plate. In: Chung KR, editor. Textbook of speedy orthodontics.
select different sizes of head attachment to avoid gingival inflammation. Seoul: Jeesung; 2001. p. 99–113.
2. Chung KR, Kim SH, Kook YA. C-orthodontic micro implant as a unique skeletal
The lumen in the head attachment can accommodate orthodontic wires for
anchorage. J Clin Orthod 2004;38:478–86.
supplemental auxiliary biomechanics if necessary. 3. Chung KR, Nelson G, Kim SH, et al. Severe bidentoalveolar protrusion treated with
Animal experiments have indicated that the removal torque of a repo- orthodontic microimplant-dependent en-masse retraction. Am J Orthod Dentofacial
Orthop 2007;132:105–15.
sitioned C-implant is not significantly different from that of the C-implant
4. Chung KR, Kim YS, Linton JL, Lee YJ. The miniplate with the tube for skeletal anchor-
being removed from its initial position.7 Partial osseointegration was age. J Clin Orthod 2002;36:407–12.
observed at the surface of the repositioned C-implant, which implies that 5. Sung SJ, Jang GW, Chun YS, et al. Effective en-masse retraction design with ortho-
dontic mini-implant anchorage: a finite element analysis. Am J Orthod Dentofacial
it could be used as a source of skeletal anchorage even when relocated.
Orthop 2010;137:648–57.
Relocation of the OBAs in most cases appears to occur without adverse 6. Chung KR, Choo H, Kim SH, et al. Timely relocation of mini-implants for uninter-
effects of bone remodeling. rupted full-arch distalization. Am J Orthod Dentofacial Orthop 2010;138:839–49.
7. Go TS, Jee YJ, Kim SH, et al. The comparison of removal torque values and SEM
It is imperative that the C-implants are handled with care and isolated
findings of orthodontic C-implant before and after recycling procedure. J Korean Assoc
from other contamination sources during repositioning. A contaminated Hosp Dent 2006;2:88–95.
C-implant body can be autoclaved and reused, but only for the same 8. Lee JH, Choo H, Kim SH, et al. Replacing a failed mini-implant with a mini-plate to
prevent interruptions during orthodontic treatment with temporary skeletal anchorage
patient. If existing C-implants have failed because of root contact, or inser-
device (TSAD). Am J Orthod Dentofacial Orthop 2011;139:849–57.
tion is not feasible, orthodontic miniplates can be used.8 For example, a
C-tube miniplate can be used where the inter-radicular alveolar bone is
narrow, the maxillary sinus is enlarged, the roots of the teeth are curved
or the alveolar bone shows severe resorption.
46 Correction of Class II malocclusion with the
bone-anchored Forsus Fatigue Resistant Device
Narayan H. Gandedkar

continued with fixed appliances (Fig. 46.1I). A Class I molar relation with
INTRODUCTION
pleasing profile was achieved at the end of treatment (Fig. 46.1B,J) and
Fixed functional appliances have been in routine use for treatment of the patient showed excellent retention 1 year after treatment with no
skeletal Class II jaw relationships arising from a mandibular deficiency relapse (Fig. 46.1C,K,L).
but do have undesired dentoalveolar effects because of the use of teeth for
anchorage. The use of temporary anchorage devices such as miniscrew Discussion
implants (MIs) and miniplates can allow treatment to proceed successfully
with none of these untoward effects. The MI insertion site between the mandibular canines and the first premo-
This chapter discusses the use of bone anchorage in treating patients lars is known to be suitable because there is no risk of damage to roots or
with Class II, division 1 malocclusion of skeletal origin arising from man- neurovascular structures. Several factors have a significant role in the
dibular deficiencies and the use of three-dimensional imaging for ortho- success of MIs as anchoring units for fixed functional appliances, includ-
dontic diagnosis and treatment planning. Cone beam CT (CBCT) allows ing the patient’s age and growth status plus the type of appliance and the
quantitative evaluation of hard tissues with accuracy and ease, and at duration of treatment.
comparatively low effective radiation doses.1 The chapter attempts to Ideally, treatment should occur when the patient is in an acceleration
answer the following questions with regard to the use of MIs and mini- phase of the pubertal growth spurt, with 65–85% residual pubertal growth
plates in treating Class II, division 1 malocclusion: remaining. This typically corresponds to 14.2 ± 4 years for boys and
12.3 ± 3 years for girls.2
■ Is the approach beneficial for Class II, division 1 malocclusion The type of functional appliance has a decisive role in the success of
arising from mandibular deficiency? applying functional appliances for the correction of Class II malocclusion.
■ What are the potential benefits, merits, problems of the approach? If a removable functional appliance is used for advancement of the man-
■ Does three-dimensional evaluation of condylar growth and dible, two separate phases of treatment have to be carried out and there
the maxillary restraining effect of fixed functional appliances must be optimum patient compliance. There is also some evidence of
provide useful information on changes in the maxillomandibular intermittent condylar displacement with removable functional appliances,
complex? leading to varying degrees of glenoid fossa remodeling.3 In contrast, fixed
functional appliances show a remarkably significant change in the glenoid
fossa–condyle complex.4
MINISCREW IMPLANTS AS ANCHORING UNITS Fixed functional appliances have clear advantages over removable ones,
FOR FIXED FUNCTIONAL APPLIANCES with the correction achieved being a combination of skeletal and dental
changes. However, with fixed functional appliances anchored on the denti-
The application of MIs with the Forsus Fatigue Resistant Device (FRD) tion, most of the dental correction comes from proclination of the man-
is presented in detail with the following case report. dibular anterior teeth. This suggests that the use of MI/miniplate anchorage
for fixed functional appliances would be highly advantageous in that it
would produce all the expected changes apart from the unwanted proclina-
CASE 1: USE OF MINISCREW IMPLANTS AS tion of the mandibular anterior teeth.
ANCHORAGE FOR ADVANCEMENT OF THE MANDIBLE Treatment duration with fixed functional appliances is also of impor-
tance. Use of the Forsus Nitinol Flat Spring (less rigid than the Forsus
A 14-year-old boy in the acceleration phase of the pubertal growth spurt FRD) over a functional period of 4 months gave a mix of skeletal and
presented with a chief complaint of protruding maxillary front teeth and dental effects, with the dental effects contributing to 66% of the changes.5
small mandible (Fig. 46.1A,D). His medical history was unremarkable, By comparison, using the Forsus FRD with MI anchorage needed a longer
and temporomandibular joint function was normal. He had a severe convex functional phase (in Case 1, 11 months) but created no mandibular anterior
facial pattern and lip trap, mild crowding in the maxillary anterior region dentition effects (Fig. 46.1L).
and severe crowding of the mandibular anterior teeth plus proclination
(Fig. 46.1D). Overjet was 14 mm and overbite 100%, with a full comple-
ment of teeth. Based on the boy’s profile and growth status, it was decided MINIPLATES AS ANCHORING UNITS FOR FIXED
to extract the maxillary and mandibular first premolars to correct the incli- FUNCTIONAL APPLIANCES
nation and alleviate crowding of the maxillary and mandibular dental
arches, and subsequently to anchor a fixed functional appliance on the Miniplates seem to provide better primary and secondary stability than
lower archwire to advance the mandible. However, such anchoring would MIs. The advantage of these plates is that they are located away from the
cause inadvertent proclination of the mandibular anterior teeth and so it dentition and do not interfere with tooth movements. However, placement
was decided to level and align the teeth (Fig. 46.1E.F) and then place the of miniplates is far more invasive than placement of MIs, and infections
MIs in the inter-radicular area between the mandibular canine and first can occur. One orthodontic miniplate system that has been widely used
premolar bilaterally for anchoring the appliance (Fig. 46.1G). is the titanium Skeletal Anchorage System.6 Other designs are the Ortho-
Treatment for 11 months with the fixed functional appliance had no Anchor System7 and the Zygoma Anchorage System.8 These systems
untoward effects linked to use of MIs (Fig. 46.1H). Treatment was have been shown to provide excellent anchorage for Class II functional

244
 Correction of Class II malocclusion with the bone-anchored Forsus Fatigue Resistant Device 245

A B C

D E F G

H I J K

a b c e

L
Fig. 46.1 Case 1: use of miniscrew implants as anchorage for advancement of the mandible. (A,D) Pretreatment. (E) Fixed appliances bonded and initial arch wire placed.
(F) Prefunctional view. (G) Forsus FRD anchored on miniscrew implants. (H) After functional treatment. (I) Before continuation of treatment with fixed appliances. (B,J)
Post-treatment. (C,K) One year after completion of treatment (with Hawley’s retainers). (L) Superimposition of the cephalometric tracing before (a) and after (b) treatment
on the anterior cranial base (c), the maxilla (d) and the mandible (e).

treatment but their use in Class II, division 1 malocclusion has not been the plate lies immediately at the mucogingival junction level. The fixation
thoroughly evaluated. screws are 8 or 10 mm in length, with a 1.2 mm head dimension.
Almost any type of skeletal miniplate can be used as an anchor unit but
the triangular design with its three parts is versatile and can be used in
many indications. The first part, the retentive plate, has three holes at three
CLINICAL PROCEDURE
corners of a triangular plate, which can resist the force applied in a com- The miniplate is inserted in the area between the mandibular first premolar
prehensive fashion through its tripod design (see Fig. 13.1). The second and incisors (see Chapter 13 for the insertion technique). Although the
part is an extension arm and the third is the anchor, which is essentially a miniplate can be loaded immediately, a period of 5–7 days before loading
fourth hole extending from the retentive plate. The extension arm’s length is recommended to allow the soft tissues to heal.
(8, 10, 12 or 14 mm) depends on the mandibular height at the canine and The distance from the distal aspect of the maxillary first molar headgear
premolar region, and the skeletal plate is placed so that the anchor part of tube to the hole of the anchor plate is measured with the Forsus FRD
 246 SECTION VIII: TREATMENT OF CLASS II MALOCCLUSION WITH DIFFERENT TEMPORARY ANCHORAGE DEVICES

A B C

Fig. 46.2 Anchorage of the Forsus Fatigue Resistant Device to the hook of miniplates. (A,B) Attachment of the device. (C) Assessing mouth opening to ensure that the
device does not roll into occlusion while functioning.

measuring jig (usually 29–32 mm). The push rod hook of the Forsus FRD Effects on the maxilla and maxillary teeth include:
is crimped on to the hook of the anchor part of the miniplate (Fig. 46.2A,B),
■ primarily, the maxillary first molar is affected as it is hooked on the
and the patient is asked to open and close the mouth several times to check
headgear tube of the maxillary first molar band (Fig. 46.3A–C)
whether the appliance is injuring the soft tissues or the push rod is rotating
■ there is a clockwise rotation of the maxilla with restraining effect of
into the bite (Fig. 46.2C). Once the push rod is correctly fitted, the patient
the maxillary complex (Fig. 46.3E).
is asked not to open the mouth too wide and is given regular instructions
plus advice with special emphasis on oral hygiene maintenance, particu- Effects on the mandible and on mandibular teeth include:
larly around the miniplate extensions.
■ clinically, cephalometrically and tomographically, no effect is
evident on the mandibular teeth in terms of labial flaring, anterior
ASSESSMENT OF THE USE OF BONE ANCHORAGE teeth intrusion, anterior teeth root resorption
FOR FIXED FUNCTIONAL APPLIANCES ■ MIs and miniplates are placed closer to the center of resistance of
the mandibular arch to allow derived force to be most effective in
The benefits of using bone anchorage for the application of a fixed func- advancing or anterior repositioning of the mandible (Fig. 46.3D).
tional appliance in treating Class II, division 1 malocclusion include:
■ does not require teeth leveling and alignment before initiating EVALUATION OF CONDYLAR GROWTH AND THE
mandibular advancement and so the fixed functional appliances are EFFECT ON THE MAXILLARY COMPLEX OF THE
incorporated into the treatment plan at its initiation, thus allowing FIXED FUNCTIONAL APPLIANCES
maximum benefit from growth potential in growing patients
A prospective CBCT study assessed the effect of the Forsus FRD on the
■ linking the device directly to the miniplates or MI avoids the need
maxilla and mandible in six growing individuals (four girls, two boys;
for bypass wires or heavy rectangular wire
mean age, 13 ± 0.6 years) with skeletal Class II jaw relationships (SNA
■ labial flaring of the mandibular anterior teeth is avoided, which
angle, 84 ± 2°; SNB angle, 76 ± 2°), and Class II, division 1 malocclusion,
eliminates root resorption of the mandibular anterior teeth and
as well as an overjet of more than 7 mm with minimal or no crowding of
alveolar bone dehiscence
the maxillary and mandibular dental arch. The exclusion criteria included
■ rapid flaring of the mandibular anterior teeth is avoided
the presence of any primary teeth, absence of maxillary posterior perma-
■ no requirement to use brackets, thus avoiding additional bracket
nent teeth, prosthetic restorations on the maxillary posterior teeth, perio-
inventory, negative crown torque on the mandibular anterior teeth
dontal disease and previous orthodontic treatment. Figure 46.4 illustrates
and the frequent debonding of canine brackets.
the treatment of a typical patient. All the teeth were bonded with slot
There are also disadvantages, which should not be underestimated: brackets (0.022 inch) and the maxillary first molars were banded with
■ placement and removal of MIs and miniplates is an invasive triple tube buccal attachments incorporating a headgear tube. Initially,
procedure with all the attendant issues Ni-Ti archwires (0.014 inch) were placed in the maxillary and mandibular
■ a potential for damage to adjacent roots or other neighboring dental arch, and an SS transpalatal arch (0.032 inch) was placed on the
structures, such as the neurovascular bundle, during placement, maxillary first molars. Two miniplates with a triangular design were placed
particularly if the clinician is inexperienced bilaterally in the anterior part of the mandible and were loaded 5–7 days
■ migration of MIs is always possible, particularly if dimensions after insertion (Fig. 46.4B). The functional phase lasted 11.0 ± 0.8 months.
are smaller; MIs of 1.4 mm diameter and 14.0 mm length and All patients were subjected to CBCT imaging before treatment, immedi-
miniplates with a triangular configuration are recommended ately after completion of the advancement of the mandible and 1 year after
■ soft tissue injury can occur, particularly in individuals with a treatment (Table 46.1). The images were converted into a DICOM (digital
shallow mandibular vestibular depth; vestibuloplasty can increase imaging and communications in medicine) format and evaluated using
vestibular height if required. InVivo 5.1 software (Anatomage, San Jose, CA, USA). The images were
superimposed using the software by selecting certain stable skeletal struc-
tural landmarks of the anterior cranial base (Fig. 46.4C,D).
BIOMECHANICAL ASPECTS OF BONE ANCHORAGE Data analysis shows that the treatment outcome was significant, with
FOR THE FORSUS FATIGUE RESISTANT DEVICE overall reduction of overjet of 0.67 mm on average. The greatest effect was
The impact of fixed functional appliances can be considered for the maxilla on the mandible, with a significant increase of total mandibular length
and mandible separately. (GoGn) and in the sagittal positioning of the mandible, with an increase in
 Correction of Class II malocclusion with the bone-anchored Forsus Fatigue Resistant Device 247

A B

C D E

Fig. 46.3 The effects on the maxillary posterior teeth of the Forsus Fatigue Resistant Device with miniplates. (A–C) The first molar is affected in all three dimensions with
buccal tipping (A) distal tipping (B) and distopalatal rotation (C). A transpalatal arch is essential to counter these untoward effects. (D,E) The appliance anchored on the
miniplate is placed close to the center of resistance of the upper (D) and lower (E) dentition.

A B

C D

Fig. 46.4 Treatment of a typical patient in the study of the Forsus Fatigue Resistant Device. (A) Pretreatment. (B) Panoramic radiograph taken immediately after insertion
of the miniplate, showing sufficient clearance from the mental foramen. (C,D) Use of InVivo software to assess changes in the mandible, where there was a forward and
downward movement (C), and the maxilla, where there was an overall restraining effect along with backward and downward movement (D).

bony chin position. There was little change in the inclination of the anterior on the maxillary molars, followed by the anterior teeth. The maxillary
mandibular teeth, which contrasts with the significant proclination and molars, and particularly the first molars, showed an intrusive and distal
intrusion of mandibular incisors seen with tooth-borne fixed functional tipping effect despite the presence of a transpalatal arch, with mild retru-
appliances. This supports the fact that anchorage via the miniplate sion and extrusion of the maxillary anterior teeth.
rather than via the anterior teeth completely eliminates unwanted tooth The lack of a control group is an inherent defect of this study. However,
movements. the data presented here are part of an ongoing study with a larger sample
The maxilla showed mild clockwise rotation with a restraining effect and an appropriate control group; this study will be published when
on the entire maxillary complex; the main influence of the appliance was completed.
 248 SECTION VIII: TREATMENT OF CLASS II MALOCCLUSION WITH DIFFERENT TEMPORARY ANCHORAGE DEVICES

Table 46.1 Cone beam CT evaluation

overjet and overbite has been documented 1-year after treatment, caused
by relapse in mandibular incisor inclination.9 In our study, no relapse was
Variables T1 T2 T3
noted in the 1-year retention period, because the prefunctional incisor
Anteroposterior inclination was maintained by the fixed functional appliance being
ANB (°) 8±1 2±1 2±1 anchored directly on the bone.
A-B (mm) 14 ± 3 4±1 3±1 The functional phase in our study was 11 months, which is longer than
Wits appraisal 6 ± 2.5 2 ± 0.5 2 ± 0.5 many other studies with fixed functional appliances (approximately 6
(mm)
months on average); this might explain the excellent orthopedic response
NA-Pog (mm) 10 ± 2.5 3.5 ± 1 3±1
and stability. Moreover, there is histological evidence to suggest that addi-
Vertical tional growth occurs with longer treatment times, perhaps through miner-
SN-GoGn (°) 23 ± 4 27 ± 2 27 ± 2 alization and adaptation of muscle attachments.10–12
FH-GoMe (°) 21 ± 2 24 ± 2 24 ± 1
MM plane (°) 18 ± 3 20 ± 1 20 ± 1
Y-axis (°) 86 ± 2 90 ± 2 90 ± 1 REFERENCES
Maxilla
SNA (°) 86 ± 2 82 ± 2 82 ± 1 1. Kau CH, English JD, Muller-Delgardo MG, et al. Retrospective cone-beam computed
tomography evaluation of temporary anchorage devices. Am J Orthod Dentofacial
A-N (mm) 3±1 1±1 1±1 Orthop 2010;137:166.
A-Ptm (mm) 52 ± 1.5 51 ± 1 51 ± 1 2. Rajagopal R, Kansal S. A comparison of modified MP3 stages and the cervical verte-
S-Ptm (mm) 21 ± 1 21 ± 1 21 ± 1 brae as growth indicators. J Clin Orthod 2002;36:398–406.
3. Baume L, Derichsweiler H. Is the condylar growth centre responsive to orthodontic
Mandible therapy? An experimental study in Macaca mulata. Oral Surg Oral Med Oral Path
SNB (°) 76 ± 2 81 ± 2 81 ± 1 1961;14:347–62.
4. Ruf S, Pancherz H. Temporomandibular joint remodeling in adolescents and young
Go-Pg (mm) 70 ± 2 75.5 ± 2 76 ± 1.5
adults during Herbst treatment: a prospective longitudinal magnetic resonance imaging
Dental and cephalometric radiographic investigation. Am J Orthod Dentofacial Orthop
1999;115:607–18.
U1-SN (°) 114 ± 4 102 ± 3 102 ± 2
5. Heinig N, Göz G. Clinical application and effects of the Forsus spring. A study of a
U1-NA (°) [mm] 26 ± 3 [8 ± 4] 18 ± 2 [2 ± 1] 18 ± 2 [2 ± 1] new Herbst hybrid. J Orofac Orthop 2001;62:436–50.
L1-MP(°) 96 ± 2 96 ± 2 96 ± 2 6. Umemori M, Sugawara J, Mitani H, et al. Skeletal anchorage system for open-bite
L1-NB (°) [mm] 24 ± 2 [3 ± 1] 22 ± 2 [2 ± 1] 22 ± 2 [2 ± 1] correction. Am J Orthod Dentofacial Orthop 1999;115:166–74.
7. Chung KR, Kim YS, Linton JL, et al. The miniplate with tube for skeletal anchorage.
U1-L1 (°) 124 ± 2 128 ± 2 128 ± 2 J Clin Orthod 2002;36:407–12.
Overjet (mm) 7 ± 1.5 1.8 ± 0.5 1.2 ± 0.5 8. De Clerck H, Geerinckx V, Siciliano S. The Zygoma Anchorage System. J Clin Orthod
Overbite (mm) 7 ± 1.2 1.0 ± 0.8 1.2 ± 1.0 2002;36:455–9.
9. Pancherz H. The Herbst appliance: its biologic effects and clinical use. Am J Orthod
Temperomandibular joint 1985;87:1–20.
Gl-Cpr (mm) 4.5 ± 1.2 6.8 ± 1.3 6.7 ± 1.2 10. Buschang PH, Santos-Pinto A. Condylar growth and glenoid fossa displacement
during childhood and adolescence. Am J Orthod Dentofacial Orthop 1998;113:
Gl-Cdis (mm) 5.2 ± 0.8 7.3 ± 0.7 7.1 ± 0.4
437–42.
Gl-Cmed (mm) 4.2 ± 0.7 6.1 ± 0.5 6.4 ± 0.2 11. Voudouris JC, Woodside DG, Altuna G, et al. Condyle-fossa modifications and muscle
interactions during Herbst treatment. Part 2. Results and conclusions. Am J Orthod
Dentofacial Orthop 2003;124:13–29.
T1, pretreatment; T2, post-functional treatment; T3, 1-year follow-up; IMPA, incisor 12. Auf der Maur HJ. Electromyographic recordings of the lateral pterygoid muscle activ-
mandibular plane angle; Gl, inside innermost concavity of glenoid fossa of temporal ity in activator treatment of Class II, Division 1 malocclusion cases. Eur J Orthod
bone; Cpr, center of head of condyle; Cdis, head of the condyle distal aspect; Cmed, 1980;2:161–71.
head of the condyle medial aspect.

The study results also show that use of the Forsus FRD with a miniplate
anchorage allowed the growing mandible to express its full growth poten-
tial without any labial flaring of the anterior teeth.
Post-treatment stability needs to be ensured through stable cuspal inter-
digitation of the maxillary and mandibular dentition; minor relapse of
 The Twin Force Bite Corrector and skeletal
anchorage for Class II correction
47
Aditya Chhibber, Ravindra Nanda and Flavio Uribe

redistributing the intrusive force along the entire denture base. The appli-
INTRODUCTION
ance is placed on the two archwires for a period of 3 months. A transpalatal
arch is placed to counteract the buccal forces exerted by the appliance on
Fixed functional appliances may be broadly classified as rigid, flexible and
the maxillary dentition.
semirigid appliances.1 The major difference between functional appliances
Class II correction using the TFBC appliance occurs through a combina-
and fixed functional appliances is probably that the mandible is forcefully
tion of skeletal and dental effects.3 Retention of the correction of any type
postured in an anterior position with the latter, with the help of interarch
of malocclusion is a challenge in orthodontics and relapse is a common
anchorage using the maxillary denture base as the anchor unit. As dis-
problem reported in the literature.4 Therefore, assessment of outcomes
cussed in many chapters in this book, the use of temporary anchorage
must consider both short- and long-term effects with an appliance to deter-
devices such as miniscrew implants (MIs) to provide the anchorage for
mine which therapies may be considered stable. Examination of patient
fixed functional appliances avoids the unwanted effects of using teeth as
groups at the end of treatment with the TFBC appliance and after at least
the only anchorage. This chapter describes the use of the Twin Force Bite
2 years of retention shows that the occlusal plane clockwise canting and
Corrector (TFBC), which is a hybrid type of fixed functional appliance,2
intrusion of maxillary molars that occurred with the TFBC appliance is
together with direct and indirect anchorage supplied by MIs.
not stable and reverts back, leading to flattening of the functional occlusal
plane. Flaring of the mandibular incisors could possibly limit the amount
of anterior displacement of the mandible during the Class II correction
THE TWIN FORCE BITE CORRECTOR
phase and, therefore, limit the amount of skeletal correction. A mechanism
The TFBC is a fixed push type appliance clamped bilaterally to SS arch- capable of minimizing the dental effects in the anterior region could capi-
wires in both the maxillary and mandibular dental arches (upper, talize on the significant skeletal change, observed as orthopedic mandibu-
0.019 × 0.025 inch; lower, 0.021 × 0.025 inch) (see Fig. 2.7C). Each unit lar lengthening, and improve outcomes in the long term. The use of
is made of two 15 mm telescopic parallel cylinders containing a Ni-Ti coil skeletal anchorage could provide such a mechanism, and temporary
that is activated as the patient occludes. A plunger is incorporated within anchorage devices such as MIs and miniplates have been shown to avoid
each cylinder on opposite ends. Hex nuts at the free end of each plunger the unwanted effects of reactive forces on dental anchor units, limiting
attach the appliance mesial to the maxillary molars and distal to the man- mandibular incisor flaring and possibly maximizing mandibular advance-
dibular canines on the archwires. At full compression, a force of approxi- ment (see Chapter 46).
mately 210 g is delivered on each side by the compression of the coil
spring. This force is synergistic to that applied indirectly by the muscles
of mastication to the denture bases through the anterior positioning of the
THE TWIN FORCE BITE CORRECTOR WITH TEMPORARY
mandible. A unique feature of the appliance is that, since the point of force
ANCHORAGE DEVICES
application is closer to the center of resistance (CR) of the maxillary denti-
tion, less clockwise moment is generated with the appliance (Fig. 47.1A)
DIRECT ANCHORAGE
than with other fixed functional appliances, where the point of force appli- Various possible combinations of miniplates and MIs could be imple-
cation on the maxillary arch is distal to the maxillary molars (Fig. 47.1B). mented for direct anchorage with the TFBC. Since the magnitude of force
In addition, since the appliance is clamped on to the archwire, the intrusive indirectly exerted to the appliance by the musculature is high, a single MI
component of the spring force is dissipated along the entire arch, at each end would be unlikely to tolerate this load. Therefore, two MIs

i
i
F
Mu Mu
F
r
r

i i

r F r F

MI Ml
A B
Fig. 47.1 Biomechanics of the Twin Force Bite Corrector (A) and a conventional fixed functional appliance (B). F, total force; i, vertical (intrusive) component; r, horizontal
component; Mu, moment created on the upper arch; Ml, moment created on the lower arch.

249
 250 SECTION VIII: TREATMENT OF CLASS II MALOCCLUSION WITH DIFFERENT TEMPORARY ANCHORAGE DEVICES

splinted together, resembling a miniplate, may be placed between the also be compromised through jiggling forces generated by the appliance
maxillary first and second molars and distal to the mandibular canines with spring and the muscles when the patient forcefully bites in a forward
the head of the TFBC appliance stabilized to a wire segment (Fig. 47.2A). posture.
However, analysis of the force system indicates that there will be a greater Excessive vertical forces could be reduced by using a miniplate on the
vertical component of the force and so the moment generated on the maxil- maxillary zygomatic buttress splinted to the two MIs with a rigid wire in
lary dentition would be less as the point of force application would be very the mandibular arch (Fig. 47.2B). The advantage is that the forces would
close to the CR of the maxillary dentition. The stability of the MIs may be more horizontal on both the maxilla and mandible and that the miniplate

A B

i
F Mu

M I′ i F

MI
C D

Fig. 47.2 Biomechanics with the Twin Force Bite Corrector. (A) Anchored with miniscrew implants
(MIs). (B) Anchored with miniplates. (C) Tooth-borne appliance anchored indirectly from MIs.
i (D) Tooth-borne appliance with a ligature tie for indirect anchorage to the MI. (E) Tooth-borne
appliance with an elastic chain for indirect anchorage to the MI. F, total force; i, vertical (intrusive)
F Mu component; r, horizontal component; Mu, moment created on the upper arch; Ml, moment created
on the lower arch; Ml′, moment created on the lower arch from ligation; r′, retractive force applied
r on the lower arch equal to r of the TFBC when the anterior segments move forward; a, horizontal/
retractive component of elastic force; b, vertical component of elastic force; Me, moment in lower
arch from elastic force.
r
a

Me i b F

MI
E
 The Twin Force Bite Corrector and skeletal anchorage for Class II correction 251

A B

C D

Fig. 47.3 Case example of Twin Force Bite Corrector with miniscrew implant anchorage. (A,B) Leveled and aligned arches just prior to appliance fitting. (C,D) Placement
of the appliance with indirect anchorage using a miniscrew implant between the premolars in the mandible.

would be better suited to bear the high forces exerted by the TFBC appli- mandibular dental arch. Overall, a passive ligature seems to have a more
ance. However, a very large moment would be generated in the maxilla as favorable effect in preventing incisor flaring with minimal side effects, as
the point of force application would be further away from the CR. shown in the case example in Fig. 47.3.

