Professional Documents
Culture Documents
Orthodontic Miniscrew Implants Clinical Applications
Orthodontic Miniscrew Implants Clinical Applications
Orthodontic Miniscrew Implants Clinical Applications
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Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2009
An imprint of Elsevier Limited
ISBN: 978-0-7234-3402-3
Notice
Neither the Publisher nor the Authors assume any responsibility for any loss or
injury and/or damage to persons or property arising out of or related to any use of
the material contained in this book. It is the responsibility of the treating practitioner,
relying on independent expertise and knowledge of the patient, to determine the best
treatment and method of application for the patient.
The Publisher
The idea of writing of this book began when we implant anchorage might have helped complete the
made a presentation at a meeting of the Southern treatment without the need for orthognathic surgery.
Californian Component of the Edward H Angle Society
of Orthodontists, of which two of the authors, Cheol- Skeletal Class II malocclusions with vertical excess
Ho Paik and In-Kwon Park, are members. Immediately are common in the Caucasian population, and such
after the meeting, we were offered an opportunity patients are often treated with orthognathic surgery
to publish a textbook on the orthodontic miniscrew involving maxillary impaction and autorotation of
implant. We would like to thank Dr Richard P the mandible. However, this aggressive procedure may
McLaughlin and Dr John C Bennett for encouraging us be substituted by intrusion of the maxillary dentition
in writing this textbook. using midpalatal miniscrew implant anchorage. This is
one of the reasons we have written this book in English.
Orthodontic movements that are considered difficult to Our work will be worthwhile if even a few patients are
accomplish with traditional methods can be achieved spared unnecessary orthognathic surgery with the help
with minimal patient cooperation by using miniscrew of the orthodontists who read this book.
implants. This book brings together our knowledge and
experience of using miniscrew implants in orthodontic In Asian populations, Class III malocclusions are more
practice. As practicing orthodontists, we have mainly common. However, many of these patients have mild
focused on the clinical applications of the miniscrew to moderate Class III malocclusion and orthognathic
implant, illustrated with cases treated at our clinic. surgery is not always an acceptable treatment option.
Details of basic research have been kept to a minimum, In such patients, miniscrew implants can be used very
as the book is designed to be an easy to read guide, effectively to retract the entire mandibular dentition. In
aimed at the orthodontist wishing to adopt miniscrew South Korea, most of the orthodontists use miniscrew
implant anchorage in their everyday practice. We have implants in daily clinical practice. This phenomenon
attempted to demonstrate how miniscrew implants can is unique, and it may have been triggered by the
be used to simplify orthodontic treatment. publication in 2001 of a textbook on the microscrew
implant in Korean by Dr Hyo-Sang Park.
We remember an impressive case presented by an
orthodontic resident more than 10 years ago. The We specially thank Dr Youn Sic Chun, Dr Jong-Suk Lee
patient, who presented with the complaint of mild and Dr Jong-Wan Kim, who shared their data with us,
crowding of his front teeth, had undergone bimaxillary and we appreciate the passion and commitment of Dr
surgery following a reassessment of his malocclusion Sungmin Kang, which helped complete the writing of
midway through his orthodontic treatment. This was this book in a short time.
required because with the orthodontic leveling of
the teeth his underlying mild vertical skeletal excess Cheol-Ho Paik
led to the development of an anterior open bite with
In-Kwon Park
asymmetry. If orthodontic miniscrew implants had
been available back then, a small amount of intrusion Youngjoo Woo
and retraction of the dentition using miniscrew Tae-Woo Kim
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m Korean norms and cephalometric abbreviations
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SNA Sella-nasion-point A
SNB Sella-nasion-point B
ANB Point A-nasion-point B
GoMe/SN Gonion-menton/sella-nasion
FMPA Frankfurt-mandibular plane
PP/MP Palatal plane/mandibular plane angle
ANS-Me (mm) Anterior nasal spine-menton
UI/SN Upper incisor/sella-nasion
LI/GoMe Lower incisor/gonion-menton
SN/OP Sella-nasion/occlusal plane
Is-Isʹ (mm) Upper anterior dentoalveolar height
(UI-NF*)
Mo-Ms (mm) Upper posterior dentoalveolar height
(U6-NF*)
Ii-Iiʹ (mm) Lower anterior dentoalveolar height
(LI-GoMe)
Mo-Mi (mm) Lower posterior dentoalveolar height
(L6-GoMe)
U Lip-E (mm) Upper lip-esthetic plane
L Lip-E (mm) Lower lip-esthetic plane
NLA Naso labial angle
*NF, nasal floor.
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Chapter &
Introduction
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' ORTHODONTIC MINISCREW IMPLANT
When Brånemark1 invented the first successful as the cost, need for extensive surgery, time required for
osseointegrated implant, he certainly would not have osseointegration, and limited availability of sufficient
envisaged how it would transform the practice of bone to act as an implant site. More recently, titanium
dentistry in the years to come. Such implants have miniplates have been shown to successfully intrude
significantly enhanced the scope and quality of dental posterior teeth in patients with skeletal open bite,5 but
treatment and to a lesser extent, this has included flap surgery for placement and removal is unavoidable.
orthodontic treatment. In spite of these disadvantages, osseointegrated
implants are proving to be an extremely useful adjunct
For a long time, orthodontists have struggled to achieve to conventional orthodontic treatment in a minority of
efficient control of anchorage. However, their efforts cases.
have only had partial success owing to Newton’s third
law of motion, which states that for each action there The miniscrew, which was originally designed to fix
is an equal and opposite reaction. A variety of extraoral bony segments, has shown great promise as a simpler
appliances have been designed to overcome this and more versatile solution for obtaining absolute
limitation, but these have their own problems, such as anchorage. Many authors have reported successful use
inadequate patient compliance. of miniscrews in a wide range of orthodontic tooth
movements.6–8 Miniscrews are used as temporary
Dissatisfaction with conventional methods of fixtures in bone and their greatest advantage lies in
anchorage led some pioneer orthodontists to explore their small size, which permits rapid and atraumatic
the use of implants as a source of absolute anchorage. placement in almost all sites within the mouth. In the
In 1990, a temporary retromolar implant was shown to past decade, there have been rapid advances in the
work as an absolute anchor to move molars mesially.2 development of miniscrews and they are increasingly
In 1995, the midpalatal onplant was proposed as used in orthodontics. It is the authors’ goal, and the
another means of providing absolute anchorage aim of this book, to popularize the use of the miniscrew
for tooth movement,3 and this has since become an implant among orthodontists and to reduce the need
accepted form of treatment mechanics.4 From the for orthognathic surgery in patients with mild or
orthodontic viewpoint these conventional endosseous moderate skeletal discrepancy.
implants and onplants have many disadvantages, such
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If this patient had presented in the era before the dental relapse and no realistic possibility of intruding
introduction of the miniscrew implant, the treatment the molars and therefore reducing the face height.
options would have been either the extensive and However, this patient was fortunate that her
invasive procedure of bimaxillary anterior subapical orthodontist offered non-surgical treatment using
osteotomy with simultaneous impaction of the miniscrew implants. The improvement in esthetics and
maxilla, or conventional orthodontic treatment with function following this treatment has remained stable
the probability of some degree of post-treatment for 3 years (Figs 1.6–1.10).
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This book shows how many of the difficult problems • Transverse and asymmetry control
encountered by orthodontists in everyday practice, • Other applications
such as a midline shift or a canted occlusal plane,
can be successfully treated with the use of miniscrew Dr Robert M Ricketts said, ‘Orthodontics is a profession
implant anchorage. For ease of description, the where one enhances the facial esthetics by using the
applications of the miniscrew have been categorized as dentition as a tool.’ This is even more valid in the
follows: twenty-first century when teeth can be moved much
more easily and in a more controlled fashion with
• Anteroposterior control miniscrew implants.
• Vertical control
+ ORTHODONTIC MINISCREW IMPLANT
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1. Brånemark P I, Adell R, Breine U et al 1969 Intra-osseous 5. Umemori M, Sugawara J, Mitani H et al 1999 Skeletal
anchorage of dental prostheses. I. Experimental studies. anchorage system for open-bite correction. American Journal
Scandinavian Journal of Plastic and Reconstructive Surgery of Orthodontics and Dentofacial Orthopedics 115:166–174
3:81–100 6. Kanomi R 1997 Mini-implant for orthodontic anchorage.
2. Roberts W E, Marshall K J, Mozsary P G 1990 Rigid Journal of Clinical Orthodontics 31:763–767
endosseous implant utilized as anchorage to protract molars 7. Costa A, Raffaini M, Melsen B 1998 Miniscrews as
and close an atrophic extraction site. Angle Orthodontist orthodontic anchorage: a preliminary report. International
2:135–152 Journal of Adult Orthodontics and Orthognathic Surgery
3. Block M S, Hoffman D R 1995 A new device for absolute 13:201–209
anchorage for orthodontics. American Journal of 8. Kyung S H, Hong S G, Park Y C 2003 Distalization of
Orthodontics and Dentofacial Orthopedics 107:251–258 maxillary molars with a midpalatal miniscrew. Journal of
4. Cousley R 2005 Critical aspects in the use of orthodontic Clinical Orthodontics 37:22–26
palatal implants. American Journal of Orthodontics and
Dentofacial Orthopedics 127:723–729
8=6EI:G'
Chapter '
A brief review of the use of
implants in orthodontics
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- ORTHODONTIC MINISCREW IMPLANT
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1. Gainsforth B L, Higley L B 1945 A study of orthodontic 16. Cousley R R J, Parberry D J 2005 Combined cephalometric
anchorage possibilities in basal bone. American Journal of and stent planning for palatal implants. Journal of
Orthodontics and Oral Surgery 31:406–416 Orthodontics 32:20–25
2. Brånemark P I, Adell R, Breine U et al 1969 Intra-osseous 17. Cousley R R J 2005 Critical aspects in the use of orthodontic
anchorage of dental prostheses. I. Experimental studies. palatal implants. American Journal of Orthodontics and
Scandinavian Journal of Plastic and Reconstructive Surgery Dentofacial Orthopedics 127:723–729
3:81–100 18. Wehrbein H, Merz B R, Diedrich P 1999 Palatal bone
3. Brånemark P I, Breine U, Hallen O et al 1970 Repair of support for orthodontic implant anchorage – a clinical and
defects in mandible. Scandinavian Journal of Plastic and radiological study. European Journal of Orthodontics 21:65–
Reconstructive Surgery 4:100–108 70
4. Brånemark P I, Hansson B O, Adell R et al 1977 19. Wehrbein H, Feifel H, Diedrich P 1999 Palatal implant
Osseointegrated implants in the treatment of the edentulous anchorage reinforcement of posterior teeth: A prospective
jaw. Experience from a 10-year period. Scandinavian Journal study. American Journal of Orthodontics and Dentofacial
of Plastic and Reconstructive Surgery Supplement 16:1–132 Orthopedics 116:678–686
5. Roberts W E, Smith R K, Zilberman Y et al 1984 Osseous 20. Block M S, Hoffman D R 1995 A new device for absolute
adaptation to continuous loading of rigid endosseous anchorage for orthodontics. American Journal of
implants. American Journal of Orthodontics 86:95–111 Orthodontics and Dentofacial Orthopedics 107:251–258
6. Roberts W E, Helm F R, Marshall K J et al 1989 Rigid 21. Lang J 1989 Clinical Anatomy of the Nose, Nasal Cavity and
endosseous implants for orthodontic and orthopedic Paranasal Sinuses. Thieme, New York, p. 103, cited in Kyung
anchorage. Angle Orthodontist 59:247–256 S H, Hong S G, Park Y C 2003 Distalization of maxillary
7. Roberts W E, Nelson C L, Goodacre C J 1994 Rigid implant molars with a midpalatal miniscrew. Journal of Clinical
anchorage to close a mandibular first molar extraction site. Orthodontics 37:22–26
Journal of Clinical Orthodontics 28:693–704 22. Paik C H, Woo Y J, Boyd R L 2003 Treatment of an adult
8. Turley P K, Kean C, Schur J et al 1988 Orthodontic force patient with vertical maxillary excess using miniscrew
application to titanium endosseous implants. Angle fixation. Journal of Clinical Orthodontics 37:423–428
Orthodontist 58:151–162 23. Kyung S H, Hong S G, Park Y C 2003 Distalization of
9. Turley P K, Shapiro P A, Moffett B C 1980 The loading of maxillary molars with a midpalatal miniscrew. Journal of
bioglass-coated aluminium oxide implants to produce sutural Clinical Orthodontics 37:22–26
expansion of the maxillary complex in the pigtail monkey 24. Kanomi R 1997 Mini-implant for orthodontic anchorage.
(Macaca nemestrina). Archives of Oral Biology 25:459–469 Journal of Clinical Orthodontics 31:763–767
10. Kokich V G 1996 Managing complex orthodontic problems: 25. Umemori M, Sugawara J, Mitani H et al 1999 Skeletal
the use of implants for anchorage. Seminars in Orthodontics anchorage system for open-bite correction. American Journal
2:153–160 of Orthodontics and Dentofacial Orthopedics 115:166–174
11. Creekmore T D, Eklund M K 1983 The possibility of skeletal 26. Park H S 2001 The Use of Micro-implant as Orthodontic
anchorage. Journal of Clinical Orthodontics 17:266–269 Anchorage. Narae Publishing, Seoul
12. Kokich V G, Shapiro P A, Oswald R et al 1985 Ankylosed 27. Park H S, Bae S M, Kyung H M et al 2001 Micro-implant
teeth as abutments for maxillary protraction: a case report. anchorage for treatment of skeletal Class I bialveolar
American Journal of Orthodontics 88:303–307 protrusion. Journal of Clinical Orthodontics 35:417–422
13. Celenza F, Hochman M N 2000 Absolute anchorage in 28. Park H 2003 Clinical study on success rate of microscrew
orthodontics: direct and indirect implant-assisted modalities. implants for orthodontic anchorage. Korea Journal of
Journal of Clinical Orthodontics 34:397–402 Orthodontics 33:151–156
14. Wehrbein H, Merz B R, Diedrich P et al 1996 The use of 29. Park H S, Kwon T G, Kwon O W 2004 Treatment of open bite
palatal implants for orthodontic anchorage. Design and with microscrew implant anchorage. American Journal of
clinical application of the orthosystem. Clinical Oral Implants Orthodontics and Dentofacial Orthopedics 126:627–636
Research 7:410–416 30. Sugawara J, Baik U B, Umemori M et al 2002 Treatment and
15. Tinsley D, O’Dwyer J J, Benson P E et al 2004 Orthodontic posttreatment dentoalveolar changes following intrusion of
palatal implants: clinical technique. Journal of Orthodontics mandibular molars with application of a skeletal anchorage
31:3–8 system (SAS) for open bite correction. International Journal
of Adult Orthodontics and Orthognathic Surgery 17:243–253
&' ORTHODONTIC MINISCREW IMPLANT
31. Park Y C, Lee S Y, Kim D H et al 2003 Intrusion of posterior 35. Chung K, Kim S H, Kook Y C 2005 Orthodontic microimplant
teeth using mini-screw implants. American Journal of for distalization of mandibular dentition in class I II
Orthodontics and Dentofacial Orthopedics 123:690–694 correction. Angle Orthodontist 75:119–128
32. Chang Y J, Lee H S, Chun Y S 2004 Microscrew anchorage 36. Cope J B 2005 Temporary anchorage devices in orthodontics:
for molar intrusion. Journal of Clinical Orthodontics 38:325– paradigm shift. Seminars in Orthodontics 11:3–9
330 37. Mah J, Bergstrand F 2005 Temporary anchorage devices: a
33. Dalstra M, Cattaneo P M, Melsen B 2004 Load transfer of status report. Journal of Clinical Orthodontics 39:132–136
miniscrews for orthodontic anchorage. Orthodontics 1:53–
62
34. Hong R K, Heo J M, Ha Y K 2004 Lever arm and mini-implant
system for anterior torque control during retraction in
lingual orthodontic treatment. Angle Orthodontist 75:129–
141
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Chapter (
Miniscrew implants:
concepts and controversies
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Another issue that has been debated is the timing of The forces acting on miniscrew implants for the
loading. The reader should note that waiting for a purpose of orthodontic anchorage are different from
short period to allow the oral soft tissue to heal after the forces that act on other dental implants. Dental
placement of the screw comes in the ‘immediate implants are subjected to intermittent occlusal forces
loading’ category. that vary in direction and magnitude. Often these
forces can be quite heavy. However, the forces applied
It has been reported that the micromotion following to the orthodontic miniscrew implant are mostly light,
early loading interferes with osseointegration.16,17 uniform and predictable.12 Studies evaluating the
In experiments on rabbit femurs, Roberts et al10 effect of different loads on osseointegrated implants
recommended a 6-week preloading healing period to have shown that static loads (constant loads with
allow sufficient mature bone to adhere directly to the uniform force levels) stimulate production of more
implant surface. Six weeks in rabbits is equivalent to dense cortical lamellar bone and greater amount of
4–5 months in humans. bone–implant contact at the interface than no load
or dynamic loads (cyclic loads with variable force
However, many clinicians have shown that the levels).23–25
miniscrew can be successfully loaded without having
to wait for several months. Creekmore and Eklund18 Bone usually adapts to its environment as long as it is
applied orthodontic force 10 days after insertion of the loaded within its physiologic range. Figure 3.2 shows
implant. Melsen and colleagues19 performed a histologic
Dynamic loading
evaluation of the bone–screw contact after 1, 3 and
6 months intervals prior to loading based on which Magnitude
Frequency
they advocated immediate loading. Melsen and Costa12
loaded 16 titanium vanadium screws with 25–50 g of
Peak strain history
force immediately after insertion; all but two screws
were successfully osseointegrated. Park1 stated that it is Microstrain
(10–6)
possible to apply orthodontic force once the soft tissues
have healed. Huja20 also recommended a short healing
Spontaneous
period of 1 week prior to loading with relatively light 0
~2500 fracture
loads (3–5 N [305–510 g]). It is considered important
>2
>40
<200
5
00
0
00
that a low initial loading force is used, less than 50 cN Atrophy
0
–
–25
40
0
R>F
0
200
Fatigue failure
screw can loosen as a result of application of strain that R>F
exceeds the amount that can cause microfractures in
the thin cortical bone.21,22
Maintenance
In all the cases presented in this book, the force was R=F Hypertrophy
R<F
applied 1 week after insertion of miniscrew, when the
soft tissue had healed. ;^\#(#' ;gdhi¼hbZX]VcdhiVi'+!',h]dl^c\i]ZZ[[ZXihd[YncVb^XadVY^c\
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Frost’s mechanostat model of bone modeling activity shows a sustained high rate of bone remodeling within
under loading.26,27 Strain is a dimensionless parameter, 1 mm of the implant surface. This bone remodeling is
defined as deformation per unit length. For example, considered to be responsible for the integration and
when a bone of 100 mm length is elongated by 3 mm maintenance of the implant in the bone.30 The rate
the associated strain is expressed as 3% strain, 0.03 of remodeling around an implant has been reported
strain, or 30 000 microstrain (με). When the bone is to be 30% per year, which is almost 10 times that
subjected to repetitive loading within the physiologic normally seen in adult human cortical bone (3%).29
range (200–2500 με), the bone mass remains constant As seen in Figure 3.1, the orthodontic miniscrew
and the bone’s structural integrity is maintained by implant seems to be at least partly osseointegrated
remodeling.28 It is assumed that the light, uniform and remains stable through active bone remodeling,
forces applied to miniscrew implants are within similar to the conventional endosseous implants used in
this range. Bone adjacent to an unloaded implant prosthodontics.
experiences strain of less than 200 με and may undergo
atrophy, whereas if the miniscrew is subjected to
intermittent, heavy occlusal loads greater than 2500 με
it may loosen because of bone hypertrophy or fatigue
failure (fracture).
