Temporary Anchorage Devices

IN ORTHODONTICS

Temporary Anchorage Devices

IN ORTHODONTICS

Ravindra Nanda, BDS, MDS, PhD UConn Orthodontic Alumni Endowed Chair Professor and Head

Department of Craniofacial Sciences Chair, Division of Orthodontics School of Dental Medicine

University of Connecticut Health Center Farmington, Connecticut

Flavio Andres Uribe, DDS

Assistant Professor

Division of Orthodontics Department of Craniofacial Sciences School of Dental Medicine

University of Connecticut Health Center Farmington, Connecticut

ELSEVIER

MOSBY

ELSEVIER

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Contributors

Ahu Acar, DDS, PhD Associate Professor Department of Orthodontics Faculty of Dentistry Marmara University Istanbul, Turkey

Martin Kunkel, Prof Dr med, Dr med dent Senior Consultant

Department of Oral and Maxillofacial Surgery Johannes Gutenberg-University Mainz

Mainz, Germany

George Anka, DDS, MS Associate Professor

Department of Orthodontics Nihon University Dental College Tokyo, Japan

Head Orthodontist

Sekido Orthodontic Office Tama-shi, Tok-yo, Japan

Morten Godtfredsen Laursen, DDS Clinical Assistant Professor Department of Orthodontics University of Aarhus

Aarhus, Denmark

Certified Specialist in Orthodontics

Private and Community Orthodontic Practice Aarhus, Denmark

Peter R. Diedrich, Prof Dr Dr Department of Orthodontics University of Aachen

Aachen, Germany

Kee-Joon Lee, DDS, PhD Assistant Professor Department of Orthodontics College of Dentistry

Yonsei University

Seoul, Korea

Nejat Erverdi, DDS, PhD Professor

Department of Orthodontics Faculty of Dentistry Marmara University Istanbul, Turkey

James Cheng-Vi Lin, ODS Clinical Assistant Professor

Department of Orthodontics and Pediatric Dentistry School of Dentistry

National Defense Medical University Taipei, Taiwan

Attending Orthodontist

Department of Orthodontics and Craniofacial Dentistry

Chang Gung Memorial Hospital Taipei, Taiwan

Dr. James Lin and Associates' Orthodontic and Implant Center (private practice)

Taipei, Taiwan

Ulri.ke B. Fritz, Prof Or Department of Orthodontics University of Aachen Aachen, Germany

Peter Goellner, Or med dent Department of Orthodontics University of Berne

Berne, Switzerland

Private Orthodontic Practice Berne, witzerland

Eric [ein-Wein Liou, DDS, MS Associate Professor Department of Orthodontics

Graduate School of Craniofacial Medicine Chang Cung University

Taoyung, Taiwan

Associate Professor and Director

Department of Orthodontics and Craniofacial Dentistry

Chang Cung Memorial Hospital Taipei, Taiwan

Britta A. lung, Or med dent Department of Orthodontics Johannes Gutenberg- U niversity Maim:

Mainz, Germany

Ryuzo Kanoml. DOS, PhD Private Practice, Orthodontics Himeji, Japan

Hiroshi Kawamura, DDS, DOSe Professor and Chair

Department of Maxillofacial Surgery Tohoku University

Sendai, Miya,gi, Japan

vii

viii Contributors

Blrte Melsen, Dr Odour, DDS Professor

Departm nt of Orthodontics University of Aarhus

chool of Denrlstry Aarhus, Denmark

Kuniaki Mil'ajim3, DDS, MS, PhD Adjunct Professor

Depanment of Orthodontics

St. Louis University Center for Advanc d Dental Education

St, Louis, MissoW"i

Hiroshi Nagasaka, DDS, DOSe Clinical Professor

Department of Maxillofacial Surgery Tohoku University

Sendai, M1yagi, lapan

Director

Department of Oral Surgery Miyagi Children's Hospital Sendai, Miyagi, lapau

Ravindra Nanda, BDS, MDS, PhD

UC<:ll1n Orthodontic Alumni Endowed Chai!' Professor and Head

Department of Craniofadal Sciences Chair, Division of Orthodontics School of Dental Medicine

University of Connecticut lleahh Center Parmillgton, Connecticut

Makoto Nlshimura, DDS, DOSe Pa rt-Ti me lecturer

Division of Oral Dysfunction Scien e

Department of Oral Health and Development Sciences Graduate School of Denristy

1'ohoku University

Sendai, Japan

Orthodontic Faculty

SAS Orthodontic Centre

Ichiban-cho Dental Office

Sendai, Miyagi, Japan

Hyo-Sang Park, DDS. MS, PhD Associate Professor

Depa runeru of Orthodontics Kyungpock National Llniversity School of Dentistry

Daegu, Korea

Clinical Director in the Student Oink Department of Orthodonrics Kyungpook Unive:rsity Hospital Daegu, Korea

Young-Chel Park, DDS, PhD Professor and Dean Department of Orthodontics College of Dentistry

Yonsei University

Seoul, Korea

A. Korrodi Ritto, DDS, PhD Pri va te Prarti ce

leiria. Portugal

Jeffery A. Roberts, DDS, MSD Private Practice

Roberts Orthodontic;

I ndianapolis, Indiana

W. Eugene Roberts, DDS, PhD, DHC(Med} Iarabak Professor and Head

Section of Orthodontics

Indiana University School of Dentistry lndianapolis, Indian"

Associate Professor

Department of Oral and Maxillofacial Irnplantology University of Lille II

Faulity of MedionI'.

Lille, France

Iunji Sugawara, DDS, DOSe Visiting Clinical l'rofessor

Division of Orthodontics Department of Craniofacial Science School of Dental Medicine University of Connecticut Farmington, Connecticut

Director

SAS Orthodontic Cerure lchiban-cho Dental Office Sendai, Miyagi, lapen

Flaviu Andres Uribe, DDS Ass i S tarn Pro fessor

o [vision of Orthodoruics Department of Craniofacial Sciences School of Dental Medicine

University of Connecticut Health Center Farmington. Connecticut

Serdar O~i.imez, DDS, PhD Associate Professor and Chair Deparunent of Orthodontics Caziantep University

Fuculty of Dentistry Caziaruep, Turkey

Sunil Wadhwa, DDS Assis ta nt Pro fesso r

Department of Craniofacial Sciences U ni versi ty 0 f CO!l nectkut

School of Dental Medicine Farmington. Connecticut

Contribu tors i x

Heiner Wehrbein, Prof Dr rned, Dr rned dent Professor and Head

Department of Orthodontics

Johannes Gutenberg-University Mainz

Mainz. Germany

Preface

Patient compliance, anchorage preservation, and lack of anchor units often present a perplexing problem for orthodon lists, mainly because of a lack of effective devices. Headgear, which is used to CO ntro I anchorage and requ ires patient cooperation, is a device that bas been used in orthodontics for at least 100 years. Despite longevity in the field, however, the use of headgear has enjoyed only moderate success. In recent years. with the introduction of temporary anchorage devices (TAOs j, a paradigm shift has occurred ill the overall perspective toward patient compliance, preservation of anchorage. and facilitation of treatment for various difficult malocclusions. As happens with every innovation, the learning curve is steep as a result of lack of evidence-based prospective studies related to stability, appl ications, and long-term results.

No one person can claim to be an expert in theapplication ofTADs, since the tech nique is young and results are still short term. For this reason, 1 invited clinicians who have been instrumental in pioneering this technique to participate in the creation of this book They have helped me to compile a book that is clear and concise in describing some of the basic principles involved in the application of TADs for different types of malocclusions. The book is nOL designed to be an exhaustive compendium of ever), application of TAOs that bas been reported. Instead, the primary emphasis is on the detailed descrtpuon of methods thai have been shown to be successful and have the potential to become mainstream in clinical orthodontics. The text will appeal LO both academics and clinicians. since equal importance has been given to both theoretical and practical aspects. Each chapter covers its topics in great detail and is accompanied by extensive lllustrations and references.

ORGANIZATION

Part I, Biological Perspective, addresses the use of endosseous rniniscrews and the biological response to TAOs. Chapter 1 reviews the historical perspecti ve of implant development relative 10 the current concepts of bone physiology, surgery, heal mg, and Integration. It is written 10 help cl in icians develop a scientific perspective for th e effective use of rniniscrews. Chapter 2 looks at bone biology and the factors that predict stability behind median ically retained and osseous-integrated orthodontic TADs.

Part II, Diagnosis and Treatment Planning, looks at these aspects for orthodontic cases that requi re skeletal an horage. Chapter 3 reviews ideal SiLl'S £0£ the placement of mini-implants and how to apply orthodontic force using three-dimensional fin ite element

models (3D FEM). Chapter 4 provides a unique perspective of the K-l system, since the chapter author designed the K-l System. Chapter ~ details what factors should be addressed when deciding to use skeletal anchorage, including the indications for when skeletal anchorage should be used and the possible failures and adverse effects.

Part 1)1, Biomechanics Considerations, offers pragmatic discussions regarding the application of sound biomechanical principl s involved in moving teeth with the help of skeletal anchorage. Chapter 6 addresses the fundamental biomechanical principles of miniscrew-driven orthodontics and explains the practical application of these principles. Chapter 7 reviews different clinical scenarios in which skeletal anchorage may provide an advantage to conventional treatment mechanics.

Part IV, Anchorage Device Systems and Clinical Applications, explores the different types of anchorage device systems and the "clinical applications" of these systems, with an emphasis on practical applications and avoidance of common mistakes and pitfalls. Chapter 8 addresses the appliances, mechanics, and treatment strategies for orthognathic-Iike orthodontics in Class J and II dentoalveolar protrusion, Class III dentoalveolar protrusion, anterior open bite, and ClassIl mandibular retrognathism, Chapter 9 details the management of the occlusal plane using TADs and looks at the dimensions of occlusal plane in space and force application and devices. Chapter 10 reviews the treatment lirnitations that come with missing teeth, tooth movement using TAOs, and congenital missing teeth. Chapter 11 addresses various methods for bone anchorage, induding microimplants, resorbable screws, bracket headtype microimplants, and noninvasive mlniplates, Chapter 12 provides information on mini- or microscrew implants. Chapter 13 detai Is the advantages and disadvantage of H ing titanium rnicroscrews, as well as screw design, implant insertion, typical implant sites, complications, and failure rates. Chapter J 4 looks at the use of conventlonal dental implants versus TADs for orthodontic anchorage,

Part V, Skeletal Anchorage, concludes the book by looking specifically at the different aspects of skeletal anchorage. Chapter 15 addresses the features of orthodontic rniniplates and screws, indications for skeletal anchorage systems (SAS) treatment. timing of treatment, positioning of mlniplates, orthodontic mechanics ofSAS, and surgical procedures for implantation and removal of nuniplates. Chapter 16 details the clinical use of different orthodontic implants to orrect different malocclusions. The treatment methods presented in this chapter are compared with the conventional method and the benefits of the implant method are clarified.

xi

)(il Preface

Chapter 17 reviews the anatomical considerations in palatal implant placement, radiographic evaluation of bone height at the implant site, preparation of the surgical template for positioning the implant, the surgical method, eva I uation of the i rnplant placement method, and various orthodontic mechanics used with palatal implarus. Chapter 18 looks ar commonly used skeletal orthodontic anchorage devices and discusses their clinical use and potential benefits. Specifically, the chapter focuses on the use of palatal implants for orthodontic treatment tasks.

CONTRIBUTORS

The authors who have contribute I to this book are linicall), active; many of them are engaged in clinical and laboratory research in bone biology, tooth movement,

clinical orthodontics, and biomechanics. Therefore, most of the arguments put forward in this textbook are based on current research findings. However, when conclusive vidence was not available, we presented a consensus founded on a signi ficant depth of experience and available scientific data.

NOTE FROM THE EDITOR

-I was fortunate to work with a group of authors who are among the most prcminent in the field of orthodontics. We hope that our efforts will serve as a sri mulus [or further research in til is i nrreasi '1gly irnporta n t area of clinical orthodontics and also provide the muchneeded impetus toward general acceptability ofTADs in day-to-day orthodontics.

Ravindra Nanda

Acknowledgments

lowe a heartfelt thanks to my contributors. Without their cooperation, this effort could not have come to fruition. They are innovators, scientists, and super clinicians in the truest sense, and they have helped to pioneer a new way to address the correction of malocclusions. I hope they will appreciate me final result and will forget about my constant pleas to meet deadlines.

Flavio Uribe deserves special recognition for help; ng me prepare this book during every stage of its development. I am very fortunate to have a colleague like him, who in his own right is a thoughtful e1ini ian and a prolific writer. A special thanks to Sunil Wadhwa for his advice and comments, which were easy to incorporate in development of the book

I also express my gratitude both to Gaby Hricko, who during her residency did exhaustive literature research mat was instrumental in helping me decide on potential contributors, and Madhur Upadhyay, who helped me in the final stages of preparing the manuscript, especially with proofreading of various chapters,

A book like this is no! possible without the encouragement of the publisher. I express my sincere thanks to Senior Editor John Dolan for taking up this project and helping me at every step, and my deep gratitude to Courtney Sprehe, my developmental editor, for being the driving force for this book from day one.

Ravindra Nanda

xiii

Contents

Part I Chapter I

Chapter Z

Part II Chapter 3

Chapter 4

Chapter s

Part III Chapter 6

Chapter 7

Part IV

BIOLOGICAL .PERSPECT.IVE

Endosseous Miniscrews: Historical, Vascular, and Integration Perspectives, 3 W Eugene Robens and. J elfe,y A. Roberts

Biological Response to Orthodontic Temporary Anchorage Devices, 14 Sunil Wadhwa "nd Raulnd'l1 Nanda

DIAGNOSIS AND TREATMENT PLAN.NING Radiographic Evaluation of Bone Sites for Mini·lmplant Placement, 25 Kumalli Miyajima

Miniature Osseointegrated Implants for OrthOdontics Anchorage, 49 RYllm Kanomi and W, Eugene Robens

Factors in the DeCision to Use Skeletal Anchorage, 73 Bine Me/sen and MOr/.ell Godtfredsen Laursen

BIO.MECHANICS CONSIDERATIONS Biomechanical Principles in Miniscrew·Driven Orthodontics, 93 You>1g·C/wl Park and Kee-loo« Lee

Skeletal Anchorage Based on Biomechanics, 145 Flauio AndTel U,-jbe and R~vindra Nand"

ANCHORAGE DEVICE SYSTEMS AND CLlN.ICAL APPLICATIONS

Chapter 8 Appliances, Mechanics, and Treatment Strategies Toward OIThognathic-Like Treatment Results, 167 Eric Jein·Wein LiQU and James Cheng-Yi Lin

Chapter 9 Controuec Occlusal Plane Changes Using Temporary Anchorage Devices, 198 George Anka

Chapter 10 Management of Missing Teeth Using Temporary Anchorage Devices. 223 George Anka

Chapter 11 Skeletal Anchorage: Different Approaches, 238 A_ Korrod i R i no

Chapter 12 Clinical Application of Microimplants, 260 Hyo-Sang Park

Chapter 13 Clinical Suitability of Titanium Microscrews for Orthodontk Anchorage, 287 UI rike B. Prlu: ~nd Psrsr R D jedrich

Chapter 14 Treatment Planning witll Endosseous Implants for Orthodontic Anchorage and Prosthodontic Restorations, 295

Flav,a Andres Uribe and Riwindra Nal1da

Part V S.KE.L.ETAL ANCHORAGE

Chapter 15 Skeletal Anchorage System Using Orthodontic Miniplates, 317

jUl1ji Sugmuam, Maiw/o Ni$hi",ura, HiTruhi Naga.saha, and Hiroshi Kawamura

Chapter 16 Bone Anchorage: a New Concept in ortnodomks. 342 Neja t Eru/Jrdiarid S erdar UJilm ez

Chapter 17 Palatal Anchorage. 374 Neja.t Erwrdi and An!, Acar

Chapter 18 Skeletal Anchorage in Orthodontics Using Palatal Implants, 392 Heiner Wei1rbein. Bl1tta A. lung. Marlin Kunkel, and Peter Ciiellner

PART I

BIOLOGICAL PERSPECTIVE

CHAPTER

£ndosseous Miniscrews: Historical, Vascular, and Integration Perspectives

W. Eugene Roberts and Jeffery A. Roberts

The explosive development of temporary anchorage devices (TADs) presents a professional dilemma ror orthodontists. Although a large body of evidence supparlE osseoimegrated anchorage, most rniniscrew and rnicrosrrew systems currently are not designed for osseous integration (osseoiruegration) and were marketed with little or no fundamental scientific venficalion, Clinical applications have superseded the scien tific rationale for weir effective use. III the absence of adeq uate (evidence-based) research, dinicians must rely Oil a I imited number of basic science studies, supplemented by scientific in terpolation or fundamental data derived from investigations of other types of endosseous i mplarus. H istorically, the current surge in miniscrews resembles the -inhial development of dental implants. At present the only reliable means for discriminating among rniniscrew systems is using the fundamental principles of bone biology, osseointegration. and blocompaubility. The "state of the art' is "d inician, beware."

This chapter reviews the historical perspective of implant development relative (0 current concepts of bone physiology, .surgery, healing, and integration .. The purpose is to help dlrudans develop asdennfic perspeclive for effective use of miniscrews, Bone physiological principles are important in selecting a device and developing a realis ti c pers pecuve fo r us i n gil effecti vel y to treat specific malocclusions. No single system is optimal for an clinical applications, The anchorage needs of each patient <l.r€ uniq ue because of the nature of'the malocclus ion. th e host response to ih e i nvas ive d evi ce( s ), and the biomecharucal approaches favored by the clinician.

DEFINITION AND DESIGN

The TADs compose a broad array of implants used to support orthodontic treatment .. As presently defined, all TADs. are in va si ve d evi ces a nd are b est reserved Jo r problems L\1al can not be effectively managed with

conventional mechanics (Figure l-L, A). The anchorage component may be a biocompatible wire attached to the endosseous base of an implant designed for prosthetic use. Furthermore, a nonfunctional osseointegrated implant may serve as an abutment for surgically assisted, rapid palatal expansion (Figure 1-1, 8). The products with the Icngest eli nical history of efficacy are csseointegraied fixtures originally designed for prosthetic pllrposes. ,.,

MOSI current rniniscrews are titanium (1l) or utanium alloy and are manufactured with a smooth, in achin ed surface tha l is no 1 desi gned to osseo i ntegra t e. By definition, TADs are temporary devices; no long-term functional or esthetic role is planned. Thus. most TADs arc removed afier onhodontic treatment. However, some osseormegrated TADs may be covered with soft tissue ('put to sleep") or retained for sustained prosthetic function (see Figure 1-1, B). At present, the most common TlIDs include rniniscrews, rnicroscrews, miniatlJr€ implants (mini-implants), palatal implants, modified bone plates, and retromolar implants, as well as functionally loaded prosthetic i rnplants. In addition, a TAD may be a temporary prosthetic component (e.g., bracket attached to gold crown) that is removed after treatment (Figure ]-2). Therefore, TADs can range lTom nonintegrated miulscrews to i rnplant-supported prostheses (ISPs 1 with temporary orthodontic attachments.

BACI(GROUND

Al the Bone Research Laboratory at we U niversi tY of Pacific -in San Francisco, the amh·ors performed a series of experiments to develop orthodontic anchorage devices. ',4·' Titanium mi n iscrews. 2 mrn in diam eier with an acid-etched surface, were tested in rabbits, dogs, and monkeys from 1980 \0 1988_ The devices were very predictable when placed in extraoral sites SUd1 as rabbit femur and nasal bones, ;.'.'.10 but we intraoral use of Lh~ min iscrews in dogs and monkeys W'dS less successrul (failure rate, -25%-50%). Failure was defined as

3

4 PART I Biological Perspective

Figure 1-1 A. Sever", Class 1Jl, partially edentulous malocclusion in 41-year-old woman complicated by insulin-dependent diabetes mellitus and end-stage renal disease. B, Left retromolar implant

(TAD) was used to align and move the third molar mesially to serve as an abutment for a

fixed prosthesis; it will be removed. Because of the pauenr' health problems, orthognathic

surgery was not a viable option. The compromise treatment in the maxillary arch was pre-

prosiheuc alignment (0 open space between the teeth and move the left segment mesially,

The right maxillary implant in the tuberosity region was original Iy a temporary anchorage

device (TAD), but it was retained [0 serve as a posterior abutment ror a removable partial

demure,

mobility or exfoliation of the anchorage fixture. Similar to current reports,' i-ra there were significant anatomical limitations relative to where rniniscrews could be placed. Funhermore, soft tissue irritation of cheek, tongue, and alveolar mucosa was a significant problem. TI)e biomechanical possibilities were compromised because of a lack of torsional resistance, particularly when immediately loaded. Unless miniscrews are osseointegrated, the roost reliable mechanics are for the line of force to pass through the implant, not ideal for treatment of most malocclusions. The use of lever arms to improve the line of force may result ill unfavorable moments on the implant.

