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 Temporary Anchorage
Devices in Orthodontics
..

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Temporary Anchorage
Devices in Orthodontics

SECOND EDITION

Ravindra Nanda, BDS, MDS, PhD

Professor Emeritus
Division of Orthodontics
Department of Craniofacial Sciences
School of Dental Medicine
University of Connecticut
Farmington, Connecticut, USA

Flavio Uribe, DDS, MDentSc

Burstone Professor of Orthodontics
Graduate Program Director
Division of Orthodontics
Department of Craniofacial Sciences
School of Dental Medicine
University of Connecticut
Farmington, Connecticut, USA

Sumit Yadav, DDS, MDS, PhD

Associate Professor
Division of Orthodontics
Department of Craniofacial Sciences
School of Dental Medicine
University of Connecticut
Farmington, Connecticut, USA

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© 2021, Elsevier. All rights reserved.

First edition 2009

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in p­ articular, independent verification of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors
or contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

ISBN: 978-0-323-60933-3

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Contents
Preface, vii
Contributors, ix
Acknowledgements, xiii
Dedication, xv
Part I: Biology and Biomechanics of
Skeletal Anchorage
1 Biomechanics Principles in Mini-Implant
Driven Orthodontics, 3
Madhur Upadhyay and Ravindra Nanda
Part II: Diagnosis and Treatment Planning
2 Three-Dimensional Evaluation of Bone Sites
for Mini-Implant Placement, 23
Aditya Tadinada and Sumit Yadav
3 Success Rates and Risk Factors Associated
With Skeletal Anchorage, 29
Sumit Yadav and Ravindra Nanda
Part III: Palatal Implants
4 Space Closure for Missing Upper Lateral
­Incisors, 35
Bjöern Ludwig and Bettina Glasl
5 Predictable Management of Molar Three-
Dimensional Control with i-station, 43
Yasuhiro Itsuki
6 MAPA: The Three-Dimensional Mini-Implants-­
Assisted Palatal Appliances and One-Visit
­Protocol, 61
B. Giuliano Maino, Luca Lombardo, Giovanna Maino,
Emanuele Paoletto and Giuseppe Siciliani
7 Asymmetric Noncompliance Upper Molar
­Distalization in Aligner Treatment Using
­Palatal TADs and the Beneslider, 71
Benedict Wilmes and Sivabalan Vasudavan
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Part IV: Skeletal Plates
8 Nonextraction Treatment of Bimaxillary
Anterior Crowding With Bioefficient Skeletal
Anchorage, 89
Junji Sugawara, Satoshi Yamada, So Yokota and
Hiroshi Nagasaka
9 Managing Complex Orthodontic Problems
With Skeletal Anchorage, 109
Mithran Goonewardene, Brent Allan and Bradley Shepherd
Part V: Zygomatic Implants
10 Zygomatic Miniplate-Supported Openbite
Treatment: An Alternative Method to
Orthognathic Surgery, 149
Nejat Erverdi and Çağla Şar
11 Zygomatic Miniplate-Supported Molar
Distalization, 165
Nejat Erverdi and Nor Shahab
Part VI: Buccal TADs and Extra-Alveolar
TADs
12 Managing Complex Orthodontic Tooth
Movement With C-Tube Miniplates, 183
Seong-Hun Kim, Kyu-Rhim Chung and Gerald Nelson
13 Application of Buccal TADs for Distalization
of Teeth, 195
Toru Deguchi and Keiichiro Watanabe
14 Application of Extra-Alveolar Mini-Implants to
Manage Various Complex Tooth Movements, 209
Marcio Rodrigues de Almeida
Part VII: Management of Multidisciplinary
and Complex Problems
15 Management of Skeletal Openbites
With TADs, 223
Flavio Uribe and Ravindra Nanda
v
vi Contents

16 Orthognathic Camouflage With TADs 19 Class II Nonextraction Treatment With MGBM

for Improving Facial Profile in Class III System and Dual Distal System, 295
Malocclusion, 243 B. Giuliano Maino, Giovanna Maino, Luca Lombardo, John
Eric JW. Liou Bednar and Giuseppe Siciliani

17 Management of Multidisciplinary Patients 20 Anchorage of TADs Using Aligner

With TADs, 263 Orthodontics Treatment for Lower Molars
Flavio Uribe and Ravindra Nanda Distalization, 305
Kenji Ojima, Junji Sugawara and Ravindra Nanda
18 Second Molar Protraction and Third Molar
Uprighting, 283 Index, 321
Un-Bong Baik

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Preface
The new millennium brought about a new era in orthodon-
tics with the advent of temporary anchorage devices (TADs).
The realm of possibilities to correct malocclusions that in the
past were only treatable by means of orthognathic surgery
was made available in a cost-effective manner through the
insertion of small screws and miniplates during orthodontic
treatment. Clinicians quickly became interested in adopting
this new approach in their patients, and precise indications
for the use of skeletal anchorage started to shape up. The
first edition of Temporary Anchorage Devices in Orthodontics,
which was compiled in the early days of skeletal anchorage,
was a very timely book that introduced many aspects of this
new approach. The chapters of this first book described the
use of miniplates and screws with emphasis on the multiple
locations of placement in the maxilla and mandible and a
myriad of screw systems and appliances. The biomechanics
involved with new skeletal anchorage orthodontic adjuncts
was described in detail, with many case reports illustrating
the expanded possibilities to correct complex malocclusions
and enhance smile esthetics.
Approximately a decade has transpired since the first
edition, and significant refinements to the techniques and
appliances have been developed. In this second edition, we
wanted to highlight these advances described by multiple
authors that had been at the forefront of skeletal anchor-
age era since the early days. The first chapters in this edi-
tion review the biology and interaction of the titanium
hardware and bone and the basic biomechanic principles
that apply when using skeletal anchorage. The application
of space closure, distalization, and overall molar control
form palatal appliances is described in depth with different
approaches. Later in the book, the versatility of miniplates
and infrazygomatic mini-implants is presented by multiple
authors managing cases of significant complexity. Finally,
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the management with skeletal anchorage of anteroposterior
and vertical problems, such as the management of the Class
III malocclusion, second molar protraction, anterior open-
bite correction, and the mechanical advantages of TADs in
multidisciplinary patients, are described.
A very interesting development in skeletal anchorage
presented in this new edition is the integration of three-
dimensional (3D) technologies for the placement of mini-
implants and the fabrication of TAD-supported appliances.
With the advent of 3D-printing, precise palatal appliances
are now available as described in this book with the MAPA
appliance. Overall, this new approach sets a trend where the
application of 3D-printing facilitates the insertion of mini-
implants and the delivery of appliances in a single visit in
a very precise and predictable manner. Another novel and
interesting approach is the combination of clear aligner
therapy with skeletal anchorage. Clear aligners are increas-
ingly becoming the elected orthodontic appliance by adults,
and a tightly coupled synergy with TADs for the treatment
of more complex malocclusions in patients demanding non-
visible appliances is described in this book.
We want to thank all the contributors who have invested
time and effort to advance our knowledge regarding skeletal
anchorage. We also appreciate the contributions of numer-
ous individuals who are not part of this book but who have
influenced all of us with their scientific publications. We
hope you will enjoy reading it, and various methods of skel-
etal anchorage usage shown will help in efficient treatment
of patients.
Ravindra Nanda
Flavio Uribe
Sumit Yadav
Farmington, Connecticut, USA
vii
Contributors

The editor(s) would like to acknowledge and offer grateful Nejat Erverdi, DDS, PhD
thanks for the input of all previous editions’ contributors, Professor
without whom this new edition would not have been possible. Faculty of Dentistry
Department of Orthodontics
Brent Allan, BDS, MDSc, FRACDS, FFD RCS (Ireland), Okan University
FDS RCS (England) Istanbul, Turkey
Oral and Maxillofacial Surgeon
Department of Orthodontics Bettina Glasl, MD
The University of Western Australia Orthodotics
Nedlands, Western Australia, Australia; Praxis Dr. Ludwig Dr. Glasl
Private Practice Traben-Trarbach, Germany
Leederville, Western Australia, Australia
Mithran Goonewardene, BDSc, MMedSc
Marcio Rodrigues de Almeida, DDS, MSc, PhD Orthodontics
Unopar The University of Western Australia
Orthodontics Nedlands, Western Australia, Australia
UNOPAR
Londrina, Parana, Brazil Yasuhiro Itsuki, PhD, DDS
Private Practice
Un-bong Baik, DDS, MS, PhD Jingumae Orthodontics
Second Molar Protraction and Third Molar Uprighting Tokyo, Japan
Head
Smile-with Orthodontic Clinic Seong-Hun Kim, DMD, MSD, PhD
Seoul, Republic Of Korea Professor and Head
Department of Orthodontics
John Robert Bednar, BA, DMD Graduate School, Kyung Hee University
Assistant Clinical Professor in Orthodontics (Ret) Seoul, Republic Of Korea
Department of Orthodontic
Boston University Henry M. Goldman School of Dental Eric J.W. Liou, DDS, MS
Medicine Associate Professor
Boston, Massachusetts, USA Department of Craniofacial Orthodontics
Chang Gung Memorial Hospital
Kyu-Rhim Chung, DMD, MSD, PhD Taipei, Taiwan
Clinical Professor
Department of Orthodontics Luca Lombardo, DDS
Graduate School, Kyung Hee University Associate Professor
Seoul, Republic of Korea Postgraduate School of Orthodontics
Ferrara University
Toru Deguchi, DDS, MSD, PhD Ferrara, Italy
Associate Professor
Orthodontics Björn Ludwig, PhD
The Ohio State University Orthodontics
Columbus, Ohio, USA Praxis Dr. Ludwig Dr. Glasl
Traben-Trarbach, Germany

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x Contributors

Giovanna Maino, DMD Bradley Shepherd, BDSc, MDSc, FRACDS

Dentistry Prosthodontist
Adjunct Professor Department of Prosthodontics
Postgraduate School of Orthodontics The University of Western Australia
Ferrara University; Nedlands, Western Australia, Australia;
Private practice Private Practice
Vicenza, Italy Leederville, Western Australia, Australia

B. Giuliano Maino, MD, DDS Giuseppe Siciliani, DDS

Postgraduate School of Orthodontics Chairman
Ferrara University and Insubria University; Postgraduate School of Orthodontics
Private Practice Ferrara University
Vicenza, Italy Ferrara, Italy

Hiroshi Nagasaka, DDS, PhD Junji Sugawara, DDS, DDSc

Chief Sendai Aoba Clinic
Department of Oral and Maxillo-facial Surgery Orthodontics
Sendai Aoba Clinic Dentistry
Sendai, Japan Sendai, Japan

Ravindra Nanda, BDS, MDS, PhD Aditya Tadinada, DDS, MS, MDS
Professor Emeritus Director of Student Research, Program Director of the
Division of Orthodontics Residency Program
Department of Craniofacial Sciences Oral and Maxillofacial Radiology
School of Dental Medicine UCONN School of Dental Medicine
University of Connecticut Farmington, Connecticut, USA
Farmington, Connecticut, USA
Madhur Upadhyay, BDS, MDS, MDentSc
Gerald Nelson, DDS Associate Professor
Clinical Professor Orthodontics
Orofacial Sciences UCONN Health
UCSF School of Dentistry Farmington, Connecticut, USA
San Francisco, California, USA
Flavio Uribe, DDS, MDentSc
Kenji Ojima, DDS, MDSc Burstone Professor of Orthodontics
Smile Innovation Orthodontics Graduate Program Director
Hongo Bunkyo-ku Division of Orthodontics
Tokyo, Japan Department of Craniofacial Sciences
School of Dental Medicine
Emanuele Paoletto, SDT University of Connecticut
Certified Orthodontic Technician (COT) Farmington, Connecticut, USA
Teacher
Postgraduate School of Orthodontics Sivabalan Vasudavan, BDSc, MDSc, MPH, M Orth, RCS,
Ferrara University FDSRCS, MRACDS (Orth)
Ferrara, Italy; Certified Craniofacial and Cleft Lip/Palate Orthodontics
Private practice Specialist Orthodontist
Thiene, Italy Orthodontics on Berrigan
Orthodontics on St Quentin
Çağla Şar, DDS, PhD Perth, Western Australia, Australia
Associate Professor
Private Practice
Istanbul, Turkey

Nor Shahab, MSc Orthodontics

Faculty of Dentistry
Department of Orthodontics
Istanbul Aydın University
Istanbul, Turkey
 Contributors xi

Keiichiro Watanabe, DDS, PhD Sumit Yadav, DDS, DMD, PhD

Postdoctoral Researcher
Orthodontics
The Ohio State University
Columbus, Ohio, USA;
Assistant Professor
Orthodontics and Dentofacial Orthopedics
Tokushima University Graduate School
Tokushima, Japan
Benedict Wilmes, DDS, DMD, PhD
Professor
Department of Orthodontics
University of Duesseldorf
Duesseldorf, Germany
Associate Professor
Division of Orthodontics
Department of Craniofacial Sciences
School of Dental Medicine
University of Connecticut
Farmington, Connecticut, USA
Satoshi Yamada, DDS, PhD
Chief
Department of Orthodontics
Sendai Aoba Clinic
Sendai, Japan
So Yokota, DDS, PhD
Sendai Aoba Clinic
Department of Oral and Maxillo-facial Surgery
Sendai Aoba Clinic
Sendai, Japan
Acknowledgements

We would like to acknowledge all the residents and faculty at UConn Health that contributed to their dedicated care of the
patients illustrated in our chapters.

xiii
We dedicate this book to our parents for all that we have and all that we do.
 PART I

Biology and Biomechanics of

Skeletal Anchorage

1. Biomechanics Principles in Mini-Implant Driven Orthodontics

Madhur Upadhyay and Ravindra Nanda

1 1
1
Biomechanics Principles in Mini-Implant
Driven Orthodontics
MADHUR UPADHYAY, RAVINDRA NANDA
Introduction
The physical concepts that form the foundation of orthodon-
tic mechanics are the key in understanding how orthodontic
appliances work and are critical in designing the treatment
methodologies and appliances that carry out these plans.
Mechanics can be defined as a branch of physics con-
cerned with the mechanical aspects of any system. This can
be divided into two categories:
Statics, the study of factors associated with nonmoving
(rigid) systems, and
Dynamics, the study of factors associated with systems in
motion: a moving car, plane etc. When the knowledge
and methods of mechanics are applied to the struc-
ture and function of living systems (biology) like, for
example, a tooth together with its surrounding oral
architecture, it is called biomechanics. It is our belief
that the study of biomechanics of tooth movement
can help researchers and clinicians optimize their
force systems applied on teeth to get better responses
at the clinical, tissue, cellular, or molecular level of
tooth movement.
  
Approaches for Studying Tooth Movement
Two approaches are used for studying the biological and
mechanical aspects of tooth movement—a quantitative
approach and a qualitative approach. The quantitative
approach involves describing movement of teeth or the
associated skeletal structures in numerical terms. We all are
familiar with terms like 3 millimeters of canine retraction,
or 15 degrees of incisor flaring. However merely describ-
ing tooth movement quantitatively does not describe the
complete nature of the movement. It is also important to
understand the type or nature of tooth movement that has
occurred. A qualitative approach describes movement in
nonnumerical terms (i.e., without measuring or counting
any parts of the performance). This approach is often fol-
lowed at the clinical level or inferred from x-rays and/or
stone models like tipping, translation, etc.
Both qualitative and quantitative analyses provide valu-
able information about a performance; however, a qualitative
assessment is the predominant method used by orthodon-
tists in analyzing tooth movement. The impressions gained
from a qualitative analysis may be substantiated with quan-
titative data, and many hypotheses for research projects are
formulated in such a manner.
Basic Mechanical Concepts
Force
The role of force in everyday life is a familiar one. Indeed, it
seems almost superfluous to try to define such a self-evident
concept as force. To put it in a simple way, force can be
thought of as a measure of the push or pull on an object.
However, the study of mechanics of tooth movement
demands a precise definition of force. A force is something
that causes or tends to cause a change in motion or shape of
an object or body. In other words, force causes an object to
accelerate or decelerate. It is measured in Newton (N), but
in orthodontics nearly always force is measured in grams (g).
1 N = 101.9 g (≈ 102 g) (see appendix).
Force has four unique properties as shown by graphic
representation of a force acting at an angle to a central inci-
sor in Fig. 1.1:
• Magnitude: how much force is being applied (e.g., 1 N,
2 N, 5 N).
• Direction: the way the force is being applied or its orien-
tation to the object (e.g., forward, upward, backward).
• Point of application: where the force is applied on the
body or system receiving it (e.g., in the center, at the bot-
tom, at the top).
• Line of action/force: the straight line in the direction of
force extending through the point of application.
3
4 PA RT I Biology and Biomechanics of Skeletal Anchorage
Line of action of
force
Direction of force
relative to the
θ
horizontal
(-) x-axis
• Fig. 1.1 The four properties of an external force applied to a tooth illustrated by an elastic chain applying
a retraction (distalizing) force on a maxillary incisor to a mini-implant.
F1
F2
F3
• Fig. 1.2The length of the force vector describes the magnitude of the
force vector. Example: F1 = 2 N, F2 = 3 N, F3 = 1 N.
Force Diagrams and Vectors
Physical properties (such as distance, weight, temperature,
and force) are treated mathematically as either scalars or vec-
tors. Scalars, including temperature and weight, do not have
a direction and are completely described by their magni-
tude. Vectors, on the other hand, have both magnitude and
direction. Forces may be represented by vectors.
To a move a tooth predictably, a force needs to be applied
with an optimal magnitude, in the desired direction, and
at the correct point on the tooth. Changing any property
of the force will affect the quality of tooth displacement.
A force may be represented on paper by an arrow. Each of
its four properties may be represented by the arrow whose
length is drawn to a scale selected to represent the magni-
tude of the force—for example, 1 cm = 1 N or 2 cm = 2 N,
etc. (Fig. 1.2). The arrow is drawn to point in the direction
in which the force is applied, and the tail of the arrow is
placed at the force’s point of application. The line of action
of the force may be imagined as continuing indefinitely in
both directions (head and tail end), although the actual
arrow, if drawn to scale, must remain of a given length. A
graphic representation of a force of 1 N acting at an angle of
30 degrees to a central incisor is shown in Fig. 1.1.
Point of application of
force
Length = Magnitude of
force
(+)
Principle of Transmissibility
This concept is very important for vector mechanics, espe-
cially in understanding equilibrium and equivalent force
systems as we will see later. It implies that a force acting on
a rigid body results in the same behavior regardless of the
point of application of the force vector as long as the force is
applied along the same line of action.
The Effect of Two or More Forces on a System:
Vector Addition
Teeth are often acted on by more than one force. The net effect
or the resultant of multiple forces acting on a system, in this
case teeth, can then be determined by combining all the force
vectors. This process of combining all the forces may be found
by a geometric rule called vector addition, or vector composi-
tion. We place the vectors head to tail, maintaining their mag-
nitudes and directions, and the resultant is the vector drawn
from the tail of the first vector to the head of the final vector.
Vector addition can be accomplished graphically by drawing
diagrams to scale and measuring or by using trigonometry.
Fig. 1.3 shows how the two forces are visualized as two sides
of a parallelogram and how the opposite sides are then drawn
to form the whole parallelogram. The resultant force, R, is
represented by the diagonal that is drawn from the corner of
the parallelogram formed by the tails of the two force vectors.
The Directional Effects of Force: Vector Resolution
Often an occasion arises in which the observed movement
of a system or single force acting on a system is to be ana-
lyzed in terms of identifying its component directions. In
such cases, the single vector quantity given is divided into
two components: a horizontal component and a vertical
component. The directions of these components are rela-
tive to some reference frame, such as the occlusal plane or
the Frankfort horizontal plane (FHP), or to some axis in
the system itself. The horizontal and vertical components
are usually perpendicular to each other. Such a process
maybe thought of as the reverse of the process of vector
 CHAPTER 1 Biomechanics Principles in Mini-Implant Driven Orthodontics 5

FR

FE FE
FR+
R=

FE

FR

• Fig. 1.3Illustration showing the law of vector addition by the parallelogram method. Here, FR can be
thought of as a retractive force on the incisor and FE as a force from a Class II elastics. The net effect of
the two forces is represented by the resultant R.

F Vertical component
of the total force(FV)

F
Horizontal component of the total force (FH)

A FV

FH

C
• Fig. 1.4 The process of vector resolution.

composition. The operation is called vector resolution and
is the method for determining two component vectors that
form the one vector given initially.
For example, a mini-implant as shown in Fig. 1.4A is
being used for retraction of anterior teeth. It may be useful
to resolve this force into the components that are parallel
and perpendicular to the occlusal plane, to determine the
magnitude of force in each of these directions. Resolution
consists of these steps (Fig. 1.4B–C): (1) draw the vector
given initially to a selected scale; (2) from the tail of the
vector, draw lines representing the desired directions of the
two perpendicular components; (3) from the head of the
vector, draw lines parallel to each of the two direction lines
so that a rectangle is formed. Note that the new parallel lines
constructed have the same magnitude and direction as the
corresponding lines on the opposite side of the rectangle.
6 PA RT I Biology and Biomechanics of Skeletal Anchorage
It is important to note that if it is desirable to estimate
the magnitude of the components, then simple trigonomet-
ric rules can be invoked to do so. The sine and cosine are in
particular very useful in finding the horizontal and vertical
components of the force vector. In this case if, for example,
the horizontal component of magnitude FH makes an angle
θ with the force (F), we can derive the components using
the definitions of sine and cosine:
Horizontal component (FH): FH/F = cos θ; FH = F cos θ
Vertical component (FV): FV/F = sin θ; FV = F sin θ
With a little practice, it is easy to get the component
directly as a product, skipping the step involving the pro-
portion. Think of sin θ and cos θ as fractions that are used
to calculate the sides of a right triangle when the hypotenuse
is known. The side is always less than the hypotenuse and
the sine and cosine are always less than one. To get the side
opposite the angle, simply multiply the hypotenuse by the
sine of the angle. To get the side adjacent to the angle, mul-
tiply the hypotenuse by the cosine of the angle.
Center of Resistance, Center of Gravity, and Center
of Mass
The center of mass of a system may be thought of as that
point at which all the body’s mass seems to be concentrated
(i.e., if a force is applied through this point, the system or
body will move in a straight line). On similar lines recall
that the earth exerts a force on each segment of a system in
direct proportion to each segment’s mass. The total effect of
the force of gravity on a whole body, or system, is as if the
force of gravity were concentrated at a single point called
the center of gravity. Again, if a force is applied through
this point, it will cause the body to move in a straight line
without any rotation. The difference between the center of
mass and center of gravity is that the system in question in
the latter is a ‘restrained system’ (restrained by the force of
gravity).
Teeth are also a part of a restrained system. Besides
gravity, they are more dominantly restrained by periodon-
tal structures that are not uniform (involving the root but
not the crown) around the tooth. Therefore the center of
mass or the center of gravity will not yield a straight line
motion if a force is applied through it because the surround-
ing structures and their composition alter this point. A new
point analogous to the center of gravity is required to yield
a straight-line motion; this is called the center of resistance
(CRES) of the tooth (Fig. 1.5).
The CRES can also be defined by its relationship to the
force: a force for which the line of action passes through the
CRES producing a movement of pure translation. It must
be noted that, for a given tooth, this movement may be
mesiodistal or vestibulolingual, intrusive or extrusive. The
position of the CRES is directly dependent on what may be
called the “clinical root” of the tooth. This concept consid-
ers the root volume, including the periodontal bone (i.e.,
the distance between the alveolar crest and the apex), incre-
menting this value with the thickness (i.e., the surface) of
the root.1
Center of resistance (CRES)
Center of mass or center of gravity(CG)
• Fig. 1.5 The center of resistance (CRES) of a tooth is usually located
slightly apical to the center of gravity (CG). The periodontal structures
surrounding the tooth root cause this apical migration of the CRES.
Thus the position of the CRES is also a function of the
nature of the periodontal structures, and the density of
the alveolar bone and the elasticity of the desmodontal
structures that are strongly related to the patient’s age.2–4
These considerations implore us to speak of the “CRES
associated with the tooth,” rather than of “the CRES of
the tooth.”
Moment (Torque)
When an external force acts on a body at its center of gravity
(CG), it causes that body to move in a linear path. Such a
type of force with its line of action through the CG or CRES
of a body is called a centric force. On similar lines, eccentric
forces (off-center) act away from the CRES of a body.
What kind of effect will these forces have? Besides caus-
ing the body to move in a linear path, it will have a turning
effect on the body called torque, or in other words the force
will also impart a “moment” on the body. The off-axis dis-
tance of the force’s line of action is called the force arm (or
sometimes the moment arm, lever arm, or torque arm). The
greater this distance, the greater the torque produced by the
force. The specifications of the force arm are critical. The
force arm is the shortest distance from the axis of rotation
to the line of action of force. Invariably the shortest distance
is always the length of the line that is perpendicular (90
degrees) to the force’s line of action (d⏊). The symbol “⏊”
designates perpendicular. Force arm is critical in determin-
ing the amount of moment acting on the system.
The amount of moment (M) acting to rotate a system is
found by multiplying the magnitude of the applied force (F)
by the force arm distance (d⏊):
M = F(d⏊), where F is measured in Newton and d⏊
in millimeter (Fig. 1.6A). Therefore the unit for moment
as used in orthodontics is Newton millimeter (Nmm). As
mentioned previously, often for force Newton is replaced
 CHAPTER 1 Biomechanics Principles in Mini-Implant Driven Orthodontics 7

M
M

Tp Tp

A B
• Fig. 1.6(A) The moment of a force is equal to the magnitude of the force multiplied by the perpendicular
distance from its line of action to the center of resistance. (B) The direction of the moment of a force can
be determined by continuing the line of action around the center of resistance.