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Primary stability of miniscrew implants comes from
mechanical interlocking with the cortical bone, so
the thickness and integrity of the cortical bone are
critical factors. Mostly monocortical anchorage is
used, although it is possible to use bicortical anchorage
(where the screw reaches the cortex on the far side
of the medullary bone) in partially edentulous areas
and extra-alveolar sites.20 Secondary stability of the
miniscrew implant relies mainly on bone remodeling
or turnover, which not only maintains the integrity of
the osseous support but also provides a continuous flow
of calcium necessary for bone metabolism. Remodeling
differs from bone modeling in that the latter refers to
the changes occurring in a bone’s external structure in
response to mechanical loading and/or trauma,28 that ;^\#(#( 9^\^iVagVY^db^Xgd\gVe]d[V&%%¥bi]^X`adc\^ijY^cVahZXi^dc
is changes the shape, size and/or position of the bone. d[VYZciVa^beaVcih]dl^c\WdcZgZbdYZa^c\#'.>cYZhXZcY^c\dgYZgd[
WdcZYZch^ini]ZXdadghVgZ/\daY!WajZ!gZYVcYnZaadl#I]^hbdge]dad\n^h
Xdch^hiZcil^i]V]^\]gViZd[WdcZgZbdYZa^c\l^i]^c&bbd[i]Z^beaVci
The duration of the remodeling cycle (sigma) in hjg[VXZ#GZegdYjXZYl^i]eZgb^hh^dc[gdbN^e<!HX]cZ^YZgE!GdWZgihL:
'%%)B^Xgd"XdbejiZYidbd\gVe]n/=^\]gZhdaji^dc^bV\^c\d[WdcZVcY
humans is about 4 months (17 weeks).29 Figure 3.3
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&- ORTHODONTIC MINISCREW IMPLANT
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1. Park H S 1999 The skeletal cortical anchorage using 14. Roberts W E, Helm F R, Marshall K J et al 1989 Rigid
titanium microscrew implants. Korean Journal of implants for orthodontic and orthopedic anchorage. Angle
Orthodontics 29:699–706 Orthodontist 59:247–256
2. Heidemann W, Terheyden H, Gerlach K L 2001 Analysis 15. Deguchi T, Takano-Yamamoto T, Kanomi R et al 2003 The
of the osseous/metal interface of drill free screws and self- use of small titanium screws for orthodontic anchorage.
tapping screws. Journal of Craniomaxillofacial Surgery Journal of Dental Research 82:377–381
29:69–74 16. Brunski J B 1988 Biomaterials and biomechanics in
3. Kim J W, Ahn S J, Chang Y I 2005 Histomorphometric and dental implant design. International Journal of Oral and
mechanical analyses of the drill-free screw as orthodontic Maxillofacial Implants 3:85–97
anchorage. American Journal of Orthodontics and 17. Pillar R M, Cameron H U, Welsh M B et al 1981 Radiographic
Dentofacial Orthopedics 128:190–194 and morphologic studies of load-bearing porous-surfaced
4. Lundström J 1972 Heat and bone tissue. An experimental structured implants. Clinical Orthopaedics and Related
investigation of the thermal properties of bone tissue and Research 156:249–257
threshold levels for thermal injury. Scandinavian Journal of 18. Creekmore T D, Eklund M K 1983 The possibility of skeletal
Plastic and Reconstructive Surgery (Supplement 9):71–80 anchorage. Journal of Clinical Orthodontics 17:266–269
5. Eriksson A, Albrektsson T 1984 The effect of heat on bone 19. Melsen B, Verna C 2005 Miniscrew implants: the Aarhus
regeneration: An experimental study in the rabbit using the anchorage system. Seminars in Orthodontics 11:24–31
bone growth chamber. Journal of Oral and Maxillofacial
20. Huja S S 2004 Biological parameters that determine the
Surgery 42:705–711
success of screws used in orthodontics to supplement
6. Ueda M, Matsuki M, Jacobsson M et al 1991 Relationship anchorage. Moyers Symposium, pp. 177–188
between insertion torque and removal torque analyzed
21. Melsen B 2005 Mini-implants: Where are we? Journal of
in fresh temporal bone. International Journal of Oral and
Clinical Orthodontics 39:539–547
Maxillofacial Implants 6:442–447
22. Frost H M 1992 Perspectives: bone’s mechanical usage
7. Brånemark P I, Adell R, Breine U 1969 Intra-osseous
windows. Bone and Mineral 19:257–271
anchorage of dental prostheses. Experimental studies.
Scandinavian Journal of Plastic and Reconstructive Surgery 23. Cope J B 2005 Temporary anchorage devices in orthodontics:
3:81–100 a paradigm shift. Seminars in Orthodontics 11:3–9
8. Lee S J, Chung K R 2001 The effect of early loading on the 24. Duyck J, Ronold H J, Van Oosterwyck H et al 2001 The
direct bone-to-implant surface contact of the orthodontic influence of static and dynamic loading on marginal bone
osseointegrated titanium implant. Korean Journal of reactions around osseointegrated implants: an animal
Orthodontics 31:173–185 experimental study. Clinical Oral Implants Research 12:207–
218
9. Albrektsson T, Brånemark P I, Hansson H A 1981
Osseointegrated titanium implants. Requirements for 25. Szmukler-Moncler S, Salama H, Reingewirtz Y et al 1998
ensuring a long-lasting direct bone-to-implant anchorage in Timing of loading and effect of micromotion on bone-dental
man. Acta Orthopaedica Scandinavica 52:155–170 implant interface: review of experimental literature. Journal
of Biomedical Materials Research 43:192–203
10. Roberts W E, Smith R K, Ziberman Y et al 1984 Osseous
adaptation to continuous loading of rigid endosseous 26. Frost H M 1987 Bone ‘mass’ and the ‘mechanostat’: A
implants. American Journal of Orthodontics 86:95–111 proposal. Anatomical Record 219:1–9
11. Gary J B, Steen M E, King G J et al 1983 Studies on the efficacy 27. Frost H M 1990 Skeletal structural adaptations to
of implants as orthodontic anchorage. American Journal of mechanical usage (SATMU): 1. Redefining Wolff’s law: the
Orthodontics 83:311–317 bone modeling problem. Anatomical Record 226:403–413
12. Melsen B, Costa A 2000 Immediate loading of implants 28. Roberts W E, Huja S, Roberts J A 2004 Bone modeling:
used for orthodontic anchorage. Clinical Orthodontics and Biomechanics, molecular mechanism, and clinical
Research 3:23–28 perspectives. Seminars in Orthodontics 10:123–161
13. Ohmae M, Saito S, Morohashi T et al 2001 A clinical and 29. Roberts W E, Marshall K J, Mozasary P G 1990 Rigid
histological evaluation of titanium mini-implants as anchors endosseous implant utilized as anchorage to protract molars
for orthodontic intrusion in the beagle dog. American and close an atrophic extraction site. Angle Orthodontist
Journal of Orthodontics and Dentofacial Orthopedics 2:135–152
119:489–497 30. Yip G, Schneider P, Roberts W E 2004 Micro-computed
tomography: High resolution imaging of bone and implants
in three dimensions. Seminars in Orthodontics 10:174–187
'% ORTHODONTIC MINISCREW IMPLANT
31. Kim J W, Cho I S, Lee S J et al 2006 Mechanical analysis of the 32. Kim J W, Cho I S, Lee S J et al 2006 Effect of dual pitch mini-
taper shape and length of orthodontic mini-implant for initial implant design and diameter of an orthodontic mini-implant
stability. Korean Journal of Orthodontics 36:55–62 on the insertion and removal torque. Korean Journal of
Orthodontics 36:270–278
8=6EI:G)
Chapter )
Terminology, design features
and armamentarium
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'' ORTHODONTIC MINISCREW IMPLANT
A screw is defined as a simple machine that changes Until miniscrew implants designed specifically for
rotational motion into translational motion while orthodontic use became available, the titanium
providing a mechanical advantage. The commonly used miniscrews used to fix bone plates in plastic and
screw has three parts: head, core and thread (helix) reconstructive surgery (Martin®: diameter 1.5/2.0 mm;
(Fig. 4.1). The thread is wrapped around the core. The OsteoMed®: diameter 1.2/1.6 mm) were also used in
orthodontics. Nowadays, many orthodontic companies
are producing miniscrews, and these are widely used.
In this book, the discussion on the structure and use of
miniscrews will mostly be in reference to the systems
Head the authors mainly use, that is, OSAS® (Osseodyne
Skeletal Anchorage System; Epoch Medical, Seoul,
Korea) and ORLUS® (Ortholution, Seoul, Korea).
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Dual head
Neck (collar)
Outer diameter
Core
Thread
Inner diameter (helix)
features to consider when selecting a miniscrew (Fig. drilling or drilled miniscrews. In the OsteoMed® bone
4.4). A few orthodontic miniscrew implants require screw system, which was more widely used in the past,
drilling, that is, preparing a small hole before insertion drilling was required for screws with a diameter of
(Fig. 4.5). Such miniscrews are referred to as pre- 1.2 mm, but not for screws with a diameter of 1.6 mm
or greater. Most of the current orthodontic miniscrew
implants are of the drill-free or self-drilling type (Fig.
4.6) and have a diameter of 1.6 mm. These drill-free
miniscrews have a specially formed cutting flute that
allows insertion without drilling. At the tip of the core,
there is a vertical groove that prevents clogging of bone
debris during insertion (Fig. 4.7).
IVWaZ)#' HdbZ[ZVijgZhd[dgi]dYdci^Xb^c^hXgZl^beaVcih
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Hand instruments comprise the basic armamentarium
required for the placement of orthodontic miniscrew
implants. The straight hand driver (Fig. 4.10, ORLUS®)
has two components, the handle and driver shaft,
which are sterilized separately and connected just ;^\#)#&& 6h]dgi]VcYYg^kZg!l^i]]VcYaZVcYYg^kZgi^e#
before the placement procedure. The short hand driver
(Fig. 4.11, ORLUS®) similarly has a handle and a driver
shaft that need to be assembled before use. This driver is
used for sites that are difficult to reach with the straight
hand driver, such as the midpalatal area. The surgical
8=6EI:G)
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kit (Fig. 4.12, OSAS®) consists of the instrument driver and force transmission is not as good as with
organizer with the hand drivers and miniscrews, and the motor handpiece. In the authors’ experience even
optionally, the connecting burs, which are used with a if the driver is held firmly with one hand, the shaft
handpiece. rotates with the handle when the bone is dense and
offers high resistance. Consequently, an undesirable
The contra-angle hand driver (torque driver) (Figs 4.13, lateral force is transmitted to the miniscrew. Another
4.14) may also be used for locations where access with factor to consider is the inherent defect in the design of
the straight hand driver is difficult, such as the palatal the mechanical grip, due to a minute ‘gap’ between the
area, retromolar pad and maxillary tuberosity. It looks miniscrew and the connecting bur. The gap causes the
similar to the motor-driven contra-angle handpiece, rotating miniscrew to ‘wobble’ during insertion.
but is manually driven. The driver itself is held with
one hand while the other hand rotates the wheel at the
rear end of the driver. The rotating force is transmitted Bdidg"Yg^kZcgdiVgn^chigjbZcih
to the connecting bur and then to the miniscrew.
However, manipulation is not as convenient as it was Motor-driven rotary instruments are used mainly
designed to be; it is less precise than the straight hand for sites that are less accessible, such as the palatal
alveolar and midpalatal areas, maxillary tuberosity
and retromolar pad area. Care must be taken to use
controlled, slow speed and to apply light pressure to the
bone when using these instruments, whether for pre-
drilling or inserting the miniscrew.
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'- ORTHODONTIC MINISCREW IMPLANT
The low-speed handpiece with contra-angle head A connecting bur (Fig. 4.18) is mounted on a
running at a reduced speed (1/128, 1/256 or handpiece with a mechanical or frictional grip to
1/1024 of the original speed) may be used with the connect the handpiece with the miniscrew. These burs
conventional motor attached to the dental unit. To come in two lengths (19 mm and 24 mm). Usually
achieve a speed less than 30–60 rpm for miniscrew the shorter connecting bur is used. The longer bur is
placement, a handpiece that reduces the original speed convenient when a midpalatal screw is placed in a deep
to less than 1/256 should be used. The connecting palatal vault.
bur is used to engage the miniscrew and is attached
to the handpiece by a mechanical or friction grip (Figs
4.16, 4.17). The friction grip is more stable than the
mechanical grip. As explained earlier, a mechanical
grip has some inherent play and causes the miniscrew
to wobble during the insertion procedure. The
handpiece has quite low torque and the motors stops
when high bone resistance is encountered during
insertion of the miniscrew. This is an advantage
because it prevents breakage of the miniscrew. It is less
expensive than the implant motor and is autoclavable.
;^\#)#&- 8dccZXi^c\Wjgh#
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;^\#)#&, 6adl"heZZY]VcYe^ZXZl^i]gZYjXZY"heZZY[g^Xi^dc\g^eCH@HE<
hZg^Zh!CV`Vc^h]^>cX!IdX]^\^!?VeVc#
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(% ORTHODONTIC MINISCREW IMPLANT
B^c^hXgZle^X`"je
When mounting a miniscrew on the tip of the shaft of
the hand driver (Figs 4.23, 4.24) or on the connecting
bur of a handpiece (Fig. 4.25–4.27), the core of the
miniscrew should not come in contact with anything
other than sterilized instruments. The miniscrew
should be picked up directly from the instrument
organizer tray, and the fit between the miniscrew head
and the shaft tip or connecting bur should be checked.
)#'*
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1. ASTM Index, 2004. 4. Heidemann W, Terheyden H, Gerlach K L 2001 Analysis
2. Mah J, Bergstrand F 2005 Temporary anchorage devices: a of the osseous/metal interface of drill free screws and self-
status report. Journal of Clinical Orthodontics 39:132–136 tapping screws. Journal of Craniomaxillofacial Surgery
29:69–74
3. Heidemann W, Gerlach K L, Grobe K H et al 1998 Drill free
screws: a new form of osteosynthesis screw. Journal of 5. Kim J W, Ahn S J, Chang Y I 2005 Histomorphometric and
Craniomaxillofacial Surgery 26:163–168 mechanical analyses of the drill-free screw as orthodontic
anchorage. American Journal of Orthodontics and
Dentofacial Orthopedics 128:190–194
8=6EI:G*
Chapter *
Anatomic considerations
and placement/removal of
orthodontic miniscrew
implants
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;^\#*#& EaVX^c\b^c^hXgZl^beaVcihV[iZgXdbeaZi^dcd[aZkZa^c\#
with Class III malocclusion with lower crowding. In Greater palatine neurovascular bundle
such cases, distal traction force is applied between the The greater palatine neurovascular bundle consists
molars and miniscrews (see Chapter 6, Case 6.4) placed of a nerve, artery and vein that enter the oral cavity
in the buccal alveolar bone or in the retromolar pad through the greater palatine foramen (Figs 5.2, 5.3),
area. The molars should be well aligned though and the
miniscrew should be placed with vertical orientation
to minimize root contact. Miniscrew anchorage can
also be used early in the treatment to apply a light
retraction force to a mesially angulated canine in an
extraction case. It is important to keep a check on
the root proximity of the miniscrew, as teeth are still
moving when a miniscrew is placed before alignment is
complete.
;^\#*#( I]Z\gZViZgeVaVi^cZcZjgdkVhXjaVgWjcYaZ^h[djcY^ci]ZXdgcZgd[
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(+ ORTHODONTIC MINISCREW IMPLANT
at the junction between the palatine process of the thick enough to place a miniscrew with a diameter of
maxillary bone and the oral surface of the palatine 1.6 mm and length of 5 mm.
bone. The two greater palatine foramina are typically
located medial to the third molars. The bluish color of However, miniscrew placement in the midpalatal
the vein and softer texture of the gingiva in this region suture area should be avoided in growing children. This
provide clues to the location of the neurovascular is because ossification of the suture is incomplete before
bundle in the corner of the palatal vault. the age of 23 years.5 In patients younger than 20 years
the paramedian area of the palate is a more favorable
The greater palatine neurovascular bundle must be site for miniscrew placement rather than along the
taken into consideration when inserting a palatal suture. As the bone thickness in this region is limited
alveolar miniscrew. The average distances of each the nasal cavity may be perforated if the miniscrew
component of the bundle from the midpoint between used is too long. Bone in the area 1 mm lateral to the
the cementoenamel junctions of two adjacent midpalatal suture line is thickest in the posterior palate.
maxillary posterior teeth are:2 However, not all patients have bone height greater than
4 mm. The palatal bone thickness decreases laterally,
• artery – 12.7 mm (between the first and second so the paramedian miniscrew should be placed quite
premolars); 11.8 mm (between the second premolar close to the midpalatal suture, and it should be shorter
and first molar); and 13.4 mm (between the first in length to avoid perforating the nasal cavity and
and second molars) compromising stability.6
• nerve – 15 mm (between the first and second
premolars); 14 mm (between the second premolar
Maxillary sinus
and first molar); and 15 mm (between the first and
The stability of a buccal alveolar miniscrew is
second molars).
compromised when the floor of the maxillary sinus
extends inferiorly to the alveolar bone between
The nerve tends to be located more medial to the
the maxillary posterior teeth. Although minimal
artery and the vein lies between the nerve and the
complications have been reported following maxillary
artery.2 These distances are average values and placing
sinus perforation during orthodontic screw placement,7
palatal alveolar miniscrews within 10 mm from the
it may be wise to avoid this area in patients with
cementoenamel junction reduces the risk of damaging
marked pneumatization (Fig. 5.5).
the greater palatine neurovascular bundle.
Nasal cavity
The midpalatal suture, the region with the thickest
cortical bone in the palate, is one of the most suitable
sites for miniscrew placement in adults. There is no
critical anatomic structure to avoid in this area. The
vomer lies superior to the suture (Fig. 5.4). The nasal
crest is triangular in shape with a width of 5.4 mm at
its base and a height of 5.6 mm in the average adult,
which is sufficient for miniscrew placement.3 The nasal
crest between the anterior and posterior nasal spines
(ANS and PNS) has been reported to be at least 2 mm ;^\#*#) I]Zb^YeVaViVahjijgZ^hXdbedhZYd[i]^X`Xdgi^XVaWdcZ!VcYi]Z
thicker than it appears on a lateral cephalogram.4 kdbZg^h^cXdciVXil^i]^ihcVhVahjg[VXZ#GZegdYjXZYl^i]`^cYeZgb^hh^dc
d[9ZeVgibZcid[Dgi]dYdci^Xh!8daaZ\Zd[9Zci^hign!NdchZ^Jc^kZgh^in!
Therefore, in most patients, the bone in this region is HZdja!@dgZV#
8=6EI:G*
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^beaVcieaVXZbZci^ci]ZWjXXVaVakZdaVgWdcZ#
*#+ *#,
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(- ORTHODONTIC MINISCREW IMPLANT
7dcZfjVa^in I]ZB^hX]XaVhh^ÄXVi^dcd[WdcZYZch^in-
The stability of miniscrew implants depends on the
9&·9ZchZXdbeVXiWdcZ
quality and quantity of the cortical bone. In dense,
9'·9ZchZidi]^X`edgdjhXdbeVXiWdcZdci]Zdjih^YZ
thick cortical bone, adequate retention can be achieved
VcYXdVghZigVWZXjaVgWdcZdci]Z^ch^YZ
with lesser depth of penetration by the miniscrew.
9(·EdgdjhXdbeVXiVcYÄcZigVWZXjaVgWdcZ
However, the thickness and density of the bone varies
9)·;^cZigVWZXjaVgWdcZ
between different anatomic sites in the same patient
9*·>bbVijgZ!cdc"b^cZgVa^oZYWdcZ
and between patients.
10
9 E' BP
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The soft tissue thickness must also be taken into
account when determining the length of miniscrew
to be used. The soft tissue covering the palatal slopes
is thicker than that in the maxillary buccal alveolar
area.2,9 In the palate, soft tissue thickness is greater
between the first and second molars than between
the premolars and between the second premolar and
first molar. Soft tissue thickness increases gradually
from the cementoenamel junction toward the apical
;^\#*#&% I]Zb^YeVaViVagZ\^dc^hXdbedhZYd[YZchZXdgi^XVaWdcZl^i]
region.2,9
hj[ÄX^ZcikdajbZ[dgb^c^hXgZl^beaVcieaVXZbZci#
The midpalatal region has excellent soft tissue
stable enough to withstand orthodontic forces. When characteristics for miniscrew placement, as with bone
using a longer length miniscrew, it is unnecessary to quality. The thin, keratinized soft tissue in this area is
embed the threaded part of the miniscrew fully into the more favorable for miniscrew placement than the thick
retromolar bone. The threaded part is partly inserted soft tissue on the palatal slopes. Along the midpalatal
in the bone and in this way the miniscrew head is suture, the mucosa is thickest at the area 4 mm distal
sometimes accessible in the oral cavity (Figs 5.11, to the incisive papilla, and the rest of the posterior area
5.12). has a uniform soft tissue thickness of 1 mm.2,9
*#&& *#&'
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)% ORTHODONTIC MINISCREW IMPLANT
The retromolar pad is covered with thick keratinized patients with a shallow buccal vestibule or in areas
gingiva, and an incision is required before placement of with little attached gingiva. Another potentially
the miniscrew. The miniscrew head may be embedded uncomfortable situation is during space closure using
in the soft tissue (closed-pull method) or lie exposed in sliding mechanics. The elastomeric module, such as
the oral cavity (open-pull method; see next section for an elastic ligature, may impinge on the gingiva in
details). A miniscrew with a longer soft tissue interface the more prominent part of the arch (Fig. 5.14). This
or ‘neck’ is useful for this purpose (Fig. 5.13). happens more often when the miniscrew is inserted in
the more posterior part of the arch, between the first
and second molars than between the second premolar
EVi^ZciXdb[dgi and first molar. A ‘guidewire’ added on the archwire
Patients rarely complain of pain after routine by soldering or welding a long hook can cause the
miniscrew placement. The placement procedure arch to collapse lingually, and the occlusion may be
itself causes little or no discomfort. If there is any inadvertently affected with a tendency toward posterior
discomfort it typically lasts for a day or two at most. crossbite. (See Chapter 6 for clinical tips to avoid such
However, the protruding miniscrew head or the problems.) Such problems do not usually occur with
orthodontic attachments (e.g. elastic chain) on it palatal alveolar miniscrews; most patients tolerate the
can cause discomfort. Soft tissue irritation is noted in palatal miniscrew and appliances quite well.
