WORKBOOK

TABLE OF CONTENTS
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02
Section I – The VectorTAS System. . . . . . . . . . . . . . . . . . 05
Section II – Placement Procedures . . . . . . . . . . . . . . . . 15
Section III – Common Cases. . . . . . . . . . . . . . . . . . . . . . 21
Section IV – Marketing. . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Appendix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
“Toothborne anchorage is one of the greatest limitations
of modern orthodontic treatment because teeth move
in response to forces.”
– Thomas D. Creekmore, DDS
PREFACE
Introducing VectorTAS
I have long admired Ormco's willingness to step into the
breach – to be on the cutting edge of new technology.
From lingual orthodontics to the Damon® System, their
thought leaders have been willing to take the arrows
that often come with being the progenitor of a new
and different idea. Once again, we have something
entirely different: miniscrews for temporary orthodontic
anchorage. This exciting technology was first mentioned
in orthodontic literature by Dr. Thomas Creekmore but
has seen much of its early clinical work accomplished
in other countries, most notably throughout Asia and
Europe. Up to this point, the United States has not been
at the forefront of this technology.
I'm beginning to see this situation as
a blessing. There are now 18 or
more miniscrews available on the
market, all with their own twists (no
pun intended). I never thought a
simple screw could be designed in
so many different ways.
Ormco has taken a wholly different tack. A team of
engineers and experienced orthodontists started with a
blank slate to develop a unique and highly user-friendly
system that resulted in not only the VectorTAS temporary
anchorage device but also the adjunctive mechanics
and attachments that, I believe, make this the state-of-
the-art temporary anchorage system.
Throughout all of this, we had one thing in mind: Make
this a technology that the orthodontist can apply
themselves without having to go to other professionals
for placement or guidance. The need to load
miniscrews immediately, place them at will, and replace
failures will result in unparalled frustrations if we depend
on other specialists for delivery and maintenance. It is
my strong belief that miniscrews will be relegated to a
niche technology unless we embrace them as part of
our everyday orthodontic sphere.
Although the literature is replete with clinical
demonstrations of the use of miniscrews in unusual
and difficult cases, it is my belief that is not where their
ultimate strength will lie. Although I certainly understand
their use for complex orthodontic problems, their greatest
strength lies in the treatment of everyday malocclusions.
There is virtually no Class II case, or maximum anchorage
extraction case for that matter, that can't be simplified
with the use of a miniscrew and a well-conceived system
of applied mechanics. In short, temporary skeletal
anchorage will give us greater control of our outcomes
than we've ever had before. In the not-too-distant future,
orthodontic residents will wonder how orthodontists ever
practiced without temporary skeletal anchorage.
The orthodontic team that designed and clinically
evaluated VectorTAS over the last two years is a unique
one. Dr. Steve Tracey, a highly innovative orthodontist
with a large productive practice, brought his innate sense
of practicality and years of miniscrew use to the group.
Dr. John Graham is a unique blend of orthodontist and
physician and has trained in oral and maxillofacial
surgery. He brought his skill and knowledge of anatomy,
surgery and theoretical design to the group. Dr. Nicole
Scheffler, a bright young educator, researcher and
practicing orthodontist, contributed her experience in
miniscrew design, mechanics and research to the group.
And I guess they brought me along because they
thought they could teach an old dog new tricks, but
probably because I have a tendency to bring simplicity
and systemization to any orthodontic project. This group is
eager to convey its knowledge of this highly innovative
miniscrew system to the orthodontic community.
This workbook is designed to teach orthodontists how to
place and use VectorTAS in the most comfortable and
productive ways. It certainly doesn't pretend to cover the
myriad uses of the miniscrew that only time will unearth. It
is a practical, no-nonsense approach that we believe will
start to bring curious and willing orthodontists into the fold.
Yes, sometimes being second is a good thing.
James Hilgers, DDS, MS
01
INTRODUCTION
Rationale for Temporary Anchorage Devices in Orthodontics
“In planning orthodontic therapy, it is
simply not possible to consider only the
teeth whose movement is desired.”
– William R. Proffit, DDS, PhD
Orthodontists have always practiced their craft under the
demands of tooth-borne anchorage – tooth against tooth,
teeth against teeth. Intraoral modalities to prevent loss of
anchorage are many and include transpalatal, Nance
holding and lower lingual arches, lip bumpers, elastics and
even so-called “Tweed setups.” Expanding anchorage
beyond the dentition via headgear and the facemask,
for example, introduces the additional variable of patient
compliance. For many necessary dental movements,
these traditional orthodontic mechanisms have been
woefully inadequate. The advent of temporary skeletal
anchorage through miniscrew placement offers treatment
options that have heretofore not been available to
orthodontists. Temporary anchorage devices introduce a
method of anchorage control that is safe and
predictable. In many cases these devices simplify
mechanics, eliminate compliance and decrease
treatment time.
Many indications exist to establish temporary skeletal
anchorage as the new gold standard for orthodontic
mechanics. While edentulous space closure, segmental
intrusion/extrusion, correction of occlusal cants, molar
uprighting and many other tooth movements tax
conventional orthodontic mechanics to its limits, the
simple placement of one or more miniscrews provides
the orthodontist a fixed, immovable anchor with which a
myriad of movements may be performed while leaving
adjacent dentition unaffected.
02
The Evolution of Temporary Anchorage Devices
We can thank our orthopedic surgery colleagues for
providing the framework for introducing metal screws into
human bone. We can thank ankylosed tooth roots for
introducing orthodontists to the advantages of using fixed
skeletal anchorage as adjuncts in biomechanics. History
has brought us to the breakthrough of temporary skeletal
anchorage on a firm foundation of osseointegrated
implants, orthognathic surgery, bold clinicians and the
increasing anchorage demands of adult orthodontics.
In the late 1990s, a slow trickle of skeletal anchorage case
reports began entering the orthodontic literature. Nearly
10 years later, interest in miniscrew anchorage has grown
dramatically. Many orthodontists now look forward to
mastering the wonder of fixed skeletal anchorage, no
longer trapped within the confines of anchorage loss due
to reciprocal tooth movement. It is this environment that
has given rise to VectorTAS.
To date, most miniscrews have been just that – miniature
screws. The majority of orthodontic miniscrews have been
borrowed from maxillomandibular fixation or dental
implant systems and have not been designed exclusively
for orthodontic anchorage. In addition, the lack of a
systematized approach to the placement and utilization
of miniscrews has led to less-than-optimal results and
frustration among those orthodontists attempting to use
them. Orthodontists have largely been left to their own
devices and, in many cases, inefficient treatment
mechanics and often improper force levels. These
variables often conspire to yield unsatisfactory results.

Innovation Born of Necessity
The acceptance of miniscrews as temporary skeletal
anchors in mainstream orthodontics revealed a scarcity
of well-designed, well-thought-out skeletal anchorage
systems. Enter Ormco. The company appointed an
expert development team of orthodontists experienced
in skeletal anchorage, biomechanics and surgery to
develop the most complete temporary skeletal
anchorage system ever created. VectorTAS addresses
nearly every issue a clinician might encounter in
managing skeletal anchorage cases.
The proprietary system of miniscrews is color-coded to
indicate ideal miniscrew selection, which helps take the
guesswork out of miniscrew placement. Incorporated into
the architecture of each miniscrew are key design
features that facilitate simplicity of placement and low
failure rates. System-specific attachments with discrete,
identifiable force levels and easy-placement/self–locking
eyelets foster straightforward mechanics and predictable
tooth movement.
In sum, VectorTAS is a complete system that provides the
practitioner with all the tools and guidance necessary to
be proficient in temporary skeletal anchorage for quality
patient care.
Why Orthodontists Should Place
Temporary Anchorage Devices
The most important factor affecting the success
of miniscrew treatment is the orthodontist's grasp
of the biomechanics necessary to produce the
desired outcome. The success of this outcome is
predicated on the precision of the miniscrew
placement, which then begs the question:
Who should place miniscrews?
Only the orthodontist has the training and
experience in biomechanics necessary to
determine how even a millimeter of difference in
the placement of a miniscrew can change the
outcome of a given case. This, compounded by
the need for immediate attachment and the
replacement of a miniscrew if it fails, points to the
orthodontist as the specialist best suited to place
the miniscrew. This is not to say that other dental
specialists cannot or should not place miniscrews
for orthodontic anchorage, but if they do, the
orthodontist must be prepared to manage the
consequences of miniscrew misplacement and
failure. These outcomes happen to everyone on
occasion, but when addressed wholly in the
orthodontic office, the patient ultimately benefits.
The purpose of each of the VectorTAS design
elements and this workbook is to provide
orthodontists with the armamentarium and skill
sets required for miniscrew placement, and
assist them in developing the confidence and
competence to place miniscrews themselves.
By offering tools that take the ambiguity out
of positioning, placing, and activating
orthodontic miniscrews, orthodontists every-
where will be able to take advantage of this
remarkable technology.
03
SECTION I
The VectorTAS System
SECTION I: The VectorTAS System
Meet the VectorTAS Team
One of the key philosophies behind the development of VectorTAS was to design and build an orthodontic-specific implant
system at the direction of a team of orthodontists with distinguished and varied clinical experience.