F F d
D

Mc mc

F F

A B
• Fig. 1.7 (A) The moment created by a couple is always around the center of resistance (CRES) or center
of gravity (CG) (MC = F × D). (B) No matter where the pair of force are applied, the couple created will
always act around the CRES or CG. As the distance between the two forces decreases (d<D), the overall
magnitude of the couple decreases (mc<MC).

with gram (g), therefore the unit for moment becomes:
Grammillimeter (gm-mm). The larger the force and/or lon-
ger the force arm, larger the moment. Because of this intrin-
sic relationship of the moment and the associated force, it is
also known as moment of the force (MF).
If forces are indicated by straight arrows, moments can
be symbolized by curved arrows. With two-dimensional dia-
grams, clockwise moments will be arbitrarily defined as positive
and counterclockwise moments negative or vice versa. Values
can then be added together to determine the net moment on a
tooth relative to a particular point, such as the CRES.
Point of application and line of action are not needed;
nor are graphic methods of addition. The direction of a
moment can be determined by continuing the line of action
of the force around the CRES, as shown in Fig. 1.6B.
Couple (A Type of Moment)
A couple is a form of moment. It is created by a pair of forces
having equal magnitudes but opposite sense (direction) to one
another with noncoincidental line of action (parallel forces).
Because the forces have the same magnitude but are oppositely
directed, the net potential of this special force system to trans-
late the body on which it acts is nil and there is only rotation.
A typical couple is shown in Fig. 1.7A. Although the cou-
ple’s vector representation is shown midway between the two
forces, the vector has no particular line-of-action location and
maybe drawn through any point of the plane of the couple.
Therefore a couple is also known as a free vector. This freedom
associated with the couple vector has far reaching implica-
tions in clinical orthodontics and to certain force analysis pro-
cedures (Fig. 1.7B). As an example, no matter where a bracket
is placed on a tooth, a couple applied at that bracket can only
cause the tooth to feel a tendency to rotate around its CRES.
This is also referred to as the moment of the couple (MC).
The magnitude of the moment of the couple (MC) is
dependent on both force magnitude and distance between
the two forces. The moment created by a couple is actually
the sum of the moments created by each of the two forces.
Now if the two forces of the couple act on opposite sides
of the CRES, their effect to create a moment is additive. If
they are on the same side of the CRES, they are subtractive
8 PA RT I Biology and Biomechanics of Skeletal Anchorage
m2 M
m1
d2
F2
d1
F1
• Fig. 1.8A couple created by two equal and opposite forces acting on a
tooth. The total moment (MC) is the vector addition of the two moments
(m1, m2) generated by the two forces (F1, F2). Here, m1 = F1 × d1, m2
= F2 × d2. Because the two moments are in the opposite direction, one
of the moments will be assigned a negative sign and the other positive.
The net moment (M) will be obtained by adding the two: M = m1+ (−m2)
(Fig. 1.8). Either way, no net force is felt by the tooth, only
a tendency to undergo pure rotation.
Concept of Equilibrium
The word “equilibrium” has several different meanings, but
in statics it is basically defined as state of rest; in particular it
means that an object or system is not experiencing any accel-
eration. Therefore statics is that branch of physics that deals
with the mechanics of nonaccelerating objects or for our
convenience and understanding “nonmoving” objects. Such
a system is said to be in equilibrium. To achieve equilibrium,
we must see to it that no unbalanced force is applied to the
body in question or in other words any force acting on a
system should be balanced by contrary forces.
Therefore sum of all the forces should be zero (i.e., ΣF = 0),
(according to Newton’s second law if a system is not accelerat-
ing then a = 0, so F = ma, or F = m(0); ΣF = 0, i.e., there is no
net force acting on the system).
A vector can only be zero if each of its perpendicular
components is zero; thus the single vector equation ΣF = 0
is equivalent to three component equations:
ΣFx = 0, ΣFy = 0, ΣFz = 0 (x,y,z are the three spatial axes
described previously).
On similar lines, the net moment too in all the three planes
should be equal to zero, i.e., ΣMx = 0, ΣMy = 0, ΣMz = 0.
Equilibrium in Orthodontics (The Quasi-
Static System)
Equilibrium only applies to static systems (nonaccelerating
systems). However, in orthodontics, we do move teeth. They
move, stop, tip, upright. So how can they be governed by
F’
F
• Fig. 1.9 A cantilever spring exerting a force (F) on the bracket (in
red). As per the third law of Newton, the bracket will put an equal and
opposite force (F’) on the cantilever wire (in blue).
the laws of statics? To answer this question, we will have to
redefine the state of the teeth subjected to orthodontic forces
as a Quasi Static System. This can be defined as a system or
process that goes through a sequence of states that are infini-
tesimally close to equilibrium (i.e., the system remains in
quasi-static equilibrium). When orthodontic appliances are
activated and inserted, the tooth displacement that take place
is very small and take place over a relatively long period of
time. At any point of time if you look in the patient’s mouth,
you do not see any movement, however after waiting for a
sufficient period of time, the movement can be appreciated.
Therefore at any instant, a force analysis may be carried out
by invoking the laws of equilibrium without erring apprecia-
bly. In other words, the inertia of any appliance element or
a tooth is negligibly smaller and may be neglected. For this
reason, the physical laws of statics are considered adequate to
describe the instantaneous force systems produced by orth-
odontic appliances. However, these laws cannot be used to
describe how the force systems will change as the teeth move
and an appliance deactivates and alters its configuration.
The solution of problems in statics involving forces and
moments calls for ingenuity and common sense. There are
no simple rules of procedure. The most common source of
error is failure to identify the object whose equilibrium is
being considered. You must learn to consider all the forces
acting on the body. Of course, Newton’s second and third
law is of great help in this regard. By using the third law it
can be easily figured out that if an appliance is exerting a
force on a tooth, the same force the tooth is exerting on the
appliance (Fig. 1.9), and the same applies to all the other
teeth to which the appliance is connected to. Because the
appliance is not moving (static), the sum of all the forces
and moments produced by the appliance should be zero.
Principle of Equivalent Force Systems
This principle is an elegant way of redefining the forces and
moments acting on a body. It helps visualize not only the
bodily movement of a tooth but also the rotation, tip, and
torque experienced. An equivalent system is a system of
 CHAPTER 1
Relocated force
Forces cancel
-FA’
+FA’
B B
FA FA
A A
• Fig. 1.10Creating equivalent force systems. The net effect of the force system depicted in (A) and (D) is
same. (B) and (C) show how to transform (A) to (D).
forces and/or moments that you can replace with a differ-
ent set of forces and/or moments and still achieve the same
basic translational and rotational behavior. To understand
the practical implication of this principle, lets discuss relo-
cating a force system on a molar.
Application of Equivalent Force Systems:
Moving the Force System to a Different
Location
In Fig. 1.10, there is a force FA acting on the tooth at Point
A. Now suppose you want to compute the effects of this
force system at a different location, such as Point B, which
in this case is the CRES of the molar (remember CRES of the
molar has been arbitrarily chosen; point B can be any other
point on the molar). To determine the required translational
effect, introduce two equal but opposite forces (+FA, and −
FA,) at point B. We can easily do this because such an intro-
duction of forces will not affect the system in any way, as
these forces are equal and opposite, therefore the result of
these newly added forces is FA, +(−FA,) = 0, or zero net trans-
lational effect. Make sure that the magnitude of these new
forces is equal to FA acting at point A. Now by applying law
of vector addition, the original force FA plus the new nega-
tive force –FA, will cancel each other out. With this in mind,
you can see that the only force that now remains on the
molar is the newly relocated force FA, which is now acting
at point B. Congratulations! You have relocated the force.
Now that you have relocated the force, examine the two
other forces on the molar, namely FA acting at point A and
−FA, acting at point B. These two forces are parallel, act-
ing in opposite directions and separated by a distance “d.”
This setup is the very definition of a moment (couple) that
we have previously discussed. Remember, moments and
couples cause rotation of a body, therefore the added rota-
tional effect of this couple is what you have to include when
you move a force. Also a couple is a free vector, therefore
they apply the same rotational behavior regardless of where
on the body it is acting. As a result, you can freely move
Biomechanics Principles in Mini-Implant Driven Orthodontics 9
Translational effect
Rotational effect
Force couple
+FA’
-FA’ MA
B
d
FA
A
FA X d = MA
the moment of the couple to point B on the molar as long
as the magnitude and sense of the moment vector remains
unchanged. The magnitude of this moment can be calcu-
lated by multiplying the force FA or –FA, by d (MA = FA ×
d). The point of application of a moment or couple does
not matter when creating an equivalent force system. If you
want to move a moment, just move it.
In summary, to relocate a force system, you simply need to
take the original force and apply it to the new location, plus
compute the newly applied moment (which is the product of
the force and the distance between the two points) and apply
that at the new location maintaining its sense/direction.
There are three simple rules that allow the calculation of
equivalent force systems. Two force systems are equivalent
if: (1) the sums of the forces in all the three planes of space
(X, Y, and Z) are equal, and (2) the sum of moments about
any point are identical.
Center of Rotation
Centre of Rotation (CROT) is a fixed point around which a
two-dimensional figure appears to be rotated as determined
from its initial and final position (note: a two-dimensional
figure always rotates around a point, while a three-dimen-
sional figure rotates around an axis [i.e., a two-dimensional
object has a CROT, while a three-dimensional object has an
axis of rotation]). In other words, in rotation the only point
that does not move is called the CROT (Fig. 1.11). The rest of
the plane rotates around this one fixed point.
Although a single CROT can be constructed for any starting
and ending positions of a tooth, it does not follow that the sin-
gle point actually acted as the CROT for the entire movement.
The tooth might have arrived at its final position by follow-
ing an irregular path, tipping first one way and then another.
As a tooth moves, the forces on it continuously undergo slight
changes, so that a changing CROT is the rule rather than the
exception. In determining the relationship between a force sys-
tem and the CROT of the resulting movement, all that can really
be determined is an “instantaneous” CROT.5
10 PA RT I Biology and Biomechanics of Skeletal Anchorage

B’

A’
• Fig. 1.12(A) and (B) represent the cusp tip and the root apex before
• Fig. 1.11Center of rotation (red dot) of a tooth. Note how the center
and after movement. A line has been drawn connecting these points.
of rotation is the only point that has remained stationary.
At the midpoint of this line a perpendicular has been constructed. The
point at which this perpendicular intersects any other perpendicular
constructed in a similar manner (the apex has been selected as the
other point) is the center of rotation.

A B C D
• Fig. 1.13Types of tooth movement: (A) Uncontrolled tipping, (B) controlled tipping, (C) root movement
(torqueing), (D) translation or bodily movement. The center of rotation (CROT) in every case is depicted by a
red dot. Note that during translation, the CROT is at infinity or, in other words, does not exist.

Estimating the Center of Rotation
The CROT can be easily estimated as shown in Fig. 1.12. Take
any two points on the tooth and connect the before and
after positions of each point with a line. The intersection of
the perpendicular bisectors of these lines is the CROT.6
Types of Tooth Movement (Fig. 1.13)
As we saw in the preceding section, the CROT is key in defin-
ing the nature of tooth movement. Controlling the CROT
automatically gives precise control over the type (extent) of
tooth movement. When a single force is applied on a tooth,
the tooth will move in the direction of the force applied. In
addition, depending on the distance of the force from the
CRES, the tooth will experience a moment (MF) around the
CRES. This combination of a force and a moment will cause
the tooth to rotate as it moves, placing its CROT slightly apical
to the CRES.5,6 This type of tooth movement is called simple
tipping or uncontrolled tipping. It is easy to visualize here that
both the crown and the root will move in the opposite direc-
tion. Tipping can happen in many different ways depending
 CHAPTER 1 Biomechanics Principles in Mini-Implant Driven Orthodontics 11

A B C D
• Fig. 1.14 The application of a power arm to create different types of tooth movement. Note, the force has
been kept constant through A–D. (A) Uncontrolled tipping, no power arm. (B) Controlled tipping produced
by a power arm below the CRES of the tooth. (C) Translation as the force is now being applied through the
CRES made possible by increasing the length of the power arm. (D) Root movement with minimal crown
movement; here the power arm extends beyond the center of resistance (CRES) (the red dot is the CROT
while the blue dot is the CRES). Note how the MF is increasing or decreasing with an increase or decrease
in the distance of force application from the CRES.

on where the CROT is along the tooth. But for ease of classifica-
tion they can be bunched up into two other groups:
Controlled Tipping
During such a movement the CROT is located at the root
apex. The tooth moves similar to a pendulum on the clock,
with its apex fixed at a particular point and the crown mov-
ing from one side to the other.
Root Movement
Here the CROT is located at the crown tip while the root is
free to move in the direction of the force. Traditionally, in
the orthodontic literature, this is not characterized as a tip-
ping movement, but mechanically the movement is similar
to controlled tipping. Almost the entire universe of tooth
movement primarily consists of tipping the crown, the
root (rare), or a combination (most common). However,
there is one tooth movement that is extremely rare and
very difficult to achieve in its strictest sense (i.e., transla-
tion, sometimes also known as bodily movement). Here,
both the crown and the root move in equal amounts and
in the same direction with no rotation. In this case, the
CROT is nonexistent, or in mathematical terms approaches
infinity.
Moment-to-Force (M/F) Ratios
Tipping (uncontrolled) is the most common tooth move-
ment in everyday orthodontics, but not always the preferred
one. To modify this pattern of tooth movement and create
a new one, the force system acting on the tooth needs to be
altered. There are primarily two ways to do this based on the
mechanics involved:
1. Altering the Point of Force Application (Fig. 1.14)
A simple way of doing this is by applying a force closer to
the CRES of the tooth. A rigid attachment, often called a
power arm, can be attached to the bracket on the crown
of the tooth. Then the force can be applied to this power
arm. In this way, the line of force can be moved to a dif-
ferent location, thereby altering its distance from the CRES.
This causes a change in the moment of the force too. For
example, if the power arm can be made long and rigid to
extend till the CRES of the tooth, the moment arm (MF) can
be entirely eliminated, as the applied force will now pass
through the CRES. This method works beautifully for alter-
ing the tipping movement of the crown; however, for move-
ments requiring higher levels of control, like translation and
root movement, this method possesses certain problems.
The “long” arms can be a source of irritation to the patient,
by extending into the vestibule and/or impinging on the
gingiva and cheeks. In addition, the arms are sometimes not
rigid enough and can undergo some degree of flexion under
the applied load/force.
2. Altering the Moment-to-Force Ratio (Fig. 1.15)
An alternative method to alter the tooth movement is to
play with the rotational component of the applied force
(i.e., the MF). This is done by adding a counterbalancing
moment (i.e., a moment in the opposite direction to that
of the MF) to the system. This new moment can be created
in two ways. First is the traditional way of applying a force
(this would be a different force than the one generating the
MF). However, with a bracket fixed on the tooth, it is usu-
ally difficult to apply a force at some other point. Therefore
this approach is usually not practical or efficient. The second
approach involves creating a couple in the bracket. A rectan-
gular archwire fitting into a rectangular bracket slot on the
tooth is most widely used. This new moment (Mc) together
with the applied force determines the nature of tooth move-
ment. This combination is popularly known as the moment-
to-force (M/F) ratio. By varying this moment-to-force ratio,
the quality of tooth movement can be changed among tip-
ping, translation and root movement (i.e., different centers
12 PA RT I Biology and Biomechanics of Skeletal Anchorage
f
Mc
MF = F X D
D force applied is always at an angle. (Note: the preferred
F f
d gingival junction. Care should be taken that the MIs
Mc = f X d
• Fig. 1.15 A schematic diagram depicting the generation of a moment
caused by a couple (MC). It is the ratio of the MC to the force applied (F)
that determines the nature of tooth movement (M/F ratio). The higher
the ratio, the greater will be the control over the tooth movement.
of rotation along the long axis of the tooth are created by
changing the magnitude of the couple and the applied
force). In terms of the direction, the moment of the couple
is almost always going to be in the direction opposite the
moment of the force about the CRES.
Note that in orthodontics, moments are measured in gram-
millimeters and forces in grams, so that a ratio of the two has
units of millimeters. This ratio is also indicative of the distance
away from the bracket that single force will produce the same
effect (i.e., through a power arm as discussed earlier).
Space Closure Mechanics With
Mini-Implants
The extraction of premolars and anterior teeth retraction
is generally indicated when there is obvious protrusion of
teeth and there is a strong esthetic need. While retracting
anterior teeth in a full unit Class II malocclusion or in a
Class I bialveolar dental protrusion case, anchorage control
assumes profound importance because maintaining the pos-
terior segment in place is critical. A loss in molar anchorage
not only compromises correction of the anterior-posterior
discrepancy but also affects the overall vertical dimension
of the face.7–9 The application of mini-implant (MI) sup-
ported anchorage can circumvent the anchorage issues in
such situations and maintain a Class II molar or Class I rela-
tionship, while establishing a Class I canine relationship for
esthetics and functional guidance. In this chapter, we will
use space closure as a basis for understanding the nuances of
MI-assisted biomechanics in clinical practice.
Mechanical differences in incisor retraction
between MIs and conventional techniques
Using MIs for retraction of anterior teeth presents a para-
digm shift from the conventional method of space closure.
The shift is seen not only in the anchorage demand between
the two techniques but also in the mechanics involved in
space closure. Some of these differences are:
1. 
When using conventional mechanics, force applica-
tion is usually parallel to the occlusal plane, and hence
we are required to analyze the force only in one plane.
However, because MIs are usually placed apical to the
occlusal plane into the bone between the roots of teeth,
location for MI placement is between the roots of the
second premolars and first molars close to the muco-
are not inserted too far apically in the movable mucosa,
since this can lead to implant failure because of persis-
tent inflammation around the MI site.) This angulated
force lends itself to be broken into two components
by the law of vector resolution10: a horizontal retrac-
tion force (r) and a vertical intrusive force (i). The force
applied with MIs in such a setup is also closer to the
CRES of the anterior unit. Therefore the MF (moment
caused by the force) is significantly less compared to that
generated in conventional mechanics.7–9,11,12 Clinically,
it translates to a decreased tendency for the teeth to tip
(Fig. 1.16).
2. 
With conventional mechanics, the posterior segment
usually serves as the passive unit (anchor unit), while
the anterior teeth as the active unit. The force system is
therefore differentially expressed in the active unit and
the anchorage or passive unit within the same arch. In
contrast, when MIs are incorporated as the third coun-
terpart, precise movement of the anterior and posterior
segments is possible. Accurate planning for the amount
of the desired tooth movement is thus a prerequisite
before active treatment can be initiated.
3. The clinical observation of the amount of tipping will
depend on the amount of space closure. A greater amount
of space closure will yield greater degrees of side effects or
in this case tipping. With conventional techniques part
of the space is taken up by molar mesialization. Previ-
ous research has shown that in contrast to MI-supported
anchorage, conventional methods show 2 to 3 mm of
anchor loss in a typical extraction case.7–11 Therefore the
anterior teeth during space closure with MIs are auto-
matically predisposed to more tipping and “dumping,” as
they have to be distalized a greater distance to close the
extraction space (Fig. 1.17). Therefore greater degrees of
torque control might be warranted for space closure using
skeletal anchorage. These and other differences have led
to a gradual evolution of implant-based mechanics in
orthodontics. However, before exploring this further, the
mechanics of space closure will be discussed.
Basic Model for Space Closure
In incisor retraction, the objective is to apply a force between
the incisor and the posterior segment to close the space that
exists between them. This force is usually applied on the
bracket attached to the crown of the teeth (Fig. 1.18) and is
 CHAPTER 1 Biomechanics Principles in Mini-Implant Driven Orthodontics 13

M i

FI

FO

• Fig. 1.16 Biomechanical design of the force system involved during ‘en masse retraction of anterior
teeth. The vector of force varies between conventional mechanics (FO) and implant-based mechanics (FI)
for space closure. Here, FI > > r > i, (F = total force, i = intrusive component and r = retractive compo-
nent). Also the moment created by the implant will be significantly less than that created by conventional
mechanics (force application with implants is closer to the center of resistance (CRES) and M = F × distance
to the CRES). Note: with the conventional approach, there is no intrusive force generated.

A B
6-7 mm 2-3 mm 3-4 mm
• Fig. 1.17Anterior teeth that have to be distalized a greater distance (A) and will be automatically predis-
posed to greater degrees of tipping than those requiring less distalization (B). Note: the molar represents
the posterior segment while the incisor represents the anterior teeth.

occlusal and buccal to the CRES of the units experiencing the

MF force. This generates moments (moment caused by force, or
MF as described previously), which cause tipping and rota-
tion of the teeth in the direction of the applied force.13,14
Here, it is easy to see that by simply controlling the MF,
different types of tooth movement can be achieved (e.g., tip-
MC
ping, translation, etc.). But how can we manipulate the MF?
In the entire orthodontic spectrum, there are only two
broad mechanical pathways to achieve this:
1. Changing the line of force application (or reducing the
F
magnitude of MF)
2. Counterbalancing the MF (adding another moment in
• Fig. 1.18
Basic mechanics of tooth movement. Here, F = retraction
force, MF = moment caused by the force, MC = counterbalancing
the opposite direction).
moment. Let us consider each of these options.
14 PA RT I Biology and Biomechanics of Skeletal Anchorage
10-11 mm
8-9 mm
6.5-7.5 mm
3-5 mm
0 mm
• Fig. 1.19 Altering the line of force application can change the center of rotation and/or the type of tooth
movement. Orange: uncontrolled tipping, Blue: controlled tipping, Pink: translation, Purple: root move-
ment, Green: root movement with crown moving forward. Red dot: center of resistance, other dots: center
of rotations corresponding with the line of force.
1. Changing the Line of Force Application
A simple way of accomplishing this is to apply the force
closer to the CRES of the anterior teeth. A rigid attachment,
often called a power arm, can be attached to the bracket on
the crown of the tooth or on the wire itself. Force can then
be applied to this power arm. In this way, the line of force
is moved to a different location, thereby altering its distance
from the CRES. This also causes a change in the moment of
the force. For example, if the power arm can be made long
and rigid to extend to the CRES of the tooth, the moment
arm (MF) can be entirely eliminated, as the applied force
will pass through the CRES (moment = applied force × dis-
tance from the CRES).
Based on theoretical calculations, in vitro and in vivo
experiments, and with certain assumptions, we have come
up with a model (Fig. 1.19) describing various types of
tooth movement depending on the line of force applica-
tion,15,16–20 and by the location of the tooth’s CROT as a
rotation axis. The figure shows the CROT for every level of
force. This model only applies for maxillary incisors and
measures only the initial tooth movement.
This approach is easier to execute with skeletal anchor-
age because MIs are usually placed between the roots of the
molar and premolar. Here, the height of both the power
arm and MI can be varied depending on the line of force
required. It works well for both large segments of teeth
or individual teeth (Fig. 1.20). However, for movements
requiring greater degrees of control, such as translation or
root movement, this method possesses certain problems.
The “long” arms can be a source of irritation to the patient,
by extending high into the vestibule and/or impinging on
the gingiva and cheeks. In addition, the arms are sometimes
not rigid enough and can undergo some degree of flexion
under the applied force. Therefore retraction of incisors is
often performed without the use of a power arm. However,
without the power arm, the ability to reduce the MF is also
lost. In this situation, how do we control the tooth move-
ment? How do we bring about the desired tooth movement,
which can be so easily achieved with “power arms?”
2. Counterbalancing the MF (Sliding Mechanics With
Mini-Implants)
Force system through time. The en masse retraction
described at the beginning of the chapter outlined the forces
and moment during the initial stages of space closure, i.e.,
it represented only the beginning phase of retraction. What
happens later? We are well aware of the fact that space clo-
sure is a dynamic process, and things change as teeth move.
Considerable research in this area has provided us with a
more detailed representation of the incisor movement and
its effect on the entire dentition.11–18 Based on the evidence
gathered from this pool of research, we have further refined
the mechanic model of incisor retraction with MIs. Essen-
tially, incisor retraction can be divided into four phases
(please refer to Fig. 1.6 for each phase).
  