It is important to note that (he limitations of the rniniscrews tested more than 20 years ago in the authors' laboratory are similar to the current predictability for these devices. U·11 Thus, it is apparent that the biological efficacy of miniscrews is Jagging the rapid increase in their clinical use. This scenario is similar to the initial development of dental implants before the welldocumented introduction of "osseointegration" in the early 1980s,"

The 2-mm, acid-etched Ti rniniscrews developed in the authors' laboratory were never used in pati ents because the i ntraoral ani mal data were considered inadequate to secure institutional review board (!RE) approval for a clinical trial. Because of the long history of clinical success without any serious complications (e.g., osteomyelitis, neoplasms), standard Branemark ( wed ish) prosthetic fixtures were adapted for orthodontic anchorage. These relatively large implants (3.75 x 7 mm) could not be placed in the alveolar ridge if space Insure and arch consolidation were the objectives of treatment (see Fig. 'I-L]. For mandibular anchorage,

the retromolar area was selected as the optimal site. Indirect anchorage evolved as the most effective mechanism for most applications' To a lesser extent, the tuberosity region of the maxilla has served as an osseous site for anchorage implants (see Fig, 1-1, B) A prospective clinical trial of implant anchorage demonstrated that osseointegrared anchorage is a highly reliable clinical procedure."

The mach ine tools and methods for manufacturing 11 and Ti alloy screws have improved dramatically in the past 20 years, as illustrated by the functional designs of suprarnucosal heads for many miniscrew systems. At present, the major problem with TADs is the inability to achieve osseointegration routinely with most current devices. To our knowledge, the osseo integrated K-l System (see Chapter 4) developed by Dr. Ryuzo Kanorni is the only osseo integrated miniscrew for orthodomic applicauon.f:" As miniscrew technology matures, other osseo integrated systems will likely evolve,

PERSPECTIVES

Dental implant anchorage has progressed from nonintegrated screws 11940SY to osseointegrated devices (1972 to present), The first documented use of osseo integrated. orthodontic anchorage apparently was in a patient treated from 1972 10 1975 by Dr. Tom Horton (Columbus; Georgia) and Dr. Hilt Tatum (Opelika, Alabama}, Dr. Horton corrected a buccal crossbite (scissors-bite) with a bite plate and cross-elastics anchored by an osseointegrated TI blade implant, custom-made and placed by Dr. Hilt Tatum, a pioneer in the field of implant dentistry. In addition to placing the first osseointegrated implant for orthodontic

Endmseou, Miniscrews: Historical. Vascular. and Integration Perspectives 5

c

Figure 1-2 Severe relapse of Class II. Division 1 malocclusion in 47-year-old brachycephalic woman, A deep-bile malocclusion was treated 35 years earlier with extraction of four first premolars.

A, Treatment required opening spaces to replace the mandibular premolars with implants,

B, Orthodontic brackets were artached to the wax pattern for the crowns before investing

and casting in gold. C, The crowns with attached brackets served as TADs for leveling and

finishing the mandibular arch, D. After treaunent the gold crowns were recovered and the

brackets removed with a Stone. The crowns were polished and retained as the permanent

prostheses,

anchorage. Dr, Tatum was the developer of the maxillary sinus bone graft procedure" and numerous other dental implant innovations.":"

The field of dental implantology originally embraced what was actually an osseolntegration "failure' (fibrous implant interface) with the serniphysiological term "pseudoperiodontium.Y"?" However, subsequent research demonstrated that the fibrous interface was actually avascular scar tissue; furthermore, mobile implants with a "pseudoperiodcntium" had a high failure rate. Titanium blade or cobalt-chromium alloy

(Vitallium) blade dental implants have had many years of functional service. Most favorable reports involve blades that achieved osseointegrarion despite being immediately loaded.":" The most reliable dental implant devices currently in use are osseointegrated systems. based directly or indirectly on the biological concept introduced by Branernark and his ccllegues. ,",," This developmental progression likely will repeat itself with respect to rniniscrews because osseointegration is a mature technology with high reliability, Extension of the biotechnology of

6 PART I Biological Perspective

osseciruegraticn to miniscrews would be all important advance [or TAD anchorage.

COMMON QUESTIONS

To frame the current development of rniniscrews in a dinical context, ir is helpful to address questions frequently asked by clinicians.

Are Miniscrews a New Concept in Bone Biology? No; there is a long history of similar devices in bone biology and Osseous surgery. Mlniscrews have long been used for auaching bone plates in orthopedic," plastic." onhognathic," and neurosurgical" procedures. The principal use of rnintscrews in orthognathic surgery is for attaching bone fixation plates to stabilize fractures and osteotomy segments. One of the first reports of clinical orthodontics using rniniscrew anchorage employed the screws typically used 10 attach bone plates."

Is Osseointegration an Important Goal for Miniscrew Anchorage?

Yes; for optimal reliability and stability. osseointegraticn has been a proven scientific concept in medicine and dentistry for more than three decades. Osseointegrated m in is rews have also s rved as anchorage for orthopedic devices if the 'therapeuticIoad is less than 3 newtons (N).'"'fo date, the only mini-implant (miniscrew) that attempts to achieve osseointegration routi nefy is the K-1 System of [(3nomtO,2Ll

Are Nonintegrated Mlniscrews an Important Step in the Progression to User-Friendly Osseointegrated Devices7

Yes; the wide interest in rninisrrews has focused the orthodontic profession on the importance. of 'rigid osseous' anchorage. Much I iterarure from outside the United Stales has failed to document the serious health risk associated with the clinical use of miniscrew TAOs. This safety data will assist North American investigators in securing ethical approval for future developmental studies at the. dinical level. Continuing research and development will provide improved products to serve 11. large. newly created market,

DENTAL IMPLANTS FOR ORTHODONTIC ANCHORAGE

In 1984, Roberts et 31' reviewed the Jueratur on the use of endosseous devices for orthodontic anchorage. The first eli nica I report of implant anchorage was in 1969 by Dr. Leonard Li n kow, '\I-I~ (The senior author has interacted with Dr. Linkow as a fellow faculty member at the Maxi I lofacial lmplantology Program. t.lnivershy of Lille, Faculty 0 Medicine. for more than 20 years.] Although not well known to orthodontists. Dr. Linkow pioneered many aspects of dental implants with respect to prosthetic dentistry and has rernai ned active in the field for more than 50 years, The blade implants origi .• nally used by Linkow and his orthodornic colleagues were limited in effectiveness because they were nOL

osseointegrated. Mobili.ty caused by the "pseudo periodontium' an he interface (scar tissue) probably limited the lifo expectancy of most blade implants used for orthodontic anchorage. Thus. it can be argued that the blade-anchored "irnplaruodonrics" of Linkow and his colleagues were indeed the first orthodontic TAOs that had the potential for long-term masticatory function. Importantly. blade-supported prostheses were the first devices to serve the critical function of restoring and maintaining theVe!1iCllI dimension of occ/w;ioll (VDO). ,0 correct and maintain the VDO in a patient with a partially edentulous acquired malocclusion, a TAD must resist masticatory loading and maintain the VDO at least during active orthodontic treatment (Figure 1-3). Most current miniscrews and other TAOs do not have the capability for restoring the VDO.

The first report of a surgical fixation screw for orthodontic anchorage was in 1983 by Creekmore and Eklund.H In 1990, Roberts et al.' published the first documented case report with posttreatment follow-up of an osseointegrated screw used for retromolar anchorage. Use of a nonintegrated miniscrew for orthodontic anchorage was first reported by Kanomi in 1997?" Much TAO literature has been published in the past decade and is reviewed throughout this text.

BONE VASCULAR CONSIDERATIONS

A schernatlc series of drawings based on histological studies·,;,7.'o is helpful for understanding the bone response to insertion of a Ti screw. A drawing of cortical bone with an internal trabecular network shows the fundamental osseous features: periosteum, cortical bone. trabecular bone, and marrow (Figure 1-4). The blood supply of trabecular bone and marrow is derived from transcortical vessels that traverse the (011"" in haversian and Volkmann canals.

Tn the mandible the vascular supply of the marrow and endosteal trabecular bone is primarily through the inferior alveolar artery. lnternal vascularity of the maxilla is provided primarily by transcortical branches of the greater palau ne and posterior superior maxillary arteries. Thus, the buccal and lingual cortices of the alveolar processes have a radial arterial system, meaning the arterial supply is through transcortical arteries that enter the endosteal space and supply capillaries that permeate the peripheral cortex. -11,e venous return for cortical bone is provided by the subperiosteal venous plexus (Figure 1·5)."

It is important to remember that any disruption of the periosteum. such as reflecting a mucoperiosteal flap, will compromise the venous return of the operated site. increase the size of the postoperative blood clot (potentially a hematoma), and decrease the localized healing potential. When placing a TAD, it is best [0 minimize the disruption of the mucoperiosteum by opening the operative site with a soft tissue punch rather than

E.ndo",eous Miniscrews: Historical, Vascular, and Integration Perspectives 7

)

~

Figure 1-3 Prosthodontist referred this 65-year-old female because her partially edentulous malocdu-

sion was "unrestorable." The verucal dimension of occlusion (VDOj was opened about I em

with fOUI osseoimegrared TAOs (3.75 x 4-mm Nobel Bincare Craniofacial Fixtu.res) support-

ing a bilateral temporary fixed prostheses that was removed after treatment. The patient's

occlusion was restored with bilateral fixed prostheses in the maxillary arch and a removable

partial denture in the mandibular arch, Note that the restoration of me VOO and maxillary

space closure was associated with more Inferior repositioning of the maxilla and mandible.

In addition, the mandible increased about 4 rnrn in length over the 36-month course of

treatment.

making an incision and raislng a mucoperiosteal flap. To avoid mucosal trauma, the punch should be of a sl ightly larger diameter than the surgical instruments used to prepare the mlniscrew Sill' (Figure loG). The trend to limit periosteal disruption when placing miniscrews parallels the current emphasis on flapless implant placement.' ... ' Three-dimensional (3D) imaging of the implant site is particularly important for flapless implant placement."

PRESURGICAL ASSESSMENT OF MINISCREW SITE

A critical presurgical consideration is selection of a site with adequate bone to support a rniniscrew.":" Schnelle ei al'o digitally assessed pretreatment and posttreatment panoramic radiographs and found that the most favorable sites for miniscrew placement were at the midroot level mesial to the maxillary first molars

and mesial or distal. to mandibular first molars. Other studies have shown that panoramic radiographs are unreliable for demonstrating osseous structure" or axial ind ination of teeth" because they are two-dimensional (10) compressions of distorted 3D projections.":" Panoramic imaging has been used for determining relative bone thickness" but is notoriously inaccurate for demonstrating 3D anatomical features critical to miniscrew placement" Periapical radiographs provide a more reliable 2D view, but the only practical methods for accurately determining anatomical details of mineralized tissues are 3D imaging (cone-beam or spiral en.

Recently, Deguchi et al." used computed tomography (cr) to demonstrate that subperiosteal cortical bone thickness was greatest neat first molars in both arches. Selection of a miniscrew site in partially edentulous patients may be more problematic because of alveolar ridge atrophy and expansion of the maxillary

a PART I Biological Perspective

Periosteum

Corneal bone

Trabecular bone

Figure 1-4 Section of a long bone shows the periosteum, conical bone, and trabecular bone. Note that the arterial supply (red) originates from the internal ruurient artery (left) in the marrow (M). Arteriole and capillaries provide surface circulation for trabeculae but S.I>'e as an internal blood supply for cortical bone via the haversian (HJ and Volkmann (V) canals. The venous circulation (blufJ for trabecular bone is through (he internal nutrient vein in the marrow (left), but venous return of the cortical bone is provided by periosteal veins,

Figure 1·5 Blood flow through cortical bone is from the marrow to the periosteum, It is important for surgeons to realize that raising a mucoperiosteal nap during implant placement comprorulses the blood supply and destroys the carnblurn (inner osteogenic) layer of the periosteum. /-1, Haversian canal; V, Vol kmann canal: M, marrow.

Mu-cosa

Devitalized bone

Figure 1-6

,~ minimal surgical procedure is recommended for placing minisrrews in cortical bone. The least disruptive approach for r moving mu osa is a tissue punch; (hen a hole is drilled in rhe bone and the self-tapping TAD screwed into place. Even with the most atraurnatic technique, the internal collateral blood supply is disrupted, result i ng in a layer of devitalized bone within about. 1 111m of the implant surface.

sinus, Using skulls and radiographic studies 0 other patiel](SII.13.so to predict the mass and quality of alveolar bone for a specific patient is unreliable, In Figure t·7, for example, a partially edentulous woman has an enlarged sinus mesial to the maxillary righl second molar but appears to have adeq 1.131e mass of cortical and trabecular bone in the tuberosity area (see Figure 1·7, A). Presurgical cone-beam cr is essential for reliably assessing the thickness of cortical bone. the trabecular density, and the position or surgical hazards such as the maxillary sinus, greater palatal neurovascular bundle, mental foramen, and inferior alveolar canal (see Figure 1· 7, B), The need for precise placement of IJ1 iniscrews in this patient cannot be reliably predicted from a panoramic radiograph.

POSTOPERATIVE HEALING AND INTEGRATION

When installed, a self-tappmg endosseous implant (with miniscrew) is retained by a layer of nonvital bone about

Figure 1-7

A, Conventional panoramic radiograph shows an enlarged maxillary sinus on the mesial side of the right second molar [dotted circle}. Bemus of the distortions inherent in panoramic radiographs, it is unclear jf there is adequate bone mesial LO (he molar for placement of a minisrrew, B, An i·CAT cone-beam cr scan of the same patient demonstrates that <he area mesial 10 the right maxi I lary molar is 3 high-risk site (or a miniscrew because the bone beneath the sinus is only about 2 mrn thick, as shown in sections 79 to 81.

10 PAllT I Biological Perspective

1 mrn in thickness." .s ·, The devitallzation is caused by surgical trauma, inflammation, and disruption of the complex collateral (haversian) blood supply of cortical b ne. The layer of devitalized bone is increased by more traumatic surgery and overheating of the osseous tissue with burs, laps, and insertion or the implant.

SeJ f-drilling screws have been used for osseous surgery for more than half a century." The interface devirahzauon and postoperative healing response for seJf:driIJing miniscrews are Jess dear than for tapped preparations and sel f-lapping screws, After G weeks in situ, more bone formation is noted "ear miniscrews in the mandible than in the maxilla. '6 However, the bone-labeling pattern of both sites is consistent with a regional accelerawry phenomenon (RAP), meaning the rate of bone turnover progressively decreases when rnovi ng away from (he implant surface.

The crushing of bone to create an inrraosseous site for 11 self-drilling rniniscrew is an. Important variable in TAD compatibility chat should be studied in detail. The crushing may significantly disrupt the vascular supply of supporting bone, creau ng a denser layer of nonvital bone that is more resistant to bone resorption, This may be an advantage for short-term retention of a nonintegrated min iscrew, On the contrary, bone crushing may; ncresse intraosseous inflammation, enhancing tile postoperative restorative response. 'It is difficult to predict whether a crushed interface will be an advantage or ad isadvantage for rni n iscrew retention,

Tapered screws, along with self. tapping and sel fdrilling designs, -are currently in use. Each design is advantageous for different types of bone:" Tapered screws are the preferred design for retention in cancellous bone; cylindrical sell-tapping screws are advantageaus far relatively thick cortical bone; and the self-drilling design is optimal for thin cortical bone. Whell cortical bone is thicker, self-drilling screws can produce substantial bone damage because the compression of a rigid structural material (mineralized bone) may produce a blowout defect at the endosteal surface of cortical bone." If screws with an endosteal blowout defect are immediately loaded, there is likely to be less intact osseous interface [0 resist displacement. All osseous wounds (e.g., fractures, osteotomies, bone screws) produce a postoperative healing reaction, which FrostS' defined as an RAP. With miniscrews, the RAP manifests as intense bone remodeling within 1 mm of the screw interface; the prevalence of remodeling foci progressively decreases as the distance increases from the implant surface."

TIle failure of minis crews is usually noted during the postoperative healing period .. Six weeks after inserting 102 rniniscrews (6·8 rnrn in length) in multiple intraoral sites in dogs, 20 failed (were 100se or lost)." All these screws were unloaded. Th re was no significant difference in pull-out strength at 6 weeks compared wi th the immediate postoperative period for miniscrews

that were retained and had not become loose. For these successful screws, bone contact at the interface ranged from 79% to 95%. This study demonstrates that miniscrews have about a 20% failure rate for the first 6 weeks, even in the absen I' of therapeutic loading. Immediate loading may increase the failure rate, but there are no speci fic, well-corurolled studies of miniscrew failure caused by immediate loading.

OSSEOINTEGRATION

Metallic screws are manufactured by turning a redshaped blank on a lathe. The usual machining process results in a smooth, polished surface that is contarninated with residue from the tools, Osseoiruegrauon of the titanium surface is i rihibited by both the smooth surface and the manufacturing contaminants (e.g., iron, nickel) that permeate the surface!' Acid etching of Ti miniscrews removes contaminants and increases the. roughness {microtexture] of the surface. Acid-etched Ti screws ro u Ii riel y ach i eve osseo integra [i a n. 7

Postoperative healing and the response to therapeutic loads have been described for Ti miniscrews with an add-etched surface that are installed as self-tapping fixtures. Healing of cortkal bone devitalized or otherwise compromised by end osseous swgery occurs through a bone-remodeling me hanisrn (Figure 1-8). After a 6-week healing phase, these TADs routinely osseointegrate in rabbit bone,' A comparable healing period in humans is 4 months." The nonvital interface and supporting bone remodel through an RAP,",GO which lasts about 1 year f r most bone screws in human cortical

Figure 1-8 Postoperarlve healing of the conical bone' supporting 3 mlnlscrew involves the formation of an endosteal callus and an intense remodel i ng response, deemed a regional acceleratory phenomenon (RAP). NOle that cutting/filling cones, remodel. ing interfacial bone in a vertical direction, emanate from the endosseous surface. If the interface is biocornpatible and micromotion is controlled, titanium implants usually osseoiruegrare because of progressive remodeling io replace the nonvltal bone interface.

Endo .. eous Miniscrews: Historical. Vascular, and Integrallon Perspectives 11

Figure 1-9 In the presence of micromotion [amuos] the pcstoperative bone-rernodeling response may fail to osseolruegrate me implant. and the interface reverts to fibrous connective (issue. The fibrous interface of nonlmegrated rniniscrews is responsible for mobility and movement of the loaded TADswimi.D bone,

bone, The postoperauve stabilny ofa miniscrew depends On the thickness of the cortex and Liming of the remodeling response to replace devitalized bone. S13biUIY at any poi ru in time is difficult 10 predict far mi niscrews because most current devices have a smooth, machined surface that is unlikely to osseointegrate, Funherrnore, the micromotion associated with functional and therapeutic loading is conducive to forming a layer offibrous connective tissue at the interface (Figure 1-9). This layer of scar tissue is the functional equivalent of a nonunion In orthopedics.v"

The postoperative implant RAP has been demontrated with bone scintillation (scintigraphy) scans in humans.t' High bone turnover activity is noted for 12 weeks in the mandible and 10 weeks in the maxilla. When endosseous implants fail to integrate, the amount of bone remodeling neat the interface decreases,"

STABILITY AND FAILURE

The failure of 11 minlscrews to ossecintegrate contributes to instability and a relatively high fairure rate. Miniscrews are usually loaded immediately and have a 'success rate" of 50% 10 89%, '~,I? Conversely, up La 11 % to 50% of current rn iniscrews fail to serve as adequare TAOs during orthodontic treatment. Although nonlntegrauon renders miniscrews easier to remove at the end of active treatment. this advantage is nOI sufficient to offset the high failure, rate.

Because of the fibrous connective tissue interface, rninisrrews used for orthodontic anchorage move relative to supporting bone." The bone-modeling mechanism [or movement of nonintegrated TI implants has been described,' Orthodontic anchorage is of len critical when miniscrews are the preferred trearrneru option.

Even a I-rnrn to 2-m.n lack of stability far a Tt\O may significantly compromise treatment outcome. Similar to prosthetic implants. ossecintegrauon would probably improve the stability and success rate of miniscrews. Developing an osseointegrared miniscrew that could be easily removed at the end of treatment would be a significant advance in the field.

SUMMARY

• Most current rniniscrew and rnicroscrew svstems have been marketed with little or 110 fundam'entaJ scientific verification of their osseous compatibility under unloaded and loaded condiuons.

• The most popular temporary anchorage devices (TADs) are miniscrews made of commercially pure titanium (Ti) or titanium alloy.

• Most current rniniscrews have a smooth, machined surface 'that is not conducive La osseointegration,

• TIle bone supporting self-lapping miniscrews is subject to an intense postoperative remodeling response known as rapid acceleratory phenomenon

(RAP),

• Mast rniniscrews fail to integrate, so the bone-implant interface tends to evolve into a layer of fibrous connective tissue.

• During clinical use, miniscrews are expected to display varying degrees of mobility relative to supporting bone.

• The current 25% to 50% failure rate is unlikel; LO improve for nonintegrated miniscrews.

• Osseointegrauon would considerably improve miniscrew reliability.

• The profession should demand more scientific rigor in the development of skeletal anchorage devices,

• TI,e current approach. is 'clinician, beware." REFERENCES

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12 PART I Biological Perspecerve

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58. Fro.t HM: The bioi,,!;), of f,.cm", healing, ,n overview for C]JJlld"n" PMtll, Cli" Onl .. p (24S):19lJ.-30~, l ~89

59. PW51 H,M; 'rhl;' It.:ogi:onal ar.cckrtllory phenomenon: iii.. rl"Vie.w. 1I1!1I'Y R.>rtl Has!, M .. I/31( l ):3.,. 1983.