;^\#*#&) 9jg^c\heVXZXadhjgZjh^c\ha^Y^c\bZX]Vc^Xh!i]ZZaVhidbZg^X
;^\#*#&( 6b^c^hXgZl^beaVcil^i]Vadc\cZX` bdYjaZhbVn^be^c\Zdci]Z\^c\^kV#
hd[ii^hhjZ^ciZg[VXZ#
8=6EI:G*
6cVidb^XXdch^YZgVi^dch!b^c^hXgZleaVXZbZciVcYgZbdkVa )&
As mentioned in the previous section, when using a A miniscrew may also be placed on the inferior surface
retromolar pad miniscrew, its head could be exposed of the ANS, for example, for intrusion of incisors (Fig.
in the oral cavity (open-pull method; Figs 5.11, 5.17). An orthodontic force module from the archwire
5.12). This method offers superior patient comfort to the miniscrew, such as a nickel-titanium coil spring,
than the closed-pull method, in which the miniscrew may impinge on the gingiva due to its convex contour.
is embedded in the soft tissue and a braided wire Use of a guidewire has been suggested, but this may
extension exits through the gingiva (Figs 5.15, 5.16). cause the incisors to incline more labially.
This often irritates the mucosa.
*#&* *#&+
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VciZg^dgcVhVahe^cZ#
)' ORTHODONTIC MINISCREW IMPLANT
B>C>H8G:L>BEA6CIEA68:B:CI6C9 B^c^hXgZleaVXZbZci/\ZcZgVaeg^cX^eaZh
G:BDK6A After the placement site is anesthetized, a sterile
miniscrew is inserted into the preparation site,
Once a decision has been made to use miniscrew observing the following principles of placement.
implants during orthodontic treatment, informed
consent should be obtained from the patient. A full There are two methods of insertion. The drill-free
explanation is given to the patient about the benefits method, in which the screw is placed directly into
and side effects of having miniscrews incorporated the cortical bone, is used routinely. In the pre-drilling
in the treatment procedure. A potential side effect is method, a hole is drilled prior to insertion of the screw.
loosening of the miniscrew. Mobility can be noted by When only bone screws were available, drill-free
the patient during brushing or by the orthodontist screws had a diameter greater than 1.5 mm. When
during the monthly checkup. Generally orthodontists using screws with 1.2 mm diameter, pre-drilling was
themselves can place drill-free miniscrews without done prior to placement of the screw.11,12 As explained
difficulty. However, the patient is referred to an oral in Chapter 4, drill-free miniscrews with a smaller
surgeon when it is planned to have miniscrews in the diameter of 1.2–1.4 mm with additional features for
retromolar area, which often requires a more invasive orthodontic use are now available on the market. These
procedure. It is important to describe the miniscrew have improved access to narrow inter-radicular bone.
location, possibly by marking on a study model, when Moreover, bone–screw contact with drill-free screws
referring the patient. has been shown to be superior to that with pre-drilled
screws.13 A recent study comparing drilled and drill-
free miniscrews (diameter 1.6 mm) found that the
HiZg^a^oVi^dcVcYegZeVgVi^dc[dgeaVXZbZci drill-free group showed less mobility and more bone-to-
egdXZYjgZ metal contact.14 In addition, the heat generated during
1. The patient is instructed to rinse with a drilling can compromise bone regeneration and thus
chlorhexidine solution. jeopardize implant stability.15
2. Wipe the patient’s mouth area with an oral
disinfectant. The authors use a disinfectant
with hypochlorous acid (30 ppm) as the active
substance. Chlorhexidine may also be used.
3. Place a sterile drape over the patient’s face to isolate
the field.
4. Wipe the recipient area with an oral disinfectant
(Fig. 5.18).
5. Apply a topical anesthetic gel.
6. Infiltrative anesthesia is given with 2% lidocaine
with epinephrine 1:50 000. Usually injection of a
quarter of a single 1.8 mL ampule is sufficient for
alveolar miniscrew placement. The small amount
of local anesthetic will probably not completely
anesthetize the periodontal ligaments so the patient
will feel discomfort if the miniscrew touches a
root. A buccal alveolar miniscrew requires buccal
anesthesia only, and the palatal alveolar miniscrew
requires palatal anesthesia only. ;^\#*#&- L^e^c\i]Zbdji]VcYbjXdhVl^i]VcdgVaY^h^c[ZXiVci#
8=6EI:G*
6cVidb^XXdch^YZgVi^dch!b^c^hXgZleaVXZbZciVcYgZbdkVa )(
With drill-free method, pilot drilling is sometimes retraction, it is easy to err, with the miniscrew placed
necessary in the bone area that is unusually dense, obliquely to the cortical surface of the bone and its
for example, in the mandibular alveolar bone and head tilted mesially. This not only has an adverse effect
retromolar pad area. Pilot drilling is different from on its stability but it also increases the risk of damaging
pre-drilling. For pilot drilling, a small round or fissure the root of the distal tooth. The electrical handpiece is
bur is used to make a dent in the cortical bone surface. more convenient to use in posterior areas in patients
This helps to secure initial penetration of the drill-free with a small mouth.
miniscrew into the bone. In contrast, in pre-drilling, a
bur that has smaller diameter than the miniscrew to be The buccal alveolar miniscrew is inserted into
inserted is used and drilled to a depth shorter than the the inter-radicular bone. As stated earlier, careful
thread length of that miniscrew. Drill depth is greater evaluation of the available space on a panoramic
with pre-drilling. or periapical radiograph is essential prior to the
placement procedure. Although the safest location
Hand instruments, such as a straight hand driver in terms of width of inter-radicular space is between
or short hand driver, and/or motor-driven rotary the second premolar and the first molar in the maxilla
instruments are used for miniscrew placement, and between the first molar and second molar in
depending on the accessibility of and bone density the mandible,1 interindividual variations in root
at the chosen site. The basic principle of placement convergence/divergence must be taken into account.
is that a speed of less than 30 rpm should be used at
all times to minimize bone damage. Saline irrigation Ideally the miniscrew should be placed in the attached
is not needed during the procedure unless the speed gingiva, which is more resistant to inflammation.
used exceeds the recommended value. However, if pilot However, the width of the attached gingiva is quite
drilling or pre-drilling is planned, simultaneous cooling narrow in many patients. Hence, it is not always
of the area with saline irrigation is mandatory. possible to place the miniscrew in the attached gingiva.
In such instances, the miniscrew must be placed in
the non-keratinized gingiva or at the border between
the attached and free gingiva. A vertical stab incision
is made prior to insertion of the screw to prevent the
6akZdaVgWdcZ loose soft tissue of the non-keratinized gingiva from
wrapping around the miniscrew. A #12 blade is used
BVm^aaVgnVcYbVcY^WjaVgWjXXVaVakZdaVg for this incision.
WdcZ
The buccal alveolar miniscrew is commonly used as Before and during the insertion procedure, the site and
anchorage for anteroposterior control during tooth direction of insertion should be checked using a mouth
movement – for example, in patients with severe mirror to avoid drilling into the neighbouring roots.
protrusion in whom maximum anchorage is required. The miniscrew should be located directly above the
Both the upper and the lower buccal alveolar areas are contact point of the two adjacent teeth, and it should
relatively undemanding sites for miniscrew placement be perpendicular to the alveolar bone in the occlusal
in terms of accessibility, and generally the hand driver view. Ideally the miniscrew is placed perpendicular
is advocated. The patient is told not to open the mouth to the bone surface. But this is not always advocated.
so wide, so that the corners of the mouth relaxed When viewed in the coronal plane, the miniscrew is
and lips can be retracted easily. Without sufficient lip inserted at an angle to the alveolar bone. When the
)) ORTHODONTIC MINISCREW IMPLANT
buccal alveolar bone volume is sufficient, the miniscrew digital radiograph is recommended for immediate
is placed at a more vertical orientation (Fig. 5.19). confirmation. Unless root–screw contact is negative,
Root contact is minimized. If there is a thin covering usually two views are taken with the x-ray cone
of alveolar bone, the miniscrew is placed closer to directed at different angles. For example, if the tip of the
perpendicular to the bone surface. Its mesiodistal miniscrew seems to overlap the root of the distal tooth
placement would be critical to avoid perforating the in the first radiograph, a second radiograph is taken
neighbouring tooth roots (Fig. 5.20). from a different angle, with the beam more distal (Fig.
5.21). One image with the tip of the miniscrew located
The patient is instructed to signal if they feel pain between the roots is enough to verify safe placement
during the procedure. Pain does not necessarily mean (Fig. 5.22).
the miniscrew has penetrated a root because the
periodontal ligament is not fully anesthetized and
retains some sensation. The operator should also pay EVaViVaVakZdaVgWdcZ
attention to their tactile sense, as the density of the A palatal alveolar miniscrew can be used as anchorage
tooth root is greater than that of the surrounding bone. during retraction of maxillary anterior teeth in patients
When in doubt take a check periapical radiograph after wearing a lingual orthodontic appliance and who need
about half of the miniscrew length has penetrated the maximum anchorage, or for intrusion of the upper
bone. molars. The inter-radicular distance is greater on the
palatal side than on the buccal side in the maxillary
After full length placement, a periapical radiograph arch, but the thicker soft tissue2 makes the palatal side
is taken to verify absence of root–screw contact. A a less favorable location. Soft tissue thickness is assessed
with a sharp instrument such as a probe. A #15 blade
is used and through the gingiva up to the bone surface.
A #12 blade, which is used for making a stab incision
in the buccal alveolar mucosa, is not recommended,
because it cuts into the thick palatal mucosa and causes
too much bleeding. Taking the soft tissue thickness into
consideration, a miniscrew with a longer neck may
be used (see Fig. 5.13). The motor-driven instrument
should be used, as access with a straight hand driver is
difficult. The miniscrew is placed between the palatal
roots.
;^\h*#'&!*#'' >c;^\jgZ*#'&i]Zb^c^hXgZlhZZbh
idWZ^be^c\^c\dci]Zgddid[i]ZhZXdcYbdaVg#
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)+ ORTHODONTIC MINISCREW IMPLANT
Maxillary buccal alveolar area – using a rotary Palatal alveolar bone – using a rotary instrument
instrument 1. Determine the site and mark the soft tissue at the
Rotary instruments may be used for placing miniscrews planned insertion site.
in the buccal alveolar bone especially in the area 2. Make a vertical incision through the gingiva to the
between the first and second molars. The procedure is bone surface using a #15 blade (Fig. 5.30).
basically the same as that with the hand instrument, 3. Mark on the surface of the cortical bone with an
except that the handpiece connected to the implant explorer. Check with mouth mirror.
motor or a contra-angle low-speed handpiece run 4. Insert the screw using a low-speed handpiece, with
at reduced speed is used to insert the miniscrew. A a light pressure, at a speed of less than 30 rpm (Fig.
connecting bur is required to mount the miniscrew on 5.31). The miniscrew is inserted perpendicular to
the handpiece. the bone surface, with the tip directed apical to the
head. No saline irrigation is required, unless the
1. Determine the site and mark the soft tissue at the speed exceeds the recommended rate.
planned location. 5. Finish and detach the handpiece from the inserted
2. Mount the miniscrew on the handpiece (Fig. 5.28). miniscrew (Fig. 5.32).
Secure the miniscrew at the insertion site and
Mandibular buccal alveolar area – using a hand
check the orientation of the miniscrew with the
driver
mouth mirror.
The procedure for placing a miniscrew in the
3. Drive the screw into the bone using a low-speed
mandibular buccal alveolar area is basically the same
handpiece, with light pressure at a speed of less
as that in the maxillary buccal alveolar area. However,
than 30 rpm (Fig. 5.29). No saline irrigation
a stab incision will be required if the miniscrew is
is required, unless the speed exceeds the
placed in the unattached gingiva (Fig. 5.33). The
recommended rate.
mandibular cortical bone tends to be more dense than
5. After placement detach the handpiece from the
the maxillary alveolar bone, i.e. greater torque may be
inserted miniscrew. This may not be easy because
necessary for miniscrew placement.
owing to the tight contact between the connecting
bur and the miniscrew head, and the confined
The step-by-step procedure of miniscrew placement
space at the back of the oral cavity. Detach the
in the mandibular buccal alveolar area is depicted in
connecting bur first from the handpiece and then
Figures 5.34–5.37.
the bur from the miniscrew.
*#'- *#'.
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;^\h*#(%·*#(' EaVX^c\i]Zb^c^hXgZl^ci]ZeVaViVaVakZdaVgVgZV#
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bVcY^WjaVgWjXXVaVakZdaVgVgZV#
*#)(
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VciZgdedhiZg^dgedh^i^dcd[i]Zb^c^hXgZl!jh^c\i]ZgVY^d\gVe]VhV
;^\#*#)& IV`^c\VgVY^d\gVe]l^i]@^b¼hhiZci^ceaVXZ#I]ZY^gZXi^dc\j^YZ gZ[ZgZcXZ#I]Zb^c^hXgZl^heaVXZY'·(bbdXXajhVaidi]Z]dg^odciVaVgb#
ZmiZcYheZgeZcY^XjaVgidi]ZdXXajhVahjg[VXZeVgVaaZaidi]Zm"gVnWZVb#I]Z CZmi!jh^c\Vbdji]b^ggdgidhZZi]ZdXXajhVahjg[VXZ!i]ZYg^kZgVm^h^h
edh^i^dc^c\\Vj\Zh]dlhi]Vii]ZgZ^hVWdji(bbd[^ciZg"gVY^XjaVgheVXZ# bVYZeVgVaaZaidi]ZY^gZXi^dc\j^YZWZ[dgZi]Zb^c^hXgZl^h^chZgiZY#
*% ORTHODONTIC MINISCREW IMPLANT
The shortest thread length miniscrew (5 mm) is Usually a motor-driven handpiece and short hand
adequate. Although the nasal crest is present on its driver are used in combination; the handpiece is used
dorsal aspect, the bone thickness is limited and cannot in the initial stage of insertion when a high torque, or
be accurately measured on a conventional radiograph. strong rotating force, is required. After more than half
A miniscrew that is too long could penetrate into the of the threaded part has been inserted into the bone,
nasal cavity. Since the midpalatal region is composed the short hand driver is used to drive in the rest of the
of hard, dense cortical bone, a miniscrew does not have miniscrew. The advantage of using the hand driver is
to be embedded too deeply in the bone for adequate the ability to have tactile sense during insertion. The
stability. subtle bone resistance can be detected and miniscrew
breakage due to too heavy a rotating force is prevented.
When selecting the connecting bur, the depth of the
palatal vault and the angle of placement need to be A torque driver (BIOMET 3i Florida, USA) is also
considered. A deep palatal vault requires a longer available, but the authors have not found it convenient
connecting bur (24 mm) to avoid collision of the to use. As explained in Chapter 3, its precision is
handpiece with the upper incisors during placement. inferior to the hand driver and its force transmission is
Regarding the direction of placement, the miniscrew inferior compared with the motor-driven handpiece.
should be inserted perpendicular to the roof of the Therefore the motor-driven handpiece and/or short
oral cavity. However, in deep palates, the miniscrew hand driver is recommended.
may have to be inserted slightly from posterior to
anterior direction in the sagittal plane (Fig. 5.44). The
miniscrew then may not be perpendicular to the palatal
roof, but this slight deviation is actually advantageous.
The length of the miniscrew engaged in the bone
is greater. This not only improves its retention by
increasing the contact between the screw and the bone
but also reduces the risk of perforation of the nasal
cavity. It is also often easier to engage an elastic module
on a miniscrew inserted in this way.
;^\#*#)) 9^gZXi^dcd[^chZgi^dcd[i]Zb^c^hXgZl^cVYZZeeVaViZhV\^iiVa
k^Zl#
8=6EI:G*
6cVidb^XXdch^YZgVi^dch!b^c^hXgZleaVXZbZciVcYgZbdkVa *&
*#)* *#)+
*#), *#)-
;^\h*#)*·*#). EaVX^c\Vb^c^hXgZl^ci]Zb^YeVaViVagZ\^dc#
*#).
*' ORTHODONTIC MINISCREW IMPLANT
*#*' *#*(
*#*) *#**
;^\h*#*'·*#** EaVX^c\Vb^c^hXgZl^ci]ZbVm^aaVgnijWZgdh^inVgZV#
*) ORTHODONTIC MINISCREW IMPLANT
GZbdk^c\VgZigdbdaVgb^c^hXgZl
Closed-pull retromolar miniscrews should be removed
by an oral surgeon. Open-pull retromolar miniscrew
can be removed by an orthodontist. Infection may
occur when the soft tissue is thick. Chlorhexidine
mouth rinse is prescribed to prevent inflammation.
*+ ORTHODONTIC MINISCREW IMPLANT
GZ[ZgZcXZh
1. Park H S 2002 An anatomical study using CT images for 11. Kyung H M, Park H S, Bae S M et al 2003 Development of
the implantation of micro-implants. Korean Journal of orthodontic micro-implants for intraoral anchorage. Journal
Orthodontics 32:435–441 of Clinical Orthodontics 37:321–328
2. Yun H S 2001 The thickness of the maxillary soft tissue 12. Kanomi R 1997 Mini-implant for orthodontic anchorage.
and cortical bone related with an orthodontic implantation Journal of Clinical Orthodontics 31:763–767
[master’s thesis]. Seoul, South Korea: Yonsei University 13. Heidemann W, Terheyden H, Gerlach K L 2001 Analysis
3. Lang J 1989 Clinical Anatomy of the Nose, Nasal Cavity and of the osseous/metal interface of drill free screws and self-
Paranasal Sinuses. Thieme, New York, p. 103 tapping screws. Journal of Craniomaxillofacial Surgery
4. Wehrbein H, Merz B R, Diedrich P 1999 Palatal bone 29:69–74
support for orthodontic implant anchorage – a clinical and 14. Kim J W, Ahn S J, Chang Y I 2005 Histomorphometric and
radiological study. European Journal of Orthodontics 21:65– mechanical analyses of the drill-free screw as orthodontic
70 anchorage. American Journal of Orthodontics and
5. Schlegel K A, Kinner F, Schlegel K D 2002 The anatomic basis Dentofacial Orthopedics 128:190–194
for palatal implants in orthodontics. International Journal of 15. Eriksson R A, Albrektsson T 1984 The effect of heat on bone
Adult Orthodontics and Orthognathic Surgery 17:133–139 regeneration: an experimental study in the rabbit using the
6. Kang S, Lee S J, Ahn S J et al 2007 Bone thickness of bone growth chamber. Journal of Oral and Maxillofacial
the palate for orthodontic mini-implant anchorage in Surgery 12:705–711
adults. American Journal of Orthodontics and Dentofacial 16. Lee J S, Kim D H, Park Y C 2004 The efficient use of
Orthopedics 131(4 Suppl):S74–81 midpalatal miniscrew implants. Angle Orthodontist 74:711–
7. Costa A, Raffainl M, Melsen B 1998 Miniscrews as 714
orthodontic anchorage: a preliminary report. International 17. Paik C H, Nagasaka S, Hirashita A 2006 Class III
Journal of Adult Orthodontics and Orthognathic Surgery nonextraction treatment with miniscrew anchorage. Journal
13:201–209 of Clinical Orthodontics 40:480–484
8. Misch C E Contemporary Implant Dentistry, second ed. 18. Umemori M, Sugawara J, Mitani H 1999 Skeletal anchorage
Mosby, St Louis, pp. 110–118 system for open-bite correction. American Journal of
9. Kim H J, Yun H S, Park H D et al. 2006 Soft-tissue and Orthodontics and Dentofacial Orthopedics 115:166–174
cortical-bone thickness at orthodontic implant sites. 19. Brunski J B 1988 Biomaterials and biomechanics in
American Journal of Orthodontics and Dentofacial dental implant design. International Journal of Oral and
Orthopedics 130:177–182 Maxillofacial Implants 3:85–97
10. Kim H J, Lee H Y, Chung I H 1997 Mandibular anatomy 20. Roberts W E, Smith R K, Zilberman Y 1984 Osseous
related to sagittal split ramus osteotomy in Koreans. Yonsei adaptation to continuous loading of rigid endosseous
Medical Journal 38:19–25 implants. American Journal of Orthodontics 86:95–111
8=6EI:G+
Chapter +
Miniscrew implant
anchorage for
anteroposterior tooth
movement
>cigdYjXi^dc +%
JhZd[b^c^hXgZl^beaVcih[dgVWhdajiZVcX]dgV\Z
l]ZcbZh^VabdkZbZcid[edhiZg^dgiZZi]^hcdi^cY^XViZY +%
86H:+#& BVm^bjbVcX]dgV\Z^cVeVi^Zcil^i]W^bVm^aaVgn
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l^i]VhnbbZig^XZmigVXi^dch ,(
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86H:+#) GZigVXi^dcd[i]ZjeeZgVcYadlZgYZci^i^dc^c
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86H:+#* GZigVXi^dcd[adlZgiZZi]^cVeVi^Zcil^i]
h`ZaZiVa8aVhh>>>bVadXXajh^dcl^i][VX^VaVhnbbZign &%(
B^c^hXgZl^beaVciVcX]dgV\Z[dgbdaVgY^hiVa^oVi^dc &&'
86H:+#+ GZigVXi^dcd[VciZg^dgiZZi]V[iZgbdaVg
Y^hiVa^oVi^dcl^i]i]ZeZcYjajbVeea^VcXZ^cVcVYjai
eVi^Zcil^i]8aVhh>>bVadXXajh^dc &&(
86H:+#, GZ^c[dgXZbZcid[edhiZg^dgVcX]dgV\ZV[iZgbdaVg
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d[jeeZgVgX]Y^hiVa^oVi^dc^cV\gdl^c\eVi^Zcil^i]V
8aVhh>>bVadXXajh^dc &''
B^c^hXgZl^beaVciVcX]dgV\Z[dgVciZg^dgbdkZbZci
d[edhiZg^dgiZZi] &'.