Phase I. This is the initiation of incisor retraction. A single force
(F) is applied in an upward and backward/distal direction
(Fig. 1.21A). This force produces a moment (MF) acting
at the CRES of the incisor segment, causing it to tip as it is
being distalized. Since there is some degree of play between
the archwire and the bracket slot at this stage, the tooth is
free to tip in the mesiodistal direction in an uncontrolled
manner, creating a CROT slightly apical to the CRES13,14 (see
Fig. 1.19). This can also be referred to as the unsteady state
of incisor retraction, characterized by uncontrolled tipping.
Here, it is easy to see that the greater the play, the more will
be the tipping, or in other words, the smaller the size of the
archwire, the greater will be the tipping.
Phase II. The incisor is now tipped to the extent that the
aforementioned clearance (or play) between the bracket
 CHAPTER 1
B
• Fig. 1.20 Power arm–based space closure. (A) En masse retraction of anterior teeth shows controlled
tipping. (B) Translation of canine.
slot and the wire is eliminated. The sketch in Fig. 1.21B
depicts the incisors somewhat later in time relative to
Fig. 1.21A. Archwire–bracket slot contact now exists.
This two-point contact by the archwire creates a moment
(MC) in the opposite direction of MF resulting in less
tipping of the incisors when compared to phase I. This is
the “counterbalancing moment” or “moment caused by a
Biomechanics Principles in Mini-Implant Driven Orthodontics 15
couple” (MC). As the wire further deflects, MC continues
to increase (force a deflection, as we will see later), and
the CROT moves apically, creating controlled tipping of
the incisors. This can also be called the controlled state of
incisor retraction. From this point onward, the move-
ment of the teeth will depend on the nature of the re-
traction force (i.e., a steady continuous force or a force
16 PA RT I Biology and Biomechanics of Skeletal Anchorage

• Fig. 1.21 Mechanics of incisor retraction with mini-implants (red dot:

center of rotation). (A) Phase I (the unsteady state/uncontrolled tip-
ping). The archwire–bracket play allows for uncontrolled tipping of the
incisor. Note; because of the play there is no MC (moment caused by a
couple) generated. (B) Phase II (the controlled state/controlled tipping).
The archwire–bracket play does not exist anymore. There are signs
MF of initial contact between the archwire and the bracket edges giving
rise to MC. However still MF >> MC. (C) Phase III (restorative phase/
root uprighting because of decreasing force). There is a decrease in
F
the force levels causing a decrease in MF. Here MF << MC. Note the
deflected wire now springs back as the retraction force is reduced
causing a reduction in the moment. (D) Phase IV (continuous/heavy
force). Permanent deflection of the archwire caused by the continu-
ous/heavy F making the MC ineffective in creating any root correction.
Here again MF >> MC.

decreasing with time). This at the clinical level is a very

relevant supposition.
Phase III (decreasing force). For the space closure to enter
Mc this phase, it must be assumed that the distal driving
MF
force is undergoing a constant decay through the retrac-
tion process. This is often seen with an elastomeric chain
F or active tiebacks.21–23 As the force decreases, so does the
MF; however, because of the angulated bracket and the
local bending of the archwire, the MC remains constant.
Therefore here MC >> MF (Fig. 1.21C). This results in
restoration of the axial inclination of the incisors (up-
righting or root correction). This can be called the re-
B
storative phase of incisor retraction and can be clinically
referred to as the third-order torqueing of the incisors.
With the reactivation of the elastomeric chain, the pro-
cess resumes from Phase I.
Phase IV (continuous force or heavy force). Incisor retraction
Mc
MF
enters this phase if the retraction force is either constant
or heavy to begin with. Examples can be: nickel titanium
closed coil springs, heavy elastomeric chain, etc. Here,
because of the heavy retraction force, MF is always >>
MC, therefore there is anterior bending or deflection of
F the archwire and the tipping of incisors continues (Fig.
1.21D). Clinically, the incisors might appear as “dumped”
or retroclined (loss of torque) with deep bite and some-
C times accompanied with a lateral open bite with the mo-
lars tipped forward because of a similar wire deformation.
This deformation is accompanied with an increase in fric-
tion and/or binding at the wire bracket interface making
tooth movement slow. (Note: It is important to mention
here that at any point if MC = MF the incisors would
Mc
MF
theoretically undergo translation. But this almost never
happens, as it is very difficult to maintain such a balance
between the moments for any measurable period of time).

F
Sequela of Phase IV: Distalization Effect of
Mini-Implant Assisted Retraction
It has been widely reported that MI-assisted retraction of
incisors has the potential to distalize the whole arch en
D masse.7–9,11,12 This can occur primarily in two situations
 CHAPTER 1
M i
F
r
• Fig. 1.22 Biomechanical design for the force system involved after
space closure. Retraction of the upper anterior teeth still in progress.
Note the increase in the angulation of the total force relative to the
occlusal plane. (Here, F >> r ≈ i). Such a mechanical configuration has
important implications for vertical control and Class II correction.
that are not necessarily mutually exclusive. At the end
of phase IV, as we saw in the previous section, there is
increased binding and interlocking of the wire to the
bracket. This causes the upward and backward retraction
force to be transmitted to the posterior segment through
the archwire. The stiffer and thicker the archwire, the more
pronounced will be this effect. A similar effect is also seen
when the space between the anterior and posterior teeth
is completely closed but the retraction force is continued
for closing residual anterior spaces. This results in transmis-
sion of the total force to the posterior segments through the
interdental contacts, producing a distal and intrusive force
on the posterior teeth and a moment (M) on the entire arch
(Fig. 1.22). These mechanics have often been used to cor-
rect Class II molar relationships without extractions.24,25
Distalization with MIs also helps in efficient control of
the vertical dimension by preventing the extrusion of the
molars (see Fig. 1.22), thereby maintaining the mandibular
plane angle and in some situations even resulting in intru-
sion of the posterior teeth and consequent upward and for-
ward rotation of the mandibular plane.7–9,25
Mechanical Factors Affecting Incisor
Retraction
It is evident from the previous discussion that the archwire
bracket clearance is a very important factor in determining
the type of anterior tooth movement in sliding mechanics.
The greater the degree of play between the archwire and the
bracket, the greater will be the tipping, as the incisor brack-
ets can rotate in that space, causing the roots to move labi-
ally.20 In other words the incisors will undergo a prolonged
phase I space closure. Table 1.1 shows the approximate
Biomechanics Principles in Mini-Implant Driven Orthodontics 17
  Archwire-Bracket Clearance Angle (Play) for
TABLE
1.1 Various Archwires When Placed in a 0.022 ×
0.028–Sq. Inch Bracket
Wire Size (in inches) Amount of Play (degrees)
0.016 × 0.022 16–18
0.017 × 0.025 12–14
0.019 × 0.025 6–8
0.021 × 0.025 2–3
values of play between archwires and a 0.022 × 0.028–sq.
inch bracket.26–29 Needless to say that a 0.016 × 0.022–sq.
inch wire will show more tipping than a 019 × 025–sq. inch
wire (Fig. 1.23).
Another important mechanical aspect to consider is the
flexural rigidity of the archwire, which is critical in regulat-
ing the wire deformation. Flexural rigidity (D) is denoted
by EI, where E is Young’s modulus of the archwire mate-
rial, and I is the moment of inertia of the cross-sectional
area. Once the tipping of incisors has occurred and there is
no wire bracket clearance, the flexural rigidity of the arch-
wire or the archwire deformation under the applied load
(retraction force) will largely determine the type of tooth
movement.20,30 If the wire undergoes elastic deformation,
the incisors will keep on tipping in spite of the “zero” clear-
ance between the archwire and bracket. The amount of
archwire deformation can be estimated depending on both
the flexural rigidity of the archwire and net force acting
on the incisors. As a rule, smaller-size wires and less stiff
wires show increased flexion when subjected to retraction
forces.25 Therefore it is advisable to carry out “en masse”
space closure with rigid stainless steel archwires as opposed
to the more flexible nickel-titanium based archwires.
The mechanical factors explained in the preceding sec-
tion can be elegantly described by an equation from beam
mechanics30–32:
3
Δ= FL
K.D
Here, Δ is the amount of deflection of the archwire under
the applied load F from its original position (as shown in
Fig. 1.21C–D), L is the length of the archwire between the
two attachments (here it can be assumed between the molar
and the incisors), D is the flexural rigidity described earlier,
and K is a constant that reflects the stiffness of the beam and
is dependent on the brackets supporting it. Please note, this
equation will be more suitable to describe tooth movement
that mimics a “three-point bending test” or a cantilever
beam with the load concentrated at the free end.
The “Hybrid Model” With Mini-Implant
Anchorage
The hybrid approach combines the two methods of con-
trolling anterior teeth retraction, that is, applying a
18 PA RT I Biology and Biomechanics of Skeletal Anchorage

019 x 025 -inch 016 x 022 -inch

• Fig. 1.23 The amount of play between the bracket and archwire depends on the size of the archwire.

Pre Post

• Fig. 1.24Clinical application of power arm soldered on 0.019 × 0.025 SS archwires for space closure.
The blue arrow shows the root movement obtained.

A B
• Fig. 1.25Sliding mechanics with power arm. (A) Moment (blue) caused by retraction force. (B) Moment
(red) generated by the torsional effect of the archwire.
 CHAPTER 1
• Fig. 1.26 A clinical example of power arm–based space closure.
counterbalancing moment and changing the line of force
application (Fig. 1.24). In this approach, a power arm is
soldered onto the archwire mesial to the canine, bilaterally.
In this way, the clinician can choose the line of force appli-
cation from the CRES through the power arm to the MI. In
addition, the retraction force from the power arm causes
the upward deformation and the torsion of the anterior seg-
ment of the archwire. This torsion of the archwire produces
a couple that works as anti-tipping moment to the anterior
teeth (Figs. 1.25 and 1.26). In other words, this couple has
a lingual root tipping effect on the incisors. Longer power
arms are more effective in minimizing archwire deflection
than are shorter ones, as the MF is reduced. Also thicker
wires will provide better torsional control than lighter wires
will, as we saw in the preceding section.
Conclusions
MIs in the present day and age are one of the best modalities to
maintain “absolute” anchorage. However, they by themselves
do not guarantee a well-defined and controlled movement of
teeth without side effects. Line of force application, amount of
force, force decay/constancy, archwire–bracket play, and arch-
wire deflection (regulated primarily by the archwire proper-
ties) are critical factors for controlling incisor retraction with
MI-supported anchorage. It is imperative to regulate these fac-
tors to minimize archwire deflection for unwanted side effects
like loss of torque control on the incisors, resulting deep bite
and/or lateral open bite caused by tipping of the anterior and
posterior teeth, increase in friction/binding forces leading to
stagnant or slowing of tooth movement, etc.
Biomechanics Principles in Mini-Implant Driven Orthodontics 19
References
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bution on the root of the maxillary central incisor, Am J Orthod
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3. Hay GE: The equilibrium of a thin compressible membrane, Can
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5. Christiansen RL, Burstone CJ: Centers of rotation within the
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6. Smith RJ, Burstone CJ: Mechanics of tooth movement, Am J
Orthod 85(4):294–307, 1984.
7. Upadhyay M, Yadav S, Nagaraj K, Patil S: Treatment effects of
mini-implants for en-masse retraction of anterior teeth in bial-
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Am J Orthod Dentofacial Orthop 134:18–29. e1, 2008.
8. Upadhyay M, Yadav S, Patil S: Mini-implant anchorage for en-
masse retraction of maxillary anterior teeth: a clinical cephalo-
metric study, Am J Orthod Dentofacial Orthop 134:803–810,
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9. Upadhyay M, Yadav S, Nanda R: Vertical-dimension control
during enmasse retraction with mini-implant anchorage, Am J
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10. Upadhyay M, Nanda R: Biomechanics in orthodontics. In
Nanda R, editor: Esthetics and biomechanics in orthodontics, ed 2,
Philadelphia, PA, 2015, WB Saunders, pp 74–89.
11. Upadhyay M, Yadav S, Nagaraj K, Nanda R: Dentoskeletal and
soft tissue effects of mini-implants in Class II, division 1 patients,
Angle Orthod 79:240–247, 2009.
20 PA RT I Biology and Biomechanics of Skeletal Anchorage
12. U padhyay M, Yadav S, Nagaraj K, Uribe F, Nanda R: Mini-
implants vs fixed functional appliances for the treatment of
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13. Smith RJ, Burstone CJ: Mechanics of tooth movement, Am J
Orthod 85:294–307, 1984.
14. Upadhyay M, Yadav S, Nanda R: Biomechanical basis of extrac-
tion space closure. In Nanda R, editor: Esthetics and biomechanics
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108–120.
15. Tanne K, Koenig HA, Burstone CJ: Moment to force ratios and
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16. Kojima Y, Kawamura J, Fukui H: Finite element analysis of the
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mination of optimal force system required for control of anterior
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Orthop 135:36–41, 2009.
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N: Optimal loading conditions for controlled movement of ante-
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19. Kojima Y, Fukui Hisao: A finite element simulation of initial
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Orthod Advance Access.1–7, 2011.
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138:702.e1–6, 2010.
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ing mechanics, Eur J Orthod 15:235–241, 1993.
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chains, Semin Orthod 3:189–197, 1997.
24. Park HS, Lee SK, Kwon OW: Group distal movement of teeth using
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plant-aided sliding mechanics on distal retraction of posterior
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dimensions: manufacturing precision and third order clearance, J
Orthod 37:241–249, 2010.
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stiffness of an archwire, Am J Orthod Dentofac Orthop 91:131–
136, 1987.
31. Ouchi K, Watanabe K, Koga M, Isshiki Y, Kawada E, Oda Y:
The effect of retraction forces applied to the anterior segment of
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 PART II

Diagnosis and
Treatment Planning

2. Three-Dimensional Evaluation of Bone Sites for Mini-Implant Placement

Aditya Tadinada and Sumit Yadav
3. Success Rates and Risk Factors Associated With Skeletal Anchorage
Sumit Yadav and Ravindra Nanda

21 21
This page intentionally left blank

     
2
Three-Dimensional Evaluation of Bone
Sites for Mini-Implant Placement
ADITYA TADINADA, SUMIT YADAV
Recent years have seen a significant increase in the use of
mini-implants or temporary anchorage devices (TADs)
in orthodontics. This is a valuable alternative method for
improving orthodontic mechanics.1–3 With TADs being
considered an absolute source of skeletal anchorage4,5 for
orthodontics, stability of the TAD plays a key role in the
success of this entire treatment orchestra. Osseointegration
of the TAD or mini-implant was considered key to provid-
ing the desired anchorage to move teeth, but a significant
change and variation in implant screw design has changed
this paradigm to a large extent. Mechanical locking of the
TAD into the bone is considered adequate to provide the
desired primary stability required for orthodontic tooth
movement. While osseointegration may help in en masse
retraction or moving larger tooth segments, lack of com-
plete osseointegration actually helps in easy removal of the
TAD, after the desired results have been accomplished.
A pivotal step that determines the success of orthodontic
tooth movement using TADs is surgical placement of the
TAD, without causing any perforation or trauma to impor-
tant structures in the area. Atraumatic placement involves
the consideration of several important factors like soft tissue
status at the site, anatomy of the bone, tooth, the interra-
dicular distance at the TAD site and proximity to critical
anatomic structures.6
Several sites have been proposed for TAD placement, and
they include the palate, anterior nasal spine, maxillary tuber-
osity, anterior ramus, and the mandibular retromolar areas.7
One of the most commonly used locations is the interra-
dicular area between two teeth (see Fig. 3.1). Because the
placement of these TADs requires drilling the cortical bone
plate and the trabecular compartment to achieve primary
stability and integration, having adequate space between the
roots is critical (Fig. 2.1).
Since root damage (Fig. 2.2) is a likely possibility because
of the lack of adequate space, a few studies have proposed
some “safe zones” for TAD placement.8 However, a safe
zone can vary for different individuals and a generalized area
cannot be deemed safe for all patients. If there was adequate
information regarding the critical pointers to be considered
for TAD placement, the location could be changed to a true
safe zone that is specific to the patient, thus avoiding any
untoward perforation of critical anatomic structures in the
area (see Fig. 2.2).
Several critical anatomic structures, like the inferior
alveolar nerve canal in the mandible and the floor of the
maxillary sinus in the maxilla, must be taken into con-
sideration during TAD placement. The size and type of
the TAD and thickness of the buccal, lingual, or palatal
bone plate play a crucial role in the success of TAD place-
ment. Along with the cortical bone, trabecular bone pat-
tern also plays a key role in integration and must be taken
into consideration while treatment planning the TAD. A
majority of TADs, until recently, were placed blind with-
out any preoperative radiographic evaluation and was one
of the causes for the failure of the TAD. Occasionally, a
periapical radiograph or a panoramic radiograph was used
to evaluate the potential TAD site, but these radiographs,
although helpful, did not adequately contribute to eval-
uation of the TAD site. The solution was three-dimen-
sional (3-D) evaluation of the TAD site, but the only 3-D
radiographic modality available for many decades was the
multislice medical computerized tomography scan (CT).
Multislice CT could depict the area of interest in three
dimensions, but the associated radiation was very high
to be routinely used for tasks like TAD placement. The
risk-benefit ratio and the governing principles of radia-
tion safety-ALARA (as low as reasonably achievable) did
not support its use for this task. The evolution of cone
beam CT (CBCT) as a low-dose, high-resolution 3-D
imaging alternative proved to be a major advantage for
imaging the osseous structures of the maxillofacial region.
A significant improvement in CBCT technology is the
development of small field of view to collimate the scan
to specifically capture smaller areas of interest like the
TAD site.
Important considerations for 3-D evaluation of the
TAD/mini-implant site would be to evaluate the continuity
23
24 PA RT I I Diagnosis and Treatment Planning

Key Pointers for Preoperative Treatment

60
(mm)
4.04 mm
Mean : 401
3.60 mm
Max :1655
Min : -177
SD : 288
R Area : 4 mm2 L
Mean : 228
Max :1631
Min : -863
SD : 588
Area : 5 mm2
0 120
0 (mm)
• Fig. 2.1
Planning of a TAD site in the posterior mandible on an axial
cone beam computerized tomography image.
60
(mm)
P A
0
120
0 (mm)
• Fig. 2.2Cross-sectional image showing perforation of the mesial root
of tooth #14 during TAD placement.
and quality of the buccal and lingual/palatal cortical bone
plates, trabecular bone pattern, interradicular distance,
and the proximity to critical anatomic structures in the
area. Axial sections serve as best views to evaluate the buc-
cal and lingual bone plates and to measure interradicular
distance (see Fig. 2.1). Generating cross-sectional views
of the TAD site will help in measuring the available buc-
colingual width and mesiodistal dimensions. Presence of
pathology, if any, at the site must also be evaluated. Several
times, the preoperative evaluation provides information to
the clinician that may lead to change of the implant site
to prevent damage to critical structures in the vicinity of
the site.
Regardless of the TAD site and type of TAD being
used, the fundamental principles for radiographic plan-
ning of TADs remain the same. TAD should be in sound
bone and must have adequate stability to withstand the
forces being applied. TAD placement must not lead to
perforation or damage of any critical anatomic structures
in its vicinity.
Planning of TADs Using Three-Dimensional
Imaging
1. Quality and integrity of the buccal and lingual/palatal
cortical bone plates.
2. Quality of the trabecular bone.
3. Proximity to critical anatomic structures like the inferior
alveolar nerve canal in the mandible and the floor of the
maxillary sinus in the mandible.
4. Density of the bone at the TAD site.
5. Interradicular distance at the TAD site.
While CBCT depicts the area of interest in three
dimensions, the challenge of radiation dose optimization
and effective field size have continued to remain as limit-
ing factors. Radiation dose from a standard CBCT expo-
sure is approximately 20 to 40 micro Sieverts for a small
volume CBCT and 80 to 200 micro Sieverts for a mid-
sized to a large field of view scan depending on the CBCT
machine.9 Dose and use are particularly critical because
of the age group of most orthodontic patients. There are
several techniques to optimize dose by manipulating the
exposure factors like kVp and mA and time. A more recent
technique is to acquire the CBCT scan with a modified
rotational acquisition that rotates 180 degrees as opposed
to the conventional 360 degrees rotational acquisition.
This modified technique acquires images with a major-
ity of the radiation exposure being delivered to the pos-
terior aspect of the skull, thus avoiding direct exposure to
more radiosensitive organs like the eyes, thyroid, salivary
glands, and intraoral membranes.10 According to a study
by Morant et al., this modified arc-based acquisition tech-
nique reduces the radiation delivered by approximately
40%, making this a much more acceptable radiographic
examination for evaluating TAD sites even in younger
patients.11
Significant mitigation of risk and avoiding root perfo-
ration can be achieved by preoperative treatment planning
using CBCT. A major challenge is in translating the surgi-
cal plan and simulation from a virtual environment to the
physical environment while placing the TAD. This in part
can be overcome by fabricating a simple radiographic guide
that can be modified to be a surgical guide, much like the
method that is standard in planning and placement of den-
tal implants. The radiographic guide helps in bridging the
virtual environment with the physical environment. Key
steps in this process include making an impression of the
teeth and surrounding structures at the proposed TAD site,
and then making a stone cast model of the impression and
using a plastic sheet in a vacuum forming system to cre-
ate a radiographic guide using a suck-down technique. A
small radiographic marker can be fused to the guide at the
proposed TAD site. Several commercially available radio-
graphic markers can be used to mark the TAD site, but a
small dot of heated gutta-percha serves well as an easy and
 CHAPTER 2 Three-Dimensional Evaluation of Bone Sites for Mini-Implant Placement
60 5.77 mm
4.47 mm
(mm)
4.39 mm 3.36 mm
Mean : 934
Max :1915
Min : –86
SD : 409
Area : 4 mm2
P A
120
(mm)
• Fig. 2.3
Planning of a TAD site in the palate on a sagittal cone beam
computerized tomography image.
practical radiographic marker. With the radiographic guide
in the mouth, a small-volume focused field of view CBCT
scan must be acquired. The scan will now show the area
of interest in three dimensions along with the radiographic
marker. Now a thorough evaluation of the potential TAD
site can be done using any of the several CBCT reconstruc-
tion programs. Several CBCT reconstruction programs also
provide the ability to simulate a surgical TAD placement
with TADs in a variety of lengths and widths. Once the pre-
operative evaluation is done, the right-sized TAD and the
location can be chosen and, if need be, an alternate site can
be scoped out if the originally planned site shows anatomic
challenges or if the site just does not have adequate inter-
radicular space.
The radiographic guide can be modified to be a surgical
guide by placing a small sleeve or an opening at the planned
site. The guide can be inserted into the mouth during TAD
placement, and using the radiographic marker as a reference
point, the TAD can be placed at the site as planned on the
CBCT reconstruction program.
Three-Dimensional Evaluation of a Potential
TAD Site in the Palate
The palatal area is increasingly being used as a TAD site
for molar intrusion, molar protraction, segment protrac-
tion, and anterior tooth retraction. A big reason for this
is the access of this area for TAD placement, less soft tis-
sue irritation, no interference with the desired orthodontic
tooth movement, and good quality and quantity of bone.
Palatal TADs are commonly inserted in the anterior region
of the palate, midpalatal area, and the posterior region of
the palate. Key considerations for success of TADs in the
palatal area are bone quantity or the total amount of avail-
able bone for TAD insertion and bone quality as measured
by density. Although the areas corresponding to the canine
and second premolar in the center of the palate have been
25
60
(mm)
3.43 mm
1.93 mm
Mean : –651
Max : 298 3.63 mm
1.70 mm Min :–1017
R SD : 209 L
Area : 2 mm2
Mean : –4
Max : 1208
Min : –835
SD : 409
Area : 1 mm2
0
120
0 (mm)
• Fig. 2.4 Planning of a TAD site in the posterior maxilla on an axial
cone beam computerized tomography image.
shown to have better bone quality and quantity, this is
dependent on the age, gender, race, and stage of growth
maturation.12 A careful evaluation using cross-sectional
images, typically sagittal views that help in determining
the best location, is helpful (Fig. 2.3). Evaluation should
include setting the scanned volume aligned in the Frank-
fort horizontal plane, choosing the area of interest on the
axial section, and then finding the corresponding area on
the sagittal plane, or by generating a cross-sectional image
of the site. Measurements along the palatal area for the
available bone and the density of the bone should be care-
fully done considering the size of the TAD, as the hard pal-
ate shares a common boundary with the nasal cavity. The
roof of the hard palate is the floor of the nasal cavity, and
any perforation will lead to an oronasal communication
and associated complications.
Three-Dimensional Evaluation of a Potential
TAD Site in the Maxillary Posterior Area
Maxillary posterior sites are also commonly used for TAD
placement, and depending on the site and choice of TAD,
key principles remain the same as with most other TAD
sites, but since the maxillary bone is typically thinner and
less dense then the mandible, a careful evaluation of the
bone density is recommended. If the TAD site is inter-
radicular, measuring the interradicular distance at the
crest and at the midroot level on cross-sectional images
is valuable in the success of the procedure (Fig. 2.4). Use
a radiographic guide that can be modified, as explained
earlier in the chapter.
Three-Dimensional Evaluation of a Potential
TAD Site in the Buccal Shelf Area
The buccal shelf area in the mandible can be used for
placing a TAD. In this location, the TAD is placed
26 PA RT I I Diagnosis and Treatment Planning
A
F
A C
• Fig. 2.5
Planning of a TAD site in the buccal shelf area on a cross-sectional (A) and a volumetric (B and C)
CBCT images.
parallel to the long-axis of the tooth typically distal to the
distal root of the mandibular second molars. Key point-
ers for this location are choosing the right length of the
TAD and ensuring that there is adequate circumferential
bone support to prevent tipping or shearing of the TAD
leading to failure. CBCT can help in locating the ideal
location, and to ensure that the TAD is placed in the
buccal shelf and no damage to the adjacent structures is
caused (Fig. 2.5).
References
1. Papadopoulos MA, Tarawneh F: The use of miniscrew implants
for temporary skeletal anchorage in orthodontics: a comprehen-
sive review, Oral Surg Oral Med Oral Pathol Oral Radiol Endod
103:e6–e15, 2007.
2. Nienkemper M, Pauls A, Ludwig B, Wilmes B, Drescher D: Mul-
tifunctional use of palatal mini-implants, J Clin Orthod 46:679–
686, 2012.
B
3. Chandhoke TK, Nanda R, Uribe FA: Clinical applications of
predictable force systems, part 2: miniscrew anchorage, J Clin
Orthod 49:229–239, 2015.
4. Upadhyay M, Yadav S, Patil S: Mini-implant anchorage for en-
masse retraction of maxillary anterior teeth: a clinical cephalo-
metric study, Am J Orthod Dentofacial Orthop 134:803–810,
2008.
5. Upadhyay M, Yadav S, Nagaraj K, Patil S: Treatment effects of
mini-implants for en-masse retraction of anterior teeth in bial-
veolar dental protrusion patients: a randomized controlled trial,
Am J Orthod Dentofacial Orthop 134:18-29, 2008. e1.
6. Landin M, Jadhav A, Yadav S, Tadinada A: A comparative study
between currently used methods and small volume-cone beam
tomography for surgical placement of mini implants, Angle
Orthod 85:446–453, 2014.
7. Creekmore TD, Eklund MK: The possibility of skeletal anchor-
age, J Clin Orthod 17:266–269, 1983.
8. Poggio PM, Incorvati C, Velo S, Carano A: “Safe zones”: a guide
for miniscrew positioning in the maxillary and mandibular arch,
Angle Orthod 76:191–197, 2006.
 CHAPTER 2 Three-Dimensional Evaluation of Bone Sites for Mini-Implant Placement 27

