Dedication This book is dedicated to my wife Despina, for her unfailing love, understanding, and full support over the years, and to my two sons, Apostolos and Harry, with the wish to serve as an inspiration for their future professional endeavors “Give me a place to stand on, and I will move the earth.” Archimedes (287 BC – 212 BC) The engraving is from Mechanic’s Magazine (cover of bound Volume II, Knight & Lacey, London, 1824) Courtesy of the Annenberg Rare Book & Manuscript Library, University of Pennsylvania, Philadelphia, USA www.ajlobby.com For Elsevier Content Strategist: Alison Taylor Content Development Specialist: Barbara Simmons/Carole McMurray Project Manager: Andrew Riley Designer/Design Direction: Christian Bilbow Illustration Manager: Karen Giacomucci Illustrator: Electronic Publishing Services Inc., NYC www.ajlobby.com Skeletal Anchorage in Orthodontic Treatment of Class II Malocclusion Contemporary applications of orthodontic implants, miniscrew implants and miniplates Edited by MOSCHOS A PAPADOPOULOS, DDS, DR MED DENT Professor, Chairman & Program Director Department of Orthodontics School of Dentistry Aristotle University of Thessaloniki Thessaloniki, Greece Edinburgh London New York Oxford Philadelphia www.ajlobby.com St Louis Sydney Toronto 2015 © 2015 Moschos A Papadopoulos Published by Mosby, an imprint of Elsevier Ltd No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) Parts of the text and images in Chapter have been previously published in Papadopoulos MA, Tarawneh F The use of miniscrew implants for temporary skeletal anchorage in orthodontics: a comprehensive review Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e6–15 as per references ISBN 9780723436492 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein The publisher’s policy is to use paper manufactured from sustainable forests Printed in China www.ajlobby.com Foreword In our millennium we are acutely aware of the many challenges that confront us in diverse fields The field of orthodontics has seen no cataclysmic events – financial or economic quicksand – but only steady progress based on extensive research around the world Commercial firms provide the armamentarium we need and technical developments have kept pace with scientific progress Long-term evidence-based assessment of treatment results is now available The question as to what we can and what are the borderline situations can be answered in biological, biomechanical and risk-management terms There are many roads to Rome: many appliances that can accomplish similar results but only one set of fundamental tissuerelated principles Orthodontics itself has seen a fundamental change (paradigm shift) in direction and treatment emphasis, with greater attention being given to the problem of stationary anchorage without a requirement for patient compliance This is achieved by using implants instead of extraoral anchorage This non-compliance approach enables intraoral extradental stationary anchorage without the side effect of anchorage loss The use of stationary anchorage with implants has been improved our success in reaching the “achievable optimum,” the goal of the treatment Since the introduction of implants in orthodontics, much information has been generated, mostly disorganized and contradictory with anecdotal case presentations Dr Papadopoulos has assembled world-class experts from all over the world to cover all aspects of skeletal anchorage using contemporary application of various orthodontic implants and miniplates Dr Papadopoulos is an innovative, enthusiastic pioneer with a holistic approach in his research millennium All the available skeletal anchorage devices are presented and discussed by experts in the specific areas The presented results are evidence based with a combination of internal evidence (individualized clinical expertise and knowledge of the clinicians) and external evidence (randomized controlled clinical studies, systemic reviews) to conclude on what is scientifically recognized therapy Admittedly, reading this book for the first time may confuse some novice orthodontic students, but like a sacred text, it must be read again and again The book provides an exact description of techniques, their biomechanical justifications and examples of their potential for correcting orthodontic problems if the technique is handled properly The criteria for successful treatment are stability, tissue health and esthetic achievement The book discusses all aspects of a more efficient use of skeletal anchorage devices and also biological and biomechanical considerations, biomaterial properties and radiological evaluation Within the book, all the available methods are described, such as the Strauman Orthosystem, the Graz Implant-Supported Pendulum, the Aarhus Anchorage System, the Spider Screw anchorage, the Advanced Molar Distalization Appliance, the TopJet Distalizer, and many others Utilizing implants in lingual orthodontics is described in two chapters, The book is completed by an in-depth discussion of complications and risk management This unique book makes a deep impression on the reader and shows that the nature of orthodontics does not permit a limited narrow view; it deserves understanding of conflicting opinions and evidence This book is a comprehensive publication, presenting methods and views of 96 authors from 20 countries in 52 chapters It is a unique work in the orthodontic literature; it is the most extensive compendium of the new Thomas Rakosi, DDS, MD, MSD, PhD Professor Emeritus and Former Chairman Department of Orthodontics, University of Freiburg, Germany v www.ajlobby.com Acknowledgements The editor is most grateful to all colleagues involved in the preparation of the different chapters included in this book for their excellent scientific contributions Dr Jane Ward, Medical Editorial Consultant, is given particular thanks for her invaluable input into the rewriting of many of the contributions Finally, Ms Alison Taylor, Senior Content Strategist, and all other Elsevier staff members are also acknowledged for their excellent cooperation during the preparation and publication of this volume Elsevier Ltd is acknowledged for the high quality of the published Work vi www.ajlobby.com Preface Class II malocclusion is considered the most frequent treatment problem in orthodontic practice Conventional treatment approaches require patient cooperation to be effective, while non-compliance approaches used to avoid the necessity for patient cooperation have a number of side effects Most of these side effects are related to anchorage loss, and therefore, they can be avoided by the use of skeletal anchorage devices Anchorage is defined as the resistance to unwanted tooth movements and is considered as a prerequisite for the orthodontic treatment of dental and skeletal malocclusions In addition to conventional orthodontic implants, which have been used for anchorage purposes for some years, miniplates and miniscrew implants have been recently utilized as intraoral extradental temporary anchorage devices for the treatment of various orthodontic problems, including Class II malocclusions All these modalities may provide temporary stationary anchorage to support orthodontic movements in the desired direction, without the need for patient compliance in anchorage preservation, thus reducing the occurrence of side effects and the total treatment time The main remit of this book was to address the clinical use of all the available skeletal anchorage devices, including orthodontic implants, miniplates and miniscrew implants, that can be utilized to support orthodontic treatment of patients presenting with Class II malocclusion The book provides a comprehensive and critical review of the principles and techniques as well as emphasizing the scientific evidence available regarding the contemporary applications and the clinical efficacy of these treatment modalities The book is divided into nine sections, starting from an introduction to orthodontic treatment of Class II malocclusion (Section I) and an introduction to skeletal anchorage in orthodontics (Section II) After a detailed presentation of the clinical and surgical considerations of the use of skeletal anchorage devices in orthodontics (Sections III and IV, respectively), the book continuous with sections devoted on the treatment of Class II malocclusion with the various skeletal anchorage devices, such as orthodontic implants (Section V), miniplates (Section VI) and miniscrew implants (Section VII) A further section is devoted to the treatment of Class II malocclusion with various temporary anchorage devices (Section VIII) Finally, the last section discusses the currently available evidence related to the clinical efficiency as well as the risk management of the skeletal anchorage devices used for orthodontic purposes (Section IX) The editor invited colleagues who are experts in specific areas related to orthodontic anchorage to contribute with chapters Most of the authors have either developed or introduced sophisticated devices or approaches, or they have been actively involved in their clinical evaluation In total, 96 colleagues from 20 different countries participated in this exciting project The detailed discussion by a large number of experts of a variety of issues related to skeletal anchorage may be considered as a breakthrough feature not previously seen in this form in orthodontic texts At present, there is no other book dealing with all possible anchorage reinforcement approaches (including orthodontic implants, miniplates and miniscrew implants) used for the treatment of patients with Class II malocclusion It is the hope of the editor that this textbook will provide all the necessary background information for the better understanding and more efficient use of the currently available skeletal anchorage devices to reinforce anchorage during orthodontic treatment of patients presenting Class II malocclusion, and that it will be used as a comprehensive reference by orthodontic practitioners, undergraduate and postgraduate students, and researchers for the clinical management of these patients Prof M A Papadopoulos vii www.ajlobby.com Contributors YOUSSEF S AL JABBARI Associate Professor, Dental Biomaterials Research and Development Chair, College of Dentistry, King Saud University, Riyadh, Saudi Arabia GEORGE ANKA ADITYA CHHIBBER Resident, Division of Orthodontics, Department of Craniofacial Sciences, School of Dental Medicine, University of Connecticut, Farmington, CT, USA HYERAN CHOO Orthodontist in private practice, Tama-shi, Tokyo, Japan AA ARMAN ƯZÇIRPICI Associate Professor and Head, Department of Orthodontics, Faculty of Dentistry, Başkent University, Ankara, Turkey KARLIEN ASSCHERICKX Researcher and Lecturer, Vrije Universiteit Brussel, Dental Clinic, Department of Orthodontics, Brussels, Belgium; orthodontist in private practice, Antwerp, Belgium MUSTAFA B ATES Assistant Professor, Department of Orthodontics, Faculty of Dentistry, Marmara University, Istanbul, Turkey UGO BACILIERO Director, Department of Maxillofacial Surgery, Regional Hospital of Vicenza, Vicenza, Italy MARTIN BAXMANN Visiting Professor, Department of Orthodontics and Pediatric Dentistry, University of Seville, Seville, Spain: Orthodontist in private practice, Kempen & Geldern, Germany THOMAS BERNHART Professor, Division of Oral Surgery, Bernhard Gottlieb University Clinic of Dentistry, Medical University of Vienna, Austria MICHAEL BERTL Lecturer, Division of Orthodontics, Bernhard Gottlieb University Clinic of Dentistry, Medical University of Vienna, Austria LARS BONDEMARK Professor and Head, Department of Orthodontics; Dean, Faculty of Odontology, Malmö University, Malmö, Sweden S JAY BOWMAN Director of Craniofacial Orthodontics