JAMES HILGERS, DDS, MS, MISSION VIEJO, CA

Dr. Hilgers is one of the most widely esteemed clinicians in orthodontics today. He is an internationally
recognized lecturer, teacher, author and mentor, bringing 35 years of varied clinical experience to the
VectorTAS team, including several years of experience with miniscrew temporary skeletal anchorage.
He has published over 100 articles in scientific and clinical journals, has given seminars throughout the
Americas, Europe and Asia, and has been a major essayist at 12 national meetings of the American
Association of Orthodontists.

JOHN GRAHAM, DDS, MD, LITCHFIELD PARK, AZ

Dr. Graham is one of only a few orthodontists in the U.S. who is also a licensed physician and trained in
oral and maxillofacial surgery. He has considerable clinical experience in miniscrew temporary orthodontic
anchorage and has multiple publications in books and journals on the subject. His understanding of
craniofacial growth, facial aesthetics and jaw surgery offers a unique perspective to the VectorTAS team.
Dr. Graham is a Diplomate of the American Board of Orthodontics, Past President of the Arizona
Orthodontic Association, and an Adjunct Associate Professor at the University of the Pacific Arthur A.
Dugoni School of Dentistry.

NICOLE M. SCHEFFLER, DDS, MS, BOONE, NC

Dr. Scheffler is a strong proponent of evidence-based orthodontics. What she brings to the VectorTAS team
is her considerable experience in research and clinical use of miniscrew temporary skeletal anchorage.
A Diplomate of the American Board of Orthodontics and in private practice with Dr. Michael Mayhew
in Boone, North Carolina, Dr. Scheffler also serves as an Adjunct Associate Professor at the University of
North Carolina (UNC) where she teaches, researches and oversees cases that utilize temporary skeletal
anchorage and self-ligation.

STEPHEN TRACEY, DDS, MS, UPLAND, CA

A proponent of technological innovation for greater efficiency and effectiveness of care, Dr. Tracey is
widely recognized as a pioneer in the design and use of emerging orthodontic technologies, including
cone-beam computed tomography. He holds a U.S. patent for an orthodontic device and was the first
orthodontist to receive certification from the Academy of Laser Dentistry for the use of soft-tissue lasers. He
and Dr. Hilgers were early proponents of miniscrew temporary orthodontic anchorage and, in order to
ensure its clinical efficacy and develop its recommended protocols, were the first clinicians to volunteer
their time and talents to the development of VectorTAS.

07
 More Than a Miniscrew
A Comprehensive, Integrated System
The design philosophy behind VectorTAS was to create a
complete orthodontic-specific system – not just a
miniscrew – by spending the time and energy necessary to
develop all the aspects required for an integrated
approach. The VectorTAS design requirements were three:
simplicity, design intelligence and educational support.
Simplicity – Ensure every clinical need is addressed
and that each aspect of the system works easily and
effectively in the orthodontic environment.
Design Intelligence – Build each component of
the system to ensure the greatest possible efficiency
for each.
Educational Support – Develop a clinical workbook
that provides clinicians guidance in treating the most
typically seen cases.
VectorTAS Atlas
08
Simplicity
The VectorTAS Atlas
Selecting the correct miniscrew for the specific case
at hand and determining its ideal position in the oral
cavity is critical to assuring successful temporary skeletal
anchorage. Factors such as cortical bone thickness,
interradicular space availability and soft-tissue thickness all
play important roles in determining which miniscrew best
suits a given location.
One of the key differentiators of VectorTAS is the guidance
it provides clinicians in choosing the correct miniscrew for
each particular anchorage need. This approach minimizes
the chance of miniscrew failure. For ease in matching
a miniscrew with its ideal implant site, the color of each
corresponds with its recommended placement area
designated on the proprietary VectorTAS Atlas, which
takes into consideration bone type and bone density,
interradicular space and tissue depth.
The Atlas and its corresponding color-coded miniscrews
serve only as a guide. As the clinician's proficiency in
miniscrew placement increases, so too will the placement
options for each screw in VectorTAS.
Color Recommended Implant Sites
Facial Surface – Maxillary/mandibular
alveolar ridge (mesial to cuspid),
mandibular symphysis
Facial and Lingual Surfaces –
Maxillary/mandibular alveolar ridge
(mesial to second molar)
Retromolar Area
Infrazygomatic Crest
The proprietary VectorTAS Atlas eliminates placement
guesswork by matching the color of each VectorTAS
miniscrew with its ideal anatomical and
biomechanical implant site.
MADAJet XL*– Painless, Needle-Free Anesthesia
Since orthodontists hate needles almost as much as their patients, the MadaJet XL is the perfect companion to
VectorTAS. The MadaJet deposits 0.1 cc of local anesthesia submucosally for a more profound anesthetic effect than
a topical alone can deliver.

Color Recommended Anesthesia by Site(s)

Topical + MadaJet XL

Topical + MadaJet XL
Simple to use.
Virtually pain-free.
Topical + MadaJet XL
No needles; no disposal or safety issues
associated with needles.
Topical + Supplemental injection Excellent patient acceptance for over 20 years.
may be necessary

“The VectorTAS kit is extremely well thought out – from the color–coded screws down to
the intuitive packaging. I’m elated over how easy this kit makes placing miniscrews ”
– Stuart Frost, DDS

†
10-Patient Starter Kit –
One-Stop Shopping
Includes all components required
to treat up to 10 patients.

Miniscrew assortment.
Driver and tips.
Spring assortment.
Crimpable posts.
Initiators.
Tissue punches.
Instrument sterilization
cassette.
Technique Guide.

* MadaJet XL is a trademark of Mada, Inc.

†
MadaJet needle-free anesthetic delivery not included

09
 Design Intelligence
The VectorTAS Miniscrew
Over two years in the making, the VectorTAS miniscrews are designed with elegant form
and function for maximum reliability and patient comfort. Every element has been
developed with clinician-tested, research-supported features to provide greater strength
and varied attachment capabilities.

Eyelets for easy and

effective indirect
anchorage ligation

Tissue-suppression
stops to discourage
tissue overgrowth

Smooth and polished

transmucosal collars
help to minimize the
chance of infection

Asymetric buttress
threads for enhanced
pullout strength

Dual-cutting threads
remove bone debris in
higher density bone

10
 Unique Delta-Shaped Head
• Eases loading and removal via alignment with delta-shaped eyelet of auxiliaries.
• Maximizes patient comfort via smooth rounded edges.
• No bracket head corners, trailer–hitch heads, screwdriver grooves or other potential
sources of cheek or lip irritation.
• Maximizes retention by capitalizing on unique geometric undercuts.
• No archwire slots, which can cause unwanted force moments.

Matching Delta Geometries for Self-Ligation

• Unique mating geometry between miniscrew head and attachment eyelet offers
simple seating and removal.
• Slight turn locks attachment into place.
• Offers mid–treatment adjustment without removing attachments.

Dual-Action Driver Tip

• Seats fully over head of miniscrew with friction grip for easy retrieval from the sterile
packaging and secure transfer and placement.
• Loose fit for snugging up without removing attachments.

Eyelet for Optional Ligation

• Oval .028 x .020 eyelet for simple and effective indirect anchorage ligation.

Tissue Suppression Stop

• Keeps attachments away from tissues to help prevent irritation and overgrowth.
• Provides valuable visual cue for determining when the miniscrew is engaged to the appropriate depth.

Hygienic Transmucosal Collar

• Provides hygienic, tissue-friendly transition from miniscrew threads to miniscrew head.
• Lengths vary specific to likely soft-tissue depth at recommended location to minimize infection.

Advanced Thread Design

• All self-tapping and self-drilling.
• Requires only light to moderate pressure.
• Minimizes the need for tissue punches.
• Simple pilot notch via VectorTAS Initiator is all that's required for areas of dense cortical bone or hard-to-access areas.
• Pitch, lead, size and depth optimized and clinically tested for level of excellence second to none.
• Sharp asymmetric buttress threads provide insertion ease with strong pullout resistance.

11
 Thread–Forming/Cutting Chart
Color Diameter Collar Tip Recommended Implant Sites
Thread Facial Surface –
1.4 mm 1.4 mm Maxillary/mandibular alveolar ridge
forming
(mesial to cuspid), mandibular symphysis

Thread Facial and Lingual Surfaces –

1.4 mm 1.4 mm Maxillary/mandibular alveolar ridge
forming
(mesial to second molar)

Thread
2.0 mm 2.0 mm Retromolar Area, External Oblique Ridge
cutting

Thread
2.0 mm 2.0 mm Infrazygomatic Crest
cutting

Thread–Forming Design Thread–Cutting Design

• Ideal for areas of thinner bone. • Ideal for areas of thick, dense bone, which
• Creates intimate purchase requires cutting because of decreased
stress adaptation.
when cortical bone adapts to
• Dual-cutting threads remove bone debris to
hoop stress.
aid in advancing screw into bone.
• Decreases bone stress for increased success.

