CLINICIAN’S CORNER

Clinical observations and success rates

of palatal implants
Karlien Asscherickx,a Bart Vande Vannet,b Peter Bottenberg,c Heiner Wehrbein,d and Mehran Moradi Sabzevare
Jette, Belgium, and Mainz, Germany

Introduction: Anchorage control is a challenge in orthodontics. Implants can be used to provide absolute
anchorage.The aim of this study was to evaluate the success rates of palatal implants used for various anchor-
age purposes. Methods: Thirty-four palatal implants were placed in 33 patients. In the adults (n 5 9), the
implants (n 5 9) were placed in the median palatal suture. In the adolescents (n 5 24), the implants (n 5 25)
were placed in the paramedian region. The implants were used to support a transpalatal arch, a modified distal
jet appliance, or a modified hyrax screw. An implant was considered successful if it could be used as planned
throughout the orthodontic treatment. The patients were asked to evaluate their pain perception after place-
ment and explantation procedures. Results: Three implants failed early (during the waiting period before
orthodontic loading, within 3 months after placement). During the orthodontic loading period, no implants
were lost. No statistically significant correlations were found between success rate and sex, age, primary
stability, placement site (median or paramedian), implant size, or palatal depth. Pain perception after surgery
was acceptable. The success rate of the palatal implants in this study was 91%. Conclusions: Palatal
implants are a reliable method of providing absolute anchorage control in a variety of patients for different
indications. They can be loaded both directly and indirectly. (Am J Orthod Dentofacial Orthop
2010;137:114-22)

A
nchorage control is a challenging problem in
orthodontics. Several solutions have been pro-
posed and tested. Grouping several teeth as
anchorage has been suggested.1 Burstone and Kuhl-
berg2 tried to improve anchorage control by making
use of the fact that tooth tipping is easier to achieve
than axial or root movement. Extraoral anchorage has
been suggested when anchorage in the dental arch is
insufficient. None of these solutions has proven to be
absolutely successful. For this reason, implant-like
devices have been introduced in orthodontics for abso-
lute anchorage. They are referred to as orthodontic
implant anchors or temporary anchorage devices.3
a
Lecturer, Dental Clinic, Department of Orthodontics, Vrije Universiteit
Brussel, Jette, Belgium.
b
Professor, Dental Clinic, Department of Orthodontics, Vrije Universiteit
Brussel, Jette, Belgium.
c
Professor, Dental Clinic, Department of Operative Dentistry, Vrije Universiteit
Brussel, Jette, Belgium.
d
Professor, Klinik für Kieferorthopädie, Universitätsklinik Mainz, Mainz,
Germany.
e
Professor, Dental Clinic, Department of Periodontology, Vrije Universiteit
Brussel, Jette, Belgium.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Karlien Asscherickx, Vrije Universiteit Brussel, Dental
Clinic, Department of Orthodontics, Laarbeeklaan 103, 1090 Jette, Belgium;
e-mail, kasscher@vub.ac.be.
Submitted, September 2007; revised and accepted, February 2008.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.02.022
114
A placement site commonly used to provide anchor-
age with temporary anchorage devices is the palate,
which has been studied by several investigators.4,5
The midpalatal suture area seems especially to be an
ideal placement site, since it has both thin soft tissue
and thick cortical bone.4 This is interesting when a screw
is to be placed, since the main objective of an orthodon-
tic screw is to gain maximum retention (good quality
and quantity of bone) and prevent soft-tissue inflamma-
tion. Miniscrews can be placed nearly everywhere in the
mouth and also in the midpalatal suture area.
One temporary anchorage device designed specifi-
cally to be used in this region is the palatal orthodontic
implant anchor of the Orthosystem (Straumann, Basel,
Switzerland). Although not as popular as miniscrews, pal-
atal implants are gaining acceptance as an important alter-
native for achieving maximum intraoral orthodontic
anchorage.6 In adult patients, the median palatal suture
zone is the area of choice for placement of palatal im-
plants. In adolescents, however, the paramedian region
is preferred to avoid possible growth impairment of the
maxilla in a transverse direction by placing an implant
in the median palatal suture.7 The paramedian region
has been described as a suitable placement site for
implants.5,8 The site for palatal implants is standardized
(median or paramedian palate); this is a major advantage,
since a standard surgical procedure that is simple and eas-
ily controlled in all stages is essential for the success of an
implant.9 Various rates of success for implants have been
American Journal of Orthodontics and Dentofacial Orthopedics Asscherickx et al 115
Volume 137, Number 1