86H:+#. BZh^VabdkZbZcid[i]ZedhiZg^dgiZZi]^cV
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+% ORTHODONTIC MINISCREW IMPLANT
>CIGD9J8I>DC JH:D;B>C>H8G:L>BEA6CIH;DG
67HDAJI:6C8=DG6<:L=:CB:H>6A
Depending on the location of the miniscrew implant, BDK:B:CID;EDHI:G>DGI::I=>H
a tooth or a group of teeth can be moved in the CDI>C9>86I:9
anterior or posterior direction with the miniscrew
implant providing anchorage. This chapter describes
The term ‘anchorage’ in orthodontics is used to
four applications of miniscrew implant anchorage for
describe the resistance to tooth movement resulting
anteroposterior movement of teeth:
from reciprocal forces.1 Maximum anchorage refers
to the situation where, strictly speaking, no such
• Providing absolute anchorage when mesial
movement must occur if treatment goals are to be
movement of posterior teeth is not indicated
achieved. Anchorage can be quantified according to
• For distal movement of the maxillary or
the amount of movement of the posterior teeth desired
mandibular dentition or both
to close the residual extraction space.2 In that context,
• For molar distalization
these authors defined maximum anchorage as a
• For mesial movement of the posterior teeth
situation in which not more than 25% of the extraction
space must close by mesial movement of posterior
teeth.
CASE 6.1
BVm^bjbVcX]dgV\Z^cVeVi^Zcil^i]W^bVm^aaVgnegdigjh^dc
EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
ZmVb^cVi^dc
A 22-year-old Korean woman presented with asymmetric with the left side appearing longer. Her
bimaxillary protrusion. She had a convex profile with smile line was also asymmetric (Figs 6.1–6.4). She
severe lip protrusion and incompetence, and mentalis was a mouth breather. There was clicking in both
strain was noted on closure of the lips. The face was temporomandibular joints, but there was no pain.
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+' chapter 6 clinical case
;^\#+#&&
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Cephalometric analysis (Figs 6.12, 6.13; Table 6.1) lower lip was protrusive relative to the E (esthetic) line.
revealed skeletal Class I bimaxillary protrusion. Both The maxillo-mandibular planes angle and GoMn/SN
the upper and the lower incisors were proclined. The angle were increased.
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J+·C;
Bd·B^/AdlZgedhiZg^dgYZcidVakZdaVg]Z^\]i
A+·<dBZ
;^\#+#&(
+) chapter 6 clinical case
IgZVibZci
After extraction of the four first premolars, the ;^\#+#&)
upper and lower arches were bonded with .022/.028
preadjusted fixed appliances. A transpalatal arch was
fitted on the upper first molars. Following leveling and
aligning, .019/.025 stainless steel working archwires
were inserted in both arches.
B^c^hXgZl^beaVciVcX]dgV\ZVcYheVXZ
XadhjgZ ;^\#+#&*
When the treatment plan requires miniscrew the miniscrews on both sides to retract the mandibular
placement in the inter-radicular space, it is anterior teeth.
recommended to place the miniscrews after leveling
and aligning of the teeth is complete. This aids in At the same visit, the upper left miniscrew became
determining the best possible location for the miniscrew loose and was replaced with an OsteoMed® miniscrew
and avoids root damage during and after placement. (diameter 1.6 mm, length 6.0 mm). As the tieback
Depending on the initial alignment of the teeth, the ligature wire was impinging on the soft tissue it was
timing of miniscrew placement in the upper and covered with a plastic sleeve to reduce the gingival
lower arches may vary, and some anchorage loss is irritation (Fig. 6.20). When this patient was being
inevitable during this initial stage of treatment. This treated, only single head bone screws were available.
patient presented with loose brackets, particularly Soft tissue irritation was commonly seen around
the mandibular brackets, on several visits during the the screw when elastics or wires were attached to it.
initial phase, which resulted in a longer time than The longer the distance between the screw and point
usual before the stainless steel wires were inserted. As a of force application, the more likely it was that the
result, there was more anchorage loss than expected in traction devices would impinge on the soft tissues in
this phase of treatment. that area. Currently, orthodontic miniscrews with dual
heads (see Chapter 4) are available on the market and
At 8 months, two Martin® miniscrew implants their use can minimize this problem.
(diameter 1.6 mm, length 6.0 mm) were placed in the
lower arch, in the inter-radicular alveolar bone between For bodily retraction of the upper anterior teeth, the
the second premolar and first molar on both sides hooks on the upper archwire were extended gingivally
(Figs 6.18, 6.19). On the right side another periapical so that the traction force passed through the center of
view was taken with the cone of the x-ray machine resistance of the anterior teeth (Figs 6.21, 6.22). The
placed more distally and directed toward the mesial to total treatment time was 27 months. After bracket
verify that the tip of the miniscrew was not in contact removal, an upper palatal retainer and a lower lingual
with the neighboring root. Again active tiebacks were retainer were bonded and the patient was also given
placed between the hooks on the lower archwire and wraparound removable retainers.
;^\#+#&- ;^\#+#&.
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The lip protrusion was greatly reduced. Facial esthetics There was minimal root resorption (Fig. 6.33) despite
were satisfactory, and good dental occlusion was the significant amount of anterior tooth movement.
obtained (Figs 6.23–6.32).
;^\#+#'( ;^\#+#')
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+- chapter 6 clinical case
The cephalometric superimpositions show considerable by 1.5 mm and 2.0 mm, respectively. There was little
change in the position of the anterior teeth. The upper overlap between the pre- and post-treatment incisor
incisors were retracted by 10.0 mm with a 17.0° position in the superimposition. Considerable amount
reduction in labial inclination. The lower incisors were of alveolar bone remodeling was seen. The mentalis
retracted by 10.0 mm with a 16.0° reduction in labial strain on lip closure had disappeared. Vertically, there
inclination. The upper and lower molars moved forward were minimal changes (Figs 6.34–6.37; Table 6.2).
;^\#+#() ;^\#+#(*
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;^\#+#(,
,% chapter 6 clinical case
At a review visit 2 years 10 months into retention, a slight opening of the upper left extraction site because
there were no remarkable changes. The soft tissue of the patient had not been compliant with retainer wear
lower face appeared more natural. However, there was (Figs 6.38–6.48).8]VeiZg+6ciZgdedhiZg^dgiddi]bdkZ
;^\#+#(- ;^\#+#(.
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;^\#+#)-
,' chapter 6 clinical case
8a^c^XVai^eh
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Veea^XVi^dcd[ZaVhi^X[dgXZZVh^ZgVcYXVjhZaZhhhd[ii^hhjZ
Y^hXdb[dgiidi]ZeVi^Zci#I]ZX]V^c^hhigZiX]ZYWZilZZc
i]Zb^c^hXgZlVcYi]ZVgX]l^gZ]dd`;^\#+#).#
6aiZgcVi^kZan!V#%&'a^\VijgZl^gZXVcWZi^ZYVgdjcYi]Z
b^c^hXgZl]ZVY#I]Zl^gZ^hWgV^YZYVcYi]Z[gZZZcYWZci
^cidV]dd`;^\#+#*%#I]ZZaVhi^XX]V^c^hi]ZchigZiX]ZY
WZilZZci]ZVgX]l^gZ]dd`VcYi]ZWgV^YZYhiZZaa^\VijgZ
]dd`#I]Zb^c^hXgZl^beaVciYdZhcdicZZYidWZ]VcYaZY
ZVX]i^bZX]V^c^hgZeaVXZY#
EaVX^c\VcVXi^kZi^ZWVX`Y^gZXiandci]Zb^c^hXgZl
^beaVci^hnZiVcdi]Zgdei^dc;^\+#*&# ;^\#+#).
;^\#+#*% ;^\#+#*%W
;^\#+#*& ;^\#+#*&W
,(
CASE 6.2
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EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
ZmVb^cVi^dc
A 21-year-old Korean woman presented with the chief
complaint of lip protrusion. She had thick lips and
showed mentalis strain on lip closure (Figs 6.52–6.54).
Intraoral examination showed bilateral Class I molar The panoramic radiograph revealed a full complement
relationships. The upper dental midline was deviated to of teeth, and all four third molars were impacted. A
the left side and the lower dental midline was deviated periapical radiolucency was evident in relation to the
to the right side. The upper left arch form was distorted lower left second premolar tooth, which had been
because the left second premolar was blocked out treated endodontically (Fig. 6.60).
palatally (Figs 6.55–6.59).
;^\#+#*- ;^\#+#*.
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9:CI6A6C6ANH>H
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IgZVibZcidW_ZXi^kZhVcYeaVc B^c^hXgZl^beaVciVcX]dgV\ZVcY[jgi]Zg
igZVibZci
The treatment objective was to reduce the
At 3 months, two Jaeil® miniscrew implants (diameter
dentoalveolar protrusion with extraction treatment.
1.4 mm, length 8.0 mm) were inserted between the
As the patient preferred to have the teeth with crowns
upper right second premolar and first molar and just
extracted, it was planned to extract the first premolars
mesial to the first molar on left side under infiltrative
on the right side and the second premolars on the left
local anesthesia. The archwires were progressively
side. Miniscrew implant anchorage was planned to
increased up to .019/.025 stainless steel working
compensate for the asymmetric extraction pattern,
archwires (Figs 6.62–6.64).
with the greater anchorage value on the left side to
achieve bilaterally symmetric anterior retraction.
As the upper anterior teeth were retracted, a Class III
relationship developed on the left side. An ORLUS®
miniscrew implant (diameter 1.6 mm, length 7.0 mm)
IgZVibZci was placed in the inter-radicular bone between the
lower left first and second molars 9 months into
After extraction of the four premolars, the upper and
treatment. Retraction of anterior teeth was continued
lower arches were bonded with .022/.028 preadjusted
with nickel-titanium coil springs (Figs 6.65–6.67). The
fixed appliances. A transpalatal arch was fitted on the
implants were stable throughout the treatment. The
upper first molars, and leveling and aligning of both
total active treatment time was 30 months.
arches initiated.
;^\#+#,) ;^\#+#,*
,- chapter 6 clinical case
Superimposition of the pre- and post-treatment inclination. The upper and lower lips were retrusive to
cephalometric tracings showed reduction of lip the E line. As the anterior teeth were retracted with the
protrusion and elimination of mentalis strain. The help of the miniscrew implants, minimal vertical change
upper incisors were retracted by 7.5 mm with a 13.0° was noted in the posterior teeth. The post-treatment
reduction in labial inclination. The lower incisors were panoramic radiograph showed slight amount of root
retracted by 8.5 mm with a 17.0° reduction in labial resorption throughout (Figs 6.76–6.79; Table 6.4).
;^\#+#,+
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-% chapter 6 clinical case
CASE 6.3
GZigVXi^dcd[i]ZjeeZgVcYadlZgYZci^i^dch^cVeVi^ZcijcYZg\d^c\cdc"
ZmigVXi^dcigZVibZci
EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
ZmVb^cVi^dc
An 18-year-old Korean woman presented with chief lip protrusion and mild mentalis strain on lip closure
complaint of protruded and prominent upper incisors. (Figs 6.80–6.83). Upper incisor display at lip repose was
Her face was symmetric with a convex profile and 5.0 mm.
relatively thick lips. There was a moderate amount of
;^\#+#-% ;^\#+#-&
;^\#+#-' ;^\#+#-(
-' chapter 6 clinical case
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9:CI6A6C6ANH>H
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IgZVibZci
A transpalatal arch was fitted on the upper molars Two months later, the rest of the upper teeth were
and interproximal stripping of the upper and lower six bonded and the archwire size progressively increased
anterior teeth was done. The upper central incisors and up to .019/.025 stainless steel (Fig. 6.95).
lower arch were bonded with .022/.028 preadjusted
fixed appliances. The upper central incisors were After a year of treatment, the patient complained that
intruded using a utility archwire during leveling and her lips were still protrusive. Her smile was slightly
aligning of the lower arch (Figs 6.92–6.94). A high- gummy and showed too much teeth, with no buccal
pull headgear was also worn. corridors (Figs 6.96–6.98).
;^\#+#.*
B^c^hXgZl^beaVciVcX]dgV\ZVcY[jgi]Zg
igZVibZci
Further treatment was planned with extraction of all
four third molars to facilitate distalization of the entire
maxillary and mandibular dentitions using miniscrew
implants as skeletal anchorage. Three miniscrews
(OsteoMed®; diameter 1.6 mm, length 6.0 mm) were
inserted under infiltrative anesthesia: one in the
midpalatal region, between the first and second molars
in the sagittal plane and the remaining two miniscrews
between the right and left mandibular second
premolars and first molars. A lateral cephalogram and
periapical radiographs were taken after placement of
the screws to verify their positions (Figs 6.99–6.101).
;^\#+#&%% ;^\#+#&%&
Edhi"igZVibZciZkVajVi^dc
There was an improvement in the patient’s profile. Lip relationships. Ideal overjet and overbite had been
protrusion was reduced, and although they were still established, with alignment of the upper and lower
mildly protrusive, the mentalis strain had disappeared. midlines (Figs 6.105–6.114).
The buccal corridors were visible during smiling. The
axial inclination of the upper and lower incisors was The post-treatment panoramic radiograph showed
improved, with bilateral Class I canine and molar uprighting of the posterior teeth as the teeth had
moved distally (Fig. 6.115).
;^\#+#&%* ;^\#+#&%+
;^\#+#&%, ;^\#+#&%-
-- chapter 6 clinical case
;^\#+#&&*
86H:+#( -.
Superimposition of the pre- and post-treatment lower molars moved distally by 1.8 mm and 0.8 mm,
cephalometric tracings showed distal movement of the respectively. The upper molars were intruded by 0.8 mm
entire upper and lower dentitions. The upper incisors as intrusive force had been applied in the upper arch.
were retracted by 5.0 mm with 5.5° reduction in In contrast, the lower molars were extruded by 0.8 mm
labial inclination. The lower incisors were retracted by and minimal change was noted in the lower anterior
3.0 mm and tipped lingually by 9.0°. The upper and facial height (Figs 6.116–6.118; Table 6.6).
IVWaZ+#+ EgZigZVibZciVcYedhi"igZVibZcih`ZaZiVa!YZciVaVcY
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;^\#+#&&, ;^\#+#&&-
.% chapter 6 clinical case
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b^YeVaViVab^c^hXgZl^beaVci#>ceVi^Zcihl^i]VYZZe
eVaViVakVjai!i]Za^cZd[i]ZgZigVXi^dc[dgXZeVhhZh
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d[i]ZbdaVgh;^\h+#&'.!+#&(%#>chjX]Vh^ijVi^dc!i]Z
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gZaVi^kZanh]VaadleVaViZVcYi]ZjeeZgYZci^i^dclVh
gZigVXiZYjh^c\b^YeVaViVab^c^hXgZlVcX]dgV\Z#
;^\#+#&(%
.'
CASE 6.4
GZigVXi^dcd[i]ZjeeZgVcYadlZgYZci^i^dc^cVeVi^Zcil^i]h`ZaZiVa8aVhh>>>
W^bVm^aaVgnegdigjh^dc
EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
ZmVb^cVi^dc
A 22-year-old Korean man presented with the chief mandibular deviation to right side. Occlusal canting
complaint of lip protrusion. He had thick lips, and was seen on smiling, and he had a lip biting habit (Figs
lip and mentalis strain was noted on lip closure. The 6.131–6.134).
frontal view showed the face was asymmetric with
;^\#+#&(& ;^\#+#&('
;^\#+#&(( ;^\#+#&()
86H:+#) .(
;^\#+#&)&
.) chapter 6 clinical case
Cephalometric analysis revealed a skeletal Class posteroanterior (PA) cephalogram revealed mandibular
III relationship with a prognathic mandible. The deviation to the right side, with asymmetry of the
upper incisors were proclined and lower incisors mandibular contour (Figs 6.142, 6.143; Table 6.7).
were well positioned relative to the apical base. The
IVWaZ+#, EgZigZVibZciYZciVaVcY[VX^Va
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The treatment objectives were to reduce the lip After a transpalatal arch and a lower lingual arch were
protrusion, and establish optimal overbite and Class I fitted, the patient was referred to an oral surgeon for
canine and molar relationships, with alignment of the extraction of all four third molars. At the following
dental midlines. visit, four miniscrews were placed. In the maxillary
arch two OSAS® miniscrews (diameter 1.6 mm, length
Two treatment plans were discussed with the patient. 8.0 mm) were placed in the alveolar bone between
The first plan involved combined orthodontic treatment the first and second molar palatal roots. The soft
and bimaxillary orthognathic surgery. The surgical tissue thickness was checked before selection of the
procedures would be a LeFort I osteotomy of the miniscrew length because the soft tissue in this area
maxilla to intrude the posterior teeth and a bilateral is quite thick. After giving infiltrative anesthesia, the
sagittal split osteotomy for mandibular setback with depth of the overlying mucosa was assessed with the tip
advancement genioplasty. The second plan involved of an explorer. A stab incision to the bone surface was
extraction of all four first premolars, followed by made to prevent the thick soft tissue from extending
retraction of anterior teeth with moderate anchorage into the bone, which can compromise miniscrew
to reduce dentoalveolar and lip protrusion. However, retention. A low-speed 256:1 contra-angle handpiece
the patient declined both treatment plans. was used to place the miniscrew. As the posterior teeth
have only one palatal root, the inter-radicular distance
A third plan was devised, involving extraction of all between the roots is sufficient and palatal root contact
four third molars with retraction of the upper and is not a major concern during implant placement.
lower dentitions with the help of miniscrew implant However, care should be taken not to perforate the
anchorage. A total of four miniscrews would be greater palatine vessels.
required, two in the palatal alveolar bone between the
upper first and second molars on both sides and the In the mandibular arch, two OSAS® miniscrews
other two in the buccal alveolar bone between the lower (diameter 1.6 mm, length 8.0 mm) were placed in the
first and second molars on both sides. A transpalatal buccal alveolar bone between the first and second
arch and a lower lingual arch would be fitted to stabilize molars. The alveolar bone in this area was bulbous in
the dentitions during the distal movement. The patient this patient and the miniscrews were placed with more
consented to undergo this treatment. vertical orientation, at an angulation of approximately
45° to the bone surface, thus reducing the possibility of
root contact. Nevertheless, root proximity was checked
on a panoramic radiograph prior to placement, and
periapical radiographs were taken after placement to
verify the absence of miniscrew–root contact.
.+ chapter 6 clinical case
In the following week, both arches were bonded with elastic chains between the hooks on the transpalatal
.022/.028 preadjusted fixed appliances and leveling arch and the miniscrews. In the mandible, active
and aligning started. As a transpalatal arch and a tiebacks were used between the archwire hooks and the
lingual arch had already been placed to stabilize the miniscrews (Figs 6.149–6.153).
dentitions, an elastic force of 150–200 g per side from
each implant was applied right away (Figs 6.144– After 7 months of retraction, a cephalogram was taken
6.148). to assess the amount of lingual alveolar bone available
for further incisor retraction (Fig. 6.154).
The archwires were progressively increased up to
.019/.025 stainless steel working archwires. A The total treatment time was 14 months.
retraction force was applied in the maxillary arch with
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Edhi"igZVibZciZkVajVi^dc
Dentoalveolar protrusion was reduced, thus decreasing remained and the labiomental sulcus was still shallow
the lip fullness. Mild lip protrusion and lip strain (Figs 6.155–6.158).
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Super Class I canine and molar relationships were were removed on the following visit. Uprighting of
established on the right side. On the left side, a 1.0 mm upper and lower molars was evident due to the distal
Class III relationship was seen. Ideal overjet and movement of the upper and lower dentitions against
overbite were established with alignment of the upper the miniscrew implant anchorage. Bone levels were
and lower dental midlines (Figs 6.159–6.164). maintained and minimal apical root resorption was
seen in the upper and lower incisors and molars.
A panoramic radiograph taken after appliance removal
shows the palatal miniscrews (Fig. 6.165). The screws
;^\#+#&+*
&%% chapter 6 clinical case
Superimposition of the pre- and post-treatment were retracted by 3.5 mm with 8.5° reduction in labial
cephalometric tracings showed lower lip retraction inclination. The lower teeth were slightly extruded (Figs
with no change in the vertical dimension. The upper 6.166–6.169; Table 6.8).
incisors were retracted by 3.0 mm. The lower incisors
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&%' chapter 6 clinical case
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+#&,'!+#&,(#
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idVeean[dgXZ;^\#+#&,)#@ZZe^cb^cY!]dlZkZg!i]ViVc
^cigjh^kZ[dgXZ^h\ZcZgViZYWZXVjhZi]Za^cZd[[dgXZ]Vh
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deZc"ejaabZi]dY[dgXdbeVg^hdc#
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CASE 6.5
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A 30-year-old Korean man presented with an edge- retrusion. His upper incisors were not visible in lip
to-edge bite. He had a concave profile with upper lip repose (Figs 6.176–6.178).