The VectorTAS Auxiliaries

VectorTAS is more than just a miniscrew. It includes TAD-specific attachments and appliances developed specifically
for the vectors and forces required in temporary anchorage.

Single-Delta Ni-Ti Coil Spring Double-Delta Ni-Ti Coil Spring

Coil Spring Attachments

• Delta-shaped eyelet matches screw head for ease of loading/unloading. Helps avoid rotational moments on the screw.
• Unique swivel mechanism eliminates undesirable torsion forces associated with loading/unloading springs. Allows spring
freedom to rotate to desired force vector.
• No need to ligate.
• Available in a variety of lengths and force levels.

Crimpable Post
• Clinically robust to withstand clinical forces.
• Clinically adaptive, offering multiple force vectors.
• Crimping option offers flexibility.
• Anti-tip mechanism minimizes wire friction.
• Labial–lingual adjustment allows post to be bent away
from gingiva, which minimizes tissue impingement.
• Flat profile ensures patient comfort.

12
Educational Support
A number of VectorTAS courses are offered by Ormco each year in major cities around the world. With discussions
led by industry veterans, these hands-on and highly interactive courses provide attendees with the clinical
information they need to achieve a wide range of orthodontic movements using temporary skeletal anchorage.

• Evidence-based advantages for the proper and rational use

of temporary anchorage devices in orthodontics.
• How to use VectorTAS to achieve a wide range of
orthodontic movements.
• How to easily and painlessly place and remove VectorTAS
miniscrews and attachments in your practice.
• How VectorTAS can increase your efficiency by shortening
treatment times and make a positive difference in
your practice.
• How to optimize temporary anchorage with passive self-
ligating mechanics.
• How to increase your conversion rate by enhancing your
practice with VectorTAS.

What Doctors Are Saying About the VectorTAS Courses

“The VectorTAS course demystified the miniscrew concept. I

now feel comfortable using the system in my office.”

“The VectorTAS course provided the needed hands-on

practice and education so that I can place
miniscrews in my office with better results.”

For a list of upcoming VectorTAS seminars, visit www.ormco.com/VectorTAS.

13
SECTION II
Placement Procedures
SECTION II: Placement Procedures
Anatomical Considerations for Temporary Anchorage Placement
VectorTAS provides specific guidance on how to match the
appropriate miniscrew to its ideal placement site, which
fosters greater success by taking the guesswork out of
miniscrew selection and positioning. The recommendations
were developed from information derived from 3-D cone-
beam scans. In evaluating potential locations for the
placement of miniscrews for skeletal anchorage, several
key anatomical factors were considered: cortical bone
thickness and availability, soft-tissue thickness and the
possibility for neurovascular and sinus encroachment.
Other considerations included the fact that the
interradicular space in the suggested region is sufficient;
visual access, good; and the force vectors, favorable.
Since the color-coded VectorTAS Atlas and miniscrew
placement recommendations address cortical bone and
soft-tissue considerations as well as space, access and
force vectors, the issues addressed in this section will cover
the other matters.
Neurovascular Considerations
In order to avoid neurovascular encroachment when
designing a treatment strategy for miniscrew placement,
be cautious of five specific locations (three of which are
located in the palate):
• The incisive canal – the area in the palate immediately
adjacent to the incisive papilla behind the maxillary
central incisors.
– The incisive canal communicates from the floor of
the nasal cavity into the incisive fossa, transmitting
the nasopalatine nerves and branches of the
greater palatine arteries.
• The two greater palatine foramina – the area on either
side of the posterior palatal vault.
– Generally speaking, each foramen is adjacent to
the second molar near the transition of the
horizontal palate to the alveolar process.
• The two mental foramina – generally located between
the root apices of the mandibular premolar teeth
below the depth of the labial vestibule.
16
Maxillary Sinus Considerations
In most cases, the maxillary sinus closely approximates
the molar root apices. Pneumatization may bring the
sinus walls lower than the apices themselves, a finding
readily demonstrated on panoramic radiography.
Applying slow, light, continuous force fosters sinus
remodeling during active tooth movement. Inadvertent
maxillary sinus membrane perforation of 2 mm or less will,
in nearly all instances, spontaneously heal soon after the
miniscrew is removed.
General Contraindications
General contraindications for temporary skeletal
anchorage include those situations where the risks of
proceeding with miniscrew placement are greater than
the proposed benefits. Such contraindications include
but are not limited to the following issues, which can be
categorized as absolute or relative.
Absolute contraindications include:
• Disturbances of bone physiology such as severe
osteoporosis, cancer or bisphosphonate treatment.
– Intravenous bisphosphonate therapy is an absolute
contraindication due to the increased risk for
osteonecrosis of the jaw, while oral bisphosphonate
therapy is a relative contraindication.
– As this workbook goes to press, current research
points to the possibility that some patients on
chronic oral bisphosphonate therapy might also be
at slight risk for the development of osteonecrosis
of the jaw.
Relative contraindications include:
• Patients with poor hygiene.
• Smokers.
Troubleshooting
Most complications encountered during the placement
and use of miniscrews are minor and easily manageable.
A full discussion of these issues and their treatment goes
beyond the scope of this workbook; however, three will be
briefly addressed: root impingment, tissue irritation and
tissue overgrowth. Clinicians are encouraged to study the
available literature for a complete understanding of the
topics.
Root Impingement. Root impingement encompasses both
root perforation and damage of the periodontal ligament
(PDL). As of the writing of this workbook, the literature
suggests that permanent damage to teeth by either root
perforation or PDL damage via miniscrew placement is
unlikely. See the bibliography at the end of this page.
Tissue Irritation. The clinician must be acutely aware of
potential gingival irritation either from the miniscrew or
the auxiliary attached to it. Evaluate proper miniscrew
emergence prior to placement of auxiliaries in order to
assure that cheek and gingival tissues are free from
irritation. After applying the desired auxiliary, evaluate
the gingival tissue again to ensure that it is clear from
impingement. Educate the patient about how to maintain
proper hygiene around both the miniscrew and the
attachments, as well as what constitutes the necessity of
contacting the practice for an emergency appointment.
Tissue Overgrowth. While uncommon with VectorTAS,
tissue overgrowth, if it occurs, can prove problematic
when changing attachments and removing miniscrews.
In instances where gingival overgrowth occurs, applying
a topical anesthetic, followed by minor curettage, is
typically all that is required. The preferred method for
a minor gingival curettage procedure such as this involves
a diode laser.
When the Uncommon Becomes Common
One of the most exciting aspects of miniscrew anchorage
is the marvelous world of opportunity that awaits the
clinician confident enough to utilize miniscrew temporary
anchorage. Once the predictable, pain-free placement
of orthodontic miniscrews becomes routine for the
clinician, skeletal anchorage becomes another reliable
component of the routine orthodontic armamentarium.
The opportunities are endless: correcting class
discrepancies, tooth impactions, cants and open bites,
uprighting, retracting, protracting, segmental intrusion and
extrusion and single anterior tooth replacement, to name
a few. To be clear, miniscrew skeletal anchorage is not
appropriate for certain types of cases, but with the
addition of miniscrew temporary skeletal anchorage,
treatment options have never been greater.
Bibliography
Borah GL, Ashmead D. The fate of teeth transfixed by osteosynthesis screws.
Plast Reconstr Surg 1996; 97:726-9.
Fabbroni G, Aabed S, Mizen K, Starr G. Transalveolar screws and the
incidence of dental damage: a prospective study. Int J Oral Maxillofac Surg
2004; 33: 442-6.
Asscherixkx K, Vannet BV, Wehrbein H, Sabzevar MM. Root repair after injury
from mini-screw. Clin Oral Impl 2005; 16: 575-78.
17
 Technique Guide
Evaluate root proximity and bone availability with a panoramic radiograph.

STEP 1 – PREPARE INSERTION SITE

• Have patient rinse for 30 seconds with 0.12% chlorhexidine gluconate.
• Dry gingival tissues.
• Apply topical anesthetic for a minimum of two minutes. Rinse or wipe thoroughly.
• Administer two deliveries of local anesthetic with MadaJet XL.Supplement with infiltrative anesthesia in
areas of thicker tissue as needed.
• In areas of mobile mucosa, use a tissue punch.
• In areas of dense cortical bone, use the provided Pilot Notch Initiator.

STEP 2 – GRIP DRIVER PROPERLY

• Grip driver with its butt firmly seated in your palm, forefinger and thumb on turning shank.