Table I. Composition of study group

Adolescent girls Adolescent boys Women Men

Patients (n) 11 13 8 1
Mean age 12 y 2 mo 13 y 7 mo 35 y 8 mo 47 y 5 mo
Age range 10 y 3 mo-14 y 6 mo 11 y 5 mo-15 y 6 mo 21 y 5 mo-53 y 2 mo 47 y 5 mo

Fig 1. A, Implant-anchored transpalatal arch to reinforce the maxillary first molars to distalize the an-
terior segment after extraction of the maxillary second premolars; B, transformation of the transpa-
latal arch, once a Class I occlusion is achieved in the canine region, to reinforce the anchorage
potential of the maxillary first premolars to mesialize the molars to establish a Class I molar relation-
ship; C, extraction sites of the maxillary second premolars almost completely closed.

reported. For dental implants, 5-year cumulative success
rates of 90% to 95% were reported10; success rates varied
from 70% to 90% for miniscrews11-15 and from 84.8% to
100% for palatal implants.16-19
The use of palatal implants is mainly indicated for
adult patients. However, more adolescents are reluctant
to wear extraoral appliances, with the result that compli-
ance is greatly reduced with these treatment options. To
avoid wearing extraoral appliances, children as young
as 10 years now receive palatal implants.
The aims of this study were to evaluate (1) the success
rate of palatal implants used for orthodontic purposes; (2)
whether the success rate of palatal implants can be corre-
lated to sex, age, primary stability, placement site (me-
dian or paramedian), form of the palate (wide or deep),
implant size, and type of suprastructure (loading type);
and (3) the patients’ pain after placement and removal.
The working hypothesis of this study was that a pal-
atal orthodontic anchorage implant is a safe and predict-
able therapeutic technique, applicable to many clinical
situations.
MATERIAL AND METHODS
The study group consisted of 32 patients, each with
1 implant, and 1 patient with 2 implants. They were con-
secutive patients, treated at the Dental Clinic of the
Department of Orthodontics at Vrije Universiteit Brus-
sel in Jette, Belgium, between October 1998 and May
2003, who had finished their orthodontic treatment.
Table I shows the composition of the group by sex
and age. A division was made between adolescent and
adult patients. The adolescent group comprised 24
patients, all under the age of 16 years. The adult group
comprised 9 patients, all above the age of 20 years.
Most patients had an Angle Class II malocclusion.
They were treated by extraction of the maxillary first
or second premolars or distalization of the maxillary
posterior segments. In the extraction patients, the
implants were loaded indirectly and provided anchorage
reinforcement for the posterior teeth (n 5 18, Fig 1).
When the aim of treatment was distalization of the max-
illary posterior teeth, the implants were loaded directly
and used to anchor a modified distal jet appliance for
maxillary molar distalization (n 5 13, Fig 2). In a patient
with multiple agenesis, the implant was used to anchor
a cantilever for aligning a palatally positioned canine. In
1 patient, 2 palatal implants were used to anchor a mod-
ified hyrax screw for skeletal palatal expansion (n 5 2,
Fig 3).
All patients, or their parents, signed a consent form
to take part in the study. This study was approved by the
Ethical Committee of Vrije Universiteit Brussel.
The palatal implant used was the Ortho-implant
(Straumann). This is an endosseous orthodontic implant
anchor system for palatal or retromolar anchorage. The
116 Asscherickx et al American Journal of Orthodontics and Dentofacial Orthopedics
January 2010

Fig 2. A, Implant-anchored distal jet to distalize the maxillary molars to create space for buccally
impacted canines; B, end of distalization, with the maxillary molars passively stabilized in position,
ready to start retraction of the premolars and align the maxillary arch.