INDIRECT ANCHORAGE CONCLUSIONS

To overcome the issues of direct anchorage, MIs can be placed mesial to
the maxillary first molar with an archwire connecting the first molar and The TFBC is a very versatile appliance for the correction of the Class II
the MI to provide indirect anchorage against the distal movement of the malocclusion. Short- and long-term results appear to be favorable and
maxillary molar (Fig. 47.2C). However, based on the magnitude of distal stable; however, true orthopedic effects seem to be minimal if any. Skeletal
movement of the maxillary molar observed with the TFBC, this approach anchorage could, in theory, provide an avenue to increase the orthopedic
seems unnecessary. Furthermore, our long-term results support the fact effect, reflected in enhanced mandibular growth. Although this is an
that the maxillary molar will revert back to its original position with the appealing approach, the preliminary clinical research results do not show
natural mesial drift of the dentition. In order to prevent the undesired promising evidence supporting the use of MIs in tandem with fixed func-
flaring of the mandibular incisors, a MI can be placed distal to the canine tional appliances. It could be argued that dentoalveolar effects are at the
with an arm extending from the MI to an auxiliary tube bonded on the heart of the correction of this type of malocclusion and, therefore, should
canine. not be prevented. True skeletal changes of significant magnitude would
The most practical way to implement indirect anchorage is by utilizing probably require an extended period of appliance wear.
a single MI on each side in the mandibular arch to prevent mandibular
incisor flaring. The MI would be placed between the roots of the mandibu-
lar first molar and second premolar or between the two premolars. The
REFERENCES
TFBC appliance is then placed mesial to the maxillary molar and distal to 1. Papadopoulos MA. Classification of the non-compliance appliances used for Class II
the mandibular canine and the MI can either be ligated to the canine correction. In: Papadopoulos MA, editor. Orthodontic treatment of the Class II non-
bracket (Fig. 47.2D) or an active force can be applied from the MI to the compliant patient: current principles and techniques. Edinburgh: Elsevier-Mosby; 2006.
p. 9–17.
canine by placing a coil spring or elastic chain (Fig. 47.2E). The vertical 2. Rothenberg J, Campbell ES, Nanda R. Class II correction with the Twin Force Bite
component of force increases drastically with an elastic chain, which may Corrector. J Clin Orthod 2004;38:232–40.
generate an unfavorable open bite tendency. Against this, based on the 3. Campbell E. A prospective clinical analysis of a push-type fixed intermaxillary Class
II correction appliance, Master Thesis. Farmington: University of Connecticut; 2003.
vertical positioning of the MI, there may be a mild favorable (if mandibular 4. Proffit WR. Retention. In: Profitt WR, Fields HW Jr, Sarver DM, editors. Contemporary
incisor flaring is to be avoided) counterclockwise moment generated in the orthodontics. 4th ed. St. Louis, MO: Elsevier; 2007. p. 617–34.
Section IX: Efficiency of skeletal anchorage and risk management

48 Success rates, risk factors and complications of

miniplates used for orthodontic anchorage
Marie A. Cornelis and Catherine Nyssen-Behets

local anesthesia with or without intravenous sedation. Placement surgery

INTRODUCTION
requires a mucoperiosteal flap, sometimes pilot drilling, positioning of the
screws to fix the plate, and sutures (see Chapter 13). Orthodontic force is
Miniscrew implants (MIs) and miniplates have been developed specifically
usually applied after soft tissue healing, at 1–4 weeks after placement.
for orthodontic purposes and can be inserted in multiple locations close to
Removal surgery is recommended immediately after completion of ortho-
the dental arch. Their primary stability allows immediate loading, or early
dontic treatment, and again requires an incision before removal of the
loading within 4 weeks of placement. Their surface is generally smooth,
plates and screws, and stitches.
in contrast to dental implants, to avoid levels of osseointegration that
Miniplates are indicated particularly for intrusion of maxillary and/or
would hinder their removal with a screwdriver.
mandibular molars in non-surgical treatment of open bite.12,13 Beside intru-
Ideally, such temporary skeletal anchorage devices should not require
sion, which is the most documented application, miniplates have also been
invasive surgery for placement and removal, should be simple to connect
used for distalization of the anterior teeth after premolar extractions,14,15
to the orthodontic appliance and be able to withstand orthodontic forces.
and for maxillary9,16 and/or mandibular17 molar distalization in non-
They are also expected to be inexpensive, early loadable, biocompatible
extraction treatment. Finally, a promising indication for miniplates is
and to provide superior clinical results to traditional anchorage systems.1
orthopedic protraction of the maxilla.18 Use of miniplates in these multiple
MIs are of smaller size than miniplates and are frequently placed by
applications tends to reduce the need for extractions and orthognathic
orthodontists themselves, but have a high risk of failure when placed in
surgery.
unattached gingiva and a high risk of root injury when placed in kerati-
The specific issues of success rates, risk factors and complications are
nized mucosa.2,3 While root impingement is less likely with the smaller
addressed below.
MIs, the risk of failure and fracture during placement increases as the MI’s
diameter decreases.4,5 Unscrewing moments must be avoided during force
application, and MIs inserted between roots might need to be repositioned
during treatment to complete tooth movements. SUCCESS RATES
Orthodontic miniplates are surgical osteosynthesis plates modified to
Case series report success rates varying from 85 to 98% (Table 48.1). A
allow a connection to orthodontic appliances.6–8 Miniplates work as an
meta-analysis of temporary anchorage devices estimated the failure rate
onplant screwed on the bone surface, while the fixation screws act as an
of miniplates at 7.3% and concluded that miniplates and palatal implants,
implant. Both plates and fixation screws are affected by a certain amount
when grouped together, showed a 1.9-fold lower failure rate than MIs.11
of osseointegration if they are made of titanium, but this is usually limited
Success rates are usually higher in the maxilla than in the mandible,8,23
because the surfaces are smooth.
and in adults than in growing patients.23 Definition of success generally
Miniplates have some advantages over MIs. The fixation screws are
implies achievement of orthodontic objectives with the initial miniplate,
typically shorter than MIs and placed at a safe distance from the roots,
some miniplates being successfully used throughout treatment even
while the connection to the orthodontic appliances is still located in attached
though slightly mobile.8,22,23 Although the vast majority of failures can
gingiva close to the dental arch. The roots can, therefore, slide past the
be linked to increased mobility, failure can also be caused by anchor
device and en masse distalization of an entire dental arch, for example, can
occur without any root–screw impingements.9 Miniplates can also sustain
torquing moments and have higher success rates.10,11 Consequently, they
may provide more secure anchorage when higher forces are needed and
may allow orthopedic forces.18 Their disadvantage is that placement Table 48.1 Success rates reported in miniplate case series
requires flap elevation, an invasive approach, and so is usually carried out No. No. Success
by an oral surgeon or periodontist. Study patients miniplates rate (%)
A number of miniplate systems have been developed, such as the Skel- Retrospective
etal Anchorage System (Chapters 13 and 46), the C-tube system (KLS Miyawaki et al., 20034 7 17 96.4
Martin, Umkirch, Germany; Chapter 45), the Bone Anchor system (Surgi- Choi et al., 20058 17 68 92.6
Tec, Belgium), the Dentsply-Sankin system (Tokyo, Japan) etc. Miniplates Kuroda et al., 200719 22 38 86.8
are usually made of titanium grade II, while their stabilizing screws are Chen et al., 200720 25 44 95.5
made of either commercially pure titanium or titanium grade V (Ti-Al6-V4), Chen et al., 200821 194 171 95.3
which has superior strength. The screws are self-tapping or self-drilling Prospective
and usually measure between 4 and 7 mm in length. Cheng et al., 20043 N/A 48 85.4
The recommended locations in the maxilla are the zygomatic buttress Mommaerts et al., 200522 18 35 91.4
and the piriform rim (in between, the bone covering the sinus is very thin), Cornelis et al., 200823 97 200 92.5
while in the mandible, the alveolar bone apical to the roots is suitable, Eroglu et al., 201024 37 74 98.6
apart from the mental foramen area. Miniplates are usually placed under

252
 Success rates, risk factors and complications of miniplates used for orthodontic anchorage 253

RISK FACTORS

According to the literature, some possible risk factors can be advanced,

including the insertion location, lack of primary stability of the screws,
screw-to-root contact, soft tissue inflammation patient’s age and occlusal
interferences.

INSERTION LOCATION
An increased failure rate in the mandible compared with the maxilla has
been shown in many studies, both clinical 3,8,21,23,33 and experimental.28,34
The higher failure rate in the mandible could be attributed to the smaller
amount of attached gingiva or it might be that maxillary trabecular bone
responds better to miniplate placement than compact mandibular bone,
since ensuring a better transition between primary and secondary stability.
This would suggest that successful anchorage depends not only on bone
density but also on specific features of the receptor site.27

LACK OF PRIMARY STABILITY OF THE SCREWS

Fig. 48.1 Undecalcified longitudinal section through a dog mandible supporting
a two-screw miniplate. The miniplate was loaded 2 weeks after placement, and Although no specific data are available for miniplates, it is evident that
loading was maintained for 27 weeks. The miniplate (m) is visible around the lack of primary stability of the screws fixing the plates is a major factor
inferior screw and is in contact with abundant periosteal new bone (p). Remodeled for failure. It is known from dental implants that excessive surgical trauma
bone is present at the surface of both screws, as attested by cementing lines
(arrows). (Methylene blue staining; bar = 1 mm.)
impedes the ability to establish the necessary intimate bone–implant
contact.35 For example, when the initially drilled hole had to be redrilled
on a slightly different axis during miniplate placement, woven bone could
breakage, cheek ulceration or poor location, all requiring miniplate removal be observed in dogs as a repair process,27 which might argue in favor of a
and replacement. drill-free technique. Screw-to-bone contact with self-drilling screws has
The issue of success rate raises the question of optimal time before been shown to be superior to that of self-tapping screws when used for
loading. Whereas for MIs it is stated that immediate loading is as success- osteosynthesis after orthognathic surgery or fracture.36
ful as loading after a few weeks of healing,25,26 healing times for miniplates From MI reports, it is clear that primary stability depends on the thick-
vary between 1 and 4 weeks. However, various healing times have not ness and quality of the cortical bone. Although this issue has not been
been compared under experimental conditions. Although optimal healing clearly established for orthodontic miniplates, miniplates placed in hyper-
time is not clearly defined, it has been shown that mobility occurs in divergent patients were reported to be more at risk, possibly because corti-
general 5 weeks after miniplate placement in dogs,27,28 which is consistent cal bone is usually thinner in these patients.4
with MI failure. This might represent the critical stage of transition between
primary stability obtained by tight fitting of the screws in cortical bone
and secondary stability generated by remodeling (Fig. 48.1).29 If correct, SCREW-TO-ROOT CONTACT
this observation would suggest that loading should be planned either For MIs, root proximity seems to be a major risk factor, either because
earlier or later than this transition period, but not close to it. there is less bone surrounding the screw or because of the transmission of
The effect of magnitude of load on bone healing around miniplates is occlusal forces to the screws; however, for miniplates, root proximity
another important question raised by the issue of success rate. No com- and contact of the anchoring screws seem to have minimal effects on
parative data are available at present with regard to the selection of appro- stability.37
priate forces and so it is impossible to know what the lower and upper
thresholds might be that would trigger a positive balance, which if exceeded
might possibly compromise the ease of removal of the plate, to a negative SOFT TISSUE INFLAMMATION
one, perhaps decreasing stability. This is an important area for future Failures are associated with inflammation of the soft tissues.4,8,20,24 Good
research as applications of miniplates have already broadened to include oral hygiene, with mouth rinses during the first week after placement and
such indications as single tooth or whole arch intrusion, and orthopedic careful brushing of the exposed parts of the miniplate and surrounding
correction of skeletal problems. mucosa throughout treatment, is, therefore, critical for miniplate
The effect of loading on dental implants has been studied in detail; success.4,8,20,24,38 Indeed, crevices around miniplates have been shown to be
remodeling around implants generates a compliant layer of bone prevent- supportive of anaerobic growth of bacteria likely to stimulate soft tissue
ing microdamage accumulation and allowing long-term success of endos- inflammation.39 Although antibiotic coverage appears to be the preferred
seous implants.30 Microcalli have been observed under orthodontic load, protocol after placement surgery, high success rates even without antibiot-
and attributed to microrepair.31 However, as the bone–implant contact is ics suggest that antibiotic prophylaxis might not be so important.38 Clinical
not affected by the orthodontic load of dental implants, strain levels are trials should be conducted to confirm this hypothesis. Concentration on
probably lower than the adapted window magnitudes.32 With regard to surgical asepsis would probably further reduce the risk of introducing
miniplates, loading in the range of orthodontic forces appeared to have no pathogens at the surgical site.
effect on stability under experimental conditions in dogs, since the success Sof tissue perforation through the non-keratinized mucosa is a risk
rate was not significantly different in loaded versus unloaded plates, and factor, possibly impeding tight closure of the tissues around the miniplate
loading did not affect bone-to-screw contact or bone density.27,28 in this more mobile mucosa and thus stimulating inflammation through
 254 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

A B C

D E F

Fig. 48.2 Placement surgery in the maxilla and mandible. (A) L-shaped incisions with the horizontal part of the incision being 1 mm into the attached gingiva.
(B) Mucoperiosteal flap. (C) Drilling of the middle hole (for the three-hole plate) or of the hole located closest to the attachment unit (for the two-hole plate). (D) Insertion
of the screws. (E) Closure with resorbable sutures. (F) Bollard miniplates with the attachment units facing anterior in the posterior maxilla and posterior in the anterior
mandible. (With permission from Cornelis et al., 2008.38)

exposure to the oral cavity.3 Soft tissue perforation is, therefore, recom- occur at the mucogingival junction or immediately within the attached
mended to occur at either the mucogingival junction or immediately within gingiva.
the keratinized mucosa in order to allow for good soft tissue healing
(Fig. 48.2).23
Combining miniplate placement with extractions in the same area COMPLICATIONS
should also be avoided since the inflammation around the extraction socket
may interfere with bone and soft tissue healing.38 Complications can be divided into postoperative complications, soft tissue
complications, damage to teeth and adjacent structures, miniplate mobility,
PATIENT’S AGE practical complications and complications during miniplate removal.

Miniplate placement in children and adolescents has not been documented

extensively. However, one study revealed that the majority (73%) of the POSTOPERATIVE COMPLICATIONS
failures occurred in growing patients.23 It may be that during placement of
Swelling
the miniplates, perforating the soft tissues at the mucogingival junction is
more difficult in younger patients where the alveolar height tends to be The most frequent problem reported by patients is postsurgical swelling,
shallow, the width of attached gingiva decreased and the access restricted. lasting on average 5 days after miniplate placement and after removal (Fig.
48.3A).38 Swelling is sometimes accompanied by hematoma (Fig. 48.3B).
After surgery, anti-inflammatory agents and/or painkillers are usually rec-
OCCLUSAL INTERFERENCES ommended to patients. It is probable that more aggressive management of
The presence of occlusal interferences has been reported to be critical postoperative edema, including the use of ice packs 1–2 hours postopera-
for miniplates success.20 However, this is seldom a problem in clinical tively, the addition of preoperative anti-inflammatory agents or corticos-
conditions as the part of the miniplate exposed to the oral cavity is gen- teroids delivered intravenously, could prevent or at least reduce this
erally away from the teeth, since mucosal perforation is recommended to complication.
 Success rates, risk factors and complications of miniplates used for orthodontic anchorage 255

60

None
50 Mild amount
Moderate amount
Lots
40
Surgeries (%)

30

20

10

0
B C
A Placement Removal
Fig. 48.3 Postoperative complications. (A) Frequency of swelling reported by patients for placement and removal surgery. (B) Cheek and infraorbital hematomas on the
right side of the face 1 week after placement of four miniplates. (C) Gingival dehiscence of the lower part of the miniplate. (A with permission from Cornelis et al.,
2008.38)

DAMAGE TO TEETH AND ADJACENT STRUCTURES

Root Damage
Root damage was probably underestimated initially but has been reported
since 2005 for MIs40 and, more recently, for miniplates.37 Surprisingly,
although the risk should theoretically be less for miniplates than for MIs,
a cone beam CT evaluation of miniplates in the posterior maxilla showed
that 1 out of 10 anchoring screws penetrated the dental roots, even when
very short (4 mm) and self-drilling fixation screws were used.37 However,
this happened with a relatively short plate (C-tube), forcing the anchoring
screws closer to the roots. Although the authors concluded that root contact
Fig. 48.4 Four miniplates placed in a growing child to achieve maxillary protraction did not interfere with miniplate stability, this raises the question of cemen-
with interanchor elastics. The mandibular miniplates were placed between the
lateral incisors and canines to reduce the risk of cheek irritation.
tum repair after root impingement.37 While experimental studies describe
cementum repair and healing of the periodontal structure a few weeks after
MI removal when the damage is limited to cementum or dentin, abnormal
Pain healing responses are observed when pulpal invasion occurs.40–42 The
Although the placement of miniplates requires surgery to raise a mucope- finding that MI placement less than 1 mm from the root surface can cause
riosteal flap and retract the tissues, the procedure appears to be associated root resorption is also of considerable concern.42
with minimal perioperative pain. Four out of five patients report that the
surgical experience is better than expected, with little or no pain, while Sinus Perforation
their discomfort is less or equivalent to extractions.23
Miniplate anchoring screws have been shown to penetrate the maxillary
sinus, but no harmful consequences were reported.37
SOFT TISSUE COMPLICATIONS
Cheek Irritation MINIPLATE MOBILITY
Cheek irritation is experienced initially by more than one-third of the Miniplate mobility is the most frequent reason for failure. Histologically,
patients but reduces over time.23 In the mandible, locating the miniplates screws without the bone-to-screw contact needed for stability are sur-
between the lateral incisor and canine generates less cheek irritation than rounded with a large radiotransparent space, with bone resorption and
between the canine and first premolar, probably because the miniplate head absence of osteoblastic activity, and are exclusively in contact with dense
is then more prominent in the region of the orbicularis oris musculature fibrous tissue.27 However, although miniplates can become mobile, some
(Fig. 48.4). are still sufficiently firm to provide the necessary anchorage to achieve the
treatment objectives (Fig. 48.5).23
Gingival Dehiscence
Poor adaptation of the miniplate to the bone at the exit point into the oral PRACTICAL COMPLICATIONS
cavity can generate gingival dehiscence with consequent exposure of part
Anchor Breakage
of the miniplate (Fig. 48.3C).22,38 Importantly, the connection bar must be
slightly bent at the lower limit of the plate to ensure tight contact with the Breakage is a complication that occurs in less than 2% of miniplates. It
bone surface where the bar emerges through the mucosa and good soft seems to be associated with repeated bending, causing in order to change
tissue healing (see Fig. 22.2C). the force vector (Fig. 48.6).23
 256 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

A B C

Fig. 48.5 Miniplate used for uprighting and mesializing a mandibular molar. Although the miniplate was clearly mobile and the gingival conditions were far from ideal,
planned molar movement was achieved with the initial inserted miniplate. (A) Initiation of molar mesialization. (B) Miniplate displaced to the distal but still used. (C) Final
position of the molar, a few months after miniplate removal. (Courtesy of Drs. Diane Pham and Fabienne Pernet.)

A B C

Fig. 48.6 Fracture of an upper right miniplate in a child having four miniplates placed for maxillary protraction. (A) Intraoral view of fracture. (B) Panoramic radiograph
showing the upper right miniplate fractured. (C) Fractured button of the miniplate.

A B C

D E F

Fig. 48.7 Miniplates with tooth movement during molar intrusion in two open bite patients. (A–C) Progress of open bite closure in one patient. (A) After miniplate
placement, with sutures still present. (B) Intrusion with a bonded acrylic plate. (C) Occlusion at the end of the molar intrusion phase. Overcorrection could not be achieved
because of the proximity of the miniplates to the intruded molars. (D–F) Alteration of the shape of a miniplate interfering with movement. (D) Miniplate placed correctly at
the left side. (E) Miniplate placed too low on the right side; a connecting wire had to be inserted into the miniplate button in order to increase the distance between the
acrylic plate and the miniplate. (F) In order to proceed with the intrusion, a flap was later reopened, the lower screw was removed, the button was cut away and the
plate was bent upwards, in order to make a hook. (A–C courtesy of Dr. Alexander Johner.)

Interference with Tooth Movement reported for more than 1 in 10 patients, but it did not seem to be correlated
with the location of the plate (maxilla or mandible, anterior or posterior)
During molar intrusion, a miniplate may interfere with the tooth in its new
or with the age of the patient.38 As long as titanium is used for miniplate
position; consequently the miniplate needs to be repositioned to allow the
fabrication, even if uncoated and polished, some degree of bone-to-screw
completion of intrusion (Fig. 48.7A–C).23 Alternatively, a less traumatic
contact does occur, which increases with time and in some cases even
solution would be to open a flap, cut away the part of the miniplate inter-
extends from the screws to the plate.27 Therefore, it is recommended that
fering with movement and bend the remaining part in order to make a hook
plates are removed as soon as they are no longer needed.
(Fig. 48.7D–F).

CONCLUSIONS
COMPLICATIONS AT REMOVAL
Bone Overgrowth The most important clinical conclusions can be summarized as follows.
The main difficulty encountered during removal surgery is bone over- ■ Before surgery, patients should be informed about postoperative
growth over the plates, although this varies considerably from patient to swelling. They might be reassured about pain, which is usually
patient (Fig. 48.8). Bone covering 25% or more of the plate has been milder than expected.
 Success rates, risk factors and complications of miniplates used for orthodontic anchorage 257

14. Erverdi N, Acar A. Zygomatic anchorage for en masse retraction in the treatment of
severe Class II, division 1. Angle Orthod 2005;75:483–90.
15. Iino S, Sakoda S, Miyawaki S. An adult bimaxillary protrusion treated with
corticotomy-facilitated orthodontics and titanium miniplates. Angle Orthod 2006;76:
1074–82.
16. Cornelis MA, De Clerck HJ. Maxillary molar distalization with miniplates assessed
on digital models: a prospective clinical trial. Am J Orthod Dentofacial Orthop
2007;132:373–7.
17. Sugawara J, Daimaruya T, Umemori M, et al. Distal movement of mandibular molars
A B in adult patients with the skeletal anchorage system. Am J Orthod Dentofacial Orthop
2004;125:130–8.
Fig. 48.8 Bone overgrowth. (A) Miniplate covered by bone overgrowth after flap 18. Kircelli BH, Pektas ZO, Uckan S. Orthopedic protraction with skeletal anchorage in
opening, before miniplate removal. (B) Imprint of miniplate appearing in bone after a patient with maxillary hypoplasia and hypodontia. Angle Orthod 2006;76:156–63.
miniplate removal, clearly demonstrating the bone overgrowth. 19. Kuroda S, Sugawara Y, Deguchi T, et al. Clinical use of miniscrew implants as ortho-
dontic anchorage: success rates and postoperative discomfort. Am J Orthod Dentofa-
cial Orthop 2007;131:9–15.
20. Chen CH, Hsieh CH, Tseng YC, et al. The use of miniplate osteosynthesis for skeletal
■ Surgery should respect strict guidelines and avoid excessive trauma. anchorage. Plast Reconstr Surg 2007;120:232–5.
In particular, redrilling, which is associated with bone-remodeling 21. Chen YJ, Chang HH, Lin HY, et al. Stability of miniplates and miniscrews used for
orthodontic anchorage: experience with 492 temporary anchorage devices. Clin Oral
healing reactions, has to be avoided in order to optimize primary Implants Res 2008;19:1188–96.
stability. 22. Mommaerts MY, Michiels ML, De Pauw GA. A 2-year outcome audit of a versatile
■ When possible, the maxilla should be preferred as receptor site over orthodontic bone anchor. J Orthod 2005;32:175–81.
23. Cornelis MA, Scheffler NR, Nyssen-Behets C, et al. Patients’ and orthodontists’ per-
the mandible, since the number of failures is higher in the mandible. ceptions of miniplates used for temporary skeletal anchorage: a prospective study. Am
■ Placement in children is more subject to failures than in adults, J Orthod Dentofacial Orthop 2008;133:18–24.
which needs to be clarified to the parents during consultation. 24. Eroglu T, Kaya B, Cetinsahin A, et al. Success of zygomatic plate-screw anchorage
system. J Oral Maxillofac Surg 2010;68:602–5.
■ Oral hygiene is of major importance to avoid inflammation of the 25. van de Vannet B, Sabzevar MM, Wehrbein H, et al. Osseointegration of miniscrews:
soft tissues. Even though the need for patient compliance is reduced a histomorphometric evaluation. Eur J Orthod 2007;29:437–42.
compared with other anchorage devices, it remains essential in 26. Freire JN, Silva NR, Gil JN, Magini RS, et al. Histomorphologic and histomorpho-
metric evaluation of immediately and early loaded mini-implants for orthodontic
terms of plaque control. anchorage. Am J Orthod Dentofacial Orthop 2007;131:704.
■ It is recommended that miniplates are removed as soon as they are 27. Cornelis MA, Vandergugten S, Mahy P, et al. Orthodontic loading of titanium mini-
no longer necessary, since osseointegration of the screws increases plates in dogs: microradiographic and histological evaluation. Clin Oral Implants Res
2008;19:1054–62.
with time which may in some cases impede miniplate removal. 28. Cornelis MA, Mahy P, Devogelaer JP, et al. Does orthodontic loading influence bone
mineral density around titanium miniplates? An experimental study in dogs. Orthod
Craniofac Res 2010;13:21–7.
29. Schenk RK, Buser D. Osseointegration: a reality. Periodontol 2000 1998;17:22–35.
REFERENCES 30. Huja SS, Katona TR, Burr DB, et al. Microdamage adjacent to endosseous implants.
Bone 1999;25:217–22.
1. Cope JB. Temporary anchorage devices in orthodontics: a paradigm shift. Semin 31. Trisi P, Rebaudi A. Progressive bone adaptation of titanium implants during and after
Orthod 2005;11:3–9. orthodontic load in humans. Int J Periodontics Restorative Dent 2002;22:31–43.
2. Poggio PM, Incorvati C, Velo S, et al. “Safe zones”: a guide for miniscrew positioning 32. Cattaneo PM, Dalstra M, Melsen B. Analysis of stress and strain around orthodonti-
in the maxillary and mandibular arch. Angle Orthod 2006;76:191–7. cally loaded implants: an animal study. Int J Oral Maxillofac Implants 2007;22:
3. Cheng SJ, Tseng IY, Lee JJ, Kok SH. A prospective study of the risk factors associated 213–25.
with failure of mini-implants used for orthodontic anchorage. Int J Oral Maxillofac 33. Chen CH, Chang CS, Hsieh CH, et al. The use of microimplants in orthodontic anchor-
Implants 2004;19:100–6. age. J Oral Maxillofac Surg 2006;64:1209–13.
4. Miyawaki S, Koyama I, Inoue M, et al. Factors associated with the stability of titanium 34. Owens SE, Buschang PH, Cope JB, et al. Experimental evaluation of tooth movement
screws placed in the posterior region for orthodontic anchorage. Am J Orthod Dento- in the beagle dog with the mini-screw implant for orthodontic anchorage. Am J Orthod
facial Orthop 2003;124:373–8. Dentofacial Orthop 2007;132:639–46.
5. Buchter A, Wiechmann D, Koerdt S, et al. Load-related implant reaction of mini- 35. Esposito M, Thomsen P, Ericson LE, et al. Histopathologic observations on early oral
implants used for orthodontic anchorage. Clin Oral Implants Res 2005;16:473–9. implant failures. Int J Oral Maxillofac Implants 1999;14:798–810.
6. De Clerck H, Geerinckx V, Siciliano S. The Zygoma Anchorage System. J Clin Orthod 36. Heidemann W, Terheyden H, Gerlach KL. Analysis of the osseous/metal interface of
2002;36:455–9. drill free screws and self-tapping screws. J Craniomaxillofac Surg 2001;29:69–74.
7. Chung KR, Kim YS, Linton JL, et al. The miniplate with tube for skeletal anchorage. 37. Kim GT, Kim SH, Choi YS, et al. Cone-beam computed tomography evaluation of
J Clin Orthod 2002;36:407–12. orthodontic miniplate anchoring screws in the posterior maxilla. Am J Orthod Dento-
8. Choi BH, Zhu SJ, Kim YH. A clinical evaluation of titanium miniplates as anchors facial Orthop 2009;136:628, discussion 628–9.
for orthodontic treatment. Am J Orthod Dentofacial Orthop 2005;128:382–4. 38. Cornelis MA, Scheffler NR, Mahy P, et al. Modified miniplates for temporary skeletal
9. De Clerck HJ, Cornelis MA. Biomechanics of skeletal anchorage. Part 2: Class II anchorage in orthodontics: placement and removal surgeries. J Oral Maxillofac Surg
nonextraction treatment. J Clin Orthod 2006;40:290–8, quiz 307. 2008;66:1439–45.
10. Chen YJ, Chang HH, Lin HY, et al. Stability of miniplates and miniscrews used for 39. Sato R, Sato T, Takahashi I, et al. Profiling of bacterial flora in crevices around tita-
orthodontic anchorage: experience with 492 temporary anchorage devices. Clin Oral nium orthodontic anchor plates. Clin Oral Implants Res 2007;18:21–6.
Implants Res 2008;19:1188–96. 40. Asscherickx K, Vannet BV, Wehrbein H, et al. Root repair after injury from mini-
11. Schatzle M, Mannchen R, Zwahlen M, et al. Survival and failure rates of orthodontic screw. Clin Oral Implants Res 2005;16:575–8.
temporary anchorage devices: a systematic review. Clin Oral Implants Res 41. Brisceno CE, Rossouw PE, Carrillo R, et al. Healing of the roots and surrounding
2009;20:1351–9. structures after intentional damage with miniscrew implants. Am J Orthod Dentofacial
12. Sherwood KH, Burch JG, Thompson WJ. Closing anterior open bites by intruding Orthop 2009;135:292–301.
molars with titanium miniplate anchorage. Am J Orthod Dentofacial Orthop 2002;122: 42. Kim H, Kim TW. Histologic evaluation of root-surface healing after root contact or
593–600. approximation during placement of mini-implants. Am J Orthod Dentofacial Orthop
13. Sugawara J, Baik UB, Umemori M, et al. Treatment and post-treatment dentoalveolar 2011;139:752–60.
changes following intrusion of mandibular molars with application of a skeletal
anchorage system (SAS) for open bite correction. Int J Adult Orthodon Orthognath
Surg 2002;17:243–53.
 49 Success rates and risk factors of miniscrew
implants used as temporary anchorage devices
for orthodontic purposes
Moschos A. Papadopoulos, Spyridon N. Papageorgiou and Ioannis P. Zogakis