;^\#+#&-' ;^\#+#&-(
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cranial base. The upper and lower incisors were well The PA cephalogram showed the mandible deviated
positioned over the basal bone. The upper lip was to the left with an asymmetric mandibular border.
retrusive relative to the E line (Fig. 6.185; Table 6.9). The lower dental midline deviation was also seen (Fig.
6.186).
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&%+ chapter 6 clinical case
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&%- chapter 6 clinical case
Edhi"igZVibZciZkVajVi^dc
Lower lip protrusion reduced as the lower dentition had Uprighting of the molars was noted on the post-
been retracted. The dental midlines were aligned. Super treatment panoramic radiograph. The horizontal
Class I canine and molar relationships were attained alveolar bone level was maintained (Fig. 6.199).
on both sides. The crossbite was corrected (Figs 6.191–
6.198).
;^\#+#&., ;^\#+#&.-
;^\#+#&..
&&% chapter 6 clinical case
The pre- and post-treatment cephalometric 0.7 mm and 1.7 mm, respectively, was noted because
superimpositions show retraction of the lower teeth. the retraction force on the lower teeth was applied
The difference in the anteroposterior position of from retromolar miniscrews at the level of the gingiva.
the right and left molar teeth decreased following Minimal movement was seen in the upper teeth. A
treatment as the lower right molar, which had been slight increase in upper incisor proclination and slight
more anteriorly positioned initially, was retracted. The decrease in the facial height was noted (Figs 6.200–
lower incisors were retracted by 3.0 mm and retroclined 6.203; Table 6.10).
8.5°. Intrusion of the lower incisor and molars,
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&&' chapter 6 clinical case
CASE 6.6
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An 18-year-old Korean woman presented with lip
protrusion. There was minor upper and lower anterior 6ciZgdedhiZg^dg
crowding with bilateral Class I molar relationship (Figs HC6YZ\ ,-#%
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IgZVibZcieaVc IgZVibZci
The patient refused extraction treatment. Therefore, In the first phase of treatment, after 5 months of
molar distalization with the pendulum appliance was second molar distalization (Figs 6.206, 6.207), the
planned. appliance was removed. A Nance holding arch was
cemented to the upper second molars and bonded to
the first premolars while the first molars and second
premolars were retracted (Fig. 6.208).
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B^c^hXgZl^beaVciVcX]dgV\ZVcY[jgi]Zg was used for placement. Then the upper and lower
igZVibZci teeth were bonded with .022/.028 preadjusted fixed
appliances, and leveling and aligning was started
After the second premolars had been retracted, two (Figs 6.209–6.211). The anterior teeth and the first
Martin® miniscrews (diameter 1.6 mm, length 6.0 mm) premolars were retracted against the miniscrew
were placed in the buccal alveolar inter-radicular bone implants. Thus there was no anchorage strain on the
between the second premolars and first molars. Root second premolars and molars (Figs 6.212, 6.213)
proximity was checked on a panoramic radiograph during this second phase of treatment.
before placement. A manual screwdriver (hand driver)
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After bracket removal, superimposition of the pre- and reduced. The lower incisors were retracted by 2.0 mm.
post-treatment cephalometric tracings showed 2.5 mm There was some extrusion of the lower molars (Figs
distal movement of molars. The upper incisors were 6.214–6.218; Table 6.12).
retracted by 4.0 mm and their labial inclination was
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CASE 6.7
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ZmVb^cVi^dc inclinations. There was minor lower anterior crowding
(Figs 6.219–6.223; Table 6.13).
A 13-year-old Korean boy presented with the chief
complaint of a high left upper canine. The skeletal
pattern was Class I. The upper left canine was erupting IgZVibZcidW_ZXi^kZhVcYeaVc
buccally and was blocked out of the arch. The upper
dental midline was deviated to the left side and lower Non-extraction treatment with molar distalization
dental midline was correct. There was an anterior using the pendulum appliance was planned.
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CASE 6.8
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&') chapter 6 clinical case
In the following week, a palatal arch was cemented to engaged in the brackets and nickel-titanium open coil
the upper first premolars. The miniscrew implants were springs were placed to distalize the first molars (Figs
connected passively to this with steel ligature wires to 6.243–6.246). A panoramic radiograph was taken to
negate the reciprocal forces produced by the push coil check any miniscrew contact with second premolars
springs placed between the first premolars and first (Fig. 6.247). Molar distalization was continued and the
molars. Segmental .016/.022 stainless steel wires were second premolars drifted distally as well (Fig. 6.248).
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After 12 months, sufficient arch length was gained Another panoramic radiograph was taken (Fig 6.252).
with minimal change in the anterior dentition (Figs The second premolars were near the miniscrews and so
6.249–6.251). molar distalization was stopped.
;^\#+#')-
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The lingual arch was removed and a transpalatal arch, the miniscrew implant was replaced regularly to
with a hook soldered in the center to facilitate elastic continuously refresh the intrusive and retractive force
chain application, was fitted on the first molars. The on the molars (Fig. 6.258 ).
buccal alveolar miniscrew implants were removed
under topical anesthesia. Under infiltrative anesthesia,
another OSAS® miniscrew implant (diameter 1.6 mm,
length 6.0 mm) was placed in the midpalatal region Edhi"igZVibZciZkVajVi^dc
level with first molars anteroposteriorly. The upper
anterior teeth and all lower teeth were bonded with An ‘over-corrected’ Class I molar relationship was
.022/.028 preadjusted fixed appliances. Distal traction attained (Figs 6.259–6.263). Superimposition of
was applied between the transpalatal bar and the the pre- and post-treatment cephalometric tracings
miniscrew to prevent the molars from moving mesially. showed 2.5 mm bodily distal movement and 1.0 mm
The archwires were engaged in the canines from the intrusion of the upper molars. Eruption of lower
start of this phase (Figs 6.253–6.257). molars was seen. There was favorable downward and
forward mandibular growth during the treatment
Archwire size was progressively increased and the with proclination of the upper and lower incisors (Figs
chain between the transpalatal arch hook and 6.264–6.266; Table 6.16).
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Mesial movement of teeth is generally easier than distal traction using a facemask to apply a mesially directed
movement. However, mesial movement of posterior force.
teeth without reciprocal retraction of anterior teeth is
not so easy. There are several methods for reinforcing With miniscrew implants, such methods of anchorage
the anchorage unit – the anterior teeth. One way is to reinforcement are unnecessary. Treatment mechanics
incorporate as many teeth as possible in the anterior are simplified and the treatment is not dependent on
anchor unit. Other ways include applying lingual/ patient compliance.
palatal root torque to the incisor teeth and extraoral
&(%
CASE 6.9
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EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
ZmVb^cVi^dc
A 27-year-old Korean woman presented with the the left corner of her mouth was higher than the right.
chief complaint of lip protrusion and asymmetry. Her lips were protrusive and slight mentalis strain
On examination, her face was asymmetric with the was seen on lip closure (Figs 6.270–6.273). She had
mandible deviated to the left. Her lips were canted and clicking in both temporomandibular joints since the
past 7 years, but with no pain.
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Intraoral examination showed Class III canine and dental midline was centered within the face but the
molar relationships on the right side and Class I lower dental midline was 4.0 mm to the left. There
canine and molar relationships on the left side. She was minor upper and lower anterior crowding. Given
had no overjet and 1.0 mm overbite. The upper the morphology of the crowns of the upper molars,
laterals were in crossbite with the lower canines and congenital absence of the upper first molars was
there was a unilateral posterior crossbite on left side suspected (Figs 6.274–6.279).
as the mandible shifted to the same side. The upper
GVY^d\gVe]^XZkVajVi^dc IgZVibZcidW_ZXi^kZhVcYeaVc
The panoramic radiograph revealed a full complement The patient did not want to undergo surgical treatment.
of teeth apart from a missing molar in each quadrant Extraction of the upper second premolars was planned
(Fig. 6.280). Cephalometric analysis revealed a because the upper incisors had normal inclinations
skeletal Class I relationship. The upper incisors had and the lips were mildly protrusive. In the lower arch,
normal axial inclination and the lower incisors were asymmetric extraction – the right first premolar and
proclined. The lips were protrusive relative to the E line the left second premolar – was planned for retraction
(Fig. 6.281; Table 6.17). The PA cephalogram showed of the lower anterior teeth and midline correction. A
deviation of the mandible to the left with a canted transpalatal arch would be used to increase intermolar
maxilla (Fig. 6.282). width for correcting the posterior crossbite. The skeletal
asymmetry would be maintained.
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There was an improvement in the profile. Lip protrusion the lower anterior teeth. Mandible asymmetry was
was reduced and the mentalis strain had disappeared. still present, as the patient had been informed prior to
The chin appeared prominent due to retraction of treatment (Figs 6.294–6.297).
;^\#+#'.) ;^\#+#'.*
;^\#+#'.+ ;^\#+#'.,
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The lower midline was still off by 1.0 mm, but the upper The post-treatment panoramic radiograph showed
and lower axial inclinations had improved. Class I that bone level was maintained with slight apical root
canine and molar relationships were established on the resorption in the upper and lower incisors (Fig. 6.304).
right side, but a Class III molar relationship was seen on
the left side. The anterior crossbite and the left posterior
crossbite had been corrected (Figs 6.298–6.303).
;^\#+#(%)
&(- chapter 6 clinical case
Superimposition of the pre- and post-treatment upper molars had moved forward by 5.0 mm and the
cephalometric tracings showed retrusion of the upper lower incisors were retracted by 6.0 mm with 14.0°
and lower lips. The upper incisors were retracted by reduction in labial inclination. The lower molars moved
3.5 mm with 5.0° reduction in labial inclination. The forward by 1.0 mm (Figs 6.305–6.307; Table 6.18).
IVWaZ+#&- EgZigZVibZciVcYedhi"igZVibZcih`ZaZiVa!YZciVa
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;^\#+#(%+ ;^\#+#(%,
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&)' ORTHODONTIC MINISCREW IMPLANT
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1. Proffit W R, Fields H W 2000 The biologic basis of orthodontic 8. Kang S, Ahn S J, Lee S J 2007 Bone thickness of the palate
therapy. In: Proffit W R, Fields H W, eds. Contemporary for orthodontic mini-implant anchorage in adults. American
Orthodontics, 3rd ed. Mosby, St Louis, p. 308 Journal of Orthodontics and Dentofacial Orthopedics 131(4
2. Nanda R, Kuhlberg A 1997 Biomechanical basis of extraction Suppl):S74–81
space closure. In: Nanda R, ed. Biomechanics in Clinical 9. Kyung S H, Lim J K, Park Y C 2001 The use of miniscrew as
Orthodontics. W B Saunders, Philadelphia, pp. 156–159 an anchorage for the orthodontic tooth movement. Korean
3. Costa A, Raffaini M, Melsen B 1998 Miniscrews as Journal of Orthodontics 31:415–424
orthodontic anchorage: a preliminary report. International 10. Geiger S A, Pesch H J 1977 Animal experimental studies on
Journal of Adult Orthodontics and Orthognathic Surgery the healing around ceramic implantation in bone lesions
13:201–209 in the maxillary sinus region. Deutsche zahnärztliche
4. Wehrbein H, Merz B R, Diedrich P 1999 Palatal bone Zeitschrift 32:396–399
support for orthodontic implant anchorage – a clinical and 11. Branemark P I, Adell R, Albrektsson T et al 1984 An
radiological study. European Journal of Orthodontics 21:65– experimental and clinical study of osseointegrated implants
70 penetrating the nasal cavity and maxillary sinus. Journal of
5. Giancotti A, Greco M, Mampieri G et al 2004 Clinical Oral and Maxillofacial Surgery 42:497–506
management in extraction cases using palatal implant for 12. Sugawara J, Daimaruya T, Umemori M et al 2004 Distal
anchorage. Journal of Clinical Orthodontics 31:288–294 movement of mandibular molars in adult patients with the
6. Henriksen B, Bavitz B, Kelly B et al 2003 Evaluation of bone skeletal anchorage system. American Journal of Orthodontics
thickness in the anterior hard palate relative to midsagittal and Dentofacial Orthopedics 125:130–138
orthodontic implants. International Journal of Oral and 13. Paik C H, Nagasaka S, Hirashita A 2006 Class III
Maxillofacial Implants 8:578–581 nonextraction treatment with miniscrew anchorage. Journal
7. Kyung S H, Lim J K, Park Y C 2004 A study on the bone of Clinical Orthodontics 40:480–484
thickness of midpalatal suture area for miniscrew insertion.
Korean Journal of Orthodontics 34:63–70
8=6EI:G,
Chapter ,
Miniscrew implant
anchorage for intrusion of
teeth
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9Zh^\cd[i]ZVeea^VcXZ &)*
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i]ZjeeZgedhiZg^dgiZZi] &)*
>cigjh^dcd[i]ZZci^gZadlZgYZci^i^dcdgi]ZadlZg
edhiZg^dgiZZi] &).
>cigjh^dcd[i]ZjeeZgVciZg^dgiZZi] &).
>cigjh^dcd[i]ZadlZgVciZg^dgiZZi] &*%
Dei^bjb[dgXZaZkZah &*%
DXXajhVaVcY[VX^VaXdchZfjZcXZhd[dgi]dYdci^X^cigjh^dc &*%
B^c^hXgZl^beaVciVcX]dgV\Z[dg^cigjh^dcd[i]Z
Zci^gZYZci^i^dc &*&
86H:,#& >cigjh^dcd[i]ZbVm^aaVgnYZci^i^dc^cV
eVi^Zcil^i]kZgi^XVabVm^aaVgnZmXZhh &*'
B^c^hXgZl^beaVciVcX]dgV\Z[dg^cigjh^dcd[edhiZg^dgiZZi] &+'
86H:,#' Jc^aViZgVa^cigjh^dcVcYgZigVXi^dcd[edhiZg^dg
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VcYYZZedkZgW^iZ &+'
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^cVeVi^Zcil^i]8aVhh>VciZg^dgdeZcW^iZ &,*
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&)) ORTHODONTIC MINISCREW IMPLANT
9:H><CD;I=:6EEA>6C8:
The authors advocate two main appliance designs for
intrusion of posterior teeth with miniscrew anchorage:
>cigjh^dcd[i]ZZci^gZjeeZgYZci^i^dcdg ,#&
^cigjh^dcd[i]ZjeeZgedhiZg^dgiZZi]
For intrusion of the entire upper dentition (via intrusive
archwires) or intrusion of just the upper posterior
teeth, the anteroposterior position of the midpalatal
miniscrew implant is usually level with the first molars.
The transpalatal arch should lie approximately 5.0 mm
away from the palatal soft tissue to avoid soft tissue
contact as intrusive movement progresses. An elastic
chain is attached between hooks soldered to the arch
and the miniscrew to generate the intrusive force
(Figs 7.1–7.3). As the entire dentition is intruded, the
anterior facial height is reduced and the chin point
advances. ,#'
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&)+ ORTHODONTIC MINISCREW IMPLANT
The midpalatal miniscrew design is preferred for several In addition, full size rectangular archwires should
reasons: be placed to avoid distortion of the arch shape by
the intrusive forces. Another way to avoid tipping in
• Placement of the miniscrew is easier as there are no the upper arch is to insert additional buccal alveolar
critical anatomic structures to avoid in this area. miniscrews and apply intrusive force buccally and
• Midpalatal bone quality is excellent for miniscrew lingually at the same time (Fig. 7.6).
retention.
• The vertical location of the miniscrew in the buccal
inter-radicular bone is limited by the vestibular
depth and the width of the attached gingiva in
some patients.
• As the intrusive movement progresses, the distance
between the miniscrew and the archwire decreases
and the magnitude of intrusive force is difficult to
assess. With midpalatal miniscrews, an adequate
distance remains between the hook on the
palatal arch and the miniscrew for intrusive force ,#)
application. However, low-lying palatal arch design
has disadvantage of some tongue discomfort and
speech disturbance.
There are several ways of applying the intrusive force in head, which helps to hold the elastic chain in place
the upper arch: (Fig. 7.8).
• An elastomeric ring can also be used to secure the
• The simplest way is to attach an elastic chain from chain to the miniscrew head in some cases (Fig.
the miniscrew to hooks made with 0.8 mm brass 7.9).
wire which are soldered to the transpalatal arch • When there are no hooks on the transpalatal arch,
(Fig. 7.7). stops made of composite can be bonded to it on
• If the angulation between the two points of force either side. The elastic chain is first tied around the
application is increased in the vertical direction, transpalatal arch occlusal to the composite stop.
it can be difficult to secure the elastic chain to the Then the other end is hooked on to the miniscrew
miniscrew. As the chain is stretched, it slips off the (Fig. 7.10).
miniscrew. In such cases, a Kobayashi hook made • Patients with a low palatal vault may experience
with a ligature wire can be tied to the miniscrew discomfort as the miniscrew may irritate the
tongue. Covering the miniscrew head with
;^\#,#&& 6b^c^hXgZl]ZVYXdkZgZYl^i]Xdbedh^iZidegZkZciidc\jZ
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[gZZan^ci]Zbdji]#
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adlZgedhiZg^dgiZZi]
In the lower arch, miniscrews are inserted in the inter-
radicular bone between the first and second molars
for intrusion of the entire lower dentition or the lower
posterior teeth. A rectangular archwire is engaged in
the lower fixed appliance and a lingual arch is placed.
An elastic chain is tied between the archwire and
buccal alveolar miniscrews to apply intrusive force on
the lower teeth (Figs 7.14–7.16).
,#&)
>cigjh^dcd[i]ZjeeZgVciZg^dgiZZi]
For intrusion of upper anterior teeth, the miniscrew is
placed between the roots of the incisor teeth. A single
miniscrew can be placed between the central incisor
roots. In this design, since a single force is applied at the
center of the arch, a reverse smile line can be created
as the incisors are intruded. To reduce the likelihood
of this problem, two miniscrews can be placed instead,
one on either side of the arch, between the lateral
incisor and canine roots. The transverse distance
between the roots of the incisors increases toward
,#&*
the root apices. Therefore more apical placement of a
miniscrew will minimize the possibility of miniscrew–
root contact. When determining the vertical location of
the miniscrew, it must be kept in mind that the vertical
distance between the archwire and the miniscrew
will decrease as the anterior teeth are intruded. If the
miniscrew will be placed in the unattached gingiva, the
closed-pull method (see Chapter 5) should be used.
,#&+
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For intrusion of lower anterior teeth, the miniscrew 8DCH:FJ:C8:HD;DGI=D9DCI>8
is placed between the roots of the incisor teeth. The >CIGJH>DC
inter-radicular space is narrow between the lower
incisors, therefore it is better to use a smaller diameter The vertical position of the maxilla has a strong
(<1.6 mm) miniscrew and place it more apically to influence on both the anteroposterior and vertical
avoid root–miniscrew contact. If the miniscrew will positions of the mandible and the lower incisors. As
be placed in the unattached gingiva, the closed-pull the maxilla moves downward, the mandible rotates
method (see Chapter 5) should be used. backward and vice versa. For example, in a patient
with excessive vertical growth of the maxilla there is
downward and backward rotation of the mandible.
DEI>BJB;DG8:A:K:AH Conversely, when the maxilla is intruded, the mandible
moves upward and forward. Hence a Class II dental
A force gauge is used for accurate measurement of relationship improves with maxillary molar intrusion
the intrusive force. The authors advocate a force of but a Class III dental relationship becomes worse.
250–300 g per side for intrusion of entire dentition. As
the first molars are joined by a heavy palatal/lingual Therefore, an important consideration for molar
arch and the entire dentition is held together with a intrusion, other than the periodontal health of the
rectangular archwire, the intrusive force is distributed teeth, is the incisor relationship. There should be
to the entire dentition. Therefore it is reasonable sufficient amount of overjet prior to molar intrusion
to apply a heavier intrusive force than is usually to accommodate the upward and forward movement
recommended with traditional orthodontic mechanics of the lower incisors along with the mandible (Fig.
(Fig. 7.17). Lighter force of 60–120 g (10–20 g per 7.18). A patient who initially had a normal incisor
tooth) is applied for intrusion of anterior teeth. relationship may show anterior edge-to-edge bite or
CASE 7.1
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ZmVb^cVi^dc
A 26-year-old Korean woman presented with skeletal She also had severe lip protrusion and mentalis strain
class II malocclusion. Three second premolars had been on closing (Figs 7.19–7.28).
extracted prior to her initial orthodontic examination.
;^\#,#&. ;^\#,#'%
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Cephalometric analysis revealed a retrognathic angle – features commonly associated with vertical
mandible, excess anterior and posterior dentoalveolar maxillary excess (Figs 7.29, 7.30; Table 7.1).16
height and an increased maxillo-mandibular planes
;^\#,#'.
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The aim of the treatment was to achieve maximum Bd·Bhbb ('#*
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vertical dimension.