Fig 3. A, Implant-anchored hyrax screw to skeletally expand the maxilla; B, fixation of the screw after
expansion; C, occlusal radiograph with widening of the median palatal suture after expansion clearly
visible.

fixture is designed for 1-stage application. The endo-
sseous part of the implant is cylindrical and made of
pure titanium. It has a diameter of 3.3 or 4.0 mm and
a length of 4.0 or 6.0 mm. The implant has a sandblasted
and acid-etched surface. Above the polished transmu-
cosal neck is an abutment on to which the desired supra-
structure is soldered or laser-welded.
The implant was placed under local anesthesia. The
placement procedure is easy and fast when performed
by an experienced surgeon. First, the palate was anes-
thetized. Then, a trephine bur was used to make a punch
of the palatal mucosa. With a curette, the palatal mucosa
was removed. By using a pilot drill and a standardized
profile drill, the implant bed was prepared. The implant
was hand turned as far as possible, and, if necessary,
a ratchet was used to tighte it into its final position. After
placement, some implants had a healing abutment; in
the others, only a screw was placed in the implant.
Implant selection for each patient was based on the
vertical height of the anterior palate as determined on
the lateral cephalogram (Fig 4). All implants were
placed by the same surgeon (M.M.S). In the adolescent
patients (\16 years, n 5 24), the implants were placed
in the paramedian region (first or second quadrant) to
avoid possible growth impairment at the palatal suture7
(Fig 5). In the adults (.20 years, n 5 9), the implants
were placed in the median palatal suture (Fig 6).
When primary stability was not achieved, the surgeon
decided whether to place another (wider or longer)
implant immediately or whether to leave the nonstable
implant in place.
After surgery, patients were instructed to use
chlorhexidine digluconate 0.2% mouth rinse twice
a day during the first 8 weeks after placement. After 8
weeks, the patients were instructed to brush the implant
with an Interspace brush (Oral-B, P&G, Cincinnati,
Ohio). In some cases, the patients were instructed to
wear a covering plate to prevent tongue pressure on
the implant (Fig 7). Whether or not to use such a plate
was always evaluated before placement of the implant
in consultation with the patient and the parents. A heal-
ing period of at least 12 weeks was allowed before
impressions were taken to manufacture the appropriate
suprastructure.
Since no findings on ‘‘sleeping orthodontic
implants’’ (implants that are no longer used for
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 1
Fig 4. Lateral headfilm with palatal implant in situ.
orthodontic or prosthetic purposes) have been published
to date, the implants were retrieved after use. This pro-
cedure was performed with a special drill (cylindrical
and open), with which the implant and the surrounding
bone were removed.
An implant was assigned to 1 of 3 categories defined
as follows.
1. Success: an implant was considered successful if it
could be used for anchorage purposes throughout
the orthodontic treatment as planned.
2. Early failure: an implant was classified as an early
failure if it loosened during the healing phase
(before 12 weeks).
3. Late failure: an implant was classified as a late fail-
ure if it loosened during the orthodontic loading
period.
Correlations were evaluated between failure rate
and sex (male or female), age (adult or adolescent),
primary stability (yes or no), placement site (median
or paramedian), form of the palate (wide or deep), and
implant size (4 or 6 mm length).
The form of the palate was categorized as either
wide or deep. On the pretreatment study casts, the width
and the depth of the palate were measured with a digital
caliper to the closest 0.1 mm, at the level of the second
premolars. Width was measured between the palato-
gingival borders of both maxillary second premolars.
Asscherickx et al 117
Depth was measured between the palate and the occlu-
sal plane at the level of the second premolars. When the
ratio of width to depth was less than 1.4, the palatal form
was classified as deep. When the ratio was more than
1.4, the palatal form was classified as wide.