Endosseous Miniscrews: Historical, Vascular, and Integration Perspectives 13

60. Mueller (VI et al: 1\ 'Y ... mk aocelerarory phenomenon (SAP) accompanies the regional arxeleratoryphenomencn (RAP) during healing ofa bone defec in II,. rat, IXmd"ji"" R"" 6(4):401.410, 1991.

G I. Me.ida1'3 Z 12:( al; Technetium 99m-MDP scintigraphy of patients undergoing Implant prostheuc procedures: a follow-up study, I PcriodO"lol 65(4):330-,,5, 1994.

62. SchllephakeH, Berding C: Evaluation of bon. healing in padems with bone grafts and endosseous lmplams using single photon emission tomography (SPEer), eli" Orallmpl""" Res 9( J ):34·42, 1998.

63. LLOU EJ. Paj Be, Lin JC: Do mtnlscrews remain stationary under orthodontic forrest Am JOn/lad De"wfac;,,1 On/lOp 126(1):42-47, 20()4.

CHAPTER

2

Biological Response to Orthodontic Temporary Anchorage Devices

Sunil Wadhwa and Ravifldra Nanda

In the past decade, use of implantable devices for anchorage control during orthodontic treatment has increased dramatically. These implantable devices include conventional titanium (Ti) end osseous dental implants, palatal implants, TI miuiscrews, and minibone plates.' To be successfu I. these implantable devices must be stable in the bone for the duration of orthodontic treatment, Retention of orthodontlc implantable devices is obtained either by allowing for osseointegration 0 the device or by the intrinsic design of the device (screw threads), which renders immediate retention within the bone.

This chapter reviews the bone biology and factors predicring stability for mechanically retained and osseointegrated orthodontic temporary anchorage devices (TAOs). Frequently prescribed drugs that may affect orthodontic TADs are also reviewed.

HISTORY OF ORTHODONTIC IMPLANTABLE DEVICES

Almost 60 years ago, the first orthodontic TAD was placed in the mandibles of dogs. Cainsforth 1'1 al.' placed cobalt-chromium alloy (Vitallium) screws in the mandibles of dogs as anchors for the application of orthodonti forces. Despite some success, the resultant tooth movement was limited because implants loosened within] month after application of orthodontic forces. Over the next 40 years. few studies were published on orthodonlicTADs. Linkow et al.' reported on blade implants to retract teeth using rubber bands. and Sherman' recommended that implants be stabilized by a nonloadi ng bone-heal ing period before appl ication of orthodoruic forces.

In the ]980s, animal studies laid the framework for analyzing the effectiveness of orthodontic TADs. Gray ei at' examined the movement of Bioglass-coated and Vitallium endosseous implants loaded with constant orthodontic forces in the femurs of rabbits. After 28 days of healing, no statistically significant movement OCCUlTed at any of the force levels (60, 120. and 180

14

grams [g]) for either type of implant. In addition. histological evaluation revealed a connective tissue encapsulation wi ih the Vilal1i tim implant and an implant-bone bond with the Bioglass implant. Roberts et al.' reported simi lar resu Its with Ti i 111 plants in the femurs of rabbits (6-12 weeks of heali ng) loaded with \00 g for 4 to 8 weeks, During the healing period, 3 days after implant placement. there was extensive bone formation, particularly at the endosteal margin of the surgical defect. In addiuon, by the end of 6 weeks. a rigid bone-implant interface was achieved. During the loading period, 19 of 20 loaded implants remained rigid. The authors (00- eluded that "6 week is an adequate healing period, prior to loading, to attain rigid stability and avoid spontaneous fracture and [hat titan iurn endosseous implants have potential as a source of firm osseous anchorage for onhodonucs and dento facia I orthopedics:'

I lurnan casereports on the use of orthodontic TADs were also published in the early 1980s. for example, Creekmore and Eklund' insetted a Vltallium screw just below the anterlor nasal spine in a patient with maxillary incisor elongation. After '10 days, they attached an elastic thread from the archwire to the head of the screw. In 1 year the upper incisor had intruded 6 mrn, and the vitallium bone screw had remained stable throughout the treatment. Roberts et al." used a traditional twostage endosseous implant for orthodontic anchorage to translate 1\;10 mandibular molars mesially 10 to 12 mm into an atrophic edentulous ridge. After the 3 years of treatment, the endosseous implant rernai ned rigid. Polarized light analyses revealed that about 80% of the. endosseous portion of the im plant was in direct contact with mature lamellar bone.

Other orthodontic TAOs besides traditional dental implants were developed in the early 19905. Block and Hoffman' used a textured disk with a hydroxyapatite coaling on one side and an internal thread 011 the other side to provide palatal orthodontic anchorage. They found that placement of palatal implants in dogs and monkeys provided absolute anchorage to move teeth orthodontically without moving the implant. Kanorni'"

2 Biological Response to ortncdonetc Temporary Anchorage Devices 1 5

de cribed the use of small Ti bone screws for orthodontic anchorage. Mini-bone screws (1.2 rnrn in diameter, G rum in length) were placed in the alveolar bone between the root apices of the mandibular central incisors. After healing and the uncovering of the miniimplant, an elastic chain was lied to mandibular central incisor brackets and the implant. After 4 months [be mandibular incisors had been intruded 6 mrn without any patient discomfort, root resorption, or periodontal pathology. Sugawara and his team in Japan reponed a new skeletal anchorage system consisting of a 11 rniniplate temporarily fixed in th maxilla or mandible. The miniplates were used for intrusion of lower molars in open-bite malocclusions; the open bite improved significantly with little extrusion of the lower incisors, I '-13

Freudenthaler et al, I' described one of the first r e pons on immediately loaded, mechanically retained orthodontic TADs. Eight patients received 12 blcortical Ti screws as anchorage units for orthodontic molar protraction. After insertion of the screws, orthodontic forces were applied immediately. Of the 12 screws, three were prematurely removed. The remaining nine screws rernai ned stationary throughout the duration of treatment. The authors conduded that "the total treatment time is reduced as the screws can be loaded immediately ." ,.

In 2005, Kim et al." described the use of drill-free screws; 32 (16 self-tapping, 16 drill-free) screws were inserted into the jaws of two beagles. A pilot-drilling bur was used before inserting the traditional self-tapping screws. Forces of200 lO 300 g were applied using nickeltitanium ( li-Ti] (oil springs 1 week after insertion. At 12 weeks, mobility was rested, and the screws with the surrounding bene were prepared for histomorphornetric eva I nation .. The screws in the drill-free group showed less moblllty and mote bone-to-metal contact compared with the self-tapping group, although osseoinregradon was generally found in both groups. Huja et al.'''I~ found similar results with drill-free Ti screws.

BIOLOGICAL PROCESSES

Or, J .8. Cope proposed classifying orthodontic TAOs into two groups: (1) those that are osseoimegraied and (2) rhose that have mechanlcal retention (Figure 2-1). The biological processes are quite different between the two groups (Table 2-1).

OSSEOINTEGRATED DEVICES

The insertion of an onhodonticTAO into bone initiates a series of biological processes, including formation of a blood dot, alteration in nuclear morphology of the osieocytes surrounding the site of implantation, and formation of new bone,

After placement of an orthodontic TAD, the surface comes in contact with blood and is covered by ablofilm,

Figure z.i Biocomparlble Temporary Anchorage Device. (TAD,), (Redraum from Cope IS: Clas,i/icntfon of temporary anchorage fl""'ces, 2005. "',,,,,I.orrlu)TADS,com,)

TABLE 2-1 Biological Re5ponse to Osseointegrated and Mechanically Retained Temporary Anchorage Devices fTAD5J

PoStimplant MeChanicallY
Period Osseointegrated Retained
Immediate Biofilm, formation
of blood clot
1 day lled blood cells and Attachment of
inflammatory cells osteo b lasts to
[il'lnium surfaces
3,5 days Appearance of
0' teo blasts
Decrease in
inllamrnatory cells
1-4 weeks Bone remodeling Bone remodeling The blofilm contains fibrinogen and serine prou"ases of the complement and coagulation system." Red blood cells (RBCs) and platelets then attach to the biofilm, resulting in a fibrin-containing blood dot that forms at the bone-TAD interface, III," The blood dOL also may contain polygonal bone chips, apparently resulting from the surgical preparation or TAD insen.ion.lo

After 1 day, RBOJ and inflammatory cells (mainly neutrophils] are present between the bone and TAD, Within the bone adjacent to the device, appearance of the osteocyte.s is altered, with empty osieocyuc lacunae and pyknotic osteocyticnudei extending up to 100 Ii-JJt m the bone ad] cent to the TAD!""

From 3 to 7 days after implantation, inflammatory cell infiltration gradually disappears; and spindleshaped or flattened cells start to appear in the interface between preexisting bone and orthodontic TADS,21

,6 PART I Biological Perspective

fJrom 2 to 'l weeks after TAD placement, cuboidal osreoblasts are dearly visible at the bcue-TzvO interface. Interestingly, new collagen fibers run circumferemlally around the TAD cavity, whereas the course of the fibers of existing bone corresponds to the long axis of the bone. Numerous bone-modeling units containing rnulti nucleated csteodasts and blood vessels? also appear ill the cortical bone surrounding the device,

Six weeks after TAD placement" ctlve bone remodeling appears to decrease, and a region of empty osteocy!ic lacunae 15 still seen adjacent to the newly deposited bone."

After the nonloading healing period and osseous integration, application of orthodontic loadi ng LO the TAD causes increased bone tissue turnoverand increased densi Iy of the adjacent alveolar bon compared wi I h 1 he unloaded COIlU·OJ. Despite increased bone tissue turnover/ however, the TAD maintains osseoiuiegrarion even after 32 weeks of orthodontic Ioadlng.": ss In addition, no signifirnru differences in bone remodeling are seen around the bone·TAD interface within areas of compression, tension, 01' shear.'·); [See Table 2-1.)

MECHANICALLY RETAINED DEVICES

In screw-shaped, mechanically retained orthodontic TADs, areas of the screw in direct contact with me bone are responsible for pri mary mechanlcal Slab iliry Or the device; other areas show gaps hundreds of microns in, size between the device surface and the bone. In the areas where small gaps exist between the screw surface and bone, the biological process is similar to that previously described. In direct-contact areas, however, the biological response is different. In areas of direct contact with the screw, no invasion of irrflamrnatory cells occurs in Ille first week. lnstead, 1 day after insertion, 110t only are mineralized bone tissue contacts present between the surface of the implant and b ne, but the osteoblasis are also attached Ih111ly to me Ti implant surface." After 1102 weeks, in the areas in direcr contact with duo bone. the bone is resorbed and replaced with newly fanned. viable bone. Despite this temporary loss of hard-bone contact, the implants remain clinically stable." This process does not seem to be affected if the screw is immediately loaded or if mere is a healing period before external loading begins." (See Table 2-1.)

STABILITY OF ANCHORAGE .DEVICES

As wi th the biological processes, th e factors that predict stability also differ between osseoimegrated and mechanically retained 'fADs,

MECHANICALLY RETAINED DEVICES Stability of TADs immediatelyafter insertion. called pl'ill/my swbilill', is critical in deLerl11111JIlg success in the early loading phase, particularly in TADs immediately loaded. Primary stability iepends on the geometric

design ofthe lrnplam, bone quality, insertion technique, and tip moment,"

Many studies have examined the geometric de ign and stability of orthodontic TAOs. Geometric designs of screws that seem to have a positive effect on pri mary stabl' i ry i nrlude conical shape, greater outer diameter. so increased lengLh;"'3' and use of abutments [attachments to screw for placing orthodonti force)."

Placement ofTADs in areas of higher bone mineral density (BMDJ increases the primary srobility.,·,3o." HowTADs are placed also influences the primary stability. Initially, placement of screw-type TADs either requires or does not require the drilli ng of a pi lot hole. A recent study indicated that drill-free screws have increased bone-metal contact. greater bone area, and less mobility than screws that require the drilling of a pilot hole." In addition, for screws that require 3 pilot hole, the smaller predrilllng diameters in rease the. insertion and removal torques. <0

Excessive loading of mechanically retained TADs has been associated with increased failure rates. Butcher er al." recently found that increased liP momellt, [magnitude of orthodontic force x length of lever arm) at me bone rim caused decreased stability mechanically retained TAD~. Tip moments greater than 900 centinewtons (eN) mm were found to cause decreased stability of mechanically retained TAOs after 22 arid 70 days of loading,

To increase primary stablllry of mechanically retained TAOs, particularly in areas of decreasedBMD (maxilla), these studies suggest using a longer, wider, drill-free screw with 11 short abutment.

OSSEOINTEGRATED .DEVICES

Two major factors affecting osseointegration are primary stability and a no-loading healing period. Primary stability is critical LO the processes of osseointegration of the TAD. ln one study, when 11 implants were placed in the mandible of rats so that they did nut make contact with the mandibular bone, no bone-irnplarn contact was observed. even after 9 months of a no-load healing period."

Roberts N al." and Sherman' both advocated " noload healing before the application of orthodontic forces to the osseolntegrated TAOs. Immediate or early loading of these '['ADs caused decreased stability" and spon taneous fracture of me bone' in an irnal models ..

OVERLAP BETWEEN OSSEOINTEGRATED AND MECHANICALLY RETAJNED ANCHORAGE DEVICES

Mechanically retained orthodontic TADs are associated with early or immediate loading. 3 lack of osseointegraLion, and the ability to withstand lesser onhodontic forces. r n contrast osseoiutegrared TADs are associated

2 Biological Response to Orthodontic Temporary Anchorage Devices 17

(u', coefficient 01 resistance on conlact poln\: k, coe!(ieient of bone oomacf ratio) Figure 2-2

Difference In Removal Torque for Screws with Different Radii. Removal terque is properI ional LO the screw radius and bone contact area, which is proportional to the screw radius under the same bone contact ratio. Therefore, removal torque is proportional to the square of the screw radius. If the radius is reduced to one third or one fourth, removal torque will decrease co one nimh or one sixteenth, respectively, (Hom Kim IW, AIIII SI, Chang YI; Am I Orthod Dentofacial Orthop 128(2):/90-194, 2005.)

Total M ; AREA X R X uF (AREA; k x Z."R X Length)

Total M ; k X Z;rA' X Length x u'F

with delayed loading, osseo integration, and the ability to wi ihstand greater orthodontic forces. However, recent research and the development. of new types of TADs have made the distinction between the two types less dear.

EARLY LOADING ON OSSEOINTEGRATED DEVICES

Waiting for osseointegrarion before applying orthodonuc forces may not he important in predicting TAD failure. Chen et at" used finite element analysis to com pare the stress and failure of osseoi n tegra ted and nonosseoimegrated palatal implants caused by the application of a 5-n wton (N) orthodontic force. They found that noncsseoi niegrared implants had greater stresses on the surface Ulan osseolruegraied irnplarus, However, the stresses did not result ill loss of anchorage or failure of the implant. Th authors concluded that "waiting for osseolniegrauon might be unnecessary for an orthodontic implant.'?"

OSSEOINTEGRATION OF MECHANICALLY RETAINED DEVICES

For all miniscrew TADs, wailing for osseointegrauon before applying orthodontic loads is unnecessary. However. whether the 111 in iscrews become osseointegrated during orthodontic treatment depends on the type and surface properties of the rniniscrew. Studies using the Aarhus Anchorage System screw suggested that a fibrous interface between the screw and bone allows easy removal of Ill!' orthodontic rniniscrew.":" Another study showed that rniniscrews 2 mrn in diameter and 17 mm in length (Leibinger, Tuttlingen, Cerrnany] do not remain absolutely stationary through-

Total m ~ area" r '" u'F (area - k l< 2'lTf Length)

Total m : k " 2'lTr" " Length x U 'F

OUl orthodontic loading; the rniniscrew tipped forward significantly, by 11.11 average of 0.4 nun at the screw head" The authors hypothesized that the miniscrews moved because they were not osseointegrated and because a Iayer of fibrous tissue was int rposed between the miniscrews and the surrounding bone. Histolcgica II y, he weve r, osseo in tegra tion has been d oeu mented in rninisrrews [Osas: Epoch Medical. Seoul. South Korea). measuring 1.6 mrn in diameter, after waiting 1 week before applying an orthodontic force of 200 to 300 g for 11 weeks." Deguchi et a]," reported similar results. Miniscrews may be easy to remove because of the decreased width of the screw, not the lack of osseointegration (Figure 2·2)

ORTHODONTIC FORCES APPLJED TO ANCHORAGE DEVICES

A recent review compared loading protocols for osseointegrated and mechanically retained orthodontic TI\Ds"; 11 articles met selection crltena," In rhe five studies with osseoirnegrared TADs, the no-load healing period was 2 to 12 months. and the range of applied orthodontic forces was 80 to 550 g. In 1.I)e six studies with mechanically retained TADs, four applied onhodcnuc forces immediately after TAD insertion two applied force after 2 weeks .. The orthodontic forces in the studies ranged from ]50 to 500 g. Therefore, a similar magnitude of orthodontic forces is used for both osseoinregrated and mechanically retained TADs (Table 2- 2).

18 PART I Blol09'cal PerspecTive

, TABLE 2-2 Comparison Review of TAD loading Protocols

Force Anchorage
Numberrrype Time Befor'e Applied TIme
Siudy Samp!e~/Age of Appliance Loading (gram'J (month,) Failure
Bernhart et 3 L" 21: 15 F, " M 2I mini-implants 4.1 mo IlG 3
15.8 ± 9.9 (12.7-481) yr
Cheng et al .' .• 44: 38 P," M 91 m i ruscrews 2-4 wk 100-200 15
29 ± 8,9 (13-55) yv
Costa e! a I!' 14 ] 6 mi n [screws Immediately
loaded
Preudernhaler et al -'" 8: 4 E 4 M 15 screws Immedialely 150 11.3
zz.i (13-46J yl loaded
Celgor .1 al." 25: 18 F. 7 M 25 'screws immediately 500 3-6.2 (4,6)
139 (l 1.3-16.5J yt loaded
Hi guch iand Slack'" 7: 5 F. 2 M 14 implants 4-6 mo [nlttally, 36 0
331 (22-4IJ yr 150-200
Later, qOO
Lieu er al." 16 32 rninlscrews 2 wk 400 9
22-29 yr
Miyawaki eL~I." 51: 42 p, 9 M 134 screw' I mmed iately <200 12 10
21,8 ± 7.8 yt loaded
adman et al:" 9: 6 f,3 M 23 implants 3-9 rno 4-33 [17) 0
47 (17-64J yr
'lrlsi and Rebau di" 41 patients o r1b oim pi ants 2-12 mo 80-120 2-'15 0
Wenrbein et al." 4 2 F. 2 M 6 orthoimplams I {OJ. others 200-600 8-20 II
IB-27 yr (12 wk)
from Ohash t " or .1: iln81e Or!!!od 7 o( 4 ).72 1-727, 200 G,
"To," l 1\ remales; M. mal es, COMMON DRUGS THA:T MAY AF.FECT ANCHORAGE DEVICES

CYClOOXYGENASE-2 INHIBJTORS Cydooxygenase lCOX) is the rate-limiting enzyme responsible for me conversion of arachidonic acid into prostagland ins. There are two isoforms of the enzyme:

COX-I, which is constitutively expressed. and COX-2, which is inducible, In bone cells, the increase in prosiaglandin levels caused by various stimuli depends on the induction of COX-2. In animal models. inhibitors of COX-2 cause a delay in fracture healing." However, mere are no reports of COX-2 inh ibitors "ffecting the osseointegraricn of de mal implants, possibly because of a lack of studies, or because osseointegration and bone healing occur by separate biologicalprocesses, A recent re port showed tha l gen es are exp ressed d i fferen tl y during csseciruegration ofTi implants than in normal bone osteotomy healing."

BISPHO$PHONATE$

Bisphosphonates are a class of drugs ihar inhibits the resorption of bone, Administered orally or in travenously, the two classes of bisp hosphonates are non-

'111 trogenous and nitrogenous, each with different mechanisms of action. The l1ol'lnilrogen.oas bisphosphonates are metabolized ill the cell to compounds that compele with adenosine triphosphate (ATP); the nitrogenous bisphosphonates block the enzyme farnesyl d i phosp hale sy n III ase. B isph os p ho nates are us ed ill a variety of conditions thai cause bone fragility, including osteoporosis, osteitis deformans. osteogenesis irnperfecta, and ill cancer patients, bone metastasis.