at The Children’s Hospital of Philadelphia; Clinical Associate, Department of Orthodontics, University of Pennsylvania, Philadelphia, PA, USA KYU-RHIM CHUNG Professor and Chairman, Division of Orthodontics, Ajou University, School of Medicine, Suwon, South Korea MARIE A CORNELIS Assistant Professor, Department of Orthodontics, School of Dentistry, University of Geneva, Switzerland MAURO COZZANI Professor of Orthodontics and Gnathology, School of Dental Medicine University of Cagliari, Italy ADRIANO CRISMANI Professor and Head, Clinic of Orthodontics, Medical University of Innsbruck, Austria MICHEL DALSTRA Associate Professor, Department of Orthodontics, School of Dentistry, University of Aarhus, Denmark HUGO DE CLERCK Adjunct Professor, Department of Orthodontics, School of Dentistry, University of North Carolina, Chapel Hill, NC, USA; orthodontist in private practice, Brussels, Belgium GLADYS C DOMINGUEZ Associate Professor, Department of Orthodontics, Faculty of Dentistry, University of Sao Paulo, Brazil GEORGE ELIADES Professor and Director, Department of Biomaterials, School of Dentistry, University of Athens, Greece Adjunct Associate Professor, Saint Louis University; Instructor, University of Michigan; Assistant Clinical Professor, Case Western Reserve University; orthodontist in private practice, Portage, Michigan, USA THEODORE ELIADES FRIEDRICH K BYLOFF Professor, Department of Orthodontics, Faculty of Dentistry, Marmara University, Istanbul, Turkey Former Clinical Instructor, Department of Orthodontics, School of Dentistry, University of Geneva, Switzerland; orthodontist in private practice, Graz, Austria Professor and Head, Department of Orthodontics and Paediatric Dentistry, Center of Dental Medicine, University of Zurich, Switzerland NEJAT ERVERDI INGALILL FELDMANN VITTORIO CACCIAFESTA Orthodontist in private practice, Milan, Italy Senior consultant, PhD, Orthodontic Clinic, Public Dental Helth Service, Gävle and Centre for research and Development, Uppsala University/ County Council of Gävleborg, Gävle, Sweden LESLIE YEN-PENG CHEN MATTIA FONTANA Orthodontist in private practice, Taipei, Taiwan Orthodontist in private practice, La Spezia, Italy viii www.ajlobby.com Contributors TADASHI FUJITA Assistant Professor, Department of Orthodontics and Craniofacial Developmental Biology, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan NARAYAN H GANDEDKAR Former Assistant Professor, Department of Orthodontics and Dentofacial Orthopedics, SDM College of Dental Sciences and Hospital, Dharwad, India; Dental Officer Specialist and Clinical Researcher, Cleft and Craniofacial Dentistry Unit, Division of Plastic, Reconstructive and Aesthetic Surgery, K.K Women’s and Children’s Hospital, Singapore BEYZA HANCIOGLU KIRCELLI Former Associate Professor, Department of Orthodontics, University of Baskent; orthodontist in private practice, Adana, Turkey NAZAN KUCUKKELES Professor and Head, Department of Orthodontics, Faculty of Dentistry, Marmara University, Istanbul, Turkey KEE-JOON LEE Associate Professor, Department of Orthodontics, College of Dentistry, Yonsei University, Seoul, South Korea COSTANTINO GIAGNORIO GARY LEONARD BETTINA GLASL SEUNG-MIN LIM Orthodontist in private practice, SanNicandro Garganico (FG), Italy Oral surgeon in private practice, Dublin, Republic of Ireland Clinical Professor, Department of Orthodontics, Kangnam Sacred Heart Hospital, Hallym University; orthodontist in private practice, Seoul, South Korea Orthodontist in private practice, Traben-Trarbach, Germany ANTONIO GRACCO Assistant Professor, Department of Neurosciences, Section of Dentistry, University of Padua, Italy HIDEHARU HIBI Associate Professor, Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan RYOON-KI HONG Chairman, Department of Orthodontics, Chong-A Dental Hospital, Seoul; Clinical Professor, Department of Orthodontics, School of Dentistry, Seoul National University, Seoul, South Korea MASATO KAKU Assistant Professor, Department of Orthodontics and Craniofacial Developmental Biology, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan HANS KÄRCHER JAMES CHENG-YI LIN Clinical Assistant Professor, School of Dentistry, National Defense Medical University; Consultant Orthodontist, Department of Orthodontics and Craniofacial Dentistry, Chang Gung Memorial Hospital; private practice of orthodontics and implantology, Taipei, Taiwan ERIC JEIN-WEIN LIOU Chairman, Faculty of Dentistry, Chang Gung Memorial Hospital; Associate Professor, Department of Orthodontics and Craniofacial Dentistry, Chang Gung Memorial Hospital, Taipei, Taiwan GUDRUN LÜBBERINK Assistant Clinical Professor, Department of Orthodontics, School of Dentistry, University of Duesseldorf, Germany BJÖRN LUDWIG Professor and Head, Department of Maxillo-Facial Surgery, School of Dentistry, University of Graz, Austria Scientific collaborator, Department of Orthodontics, University of Saarland, Homburg/Saar; orthodontist in private practice, TrabenTrarbach, Germany HASSAN E KASSEM CESARE LUZI Assistant Lecturer, Department of Orthodontics, School of Dentistry, Alexandria University, Alexandria, Egypt BURÇAK KAYA Assistant Professor, Department of Orthodontics, Faculty of Dentistry, Başkent University, Ankara, Turkey HYEWON KIM Orthodontist in private practice, Rome, Italy B GIULIANO MAINO Visiting Professor of Orthodontics at Ferrara University and Insubria University; orthodontist in private practice, Vicenza, Italy FRASER MCDONALD Orthodontist in private practice, Seoul, South Korea Professor and Head, Department of Orthodontics, King’s College London Dental Institute, London, UK SEONG-HUN KIM BIRTE MELSEN Associate Professor, Department of Orthodontics, School of Dentistry, Kyung Hee University, Seoul, South Korea TAE-WOO KIM Professor, Department of Orthodontics, School of Dentistry, Seoul National University, Seoul, South Korea GERO KINZINGER ix Professor, Department of Orthodontics, University of Saarland, Homburg/Saar; private practice, Toenisvorst, Germany Professor and Head, Department of Orthodontics, School of Dentistry, University of Aarhus, Denmark ANNA MENINI Orthodontist in private practice, Monterosso al Mare (SP), Italy CAMILLO MOREA Postdoctoral Researcher, Department of Orthodontics, Faculty of Dentistry, University of Sao Paulo, Brazil www.ajlobby.com Complications of miniscrew implant insertion: maxillary sinus perforation allows for considerations of individual anatomical variation in sinus pneumatization and the length and inclination of the tooth roots The safest area for MI insertion in the maxilla in all patients (regardless of their different skeletal growth patterns) seems to be between the second premolar and the first maxillary molar (Fig 51.3).9 The zygomatic crest gets gradually thinner in an apical direction and the risk of sinus perforation increases.10 The most common cause of this type of iatrogenic damage is the insertion of graft material in the maxillary sinus in order to raise its floor and aid implantation in patients with atrophic alveolar crests.5 Perforation is most frequent at the crestal margin, particularly in the presence of bony protrusions or septa, and may be inevitable when there is excessively thin sinus mucosa or improper surgical technique A small perforation that occurs where the membrane is folded over itself will heal spontaneously.11 A perforation of the Schneider membrane of less than 2 mm in diameter is unlikely to become inflamed,12 and upon MI removal heals completely over a short period of time Consequently, MIs with diameters 2 mm or less should be used in the palatal area of the maxilla.13 An experimental and clinical study of osseointegrated titanium implants penetrating the nasal cavity and maxillary sinus showed healthy, noninflamed tissue around implants and normal bone regeneration, indicating that penetration does not have adverse effects in the maxillary sinus during the healing process.14 Rhinoscopic investigations after perforation have also shown the presence of healthy tissue and lack of sinusitis or other pathological events (Fig 51.4).15 In fact, healing processes have been shown to commence spontaneously within 48 hours of a traumatic event.16 (Videos of MI insertion into the maxillary sinus can be viewed at https://www.youtube.com/watch?v=JX5MdKbNhK8 and http://youtu be/Lp9OPbED4GE.) A Fig 51.2 Miniscrew implant inserted with proper angulation to avoid iatrogenic damage A 279 B Fig 51.4 Images taken during a sinuscopy evaluation (A) An orthodontic miniscrew implant (MI; diameter, 2 mm; length, 10 mm) passing through the sinus cortex and mucosa (B) Image showing a MI (diameter, 1.4 mm; length, 8 mm) passing through the sinus mucosa close to a mucosal cyst B Fig 51.3 Cone beam CT (A) Orthodontic miniscrew implant correctly inserted in the inter-radicular space between the maxillary second premolar and first molar (B) Sinus cortex perforation by an orthodontic MI www.ajlobby.com 280 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT Fig 51.5 Cone beam CT (A) Coronal section showing inflammatory hypertrophy of the left sinus mucosa, nasal septum deviation, nasal turbinate hypertrophy and radiopaque alterations located in the right sinus cavity (B) Axial image showing the difference between a normal right sinus cavity and a pathological mucosal hypertrophy in the left one A CONCLUSIONS The maxillary sinus may have pathological alterations before any orthodontic treatment is commenced; cone beam CT carried out before treatment showed incidental pathological alterations in approximately 50%, including mucosal thinning, polyps and acute sinusitis (Fig 51.5).17 This would suggest that a preliminary otorhinolaryngology consultation would be useful to evaluate the condition of the sinus, detect any predisposing factors for iatrogenic damage and solve any pathological problems before initiation of orthodontic treatment.13 REFERENCES McGowan DA, Baxter PW, James J The maxillary sinus and its dental implications Oxford: Wright, Butterworth-Heinemann; 1993 p 1–125 Baumgaertel S, Hans MG Assessment of infrazygomatic bone depth for mini-screw insertion Clin Oral Implants Res 2009;20:638–42 Koymen R, Gocmen-Mas N, Karacayli U, et al Anatomic evaluation of maxillary sinus septa: surgery and radiology Clin Anat 2009;222:563–70 Ardekian L, Efrat Oved-Peleg E, Mactei EE, et al The clinical significance of sinus membrane perforation during augmentation of the maxillary sinus J Oral Maxillofac Surg 2006;64:277–82 Pommer B, Unger E, Sütö D, et al Mechanical properties of the Schneiderian membrane in vitro Clin Oral Implants Res 2009;20:633–7 B Poggio PM, Incorvati C, Velo S, et al “Safe zones”: a guide for miniscrew positioning in the maxillary and mandibular arch Angle Orthod 2006;76:191–7 Wang Z, Li Y, Deng F, et al A quantitative anatomical study on posterior mandibular interradicular safe zone for miniscrew implantation in the beagle Ann Anat 2008;190:352–7 Liou EJ, Chen PH, Wang YC, et al A computed tomographic image study on the thickness of the infrazygomatic crest of the maxilla and its clinical implications for miniscrew insertion Am J Orthod Dentofacial Orthop 2007;131:352–6 Chaimanee P, Suzuki B, Suzuki EY “Safe zones” for miniscrew implant placement in different dentoskeletal patterns Angle Orthod 2011;81:397–403 10 Baumgaertel S, Hans MG Assessment of infrazygomatic bone depth for mini-screw insertion Clin Oral Implants Res 2009;20:638–42 11 Pikos MA Maxillary sinus membrane repair: update on technique for large and complete perforations Implant Dent 2008;17:24–31 12 Raiser GM, Rabinovitz Z, Bruno J, et al Evaluation of maxillary sinus membrane response following elevation with the crestal osteotome technique in human cadavers Int J Oral Maxillofac Imp 2001;16:833–40 13 Gracco A, Tracey S, Baciliero U