STEP 3 – RETRIEVE SCREW VIA FRICTION GRIP

• Peel lid open on VectorTAS packaging tube and hold tube in one hand.
• Keep tube upright as sterile screw is freely suspended in tube.
• Grasp driver in opposite hand, aligning and pressing it into head of screw.
• Pull screw straight back and out of tube.

STEP 4 – INSERT MINISCREW INTO GINGIVA

• Press screw tip firmly through gingival tissue and seat against bone.
• Evaluate long axis of screw, ensuring proper trajectory between tooth roots. Confirm proper distance
from point of activation.
• Advance screw with firm, constant pressure. Do not allow screw to wobble, which can widen hole and
increase chance of failure. Observe the threads of the miniscrew closely as they advance into the
gingival tissue. Each thread should disappear, turn by turn. The first indication that a miniscrew has the
potential to contact a tooth root is the lack of thread advancement into the gingiva.
• Stop engagement when driver makes contact with tissue.
• Ensure secure engagement. Grip screw head with cotton pliers and move back and forth. If mobility is
detected, remove screw and replace nearby.
• Have patient rinse again for 30 seconds with 0.12% chlorhexidine gluconate.
IF INCREASED RESISTANCE IS FELT WHEN ADVANCING MINISCREW... redirect the trajectory of the screw if its
conical apex has not completely entered bone. As the miniscrew advances, you may or may not feel a drop
into medullary bone. The feeling of the drop is not as critical as the feeling of constant advancement without
an increase in resistance. If you feel an increase in resistance, it is prudent to redirect the miniscrew away from
any potential contact with tooth roots. Note: Redirecting a miniscrew already in bone is
recommended only if the full diameter of the miniscrew has not been engaged in bone.
That is, if the tip of the miniscrew has not fully disappeared into tissue, the miniscrew may
be redirected without taking it out of the bone. If the full diameter of the miniscrew HAS
been reached, however, redirecting while still in bone may serve only to increase the
hole width. It would be prudent at this juncture to back the miniscrew out and place it in
a nearby location [Figure 1]. If you experience an increase in resistance after the tip has
completely entered bone (and the full diameter of the miniscrew has engaged in bone),
back the screw out and place it in a new location. Figure 1
STEP 5 – LOAD MINISCREW IMMEDIATELY AFTER INSERTION
Activating the miniscrew with auxiliaries immediately after placement provides the positive, continuous
force necessary to maintain the anchor in bone. Well-documented studies demonstrate an increase in the
density of bone immediately adjacent to miniscrews that exhibit continuous force application. Avoid
cyclical on-again, off-again forces due to the increased likelihood of miniscrew failure.
• Align delta-shaped eyelet of coil spring attachment with
delta-shaped head of screw [Figure 2].
• Secure spring to screw and turn slightly [Figure 3].
• Ensure force load does not exceed 300 gm.
• Ensure extension of coil springs does not exceed 300%, which
may cause eyelet-spring separation.
• Instruct patient to brush screw lightly with soft toothbrush and
0.12% chlorhexidine gluconate twice daily.
Figure 2 Figure 3

18
STEP 1 STEP 2

STEP 3 STEP 4

STEP 5

19
SECTION III
Common Cases
SECTION III: Common Cases

Clinical Case Management Overview

While temporary skeletal anchorage has a myriad of clinical applications, the seven cases outlined in the VectorTAS
Workbook represent the types of cases recommended for the initial application of this technology.

Direct and Indirect Biomechanical Approaches to Temporary Skeletal Anchorage

There are two categories of biomechanical activation for temporary skeletal anchorage: direct and indirect. Direct
activation entails connecting an attachment or attachments directly to a miniscrew. Direct activation is often the most
efficient means of clinical case management.

Employing an indirect setup is sometimes necessary in cases where there is not

sufficient space or access to the most desirable location to place a miniscrew that
would offer the necessary force vector for efficient tooth movement. Indirect
activation involves attaching the miniscrew to a tooth that is not involved in the
desired tooth movement. This type of biomechanical setup accomplishes two
important objectives: (1) It allows the force load to be shared between the
miniscrew and an additional tooth or teeth and (2) It offers a wider variety of
miniscrew placement locations in a given situation. Indirect anchorage allows the
orthodontist to employ traditional mechanics with the added advantage of a fixed,
immovable anchor.

Of the seven cases included in the first edition of the VectorTAS Workbook, two
include secondary indirect biomechanical setup recommendations. They are
provided specifically for the purpose of offering alternatives for cases in which there
may be limited space for a direct setup.

Clinical Expectations
There are a number of clinical expectations that apply to each of the cases employing Ni-Ti® coil springs for
activation. Rather than include them for each applicable case, this discussion is included here.
• Ni-Ti coil springs apply light, continuous forces so no reactivation is necessary unless the coils become inactive.
To prevent overloading the spring and/or the screw, the spring should not be activated more than 300% of
its length.
• The overall treatment time is dependent upon a number of factors, but treatment should progress faster than
conventional mechanics alone given that there is minimal chance of tipping, rotation or loss of anchorage.
• Maintain four- to six-week appointment intervals. At each appointment:
– Ensure springs are still active.
– Monitor progress of space closure.
– Ensure there is no interference that would impede movement.
– Ensure there is no tissue impingement.
– Ensure screws are firmly in place.
– If SLIGHT mobility is observed, gently tighten the screw with the driver. (With the
VectorTAS System, removing the attachment is unnecessary.)
– Ensure there is no tissue overgrowth, especially if miniscrew was placed on the
infrazygomatic crest.

Slight Mobility Does Not Mean Clinical Failure

Clinical failure is defined as the inability of the miniscrew to provide the necessary anchorage
required for the desired orthodontic movement. Slight mobility, even after tightening the
miniscrew, does not constitute failure; it simply requires heightened vigilance at each
appointment to evaluate the viability of the miniscrew as an effective anchor.

Patient Instructions/Expectations
• The patient's comfort level should be no different from that experienced after any other
routine orthodontic visit.
• Once home, if a patient continues to experience discomfort, conduct a follow-up visit to
ensure that there is no root or soft-tissue impingement and that the miniscrew is secure.

22
CASE
1
Indications
SPACE CLOSURE
BY ANTERIOR
RETRACTION

• To retract the anterior segment of teeth into an edentulous space.

• To retract anterior teeth after distalization of posterior teeth.

Benefits of VectorTAS vs. Conventional Mechanics

• Provides absolute anchorage for anterior segment retraction without the unwanted reciprocal effect
of posterior segment mesialization.
• Fully controls molar anchorage, avoiding the need for intraoral or extraoral devices (e.g., Class II elastics,
Nance holding arch, headgear).

Prior to Miniscrew Placement

• Align the teeth, consolidate any anterior spacing and complete arch leveling (except, perhaps,
in deep-bite cases) before retracting the anterior segment.
- Aligning the teeth sufficiently to employ a full-size stainless steel wire fosters sliding mechanics necessary
for efficient retraction.
- Attaching the miniscrew before the arch is level increases friction, which slows retraction and
could possibly overload the miniscrew.
• For deep-bite cases, it may be desirable to intrude teeth in conjunction with retraction.

Items Required for Placement

• Topical anesthetic.
• Supplemental local anesthetic delivered via MadaJet XL.
• VectorTAS Straight Driver.
• Two VectorTAS Orange 8 mm Miniscrews.
• Two VectorTAS 150 g 10 mm Single-Delta Ni-Ti Coil Springs.
• Two VectorTAS Crimpable Posts.

Direct Biomechanical Setup

MINISCREW PLACEMENT
TYPE POSITION
Maxilla: Between second bicuspid and first molar.
As high in the maxillary vestibule as possible while
8 mm remaining in attached gingiva.
This placement is recommended because the
interradicular space in this region is fairly large, visual
access is good, cortical bone thickness is acceptable
and force vectors are favorable.

ATTACHMENT
Ensure spring is parallel to archwire, unless an intrusive
vector is desired (i.e., for a deep-bite case). Place TYPE POSITION
crimpable post distal to the cuspid to prevent tissue
impingement of the canine eminence. Attach each coil spring from miniscrew high on the
VectorTAS Crimpable Post, which brings the retraction force
To reduce friction in the posterior, round the posterior close to the center of resistance, reducing friction and
segment of the archwire with a gray stone. 150 g fostering translational movement rather than tipping.
10 mm Crimping the coil spring eyelet on the Crimpable Post may
(Single or help prevent dislodgement.
Double)

23
 2
SPACE CLOSURE
CASE BY MOLAR
PROTRACTION

Indications
• To protract the posterior segment to close a space caused by tooth loss or a congenitally missing tooth.
• In a Class II case: To protract the mandibular posterior segment after obtaining ideal anterior occlusion. Obviates the
need for Class II elastics while maintaining good lip support in the maxilla.
• In a Class III case: To protract the maxillary posterior segment after obtaining ideal anterior occlusion. Obviates the
need for Class III elastics.