systematic reviews.8–10 However, these reviews only included a limited

INTRODUCTION
number of studies, assessed only a few factors qualitatively and included
other methods of anchorage reinforcement such as miniplates. Cohort
Miniscrew implants (MIs) are widely used as supporting anchorage aux-
studies can provide reliable evidence under controlled experimental condi-
iliaries in orthodontics. They are usually manufactured from pure titanium
tions, and they usually include larger samples. Nevertheless, prospective
or titanium alloy (Ti6-Al4-V) with a diameter of 1–2 mm and length of
studies tend to have higher reporting quality and more complete data than
8–20 mm. Their value lies in their ability to remain relatively stationary
retrospective ones, although both present medium or high risk of bias.
in bone and to increase anchorage capacity without adverse effects or
Failure is considered to mean the need for MI removal or its inability
anchorage loss. MIs seem to be more effective in supporting anchorage
to act as the required stationary anchor. Based on three retrospective cohort
when they are used in the mandible between the second premolar and the
studies that investigated MI failures by month of treatment, it seems that,
first molar; when two MIs are inserted instead of one; when the MIs are
on average, the first 2 months after insertion are crucial, with 58% of all
directly connected; when they are used in adults; and when treatment lasts
failures occurring in this period and with 20% of the overall failures taking
more than 12 months.
place between months 2 and 3 (Fig. 49.1).4,5,11 At this point change in
treatment plan may be difficult or even impossible.
COMPLICATIONS OF MINISCREW USE This chapter presents a meta-analysis of the existing knowledge from
published controlled and uncontrolled clinical trials regarding the success/
Complications can occur at various stages;
failure rates of MIs used for orthodontic anchorage purposes in order to
1. during insertion identify associated risk factors.12 An unrestricted electronic search for
♦ lack of initial stability if placed in inadequate cortical bone published and unpublished studies in any language was followed by study
thickness selection, data extraction and risk of bias evaluation in duplicate by two
♦ injury of adjacent structures (periodontal ligament, tooth root, investigators. Random-effects meta-analyses were performed implement-
nerves, blood vessels or sinus perforation) ing failure rates in percentages, relative risks and the corresponding 95%
2. during orthodontic treatment confidence intervals (CIs). Additional analyses included subgroup analy-
♦ inflammation and infection of surrounding tissues ses, meta-regression and stratification by jaw.
♦ loss of MI stability attributable to inflammation or bone Following proper selection according to specific inclusion and exclusion
remodeling criteria, a total of 52 studies were identified: 5 randomized controlled trials
3. during MI removal (RCTs), 8 prospective controlled trials, 27 prospective cohort studies and
♦ fracture. 12 studies with unclear design that were considered through detailed
reading to be prospective cohort studies (Table 49.1). Reporting quality
varied among studies, and risk of bias analysis indicated that most of the
ASSESSMENT OF SUCCESS RATES AND RISK FACTORS studies were of medium quality.
The 52 studies included a total of 4987 MIs, which were placed in 2281
Factors possibly associated with the success or survival of orthodontic MIs patients in order to reinforce orthodontic anchorage. The reported percent-
have been assessed in several clinical studies1–7 and partially in published age of failure rates in these original studies ranged between 0.0% and

35 Fig. 49.1 Distribution of the percentages of miniscrew

implant failures over treatment duration according to the
data derived from three retrospective cohort studies.4,5,11
30

25
Failures (%)

20

15

10

0–1 1–2 2–3 3–4 4–5 5–6 6–7

Treatment duration (months)

258
 TEMPORARY ANCHORAGE DEVICES FOR ORTHODONTIC PURPOSES 259

Table 49.1 Characteristics of the trials included in the meta-analysis

Total MIs per
No. patient Diameter Length
Source Setting MIs (per jaw) Branda (mm) (mm) Success criteria Failure rate (%) Action
RCT (randomized anchorage type per patient
Basha et al. (2010)13 U 14 2 (2) SS 1.3 8 Stability 28.6 New
Liu et al. (2009)14 NR 68 2 (2) Ningbo Cibei 1.2 8 Stability 11.8 New
Upadhyah et al. U 72 4 (2) Modified Ti 1.3 8 Stability 6.9 New
(2008)15 fixation screws
RCT (risk factors per patient)
Aboul-Ela (2011)16 U 26 2 (2) AbsoAnchor 1.3 8 Stability 7.7 Repositioned
Lehnen et al. (2011)17 NR 60 2 (2) Tomas-pin 1.6 8 NR 11.7 Excluded
PCCT (randomized anchorage type per patient)
Hedayati et al. (2007)18 U 27 3 (1/2) Orthognathic 2 9/11 Stability 18.5 Repositioned
screws
Maddalone et al. NR 25 NR 3M Unitek 1.8 8 Stability 8.0 NR
(2010)19
Park et al. (2008)20 U 46 2/4 (2) AbsoAnchor/ 1.2 6/8 Tx completion 13 New
Osteomed/
Leibinger
Shi et al. (2008)21 U 28 2 (2) Miniscrew 1.5 8 NR 10.7 New
Anchorage
System
Upadhyah et al. U 30 2 (2) Modified Ti 1.3 8 Stability 10.0 New
(2008)22 fixation screws
Wilmes et al. (2009)23 NR 10 1 (1) Dual-Top 2 10 NR 0.0 NR
PCCT (risk factors per patient)
Apel et al. (2009)24 U 76 2/4 (2) Tomas-pin 1.6 8 Stability/Infection 10.5 Excluded
Garfinkle et al. (2008)25 U/Private 82 4/8 (4) Osteomed 1.6 6 Stability/Tx 19.5 (Only loaded NR
completion MIs included )∧
PCS
Upadhyay et al. U 46 2 (2) Ti mini-implants 1.3 8 NR 4.3 New
(2009)26
Blaya et al. (2010)27 U/Private 30 1 (1) Sin Implant 1.2 10 Stability 0.0 NR
System
Brandão & Mucha U 40 4 (2) Ortoimplante 1.5 9 Stability 0.0 NR
(2008)28 Básicos
Cheng et al. (2004)29 U 92 NR Leibinger/ 2 5–15 Stability/ 8.7 (Only MI data are NR
Mondeal Infection/Tx reported from the
completion various anchorage-
reinforcement
methods)
Gelgör et al. (2004)30 U 25 1 (1) IMF Stryker, 1.8 14 Stability 0.0 NR
Leibinger,
Germany)
Herman et al. (2006)31 NR 49 1/2 (1/2) Ortho Implant, 1.8 6/8/10 Stability 40.8 New/Excluded
Sendax MDI
Justens & de Bruyn U 50 NR Dual-Top 1.8/2 8/10 Stability/Tx 34.0 (Including failed New
(2008)32 completion miniscrews which
did not need to be
replaced to
complete
treatment)
Kim et al. (2010)33 U 50 2 (2) C-Implant 1.8 8.5 Stability 4.0 New
Liou et al. (2004)34 NR 32 2 (2) Leibinger 2 17 Stability 0.0 NR
Luzi et al. (2007)35 U 140 NR Aarhus Mini- 1.5/2 9.6/11.6 Stability/Tx 15.7 (Including failed Excluded
Implants completion miniscrews which
did not need to be
replaced to
complete
treatment )***
Miyazawa et al. U 44 NR Dual-Top 1.6 8 Tx completion 9.1 NR
(2010)36
Motoyoshi et al. U 124 1–4 (1/2) ISA orthodontic 1.6 8 Stability 14.5 NR
(2006)37 implants
Motoyoshi et al. U 169 1–4 (1/2) ISA orthodontic 1.6 8 Stability/Tx 14.8 NR
(2007)38 implants completion
Motoyoshi et al. U 87 NR ISA orthodontic 1.6 8 Stability/Tx 12.6 NR
(2007)39 implants completion

Continued
 260 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

Table 49.1 Characteristics of the trials included in the meta-analysis—cont’d

Total MIs per
No. patient Diameter Length
Source Setting MIs (per jaw) Branda (mm) (mm) Success criteria Failure rate (%) Action

Motoyoshi et al. U 209 1–4 (1/2) ISA orthodontic 1.6 8 Stability/Tx 11.5 NR
(2009)40 implants completion
Motoyoshi et al. U 148 NR ISA orthodontic 1.6 8 Stability 9.5 Excluded
(2010)41 implants
Oh et al. (2011)42 U 78 NR AbsoAnchor/ 1.2/NR NR NR 10.3 (4 MIs omitted New
Osteomed as intentionally
moved to another
location)‡
Park et al. (2006)2 U 227 NR Stryker Leibinger/ 1.2/2 4–15 Stability/Tx 8.4 New
Osteomed/ completion
KLS-Martin
Polat-Ozsoy et al. U 22 2 (2) AbsoAnchor 1.2 6 Stability/Infection 13.6 (One MI was New
(2009)43 replaced due to
root proximity and
was also classified
as failure )§
Suzuki et al. (2011)44 U 280 NR Sistema Nacional 1.5 6/8 NR 6.8 NR
de Implantes/
ACR Mini-
Implant
Thiruvenkatachari U 18 1/2 (1) Titanium 1.3 8 Stability 0.0 NR
et al. (2006)45 microimplant
Türköz et al. (2010)46 U 112 1/2 (1/2) AbsoAnchor 1.4 7 Stability 22.3 NR
Viwattanatipa et al. U 97 2 (2) Osteomed 1.2 8–12 Mobility/ 33.0 NR
(2009)47 Dislodgement/
Infection
Wang et al. (2009)48 U 298 2 (2) Micro-planting 1.6 11 Stability/Tx 22.8 Excluded
nail completion
Wiechmann et al. NR 133 AbsoAnchor/ 1.2/1.6 5–10 Stability/Tx 23.3 NR
(2007)49 Dual-Top completion/
Infection
Wu et al. (2009)7 U 414 NR AbsoAnchor/ 1.1–1.7/2 7–13 Stability/Tx 10.1 NR
LOMAS/A1 completion
Alves et al. (2011)50 U 41 2/3 (2/3) INP 1.4/2 6/8 NR 14.6 New (in an
adjacent
location)†
PCS, unclear designb
Baek et al. (2008)11 NR 109 1/2 (1/2) THOplant 2 5 Stability/ 24.8 (Reinstalled MI New
Infection/Tx failures not
completion considered)
Bayat & Bauss (2010)51 Private 110 1–4 (1/2) LOMAS 2 7/9/11 Stability/Infection 18.2 NR
Berens et al. (2006)52 Private 239 1–3 (1/2) AbsoAnchor/ 1.4/1.8/2 NR Stability 15.1 Rescrewed/
Dual-Top Excluded
Chaddad et al. (2008)53 NR 32 2/4 (2) C-Implant/ 1.4–2 6–10 Stability/ 12.5 NR
Dual-Top Infection/Tx
completion
El-Beialy et al. (2009)54 U 40 NR AbsoAnchor 1.2 8 Stability 17.5 Excluded
Freudenthaler et al. NR 15 NR Leibinger 2 13 Stability/Soft 6.7 Excluded/New
(2001)55 tissue problem
Gelgor et al. (2007)56 NR 40 1 (1) IMF 1.8 14 Stability 0.0 NR
Fritz et al. (2004)57 U 36 NR Dual-Top 1.4/1.6/2 6/8/10 Stability 30.6 NR
Kim et al. (2010)58 U 197 1 (1) KLS-Martin/ 1.5/2 5 Stability 9.2 New
Orthoplant
Kuroda et al. (2007)59 U 216 NR AbsoAnchor/ 1.3/1.5 6–12 Tx completion 16.2 NR
Gebrüder
Martin
Lee et al. (2010)6 NR 260 2 (2) C-Implant 1.8 8.5 NR 8.5 NR
Wang et al. (2009)60 U 77 NR MIA system/SDIA 1.2/2 7/8 NR 7.8 NR
system

a
3M Unitek A1, Bio-ray, Syntec Scientific Co, Chang Hua, Taiwan; Aarhus Mini-Implants, Medicon, Germany; AbsoAnchor, Dentos, Daegu, Korea; ACR Mini-Implant, BioMaterials
Korea, Guro-gu, Seoul, Korea; C-Implant, Implantium, Seoul, Korea; Dual-Top, Jeil Medical, Seoul, Korea; Gebrüder Martin, Tuttlingen, Germany; IMF, Stryker Leibinger, Germany;
INP, São Paulo, Brazil; ISA orthodontic implants, BIODENT, Tokyo, Japan; Jeil Medical, Seoul, Korea; KLS-Martin, Jacksonville, FL, USA; Leibinger, Freiburg, Germany; LOMAS,
Mondeal Medical Systems; MIA system, Dentos, Daegu, Korea; Micro-planting nail, North Medical, Ningbo Chi, China; Miniscrew Anchorage System, Titanium Biological Products,
Xi’an Bang, China; Mondeal, Tuttlingen, Germany; Ningbo Cibei, Ningbo City, China; Ortho Implant, IMTEC, Ardmore, OK, USA; Ortoimplante Básicos, Conexão, Arujá São Paulo,
Brazil; Osteomed, Addison, TX, USA; SDIA system, Zhejiang Cixi Oral Biomaterials, Cixi City, China; Sendax MDI, Irvine, CA, USA; Sin Implant System, São Paulo, Brazil; Sistema
Nacional de Implantes, São Paulo, Brazil; SS, Surgical Steel; Stryker Leibinger, Freiburg, Germany; THOplant, Biomaterials Korea, Seoul, South Korea; Tomas-pin, Dentaurum,
Ispringen, Germany
b
Unclear design, judged to be prospective cohort study.
NR, not reported; PCCT, prospective controlled clinical trial; PCS, prospective cohort study; RCT, randomized controlled trial; Tx, treatment; U, university.
 TEMPORARY ANCHORAGE DEVICES FOR ORTHODONTIC PURPOSES 261

Risk ratio Risk ratio Fig. 49.2 Non-significant findings as risk ratios (Mantel–
Reference Weight random, 95% Cl random, 95% Cl Haenszel method) of the meta-analyses of miniscrew
implant failures supported by numerous studies regarding
11 19.4% 2.10 (1.10–3.98)
gender (nine studies; A), age (five studies; B) and side of
58 11.7% 1.43 (0.57–3.62)
6 12.4% 1.28 (0.52–3.12) insertion (eight studies; C). CI, confidence interval.
37 3.3% 0.67 (0.10–4.53)
40 8.1% 0.52 (0.16–1.67)
39 3.2% 0.69 (0.10–4.89)
2 13.1% 1.72 (0.73–4.07)
47 13.6% 0.56 (0.24–1.30)
7 15.2% 0.85 (0.39–1.84)

Total (95% Cl) 100.0% 1.11 (0.77–1.60)

Total events
Heterogeneity: Tau2 = 0.07; Chi2 = 10.37, df = 8 (p = 0.24); I2 = 23% 0.01 0.1 1 10 100
Test for overall effect: Z = 0.57 (p = 0.57) More fails female More fails male
A

Risk ratio Risk ratio

Reference Weight random, 95% Cl random, 95% Cl
11 20.6% 0.86 (0.41–1.66)
58 18.6% 2.13 (0.89–5.10)
6 19.5% 2.84 (1.28–6.27)
39 19.3% 0.32 (0.14–0.72)
7 22.0% 1.55 (0.87–2.77)

Total (95% Cl) 100.0% 1.20 (0.59–2.44)

Total events
Heterogeneity: Tau2 = 0.51; Chi2 = 18.40, df = 4 (p = 0.001); I2 = 78% 0.01 0.1 1 10 100
Test for overall effect: Z = 0.50 (p = 0.62) More fails adolescent More fails adult
B

Risk ratio Risk ratio

Reference Weight random, 95% Cl random, 95% Cl
11 24.9% 1.04 (0.62–1.75)
6 10.8% 1.06 (0.48–2.37)
37 9.5% 1.00 (0.43–2.35)
40 11.8% 0.71 (0.33–1.52)
38 12.5% 0.72 (0.34–1.50)
39 5.7% 0.78 (0.26–2.36)
2 4.8% 0.20 (0.06–0.67)
47 20.0% 0.79 (0.44–1.41)

Total (95% Cl) 100.0% 0.81 (0.62–1.06)

Total events
Heterogeneity: Tau2 = 0.00; Chi2 = 7.17, df = 7 (p = 0.41); I2 = 2% 0.01 0.1 1 10 100
Test for overall effect: Z = 1.51 (p = 0.13) More fails right More fails left
C

40.8%. Using the random-effects model, the meta-analysis of all trials

RISK FACTORS ASSOCIATED WITH FAILURES
yielded an overall failure rate of 13.5% (95% CI, 11.5–15.8), in other
words a success rate of 86.5%. Meta-analysis of “large” trials with ≥100 A total of 30 original studies including 4008 MIs in 1827 patients reported
MIs each (including a total of 3385 MIs), yielded an overall failure rate two or more MI failure rates in relation to various characteristics and they
of 14.0% (95% CI, 11.5–17.0). This failure rate is close to another meta- were compared through subgroup analyses. In many of the comparisons
analysis of uncontrolled studies (16.4%),8 as well as to previous work of however, a limited number of studies contributed and therefore no reas-
the authors on prospective controlled studies (13.3%).61 suring conclusions could be drawn. The non-significant findings (Fig.
This translates to 14 failed implants per 100 inserted, which is a rela- 49.2), as well as the major significant findings (Fig. 49.3) supported by
tively low rate. In addition, although more than one MI was placed in each adequate studies, are also expressed as risk ratios. The observed MI failure
patient, it was a rare event for a patient to experience multiple MI failures. rates can be considered in six categories:
Most of the “failed patients” (80.5%) experienced only one loss of MI.
Only 12.2% of the patients with MI failure experienced loss of two MIs, ■ patient related
4.9% experienced loss of three MIs, and 2.4% experienced loss of four ■ clinician related
MIs. However, MI failures can be successfully handled in most cases by ■ characteristics and properties of MIs
reinstalling the MI in the same or adjacent areas without penalty, replacing ■ insertion procedure
it with another anchorage-reinforcing device or continuing treatment ■ type of MI utilization during orthodontic treatment
without it, when a new MI is no longer needed. ■ treatment outcome related.
 262 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

Fig. 49.3 Significant findings as risk ratios (Mantel– Risk ratio Risk ratio
Haenszel method) of the meta-analyses of miniscrew Reference Weight random, 95% Cl random, 95% Cl
implant failures regarding jaw (17 studies; A), cortical
52 8.2% 3.27 (1.71–6.27)
bone thickness (CBT) (2 studies; B), insertion torque
53 1.9% 0.38 (0.04–3.26)
(IT) (2 studies; C) and root contact (4 studies; D). 54 3.8% 0.92 (0.23–3.58)
CBT, cortical bone thickness; CI, confidence interval; 25 4.1% 0.85 (0.23–3.08)
IT, insertion torque. 18 3.0% 0.75 (0.15–3.72)
32 5.9% 1.53 (0.59–3.96)
59 8.7% 3.09 (1.70–5.60)
35 7.2% 0.60 (0.28–1.29)
36 1.9% 1.13 (0.13–9.73)
37 6.6% 1.82 (0.78–4.24)
40 7.3% 1.04 (0.49–2.20)
38 7.3% 0.82 (0.38–1.74)
39 4.8% 1.03 (0.33–3.25)
2 5.7% 3.37 (1.26–9.05)
44 6.4% 2.89 (1.20–6.96)
49 8.4% 3.31 (1.77–6.19)
7 8.8% 1.41 (0.79–2.51)

Total (95% Cl) 100.0% 1.56 (1.13–2.15)

Total events
Heterogeneity: Tau2 = 0.22; Chi2 = 34.02, df = 16 (p = 0.005); I2 = 53% 0.01 0.1 1 10 100
Test for overall effect: Z = 2.71 (p = 0.007) More fails maxilla More fails mandible
A
Risk ratio Risk ratio
Reference Weight random, 95% Cl random, 95% Cl

40 31.7% 3.15 (1.06–9.37)

39 68.3% 2.31 (1.10–4.86)

Total (95% Cl) 100.0% 2.55 (1.38–4.71)

Total events
Heterogeneity: Tau2 = 0.00; Chi2 = 0.21, df = 1 (p = 0.65); I2 = 0% 0.01 0.1 1 10 100
Test for overall effect: Z = 2.99 (p = 0.003) More fails CBT ≥ 1mm More fails CBT < 1mm
B
Risk ratio Risk ratio
Reference Weight random, 95% Cl random, 95% Cl
37 65.0% 4.39 (1.96–9.83)
39 35.0% 2.53 (0.84–7.58)

Total (95% Cl) 100.0% 3.62 (1.89–6.93)

Total events
Heterogeneity: Tau2 = 0.00; Chi2 = 0.65, df = 1 (p = 0.42); I2 = 0% 0.01 0.1 1 10 100
Test for overall effect: Z = 3.88 (p = 0.0001) More fails IT < 10Ncm More fails IT > 10Ncm
C
Risk ratio Risk ratio
Reference Weight random, 95% Cl random, 95% Cl
54 2.0% 28.80 (1.69–490.06)
33 2.2% 2.33 (0.16–34.89)
59 28.2% 3.70 (1.76–7.78)
48 67.6% 2.67 (1.68–4.23)

Total (95% Cl) 100.0% 3.06 (2.04–4.58)

Total events
Heterogeneity: Tau2 = 0.01; Chi2 = 3.09, df = 3 (p = 0.38); I2 = 3% 0.01 0.1 1 10 100
Test for overall effect: Z = 5.42 (p < 0.00001) More fails no contact More fails contact
D

PATIENT-RELATED FACTORS had significantly more females. A retrospective study found that males had
twice the risk of MI failure compared with females.65 This may be related
Patient-related factors that may possibly affect the failures of MIs are to lower cortical bone thickness under the attached gingiva mesial to the
outlined in Table 49.2. Within the analysis, there were a sufficient number maxillary first molar in women.
of studies to provide data on gender and age, while the other factors need
additional evidence to support any association.
Age
Gender
No evidence for the association of age with MI failure was found in the
Non-significant differences in MI failures related to the patient’s gender meta-analysis or in large retrospective studies.1,3–5,62–64 There is some
were observed in the prospective studies included in our analy- evidence of a higher risk of failure (multivariate odds ratio, 4.22; p = 0.016)
sis,2,6,7,11,37–40,47,58 which agrees with the results of large retrospective in younger patients (<20 years) than older patients (>30 years);66
studies1,3–5,62–64 and a systematic review.10 Interestingly, most of the studies however, this retrospective study included miniplates and MIs. A possible
 TEMPORARY ANCHORAGE DEVICES FOR ORTHODONTIC PURPOSES 263

Table 49.2 Summary estimates of miniscrew implant failure rates with patient-related factors
Heterogeneity Between subgroups
Factor Studies (p value) Event rate 95% CI p value
Gender
Male 9 0.006 13.4 8.4–20.7 0.907
Female 9 <0.001 12.9 8.9–18.5
Smoking
Non-smokers 1 1.000 9.6 4.6–18.8 0.002**
Smokers 1 1.000 35.1 21.6–51.5
Subgroup smokers
Light (<10 per day) 1 1.000 11.1 2.8–35.2 0.007**
Heavy (>10 per day) 1 1.000 57.9 35.6–77.4
Age
Adult (>20 years) 5 0.136 15.5 11.2–21.0 0.575
Adolescent (<20 years) 5 <0.001 12.6 6.4–23.3
Malocclusion
Class I 2 <0.001 23.4 4.8–65.1 0.191
Class II 2 0.034 17.3 5.1–45.1
Class III 1 1.000 2.9 0.4–18.1
Skeletal sagittal: ΑNΒ (°)
<0 1 1.000 11.8 5.4–23.8 0.002**
0–4 1 1.000 52.2 32.5–71.2
>4 1 1.000 25.7 14.0–42.5
Skeletal vertical: FMA (°)
Low (20) 2 0.117 16.6 8.9–28.3 0.836
Middle (30) 2 0.016 18.3 7.2–39.1
High (40) 2 0.032 9.3 1.0–51.0
Skeletal vertical: Sn-GoGn (°)
Low (28) 1 1.000 10.0 3.3–26.8 0.456
Middle (38) 1 1.000 10.1 6.1–16.4
High (48) 1 1.000 2.9 0.4–18.1
Plaque index (%)
<20 1 1.000 37.9 22.4–56.4 0.187
20–40 1 1.000 44.4 17.7–74.9
>40 1 1.000 8.3 1.2–41.3
Gingival index (%)
<20 1 1.000 36.4 23.6–51.4 0.037*
20–40 1 1.000 92.9 42.3–99.6
Oral hygiene
Good 2 0.872 7.5 5.0–11.1 0.376
Bad 2 0.979 9.8 6.3–14.8

CI, confidence interval; FMA, FMA, Frankfort-mandibular plane angle.

*p < 0.05; **p < 0.01.

explanation is a variation in cortical bone thickness of the mandible mesial Type of Malocclusion
to the first molars with age.38
No association was identified with the patient’s type of malocclusion
according to Angle’s classification, which is in agreement with other ret-
Smoking rospective studies.1,5,62,66
Higher MI failure rates were observed in smokers (35.1%) than in non-
smokers (9.6%), as well as in heavy smokers (>10 cigarettes per day;
Sagittal Skeletal Relationships
57.9%) compared with light smokers (<10 cigarettes per day; 11.1%).
Lower bone–implant contact and lower peri-implant bone density have Sagittal skeletal relationships seem to affect MI failures. More specifically,
been reported in smokers, with marginal bone loss, gap and fibrous tissue patients with an ANB angle between 0 and 4° (i.e. skeletal Class I skeletal
around implants.67 Both wound healing and bone healing are known to be relationships) presented higher MI failure rates (52.2%) than patients with
impaired in smokers. Modification of the MI surface could possibly an angle greater than 4° (i.e. skeletal Class III skeletal relationships;
improve outcome in such patients. 25.7%) or less than 0° (i.e. skeletal Class II skeletal relationships; 11.8%).
 264 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

Vertical Skeletal Relationships Oral Hygiene

No linkage between MI failure and vertical skeletal relationships Two of the studies in the meta-analysis assessed oral hygiene at MI inser-
was found for Frankfort–mandibular plane angle or the Sn–mandibular tion subjectively,2,59 but the pooled MI failures did not differ significantly.
length angle. However, patients with high mandibular plane angle did The one study that reported plaque and gingival indexes at the time of
have four times the failure rate compared with patients with average insertion found significantly higher failure rates in patients with increased
or low mandibular plane angle in a retrospective study.3 Data from gingival indexes: indexes between 20 and 40% with a failure rate of 92.9%
a retrospective cohort study indicate that dental relationships are compared with 36.4% in patients with an index less than 20%.32 There
important, with higher MI failure rates associated with patients with appears to be no differences between patients verbally instructed to avoid
open bite.1 irritating/traumatizing the MI head and those who were not.
A recent retrospective study included a comprehensive investigation of The basis for these factors in terms of MI stability and maintenance lies
various skeletal cephalometric variables and their association with MI in the crucial role for inflammation control.3,29,59,63 Prophylactic oral anti-
failures using multiple logistic regression analysis.5 No significant asso- inflammatory drugs have been prescribed for 5 days after the surgical
ciation was observed for articular angle, mandibular plane to palatal procedure, and the use of single tufted brushes, 0.2% chlorhexidine mouth
plane angle, mandibular plane angle, gonial angle and lower gonial rinses or dental floss dipped in 2% chlorhexidine have been proposed as
angle. In contrast, patients with a low Frankfort–mandibular plane angle useful aids.
(<20°) were likely to present approximately a five times higher success
rate compared with patients with a high angle (≥30°). In addition, patients
Periodontal and Temporomandibular Joint Problems
with an average upper gonial angle (44–50°) had fewer MI failures
(almost double the success rate) than those with an angle below this Periodontal and temporomandibular problems do not seem to affect MI
range. success.3 Controlled periodontitis and peri-implant inflammation alone
seem also not to be predictive of MI failure. MIs have been used success-
fully in patients with symptoms of temporomandibular disorder.
Crowding
Crowding of teeth (maxillary and mandibular arch length discrepancies of
less than 6 mm) was not identified by retrospective studies as a significant CLINICIAN-RELATED FACTORS
risk factor for MI failures.3,5 Although case reports have described success- The number of clinicians who insert the MIs, the clinician’s expertise and
ful treatment of patients with crowding using MI anchorage,68,69 evidence the operator’s learning curve are all potential risk factors (Table 49.3).
on influencing factors is scarce. However, there is little strong evidence evaluating these factors.