9. Tadinada Aditya, Schneider Sydney, Yadav Sumit: Role of cone
beam computed tomography in contemporary orthodontics,
Semin Orthod 24(4):407–415, 2018.
10. Tadinada Aditya, Marczak Alana, Yadav Sumit: Diagnostic effi-
cacy of a modified low-dose acquisition protocol for the pre-
operative evaluation of mini-implant sites, Imaging Sci Dent
47(3):141–147, 2017.
11. Salvadó M, López M, Morant JJ, Calzado A: Monte carlo cal-
culation of radiation dose in CT examinations using phantom
and patient tomographic models, Radiat Protect Dosimetry 114(1-
3):364–368, 2005.
12. Yadav Sumit, Sachs Emily, et al.: Gender and growth variation in
palatal bone thickness and density for mini-implant placement,
Prog Orthod 19(1):43, 2018.
This page intentionally left blank

     
3
Success Rates and Risk Factors
Associated With Skeletal Anchorage
SUMIT YADAV, RAVINDRA NANDA
Introduction
Anchorage control plays a pivotal role in the effective man-
agement of orthodontic cases for attaining both structural
and facial esthetics.1–3 Assuming ideal treatment goals,
anchorage requirements should be evaluated in all three
planes of spaces: anterior-posterior, transverse, and vertical.
Attaining maximum or absolute anchorage has always been
an arduous goal for orthodontist clinicians, often resulting
in a condition, dreaded by most, called anchor loss.4 In recent
years, titanium mini-implants have gained enormous popu-
larity in the orthodontic community and are being consid-
ered as absolute source of skeletal orthodontic anchorage.3,4
However, the clinical application of a mini-implant does
not guarantee treatment success, and its stability is essential
before it can be used for different treatment modalities.
Mini-implant success rates have been the subject of
uncontrolled trials, case-control study, prospective clinical
study, randomized clinical trials, and systematic reviews in
the past decade.3,4 Long-term studies report the success rates
of more than 90% for the dental implants, whereas the suc-
cess rates of orthodontic mini-implants have been reported
at the rate of 35% to 95% in the literature.5 The success
rates of mini-implants described in the literature show great
variation, as the survival of mini-implant in the surrounding
bone depends on varied factors.6,7 The success of the mini-
implants usually depends on the extent to which it inte-
grates (both mechanical and biologic) with the surrounding
hard (bone) and soft tissue (gingiva and palatal mucosa).7–9
Site of Placement and Success Rates
Different anatomic sites have been used for the placement
of the mini-implant. Kanomi and Costa and colleagues
implanted mini-implants (1.2 mm in diameter) and mini-
implants (2.0 mm in diameter) into the basal alveolar bone
below the roots of the teeth to prevent the damage to the
adjacent roots.10,11 However, because of ease of placement
and application of orthodontic force, maxillary and man-
dibular buccal alveolar sites are still the preferred locations
for the placement of mini-implants. Park et al. implanted
mini-implants (1.2 mm in diameter) into the alveolar bone
between the roots of the posterior teeth to increase the hori-
zontal component of the applied force.12 In the last 5 years,
palatal mini-implants have gained popularity, as the quality
of underlying bone is excellent and there are no interfer-
ing morphologic structures that prevent the placement of
the mini-implants.13 Recently, Chang et al. popularized the
placement of Mandibular Buccal Shelf Screw (MBS) for the
correction of skeletal malocclusion without orthognathic
surgery, correction of severe crowing and dental proclina-
tion without the extraction of the teeth.14
Buccal Alveolar Mini-Implants/Interradicular
Mini-Implants
The buccal alveolar mini-implants are the most commonly
placed mini-implants within the alveolar bone. The success
rates of buccal alveolar/interradicular (IR) mini-implants is
varied in the literature, ranging from 57% to 95%, with a
mean of approximately 85%.15–17 The overall success rate
of the posterior mini-implants (distal to first premolar) in
the mandible and maxilla is about 83%, and with regards to
individual jaw (maxilla and mandible) and success rate, the
evidence is conflicting.9 Park et al.18 reported that the mini-
implants in the maxilla had a higher success rate, whereas
Miyawaki et al.19 and Moon et al.9 stated that the placement
site of the mini-implant in the maxilla and the mandible
was not related to the success rates. The success rate of mini-
implants depends on numerous factors; however, for buccal
alveolar/IR mini-implant, apart from other factors, the suc-
cess depends on the space between the roots of the adjacent
teeth where the mini-implant is supposed to be inserted.
It has been shown that, for the mini-implant diameter of
1.5 mm in the maxilla, the IR distance between the adja-
cent teeth should be ≥3.1 mm to avoid root contact and
still leave sufficient alveolar bone for the stability.20 Pog-
gio et al. stated that safe zones for the placement of mini-
implants in the maxillary arch based on the IR spaces is 5
to 11 mm above the alveolar crest in the area between the
29
30 PA RT I I Diagnosis and Treatment Planning
second and first premolar and first premolar and canine and
5 to 8 mm above the alveolar crest for the area between first
molar and second premolar. They also stated that in maxilla,
the more anterior and the more apical, the safer the location
becomes.20 To avoid any possible complications of implant–
root contact, various mini-implant placement guides, using
two-dimensional or three-dimensional imaging techniques
have been proposed in orthodontic literature.21–24 Besides
the diameter, angulation of mini-implant can be another
important factor that should be considered. Kuroda et al.
proposed the angulation of 20 to 40 degrees to the long axis
of teeth would reduce the risk of perforating the roots of the
adjacent tooth.25
Another important factor for the success of mini-implants
is the quality or type of soft tissue (mucosa) at placement
sites. Cheng et al. reported that the absence of keratin-
ized mucosa around mini-implants significantly increased
the risk of infection and failure (71% failure rate).26 Mini-
implants in the posterior mandible are more susceptible
to failure than the mini-implants in the posterior maxilla
because of increased chances of infection, as there is signifi-
cantly less attached gingiva available in posterior region of
the mandible. Furthermore, alveolar bone in the posterior
mandible is dense and overheating is more likely to occur
during mini-implant placement.26
Palatal Mini-Implants
In the last decade palatal mini-implants have gained pop-
ularity as palate seems to be an ideal mini-implant place-
ment site because of its good bone stock (bone quantity
and bone quality).27 The palatal mini-implants are usually
preferred because they do not interfere with the desired
orthodontic tooth movement, the placement site is easily
accessible, and no major blood vessels and nerves are pres-
ent to interfere with the palatal mini-implant placement.27
The palatal implants are usually placed either median (in
the suture area) or para-median. Investigators have studied
the success of median palatal mini-implants in detail and
have shown approximately 90% success rate. Karagkiolidou
et al.7 showed that approximately 98% of mini-implants are
stable when they are inserted in the anterior region of the
palate, whereas Ono et al. have showed 85% success rate
when the mini-implants are placed in mid-palatal suture
area.6
Extraalveolar Mini-Implants
Extraalveolar (EA) mini-implants have gained popularity,
and various placement sites have been evaluated to over-
come side-effects of IR mini-implants. The common EA
sites for mini-implant placement are: (1) infrazygomatic
ridge, (2) retromolar pad area, (3) anterior border of the
ramus, and (4) MBS. A need for repositioning the mini-
implants during ongoing orthodontic treatment is elimi-
nated with EA locations as they are placed away from the
path of desired orthodontic tooth movement. Chang et al.
showed a higher success rate of MBS mini-implants (over-
all failure rate 7.2%) when compared to IR mandibular
mini-implants.14 In another study, Chang et al. reported
a failure rate of 5% for ramus mini-implants and stated
these mini-implants as expedient, efficient, and predictable
for molar uprighting.28 Although infrazygomatic region
can be counted as a possible alternative to maxillary buccal
IR mini-implants in maxilla, their close proximity to maxillary
sinus and soft tissue overgrowth makes the infrazygomatic
ridge a less suitable site for mini-implant placement.
Uribe at al. reported a 21.8% failure rate of infrazygomatic
mini-implants, which is way higher than a 12% failure
rate of maxillary IR region.29a Furthermore, Jia et al.
reported that 78.3% infrazygomatic mini-implant perfo-
rated the maxillary sinus and should be used with caution
when alternative sites are not feasible for mini-implant
placement.29b
Risk Factors
The risk factors associated with the success/failure of mini-
implants can be categorized into host factors and mini-
implant factors (Table 3.1). The host factors, such as age,
gender, bone quality and quantity, and root proximity, have
been extensively studied.15,19,27,30–32 With regards to age and
mini-implant stability, the evidence is inconclusive. Park
et al.33 reported that subjects younger than 15 years had
more mini-implant failure than the subjects older than 15
years because of poor bone quantity and quality, whereas
Park concluded that subjects younger than 20 years had sig-
nificantly less mini-implant failure than the subjects ages 20
years and older.34 However, Miyawaki et al. and Moon et al.
stated that there is no significant difference in mini-implant
failure when compared among adolescent subjects, young
adults subjects, and adult subjects.9,19 Most of the studies
have reported no significant gender difference in the success
rates of the mini-implants.6,18,19 Similarly, Papageorgiou
et al.5 metaanalysis lacked evidence for a positive associa-
tion between mini-implant failure and patient sex or age.
The quality and quantity of the alveolar bone are consid-
ered important influential factors affecting the success rate
of orthodontic mini-implants.35 The cortical bone thickness
is considered a decisive factor in the overall success/failure
of the mini-implant. It has been shown that an increase in
the cortical bone thickness in the alveolar bone of maxilla and
TABLE
3.1
  Risk Factors for the Stability of Mini-Implants
Host Factors Mini-Implant Factors
• Bone quantity and quality • Length
• Age • Diameter
• Gender • Material
• Surface
 CHAPTER 3
mandible significantly increases the primary stability of the
mini-implant.36,37 A recent metaanalysis showed positive
association between mini-implant stability and amount of
cortical bone.35
The most important mini-implant factors that affect
the success rates are the diameter and length of the mini-
implant, and both these factors have been thoroughly
researched and studied.19,38 The published evidence has
shown contradictory results with respect to the effect
of the parameters of diameter and length on the mini-
implant stability because of the variability of methods
and samples used in the studies conducted.5,19,38 Miy-
awaki et al. reported that diameter and length of the mini-
implant affect the stability. Increase in diameter and length
of mini-implant increases the success rate of the mini-
implant.19 Tseng et al. found that mini-implant length
is an important variable affecting the success/failure
rates. Their research showed that the length of the mini-
implant was related to success rate: 80% for 8 mm, 90%
for 10 mm, and 100% for 12 mm and 14 mm.39 Similarly,
Sarul et al.38 in their prospective clinical study showed
that the 8-mm mini-implants are significantly more stable
than 6-mm mini-implants. In contrast to aforementioned
studies, Antoszewska et al.40 in their retrospective study
showed no significant relationship between the mini-
implant length and increased stability. Similarly, Wilmes
et al.15 showed that the length of the mini-implants does
not have significant effects on their success when measur-
ing the primary stability. Similarly, Papageorgiou et al.5 in
their metaanalysis revealed no significant association with
mini-implant stability and mini-implant length.
The mini-implant diameter also affects the primarily sta-
bility (i.e., success rate). Miyawaki et al. reported that suc-
cess rate of mini-implants with 1.5 mm or 2.3 mm diameter
was significantly greater than mini-implant with a diameter
of 1 mm. Similarly, Berens et al.41 reported that 2-mm mini-
implant (vs. 1.2 mm) had a higher success rate in the man-
dible and 1.5-mm mini-implant had a higher success rate
in the palate.
Conclusion
In conclusion, selection of the location of mini-implants
should be based on quality and quantity of cortical bone,
knowledge of adjacent anatomic structures like roots of teeth,
maxillary sinus, inferior alveolar canal, and proposed bio-
mechanics to maximum success. Three-dimensional imag-
ing technique should be used as and when required to avoid
the possible penetration of sensitive anatomic structures.42
Lastly, proper oral hygiene practice should be encouraged to
minimize the potential risk of peri-implantitis.
References
1. Yadav S, Upadhyay M, Roberts WE: Biomechanical and histo-
morphometric properties of four different mini-implant surfaces,
Eur J Orthod. 37(6):627–635, 2015.
Success Rates and Risk Factors Associated With Skeletal Anchorage 31
2. Yadav S, et al.: Microdamage of the cortical bone during mini-
implant insertion with self-drilling and self-tapping techniques:
a randomized controlled trial, Am J Orthod Dentofacial Orthop
141(5):538–546, 2012.
3. Upadhyay M, et al.: Treatment effects of mini-implants for en-
masse retraction of anterior teeth in bialveolar dental protrusion
patients: a randomized controlled trial, Am J Orthod Dentofacial
Orthop 134(1):18–29 e1, 2008.
4. Upadhyay M, Yadav S, Patil S: Mini-implant anchorage for en-
masse retraction of maxillary anterior teeth: a clinical cephalo-
metric study, Am J Orthod Dentofacial Orthop 134(6):803–810,
2008.
5. Papageorgiou SN, Zogakis IP, Papadopoulos MA: Failure rates
and associated risk factors of orthodontic miniscrew implants: a
meta-analysis, Am J Orthod Dentofacial Orthop 142(5):577–595
e7, 2012.
6. Uesugi S, et al.: Stability of secondarily inserted orthodontic
miniscrews after failure of the primary insertion for maxillary
anchorage: maxillary buccal area vs midpalatal suture area, Am J
Orthod Dentofacial Orthop 153(1):54–60, 2018.
7. Karagkiolidou A, et al.: Survival of palatal miniscrews used for
orthodontic appliance anchorage: a retrospective cohort study,
Am J Orthod Dentofacial Orthop. 143(6):767–772, 2013.
8. Manni A, et al.: Factors influencing the stability of miniscrews.
A retrospective study on 300 miniscrews, Eur J Orthod 33(4):388–
395, 2011.
9. Moon CH, et al.: Factors associated with the success rate of orth-
odontic miniscrews placed in the upper and lower posterior buc-
cal region, Angle Orthod. 78(1):101–106, 2008.
10. Kanomi R: Mini-implant for orthodontic anchorage, J Clin
Orthod 31(11):763–767, 1997.
11. Costa A, Raffainl M, Melsen B: Miniscrews as orthodontic
anchorage: a preliminary report, Int J Adult Orthodon Orthognath
Surg 13(3):201–209, 1998.
12. Park HS, et al.: Micro-implant anchorage for treatment of skel-
etal Class I bialveolar protrusion, J Clin Orthod 35(7):417–422,
2001.
13. Kim HJ, et al.: Soft-tissue and cortical-bone thickness at
orthodontic implant sites, Am J Orthod Dentofacial Orthop
130(2):177–182, 2006.
14. Chang C, Liu SS, Roberts WE: Primary failure rate for 1680
extra-alveolar mandibular buccal shelf mini-screws placed in
movable mucosa or attached gingiva, Angle Orthod 85(6):905–
910, 2015.
15. Wilmes B, et al.: Parameters affecting primary stability of orth-
odontic mini-implants, J Orofac Orthop 67(3):162–174, 2006.
16. Huja SS, et al.: Pull-out strength of monocortical screws placed
in the maxillae and mandibles of dogs, Am J Orthod Dentofacial
Orthop 127(3):307–313, 2005.
17. Ure DS, et al.: Stability changes of miniscrew implants over time,
Angle Orthod 81(6):994–1000, 2011.
18. Park HS, Jeong SH, Kwon OW: Factors affecting the clinical
success of screw implants used as orthodontic anchorage, Am J
Orthod Dentofacial Orthop 130(1):18–25, 2006.
19. Miyawaki S, et al.: Factors associated with the stability of titanium
screws placed in the posterior region for orthodontic anchorage,
Am J Orthod Dentofacial Orthop 124(4):373–378, 2003.
20. Poggio PM, et al.: “Safe zones”: a guide for miniscrew positioning
in the maxillary and mandibular arch, Angle Orthod 76(2):191–
197, 2006.
21. Dasari AK, et al.: A simple 2D accurate mini implant positioning
guide, JCDR(7)8, ZM03-ZM4. 2014.
32 PA RT I I Diagnosis and Treatment Planning
22. Gandhi VMF: Simple and chairside construction and place-
ment of guide for accurate positioning of orthodontic mini-
implants, J Orthod Endod.(2)1, 2015.
23. Sharma K, Sangwan A: KS. Micro-implant placement guide,
Ann Med Health Sci Res. 4(Suppl 3):S326–S328, 2014.
24. Ludwig B, et al.: Anatomical guidelines for miniscrew insertion:
vestibular interradicular sites, J Clin Orthod 45(3):165–173,
2011.
25. Kyung HM, et al.: Development of orthodontic micro-implants
for intraoral anchorage, J Clin Orthod 37(6):321–328, 2003;
quiz 314.
26. Cheng SJ, et al.: A prospective study of the risk factors associ-
ated with failure of mini-implants used for orthodontic anchor-
age, Int J Oral Maxillofac Implants 19(1):100–106, 2004.
27. Yadav S, et al.: Gender and growth variation in palatal bone
thickness and density for mini-implant placement, Prog Orthod
19(1):43, 2018.
28. Chang CH, Lin JS, Eugene Roberts W: Ramus screws: the
ultimate solution for lower impacted molars, Semin Orthod.
24(1):135–154, 2018.
29a. Uribe F, et al.: Failure rates of mini-implants placed in the infra-
zygomatic region, Prog Orthod 16:31, 2015.
29b. Jia X, Chen X, Huang X. Influence of orthodontic mini-implant
penetration of the maxillary sinus in the infrazygomatic crest
region. Am J Orthod Dentofacial Orthop. 153(5):656–661,
2018. https://doi.org/10.1016/j.ajodo.2017.08.021.
30. Deguchi T, et al.: Quantitative evaluation of cortical bone
thickness with computed tomographic scanning for orthodontic
implants, Am J Orthod Dentofacial Orthop 129(6):721 e7–12,
2006.
31. Farnsworth D, et al.: Cortical bone thickness at common mini-
screw implant placement sites, Am J Orthod Dentofacial Orthop
139(4):495–503, 2011.
32. Park J, Cho HJ: Three-dimensional evaluation of interradicular
spaces and cortical bone thickness for the placement and initial
stability of microimplants in adults, Am J Orthod Dentofacial
Orthop 136(3):314 e1–12, 2009; discussion 314–315.
33. Park YC, Lee KJ, Lee JS. Atlas of contemporary orthodontics. Shin
Hung International, ed. Seoul: S.H. International; 2005.
34. Park HS: Clinical study on success rate of microscrew implants
for orthodontic anchorage, Korea J Orthod 2003(33):151–156,
2003.
35. Marquezan M, et al.: Does cortical thickness influence the pri-
mary stability of miniscrews? A systematic review and meta-­
analysis, Angle Orthod 84(6):1093–1103, 2014.
36. Motoyoshi M, et al.: Factors affecting the long-term stability
of orthodontic mini-implants, Am J Orthod Dentofacial Orthop
137(5):588 e1–5, 2010; discussion 588–589.
37. Motoyoshi M, et al.: Effect of cortical bone thickness and implant
placement torque on stability of orthodontic mini-implants, Int J
Oral Maxillofac Implants 22(5):779–784, 2007.
38. Sarul M, et al.: Effect of the length of orthodontic mini-screw
implants on their long-term stability: a prospective study, Angle
Orthod 85(1):33–38, 2015.
39. Tseng YC, et al.: The application of mini-implants for orthodon-
tic anchorage, Int J Oral Maxillofac Surg 35(8):704–707, 2006.
40. Antoszewska J, et al.: Five-year experience with orthodontic
miniscrew implants: a retrospective investigation of factors influ-
encing success rates, Am J Orthod Dentofacial Orthop 136(2):158
e1–10, 2009; discussion 158–159.
41. Berens A, Wiechmann D, Dempf R: Mini- and micro-screws for
temporary skeletal anchorage in orthodontic therapy, J Orofac
Orthop 67(6):450–458, 2006.
42. Tadinada A, Schneider S, Yadav S: Role of cone beam computed
tomography in contemporary orthodontics, Semin Orthod.
24(4):407–415, 2008.
 PART III

Palatal Implants

4. Space Closure for Missing Upper Lateral Incisors

Bjöern Ludwig and Bettina Glasl
5. Predictable Management of Molar Three-Dimensional Control with i-station
Yasuhiro Itsuki
6. MAPA: The Three-Dimensional Mini-Implants-Assisted Palatal Appliances and One-Visit
Protocol
B. Giuliano Maino, Luca Lombardo, Giovanna Maino, Emanuele Paoletto and Giuseppe Siciliani
7. Asymmetric Noncompliance Upper Molar Distalization in Aligner Treatment
Using Palatal TADs and the Beneslider
Benedict Wilmes and Sivabalan Vasudavan

33 33
This page intentionally left blank

     
4
Space Closure for Missing Upper
Lateral Incisors
BJÖERN LUDWIG, BETTINA GLASL
Aplasia of permanent teeth is not uncommon1—it has a
prevalence of 1.5% to 11.3%.2–4 Aside from wisdom teeth,
lower second premolars are the most commonly affected,
followed by upper lateral incisors.2 The prevalence of this
is between 1% and 2%,5 but there is evidence of a slightly
increased prevalence for women.6 Although the mecha-
nism of occurrence has not yet been fully explained, genetic
causes are considered important (co)factors in this regard.7,8
Previous studies have expressed suspicion that genetic fac-
tors may influence aplasia of permanent teeth. This matter
has been investigated, for example, in comparative studies
on identical twins.9
Therapy Options to Replace Upper Lateral
Incisors
There are different treatment options in the event of
aplasia of upper lateral incisors. In terms of differential
types of diagnosis, this can include leaving the deciduous
tooth, as long as possible,10 tooth transplant,11 single-
tooth implant,12 or prosthetic restoration with an adhe-
sive bridge.13,14,15 This article points out the diagnostic
and therapeutic aspects of orthodontic space closure.16
It should be noted that regardless of the chosen therapy
(space closure or space opening), it is necessary to weigh
the patient-specific aspects to satisfy the individual, aes-
thetic, and functional requirements in the best possible
way. For example, the following aspects play a role in diag-
nosis and therapy planning12,14–18 (Fig. 4.1).
• Profile type
• Skeletal and dental relations and occlusion
• Shape and color of the canine, as well as the root shape
and length
• Eruption position of the canine and symmetric or asym-
metric distribution of aplasia
• Oral hygiene, patient motivation, and the condition of
the dentition
• Smile and gingival line
Prosthetic–Implantologic Solution
A prosthetic–implantologic solution is not recommended in
younger patients with incomplete growth, since an infra-
position of the implant can occur in the course of further
vertical development of the alveolar process, after early
implantation.19–24 Not only growth, but aging can also
affect the vertical eruption of teeth (Fig. 4.2). However, if
the decision is made in favor of an implant, a number of
different critical aspects have to be considered.25–27 Root
reapproximation of central incisors and canines after orth-
odontic treatment has also been reported.27 The toothless
alveolar process is also subject to constant changes.28 In
this regard, it has been found that during the orthodontic
space opening, in the area of the missing lateral incisors,29 a
decrease in the vestibulooral width by up to 15% can occur.
Orthodontic Space Closure: Anchorage
and Biomechanics
If the decision is made in favor of orthodontic space clo-
sure, several aspects must be considered that significantly
influence the final treatment results. These can be classified
into esthetic, functional, and biomechanical aspects. To
move teeth, anchorage is needed. The forces acting on the
teeth are reciprocal in accordance with Newton’s third law.17
Reclined anterior teeth and, especially in unilateral spaces,
deviations of the middle of the arch, can have undesirable
side effects. If the movement of a tooth segment is undesir-
able, it must be anchored in a stable manner. This can be
done reliably by means of skeletal anchorage.30 As some sort
of possible biomechanics, the so-called mesial slider is pri-
marily used these days31 (Fig. 4.3).
Palatal Screw Selection and Insertion
Searching for the best insertion site in the maxilla, the ante-
rior palate appears to be the best.67,68 It is characterized by
35
36 PA RT I I I Palatal Implants

4 3 1

A B
• Fig. 4.1 Esthetic aspects influencing space closure or space opening. (A) Male patients with a low smile
line, without gingival display. Therapy: space opening and insertion of dental implants in regions 12 and
22. (B) Female patient with a high smile line and “gummy-smile.” Therapy: orthodontic space closure and
cosmetic tooth reshaping of the mesialized teeth.