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The lower right second premolar and lower left third
molar were extracted. Upper and lower teeth were CA6YZ\ -'#%
banded/bonded with .022/.028 preadjusted fixed HZZeV\Z^m[dg@dgZVccdgbh#
>h·>hʹ/JeeZgVciZg^dgYZcidVakZdaVg]Z^\]iJ>·C;
appliances. Two Martin® miniscrews (diameter 1.6 mm, >^·>^ʹ/AdlZgVciZg^dgYZcidVakZdaVg]Z^\]iA>·<dBZ
length 6.0 mm) were placed between the upper first Bd·Bh/JeeZgedhiZg^dgYZcidVakZdaVg]Z^\]i
J+·C;
and second molars under local infiltrative anesthesia. Bd·B^/AdlZgedhiZg^dgYZcidVakZdaVg]Z^\]i
Leveling and aligning of the upper and lower dentitions A+·<dBZ
;^\#,#() ;^\#,#(*
location for the miniscrew and avoids root damage After 7 months of treatment, .019/.025 stainless
during and after placement. Therefore, depending on steel working archwires were engaged in both arches.
the initial alignment of the teeth, timing of miniscrew The upper right miniscrew showed mobility and was
placement in the upper and lower arches may vary removed. Another miniscrew implant was placed in the
and some anchorage loss is inevitable during the posterior midpalatal suture area, anteroposteriorly level
initial aligning and leveling stage of treatment. For with the first molars, under local infiltrative anesthesia.
this patient, the miniscrews were placed before the The upper left miniscrew was removed as it was no
teeth were aligned. When doing this, there is a risk longer needed. As anchorage was needed for intrusion
of miniscrew–root contact as the teeth are aligned. of upper posterior teeth in this patient, the midpalatal
However, in this patient the teeth were initially well suture area was selected for placing a new miniscrew.
aligned and the risk of miniscrew–root contact was The midpalatal suture area has excellent bone quality
not a concern in the leveling and aligning phase. for miniscrew retention in adults and only single screw
When placing a miniscrew before alignment is is needed. A 256:1 contra-angle handpiece was used
complete, apical positioning and vertical orientation for insertion of the miniscrew. A transpalatal arch
is advocated. This was one of our first cases involving was fitted on the first molars and an elastic chain was
use of miniscrew implant anchorage, and along with connected from the arch to the midpalatal screw. The
our other early cases informed our learning regarding transpalatal arch was designed such that the central
the appropriate time for miniscrew placement, optimal loop was located approximately 5 mm from the palatal
force magnitude, appliance design, etc. tissue and 10 mm anterior to the midpalatal miniscrew
&*+ chapter 7 clinical case
to provide anchorage for the retraction of anterior teeth 1.4 mm, length 8.0 mm) was placed in the interdental
and to apply intrusive forces on the upper posterior bone between the lower first premolar and first molar.
teeth. With a low transpalatal arch as this, there is This time a pilot hole was drilled prior to placement
usually some tongue irritation and speech disturbance. of the miniscrew to prevent its breakage. In the past,
Composite stops were bonded on the transpalatal arch when this patient was being treated, only bone screws
and elastic chains used to apply intrusive force on the were available. Those bone screws with diameters less
maxillary dentition (Fig. 7.36). Two more OsteoMed® than 1.6 mm did not have self-drilling qualities. When a
miniscrew implants (diameter 1.6 mm, length 8.0 mm) miniscrew becomes loose, an alternative site is selected
were placed in the interdental alveolar bone between for the replacement miniscrew. If the new one is to
the lower first and second molars under local infiltrative be placed in the same location, it is necessary to wait
anesthesia (Figs 7.37–7.41). for 10–12 weeks for the bone to fill the hole created
and mineralize. This is associated with a prolonged
Two months later, the lower right miniscrew became treatment period.
mobile and was removed; another miniscrew (diameter
;^\#,#(. ;^\#,#)%
86H:,#& &*,
;^\#,#)&
;^\#,#)' ;^\#,#)(
;^\#,#)) ;^\#,#)*
&*- chapter 7 clinical case
Edhi"igZVibZciZkVajVi^dc
Excellent improvement was noted in the nose–lip–chin A small amount of apical root resorption was seen in
relationship because of the reduction in the lower the post-treatment panoramic radiograph (Fig. 7.56).
anterior facial height. The chin showed a more esthetic Several factors may have contributed to this finding
appearance (Figs 7.46–7.55) in this patient. There was a considerable amount of
;^\#,#)+ ;^\#,#),
;^\#,#)- ;^\#,#).
86H:,#& &*.
tooth movement, to the extent that there was minimal large amount of incisor retraction and intrusion. Teeth
overlap of the pretreatment and post-treatment incisor that are moved through greater distances and intrusive
position. Considerable remodeling in the subspinale movements are more prone to root resorption. Also, in
and lower alveolar regions occurred as a result of the this patient, as the upper posterior teeth were intruded,
;^\#,#*+
&+% chapter 7 clinical case
;^\#,#*- ;^\#,#*.
86H:,#& &+&
A>E6C6ANH>H
JA^e·:bb &#-
&#- −'#,
AA^e·:bb ,#%
,#% −%#(
CA6YZ\ -'#%
-'#% --#%
HZZeV\Z^m[dg@dgZVccdgbh#
HZZIVWaZ,#&VcYeV\Zm[dgVWWgZk^Vi^dch#
8a^c^XVai^e
L]ZcbdaVg^cigjh^dc^hcdiVeVgid[i]Z^c^i^VaigZVibZci
eaVc!Wji^hYZZbZYcZXZhhVgn^ci]Zb^YYaZd[i]Z
igZVibZci!VigVcheVaViVaVgX]l^i]]dd`hbVnWZWdcYZY
idi]ZÄghibdaVgh;^\#,#+%#
;^\#,#+%
&+'
B>C>H8G:L>BEA6CI6C8=DG6<:
;DG>CIGJH>DCD;EDHI:G>DGI::I=
Miniscrew implant anchorage for intrusion of unilaterally or bilaterally. The following case illustrates
the posterior teeth can be used in both arches and some of these possibilities.
CASE 7.2
Jc^aViZgVa^cigjh^dcVcYgZigVXi^dcd[edhiZg^dgiZZi]^cVeVi^Zcil^i]h`ZaZiVa
8aVhh>>bVadXXajh^dcVcYYZZedkZgW^iZ
EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
ZmVb^cVi^dc
A 31-year old Korean woman presented with the chief
complaint of anterior crowding and protrusive lips. She
had a convex profile with a recessive chin. There was
mentalis strain on lip closure. The philtrum and the
upper central incisors were skewed to the left. Occlusal
canting was also present with greater gingival exposure
of right buccal segment (Figs 7.61–7.64).
;^\#,#,&
&+) chapter 7 clinical case
Cephalometric analysis revealed a skeletal Class II The PA cephalogram showed deviation of the chin
relationship with a retrognathic mandible. The palatal point to the left by 3.0 mm from the skeletal midline
plane to mandibular plane, lower gonial and the GoMe/ owing to vertical maxillary asymmetry. The maxillary
SN angles were increased indicating an increased right first molar was positioned more inferiorly by
maxillo-mandibular planes angle. Axial inclination of 2.5 mm compared with the left. The maxillary dental
the maxillary and mandibular incisors was normal. midline was deviated to the left but the mandibular
The lips were protrusive to the esthetic (E) line owing to midline was coincident with the facial midline (Fig.
the retrusive position of the chin (Fig. 7.72; Table 7.3). 7.73).
;^\#,#,' ;^\#,#,(
86H:,#' &+*
;^\#,#,, ;^\#,#,-
Edhi"igZVibZciZkVajVi^dc
There was an improvement in the lip profile as the
lip protrusion was reduced and mentalis strain had
disappeared. The maxillary central incisors had been
uprighted and the occlusal plane had been leveled (Figs
7.85–7.88).
;^\#,#-* ;^\#,#-+
;^\#,#-, ;^\#,#--
86H:,#' &+.
Both arches were well aligned and coordinated. The The post-treatment panoramic radiograph showed
upper and lower dental midlines were aligned and good overall root parallelism except for mandibular
optimal overbite and overjet were established. Bilateral central incisors. Only slight root resorption was noted
Class I canine and Class II molar relationships were on the upper incisors despite the considerable amount
attained (Figs 7.89–7.94). of movement of these teeth (Figs 7.95–7.97).
;^\#,#.+
;^\#,#.* ;^\#,#.,
&,% chapter 7 clinical case
;^\#,#..
;^\#,#.-
;^\#,#&%%
86H:,#' &,&
6ciZgdedhiZg^dg
HC6YZ\ -'#%
-'#% ,.#*
HC7YZ\ ,)#*
,)#* ,)#*
6C7YZ\ ,#*
,#* *#%
KZgi^XVa
<dBZ$HCYZ\ )'#*
)'#* )%#%
;BE6YZ\ (+#*
(+#* ((#%
EE$BEYZ\ (&#%
(&#% ',#%
AdlZg\dc^VaYZ\ -&#%
-&#% ,.#%
6CH·BZbb +,#*
+,#* +,#%
9:CI6A6C6ANH>H
DkZg_Zibb +#%
+#% (#%
DkZgW^iZbb *#%
*#% '#*
J>$HCYZ\ &%'#%
&%'#% &%&#%
A&$<dBZYZ\ .,#%
.,#% .*#*
HC$DEYZ\ &-#%
&-#% &.#%
>h·>hʹbb (&#%
(&#% '.#*
;^\#,#&%&
Bd·Bhbb '*#%
'*#% '*#%
>^·>^ʹbb ).#%
).#% ))#%
Bd·B^bb (+#%
(+#% (*#'
A>E6C6ANH>H
JA^e·:bb '#%
'#% −&#*
AA^e·:bb ,#%
,#% &#,
CA6YZ\ ..#%
..#% -.#%
HZZeV\Z^m[dg@dgZVccdgbh#
HZZIVWaZ,#&VcYeV\Zm[dgVWWgZk^Vi^dch#
&,' chapter 7 clinical case
;^\#,#&%' ;^\#,#&%(
;^\#,#&%) ;^\#,#&%*
86H:,#' &,(
;^\#,#&&'
&,) chapter 7 clinical case
;^\#,#&&( ;^\#,#&&)
&,*
CASE 7.3
>cigjh^dcd[jeeZgVcYadlZgedhiZg^dgiZZi]^cVeVi^Zcil^i]8aVhh>VciZg^dg
deZcW^iZ
EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
ZmVb^cVi^dc
A 30-year-old Korean woman presented with a chief had a mild lisp. Her profile was moderately convex with
complaint of poor facial esthetics due to a severe full, incompetent lips. From the frontal view, the face
anterior open bite. She had a tongue thrust, which had was symmetric with no tooth display in lip repose. Less
contributed to the formation and maintenance of her than 1 mm of the teeth were visible on smiling (Figs
anterior open bite. She was also a mouth breather and 7.115–7.118).
;^\#,#&&* ;^\#,#&&+
;^\#,#&&, ;^\#,#&&-
&,+ chapter 7 clinical case
;^\#,#&'*
86H:,#( &,,
KZgi^XVa
<dBZ$HCYZ\ (+#%
;BE6YZ\ '.#'
EE$BEYZ\ '-#%
AdlZg\dc^VaYZ\ ,.#)
6CH·BZbb -&#(
9:CI6A6C6ANH>H
DkZg_Zibb (#+
DkZgW^iZbb −,#'
J>$HCYZ\ &&&#*
A&$<dBZYZ\ &%(#-
HC$DEYZ\ '%#*
>h·>hʹbb ((#-
Bd·Bhbb ('#%
>^·>^ʹbb )+#,
Bd·B^bb )'#%
A>E6C6ANH>H
JA^e·:bb (#)
AA^e·:bb ,#&
CA6YZ\ -+#%
;^\#,#&'+ HZZeV\Z^m[dg@dgZVccdgbh#
HZZIVWaZ,#&VcYeV\Zm[dgVWWgZk^Vi^dch#
&,- chapter 7 clinical case
IgZVibZci
After extraction of the four first premolars and the ;^\#,#&',
three third molars, the upper and lower arches were
bonded with .022/.028 preadjusted fixed appliances. A
low transpalatal arch was fitted to the upper molars. A
hook was soldered in the center of the loop to facilitate
elastic chain application. A miniscrew implant was
placed in the posterior midpalatal suture area level with
the first molars under local infiltrative anesthesia. The
lateral cephalogram was used for assessing the vertical
bone height in the palatal suture area to determine the
;^\#,#&'-
appropriate implant length. An OsteoMed® miniscrew
(diameter 1.6 mm, length 6.0 mm) was inserted using
a low-speed 256:1 contra-angle handpiece. Copious
irrigation is necessary in this area to prevent cortical
bone damage by the heat generated. There are no roots,
nerves or blood vessels in this area to complicate the
implant placement. In the lower arch, two OsteoMed®
miniscrews (diameter 1.6 mm, length 6.0 mm) were
placed in the inter-radicular bone of the first and
second molars. Root proximity was checked on a
;^\#,#&'.
86H:,#( &,.
Leveling and aligning of the upper and lower arches tipping of the lower posterior teeth from the intrusive
was initiated. An elastic chain was placed from the force was controlled with rectangular archwire. It is
hook on the transpalatal arch to the midpalatal screw preferable to place a lingual arch on the first molars
so that a vertical intrusive force was applied to the than incorporating bends in the archwire.
upper posterior teeth. In the lower arch, elastic chains
were secured from the lower archwire between the Retraction of anterior teeth was continued by replacing
first and second molars to the right and left buccal the elastomeric ties at each appointment until space
miniscrew implants to put an intrusive force on the closure was complete. During space closure, the elastic
lower posterior teeth. The archwires were progressively chains connected to the miniscrews were also replaced
increased up to .019/.025 stainless steel, the working to provide a continuous intrusive force for the upper
archwires. Space closure was begun with light and and lower molars. The implants were stable throughout
continuous forces delivered by active tiebacks from the treatment period. There was no need for vertical
the anterior hooks on the archwire to the second elastics to close the bite.
molar attachment hooks (Figs 7.130–7.134). This
patient was the first case of molar intrusion with use The total active treatment time was 15 months.
of miniscrews as anchorage. At that time the buccal
;^\#,#&(( ;^\#,#&()
&-% chapter 7 clinical case
Edhi"igZVibZciZkVajVi^dc
The final outcome of the treatment was a marked Proper functioning of the anterior teeth was achieved
improvement in function and esthetics. An attractive by the establishment of appropriate contact between
smile was achieved with up to 80% of the upper them, overjet and overbite. Class I canine and molar
incisors visible during smiling. The nose–lip–chin relationships were also established. Because of the
balance was greatly improved and dentoalveolar large amount of distal movement and retroclination of
protrusion reduced with consequent decrease in the lip the lower incisors, the gingival recession on the labial
fullness (Figs 7.135–7.138). surfaces of the mandibular incisors slightly increased.
This may have been due to the thin gingival tissue and
;^\#,#&(* ;^\#,#&(+
;^\#,#&(, ;^\#,#&(-
86H:,#( &-&
the root prominence present before treatment. Slight The panoramic and periapical radiographs showed that
amount of residual extraction space remained in each the bone levels were maintained and minimal apical
quadrant. However, the patient requested the removal root resorption was seen in the upper and lower incisors
of brackets at this stage for personal reasons (Figs and molars (Figs 7.144–7.150).
7.139–7.143).
;^\#,#&)' ;^\#,#&)(
;^\#,#&))
&-' chapter 7 clinical case
;^\#,#&*&
86H:,#( &-(
IVWaZ,#+ EgZigZVibZciVcYedhi"igZVibZcih`ZaZiVa!YZciVaVcY
[VX^VaXZe]VadbZig^XbZVhjgZbZcih
EgZigZVibZci Edhi"igZVibZci
H@:A:I6A6C6ANH>H
6ciZgdedhiZg^dg
HC6YZ\ .'#%
.'#% .'#%
HC7YZ\ -)#%
-)#% -)#,
6C7YZ\ -#%
-#% ,#(
KZgi^XVa
<dBZ$HCYZ\ (+#%
(+#% (*#%
;BE6YZ\ '.#'
'.#' '-#%
EE$BEYZ\ '-#%
'-#% '+#+
AdlZg\dc^VaYZ\ ,.#)
,.#) ,,#*
6CH·BZbb -&#(
-&#( ,,#-
9:CI6A6C6ANH>H
;^\#,#&*' DkZg_Zibb (#+
(#+ '#+
DkZgW^iZbb −,#'
−,#' '#%
J>$HCYZ\ &&&#*
&&&#* &%&#%
A&$<dBZYZ\ &%(#-
&%(#- -,#%
HC$DEYZ\ '%#*
'%#* &+#%
>h·>hʹbb ((#-
((#- ()#%
Bd·Bhbb ('#%
('#% (%#%
>^·>^ʹbb )+#,
)+#, ),#%
Bd·B^bb )'#%
)'#% )%#%
A>E6C6ANH>H
JA^e·:bb (#)
(#) %#%
AA^e·:bb ,#&
,#& )#'
CA6YZ\ -+#%
-+#% .%#%
HZZeV\Z^m[dg@dgZVccdgbh#
HZZIVWaZ,#&VcYeV\Zm[dgVWWgZk^Vi^dch#
;^\#,#&*(
&-) chapter 7 clinical case
A new set of records taken 3 years and 3 months instability of the correction.8 For growing patients,
after retention showed no remarkable changes in treatment approaches that aim to restrain vertical
the anterior overbite. There was a slight opening of maxillary growth and control the eruption of posterior
the extraction sites because the patient was not fully teeth in both arches are recommended.19 However,
compliant with retainer wear. The substantial amount appliances that apply intrusive forces to upper and
of incisor retraction over a relatively short period of lower posterior teeth have been described as providing
treatment time in this case may also have contributed less consistent results.8
to opening of the extraction spaces after appliance
removal (Figs 7.154–7.163). Extrusion of anterior teeth via elastics is another
method of overbite reduction. However, extruded teeth
are unstable.20 Elastic wear can extrude anterior teeth
9^hXjhh^dc beyond the limits of eruption and may consequently
lead to redevelopment of the open bite due to stretched
Skeletal open bite is considered to be one of the most gingival fibers. Subtelny suggested that intrusion of the
difficult problems to correct with orthodontic treatment maxillary and mandibular molars is more beneficial in
alone because of the multiple etiological factors18 and closing the anterior open bite.18
;^\#,#&*) ;^\#,#&**
;^\#,#&*+ ;^\#,#&*,
86H:,#( &-*
;^\#,#&+& ;^\#,#&+'
;^\#,#&+(
&-+
CASE 7.4
Jc^aViZgVa^cigjh^dcd[jeeZgedhiZg^dgiZZi]^cVeVi^Zcil^i]VhnbbZig^X
h`ZaZiVa8aVhh>>>bVadXXajh^dc
EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
ZmVb^cVi^dc
A 21-year-old Korean man presented with a chief mandible were deviated to the right side. His lips and
complaint of facial asymmetry. There was history of upper occlusal plane were canted. He had a straight
injury to his left temporomandibular joint following a profile. He was a mouth breather and had a mild lisp
fall in childhood. On frontal view, his chin point and (Figs 7.164–7.167).
;^\#,#&+) ;^\#,#&+*
;^\#,#&++ ;^\#,#&+,
86H:,#) &-,
On intraoral examination, the upper dental midline was was detected on closure. There were no signs or
centered in relation to the facial midline but the lower symptoms of temporomandibular joint disorder.
dental midline was deviated 6.0 mm to the right side.
There was a posterior crossbite on the right side. There
was a Class II canine and Class III molar relationship GVY^d\gVe]^XZkVajVi^dc
on the right side and Class III canine and molar
relationships on the left side. The overjet was −2.5 mm. The panoramic radiograph revealed a full complement
There was a minor upper and lower anterior crowding of teeth except for the left upper and lower third molars.
(Figs 7.168–7.173). The upper and lower right third molars were impacted.
The lower left third molar had been extracted at
Premature contact was present on upper and lower another clinic prior to consultation. Slight horizontal
right canines when the mandible was guided into alveolar bone loss was evident. The distance from the
centric relation. A mandibular shift to the right side condylar head to the antegonial notch was greater on
the left side by 8.0 mm (Fig. 7.174).
;^\#,#&,)
&-- chapter 7 clinical case
Cephalometric analysis revealed a skeletal Class III On the PA cephalogram, the left first molar was 2.0 mm
relationship with prognathic mandible. The maxillary inferior to the right first molar. Mandible deviation to
incisors were proclined and the upper lip was retrusive right side was evident (Fig. 7.176).
relative to the E line (Fig. 7.175; Table 7.7).
;^\#,#&,* ;^\#,#&,+
86H:,#) &-.
;^\#,#&-% ;^\#,#&-&
;^\#,#&-'
86H:,#) &.&
;^\#,#&-(
&.' chapter 7 clinical case
Edhi"igZVibZciZkVajVi^dc
The post-treatment photographs showed that the facial midlines were aligned with the facial midline. Class I
asymmetry and lip canting although still present were canine and molar relationships with optimum overjet
reduced. The maxillary occlusal plane was leveled and overbite were established (Figs 7.184–7.194).
and the chin point centered. Upper and lower dental
;^\#,#&-) ;^\#,#&-*
;^\#,#&-+ ;^\#,#&-,
86H:,#) &.(
;^\#,#&.)