Patients were asked about the amount of painkillers
taken after surgery and during the following days. A
differentiation was made between no painkillers, 1 pain-
killer immediately after surgery, 1 painkiller immediately
after surgery and 1 in the evening, and more than 2 pain-
killers in total.
The patients were instructed to rate their perception
of pain 1 day, 1 week, and 1 month after surgery on
a visual analog scale (VAS) from 0 (no pain at all) to
10 (extremely painful).
At placement, length and diameter of the implant
(endosseous part), duration of placement time, and
special remarks, such as presence or lack of primary
stability, were noted.
Satistical analysis
To examine correlations between the success rate and
respective classification of each variable, the Fisher exact
probability test was used. A probability of P \0.05 was
considered significant. These analyses were carried out
with statistical analysis software (version 12.0, SPSS,
Chicago, Ill).
RESULTS
A total of 34 implants were placed in 33 patients.
The overall success rate was 91%. In the adult group
(median placement), the success rate was 88.8%. In
the adolescents (paramedian placement), the success
rate was 92%. Three implants failed early; they were
lost during the healing phase (within 12 weeks after
placement). No late failures (during loading phase)
occurred. Eight implants did not have primary stability,
and the surgeon (M.M.S.) decided to replace 2 of them
with longer ones (length, 6 mm; diameter, 3.3 mm) and
2 with wider ones (length, 4 mm; diameter, 4 mm). The
4 other implants without primary stability were left in
place. Three became stable after a week, and 1 was
lost after 3 weeks. No implants were lost during the or-
thodontic loading phase. Both direct (hyrax screw and
distal jet) and indirect (transpalatal arch) loading were
successful.
Table II shows the results of the correlation analysis.
No statistically significant correlations were found be-
tween failure and sex (P 5 0.409), age (P 5 0.616), pri-
mary stability (P 5 0.389), placement site (P 5 0.616),
palatal form (P 5 0.616), or implant size (P 5 0.662).
118 Asscherickx et al
Fig 5. Palatal implant placed in an adolescent patient in the paramedian region in the maxillary left
quadrant: A, clinical view; B, radiologic view.
Fig 6. Palatal implant placed in an adult patient in the median palatal suture zone: A, clinical view;
B, radiologic view.
Fig 7. Covering plate can be used to cover the palatal
implant with the healing abutment after placement and
prevent tongue pressure on the implant.
In 2 subjects who had early failure, a specific reason
was identified. One patient admitted to have played with
the tongue on the implant. Another patient started
brushing the implant after 1 month. New implants
were placed in these patients; all were successfully
used but not included in this study.
American Journal of Orthodontics and Dentofacial Orthopedics
January 2010
The amounts of painkillers taken are shown in Table
III. Most patients took 1 painkiller immediately after
placement. No patient needed to take more than 2 pain-
killers. After removal, the amounts of painkillers were
similar to those after placement. The amounts of pain-
killers were similar for the adolescent and adult patients.
In 1 adult, an abscess had developed at the removal site.
After antibiotic therapy and curettage, wound healing
was uneventful. This patient needed to take painkillers
for a week.
The scores for pain on the VAS are shown in Table
IV. The results were similar for both placement and
removal. One day after surgery, averages of 1.61 and
1.48, respectively, were scored. The maximum score
1 day after placement was 6.5. One month after place-
ment, no patient felt pain. The maximum score 1 day
after removal was 3.9. One month after removal, no
patient felt pain.
The implant sizes according to sex and age are
shown in Table V. Although the 6-mm implants
were used more often in male patients (7 of 15)
than in female patients (3 of 19), this difference
was not statistically significant (P 5 0.057). No rela-
tionship was found between age and implant size
(P 5 0.165).
American Journal of Orthodontics and Dentofacial Orthopedics Asscherickx et al 119
Volume 137, Number 1