B
• Fig. 4.2 Vertical change in the tooth-implant relation in adulthood. (A) After the implant insertion, the natu-
ral teeth erupted by about 2 mm during 8 years, in relation to the implant. (B) The implant is infrapositioned
in relation to the lips.

the least loss rates,32 a reliable and easy clinical identification
of the ideal insertion spot, and unlimited biomechanical
diversity.33 The amount of horizontal bones at the anterior
palate is huge, and thus the mini-implants (MIs) diameter
is not limited. The length of the MIs should not exceed 8
to 9 mm because the vertical bone availability is limited.34
Moreover, the thinly attached gingiva is required for a com-
plication-free usage period of the MIs.35 The anterior palate
is covered by only a thin layer of keratinized gingiva, with a
thickness of about 1.5 mm.36,37 In conclusion, two MIs, 7
to 9 mm in length, about 1.8 to 2.3 mm in diameter, and
with a 1.5- to 2-mm transgingival neck are recommended.
Since palatal placed MIs, unlike those placed interradicular,
never interfere with tooth movement, their use provides the
maximum level of flexibility for biomechanical consider-
ations, in terms of treatment planning.38,39
 CHAPTER 4 Space Closure for Missing Upper Lateral Incisors 37

4 3 1

A C
• Fig. 4.3
Orthodontic space closure with aplasia of upper lateral incisors. (A) Initial situation—missing 12
and 22. (B) Mini-implants supported T-mesial slider. (C) Final situation after cosmetic reshaping of the
upper anterior teeth and the insertion of a fixed retainer.

A
C

• Fig. 4.4 T-Mesial slider and components. (A) A universal key (screwdriver) is used to fix all screw parts.
(B) Mobile locks with hooks for the coil spring or elastic traction. (C) The sliding tubes are inserted into
the standard lingual sheaths on the first molars. (D) A superelastic closed coil spring is used between the
anterior lock and the sliding tube. (E) A compressed push coil can be applied to the sliding tube from a
distal lock, without a hook on the U-shaped bar.

Mesial Sliding Appliance

The basic part of the T-Mesial slider is a prefabricated
abutment plate attached with two laser-welded wires
(Fig. 4.4).40,41 Both wires are made from stainless steel.
The anterior wire has a dimension of 0.8 mm and the
posterior one of 1.1 mm. The anterior wire is adapted
to touch (or be bonded to) the lingual surfaces of the
central incisors, while the posterior wire is shaped to be
almost parallel the posterior teeth. After adaptation of
the basic framework, the different individual components
38 PA RT I I I Palatal Implants

C
1 = 1N
2 = 2-2.5 N
3 = 2-2.5 N

2
A

• Fig. 4.5 Shows a diagrammatic representation of the optional force systems for the protraction.
• The force level of the nickel-titanium springs between the anterior lock and the posterior sliding tube
should be about 250 grams.
• Elastic chains are used between the central incisors and canines. Additional elastics and/or com-
pressed coil springs can be used labially or lingually, ad libitum, between the molars and premolars
since the anchorage is stationary.
• The U-shaped bar can be activated to guide the first molars for expansion/compression and/or for
intrusion/extrusion.

selected are attached, as shown in Fig. 4.4. After selec-
tion of appropriate components of the T-Mesial slider,
it is attached to the palatal mini-implants and then acti-
vated. Fig. 4.5 shows a diagrammatic representation of
the optional force systems for the protraction.
subsequent veneer or composite restoration of the first premolar,
is recommended.41,46,47 This can also enable group guidance.
The palatal cusp of the first premolar can cause occlusal interfer-
ence in lower jaw movement, which can be countered by selec-
tive odontoplasty,48,49 as well as by a slight mesial rotation.50–52

Interdisciplinary Aspects of Finishing
When Closing the Space
The final reshaping restoration that makes the “role reversal”
perfect can be done using composite or ceramic.39,42,60–62
There is evidence in the literature that in the case of aplasia
of upper lateral incisors, the central incisors are generally nar-
rower40—this may also necessitate their widening.41 But before
this can be done in an ideal way, orthodontic “finishing” must
be performed. The important tasks here are as follows.
The First Premolar
Various authors have considered the first premolars to be
suitable to establish a “canine-equivalent” closure via veneers
or composite abutments.41–44
Torque
The root of the first premolar, which replaces the canine,
must be provided with a buccal root torque to mimic (for
aesthetic reasons) the root prominence of a canine.45
Intrusion
For esthetic and functional reasons, an intrusion (to achieve the
optimal gingival course in relation to the adjacent teeth), with
Gingivectomy
It may be useful to perform a circumscribed modeling per-
taining to gingivectomy/ostectomy of the canine, in addi-
tion to the intrusion.16,41
The Canine
Torque
The anatomic difference of the root morphology between
the lateral incisor and the canine often requires a palatal
root torque of the mesialized canine—this can be applied,
for example, via a suitable bracket, and, if necessary, can be
additionally amplified by third order (= torque) bends.
Extrusion
In addition to mesialization, the tooth is extruded to match
the higher localized gingival curve of the canine to the mar-
ginal aspect of a lateral incisor. The fact that the gingival
margin follows crownward in an extrusive orthodontic
movement53 is exploited here. The canine tip can be succes-
sively remodeled via odontoplastics.54
Occlusion After Space Closure
An average lateral incisor has a mesiodistal extension of
about 7 mm, corresponding to the width of a premolar. The
incisor is set neutral in the “canine area” (angle class 1) and
distally in the molar area (angle class 2)17 (Figs. 4.6 and 4.7).
 CHAPTER 4 Space Closure for Missing Upper Lateral Incisors 39

1 3 4

A B C
• Fig. 4.6 Vertical tooth movement during the orthodontic space closure to establish a harmonious gingiva
line and the design of functional and esthetic canine reshaping. (A) Initial situation with failure 12 and 22.
(B) Bracket repositioning after successful space closure for single tooth corrections that are still necessary.
(C) Final situation before reshaping the tooth numbers 1, 3, and 4.

B
• Fig. 4.7
Orthodontic space closure and SMILE–design. (A) Virtual SMILE design. (B) Final situation after
reshaping the teeth by means of ceramic veneers.

Conclusion 6. Aasheim B, Ogaard B: Hypodontia in 9-year-old Norwegians

The T-Mesial slider, secured by two splinted palatal mini-
implants, is an efficient noncompliance appliance that enables
fast and secure space closure by the protraction of an entire
maxillary dentition. By integrating such space closure with
esthetic dentistry, an attractive display of the anterior den-
tition is obtainable in patients with unilateral or bilateral
agenesis of maxillary lateral incisor(s) and concomitant mal-
occlusions, even in cases that previously were deemed diffi-
cult or impossible to treat. Orthodontic space closure offers
the ability to replace a missing tooth with a different tooth of
the same person. When treatment starts on a young patient,
it is usually completed during his/her adolescence. Close
interdisciplinary coordination is very helpful in this regard.
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5
Predictable Management of Molar
Three-Dimensional Control with i-station
YASUHIRO ITSUKI
Extraalveolar Anchorage Through the
i-station Device
Extraalveolar sites for placement of skeletal anchor-
age units enable the fabrication of different appliances
that can deliver more complex force systems than those
achieved with interdental mini-implants. The appli-
ances that can be designed allow force delivery systems
that assist in correcting a large number of malocclusions
that would otherwise be difficult to manage with con-
ventional mechanotherapy. We have designed a unique
appliance from which a large number of interchangeable
components may be added depending on the biomechan-
ical needs. The i-station consists of two mini-implants
(i-screws), on which an abutment (i-platform) is placed.
A suprastructure (i-arm plate/i-arm square wire) that
controls the force systems is secured to this platform
through three fasteners (i-caps). The components assem-
ble together in the following manner: i-platform connects
to the i-screws and the i-arm/i-arm square wires are fixed
to the i-platform.1–4
The i-station can be used both in the maxilla (Fig.
5.1A–B) and mandible (Fig 5.1C–D), with minor changes
in the components of the device. The main difference is in
the i-platform size, which is larger in the mandible and also
adjustable by cutting the length, depending on the ana-
tomic characteristics of each patient.
The maxillary i-station consists of two i-screws that are
placed along the posterior region of the midpalatal suture
from which the suprastructure (i-arm plate/i-arm square
wire) is fixed to an i-platform connection. On the other
hand, the mandibular i-station is placed in the oblique
ridge of the mandible and consists of two screws that fix the
i-platform3 at each end.
The i-station has the following attributes:
1) No incision is required for its insertion either in the
maxilla or mandible. The i-screw has a broad base on
the attachment head that acts as a stop, preventing the
i-platform from burying into the mucosa and causing tis-
sue irritation (Fig. 5.2A).
2) The i-platform allows for i-screw placement freedom.
Only one of the i-screws has a precise fit within the
i-platform, allowing the second i-screw to be placed
within a range of positions. This ensures flexibility dur-
ing insertion based on patient’s anatomy (Fig. 5.2B).
3) Tight fit (Fig. 5.2C). The i-screw head and the i-platform
hole are both hexagonal. The tight interaction of both
components prevents the i-platform from resulting in a
loose fit.
4) Easy assembly (Fig. 5.2D). Even if the two i-screws are
not parallel, or if the height of the attachment head is at
different levels, the i-platform can still be installed. There
are two grooves in the i-platform, which can be adjusted
to conform to different i-screw angles and heights. This
adjustment can be easily done with a band pusher.
5) Interchangeable i-arm plate/i-arm square wire (Fig. 5.2E).
The i-arm plate/i-arm square wire can easily be replaced
by removing the i-cap. Therefore it is interchangeable to
conform to different force delivery systems.
6) Tooth movement along 360 degrees (Fig. 5.2F). The
i-arm plate/i-arm square wire can be attached at dif-
ferent angles (in 45-degree increments) to the flower
attachment head of the i-platform, allowing a full cir-
cumferential range of force delivery vectors.
7) Weldable components (Fig. 5.2G). Brackets can be
welded to the i-arm plate, and beta-titanium wires can
be used to create complex force systems.
Light and Efficient Force Systems
In theory, to perform bodily tooth movement, a force vector
must be created that passes through the center of resistance
of the entire dentition (Fig. 5.3A). However, the dentition is
not a rigid body; each tooth has its own center of resistance,
and any given archwire tends to bend when applying a force
(Fig. 5.3B). Increasing the rigidity of the wire may allow
bodily tooth movement, but the tooth will not move unless
a very strong force is applied (Fig. 5.3C). If this applied
force is very high, the possibility of anchor mini-implant
failure increases.
43
44 PA RT I I I Palatal Implants
A B
C D
• Fig. 5.1i-station structure. (A) Maxillary i-station. a. i-screw; b. i-platform; c. i-cap; d. i-arm square wire;
e. i-arm plate. (B) i-station placed in the posterior midpalatal suture. (C) Mandibular i-station (same as A
except for b which is i-platform3). (D) Mandibular i-station placed in the oblique ridge.
Controlling the first molar in three dimensions is criti-
cal in orthodontics. The i-station provides this control as
it counteracts the resulting rotational tendencies of the
applied forces at the coronal level. For example, when exert-
ing a distalizing force on a lingual tube on the first molar
with an open coil from the mesial side, a rotational moment
is generated and the tooth will tip distally (Fig. 5.4A). The
reason for this type of molar tooth movement is because the
center of resistance of the tooth and the point of force appli-
cation are different. This also results in binding, which fur-
ther suppresses tooth movement. This same principle ensues
when evaluating the force system from an occlusal perspec-
tive, where molar rotation is observed with the applied force
(Fig. 5.4B).
In loop mechanics, the following wire adjustments can
be done to offset the tipping and rotational tendencies
described earlier. A 0.032 × 0.032-in vertical loop in a beta-
titanium wire is inserted from the i-arm plate to the bracket
on the lingual surface of the molar (Fig. 5.4C). From a
second-order perspective, to offset the tipping of the molar
that will be generated with a distal force, the loop is pre-
bent to create an uprighting moment. Hence when the wire
is inserted into the lingual bracket, tipping and upright-
ing moments are simultaneously generated, which causes
bodily movement of the tooth without distal tipping. In
addition, from the occlusal perspective, the loop is twisted
so a disto-palatal rotation moment is applied to the tooth
(Fig. 5.4D). This results in translation from the simulta-
neous mesio-palatal rotation of the molar from the activa-
tion of the vertical component of the loop and disto-palatal
rotation from the twisting of the loop. Furthermore, this is
a frictionless approach, which has the potential of moving
the teeth more efficiently with a light force, since binding
will not occur.
To distalize the whole maxillary dentition, a 0.016 ×
0.022-in nickel-titanium (NiTi) wire is placed on the lin-
gual brackets of all maxillary teeth. This wire also engages
the first molar, which also has the loop activated from the
i-station (Fig. 5.5A). In this manner, all teeth except for the
first molar initially tip distally, and then are straightened
to the correct position by the elastic deflection of the wire
based on the position of the first molar.(Fig. 5.5B–C).
Another advantage of loop mechanics is the possibility of
vertical activation of the horizontal component of the loop
to achieve either extrusion or intrusion (Fig. 5.6A). Simi-
larly, the loops can be opened or closed in the transverse
dimension to achieve expansion or constriction of the max-
illary arch (Fig. 5.6B). As described earlier, the appliance
also allows for anteroposterior control of the molars (Fig.
5.6C). Thus this appliance offers three-dimensional control
of the maxillary first molars with 6 degrees of freedom and
without generating frictional forces (Fig. 5.6D). Conse-
quently, first molar control is paramount for the successful
correction of the malocclusion.
 CHAPTER 5 Predictable Management of Molar Three-Dimensional Control with i-station 45

A B C

D E

F G
• Fig. 5.2 i-station components and features. (A) The i-screw has a broad base on the attachment head
which acts as a stop, preventing the i-platform from burying into the mucosa. (B) Only one of the i-screws
has a precise fit within the platform, allowing the second i-screw to be placed within a range of positions.
(C) The i-screw head and the i-platform hole are both hexagonal. (D) There are two grooves in the i-plat-
form, which can be adjusted to conform to different i-screw angles and heights. (E) The i-arm plate/i-arm
square wire can easily be replaced by removing the i-cap. (F) The i-arm plate/i-arm square wire can be
attached at different angles (in 45-degree increments) to the flower attachment head of the i-platform. (G)
Brackets can be welded to the i-arm plate and beta-titanium wires can be used to create complex force
systems.

Mechanics to Apply Labial Crown Torque
to the Incisors
When labial torque is applied to the maxillary incisors, a simul-
taneous extrusion force acts on the incisors and an exact equal
and opposite force acts on the molars to produce intrusion
(Fig. 5.7A). This intrusive force on the molars can be counter-
acted with i-station loop mechanics, effectively placing labial
crown torque on the incisors (Fig. 5.7B). By controlling the
first molars, incisors inclination can be thoroughly controlled
without any incisor extrusion.
Case 1
A 21-year-old male presented with chief complaint of facial
and dental midline deviation and crowded dentition (Fig.
5.8). Extraoral examination revealed mandibular devia-
tion to the left side with an orthognathic soft tissue profile
and lower lip protrusion. Intraorally, a midline discrepancy
of 9 mm was observed, with the maxillary dental midline
deviated 3 mm to the right from the facial midline, while
the mandibular dental midline was shifted 6 mm to the
left. Maxillary lateral incisors showed linguoversion. The
amount of crowding was approximately 12 mm in maxilla
and 6 mm in the mandible. Class I canine and molar rela-
tionship on the right and a Class II relationship on the left
with minus 1 mm overjet and 0 mm overbite was observed.
The panoramic radiograph exhibited vertically impacted
maxillary third molars and horizontally embedded mandib-
ular third molars. The lateral cephalometric analysis revealed
a skeletal Class III relationship with a retrognathic maxilla
and normally positioned mandible. The mandibular plane
angle was within the norm (Fig. 5.9). Maxillary incisor
inclination was average and the mandibular incisors were
lingually inclined, creating an obtuse interincisal angle.
Treatment Plan and Alternatives
Orthognathic surgery was recommended because of the man-
dibular asymmetry and a significant midline discrepancy;
however, this treatment option was rejected by the patient. Fur-
thermore, the patient requested for a treatment approach with-
out extractions. To improve the maxillary tooth size-arch length
discrepancy and midline deviation to the right, an i-station was
planned. The i-station would secure anchorage to distalize the
46 PA RT I I I Palatal Implants
A B
C
• Fig. 5.3(A) Theoretical translatory movement of the maxillary dentition. (B) Translatory tooth movement
of the maxillary dentition represented by each tooth having its own center of resistance. (C) High force level
increases the risk of mini-implant failure.
right molars 5 mm and the left molars 7 mm, as well as displac-
ing the midline laterally to the left approximately 3 mm.
In addition, to improve mandibular tooth size-arch
length discrepancy and midline deviation to the left, a man-
dibular i-station was planned to be used on the right oblique
ridge. This anchorage unit would be used to distalize the
right molars by 5 mm and move the midline to the right
approximately 6 mm. Finally, Class III intermaxillary elas-
tics would distalize the mandibular left molars by 1 mm.
Treatment Progress
Fixed lingual orthodontic appliances were placed on both
arches and a 0.016-in NiTi archwire inserted. An i-station
was placed in the posterior maxillary midpalatal suture
and a mandibular i-station was placed in the mandibular
oblique ridge on the right. On the maxilla, four brackets
were welded to the i-arm plate. Stainless steel wires (0.047-
in) were extended posterior to the molars, and distalization
of the right and left molars was performed using NiTi closed
coils.
A 0.047-in stainless steel wire was extended to the left max-
illary canine and connected to the right lateral incisor with a
NiTi closed coil to move the midline to the left (Fig. 5.10).
In the mandible, an i-arm square wire was extended poste-
riorly and anteriorly to the right first molar, and NiTi closed
coils were used to simultaneously perform distalization of
the right first molar and rightward lateral movement of the
right lateral incisor. Arch wires were exchanged sequentially
from 0.018-in, to 0.016- × 0.022-in, and to 0.018- × 0.025-
in NiTi dimensions.
The i-arm was changed for the next stage of treatment
in the maxillary i-station (Fig. 5.11). The maxillary right
canine was constricted using an elastic thread from a 0.047-
in stainless steel wire extended to the right canine. Again, a
0.047-in stainless steel wire was extended to the left canine
and connected to the right lateral incisor with a NiTi closed
coil to displace the midline to the left. Using 0.032- ×
0.032-in beta-titanium wires, right molars were distalized
while the left molars were expanded, distalized and rotated
distobuccally. Detailing during the finishing phase was per-
formed using 0.018- × 0.025-in beta-titanium wires after
the dental and facial midlines aligned and both canine and
molar relationships were corrected to Class I.
Treatment Result
The significant amount of crowding was corrected and
canine and molar Class I relationships achieved (Fig. 5.12).
The 9-mm midline discrepancy improved, with the upper
and lower dental midlines matching the facial midline. Pre-
and posttreatment cephalometric superimpositions showed
distal movements of 5 mm for the maxillary right molar, 7
mm for the left molar, 4 mm for the mandibular right molar,
 CHAPTER 5 Predictable Management of Molar Three-Dimensional Control with i-station 47

A B

C D
• Fig. 5.4 Comparison of sliding mechanics and loop mechanics. (A) Distalizing force on a lingual tube on the
first molar with an open coil from the mesial side generates a rotational moment and causes distal tipping and
binding which suppresses tooth movement. (B) This same principle is observed from an occlusal perspective,
where molar rotation occurs with the applied force. (C) In loop mechanics, a vertical loop is inserted from the
i-platform to the molar bracket. To offset the molar tipping, the loop is pre-bent to create an uprighting moment.
Thus, tipping and uprighting moments are simultaneously generated causing bodily movement of the tooth. (D)
From the occlusal perspective, the loop is twisted so a disto-palatal rotation moment is applied. This results in
translation. This is a frictionless approach which avoids wire binding.

and 1 mm for the left molar (Fig. 5.13). Treatment results clockwise rotation of the mandible and consequently an
were stable at the 1-year posttreatment visit (Fig. 5.14). anterior openbite, resulting in a Class II skeletal relation-
ship. The maxillary and mandibular incisal angles showed
Case 2 labial inclination and an acute interincisal angle was present.

A 26-year-old woman presented for an orthodontic consult
with chief complaints of an openbite, lip protrusion, and a
retrusive mandible (Fig. 5.15). Extraoral findings revealed
perioral muscle tension, which included the chin, and
incompetent lips. Lip protrusion as well as convex profile
because of a significant retrognathic mandible were noted.
Intraoral findings revealed a severe anterior openbite (-9
mm), severe overjet (8 mm), and approximately 8 mm of
crowding in the maxilla and 3 mm in the mandible. Canine
and molar relationships were Class II.
The panoramic radiograph showed microdontia of the
maxillary right third molar and missing left third molar,
and both mandibular third molars were practically erupted
(Fig. 5.16). Also the mandibular condyles were remarkably
resorbed bilaterally.
Cephalometric analysis indicated that the severe resorp-
tion of the mandibular condyles had caused a remarkable
shortening of the mandibular ramus, which led to extreme
Treatment Plan and Alternatives
To reduce the magnitude of the severe openbite and the
mandibular retrognathism, orthognathic surgery with
maxillary impaction and mandibular advancement was
the most appropriate treatment strategy. However, per-
forming mandibular advancement surgery with the
present condylar condition increased the possibility of
further mandibular condylar resorption postsurgically and
relapse. Furthermore, the patient was reluctant to undergo
surgery.
Bilateral extraction of maxillary and mandibular first
premolars was also suggested for improvement of lip pro-
trusion and openbite. However, this method is based on
extrusion of the anterior teeth, with no improvement in the
mandibular anteroposterior and vertical positioning and
with potential of relapse in the openbite. The patient also
rejected this treatment option, since she was averse to the
temporary unesthetic results of premolar extraction therapy.
48 PA RT I I I Palatal Implants

The final treatment plan was to extract the mandibular

third molars and use that space to distalize the mandibular
dentition and to extract the maxillary right third molar and
distalize the maxillary dentition. These movement were to
be performed using i-stations in the maxilla and mandible.
Furthermore, to correct the openbite, the maxillary and
mandibular molars were to be intruded from the i-stations,
A in conjunction to intrusion of the mandibular anterior
teeth, which would result in a remarkable counterclockwise
rotation of the mandible, improving the projection of the
chin and reducing the anterior lower facial height.