Physical and Dental Statuses Number of Clinicians

Health and dental status have been reported in a few studies but none The number of clinicians who insert the MIs seems not to be associated
associated them with MI failures. Osteoporosis, uncontrolled diabetes, with MI failures.6
radiotherapy, reduced mouth opening and various drugs (e.g. bisphospho-
nates) have been indicated as risk factors for osseointegrated dental
Expertise
implants2 due to lower bone quality, poor wound healing or proneness to
gingival inflammation. However, whether these risk factors may also com- Clinician expertise is significantly associated with fewer failures: MI
promise the outcome of MI-assisted orthodontic therapy remains to be failure rates were 29.2% for postgraduate students and 1.9% for faculty
investigated. members.

Table 49.3 Summary estimates of miniscrew implant failure rates with clinician-related factors
Heterogeneity Between subgroups
Factor Studies (p value) Event rate 95% CI p value
No. clinicians
One 1 1.000 8.6 5.3–13.8 0.896
Two 1 1.000 8.1 3.9–16.1
Clinician
Professor 1 1.000 1.9 0.3–12.0 0.005**
Postgraduate student 1 1.000 29.2 14.6–49.8
Learning curve (per 18 MI insertions)
1st 1 1.000 25.0 13.6–41.5 0.009**
2nd 1 1.000 8.8 4.0–18.3
3rd 1 1.000 2.1 0.3–13.6
4th 1 1.000 4.3 1.1–15.8

MI, miniscrew implant; CI, confidence interval.

**p < 0.01.
 TEMPORARY ANCHORAGE DEVICES FOR ORTHODONTIC PURPOSES 265

Operator’s Learning Curve effect,73,74 and another study showed a non-significant trend approaching
significance.66 A possible explanation for these contradictory results might
Learning curve of insertion technique is a significant factor, as for every
be that MI length may significantly influence MI displacement only when
additional group of 18 MIs inserted, the failure rate decreased: a failure
high forces (2.5 N) are applied.72 There may also be an interaction between
rate of 25% was observed for the first 18 MIs, 8.8% for the second ones,
diameter and length, whereby a decrease in diameter requires an increase
2.1% for the third ones and 4.3% for the fourth ones.49 A retrospective
in length for the same stability.
study also reported lower failure rates after the first 40 MIs.64 This can be
attributed, at least partially, to the lower risk of root contact during predrill-
ing among experienced operators compared to inexperienced ones. Head Length
A retrospective analysis of MIs and miniplates indicated that the risk
No association was found between the length of the MI head and failure
for failure was three times higher when they were placed by an orthodon-
rates in the one study that examined this parameter.55 However, in
tist than when placed by an oral surgeon.62
vitro/in silico studies do indicate that the length of the exposed head is
one of the main factors influencing increased strain. This is not surpris-
MINISCREW-RELATED FACTORS ing as an increased moment of force would increase bending moment at
the neck.
Table 49.4 summarizes the MI-related factors of significance. Thread
length, diameter and design were assessed by many studies but the diver-
sity of data collected, and its variation, suggests that additional studies are Thread Shape
needed to reach definite conclusions.
The thread shape was not investigated in any of the prospective cohort
studies included in the analysis, but in vitro studies indicate better mechan-
Brand ical stability for dual-threaded MIs than for cylindrical or tapered ones,75
as well as better mechanical properties for cylindrical MIs compared with
Data concerning failures of MIs of different brands could be pooled from conical ones (see Chapter 6). Thread shape, depth and pitch have been
three studies included in the meta-analysis2,7,49 and indicated no significant reported to influence load both at pitch and at break but this may only be
differences, which is in agreement with the results of other retrospective a minor influence on developed strain in cortical bone (shape, 2%;
studies.1 However, future studies would benefit from more emphasis depth, 1%).76
on the individual characteristics of each specific MI rather than the
manufacturer.
Thread Design: Self-drilling or Non-self-drilling

Thread Diameter Lower MI failure rates were observed for self-drilling MIs (7.7%) com-
pared with non-self-drilling MIs (17.3%) in pooled data from three
Seven studies evaluated the association between MI thread diameter and studies,44,46,50 but this was not significant. Although animal studies support
MI failure rates and showed a non-significant effect.2,7,50,53,59,60 This is in these lower failure rates of self-drilling MIs, retrospective analyses have
agreement with some retrospective data,64 while other data indicate that varied in results, with one reporting more than two times more failures for
MIs of increased diameter have a lower risk of failure.65 One retrospec- self-drilling MIs compared with non-self-drilling62 and another detecting
tive study reported higher failure rates for MIs with diameters of 1 mm no significant differences after adjusting for possible confounders.64
or less,3 which is smaller than the diameter of MIs used in the included A possible explanation for the lower failure rates observed with self-
studies. drilling MIs might be that drill-free insertion tends to increase primary
The actual effect of MI diameter on outcome might be distorted by a stability or it may be that the pilot drilling of the bone needed for non-
small number of implants being used in many different ways and by pos- self-drilling MIs may cause overheating and consequently bone damage.9
sible uncontrolled confounding factors. When deciding on the diameter of The temperature of manually inserted self-drilling MIs may affect bone
a MI, it seems important to take into consideration the tipping moment at response around the implant: cold MIs (0.7°C) produced a significant
the bone rim.70 The clinician must also bear in mind that increasing the increase in cortical bone necrosis when compared with ones at room tem-
MI diameter also raises the risk of root damage during placement, particu- perature (22.0°C).77
larly when the MIs are inserted inter-radicularly.38 MI diameter is closely
related to where they can be safely inserted: MIs up to 1.3 mm in diameter
can be inserted in several “safe zones” but should be avoided in areas of Thread Surface
thick cortical bone; MIs up to 1.5 mm in diameter can be used inter- The preparation of the surface of the MI thread does not appear to alter
radicularly; MIs of 2 mm in diameter can only be considered for placement MI success since no significant differences were found between machined
in the posterior inter-radicular spaces of the maxilla between the first molar MIs compared to sandblasted and acid-etched MIs in the one study that
and the second premolar on the palatal side and between the canine and examined this parameter.53 A number of studies have indicated that sand-
the first premolar on the palate (median or paramedian).71 MI diameter blasting and acid etching increase bone–MI contact and consequently
appears to be one of the main factors negatively influencing strain develop- osseointegration and removal torques (see Chapter 6).
ment in vitro, but in vivo a significant influence on stability is only seen Other modifications, such as the incorporation of microgrooves on the
at high applied forces (2.5 N).72 thread surface, might also be worth investigation.

Thread Length INSERTION-RELATED FACTORS

Seven studies showed a non-significant association of thread length with A number of factors related to the insertion of MIs are discussed that could
MI failures.7,18,44,47,50,53,60 A negative correlation between MI thread length possibly affect success (Table 49.5) and these are subdivided into the data
and MI failure was reported by two retrospective analyses as a significant for the maxilla and mandible in Table 49.6.
 266 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

Table 49.4 Summary estimates of miniscrew implant failure rates with miniscrew-related factors
Heterogeneity Event Between subgroups
Factor Studies (p value) rate 95% CI p value
Product
AbsoAnchor 3 <0.001 16.8 6.4–37.4 0.223
Aarhus 1 1.000 13.0 6.3–24.8
Osteomed 1 1.000 15.8 5.2–39.2
LOMAS 2 0.416 5.9 3.3–10.3
A1 1 1.000 20.0 7.7–42.8
Microsrew, Mondeal 1 1.000 5.3 0.7–29.4
C-Implant 1 1.000 8.5 5.6–12.5
KLS-Martin 1 1.000 20.0 2.7–69.1
Diameter (mm)
1.1 1 Meta-regression 0.387
1.2 3
1.3 2
1.4 3
1.5 2
1.6 1
1.7 1
1.8 1
2 6
Diameter category (mm)
1.1–1.3 4 0.042 10.9 7.7–15.3 0.729
1.4–1.6 5 0.796 12.7 8.1–19.3
1.7+ 6 0.013 14.3 7.4–25.8
Thread length (mm)
6 3 Meta-regression 0.183
7 2
8 6
8.5 1
9 1
10 3
11 2
12 2
13 1
14 1
15 1
Thread length category (mm)
5–8 11 0.101 12.3 8.3–17.9 0.281
8.5–12 9 <0.001 20.1 10.8–34.3
13–15 3 0.561 7.8 1.9–26.7
Head length (mm)
4.5 1 1.000 8.3 1.2–41.3 0.806
2.5 1 1.000 12.5 0.7–73.4
Thread design
Self-drilling 3 0.824 7.7 4.8–12.0 0.210
Not-self-drilling 3 <0.001 17.3 5.1–44.9
Thread surface
Machined 1 1.000 17.6 5.8–42.7 0.366
Sandblasted & acid-etched 1 1.000 6.7 0.9–35.2

CI, confidence interval.

 TEMPORARY ANCHORAGE DEVICES FOR ORTHODONTIC PURPOSES 267

Table 49.5 Summary estimates of miniscrew implant failure rates with insertion-related factors
Heterogeneity Between subgroups
Factor Studies (p value) Event rate 95% CI p value
Cortical notching
No 3 0.734 6.8 4.1–11.1 0.154
Yes 3 <0.001 13.7 5.9–28.4
Flap
No 1 1.000 51.3 36.0–66.4 0.037*
Yes 1 1.000 4.5 0.3–44.8
Insertion torque (Ncm)
<10 2 0.925 8.8 5.3–14.2 0.004**
>10 2 0.172 29.9 15.5–49.7
Insertion angle (°)
10–20 1 1.000 9.0 4.1–18.5 0.113
30–40 1 1.000 4.8 2.0–10.9
90 1 1.000 14.8 7.6–26.9
Screw head exposed
No 2 <0.001 21.2 1.3–84.8 0.696
Yes 2 0.849 12.8 8.3–19.1
Cortical bone thickness (mm)
≥1 2 0.892 8.3 5.3–12.8 0.003**
<1 2 0.592 21.3 13.7–31.7
Jaw
Maxilla 17 0.014 12.0 9.6–14.9 0.012*
Mandible 17 <0.001 19.3 14.3–25.6
Side
Left 8 <0.001 13.2 7.9–21.3 0.382
Right 8 <0.001 17.4 11.9–24.6
Region
Posterior 2 <0.001 16.1 4.7–42.6 0.771
Anterior 2 0.680 22.0 2.9–72.6
Soft tissue
Keratinized 3 0.459 12.5 7.0–21.5 0.450
Non-keratinized 3 <0.001 21.6 5.5–56.7
Site
Inter-radicular 5 0.268 10.9 8.3–14.0 0.412
Palate 5 0.108 15.6 6.6–32.7
Palate subgroup
Midpalatal 4 0.113 16.8 6.6–36.7 0.135
Para-palatal 1 1.000 7.5 4.4–12.5
Inter-radicular subgroup
Teeth: P2M1 1 1.000 23.3 15.0–34.3 0.553
Teeth: M1M2 1 1.000 28.6 16.1–45.4
Root contact
Yes 4 0.102 29.9 21.0–40.7 <0.001***
No 4 0.122 7.8 3.9–15.0

CI, confidence interval; P2M1, between the second premolar and the first molar; M1M2, between the first and second molar.
*p < 0.05; **p < 0.01; ***p < 0.001.

Notching of the Cortical Bone Use of Flap Surgery

Three prospective studies7,44,46 examined notching of cortical bone prior to Insertion of MIs following flap surgery was associated with lower
MI insertion and found no significant association. Another retrospective MI failure rates.31 More specifically, higher MI failure rates were
study also showed no difference when MIs were inserted with a reduction observed in flapless insertion of the MIs (51.3%) compared with
handpiece or a normal handpiece or whether cooling was used for notching flap deflection (4.5%). Other studies found no difference between
of the cortical bone.65 MI insertion without flap or incision and insertion by making a
 268 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

Table 49.6 Summary estimates of miniscrew implant failure rates with insertion-related factors, stratified by jaw
Heterogeneity Between
Factor Studies (p value) Event rate 95% CI subgroups p value
Maxilla
Side
Left 4 0.035 15.8 7.4–30.7 0.307
Right 4 0.035 20.1 12.6–30.4
Region
Posterior 2 0.459 23.7 9.7–47.4 0.006**
Anterior 1 1.000 4.2 1.7–9.6
Soft tissue
Keratinized 1 1.000 8.8 2.9–24.0 0.635
Non-keratinized 1 1.000 6.4 2.9–13.5
Cortical bone thickness (mm)
≥1 1 1.000 3.0 0.4–18.6 0.031*
<1 1 1.000 26.1 12.2–47.2
Site 1
Alveolar process 4 0.069 12.0 7.0–19.9 0.924
Palate 4 0.027 11.1 2.3–39.8
Site 2
Midpalatal 2 0.017 6.6 0.2–73.3 0.948
Inter-radicular 2 0.538 7.4 4.5–11.8
Inter-radicular subgroup 1
Buccal 2 0.802 9.7 4.4–20.0 0.107
Palatal 2 0.381 21.1 11.5–35.4
Inter-radicular subgroup 1
Teeth: P1P2 1 1.000 6.3 0.4–53.9 0.357
Teeth: P2M1 2 0.187 18.7 9.3–34.0
Teeth: M1M2 1 1.000 28.6 16.1–45.4
Mandible
Side
Left 3 0.516 15.9 9.0–26.5 0.935
Right 3 0.899 15.4 8.7–25.7
Region
Posterior 3 <0.001 18.8 7.4–40.3 0.679
Anterior 3 0.837 23.7 11.4–42.9
Site 1
Symphysis 1 1.000 23.5 9.1–48.6 0.271
Retromolar 1 1.000 20.0 5.0–54.1
Inter-radicular 1 1.000 9.7 4.7–19.0
Inter-radicular subgroup 1
Buccal 2 0.905 9.1 3.0–24.7 <0.001***
Lingual 1 1.000 73.3 46.7–89.6
Inter-radicular subgroup 2
Teeth: P1P2 1 1.000 5.6 0.3–50.5 0.565
Teeth: P2M1 1 1.000 16.7 1.0–80.6

CI, confidence interval; SG, Subgroup; P1P2, between the first and second premolar; P2M1, between the second premolar and the first molar; M1M2, between the first and
second molar.
*p < 0.05; **p < 0.01; ***p < 0.001.

cross-shaped incision and reflecting a flap.3–5 However, the latter was

Dimension of Pilot Hole
associated with higher patient discomfort and is not preferred by
patients.3 Although flapless insertion is simple enough and can be easily Pilot hole diameter was not assessed by any prospective studies included
done by the orthodontist, sometimes flap deflection is still needed in in our analysis. However, one study found that the larger the diameter of
order to achieve the precise location and the prescribed angle during MI the pilot hole in relation to the diameter of the MI the lower the primary
insertion.31 stability of the MI, but the smaller the pilot hole in relation to the MI
 TEMPORARY ANCHORAGE DEVICES FOR ORTHODONTIC PURPOSES 269

diameter, the more likely was implant fracture.78 It was suggested that MIs PLACEMENT IN THE MAXILLA
of 2.0 mm in diameter inserted into dense compact bone should have a
pilot hole of 1.3 mm. No significant difference was observed in the MI failure rate with the side
of insertion, type of soft tissue (keratinized or non-keratinized) or the site
of insertion (alveolar process or palate; midpalatal or inter-radicular;
Insertion Torque buccal or palatal; between the first and second premolars, the second
premolars and first molars and the first and second molars). However,
Insertion torque was positively associated with MI failure rates in pooled significantly higher failure rates were observed for MIs inserted in the
data from two studies.37,39 More specifically, higher MI failure rates were posterior region of the maxilla (23.7%) compared with the anterior region
observed when insertion torque exceeded 10 Ncm (29.9%), compared with (4.2%), as well as for a cortical bone thickness of less than 1 mm (26.1%)
8.8% with smaller torque values. As high levels of stress could cause compared with 1 mm or more (3.0%).
necrosis and local ischemia of the surrounding bone, specific values of
insertion torque have been proposed.37–39
PLACEMENT IN THE MANDIBLE
Angle of Insertion No significant difference was observed in the MI failure rate with the side
of insertion, the region of insertion (anterior or posterior) or the site of
The angle of MI insertion was not associated with MI failure in our analy- insertion (symphysis, retromolar or inter-radicular; between the first and
sis. A cohort study identified the angle of MI insertion as a secondary risk second premolars or between the second premolars and first molars). The
factor, with higher angles associated with less oral trauma,79 which can be only exception was the higher failure rates observed for inter-radicular MIs
attributed to the reduced retention of obliquely inserted MIs. Other studies inserted lingually (73.3%) compared with buccally (9.1%). Some studies
have supported an insertion angle of 60–70° in order to increase insertion have shown differentials in failures rates: slightly more failures in the
torque and primary stability.80 In some locations, the insertion angle is posterior region of the mandible;29 higher failure rates for placement
predetermined (e.g. at the infrazygomatic crest where a steeper angle is between the mandibular second premolars and first molars compared with
required) but, in general, placing MIs at an obtuse angle may lower the between first and second premolars;4 highest failure rates (30.9%) between
risk of root damage and increase contact with cortical bone. the mandibular first and second molars and lowest between the mandibular
first and second premolars (11.0%);4 higher failure rates for buccal place-
Exposure of Miniscrew Implant Head ment in the molar area than in the premolar area;4 and higher failure rates
in the right side of the mandible between the first and second molars
Whether the head of the MIs was exposed to the oral environment does compared with all other sites of both jaws.1 By comparison, one retrospec-
not seem to affect failure rates. tive study found no significant associations of MI failure with the site
(buccal, lingual or crest) or the inter-radicular area of insertion after adjust-
ing for possible confounding factors.66
Cortical Bone Thickness
Cortical bone thickness seems to be important for the success of MIs, with
a cortex zone of 1 mm being the limit. Data from the meta-analysis indi- Side of Placement
cate that higher failure rates (2.5 times more failures) were observed at No differences were observed in MI failure rate according to side of place-
insertion sites with a cortical bone thickness less than 1 mm (21.3%; 8.3% ment in the eight studies examining this (when pooling data from both
for ≥1 mm). One numerical analysis indicated that higher cortical bone jaws).2,6,11,37–40,47 This agrees with the findings of other studies,1,4,5,65
thickness was associated with less deflection of the MI,81 while another although, where studies have found differences, these have been explained
indicated that a cortical bone thickness of less than 2 mm led to increased by various factors such as unilateral preference for mastication, unequal
stresses that could possibly cause resorption of the cancellous bone.82 level of oral hygiene among left- and right-handed patients or random
Since the risk of overheating is higher when drilling sites of dense cortex, statistical error.
continuous saline irrigation must be used to avoid necrosis.

Region of Placement
Jaw of Placement
Region of MI placement (posterior or anterior) was not associated with
There are significant differences between the maxilla and the mandible for MI failures when pooling the data from MIs inserted in both the maxilla
MI failure rates in pooled data from 17 studies.2,7,18,25,32,35–37,39,40,44,49,52–54,59 and mandible,2,32 which is in agreement with the findings of retrospective
More specifically, in our investigation higher overall MI failure rates were studies.62,65
observed in the mandible (19.3%) than the maxilla (12.0%). This is in agree-
ment with some retrospective studies (two times more failures for mandibu-
Soft Tissues
lar MIs),65,66 while other retrospective studies and animal studies report
non-significant differences.1,4,64 The higher MI failure rates observed for the Keratinized gingiva is regarded by many clinicians as presenting a lower
MIs inserted in the mandible can be attributed to higher bone density, which risk of developing hypertrophic tissues and inflammation, with the oral
can lead to higher insertion torque value and bone overheating during inser- mucosa having the highest risk around MIs. However, the current meta-
tion; less cortical bone at the upper part of the MI in the mandible; and/or analysis found no significant differences in MI failure rates when the MIs
a narrower vestibule, which makes thorough cleaning harder. were placed in areas covered by keratinized (attached) gingiva or in areas
Overall failure comparisons between the two jaws are of no great clini- of oral mucosa, which is in agreement with one retrospective study.64 Other
cal significance to the orthodontist. The reported failure rates were also studies have found lower failure rates for MIs placed in attached gingiva
stratified separately by the jaw of insertion (Table 49.6) in order to facili- of the maxilla than in all other keratinized or non-keratinized tissues.1,29,65
tate clinical decision making. Full coverage of the MIs with oral mucosa has been proposed for MIs
 270 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

Table 49.7 Summary estimates of miniscrew implant failure rates with treatment-related factors
Heterogeneity Between subgroups
Factor Studies (p value) Event rate 95% CI p value
Two MIs splinted
Yes 1 1.000 4.1 1.7–9.4 0.003**
No 1 1.000 17.6 10.5–27.9
Loading time
Early (up to 2 weeks) 3 0.125 26.8 16.4–40.6 0.304
Delayed (after 2 weeks) 3 0.073 15.6 5.6–36.7
Tooth movement
Intrusion 1 1.000 11.1 4.2–26.1 0.826
Distalization 1 1.000 7.3 2.8–17.8
Mesialization 1 1.000 10.0 1.4–46.7
En masse retraction 1 1.000 11.3 5.7–20.9
Combination 1 1.000 4.0 0.6–23.5
Treatment duration
<6 months 1 1.000 27.3 9.0–58.6 0.046*
>6 months 1 1.000 8.1 4.9–12.9

MI, miniscrew implant; CI, confidence interval.

*p < 0.05; **p < 0.01.

placed in non-keratinized tissues, with wires or attachments passing with dense mature bone responding better to immediate loading. Premature
through the mucosa.2 loading leads to healing characterized histologically by formation of
fibrous tissue between the bone and the MI (see Chapter 4).
Differences between loaded and unloaded MIs are considered to be of
Root Contact
no clinical relevance.
Root contact was associated with more MI failures in all four studies
included in the meta-analysis, yielding a significant association.33,54,59,48
Magnitude of Orthodontic Forces
More specifically, root contact during insertion increased failure rates to
29.9%, from 7.8% for no root contact (p < 0.001). The rate and pattern of No comparison was possible concerning MI failure rates and the magni-
root contact have been reported to be associated with surgery site and tude of orthodontic forces applied to the MIs, since no such data were
operator experience.83 Root contact produces increased stresses and inflam- included in the studies of our analysis. However, a retrospective study
mation, which could affect MI stability.82 There is evidence that damaged found no difference for applied forces of 150 g and 250 g.65 Significant
root is finally repaired after MI removal with a narrow zone of mineralized MI displacements have been reported after applying immediate forces of
tissue.84 Successful restoration of the damaged roots has been reported 400 g34 and in vitro data indicate that MI length and diameter significantly
using surgical treatment and mineral trioxide aggregate.85 influence MI stability, but only when the applied forces exceeded 1 N.72
Both very low and very high strains can induce bone resorption and a
negative bone-remodeling balance.88
TREATMENT-RELATED FACTORS
Treatment-related factors are discussed below and summarized in
Method of Force Application
Table 49.7.
No correlation was found with the method of force application (e.g. power
chains, super threads, Ni-Ti coil springs and ligature tiebacks) or force
Use of Splinted Miniscrew Implants
direction and MI failure, which agrees with previous data.2 Torsional stress
The use of two splinted MIs reduced failure rates (4.1%) compared with has been proposed as a significant factor, and some investigators recom-
a single MI (17.6%). Various types of connections have been investigated mend avoiding lateral, torsional and extrusive orthodontic forces, if
in vitro.86 possible.29

Loading of Orthodontic Forces Type of Anchorage

Application of orthodontic forces to MIs can be immediate, early (during No comparison of type of anchorage provided by the MIs (direct or indi-
the first 2 weeks) or delayed (later than 2 weeks). Three studies in the rect) could be made in the meta-analysis. One retrospective study showed
meta-analysis considered this25,32,38 and indicated that delayed loading pre- no significant differences between direct and indirect anchorage,1 while
sented lower failures, but this was not statistically significant. Other studies another found indirectly loaded MIs to be successful but with a slight
have reported both an advantage from immediate loading65 and a disad- anchorage loss observed in terms of maxillary incisor proclination and
vantage.62,87 Differences may reflect the type of bone used for the insertion, increased overjet at the end of movement.30
 TEMPORARY ANCHORAGE DEVICES FOR ORTHODONTIC PURPOSES 271

Table 49.8 Summary estimates of miniscrew implant failure rates with outcome-related factors
Heterogeneity Between subgroups
Factor Studies (p value) Event rate 95% CI p value
Inflammation
Yes 2 <0.001 48.7 3.4–96.2 0.260
No 2 0.001 10.3 2.2–36.9
Mobility
Yes 1 1.000 24.4 14.1–39.0 <0.001***
No 1 1.000 1.4 0.4–5.6
Unclear 1 1.000 14.0 6.4–27.8
MI reinstallation
No 1 1.000 24.8 17.6–33.7 0.130
Yes 1 1.000 38.2 23.7–55.3
MI reinstallation site
Same 1 1.000 31.6 14.9–54.8 0.371
Adjacent 1 1.000 46.7 24.1–70.7

MI, miniscrew implant; CI, confidence interval.