Miniscrew insertion and the maxillary sinus: an endoscopic evaluation J Clin Orthod 2010;44:439–43 14 Branemark PI, Adell R, Albrektsson T, et al An experimental and clinical study of osseointegrated implants penetrating the nasal cavity and maxillary sinus J Oral Maxillofac Surg 1984;42:497–505 15 Raghoebar GM, Batenburg RH, Timmenga NM, et al Morbidity and complications of bone grafting of the floor of the maxillary sinus for the placement of endosseous implants Mund Kiefer Gesichtschir 1999;3(Suppl 1):65–9 16 Skoglund LA, Pedersen SS, Holst E Surgical management of 85 perforations to the maxillary sinus Int J Oral Surg 1983;12:1–5 17 Pazera P, Bornstein MM, Pazera A, et al Incidental maxillary sinus findings in orthodontic patients: a radiographic analysis using cone-beam computed tomography (CBCT) Orthod Craniofac Res 2011;14:17–24 www.ajlobby.com Risk management of skeletal anchorage devices in orthodontics 52 Gudrun Lübberink and Vittorio Cacciafesta INTRODUCTION The availability of miniscrew implants (MIs) and miniplates has facilitated many aspects of orthopedic treatment, and in some cases actually makes such treatments possible However, MI-based treatments, in common with all medical procedures, are not without problems, complications and risks A single problem or mistake during planning and insertion of a MI can have a range of consequences Very often, a whole cascade of adverse events is triggered Orthodontists are becoming increasingly aware of what works well, what lies in the gray area between success and failure and what is bound to fail Because of this, it is essential that the patient is informed of the potential risks and of the availability of alternative treatments SUCCESS AND FAILURE RATES Chapters 48 and 49 discuss in detail the success rates and risk factors for miniplates and MIs Because published studies will have used different brands of MI, different MI diameters and lengths, different sites of insertion and in a variety of patients, it is difficult to draw simple straightforward conclusions on causes and effects What is frequently not mentioned in published studies is the level of experience of the operating practitioner at the start of the study, which is also an important factor that determines outcome Consequently, a clinician who intends to use MIs needs to be aware of the numerous influencing factors but also have a willingness to learn, from both his/her own mistakes and those of others The success rate, in theory, should be well above 90%, although this is unlikely to be achieved by an inexperienced practitioner starting to use MIs, and clinicians may experience a 75–80% success rate, depending on skill levels.1 There is a demonstrable learning curve with this type of treatment, particularly with regard to the insertion procedure itself The cause of most problems lies within this surgical procedure The main, or most common, problem is the loss of a MI There is a whole range of possible causes for such a loss These are covered in detail in Chapters 48 and 49 and only a few aspects will be discussed in this chapter TREATMENT PLANNING AND MINISCREW IMPLANT LOCATION The location of the insertion site appears to be the most important factor determining the success of MIs Patients have shown significantly different success rates in different insertion areas MIs inserted in the anterior palate present a success rate of more than 97% (see Fig 30.1B), whereas those inserted in the mandibular lingual aspects, the retromolar areas (Fig 52.1) and inter-radicularly between the incisors (see Fig 39.1E) have a success rate of 60% or less.3 The morphology of the insertion site is also significant A MI placed in a location that has a characteristically higher success rate (e.g between the mandibular second premolars and first molars) is more likely to fail if inserted too high or too low The ideal insertion site is the mucogingival junction within the attached gingiva, with a slight apical angulation of the MI.4,5 However, even MIs inserted in these wellchosen sites can be troublesome when placed by an operator with inferior skill, knowledge and experience For example, failure rates increase significantly with incorrect MI diameter or length, when using an insertion technique that compromises primary stability or with improper loading forces and vector biomechanics (Fig 52.2).4,5 MINISCREW IMPLANT INSERTION SITES The best site for the insertion of MIs should be selected on the basis of the planned biomechanical approach The following should be taken into consideration: ■ ■ at least 0.5 mm bone around the MI on all sides MI head should be positioned on inflammation-free, attached gingiva It is very important to determine the quantity and quality of bone at the selected site However, radiography only provides limited information in Fig 52.1 Insertion of miniscrew implant in the retromolar area Carefully planning is undoubtedly one of the key factors to success The documentation and information required for other maxillary orthopedic procedures are perfectly adequate and should be used also when planning treatment involving MIs The biomechanical approach should be based on medical history, assessment findings (including possible contraindications), diagnosis and treatment outcome desired The main contraindications are those of implant procedures in general, such as systemic diseases associated with increased bone metabolism or negative bone balance (e.g osteoporosis or uncontrolled diabetes), which can reduce the chances of success.2 Fig 52.2 Improper biomechanics with high loading force and wrong vector 281 www.ajlobby.com 282 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT A B Fig 52.3 Root injury (A) Root approximation with a miniscrew implant (MI) (B) Panoramic radiograph depicting root injuries following insertion of MIs two dimensions and can have distortions arising from the direction of exposure The spatial situation can also be assessed by reproducing the mucogingival line, the tooth axes and the roots on a cast The required direction of tooth movement must also be considered during planning, as the spatial arrangement of the dentition will change during the course of treatment A MI must not interfere with or obstruct the desired movement and may need to be moved part way through the treatment course (Fig 52.3A) In alveolar bone, the best sites are between the first molars and second premolars, where sufficient inter-radicular space is available, while midpalatal and retromolar pad areas have sufficient cortical bone thickness and provide excellent sites.6 Adequacy of inter-radicular space should always be ascertained with at least a panoramic radiograph; cone beam CT is even better If possible, it is best to place MIs in the attached gingiva to lessen the chance of inflammation, a factor associated with a higher failure rate.6 When placement in unattached mucosa is essential, careful insertion technique (by stretching the mucosa during insertion) and careful hygiene instruction could help to achieve satisfactory stability INSERTION RISKS AND COMPLICATIONS OPERATOR There is much in favor of MI insertion being done by the orthodontist Studies have shown that orthodontists have a far better developed sensitivity and biomechanical knowledge in this regard.7 If the orthodontist is not the one to insert the MI, a good line of communication with the surgeon must be maintained as surgeons usually insert MIs simply where there is plenty of space, which may not be a useful place Inappropriate insertion could cause clinical and biomechanical problems such as root injury (Fig 52.2), obstruction of tooth movement or the wrong location for the connecting systems, which could be too short and ineffective OPERATOR EXPERIENCE Many problems can arise because of inadequate training or lack of experience of the operator (see Table 49.3): for every additional group of 18 MIs inserted, a failure rate of 25% was observed for the first group of MIs, 8.8% for the second, 2.1% for the third and 4.3% for the fourth group.8 The personal learning curve can be greatly improved by practicing on porcine bone samples to get a “feel” for bone resistance In order to minimize potential risks, particularly during insertion, it is advisable to adopt a standardized procedure for routine use BONE QUALITY It is only possible to test bone quality at the selected site immediately prior to insertion A probe should be first inserted in the bone If the probe penetrates deeply, the bone quality is not adequate and a different site should be selected ROOT INJURIES The MI must not be in contact with the dental roots, with consequences that vary with the level of contact (see Chapter 50) The risk of injury to dental roots during placement is one of the greatest concerns with orthodontic MIs (Fig 52.3B), particularly when they are inserted between teeth Placement of a MI too close to a root can also result in insufficient bone remodeling around the MI and transmission of occlusal forces through the teeth to the MIs, which can lead to implant failure (Fig 52.3A) Even though periodontal structures can heal after being injured by temporary anchorage devices, it is important to select the insertion sites carefully to avoid damage that cannot be retrieved FRACTURE OF MINISCREW IMPLANTS Some MIs have depth stops that signal that screwing must stop when they touch the bone surface However, depending on clinical factors, such as bone quality, site, angle of insertion and insertion technique, the moment of contact is not generally detectable There is, therefore, a risk of overinsertion (Fig 52.4A) and destruction of bone structure by the MI thread The initial (or primary) stability of the MI appears to be good, but the MI is rapidly lost In order to avoid this problem, it is advisable to measure the thickness of the gingiva prior to MI insertion as this gives a good indication of how far the MI can be inserted in the bone www.ajlobby.com Risk management of skeletal anchorage devices in orthodontics A A 283 B Fig 52.5 Micromovement of a miniscrew implant (A) Before molar mesialization (B) After molar mesialization B Fig 52.4 Miniscrew implant problems (A) Overinsertion (B) Fracture Fracture of a MI is a very rare occurrence (Fig 52.4B) The following parameters (alone or in combination) determine the risk of fracture: ■ ■ ■ MI design: thin (diameter, 10 mm) MIs tend to fracture more easily anatomical factors: thick cortical layer (>2 mm) without a pilot hole created prior to MI insertion insertion conditions: too much torque and/or inconsistent rate of insertion The most important way to avoid fractures is to place the MIs very gently, with a steady speed A torque driver can be used, as the driver rotates freely if the resistance reaches the fracture limit.9 If a MI fractures during insertion, it is advisable to remove the fractured part of the MI from the bone immediately, raising a flap and carefully eliminating the surrounding bone The simple way to remove a MI at the end of treatment is by turning the manual screwdriver counterclockwise very gently Touching the head of the MI with a round carbide bur can loosen it so that removal can be swift and safe.10,11 A MI that is fractured during removal is better left in place, because removal involves flap opening, grinding of the surrounding bone and grasping and turning the MI with Weingart pliers Because buccal MIs are inserted near the gingival margin, removal of marginal bone may produce periodontal breakdown A small piece of titanium MI would not cause serious complications, and if the patient accepts leaving it in place, it is less traumatic Another strategy that makes it easy to remove a fractured MI is to use an ultrasonic scaler to stir up the interface, then wait for 1–2 weeks and apply gentle