Bisphosphonates do not seem LO interfere with osseointegration of Ti i rnplanrs in animal models" and may even increase bone-implant contact and removal torque in animal models with. reduced bone mass."'" However, an increase in the incidence of osteonecrosis of the jaws has recently become evident in cancer patients taking nitrogenous bisphosphonates intravenously.

eli rrical diagnosis of osteonecrosis of the jaws is usually made by the presence of exposed bone in the oral cavity for an extended time (Figure 2-3). Although some patients may be asymptomatic, more frequently they have symptoms when the site becomes secondarily in fected or the soft tissues are trau rnatized by the sharp edges of the exposed bone. Typical signs and symptoms include pain soft tissue swell ing, and tooth

2' B.o log i c a IRe. ponse to a rthodon uc Tempo rary Anchorage Device" I 9

Figure 2.3~:;;:::::::::::==~:::::::~~~

A, Spon taneous bo ne exposure or th e pas terio r m andib le, Jl ngua I aspect, B, N onh ealin g extraction sites with exposed alveolar bone, (From R~ggiero SL, Fammia t; c"r,iwH E: Oral Surg Oral M,e<! Oral Pathol Oral Radiol Endod 102(4):433-441, 2006)

looseni I1g, Histopathological analysis of biopsy specimens from csteonecrotic bone demonstrates tissue with lacunae devoid of bone cells, If the site is secondarily infected, the presence of bacteria and in flamrnatory cells consistent. with osteomyelitis may also be noted. «,"

Of patients who develop bisphosphonate-reiated osteonecrosis of the jaw. 94% are cancer patients receiving intravenous nitrogenous bisphosphonate therapy. The mandible is more likely to be affected than the m axilla, and 60% of these cancer patients recently had dental surgical procedures." Expert panels recommend thai elective dental procedures should nor be performed in cancer patients taking bispbosphonates."?" Therefore, clinicians should not perform orthodcnucs, let alone place TAOs, in these patients.

In other recent case reports, osteoporosis patients taking nitrogenous bisphosphoriate have developed osteonecrosis of the Jaw. The estimated incidence of nitrogenous bisphosphonate-related osteonecrosis of the jaw in patients laking oral bisphosphonate fOI osteoporosis is I : 140,QOO.M (To pUl this risk in perspective, the National Weather Service estimates thai the chance of being struck by lightning is 1: 400,,000.) However, some experts believe thai !TId[JY new cases of bisphosphcnate-related osteonecrosis of the jaw are emerging, and that the incidence will be much greater. Nevertheless, the American Dental Association now recommends the following:

Treatment plan, for patients laking oral bisphosphonal.' should be considered carefully, since implant placement requires the preparation of tho osteotomy site,. Before im.plant placement, the denus and the pa tient shou Id discuss In. risks, benefus and treatrneru ahernati ves, whi ch may i nclu de bu t a ~ [lot l:i m i led to perlcdontal, endodontic or ricniruplant prosthetic treatments ' IT] h is d iscu "ion shou I d be dOC'l1n1 en ted and the

patient's written acknowledgment of that discussion and co nsent [or Ill. chose" cours of rreatrneru should b. obtalued."

I n add I I; 0 n, the Am eel can Society of Bo ne and Mineral Research 'recommends that in osteoporosis patients taking bisphosphonates "Dentalsurgery should be I lrnited to thai required for good denial health and undertaken only when more conservative non-surgical therapies are either 'not nppropriaie or ineffective ..... .:;1

Th erefo re, p lacern ent 0 f TA Ds i n p a li ents taking ni uogenous bisphosphonates for osteoporosis is inadvisable,

CO.NCLUSION

The biological response and the factors that predict stabil ity differ between rnechan ically retained and osseous integrated TADs, However, recent research and the development of new types of TAOs have made the dis" tinction less clear. Oespi te the relaliv€ ease in placing these devices, careful attention should be paid to the medical history of these patients.

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20 PART I Biological Perspective

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2 0_ Franchi M et ;]J.: Biologjcal fixa tlun of endossecr l:i imp lnnrs, M,cro" 36(7-8):6(,5-671. 1005.

21. pumml r et al: 'Ti:SSLlf' response to titanium implants ln the: rat ma:d.ll n: U hrastructural and hJsl oc.h emtea I 'obselV!J.u ()!\S of th e bonn-tiraaium interface, / Pen·odomol 71 (1);287-2'8. 2000.

1:2_ Trauu T et 31: BUll!! micro'Vasru!af pattern around loaded derunl implants in a cantne model. Cli" 0'01 1'''''''1 I Or})' 15 H '6. 2006.

23. Slnets E 01 aI; E.rl.y <011\,1., responses In cortical bono healing il round un leaded tl taniu rn l mpla nts; an an im a J study, I l'.IIJrliWml· 10177(6); 10 15-11l2~, 2006.

~4. wehrheln [-I et "ill: Bcne-to-trnplcru rontact of orthodontic implants in h umans subl ected to ho riaon tal load b'lgl Ci if"! Oml Imp",,,,, Ii'" 9(5J03118-353. 1995.

25 _ S'] lito S '~L .1.1: Endosseous :U litnh.li1n lmp lliuu.:s iI:S i.I ndlots for rn ~ LO~ d t!iiltll .utnl. tlloVCI' l~ ~l. i r I the:: heag,] ~ dog, A m I OI'1Jw.n rkn r~f'Jdi1/ Ortl,op 11S(G]:IiDl·GQ7. lOOO.

lG. Wehruein II. Yijdirim ~I, Di«lrich p- O",,,d'yna.mios around orthodonlic:lll:yloaded Snarl rn.axiHary imprllnts~.ln ·~pert.ment&!l pUOI ",,,dy.! Orol"' OrIP,op ClO( (i):40~.!, 15,' ~~9.

27. Melsen [3'1 I..:'--lllg Nr; llin'IQgical reacliofl,~ orHlvcolar bone 10 oLlh~ ~donlk load i ng 0 f 0,," I im pI anlS. eli .. Om Ilm~I,,"" RR; 12 (2); 14 qlj.2. 2001.

1.S. ,\<leyer U i!! aH Uh:raslr!Jcturil.l m_'lmrtedzaLion of r.h~ "l.mpl'OIJ1t/ bQn~ Lnlerfille or lInjll~.i;HoIt.l.)' IOi"1cl~d dEJ.ll:i3_1 impl::l.Ilt.ii, Biomlt«rilll, <s( IOJ;I~59-1%7. 20Q.I.

29. Ilerglundh I' eL ill]: lie 1l0VO :al .... eolar bone f"nnmuiQn acij,,]C't.:111 IQ ."dos.eo"", im pl'.n IS, dil, ami I ",pi"",. nos 1<1 (~ ) ;25.1·11)2, 1003.

30. WHm e.s. B If: L aJ: Ijoaramel-e.r5; .affert..ing prl_I:fi.11Y :.'iota L i I ~ ly 0 r 0 Ith~ udollli< "';r1i.;mpl.,,,", I (Jro{ilr Qnlwp 67(3): 16~-17/1. l()O('.

3"_ Cedm !1:ge:. T~ L i1 l; A.n ev~ Itl2tiPI1 of resonl3!1 (€ freq uen c;y analys is for Ihe do/ermin' tio n of tho p ri "' •. ry s,"bi Ii 'Y of ofl.hodmlllc

palatal implants: L\ study iu human cadavers, Oilr Oral lmprtlmS Res l6(~l~Z5-~31. ZO()S.

32, Chen CH et a J: The use of mlzrolmplants In. orthodontic anchor'SO. lOr" I Mruillojar; :5urg M (8); 120 9·11 13, ).006.

3.3. M[WWil kl S L?! ill:: l:a(lO rs associated with the si abUi ty of ['i:, a III lu m strews placed in the posterior reglou for onhodomlc anchorage, Am) n"lwd o...""j.<',,1 Onhop 121[~J'373-37S • .:!003.

34_ ,r..'iQtPY05h"L M et ah Bl om ethan ical effect or abutment on stab LU ty o ( onhcdomiL "" n i -i In planea ~ nile d.", en I aoalys;.s. di" Oml Imp!."" R',,", 1 G( 4),QSO-4B5, "2005.

35. Buchler A er sl; LOild~T.t.hued i ruplaru reacnon of miai-lruplants used r 0 r on nodon,i c anch O"'&<'. Cli" 0",11 ",pi,,,,,, UOS lli (~J: ,I 73- ,j79.2005.

:36. Uflubavina-Hae:k Nj Lang NP. K.a.rrr!"lS 'J'! Si:gni!jcallC'~ ofprim,a_ry stab U i r}' for oxsecin tegrauc n or den tal im pla III is,. CUll Oml1 mpriHl r_, ~~, 17(3):2/1~-250, 2006.

~7, "hon r ct sl- Ao"horng e e rrod or csseoimegraied vs nouossectnregrated palatal im~1011t>, tlI'llle Orll,od 76(4):660·&65. 2006.

38. Me\son ~V 01 aI: Min [screw imp lams: ill~ Aarhus Md\o",g~ System, S,mi" Orll'"" 11 (ll:24~31. 2005,

3~. CUSla. f\. RafFainl ~\>1j Mtt'St:.~l. H: Mil .. lscrews .1S onhedonuc anchor.go: " prellrntnarv report, 1m I illl,d, 0"1,,,,/ Orll,~g"",I, S,,"II 13(3);lQl-109. 1998 ..

-1 o. ueu FU I Pai Bej U 11 J C:. Do mi n i's.c~:!!i remain stationary under orthodontic rmCl"~ ;10" I Orlhoo V"",.[ad,,/ Orll1Vr·126( 1 ):~~-47. l()o4.

41. Deguch i T et ELI: fhe ~J;S:C of sm o! I Ii La II lu n! screws fnr onhodonu c anrnGmEt. I De", R", 82(5 ),377-'lS 1. 20{)3.

H_ 0 h ash j £.1 .1; I m plan I vs screw loading P'OlOCOl., in onho d DOli". III]s/" Qrlhoo 76(4),721-72.7. 2Q05.

13. fh.:.rnl'i"lr1 T Cl '31: Shcnepltbeuc lmplanu, for onbodontjc andiorage' in the paramedian region of .he. palare: .a dlnlcal s,udYI CUt! Or"'lmp.la.,," Ro! 12",24·63 j. 2001.

4 <I. dlong 51. 'Isong .lY. tee II. Kok SI-I' A prospective study of the risk factors aasoclated with failure of mtnt-implams used for onhodon~ i C oil ncho ri!,~~J 1m Oral MaxIUl')jlJc lmpllll11.3 19: 1 QO~ 1 061 2004.

0.1: 3 _ GeIger I Eo et ,..1: Intraosseous screw-sup ponce! UP permcla r dlstalizalion, Angle Onll",174:S3S-<!SO. 2004.

46_ Higuchi KW1 Slack, JM: The use of tttanrum ~~\'Ures for inlraoral aJ icho r~~ 10 fad I hate orth odoruk tooth rncvemen I". j.u J 01l1l M",11Iojlrr l"'II'aol, 6:338-3~4.19~ 1.

47. Od m an J. Lekho I m U. Ierru T. Th;1 ander B: 0".0; m "groton ifnp1ant .. as onhodonnc -arl(hQ.t.3g-~ in the tr€atmen[ of partislly edentulous adult paden ... Eu'l Or\l,oo 16: I 67-10J • 1994,

·lB, Tri.'i.i Pt Rebaudr /t..~ Progressive hone adaptarlcn of titanium Implants during and ;afte,r onhcdonuc 10:-3<1 iLl human, "1r J Pl!fr[.dam R.cs!'(lf DIl!~ n .22: 31·JI3. l002.

~~. n.di 7.JI. !(hal] NK! Elfero of cyd.om)'g"nas. inhibilloll an bono.

I."don. and IiB~me"' healing, I"fi""'''' !le, 5q(~);358-36G, 2005.

SO. Og;;lW"a TI Nishit1HH'il I: Ge.lleS! di.ITerentla1ly 'e-:(pres..·H~d In li'l"ani,um impl.n' h.,ling, I 0.101 Res 65(G):566-570, 21106.

51. Cbacon GE. N at E.m::C[ of aJ.endrnmH'C pn -cndQSSWBS inlplarll in"'ll ... ~on: on In .ivo <wdy jn rIIbbllS. I Oml M, .. illvjar Sri'S 64(7); I (]llS·]O{)9, 200G.

52. DLI-i!ine PM -eL a': Alt:mhuml[£ thempy may be df'tttiYe" in ilie. rl'ft'e:nrion of b~me !os,..~ 3TOIIIld 'l~J11llm il~lpial'ls insened ill ·"''''ge,,-dofickn, "'''. I PitrlMonJol 76( I):1(I7·1 T 4. 2005.

53. !>Jam; S. N"ll,hata 50 /iff."" of "I.cocironmo on Ihe rtmO",,1 torque of il1lpI3_L1lS l"n f:illS with in.du~d Q;~aeopOfOSiIs.J 1m J urol M{J.,<o,;IlI(Jfuc I .. ,plm,lj" 18(2);218-223. 20()3.

54. Ruggi~ro S L. F.l n '-tU!:.:I '1 C1 rI:so n Po: Hisphospho. ~a II!-r~1 i.'IlC<! USloom.:crosi:o; of m.t jaw: bal:kgIDund iltld guid~lllle!i for di;flgTlo.si:!'i, 'IOgi ng and m> n agom en I. 0",1 ''''8 01'/,1 Mild Or,,1 P. ,h~1 0",1 Rndloi E"ilai/ lO2(4J:43J.44L. 2006.

';5. 1'1"",,) fl. S, "" ki ) B: 0"<0"0«0'" U r ~,~ ,i ,ward ",.1 b f:;pho •• pbomle ",,.'monl, I ",,' f.)nO' iI.I5"" 137(SlI t J 5· 11 19 (<lU'". 1 1 G9-J 170).2006.

2 Biological Response to Onhodontic Temporary Anchorage Devices 21

56_ woo S8, Hellsteln JW. Kalmar JR: Narrative [corrected I review: bisphosphonares and osteonecrosis of the jaws, ibm /fIl,(''l'11 Med 144(JO):753-76I. 2006_

57. Van Poznak C, Eetilo C: Osteonecrosis of the jaw I.II cancer parienrs receiving IV bisphosphonar es , 0"",,108)' (H"I!I;nstj 20(9): 1053·1062 (discussion, 1065.1066), 2006_

.58. Tanvetyanon TI Suff Pl: M,a.tlage_me-.nl of the adverse effects associated with intravenous blsphosphcnares, Am, Oneol 17(6):8~7- 907. 2006.

59. : v ugliorati CA el al: Managing rhe care ofpatients with bisphosphonare-assodated osteonecrosis: an American Academy of Oral Medicine position paper. J tim Vent Assoc 136(12):1658.1668, ~005_

60. American Dental Associaucn: Dental management of patients receiving oral b tsphospho n ale therapy: expert pOl nel recommendarions, JAm D,,,, Ai"''' 137(8):1144.1150. 2006.

61_ Shane E. Goldring S. Christakos 5: Osteonecrosis of the jaw: more res ea rch needed.j Il"". Mi"er Res 21(10):1503.1505,2006.

PART II

DIAGNOSIS AND TREATMENT PLANNING

23

CHAPTER

3

Radiographic Evaluation of Bone Sites for Mini-Implant Placement

Kuniaki Miyajima

Temporary anchorage devices (TADs) such as the mini-implant have proven efficacy in providing "absolute anchorage' in orthodontics. However. some failures have been reported at insertion and during tooth movement. The most serious adverse out orne is injury to the root, which may occur not only at insertion, but

lso with tooth movement if the screw and root are in dose contact, A less serious complication is loosening of the mini-implant, resulting from inflammation or excessive ortbcdcntic force. regardless of primary stabili(y obtained during surgery.

RA.DIOGRAPHY AND COMPUTED TOMOGRAPHY

To avoid TAD failures. clinicians must.consider the Ideal sites for mini-implant placement and understand how forces need to be applied, Radiographic information is a prerequisite in determining the ideal site for miniimplant placement. A two-dimensional (2D) panoramic radiograph usually suffices to determine the implant placernen 1 area. although there are Inherent limitations, In Figure 3-1, for example. the panoramic radiograph (A) sl,OWS a mini-lmplant placed through what appears to be the WO! of a tooth. whereas the' posteroanterior (PA} cephalometric radiograph (B) shows that th miniimplant was actually fur from the teeth. in the external oblique ridge,

Three-dimensional computed tomography (3D CT) is sometimes required to obtain more detailed information ofthe potentialimplant sites. such as bone depth. bone density. and distance between adjacent rOOlS. Software applications are useful in devising a precise plan. especially when the mini-implant is to be placed between roots or near the sinus.

The cr scanner, first described for medical use by H ounsfield 1 ill 1973. has sincebeen applied 1:0 analyze bone depth. width, and density of teeth. as well as the distance between rOOIS, and to map precisely other ana-

tomiral Structures, such as the maxillary sinus.' With. this information. clinicians can find the most suitable site for TAD placement,

Many cr scanners use cone beams. resulting in less irradiation to the rest of the body while providing sharper and realistic images. The cone-beam (CB) cr scanners currently available for craniofacial applications are NewTo.m 3G (Aperto Services, Sarasota. Florida). i·CAT (( rnaging Sciences International, Hatfield, Pennsylvania). cn MerwRay (Hitachi Medical. Tokyo, Japan), and the 3DX rnultiimage micro cr scanner (Morita, Tokyo).

Radiographic analysis software has also been developed, including SimPlam (Materialise. Belgium), i·VlEW (Morita), i-dem (iG$, Israel), i-cat (t-eat Corp, Osaka.Japan).' Most of these programs were developed originally for use with dental implants in edentulous areas, However, such software allows visual and quantitative assessment of the site, as well as calculation of the distances between anytwo points on the3D models, making it also useful in orthodontic treatment planning,

1111' radiograpbic data provided by the cr scan can then be used for (he fabricati on of (he surgical stern. During surgery, a surgical guide is a safe and reliable [001 that allows precise insertion of the mini-implant at the designated site.

STUDY MODELS

The mini-i rnplant is one of several 'fADs widely accepted and used by clinicians. j and my colleagues have performed 3D finite element model (fEM) analysis" and animal studies" using miniscrews for orthodontic anchorage,

FINITE ELEMENT MOD.EL ANALYSIS

Using the software program COSMOS/M (version 1.75), alveolar bone was modeled to a width of 10 rum,

25

26 PART II Diagnmi, i.!nd Tr,e<!tment Planning

Figure 3-1 M,in;.!mp!ant Placed on l'..'<Iernal Oblique Ridge, A, In ,l1e rwo-dirnenslonal (2D) pan-

oramic radiograph, the mini-implant appears to be placed into the [oath root. This is an

example of ~le limitation of 2D radiography, B, III the periapical Nay study, taken from the

.xial directlcn, me same mlnl-lrnplaru is seen [0 be far from lhe teell1.

depth of to mrn, and height of 30 mm (comprising 20 mm of conical bone covering 28 mm of spongy bone). A linear static model for the 3D FEM analysis was applied.' This model consisted of 6193 elements and 18,879 degrees of freedom. To lest th is 3D FEM, all the experiments were performed based on the assumption that the unplants and the su <rounding alveolar bone were osseoi ntegn at ed. The proposed miniscrew implant for model I was 1.0 mm in diameter and 5 rnm in length (Figure 3·2), whereas that of model 2 was 2.0 rn min diameter and 15m min length. The followingIoadcombmauons were applied 'on these two models;

1. Amou nt: 100 grams (gJ of tracrional load.

2. 'Th ree dl ffurent angles of direction • loads at 0, 45. and 90 degrees perpendicular to the bone surface were applied individually on the implant head and 4 rnrn away from the neck (Figure 3-3).

To determine the effect of varying tl1e height of the tractional point above the alveolar surface, I·, 2·, and 4-mm distances above the cortica I bone surface were tested using model 1 (Figure 3"4).

Table 3·1 shows the mechanical properties of different component> of current 3D F'EM models. The stress distributions and deflertions in the implants and surrounding alveolar bone were calculated using the COSMOS/M linear static module.

Results

TIle 3D FEM analysis revealed the same "pattern" of mess distributions and deflections tn both model I. and model 2, although the values were much larger in model 1 than in model 2. 'The findings are summarized as follows"

I. The greatest stress onthe surrounding alveolar bone was distributed at thecervical area (Figure 3·5).

2. The greatest stress on the implant was distributed at the cervical area [Figure 3·6),

3. Stress increased with (he angle, from 0 degrees to 45 1IJld to 90 degrees (Table 3·2),

4. Values of stress distribution in model 1 were almost six ti rnes larger with a di rectional angle of 0 and 45 degrees, and 3.4 times larger with an a ngle of 90 degrees, com pared with those of model 2 (see Table 3-2).

5. Stress created at a point 4 m m above the bone surface was about 3.2 times greater than that at I mm above the surface when tract; anal force was applied horizontally (Table 3-3).

Conclusions

S tress was dis tribu ted on th e neck a reas of both th e implant and the alveolar bone, where most inflamrnalion is seen after mini-implant insertion. One significant issue is the diameter of the mini-implant. A mini-implant 1 mm in diameter created almost .six times more stress at the neck of the alveol ar bone area than one with a l·mm dlarneter.

In addition 10 the magnitude of force applied, the direction of the force application should also be considered to prevent fail me ofthe min i-i rnplant, Even when the amount of force is the same, the poi nt of force application on the mini-implant is critical. Therefore, gingiva! depth should be considered i n addition 10 cortical bone depth.

ANIMAL STUDY

The purpose of the animal study was 10 prove the applicabiliry of the FEM study to live subjects,' The actual irnraoral situation may be different from that premised by a computer as a result or factors such as bacterial plaque and the chewing function in animals.

3 Radiogr~phic Evaluation of Bone Sites fo., Mini-Implant Placement 27'

y

x

c

o ..

o .,.;

" ...J

Figure 3·2 , _

Finite Element Mod.1 (FEM) Analysis: Model I"~ The alveolar bone was modeled with 10 rnm of width. 10 mrn of height, and 30 mm of depth. The mini-lrnplaru in model 1 was 1.0 mm in diameter with ~ length of 5 rnm. A. Overall view. B, Alveolar bone. C,' Implant.