B An i-station was implanted in the posterior midpalatal
C Bilateral mandibular i-stations were implanted distal to
• Fig. 5.5 Distalization of dentition using loop mechanics. (A) For
whole maxillary dentition distalization, a 0.016- × 0.022-in nickel-tita-
nium (NiTi) wire is placed on all maxillary brackets. This wire engages
the first molar which also has the loop activated for bodily movement.
(B) All teeth except for the first molar tip distally and are straightened by
the elastic deflection of the wire. (C) All teeth have been straightened
based on the first molar control.
Treatment Progress
The appliances were bonded on the maxillary lingual and
mandibular labial sides, and 0.016-in NiTi archwires were
inserted.
suture and an impression was taken for fabrication of a
working cast. Two brackets were welded to the i-arm plate
and 0.032- × 0.032-in beta-titanium wires with horizontal
and vertical loops were fitted between the i-arm plate and
first molar brackets (Fig. 5.17). The fabricated i-arm plate
was fixed to the i-platform and activated by opening the ver-
tical loops and constricting the horizontal loops to distalize
and intrude the molars simultaneously.
the mandibular molars and a working cast was made. Bilat-
eral i-arm square wires were extended distal to the canine
roots, and helical loops were placed distal to the first molar
roots (Fig. 5.18). The fabricated i-arms were screwed to the

A B

C D
• Fig. 5.6 Loop mechanics range of movement. (A) Intrusion and extrusion. (B) Expansion and constric-
tion. (C) Distalization and mesialization. (D) Three-dimensional movement with 6 degrees of freedom.
 CHAPTER 5 Predictable Management of Molar Three-Dimensional Control with i-station 49

A B
• Fig. 5.7 Mechanics of labial crown torque to the maxillary incisors. (A) Forces generated when applying
labial crown torque to the incisors. (B) Vertical loop from i-station for molar vertical control while applying
labial crown torque to the maxillary incisors.

• Fig. 5.8 Pretreatment extraoral and intraoral photographs, and panoramic radiograph. The maxillary
and mandibular midlines are shown by the yellow arrows.
50 PA RT I I I Palatal Implants

Parameter Norm SD Value

∠SNA 81.8 3.1 79.1

∠SNB 78.6 3.1 80.6

∠ANB 3.3 2.7 -1.5

Mandibular pl. to FH 26.3 6.3 30.3

Mandibular pl. to SN 40.2 4.6 36.7

U1 to FH 114.3 6.5 109

IMPA 94.7 7.2 80.7

FMIA 59 6.7 69

Interincisal angle 129.7 9 140.1

Occlusal pl. to SN 20.2 3.5 14.2

Lower lip 1 1 0.5

Upper lip -2.5 1.5 -3.2

AB to Occlusal plane (Wits) -5.9

• Fig. 5.9 Pretreatment lateral cephalogram and cephalometric analysis.

• Fig. 5.10 Maxillary bilateral molar distalization with leftward movement of the midline, and mandibular
right molar distalization and rightward midline movement (blue arrows show force vectors). Both move-
ments effected by lever arms extended from i-stations. The yellow arrows show maxillary and mandibular
midlines.
 CHAPTER 5 Predictable Management of Molar Three-Dimensional Control with i-station 51

• Fig. 5.11
In the maxilla, right canine constriction and midline leftward movement was achieved using lever
arms. Right and left molar distalization, distal rotation and expansion was achieved using loop mechanics.
The blue arrows show force vectors and the yellow arrows show maxillary and mandibular midlines.

i-platform3. From these appliances, elastic threads extend-
ing from the helical loops and front arms were used to dis-
talize and intrude the first molars and canines. A lingual
archwire was installed between the first molars to prevent
the first molars from rolling buccally as they were being
intruded.
Treatment Result
Lip protrusion was significantly reduced. Mandibular
anteroposterior projection and reduction in the lower facial
height was achieved, which resulted in significant improve-
ment in the perioral muscular tension and elimination of
the lip incompetency (Fig. 5.19). Class I molar and canine
relationships with good intercuspation and an ideal overbite
were achieved.
The superimposition from before and after treatment lat-
eral cephalograms revealed that the maxillary molars were
distalized 9 mm and intruded 5 mm, while the mandibular
molars were distalized 8 mm and intruded 2 mm. In addi-
tion, the mandibular anterior teeth were intruded 3 mm
(Fig. 5.20). Consequently, significant mandibular coun-
terclockwise rotation occurred, resulting in 8 mm forward
and 5 mm upward mandibular movement of the chin. In
addition, the mandibular condyles did not display further
resorption changes.
Summary
The i-station system has great versatility that allows three-
dimensional tooth movement with 6 degrees of freedom.
The i-station can be applied to the correction of any type
of malocclusion, including severe crowding, maxillary pro-
trusion, mandibular protrusion, deep bite, and hypodon-
tia. The dental movements can result in significant skeletal
52 PA RT I I I Palatal Implants

• Fig. 5.12 Posttreatment extraoral, intraoral photographs, and panoramic radiograph.

A B
• Fig. 5.13
(A) Posttreatment lateral cephalogram. (B) Superimposition. Black, pretreatment; red, posttreat-
ment. Dotted lines, right; solid lines, left.
 CHAPTER 5 Predictable Management of Molar Three-Dimensional Control with i-station 53

• Fig. 5.14 One-year postretention extraoral and intraoral photographs.

54 PA RT I I I Palatal Implants

• Fig. 5.15 Pretreatment extraoral and intraoral photographs.

 CHAPTER 5 Predictable Management of Molar Three-Dimensional Control with i-station 55

• Fig. 5.16 Pretreatment lateral cephalogram, cephalometric analysis, temporo-mandibular joint radio-
graphs and panoramic radiograph.
56 PA RT I I I Palatal Implants

• Fig. 5.17 Maxillary bilateral molar distalization and intrusion using loop mechanics. The blue arrows show
the direction of the force vectors.
 CHAPTER 5 Predictable Management of Molar Three-Dimensional Control with i-station 57

• Fig. 5.18Whole mandibular dentition intrusion and distalization using i-stations. The blue arrows show
force vectors.
 • Fig. 5.19 Posttreatment extraoral, intraoral photographs and panoramic radiograph.

• Fig. 5.20 (A) Posttreatment lateral ceph-

alogram. (B) Superimposition. Black,
Pretreatment; red, posttreatment. Maxillary
molars distalized 9 mm and intruded 5 mm.
Mandibular molars distalized 8 mm and
intruded 2 mm. Mandibular incisors intruded
3 mm. Mandibular counterclockwise rotation, A
causing 8 mm forward and 5 mm upward
B
mandibular movement.
 CHAPTER 5 Predictable Management of Molar Three-Dimensional Control with i-station 59

effects when the molars are controlled vertically, thus greatly
expanding the scope of treatment. This approach allows for
orthodontic treatment of patients who in the past could
only be treated by orthognathic surgery. The i-station is a
powerful adjunct in orthodontics, especially in patients with
significant dentofacial deformity and treatment complexity.
3. Itsuki Y, Imamura E: Multipurpose orthodontic system using
palatal implants for solving extremely complex orthodontic prob-
lems, J World Fed Orthod 6:80–89, 2017.
4. Itsuki Y, Imamura E, Sugawara J: Temporary anchorage device
with interchangeable superstructure for mandibular tooth move-
ment, J World Fed Orthod 2:e19–e29, 2013.

References
1. Itsuki Y, Imamura E: A new palatal implant with interchangeable
upper units, J Clin Orthod 43:318–323, 2009.
2. Itsuki Y, Imamura E, Sugawara J, Nanda R: A TAD-based system
for camouflage treatment of severe skeletal Class III malocclusion,
J Clin Orthod 50:401–412, 2016.
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6
MAPA: The Three-Dimensional Mini-
Implants-Assisted Palatal Appliances
and One-Visit Protocol
B. GIULIANO MAINO, LUCA LOMBARDO, GIOVANNA MAINO, EMANUELE PAOLETTO,
GIUSEPPE SICILIANI

Introduction laterolateral teleradiography are comparable to those mea-

Insertion of mini-implants for orthodontic anchorage into
the palatal vault is finding ever more applications in the field
of dentistry.1–5 This anchorage site is useful for both biome-
chanical and, especially, anatomic reasons, as there are no
roots that could interfere with mini-implants insertion.6–8
Nevertheless, the palate does not present a uniform thickness,
varying from individual to individual,9 and great care there-
fore needs to be taken to analyze the availability of bone to
guarantee good primary stability and reliable anchorage.10
In recent years, volumetric tomography and purpose-
designed software have enabled the design and construction of
templates that allow the available bone to be exploited well,
making mini-implants placement safer and more precise.11
These three-dimensional (3D) guides are generally constructed
with mini-implants placement in the interradicular spaces in
mind, specifically to prevent any damage to tooth roots.12–14
However, we present here a mini-implants insertion guide
designed specifically for palatal application. This template is
able to ensure not only that mini-implants are placed at the
correct depth in the maxillary bone but also that multiple
implants are parallel. It is therefore suitable for mini-implants
destined for anchorage of removable devices, as well as pre-
formed and tailored appliances used in fixed orthodontics.
sured on CBCT scans taken roughly 5 mm from the midsag-
ittal plane.15 Mini-implants are positioned to realize a
bicortical anchorage without the risk to damage the roots of
the teeth. Lombardo et al. have shown that placement of the
mini-implants into both cortical layers markedly reduces the
load at the trabecular bone and increases stability.16 The use
of CBCT is strictly recommended in all cases of impacted
canines, laterally displaced lateral incisors, narrow maxilla, or
anatomic abnormalities that may affect the correct insertion
of the mini-implants. After scanning, a digital model (stereo-
lithography [STL] files) of the upper arch is superimposed
onto the DICOM (Digital Imaging and Communications in
Medicine) file (Fig. 6.3) or the lateral X-ray (Fig. 6.4),
enabling identification of the most suitable anteroposterior
mini-implants placement sites (Fig. 6.5) based on the width
and thickness of the palatal vault. This operation is performed
using suitable software (eXam Vision software integrated
with Rhinoceros software), which is also used to design a vir-
tual surgical guide to fit the morphology of the palate and the
teeth in the lateral and posterior sectors of the upper arch

Surgical Guide Fabrication

The optimal site and direction of mini-implants insertion
can be identified on a cone beam computed tomography
(CBCT) scan of the maxillary bone (Fig. 6.1) or lateral tele-
radiography acquired after intraoral positioning of a thermo-
plastic polyethylene terephthalate-glycol (PET-G) bite, cast
on the patient’s plaster model and featuring a series of radio-
opaque markers along the medial palatine raphe (Fig. 6.2). • Fig. 6.1
Digital Imaging and COmunication in Medicine (DICOM) le of the
According to Kim et al., palatal thicknesses measured via cone-beam computed tomography scan with the digital mini-implants.

61
62 PA RT I I I Palatal Implants
(Fig. 6.6). The virtual guide can be reproduced in resin (com-
patible for intraoral use) using a 3D printer (Everes Uno,
SISMA S.p.A.), and it is also designed to feature two cylin-
drical metallic guides, designed to replicate the angle of
insertion and prevent the mini-implants from penetrating
beyond the required depth, in the central portion (Fig. 6.7).
Mini-implants Application
After local anesthesia to the palatal site in question (2% lido-
caine), the surgical guide is fitted, making sure that it rests on
the occlusal surfaces of the posterior teeth (Fig. 6.8). If required,
a small amount of light-cure resin (Triad by Dentsply) can be
used to bond this to the occlusal surfaces of the first premolars.
Self-drilling mini-implants (Spider screw Regular Plus
and Konic Plus by HDC) of the programmed length and
diameter are selected, picked up with the apposite driver—
mounted on a low-velocity contra-angle handpiece (30
rpm)—and by these means inserted through the apposite
metallic cylinder of the template. Indeed, the guide is able
to replicate with extreme precision the transmucosal portion
of the mini-implants and driver, and can prevent the mini-
implants exceeding the preprogrammed depth (Fig. 6.9).
Appliance Fabrication
STL is used to obtain a model of the maxillary arch, repro-
ducing the heads of two, three, or four mini-implants from
the STL file of the digital model. The printed 3D model is
then duplicated in a plaster model (Fig. 6.10), metal abut-
ments designed to fit over the heads of the mini-implants are
positioned into the plaster, and different kinds of orthodontic
appliances can be created. The precision currently achieved by
the mini-implants insertion guide designed specifically for
palatal application (MAPA) system allows the clinician to
apply the mini-implants through the surgical guide and sub-
sequently to apply the orthodontic appliance during the same
session without the need to make new impressions.17 Once
the appliance has been positioned on K2 Spider screw or
Konic Spider Screw (in case the inserted mini-implants are
not parallel for anatomic reasons), it is locked by means of a
mini-implants fitted with an appropriate driver (Fig. 6.11).
• Fig. 6.2 X-ray and lateral cephalogram showing radio-opaque markers along the medial palatine raphe
with the digital mini-implants. Digital model cast and the vacuum-formed retainer with the markers.
Clinical Cases
The MAPA system is very versatile and is used to treat dif-
ferent types of malocclusion (Class III, Class II, narrow
maxilla, and asymmetric cases).
Class III Growing Patients
One of the most challenging orthodontic treatments to per-
form is the correction of skeletal Class III malocclusion,18
since a potentially unfavorable growth pattern usually
requires early intervention to be effective.19 However, early
treatment using a protraction facemask in conjunction with
a rapid palatal expansion (RPE) appliance has proven suc-
cessful in correcting skeletal Class III malocclusions that are
caused primarily by deficient maxillary development.20,21
The goal of facemask therapy is to obtain purely skeletal
changes with minimal effects on the dentition.22 Previous
studies have shown that these undesirable side effects, which
include excessive forward movement and extrusion of the
maxillary molars, excessive proinclination of the maxillary
incisors, and an increase in lower face height, can easily result
from tooth-borne protraction facemask therapy,23–25 a par-
ticular concern in situations in which preservation of arch
length is necessary.22 To simplify the procedure for the treat-
ment of Class III patients, Maino et al.26,27 developed a 3D
surgical guide to provide a safe and reliable palatal mini-
implants insertion. The associated protocol that proposed
alternating expansion and compression of the maxillary com-
plex28 by means of a hybrid palatal expander, anchored to
both the bone and the teeth, to be followed by 4 months of
facemask therapy in a sample of 28 growing Class III patients,
has resulted in interesting clinical findings29 (Figs. 6.12 and
6.13). Point A advanced by a mean of 3.4 mm with respect
to the reference plane Vert–T. The mandibular plane rotated
clockwise, improving the angle between points A, Nasion,
and point B (ANB) (+3.41 degrees) and the Wits index
(+4.92 mm). The upper molar displayed slight extrusion
(0.42 mm) and mesialization (0.87 mm). The cephalometric
analysis results were very similar to those reported in the
metaanalysis of three randomized controlled trials conducted
by Cordasco,30 in terms of both sagittal (angle between
 CHAPTER 6 MAPA: The Three-Dimensional Mini-Implants-Assisted Palatal Appliances and One-Visit Protocol 63

• Fig. 6.3 Superimposition of the digital model with mini-implants on • Fig. 6.4 Superimposition of the digital model with mini-implants on
cone-beam computed tomography. (With permission from HDC.) lateral cephalograms.

• Fig. 6.5 Stereolithography model and ideal mini-implants insertion point (IIPS).

• Fig. 6.7 The three-dimensional printed surgical guide.

• Fig. 6.6The three-dimensional surgical guide resting on the occlusal
surface of the posterior teeth.

points S, N, and A [SNA], angle between points S, N, and B
[SNB], and ANB) and vertical (angle between cranial base
plane SN and palatal plane PP [SN-PP] and angle between
cranial base plane SN and mandibular plane MP [SN-MP])
measurements. However, it should be noted that the mean
duration of treatment in the articles cited by Cordasco was
roughly 1 year, whereas ours was completed in 4 months.
Moreover, the mean age of our sample was considerably
greater (11 years 4 months vs. 8 years 5 months).
Class II Patient
Maxillary molar’s distalization represents an orthodontic
procedure frequently required in patients with Class II
64 PA RT I I I Palatal Implants
malocclusion. Patient cooperation is one the most impor-
tant aspect every clinician must face,27 and unavoidably, it
tends to decrease,29–33 making treatment with extraoral and
intraoral appliances unpredictable.34 To facilitate this proce-
dure, a wide range of distalizing devices have been devel-
oped and several more have been designed over the years.
The growing demand for orthodontic treatment methods
requiring minimal cooperation but maximum anchorage con-
trol has led clinicians to search for “bone-supported anchorage.”
After years of research, mini-implants, as a temporary
• Fig. 6.8 The three-dimensional printed surgical guide in the patient
mouth.
•Fig. 6.9 The mini-implants position after three-dimensional surgical
guide removal.
• Fig. 6.10 Three different examples of printed digital model cast with inserted mini-implants.
anchorage device, have been recognized as a valuable tool
because of their small size, ease of insertion and removal, low
cost, immediate loading, and ability to be safely inserted in dif-
ferent locations.
The MAPA system can be used to ensure a skeletal
anchorage to a sliding device on pistons with nickel-tita-
nium springs. The new digital technologies today allow
these devices to be built using laser metal fusion procedures
(Mysint 100, SISMA S.p.A.) (Fig. 6.14). This appliance
design eliminates anchorage loss risks and minimizes the
need for the clinician to perform complex procedures until
Class I molar relationship is reached.
In Class II patients requiring a first phase of expansion of
the upper maxilla and then a distal rotation of the first upper
molars, it is possible to use the combination of two different
skeletal anchorage devices. For example, it is possible to first
place two K2 spider screws (9 and 11 mm) on the palate and
subsequently cement a hybrid rapid expander (Fig. 6.15).
Once the expansion is achieved, a new impression is realized
• Fig. 6.11 K2 Regular Plus Spider Screw or Konic Spider Screw (in
case the inserted mini-implants are not parallel for anatomic reasons),
the abutment, and the mini-implants used to fix the appliances.
 CHAPTER 6 MAPA: The Three-Dimensional Mini-Implants-Assisted Palatal Appliances and One-Visit Protocol 65

and a pendulum is built without the need to insert new
mini-implants. By the pendulum, a super Class I molar rela-
tionship is achieved and then a fixed straight wire multi-
brackets fixture is used for the space closure, alignment, and
coordination of the arches.
Narrow Maxilla
For many years surgically assisted rapid palatal expansion
(SARPE) has been the treatment of choice to resolve the
maxillary constriction in young adults, although several
authors have reported successful nonsurgical expansion in
young and adult patients.31–35 Nevertheless, in 2010, Lee
et al.36 introduced an expansion appliance secured to the
palate by means of mini-implants, the MARPE (mini-
implants-assisted rapid palatal expander), which used to
treat a 20-year-old patient with severe transverse discrep-
ancy before orthognathic surgery for mandibular progna-
thism. Expansion was successfully achieved with minimal
damage to the teeth and periodontium.

• Fig. 6.12
Intraoral photos of a Class III patient before and after hybrid rapid palatal expansion and face
mask protocol.

• Fig. 6.13 Cephalometric analysis of

the Class III patient before and after
hybrid rapid palatal expansion and
face mask protocol.
66 PA RT I I I Palatal Implants

• Fig. 6.14 Records of a Class II patient treated by a sliding distalizing appliance fixed on palatal mini-
implants and upper first premolars.

• Fig. 6.15Records of a Class II patient treated by a hybrid rapid palatal expander and a pendulum appli-
ance fixed on palatal mini-implants.
 CHAPTER 6 MAPA: The Three-Dimensional Mini-Implants-Assisted Palatal Appliances and One-Visit Protocol
In a 16-year-old female presenting with a hyperdiver-
gent face, a gummy smile, an anterior openbite, narrow
maxilla, and a crossbite on the left side (Fig. 6.16), prelimi-
nary expansion of the upper arch was advised before any
orthodontic intervention. To avoid periodontal complica-
tions during palatal expansion, we offered the patient a
BBRME (Bone Born Rapid Palatal Expansion). CBCT
images were used to plan the virtual insertion of two self-
tapping, self-drilling Spider Screw Regular Plus† mini-
implants (11 mm long, 2 mm in diameter) in the
paramedian areas at the level of the first premolars (see Fig.
6.16). Two similar mini-implants were then virtually
inserted between the second premolars and first molars on
each side, with a divergent inclination to maximize bony
support (see Fig. 6.9). With the patient under local anes-
thesia, the four mini-implants were mounted using a low-
speed contra-angle handpiece (50 rpm) and directed
through the custom-designed guide sleeves of the insertion
stent, precisely positioning them in the palate. The BBRME
was attached immediately by connecting it to the anterior
mini-implants through two abutments embedded in the
acrylic and fixed by mini-implants (Fig. 6.17). The two
posterior abutments were attached to the posterior mini-
implants through predrilled holes in the acrylic portion of
the appliance. These two abutments were then affixed to
the body of the BBRME using a small amount of flowable
light-cured composite. The expander was activated under a
protocol of three quarter-turns per day to determine
whether the BBRME would show immediate results; if not,
SARPE would be required. After 6 days of activation, a
small diastema had appeared. Activation was completed in
• Fig. 6.16 Frontal initial intraoral photo and cone-beam computed tomography-stereolithography model
cast. Digital mini-implants superimposition.
• Fig. 6.17 First and second rapid palatal expander applied to four palatal mini-implants to achieve the
correct maxillary expansion.
67
14 days (see Fig. 6.17). Because the transverse dimension
had not been completely corrected, however, a new BBRME
was constructed from an impression taken over the four
mini-implants after the first device was removed (see Fig.
6.17). Twelve days after activation of the second BBRME,
sufficient overcorrection of the transverse diameter had
been achieved. CBCT performed after expansion demon-
strated the skeletal effects of the appliance (Fig. 6.18).
In adult patients, the maxillary suture opening is more
difficult to be realized and conventional rapid palatal
expanders can fail. To achieve a more parallel and reliable
suture opening and overcome some anatomic impair-
ments because of the narrow palatal vault, a Tandem Skel-
etal Expander (TSE) is usually constructed (Fig. 6.19).
After four mini-implants (Spider screw K2) insertion on
the maxillary bone according to MAPA system, two
expanding mini-implants are positioned to be active
simultaneously. The CBCT scan 3D reconstruction made
after the expansion showed a considerable maxillary suture
opening of about 6 mm.
Asymmetrical Cases
MAPA system is also useful in cases requesting asymmetrical
biomechanics. The bicortical anchorage of two palatal
­mini-implants can be used in a different way in the right
and left side. For example, on the right side a Pendulum
spring is used to distalize the upper molar, while the on left
side a metallic arm was used to move canine, premolar and
molar on the palatal side to achieve a more negative torque
and correct the transversal problem (Fig. 6.20).
68 PA RT I I I Palatal Implants

• Fig. 6.18
Frontal intraoral photo after the end of the expansion and after/before cone-beam computed
tomography superimposition.

• Fig. 6.19Before and after occlusal intraoral photos and after expansion cone-beam computed tomog-
raphy of an adult patient with severe narrow maxilla treated by Tandem Skeletal Appliance (TSA). (With
permission from HDC.)

• Fig. 6.20 Intraoral occlusal photos and digital model casts of an asymmetric patient treated to distalize
upper right molars and to lingually upper second premolars and molars. (With permission from HDC.)