Benefits of VectorTAS vs. Conventional Mechanics

• Provides absolute anchorage for posterior segment protraction without the unwanted reciprocal side effect of
anterior tooth distalization.
• Achieves Class I molar relationships without elastics or affecting the torque and/or position of the anterior teeth of
the opposing arch.

Prior to Miniscrew Placement

• Complete leveling and aligning, including leveling the curve of Spee.
• In Class II and III cases, obtain Class I cuspids by idealizing the anterior segment first.
• Progress through the archwire sequence to a full size rectangular stainless steel archwire (for example, .019 x .025 if
using the Damon® System) to prevent tipping when protracting the posterior segment and to prevent tissue
impingement with the crimpable posts (left uncrimped in this case).

Items Required for Placement

• Topical anesthetic.
• Supplemental local anesthetic delivered via MadaJet XL.
• VectorTAS Straight Driver.
• Two VectorTAS Orange 8 mm Miniscrews.
• Two VectorTAS 150 g Single-Delta Ni-Ti Coil Springs (5 or 10 mm).
• Two VectorTAS Crimpable Posts (left uncrimped).
• Indirect Method: Eliminate the two VectorTAS Crimpable Posts. Add two ligature wires.

Direct Biomechanical Setup

MINISCREW PLACEMENT
TYPE POSITION
Between roots of cuspid and first bicuspid at the
mucogingival junction.
8 mm

ATTACHMENT
TYPE POSITION
Attach each coil spring from the miniscrew to the
VectorTAS Crimpable Post (left uncrimped).

150 g
Clinician may tie the second molar to the first molar or
5 or allow the second molar to drift behind the first molar.
10 mm

24
 Indirect Biomechanical Setup
MINISCREW PLACEMENT
TYPE POSITION
Between roots of cuspid and first bicuspid.

8 mm

ATTACHMENT
TYPE POSITION
Attach a ligature wire from each miniscrew to the first
Rationale for Indirect Approach bicuspid bracket.
The indirect biomechanical setup addresses Attach each coil spring from the first molar hook to the first
cases in which the vestibule is too shallow to 150 g
5 or bicuspid hook.
comfortably accommodate the VectorTAS
10 mm Clinician may tie the second molar to the first molar or
Crimpable Post.
allow the second molar to drift behind the first molar.

For rotational control, bond a button on the lingual surface of the molar being protracted and the lingual surface of the ipsilateral first bicuspid or
cuspid. Connect a light elastic chain to each button.
Note: Keep in mind that the force being applied to the lingual surface of the molar is an anti-rotational force, not a protraction force. Any
force greater than that required to prevent molar rotation will likely result in rotation and movement of the involved bicuspid or cuspid.
Indirect Approach: To reduce friction in the posterior, round the posterior segment of the archwire with a gray stone.

Clinical Expectations
• Be alert to anterior tooth flaring due to the archwire binding in the brackets during protraction.

25
 3
CLOSURE OF
CASE ANTERIOR
OPEN BITE

Indications
• To close an anterior open bite.
• To correct Class II or III malocclusions with open-bite tendencies where elastics would open the bite and
be contraindicated.
• To correct a reverse smile arc due to posterior tooth extrusion.

Benefits of VectorTAS vs. Conventional Mechanics

Conventional treatment of anterior open bites typically requires orthognathic surgery to impact the posterior maxilla, which
allows the mandible to autorotate, thereby decreasing the anterior facial height. The risks, postoperative morbidity and costs
of surgery have led to the use of alternative measures such as MEAW treatment, HPHG with comprehensive orthodontics,
posterior bite plates, magnets on opposing arches and anterior tooth extrusion. None of these alternatives are without
adverse side effects nor are most satisfactory in terms of stability.

With the VectorTAS, the clinician can obtain results similar to surgery without the risks and cost by intruding the posterior teeth,
thus allowing the mandible to autorotate and close the bite. With the VectorTAS, the same miniscrews used to close the bite
can be used to retain the intrusion and correct any AP discrepancies without typical extrusive dental side effects.

How the VectorTAS Open-Bite Splint Works

The VectorTAS approach relies on miniscrews placed bilaterally in the posterior maxilla from which Ni-Ti coil springs attach
directly to hooks on an open-bite splint. The splint fosters posterior intrusion from:
• The force of the Ni-Ti coils.
• The pressure of the tongue on the two transpalatal bars.
• The pressure of the bite on the acrylic covering the occlusal surfaces.

The transpalatal bars off the palate combine with the overlapping of acrylic on the facial and lingual surfaces of the teeth to
minimize possible side effects, such as buccal flaring. The splint can be placed at the beginning, during or toward the end of
treatment. Two archwire tubes may be imbedded in the facial acrylic of the splint so anterior alignment can occur while the
splint is in place.

Items Required for Placement: Items Required for Placement:

Class I Open Bite or Reverse Smile Arc Class II and Class III Open Bites
• Topical anesthetic. • Topical anesthetic.
• Supplemental local anesthetic delivered via • Supplemental local anesthetic delivered via
MadaJet XL. conventional injection.
• VectorTAS Straight Driver. • VectorTAS Straight Driver.
• Two VectorTAS Orange 8 mm Miniscrews. • VectorTAS Tissue Punch.
• Initial Appointment: Two VectorTAS 150 g • VectorTAS Pilot Notch Initiator.
Single-Delta Ni-Ti Coil Springs (5 or 10 mm, • Two VectorTAS Yellow 12 mm Miniscrews.
depending on length of attached gingiva). • Initial Appointment: Two VectorTAS 150 g
• Subsequent Appointment: Two additional Single-Delta Ni-Ti Coil Springs (5 or 10 mm,
VectorTAS 150 g Single-Delta Ni-Ti Coil Springs depending on length of attached gingiva).
(5 or 10 mm, depending on length of • Subsequent Appointment: Two additional
attached gingiva). VectorTAS 150 g Single-Delta Ni-Ti Coil Springs
• AOA VectorTAS Anterior Open-Bite Splint. (5 or 10 mm, depending on length of
attached gingiva).
• AOA VectorTAS Anterior Open-Bite Splint.
• Syringe with 30-gauge needle.*

*Supplementation of MadaJet XL anesthetic delivery via local infiltration may be necessary due to tissue thickness.

26
 Direct Biomechanical Setup

To keep force levels biologically compatible with efficient tooth

movement, load only one spring on each side of the splint
during initial activation. At a subsequent appointment, load the
second spring.

It is essential that when activated, the line of force of the springs do

not create an AP discrepancy.

MINISCREW PLACEMENT ATTACHMENT

Class type position type position
Class I Between the maxillary first and second Initial Appt: Attach one spring from each
Open Bite molars (or in some cases between the miniscrew to the hook on the splint directly
or Reverse first molar and second premolar) at or below it.
Smile Arc 8 mm slightly above the mucogingival 150 g Subsequent Appt: Use two springs in an
junction at a 45º angle. 5 or 10 mm
isosceles (symmetrical) triangle arrangement
depending
on length of
so there is no AP movement of roots toward
attached the miniscrews.
gingiva

Class II Somewhat posteriorly on the Initial Appt: Attach one spring from each
Open Bite infrazygomatic crest.* miniscrew to an anterior hook on the splint
to simultaneously intrude and distalize the
12 mm 150 g splinted teeth.
5 or 10 mm
Subsequent Appt: Add second spring from
depending
each miniscrew to another anterior hook on
on length of
attached the splint for continued intrusion and
gingiva distalization.

Class III Somewhat anteriorly on the Initial Appt: Attach one spring from each
Open Bite infrazygomatic crest.* miniscrew to a posterior hook on the splint
to simultaneously intrude and mesialize the
12 mm 150 g splinted teeth.
5 or 10 mm
depending Subsequent Appt: Add second spring
on length of from each miniscrew to another posterior
attached hook on the splint for continued intrusion
gingiva and mesialization.

Clinical Expectations
• Closure of the open bite usually occurs at a rate of approximately 1 mm per month.
• Typically, the splint should be left in place for six months, but the timeframe is dependent upon the extent of the vertical
and/or AP discrepancy.
• The patient's comfort level should be similar to that experienced with the delivery of other types of intraoral appliances;
however, some patients may require an adjustment period of approximately two weeks.
• Assure the patient that the appliance will at first appear to make the open bite worse but will close with time.

*Tissue overgrowth is often observed when placing miniscrews on the infrazygomatic crest. Ni-Ti coils are
recommended for continuous activation in case the head of the miniscrew becomes overgrown with tissue.

27
 4
MAXILLARY
CASE OCCLUSAL
CANT

Indication
• To correct an isolated occlusal cant.

Benefits of VectorTAS vs. Conventional Mechanics

• Can fully intrude the cant without the typical extrusive side effects in the non-affected side.
• The same miniscrew used to intrude the cant can be employed to retain the intrusion and extrude the mandibular teeth,
which closes the resulting open bite.

Prior to Miniscrew Placement

• Progress through the archwire sequence to a stainless steel archwire to provide sufficient rigidity during miniscrew use
and to maintain torque control.