28 PART II Diagnosis and Treatment Planning

Direction
90'
IL
O'
Stress 100 91







re 3·3 Figu Tractional loads of 100 g W grams of force) are individually applied 00 the implant head, 4 mm "way from the neck ill three directions (0, 45, and 90 degrees perpendicular to the bone surface).

100g1

Figure 3-4 Using model t , assumed beighis of}, 2, and 4 mm were used to determine the effect of varying the placement of the tractional point [helght] from the alveolar surface.

TABLE 3·1 Mechanical Properties of ThreeDlmensional 130) Finite Element Model (FEMJ

Component Elasticity Coefficient Poisson's Ratio

Conical bone 1.4 x 10" MPa 0.30

(143 x 10' gf/mm')

Spongy bone 7.9 x 10' MPa 0.30

(8.06 x 10' gf/mm')

Implant t.i x 10' MPa 0.34 (1.085 x 10' gf/nun')

MP<r. megapascals: gf, gram, of force.

Four adult beagle dogs were used to study maxillary canine intrusion. On one side, the labial alveolar bone mesial to the canine received a miniscrew implant 6 rnrn long, while the labial alveolar bone mesial to the other canine received an implant 3 mm long. Both had the same screw diameter of ].0 mm. A lingual button with a band was placed on the can ine. The mucoperiosteal flap was opened and the alveolar bone denuded, Denuded cortical bone was drilled to the length of each minl-lmplaru (3 mm and 6 mm) with a O.9·mm watercooled pilot drill. The mini-implants were inserted with a miniature screwdriver. Soon after implant placement, 100'g nickel-titanium [Ni-Ti] closed-coil springs were placed between the implant head and the canine lingual button on both sides (Figure 3-7).

Data were collected soon after the placement of the implant and 3 months later, at the end of the experiments, using photographs of the oral cavity and periapical radiographs. At the end of the orthodontic intrusion, the animals were anesthetized, and the periirnplant alveolar bone with the implants was dissected and soft x-ray studies performed (SRO-M50, Sofron.Tokyo). The mini-implants and the surrounding bone were prepared for histologic calcified tissue sections using conventional laboratory techniques.

Results

No implant failure was found during the 3-month experi mental period in either the shon-screw or longscrew implants. Clinical measurements indicated that the canines on both sides were intruded and tipped mesially by an average of 3.5 mm over the 3-monlh period. There was no difference between the long and the short screw lengths in the amount of canine movemerit. Radiographic findings also indicated no significant difference in the periodontal condition Oil both sides (Figure 3-8) or any observable signs of root resorption.

3 Radiographic Evaluation of Bone Sites for Mini.lmplant Placement 29

D~lmm L~5 mm

D 1.48E+03 Dl.09E+OO D 58.70000
1.33E ... 03 .9770000 t 52.90000
0: 1.18E+03 / 868,0000 047.00000
.. n 1.03E ... 1)3 87600000 04110000
0885.0000 851,0000 £:]35.20000
t:J 738.0000 0543,0000 029.40000
05900000 04340000 '023.50000
0' 0443.0000 4.5' 0326,0000 90' D 17.60000
.2950000 , 2170000 11.70000
148,0000 0109_0000 [;;;IS.S70000
·0.000000 0,000000 0.000000
Siresslarea (ratio) 100 74
A 4 D~2mm L~1Smm

D 249.0000 D 188.0000 017.30000
224.0000 / ~169.0000 1 15.60000
0199.0000 151.0000 0'3.90000
... 0"32.0000
0174.0000 .1130000 012.10000
[3149.0000 Ell: 10.40000
0124.0000 EJ94.10000 b8.660000
099.60000 m7530000 D6.930000
O· 45' C]56,5Q000 90" 05.200000
074.70000 3.470000
• 49.aOOOO .3760000 1.730000
24.90000 01S,00000
~o.oooooo 0,000000 0.000000
B Ratio 17 12 Figure 3·5

Resul_ts of FilM Study, Bone Stress. Maximum stress on the su rrounding alveolar bone was dlsirlbuied on the cervical area. A, Modell B, Model 2.

30 PART 1/ Diagnosis and Treatment Planning

D_lmm
L-Smm
.. / t

O' 45' Y 90·
3.86E+OO 2.82E+OO
3A8E..o.3 2.54E...o3 132.0000
3.09E...o3 o 2.26E+03 119.0000
2.70E+03 10S.0GOG
D 1.98E+03 92.20000
2.32E+03 1.69E+03 79.10000
1.93E+03 D 1.41E+03 65.90000
1.5SE+03 1.13E+03 52.70000
1.16E .. 03 8470000 39.50000
n3.00OO 565 .. 0000 26.40000
366.0000 282.0000 13.20000
0.000000 0.000000 0,000000
Ratio 100 73
A
D-2mm
L= 15 mm to / t
O' 45' 90'
479,0000 362.0000 32.30000
431.0000 325.0000 29.10000
383.0000 289.0000 25.90000
335.0000 253,0000 22.60000
266.0000 2170000 19.40000
240.0000 181,0000 16,20000
192.0000 145,0000 12.90000
1440000 106.0000 9.7()()()()()
95,90000 72.30000 6.470000
47,90000 36.20000 3.230000
0.000000 0.000000 ().OOOOOO
B RaUo 12 9 Figure 3·6 Results ofFEM Study: Implant Stress. Maximum Sir ss of the implant body was distributed on the cervical area. A, Model I. B, Model 2.

3 Radiographk Evaluation of Bone Site. for Mini-Implant Placement 31

TABLE 3-2 Stress Distribution on Alveolar Bone and Implant in 3D FEM Analysis'

Model (dimensions) Force Direction (degrees) Alveolar Bone (gf/mm', Implant (gf/mm',
Model 1 0 1480 3860
D: I mm 45 1090 2820
l: Smm 90 59 132
Model 2 0 249 479
D:2mm 45 188 362
L: 15mm 90 17 32 .._ FEM analysis revealed that vertical uacuon causes about 25 times more stress on the alveolar bone in model 1 and 14 times more in model 2 than horizomal tract jon, Model I received six times more stress On the alveolar bone than model 2.

D, Diameter. gf. grams of force L, length.

TABLE 3-3 Amount of Stress Produced at DIfferent Heights of Applied Force

Height of Tractional Point above Bone

Implant (Model I, (eN/mm',

925 1860 3860

Alveolar Bone leN/mm',

lmm 2mm 4mm

459 796 1480

eN, centinewtons.

Figure 3-7 The IOO-g Ni-Ti closed-coil springs were placed between the i rnplaru head and ih canine Ii ngual button On both sides.

Figure 3-8 Periapical x-ray (Al and soft x-ray (B) studies show no significant difference in the periodontal conditions on both sides.

32 PART" Diagnosis and Treatment Planning

Histological study revealed that the surrounding bone did not osseointegrate to most of me implant surface of either short-screw or long-screw implants.

evertheless, 111<" teem moved, and no implant failure was seen. Therefore. complete osseointegration may not be needed for orthodontic anchorage purposes. Conclusions

"(he FEM study proved mat screw length does not affect results as long as the screw diameter is the same. Miniimplants with a I-rnrn diameter were stable with 100 g of tractional force.

CASE STUDIES

Based on I'EM and animal studies. mini-implants of t-mm diameter and 6-mm length were fabricated for clinical lise. However. most rnini-irnplarus of this size were not stable, presumably because of the difference in bone density between beagle dogs and humans. Therefore. larger miniscrews were selected, ISA (Bicdent, Tokyo). with a 1.4-mm diameter and a 6-mm length, which were found to be stable.

111e following lWO case reports describe patients with dolicofacial and brachyfacial features.

CASE REPORT 3-1: DOLICOFACI . _9.

Figure 3-9 shows a .30 reconstructlon of the skull of this dolicofacial patlent, initially planned to undergo orthoqnathic surgery. However, orthodontic treatment using TAOs was considered when the patient rejected orthognathic surgery. Upper and lower anterior. premolar. and molar alveolar bone areas were used to plan the placement of the mini-implants, A medical a scan was obtained for this purpose,

Nine sliced images on <I panoramic view were selected in the upper anterior area, after determining the approximate area where <1 mini·implant would be placed IFigure .3-10. AI. One of tMe views was selected for <I close-up and used to measure bone depth between tMe labial and palatal cortical layers. Because this patient h"d a long face. 111 ere was sufficient alveolar bone space vertically (Figure 3-10. BJ. The alveolar bone width measured 7.39 mm.

Figure .3-9 Th ree-dirnensional (30) reconstruction using 3 D cr and associated software shows skull of the patient with dol lcofacial features.

Bone density for the upper anterior area was atse measured: the red bar on tile left in Figure 3·1 1 indicates the mini-implant. 111e bone density both inside "nd outside the implant area was evaluated, The mean density value inside th e imp lant area was 603.9 I Hou nsfield un its (HU J, wl1 ereas the bone density outside the implant area was 691.03 HU. Both the labial and the palatal cortical bone had high density values. and IMe bone farther from the implant was denser than the bone surrounding the Implant.

Another nine sliced views are shown on Figure .3-12. A. depicting the alveolar area selected for mini-implant placement distal to the canine. Figure 3-12, B. shows a close-up view of tMis area, The upper-right figure shows <I crosssectional view of this bone and the mini.implant (red oar). The horizontal distance between the bucC<l1 and the palatal cortical bone was 8,54 rnm. The bone density of this "rea appeared deficient. as seen in Figure 3-1.3. Which suqgestedthat immediate loading was contraindicated.

For the molar area. a site distal to tne first molar was chosen to receive the implant [Figure 3-1 4, AJ. The verucai distance from the selected implant site to the maxillary sinus !Figure 3-14, BJ was measured at 10.23 mm. This distance W<ls large enough to accommodate a monocortlcal implant

The anatomical characteristics of the lower incisor <Ire" were different from tn ose of the upp er incisor area. Indeed, morphologically the alveolar bone width between Ihe labial and the lingual cortical bone is generally smaller in the lower incisor region. especially in patients with long-face pa rterns [Fig ure 3-1 s. A). The cross-sectional view of the lower incisor area revealed a very thin "lvEOlar bone width. only 4.78 rnrn !Figure .3-' S. BJ. Careful selection of the implant length was required. Fortunately, the bone demity for the implant site under consideration was sufficiently high for good primary stability on insertion of the miniimplant !Figure 3-1 oj.

In the lower premolar area, the mini-implant was designed to be placed between the canine and the (jrst

3 Radiographic Evaluation of Bone Sites for Mini-Implant Placement 33

. -

CASE REPORT 3-1: DOLICOFAC

---

figure 3-10 A. Nine sliced images of the upper anterior area. Panoramic view was used to estimate where the mini-implant should be placed. B, Close-up view was used to measure bone depth between the labial and palatal conical layers. This patient demonstrated a long facial vertical pattern. There was enough vertical space, but the horizontal distance was short. Actual measurement. is 7.39 rnm.

34 PART" Diagnosis and Treatment Planning

CASE REPORT 3·1: DOLICOFACIAI.:

A

B

Figure 3-11 A. Bone density graphs of the upper anterior area based on bone quality classification system (0 I. compact bone to D4, low-density trabeco lar bone) where the labial and palatal cortical bones showed high-density values, The bone outside the implant was denser than the bone inside the implant. B. Same bone density graph in Hounsefield units.

premolar (Figure 3·17. AI, The cross-secnooai view of this area reveals that bone depth along the mini-implant from the buccal surface (0 the lingual surface was I 1,20 mm (Figure 3·17. 8). In cases where the bone density might not be sumcrem, a long screw that can reach the lingual corncal layer and provide bicor(ical anchorage is required. In this case. however. the bone density around tne minlimplant site appeared adequate. although the buccal surface hild less bone density (Figure 3-181.

The lower premolar area was deemed appropriate to retain the mini-implant. In the lower molar area, a site mesi", to the first molar area was designated to receive the rnlnl-Imptant as temporary anchorage (Figure 3-19. AI.

In this doJicof"ci", patient. the dist"nce along the planned mini·implant site from the buccal to the lingual bone surface was 15,94 mm. TMe vertical distance from the tip of the ptaoned mini-implant to the mandibular canal was 14.54 rnrn. There was no defined external oblique ridge in this high-angle patient. Thus, 1Me mlni-jmplant could not be pia ced perpendkuia r to the tooth axis, as seen by th e cross-secno n~1 view on Flgu re 3-1 9, 8. The bo ne dens ity graph showed tna t th e buccal surface hild C ompa ct bone; however, me trabecular bone in the rnanclbutar body was ,ignific<lntly less dense (Figure 3·201. Bone density analysis for this patient revealed that reliable bone did not exist in the molar area. so <l wider mini·implant was selected.

Tex-l coruinued em p. 43

3 Radiographic Evaluation of Bone Sites for Mini-Implant Placement 35

CASE REPORT 3-1: DOLICOF

~ .:':' :::; "'!

Ccmli.nuen

Figure 3-12 A. ine sliced images of the premolar area, B, Close-up view of the premolar area. Upper righI, Cross-sectional view of the bone and the mini-implant (red bar), The horizontal distance between the buccal and palatal cortical bone was 854 mrn.

36 PART II Diagnosis and Treatment Planning

-- ~;;q- ..

CASE REPORT 3·1: DOLlCqFAC

A

figure 3- J 3 A. Bone density graphs of the premolar area based on bone quality dassificalion system (D1. compact bone to 04, low-density trabecular bone). The bone density of this area appeared decreased, and immediate loading was contraindicated. B. Same bone density graph in Hounsfield units.

3 Radiographic Evaluation of Bone Sites for Mini-Implant Placement 37

~.

CASE REPORT 3-1: DOLICOFAC

<--~

Figure 3-14 A, Nine sliced images of the molar area. A site distal to the first molar was chosen to receive the implant. B, The bone depth of the infrazygornauc area was 10.23 mm if measured from the implant tip to the maxillary sinus.

Ccmillrted

38 PART II Diagnosis and Treatment Planning

CASE REPORT 3-1: DOLlCOFACIAl! PATIENT=<ont'd

r ~:N~

Figure 3-1 5 A, Lower incisor area showing a lingual conical bone layer. The long-faced patient has a short distance between the labial and the lingual cortical bone width. B, Crosssectional view of the lower incisor area revealed a very thin alveolar bone.

3 Radiographic Evaluation of Bone Site, for Mini-Implant Placement 39

CASE REPORT 3-1: DOLICOFACIAl:

-~

IIt!Ii:!'iIIIhI iIreIIrt~ ~thI!~ .......

~orAMrJr;f~ MD.

(I.'5IJI: _

ome _

A

B

Figure 3-16 A, BOil. density was high in the lower anterior area, indicating that adequate pri mary stability could be expected. B, Bone density in lhe lower anterior area. In the upper graph the bone density was almost the same from the labial surface to the lingual surface.

Comillutll

40 PART II Diagnosis and Treatment Planning

CASE REPORT 3-1: DOLlCO:FAC

Figure 3-17 A. Placement of a mini-implant was planned between (he canine and the first premolar in the lower premolar area. B. Cross-sectional view of the lower premolar area showed tha t bone d ep th along the min i· i m pi am from (he buccal su rface to (he lingua I su rface was 11.2 rnm.

3 Radiogr<lphiC Evalu<!tion of .Bone Site .. for Mini,lmpl<lnt Placement 41

--

CASE REPORT 3-1: DOLI COFACIA L

-~,:;r ~-.?"'..t.:.:

_ ....

~~~! 11_.g.~H..I

~lhIitl1kti

""""

tfiMro'l!J~!

~thdMsS!

(1.:9): ftI'I

A

figure 3-18 A, Bone density graph of the lower premolar area which appeared '0 have adequate bone qual i,y for retention of the rnini-i mplarn. B, I f bone density had been reduced, a longer screw (bicortlcal anchorage) would have been required" However, the bone density in this area, both inside and outside the mini-implant site, appeared to be adequate (ahhough slighdy reduced in the buccal surface),

42 PART" Diagnosis and Treatment Planning

"",,?~_: ...

CASE REPORT 3-1: DOLlCOFACIAI.!

_ .... ~,::OA _-

Figure 3-19 A, Three-dimensional CT image of the lower molar area. A sire mesial 10 the first molar area was planned [0 receive a mini-implant as a temporary anchorage. The distance along the planned mini-implant 10 the lingual bone surface was 15.94 mrn, and the distance from the lip of the planned mini-irnplam to the mandibular canal was 14.54 mm, There was "0 external oblique ridge (as seen in this area for thls high-angle patient], and the bone shape was almost the same as lha[ of the premolar area. B, Cross-sectional view shows that the mini-implant could not be placed perpendicular to the tooth axis.

3 Radiographk .Evaluation of Bone Sites for Mini-Implant Placement 4·3

CASE REPORT 3-1: DOLICOFACIAL PATIENT-cGnt'd

A

Figure 3-20 A, Bone density graph of the lower molar area. B, Bone density graph shows that the buccal surface had compact bone, but only weak trabecular bone existed inside the mandibular body.

CASE REPORT 3-2: BRACHYFACIAL PATIENT

.... ,-

In contrast 10 the previa US pan em with a dol i coracta I pattern. this patient had a bra chyfacial pattern, A 3 DX Ie B en sea n was ta ken to evaluate the 3 D bon e structure and determine proper mini~mplant placerneot. Brachyfacial patients us ua Ily h<IVe denser be ne man do I icofacia I patients but have less vertical space in the alveolar bone for placement of a mini-implant. Figure 3-21. A shows 3D CT image. of the upper anterior area, A panoramic view revealed a maxillary sinus enlarged in a downward direction making the placement of the mini-implant difficult. Additionally, the 3D CT images revealed limit.ed alVeolar bone width. especially if the mini.~mplant was to be placed h orizo nrally _ The di,tan(e along the desig nered m i nii mpla nt site from tn e labial to tn e palata I surfa ce was 10.19 mm.

I n the lower enteno r ares, the CT sea Fl i Fldicated that across the designated rnlnl-imptant site. there was only 6.65 mm between the cortical surfaces (Figure 3-21. 81. Such CT data must be carefully considered when determining the length and placement direaion of the mini-Implant.

IFl the premolar area the maxillary sinus showed downward enlargemeFlt, and me buccal area looked ,malilFigure

3·22, AJ- One of the nine sliced views was selected to determine the appropriate min~jmplaFlt length and position (Figure 3-22, 81. In contrast to the dolicofacial padent, this brachyfacial patient had a reduced vertical height; only $.08 mm from the labial surface to the lower portion of the maxillary sin us. Th e cross-secnona I view reveals th e positions of the planned upper and lower mini-implants. The lower anatomical width was 12.0.2 mm to the lingual bone surface.

In the molar area (Figure 3-23. AJ. the maxillary sinus showed' downward enlargement. and there was only a small space around the roots of the upper first molar. Only 5.69 mm was observed from the buccal surface to the lateral surface of th e ma·x i lIa ry ,in us (Figure 3-23, 8) _ In contrast, the lower molar area ha d s uificient spa ce because of a prominent buccal extension of the oblique ridge; therefore the mini-implant could be placed almost vertically (Figure 3-241. the distance from the tip of the min~implant to the mandibular canal was 9.84 mm. The anatomical characteristics of this area permitted easy Jnsernon of the min~implant_

CaruiJiJled

44 PART" Diagnosis and Treatment Planning

_J~-~

CASE REPORT 3-2: BRACHYFACIAl; ~ ...... ~,....

Figure 3-21 A, Three-dimensional CT images of the upper anterior area. The panoramic view shows that the maxillary sinus has enlarged in a downward direction, making placement of the mini-implant difficult- The 3D cr image showed there was sufficient space, especially if the mini-implant were placed horizontally. B, Three-dimensional Cl images of the lower anterior area show a distance of only 6.65 mm between the cortical surfaces along the selected mini-implant site.

3 Radiographic Evalualion of Bone Sites for Mini·lmplant Placement 45

CASE REPORT 3-2: BRACHYF

::: ,.

Figure 3-22 A, Three-dimensional cr image of the upper premolar area. Downward enlargement was seen in the maxillary sinus, and the buccal area showed a small space for mini-implant placement. S, View of one of the nine sliced images, used to select the miniimplant site.

Ccmrmted

46 PART 1/ Diagnosis and Treatment I'lanning

CASE REPORT 3-2: BRACHYFACIAl.! <i!;<i ..

Figure 3-23 A, In the molar area the maxillary sinus showed downward enlargement, with only minimal space around the roots of the upper first molar for mini-implant placement. B, Measurement showed a depth of 5.69 mm from the bUOOilI surface !O the lateral borde, of the maxillary sinus.

3 Radiographic Evaluation of Bone Sites for Mini-Implant Placement 47

- -.-.;.

CASE REPORT 3-2: BRACHYFACI

Figure 3-Z4 Prominent external oblique ridge in relation 10 the lower molar area, allowing for a mini-implant to be positioned almost vertically.

CONCLUSION

Computed to mography can provide a fully reconstructed 3D model of the maxilla and the mandible, as well as additional diagnostic information on dental root positioning. morphology of sites for TAD placement, and location of critical anatomical structures. cr scanning and its associated software provide the most effective radiographic modality in the diagnostic evaluation of patients for TADs in orthodontics and permits the immediate formulation of a treatment plan. REFERENCES

1. Hounsfield eN: Computerized transverse axial scanning (tomography). 1. Description of system, Br I R,/(Uol 46:1016- 1022, 1973.

l. Macchi A. Carrafiello C. Cacdafesta VI et nl: Three .. dimensional dlgital modeling and setup. Am I Orl/"u( D"",cf"'i"1 Or/hop 129;605·610, 2006,

3 _ Gerig GI 10m ler M r Chakos M. et al: A new '1,1'8.1 idauo n tool [or assessing and improving 3-D object segmentation. In Nlessen WI Vlergever M. editors: MeJjcal image '()mpU!i~lg lmd computer·tlssis!ell ;mememion (MICCAJ: 4th International Conference, Utrecht. The Ne~>etIOlJlds), Bulin, 2001. Springer-VeriOlg.

'-l_ Miyajirna K, Sana M: FEM analysis of mini-implants as orthodontic anchorage. In Davidovitch Z, Mah L editors: BiologiCi.rl mechanisms of looth er1Jpriotf, rerol'ptiOJl ami replacement by implam5, Boston, .998. Harvard Society for the Advancement of Orthodouucs.

5. Miyajilna K.. Saito S, Sana M. el al: Three-dimensional finite element models and animal studies of the use: of mini-screws for

onhodoruk anchorage: In McNamara IAr ediror: CrtHljoJodol growtlr senes, vel 42, Implm'H5, microi,tllplanu. onplmrlS, tlrJ(/ mm5a pi""", lIn n Arbor, M lch, 2005. Needham Press,

ADDITIONAL READING

Block MS, Hoffma n DR: A new device fo r a bsolu te anchorage for onhodoruks. A", I 0'1hod DelllOfoci"1 On/top 107:251·258. 1990.

Cope BC: Temporary anchorage devices in onhodonttce- a. paradigm 'hift, Sell'itl O"lIod 1 t:3·9, 200S.

eo". A POl'la C, Betgarnaschl C: Intraoral hard and soft (issue depths for temporary anchorage devices, Semin Orll!Od 11 :10-151 2005, Creekmore TO, Eklund MK: The possibility of skeletal anchorage.

I Ciin OrrllOd J 7:266·269, J 983.

Duyck" Ronald 1-1" Van Oosterwyck J-I, el 3.1: 111e influence of static and dynamic loading on marginal bone reactions around osseointegrated implarus: an animal experimental study .. Clitl Om! Implalll Res 12:207-218, 200 L

Frost HM: The regional accelerated phenomenon: a review, f-Ie-.tlry Ford Hosp Med I 3 j :3-9. 1985.

Hoblt WF: Using the palatal nnplarn for absolute anchorage.Jn Md\.~ilR mara IA. editor: Cranl"[(lcill,/ gnmrdl series, vel 42, lmpll"HtI.sz microimpi.r::mfS. OPiphilrlS, and mm.spl(lk!lS. Ann Arbor. Mich, 2005, Needham Press.

Kanomi R: Mi.lli~illlplam Par orthodontic anchorage, J CUtr Orll'Hw 31:763·767.1997 .

Lagravere ,'v10. Hansen L, Harzer W. II;!t al: P13ne- orientation for standardlaatlon In 3·dimel'lsLonal cephalometric analysis with computerized tomography Imaging, Am J Ol1ilcd De1llojildllj Orrilap 129:60 J ·604, 2006.

tum LB/ Beirne R. Curtis DA: Histological evaluation of hydroxy lap ame-coated versus uncoated uranium blade implants in delayed and Immediately loaded applications, lilt J Oral Mluillofac ImplJlneS 6;456-461, 19 L

Meisen BI Verna C: Miniscrew implants; the Aarhus Anchorage System.

Semi" Or/hod 11:24-31, 20()S.

48 PART" Diagnosis and Treatment Planning

Melsen B: Mirt;.;mpl.",s; wilere are ,"e! I Cli" Onhad 34(9]:539·547, 2005.

Mila ni H, 13 rod i eo AG; Three plane analysis or tooth rnovernera, growd-. and angular changes with cervical traction, 1111&le Ordwd 40~8Q-94, lno.

MiYi3jima K: Diagnosis and treatment pllln.r.Jing of mlru-implam onhod onti (5, L1S Vegas, 1006. Ameli raj) Association of Orthod ont tsts.

Piva LM, Bri to H H A. Leite flR. e, a]; Err.", of cervi cal headgear and fixed appliances on the space evailabte for maxiHa.ry second molars, Am J OrtJ'M Delrlo[a<i"1 Onl,op 128:366·37L 2005. ltickens Rfo,..i: ,1le. in Iluence of orthodon tlc treatmenron faci al growth and developrneru, A,,~I< OrtllM 30: 103· 133. 1960.

Robens WE. Marshall K.I. Mozsary PC: Rigid endosseous ; m pl. ru uulized as anchorage [0 protract molars and dose an atrophic extracnon she, A"Slo OrtJlOO GD: t 35·152. 1990_

Robon. WE, SIT) i til RK. Zi I berman Y, <t at Osseous adaptation to continuous loading of ri_Sjd end osseous implants. Am J Onllod o."IO[",iol Orli,op 86:95·111. ! 984-.

Sal to SI Sugi m ow N. Morohasn.i TI el al: End 055000 us ti ta uiu m j 111 pia rUS can. luncuo n as an chors for mesiodistal roo Lh movem en .. in the beagle clog. .~'" I On),,,,1 o.rrlafa,;,,1 Orlloop I 18:60]·607. 2000.

Sugawara J. Baj k U Lt U rile mori M.et 31: Treatment and post rrearrn en .. den roalveo lar changes lollowi flS in uusi On 0 ( In and lbular In 013 ra whh applicauo n of' a skeletal a nchorage system ($AS) for open bile correeuon, I", J At),,/! 0,,1100 Ortl,08f1atl, s,"~ 17:243·253. 2002.

Suga wara J; N eM' surgtca II 0 rthcdoruics for Cl ass ll 1 correcuo n In c-omb inauon with a skeletal anchorage syste m (SAS)I tas vegas, 2 0 0 61 America [1 Asscda L ion of 0 nhodontists.

tJme.mori M. Sugav .... ara J. Nngnsaka H. er 0'11: Skeletal nnchcrage system for open-blte correction. Am J Ortl!op 1 J 5,166·174, I ~~~_

CHAPTER

4

Miniature Osseointegrated Implants for Orthodontics Anchorage

~yu;zo Kanomi and W. Euge~e Roberts

Temporary anchorage devices (TAOs) have developed into important orthodonLic adjuncts for expanding the scope of biomechanical therapy and enhancing clinical outcomes. i-s However, most of the devices ell rrenily available have significant limitations because they are not designed to osseotntegrate." The development of miniscrews is similar to the evolution of endosseous implants to support dental prostheses more than 20 rears ago."

The initial prostheses, as well as the first report of endosseous implant anchorage for orthodontics, relied on biocompatible metallic devices not designed to osseointegrate.? Immediate loading was advocated to develop persistent implant mobility, thought to be a desirable physiological characteristic and deemed 'fibre-osseous i ntegration " or a "pseudoperlodonuum." Histological studies subsequently demonstrated that 6 bra-osseo LIS integration was actually an encapsulation of the implant by relatively acellular fibrous connective tissue." A pseudoperiodontiurn was distinct from the highly vascular and cellular principal elements of the periodontium; periodontal ligament and epithelial anachrnent. Thus, fibre-osseous integration was the physiological equivalent of the scar tissue that characterizes an orthopedic nonunion. Considering this biological reality, it was not surprising that. dental implants designed to achieve fibre-osseous integration had a poor success rate in most pa tien ts, The persisten l micromotion produces inflammation and progressive resorption." resulting in a vicious cycle of inflammation that evenrually manifests as pain, infecuon, and exfoliation of the implant.

The modern era of highly successful dental implants began with the well-documented efforts of Branernark and colleagues in routlnely achieving rigid osseous fixation of endosseous titanium fixtures.' Although the obvious initial market for osseointegrated implant! was prosthetics, the similarity of the rigid fixtures to an kylosed teeth led to osseous anchorage for orthodonLics. Osseo integrated anchorage was one of the most rrnpor-

tam developments in orthodontics in the twentieth century. Rigid osseous anchorage has had a high rate of success in orthodonucs for more than 20 years. L.2.'·11

EVOLUTION OF MINISCREWS

Placement of miniscrews or microscrews in the alveolar process is an increasingly popular inrraalveolar procedure. In general, the anchorage achieved with this type of TAD is less reliable than csseointegrated devices, L~B although the surgical procedure is relatively simple, The most popular locations are on the labial surface of the alveolar process in both arches, superior to the roots of the maxillary incisors, or in the palate, The sites selected are usually between the roots of teeth or apical to them, The original rniniscrews used for orthodontic anchorage were the anchor screws supplied with surgical fixation plates."'" In general, these screws engaged the cortical plate of the alveolus as a thread-retained device, The minscrews were immediately loaded, with no attempt to achieve osseoi ntegrati on , The efficacy of mini crews as bone anchorage devices has been documented in animal studies."

After extensive experience with nonintegrated mlnlscrews, the senior author designed a one-stage, miniature inuaalveolar implant that routinely achieves osseointegration (K-l System). Clinical trial of the K-l System has been promising, Two case reports are presented to demonstrate the util ity of the K- 1. System for intruding and retracting maxillary incisors.

THE K-1 SYSTEM

The K-I System features osseoiniegrated mini-implants specifically designed for orthodontic anchorage to facilitale tooth movement that cannot be accomplished with conventional anchorage. Minimal bone and interradicular space is required for safe drilling of the 1.2-mmdiameter holes, into which the miniscrews are inserted as self-tapping fixtures. The most frequently' used implants are 4 rnrn and 6 mm in length, but 8·mm

49

SO PART II Diagnosis and Treatment Planning

implants are also available. indication.'! for implant anchorage include canine retraction. intrusion of i ncisots, intrusion of molars. and retraction of buccal segments. To intrude maxillary incisors. K-l screws are placed a few millimeters below the lower border of th e pi ri fa rm a p e rture, ln trusive fo fee is d eli vered [0 the maxillary incisors through a ligature wire Lied from the implants to an eyelet attached to the archwire,

Computed tomography (CI') imaging is used for evaluating potential implant sites. Using the threedimensional (3D) images. surgical SleNS are prepared 10 hel p ensure accurate placement of tIle TADs. Because the devices are designed 1.0 osseointegrate, (hey must be placed early in treatment to allow 3 months or more of u ndlsturbed healing to achieve ossecinregraticn before installing the transmucosal abutment and orthodonucally loading (he devices.

CASE REPORT 4-1: TEMPOROMANDIBULAR,DISORDER

A wo man age 23 yea rs. 7 rno nms with a history of ternporomandlbutar disorder ITMO) presented for orthccontk consultation with a chief complaint of "jaw pain and crooked fro nt teeth." Clinical exa m ina tion of rh e face revealed a hyperdive,gent. convex face with a decreasec lower f"ci~ I h eig ht IF igure 4-1. A an d 81· The pretrea trnent photographic series documented a Class II, Divis ion 1 malccciuslon with an $·mmoverjet and 6-mm overbite 1-60% overlap of mandiblliar incisor). About 5 mm of maxillary and 7 mm of m<lndiblliar crowding were associated with a deep curve of S pee (Fi gu re 4-1. C -<11, The pretrea trnent pa nora m Fe; rad iog raph showed a relatiVely norma I den tib on except for endodontic treatment and temporary crowns on the mandibular len and maxillary right fif>l molars. In add'~ non, the mandibular third molars were distally inclined and pa rtia lIy lmpacted (Figure 4-1. HI.,

Mo un ring the casts i n the ceo trlc reta no n (Crl position revealed' an asymmetric. 5-mm anterior-posterior 'hift seconoa ry to a prema tu rity on the pala'ta I cusp 0 f the maxilla ry rig ht third m ola r !Figure 4-1. /·01. From a (unctional per" 5 pecnve, the malocc lusion wa, a severe full-cusp Cia,s, II discrepa ncy. The pa nenrs habilua I. maxi mal i ntercu spat.i on relation was defined as the centric occlusion (Col position. The large Co ~ Cr shift and prematurity were considered the pri nci pa I enoi ogka I factors in the TMD h lstory reported by the patient.

Cephalometric analysis in the Co posrtlon documented rela tively normal pro rruslon of the max iIIary ap.ical base (SN/I. 80 .. 5 degrees) and a retrusive mandibular apical oase (SNB, 7.3.5 degrees], The AN8 of 7 degrees was deceptrvely low because of the S-mm Co --> cr shift. From a therapeurlc perspective. the ANB was greater than 1 (') degrees when tne mandible. was in the Cr position .. f'fgure 4-1, r, provrdes additional cephalometric values,

It was imponant for the patient to recognize that this was a severe skeletal malocclusion tnat usua lIy req uired' orthognathic surgefjl. The patient was concerned about jaw surgery, preferring a more conservative option. She accepted' a rreatm ent pia n wi (h min~.i m pia nts as anchorag e devices. As pa rt of the in formed-consent process. sh e was told rhat th e severity ot her rna locel us ion rna:)! exceed wha r was rea listie even wi th osseointeg",ted i no pia nt anchorage.

and that orthcqnetnlc mrgery may ul~ma(ely be necessary, A relatively long' treatment ~me was anticipated'. so good oral hygiene and pertodonn urn mai ntena nee by a periodontist were essential, TIl e pa tient accepted the treatm en t pia n i nvc Ivi ng extraction of both man dibular first m ola rs and borh max i Ilary rom premolars, S he was in formed tna ( K· I i no pia nts would be needed apical to rl1 e max ilia ry incisors to intrude and retract the rnaxltlary anterior segment.

The initial phase of rreaanent was to resolve the TMO .symptoms Wit!1 spnnt tnerapy and prepare the surgical stent to place the K- J implants apical to the maxWary incisors (Figure 4-21. While the implantS were healing and osseomteqraanq, active orthodontic treatment was initiated in the mandiblliar arch (Figure 4·3), The treatment sequence was to extract rne mandibular first molars. retract the ca nin es, resolve mandibUlar an terior crowdin g. an d achieve space closure with as much mesial movement of the buccal segments as possible. The posterior anchorage units for the alignment of the mandibular arch were (he mandibular second molars. The second molars moved' mesially. so the sup ra <;festal fi bers were expected to ti p th e thi rd molars mesfallY. improving their ~xi<ll inclination and' eliminating the soft tissue coverao e over the distal as peer of their crowns. Mer the deep curve of Spee was partiallY cor" reeted. the maxillary first premolars were extracted. and the maxillary arch was banded .. bonded. and leveled.

A cone-beam CT image was used belore the second surgical procedure to locate the healed mini4mplants IFigure 4·4). The 3D image revealed the extrusion and protrusion of the maxHiary in ci SOrS a Iter Ih e iniHal I'evel i ng a nd can i ne retractlon procedures, Figure 4-5 is a panoramic radiograph dernonsrrannq progress in alignment of the mandibular anterior segment and retraction of the maxilla ry C"<lni nes, vernca r traction was a ppl i ed to the maxillary a nterior segment with, stal mess steel ligacu res originad ng from the K-J mini~mplants. Figure 4-6 documents the pro. . gression of active treatment 10 create a lull-cusp Cia" II molar retatlonsn i p.i ntrude the maxillary in dscrs, and' reduce the maxillary anterior protrusion. It atso illustrates the Intermaxillary alig nment at th e end of 'pace closure ai1d the correcuon of the interinci~al relationship. The Co --> Cr diserepancy w.,:; eliminated. but it was necessary 00

4 Miniature O~seo.integrated Implant. for Orthodontics Anchorage 5 I

ConrinUM

Figure 4-1 Woman with Temporomandibular Disorder {age 13 yr, 7 rno}, A and B, Pretreatment facial photographs. C to G, Pretreatment intraoral photographs. H, Pretreatment panoramic radiograph. Ito 0, Photographs of the pretreatment relationship of !he casts rno U n ted i n the centric rela ti on p osi ti On docu ment a funcu 0 na I sh i ft associated wi th a pesterior prernaturi ry. P, Pretreatment cephalometric analysis. FMA, Frankfort mandibular angle; FM1A. Frankfort mandibular incisor angle; lMPA. incisor mandibular plane angle; UI, upper incisal; LI, lower incisor; NA. nasion to point A; NB, nasion to poin l B.

52 PART" Diagnosis and Treatment Planning

.' .

CASE REPORT 4-1: TEMP<:,~_~MA

•

K

FMA32.0" FMIA46.S" IMPA lOIS

Ul to NA 27.0·, 11.0 mm L1 to NB 35.5", 11.S mm

p Interincisalll0.0·

Figure 4-1, con!' d For legend see p. 51.

o

4 Miniature Osseointegrated Implants for Orthodontics Anchorage 53

. -

CASE REPORT 4-1: TEMPO -7-·

•

•

Figure 4-2 Lead makers embedded in a heat-pressure-adapted plastic stent (A) are used to plan the position for K-l anchorage implants apical to the maxillary incisors (B).

Figure 4-3 Intraoral photographs document treatment progress at 9 month. (A-C), 12 months (D-F), and 15 months (C-II.

Contimtf!'d

54 PART II Diagnosis and Treatment Planning

CASE REPORT 4-'; TEMPO ROM

Figure 4-4 Cone-beam CT images before uncovering the K-J anchorage implants show the flaring of the maxillary incisors before iniliating intrusion and retraction.

Figure 4-5 Panoramic radiograph showing treatment progress, with alignment of (he mandibular anterior segment and retraction of the maxillary canines.

hOld the maxillary molars wilh high-pull headgear and mesially translate the mandibular second molar> about 8 mm. Eliminating the Class II molar relationship. complicated by the 5-mm functional shift, required careful management of differential anchorage. This was the major factor in the relatively long duration for space closure. wh ich was not completed until 37 months into treatment.

Posttreatment facial photographs show that a favorable lip profile was achieved desplte the severe mandibular retru-

sion at presenra lion IF ig ure 4-7. A and 81. The corres pon ding Intraoral photographic series revealed that a near-ideal interdigitation was acnleved from first premolar to first premolar, and the posterior buccal occlusion was finished in a fulkusp Class" molar relationship (Figure 4-7, C-F). A posttreatment panoramic r<loiograph dernonstrered ideal secon c-order correction in the maxilla ry arc h and satisfactory axial inclination of the mandibular denntron (Figure 4·7. HI. The severily of tne malocclusion required <In active

4 Miniature Osseointegrated Implants for Orthodontics Anchorage 55

.~

CASE REPORT 4-1: TEMPOROMANDIBU

-F