force to remove it.10,11 INSERTION TECHNIQUE Generally, a self-drilling and self-tapping technique for MI insertion is preferred, using only topical anesthetic and watching for patient discomfort, which indicates possible root contact A continuous, non-wobbling force helps to keep the MI in a straight path Desired force vectors should be considered carefully when choosing direct or indirect anchorage Indirect anchorage allows the clinician to apply a force vector similar to conventional orthodontics while enhancing the stability of the MI Direct anchorage may be more beneficial for certain types of tooth movement, such as molar intrusion or en masse anterior retraction, where it can provide an intrusive component of the force vector that will facilitate control of the vertical dimension.10,11 PRIMARY AND SECONDARY STABILITY Attempts to place MIs in areas of difficult access or poor bone quality, wobbling during insertion and pilot hole drilling often result in lack of primary stability and, ultimately, in MI failure The quality of bone is the most important factor determining primary stability; the strain obtained by loading a MI perpendicular to the long axis with 50 cN leads to loss of primary stability when the cortex is equal to or smaller than 0.5 mm.12 MI stability is mainly determined by the dimensions of the cortical layer, with any part of the MI within the spongiosa contributing little towards retention The reasons for poor primary stability include: ■ ■ ■ inadequate bone quality or quantity overlarge hole in bone caused by using the wrong drilling technique (e.g repeated insertion of the drill in the hole or deviation from required axis) inappropriate MI thread (size and profile of the thread and the relation of the shaft to the external diameter) To enhance primary stability, the insertion angle should be kept stable during insertion and the threaded part should be inserted totally into bone.10,11 A MI must present primary stability immediately after insertion as it cannot be achieved subsequently If this is not achieved, then it is best to remove the MI and select an alternative insertion site The regeneration of bone required for secondary stability commences shortly after insertion Anything that inhibits this process, such as micromovements of the MI, may lead to MI failure The second factor determining primary stability is the actual MI insertion pressure Moderate initiatory pressure is required to engage the first portion of the MI threads, but after that, insertion pressure should be reduced to allow the MI to draw itself in with each rotation This will prevent stripping and hole widening Another risk is the gradual, almost indiscernible, forward movement (away from the practitioner) of the hand and driver shaft with each turn of the MI Not only does this change the initial trajectory of the MI, thus increasing the chance of root impingement, but more importantly, it again widens the hole around the MI.10,11 APPLICATION OF LOADING FORCES Whether a MI is loaded immediately or some time later probably has no influence on failure rates Forces should be such that no damage is caused to the teeth to be moved When a MI is coupled to elastic chains or springs, this can result in micromovements of the MI (Fig 52.5) While research seems to indicate maximum acceptable forces in the range 250–300 g, higher success rates can be obtained using Ni-Ti springs delivering a constant, predetermined force of 50–100 g.10,11 The distance between the MI and the site of force application, using springs directly attached to it, should be kept to a minimum Otherwise, these will be ineffective Loading a MI perpendicular to its long axis is preferable If the MI is used indirectly by adding a cantilever to a bracket-like head, a force generating a counterclockwise moment around the long axis should be avoided since this moment will unscrew the MI www.ajlobby.com 284 SECTION IX: EFFICIENCY OF SKELETAL ANCHORAGE AND RISK MANAGEMENT Fig 52.6 Peri-implantitis (A) Healthy palatal soft tissues (B) Development of peri-implantitis A B Box 52.1 Postoperative instructions for miniscrew implant care General You have just received one or more miniscrew implant(s) Your miniscrew implant will help you greatly in achieving our treatment objectives However, miniscrew implants are delicate and can loosen and fall out Here are some things to consider Home care Be careful with an electric toothbrush (particularly Sonicare or any vibrating brush) and not touch the miniscrew implant with a vibrating brush head Keep the area of the miniscrew implant clean by gently using an interdental brush Use a salt-water rinse before bed Food Please avoid eating hard, crunchy, chewy, and sticky foods They can hit or stick to the miniscrew implant and loosen it or a Waterpik should be used for cleaning There is evidence that electric toothbrushes, particularly those with rotating heads, can loosen MIs In addition to the cleaning technique itself, the frequency and intensity of cleaning are undoubtedly also important Very frequent cleaning that results in persistent micromovement of the MI could well be disadvantageous Patients are instructed to dip their toothbrush in a small bottle of 0.12% chlorhexidine solution and brush the MI twice a day Patients must understand that they should not be afraid of the MI, as proper brushing maintains a firm, healthy gingiva around it.10,11 A toothbrush, if not properly used, may irritate the marginal soft tissue and aggravate inflammation If local inflammation occurs, with signs of redness of the soft tissue margin at the neck of the MI, antibiotics are usually not prescribed Instead, the patient is instructed to enhance the hygiene regimen, for example using a Waterpik Habits There is a possibility that habits like clenching and bruxism can loosen miniscrew implants While this may be hard for you to control, we’d like you to be aware Activities Trauma to the area can loosen the miniscrew implants Be aware that sports may involve injury to the face and can increase the risk of loosening the miniscrew implants Discomfort Typically you will not need any medication for discomfort You may take an ibuprofen only if you need it Your miniscrew implant is an invaluable addition to your orthodontic treatment Please take care of it, as it is an essential part of your specialized treatment POST-INSERTION RISKS AND COMPLICATIONS INFLAMMATION There is a high probability that a MI will fail if perimucositis or periimplantitis develops (Fig 52.6) It is, therefore, important to ensure that the patient is appropriately informed (including instructions for immaculate oral hygiene) and attends follow-up examinations (Box 52.1) The stability of the MI and of the condition of the surrounding tissue is assessed at each follow-up examination Attached elements (springs, extension arms) may cause pressure sores or even ulceration of the mucosa, which needs monitoring and treating as necessary Infection control is essential during MI insertion (see Chapter 14) Prophylatic antibiotics (e.g a penicillin or cephalosporin) can be prescribed to be taken hours before or after surgical placement ORAL HYGIENE During treatment, patients are instructed to clean the MIs carefully and not to apply intentional force with a finger or implement A normal toothbrush LIABILITY ISSUES In order to protect themselves if a claim for negligence is made, orthodontists should ensure that they follow certain basic rules based on the currently existing evidence INSURANCE Orthodontists who wish to insert MIs themselves are frequently unsure about various aspects of indemnity insurance Policies available cover claims ranging from 1.5 to million euros When deciding on the extent of cover required (and so the premiums), the special circumstances of the practice need to be considered An indemnity insurance policy will cover the practice’s personnel but may exclude temporary employees If there are any changes in the activity profile of the practice, these must be covered by the policy There are insurance companies that not differentiate in their policies between dental and orthodontic practices (the policy specifies “with implants” or “with surgery”) Where an orthodontist is planning to personally insert MIs, this is usually automatically covered by the policy If there is any doubt, policyholders should always contact their insurers and inform them of the extension of the range of treatments provided in the office, particularly if the policy does not specifically cover maxillary orthopedic or implant procedures In this case, the annual premium is likely to be slightly increased DUTY OF INFORMATION Prior to the initiation of any treatment procedure, the patient must be informed of the nature and effect of potential risks, of alternative treatments and of the consequences if no treatment is provided It is a good idea to use preprinted material to gather information on medical history and provide information These can act as an aide memoire or prompt when talking to the patient Written material should never be used instead www.ajlobby.com Risk management of skeletal anchorage devices in orthodontics of a personal dialogue Printed materials used (e.g in the form of a note) must document that the relevant verbal information has been given to the patient It is not enough merely to have the signature of the patient, a witness and the practitioner DOCUMENTATION Good documentation is absolutely essential Treatment records, including patient files, radiographs, casts, photographs and so on, must clearly document the course of treatment, as well as any problems and complications Scrupulous and accurate documentation is very valuable if, for example, a legal dispute ensues Lawsuits are often lost because documentation was incomplete INSURANCE CLAIMS If a patient suffers an injury or decides to register a claim, it is advisable to get in touch with the policy provider The insurer will supervise all the financial and legal aspects CONCLUSIONS The main parameters that determine the clinical success of MIs are bone quality, the space available at the planned insertion site, the use of an insertion technique appropriate to the system employed, the use of a wellconsidered biomechanical concept and the avoidance of inflammation or infection around the MIs 285 REFERENCES Antoszewska J, Papadopoulos MA, Park HS, et al Five-year experience with orthodontic miniscrew implants: a retrospective investigation of factors influencing success rates Am J Orthod Dentofacial Orthop 2009;136:158, discussion 158–9 Luzi C, Verna C, Melsen B Guidelines for success in placement of orthodontic miniimplants J Clin Orthod 2009;43:39–44 Melsen B, Graham J, Baccetti T, et al Factors contributing to the success or failure of skeletal anchorage devices: an informal JCO survey J Clin Orthod 2010;44: 714–18 Cheng SJ, Tseng IY, Lee JJ, et al A prospective study of the risk factors associated with failure of mini-implants used for orthodontic anchorage Int J Oral Maxillofac Implants 2004;19:100–6 Park HS, Jeong SH, Kwon OW Factors affecting the clinical success of screw implants used as orthodontic anchorage Am J Orthod Dentofacial Orthop 2006;130:18–25 Park J, Cho HJ Three-dimensional evaluation of inter-radicular spaces and cortical bone thickness for the placement and initial stability of microimplants in adults Am J Orthod Dentofacial Orthop 2009;136:314 Osterman WL Who places miniscrews? An informal JCO survey J Clin Orthod 2008;42:519, discussion 519–27 Wiechmann D, Meyer U, Büchter A Success rate of mini- and micro-implants used for orthodontic anchorage: a prospective clinical study Clin Oral Implants Res 2007;18:263–7 Motoyoshi M, Hirabayashi M, Uemura M, et al Recommended placement torque when tightening an orthodontic mini-implant