***p < 0.001.

Type of Orthodontic Tooth Movement Mobility of Miniscrew Implants

Several prospective studies reported failure rates of MIs during dental Only one study in the meta-analysis assessed MI mobility.2 Higher failure
movements but few investigated any possible association.6,11,37,38,44,46,48 Uti- rates were observed for MIs that showed clinical mobility (24.4%) or
lization of MIs for different types of tooth movement does not seem to be unclear mobility (due to overlying soft tissues) (14.0%) compared with
accompanied by different failure rates,58 but en masse distalization of teeth those that were clinically stable (1.4%). Data from animal studies indicate
had the lowest failure rate (1.9%) and intrusion of molars the highest that MI mobility seems to be negatively associated with insertion torque
(11.4%) in one study.1 Other studies have shown higher (5.3 times) risk of and positively correlated with bone mineral density and thickness of the
failure for anchors (miniplates and MIs) used for uprighting compared cortical bone,89 but a study in rats showed that a significant decrease in
with intrusion62 and a two times higher risk of failure for retraction/ mobility after 3 weeks was linked to a good prognosis for subsequent
protraction compared with intrusion.66 One study found intrusion more stability.90
problematic than retraction.63
It is clear that additional evidence is needed to clarify any association
Reinstallation of Miniscrew Implant
of MI failure with the type of orthodontic tooth movement.
No failure penalty was observed for failed MIs that were reinstalled either
at the same site or at adjacent sites in the only relevant study that was
Duration of Treatment
included in our analysis.11
Higher MI failure rates were observed when treatment with MIs lasted less
than 6 months (27.3%) compared with longer treatment (8.1%). After the
first 6 months of treatment, anchorage loss appears to be statistically CONCLUSIONS
insignificant.61 This may be because of osseointegration, but often studies
do not consider a MI successful until after a minimum of 6 months of force Orthodontic MIs have a modest mean failure rate of 13.5% (or in other
application, and therefore a certain degree of confounding might be words a mean success rate of 86.5%), indicating their usefulness in clinical
present. practice. Among the potential risk factors for MI failure, there is substan-
tial evidence that patient gender and age and side of insertion were not
associated with failures. In contrast, jaw of insertion and root contact seem
OUTCOME-RELATED FACTORS to influence MI failures. More specifically, MI failure may be influenced
Outcome-related factors are summarized in Table 49.8. by smoking, oral hygiene, skeletal sagittal relationships, clinician expertise
and learning curve, cortical bone thickness, flap deflection, insertion torque
values, some insertion sites, root contact, splinting of MIs, treatment dura-
Inflammation of the Peri-implant Soft Tissues tion and MI mobility. Taking these factors into consideration during treat-
The association of inflammation with higher MI failure rates did not reach ment can lower MI failure rates to below 10%. Nevertheless, the limited
statistical significance in pooled data from two studies included in the number of studies in many categories can possibly provide a biased esti-
meta-analysis.2,47 A retrospective cohort study of MIs and miniplates3,62 mate or even fail to identify a significant effect that is present.
showed that, after adjusting for confounding factors, mild inflammation Large-scale prospective randomized or non-randomized studies under
was associated with almost seven times more MI failures and severe controlled conditions could further enrich our knowledge and enhance the
inflammation with almost 36 times more failures.47 outcome of MIs used in orthodontic treatment.
 272 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

30. Gelgor IE, Buyukyilmaz T, Karaman AI, et al. Intraosseous screw-supported upper
REFERENCES molar distalization. Angle Orthod 2004;74:838–50.
31. Herman RJ, Currier GF, Miyake A. Mini-implant anchorage for maxillary canine
1. Antoszewska J, Papadopoulos MA, Park HS, et al. Five-year experience with ortho- retraction: a pilot study. Am J Orthod Dentofacial Orthop 2006;130:228–35.
dontic miniscrew implants: a retrospective investigation of factors influencing success 32. Justens E, de Bruyn H. Clinical outcome of mini-screws used as orthodontic anchor-
rates. Am J Orthod Dentofacial Orthop 2009;136:158. age. Clin Implant Dent Relat Res 2008;10:174–80.
2. Park HS, Jeong SH, Kwon OW. Factors affecting the clinical success of screw 33. Kim SH, Kang SM, Choi YS, et al. Cone-beam computed tomography evaluation of
implants used as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2006; mini-implants after placement: is root proximity a major risk factor for failure? Am J
130:18–25. Orthod Dentofacial Orthop 2010;138:264–76.
3. Miyawaki S, Koyama I, Inoue M, et al. Factors associated with the stability of titanium 34. Liou EJW, Pai BCJ, Lin JCY. Do miniscrews remain stationary under orthodontic
screws placed in the posterior region for orthodontic anchorage. Am J Orthod Dento- forces? Am J Orthod Dentofacial Orthop 2004;126:42–7.
facial Orthop 2003;124:373–8. 35. Luzi C, Verna C, Melsen B. A prospective clinical investigation of the failure rate of
4. Moon CH, Lee DG, Lee HS, et al. Factors associated with the success rate of ortho- immediately loaded mini-implants used for orthodontic anchorage. Prog Orthod
dontic miniscrews placed in the upper and lower posterior buccal region. Angle Orthod 2007;8:192–201.
2008;78:101–6. 36. Miyazawa K, Kawaguchi M, Tabuchi M, et al. Accurate pre-surgical determination
5. Moon CH, Park HK, Nam JS, et al. Relationship between vertical skeletal pattern and for self-drilling miniscrew implant placement using surgical guides and cone-beam
success rate of orthodontic mini-implants. Am J Orthod Dentofacial Orthop computed tomography. Eur J Orthod 2010;32:735–40.
2010;138:51–7. 37. Motoyoshi M, Hirabayashi M, Uemura M, et al. Recommended placement torque
6. Lee SJ, Ahn SJ, Lee JW, et al. Survival analysis of orthodontic mini-implants. Am J when tightening an orthodontic mini-implant. Clin Oral Implants Res 2006;17:
Orthod Dentofacial Orthop 2010;137:194–9. 109–14.
7. Wu TY, Kuang SH, Wu CH. Factors associated with the stability of mini-implants for 38. Motoyoshi M, Matsuoka M, Shimizu N. Application of orthodontic mini-implants in
orthodontic anchorage: a study of 414 samples in Taiwan. J Oral Maxillofac Surg adolescents. Int J Oral Maxillofac Surg 2007;36:695–9.
2009;67:1595–9. 39. Motoyoshi M, Yoshida T, Ono A, et al. Effect of cortical bone thickness and implant
8. Schätzle M, Männchen R, Zwahlen M, et al. Survival and failure rates of orthodontic placement torque on stability of orthodontic mini-implants. Int J Oral Maxillofac
temporary anchorage devices: a systematic review. Clin Oral Implants Res Implants 2007;22:779–84.
2009;20:1351–9. 40. Motoyoshi M, Inaba M, Ono A, et al. The effect of cortical bone thickness on the
9. Chen Y, Kyung HM, Zhao WT, et al. Critical factors for the success of orthodontic mini- stability of orthodontic mini-implants and on the stress distribution in surrounding
implants: a systematic review. Am J Orthod Dentofacial Orthop 2009;135:284–91. bone. Int J Oral Maxillofac Surg 2009;38:13–18.
10. Crismani AG, Bertl MH, Celar AG, et al. Miniscrews in orthodontic treatment: review 41. Motoyoshi M, Uemura M, Ono A, et al. Factors affecting the long-term stability of
and analysis of published clinical trials. Am J Orthod Dentofacial Orthop orthodontic mini-implants. Am J Orthod Dentofacial Orthop 2010;137:588.
2010;137:108–13. 42. Oh YH, Park HS, Kwon TG. Treatment effects of microimplant-aided sliding mechan-
11. Baek SH, Kim BM, Kyung SH, et al. Success rate and risk factors associated with ics on distal retraction of posterior teeth. Am J Orthod Dentofacial Orthop 2011;139:
mini-implants reinstalled in the maxilla. Angle Orthod 2008;78:895–901. 470–81.
12. Papageorgiou SN, Zogakis IP, Papadopoulos MA. Failure rates and associated risk 43. Polat-Ozsoy O, Arman-Ozcirpici A, Veziroglu F. Miniscrews for upper incisor intru-
factors of orthodontic miniscrew implants: a meta-analysis. Am J Orthod Dentofacial sion. Eur J Orthod 2009;31:412–16.
Orthop 2012;142:577–95. 44. Suzuki EY, Suzuki B. Placement and removal torque values of orthodontic miniscrew
13. Basha AG, Shantaraj R, Mogegowda SB. Comparative study between conventional implants. Am J Orthod Dentofacial Orthop 2011;139:669–78.
en-masse retraction (sliding mechanics) and en-masse retraction using orthodontic 45. Thiruvenkatachari B, Pavithranand A, Rajasigamani K, et al. Comparison and meas-
micro implant. Implant Dent 2010;19:128–36. urement of the amount of anchorage loss of the molars with and without the use of
14. Liu Y, Ding W, Liu J, et al. Comparison of the differences in cephalometric parameters implant anchorage during canine retraction. Am J Orthod Dentofacial Orthop
after active orthodontic treatment applying mini-screw implants or transpalatal arches 2006;129:551–4.
in adult patients with bialveolar dental protrusion. J Oral Rehabil 2009;36:687–95. 46. Türköz C, Atac MS, Tuncer C, et al. The effect of drill-free and drilling methods on
15. Upadhyay M, Yadav S, Nagaraj K, et al. Treatment effects of mini-implants for the stability of mini-implants under early orthodontic loading in adolescent patients.
en-masse retraction of anterior teeth in bialveolar dental protrusion patients: a rand- Eur J Orthod 2011;33:533–6.
omized controlled trial. Am J Orthod Dentofacial Orthop 2008;134:18–29. 47. Viwattanatipa N, Thanakitcharu S, Uttraravichien A, et al. Survival analyses of surgi-
16. Aboul-Ela SM. Miniscrew implant-supported maxillary canine retraction with cal miniscrews as orthodontic anchorage. Am J Orthod Dentofacial Orthop
and without corticotomy-facilitated orthodontics. Am J Orthod Dentofacial Orthop 2009;136:29–36.
2011;139:252–9. 48. Wang HN, Liu DX, Wang CL, et al. [Influence of periodontal ligament injury on initial
17. Lehnen S, McDonald F, Bourauel C, et al. Expectations, acceptance and preferences stability for immediately loaded mini-implant.]. Hua Xi Kou Qiang Yi Xue Za Zhi
of patients in treatment with orthodontic mini-implants. J Orofac Orthop 2009;27:224–6, 236.
2011;72:214–22. 49. Wiechmann D, Meyer U, Büchter A. Success rate of mini- and micro-implants used
18. Hedayati Z, Hashemi S, Zamiri B, et al. Anchorage value of surgical titanium screws for orthodontic anchorage: a prospective clinical study. Clin Oral Implants Res
in orthodontic tooth movement. Int J Oral Maxillofac Surg 2007;36:588–92. 2007;18:263–7.
19. Maddalone M, Ferrari M, Barrilà S, et al. [Intrusive mechanics in orthodontics by the 50. Alves M Jr, Baratieri C, Nojima LI. Assessment of mini-implant displacement using
use of TADs.]. Dent Cadmos 2010;78:97–106. cone beam computed tomography. Clin Oral Implants Res 2011;22:1151–6.
20. Park H, Yoon DY, Park C, et al. Treatment effects and anchorage potential of sliding 51. Bayat E, Bauss O. Effect of smoking on the failure rates of orthodontic miniscrews.
mechanics with titanium screws compared with the Tweed–Merrifield technique. Am J Orofac Orthop 2010;71:117–24.
J Orthod Dentofacial Orthop 2008;133:593–600. 52. Berens A, Wiechmann D, Dempf R. Mini- and micro-screws for temporary skeletal
21. Shi YT, Ping Y, Shan LH, et al. [Stability of mini-implant during orthodontic treatment anchorage in orthodontic therapy. J Orofac Orthop 2006;67:450–8.
as anchorage.]. J Clin Rehabil Tissue Eng Res 2008;12:5109–12. 53. Chaddad K, Ferreira AFH, Geurs N, et al. Influence of surface characteristics on
22. Upadhyay M, Yadav S, Patil S. Mini-implant anchorage for en-masse retraction of survival rates of mini-implants. Angle Orthod 2008;78:107–13.
maxillary anterior teeth: a clinical cephalometric study. Am J Orthod Dentofacial 54. El-Beialy AR, Abou-El-Ezz AM, Attia KH, et al. Loss of anchorage of miniscrews: a
Orthop 2008;134:803–10. 3-dimensional assessment. Am J Orthod Dentofacial Orthop 2009;136:700–7.
23. Wilmes B, Olthoff G, Drescher D. Comparison of skeletal and conventional anchorage 55. Freudenthaler JW, Bantleon HP, Haas R. Bicortical titanium screws for critical ortho-
methods in conjunction with pre-operative decompensation of a skeletal Class III dontic anchorage in the mandible: a preliminary report on clinical applications. Clin
malocclusion. J Orofac Orthop 2009;70:297–305. Oral Implants Res 2001;12:358–63.
24. Apel S, Apel C, Morea C, et al. Microflora associated with successful and failed 56. Gelgor IE, Karaman AI, Buyukyilmaz T. Comparison of 2 distalization systems sup-
orthodontic mini-implants. Clin Oral Implants Res 2009;20:1186–90. ported by intraosseous screws. Am J Orthod Dentofacial Orthop 2007;131:161.
25. Garfinkle JS, Cunningham LL Jr, Beeman CS, et al. Evaluation of orthodontic mini- 57. Fritz U, Ehmer A, Diedrich P. Clinical suitability of titanium microscrews for ortho-
implant anchorage in premolar extraction therapy in adolescents. Am J Orthod Den- dontic anchorage: preliminary experiences. J Orofac Orthop 2004;65:410–18.
tofacial Orthop 2008;133:642–53. 58. Kim YH, Yang SM, Kim S, et al. Midpalatal miniscrews for orthodontic anchorage:
26. Upadhyay M, Yadav S, Nagaraj K, et al. Dentoskeletal and soft tissue effects of mini- factors affecting clinical success. Am J Orthod Dentofacial Orthop 2010;137:
implants in Class II, division 1 patients. Angle Orthod 2009;79:240–7. 66–72.
27. Blaya MG, Blaya DS, Guimarães MB, et al. [Patient’s perception on mini-screws used 59. Kuroda S, Yamada K, Deguchi T, et al. Root proximity is a major factor for
for molar distalization.]. Rev Odonto Cienc 2010;25:266–70. screw failure in orthodontic anchorage. Am J Orthod Dentofacial Orthop 2007;
28. Brandão LBC, Mucha JN. [The mini-implants acceptance rate by patients in ortho- 131(Suppl.):68–73.
dontic treatments: a preliminary study.]. Rev Dent Press Ortodon Ortopedi Facial 60. Wang ZD, Li QY, Wang L, et al. [Comparative evaluation of two kinds of micro-
2008;13:118–27. implant system with different sizes.]. Hua Xi Kou Qiang Yi Xue Za Zhi 2009;27:
29. Cheng SJ, Tseng IY, Lee JJ, et al. A prospective study of the risk factors associated 150–3.
with failure of mini-implants used for orthodontic anchorage. Int J Oral Maxillofac 61. Papadopoulos MA, Papageorgiou SN, Zogakis IP. Clinical effectiveness of orthodontic
Implants 2004;19:100–6. miniscrew implants. J Dent Res 2011;90:969–76.
 TEMPORARY ANCHORAGE DEVICES FOR ORTHODONTIC PURPOSES 273

62. Chen YJ, Chang HH, Lin HY, et al. Stability of miniplates and miniscrews used for 76. Lin CL, Yu JH, Liu HL, et al. Evaluation of contributions of orthodontic mini-screw
orthodontic anchorage: experience with 492 temporary anchorage devices. Clin Oral design factors based on FE analysis and the Taguchi method. J Biomech
Implants Res 2008;19:1188–96. 2010;43:2174–81.
63. Kuroda S, Sugawara Y, Deguchi T, et al. Clinical use of miniscrew implants as ortho- 77. Nagamatsu JBT. Bone response to orthodontic miniscrew placement: an in vivo study.
dontic anchorage: success rates and postoperative discomfort. Am J Orthod Dentofa- St. Louis University, MO: Master Thesis; 2008.
cial Orthop 2007;131:9–15. 78. Wilmes B, Rademacher C, Olthoff G, et al. Parameters affecting primary stability of
64. Lim HJ, Eun CS, Cho JH, et al. Factors associated with initial stability of miniscrews orthodontic mini-implants. J Orofac Orthop 2006;67:162–74.
for orthodontic treatment. Am J Orthod Dentofacial Orthop 2009;136:236–42. 79. Wang Z, Zhang D, Liu Y, et al. Buccal mucosal lesions caused by the interradicular
65. Manni A, Cozzani M, Tamborrino F, et al. Factors influencing the stability of minis- miniscrew: a preliminary report. Int J Oral Maxillofac Implants 2010;25:1183–8.
crews. A retrospective study on 300 miniscrews. Eur J Orthod 2010;388–95. 80. Wilmes B, Su YY, Drescher D. Insertion angle impact on primary stability of ortho-
66. Chen YJ, Chang HH, Huang CY, et al. A retrospective analysis of the failure rate of dontic mini-implants. Angle Orthod 2008;78:1065–70.
three different orthodontic skeletal anchorage systems. Clin Oral Implants Res 81. Stahl E, Keilig L, Abdelgader I, et al. Numerical analyses of biomechanical behavior
2007;18:768–75. of various orthodontic anchorage implants. J Orofac Orthop 2009;70:115–27.
67. Shibli JA, Piattelli A, Iezzi G, et al. Effect of smoking on early bone healing around 82. Motoyoshi M, Ueno S, Okazaki K, et al. Bone stress for a mini-implant close to the
oxidized surfaces: a prospective, controlled study in human jaws. J Periodontol roots of adjacent teeth: a 3D finite element analysis. Int J Oral Maxillofac Surg
2010;81:575–83. 2009;38:363–8.
68. Choi NC, Park YC, Lee HA, et al. Treatment of Class II protrusion with severe crowd- 83. Cho UH, Yu W, Kyung HM. Root contact during drilling for microimplant placement.
ing using indirect miniscrew anchorage. Angle Orthod 2007;77:1109–18. Angle Orthod 2010;80:130–6.
69. Ohnishi H, Yagi T, Yasuda Y, et al. A mini-implant for orthodontic anchorage in a deep 84. Asscherickx K, Vannet BV, Wehrbein H, et al. Root repair after injury from mini-
overbite case. Angle Orthod 2005;75:444–52. screw. Clin Oral Implants Res 2005;16:575–8.
70. Büchter A, Wiechmann D, Koerdt S, et al. Load-related implant reaction of mini- 85. Hwang YC, Hwang HS. Surgical repair of root perforation caused by an orthodontic
implants used for orthodontic anchorage. Clin Oral Implants Res 2005;16:473–9. miniscrew implant. Am J Orthod Dentofacial Orthop 2011;139:407–11.
71. Poggio P, Incorvati C, Velo S, et al. “Safe zones”: a guide for miniscrew positioning 86. Leung MTC, Rabie ABM, Wong RWK. Stability of connected mini-implants and
in the maxillary and mandibular arch. Angle Orthod 2006;76:191–7. miniplates for skeletal anchorage in orthodontics. Eur J Orthod 2008;30:483–9.
72. Chatzigianni A, Keilig L, Reimann S, et al. Effect of mini-implant length and diameter 87. Chung KR, Kim SH, Kook YA. The C-orthodontic micro-implant. J Clin Orthod
on primary stability under loading with two force levels. Eur J Orthod 2004;38:478–86.
2011;33:381–7. 88. Melsen B, Lang N. Biological reactions of alveolar bone to orthodontic loading of
73. Chen CH, Chang CS, Hsieh CH, et al. The use of microimplants in orthodontic anchor- oral implants. Clin Oral Implants Res 2001;12:144–52.
age. J Oral Maxillofac Surg 2006;64:1209–13. 89. Cha JY, Kil JK, Yoon TM, et al. Miniscrew stability evaluated with computerized
74. Tsaousidis G, Bauss O. Influence of insertion site on the failure rates of orthodontic tomography scanning. Am J Orthod Dentofacial Orthop 2010;137:73–9.
miniscrews. J Orofac Orthop 2008;69:349–56. 90. Uemura M, Motoyoshi M, Yano S, et al. Orthodontic mini-implant stability and the
75. Kim YK, Kim YJ, Yun PY, et al. Effects of the taper shape, dual-thread, and length ratio of pilot hole implant diameter. Eur J Orthod 2012;34:52–6.
on the mechanical properties of mini-implants. Angle Orthod 2009;79:908–14.
50 Root and bone response to proximity of
miniscrew implants
Hyewon Kim and Tae-Woo Kim

Various space recommendations for inter-radicular MIs have been

INTRODUCTION
made: 1 mm between the periodontal ligament and the MI,17 at least 5 mm
Use of miniscrew implants (MIs), particularly inter-radicularly in the between adjacent roots,18 3.5 mm between adjacent roots for MIs of
alveolar bone in proximity to adjacent roots, carries certain risks and clini- maximum diameter 1.5 mm19 and a minimum of 2.0 mm between the
cians need to understand the likely response of roots and surrounding bone implant and root surfaces.3
and the potential consequences.

ROOT RESPONSE
ROOT CONTACT WITH MINISCREW IMPLANTS
ROOT RESORPTION AFTER CONTACT
RISK FACTORS Root resorption during tooth movement has most often been found where
If injury to a tooth root occurs during MI insertion, loss of tooth vitality, there is overcompression of the periodontal ligament.20
osteosclerosis and dentoalveolar ankylosis may follow.1,2 During ortho- The mechanism of root resorption that occurs after iatrogenic trauma to
dontic loading, MI failure or migration may occur3 and soft tissue compli- the root surface, as is the case after contact with a MI, appears to be
cations such as inflammation or infection may also have subsequent effects repaired quite quickly and, when the damage is limited to the periodontal
on bone and tooth roots.1 ligament, with no further consequences.21 However, if the cementum layer
is mechanically damaged with exposure of the dentin surface, the process
of resorption starts. The first changes occur in the periphery of the necrotic
EXTENT OF DAMAGE AND PREVENTION METHODS tissue where multinuclear cells and cells staining for tartrate-resistant acid
A good knowledge of the average inter-radicular space in the area of phosphatase accumulate.22 These resorbing cells require continuous stimu-
planned implant insertion is essential. Stents and guides that are placed lation during phagocytosis, and without further stimulation the process
over the adjacent teeth can help to identify the insertion position4–7 and stops spontaneously.
can be used in conjunction with radiography or CT to evaluate the inter- Repair of the affected area occurs through formation of cementum-like
radicular space available and to safely insert the MIs avoiding contact with tissue within 2 or 3 weeks, depending on the area of the root that is injured.
the adjacent roots.8–10 However, radiography taken after MI insertion to Three different types of root resorption response can be described:23
verify root contact has limitations: it only provides a two-dimensional
■ when the MI is in proximity (<1 mm) but bone exists between MI
representation of a three-dimensional object, only shows lesions of a
and root (Fig. 50.1A)
certain dimension and cannot indicate the severity of root resorption.11 It
■ when the MI thread is away from the root but in contact with the
has been suggested that the use of self-drilling and self-tapping MIs may
periodontal ligament (Fig. 50.1B,C)
decrease the chances of root damage as they improve tactile feedback to
■ when the MI thread touches the root and stays in contact with it
the operator during drilling and have less overheating, more bone-to-metal
without resorption following (Fig. 50.1D,E).
contact and possible decreased mobility.12,13
An experimental study intentionally damaged roots and surrounding Fig. 50.2 shows a possible sequence of events after root contact with
structures during MI insertion for 42 MIs in seven beagle dogs and a MI.
observed that out of the MIs that contacted the root, 7.2% caused direct Root resorption has been shown to occur indirectly when the MI is
damage to the periodontal ligament, 19.0% caused damage isolated to the inserted in close proximity to the root surface even if a clear width of
cementum, 26.2% caused damage to the dentin, and 14.2% caused severe bone of around 1 mm exists between the root surface and the MI (Fig.
damage to the pulp.14 Most of the MIs that failed or were mobile showed 50.1A). This may be a result of pressure from the MI on the alveolar
bone loss and necrotic tissue in the peri-implant area, which may serve as bone, causing bone compression and compression of the periodontal lig-
a stimulus for root resorption. The presence of inflammation increased the ament. Damage to the periodontal ligament is known to cause root
damage caused by the MIs. resorption. Macrophages and osteoclasts in viable periodontal ligament
Failure rates for MIs increase when the implants invade the adjacent will initiate wound healing by removing the damaged tissue. During this
roots, being as high as 79.2%, with an average retention period of 16 activity, bone and cementum can be removed along with necrotic perio-
days.15 Proximity of MIs to dental roots, as seen by radiography and three- dontal ligament tissue.
dimensional CT, was a major risk factor for MI failure.16 Pressure from bleeding into the periodontal ligament may also elicit
minor areas of damage to the root surface. This type of edema has been
shown to directly affect the arrangement and structure of the extracellular
MINISCREW IMPLANT DIAMETER AND CLEARANCE
matrix of the periodontal ligament.24 Mechanical stresses to a tooth root
MIs with a larger diameter increase pressure on the periodontal ligament may be responsible for vascular flow alterations that trigger cellular degen-
and both inter-radicular space and MI diameter need to be considered when eration, leading to hyalinization.25 The first steps of root resorption can be
planning treatment. seen as the removal of this hyalinized necrotic tissue.

274
 Root and bone response to proximity of miniscrew implants 275

P
D
D

MI MI
D PDL
D MI
PDL PDL D MI
B B D
A B C MI D E
× 12.5 × 12.5 × 100 × 12.5 × 100
Fig. 50.1 Root resorption with miniscrew implants (MIs). (A) MI in close proximity to root causes resorption (yellow arrows) even though a clear width of bone is present
between the MI and the root surface. (B) MI in contact with the periodontal ligament and dentin. (C) Close up of the area in the red box in (B) showing cementum
deposition (red arrowheads) on the resorbed root surface. (D) MI thread in contact with root (yellow arrowheads). (E) Close up of red box in (D) showing no cementum
repair of the root surface. D, dentin; B, bone; P, pulp; PDL, periodontal ligament.

Root Healing Versus Non-healing

Root contact
approximation
When any part of the MI thread was left touching the root surface, no
definite cementum repair was observed on the damaged root surface (Fig.
50.1D,E).23 After MI contact with the root surface, the possibility of
Dentin Pulp healing through cementum deposition or no healing depends on whether
contact penetration
the MI stays in contact with the root surface.
When a MI is left in contact with the root surface, minimal healing
occurs in most cases. When a tooth was pushed against the MIs through
Root Thread in contact Osteodentin orthodontic force, there was no sign of repair in the resorption lacunae,
Ankylosis
resorption with root formation
but swift repair of tooth surfaces occurred when root contact was discon-
tinued, and abundant cellular cementum was deposited.19,21 When a MI
is drilled between two roots with large force, the implant may become
Implant immediately Cementum No root lodged between the adjacent roots (Fig. 50.1D,E) and this absence of
removed repair resorption
mobility would mean that the pressure between the root and the implant
is maintained. Resorption is an active process that requires viable cells in
the vicinity of the root surface and the first sign of it occurring is penetra-
Cementum No cementum tion of cells from the periodontal ligament into the mineralized cemen-
repair repair
tum.20 If the periodontal ligament itself is damaged or destroyed, this
Fig. 50.2 Possible sequence of events after root contact with a miniscrew implant. source of healing cells is lost. The resorbing cells also require continuous
stimulation during phagocytosis and the process stops spontaneously if
stimulation fails.
ROOT HEALING When a MI is removed immediately after root contact has been made,
Normal healing has been defined as formation of a cementum layer, normal relieving pressure on the root, cementum repair occurs on the damaged
periodontal ligament attachment and bone regeneration. Abnormal healing root surface (Fig. 50.3).
is associated with absence of periodontal ligament or bone regeneration
and may lead to root ankylosis or pulp invasion.26 The consequences of
PULP DAMAGE AND RESPONSE
root damage may include healing without root resorption, surface root
resorption that heals with cementoid tissue or replacement resorption When the MI goes beyond touching the root and penetrates the dentin,
leading to ankylosis. It is believed that a favorable environment for root much more severe damage can be expected. Dentin tissue is ruptured and
resorption includes destruction of the protective surface covering the min- rapid formation of osteodentin is observed (Fig. 50.4). Osteodentin is the
eralized tissue, presence of vascular connective tissue or an inflammatory response of dentin to a severe attack, and consists of tertiary dentin with
stimulus such as bacteria or trauma.27 Damaged roots usually heal unless sparse and irregular tubular patterns with cellular inclusions. This has a
the damage extends to the pulp.15 Deposition of cementoid tissue starts at similar appearance to bone. Rupturing the pulp tissue seems to have irre-
the periphery of a damaged area and extends to cover the entire defect versible consequences and should be avoided.
over time, with new cementum layers becoming thicker.19 Healing can
occur in as short a time as 4 weeks.21 Normal healing, reattachment of the
periodontal ligament, regeneration of bone and new cementum layers on ANKYLOSIS
exposed dentin are all evident by 6 weeks but if inflammatory infiltration
or invasion of the pulp chamber occurs, the normal healing sequence could Ankylosis may occur after severe root damage from MIs. A patent perio-
be interrupted.26 dontal ligament space is essential to prevent contact between root and
 276 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

N
B
B N
B
B
PDL

PDL MI MI
D D A B
× 100 × 100
A B
× 40 × 100 Fig. 50.5 Bone response following insertion of a miniscrew implant (MI). (A)
Osseointegration of bone and MI (long red arrows). (B) New bone formation next
Fig. 50.3 Changes seen following immediate removal of a miniscrew implant (MI)
to the MI thread (red N). B, bone.
after its insertion. (A) Mechanical damage and resorption of the root surface (long
yellow arrows) where contact with the MI was made. (B) The area in the red box
in (A) showing cementum repair of the resorbed root surface (short red arrows).
D, dentin; PDL, periodontal ligament; B, bone.
BONE RESPONSE

BONE REMODELING AROUND IMPLANT

When a MI is inserted into the alveolar bone, there is a mismatch between
O the elastic moduli of the two materials at the bone–implant interface,
which causes stresses in the bone surrounding the MI and leads to increased
O
bony remodeling at the interface. Masticatory forces may also create strain
O at the bone surfaces. The bone responds by depositing more bone, which
O is then remodeled into stronger compact bone with time. However, if there
is contact between the MI and the root surface, jiggling forces will be set
PDL up at the MI–root contact. It can be speculated that this may decrease
D
MI mechanical retention and eventually lead to a higher failure rate.15
O MI