Figure 4-6 After the anchorage implants have osseointegrated, they are used to intrude the maxillary anterior incisors. Intraoral photographs document treatment progr 5S at 20 months (A-C), 24 months (D-F), and 37 months (C-I)

treatment time of about 4 years. Additional treatment to achieve more ideal axial inclination of mandibular premolars was not indiC<lled because of evolving periodontal compromise. Gingival recession and bone loss were noted on the mesial of the mandibular second molars. It WaS deemed prudent to term. nate fixed-applia nce treatment to pu (Sue pertcconta I rreatm em to sra bilize the loss of attach ment.

Cephalometric analysis after active treatment demonstrated a primarily dentoalveolar correction of the malocclusion ,Figure 4-8. AJ. Although the mandibular plane angle (MPA) closed 1 degree. there was only a 0.5-<1egree increase in SNB. Furthermore. the cone-beam a images used to construct the sagittal plane for cephalometric analysis revealed an increase in the superior position of the right

Continuen

56 PART II Diagnosis and Treatment Planning

~"""'"

CASE REPORT 4-1: TEMPORO

Figure 4-7 A and B. Posttreatment facial photographs (age 27 yr, 7 mol. C to C, Posttreatment lruraoral photographs. H. Posttreatment panoramic radiograph.

mandibular condyle. This Change in mandibular morphology is consistent with the increase in mandibular length (Ar-PgJ documented in the cephalometric superimposition (Figure 4-8. 81. and appear, to reflect the merp hological m ecna nism for the correction of the asymmetric "·mm Co --4 Cr discrepancy.

Anterior cranial base superimposition of the initial and final cephalometric images shows that the maxillary dentllion was intruded and that a forward rotation of the mandible decreased the lower facial height (Figure 4-8, Cj. The lips were slightly retracted, and the interiabial posjtion moved superlorjy. Superimposition On the relatively stable

4 Miniature Osseo integra ted Implants for Orthodontic, Anchorage 57

FMA31.0· FMIA 45.0' IMPA 104.0'

Ul to NAZ3.0', 5.0 mm Lito N6 37.5·, 9.5 mm I nteriocisal 132.0'

- -

CASE REPORT 4·1: TEMPOROMANDI

A

o

c ~

B

23y7m

27y7m

Figure 4-8 A, Posttreatment cephalometric analysis, B, S\lperimposition of pretreatment and pcsnreat m e ru ceph ala me" it uacings dccu men lin trusion and retractl 011 of maxi llary incisors as well as a more aOlcrior position of the mandible. C, Superimpositions on the maxilla. mandible, and upper race profile reveal changes in dental and facial structures.

i nternal max ilia ry structures demonstrated the intru, i on an d retra etten of Ih e maxi Ilary inci,ors. The rnooesr i ntruston of the maxillary molar, was caused by high·pull heaoqear wear. Mandibular superlmposrttcn on the inrerior portion of the symphysis ant! mandibular plane revealed about 3 mm of incisor in trusio n and asymmetric tr a ns tatlon of the secor: d m olars to close {he first m ola r extra ction sites. Th e m~nd ibuI~r occlusal photograph shows that the right second molar

is m are <In terlorly posltlo ned tna n the contra I~teral second mol", [see Figure 4-7. C·Gj. These data cernonstrate the differentia I tooth movement {hat was necessary to resolve the severe 5keletal malocclusion. complicated by an asymmetrlc Cr ---> Co shltt, The 8 mm of mesial translation of the rna nd i bular righ t secon cI an d th i rd m cia rs to co rrect the shift was the principal faeror associated with the relatively long treatment time of a pproxirna !ely 4 years.

58 PART II Diagnosis and Treatment Planning

,~ 4,",

CASE REPORT 4-1: TEMPOROMANDIBULAR DI

:i - _._.

Figure 4-9 Comparison of A, pretreatment (age 23 yr, 7 mol, and B, posttreatment (age 27 yr. 7 mol, facial photographs shows the improvement of facial form in the frontal plane,

The excellent dental esthetics achieved are complemented by the improved facial form (Figure 4-9, A and 81, The patient was particularly pleased with the Improvement in her profile, especially because it was achieved without orthognathic surgery, The authors believe that the intrusion

and retraction of the maxillary incisors with K-l anchorage wa, essential to achieving a good result for this severe, asymmetric malocclusion, Although the periodontal deterioration of the mandibular second molars was a di,appointrnent, the overall result of treatment was gratifying,

CASE REPORT 4-2: DENTOALVEOLA-R1DYSPLASIA ~ ~.

A woman age 20 years. I I months presented for orthodontic consultation with a noncontributory medical, dental. and family history, The chief complaint was protrusive lips and crowded lower incisors, Clinical examination revealed that facial balance was near ideal (Figure 4-10, A and 81, which suggested that the malocclusion was a dentoalveolar dysplaSia, The intraoral photographic senes showed Class I buccal segments, overjet of 3 rnrn, overbite of 4 mm, and about 7 mm of crowding in the mandibular anterior segment (Figure 4-10, C-G) , Evaluation of the initial panoramic radiograph documented a relatively healthy dent~ rion compromised by two devitalized teeth with crowns (maxHiary left central incisor and mandibular right first molar) IFigure 4-10, H), The mandibular third molars were horizontally impacted, The initial cephalometric analysis showed a bimaxinary retrusion of the apical bases of the jaws ISNA 78.5 degrees; SN8, 74,5 degrees) with a modest relative retrusion of the rna nd ible (AN B, 4 deg reesl (F igu re 4-10, ~, Mounting the casts on an articulator revealed a 3- mm symmetrical mandibular shift from centric relation [Cr]

to centric occlusion (Co) IFigure 4-10, J-NJ, The patient had no history of TMD and was unaware of the asymptomatic functional shift,

The treatment plan was to extract maxillary first premolars and mandibular second premolars, Bilateral K-l implants were prescribed to intrude and retract the maxillary incisors, The surgical stent was fabricated to ensure accurate placement of the anchorage implants with respect to the roots of the incisors (Figure 4-1 II. Before initiation of active treatment, the K-I implants were Inserted according to the surgical sequence illu>erated in Figure 4-12. After extraction of both maxillary first premolars and both mandibular second premolars, the arches were leveled, Canine retraction was accomplished by placing open-coil springs between the canines and lateral incisors and cinching bilck the archwires, Simultaneously, mandibular first molars were moved mesially with open-coil springs placed between the mandibular first and second premolars, A series of intraoral ph otogra phs ill ustrates the progress of ca nine retra eli on an d rna nd ibular first molar p rotractl on (Figure 4-1 31. The

4 Miniature Osseointegrated Implants for Orthodontics Anchorage 59

CASE REPORT 4-2: DENTOALVEOLAR

~ .

Figure 4-10 Woman with Dentoalveolar Dysplasia (age 20yr, 11 mol. A and B, Pretreatment facial photographs. C to G, Pretreatment imraoral photographs. H, Pretreatment panoramic radiograph, I, Pretreatment cephalometric analysis. J 10 N, Photographs of the pretreatment relationship of the casts mounted in the centric relation position document an anterior-posterior functional shift.

Continue,}

60 PART" Diagnosis and Treatment Planning

~ ... _ ... J

CASE REPORT 4·2; DENTOA1.V ~-'-1..

FMA 19.5" FMIA53.0· IMPA 107.5"

Ul to NA 25.5°,9.5 mm L 1 to NB 30.5", 9.0 mm

I nterincisal 120·

Figure 4-10, cont'd

overbite increased as the mandibular ~rst molars tipped mesially.

Five months after placement of tne K-l mini·implants, a second surgical procedure uncovered trte implants. The submerged implants were located with an inrr"oral metal detector; the overlying mucosa was injected with local anesthetic containing a vasoconstrictor; an incision exposed the implants; and sort tissue was sutured around

the head of the TAOs !figure 4-141. After the head of the implant was exposed, " supramucosat slide-on attachment was secu red to ea cM impla nt, an d steel ligatures were used for traction between the implants and eyelets SOldered to the archwire between the maxillary central and lateral incisors (Figure 4-15). The maxillary incisors were intruded by the traction ligatures attached to tMe implants, and the mandibular arch was nanened witM a st"inless steel arch-

4 MiniaUJre Osseointegrated Implants for Orthodonti(s Ancnoraqe 61

CASE REPORT 4·2: DEN'TOALVEOLAR ; '"""~

Figure 4-1 1 Lead maker'! embedded in a heat-pressure-adapted plastic stem (AJ are used \0 plan the poshlon for J{·1 anchor~g,e irnplams apical to the maxillary incisors (B and C).

Figure 4· 12 First operation, to place K·t anchorage implants. The sequence of events follows: A, anesthesia, B, incision; C, stem in place; 0, evacuation; E, drilling; F. implant in drive r; G, inserti on; H, suture.

Continued

62 PAlrr" Diagno~is and Treatment Planning

CASE REPORT 4-2; DENTOALVEOLAR DVSPLASIA--cont'd

FIgure 4-11 lutraoral photographs document progress all 0 weeks (A·C) and 28 weeks

(P-F) after the first operation [0 place the anchorage implants,

wire. Figure 4-16 shows the progress of {h e postoperaove intrusion and space closure. Space closure was accornplished with sliding-wi", mechanics in the mandibular arch and a rectangular steel archwire with b i lateral T lOOP5 in the maxillary arch, In <ldditi on, Cla:;s II elasti cs were used to help protract the mandibular molars. Figure 4-17 provides ,adiographic and photographic documentation of the K·I' implant mechanism used for intrusion and retraction of the maxillary incisors.

After treatment th e pati en t had a less pro trus ve profile and was pleased with the result (Figure 4-18, II and 81- The intraoral photographic series depicted a near-ldea] Clas~ ,I occlusion with fixed reta i ners in th e maxillal)! and rna nd i bular anterior segments (Figure 4·18, C-GJ. A posnrearment panoramic radiograph shows good second-order correction, except for the diverging roots of the mandibular right flrst molar and second premolar (Figure 4-18, HI, Because there is no Iu ncnona I 0 celusion 0 n th e maxilla ry third' molars, it was recommended that they be extracted, A maxiuary occlu5al mm reveals "ight blunting of the maxalal)! molar roots (Figure 4-18. ~.

The immediate posrtreatrn en t cephalometric anal}" is demonstrated that a welhbala need 5keletal a nd denra I relationship was achieved (Figure 4-19, AJ- A comparison of pretrea tmenz an d posttreatmen t cepnalorn etrl c va luss showed an overall improvement in the dental and ~keletal morphology. but no net change in the ANB angle 01 4 degrees (Fig ure 4·1 '}. B a nd C). Su penmpos i non of (he in i na I a nd final cepna tcrnetrk fil rns on theanrerl Or cran ial base docum ented the retra etten 0 r the max i lIa ry an d mandibular incisors and lipslFigure 4-1 9, OJ- The maxillary superimposition reveals a ]·mm to "·mm intrusion of the maxill<ory incis ors. Ma nd i bula r superimp os i no n shows tha t tne mandibular incisors were tipped about 2 mm distally. Superimposi~on on the profJl'e of the upper face provided further documentation of the reduction in lip protrusion IFi gure 4- l' 9. E) _ It ,hould be noted {hat the redu ced lip protrus i on in this patient reflects the ide..1 of Ja P<ln es e society. which ten ds 10 p refer a naner lip p rome than tna t desired by most We,!ern Caucasians.

After active treatment and removal of the traction ligatures, soft tissue 10 rmed over th e implants and thei r supr a-

4 Miniature Osseointegrated Implants for Orthodontics Anchorage 63

CASE REPORT 4-2: DENTOAI.VEO~)~YSPlASI

Figure 4-14 Second operation, to uncover osseoimcgrated K-l implants (after healing period of 5 mornhsj.The sequence of events follows' A, detection; B, anesthesia; C, incision; D, evacuation; E, abutment; F, auachmem, G and H, surur and lying.

mucosal attachments. A third surgical procedure was performed to remove the K-l implants and attachments. The soft tissue around the implants was anesthetized; an inci· sion exposed the site; me attachments were removed with a utility plier; and (he implants were unscrewed with (he specially designed driver used to install them. Although the implants were osseointegrated and did not move during Ire" tment, the su rrace area of til e osseo i nteg rat jon did not

prevent the screws from being readily removed IFigure 4-201. However, it is important to lncrease removal torque slowly when removing the implantS to avoid shearing rnern off. This is an important design consideration for osseomtegrated TAOs. They must have adequate torsional strength, to resist sufficient shear between the implant threads and the bone, in order to disrupt the rigid osseous interface when they are unscrewed. This design object,ve is impor-

Ccmiuued

64 PART II Diagnosis and Treatment Planning

Figure 4-15 Aft r the second operation, traction is shown in the superior direction La intrude the maxillary incisors. A, Panoramic radiograph. B, Intraoral photograph. C, Maxillary occlusal radiograph.

tant for easy removal of the screws after active treatment is completed.

The patient was well satisfied with the treatment results and regularly returned for follow-up visits to evaluate the stability of the correction. Two years after treatment another set of records was collected. Facial form (Figure 4-21. A and 81 and the interdigitation of the right buccal segment (Figure 4-21. C-GI were unchanged. There was a slight relapse (-1 rnm] of the left buccal interdigit<ltion !O a more Class II relationship. No other change.> were noted. A follow-up

panoramic film documented the health of the dentition (Figure 4-21, HI. Cephalometric evaiuacon 2 years after treatment showed that the ANB angle had increased O.S degree because of a progressive increase in the SNA angle to 79.5 degrees (Figure 4-21, ~. In comparison. SNA was 78.5 degrees before treatment and 79.0 degrees at the end of active treatment, These changes were apparently caused by the more anterior position of the maxillary incisor roots as they were intruded and tipped posteriorly. Overall, the nnal result was deemed to be very good.

Text continued OfJ p. 72

4 Miniat'Ure Osseointegrated Implants for Orthodontics Anchorage 65

CASE REPORT 4-2: DENTOALVEOLAR DYSPLASIA-cont'd

Figure 4-16 intraoral photographs document progress at 4 weeks (A-C) and 9 weeks (D-F) after the second operation 10 load the anchorage implants.

66 PART" Diagnosis and Treatment Planning

-"

CASE REPORT 4-2: DENTOALVEOLAR DYSPlASIA-(ont'd

~ ,

Figure 4-17 Maxillary occlusal radiograph (A) and intraoral photographs (B-D) reveal progress at 16 weeks after the second operation 10 load the anchorage implants.

-,....

CASE REPORT 4-2: DENTOALVEOLAR,',DYSPl:ASIA-cont'd

Figure 4-18 A and B, Posttreatment photograph. document the reduction in lip protrusion (palient age: 22 yr. 2 mo}, C to G, Posttreatment intraoral photograph H, Posttreatment panoramic radiograph. L Maxillary occlusal radiograph.

ComiP1ued

68 PART II Diagnosis and Treatment Planning

fMA18SO fMIA 61_5· IMPA 100_0·

Ul to NA 15.5", 4_0 mm L 1 10 NB 23.5", '6.5 mm

A InlerinC;s.l113S·

FMA 19.5"

FMIA5$.0· IMPi\1,07S 110NA2SS,9.5mm 1 10 NB 30_5·, 9_0 mm

B Interi "eisal 120_0·

FMA lSS FMIA61.S· IMPA 100,0·

1 10 NA 15.5", 4.0 mm 1 to NB 23.S·, 6.5 mm

C interincisal, 138.0·

Figure 4-19 A, Posrtreatrneru cephalometric analysis, Band C, Comparison of pretreatme nI and pos urea trnent cep b al ometric a n a lyses,

4 Miniature Osseointegrated Implants for Orthodontics Anchorage 69

CASE REPORT 4-2: DENTOALVEOLA~!DYSPLASIA-cont'd

P retreatment Pos~realment

Pretreatment PosUreatmenl

D

E

Figure 4-19. cont'd D, Superimposition of pretreatment and posttreatment cephalometric tracings documents intrusion and retraction of maxillary incisors as well as improvement in lip profile. E, Superimpositions on the maxilla, mandible, and upper face profile reveal changes in dental and facial structures,

Cmltinu(!'d

70 PART II Diagno'is and Treatment Planning

CASE REPORT 4-2: DENTOALVEOLAR ~rSPLASI~ont'd

F

Figure 4-20 Procedure for removing K·l anchorage implants after the end of active treatment. A, K·j implant and suprarnuoosal attachment submerged under the mucosa covering the interradicular bone between the maxillary central and lateral incisors. Band C, Exposure and removal of attachments. D, Removal of the implaru. E, Sutures after removal of two K·J implants, F, K·\ implants and attachments immediately afterremoval,

4 Miniature Osseolnteqrated Implants for Orthodontic, Anchorage 71

CASE REPORT 4-2: DENTOALVEOLAR 'DYSP

"

Figure 4·21 A and II, Two years later the patient (age 23 yr, II mol has retained" pleasing facial form. C to G, I ntraoral photographs 2 years after treatment show that the Class I relationship for the right side was maintained, but the left side slipped ill to a slight Class II buccal relationship. H, ranoramic radiograph 2 years after treatmern documents the stability of the radiographic result.

72 PART II Dlagn05i5 and Treatment Planning

~.- .

CASE REPORT 4-2: DENTOALVE

FMA 19.5' FMIA57.5° IMPA 103 .. 0'

Ul to NA 14.0'. 4.0 mm L I to 'NB 27.0". 6.5 mm Interincisal135'

79.5 75.0 4.S

Figure 4-21, cont'd I, Cephalometric analysis 2 Y'M" afier treatment shows a slight increase in the ANB relationship (4.0-4-.5 degrees). Otherwise, the treatment result has b en stable,

CONCLUSION

The ](-1 mini-implant system routinely achieves osseointegration after about 3 months of postoperative healing. To avoid longer treatment time, the TAOs should be placed before or at the start of active treatment. By the time initial leveling is accomplished, healing is completed, and the osseoinregrated fixtures are available for anchorage. Case reports have documented the use of K-l implants for intruding and retracting maxillary incisors. These devices are proving to be more reliable than nonintegrated miniscrew TxDs, particularly when there is an extrusive load on the implant. The osseointegrated TADs are easily removed after treatment, an important design characteristic of the K-l System. Both cases reported were young adults, but the incisor intrusion mechanism has been used effectively in growing children and adolescents.

ACKNOWLEDGMENT

W appreciate the assistance of Dr. Jeffery A. Roberts in editing the manuscript.

REFERENCES

I, Robe", WF. Ma,.haJJ KJ. Mo zsa ry PC, Rigid endosseous ; m pl.", utilized as anchorage 1.0 protract molars and dose ,111 atrophic extraction sit ,Allgle Or1l1od 60[2);)35·152, 1990.

2, webrbein H. Men OR Aspects of the use of endossecus palatal irnplan ts in orthodontic therapy. JEll"" 0.", 10(6):315-324, 1998.

J. lanssens F' et al: Use of an onplam as cnhodonrlc anchorage. Am / Ortll",! D"molacin' OrrllOp 122(5 ),566-570, 2002.

4, Cope J B: Temporary anchorage devices in crtbodonrics- a para~ digm shir" Semi» OnllOd 11(1):3-9, 2005.

5. Mal, l. Oergstrand F: Temporary anchorage devices: a statu, report, / Clirt Orr!",,1 39(3):132-136 [discussion, 136; quiz, 153), 2005.

6, Albrektsson T et at Osseoirnegrated utaruurn irnplarus: requiremears for ensuring a Iong-Iastlng, direct bone-to-Implant anchorage in man, ACid OIl/lOp 5<"",152(2):155-170,1981.

7 _ Babbush CA.: En dosseous blade-vent i m pia n IS: a research review, I Or,,1 S"'8 30(3):168-175, 1972.

8_ Roberts WE €-t al: Rigid endosseous implants for cnhodonrlc and orthopedic anchorage, .M'gl. Onnod 59(4):247-256, 1989.

9, Odman ] et al: Ossecinregrated implants as onhodomlc anchorage in the treatment of panrally edentulous adult patients, Eur J Onl,,,,! 16(3):187-201, 1 ~94.

10. Drago CJ; Use: of osseoiruegrated irnplams in adult orthodontic treatment a clinical report, J Prosr! te 1 De," 82(5):504·509, 1999,

u. Keles Aj Erverdi N, ezen S; Bodily distalizauon of molars with absolute anchorage, Angle Or"'od 73(4):471-482,2003,

12. MiYRwaki S et al: Factors associated with the stability or utantum SCfe\VS placed in the posterior region for onhodcnrk anchorage, Am J Orthod D''''.lodol Orr/lOp 124(4):373-378, 2003.

13. Cheng 5J et .1: A prospective study of me risk factors associated with failure of mint-Implants used for orthodontic anchorage, I", J 0 ... 1 MillilloJac Impl"",, 19(1): 100-106, 2004.

14. Creekmore TD, ~.kl"nd MK: Po ss ibility of skeletal anchorage, I CIi" Orrl'od 17:2G6·267, 1983.

15, Kanomi R Mini-implant for orthodontic anchorage, J Clin Or1)Pod 31(11);763-767, 1997.

16. Deguchl T et at: The use of'sruall utanium screws for orthodontic: anchorage, J Dem ResS2(5):377-361, 2003.

CHAPTER

5

Factors in the Decision to Use Skeletal Anchorage

Birte Melsen and Morten Godtfredsen Laursen

1:'0 major factors in the increased use of skeletal anchorage devices are (1) difficulty in obtaining satisfactory compliance from patients. which has led orthodontists (0 focus on appliances that function independently of compliance [compliance-free anchorage], and 12 J the growing number of adult and elderly patients in whom reduced dentition rules out the use of conventional appliances.

Conventional anchorage is based on the rule of thumb that more teeth deliver anchorage against the displacement of fewer teeth. Because there is no lower I imit for me force mat can produce tooth movement.':" none of these appliances can deliver "absolute anchorage: Another compliance-free anchorage approach is me diffel"fmLiai momem concept, in which the stimulus to the anchorge unit is "translatory movement," whereas the srirnu Ius [0 the U ni t ofteeth to be moved is "tippi I]g.' The differential moment approach is based on lipping being easier to accomplish than translatory movement, and thus anchorage is preserved."

Although some conventional or compliance-free anchorage systems have been able 10 provide differenuated anchorage, none of the suggest d methods has yet been able to deliver the absolute anchorage desired by orthodontists:' Only through ankylosed teeth and skeletal anchorage systems has 'absolute anchorage" been achieved.Y Many different systems of skeletal anchorage have been introduced over the last decade.'

ClASSIFICATION

Skeletal anchorage systems can be das ified into two categories according to their origin (Box 5-1), One group has been developed from dental implants and is characterized by an intraosseous parrthat is surface-treated to enhance the osseoiruegration. This category includes palatal and retromolar Implants." These devices are inserted as dental implants with a predrilling procedure, followed by a healing period for osseoiruegration before loading is accomplished. A special variant in litis caregory is the onplant introduced by Block and Hoffman ,10

The on plant is considered less invasive because it is not placed i nio bone but rather between the periosteu III of the palate and the bone using a tunneling procedure, u consists of a ritaniurn-hydroxyapati ie-coated disk wi th a threaded hole that is placed toward the mucosa; an abutment can be inserted to serve as anchorage,

The other category of skeletal anchorage originates frOIT! surgical screws and is characterized by a polished intraosseous pan with a surgical screw anached. it is loaded immediately after insenion.v!':" The twO main groups are (1) miniplates with various transmucosal extensions":" and (2) single screws or rniru-implarus.v'"!" •• ,,'

Depending on the configuration of the head, miniimplants can be used as direct or indirect anchorage. The head of me rnini-unplant may be formed as a button arou nd which a wire or elastic can be tied, Some of these may also have a hole in the neck through which a wire can be pulled .. BOll these approaches allow for only one-point contact and application of a force from tile tooth or teeth to be displaced to the anchorage screw, Other mini-implants 11 ave a bracketlike head into which a wire c, n be ligated and connected with a brarket on a tooth [0 make a con olidated unit, which can then be used for anchorage."