Items Required for Placement

• Topical anesthetic.
• Supplemental local anesthetic delivered via MadaJet XL.
• VectorTAS Straight and Contra-Angle Drivers, as required.
• Two VectorTAS Orange 8 mm Miniscrews.
• Optional: One VectorTAS Orange 8 mm Miniscrew, if placing a miniscrew palatally.
• Two VectorTAS 150 g Double-Delta Ni-Ti Coil Springs, 5 or 10 mm depending on the location of the miniscrew.
• Optional to Prevent Buccal Crown Torque: One VectorTAS 150 g Single- or Double-Delta Ni-Ti Coil Spring (5 or 10 mm,
depending on length of vestibule).

Direct Biomechanical Setup

MINISCREW PLACEMENT
TYPE POSITION
Buccally.
• Miniscrew 1: Between first and second bicuspid
• Miniscrew 2: Between first and second molar
8 mm
High enough for mechanical advantage while avoiding mobile
mucosa, if possible.
If mobile mucosa is unavoidable, ensure that maxillary labial
frena are free from potential auxiliary or miniscrew impingement.

ATTACHMENT
TYPE POSITION
Attach each coil spring to the miniscrew, looping it down,
under, around the archwire and back to itself.

150 g
5 or
10 mm

28
 If buccal crown torque is an issue, there are two options to resolve it:
Option 1: Place a single opposing VectorTAS Orange 8 mm Miniscrew lingually at the midpoint between buccal miniscrews.
• Bond a button/cleat to the lingual of the maxillary bicuspid or first molar or bond a wire lingually to several maxillary teeth, much like a
lingual retainer.
• Attach a VectorTAS 150 g Single-Delta Ni-Ti Coil Spring (length depending on miniscrew position) from the lingual miniscrew to the
button/cleat or attach a VectorTAS 150 g Double-Delta Ni-Ti Coil Spring (length depending on miniscrew position) from the lingual miniscrew,
down, under the lingual archwire and back to itself.
Option 2: Incorporate buccal root torque into the archwire.
Note: Using transpalatal arches to counteract buccal crown torque is not recommended because of the potential extrusive forces that may be
encountered on the opposite side of the arch.

Clinical Expectations
• As the maxillary teeth intrude, it is quite common for a lateral open bite to occur.
– After the maxillary arch levels, close the open bite using the same miniscrew to extrude the mandibular teeth by
running interarch elastics from the miniscrew to the mandibular brackets.
– While lingual buttons/cleats may be placed on the mandibular teeth for extrusion, the lingually inclined mandibular
molars often require uprighting and lingual activation may not be required.

29
CASE
5 MOLAR
INTRUSION

Indication
• To intrude an overerupted tooth or group of teeth.

Benefits of VectorTAS vs. Conventional Mechanics

• One tooth or a group of teeth can be intruded without any extrusive side effects of adjacent teeth.
• Treatment can occur without bonding brackets to the entire dentition.

Items Required for Placement

• Topical anesthetic.
• Supplemental local anesthetic delivered via MadaJet XL.
• VectorTAS Contra-Angle Driver.
• Two VectorTAS Orange 8 mm Miniscrews.
• One VectorTAS 150 g 10 mm Double-Delta Ni-Ti Coil Spring.
• Optional: Light-Cure Composite
• Optional: Cleat or Button.

Direct Biomechanical Setup

MINISCREW PLACEMENT
TYPE POSITION
In attached gingiva as far away from the occlusal surface
of the tooth to be intruded as possible.
8 mm Buccal: As close to the mucogingival junction as possible,
mesial to mesiobuccal root.
Palatal: Distal to palatal root.

ATTACHMENT
TYPE POSITION
Attach the coil spring from the buccal miniscrew, stretch it
obliquely over the occlusal surface of the tooth and attach
it to the palatal miniscrew.
150 g To maintain spring, flow composite liberally over the
10 mm activated spring on the occlusal surface and light cure.

If you are concerned about the patient biting through the coil spring, bond a cleat or button to the molar's lingual and buccal surfaces. Attach
the coil spring from the miniscrew head directly to the cleat/button.

30
 6
CANINE
CASE IMPACTION/
ANKYLOSIS

Indication
• To assist in the extrusion of a tooth or a group of teeth when normal eruption has failed either due to impaction, ankylosis
or primary failure of eruption.
Benefits of VectorTAS vs. Conventional Mechanics
• Tooth extrusion may be attempted without any unwanted movement of the adjacent teeth, precluding potential arch
deformation when ankylosis (even partial) is discovered.
• Treatment can progress independent of adjacent dentition.
• Extrusion may be initiated prior to progression into heavy archwires.
• Teeth subject to ankylosis or primary failure of eruption may possibly be extruded into proper occlusion without the need
for a block osteotomy.
Items Required for Placement
• Topical anesthetic.
• Supplemental local anesthetic delivered via MadaJet XL.
• VectorTAS Driver.
• One VectorTAS Orange 8 mm Miniscrew.
• One medium-weight elastomeric or rigid bondable hook, depending on the setup.

Direct Biomechanical Setup

MINISCREW PLACEMENT
TYPE POSITION
In the mandibular arch where a vertical vector can be
established from the cuspid with an elastomeric or
elastic chain.
8 mm

ATTACHMENT
TYPE POSITION
If cuspid crown is partially Attach the elastic from the
erupted: Medium-weight miniscrew to a cleat bonded as
elastomeric. gingivally as possible to the facial
surface of partially erupted cuspid.

If cuspid crown is unerupted: Attach the elastic from the

Bond a rigid hook directly to miniscrew directly to the rigid hook
the tooth. on the tooth.

Clinical Expectations
• If, after several weeks of continuous elastic wear, ligature tie a mandibular tooth to the miniscrew and hook the elastic to
the ligated tooth and increase the elastic force.
• Cuspid immobility after several weeks of applying higher elastic force indicates that frank ankylosis exists and alternative
treatments (such as cuspid extraction or luxation) should be explored.

When ankylosis is suspected, luxation or the partial elevation of a tooth from its surrounding bone is often beneficial to fracture and free
the tooth from its bony fusion. Luxation may be done at the time of exposure, bonding or as a separate procedure.

The premise with luxation via miniscrew temporary skeletal anchorage is that any areas of ankylosis on the tooth root will be fractured,
thus freeing the tooth from its bony fusion. The force generated on the canine is independent of the archwire, which fosters uninterrupted
progression of treatment mechanics.

31
CASE
7 MOLAR
UPRIGHTING

Indication
• To upright a mesially inclined molar due to ectopic eruption of the molar or to premature tooth loss of an adjacent tooth.

Benefits of VectorTAS vs. Conventional Mechanics

• Uprights molar without any unwanted reciprocal movements (i.e., extrusion and/or mesialization) of the adjacent teeth.
• Treatment can occur without bonding brackets to the entire dentition.

Items Required for Placement

Direct Approach
– Topical anesthetic.
– Supplemental local anesthetic delivered via MadaJet XL.
– VectorTAS Contra-Angle Driver.
– VectorTAS Tissue Punch and VectorTAS Initiator.
– One VectorTAS Blue 10 mm Miniscrew.
– One VectorTAS 150 g 10 mm Single-Delta Ni-Ti Coil Spring.
– One Cleat.
– Syringe with 30-gauge needle.*
Indirect Approach
– Topical anesthetic.
– Supplemental local anesthetic delivered via MadaJet XL.
– VectorTAS Contra-Angle Driver.
– One VectorTAS Orange 8 mm Miniscrew.
– One double molar tube.
– One bondable tube or bondable eyelet.
– TMA® or stainless steel wire.
– TMA uprighting spring.
– Dental composite for bonding.

Direct Biomechanical Setup

MINISCREW PLACEMENT
TYPE POSITION
In retromolar region immediately distal to tipped second
molar. Such placement maintains rotational control.
10 mm

ATTACHMENT
TYPE POSITION
Attach coil spring from the miniscrew to the
cleat/button bonded to the molar, which is placed
as mesial as possible.
150 g
10 mm

To maintain rotational control, align the screw with the central groove of the tipped molar as much as possible.
To control the vertical aspect, ensure the head of the miniscrew is positioned slightly below the occlusal surface of the molar, which helps prevent
the molar from being extruded into traumatic occlusion during uprighting. You may also bond a bracket in its ideal position to the tipped molar and
actively engage the stainless steel archwire.
To prevent the molar from colliding with the screw and inhibiting molar uprighting, ensure the screw is placed outside the path of tooth movement.

*Supplementation of MadaJet XL anesthetic delivery via local infiltration may be necessary due to tissue thickness.