Clin Oral Implants Res 2006; 17:109–14 10 Cacciafesta V, Bumann A, Cho HJ, et al JCO round table skeletal anchorage, Part J Clin Orthod 2009;43:303–17 11 Cacciafesta V, Bumann A, Cho HJ, et al JCO round table skeletal anchorage, Part J Clin Orthod 2009;43:365–78 12 Dalstra M, Cattaneo PM, Melsen B Load transfer of miniscrews for orthodontic anchorage Orthod 2004;1:53–62 www.ajlobby.com Index Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes A Aachen Implant Pendulum, 105–106, 106f, 107t Aarhus anchorage system, 143–146 treatment planning of, 143 Aarhus miniscrew implant, 67–68, 68f–69f AbsoAnchor miniscrew implants, 34f, 35t, 36f–37f, 37t Absolute anchorage, 58, 104 Abutments, choosing of, for skeletal Pendulum-K appliance, 183, 184f Acrylic resin, 102 button, GISP and, 124 distalization splints, 14 Active anchorage, GISP and, 125–126, 126f Active unit, of MISDS, 156, 156f A design, of TPA-PH device, 190, 191f Adjustment module, in TopJet distalizer, 178, 178f Adolescent, with Class II malocclusion, maxillary molar distalization with GISP in, 126, 126f Adult, with Class II malocclusion, maxillary molar distalization with GISP in, 126, 127f Advanced molar distalization appliance (AMDA), 160–167, 160f advantages of, 167 clinical applications of, 161–166 clinical procedure for, 161 construction and use of, 166 removal of, 161 Age, miniscrew implants and, 262–263 Alginate impression, in skeletal Pendulum-K appliance, 183 Alveolar process, 88 Alveoloplasty direct anchorage with, for excess gingival exposure during smiling, 197–198, 198f indirect anchorage with, for simultaneous reduction in gummy smile and vertical dimension, 198–200, 199f, 200t AMDA see Advanced molar distalization appliance (AMDA) Anchor breakage, complications of miniplates, 255, 256f Anchorage Aarhus, 143–146 in class II treatment, 24 direct, 52–53, 53f, 249–251 C-implant for, 240–241, 241f during distal movement of molars, 25, 26t evidence and, 25 indirect, 52, 52f, 251 C-implant for, 240–241, 241f loss, 175–177 of molars during space closure, 25, 25f, 26t in orthodontics, 22–24 pain and discomfort in, 27 skeletal vs conventional, 25–27 Spider Screw, 147–155 types of, 62f miniscrew implants for, 62, 270 Anchorage unit of AMDA, 160–161 of MISDS, 157 Anesthesia, for miniscrew implant insertion, 83, 99 Angle of insertion, miniscrew implants and, 269 Animal studies, for miniscrew implants, 66 Ankylosis, 275–276 Anterior crowding lip protrusion and, 227–228, 227f, 228t maxillary molars, extraction treatment for, 145, 145f severe, and maxillary protrusion, 224–225, 225f, 225t Anterior open bite increasing incisor display in, 206 and protrusion, 216–217, 216f, 217t Anterior teeth retraction, 161, 225–228, 226f cephalometric analysis after, 164 for lip protrusion and anterior crowding, 227f Anterior torque control, 226 Apertura piriformis, miniplates on, 80, 80f–81f Appositional bone formation, 31 Archwires crowding of maxillary incisors, 122, 122f in en masse retraction, 113 Auxiliary anchorage, 104 Auxiliary distalization appliances C-implant with, 241, 241f C-tube miniplates with, 242 B Ball ends, positioning of, in class II correction using symphyseal bone anchorage, 129 Ball-marked splint, in lateral cephalometric radiography, 74 BAPA see Bone-anchored Pendulum appliance (BAPA) Basic appliance, 11f Bayonet bend, 171 B design, of TPA-PH device, 190, 191f Benefit system, 174f Beneplate, 174, 174f wire, 174, 175f Beneslider, 174–177, 174f–175f case example of, 175, 176f clinical application of, 174–175 discussion, 175–177 Beta-titanium alloy archwire, 138f Bilateral distalization, 111, 111f TopJet distalizer for, 181, 181f Bilateral maxillary molar distalization, 161–164 treatment, 162 Biocreative therapy, 239 non-extraction correction of class II malocclusion using, 239–243 Biomaterial properties, of orthodontic miniscrew implants, 34–38 Bollard miniplates, 118, 118f–119f, 254f Bone anchorage for fixed functional appliances, 246–248 for the Forsus Fatigue Resistant Device, 246 286 www.ajlobby.com Bone-anchored Pendulum appliance (BAPA), 186–188, 186f clinical application of, 186–187 case presentation, 186–187, 187f comprehensive treatment outcomes, 188 removal of, 186 vs conventional Pendulum appliance, 187t Bone-implant contact, 253 Bones densities of, Misch’s classification of, 89f, 89t healing of, 30–32 modeling of, 30–31 distance and contact osteogenesis, 30–31 hematoma, 31 overgrowth of, 256, 257f quality of, miniscrew implants and, 282 quantity and localization of, in orthodontic implant insertion and removal, 76 remodeling of, 31–32 in animal studies, 33 around implant, 276 response of, with miniscrew implants, 276 thickness of of infrazygomatic crest, 90 in maxilla and mandible, 91t Bone-screw locking condition, 40f Bowman modification, 168 Brackets for bidimensional technique, 147t for fabrication of Kim’s stent, 98 Bracket-like head, miniscrew implants with, 69, 69f Buccal segment distalization, 112–113, 113f Button, head design of miniscrew implants, 60t C Callus, 30 Canines distalization of, 151 retraction of, 148–150, 149f with MGBM system without extractions, 151f Canine crown tipping, 119–120, 120f Canine distalization, in extraction treatment, 113, 113f Carriere distalizer, 14 C design, of TPA-PH device, 190, 191f “Cement line matrix”, 30 Cephalometric analysis AMDA after anterior teeth retraction, 164 after distalization, 162–163, 166 at end of treatment, 164, 166 during treatment, 162t, 164t during treatment with Distal Screw, 172t during treatment with MISDS, 157t Cephalometric measurements in Jasper Jumper, 132, 133t in lip protrusion and anterior crowding, 228t in severe anterior crowding and maxillary protrusion, 225t Cephalometric tracings, superimposition of, 159, 159f Cheek irritation, 255, 255f Index 287 Chin in class II malocclusion, fixation of, miniplate for, 129, 129f C-implant, 103, 239f–240f, 240 as direct anchorage with auxiliary distalization appliances, 241, 241f for direct and indirect anchorage, 240–241, 241f recommended protocol for immediate relocation of, 240 relocation from buccal maxillary bone to palate, 242, 243f relocation within the mandible, 241–242, 242f Class II elastics, Class II high mandibular plane angle, 116f zygoma anchors for, 115 Class II malocclusion compensation with miniscrew implant-supported anchorage, 139–142 treatment objectives for, 139f correction of, 110–111 with bone-anchored Forsus Fatigue Resistant Device, 244–248 non-extraction, using biocreative therapy, 239–243 overview of orthodontic implants for, 104–108 temporary anchorage devices for, 143–146 twin force bite corrector (TFBC) and skeletal anchorage for, 249–251 diagnostic considerations of, 1–2 chin, crowding, growth potential, other factors, 1–2 upper lip, position of, division 2, 170f treatment of, 169f extraction treatment of, 151–152 phase 1, 151 phase 2, 151–152, 152f phase 3, 152, 153f management of, lingual orthodontics and use of miniscrew implants for, 211–218 maxillary molar distalization with GISP of in adolescent, 126, 126f in adult, 126, 127f miniplates and zygomatic anchorage for treatment of, 112–117 MISDS for, 158f molar distalization in, 212–213, 214f non-compliance approaches for management of, 6–21 non-extraction treatment of, 148f–150f using miniscrew implant anchorage, 189–195 orthopedic and soft tissue correction for, 115 overview of miniscrew implants in treatment of, 134–138 palatal implants for, 52–53 Straumann Orthosystem as palatal implant in, 109–111 subdivision left, 193–195, 194f treatment strategies of, 1–5 extraction, 2–3 growth modification, maxillary molar distalization, 3–4 zygoma anchors for, 115f Class II open bite malocclusion miniscrew implant-supported treatment of, 235 in adult, 235–236, 236f with impaired masticatory function, 236–237, 237f, 237t with severe open bite and difficulty in lip closure, 237–238, 238f skeletal anchorage-supported treatment for, 235–238, 235f Clinical studies, for miniscrew implants, 66 Clinicians, number of, miniscrew implants and, 264 Compact bone, 88 Compliance, problem of, in Class II malocclusion management, Computed tomography (CT), in orthodontic implants insertion and removal cone beam, 74–76, 75f dental, 74, 75f Computer simulations, for miniscrew implants, 67–68, 67f–68f Cone beam computed tomography (CBCT) assessment on the effect of Forsus FRD on maxilla and mandible, 246, 248t for optimal positioning of miniscrew implants, 103 in orthodontic implants insertion and removal, 74–76, 75f Conical miniscrew threads, 61 Consecutive crown tipping, 119 Contact osteogenesis, 30–31 Continuous/segmental approaches, on class II malocclusion, 211–212 Conventional anchorage, 23–24 Conventional fixed orthodontic appliances, 239 Conventional implants, 32 Conventional positioning guides, for radiological evaluation of miniscrew implant insertion sites, 94, 94f Cortical bone, 90 notching of, miniscrew implants and, 267 thickness of, miniscrew implants and, 84t, 269 Crossed-slot, head design of miniscrew implants, 60t Crowding in class II malocclusion, miniscrew implants and, 264 C-tube miniplate, 240, 240f used as direct anchorage with auxiliary distalization appliances, 242, 242f C-type orthodontic bone anchors, 239–240 Curve of Spee, 122 Curvilinear leaf springs, Cutting flute, of miniscrew implants, 45–46, 45f D Damage, to teeth and adjacent structures, 255 De novo bone formation, 30–31 Deep bite, control of vertical dimension, 154–155 Deep overbite and gingival display, 208–209, 209f treatment of, 207–208, 208f Degenerated dentition, retraction of the anterior segment in, 143–145, 144f Dental arch, plaster cast of, 101 Dental computed tomography, in orthodontic implants insertion and removal, 74, 75f Deviated smile line, improving, 209–210 DICOM see Digital imaging and communications in medicine (DICOM 3) Digital imaging and communications in medicine (DICOM 3), 103 Direct anchorage, 52–53, 53f, 62f, 104, 249–251 advantages/disadvantages of, 62t with alveoloplasty, for excess gingival exposure during smiling, 197–198, 198f without alveoloplasty, for simultaneous reduction in gummy smile and vertical dimension, 202–203, 202f Direction guide fabrication of, 98, 98f in Kim’s stent, 97 Distal crown tipping, 121–122 www.ajlobby.com Distal Jet appliance, 12, 168 modified, 168f, 171–173 Distal Screw, 171–173, 171f advantages of, 173 case presentation, 171–173, 171f cephalometric analysis during treatment with, 172t clinical application of, 171–173 construction of, 171, 172f treatment of bilateral dental class II malocclusion with, 172f Distalization bilateral, 111, 111f limitations of, 141 of maxillary arch, with miniplate anchorage, 118–123 of maxillary molars, 223–225 for severe anterior crowding and maxillary protrusion, 225f without extractions, 147–151, 147f segmental, using miniscrew implants, 213 unilateral, 110, 110f Distalizing arches, 14 Distalizing forces, 120f Distance osteogenesis, 30–31 Documentation, miniscrew implants and, 285 Double flexible distalization force system, palatally and buccally positioned, appliances with, 14 Drills, 80 Dual force distalizer, 135, 135f Dual occlusal plane, molar distalization biomechanics, 122, 122f Dual-thread miniscrews, 61 Dual-Top miniscrew implants, 34f, 35t, 37f, 37t Duration of treatment, miniscrew implants and, 271 Duty of information, miniscrew implants and, 284–285 E Elastics, substitutes for, 11 Electrical hand driver, 235, 236f En masse distalization, 141, 141f, 189, 189f En masse retraction, 113–114 biomechanics of, 140f of maxillary teeth, 219, 219f Endosseous dental implants, 32 Esthetics of appliance use, 211 effect of tooth movements on, 211t Eureka Spring appliance, 10, 10f Evidence-based decisions, 24–27 Expertise, miniscrew implants and, 264 Explanted implants, histologic analysis of, 29 Extension arm, 