Conclusion according to the biomechanics needs, maxillary bone pro-

traction, upper molar distalization, maxilla expansion,
MAPA system represents a reliable and safe way to position upper teeth mesialization, intrusion or lingual inclination
two or more mini-implants on the maxillary bone in grow- can be realized without the need for compliance and risks of
ing or adult patient. Endless combinations are possible, and anchorage loss.
 CHAPTER 6 MAPA: The Three-Dimensional Mini-Implants-Assisted Palatal Appliances and One-Visit Protocol
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7
Asymmetric Noncompliance Upper
Molar Distalization in Aligner
Treatment Using Palatal TADs and the
Beneslider
BENEDICT WILMES, SIVABALAN VASUDAVAN
Upper Distalization in Aligner Treatment
Class II malocclusions are frequently encountered in orth-
odontic practice, with a prevalence of approximately 15%. The
distalization of the maxillary first permanent molar teeth
may be considered as a viable treatment option for patients
presenting with an Angle Class II malocclusion character-
ized with an increased overjet and anterior crowding. Molar
distalization can be performed using intraoral or extraoral
appliances. Potential issues arising with patient compliance
may be associated with the prolonged use of headgear.1,2
There has been an increasing trend in the clinical use of
purely intraoral appliances that require minimal need for
patient cooperation. Unfortunately, most of the conven-
tional devices for noncompliance upper molar distalization
produce unwanted side effects, such as anchorage loss.3 Most
tooth-borne appliances for upper molar distalization pro-
duce an unwanted side effect of anchorage loss resulting in
maxillary incisor proclination, reported to be 24% to 55 %
of observed tooth movement.3–5 In clinical cases requiring
unilateral distalization, a midline shift of the anterior teeth
is commonly observed. One possibility to reduce unwanted
orthodontic effects of reciprocal forces is the usage of a pala-
tal acrylic pad or Nance button. However, the anchorage
stability of these soft-tissue-borne elements is not always cer-
tain. Moreover, oral hygiene is often impaired because of the
partial coverage of the palatal area. To minimize anchorage
loss, mini-implants have been incorporated into the design
of maxillary distalization appliances.6–16 Mini-implants can
be positioned intraorally with minimal degrees of surgical
invasiveness, are readily integrated with concomitant bio-
mechanical initiatives, and are relatively cost effective.16–22
An increasing number of patients seek orthodontic treat-
ment with sequential plastic aligner therapy. Pure bodily
tooth movement with sequential plastic aligner therapy is
challenging to achieve to a high degree of predictability. As
a consequence, unilateral or bilateral molar distalization is
limited when relying on aligner movement alone. While
there are limited reports of successful upper molar distaliza-
tion of up to 2.5 mm in the literature, a very long treatment
time and high level of patient compliance are expected
with requirement for intermaxillary Class II elastics to be
worn during the long period of the sequential upper molar
distalization.23–25 Moreover, the potential side effects of
Class II elastics must be considered in terms of mesial shift
of the lower anchorage teeth; this might be a severe prob-
lem, especially in unilateral Class II elastics applications
with the potential for development of a lower midline shift,
maxillary arch rotation and a yaw discrepancy, and trans-
verse occlusal canting.
Optimal Insertion Sites for Mini-Implants
Various iterations of implant-supported distalization appli-
ances have been published recently. The retromolar region is
an unsuitable area for mini-implant insertion because of the
unfavorable anatomic conditions (poor bone quality and
thick soft tissue).26 In addition, the alveolar process has also
been shown to be inappropriate in cases of a desired molar
distalization, since the mini-implants are in the direct path
of the moving teeth, resulting in a failure rate that is much
higher compared to the anterior palate.26,27 Therefore the
palatal area posterior from the rugae (Fig. 7.1, T-Zone28)
seems to be the preferred insertion site for mini-implants
where the treatment objective is for distal movement of
the maxillary first permanent molar without associated
anchorage loss and maxillary incisor displacement. Fur-
thermore, good bone quality with thin attached mucosa
71
72 PA RT I I I Palatal Implants
• Fig. 7.1
T-Zone palatal posterior from the rugae seems to be the opti-
mum TAD insertion site for distalization of molars in the maxilla. Within
the T-Zone, mini-implants can be inserted in a median or paramedian
fashion.
implies minimal risk of tooth-root injuries and a very high
success rate in the anterior palatal region.29 In contrast to
treatment strategies involving the interradicular positioning
of mini-implants, the molar teeth can be distalized and the
premolars are free to move distally because of the stretch
of the interdental fibers without any interference, since the
palatally positioned mini-implants are not in the path of
moving teeth. Within the T-Zone, the mini-implants can be
inserted in a median or paramedian orientation,28 with both
insertion sites showing a similar stability.30
Clinical Procedure and Rationale of the
Beneslider
The Beneslider (Fig. 7.2)20,31–33 is a maxillary molar tooth
distalization appliance, principally designed on the use of
one or two mini-implants coupled in a median or parame-
dian orientation in the anterior palate. Mini-implants with
exchangeable abutments are indicated (see Fig. 7.2B) with
the goal to achieve a stable and safe connection between the
mini-implants and the distalization mechanics. Following
the application of local or topical anesthesia in the anterior
hard palate, the mini-implants are inserted usually without
the need for predrilling of bone. It is advisable to choose
mini-implants with a diameter of 2 or 2.3 mm, since they
provide a superior stability.34–37 An adult patient will typi-
cally present with areas of higher bone density in the anterior
hard palate, and require a preparatory step of drilling a pilot
hole to an approximate depth of 2 to 3 mm to be performed
to keep the insertion torque within a safe range.34 Predrill-
ing can be performed using a handpiece that is adapted to a
regular contra angle, without the need for cooling. The Ben-
efit mini-implant31–33,38 abutments (see Fig. 7.2B) can be
secured with the use of an inner mini-implants or fixation
cap. If a single mini-implant is used, one abutment is fixed
for the distalization mechanics. To increase the stability and
prevent a rotational tendency leading to loosening, two
Benefit mini-implants can be coupled with the Beneplate32
(see Fig. 7.2C). To secure the Beneplate, a small fixation
screw is used. Both abutments as well as Beneplates are
available with 1.1-mm stainless steel wire configuration
(see Fig. 7.2B and C). Depending on the axis and the loca-
tion of the two positioned mini-implants, the Beneplate
framework requires adjustment. By modifying the angu-
lation of the 1.1 mm SS wire, it is possible to achieve a
simultaneous intrusion or extrusion of the molars.39–41
The distalization force is delivered by two springs (usually
240-g) activated by two locks (see Fig. 7.2A). At the same
appointment, stainless steel bands with lingual sheaths are
adapted to the maxillary molar teeth. These springs are
pushing the sliding tubes (see Fig. 7.2D) into the lingual
sheaths of the molar bands.
It seems advantageous that the Beneslider appliance can
be fitted directly without the requirement for adjunctive
laboratory work in terms of welding or soldering, or the
need to record an intraoral impression. Alternatively, the
clinician has the choice to record an intraoral impression
and transfer the clinical setup to a plaster cast model using
an impression cap and laboratory analogue from the Benefit
system.
How to Combine Beneslider and Aligners,
Strategies and Clinical Tips
If sequential plastic aligners are to be used to realize the
planned tooth movement, we recommend the use of
bonded tubes (see Fig. 7.2E) instead of bands, sheaths, or
welded tubes (see Fig. 7.2A and D). The primary advan-
tages of a bonded tube are esthetics, and the adaptability,
accuracy, and fit of the aligners are not undermined by
the presence of stainless steel molar bands. The aligner
material could cover this bonded connection (Fig. 7.3A),
or the aligner could be cut out in this connection area
(Fig. 7.3B).
Following distalization of the maxillary molar teeth,
steel ligatures can be used (see Fig. 7.3A) or springs
removed (see Fig. 7.3B) to modify the Beneslider from
an active distalization device to a passive molar anchorage
device. The primary objective is to stabilize the maxillary
molar teeth during the retraction of the maxillary anterior
teeth. Our experience in using the Beneslider appliance in
conjunction with aligners commenced with a two-phase
approach39: the initial phase involving molar distalization,
and the secondary phase for the final detailing of the occlu-
sion with sequential plastic aligners. With a two-phase
approach, an impression (or scan) is recorded after distal-
ization (Fig. 7.3C). To reduce the total treatment time,
we now recommend simultaneous distalization with the
Beneslider and alignment with sequential plastic aligners.
With a single-phase approach, the impressions for aligners
are taken before distalization of the maxillary molar teeth
and the anticipated tooth movement to be produced by the
Beneslider appliance is programmed in the digital software
platform. According to our clinical findings, a sequen-
tial step-by-step distalization is not required (ClinCheck,
Align Technology). The entire maxillary dental arch can
CHAPTER 7 Asymmetric Noncompliance Upper Molar Distalization in Aligner Treatment Using Palatal TADs and the Beneslider 73

A B

D E
• Fig. 7.2The Beneslider appliance (A) is based on one or two mini-implants with exchangeable abut-
ments (B). On top of the mini-implants, abutments and miniplates (C) can be fixed. For median para-
median mini-implants, Beneplates with a wire parallel with the plate is used (long and short); for
paramedian mini-implants, Beneplates with a wire perpendicular with the plate is used (long and
short). The distalization force is delivered by springs and activated by two activation locks (A). Sliding
tubes (D) can be stuck in lingual sheaths of upper molars, or tubes (E) can be bonded to the palatal
surface. (With permission from PSM Medical Solutions.)

be distalized simultaneously because of the absolute molar
anchorage provided by the Benefit appliance; the stretch of
the interdental fibers supports the simultaneous distal drift
of maxillary anterior teeth.
If the sequential plastic aligner material covered the con-
nection area with the molars (see Fig. 7.3A), the impres-
sions for aligners should be recorded following the fitting
and insertion of the Beneslider appliance. The Beneslider
should not be activated before the delivery of the aligners.
If the aligners have a cut out area (see Fig. 7.3B, Invisalign:
“Button cut out”), the impressions for aligners are able to
be recorded either before or after insertion of the Beneslider
appliance. Distalization forces can be applied to the first
(see Fig. 7.3A left) or second (see Fig. 7.3B right) maxil-
lary molar teeth. Our clinical experiences have shown that
force application to the first molar is a superior approach, as
direct force application to the second molar teeth is associ-
ated with precocious distalization of the second molars lead-
ing to improper tracking and fitting of the sequential plastic
aligners; a risk that is reduced if the maxillary first molar
teeth are connected to the Beneslider.
Clinical Case 1: Simultaneous Start of Aligner
and Distalization
A 33-year-old male patient presented seeking orthodontic
care to resolve an Angle Class II Division I subdivision right-
hand-side malocclusion, characterized by anterior crowd-
ing, and a maxillary midline deviated to the left (Fig. 7.4,
Table 7.1). The maxillary lateral incisor teeth were migrated
mesially to the right side resulting in an asymmetric maxillary
dental arch and an arch-length insufficiency for alignment of
74 PA RT I I I Palatal Implants

the maxillary right canine. The patient specifically requested
an invisible orthodontic treatment option, to be performed
on a nonextraction basis. Following the insertion of two
Benefit mini-implants in the anterior palate (Fig. 7.5A), the
Beneslider appliance was passively installed (Fig. 7.5B, the
spring is not activated) and the impressions were recorded
for fabrication of clear sequential plastic aligners (Orthocaps,
Hamm, Germany). The aligner manufacturer was instructed
to design the aligners in such way that the aligner material
covered the connection area (Fig. 7.6A). After delivery and
insertion of the aligners, the Beneslider was activated by
pushing the 240-g nickel-titanium (NiTi) springs distally
using the activation lock (Fig. 7.6B). In the first quadrant,
the maxillary molars were to be distalized approximately
6 mm, and in the second quadrant only 1 to 2 mm. The
patient reportedly adapted to the appliance without issue.
The panoramic radiograph denotes bodily distalization of all
maxillary posterior teeth after 5 months (Fig. 7.7). Minor
interdental spaces were noted in the maxillary arch (Fig. 7.8);
this may have happened because of inadequate wear of the
aligners or the use of an excessive distalization force resulting
in precocious distalization of the maxillary molar teeth. The
patient was encouraged to commit to the appropriate period
of wearing the aligner, and the rate of molar distalization
was reduced. After 14 months of treatment, the maxillary
molar teeth were distalized into an Angle Class I occlusion,
and a steel ligature was used between the bonded tube and
the activation lock to deactivate the Beneslider (Fig. 7.9).
The Beneslider was converted from a distalization device
to a molar anchorage device. For the final finishing phase,
absolute anchorage to stabilize the maxillary molar was no
longer required and the Beneslider appliance was removed
(Fig. 7.10). Comprehensive treatment was completed after
18 months (Fig. 7.11), and the palatal mini-implants were
removed without the adjunctive use of local anesthesia.
Clinical Case 2: Aligner Start During
Distalization
A 41-year-old female patient presented with an Angle Class
II division 1 subdivision left-hand-side malocclusion, char-
acterized by anterior arch crowding (Fig. 7.12 and Table
7.2). The maxillary posterior teeth were noted to be mesi-
ally positioned on the left side, resulting in an asymmetric
maxillary dental arch, with insufficient arch length for the
alignment of the maxillary left canine. The patient specifi-
cally requested an invisible orthodontic treatment option,
to be performed on a nonextraction basis. After insertion
of two Benefit mini-implants in the anterior palate, a Ben-
eslider appliance was adapted for the appliance. Given the

B C
• Fig. 7.3 The aligners can cover the bonded connection (A) or the aligners can be cut out in this connec-
tion area (B). After distalization, steel ligatures are used (A) or the springs are removed (B). Wax should be
used for a silicone impression (C). (With permission from PSM Medical Solutions.)
 A

D
• Fig. 7.4A 33-year-old male patient with an Angle Class II Division I subdivision right-hand-side malocclu-
sion, characterized by anterior crowding, and a midline shift to the left side.
76 PA RT I I I Palatal Implants

TABLE significant amount of distal movement of the maxillary

7.1
  Case 1, Cephalometric Summary left molar teeth required, an additional tube was used to
support the bodily distalization of the maxillary left first
Pretreatment Posttreatment
premolar tooth (Fig. 7.13). Treatment commenced with
NSBa 123.9 degrees 124.5 degrees the Beneslider being activated by compressing the lock
NL-NSL 7.9 degrees 6.3 degrees on to the 240-g NiTi spring. In the second quadrant, the
molars were to be distalized approximately 7 mm, in the
ML-NSL 35.0 degrees 38.3 degrees
first quadrant only 2 to 3 mm. After seven months of dis-
ML-NL 27.2 degrees 32.1 degrees talization, several small interdental spaces were visible in
SNA 80.5 degrees 78.5 degrees between the maxillary left lateral teeth, and an elastic chain
was added for retraction of the upper left canine (Fig. 7.14).
SNB 76.2 degrees 74.0 degrees The panoramic radiograph denotes bodily distalization
ANB 4.3 degrees 4.6 degrees of all upper lateral teeth. Subsequently, impressions were
Wits 3.7 mm 2.6 mm recorded for fabrication of clear sequential plastic aligners
(Invisalign, San Jose, United States). The aligner manufac-
U1-NL 117.6 degrees 106.6 degrees turer was instructed to design and construct the aligners
L1-ML 93.3 degrees 94.5 degrees in such way that the aligner material covered the connec-
U1-L1 121.9 degrees 126.8 degrees tion area on the palatal side of the molar (Fig. 7.15). After
16 months of treatment with the Beneslider appliance, the
Overjet 6.1 mm 3.9 mm second right molar was distalized into a Class I occlusion
Overbite 2.0 mm 1.6 mm and a steel ligature was used between the bonded tube and
the activation lock to deactivate the Beneslider in the first

A B
• Fig. 7.5 After insertion of two Benefit mini-implants in the anterior palate (A) and installation of the Beneslider mechanics (B).

A B
• Fig. 7.6 (A, B) The aligners are covering the connection areas (Beneslider with the molars). (With permission from Ortho Caps GmbH.)
CHAPTER 7 Asymmetric Noncompliance Upper Molar Distalization in Aligner Treatment Using Palatal TADs and the Beneslider 77

B
• Fig. 7.7
OPG (A) and Cephalogram (B) after 5 months of treatment. • Fig. 7.8
Interdental spacing noted after 10 months. (With permission
(With permission from Ortho Caps GmbH.) from Ortho Caps GmbH.)

A B
• Fig. 7.9
After 14 months of treatment, the molars were distalized into a Class I occlusion and a steel ligature was used between the bonded tube
and the activation lock to deactivate the Beneslider (upper jaw without aligner [A] and with aligner [B]). (With permission from Ortho Caps GmbH.)
78 PA RT I I I Palatal Implants

• Fig. 7.10 After removal of the Beneslider appliance.

C D
• Fig. 7.11 Treatment result after 18 months. Intraoral pictures (A), radiographs (B, C), and patient front view (D).
CHAPTER 7 Asymmetric Noncompliance Upper Molar Distalization in Aligner Treatment Using Palatal TADs and the Beneslider 79

C
• Fig. 7.12A 41-year-old female patient with an Angle Class II Division I subdivision left-hand-side malocclusion,
characterized by anterior arch crowding. Patient front view (A), intraoral pictures (B), and study models (C).
80 PA RT I I I Palatal Implants

D E
• Fig. 7.12 cont’d

TABLE
7.2
  Case 2, Cephalometric Summary

Pretreatment Posttreatment
NSBa 131.7 degrees 132.5 degrees
NL-NSL 11.1 degrees 11.7 degrees
ML-NSL 40.7 degrees 40.8 degrees
ML-NL 29.6 degrees 29.1 degrees
SNA 78.1 degrees 77.3 degrees
SNB 73.0 degrees 72.6 degrees
ANB 5.1 degrees 4.7 degrees
Wits 6.7 mm 3.9 mm • Fig. 7.13 Beneslider in place with an additional tube at the upper first
U1-NL 111.7 degrees 107.6 degrees left bicuspid.

L1-ML 96.2 degrees 92.5 degrees

U1-L1 122.6 degrees 130.7 degrees
Clinical Considerations
Overjet 4.7 mm 3.7 mm
Overbite 2.8 mm 2.6 mm Our initial approach to combining sequential plastic aligner
therapy and the Beneslider appliance involved a two-phase
protocol: phase 1: distalization, and after distalization of the
maxillary molar to proceed with phase 2: impression/scan
and finishing with aligners.39
quadrant (Fig. 7.16). After 20 months, all the interdental Advantages of this two-phase procedure:
spaces were closed to the distal, with the digitally planned • No need for coordination of tooth movement with
positions of the maxillary teeth realized in the final anterior- Beneslider and aligners.
posterior position. The Beneslider appliance was removed, • An expected requirement for fewer aligners to achieve
since absolute molar anchorage was not required for the treatment objectives.
final finishing phase (Fig. 7.17) of treatment. Comprehen- Disadvantages of the two-phase procedure:
sive treatment was completed after 22 months (Figs. 7.18 • An expected increased treatment time.
and 7.19), and the palatal mini-implants were removed To reduce the total treatment time, we modi-
without anesthesia. fied our approach to a single-phase protocol involving
CHAPTER 7 Asymmetric Noncompliance Upper Molar Distalization in Aligner Treatment Using Palatal TADs and the Beneslider 81

B
• Fig. 7.14 After 7 months of distalization, several small interdental spaces were visible in between the
upper left posterior dental segment. An elastic chain was added for retraction of the upper left first bicuspid.
Upper jaw (A) and radiographs (B, C).

A
• Fig. 7.16 After 16 months of treatment. A steel ligature is used
between the bonded tube and the activation lock to use the Beneslider
as a passive molar anchorage device.

simultaneous distalization and alignment with sequential

B of the aligner may be undermined with the appearance of
• Fig. 7.15Beneslider and aligner in place: the aligner material is cover-
ing the connection area on the palatal side of the molar. Upper jaw (A)
and palatal view on the second quadrant (B).
plastic aligners. We have found that a single-phase proto-
col is associated with significantly reduced overall treat-
ment time. The potential drawback with this approach is
the coordination between the Beneslider appliance and
planned aligner tooth movements. If the distalization
force and/or the rate of distal molar movement are exces-
sive compared to the aligner staging, the fit and accuracy
maxillary interdental spacing. A second factor to be con-
sidered is the possibility of insufficient aligner wear by
the patient. If this is recognized during active treatment,
82 PA RT I I I Palatal Implants

• Fig. 7.17 After 20 months: all spaces are closed to the distal.

B
• Fig. 7.18 After removal of the Beneslider in the final finishing phase. Upper jaw (A) and cephalogram (B).

the rate of distalization may be reduced or the wear time
of an aligner may be prolonged, for example, wearing
each aligner for two weeks instead of one. The rate of the
maxillary molar distal movement associated with the use
of a Beneslider appliance is approximately 0.6 mm per
month42; this rate of molar distalization speed should be
kept in mind when determining the appropriate aligner
staging (ClinCheck).
The distalization force can be directly applied to the
first or second molar teeth. To have a maximum retention
with the teeth that are to be moved distally, we recommend
bonding the Beneslider to the first molar teeth instead of the
second molars. If the distalization forces are applied to the
second molars and the aligner fitting at the second molars is
not perfect, small unexpected spaces can develop in between
the upper first and second molar teeth (see Fig. 7.16). In
this situation, the distalization force must be reduced to
regain aligner fitting.
Another point that must be recognized: when a refine-
ment is planned and new aligners are ordered, the Ben-
eslider must be maintained in a passive manner to ensure
the accuracy of the fit of the aligner.
The anterior hard palate has proven to be the most
convenient region of the maxilla for insertion of mini-
implants.27,28 Since there are no roots, blood vessels, or
nerves, the risk of a complication associated with the
placement of a mini-implant is minimal. Even the pene-
tration of the nasal cavity does not result in any problems.
CHAPTER 7 Asymmetric Noncompliance Upper Molar Distalization in Aligner Treatment Using Palatal TADs and the Beneslider 83

D E
• Fig. 7.19 Treatment result after 22 months (A, C, D, E) with a three-dimensional scan of before and
after (B, left side).

Recently, a computer-aided design/computer-aided man- Conclusions

ufacturing (CAD/CAM) manufactured insertion guide
was introduced (Easy Driver, Parma, Italy), which facili-
tates safe and precise insertion of mini-implants in the
anterior hard palate, allowing the opportunity for the
use of palatal implants to the less experienced clinician.
Secondly, these insertions guides allow for the insertion
of mini-implants and installation of the appliance in a
single office visit.43
• By using palatal mini-implants and a Beneslider device,
unilateral or bilateral distal tooth movement can be real-
ized without anchorage loss.
• The Beneslider can be easily integrated in aligner therapy
by using bonded tubes on the palatal surfaces.
• A combined, single-phase treatment approach with simul­
taneous distalization and alignment is possible.
84 PA RT I I I Palatal Implants
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Deregibus A: Maxillary molar distalization with aligners in adult
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39. Wilmes B, Nienkemper M, Ludwig B, Kau CH, Pauls A,
Drescher D: Esthetic class II treatment with the Beneslider and
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tocols for combining the Beneslider with lingual appliances in
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 PART IV

Skeletal Plates

8. Nonextraction Treatment of Bimaxillary Anterior Crowding With Bioefficient Skeletal Anchorage

Junji Sugawara, Satoshi Yamada, So Yokota and Hiroshi Nagasaka
9. Managing Complex Orthodontic Problems With Skeletal Anchorage
Mithran Goonewardene, Brent Allan and Bradley Shepherd

87 87
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8
Nonextraction Treatment of Bimaxillary
Anterior Crowding With Bioefficient
Skeletal Anchorage
JUNJI SUGAWARA, SATOSHI YAMADA, SO YOKOTA, HIROSHI NAGASAKA

T
his chapter describes the treatment of two patients
in which significant distalization of the buccal seg-
ments, using miniplates to relieve anterior crowding,
was accomplished in the maxilla and mandible.
Case 1
Chief Complaint
A 23-year-old female patient’s chief complaint was that her
upper and lower anterior teeth showed crowding and partial
anterior crossbite. The patient had no history of previous
orthodontic treatment. Medical history was noncontribu-
tory, and findings from the temporomandibular joint
(TMJ) examination were normal with adequate range of
movements.
to the space analysis with wax setup models and cone-beam
computed tomography (CBCT) evaluation, both treat-
ment options were feasible in this case. Since the patient
was reluctant to have four premolars extracted, she chose
a nonextraction approach with the application of skeletal
anchorage.
Case 2
Chief Complaint
A 31-year-old female patient’s chief complaint was that
her upper and lower anterior teeth showed crowding,
TABLE
8.1
  Extraoral Analysis

Diagnosis and Case Summary (Tables 8.1–8.4; Facial form Mesoprosopic

Figs. 8.1 and 8.2) Facial asymmetry Slight mandibular shift to the left side
She presented with a slightly concave profile because of Chin point Slightly shifted to left side
a large mandible and a mild maxillary deficiency (Wits
Occlusal plane Normal
appraisal: −6.0 mm). She had a Class III denture base with
partial anterior crossbite and anterior crowding in the upper Facial profile Slightly concave because of a prog-
nathic mandible
and lower dentition. Mandibular dental midline was shifted
to the left by 1 mm because of mandibular asymmetry. Facial height Upper facial height/lower facial
height: normal

Treatment Options (Tables 8.5 and 8.6; Figs. Lower facial height/throat depth:
normal
8.3–8.14)
Lips Competent, upper: normal, lower:
Two alternatives were considered as treatment options for protrusive
the correction of maxillary and mandibular crowding and
Nasolabial angle Normal
partial anterior crossbite. The first option was four premolar
extractions and the other one was a nonextraction treatment Mentolabial sulcus Normal
consisting of distalization of the maxillary and mandibular Malar prominence Normal
posterior teeth after extraction of all third molars. According

89
90 PA RT I V Skeletal Plates

TABLE TABLE
8.2
  Smile Analysis 8.3
  Intraoral Analysis and Functional Analysis

Smile arc Consonant Intraoral analysis

Incisor display Rest: 0 mm Teeth present 87654321/12345678
Smile: 9 mm (no gingival display) 87654321/12345678
Lateral tooth display Maxillary molar to molar Molar relation Class III bilaterally
Buccal corridor Narrow Canine relation Class III bilaterally
Gingival tissue Gingival margins: even height of Overjet 0 mm
maxillary incisors
Overbite 0 mm
Papilla Present in all teeth
Maxillary arch U shaped, anterior crossbite
Dentition No gingivitis and periodontitis (except central incisors)
and 10 mm of crowding
Tooth size and proportion:
normal Mandibular arch U shaped and 10 mm of
crowding
Tooth shape: normal
Oral hygiene Fair
No tooth wear
Functional analysis
Incisal embrasure Normal
Swallowing Normal adult pattern
Midlines Lower midline shifted to the left
side by 1 mm as compared Temporomandibular joint Normal with adequate range
with the facial midline of jaw movements

Occlusal plane Normal

TABLE
8.4
  Problem List

Pathology/others Significant short roots of the maxillary central incisors

Significant mesial angulation of the mandibular left third molar

Alignment 6 mm of crowding in maxillary arch and 8 mm of crowding in the mandibular arch

Dimension Skeletal Dental Soft Tissue

Anteroposterior Mild Skeletal Class III Overjet = 0 mm Protrusive lower lip
Class III canine and molar relation Slightly prognathic profile
bilaterally
Vertical Low mandibular plane angle Overbite = 0 mm
Edge to edge bite
Transverse Mandible is slightly shifted to Lower dental midline is shifted to the Mandible is slightly shifted to
the left left by 1 mm, as compared with the the left
facial midline
CHAPTER 8 Nonextraction Treatment of Bimaxillary Anterior Crowding With Bioefficient Skeletal Anchorage 91

• Fig. 8.1 Pretreatment extraoral/intraoral photographs and panoramic radiograph.