&.) chapter 7 clinical case
IVWaZ,#- EgZigZVibZciVcYedhi"igZVibZcih`ZaZiVa!YZciVaVcY
[VX^VaXZe]VadbZig^XbZVhjgZbZcih
EgZigZVibZci Edhi"igZVibZci
H@:A:I6A6C6ANH>H
6ciZgdedhiZg^dg
HC6YZ\ -(#%
-(#% -(#*
HC7YZ\ -)#%
-)#% -(#%
6C7YZ\ −&#%
−&#% %#*
KZgi^XVa
<dBZ$HCYZ\ (&#%
(&#% ()#%
;BE6YZ\ '+#*
'+#* '.#%
EE$BEYZ\ '%#%
'%#% '(#% ;^\#,#&.*
AdlZg\dc^VaYZ\ ,+#%
,+#% ,,#%
6CH·BZbb ,&#*
,&#* ,&#*
9:CI6A6C6ANH>H
DkZg_Zibb −'#*
−'#* '#*
DkZgW^iZbb &#%
&#% &#%
J>$HCYZ\ &&(#*
&&(#* &&*#*
A&$<dBZYZ\ .&#%
.&#% -)#%
HC$DEYZ\ &*#%
&*#% &)#%
>h·>hʹbb '-#%
'-#% '-#%
Bd·Bhbb ',#%
',#% ',#%
>^·>^ʹbb ))#%
))#% ))#%
Bd·B^bb (*#*
(*#* ()#%
A>E6C6ANH>H
JA^e·:bb −(#*
−(#* −(#%
AA^e·:bb &#%
&#% −'#%
CA6YZ\ .'#%
.'#% .'#%
HZZeV\Z^m[dg@dgZVccdgbh#
HZZIVWaZ,#&VcYeV\Zm[dgVWWgZk^Vi^dch#
;^\#,#&.+
86H:,#) &.*
9^hXjhh^dc
In this patient, asymmetric intrusion of posterior teeth
allowed mandibular setback surgery to be carried out
without the need of concurrent maxillary surgery.
Thus with the help of miniscrew implant anchorage, an
acceptable result was achieved by using less extensive
surgical procedures and at a lower cost.
B>C>H8G:L>BEA6CI6C8=DG6<:
;DG>CIGJH>DCD;6CI:G>DGI::I=
Orthodontic correction of deep overbite can be
achieved with several mechanisms that result in true
intrusion of anterior teeth, extrusion of posterior teeth,
or a combination of both. With miniscrew implant
anchorage, treatment mechanics for the intrusion of
;^\#,#&., anterior teeth are simplified and intrusive movement is
more efficient.
;^\#,#&.-
&.+
CASE 7.5
>cigjh^dcd[bVm^aaVgnVciZg^dgiZZi]^cVeVi^Zcil^i]ZmXZhh^kZ^cX^hdgY^heaVn
EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
ZmVb^cVi^dc
A 12-year-old Korean boy presented with the chief upper anterior teeth and 3.0 mm of gingiva were
complaint of gummy appearance and anterior visible. He had a straight profile and his lips were
crowding. On smiling, the full clinical crowns of his slightly protrusive (Figs 7.199–7.202).
;^\#,#&.. ;^\#,#'%%
;^\#,#'%& ;^\#,#'%'
86H:,#* &.,
On intraoral examination there was 100% overbite right side. The upper first molars were mesially rotated
(that is, the lower central incisors were not visible in and there was lack of space for the eruption of the
centric occlusion). There was some inflammation of upper right second premolar. There was a moderate
the gingival tissue behind the maxillary incisors. The arch length discrepancy with anterior crowding in the
lower incisors were lingually inclined and the upper lower arch, and the lower arch form was distorted (Figs
and lower left lateral incisors were in crossbite. There 7.203–7.208).
was Class II canine and molar relationships on the
GVY^d\gVe]^XZkVajVi^dc
The panoramic radiograph revealed a full complement
of teeth and there were no abnormal findings.
Cephalometric analysis revealed a skeletal Class I
relationship with deep anterior overbite. The upper
central incisors were extruded with the incisal edges
8–9 mm below the lower lip. The overbite was 10.0 mm.
Both the upper and the lower incisors were lingually
inclined (Fig. 7.209; Table 7.9).
;^\#,#'%.
&.- chapter 7 clinical case
KZgi^XVa
<dBZ$HCYZ\ ()#%
IgZVibZci
;BE6YZ\ ',#%
The upper incisors were bonded with .022/.028
EE$BEYZ\ '&#* preadjusted fixed appliances and aligned and leveled
AdlZg\dc^VaYZ\ ,*#% with a sectional .019/.025 stainless steel archwire.
6CH·BZbb +'#%
The transverse width of the inter-radicular bone
9:CI6A6C6ANH>H between the upper central incisors was evaluated on
DkZg_Zibb *#* a periapical radiograph prior to miniscrew implant
DkZgW^iZbb &%#%
placement (Fig. 7.210). This distance increases
from the alveolar crest toward the apex of the teeth.
J>$HCYZ\ .(#%
Therefore, as the upper central incisors are intruded,
A&$<dBZYZ\ ,'#% the initial vertical distance between the archwire
HC$DEYZ\ '%#* and the implant is expected to decrease and roots
>h·>hʹbb (%#% come closer to the miniscrew implant. It is therefore
important that the miniscrew implant is placed
Bd·Bhbb ''#%
sufficiently apical.
>^·>^ʹbb )%#%
Bd·B^bb (&#%
A>E6C6ANH>H
JA^e·:bb &#'
AA^e·:bb '#&
CA6YZ\ .*#%
HZZeV\Z^m[dg@dgZVccdgbh#
HZZIVWaZ,#&VcYeV\Zm[dgVWWgZk^Vi^dch#
;^\#,#'&%
86H:,#* &..
Hjg\^XVaegdXZYjgZ[dgb^c^hXgZleaVXZbZci the upper portion of the closed coil spring were covered
VcY[jgi]ZgigZVibZci by the flap of mucosa, which was sutured. Even if the
miniscrew implant is left exposed, it will eventually get
Under infiltrative local anesthesia, the upper lip was covered by mucosa during healing. Moreover, exposed
elevated and an incision made in the labial frenum. The miniscrews often cause soft tissue irritation, but this
bone was exposed with a periosteal elevator. An OSAS® does not happen with the miniscrew buried under the
miniscrew implant (diameter 1.6 mm, length 6.0 mm) soft tissue. When it is planned to place the implant in
was placed with a manual screwdriver (hand driver). the movable vestibular mucosa, the ‘closed’ type is
A nickel-titanium (NiTi) closed coil spring was ligated recommended (see Chapter 5 for details of closed-pull
to the head of the implant and stretched and the other and open-pull methods) (Figs 7.211–7.216).
end ligated to the upper archwire. The miniscrew and
;^\#,#'&)
;^\#,#'&* ;^\#,#'&+
'%% chapter 7 clinical case
;^\#,#''%
86H:,#* '%&
;^\#,#'')
'%' chapter 7 clinical case
At 6 months, .022/.028 preadjusted fixed appliances the miniscrew to the utility archwire to prevent
were bonded on the remaining teeth in the upper extrusion of the incisors (Figs 7.225–7.228).
arch. A .018/.025 stainless steel utility archwire and
an .014 NiTi overlay wire were tied in. The .014 NiTi At 11 months, the NiTi coil spring was replaced with
was replaced by an .018 NiTi wire at the following a passive steel ligature tie. A continuous .016/.022
appointment. A steel ligature was passively tied from NiTi archwire was inserted in the upper arch (Figs
7.229–7.232). During this time, compared with the
;^\#,#''-
;^\#,#'('
86H:,#* '%(
pretreatment condition of the lower dentition, the The lower teeth were bonded with .022/.028
anterior part of the lower arch form had changed preadjusted fixed appliances. Leveling and aligning of
without any orthodontic force application. The the teeth was carried out and archwires progressively
previously distorted arch form was now U shaped (Figs increased in size (Figs 7.235–7.237).
7.233, 7.234). This was because as the restricting
effect of upper incisors was removed, the lower incisors
moved labially. A Burstone lingual arch was placed to
apply buccal crown torque.
;^\#,#'(( ;^\#,#'()
;^\#,#'(- ;^\#,#'(.
;^\#,#')% ;^\#,#')&
86H:,#* '%*
;^\#,#')-
;^\#,#'). ;^\#,#'*%
'%+ chapter 7 clinical case
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VcY[VX^VaXZe]VadbZig^XbZVhjgZbZcih
EgZigZVibZci Edhi"igZVibZci
H@:A:I6A6C6ANH>H
6ciZgdedhiZg^dg
HC6YZ\ -(#%
-(#% -+#%
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-%#% -(#%
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(#% (#%
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()#% (%#%
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',#% ',#%
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,*#% ,)#%
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+'#% +,#%
9:CI6A6C6ANH>H
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&#' −&#'
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'#& '#%
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.*#% .+#%
HZZeV\Z^m[dg@dgZVccdgbh#
HZZIVWaZ,#&VcYeV\Zm[dgVWWgZk^Vi^dch#
;^\#,#'*'
86H:,#* '%,
At 2 year follow-up a new set of records was taken. These cases collectively illustrate the effectiveness,
There were no remarkable changes in the anterior relative simplicity and versatility of miniscrews in
overbite (Figs 7.253–7.263). achieving intrusive tooth movements, which are
acknowledged to be among the most difficult tooth
movements to achieve.
;^\#,#'*( ;^\#,#'*)
;^\#,#'** ;^\#,#'*+
'%- chapter 7 clinical case
;^\#,#'+% ;^\#,#'+&
;^\#,#'+' ;^\#,#'+(
8=6EI:G,
>cigjh^dc '%.
GZ[ZgZcXZh
1. Vig R G, Brundo G C 1978 The kinetics of anterior tooth 11. Chun Y S, Woo Y J, Row J et al 2000 Maxillary molar
display. Journal of Prosthetic Dentistry 39:502–504 intrusion with the molar intrusion arch. Journal of Clinical
2. Kanomi R 1997 Mini-implant for orthodontic anchorage. Orthodontics 4:90–93
Journal of Clinical Orthodontics 31:763–767 12. Melsen B, Fiorelli G 1996 Upper molar intrusion. Journal of
3. Costa A, Raffaini M, Melsen B 1998 Miniscrews as Clinical Orthodontics 30:91–96
orthodontic anchorage: a preliminary report. International 13. Bonetti G A, Giunta D 1996 Molar intrusion with a removable
Journal of Adult Orthodontics and Orthognathic Surgery appliance. Journal of Clinical Orthodontics 30:434–437
13:201–209 14. Mostafa Y A, Tawfik K M, El-Mangoury N H 1985 Surgical-
4. Sherwood K H, Burch J G, Thompson W J 2002 Closing orthodontic treatment for overerupted maxillary molars.
anterior open bites by intruding molars with titanium Journal of Clinical Orthodontics 19:350–351
miniplate anchorage. American Journal of Orthodontics and 15. Hwang H, Lee K 2001 Intrusion of overerupted molars by
Dentofacial Orthopedics 122:593–600 corticotomy and magnets. American Journal of Orthodontics
5. Umemori M, Sugawara J, Mitani H et al 1999 Skeletal and Dentofacial Orthopedics 120:209–216
anchorage system for open-bite correction. American Journal 16. Arnett W G, Bergman R T 1993 Facial keys to orthodontic
of Orthodontics and Dentofacial Orthopedics 115:166–174 diagnosis and treatment planning, Part II. American Journal
6. Paik C H, Woo Y J, Boyd R L 2003 Treatment of an adult of Orthodontics 103:395–411
patient with vertical maxillary excess using miniscrew 17. Bailey L J, Proffit W R 2000 Combined surgical and
fixation. Journal of Clinical Orthodontics 37:423–428 orthodontic treatment. In: Proffit WR, Fields HW, eds.
7. Sugawara J, Baik U B, Umemori M et al 2002 Treatment and Contemporary Orthodontics, 3rd ed. Mosby, St Louis, pp.
posttreatment dentoalveolar changes following intrusion of 679–682
mandibular molars with application of a skeletal anchorage 18. Subtelny J D, Sakuda M 1964 Open-bite: diagnosis and
system (SAS) for open bite correction. International Journal treatment. American Journal of Orthodontics 50:337–358
of Adult Orthodontics and Orthognathic Surgery 17:243–253
19. Proffit W R, Henry W, Fields J R 2000 Contemporary
8. Dellinger E L 1986 A clinical assessment of the active vertical Orthodontics, 3rd ed. Mosby, St Louis, p. 269
corrector: a nonsurgical alternative for skeletal open-bite.
20. Reitan K 1967 Clinical and histologic observations on
American Journal of Orthodontics 89:428–436
tooth movement during and after orthodontic treatment.
9. Karla V, Burstone C J, Nanda R 1989 Effects of a fixed American Journal of Orthodontics 53:721–745
magnetic appliance on the dentofacial complex. American
21. Denison T F, Kokich V G, Shapiro P A 1989 Stability
Journal of Orthodontics 95:467–478
of maxillary surgery in openbite versus non-openbite
10. Barber R E, Sinclair P M 1991 A cephalometric evaluation malocclusions. Angle Orthodontist 59:5–10
of anterior openbite correction with the magnetic active
vertical corrector. Angle Orthodontist 61:93–109
8=6EI:G-
Chapter -
Miniscrew implant
anchorage for transverse
and asymmetric tooth
movement
IgVchkZghZVcYVhnbbZig^Xiddi]bdkZbZci '&'
86H:-#& Jc^aViZgVaigVchkZghZZmeVch^dcd[edhiZg^dgiZZi] '&(
86H:-#' 8dggZXi^dcd[adlZgYZciVab^Ya^cZY^hXgZeVcXn
^cVeVi^Zcil^i]8aVhh>bVadXXajh^dcVcYa^eegdigjh^dc '&*
86H:-#( Jc^aViZgVa^cigjh^dcd[iZZi]idaZkZaVXVciZY
VciZg^dgdXXajhVaeaVcZ '')
'&' ORTHODONTIC MINISCREW IMPLANT
CASE 8.1
Jc^aViZgVaigVchkZghZZmeVch^dcd[edhiZg^dgiZZi]
EgZhZci^c\XdbeaV^ciVcYXa^c^XVa IgZVibZci
ZmVb^cVi^dc
An activated W-arch was cemented on the upper
A 46-year-old Korean man presented with spacing and first molars. An OSAS® miniscrew implant (diameter
lower anterior crowding. He had a unilateral posterior 1.6 mm, length 6.0 mm) was placed in the palatal bone
crossbite on the right side (Figs 8.1, 8.2). There was no between the left first and second molars. The left side
mandibular displacement on closure in centric relation. of the W-arch was tied to the miniscrew implant with
a ligature wire to prevent the left posterior teeth from
moving buccally. The palatal miniscrew was covered
IgZVibZcidW_ZXi^kZhVcYeaVc with composite to minimize irritation (Figs 8.3, 8.4).
;^\#-#& ;^\#-#'
;^\#-#( ;^\#-#)
'&) chapter 8 clinical case
;^\#-#* ;^\#-#+
Edhi"igZVibZciZkVajVi^dc
Unilateral transverse expansion of the upper arch was
achieved and the posterior crossbite on the right side
corrected. There was no reciprocal expansion on the left
side (Figs 8.7–8.8).
;^\#-#, ;^\#-#-
'&*
CASE 8.2
8dggZXi^dcd[adlZgYZciVab^Ya^cZY^hXgZeVcXn^cVeVi^Zcil^i]8aVhh>
bVadXXajh^dcVcYa^eegdigjh^dc
EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
ZmVb^cVi^dc
A 14-year-old Korean boy presented with upper side. Both upper and lower lips were protrusive with
anterior protrusion, a convex profile and facial mentalis strain on lip closure (Figs 8.9–8.12). He was a
asymmetry with a recessive chin deviating to the left mouth breather.
;^\#-#. ;^\#-#&%
;^\#-#&& ;^\#-#&'
'&+ chapter 8 clinical case
;^\#-#&+ ;^\#-#&,
;^\#-#&-
86H:-#' '&,
(Is–Isʹ, Mo–Ms, see Table 8.1 footnote for explanation), facial height was also excessive (Fig. 8.19). The PA
the palatal to mandibular planes, lower gonial and cephalogram showed the mandible to be asymmetric
GoMe/SN angles were increased. The lower anterior with the chin to the patient’s left (Fig. 8.20).
IVWaZ-#& EgZigZVibZciYZciVaVcY[VX^Va
XZe]VadbZig^XbZVhjgZbZcih
H@:A:I6A6C6ANH>H
6ciZgdedhiZg^dg
HC6YZ\ -'#%
HC7YZ\ ,-#%
6C7YZ\ )#%
KZgi^XVa
<dBZ$HCYZ\ )%#%
;BE6YZ\ ((#%
EE$BEYZ\ ('#%
AdlZg\dc^VaYZ\ ,.#%
6CH·BZbb ,+#*
9:CI6A6C6ANH>H ;^\#-#&.
DkZg_Zibb *#*
DkZgW^iZbb &#%
J>$HCYZ\ &&,#*
A&$<dBZYZ\ .(#%
HC$DEYZ\ &-#%
>h·>hʹbb ((#%
Bd·Bhbb ',#%
>^·>^ʹbb ).#%
Bd·B^bb (+#%
A>E6C6ANH>H
JA^e·:bb (#*
AA^e·:bb ,#*
CA6YZ\ ,+#%
HZZeV\Z^m[dg@dgZVccdgbh#
>h·>hʹJeeZgVciZg^dgYZcidVakZdaVg]Z^\]iJ>·C;
>^·>^ʹ/AdlZgVciZg^dgYZcidVakZdaVg]Z^\]iA>·<dBZ
Bd·Bh/JeeZgedhiZg^dgYZcidVakZdaVg]Z^\]i
J+·C;
Bd·B^/AdlZgedhiZg^dgYZcidVakZdaVg]Z^\]i
A+·<dBZ ;^\#-#'%
'&- chapter 8 clinical case
;^\#-#')
86H:-#' '&.
Once the extraction spaces had closed, an OsteoMed® traction from the right miniscrew, it was anticipated
miniscrew (diameter 1.6 mm, length 6.0 mm) was that retraction of the lower dentition would result
inserted on the right side in the inter-radicular bone in alignment of the midline and would also create
between the mandibular first premolar and first molar adequate anterior overjet.
(Figs 8.25–8.27). A manual screwdriver was used for
placement. Traction (200 g) was applied between the After 4 months, the lower dental midline was aligned
miniscrew and the lower right canine bracket. Both with the upper dental and the facial midlines (Figs
arches were tied back to maintain space closure. The 8.28–8.30). Even though the traction force was
timing of miniscrew placement depends on the planned applied from an apically positioned miniscrew, the
tooth movement. Miniscrews that serve as anchorage intrusive movement was minimal. The use of full-sized
for retraction of anterior teeth are best placed after rectangular stainless steel archwire and tying the teeth
leveling and aligning of the teeth is complete and together may have minimized the intrusion of lower
before starting active space closure. For this patient, right teeth.
it was difficult to determine the appropriate location
of the miniscrew prior to closure of extraction space. Total active treatment time was 23 months. Following
When the extraction space had closed, the lower dental removal of the fixed appliances, upper and lower
midline was still shifted to left side and there was edge canine-to-canine lingual retainers were bonded.
to edge contact between the left lateral incisors. Using Removal retainers were also given.
Edhi"igZVibZciZkVajVi^dc
The patient’s facial appearance improved remarkably. The upper and lower dental midlines were aligned
Nose–lip–chin balance was achieved and the chin was and a U-shaped upper arch form was attained with
no longer recessive (Figs 8.31–8.34). Intraorally, super coordination of arch widths (Figs 8.35–8.40).
Class I canine and molar relationships were established.
;^\#-#(& ;^\#-#('
;^\#-#(( ;^\#-#()
86H:-#' ''&
;^\#-#(- ;^\#-#(.
;^\#-#)%
''' chapter 8 clinical case
Superimposition of the pre- and post-treatment of lower incisors allowed the chin point to appear
cephalometric tracings showed reduction in lip prominent. There was favorable forward and downward
protrusion and elimination of mentalis strain. Upper mandibular growth during the treatment period
incisors proclination was reduced by 11.5°. There although mandibular asymmetry persisted (Figs 8.41–
was only 1.0 mm upper molar extrusion. Retraction 8.44; Table 8.2).
;^\#-#)& ;^\#-#)'
86H:-#' ''(
IVWaZ-#' EgZigZVibZciVcYedhi"igZVibZcih`ZaZiVa!YZciVaVcY
[VX^VaXZe]VadbZig^XbZVhjgZbZcih
EgZigZVibZci Edhi"igZVibZci
H@:A:I6A6C6ANH>H
6ciZgdedhiZg^dg
HC6YZ\ -'#%
-'#% -&#%
HC7YZ\ ,-#%
,-#% ,-#%
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)#% (#%
KZgi^XVa
<dBZ$HCYZ\ )%#%
)%#% (.#%
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,+#* -&#*
9:CI6A6C6ANH>H
;^\#-#)( DkZg_Zibb *#*
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DkZgW^iZbb &#%
&#% &#%
J>$HCYZ\ &&,#*
&&,#* &%+#%
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;^\#-#))
'')
CASE 8.3
Jc^aViZgVa^cigjh^dcd[iZZi]idaZkZaVXVciZYVciZg^dgdXXajhVaeaVcZ
EgZhZci^c\XdbeaV^ciVcYXa^c^XVa IgZVibZci
ZmVb^cVi^dc Both arches were bonded with .022/.028 preadjusted
fixed appliances, and leveling and aligning started.