OSSEOINTEGRATION
P Osseointegration can be defined as direct contact between bone and an
A B D
× 12.5 × 100 inert object, with histological evidence suggesting that new woven bone
Fig. 50.4 Penetration of the miniscrew implant (MI) into the pulp space. (A)
is formed around the inert object and, for a MI, around and within the
Formation of osteodentin cap (green arrows) around the MI tip. (B) Close-up view threads. This newly formed bone is relatively darker than surrounding
of a section showing formation of osteoids (red circles) inside the dentin tissue. P, trabecular bone (Fig. 50.5). The quality and amount of osseointegrated
pulp; D, dentin; PDL, periodontal ligament; B, bone. bone around the MIs, as well as other factors such as the degree of inflam-
mation, possible excess orthodontic force and the proximity of the MIs to
bone. If this barrier is severely damaged and bone grows towards the the roots, affect their stability and consequently their failure rates.16
resorbed root, ankylosis may occur. A MI totally perforating a root caused
ankylosis in beagle dogs.28 In such severe damage, root resorption and
ankylosis were observed on the opposite side to the MI insertion. This may CONCLUSIONS
indicate that insertion pressure on one side of the root can induce root
resorption and ankylosis on the opposite side. Ankylosis has been observed Every effort should be made to avoid contacting root surfaces when insert-
only in severe injury with displacement of root fragments, and this may ing MIs inter-radicularly into alveolar bone. If contact is made, resorption
be caused by compression of the lamina dura causing by obliteration of of the root surface occurs, with or without cementum healing, depending
the periodontal ligament space.29 on specific circumstances. Where excessive force causes penetrative injury
An ankylotic response has not been seen when the periodontal ligament to the pulp, irreversible damage occurs with possible ankylosis of the root
space was well maintained even when the pulp was penetrated.23,30 Studies with the bone. When contact between MI and root is suspected, immediate
of resorption after replanting of a tooth indicate that the healing responses removal of the MI and reimplantation is recommended, since the removal
of the periodontal ligament depend on the extent of the damage to the liga- of the contact will allow healing of the root surface. Care must also be
ment, with up to 2 mm of loss of periodontal ligament being repaired by taken when a MI is inserted closer than 1 mm to a root surface, since root
new attachment without ankylosis.19 With time, minor areas of possible resorption may occur even when a thin layer of bone and periodontal liga-
ankylotic spots are expected to be resolved. ment exists between the MI and the root surface.
 Root and bone response to proximity of miniscrew implants 277

15. Kang Y, Kim JY, Lee YJ, et al. Stability of mini-screws invading the dental roots and
REFERENCES their impact on the paradental tissues in beagles. Angle Orthod 2009;79:248–55.
16. Kuroda S, Yamada K, Deguchi T, et al. Root proximity is a major factor for screw
1. Kravitz ND, Kusnoto B. Risks and complications of orthodontic miniscrews. Am J failure in orthodontic anchorage. Am J Orthod Dentofacial Orthop 2007;131(Suppl.)
Orthod Dentofacial Orthop 2007;131(Suppl.):S43–51. :S68–73.
2. Asscherickx K, Vannet BV, Wehrbein H, et al. Root repair after injury from mini- 17. Schnelle MA, Beck FM, Jaynes RM, et al. A radiographic evaluation of the availa-
screw. Clin Oral Implants Res 2005;16:575–8. bility of bone for placement of miniscrews. Angle Orthod 2004;74:832–7.
3. Liou EJ, Pai BC, Lin JC. Do miniscrews remain stationary under orthodontic forces? 18. Gautam P, Valiathan A. Implants for anchorage. Am J Orthod Dentofacial Orthop
Am J Orthod Dentofacial Orthop 2004;126:42–7. 2006;129:174; author reply 174.
4. Choi HJ, Kim TW, Kim HW. A precise wire guide for positioning inter-radicular 19. Maino BG, Weiland F, Attanasi A, et al. Root damage and repair after contact with
miniscrews. J Clin Orthod 2007;41:258–61. miniscrews. J Clin Orthod 2007;41:762–6.
5. Cousley RR, Parberry DJ. Surgical stents for accurate miniscrew insertion. J Clin 20. Brudvik P, Rygh P. The initial phase of orthodontic root resorption incident to local
Orthod 2006;40:412–17. compression of the periodontal ligament. Eur J Orthod 1993;15:249–63.
6. Kitai N, Yasuda Y, Takada K. A stent fabricated on a selectively colored stereolitho- 21. Kadioglu O, Buyukyilmaz T, Zachrisson BU, et al. Contact damage to root surfaces
graphic model for placement of orthodontic mini-implants. Int J Adult Orthodon of premolars touching miniscrews during orthodontic treatment. Am J Orthod Dento-
Orthognath Surg 2002;17:264–6. facial Orthop 2008;134:353–60.
7. Suzuki EY, Buranastidporn B. An adjustable surgical guide for miniscrew placement. 22. Brudvik P, Rygh P. Root resorption beneath the main hyalinized zone. Eur J Orthod
J Clin Orthod 2005;39:588–90. 1994;16:249–63.
8. Kim SH, Choi YS, Hwang EH, et al. Surgical positioning of orthodontic mini-implants 23. Kim H, Kim TW. Histologic evaluation of root-surface healing after root contact or
with guides fabricated on models replicated with cone-beam computed tomography. approximation during placement of mini-implants. Am J Orthod Dentofacial Orthop
Am J Orthod Dentofacial Orthop 2007;131(Suppl.):S82–9. 2011;139:752–60.
9. Hernandez LC, Montoto G, Puente Rodriguez M, et al. “Bone map” for a safe place- 24. Khow F, Goldfaber P. Changes in vasculature of the periodontium associated with
ment of miniscrews generated by computed tomography. Clin Oral Implants Res tooth movement in Rhesus monkey and the dog. Arch Oral Biol 1970;15:1125–43.
2008;19:576–81. 25. Faltin R, Faltin K, Sander FG, et al. Ultrastructure of cementum and periodontal liga-
10. Gracco A, Lombardo L, Cozzani M, et al. Quantitative cone-beam computed tomog- ment after continuous intrusion in humans: a transmission electron microscopy study.
raphy evaluation of palatal bone thickness for orthodontic miniscrew placement. Am Eur J Orthod 2001;23:35–49.
J Orthod Dentofacial Orthop 2008;134:361–9. 26. Brisceno CE, Rossouw PE, Carrillo R, et al. Healing of the roots and surrounding
11. Heimisdottir K, Bosshardt D, Ruf S. Can the severity of root resorption be accurately structures after intentional damage with miniscrew implants. Am J Orthod Dentofacial
judged by means of radiographs? A case report with histology. Am J Orthod Dento- Orthop 2009;135:292–301.
facial Orthop 2005;128:106–9. 27. Gold SI, Hasselgren G. Peripheral inflammatory root resorption: a review of the litera-
12. Kim J, Ahn S, Chang Y. Histomorphometric and mechanical analyses of the ture with case reports. J Clin Periodontol 1992;19:523–34.
drill-free screw as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2005; 28. Lee YK, Kim JW, Baek SH, et al. Root and bone response to the proximity of a mini-
128:190–4. implant under orthodontic loading. Angle Orthod 2010;80:452–8.
13. Chen Y, Shin H, Kyung H. Biomechanical and histological comparison of self-drilling 29. Renjen RA, Maganzini AL, Rohrer MD, et al. Root and pulp response after intentional
and self-tapping orthodontic microimplants in dogs. Am J Orthod Dentofacial Orthop injury from miniscrew placement. Am J Orthod Dentofacial Orthop 2009;136:
2008;133:44–50. 708–14.
14. Hembree M, Buschang PH, Carrillo R, et al. Effects of intentional damage of the roots 30. Chen YH, Chang HH, Chen YJ, et al. Root contact during insertion of miniscrews for
and surrounding structures with miniscrew implants. Am J Orthod Dentofacial Orthop orthodontic anchorage increases the failure rate: an animal study. Clin Oral Implants
2009;135:280. Res 2008;19:99–106.
 51 Complications of miniscrew implant insertion:
maxillary sinus perforation
Antonio Gracco, Stephen Tracey and Ugo Baciliero

atrophic in smokers. Analysis of the Schneiderian membrane samples from

INTRODUCTION
20 different cadavers indicated that it has a mean thickness of 90 µm
(±45).5 The membrane could be stretched to up to 132.6% of its original
The maxillary sinus (Higmoro antrum) is a natural cavity found in maxil-
size in one direction and up to 124.7% if the stretching force was applied
lary bone on both sides of the face. Its function is not clear, but it may
in two directions. As expected, the strain needed to break the membrane
serve to amplify sounds, aid olfactory and respiratory functions (heating
is reduced as the membrane thins; the tendency to perforation occurred at
and humidifying inhaled air) or simply may reduce the weight of the
an average tension value of 7 N/mm.5
cranium.
The maxillary sinus is supplied with blood by the greater palatine artery,
The maxillary sinus is found at the level of the premolars and molars,
the infraorbital artery and the posterior superior alveolar artery.1 The latter
between the maxillary dental arches and the eye sockets, from which it is
two arteries have numerous anastomoses within the lateral wall of the sinus
separated by an extremely thin strip of bone (bilaterally with respect to
and supply the Schneiderian membrane.
the nasal fossae, and anteriorly with respect to the pterygomaxillary
The anterior wall of the sinus is made up of thin compact bone and
fissures).
houses the neurovascular system for the anterior dentition. The posterior
In adults, the maxillary sinus is pyramidal in shape. Its base corresponds
teeth are supplied by neurovascular bundles from the maxillary
to the lateral wall of the nose, while its apex is located at the level of the
tuberosity.
maxillary zygomatic process. The floor of the maxillary sinus is generally
Loss of teeth may induce resorption and remodeling of the surrounding
convex and located approximately 1 cm below the nasal cavity, while its
alveolar bone, resulting in formation of an atrophic bony ridge, loss of
maximum depth is found at the level of the first molars. The sinus meas-
vertical bone volume and progressive pneumatization of the sinus, which,
ures roughly 25–35 mm in depth, 36–45 mm in height and is approxi-
in turn, may cause craniocaudal resorption of the alveolar process.
mately 38–45 mm long in adults, although a great anatomical variability
has been noted.1 The shape and volume of the sinus vary considerably
between individuals, with irregularities in the bony floor from the protru- MAXILLARY SINUS PERFORATION
sion of roots of the underlying teeth into the antrum and bony septa in
some young adults (prevalence, 16–58%).2,3 Perforation of the Schneiderian membrane can occur easily during inser-
The internal wall of the maxillary sinus is lined with ciliated respiratory tion of an orthodontic miniscrew implant (MI) into the zygomatic crest, a
mucosa (the Schneiderian membrane), which is a continuation of that in location that is considered a suitable skeletal anchorage site for a number
the nose but is normally thinner with a less extensive network of blood of orthodontic procedures (Fig. 51.1).6,7
vessels. This ciliated respiratory epithelium transports fluids (mucus and Zygomatic crest thickness at the level of the first molar’s mesiobuccal
pus) through the nasal ostium, which links the cranial portion of the sinus root is suitable for the insertion of orthodontic MIs; here the presence
and the middle meatus of the nasal cavity. The pseudostratified Schneide- of two cortical layers (the alveolar and the sinus cortex) helps to ensure
rian membrane forms a vital barrier, protecting and defending the sinus excellent primary stability. A MI should be placed 14–16 mm above
cavities.4 It is blue-gray in color and may be particularly thin, fragile and the occlusal plane with an angulation of 55–70° (Fig. 51.2),8 which

Fig. 51.1 Miniscrew implant insertion

in the zygomatic crest. (A) Insertion
position. (B) Maxillary sinus
perforation by an orthodontic
miniscrew implant.

A B

278
 Complications of miniscrew implant insertion: maxillary sinus perforation 279

allows for considerations of individual anatomical variation in sinus than 2 mm in diameter is unlikely to become inflamed,12 and upon MI
pneumatization and the length and inclination of the tooth roots. The removal heals completely over a short period of time. Consequently, MIs
safest area for MI insertion in the maxilla in all patients (regardless of with diameters 2 mm or less should be used in the palatal area of the
their different skeletal growth patterns) seems to be between the second maxilla.13
premolar and the first maxillary molar (Fig. 51.3).9 The zygomatic crest An experimental and clinical study of osseointegrated titanium implants
gets gradually thinner in an apical direction and the risk of sinus perfo- penetrating the nasal cavity and maxillary sinus showed healthy, non-
ration increases.10 inflamed tissue around implants and normal bone regeneration, indicating
The most common cause of this type of iatrogenic damage is the inser- that penetration does not have adverse effects in the maxillary sinus during
tion of graft material in the maxillary sinus in order to raise its floor and the healing process.14 Rhinoscopic investigations after perforation have
aid implantation in patients with atrophic alveolar crests.5 Perforation is also shown the presence of healthy tissue and lack of sinusitis or other
most frequent at the crestal margin, particularly in the presence of bony pathological events (Fig. 51.4).15 In fact, healing processes have been
protrusions or septa, and may be inevitable when there is excessively thin shown to commence spontaneously within 48 hours of a traumatic
sinus mucosa or improper surgical technique. event.16 (Videos of MI insertion into the maxillary sinus can be viewed
A small perforation that occurs where the membrane is folded over itself at https://www.youtube.com/watch?v=JX5MdKbNhK8 and http://youtu
will heal spontaneously.11 A perforation of the Schneider membrane of less .be/Lp9OPbED4GE.)

A B

Fig. 51.2 Miniscrew implant inserted with proper angulation to avoid iatrogenic Fig. 51.4 Images taken during a sinuscopy evaluation. (A) An orthodontic
damage. miniscrew implant (MI; diameter, 2 mm; length, 10 mm) passing through the sinus
cortex and mucosa. (B) Image showing a MI (diameter, 1.4 mm; length, 8 mm)
passing through the sinus mucosa close to a mucosal cyst.

A B

Fig. 51.3 Cone beam CT. (A) Orthodontic miniscrew implant correctly inserted in the inter-radicular space between the maxillary second premolar and first molar.
(B) Sinus cortex perforation by an orthodontic MI.
 280 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

Fig. 51.5 Cone beam CT. (A) Coronal section showing inflammatory
hypertrophy of the left sinus mucosa, nasal septum deviation, nasal
turbinate hypertrophy and radiopaque alterations located in the right
sinus cavity. (B) Axial image showing the difference between a
normal right sinus cavity and a pathological mucosal hypertrophy in
the left one.

A B

6. Poggio PM, Incorvati C, Velo S, et al. “Safe zones”: a guide for miniscrew positioning
CONCLUSIONS in the maxillary and mandibular arch. Angle Orthod 2006;76:191–7.
7. Wang Z, Li Y, Deng F, et al. A quantitative anatomical study on posterior mandibular
The maxillary sinus may have pathological alterations before any ortho- interradicular safe zone for miniscrew implantation in the beagle. Ann Anat
2008;190:352–7.
dontic treatment is commenced; cone beam CT carried out before treat- 8. Liou EJ, Chen PH, Wang YC, et al. A computed tomographic image study on the
ment showed incidental pathological alterations in approximately 50%, thickness of the infrazygomatic crest of the maxilla and its clinical implications for
including mucosal thinning, polyps and acute sinusitis (Fig. 51.5).17 This miniscrew insertion. Am J Orthod Dentofacial Orthop 2007;131:352–6.
9. Chaimanee P, Suzuki B, Suzuki EY. “Safe zones” for miniscrew implant placement
would suggest that a preliminary otorhinolaryngology consultation would in different dentoskeletal patterns. Angle Orthod 2011;81:397–403.
be useful to evaluate the condition of the sinus, detect any predisposing 10. Baumgaertel S, Hans MG. Assessment of infrazygomatic bone depth for mini-screw
factors for iatrogenic damage and solve any pathological problems before insertion. Clin Oral Implants Res 2009;20:638–42.
11. Pikos MA. Maxillary sinus membrane repair: update on technique for large and com-
initiation of orthodontic treatment.13 plete perforations. Implant Dent 2008;17:24–31.
12. Raiser GM, Rabinovitz Z, Bruno J, et al. Evaluation of maxillary sinus membrane
response following elevation with the crestal osteotome technique in human cadavers.
Int J Oral Maxillofac Imp 2001;16:833–40.
REFERENCES 13. Gracco A, Tracey S, Baciliero U. Miniscrew insertion and the maxillary sinus: an
endoscopic evaluation. J Clin Orthod 2010;44:439–43.
1. McGowan DA, Baxter PW, James J. The maxillary sinus and its dental implications. 14. Branemark PI, Adell R, Albrektsson T, et al. An experimental and clinical study of
Oxford: Wright, Butterworth-Heinemann; 1993. p. 1–125. osseointegrated implants penetrating the nasal cavity and maxillary sinus. J Oral
2. Baumgaertel S, Hans MG. Assessment of infrazygomatic bone depth for mini-screw Maxillofac Surg 1984;42:497–505.
insertion. Clin Oral Implants Res 2009;20:638–42. 15. Raghoebar GM, Batenburg RH, Timmenga NM, et al. Morbidity and complications
3. Koymen R, Gocmen-Mas N, Karacayli U, et al. Anatomic evaluation of maxillary of bone grafting of the floor of the maxillary sinus for the placement of endosseous
sinus septa: surgery and radiology. Clin Anat 2009;222:563–70. implants. Mund Kiefer Gesichtschir 1999;3(Suppl. 1):65–9.
4. Ardekian L, Efrat Oved-Peleg E, Mactei EE, et al. The clinical significance of sinus 16. Skoglund LA, Pedersen SS, Holst E. Surgical management of 85 perforations to the
membrane perforation during augmentation of the maxillary sinus. J Oral Maxillofac maxillary sinus. Int J Oral Surg 1983;12:1–5.
Surg 2006;64:277–82. 17. Pazera P, Bornstein MM, Pazera A, et al. Incidental maxillary sinus findings in ortho-
5. Pommer B, Unger E, Sütö D, et al. Mechanical properties of the Schneiderian mem- dontic patients: a radiographic analysis using cone-beam computed tomography
brane in vitro. Clin Oral Implants Res 2009;20:633–7. (CBCT). Orthod Craniofac Res 2011;14:17–24.
 Risk management of skeletal anchorage
devices in orthodontics
52
Gudrun Lübberink and Vittorio Cacciafesta

The location of the insertion site appears to be the most important factor
INTRODUCTION
determining the success of MIs. Patients have shown significantly different
The availability of miniscrew implants (MIs) and miniplates has facilitated success rates in different insertion areas. MIs inserted in the anterior palate
many aspects of orthopedic treatment, and in some cases actually makes present a success rate of more than 97% (see Fig. 30.1B), whereas those
such treatments possible. However, MI-based treatments, in common with inserted in the mandibular lingual aspects, the retromolar areas (Fig. 52.1)
all medical procedures, are not without problems, complications and risks. and inter-radicularly between the incisors (see Fig. 39.1E) have a success
A single problem or mistake during planning and insertion of a MI can rate of 60% or less.3 The morphology of the insertion site is also signifi-
have a range of consequences. Very often, a whole cascade of adverse cant. A MI placed in a location that has a characteristically higher success
events is triggered. Orthodontists are becoming increasingly aware of what rate (e.g. between the mandibular second premolars and first molars) is
works well, what lies in the gray area between success and failure and more likely to fail if inserted too high or too low. The ideal insertion site
what is bound to fail. Because of this, it is essential that the patient is is the mucogingival junction within the attached gingiva, with a slight
informed of the potential risks and of the availability of alternative apical angulation of the MI.4,5 However, even MIs inserted in these well-
treatments. chosen sites can be troublesome when placed by an operator with inferior
skill, knowledge and experience. For example, failure rates increase sig-
nificantly with incorrect MI diameter or length, when using an insertion
SUCCESS AND FAILURE RATES technique that compromises primary stability or with improper loading
forces and vector biomechanics (Fig. 52.2).4,5
Chapters 48 and 49 discuss in detail the success rates and risk factors for
miniplates and MIs. Because published studies will have used different MINISCREW IMPLANT INSERTION SITES
brands of MI, different MI diameters and lengths, different sites of inser-
tion and in a variety of patients, it is difficult to draw simple straightfor- The best site for the insertion of MIs should be selected on the basis of
ward conclusions on causes and effects. What is frequently not mentioned the planned biomechanical approach. The following should be taken into
in published studies is the level of experience of the operating practitioner consideration:
at the start of the study, which is also an important factor that determines ■ at least 0.5 mm bone around the MI on all sides
outcome. ■ MI head should be positioned on inflammation-free, attached
Consequently, a clinician who intends to use MIs needs to be aware of gingiva.
the numerous influencing factors but also have a willingness to learn, from
both his/her own mistakes and those of others. The success rate, in theory, It is very important to determine the quantity and quality of bone at the
should be well above 90%, although this is unlikely to be achieved by an selected site. However, radiography only provides limited information in
inexperienced practitioner starting to use MIs, and clinicians may experi-
ence a 75–80% success rate, depending on skill levels.1 There is a demon-
strable learning curve with this type of treatment, particularly with regard
to the insertion procedure itself. The cause of most problems lies within
this surgical procedure.
The main, or most common, problem is the loss of a MI. There is a
whole range of possible causes for such a loss. These are covered in detail
in Chapters 48 and 49 and only a few aspects will be discussed in this
chapter.

TREATMENT PLANNING AND MINISCREW Fig. 52.1 Insertion of miniscrew implant in the retromolar area.
IMPLANT LOCATION

Carefully planning is undoubtedly one of the key factors to success. The

documentation and information required for other maxillary orthopedic
procedures are perfectly adequate and should be used also when planning
treatment involving MIs. The biomechanical approach should be based on
medical history, assessment findings (including possible contraindica-
tions), diagnosis and treatment outcome desired.
The main contraindications are those of implant procedures in general,
such as systemic diseases associated with increased bone metabolism or
negative bone balance (e.g. osteoporosis or uncontrolled diabetes), which
can reduce the chances of success.2 Fig. 52.2 Improper biomechanics with high loading force and wrong vector.

281
 282 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

A B
Fig. 52.3 Root injury. (A) Root approximation with a miniscrew implant (MI). (B) Panoramic radiograph depicting root injuries following insertion of MIs.

two dimensions and can have distortions arising from the direction of 8.8% for the second, 2.1% for the third and 4.3% for the fourth group.8
exposure. The spatial situation can also be assessed by reproducing the The personal learning curve can be greatly improved by practicing on
mucogingival line, the tooth axes and the roots on a cast. porcine bone samples to get a “feel” for bone resistance. In order to mini-
The required direction of tooth movement must also be considered mize potential risks, particularly during insertion, it is advisable to adopt
during planning, as the spatial arrangement of the dentition will change a standardized procedure for routine use.
during the course of treatment. A MI must not interfere with or obstruct
the desired movement and may need to be moved part way through the
treatment course (Fig. 52.3A). BONE QUALITY
In alveolar bone, the best sites are between the first molars and second
It is only possible to test bone quality at the selected site immediately prior
premolars, where sufficient inter-radicular space is available, while mid-
to insertion. A probe should be first inserted in the bone. If the probe
palatal and retromolar pad areas have sufficient cortical bone thickness
penetrates deeply, the bone quality is not adequate and a different site
and provide excellent sites.6 Adequacy of inter-radicular space should
should be selected.
always be ascertained with at least a panoramic radiograph; cone beam
CT is even better. If possible, it is best to place MIs in the attached gingiva
to lessen the chance of inflammation, a factor associated with a higher
ROOT INJURIES
failure rate.6 When placement in unattached mucosa is essential, careful
insertion technique (by stretching the mucosa during insertion) and careful The MI must not be in contact with the dental roots, with consequences
hygiene instruction could help to achieve satisfactory stability. that vary with the level of contact (see Chapter 50). The risk of injury to
dental roots during placement is one of the greatest concerns with ortho-
dontic MIs (Fig. 52.3B), particularly when they are inserted between teeth.
INSERTION RISKS AND COMPLICATIONS Placement of a MI too close to a root can also result in insufficient bone
remodeling around the MI and transmission of occlusal forces through the
OPERATOR teeth to the MIs, which can lead to implant failure (Fig. 52.3A). Even
though periodontal structures can heal after being injured by temporary
There is much in favor of MI insertion being done by the orthodontist.
anchorage devices, it is important to select the insertion sites carefully to
Studies have shown that orthodontists have a far better developed sensitiv-
avoid damage that cannot be retrieved.
ity and biomechanical knowledge in this regard.7 If the orthodontist is not
the one to insert the MI, a good line of communication with the surgeon
must be maintained as surgeons usually insert MIs simply where there is
plenty of space, which may not be a useful place. Inappropriate insertion
FRACTURE OF MINISCREW IMPLANTS
could cause clinical and biomechanical problems such as root injury (Fig. Some MIs have depth stops that signal that screwing must stop when they
52.2), obstruction of tooth movement or the wrong location for the con- touch the bone surface. However, depending on clinical factors, such as
necting systems, which could be too short and ineffective. bone quality, site, angle of insertion and insertion technique, the moment
of contact is not generally detectable. There is, therefore, a risk of overin-
sertion (Fig. 52.4A) and destruction of bone structure by the MI thread.
OPERATOR EXPERIENCE
The initial (or primary) stability of the MI appears to be good, but the MI
Many problems can arise because of inadequate training or lack of experi- is rapidly lost. In order to avoid this problem, it is advisable to measure
ence of the operator (see Table 49.3): for every additional group of 18 MIs the thickness of the gingiva prior to MI insertion as this gives a good
inserted, a failure rate of 25% was observed for the first group of MIs, indication of how far the MI can be inserted in the bone.
 Risk management of skeletal anchorage devices in orthodontics 283

A B

Fig. 52.5 Micromovement of a miniscrew implant. (A) Before molar mesialization.

(B) After molar mesialization.
A B

Fig. 52.4 Miniscrew implant problems. (A) Overinsertion. (B) Fracture.

The quality of bone is the most important factor determining primary
stability; the strain obtained by loading a MI perpendicular to the long axis
Fracture of a MI is a very rare occurrence (Fig. 52.4B). The following
with 50 cN leads to loss of primary stability when the cortex is equal to
parameters (alone or in combination) determine the risk of fracture:
or smaller than 0.5 mm.12 MI stability is mainly determined by the dimen-
■ MI design: thin (diameter, <1.4 mm) and long (>10 mm) MIs tend sions of the cortical layer, with any part of the MI within the spongiosa
to fracture more easily contributing little towards retention. The reasons for poor primary stability
■ anatomical factors: thick cortical layer (>2 mm) without a pilot hole include:
created prior to MI insertion
■ inadequate bone quality or quantity
■ insertion conditions: too much torque and/or inconsistent rate of
■ overlarge hole in bone caused by using the wrong drilling technique
insertion.
(e.g. repeated insertion of the drill in the hole or deviation from
The most important way to avoid fractures is to place the MIs very gently, required axis)
with a steady speed. A torque driver can be used, as the driver rotates freely ■ inappropriate MI thread (size and profile of the thread and the
if the resistance reaches the fracture limit.9 relation of the shaft to the external diameter).
If a MI fractures during insertion, it is advisable to remove the fractured
To enhance primary stability, the insertion angle should be kept stable
part of the MI from the bone immediately, raising a flap and carefully
during insertion and the threaded part should be inserted totally into
eliminating the surrounding bone.
bone.10,11 A MI must present primary stability immediately after insertion
The simple way to remove a MI at the end of treatment is by turning
as it cannot be achieved subsequently. If this is not achieved, then it is best
the manual screwdriver counterclockwise very gently. Touching the head
to remove the MI and select an alternative insertion site.
of the MI with a round carbide bur can loosen it so that removal can be
The regeneration of bone required for secondary stability commences
swift and safe.10,11 A MI that is fractured during removal is better left in
shortly after insertion. Anything that inhibits this process, such as micro-
place, because removal involves flap opening, grinding of the surrounding
movements of the MI, may lead to MI failure.
bone and grasping and turning the MI with Weingart pliers. Because buccal
The second factor determining primary stability is the actual MI inser-
MIs are inserted near the gingival margin, removal of marginal bone may
tion pressure. Moderate initiatory pressure is required to engage the first
produce periodontal breakdown. A small piece of titanium MI would not
portion of the MI threads, but after that, insertion pressure should be
cause serious complications, and if the patient accepts leaving it in place,
reduced to allow the MI to draw itself in with each rotation. This will
it is less traumatic. Another strategy that makes it easy to remove a frac-
prevent stripping and hole widening. Another risk is the gradual, almost
tured MI is to use an ultrasonic scaler to stir up the interface, then wait
indiscernible, forward movement (away from the practitioner) of the hand
for 1–2 weeks and apply gentle force to remove it.10,11
and driver shaft with each turn of the MI. Not only does this change the
initial trajectory of the MI, thus increasing the chance of root impingement,
INSERTION TECHNIQUE but more importantly, it again widens the hole around the MI.10,11
Generally, a self-drilling and self-tapping technique for MI insertion is
preferred, using only topical anesthetic and watching for patient discom-
fort, which indicates possible root contact. A continuous, non-wobbling
APPLICATION OF LOADING FORCES
force helps to keep the MI in a straight path. Desired force vectors should Whether a MI is loaded immediately or some time later probably has no
be considered carefully when choosing direct or indirect anchorage. Indi- influence on failure rates. Forces should be such that no damage is caused
rect anchorage allows the clinician to apply a force vector similar to to the teeth to be moved. When a MI is coupled to elastic chains or springs,
conventional orthodontics while enhancing the stability of the MI. Direct this can result in micromovements of the MI (Fig. 52.5). While research
anchorage may be more beneficial for certain types of tooth movement, seems to indicate maximum acceptable forces in the range 250–300 g,
such as molar intrusion or en masse anterior retraction, where it can higher success rates can be obtained using Ni-Ti springs delivering a
provide an intrusive component of the force vector that will facilitate constant, predetermined force of 50–100 g.10,11
control of the vertical dimension.10,11 The distance between the MI and the site of force application, using
springs directly attached to it, should be kept to a minimum. Otherwise,
these will be ineffective.
PRIMARY AND SECONDARY STABILITY
Loading a MI perpendicular to its long axis is preferable. If the MI is
Attempts to place MIs in areas of difficult access or poor bone quality, used indirectly by adding a cantilever to a bracket-like head, a force gen-
wobbling during insertion and pilot hole drilling often result in lack of erating a counterclockwise moment around the long axis should be avoided
primary stability and, ultimately, in MI failure. since this moment will unscrew the MI.
 284 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT

Fig. 52.6 Peri-implantitis. (A) Healthy palatal soft

tissues. (B) Development of peri-implantitis.