Table II. Success rates and number of implants accord- Table III. Amount of painkillers taken
ing to clinical variables Adolescent Adult
Clinical Success Successful/ Significance
Placement Removal Placement Removal
variable rate total implants (Fisher exact test)*
None 4 3 0 1
Sex
1 15 15 7 5
Male 86.6% 13/15 0.409
2 5 6 2 2
Female 94.7% 18/19
.2 0 0 0 1
Age group
Adult 88.8% 8/9 0.616
Adolescent 92% 23/25
Primary stability
epithetic implants in 21 patients in the paramedian
Yes 93% 27/29 0.389
No 80% 4/5 region and found a time-related survival probability of
Placement site 84.8% after 22.9 months. Adequate primary stability
Median 88.8% 8/9 0.616 was achieved for all implants. Three implants were
Paramedian 92% 23/25 lost after the start of orthodontic loading (delayed for
Form of palate
4 months after implant placement). This contrasts
Wide 92% 23/25 0.616
Deep 88.8% 8/9 with our study, in which no implants were lost after
Implant size orthodontic loading began. Bantleon et al19 reported
4.0 mm length 91.6% 22/24 0.662 a 92% success rate. Three of 40 implants were lost
6.0 mm length 90% 9/10 within 2 to 3 months after placement.
*P \0.05 is a significant difference. In our study, the failure or success of a palatal
implant could not be correlated to age or sex. It appears
Duration of the placement procedure was on aver- that palatal implants can be used in many patients with-
age 16 minutes (range, 12-23 minutes). The bone at out restrictions of age or sex.
the placement site was spongy in 4 patients (3 parame- We had 24 adolescents in this study; this was high
dian, 1 in the suture). In 3 of these patients, however, compared with the number of adults (n 5 9). Because
primary stability was obtained. In the fourth patient, so many were young, the surgeon often had to deal
the implant was removed after 3 weeks because it still with highly stressed patients. He noticed that when
had mobility. they were younger than 12 years (n 5 8), half of them
In all patients, the original or the replaced implant were highly stressed during placement. This high level
was used as planned for orthodontic anchorage purposes of anxiety resulted in more movement of the patient dur-
during orthodontic treatment. Length of treatment was ing the procedure and frequent closing of the mouth. The
on average 1 year 10 months (6 7 months). use of palatal implants in young patients is possible, but
Wound healing after removal of the implants was the procedure should be carefully explained to them, so
uneventful in all patients, except 1, who developed an that they will be relaxed before it starts. One implant
abscess. Three months after implant removal, it was without primary stability after placement was lost after
hard to tell where the implant was (Fig 8). 3 weeks, and the patient (age, 12 years) admitted to play-
ing with the tongue on the implant. The use of a covering
plate (Fig 7) might be indicated for young patients to pre-
DISCUSSION vent tongue pressure on the implant. These plates can be
In this study, we had a success rate of 91% for made before placement of the implant, because the place-
palatal implants. This was similar to the results in other ment site (first or second quadrant in adolescents) is nor-
studies. Crismani et al16 reported a 90% success rate. mally decided at treatment planning. The use of these
They placed 20 palatal implants in 20 patients. The plates should be discussed before placement of the im-
implants were loaded 1 week later. Wehrbein et al17 plant with the patients and the parents, if appropriate.
investigated prospectively 9 palatal implants placed in No correlation was found between lack of primary sta-
the median palatal suture in adults and used for anchor- bility and age, sex, implant size, placement site, or form of
age reinforcement of the posterior teeth. The mean un- the palate. When the surgeon noticed spongy or soft bone,
loaded implant healing period was 12 6 3 weeks. All this was not related to lack of primary stability. These find-
implants showed primary stability directly after place- ings suggest that primary stability is predominantly deter-
ment and were successfully used for anchorage pur- mined by the experience and skill of the surgeon.
poses throughout the examination period, for The ideal placement site for palatal implants can be
a success rate of 100%. Bernhart et al18 placed 21 short discussed. According to the manufacturer’s guidelines,
120 Asscherickx et al American Journal of Orthodontics and Dentofacial Orthopedics
January 2010