A 26-year-old Korean woman presented with The archwires were progressively increased up to
asymmetric gingival exposure. The smile photograph .019/.025 stainless steel. An OSAS® miniscrew implant
showed canting of the maxillary occlusal plane. The (diameter 1.6 mm, length 6.0 mm) was placed in the
right anterior teeth were relatively extruded and there inter-radicular bone between the upper first and second
was a difference in the height of the right and left premolars on the right side. An elastic thread was tied
canines. Hence there was greater gingival exposure around the upper right anterior hook and posteriorly to
on the right side and the upper dental midline was the second premolar and then to the miniscrew to apply
deviated to the left side (Fig. 8.45). intrusive force (Figs 8.46, 8.47). The vertical distance
between the miniscrew and the archwire decreased as
the teeth were intruded (Fig. 8.48).
IgZVibZcidW_ZXi^kZhVcYeaVc
The asymmetric gingival exposure improved with
The patient refused surgical intervention, and unilateral intrusion of the upper right anterior segment
treatment was planned around miniscrew implant via miniscrew implant anchorage. The increased
anchorage to intrude the right anterior segment. elevation of the upper lip on the right side remained
after treatment (Fig. 8.49). Gingivectomy in the upper
right lateral incisor and canine area would have
enhanced the esthetic outcome.
;^\#-#)- ;^\#-#).
8=6EI:G.
Chapter .
Other uses of miniscrew
implants
>cigdYjXi^dc ''+
Jh^c\b^c^hXgZl^beaVcih[dg^ciZgbVm^aaVgnÄmVi^dc ''+
8VhZ.#& >ciZgbVm^aaVgnÄmVi^dc^cVeVi^ZcijcYZg\d^c\
XdbW^cZYa^c\jVa"dgi]dYdci^XVcYhjg\^XVaigZVibZci '',
AdXVaiddi]bdkZbZcih '((
8VhZ.#' B^cdgiddi]bdkZbZci·jeg^\]i^c\V
hZXdcYbdaVg '()
8VhZ.#( BZh^VabdkZbZcid[Vh^c\aZiddi] '(,
8VhZ.#) >cigjh^dcd[Vh^c\aZedhiZg^dgiddi] ')&
GZ[ZgZcXZ '))
''+ ORTHODONTIC MINISCREW IMPLANT
>CIGD9J8I>DC JH>C<B>C>H8G:L>BEA6CIH;DG
>CI:GB6M>AA6GN;>M6I>DC
The small size of the miniscrew implants allows
placement in many locations in the mouth and this is Miniscrew implants can be used for intermaxillary
the source of their versatility. With slight modifications fixation in patients undergoing orthognathic surgery.
to the mechanics employed in the main applications Multiple archwire hooks are not needed with this
and appliance designs (see Chapters 6–8), miniscrews method so presurgical orthodontic preparation is
can be used as adjuncts in a further variety of simplified. Intermaxillary fixation is also difficult in
situations, some of which are covered in this chapter. surgical patients with a lingual orthodontic appliance
because there are no attachments available on the
labial surfaces of the teeth. Metal buttons can be
6YkVciV\Zhd[jh^c\b^c^hXgZl^beaVcih[dg bonded temporarily to the labial surfaces1 (Fig. 9.1).
^ciZgbVm^aaVgnÄmVi^dc However, this can be esthetically unacceptable to such
patients. Moreover, intermaxillary fixation via button
CdegZeVgVi^dc^hcZXZhhVgnidhZXjgZVadXVi^dc[dgV attachments may cause extrusion of the involved teeth.
hiVWaZVcYg^\^YÄmijgZ#
Archwire hooks can be bonded (Fig. 9.2) but this again
I]Zb^c^hXgZl^beaVcihVgZZVh^aneaVXZYVcYgZbdkZY!
can be considered unsightly by the patient. When
VcY^ciZgbVm^aaVgnl^gZhVcYZaVhi^XhXVcWZjhZY
^bbZY^ViZanV[iZg^chZgi^dc# labial attachments are not acceptable to the patient,
miniscrew implants can conveniently be used for
>[dgi]dYdci^XVeea^VcXZhVgZcdigZfj^gZY!dgVa]n\^ZcZ
^hbjX]ZVh^ZgidbV^ciV^ci]Vcl^i]XdckZci^dcVa intermaxillary fixation.
VaiZgcVi^kZbZi]dYhd[^ciZgbVm^aaVgnÄmVi^dcjh^c\Z^i]Zg
WjiidchdgVgX]WVgh#
8]V^gi^bZ^hgZYjXZY0^iiV`ZhdcanV[Zlb^cjiZhid^chZgi
ZVX]hXgZlVcYi]ZgZ^hcdcZZY[dgi]Zdgi]dYdci^hiid
lZaY!Xg^bedghdaYZghjg\^XVa]dd`hdci]ZVgX]l^gZh#
;^\#.#& ;^\#.#'
'',
Case 9.1
>ciZgbVm^aaVgnÄmVi^dc^cVeVi^ZcijcYZg\d^c\XdbW^cZYa^c\jVa"dgi]dYdci^X
VcYhjg\^XVaigZVibZci
EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
ZmVb^cVi^dc
An 18-year-old woman presented with the chief
complaint of protruding lower jaw. On examination,
she had a skeletal Class III malocclusion (Figs 9.3–9.6).
;^\#.#( ;^\#.#)
;^\#.#* ;^\#.#+
''- chapter 9 clinical case
;^\#.#&% ;^\#.#&&
;^\#.#&'
86H:.#& ''.
IgZVibZci
Presurgical orthodontic treatment was carried
out using .018 Ormco® lingual brackets. Leveling
and alignment of both arches was followed by
decompensation with Class II intermaxillary elastics
(Figs 9.14–9.18).
;^\#.#&(
;^\#.#&, ;^\.#&-
'(% chapter 9 clinical case
;^\#.#&.
;^\#.#'%
;^\#.#'&
86H:.#& '(&
Edhi"igZVibZciZkVajVi^dc
The patient’s profile greatly improved, the mentalis
strain disappeared, and the teeth were well aligned (Figs
9.22–9.32).
;^\#.#'' ;^\#.#'(
;^\#.#') ;^\#.#'*
'(' chapter 9 clinical case
;^\#.#'. ;^\#.#(%
;^\#.#(&
86H:.#& '((
AD86AIDDI=BDK:B:CIH
Another adjunctive use of miniscrew implants is in
localized tooth movement for which a partial fixed
appliance is preferred. Usually such treatment involves
mesial or distal movement of one or two teeth, vertical
movement of one or two teeth or uprighting of a
posterior tooth. Uprighting a posterior tooth with
conventional fixed appliance treatment requires
inclusion of the whole quadrant in the appliance
set-up and often of the contralateral side as well for
appropriate anchorage. Sometimes even a lingual
arch is added to supplement anchorage and prevent
undesirable tooth movement. Miniscrew implants can
;^\#.#(' reduce the number of teeth involved in the appliance
for such treatments.
8a^c^XVai^eh
BVcnXdbbZgX^VaanVkV^aVWaZdgi]dYdci^Xb^c^hXgZl
^beaVcih]VkZYjVa]ZVYh#I]ZhZb^c^hXgZlh`ZZel^gZhdg
ZaVhi^Xh[gdbXdciVXi^c\i]Zhd[ii^hhjZh!l]Zi]ZgdgcdiV
hea^ci^hegZhZci#I]ZegdigjY^c\b^c^hXgZl]ZVYh[VX^a^iViZ
Veea^XVi^dcd[l^gZhdgZaVhi^Xh!VcY^i^hZVh^Zg[dgi]Z
eVi^ZciidbV^ciV^cdgVa]n\^ZcZ;^\h.#((!.#()#
B^c^hXgZl^beaVciVcX]dgV\ZXVcWZjhZY[dg
^ciZgbVm^aaVgnÄmVi^dc[daadl^c\dgi]d\cVi]^Xhjg\Zgn
ZkZc^ceVi^Zcihl]d]VkZXdckZci^dcVaÄmZYVeea^VcXZh
;^\#.#(*#
Case 9.2
B^cdgiddi]bdkZbZci·jeg^\]i^c\VhZXdcYbdaVg
(Courtesy of Dr Youn Sic Chun, Division of Orthodontics, The length of the sectional wire is determined by the
Department of Dentistry, Ewha Womans University Mokdong distance between the miniscrew and the molar that will
Hospital, Seoul, Korea) serve as the anchorage unit (Fig. 9.37).
A simple application of miniscrew implant anchorage is After sandblasting, both the hooks are bonded with
uprighting of a single mesially tipped molar. Both ends composite adhesive, one to the anchor tooth and the
of a sectional .019/.025 stainless steel wire are bent other to the miniscrew head (Fig. 9.38).
into hooks. One end is bent to a smaller hook, which
will be bonded to the anchor tooth. The other end is
bent so that the hook fits the miniscrew head (Fig. EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
9.36). ZmVb^cVi^dc
A patient presented with a mesially tipped mandibular
second molar (Figs 9.39, 9.40).
;^\#.#(. ;^\#.#)%
86H:.#' '(*
;^\#.#)& ;^\#.#)'
Case 9.3
BZh^VabdkZbZcid[Vh^c\aZiddi]
EgZhZci^c\XdbeaV^ciVcYXa^c^XVa
ZmVb^cVi^dc
A 14-year-old Korean girl presented for orthodontic appliance orthodontic treatment for 2 years, and there
treatment following loss of a carious lower right was generalized decalcification of the teeth (Figs 9.53–
second premolar. She had previously undergone fixed 9.58).
;^\#.#*+ ;^\#.#*,
'(- chapter 9 clinical case
;^\#.#*-
IgZVibZcidW_ZXi^kZVcYeaVc
The aim of treatment was to move the molars forward
while involving the least number of teeth with the
shortest possible duration of fixed appliance treatment.
IgZVibZci ;^\#.#*.
The lower right first molar was banded; the band had
hooks extending to the level of the center of resistance
of the tooth on both the buccal and lingual sides. Two
OSAS® miniscrew implants (diameter 1.6 mm, length
6.0 mm) were placed in the alveolar bone distal to the
first premolar – one each on the buccal and lingual
sides. Chains were stretched between the hooks and the
miniscrews. The line of force passed through the center
of resistance of the tooth (Figs 9.59–9.61).
;^\#.#+%
86H:.#( '(.
Bodily movement was expected to occur, but the first miniscrew (ORLUS®; diameter 1.6 mm, length 6.0 mm),
molar was seen to tip as it approached the first premolar was placed in the buccal inter-radicular bone between
(Figs 9.62, 9.63). The hook on the band was extended the lower right first premolar and canine. Sometimes,
further inferiorly so that a mesial moment was created when bone resistance is encountered before the full
at the root when the chain was applied. The distance length of the miniscrew implant is inserted, complete
between the hook and the miniscrew decreased until placement should be avoided, as was the case in this
finally the miniscrews were removed, and another patient. Forced placement can result in fracture of the
;^\#.#+&
;^\#.#+' ;^\#.#+(
')% chapter 9 clinical case
miniscrew. In such situations, the protruding head of resulting in its uprighting and bodily mesial movement
the miniscrew can be ground with a high-speed bur to (Figs 9.67, 9.68).
prevent patient discomfort (Figs 9.64–9.66). Further
treatment included bonding of the lower teeth with Thus, space closure in cases with congenitally missing
.022/.025 preadjusted appliance. teeth or with spaces created by loss of carious teeth
may benefit from this appliance design.
A chain was continuously applied to the first molar
during the leveling and aligning phase of treatment,
;^\#.#++ ;^\#.#+,
;^\#.#+-
')&
Case 9.4
>cigjh^dcd[Vh^c\aZedhiZg^dgiddi]
;^\#.#,' ;^\#.#,(
;^\#.#,)
')' chapter 9 clinical case
;^\#.#,-
86H:.#) ')(
Edhi"igZVibZciZkVajVi^dc
Restorative replacement of lower second molar with
adequate clinical crown height was now possible (Figs
9.79–9.84).
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;^\#.#-)
')) chapter 9 clinical case
GZ[ZgZcXZ
1. Hong R K, Lee J, Sunwoo J et al 2000 Lingual orthodontics
combined with orthognathic surgery in a skeletal class III
patient. Journal of Clinical Orthodontics 34:403–408
8=6EI:G&%
Chapter &%
Complications and their
management
8dbea^XVi^dchYjg^c\VcY[daadl^c\^chZgi^dc ')+
9VbV\ZidVcVidb^XhigjXijgZh ')+
AVX`d[eg^bVgnhiVW^a^in ')+
=^\]gZh^hiVcXZid^chZgi^dc '),
9ZÅZXi^dcd[i]Z^chZgi^dceVi] ')-
Hd[ii^hhjZegdWaZbh ')-
EVi^ZciY^hXdb[dgi ')-
8dbea^XVi^dchYjg^c\i]ZadVY^c\eZg^dY ')-
BdW^a^ind[i]Zb^c^hXgZl ')-
EddgdgVa]n\^ZcZVcY^cÅVbbVi^dc '*&
EVi^ZciY^hXdb[dgi '*'
8dbea^XVi^dchYjg^c\gZbdkVa '*'
GZ[ZgZcXZh '*(
')+ ORTHODONTIC MINISCREW IMPLANT
This chapter describes some of the potential During insertion in the palatal alveolar area, the
complications that can occur during insertion, greater palatine artery or its branches may be
loading and removal of miniscrew implants, and their perforated – noted by active bleeding at the site. If
management. this occurs, the miniscrew is removed and pressure is
applied to stop bleeding. The miniscrew is placed in a
more occlusal location. However, this rarely happens
8DBEA>86I>DCH9JG>C<6C9 and is usually not a serious problem. The anatomic
;DAADL>C<>CH:GI>DC information and advice in Chapter 5 should be noted.
;^\#&%#& 6[iZg\g^cY^c\i]Z]ZVYd[VeVgi^Vaan^chZgiZYb^c^hXgZl!VWVaa"
h]VeZY]ZVYbVYZd[Xdbedh^iZXVcWZjhZY[dgin^c\i]Z[dgXZbdYjaZ#
9ZÅZXi^dcd[i]Z^chZgi^dceVi] 8DBEA>86I>DCH9JG>C<I=:
When a midpalatal miniscrew is placed using a AD69>C<E:G>D9
handpiece in a patient with a transpalatal arch (TPA),
the handpiece may collide with the TPA. Thus the BdW^a^ind[i]Zb^c^hXgZl
angle at which the screw is being driven has to be The miniscrew may become mobile or even loosen.
changed. This may cause wobbling or even fracture of Early miniscrew mobility, which occurs before or soon
the miniscrew. In such situations, place the miniscrew after loading, is considered a failure, and the miniscrew
before cementing the TPA and then take a pick-up should be removed and reinserted in another location.
impression to fabricate the TPA. If the miniscrew has Such early mobility may be caused by operator factors
to be placed after the TPA has been cemented, the U (such as wobbling during insertion (Fig. 10.4) or bone
loop of the TPA should be made large enough, or a long damage caused by too rapid insertion) or patient factors
connecting bur should be used with the handpiece. (such as active inflammation in the site of placement
or local bone remodeling). Early mobility tends to occur
more often in growing patients than in adult patients,
Hd[ii^hhjZegdWaZbh perhaps because of more active bone remodeling and
less bone density. Prevention of wobbling and bone
As described in Chapters 4 and 5, when an alveolar
damage is critical to reduce the incidence of miniscrew
miniscrew has to be inserted in the unattached mucosa
failure due to mobility. A handpiece should always be
or at the borderline between attached and unattached
used at a controlled, slow speed, and the area should be
mucosa, the loose gingival soft tissue tends to wrap
irrigated with saline if using an insertion speed greater
around the threads of the miniscrew during insertion
than 30 rpm (Figs 10.5, 10.6).
compromising its retention. A stab incision prior to
placement will prevent this.
EVi^ZciY^hXdb[dgi
Besides the pain felt during insertion of the needle
for administration of the local anesthetic prior to
miniscrew placement, patient discomfort is negligible.
Use of topical anesthesia is recommended before
administering the local anesthetic. Pain is minimal
during and after miniscrew placement. Patients can
take an over-the-counter analgesic if they have pain
after the anesthesia wears off. Antibiotics are not
necessary, except for medically compromised patients.
;^\#&%#) LdWWa^c\bjhiWZVkd^YZYidb^c^b^oZb^c^hXgZlbdW^a^inVcY
[V^ajgZ#
8=6EI:G&%
8dbea^XVi^dchVcYi]Z^gbVcV\ZbZci ').
If the miniscrew becomes slightly mobile several weeks Varied rates of success of miniscrew anchorage have
or months after orthodontic loading, it does not have been reported in the literature and several factors have
to be removed immediately. It can continue to be used been reported to be associated with success/failure
unless it irritates the mucosa or is unable to withstand (Table 10.1). However, further research is needed in
the applied forces. In such cases the miniscrew is this area. In the authors’ experience, mobile miniscrews
passively tied, that is the module should not exert any will inevitably fail, and midpalatal miniscrews are
force on the miniscrew, and the miniscrew is left in associated with the lowest rate of failure compared
place until next visit. At this visit tightening of the with other intraoral sites.
miniscrew can be attempted. If it remains mobile,
removal is recommended.
;^\#&%#+ 8dda^c\l^i]hVa^cZ^gg^\Vi^dcYjg^c\^chZgi^dcd[Vb^YeVaViVa
;^\#&%#* 8dda^c\l^i]hVa^cZ^gg^\Vi^dcl]^aZjh^c\V]VcYe^ZXZ# b^c^hXgZl#
'*%
IVWaZ&%#& HijY^Zhd[[VXidghVhhdX^ViZYl^i]i]ZhjXXZhhVcY[V^ajgZd[b^c^hXgZl^beaVciVcX]dgV\Z
B^nVlV`^ZiVa'%%() LddZiVa'%%(* 8]Zc\ZiVa'%%)+ EVg`ZiVa'%%+,
AdVY^c\ >bbZY^ViZdg&lZZ`V[iZg
>bbZY^ViZdg&lZZ`V[iZg '·)lZZ`hV[iZghjg\Zgn
hjg\Zgn
;^\#&%#, ;ddY^beVXi^dcVgdjcYVWjXXVaVakZdaVgb^c^hXgZl#
EVi^ZciY^hXdb[dgi 8DBEA>86I>DCH9JG>C<G:BDK6A
If the miniscrew is inserted through alveolar mucosa
Potential complications of removal include difficulty in
for anatomic reasons and the closed-pull method is
removing a miniscrew due to tight union with the bone
being used, the protruding wire and elastic chain can
and fracture of the miniscrew.1 However, the authors
irritate soft tissue causing discomfort (see Chapter 5,
have rarely encountered such difficulties. The removal
Figs 5.15, 5.16).1
torque force is lower than the insertion torque and
proportional to the square of the miniscrew radius.8 A
miniscrew, with its small diameter, has a low removal
torque.
;^\#&%#&% 6WjXXVab^c^hXgZlidWZgZbdkZY#
GZ[ZgZcXZh
1. Melsen B, Verna C 2005 Miniscrew implants: the Aarhus 6. Cheng S J, Tseng I Y, Lee J J et al 2004 A prospective study of
anchorage system. Seminars in Orthodontics 11:24–31 the risk factors associated with failure of mini-implants used
2. Roberts W E, Helm F R, Marshall K J et al 1989 Rigid for orthodontic anchorage. International Journal of Oral and
endosseous implants for orthodontic and orthopedic Maxillofacial Implants 19:100–106
anchorage. Angle Orthodontist 59:247–256 7. Park H S, Jeong S H, Kwon O W 2006 Factors affecting
3. Costa A, Raffainl M, Melsen B 1998 Miniscrews as the clinical success of screw implants used as orthodontic
orthodontic anchorage: a preliminary report. International anchorage. American Journal of Orthodontics and
Journal of Adult Orthodontics and Orthognathic Surgery Dentofacial Orthopedics 130:18–25
13:201–209 8. Kim J W, Ahn S J, Chang Y I 2005 Histomorphometric and
4. Miyawaki S, Koyama I, Inoue M et al 2003 Factors associated mechanical analyses of the drill-free screw as orthodontic
with the stability of titanium screws placed in the posterior anchorage. American Journal of Orthodontics and
region for orthodontic anchorage. American Journal of Dentofacial Orthopedics 128:190–194
Orthodontics and Dentofacial Orthopedics 124:373–378
5. Woo S S, Jeong S T, Huh Y S et al 2003 A clinical study
on skeletal anchorage system using miniscrew. Journal
of Korean Association of Oral and Maxillofacial Surgeons
29:102–107
INDEX