A B

Box 52.1 Postoperative instructions for miniscrew implant care

or a Waterpik should be used for cleaning. There is evidence that electric
toothbrushes, particularly those with rotating heads, can loosen MIs.
General In addition to the cleaning technique itself, the frequency and intensity
You have just received one or more miniscrew implant(s). Your miniscrew of cleaning are undoubtedly also important. Very frequent cleaning
implant will help you greatly in achieving our treatment objectives.
However, miniscrew implants are delicate and can loosen and fall out. Here
that results in persistent micromovement of the MI could well be
are some things to consider. disadvantageous.
Home care Patients are instructed to dip their toothbrush in a small bottle of 0.12%
Be careful with an electric toothbrush (particularly Sonicare or any chlorhexidine solution and brush the MI twice a day. Patients must under-
vibrating brush) and do not touch the miniscrew implant with a vibrating stand that they should not be afraid of the MI, as proper brushing maintains
brush head. a firm, healthy gingiva around it.10,11
Keep the area of the miniscrew implant clean by gently using an
interdental brush. A toothbrush, if not properly used, may irritate the marginal soft tissue
Use a salt-water rinse before bed. and aggravate inflammation. If local inflammation occurs, with signs of
Food redness of the soft tissue margin at the neck of the MI, antibiotics are
Please avoid eating hard, crunchy, chewy, and sticky foods. They can hit or usually not prescribed. Instead, the patient is instructed to enhance the
stick to the miniscrew implant and loosen it. hygiene regimen, for example using a Waterpik.
Habits
There is a possibility that habits like clenching and bruxism can loosen
miniscrew implants. While this may be hard for you to control, we’d like LIABILITY ISSUES
you to be aware.
Activities In order to protect themselves if a claim for negligence is made, orthodon-
Trauma to the area can loosen the miniscrew implants. Be aware that sports tists should ensure that they follow certain basic rules based on the cur-
may involve injury to the face and can increase the risk of loosening the rently existing evidence.
miniscrew implants.
Discomfort
Typically you will not need any medication for discomfort. You may take an INSURANCE
ibuprofen only if you need it.
Your miniscrew implant is an invaluable addition to your orthodontic Orthodontists who wish to insert MIs themselves are frequently unsure
treatment. Please take care of it, as it is an essential part of your specialized about various aspects of indemnity insurance. Policies available cover
treatment. claims ranging from 1.5 to 5 million euros. When deciding on the extent
of cover required (and so the premiums), the special circumstances of the
practice need to be considered. An indemnity insurance policy will cover
the practice’s personnel but may exclude temporary employees. If there
POST-INSERTION RISKS AND COMPLICATIONS
are any changes in the activity profile of the practice, these must be
covered by the policy. There are insurance companies that do not differ-
INFLAMMATION
entiate in their policies between dental and orthodontic practices (the
There is a high probability that a MI will fail if perimucositis or peri- policy specifies “with implants” or “with surgery”). Where an orthodontist
implantitis develops (Fig. 52.6). It is, therefore, important to ensure that is planning to personally insert MIs, this is usually automatically covered
the patient is appropriately informed (including instructions for immacu- by the policy. If there is any doubt, policyholders should always contact
late oral hygiene) and attends follow-up examinations (Box 52.1). The their insurers and inform them of the extension of the range of treatments
stability of the MI and of the condition of the surrounding tissue is assessed provided in the office, particularly if the policy does not specifically cover
at each follow-up examination. Attached elements (springs, extension maxillary orthopedic or implant procedures. In this case, the annual
arms) may cause pressure sores or even ulceration of the mucosa, which premium is likely to be slightly increased.
needs monitoring and treating as necessary.
Infection control is essential during MI insertion (see Chapter 14). Pro-
phylatic antibiotics (e.g. a penicillin or cephalosporin) can be prescribed
DUTY OF INFORMATION
to be taken 2 hours before or after surgical placement. Prior to the initiation of any treatment procedure, the patient must be
informed of the nature and effect of potential risks, of alternative treat-
ments and of the consequences if no treatment is provided. It is a good
ORAL HYGIENE idea to use preprinted material to gather information on medical history
During treatment, patients are instructed to clean the MIs carefully and not and provide information. These can act as an aide memoire or prompt
to apply intentional force with a finger or implement. A normal toothbrush when talking to the patient. Written material should never be used instead
 Risk management of skeletal anchorage devices in orthodontics 285

of a personal dialogue. Printed materials used (e.g. in the form of a note)

REFERENCES
must document that the relevant verbal information has been given to the
patient. It is not enough merely to have the signature of the patient, a 1. Antoszewska J, Papadopoulos MA, Park HS, et al. Five-year experience with ortho-
witness and the practitioner. dontic miniscrew implants: a retrospective investigation of factors influencing success
rates. Am J Orthod Dentofacial Orthop 2009;136:158, discussion 158–9.
2. Luzi C, Verna C, Melsen B. Guidelines for success in placement of orthodontic mini-
implants. J Clin Orthod 2009;43:39–44.
DOCUMENTATION 3. Melsen B, Graham J, Baccetti T, et al. Factors contributing to the success or failure
of skeletal anchorage devices: an informal JCO survey. J Clin Orthod 2010;44:
Good documentation is absolutely essential. Treatment records, including 714–18.
patient files, radiographs, casts, photographs and so on, must clearly docu- 4. Cheng SJ, Tseng IY, Lee JJ, et al. A prospective study of the risk factors associated
ment the course of treatment, as well as any problems and complications. with failure of mini-implants used for orthodontic anchorage. Int J Oral Maxillofac
Implants 2004;19:100–6.
Scrupulous and accurate documentation is very valuable if, for example, 5. Park HS, Jeong SH, Kwon OW. Factors affecting the clinical success of screw implants
a legal dispute ensues. Lawsuits are often lost because documentation was used as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2006;130:18–25.
incomplete. 6. Park J, Cho HJ. Three-dimensional evaluation of inter-radicular spaces and cortical
bone thickness for the placement and initial stability of microimplants in adults. Am
J Orthod Dentofacial Orthop 2009;136:314.
7. Osterman WL. Who places miniscrews? An informal JCO survey. J Clin Orthod
INSURANCE CLAIMS 2008;42:519, discussion 519–27.
8. Wiechmann D, Meyer U, Büchter A. Success rate of mini- and micro-implants used
If a patient suffers an injury or decides to register a claim, it is advisable for orthodontic anchorage: a prospective clinical study. Clin Oral Implants Res
to get in touch with the policy provider. The insurer will supervise all the 2007;18:263–7.
financial and legal aspects. 9. Motoyoshi M, Hirabayashi M, Uemura M, et al. Recommended placement torque
when tightening an orthodontic mini-implant. Clin Oral Implants Res 2006;
17:109–14.
10. Cacciafesta V, Bumann A, Cho HJ, et al. JCO round table. skeletal anchorage, Part 1.
CONCLUSIONS J Clin Orthod 2009;43:303–17.
11. Cacciafesta V, Bumann A, Cho HJ, et al. JCO round table. skeletal anchorage, Part 2.
J Clin Orthod 2009;43:365–78.
The main parameters that determine the clinical success of MIs are bone 12. Dalstra M, Cattaneo PM, Melsen B. Load transfer of miniscrews for orthodontic
quality, the space available at the planned insertion site, the use of an anchorage. Orthod 2004;1:53–62.
insertion technique appropriate to the system employed, the use of a well-
considered biomechanical concept and the avoidance of inflammation or
infection around the MIs.
 Index

Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.

Anchorage unit Bone-anchored Pendulum appliance (BAPA),

A of AMDA, 160–161 186–188, 186f
of MISDS, 157 clinical application of, 186–187
Aachen Implant Pendulum, 105–106, 106f, 107t Anesthesia, for miniscrew implant insertion, 83, 99 case presentation, 186–187, 187f
Aarhus anchorage system, 143–146 Angle of insertion, miniscrew implants and, 269 comprehensive treatment outcomes, 188
treatment planning of, 143 Animal studies, for miniscrew implants, 66 removal of, 186
Aarhus miniscrew implant, 67–68, 68f–69f Ankylosis, 275–276 vs. conventional Pendulum appliance, 187t
AbsoAnchor miniscrew implants, 34f, 35t, 36f–37f, Anterior crowding Bone-implant contact, 253
37t lip protrusion and, 227–228, 227f, 228t Bones
Absolute anchorage, 58, 104 maxillary molars, extraction treatment for, 145, densities of, Misch’s classification of, 89f, 89t
Abutments, choosing of, for skeletal Pendulum-K 145f healing of, 30–32
appliance, 183, 184f severe, and maxillary protrusion, 224–225, 225f, modeling of, 30–31
Acrylic resin, 102 225t distance and contact osteogenesis, 30–31
button, GISP and, 124 Anterior open bite hematoma, 31
distalization splints, 14 increasing incisor display in, 206 overgrowth of, 256, 257f
Active anchorage, GISP and, 125–126, 126f and protrusion, 216–217, 216f, 217t quality of, miniscrew implants and, 282
Active unit, of MISDS, 156, 156f Anterior teeth retraction, 161, 225–228, 226f quantity and localization of, in orthodontic implant
A design, of TPA-PH device, 190, 191f cephalometric analysis after, 164 insertion and removal, 76
Adjustment module, in TopJet distalizer, 178, for lip protrusion and anterior crowding, 227f remodeling of, 31–32
178f Anterior torque control, 226 in animal studies, 33
Adolescent, with Class II malocclusion, Apertura piriformis, miniplates on, 80, 80f–81f around implant, 276
maxillary molar distalization with GISP in, Appositional bone formation, 31 response of, with miniscrew implants, 276
126, 126f Archwires thickness of
Adult, with Class II malocclusion, maxillary molar crowding of maxillary incisors, 122, 122f of infrazygomatic crest, 90
distalization with GISP in, 126, 127f in en masse retraction, 113 in maxilla and mandible, 91t
Advanced molar distalization appliance (AMDA), Auxiliary anchorage, 104 Bone-screw locking condition, 40f
160–167, 160f Auxiliary distalization appliances Bowman modification, 168
advantages of, 167 C-implant with, 241, 241f Brackets
clinical applications of, 161–166 C-tube miniplates with, 242 for bidimensional technique, 147t
clinical procedure for, 161 for fabrication of Kim’s stent, 98
construction and use of, 166 Bracket-like head, miniscrew implants with, 69, 69f
removal of, 161 B Buccal segment distalization, 112–113, 113f
Age, miniscrew implants and, 262–263 Button, head design of miniscrew implants, 60t
Alginate impression, in skeletal Pendulum-K Ball ends, positioning of, in class II correction using
appliance, 183 symphyseal bone anchorage, 129
Alveolar process, 88 Ball-marked splint, in lateral cephalometric C
Alveoloplasty radiography, 74
direct anchorage with, for excess gingival exposure BAPA. see Bone-anchored Pendulum appliance Callus, 30
during smiling, 197–198, 198f (BAPA) Canines
indirect anchorage with, for simultaneous reduction Basic appliance, 11f distalization of, 151
in gummy smile and vertical dimension, Bayonet bend, 171 retraction of, 148–150, 149f
198–200, 199f, 200t B design, of TPA-PH device, 190, 191f with MGBM system without extractions, 151f
AMDA. see Advanced molar distalization appliance Benefit system, 174f Canine crown tipping, 119–120, 120f
(AMDA) Beneplate, 174, 174f Canine distalization, in extraction treatment, 113,
Anchor breakage, complications of miniplates, 255, wire, 174, 175f 113f
256f Beneslider, 174–177, 174f–175f Carriere distalizer, 14
Anchorage case example of, 175, 176f C design, of TPA-PH device, 190, 191f
Aarhus, 143–146 clinical application of, 174–175 “Cement line matrix”, 30
in class II treatment, 24 discussion, 175–177 Cephalometric analysis
direct, 52–53, 53f, 249–251 Beta-titanium alloy archwire, 138f AMDA
C-implant for, 240–241, 241f Bilateral distalization, 111, 111f after anterior teeth retraction, 164
during distal movement of molars, 25, 26t TopJet distalizer for, 181, 181f after distalization, 162–163, 166
evidence and, 25 Bilateral maxillary molar distalization, 161–164 at end of treatment, 164, 166
indirect, 52, 52f, 251 treatment, 162 during treatment, 162t, 164t
C-implant for, 240–241, 241f Biocreative therapy, 239 during treatment with Distal Screw, 172t
loss, 175–177 non-extraction correction of class II malocclusion during treatment with MISDS, 157t
of molars during space closure, 25, 25f, 26t using, 239–243 Cephalometric measurements
in orthodontics, 22–24 Biomaterial properties, of orthodontic miniscrew in Jasper Jumper, 132, 133t
pain and discomfort in, 27 implants, 34–38 in lip protrusion and anterior crowding, 228t
skeletal vs. conventional, 25–27 Bollard miniplates, 118, 118f–119f, 254f in severe anterior crowding and maxillary
Spider Screw, 147–155 Bone anchorage protrusion, 225t
types of, 62f for fixed functional appliances, 246–248 Cephalometric tracings, superimposition of, 159, 159f
miniscrew implants for, 62, 270 for the Forsus Fatigue Resistant Device, 246 Cheek irritation, 255, 255f

286
 Index 287

Chin Clinical studies, for miniscrew implants, 66 Distal Jet appliance, 12, 168
in class II malocclusion, 1 Clinicians, number of, miniscrew implants and, 264 modified, 168f, 171–173
fixation of, miniplate for, 129, 129f Compact bone, 88 Distal Screw, 171–173, 171f
C-implant, 103, 239f–240f, 240 Compliance, problem of, in Class II malocclusion advantages of, 173
as direct anchorage with auxiliary distalization management, 6 case presentation, 171–173, 171f
appliances, 241, 241f Computed tomography (CT), in orthodontic implants cephalometric analysis during treatment with, 172t
for direct and indirect anchorage, 240–241, 241f insertion and removal clinical application of, 171–173
recommended protocol for immediate relocation of, cone beam, 74–76, 75f construction of, 171, 172f
240 dental, 74, 75f treatment of bilateral dental class II malocclusion
relocation from buccal maxillary bone to palate, Computer simulations, for miniscrew implants, 67–68, with, 172f
242, 243f 67f–68f Distalization
relocation within the mandible, 241–242, 242f Cone beam computed tomography (CBCT) bilateral, 111, 111f
Class II elastics, 2 assessment on the effect of Forsus FRD on maxilla limitations of, 141
Class II high mandibular plane angle, 116f and mandible, 246, 248t of maxillary arch, with miniplate anchorage,
zygoma anchors for, 115 for optimal positioning of miniscrew implants, 103 118–123
Class II malocclusion in orthodontic implants insertion and removal, of maxillary molars, 223–225
compensation with miniscrew implant-supported 74–76, 75f for severe anterior crowding and maxillary
anchorage, 139–142 Conical miniscrew threads, 61 protrusion, 225f
treatment objectives for, 139f Consecutive crown tipping, 119 without extractions, 147–151, 147f
correction of, 110–111 Contact osteogenesis, 30–31 segmental, using miniscrew implants, 213
with bone-anchored Forsus Fatigue Resistant Continuous/segmental approaches, on class II unilateral, 110, 110f
Device, 244–248 malocclusion, 211–212 Distalizing arches, 14
non-extraction, using biocreative therapy, 239–243 Conventional anchorage, 23–24 Distalizing forces, 120f
overview of orthodontic implants for, 104–108 Conventional fixed orthodontic appliances, 239 Distance osteogenesis, 30–31
temporary anchorage devices for, 143–146 Conventional implants, 32 Documentation, miniscrew implants and, 285
twin force bite corrector (TFBC) and skeletal Conventional positioning guides, for radiological Double flexible distalization force system, palatally
anchorage for, 249–251 evaluation of miniscrew implant insertion and buccally positioned, appliances with, 14
diagnostic considerations of, 1–2 sites, 94, 94f Drills, 80
chin, 1 Cortical bone, 90 Dual force distalizer, 135, 135f
crowding, 1 notching of, miniscrew implants and, 267 Dual occlusal plane, molar distalization biomechanics,
growth potential, 1 thickness of, miniscrew implants and, 84t, 269 122, 122f
other factors, 1–2 Crossed-slot, head design of miniscrew implants, 60t Dual-thread miniscrews, 61
upper lip, position of, 1 Crowding Dual-Top miniscrew implants, 34f, 35t, 37f, 37t
division 2, 170f in class II malocclusion, 1 Duration of treatment, miniscrew implants and, 271
treatment of, 169f miniscrew implants and, 264 Duty of information, miniscrew implants and,
extraction treatment of, 151–152 C-tube miniplate, 240, 240f 284–285
phase 1, 151 used as direct anchorage with auxiliary distalization
phase 2, 151–152, 152f appliances, 242, 242f
phase 3, 152, 153f C-type orthodontic bone anchors, 239–240 E
management of, lingual orthodontics and use of Curve of Spee, 122
miniscrew implants for, 211–218 Curvilinear leaf springs, 4 Elastics, substitutes for, 11
maxillary molar distalization with GISP of Cutting flute, of miniscrew implants, 45–46, 45f Electrical hand driver, 235, 236f
in adolescent, 126, 126f En masse distalization, 141, 141f, 189, 189f
in adult, 126, 127f En masse retraction, 113–114
miniplates and zygomatic anchorage for treatment D biomechanics of, 140f
of, 112–117 of maxillary teeth, 219, 219f
MISDS for, 158f Damage, to teeth and adjacent structures, 255 Endosseous dental implants, 32
molar distalization in, 212–213, 214f De novo bone formation, 30–31 Esthetics
non-compliance approaches for management of, Deep bite, control of vertical dimension, 154–155 of appliance use, 211
6–21 Deep overbite effect of tooth movements on, 211t
non-extraction treatment of, 148f–150f and gingival display, 208–209, 209f Eureka Spring appliance, 10, 10f
using miniscrew implant anchorage, 189–195 treatment of, 207–208, 208f Evidence-based decisions, 24–27
orthopedic and soft tissue correction for, 115 Degenerated dentition, retraction of the anterior Expertise, miniscrew implants and, 264
overview of miniscrew implants in treatment of, segment in, 143–145, 144f Explanted implants, histologic analysis of, 29
134–138 Dental arch, plaster cast of, 101 Extension arm, 245
palatal implants for, 52–53 Dental computed tomography, in orthodontic implants Extension springs, 4
Straumann Orthosystem as palatal implant in, insertion and removal, 74, 75f Extraction
109–111 Deviated smile line, improving, 209–210 for class II malocclusion treatment, 2–3, 151–152
subdivision left, 193–195, 194f DICOM 3. see Digital imaging and communications forceps, in orthodontic implant removal, 77, 77f
treatment strategies of, 1–5 in medicine (DICOM 3) of premolars, effects on dentofacial structures, 3
extraction, 2–3 Digital imaging and communications in medicine for protrusion of maxillary anterior teeth, 220–222,
growth modification, 2 (DICOM 3), 103 221f, 222t
maxillary molar distalization, 3–4 Direct anchorage, 52–53, 53f, 62f, 104, 249–251 treatment for alleviating anterior crowding, 145,
zygoma anchors for, 115f advantages/disadvantages of, 62t 145f
Class II open bite malocclusion with alveoloplasty, for excess gingival exposure Extrusive/intrusive mechanics, in class II
miniscrew implant-supported treatment of, 235 during smiling, 197–198, 198f malocclusion management, 212
in adult, 235–236, 236f without alveoloplasty, for simultaneous reduction in
with impaired masticatory function, 236–237, gummy smile and vertical dimension,
237f, 237t 202–203, 202f F
with severe open bite and difficulty in lip Direction guide
closure, 237–238, 238f fabrication of, 98, 98f Fast Back Appliance, 13
skeletal anchorage-supported treatment for, in Kim’s stent, 97 Finite element analysis (FEA) modeling, computer-
235–238, 235f Distal crown tipping, 121–122 based, for stress distribution of implants, 32
 288 Index

First Class Appliance, 15, 15f Indirect anchorage, 52, 52f, 62f, 104, 251
Fixation screws, for miniplates, 118, 119f, 252 H advantages/disadvantages of, 62t
Fixed functional appliances, 244, 249 with alveoloplasty, for simultaneous reduction in
bone anchorage for, 246–248 Habitual asymmetric smile, 209–210 gummy smile and vertical dimension,
condylar growth and effect on maxillary complex treatment progress, 209, 209f 198–200, 199f, 200t
of, 246–248 treatment results, 209–210 without alveoloplasty, for protrusive maxillary
conventional, 249f Head, of miniscrew implants, 39, 40f anterior teeth and a gummy smile, 200–202,
miniplates as anchoring units for, 244–246 designs of, 60t 201f, 201t
miniscrew implants as anchoring units for, 244 length, 265 Indirect bonding method, 224, 224f
Fixed interarch appliances, for class II malocclusion Headgears Infections
treatment, 2–4 in conventional anchorage, 23, 24f control of, after miniscrew implant insertion, 85
Flap surgery, use of, miniscrew implants and, in maxillary molar distalization, 3 miniscrew implants and, 62–63
267–268 used for class II malocclusion treatment, 2 Infinite anchorage, 58
Flex Developer appliance, 9–10, 10f Hematoma, 254, 255f Inflammation
Flexible distalization force system, appliances with peri-implant, 31 miniscrew implants and, 62–63, 63f, 284, 284f
buccally positioned, 13–14 Herbst appliance, 2, 6–8, 7f, 130 of peri-implant soft tissues, 271
palatally positioned, 11–13 advantages of, 7 Insertion technique, in orthodontic anchorage using
Flexible intermaxillary appliances, 9–10 clinical presentation for, 131–132, 132f locking plate and self-drilling miniscrew
Foramen, incisive, 74 indication of, 7 implants for posterior maxilla, 55, 55f–56f
Force application, method of, miniscrew implants intermaxillary temporary anchorage with, 146f Insurance, miniscrew implants and, 284
and, 270 Hex nuts, 249 Inter-radicular distances
Forsus device, 130 Higmoro antrum, 278 in mandible, 92f, 92t
clinical presentation for, 130–131, 131f Hole, head design of miniscrew implants, 60t in maxilla, 91f, 92t
Forsus Fatigue Resistant Device, 10–11, 116, 117f Hook screw, 196–197 Inter-radicular space, for miniscrew implant insertion,
anchorage of, 246f head design of miniscrew implants, 60t 85, 85f
bone anchorage for, 246 Horseshoe Jet appliance, 168f Interarch compression springs, 4
measuring jig, 245–246 advantages of, 169–170 Interdental septum, 101f
typical patient in the study of, 247f case examples, 169, 169f–170f Intermaxillary non-compliance appliances, 6–11,
Forsus Fatigue Resistant Device with Direct Push clinical procedure for, 168–169 15–16, 16f–17f, 18–19
Rod (FFRD-DPR), 190 development of, 168 mandibular advancement using, 190
Forsus Nitinol Flat Spring, 244 evolution of, 168–170 Intramaxillary non-compliance distalization
Fracture, of miniscrew implants, 63–64 final modified, 169f appliances, 11–15, 17–20, 18f
Frenula, 92 Horseshoe-type archwire, 160, 160f Intraoral Bodily Molar Distalizer, 12
Fujita lingual brackets, 227, 227f Howship lacuna, 31 Intraoral non-compliance distalization appliances, 104
Functional appliances, 115–116, 129 Hybrid appliances, 10–11, 10f, 15 Intraosseous retention, of prosthetic implants, 39–40,
for class II malocclusion treatment, 2 40f
fixed, class II correction with Intraosseous screw, in conjunction with transpalatal
Forsus device, 130 I arch, 135, 135f
Herbst, 130 Intrusion auxiliary arches, 122, 123f
Jasper Jumper, 129–130 IAD. see Implant-anchored distalizer (IAD) Intrusive force, molar distalization biomechanics, 120,
Functional Mandibular Advancer, 9 Idiopathic condylar resorption, 211 121f
Impaired masticatory function, open bite and, InVivo software, for correction of class II
236–237, 237f, 237t malocclusion with Forsus Fatigue Resistant
G Implants Device, 247f
advantages of, 48
Gender, miniscrew implants and, 262 biological principles of, 29–33
Gingival dehiscence, 255 biomechanical considerations of, 29–33 J
Gingival display dental, 49
deep overbite and, 208–209, 209f orthodontic use of, 32–33 Jasper Jumper appliance, 9, 9f, 129–130, 130f
excess, etiology and treatment strategies of, design of, 32 cephalometric measurements in, 132, 133t
196t Orthosystem, 49–51 clinical presentation for, 130, 131f
GISP. see Graz Implant-Supported Pendulum (GISP) as skeletal anchorage, 48–54 for treatment of mandibular retrognathism, 116
Graz Implant-Supported Pendulum (GISP) stability of, 32 Jaw of placement, miniscrew implants and, 269
design of, 124–125, 124f types of, 48–51 Jones Jig appliance, 13, 13f
improved design of, 124–125, 124f Implant-anchored distalizer (IAD), 52, 53f
indications of, 125 Implant-based anchorage, 32
laboratory-fabricated, 125f Implant-supported anchorage, appliances for, K
maxillary molar distalization with, 124–128 105–107
clinical presentations of, 126 Implant-supported intraoral molar distalization Keles Slider, 12, 12f
orthodontic procedure of, 125–126 systems, 112 implant-supported, 106, 107t
Greenfield Molar Distalizer. see Piston appliance Implant-supported Keles Slider, 106, 107t maxillary molar distalization with, 229–230, 229f
Growth potential, diagnostic consideration of, in class Implant-supported transpalatal bar and coil springs, Kim’s stent, 97–100
II malocclusion, 1 106–107, 107f, 107t components of, 97, 97f
Gummy smiles Impression caps, 175f fabrication of, 97–98, 98f
caused by maxillary alveolar excess, 208–209 In vitro studies, for miniscrew implants, 66–67, 67f fixation of, 99, 99f
skeletal origin, treatment with miniscrew implant- Incisive foramen, 74 preparation of patient for, 97, 97f
supported biomechanics, 196–203, 196t Incisors K-Pendulum appliance, 11f
advantages of, 203 display of, increasing, 204–206, 204t
case examples, 197–203 in anterior open bite, 206
clinical approach for, 196–197 relations, in class II malocclusion, 212 L
diagnosis for, 196 retraction of, 150–151, 150f
discussion for, 203 with MGBM system without extractions, Laboratory-fabricated positioning device, 94f
treatment biomechanics, 197, 197t 151f Laceback, from canine bracket, 121–122, 121f
 Index 289