245 Extension springs, Extraction for class II malocclusion treatment, 2–3, 151–152 forceps, in orthodontic implant removal, 77, 77f of premolars, effects on dentofacial structures, for protrusion of maxillary anterior teeth, 220–222, 221f, 222t treatment for alleviating anterior crowding, 145, 145f Extrusive/intrusive mechanics, in class II malocclusion management, 212 F Fast Back Appliance, 13 Finite element analysis (FEA) modeling, computerbased, for stress distribution of implants, 32 288 Index First Class Appliance, 15, 15f Fixation screws, for miniplates, 118, 119f, 252 Fixed functional appliances, 244, 249 bone anchorage for, 246–248 condylar growth and effect on maxillary complex of, 246–248 conventional, 249f miniplates as anchoring units for, 244–246 miniscrew implants as anchoring units for, 244 Fixed interarch appliances, for class II malocclusion treatment, 2–4 Flap surgery, use of, miniscrew implants and, 267–268 Flex Developer appliance, 9–10, 10f Flexible distalization force system, appliances with buccally positioned, 13–14 palatally positioned, 11–13 Flexible intermaxillary appliances, 9–10 Foramen, incisive, 74 Force application, method of, miniscrew implants and, 270 Forsus device, 130 clinical presentation for, 130–131, 131f Forsus Fatigue Resistant Device, 10–11, 116, 117f anchorage of, 246f bone anchorage for, 246 measuring jig, 245–246 typical patient in the study of, 247f Forsus Fatigue Resistant Device with Direct Push Rod (FFRD-DPR), 190 Forsus Nitinol Flat Spring, 244 Fracture, of miniscrew implants, 63–64 Frenula, 92 Fujita lingual brackets, 227, 227f Functional appliances, 115–116, 129 for class II malocclusion treatment, fixed, class II correction with Forsus device, 130 Herbst, 130 Jasper Jumper, 129–130 Functional Mandibular Advancer, G Gender, miniscrew implants and, 262 Gingival dehiscence, 255 Gingival display deep overbite and, 208–209, 209f excess, etiology and treatment strategies of, 196t GISP see Graz Implant-Supported Pendulum (GISP) Graz Implant-Supported Pendulum (GISP) design of, 124–125, 124f improved design of, 124–125, 124f indications of, 125 laboratory-fabricated, 125f maxillary molar distalization with, 124–128 clinical presentations of, 126 orthodontic procedure of, 125–126 Greenfield Molar Distalizer see Piston appliance Growth potential, diagnostic consideration of, in class II malocclusion, Gummy smiles caused by maxillary alveolar excess, 208–209 skeletal origin, treatment with miniscrew implantsupported biomechanics, 196–203, 196t advantages of, 203 case examples, 197–203 clinical approach for, 196–197 diagnosis for, 196 discussion for, 203 treatment biomechanics, 197, 197t H Habitual asymmetric smile, 209–210 treatment progress, 209, 209f treatment results, 209–210 Head, of miniscrew implants, 39, 40f designs of, 60t length, 265 Headgears in conventional anchorage, 23, 24f in maxillary molar distalization, used for class II malocclusion treatment, Hematoma, 254, 255f peri-implant, 31 Herbst appliance, 2, 6–8, 7f, 130 advantages of, clinical presentation for, 131–132, 132f indication of, intermaxillary temporary anchorage with, 146f Hex nuts, 249 Higmoro antrum, 278 Hole, head design of miniscrew implants, 60t Hook screw, 196–197 head design of miniscrew implants, 60t Horseshoe Jet appliance, 168f advantages of, 169–170 case examples, 169, 169f–170f clinical procedure for, 168–169 development of, 168 evolution of, 168–170 final modified, 169f Horseshoe-type archwire, 160, 160f Howship lacuna, 31 Hybrid appliances, 10–11, 10f, 15 I IAD see Implant-anchored distalizer (IAD) Idiopathic condylar resorption, 211 Impaired masticatory function, open bite and, 236–237, 237f, 237t Implants advantages of, 48 biological principles of, 29–33 biomechanical considerations of, 29–33 dental, 49 orthodontic use of, 32–33 design of, 32 Orthosystem, 49–51 as skeletal anchorage, 48–54 stability of, 32 types of, 48–51 Implant-anchored distalizer (IAD), 52, 53f Implant-based anchorage, 32 Implant-supported anchorage, appliances for, 105–107 Implant-supported intraoral molar distalization systems, 112 Implant-supported Keles Slider, 106, 107t Implant-supported transpalatal bar and coil springs, 106–107, 107f, 107t Impression caps, 175f In vitro studies, for miniscrew implants, 66–67, 67f Incisive foramen, 74 Incisors display of, increasing, 204–206, 204t in anterior open bite, 206 relations, in class II malocclusion, 212 retraction of, 150–151, 150f with MGBM system without extractions, 151f www.ajlobby.com Indirect anchorage, 52, 52f, 62f, 104, 251 advantages/disadvantages of, 62t with alveoloplasty, for simultaneous reduction in gummy smile and vertical dimension, 198–200, 199f, 200t without alveoloplasty, for protrusive maxillary anterior teeth and a gummy smile, 200–202, 201f, 201t Indirect bonding method, 224, 224f Infections control of, after miniscrew implant insertion, 85 miniscrew implants and, 62–63 Infinite anchorage, 58 Inflammation miniscrew implants and, 62–63, 63f, 284, 284f of peri-implant soft tissues, 271 Insertion technique, in orthodontic anchorage using locking plate and self-drilling miniscrew implants for posterior maxilla, 55, 55f–56f Insurance, miniscrew implants and, 284 Inter-radicular distances in mandible, 92f, 92t in maxilla, 91f, 92t Inter-radicular space, for miniscrew implant insertion, 85, 85f Interarch compression springs, Interdental septum, 101f Intermaxillary non-compliance appliances, 6–11, 15–16, 16f–17f, 18–19 mandibular advancement using, 190 Intramaxillary non-compliance distalization appliances, 11–15, 17–20, 18f Intraoral Bodily Molar Distalizer, 12 Intraoral non-compliance distalization appliances, 104 Intraosseous retention, of prosthetic implants, 39–40, 40f Intraosseous screw, in conjunction with transpalatal arch, 135, 135f Intrusion auxiliary arches, 122, 123f Intrusive force, molar distalization biomechanics, 120, 121f InVivo software, for correction of class II malocclusion with Forsus Fatigue Resistant Device, 247f J Jasper Jumper appliance, 9, 9f, 129–130, 130f cephalometric measurements in, 132, 133t clinical presentation for, 130, 131f for treatment of mandibular retrognathism, 116 Jaw of placement, miniscrew implants and, 269 Jones Jig appliance, 13, 13f K Keles Slider, 12, 12f implant-supported, 106, 107t maxillary molar distalization with, 229–230, 229f Kim’s stent, 97–100 components of, 97, 97f fabrication of, 97–98, 98f fixation of, 99, 99f preparation of patient for, 97, 97f K-Pendulum appliance, 11f L Laboratory-fabricated positioning device, 94f Laceback, from canine bracket, 121–122, 121f Index 289 Lateral cephalometric radiography for molar distalization, 161 in orthodontic implants insertion and removal, 74, 75f Lateral component of force, molar distalization biomechanics, 123f Learning curve, of operator, 265 Lever arm and miniscrew implant system, 223–228 for anterior teeth retraction, 226–227 for distalization of maxillary molars, 223–224, 223f Lever arm design, 213–214, 214f Lingual arch plus hooks (LA-PH) device, 190–192, 192f Lingual brackets, 226, 227t Lingual orthodontics class II, practical guidelines for, 212–214 finishing stage, 214 lever arm design, 213–214, 214f treatment goals, 212 and miniscrew implants, for class II malocclusion management, 211–218 biomechanical considerations, 211–212 clinical applications, 214–217 Lips closure of, difficulty in, with severe open bite, 237–238, 238f position of upper, in Class II malocclusion, protrusion of, and anterior crowding, 227–228, 227f, 228t ptosis, 81 Loading forces, application of, in miniscrew implants, 283 Locking plate, orthodontic anchorage using, for posterior maxilla, 55–57, 56f–57f Locking screw, 79 LOMAS orthodontic MI system, 196–197 Loop mechanics, for treatment of class II malocclusion, 219, 219t L-shaped incision, in miniplate surgery, 118, 119f M M4 site, 179, 179f Magnetic distalization appliance, 14f Magnets, used for molar distalization, 14 Mainz Implant Pendulum (MIP), 105, 105f, 107t Malocclusion class II division I with maxillary protrusion, 192–193, 193f, 193t subdivision left, 193–195 miniscrew implant treatment for, 71 type of, miniscrew implants and, 263 Mandible intermaxillary forces to advance, 145–146, 146f placement of miniscrew implants in, 269–270 relocation of C-implant within, 241–242, 242f site for miniscrew implant placement, 85, 85f Mandibular advancement biomechanics of with intermaxillary class II elastics, 16f with intermaxillary non-compliance appliances, 16f using intermaxillary non-compliance appliances, 190 Mandibular anterior anchorage, in class II malocclusion, 2–3 Mandibular Anterior Repositioning Appliance (MARA), 2, 8–9, 8f Mandibular crowding minimal, 240–241 severe, 241–242 Mandibular incisors, protrusion of, 214–216, 215f, 215t Mandibular molars, distalization of, 190–192 Mandibular Protraction appliance, 8, 8f Mandibular retrognathism, treatment of, with miniplate anchorage, 115–116 Mantel-Haenszel method, 261f MARA see Mandibular Anterior Repositioning Appliance (MARA) Maxilla, 231 placement of miniscrew implants in, 269 site for miniscrew implant placement, 84, 84f Maxillary alveolar excess, gummy smile caused by, 208–209 Maxillary anterior protrusion, 217, 217t, 218f Maxillary anterior teeth, retraction of, 139, 140f Maxillary arch distalization of, with miniplate anchorage, 118–123 patient instructions, 118–119 en masse distalization of, 137–138, 137f–138f, 189f sequential distalization of, 136–137, 137f three segments of, 121 Maxillary canines, restriction of mesial crown tipping of, 121–122, 121f Maxillary crowding minimal, 241–242 severe, 240–241 Maxillary dentition, preparation of, 129 Maxillary incisors molar distalization biomechanics, 120 protrusion of, 214–216, 215f, 215t Maxillary incisor display, insufficient, etiologies and treatment strategies for, 204t Maxillary molar distalization, 3–4, 136, 136f, 223–225 bilateral, 15f biomechanics of, with cervical headgear, 17f for correction of class II malocclusion, 104 with Graz Implant-Supported Pendulum appliance, 124–128 insertion location of, 105 with Keles slider and miniscrew implants, 229–230, 229f non-compliance, appliances for, 105–107, 107t non-extraction treatment, 189–190, 189f with palatal implants, 230–231, 231f unilateral, with miniscrew implants, 233–234, 233f with zygomatic miniplates, 231–232, 232f with Keles slider and miniscrew implants results of, 230 treatment progress, 230 non-compliance, for severe anterior crowding and maxillary protrusion, 225f unilateral, with miniscrew implants progress of, 233 results of, 234 without extractions, 147–151, 147f Maxillary molars, 247 Maxillary posterior anchorage, for class II malocclusion, Maxillary posterior teeth, effects of Forsus Fatigue Resistant Device on, 247f Maxillary prognathism, treatment of, 112 Maxillary protrusion class II, division I malocclusion with, 192–193 cephalometric evaluation, 193t treatment course, 192–193, 193f treatment results, 193 and severe anterior crowding, 224–225, 225f, 225t www.ajlobby.com Maxillary sinus, 278, 280, 280f anterior wall of, 278 internal wall of, 278 perforation, 278–279, 278f–280f Maxillary teeth anterior en masse retraction of, 219f non-extraction treatment for protrusion of, 220f en masse retraction of, 219 extraction treatment for protrusion of, 220–222, 221f, 222t non-extraction treatment for protrusion of, 220, 220t retraction of anterior segment of, 113–114 Maxillary trabecular bone, 253 Maxillary zygomatic buttress, 250–251 Maxillofacial surgery, orthodontic miniplates used in, 78, 78f Mental foramen, 92 Mesial crown tipping, 121f Mesially extended transpalatal arch, with miniscrew implants, 135, 135f MGBM system, 147, 151f Midpalatal suture sites, for miniscrew implants, 84, 219–220, 219f Miniplates, 252 as anchoring units for fixed