Table IV. Scores on VAS for pain

1 day 1 week 1 month 1 day 1 week 1 month
after placement after placement after placement after removal after removal after removal

Average 1.61 0.21 0 1.48 0.64 0

SD 1.23 0.04 0 1.05 0.24 0
Minimum 0 0 0 0 0 0
Maximum 6.5 1.2 0 3.9 1.7 0

Table V. Implant sizes

Length Diameter Adolescent Adolescent Women Men
(mm) (mm) girls (n) boys (n) (n) (n)

4.0 3.3 8 6 7 1
6.0 3.3 2 7 1 0
4.0 4.0 1 1 0 0

palatal implants were originally designed to be placed in

the median palatal suture, since, in the broad median su-
ture zone, the bone is relatively dense. In the adults in
our study, the implants were placed in the median pala-
tal suture, whereas a paramedian site was chosen in the
adolescents to avoid possible growth impairment at the
palatal suture.7 No significant correlation was found
between placement site (median or paramedian) and
failure rate. Since the paramedian region was already
described as a good alternative for implant placement,
this is suggested as the region of choice for palatal
implants in adolescent patients.5,8,18
The size of the implant used for each patient was
determined from the lateral cephalograms. It was dem-
onstrated by Wehrbein et al20 that vertical bone support
in the midsagittal area of the palate is at least 2 mm
higher than is apparent on the lateral cephalogram.
When primary stability is not achieved, the implant
can be replaced by a longer one (length, 6.0 mm)
when sufficient bone height is apparent or by a wider
one (diameter, 4.0 mm). The benefit of longer
(6.0-mm length) implants can be questioned, since
Gedrange et al21 concluded from a study on human ca-
davers that the quality of placement and bone structure
is more important than the length of the orthodontic im-
plant for implant stability. When there is doubt about
available bone height, shorter implants can be used
(4.0 mm). Patients have great variations in vertical
bone volume.5 Several authors recommend the use of
a stent22-24 or a preoperative diagnostic evaluation
with dental computed tomography or computerized
navigation surgery for the safe placement of palatal
implants.6,25 In this study, no adverse effects of the
implants on surrounding anatomic structures were
observed. Therefore, we assume that dental computed
tomography (which inevitably leads to higher costs
Fig 8. Palatal mucosa 3 months after implant removal.
and extra radiation to patients) should be limited to
patients in whom there is doubt about sufficient bone
height for placement of 4.0-mm implants. This agrees
with Cousley,26 who questioned the justification for
a computed tomography scan for surgical planning. In
this study, the failure rate was higher in patients with
a deep palate. However, this difference in failure rates
between deep and wide palates was not statistically
significant. This might be due to the few patients with
a deep palate in this study. Placement of implants in
patients with a deep palate is possible, but, for them,
the use of a stent to guide the pilot drill might be useful.
In our study, the patients’ perception of the implant
was evaluated only in terms of pain. The need to take
painkillers after placement was limited to a maximum
of 2 painkillers, and, after 1 week, no patient had any
pain. The same results were found after removal, except
for 1 patient, who developed an abscess and needed to
take painkillers for a week. The scores on the VAS
were comparable to those found by Feldman et al.27
They evaluated by scores on a VAS the perceived pain
intensity between the placement of an Orthosystem
palatal implant and premolar extraction in adolescent
patients. The first evening after the intervention,
patients who had undergone premolar extraction had
significantly more pain than those who had received
a palatal implant. One week after the interventions,
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 1
pain was still significantly higher in patients with
extractions, compared with the patients who had
received an implant. Gunduz et al28 evaluated the accep-
tance rate of palatal implants in a questionnaire study;
85 patients, whose orthodontic treatment included a pal-
atal implant, answered the questionnaire. The results
showed that most patients became used to the implant
in about 2 weeks, and 86% of the patients would recom-
mend the treatment to others. Since the acceptance rate
of palatal implants is high and the pain after placement
and removal is acceptable, this minor surgery should
encourage clinicians to include the Orthosystem palatal
implant in orthodontic treatment plans.
The palatal implants in this study were successfully
used for various anchorage purposes. They could be
loaded indirectly (implant-anchored transpalatal arch)
or directly (implant-anchored modified distal jet appli-
ance or implant-anchored modified hyrax screw).
They could successfully be used for both orthodontic
and orthopedic anchorage purposes.
CONCLUSIONS
1. In this study, success rate of the palatal implants
was 91%.
2. Success of the implants was independent of age,
sex, primary stability, placement site, palatal
form, implant size, and type of suprastructure.
3. This success rate was comparable for palatal
implants placed in the median palatal suture zone
and the paramedian region.
Palatal implants are a reliable device for achieving
maximum anchorage control in orthodontic treatment,
even in younger patients. They can be successfully
loaded both directly and indirectly.
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