Lateral cephalometric radiography Mandibular incisors, protrusion of, 214–216, 215f, Maxillary sinus, 278, 280, 280f
for molar distalization, 161 215t anterior wall of, 278
in orthodontic implants insertion and removal, 74, Mandibular molars, distalization of, 190–192 internal wall of, 278
75f Mandibular Protraction appliance, 8, 8f perforation, 278–279, 278f–280f
Lateral component of force, molar distalization Mandibular retrognathism, treatment of, with Maxillary teeth
biomechanics, 123f miniplate anchorage, 115–116 anterior
Learning curve, of operator, 265 Mantel-Haenszel method, 261f en masse retraction of, 219f
Lever arm and miniscrew implant system, 223–228 MARA. see Mandibular Anterior Repositioning non-extraction treatment for protrusion of,
for anterior teeth retraction, 226–227 Appliance (MARA) 220f
for distalization of maxillary molars, 223–224, 223f Maxilla, 231 en masse retraction of, 219
Lever arm design, 213–214, 214f placement of miniscrew implants in, 269 extraction treatment for protrusion of, 220–222,
Lingual arch plus hooks (LA-PH) device, 190–192, site for miniscrew implant placement, 84, 84f 221f, 222t
192f Maxillary alveolar excess, gummy smile caused by, non-extraction treatment for protrusion of, 220,
Lingual brackets, 226, 227t 208–209 220t
Lingual orthodontics Maxillary anterior protrusion, 217, 217t, 218f retraction of anterior segment of, 113–114
class II, practical guidelines for, 212–214 Maxillary anterior teeth, retraction of, 139, 140f Maxillary trabecular bone, 253
finishing stage, 214 Maxillary arch Maxillary zygomatic buttress, 250–251
lever arm design, 213–214, 214f distalization of, with miniplate anchorage, 118–123 Maxillofacial surgery, orthodontic miniplates used in,
treatment goals, 212 patient instructions, 118–119 78, 78f
and miniscrew implants, for class II malocclusion en masse distalization of, 137–138, 137f–138f, Mental foramen, 92
management, 211–218 189f Mesial crown tipping, 121f
biomechanical considerations, 211–212 sequential distalization of, 136–137, 137f Mesially extended transpalatal arch, with miniscrew
clinical applications, 214–217 three segments of, 121 implants, 135, 135f
Lips Maxillary canines, restriction of mesial crown tipping MGBM system, 147, 151f
closure of, difficulty in, with severe open bite, of, 121–122, 121f Midpalatal suture sites, for miniscrew implants, 84,
237–238, 238f Maxillary crowding 219–220, 219f
position of upper, in Class II malocclusion, 1 minimal, 241–242 Miniplates, 252
protrusion of, and anterior crowding, 227–228, severe, 240–241 as anchoring units for fixed functional appliances,
227f, 228t Maxillary dentition, preparation of, 129 244–246
ptosis, 81 Maxillary incisors biological principles of, 29–33
Loading forces, application of, in miniscrew implants, molar distalization biomechanics, 120 biomechanical considerations of, 29–33
283 protrusion of, 214–216, 215f, 215t for chin fixation, 129
Locking plate, orthodontic anchorage using, for Maxillary incisor display, insufficient, etiologies and for class II malocclusion treatment, 112–117
posterior maxilla, 55–57, 56f–57f treatment strategies for, 204t complications of, 254–256
Locking screw, 79 Maxillary molar distalization, 3–4, 136, 136f, postoperative, 254–255, 255f
LOMAS orthodontic MI system, 196–197 223–225 practical, 255–256
Loop mechanics, for treatment of class II bilateral, 15f at removal, 256
malocclusion, 219, 219t biomechanics of, with cervical headgear, 17f soft tissue, 255
L-shaped incision, in miniplate surgery, 118, 119f for correction of class II malocclusion, 104 insertion location, risk factor of, 253
with Graz Implant-Supported Pendulum mobility of, 255, 256f
appliance, 124–128 placement surgery of, in the maxilla and mandible,
M insertion location of, 105 254f
with Keles slider and miniscrew implants, risk factors of, 253–254
M4 site, 179, 179f 229–230, 229f success rates of, 252–253, 252t
Magnetic distalization appliance, 14f non-compliance, appliances for, 105–107, 107t surgery, 118
Magnets, used for molar distalization, 14 non-extraction treatment, 189–190, 189f surgical insertion of, 129, 129f
Mainz Implant Pendulum (MIP), 105, 105f, 107t with palatal implants, 230–231, 231f Miniplate anchorage
Malocclusion unilateral, with miniscrew implants, 233–234, distalization of maxillary arch with, 118–123
class II 233f for treatment of mandibular retrognathism,
division I with maxillary protrusion, 192–193, with zygomatic miniplates, 231–232, 232f 115–116
193f, 193t with Keles slider and miniscrew implants Miniscrew implants (MIs), 39, 69f, 174, 174f, 212,
subdivision left, 193–195 results of, 230 219, 252
miniscrew implant treatment for, 71 treatment progress, 230 anchorage, non-extraction treatment of class II
type of, miniscrew implants and, 263 non-compliance, 3 malocclusion using, 189–195
Mandible for severe anterior crowding and maxillary clinical examples, 192–195
intermaxillary forces to advance, 145–146, 146f protrusion, 225f as anchorage for advancement of the mandible,
placement of miniscrew implants in, 269–270 unilateral, with miniscrew implants 244, 245f
relocation of C-implant within, 241–242, 242f progress of, 233 as anchoring units for fixed functional appliances,
site for miniscrew implant placement, 85, 85f results of, 234 244
Mandibular advancement without extractions, 147–151, 147f in animal studies, 33, 66
biomechanics of Maxillary molars, 247 application of loading forces in, 283
with intermaxillary class II elastics, 16f Maxillary posterior anchorage, for class II availability of, 281
with intermaxillary non-compliance appliances, malocclusion, 2 basic components of, 39f
16f Maxillary posterior teeth, effects of Forsus Fatigue biological principles of, 29–33
using intermaxillary non-compliance appliances, Resistant Device on, 247f biomechanical considerations of, 29–33
190 Maxillary prognathism, treatment of, 112 care, postoperative instructions for, 284b
Mandibular anterior anchorage, in class II Maxillary protrusion clearance of, 274
malocclusion, 2–3 class II, division I malocclusion with, 192–193 clinical applications of, 64
Mandibular Anterior Repositioning Appliance cephalometric evaluation, 193t clinical studies for, 66
(MARA), 2, 8–9, 8f treatment course, 192–193, 193f commonly used, 59t
Mandibular crowding treatment results, 193 complications of using, 62–64, 258
minimal, 240–241 and severe anterior crowding, 224–225, 225f, composition of, 58
severe, 241–242 225t computer simulations for, 67–68, 67f–68f
290 Index

design and structural characteristics of, 42–46 neck, 41, 42f Miniscrew implant-supported distalization system
cutting flute, 45–46, 45f platform, 41–42, 42f (MISDS), 156–160, 158f
diameter, 42–43 surface, 41, 41f active unit of, 156, 156f
implant type, 43–44, 44f structure of, 39 advantages of, 159
length, 42 success rates of, 40–42, 281 anchorage unit of, 157
material, 46 for temporary skeletal anchorage, 58–65 case presentation, 157–159, 158f
shaft shape, 44–45 historical development in, 58 clinical procedure for, 157–159, 157t
thread design, 45, 46f terminology for, 58 discussion in, 159, 159f
thread pitch, 45, 45f thread of, 60–61 treatment with, 157–159
designs of, 60–61, 66–68 in treatment of class II malocclusion, MIP. see Mainz Implant Pendulum (MIP)
diameter of, 61, 274 134–138 MIs. see Miniscrew implants (MIs)
extra-osseous part of, 69, 69f with extractions, 151 Misch’s classification, of bone densities, 89f, 89t
failure of, 63 treatment with MISDS. see Miniscrew implant-supported
rates, 66, 281 ability to treat all types of malocclusion, 71 distalization system (MISDS)
fracture of, 63–64, 282–283, 283f acceptance of, 71–72 Modified acrylic resin Nance button, 106
head of, 60, 60t convenient timing for, 71 Molars
exposure of, 269 economical/affordable care delivery for, 71 anchorage of, during space closure, 25, 25f, 26t
injuries to adjacent structures from, 63 efficient, 71 buccal tipping of, control of, 154f
insertion torque, 269 expectations for, 71 distal movement of, anchorage during, 25, 26t
intra-radicular sites for, 219–220, 219f ideally pain-free, 71 distalization of, 147–148, 148f
length of, 61 minimal time spent in the dental surgery for, with MGBM system without extractions, 151f
level arm and, 135–136 71 Molar distalization, 139, 140f, 143, 144f, 161
liability issues in, 284–285 preferences for, 72, 73f biomechanics, 119–122, 120f
loading of, 62 unobtrusive, 71 for class II malocclusion, 212–213, 214f
location of, and treatment planning, 281–282, types of anchorage and, 62 using bone anchorage, 229–234
281f unilateral maxillary molar distalization with, magnets used for, 14
maxillary molar distalization with, 136–138, 136f, 233–234, 233f with miniscrew implants, 232–234
229–230, 229f, 232–234 use of predrilling for, 68 with palatal implants, 230–231
mesially extended transpalatal arch with, 135, 135f used as temporary anchorage devices, success rates/ with zygomatic anchorage, 231–232
micromovement of, 283f risk factors of, 258–273 Molar protraction/mesialization, 141, 142f
mobility of, 271 assessment of, 258–261, 258f, 259t–260t conventional approach for, 142f
N1 vs. N2, 43f used for orthodontic anchorage reinforcement Mucoperiosteal flap, 254f
neck of, 60 advantages of, 64 Mucosal thickness, miniscrew implant insertion and,
non-compliant distalization systems used with, disadvantages of, 64 87–88, 88f–89f
134–136 using Kim’s stent, 99–100, 99f Multiloop edge-wise archwire (MEAW) technique,
non-self-drilling, 83 evaluation of, 100 235, 235f
optimal positioning of, surgical guides for, 101–103 in vitro studies for, 66–67, 67f
conventional, 101–102, 102f Miniscrew implant insertion, 83–84, 283
stereolithographic, 102–103, 102f–103f complications of, 278–280 N
overinsertion, 283f direction of, 84
placement of ease of access to sites, 87 Nance appliance, with coil springs, 12–13
in the mandible, 269–270 finite element modeling of, 90f Neck, of miniscrew implant, 39
in the maxilla, 269 infection control after, 85 characteristics of, 41, 42f
post-insertion risks/complications of, 284 inter-radicular space considerations for, 85, 85f New Anchor Plus miniscrew implants, 35t
primary stability of, 42–46 mandibular sites, 90 New distalizer, 15
properties of, 62 manual, 83, 83f Ni-Ti push-coil spring, GISP with, 125
region of placement of, 269 maxillary sites, 88–90 Non-compliance appliances, for class II malocclusion
reinstallation of, 271 mode of, 61 management
removal of, 85–86, 86f palatal sites for, 90f advantages/disadvantages of, 19–20
in retraction of premolars and canines, 148–149, position for, 190 characteristics/classification of, 6–11
149f preparations before, 83 indications/contraindications for, 18–19
risk factors associated with failures, 261–271, reference points for, 88f mode of action of, 15–18
261f–262f risks/complications of, 282–283 Non-compliance approaches, for management of class
clinician-related, 264–265, 264t between roots of maxillary second premolar and II malocclusion, 6–21
insertion-related, 265–269, 267t–268t first molar, 97–100 Non-compliant distalization systems, used with
miniscrew-related, 265, 266t selecting a suitable site for, 87–93, 87t miniscrew implants, 134–136
outcome-related, 271, 271t anatomical characteristics, 90–92 Non-endosseous implants, 32
patient-related, 262–264, 263t bony tissue characteristics, 88–90 Non-extraction treatment, for protrusion of maxillary
treatment-related, 270–271, 270t presurgical diagnosis for, 92 anterior teeth, 220, 220f, 220t
root and bone response to proximity of, 274–277 soft tissue characteristics, 87–88 Non-osseointegrated anchorage systems, 22–23
root contact with, 274 sites for, 68, 213f, 281–282 vs. osseointegrated, 23
selection of, 66–70 positioning guides for the radiological evaluation
self-drilling, 83 of, 94–96
sites for placement of, 84–85, 84f, 84t soft tissue considerations for, 85 O
for skeletal origin gummy smiles, 196–197 in TopJet distalizer, 179
advantages of, 203 using Kim’s stent, radiographic evaluation of, 99, Oblique insertion direction, 85
case examples, 197–203 99f Occlusal interferences, risk factor of miniplates,
in skeletal Pendulum-K appliance, 183, 184f Miniscrew implant-supported anchorage 254
splinted, use of, 270 biomechanics of en masse retraction, 140f Occlusograph, in Aarhus anchorage system, 143
stability of, 283 mechanics of class II malocclusion compensation Onplant bar, maxillary molar distalization with, 24f
structural characteristics of, 41–42 with, 139–142 Onplant system, 22, 22f, 49
diameter, 41 Miniscrew implant-supported biomechanics, altering design, 49
length, 41 the smile line with, 204–210 insertion site and surgical procedures of, 49
 Index 291

Open bite Orthopedic anchorage, 48 Pendulum B appliance, 174–177

adult with, miniscrew implant-supported treatment Orthosystem implants, 22, 22f, 49–51 case example of, 175, 176f
of, 235–236, 236f design of, 50, 50f clinical application of, 174–175
anterior, and protrusion, 216–217, 216f, 217t impression procedure and construction of discussion, 175–177
control of vertical dimension, 154, 154f–155f suprastructure, 51, 51f Pendulum springs
and impaired masticatory function, 236–237, 237f, insertion site and surgical procedures of, 50–51, of Mainz implant pendulum
237t 50f–51f unwanted effects of, 105
and poor smile, 206 Osseointegrated anchorage systems, 22, 23f with palatal miniscrew implant, 134, 134f
treatment progress, 206, 207f vs. non-osseointegrated systems, 23 of Quad Pendulum, 105
treatment results, 206 Osseointegrated implants, 58, 59f Penguin Pendulum appliance, 11f
severe, with difficulty in lip closure, 237–238, 238f Osseointegrated palatal implants, 230 Peri-implant bone, ultrastructural analysis of, 30
Operator, miniscrew implants and, 282 Osseointegrated palatal onplants, 230 Peri-implant soft tissues, inflammation of, miniscrew
Oral hygiene, miniscrew implants and, 264, 284 Osseointegrated titanium implants, 279 implants and, 271
Ortho Anchor System, 244–245 Osseointegration Peri-implantitis, 284f
Orthodontic anchorage in bone response following insertion of miniscrew Periapical radiography, miniscrew implant insertion,
implants for, 104–105 implant, 276, 276f using Kim’s stent, 99f
orthodontic miniplates for, 78, 78f of orthodontic miniscrew implants, 35 Pericytes, 31
reinforcement, miniscrew implants for, 64 in palatal implants, 109 Periodontal ligament, 274
success rates, risk factors and complications of, principles of, 29–30 Periodontal/temporomandibular joint problems,
252–257 for skeletal anchorage purposes, 58–60, 59f miniscrew implants and, 264
using locking plate and self-drilling miniscrew Osteoblasts, 31, 31f Physical/dental statuses, miniscrew implants and, 264
implants, for posterior maxilla, 55–57 Osteoclasts, 31, 31f Pilot drilling, 83
advantages of, 55 Osteodentin, 275 Pilot hole, dimension of, miniscrew implants and,
indications of, 55 Osteogenesis, distance and contact, 30–31 268–269
insertion technique, 55, 55f–56f Osteon, secondary, evolution and completion of, Piston appliance (Greenfield Molar Distalizer), 14
Orthodontic appliances 31f Plaster cast, of dental arch, 101
acting as substitutes for elastics, 11 Overbite, deep Plateau root-shaped (PRS) implants, 29, 30f
with a double flexible distalization force system and gingival display, 208–209, 209f Platform, of miniscrew implant, 41–42, 42f
positioned both palatally and buccally, 14 treatment of, 207–208, 208f Plunger, 249
with a flexible distalization force system Poor smile, open bite and, 206
buccally positioned, 13–14 treatment progress, 206, 207f
palatally positioned, 11–13 P treatment results, 206
with a rigid distalization force system palatally Positioning gauge, in Kim’s stent, 97
positioned, 14–15 Pain fabrication of, 98, 98f
Orthodontic bone anchors (OBAs), C-type, 239–240, complications of miniplate placement, 255 Positioning guides, for radiological evaluation of
240f miniscrew implant treatment and, 72 miniscrew implant insertion sites, 95–96
Orthodontic forces Palatal appliances, 2 Posterior-based mucoperiosteal flap, 118, 119f
after miniplate placement, 252 Palatal arch, preactivation of, in skeletal Pendulum-K Posterior maxilla, orthodontic anchorage using
miniscrew implants and appliance, 184, 184f locking plate and self-drilling miniscrew
loading of, 270 Palatal bone, for orthodontic implants, 230 implants for, 55–57, 57f
magnitude of, 270 Palatal coil spring systems, 105 Posterior teeth, distalization of, 139–141
Orthodontic implants Palatal implants, 48, 49f, 74f Power module, in TopJet distalizer, 178, 178f
for correction of class II malocclusion, 104–108 connection to, 109–110, 109f–110f Predrilling, use of, for miniscrew implants, 68
dimensions of, 104f indications for, in class II malocclusion treatment, Prefabricated distalizers, 181–182
inserted in the palate, 74, 74f 52–53 Preferences, for miniscrew implant treatment, 72,
insertion of, 74–77 in maxillary molar distalization, 231f 73f
bone quantity and localization of, 76 with GISP, 127 Premolars
preoperative diagnostics of, 74–76 molar distalization with, 230–231 extraction of, 3
surgical, in palate, 76–77, 76f results of, 231 retraction of, 148–150, 149f
removal of, 77, 77f treatment progress of, 230 with MGBM system without extractions, 151f
Orthodontic loading, miniscrew implants and, 63 with Pendulum appliances Pretapped miniscrew implants, 43
Orthodontic Mini Implant, 58 advantages of, 107–108 Protrusion, of maxillary anterior teeth, 217, 217t,
Orthodontic miniplates Straumann Orthosystem as, in class II 218f
insertion of, 78–82 malocclusion, 109 extraction treatment for, 220–222, 221f, 222t
on apertura piriformis, 80, 80f–81f Palatal miniscrew implant, pendulum springs with, non-extraction treatment for, 220–222, 220f, 220t
on retromolar (angulus) area, 81–82 134, 134f Pure orthodontic implant anchorage, 48
for symphyseal anchorage, 80–81 Palatal mucosa, cylinders perforating, 124, 124f Push rod hook, 245–246
for zygomatic anchorage, 78–80, 79f Palate, orthodontic implants inserted in, 74, 74f
removal of, 82, 82f Palatine neurovascular bundle, 91
types of, 78 Panoramic radiograph, of miniplate insertion, Q
Orthodontic miniscrew implants 247f
biomaterial properties of, 34–38 Patient’s age, risk factor of miniplates, 254 Quattro screw, 196–197
design principles of, 34, 34f Paul Gjessing (PG) springs, 113, 113f
electrochemical properties of, 37–38, 38f Pendex appliance, 11f
materials in, 34–35, 35f, 35t Pendulum appliances, 11–12, 11f, 105 R
structure and mechanical properties of, 39–47 bone-anchored, 186–188, 186f
surface characterization of, 35–37, 35t, 36f–37f, 37t case presentation in, 186–187, 187f Radiography
Orthodontic-prosthetic implant anchorage, 48 clinical application of, 186–187 lateral cephalometric, in orthodontic implants
Orthodontic tooth movement, type of, miniscrew comprehensive treatment outcomes, 188 insertion and removal, 74, 75f
implants and, 271 removal of, 186 periapical, miniscrew implant insertion, using
Orthodontics vs. conventional Pendulum appliance, 187t Kim’s stent, 99f
significance of anchorage in, 22–28 palatal implants with Ratchets, 83
use of implants as skeletal anchorage in, 48–54 advantages of, 107–108 Retentive plate, 245
 292 Index

Retraction Simultaneous maxillary molar distalization system Stress intensity, distribution of, in miniscrews, 68f
of anterior segment, in degenerated dentition, (SUMODIS), 147–148, 148f Subperiosteal implants, 32
143–144, 144f Single slot, head design of miniscrew implants, 60t Surface modeling, 31
forces, balancing of, against posterior unit, 2 Sinus perforation, 255 Swelling, complications of miniplates used for
of incisors, 150–151, 150f Skeletal anchorage, 22, 112 orthodontic anchorage, 254, 255f
of maxillary incisors, 152, 153f historical development of, 58 Symphyseal anchorage, orthodontic miniplates
of premolars and canines, 148–150, 149f implants as, 48–54 insertion for, 80–81, 81f–82f
Retroclination, of incisors, 231 in lingual orthodontic treatment with sliding Symphyseal bone anchorage, class II correction with
Retromolar (angulus) area, miniplates on, 81–82, mechanics, 219–222 fixed functional devices using, 129–133
82f case examples, 220–222 clinical presentations of, 130–132
Retrusion force vector, zygoma anchors and, 114 clinical application of, 219–220 discussion of, 132
Reverse smile line, 206 temporary, miniscrew implants for, 58–65 Symphyseal miniplate anchorage, 116, 117f
Rigid distalization force system, palatally positioned, Skeletal anchorage devices, risk management of,
appliances with, 14–15 281–285
Rigid intermaxillary appliances, 6–9 Skeletal Anchorage System, 244–245 T
Ritto appliance, 8, 8f Skeletal Frog Appliance, 183
Roots see also Skeletal Pendulum-K appliance Teeth, loss of, 278
damage of, 255 Skeletal Pendulum-K appliance, 183–185 Temporary anchorage devices, 32–33, 225
healing of, 275 case example for, 184, 185f for class II malocclusion correction, 143–146
healing versus non-healing, 275, 276f clinical application of, 183–184, 184f extraction treatment for alleviating anterior
pulp damage and response, 275, 276f abutments, choosing of, 183 crowding, 145, 145f
impingement of, 252 alginate impression, taking of, 183 intermaxillary forces to advance the mandible as,
injuries of, miniscrew implants and, 282, 282f intraoral mounting of, 184 145–146, 146f
proximity of, 253 laboratory fabrication procedure, 183–184 molar distalization, 143, 144f
resorption of, after contact with miniscrew miniscrew implants, 183 retraction of anterior segment, 143–144, 144f
implants, 274, 275f preactivating palatal arch, 184, 184f miniscrew implants used as, 258–273
response of, with miniscrew implants, 274–275 clinical considerations for, 184 risk factors associated with failures, 261–271,
uprighting of, 121–122 components of, 183f 262f
Root contact Sleeve positioner, 101, 102f Twin Force Bite Corrector with, 249–251
associated with MI failures, 270 Sliding mechanics, for treatment of class II Temporomandibular joint disorders, 211
with miniscrew implants, 274, 275f malocclusion, 219, 219t TFBC. see Twin Force Bite Corrector (TFBC)
extent of damage/prevention methods in, 274 Smile, habitual asymmetric, 209–210, 210f Thomas miniscrew implants, 35t
risk factors of, 274 Smile line Thread, of miniscrew implants
Roth multibracket system, 233 accompanying short face height, 204–206 design, 45, 46f, 265
Round Australian wire, molar distalization treatment progress, 204–206, 204t, 205f–206f diameter, 265
biomechanics, 120 treatment results, 206 length, 265
Round tripping, of incisors, 120 altering of, with miniscrew implant-supported pitch, 45, 45f
biomechanics, 204–210 shape, 265
deviated, improving, 209–210 surface, 265
S Smoking, miniscrew implants and, 263 Tissues
Soft tissues irritation of, miniscrew implants and, 62–63
Sabbagh Universal Spring appliance, 10, 10f correction, with zygoma anchors, 115 quality, quantity and age-related differences of, 88,
Sagittal skeletal relationships, miniscrew implants inflammation of, risk factor of miniplates, 253–254 89f
and, 263 for miniscrew implant insertion, 85 type of, miniscrew implant insertion and, 87
Sandblasted and/or acid-etched implants, 31 miniscrew implants and, 269–270 Titanium alloys
Schneiderian membrane, 278 preparation, for miniscrew implant insertion, 83 miniplates, 129
Screw root-shaped (SRS) implants, 30f punch, 72, 73f in miniscrew implants, 58
stress distribution of, 32 Space, in miniscrew implant insertion, 90–91, 91f Titanium miniplates, 78, 78f
studies of, 29, 29f Spider Screw anchorage system, 147–155 TMA spring, 125
Screw-to-root contact, risk factor of miniplates, 253 brackets used for bidimensional technique in, 147t TOMAS punch, 73f
Screwdrivers, for miniscrew implants insertion, 83, control of vertical dimension, 152–155 Tooth-anchoring system, 229–230
83f deep bite, 154–155 Tooth movements, 212
Screws, primary stability of, lack of, 253 open bite, 154, 154f–155f effect on esthetics, function and safety, 211t
Sectional Jig assembly, 13–14, 14f Spider Screw K1, 147f interference with, 256, 256f
Segmental distalization, using miniscrew implants, Spider Screw miniscrew implants, 23f, 34f, 35t, TopJet distalizer, 178–182
213 36f–37f, 37t adjustment module of, 178
Segmented arch mechanics, for class II malocclusion Splint, vacuum formed, 95 advantages of, 181–182
treatment, 2 clinical application of, 95, 96f clinical application of, 179–181
Self-drilling miniscrew implants SRS implants. see Screw root-shaped (SRS) implants distalization mechanics of, 178f
advantage of, 61 SS archwire, GISP with, 125 distalizing force of, 178–179
orthodontic anchorage using, for posterior maxilla, SS closed coil spring, molar distalization insertion of, 179, 180f
55–57, 55f–57f biomechanics, 120, 120f power module of, 178, 178f
Self-ligating Miniscrew, 155f SS segmented wire, molar distalization biomechanics, removal of, 180
Self-tapping miniscrew implants, 43, 44f, 61 122 TopJet 360, 179
Sequential distalization, 189 Stability, primary/secondary, of miniscrew implants, transpalatal arch, 178–179
Shaft shape, of miniscrew implants, 44–45 283 versions of, 179, 179f
Shank, of miniscrew implant, 39, 40f Standard miniplates, 78, 78f Torque magnitude, in miniscrew implant insertion,
Short face height, improving smile line Stenson’s duct orifice, 78–79 83–84
accompanying, 204–206 Straumann Orthosystem TPAs. see Transpalatal arches (TPAs)
treatment progress, 204–206, 204t, 205f–206f implants, 50f Trabecular bone, remodeling of, 31
treatment results, 206 as palatal implant, in correction of class II Transgingival neck, of miniscrew implants, 60
Side of placement, miniscrew implants and, 269 malocclusion, 109–111, 109f Transpalatal arch plus hooks (TPA-PH) device,
Silicon impression, 109 Straumann Palatal Implant, 76 189–190, 191f
 Index 293

Transpalatal arches (TPAs), 52, 52f, 247f

connected to palatal implants, 109–110, 110f V Z
in conventional anchorage, 23–24, 24f
insertion of, in TopJet distalizer, 179 Vacuum formed splint, 95 Zygoma anchorage
intraosseous screw in conjunction with, 135, 135f clinical application of, 95, 96f for en masse retraction, 113
mesially extended, with miniscrew implants, 135, Vector-TAS miniscrew implants, 34f, 35t, 36f–37f, 37t miniplate, for class II malocclusion treatment,
135f Veltri Distalizer, 15 112–114
for molar rotation/distalization, 15 Verbal rating scale (VRS), miniscrew implant Zygoma anchors, 113, 113f
in TopJet distalizer, 178–179 treatment and, 72 controlling vertical component of the force vector
Transpalatal bars, in conventional anchorage, 23–24, Vertical component of force vector, controlling, with, 114–115, 114f–115f
24f zygoma anchors with, 114–115, 114f orthopedic and soft tissue correction with, 115
Trepan bur, 77, 77f Vertical depression, in gingiva, 101, 101f Zygoma plates, 79–80, 112
Tubing system, of AMDA, 160, 160f Vertical skeletal relationships, miniscrew implants Zygomatic anchorage
Tweed-Merrified approach, for class II malocclusion and, 264 molar distalization with, 231–232
treatment, 2 von Mises stresses, 68f orthodontic miniplates insertion and removal,
Twin Block, for class II malocclusion treatment, 2 78–80, 79f
Twin Force Bite Corrector (TFBC), 10f, 11, 249 Zygomatic crest
biomechanics, 249f–250f W miniscrew implant insertion in, 278f
case example, 251f thickness, 278–279
for Class II correction, 249–251 Wires Zygomatic miniplates, 231
with miniscrew implant anchorage, 251f for fabrication of Kim’s stent, 98 maxillary molar distalization with, 231–232, 232f
with temporary anchorage devices, 249–251 sequence Zygomaticomaxillary buttress, 231
Two-screw miniplate, 253f for extraction treatment for protrusion of
Two-stage space closure, in class II malocclusion, 2 maxillary anterior teeth, 222t
for non-extraction treatment for protrusion of
maxillary anterior teeth, 220t
U Woven bone, 30

Unilateral distalization
for correction of class II malocclusion, 110, 110f X
of maxillary molar, 163f, 164–166, 165f
treatment, 164–166 X-ray pins, 94–95, 94f
TopJet distalizer for, 180–181, 181f clinical application of, 95, 95f
Upper lips, position of, in Class II malocclusion, 1 palatal use of, 95, 95f