functional appliances, 244–246 biological principles of, 29–33 biomechanical considerations of, 29–33 for chin fixation, 129 for class II malocclusion treatment, 112–117 complications of, 254–256 postoperative, 254–255, 255f practical, 255–256 at removal, 256 soft tissue, 255 insertion location, risk factor of, 253 mobility of, 255, 256f placement surgery of, in the maxilla and mandible, 254f risk factors of, 253–254 success rates of, 252–253, 252t surgery, 118 surgical insertion of, 129, 129f Miniplate anchorage distalization of maxillary arch with, 118–123 for treatment of mandibular retrognathism, 115–116 Miniscrew implants (MIs), 39, 69f, 174, 174f, 212, 219, 252 anchorage, non-extraction treatment of class II malocclusion using, 189–195 clinical examples, 192–195 as anchorage for advancement of the mandible, 244, 245f as anchoring units for fixed functional appliances, 244 in animal studies, 33, 66 application of loading forces in, 283 availability of, 281 basic components of, 39f biological principles of, 29–33 biomechanical considerations of, 29–33 care, postoperative instructions for, 284b clearance of, 274 clinical applications of, 64 clinical studies for, 66 commonly used, 59t complications of using, 62–64, 258 composition of, 58 computer simulations for, 67–68, 67f–68f 290 Index design and structural characteristics of, 42–46 cutting flute, 45–46, 45f diameter, 42–43 implant type, 43–44, 44f length, 42 material, 46 shaft shape, 44–45 thread design, 45, 46f thread pitch, 45, 45f designs of, 60–61, 66–68 diameter of, 61, 274 extra-osseous part of, 69, 69f failure of, 63 rates, 66, 281 fracture of, 63–64, 282–283, 283f head of, 60, 60t exposure of, 269 injuries to adjacent structures from, 63 insertion torque, 269 intra-radicular sites for, 219–220, 219f length of, 61 level arm and, 135–136 liability issues in, 284–285 loading of, 62 location of, and treatment planning, 281–282, 281f maxillary molar distalization with, 136–138, 136f, 229–230, 229f, 232–234 mesially extended transpalatal arch with, 135, 135f micromovement of, 283f mobility of, 271 N1 vs N2, 43f neck of, 60 non-compliant distalization systems used with, 134–136 non-self-drilling, 83 optimal positioning of, surgical guides for, 101–103 conventional, 101–102, 102f stereolithographic, 102–103, 102f–103f overinsertion, 283f placement of in the mandible, 269–270 in the maxilla, 269 post-insertion risks/complications of, 284 primary stability of, 42–46 properties of, 62 region of placement of, 269 reinstallation of, 271 removal of, 85–86, 86f in retraction of premolars and canines, 148–149, 149f risk factors associated with failures, 261–271, 261f–262f clinician-related, 264–265, 264t insertion-related, 265–269, 267t–268t miniscrew-related, 265, 266t outcome-related, 271, 271t patient-related, 262–264, 263t treatment-related, 270–271, 270t root and bone response to proximity of, 274–277 root contact with, 274 selection of, 66–70 self-drilling, 83 sites for placement of, 84–85, 84f, 84t for skeletal origin gummy smiles, 196–197 advantages of, 203 case examples, 197–203 in skeletal Pendulum-K appliance, 183, 184f splinted, use of, 270 stability of, 283 structural characteristics of, 41–42 diameter, 41 length, 41 neck, 41, 42f platform, 41–42, 42f surface, 41, 41f structure of, 39 success rates of, 40–42, 281 for temporary skeletal anchorage, 58–65 historical development in, 58 terminology for, 58 thread of, 60–61 in treatment of class II malocclusion, 134–138 with extractions, 151 treatment with ability to treat all types of malocclusion, 71 acceptance of, 71–72 convenient timing for, 71 economical/affordable care delivery for, 71 efficient, 71 expectations for, 71 ideally pain-free, 71 minimal time spent in the dental surgery for, 71 preferences for, 72, 73f unobtrusive, 71 types of anchorage and, 62 unilateral maxillary molar distalization with, 233–234, 233f use of predrilling for, 68 used as temporary anchorage devices, success rates/ risk factors of, 258–273 assessment of, 258–261, 258f, 259t–260t used for orthodontic anchorage reinforcement advantages of, 64 disadvantages of, 64 using Kim’s stent, 99–100, 99f evaluation of, 100 in vitro studies for, 66–67, 67f Miniscrew implant insertion, 83–84, 283 complications of, 278–280 direction of, 84 ease of access to sites, 87 finite element modeling of, 90f infection control after, 85 inter-radicular space considerations for, 85, 85f mandibular sites, 90 manual, 83, 83f maxillary sites, 88–90 mode of, 61 palatal sites for, 90f position for, 190 preparations before, 83 reference points for, 88f risks/complications of, 282–283 between roots of maxillary second premolar and first molar, 97–100 selecting a suitable site for, 87–93, 87t anatomical characteristics, 90–92 bony tissue characteristics, 88–90 presurgical diagnosis for, 92 soft tissue characteristics, 87–88 sites for, 68, 213f, 281–282 positioning guides for the radiological evaluation of, 94–96 soft tissue considerations for, 85 in TopJet distalizer, 179 using Kim’s stent, radiographic evaluation of, 99, 99f Miniscrew implant-supported anchorage biomechanics of en masse retraction, 140f mechanics of class II malocclusion compensation with, 139–142 Miniscrew implant-supported biomechanics, altering the smile line with, 204–210 www.ajlobby.com Miniscrew implant-supported distalization system (MISDS), 156–160, 158f active unit of, 156, 156f advantages of, 159 anchorage unit of, 157 case presentation, 157–159, 158f clinical procedure for, 157–159, 157t discussion in, 159, 159f treatment with, 157–159 MIP see Mainz Implant Pendulum (MIP) MIs see Miniscrew implants (MIs) Misch’s classification, of bone densities, 89f, 89t MISDS see Miniscrew implant-supported distalization system (MISDS) Modified acrylic resin Nance button, 106 Molars anchorage of, during space closure, 25, 25f, 26t buccal tipping of, control of, 154f distal movement of, anchorage during, 25, 26t distalization of, 147–148, 148f with MGBM system without extractions, 151f Molar distalization, 139, 140f, 143, 144f, 161 biomechanics, 119–122, 120f for class II malocclusion, 212–213, 214f using bone anchorage, 229–234 magnets used for, 14 with miniscrew implants, 232–234 with palatal implants, 230–231 with zygomatic anchorage, 231–232 Molar protraction/mesialization, 141, 142f conventional approach for, 142f Mucoperiosteal flap, 254f Mucosal thickness, miniscrew implant insertion and, 87–88, 88f–89f Multiloop edge-wise archwire (MEAW) technique, 235, 235f N Nance appliance, with coil springs, 12–13 Neck, of miniscrew implant, 39 characteristics of, 41, 42f New Anchor Plus miniscrew implants, 35t New distalizer, 15 Ni-Ti push-coil spring, GISP with, 125 Non-compliance appliances, for class II malocclusion management advantages/disadvantages of, 19–20 characteristics/classification of, 6–11 indications/contraindications for, 18–19 mode of action of, 15–18 Non-compliance approaches, for management of class II malocclusion, 6–21 Non-compliant distalization systems, used with miniscrew implants, 134–136 Non-endosseous implants, 32 Non-extraction treatment, for protrusion of maxillary anterior teeth, 220, 220f, 220t Non-osseointegrated anchorage systems, 22–23 vs osseointegrated, 23 O Oblique insertion direction, 85 Occlusal interferences, risk factor of miniplates, 254 Occlusograph, in Aarhus anchorage system, 143 Onplant bar, maxillary molar distalization with, 24f Onplant system, 22, 22f, 49 design, 49 insertion site and surgical procedures of, 49 Index 291 Open bite adult with, miniscrew implant-supported treatment of, 235–236, 236f anterior, and protrusion, 216–217, 216f, 217t control of vertical dimension, 154, 154f–155f and impaired masticatory function, 236–237, 237f, 237t and poor smile, 206 treatment progress, 206, 207f treatment results, 206 severe, with difficulty in lip closure, 237–238, 238f Operator, miniscrew implants and, 282 Oral hygiene, miniscrew implants and, 264, 284 Ortho Anchor System, 244–245 Orthodontic anchorage implants for, 104–105 orthodontic miniplates for, 78, 78f reinforcement, miniscrew implants for, 64 success rates, risk factors and complications of, 252–257 using locking plate and self-drilling miniscrew implants, for posterior maxilla, 55–57 advantages of, 55 indications of, 55 insertion technique, 55, 55f–56f Orthodontic appliances acting as substitutes for elastics, 11 with a double flexible distalization force system positioned both palatally and buccally, 14 with a flexible distalization force system buccally positioned, 13–14 palatally positioned, 11–13 with a rigid distalization force system palatally positioned, 14–15 Orthodontic bone anchors (OBAs), C-type, 239–240, 240f Orthodontic forces after miniplate placement, 252 miniscrew implants and loading of, 270 magnitude of, 270 Orthodontic implants for correction of class II malocclusion, 104–108 dimensions of, 104f inserted in the palate, 74, 74f insertion of, 74–77 bone quantity and localization of, 76 preoperative diagnostics of, 74–76 surgical, in palate, 76–77, 76f removal of, 77, 77f Orthodontic loading, miniscrew implants and, 63 Orthodontic Mini Implant, 58 Orthodontic miniplates insertion of, 78–82 on apertura piriformis, 80, 80f–81f on retromolar (angulus) area, 81–82 for symphyseal anchorage, 80–81 for zygomatic anchorage, 78–80, 79f removal of, 82, 82f types of, 78 Orthodontic miniscrew implants biomaterial properties of, 34–38 design principles of, 34, 34f electrochemical properties of, 37–38, 38f materials in, 34–35, 35f, 35t structure and mechanical properties of, 39–47 surface characterization of, 35–37, 35t, 36f–37f, 37t Orthodontic-prosthetic implant anchorage, 48 Orthodontic tooth movement, type of, miniscrew implants and, 271 Orthodontics significance of anchorage in, 22–28 use of implants as skeletal anchorage in, 48–54 Orthopedic anchorage, 48 Orthosystem implants, 22, 22f, 49–51 design of, 50, 50f impression procedure and construction of suprastructure, 51, 51f insertion site and surgical procedures of, 50–51, 50f–51f Osseointegrated anchorage systems, 22, 23f vs non-osseointegrated systems, 23 Osseointegrated implants, 58, 59f Osseointegrated palatal implants, 230 Osseointegrated palatal onplants, 230 Osseointegrated titanium implants, 279 Osseointegration in bone response following insertion of miniscrew implant, 276, 276f of orthodontic miniscrew implants, 35 in palatal implants, 109 principles of, 29–30 for skeletal anchorage purposes, 58–60, 59f Osteoblasts, 31, 31f Osteoclasts, 31, 31f Osteodentin, 275 Osteogenesis, distance and contact, 30–31 Osteon, secondary, evolution and completion of, 31f Overbite, deep and gingival display, 208–209, 209f treatment of, 207–208, 208f P Pain complications of miniplate placement, 255 miniscrew implant treatment and, 72 Palatal appliances, Palatal arch, preactivation of, in skeletal Pendulum-K appliance, 184, 184f Palatal bone, for orthodontic implants, 230 Palatal coil spring systems, 105 Palatal implants, 48, 49f, 74f connection to, 109–110, 109f–110f indications for, in class II malocclusion treatment, 52–53 in maxillary molar distalization, 231f with GISP, 127 molar distalization with, 230–231 results of, 231 treatment progress of, 230 with Pendulum appliances advantages of, 107–108 Straumann Orthosystem as, in class II malocclusion, 109 Palatal miniscrew implant, pendulum springs with, 134, 134f Palatal mucosa, cylinders perforating, 124, 124f Palate, orthodontic implants inserted in, 74, 74f Palatine neurovascular bundle, 91 Panoramic radiograph, of miniplate insertion, 247f Patient’s age, risk factor of miniplates, 254 Paul Gjessing (PG) springs, 113, 113f Pendex appliance, 11f Pendulum appliances, 11–12, 11f, 105 bone-anchored, 186–188, 186f case presentation in, 186–187, 187f clinical application of, 186–187 comprehensive treatment outcomes, 