INDICATIONS

Skeletal anchorage is most frequently used to replace conventional a nchorage, especially headgear, thereby reducing problems with compliance, I>, <>,,,,,,,,..,, Some

case reports and clinical studies have also demonstrated tl131 skeletal anchorage can widen the speClI1.1I1l of onhodonucs, allowing treatment previously considered impossibJe,"'-''''''H'

Table 5·1 summarizes select clinical studies that resulted from a PubMed search using the keywords skeleta! allchorage and orthodontics, Only clinical studies and case reports are jnduded": the outcome of animal

'References 7, ll, 12, 15,17,28·31,33,39,40,42·57,

73

74 PART II Diagnosis and Treatment Planning

TABLE 5-1 Select Clinical Trials and Case Reports on Skeletal Anchorage in Orthodontics

Number in
Study Year Type of Anchorage Type of Study Study' Purpose of Anchorage
Ku roda et al. ,. 2007 Miniscrews, mlniplates Clin ka I trial 75 P Not mentioned
Jean et al." 2006 Miniscrew Case report 1 P Molar and premolar intrusion
Chae" 2006 Microimplanl Case report 11' Vertical control
Kircelli et al." 2006 Minis rew Clinical trial 10 P Molar distalization
De Clerck and Camelis" 2006 Mlnlplates as" report 1 P Cla.ss III rraction
Sugawara et al." 2006 Miniplates Clinical trial 25 P Molar distalization
Tseng et al." 2006 Mi ni-implarus Clinical (rial 45 I Not mentioned
Kircelli et ai" 2006 Mlniplates Case report I I' MaxiUaIY protracnon
Sengi et al.'" 2006 Miniplares Case r port I P Canine distalization
Koudstaal et al." 2006 Miniplates Clinical trial 13 P MaxillaIY expansion
Sugaw"r~" 2005 Miniplates Cas. reports 3 P Molar intrusion
Celgor et al." 2004 Mjn;screw Clinical trial 25 P Molar distalization
Park and Kwon" 2004 Miniscrew Case report 3 P Anchorage in extraction cases
Kuroda er al." 2004 Miniscrew Case report 1 P Molar intrusion
Yao et "I:" 2004 Minis-crew Case report I P Upper molar intrusion
Erverdi et ~I." 2004 Miniplates Clinical trial ]0 P Upper molar intrusion
Ciancotti et .1:" 2004 Miniscrew Case report 1 P Eruption of ectopic molar
Sugawara et al." 2004 Miniplares Clinical trial 15 P Mandibular molar distallzauon
Mai no et at. 22 2003 Miniscrew Case reports 3 P Multiple applications
Sugawara et .1." 2002 Miniplales Clin teal trial 9 ~ Mandibu.lar molar intruslon
Sh erwood et al.' 2002 Miruplares Clinical trial 41' Maxilla')' molar intrusion
Chung et al.·· 2002 Miniplate Case r port 1 P Canine retraction
Armbruster and Block" 2001 Onplant Case report I P Retraction of anterior teeth
lee et al." 2001 Mini·implant Case report 1 P Anchorage for retraction
Park et at" 2001 Mini·implant Cas. report I P Anc.ho rage for retraction
Costa et al." 1.998 Mini·implant Case report 1 P Front retractio n
Jenner and Fitzpatrick" 1985 MiniplaleS Case rep on 1 P Front retraction
Creekmore and Eklund" 1983 Miniscrew Case report 1 P Incisor intrusion
• p, Padent (s]: I. ; m plants, Classification of Extradentat Intraoral Anchorage

I. AJ; developed from dental implant Tremed surface; lag time jar l""dinS

• Palatal implants

• Onplarns

• Retromolar i mplarns

• Onhodontic implants

I L As developed from surgical screws SnlQO/h wrface; immediate loading

• Miniplales: one-point contact

• Mini-implants: one-point contact

• Aarhus mini-irnplant: three-dimensional control

experi merits depends on the species. Randomized controlled trials (RCTs), as suggested by Feldmann and Bondenruark, ss are difficult to perform with skeletal anchorage systems.

One could argue that skeletal anchorage should not be used 10 replace conventional anchorage [ust because it is compliance free. Many other compliance-free appliances have been introduced in orthodontics, but because of ewton's third law, no intraoral appliance can deliver "absolute anchorage.' Not even satisfactory compliance carl provide absolute anchorage, which is sometimes required for the correction of alveolar prouusion.P'"

In an essential argument against skeletal anchorage, Kesling" dairned that many problems addressed by m iniscrews could even be characterized as iatrogenic, resulting from the application of a flawed biomechanlcal system. He considered that the following problems purported to be 'solved" by miniscrews are actuaJly caused by treatment

1. Deepening of the anterior bite when dosing posterior spaces.

2. Difficulties associated with intruding anterior teeth and correcting dental midlines.

3 Need for heavy forces to overcome sliding and active frictl a n an d to co rrect Class II and Cl ass III i ntera rch discrepancies.

Skeletal anchorage should not be used as a shortcut around insufficient biomechanical knowledge. It should be emphasized, however, that skeletal anchorage can help clinicians widen their spectrum of orthodontics

5 Factors in the Decision to Use Skeletal Anchorage 75

by permitting treatment previously not possible. For example, Melsen er al60 performed retraction and intrusion of anterior lee III against a surgical wire placed through the infrazygornauc crest in patients with missing molars (Figure 5-1). Roberts et ai''"'"'' used a retromolar orthodontic implant to displace the second and th ird molars into the extraction space of a Ii rst molar, without displacing any teeth in a posterior direction,

Limiting skeletal anchorage to patients who can truly benefit results in the following indications:

Figure 5-1 A to F, Adult woman with pronounced degenerated dentition and no. posterior occlusion. G to J, Zygoma ligatures used as anchorage for intrusion and retraction of upper from teeth.

K to N, Patient after treatment and reconstruction of anterior teeth.

76 PART" Diagnosis and Treatment Planning

Figure 5-1, conr'd For legend see p. 75.

• Patients with i nsufficient teeth for the application of conventional anchorage (Figure 5·2).

• Patients in whom forces to the reactive unit would generate ad verse effects [Figures 5·3 and 5 A).

• Patients with a need for asymmetric tooth movements in all planes of space (Figure 5-5).

• In select patients, as an alternative to orthognathic surgery (Figure 5·6).

• As anchorage for tooth movements, to generate bone for a dental implant (Figure 5-7).

FAILURES

Although one aspect of evaluating skeletal anchorage is to define dearly the indications for its use, another is (0 list the failures and possible adverse effects. Three types of reports have focused on the failures: laboratory tests, ani mal studies, and eli nicalcases.

Mecha nical strength of skeletal anchorage devices has been analyzed using laboratory tests or stress calculations. Carano et al." tested the resistance of three skeletal anchorage screws (Dentes, Leone, Mini-ScrewAnchorage System [MAS]) of ldentlcal length (11 mm) and diameter (1.5 rnrn) to fracture during bendi ng and torsion. They concluded that (be steel screws resisted deformation better than the titanium (Ti) screw. (Surgical steel is recommended only for emergency surgery, and Ti screws are routinely used for maxillofacial

surgery.) The torsion in relation to the applied couple did not differ among the three products Dalstra et al." , created mathernatical model o{the Impact of the diarneter on the internal Stress. They demonstrated that the stress val u es, and thus th e fracru re ris k, i no-eased d ramaucallywnh a reduction in the diameter below 1.5 mm (PigLJre S-8).

Primary stability has been studied in animal experimerits, with the pig mOS1 often used. Buchter et aL" inserted mini-implants into the mandibles of pygmy pigs, and the torsion necessary to loosen the implants was evaluated along a range of 0 to 900 centinewtons (eN) They concluded that the implants could be loaded immediately if the force level was controlled. The extrapolation of these results for lise' in humans should be done with care, as the cortex density and thickness of the minipig is [JOl comparable 10 (hat of humans. Wilmes. et aL" evaluated the i nsertion torque of five different mini-implants (rwo designs with different diameter and d ifferent lengths) into the pelvic bone of pigs. They concluded that the design, the pilot drilling, and the cortical th ickness all had a significant influence on the system's primary stabillty. The factors identified related to (he mini-implant, the handling procedure, and me host Theinfluence of the magnitude of torque applied 10 insert the orthodontic mini-implants was evaluated in 41 patients by Motoyoshi et a I.. ss who concluded that the low «S newtons per centimeter

5 Factors in the Decision to Use Skeletal Anchorage 77

Figure 5-2 A to C, Patient with large overjet and insufficient teeth for conventional anchorage. D to F, Mini-i mplant in the infrazygornatic crest was used as anchorage for distal displacement of atl reeih in the right side of the upper arm, starling with thesecond premolar. To control the rotation, a transpalatal arm was inserted into a vertical tube on the left side. G, One month of treatment. H and I, Four months of treatment. I and K, Eight months of treatment. The second premolar is now ill a Class I relationship and is consolidated to the rnlnl-implant: thus it can serve as anchorage for the distal movement of the first premolar. L to N, Consoli. dated premolars Can indirectly serve as anchorage for retraction of the upper front teeth.

rum,rrued

78 PART" Diagnosis and Treatment Planning

Figure 5-2, cont'd For legend see p. 77.

IN/cmJ) and the high (>10 N/cm) torque values increased the risk of failure. The torque needed for inserting the mini-implants depended on both the cut and diameter of the threaded part and me density and thickness of the bone; both screw and host are important,

Failure rate in the clinical setting is low, although the ample size in all cases has been limited, as seen in the number of parameters evaluated.···6& None of the reports defines the failure in detail. The devices evaluated apparently had only moderate influence on the failure rate, but the choice of implant in relation to the clinical problem may be important.

In clinical studies, failures are synonymous with the loss of the mini-implant, and the failure rate varies between 10% and 30%. Factors such as fracture of the mini-implant. infection, and damage to the teeth should also be considered.

PREDICTORS OF CLINICAL FAILURE Clinical failure is most likely related to me following:

• The design and dimension of the mini-implant.

• The handling at insertion and the timing and level of

force applied to the host.

• The quantity and qual iry of bone at the insertion site. As yet, however, a distinction has nOI been made among me different types of failures.

The initial stability is crucial for the maintenance of the anchorage. Failure rates did not differ between miniplates and freestanding minlscrews." In a prospective study, the following authors found that anatomical location and the periirn plant soft tissue were factors of importance for the prognosis. According to Miyawaki et aL" factors such as thin diameter of the screw, high mandibular plane angle, and peri implant inflammation can be considered risks. Kuroda er a,6. found that the insertion procedure was a major prognostic factor because more anchorage units were lost after flap surgery than with predrilling directly through the mucosa." Tseng et al." found four failures among 45 miniimplants of four dlfferem lengths. Because all four fail. ures involved shorter implants and three were in the mandible, the authors concluded that the site was a significant factor related to failure.

AARHUS FAILURE STUDY

To analyze the type of failure and its consequence on the treatment outcome, a prospective study was initiated in the Department of Orthodontics, School of Dentistry, University of Aarhus, Denmark, ill 2004. The anchorage devices were inserted by the author, the professors, and postgraduate students who had no previous experience with insertion of implants or skeletal anchor-

T~l conn'rwed On p. 84

5 Factors in the Decision to Use Skeletal Anchorage 79

Figure 5·3 A to C, Adult patient with agenesis of second premolar in the right side. The space is closed partly through mesial tipping of the first molar and partly th rough distal lipping of anterior teeth, D to F. During uprighting of the lower molar, the mmi-implarn is used to keep the molar crown in place. The leveling will consequently lead to mesial lipping and intrusion of the anterior teeth. G 10 I, After leveling the molar is displaced mesially with a Sentalloy coil spring. The displacement is done with sliding mechanics to avoid rotarion of the molar. I 10 L, Result of treaunent. The space of the missing premolar has been closed. and the molar relationship is consequently mesial. An equilibration is needed 10 improve the occlusion. (COurleS)' i6rg T/w01Iwn.)

80 PART II Diagnosi5 and Treatmerit Planning

Figure 5-4 A and B, Patient with agenesis of second upper premolars. C and D, Two mini-implants were inserted between the canines and the laterals and used as anchorage for the mesial displacement of the molars. To avoid imp; ngerueru of the coil spring in the canine region, the spring is extending from the molar to a wireconnectlng the screw head with the canine bracket. E to G. Height of the point of application and the force direction is controlled by heigh! of the power anTIS. H and I, Day of screw removal. The occlusion is reinforced by light up-ariddown el as ti C5. (CQilrle.sy Mrg ThQl,ntln-J

5 Factors in the Decision to Use Skeletal Anchorage 81

Figure 5-5 A to C, Patient in need of asymmetric tooth movement. The plan is to place a single dental implant in the upper first premolar region and achieve a full occlusion On the upper second molar. This is solved by 6·mm mesial displacement of the upper left second molar and slight reciprocal (mesial and distal) movement of the upper left canine and second premolar. D to F, Mini-implant is inserted between the upper left canine and the second premolar and used as direct anchorage to rnesiahze the second molar, with a Sentalloy coil attached [0 a power arm. To guide the second molal" into the planned position. a hinge is placed across the palate. The bile is raised with Triad, which serves as anchorage for the hinge and allows movement of the second molar without occlusal interferences. G, Mini-implant is used for direct and indirect anchorage. A stai nless steel wire passes from the mini-implant through the slot of the premolar bracket and on top of the attachment of the second molar band. to give an intrusive component during m esializati on. H to L Sirnul taneous mesialization and upright. ingofthe second molar. The uprlghting spring is attached to the indirect anchorage. Palatally, a Sentalloy coil is applied between power arms of the second molar, and the mini-implant is anchored to the second premolar to control for rotauon of the second molar. K to M, Mini-implant has been removed and a dernal implant placed. Nand 0, Unintentional amalgam markers in the left maxillary first molar region depict the total mesial displacement of the second molar. (Cllse IrlUlfRd Gn,i described by Mortell Codlfredsetl Lautsen.}

Continued

82 PART II Diagnosis and Treatment Planning

Figure 5-5, conrd For legend see p. 81.

5 Factors in the Decision to Use Skeletal Anchorage 83

E

Figure 5-6 A to C, Woman age 47 years with pronounced alveolar retrognathism in the mandible leading to an increased overjet, The mandibular arch was asymmetric because an ankylosed canine had been removed in the left side, The patient did not want surgery, which would have involved a saglttal split osteotomy with advancement of the mandible, followed by a reduction of the pronounced symphysis. D, Two mini-implants were in se ned into the symphysis and used as anchorage for a forward displacement of the lower arch, Hypertrophy of the mucosa occurred as a reaction to the activity of the insertion or the mentalis muscle dose to the protruding mini-implants. E to G, Profile and occlusion after treatment. An implant was used to replace the lost left canine. (Case r:rellted by Karen Haarbo.}

84 PART /I D;agnos;s and Treatment Planning

Figure 5-7 A, Patient with missing molars and lower left second premolar. Note the atrophic alveolar

process. B, The premolar is displaced distally against a submucosal screw to generate bone

for a dental implant distal to the canine. C and D, After treatment. NOle the regeneration of

the width and height of the alveolar process. (Case /rooted by Daniela Garbo.)

160,-------------------------------~ 140

~120

~ 100

~

i"2 50 ~

1:0 eo

~

-a1 40-

tx:

20 o+---~--~--~--~--~--,_~ 0.8

1.0

1.2

1.4

1 .. 6

1.8

2.0

Diameter (mm)

Figure 5·8

Relauo nsh ip between stress and Screw d ia meter. (From Dcl!stro M, C<Ula1l80 PM, Me!s~n B: Orthodontics 7;53·62, 2004)

age devices. The mini-implants were inserted following instruction by the author. The devices used were the Absoanchor screw, which was preferentially used in the interradicular area of the maxilla, and the Aarhus miniimplant (Figure 5-9). The Absoanchor screws were inserted following the procedure prescribed by Kyung et at"

To insert the Aarhus mini-implant, an orthodontic wire template indicating the approximate insertion site was fixed with light-curing composite, and a periapical radiograph was taken to provide exact information on the insertion site and direction. The mini-implants were self-cutting, and 110 mucosal incision was necessary (Figure 5-10).

After a thorough washing of the mucosa with 0.2% chlorhexidine, the mini-implants were inserted with a manual screwdriver. The shredded pan was inserted into the bone, and screwdriver turning stopped when the neck of the implant touched the periosteum.

2.2

5 Factors in the Oeclslon to Use Skeletal Anchorage a 5

Figure 5-9 A, Aarhus mini-implant with bunonlike head to which a Senralloy spring can be attached.

B, Aarhus mini-implant with bracketlike bead into whid, a wire can be inserted so that the

mini-implant Can serve as indirect anchorage.

The mini-implants were inserted in the maxilla (in the palate), the alveolar process and the infrazygomatic crest, the mandible in the symphysis, and the alveolar process, as well as in the retromolar area. The miniimplants were used both as direct and indirect anchorage, and the anchorage unit was loaded irnrnediately with 50 eN.

The following tooth movements were performed

against the skeletal anchorage:

• Molar uprighting

• Molar uprlghting and mesial movement

• Molar mesial movement

• Molar intrusion

• Premolar intrusion

• Premolar distal movement in the case of missing

molars

• Midline correction

• Incisor intrusion and proclination

• Incisor retraction

Of the first 180 mini-implants inserted. 19 failed (16 in the first few weeks). The overall failure rate was

10.5%; interestingly, all the failures were related to direct anchorage mechanics. No specific tendency was found regarding the type of IOOlh movement. The site was a factor, however, in that the implants inserted in the palate had the lowest success rate (2{4 = 50%), and those in the retromolar area in the mandible had the highest success rate (5/5 = 100%). The site played only a minor role in the failures.

Based on the records of each patient, the time and circumstances of the failures were analyzed. Most failures, occurring weeks after insertion, were the first miniimplant inserted by each dentist, indicating a certain learning curve. Success correlated highly with how the screwdriver was held during insertion and whether it was stabilized in the palm, or whether the hand drilling was stead)' without change in direction. In contrast. failure was associated with holding the screwdriver like a pencil, as often seen in novices inserting the screw. This observation led to the development of a training exercise using a plastic model to explain differences in screwdriver positioning (Figure 5-11).

86 PART II Diagnosis and Treatment Planning

A

Figure S·IO A and B, Insertion is done through the mucosa di rectly with a hand-driven screwdriver.

In all the patients who experienced failure within the first weeks. no primary stability was obtained during insertion.

Three of the seven failures observed several months after insertion were related to increased bone turnover in the region of the mini-implants, a result of either ongoing resorption of deciduous teeth (one failure) or remodeling that occurred in front of teeth being displaced toward the mini-implant (two failures). Four of the 19 i mplarus were loosened or removed because of infection, All these had been placed in non attached gingiva. and the ligature used to fix the coil spring or the wire [0 the brackeuike head of tile implants was placed around the "bracket.' similar to a bracket placed on a tooth, The loose end of the ligature can lead to both irritation and plaque accumulation (Figure 5-12).

TYPES OF FAILURE AND SOLUTIONS

Based on reports in the literature and observations from the ongoing study, implant fai lures can be related to the device, the dentist, or the patient.

FAILURE RELATED TO THE DEVICE

• Proolet»: Fracture occurs. resulting from thin screw diameter or low strength in screw neck area. wh ich will be submitted to greater stress at removal. Solutiorl: Choose a slightly conical screw with a solid

neck and a diameter compatible with the bone quality,

• Problem: Infection around the screw, because not all the transmucosal pan has a smooth surface.

Sollltion: Choo e a screw system with variable neck lengths so that all the transrnucosal part is smooth.

FAILURE RELATED TO THE DENTIST

• Problem: In the case of self-drilling screws. excessive pressure is used at the start of tile insertion. leading to fra crure of th I' cutting ti p (see Figure 5·9). Solution. Perform the insertion manually using deli-

cate force until the screw "grips."

• Problem.' The screw is tightened excessively. Once the smooth part ( tile neck) has reached me periosteum. it is crucial to stop turning tile screw; otherwise, it will become loose.

Solution: Perform the insertion manually. and be aware of manges in the force needed to turn the screwdriver .

• Problem: When screws with a bracketlike head are used. turning a ligature around me screw will make it impossible for the patient to keep the screw area free of inflammation,

Solution. The. ligature should be placed on top of the screw in tile SIOI perpendicular to the one in which the wire is resting, and it should be fixed with a composite gel (see Figure 5-12) .

• Problem: Loosening occurs. resulting from "wiggling" forces during insertion because of faulty handling of the screwdriver or during removal of the screwdriver,

Solution: During insertion, keep the base of the screwdriver stabilized toward tile palm of the hand while turning the screwdriver. It is important that

5 F<lctor. .in the Oed,ion to U,e Skeletal Ancnoraqe 87

A, Incorrect way to hold screwdriver when inserting screw. Holding (he screwdriver like a pencil leads to a continuous change in direction and microdamage to the bone. The ronsequence may be lack of primary stability or early loss of the implant. B, Correct way to hold screwdriver. The screwdriver is stabilized by letting the tOP of the handle rest in lhe palm of the hand. This leads to a stable insertion direction. C, Histologjcal image demonstraung the result of continuous change in direction during insertion; a number of rmcrofractures surrou nd (he screw.

A

Figure S~12 A. Incorrect placement of ligature, Placing the ligature arou nd the brackeuike head. as on a 100 th, will produce i rri ta uo IT and pi aq ue accu mu I a lion. B, Correct pi a ce m ent of ligat me, The loose end of the I lgature is placed OIl top of the "bracket" and fixed with a light-cured composite gel.