32
Indirect Biomechanical Setup
Rationale for Indirect Approach
The indirect biomechanical setup
addresses situations of inaccessibility of the
retromolar region (i.e., a difficult angle) or
when a third molar is present.
MINISCREW PLACEMENT
TYPE POSITION
Immediately mesial to molar being uprighted.
8 mm
ATTACHMENT
TYPE
TMA or SS wire bent around
head of miniscrew and bonded
in place. Opposing end looped
and bonded to crown of first
molar (anchor tooth) to
immobilize it.
POSITION
TMA uprighting spring bent either
chairside or indirectly with aid of
dental cast. Spring is designed to
engage in double molar tube on
anchor tooth and is then activated
via bonding to occlusal of
impacted tooth.
33
SECTION IV
Marketing
SECTION IV: Marketing

Communicating VectorTAS to Staff, Referring Dentists and Patients

One of the first questions most clinicians ask themselves when • Allay fears.
considering the use of TADs is how they will present them to – Before starting any explanation, make sure you
their patients and others. The objective of this section of the explain that having VectorTAS positioned and
wearing it will not hurt. Reiterate that point again
VectorTAS workbook is to provide sufficient material for enlisting
mid-discussion.
your staff, your referring dentists and their staffs, as well as your
– Remember: Patients will tune out if you talk about
patients, in the acceptance of this technology so that from a
VectorTAS before you tell them that it won't hurt, so
communications standpoint, the implementation process goes you must be clear about that first.
as smoothly as possible [Figure 1]. • Avoid the words screw or miniscrew.
– Use the term “anchor,” “temporary
RECOMMENDED COMMUNICATION SUPPORT MATERIALS anchorage device” or “TADs,”
Referring Dentists which sounds friendlier.
Audience Staff Patients
and Staff – Some doctors use the word “pin”
Introductory Letter X or “minipin,” but even these words
can conjure a negative
FAQs X X X
connotation and pain.
Scripts X X X
• Use a VectorTAS typodont to
PowerPoint Presentations X
demonstrate TADs.
Figure 1
– Never use actual case photographs. Patients are
Point Out the Advantages of TADs averse to seeing simple orthodontic cases showing
Many of the advantages of VectorTAS are the same for each saliva and tissues. A photograph of a TAD case may
of your audiences – your staff, your referring dentists and their frighten them out of using the procedure.
staff and your patients. You need only translate those • Have VectorTAS placed in your own mouth to be able
advantages to benefits for their unique perspective. to give a personal testimonial.
– Many orthodontists practice on one another and
Talking Points for Presenting VectorTAS even staff when learning to place VectorTAS. If you
Patients, staff and referring dentists will readily accept and/or any of your assistants have them placed,
VectorTAS if you present it with confidence. Conveying the you'll be able to give personal testament to its
comfort.
benefits of VectorTAS should follow the basic tenets of all
effective persuasive communication. • Provide patient testimonials via handouts or as text
• Present VectorTAS at the consultation. and/or video on your Web site, etc.

– Do not wait until you're ready to employ VectorTAS • Encourage word-of-mouth marketing via successfully
during treatment. treated patients.
– Reintroduce the concept when you are ready to place. – It may take a while to get comfortable with asking
patients to mention TADs when they share their
• Present VectorTAS as a solution to their problems, specific
orthodontic experiences with friends and family, but
to the individual audience.
you will soon. Since it's an innovative approach that
– Ensure that you couch the advantages and benefits in eliminates troublesome appliances, patients will feel
terms of how it solves a problem for them, not for you. comfortable mentioning that aspect when they
For example, one benefit to patients is how it will recommend your practice.
complete treatment faster. See Figure 2 for an
expanded list of benefits.
• Contrast with alternatives.
– Mention specific appliances that the patient won't have
to wear. Show pictures of those appliances, preferably
being worn.

36
 ADVANTAGES
No headgear, lip bumpers,
other auxiliaries. Fewer TPAs.
BENEFITS
Staff Dentist
Less inventory. Fewer and Less reliance on patient
shorter appointments compliance. Greater
success. Increases patient
satisfaction.
Patient
Speeds treatment. Greater
comfort. More aesthetic. Less
cumbersome treatment.
Drastically reduces compliance
required. Saves time and money.

Minimizes surgery. No surgery setup. Eliminates surgery-related Greater comfort. Eliminates

risks. Increases patient downtime associated with surgery.
satisfaction. Saves money.

Opens space for Simple treatment. Speeds up time to final Greater comfort. More aesthetic.
implants/bridges without restoration. Increases patient Saves time and money.
full bonding. satisfaction.

Closes space versus Simple treatment. Fosters more conservative Greater comfort. Eliminates
opening space for implant. dentistry. Increases patient significant dental procedures.
satisfaction. Saves time and money.

Intrudes teeth versus Fewer appointments to Fosters more conservative Eliminates significant dental
eliminating tooth structure complete intrusion. dentistry. procedures. Healthier, greater
and bonding bridge. comfort. Saves time and money.

Figure 2

Bringing Your Staff on Board

As with instituting any new protocol, the success of Having clinical assistants attend one of the seminars that
implementing VectorTAS depends first on your staff Ormco offers will go a long way in allaying fears. Once they
embracing it. Once they understand and accept TAD use work with you to place VectorTAS and they and the rest of
and can articulate its benefits convincingly (which in large your staff see the benefits in action, their confidence will
part will come from getting comfortable with the placement grow and they'll soon be touting its praises. You can also ask
technique), you can then introduce the approach to your Ormco sales representative to do a Lunch 'n Learn for
referring dentists and patients in a way that fosters your staff or do one yourself based on the enclosed FAQ or
immediate acceptance. Your conviction for the benefits of use a PowerPoint presentation. Armed with an understanding
VectorTAS and leadership in this regard is the essential of the technique and its benefits, the proper terminology,
ingredient. Your staff members, especially your clinical staff, scripts and belief in the system, your staff members will have
will most likely see the advantages of VectorTAS as soon as all they need to handle these discussions with conviction.
you point them out. (Just saying, “No patient compliance
required, no TPAs, no Nances, no banding for headgear,”
may be enough.) If you're an early adopter of new
technology, your staff members have already proved
themselves open to change. Their greatest concerns will be:
• How to convey the advantages of VectorTAS
to patients.
• How to allay patients’ fears.
• How to keep their own apprehensions masked
during the first few procedures.

37
Introducing VectorTAS to Referring Dentists
Encourages Their Support
A letter introducing VectorTAS to your referring dentists
through a mass mailing is the most expedient way of
familiarizing them with the protocol. See Sample Referring
Dentist Letter in this section of the workbook. You
can include FAQs with the letter as well as any journal
articles you think pertinent. See Sample FAQs in this
section of the workbook.
Conducting a Lunch 'n Learn for your top tier of referring
dentists and their staffs and/or local dental study clubs is
also an excellent idea. Schedule a patient during the
Lunch 'n Learn to provide the most meaningful
educational experience. If you deliver a PowerPoint
presentation or provide handouts, use the VectorTAS logo
in your materials to brand the protocol. (The logo may be
downloaded by visiting www.ormco.com/VectorTAS.)
These communications will enlist their support in your
efforts rather than undermine them and, if handled
properly, will help distinguish your therapies as innovative
and patient-centered.
Patient Acceptance is Easy with the Right Words
Patient acceptance depends primarily on the conviction
with which you present the concept. Focus first on the
pain-free aspect of the protocol and its safety. The sample
scripts and FAQs included in this section provide the basis
for discussing the protocol with patients at the consultation.
The FAQs can easily be incorporated into a handout with
your logo and other pertinent information. Obviously you
won't be doing any direct marketing using TADs as the
basis, but on your Web site and in your general marketing,
you can promote the fact that you use cutting-edge
technology and don't use headgear. (You want to be
known as the “No Headgear” orthodontist.) Be sure to
include patient testimonials with your handouts and on
your Web site.
Make Patient Testimonials a Top Priority
Testimonials are a powerful means of communicating the
efficacy and comfort of the TADs. They also help your staff
with languaging. You can use them with the FAQs you give
patients, on your Web site and with the introductory letter
you send referring dentists.

If you follow up these communications with explanations

in your letters or e-mails explaining your shared patient
treatment plans and results, they will be reinforcing your
new technique with patients. While the protocol is still
new in your practice, it is also advisable (time permitting)
that you demonstrate the miniscrew treatment results to
your referring dentists (or at least the top tier) as soon as
you have them rather than waiting until the full treatment
is complete.