188 removal of, 186 vs conventional Pendulum appliance, 187t palatal implants with advantages of, 107–108 www.ajlobby.com Pendulum B appliance, 174–177 case example of, 175, 176f clinical application of, 174–175 discussion, 175–177 Pendulum springs of Mainz implant pendulum unwanted effects of, 105 with palatal miniscrew implant, 134, 134f of Quad Pendulum, 105 Penguin Pendulum appliance, 11f Peri-implant bone, ultrastructural analysis of, 30 Peri-implant soft tissues, inflammation of, miniscrew implants and, 271 Peri-implantitis, 284f Periapical radiography, miniscrew implant insertion, using Kim’s stent, 99f Pericytes, 31 Periodontal ligament, 274 Periodontal/temporomandibular joint problems, miniscrew implants and, 264 Physical/dental statuses, miniscrew implants and, 264 Pilot drilling, 83 Pilot hole, dimension of, miniscrew implants and, 268–269 Piston appliance (Greenfield Molar Distalizer), 14 Plaster cast, of dental arch, 101 Plateau root-shaped (PRS) implants, 29, 30f Platform, of miniscrew implant, 41–42, 42f Plunger, 249 Poor smile, open bite and, 206 treatment progress, 206, 207f treatment results, 206 Positioning gauge, in Kim’s stent, 97 fabrication of, 98, 98f Positioning guides, for radiological evaluation of miniscrew implant insertion sites, 95–96 Posterior-based mucoperiosteal flap, 118, 119f Posterior maxilla, orthodontic anchorage using locking plate and self-drilling miniscrew implants for, 55–57, 57f Posterior teeth, distalization of, 139–141 Power module, in TopJet distalizer, 178, 178f Predrilling, use of, for miniscrew implants, 68 Prefabricated distalizers, 181–182 Preferences, for miniscrew implant treatment, 72, 73f Premolars extraction of, retraction of, 148–150, 149f with MGBM system without extractions, 151f Pretapped miniscrew implants, 43 Protrusion, of maxillary anterior teeth, 217, 217t, 218f extraction treatment for, 220–222, 221f, 222t non-extraction treatment for, 220–222, 220f, 220t Pure orthodontic implant anchorage, 48 Push rod hook, 245–246 Q Quattro screw, 196–197 R Radiography lateral cephalometric, in orthodontic implants insertion and removal, 74, 75f periapical, miniscrew implant insertion, using Kim’s stent, 99f Ratchets, 83 Retentive plate, 245 292 Index Retraction of anterior segment, in degenerated dentition, 143–144, 144f forces, balancing of, against posterior unit, of incisors, 150–151, 150f of maxillary incisors, 152, 153f of premolars and canines, 148–150, 149f Retroclination, of incisors, 231 Retromolar (angulus) area, miniplates on, 81–82, 82f Retrusion force vector, zygoma anchors and, 114 Reverse smile line, 206 Rigid distalization force system, palatally positioned, appliances with, 14–15 Rigid intermaxillary appliances, 6–9 Ritto appliance, 8, 8f Roots damage of, 255 healing of, 275 healing versus non-healing, 275, 276f pulp damage and response, 275, 276f impingement of, 252 injuries of, miniscrew implants and, 282, 282f proximity of, 253 resorption of, after contact with miniscrew implants, 274, 275f response of, with miniscrew implants, 274–275 uprighting of, 121–122 Root contact associated with MI failures, 270 with miniscrew implants, 274, 275f extent of damage/prevention methods in, 274 risk factors of, 274 Roth multibracket system, 233 Round Australian wire, molar distalization biomechanics, 120 Round tripping, of incisors, 120 S Sabbagh Universal Spring appliance, 10, 10f Sagittal skeletal relationships, miniscrew implants and, 263 Sandblasted and/or acid-etched implants, 31 Schneiderian membrane, 278 Screw root-shaped (SRS) implants, 30f stress distribution of, 32 studies of, 29, 29f Screw-to-root contact, risk factor of miniplates, 253 Screwdrivers, for miniscrew implants insertion, 83, 83f Screws, primary stability of, lack of, 253 Sectional Jig assembly, 13–14, 14f Segmental distalization, using miniscrew implants, 213 Segmented arch mechanics, for class II malocclusion treatment, Self-drilling miniscrew implants advantage of, 61 orthodontic anchorage using, for posterior maxilla, 55–57, 55f–57f Self-ligating Miniscrew, 155f Self-tapping miniscrew implants, 43, 44f, 61 Sequential distalization, 189 Shaft shape, of miniscrew implants, 44–45 Shank, of miniscrew implant, 39, 40f Short face height, improving smile line accompanying, 204–206 treatment progress, 204–206, 204t, 205f–206f treatment results, 206 Side of placement, miniscrew implants and, 269 Silicon impression, 109 Simultaneous maxillary molar distalization system (SUMODIS), 147–148, 148f Single slot, head design of miniscrew implants, 60t Sinus perforation, 255 Skeletal anchorage, 22, 112 historical development of, 58 implants as, 48–54 in lingual orthodontic treatment with sliding mechanics, 219–222 case examples, 220–222 clinical application of, 219–220 temporary, miniscrew implants for, 58–65 Skeletal anchorage devices, risk management of, 281–285 Skeletal Anchorage System, 244–245 Skeletal Frog Appliance, 183 see also Skeletal Pendulum-K appliance Skeletal Pendulum-K appliance, 183–185 case example for, 184, 185f clinical application of, 183–184, 184f abutments, choosing of, 183 alginate impression, taking of, 183 intraoral mounting of, 184 laboratory fabrication procedure, 183–184 miniscrew implants, 183 preactivating palatal arch, 184, 184f clinical considerations for, 184 components of, 183f Sleeve positioner, 101, 102f Sliding mechanics, for treatment of class II malocclusion, 219, 219t Smile, habitual asymmetric, 209–210, 210f Smile line accompanying short face height, 204–206 treatment progress, 204–206, 204t, 205f–206f treatment results, 206 altering of, with miniscrew implant-supported biomechanics, 204–210 deviated, improving, 209–210 Smoking, miniscrew implants and, 263 Soft tissues correction, with zygoma anchors, 115 inflammation of, risk factor of miniplates, 253–254 for miniscrew implant insertion, 85 miniscrew implants and, 269–270 preparation, for miniscrew implant insertion, 83 punch, 72, 73f Space, in miniscrew implant insertion, 90–91, 91f Spider Screw anchorage system, 147–155 brackets used for bidimensional technique in, 147t control of vertical dimension, 152–155 deep bite, 154–155 open bite, 154, 154f–155f Spider Screw K1, 147f Spider Screw miniscrew implants, 23f, 34f, 35t, 36f–37f, 37t Splint, vacuum formed, 95 clinical application of, 95, 96f SRS implants see Screw root-shaped (SRS) implants SS archwire, GISP with, 125 SS closed coil spring, molar distalization biomechanics, 120, 120f SS segmented wire, molar distalization biomechanics, 122 Stability, primary/secondary, of miniscrew implants, 283 Standard miniplates, 78, 78f Stenson’s duct orifice, 78–79 Straumann Orthosystem implants, 50f as palatal implant, in correction of class II malocclusion, 109–111, 109f Straumann Palatal Implant, 76 www.ajlobby.com Stress intensity, distribution of, in miniscrews, 68f Subperiosteal implants, 32 Surface modeling, 31 Swelling, complications of miniplates used for orthodontic anchorage, 254, 255f Symphyseal anchorage, orthodontic miniplates insertion for, 80–81, 81f–82f Symphyseal bone anchorage, class II correction with fixed functional devices using, 129–133 clinical presentations of, 130–132 discussion of, 132 Symphyseal miniplate anchorage, 116, 117f T Teeth, loss of, 278 Temporary anchorage devices, 32–33, 225 for class II malocclusion correction, 143–146 extraction treatment for alleviating anterior crowding, 145, 145f intermaxillary forces to advance the mandible as, 145–146, 146f molar distalization, 143, 144f retraction of anterior segment, 143–144, 144f miniscrew implants used as, 258–273 risk factors associated with failures, 261–271, 262f Twin Force Bite Corrector with, 249–251 Temporomandibular joint disorders, 211 TFBC see Twin Force Bite Corrector (TFBC) Thomas miniscrew implants, 35t Thread, of miniscrew implants design, 45, 46f, 265 diameter, 265 length, 265 pitch, 45, 45f shape, 265 surface, 265 Tissues irritation of, miniscrew implants and, 62–63 quality, quantity and age-related differences of, 88, 89f type of, miniscrew implant insertion and, 87 Titanium alloys miniplates, 129 in miniscrew implants, 58 Titanium miniplates, 78, 78f TMA spring, 125 TOMAS punch, 73f Tooth-anchoring system, 229–230 Tooth movements, 212 effect on esthetics, function and safety, 211t interference with, 256, 256f TopJet distalizer, 178–182 adjustment module of, 178 advantages of, 181–182 clinical application of, 179–181 distalization mechanics of, 178f distalizing force of, 178–179 insertion of, 179, 180f power module of, 178, 178f removal of, 180 TopJet 360, 179 transpalatal arch, 178–179 versions of, 179, 179f Torque magnitude, in miniscrew implant insertion, 83–84 TPAs see Transpalatal arches (TPAs) Trabecular bone, remodeling of, 31 Transgingival neck, of miniscrew implants, 60 Transpalatal arch plus hooks (TPA-PH) device, 189–190, 191f Index 293 Transpalatal arches (TPAs), 52, 52f, 247f connected to palatal implants, 109–110, 110f in conventional anchorage, 23–24, 24f insertion of, in TopJet distalizer, 179 intraosseous screw in conjunction with, 135, 135f mesially extended, with miniscrew implants, 135, 135f for molar rotation/distalization, 15 in TopJet distalizer, 178–179 Transpalatal bars, in conventional anchorage, 23–24, 24f Trepan bur, 77, 77f Tubing system, of AMDA, 160, 160f Tweed-Merrified approach, for class II malocclusion treatment, Twin Block, for class II malocclusion treatment, Twin Force Bite Corrector (TFBC), 10f, 11, 249 biomechanics, 249f–250f case example, 251f for Class II correction, 249–251 with miniscrew implant anchorage, 251f with temporary anchorage devices, 249–251 Two-screw miniplate, 253f Two-stage space closure, in class II malocclusion, U Unilateral distalization for correction of class II malocclusion, 110, 110f of maxillary molar, 163f, 164–166, 165f treatment, 164–166 TopJet distalizer for, 180–181, 181f Upper lips, position of, in Class II malocclusion, V Z Vacuum formed splint, 95 clinical application of, 95, 96f Vector-TAS miniscrew implants, 34f, 35t, 36f–37f, 37t Veltri Distalizer, 15 Verbal rating scale (VRS), miniscrew implant treatment and, 72 Vertical component of force vector, controlling, zygoma anchors with, 114–115, 114f Vertical depression, in gingiva, 101, 101f Vertical skeletal relationships, miniscrew implants and, 264 von Mises stresses, 68f W Wires for fabrication of Kim’s stent, 98 sequence for extraction treatment for protrusion of maxillary anterior teeth, 222t for non-extraction treatment for protrusion of maxillary anterior teeth, 220t Woven bone, 30 X X-ray pins, 94–95, 94f clinical application of, 95, 95f palatal use of, 95, 95f www.ajlobby.com Zygoma anchorage for en masse retraction, 113 miniplate, for class II malocclusion treatment, 112–114 Zygoma anchors, 113, 113f controlling vertical component of the force vector with, 114–115, 114f–115f orthopedic and soft tissue correction with, 115 Zygoma plates, 79–80, 112 Zygomatic anchorage molar distalization with, 231–232 orthodontic miniplates insertion and removal, 78–80, 79f Zygomatic crest miniscrew implant insertion in, 278f thickness, 278–279 Zygomatic miniplates, 231 maxillary molar distalization with, 231–232, 232f Zygomaticomaxillary buttress, 231 ... Publishing Services Inc., NYC www.ajlobby.com Skeletal Anchorage in Orthodontic Treatment of Class II Malocclusion Contemporary applications of orthodontic implants, miniscrew implants and miniplates... non-extraction treatment of Class II malocclusion with retraction of the maxillary teeth and forward www.ajlobby.com 4 SECTION I: INTRODUCTION TO ORTHODONTIC TREATMENT OF CLASS II MALOCCLUSION movement of. .. skeletal anchorage devices in orthodontics (Sections III and IV, respectively), the book continuous with sections devoted on the treatment of Class II malocclusion with the various skeletal anchorage