38
Patient Consultation Script
The following script may be of assistance to you as part of your consultation with patients about VectorTAS. This conversation will
most likely follow discussion of the diagnosis when you are presenting the treatment plan. Your Treatment Coordinator should
reinforce your messages later in the consultation with the patient and/or parent.
Communication Steps
Explain how TADs enable you to solve the patient’s problem
without the use of other auxiliary appliances like headgear.
Contrast TADs with less desirable alternatives like headgear by
showing pictures and emphasizing the benefits of TADs.
Avoid the word “miniscrew.” TAD sounds non-threatening, even
friendly.
Allay fears. Patients will tune out if you talk about VectorTAS
before you tell them that it won't hurt.
Use yourself or a staff member as a testimonial.
Use a typodont to demonstrate what VectorTAS looks like.
Reiterate the benefits of TADs by contrasting it with less
desirable alternatives like headgear. Finish with the greatest
patient benefit of all: faster treatment.
Provide patient testimonials.
Take an opportunity to ask the patient if he or she has any
additional questions. Provide a copy of the FAQ page from this
workbook if necessary.
Communication Examples
“In our practice we use a simple and comfortable orthodontic
appliance called a TAD. That means you don't need to wear
headgear to fix your bite.”
“You've seen people wearing headgear before, haven't you?
Here's a picture of a boy about your age wearing one. It's no
fun, I agree. Well, we can save you that trouble and
embarrassment while completing your treatment quickly and
easily with no pain.”
“Instead of headgear, we use something called a TAD, which
stands for temporary anchorage device.”
“The technique for putting the TAD in doesn't hurt. The TAD is a
tiny anchor that I will place between two of your upper back
teeth. I use a little numbing gel. There's no shot. Again, it
doesn't hurt.”
“I even had one put in myself just to make sure of that and I
can testify that it doesn't hurt one bit. And once it's in, you
forget it's there.”
“See what it looks like on this model? Tiny, huh?”
“This little anchor allows me to straighten teeth in ways I never
could before. In your case it will move your teeth without you
having to wear headgear – that uncomfortable contraption
you see in this picture. A TAD will also most likely make your
treatment go more quickly, because we won't have to rely on
your remembering to wear headgear.”
“Here are some testimonials we’ve received from patients who
have worn TADs. For example, this person indicated he did not
experience any pain, not even when the TAD was placed. He
even noted how exciting it was to experience a new way of
getting his bite fixed!”
“Do you have any questions? Good. Here is a list of FAQs that
addresses most questions asked by patients about TADs.”
39
Short Benefit Scripts
For Patient
We won't have to extract any teeth.
This will help us get your braces off much quicker.
You won't have to wear elastics. No hassle. No embarrassment.
We can intrude just this one tooth without you having to wear
full braces. Think of the money and time you will save.
Before TADs, there was no way we could intrude that tooth.
You would probably have ended up having to have a root
canal or maybe even an extraction and a bridge, which
means losing a lot of tooth structure on the adjacent teeth.
This treatment is truly revolutionizing orthodontics.
We can easily close that space instead of having you
experience the discomfort and expense of an implant.
40
For Referring Dentist
With VectorTAS we can easily open that space for the
implant she wants. She won't even need to wear full braces.
We can close that space so your patient won't have to have
an implant – a simple, cost-effective alternative that will
make him sing your praises to all his friends.
We can close that anterior open bite so your patient won't
have to have surgery. Save them that pain and expense
and they'll be your patients for life!
We can intrude that first molar that’s extruding into the
space below and probably save it from needing a root
canal and bridge.
Sample Referring Dentist Letter

Smith Orthodontics
Smith Orthodontics
12345 Any Street, Any Town, USA 12345
(123) 456-7890 www.website.com

Date

John Q. Dentist, DDS

1234 Main Street
Anywhere, USA 98765

Re: New Orthodontic Technology for Remarkable Results

Dear John,

We are now employing an advanced technology that is rapidly changing the way orthodontics is
practiced. It involves a uniquely designed miniscrew for use in temporary skeletal anchorage.

Miniscrews, also known as TADs (temporary skeletal anchorage devices), are made from medical-grade
titanium. When placed strategically in the mouth, they serve as stable anchors during orthodontic
treatment. Anchorage control is a critical factor in nearly every orthodontic case. Before TADs, treatment
suffered from unwanted reciprocal tooth movement in spite of our best efforts to counteract it with a
variety of uncomfortable and unsightly appliances.

TADs or temporary anchorage devices:

• Enhance patient comfort.
• Reduce the need for compliance.
• Shorten treatment times.
• Eliminate the necessity for troublesome appliances, such as headgear, facemasks and holding arches.
• Often allow us to avoid more costly and painful procedures such as extractions, endodontic therapy
and orthognathic surgery.

Perhaps best of all, the protocol to place TADs is safe and painless and we perform it chairside in our office
in just a few seconds.

The unique system I have chosen to use is VectorTAS, developed by a team of orthodontists and physicians
through Ormco, a premier orthodontic research and development company and one of the largest
appliance manufacturers in the world. VectorTAS is truly revolutionizing orthodontic treatment.

I would greatly appreciate the opportunity to meet with you soon so we can discuss how best to
incorporate TADs into our multidisciplinary treatment plans. I know that once you learn more about the
benefits of this important new protocol, you'll be as excited as I am about its applications. I will call you next
week to schedule an appointment.

Best regards,

John Smith, DDS, MS

41
 Patient FAQ
What is a TAD?
A TAD is a miniature screw that we position in the mouth. It serves as an anchor for moving specific teeth in the
most controlled and predictable way possible. TADs are made of a sterile medical-grade titanium alloy. They
eliminate cumbersome appliances (e.g., headgear) and allow us to treat certain cases that were nearly
impossible before this technique was refined. TADs also allow us to treat cases better and faster than ever before.
TADs are truly revolutionizing orthodontic treatment.

How exactly is the TAD positioned?

After numbing the area where the TAD is to be placed, we use gentle pressure to insert it through the gums and
into the bone between your teeth.

Having a TAD placed sounds painful. Should I be worried?

Absolutely not! While it's normal to assume that the procedure would be painful, it is actually pain-free. You may
feel some slight pressure during insertion but no pain. The entire procedure takes only a few seconds.

Do I need to get a shot?

No. There's an effective way of numbing the gums that is 100% pain- and needle-free. First, we apply a fast-
acting numbing gel where the TAD will be inserted. After the gel desensitizes the area topically, we power-spray
the gums with a small amount of local anesthetic that completely numbs it. The entire procedure is totally
pain-free.

Will it hurt after the anesthetic wears off?

No. Some patients say they feel a little pressure for a short period afterward. Only a few patients have reported
needing to use an over-the-counter medication such as acetaminophen or ibuprophen.

What if it aches the next day?

There is no call for alarm. Minor aching associated with new tooth movement is not only normal, but expected;
however, if you have concerns, simply call our office or the after-hours number we provide and we'll make an
appointment to see you. We'll probably suggest that you to take an over-the-counter remedy to lessen the ache.

What if the TAD or its attachment causes an irritation inside my cheeks or lips?
For immediate relief, you may be able to cover the attachment that is causing the irritation with a cotton swab
or a small amount of wax. Call the office or the after-hours number we provide and we'll give you instructions
and/or make an appointment to see you.

What if the TAD comes loose?

On occasion, a TAD might become a little loose. In most cases this minor mobility is nothing to be concerned
about; however, if you feel the TAD is excessively loose, or it is causing you discomfort, call the office and we'll
make an appointment to see you to determine if the amount of give is normal.

How do I keep it clean?

We'll give you a solution with which you will brush the TAD twice daily with a soft toothbrush.

How long will the TAD need to stay in place?

As the name implies, the anchorage device is temporary and is typically removed in a few months when it is no
longer needed to assist in tooth movement.

Will it hurt when you remove it?

No. Before we remove it we'll place numbing gel around the TAD and then back it out gently. The entire process
takes only a few seconds.

I've never heard of TADs before. Are they new?

Not really. Orthodontists have used TADs since 1983 and oral surgeons and orthopedists have used miniature
screws like this for decades longer. Recent refinements in the devices and the procedures for their use have
propelled the application of TADs to a heightened level in orthodontics. With TADs, orthodontic treatment options
have never been greater. We are proud to be at the forefront of this exciting technology and feel confidant that
your experience with it will be comfortable and the results exemplary.

42
APPENDIX

Informed Consent Form

The American Association of Orthodontists (AAO) consent document, “Informed Consent for the
Orthodontic Patient – Risks and Limitations of Orthodontic Treatment,” now covers the use of TADs.

To download the form, log in to www.AAOmembers.org. Select the “Practice Resources” link and then the
“Office Management” link.

The form is also available for purchase. To order, contact the AAO Order Department at
800-424-2841, ext. 222 or ext. 238, or send an e-mail to orders@aaortho.org.

Insurance Codes
The AAO has created three new insurance codes for TADs, effective Jan. 1, 2007:

• D7292 – Surgical Placement: Temporary anchorage device (screw retained plate) requiring surgical flap.
• D7293 – Surgical Placement: Temporary anchorage device requiring surgical flap.
• D7294 – Surgical Placement: Temporary anchorage device without surgical flap.

The TAD codes have been categorized as surgical codes. Because of this categorization, the cost of
TADs may not be deducted from an insured’s orthodontic lifetime maximum benefit.

As long as the flap is not raised, the placement of TADs should be covered. However, clinicians
are encouraged to review their insurance coverage for all the details.

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www.ormco.com 800.854.1741 714.516.7400 © 2007 Ormco Corporation