A B
• Fig. 8.2
(A) Pretreatment lateral cephalogram. (B) Template cephalometric analysis (Black, patient; red,
Japanese norm).
92 PA RT I V Skeletal Plates

TABLE
8.5
  Treatment Objectives

Pathology/others Monitor short roots of maxillary central incisors

Extract all third molars

Alignment Distalize maxillary and mandibular posterior teeth

Dimension Skeletal Dental Tissue

Anteroposterior Maintain mild Skeletal Class III Distalize maxillary and mandibular Slightly improve on the
posterior teeth, and improve lower lip eversion
anterior crowding and Class III
denture base
Retrocline mandibular incisors
Vertical Maintain present mandibular Retrocline maxillary and mandibular
plane angle incisors
Transverse Maintain present transverse relation Maintain present mandibu-
between maxillary and mandibu- lar position
lar dentition

TABLE
8.6
  Treatment Sequence and Biomechanical Plan

Maxilla
Extracted maxillary third molars bilaterally
Bonded posterior teeth, inserted passive segmental 0.016 ×
0.022 -inch CNA archwires.
Placed SAS bone plates bilaterally at the zygomatic but-
tresses next to the first molars. Delivered 200 g of distaliza-
tion force on each posterior tooth with elastometric chains.
Placed 0.016 × 0.022 -inch CNA archwires and changed to
0.017 × 0.025 -inch CNA wire segments after leveling of
posterior teeth was complete.
Bonded anterior teeth and started overall alignment with
0.014, 0.016, 0.016 × 0.016, 0.016 × 0.022, 0.017 ×
0.025 -inch NiTi archwires. Continued distalization force.
After making space between lateral incisors and canines,
0.016 × 0.022 -inch SS retraction arch with L-loop was
engaged.
0.016 × 0.022, 0.017 × 0.025 -inch SS archwires were
placed for finishing and detailing.
Debond and lingual bonded retainers.
6-month recall appointment for retention check.
Mandible
Extracted mandibular third molars bilaterally
Bonded posterior teeth, inserted passive segmental 0.016 ×
0.022 -inch CNA archwires were placed.
Placed SAS bone plates bilaterally at the mandibular body next
to the first molars. Delivered 200 g of distalization and intrusion
force on each posterior tooth with elastometric chains.
Placed 0.016 × 0.022 -inch CNA archwires and changed to
0.017 × 0.025 -inch CNA wires segments after leveling of
posterior teeth was complete
Bonded anterior teeth and started overall alignment with 0.014,
0.016, 0.016 × 0.016, 0.016 × 0.022, 0.017 × 0.025 -inch
NiTi archwires. Continue distalization force.
0.016 × 0.022, 0.017 × 0.025 -inch SS archwires were placed
for finishing and detailing.
Debond and lingual bonded retainers
6-month recall appointment for retention check

CNA, Connecticut new archwire; NiTi, nickel titanium; SAS, skeletal anchorage system; SS, stainless steel
 CHAPTER 8 Nonextraction Treatment of Bimaxillary Anterior Crowding With Bioefficient Skeletal Anchorage 93

A B
• Fig. 8.3 (A) Visualized treatment goal (Blue, pretreatment; red, goal). (B) Wax setup model.

A B
• Fig. 8.4 (A) Cone-beam computed tomography (CBCT) of right side posterior teeth (see root apex of
#47). (B) CBCT of left side posterior teeth (see root apex of #37).
94 PA RT I V Skeletal Plates

A B

C
• Fig. 8.5 (A and B) Biomechanics for distalization of bimaxillary posterior teeth. (C) Panoramic radiograph
after implantation of orthodontic miniplates.

• Fig. 8.6
Simultaneous distalization of maxillary and mandibular posterior teeth using Skeletal Anchorage
System and segmental archwires with power hooks (2.6 months later).
• Fig. 8.7Bonding brackets on maxillary anterior teeth except for #22. Distalization of bimaxillary posterior
teeth continued (4.2 months later).

• Fig. 8.8Bonding brackets on the remaining teeth. Distalization of bimaxillary posterior teeth continued
(6.4 months later).

• Fig. 8.9Alignment of the bimaxillary dentition and distalization of the maxillary right posterior teeth (8.4
months later).
96 PA RT I V Skeletal Plates

•Fig. 8.10 Aligning of the bimaxillary dentition and distalization of maxillary right posterior teeth (10.5
months later).

• Fig. 8.11 Detailing and finishing (13.7 months later).

 CHAPTER 8 Nonextraction Treatment of Bimaxillary Anterior Crowding With Bioefficient Skeletal Anchorage 97

• Fig. 8.12 Posttreatment extraoral/intraoral photographs and panoramic radiograph.

A B C
• Fig. 8.13 (A) Lateral cephalometric radiograph at debonding. (B) Cephalometric superimposition before
and after. (C) Occlusogram superimposition before and after. Blue, Pretreatment; red, posttreatment.
98 PA RT I V Skeletal Plates

A B
• Fig. 8.14 (A) Cone-beam computed tomography (CBCT) of right hand side posterior teeth (see root apex
of #47). (B) CBCT of left hand side posterior teeth (see root apex of #37).

TABLE
TABLE
  Extraoral Analysis 8.8
  Smile Analysis
8.7

Facial form Mesoprosopic Smile Analysis

Smile arc Consonant
Facial asymmetry Normal
Incisor display Rest: 3.5 mm
Chin point Normal
Smile: 12 mm (100% with 3 mm
Occlusal plane Normal of gingival display)
Facial profile Straight Lateral tooth display Maxillary first molar to first molar
Facial height Upper facial height/lower facial Buccal corridor Narrow
height: long lower facial height
Gingival tissue Margins: right maxillary canine
Lower facial height/throat depth: margin is high
normal
Papilla: present
Lips Competent, upper: protrusive,
lower: protrusive Gingivitis and periodontitis at
bimaxillary posterior teeth
Nasolabial angle Acute (Deep pocket depth between
Mentolabial sulcus Shallow the maxillary second and third
molars)
Malar prominence Normal
Dentition Tooth size and proportion:
normal

particularly a high canine of the right side. The patient Tooth shape: normal
had no history of previous orthodontic treatment. Medi- No tooth wear
cal history was noncontributory, and findings from the
Incisal embrasure Normal
TMJ examination were normal with adequate range of
movements. Midlines Upper and lower midline shifted
to the right side by 2.5 mm
and 1 mm, respectively
Diagnosis and Case Summary (Tables 8.7–
8.10; Figs. 8.15 and 8.16)
Her skeletal profile was classified into skeletal Class I with
long face. She presented with a bimaxillary dento-alveolar
 CHAPTER 8 Nonextraction Treatment of Bimaxillary Anterior Crowding With Bioefficient Skeletal Anchorage 99

TABLE
8.9
  Intraoral Analysis and Functional Analysis

Intraoral Analysis
Teeth present 87654321/12345678
87654321/12345678
Molar relation Class III bilaterally
Canine relation Class III bilaterally
Overjet 2 mm
Overbite 2 mm
Maxillary arch U shaped and 7.7 mm of crowding
Mandibular arch U shaped and 7.1 mm of crowding
Oral hygiene Poor
Functional Analysis

Swallowing Normal adult pattern

Temporomandibular Joint Normal and adequate range of jaw movement

TABLE
8.10
  Problem List

Pathology/­others Significant vertical alveolar bone loss between the maxillary second and third molars bilaterally
Alignment 7.7 mm of crowding present in maxillary arch
7.1 mm of crowding in mandibular arch

Dimension Skeletal Dental Soft Tissue

Anteroposterior Crossbite on right lateral incisor Protrusive upper and lower lips
Class III canine and molar relation
Vertical Overbite = 2 mm
Transverse Upper and lower dental midline is shifted to the
right by 2.5 mm and 1 mm respectively as
compared with the facial midline

protrusion profile because of large maxilla and mandible,
and proclination of upper and lower incisors. She had a
mild Class III denture and anterior crowding in the upper
and lower dentition. Both maxillary and mandibular den-
tal midline shifted to the right by 2.5 mm and 1.0 mm,
respectively.
Treatment Options (Tables 8.11 and 8.12; Figs.
8.17–8.28)
Her treatment options were quite similar to Case 1. We
proposed two options for the correction of her orthodon-
tic problems, particularly for the correction of bimaxillary
anterior crowding. The first option consisted of four premo-
lar extraction, and the other one was nonextraction treat-
ment by distalization of maxillary and mandibular posterior
teeth after extraction of maxillary second molars and man-
dibular third molars. Since vertical alveolar bone loss was
observed between maxillary second and third molars, bone
regeneration was expected following distal movement of the
maxillary first molars and mesial movement of the maxillary
third molars. According to the space analysis observed in the
wax setup models and CBCT evaluation, both treatment
options were feasible in this case. After considering risks and
benefits of these two options, the patient chose nonpremo-
lar extraction treatment.
100 PA RT I V Skeletal Plates

• Fig. 8.15 Pretreatment extraoral/intraoral photographs and panoramic radiograph.

A B
• Fig. 8.16
(A) Pretreatment lateral cephalogram. (B) Template cephalometric analysis (Black, patient; red,
Japanese norm).
 CHAPTER 8 Nonextraction Treatment of Bimaxillary Anterior Crowding With Bioefficient Skeletal Anchorage 101

TABLE
8.11
  Treatment Objectives

Pathology/others Extract upper second molars and lower third molars

Expect bone regeneration of upper second molar region

Alignment Distalize maxillary and mandibular posterior teeth, and mesialize maxillary third molars

Dimension Skeletal Dental Soft Tissue

Anteroposterior Maintain Distalize maxillary and mandibular posterior Reduce lip protrusion
teeth and improve Class III canine and molar
relation, and anterior crowding
Retrocline mandibular incisors
Correct anterior crossbite on
maxillary right lateral incisor
Vertical Maintain Maintain overbite and present maxillary incisor Maintain
display
Transverse Maintain Match midlines

TABLE
8.12
  Treatment Sequence and Biomechanical Plan

Maxilla
Extracted maxillary second molars bilaterally
Bonded posterior teeth, passive segmental 0.016 × 0.022
-inch CNA archwires.
Placed SAS bone plates bilaterally at the zygomatic but-
tresses next to the first molars. Delivered 200 g of distaliza-
tion force on each posterior tooth with elastometric chains.
Placed 0.016 × 0.022 -inch CNA wires segments and
changed to 0.017 × 0.025 inch CNA archwire segments
after leveling of posterior teeth was complete. Retracted
canines with segmental T-loop wires.
Bonded anterior teeth (except for right lateral incisor) and
started alignment with 0.014, 0.016, 0.016 × 0.016, 0.016
× 0.022, 0.017 × 0.025 -inch NiTi archwires. Continued
distalization force. After making space for right lateral inci-
sor, bonded and aligned entire dentition.
After making space between lateral incisors and canines,
0.017 × 0.025 -inch CNA contraction arch with Bull-loop
was engaged.
0.016 × 0.022, 0.017 × 0.025 -inch SS archwires were
placed for finishing and detailing.
Debonded and placed lingual bonded retainers.
6-month recall appointment for retention check.
Mandible
Extracted mandibular third molars bilaterally
Bond posterior teeth, passive segmental with 0.016 × 0.022
-inch CNA archwires were placed.
Placed SAS bone plates bilaterally at the mandibular body next
to the first molars. Deliver 200 g of distalization force on each
posterior tooth with elastometric chains.
Placed 0.016 × 0.022 -inch CNA wires segments and changed
to 0.017 × 0.025 -inch CNA archwire segments after leveling
of posterior teeth was complete.
Bonded anterior teeth and started overall alignment with 0.014,
0.016, 0.016 × 0.016, 0.016 × 0.022, 0.017 × 0.025 -inch
NiTi archwires. Started to distalize entire dentition with elasto-
metric chains.
.016 × 0.022, 0.017 × 0.025 -inch SS archwires were placed for
finishing and detailing.
Debonded and placed lingual bonded retainers
6-month recall appointment for retention check

CNA, Connecticut new archwire; NiTi, nickel titanium; SAS, skeletal anchorage system; SS, stainless steel
102 PA RT I V Skeletal Plates

A B
• Fig. 8.17 (A) Visualized treatment goal (Blue, pretreatment; red, goal). (B) Wax setup model.

A B
• Fig. 8.18 (A) Cone-beam computed tomography (CBCT) of right hand side posterior teeth (see root apex
of #47). (B) CBCT of left hand side posterior teeth (see root apex of #37).
CHAPTER 8 Nonextraction Treatment of Bimaxillary Anterior Crowding With Bioefficient Skeletal Anchorage 103

A B

C
• Fig. 8.19(A and B) Biomechanics for distalization of bimaxillary posterior teeth. (C) Panoramic radiograph
after implantation of orthodontic miniplates.

• Fig. 8.20
Simultaneous distalization of maxillary and mandibular posterior teeth using Skeletal Anchorage
System and segmental archwires with power hooks (2.0 months later).
104 PA RT I V Skeletal Plates

• Fig. 8.21 Maxillary canine retraction and simultaneous distalization of maxillary and mandibular posterior
teeth using Skeletal Anchorage System and segmental archwires. Bonding brackets on mandibular ante-
rior teeth (2.8 months later).

• Fig. 8.22 Bonding brackets on maxillary anterior teeth. Distalization of maxillary left and mandibular pos-
terior teeth continued. Labial movement of #12 began (4.6 months later).
CHAPTER 8 Nonextraction Treatment of Bimaxillary Anterior Crowding With Bioefficient Skeletal Anchorage 105

•Fig. 8.23 Distalization of maxillary right posterior teeth and mandibular entire dentition continued (6.7
months later).

• Fig. 8.24 Distalization of mandibular entire dentition continued (9.1 months later).
106 PA RT I V Skeletal Plates

• Fig. 8.25 Contraction of maxillary incisors using Bull loops. Tying back of all canines (12.3 months later).

• Fig. 8.26 Posttreatment extraoral/intraoral photographs and panoramic radiograph.

 CHAPTER 8 Nonextraction Treatment of Bimaxillary Anterior Crowding With Bioefficient Skeletal Anchorage 107

A B C
• Fig. 8.27 (A) Lateral cephalometric radiograph at debonding. (B) Cephalometric superimposition before
and after. (C) Occlusogram superimposition before and after. Blue, Pretreatment; red, posttreatment.

A B
• Fig. 8.28 (A) Cone-beam computed tomography (CBCT) of right hand side posterior teeth (see root apex
of #47). (B) CBCT of left hand side posterior teeth (see root apex of #37).
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9
Managing Complex Orthodontic
Problems With Skeletal Anchorage
MITHRAN GOONEWARDENE, BRENT ALLAN, BRADLEY SHEPHERD
Introduction
Biomechanical principles are the foundation for all orthodon-
tic treatment. In particular, comprehension of Newton’s laws
is essential in understanding force systems and the principles
of “equilibrium,” effecting efficient biomechanical strategies
and minimizing side effects from these force systems.
Burstone described anchorage requirements as Group
A (maximum), Group B (moderate), and Group C (mini-
mum) (Fig. 9.1).1–3 Although Group B anchorage require-
ments are usually less challenging to achieve with most
contemporary approaches, orthodontists are routinely chal-
lenged by treatment goals that may require Group A and
Group C anchorage considerations. Patient cooperation
with adjuncts such as elastics, extraoral traction, or remov-
able appliances are often required. Moreover, specific types
and magnitudes of tooth movement may be extremely dif-
ficult or impossible to achieve, such as complex intrusion,
whole arch retraction, and molar protraction.
The application of temporary anchorage devices (TADs)
has progressively become a routine adjunct for challeng-
ing cases in most contemporary clinical practices since
initially being introduced in the 1980s for direct or indi-
rect anchors.4–8 Clinicians may now elect to manage most
Group A and C anchorage cases with adjunctive application
of TADs rather than the uncertainty and stress associated
with adjuncts dependent on patient compliance.9 TADs
have also expanded the envelope of predictable tooth move-
ments that may be performed to compensate the dentition
to camouflage skeletal discrepancies, reducing the need for
orthognathic surgery. Moreover, complex tooth movements
may now be considered in three dimensions including
anchorage preservation during space closure,10 protraction/
retraction,11–13 intrusion/extrusion,14,15 and to assist in
dento-facial orthopedics.16,17
Success rates in TAD devices ranged from 37% to
94%,15,18,19 and it is difficult to make valid comparisons.20,21
Complications have been reported, including screw loosen-
ing, fracture,22,23 infection, and damage to adjacent struc-
tures.22 Intimate screw-root proximity has been reported to
reduce success by as much as one-third.22–24 Screw placement
in the alveolar bone is complicated by uncertainty with bone
quality to guarantee successful placement.25
Miniplates have been suggested by Sugawara and Nishimura
to overcome some of the limitations associated with alveolar
placement of mini-implants.25,26 These may be fixed to corti-
cal bone by several self-threaded titanium screws in areas of
more predictable bone quality, such as the zygomatic buttress,
retromolar pad, and along the mandibular body (Fig. 9.2).
The arm of the bone plate exits transmucosally and may range
from 10.5 mm (short) to 16.5 mm (long). The hook on the
plate has a number of hooks to provide various level of force
application dependent on the desired tooth movement. The
body of the plate is positioned subperiosteally and is available
in three different configurations (T, Y, or I).
Although clinicians cite a lack of clinical guidelines and/
or skepticism of the evidence,27 and are concerned with the
need for a more invasive surgical procedure, miniplates pro-
vide a more predictable and highly successful for a range of
complex orthodontic movements.28–30
Bone plates may be preferred because their placement is
more apical along the mandibular body or in the zygomatic
buttress where bone quality is adequate and do not interfere
with the path of most tooth movement. Bone plates may
also be indicated difficult when root proximity limits the
placement of mini-implants or when repeated failures may
limit alternative locations.25 Moreover, greater forces may
be applied in circumstances where whole arch retraction/
protraction may be required.31–33
It is important to note that even though studies report
clinical success, there are often complications such as swell-
ing, soft tissue hyperplasia, nerve damage, sinus perforation, or
infection (15%).29 For screws, these complications often result
in mobility and failure of the screw, but with miniplates, com-
plications can usually be managed by excellent hygiene, topical
application of antimicrobial agents, or antibiotics.31–34
It is important to appreciate that experience in treatment
planning, placement, and managing any complication dur-
ing treatment is necessary to ensure favorable outcomes of
Skeletal Anchor System (SAS) plates.
This chapter will demonstrate a number of selected
applications of the SAS.
109
110 PA RT I V Skeletal Plates

1/3 2/3 2/3 1/3

Maximum Anchorage (Group A) Minimum Anchorage (Group C)

• Fig. 9.1 Maximum anchorage (Group A) mechanics describes tooth movements when posterior teeth
are anticipated to move anteriorly no more than one-third of the extraction space during space closure.
Conversely minimum anchorage (Group C) facilitates at least two-thirds of the extraction space closure by
posterior teeth moving forward.

A B

C D
• Fig. 9.2 Y-type (A) and L-type (B) miniplates placed in the zygomatic buttress and mandibular body.
Miniplates exiting transmucosally high in the upper to facilitate significant intrusion and retraction (C) and
in the lower (D).

Case 1: Reversing the Effects of Failed adenoids appeared enlarged on the lateral cephalogram, but
Growth Modification/Camouflage in a follow-up with an ear, nose, and throat specialist did not reveal
any significant clinical indications for intervention (Fig. 9.3).
Skeletal Class II
An 8-year-old male presented with his parents for treatment Problem List
of a significant Class II division 1 type malocclusion in the
early mixed dentition because of concerns with the possibil- Increased overjet
ity of incisor trauma from a large overjet.35 Facial evaluation Significantly retrognathic mandible
revealed a significantly retrusive chin and incompetent lips. His Upper spacing
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 111

A B C

D E F

G H I

J
• Fig. 9.3 Facial (A–C) and intraoral (D–H) photos exhibit the significant Class II malocclusion and chin
retrusion. Cephalometric radiograph with Mesh template overlay reveals a significant skeletal mandibular
retrognathism and proclined upper incisors (I) and panoramic radiograph (J).
112 PA RT I V Skeletal Plates
Treatment Goals
Reduce overjet by a combination of incisors retraction and
increase in the horizontal projection of the mandible.
Considerations
The magnitude of the skeletal mandibular retrogna-
thism is significant enough to discuss the possibility of
surgery, as it is important to determine how the patient
and parents will perceive success. Early treatment at this
stage with a fixed or removable functional appliance may
improve the dental relationships to some extent, but even
with expression of the upper percentiles of jaw growth,
the chin position will probably remain somewhat retru-
sive. The parents were also informed that early treatment
is unlikely to provide significant benefit in the long term
except for possible improvement in self-esteem at an ear-
lier age.
After careful consideration, the parents wished to pro-
ceed with a removable functional appliance.
Treatment (Phase 1)
A removable activator-type appliance with a headgear was
selected by the patient and parents because of the sugges-
tion that it may only need to be worn at home and to bed.
The appliance was delivered and cooperation was excellent,
with significant reduction of the overjet. After 9 months of
treatment, the appliance was placed into a retention mode
whereby night time wear was continued until all deciduous
teeth had exfoliated. The acyclic on the appliance was modi-
fied as teeth exfoliated.
Summary
Although the dental relationships improved dramatically
with reduction in overjet, the chin position remained sig-
nificantly retrusive, and cephalometric analysis revealed a
predominantly vertical response from the mandible and
significantly protrusive lower incisors (Fig. 9.4). The func-
tional appliance had effected significant proclining forces on
the lower labial segment as has been reported.36
Moreover, this proclination has been reported to influ-
ence extraction decisions in the second stage of treatment
with fixed appliances.36
Although the patient and parents were happy with the
improvement, the patient lost interest in the appliance and
ceased wearing it as a retainer. As a consequence, mild to
moderate relapse of the dental relationships was observed
(Fig. 9.5).
Discussion now ensued, directed toward a surgi-
cal solution as the patient and parents now focused on
his significant chin retrusion. However, a new problem
of lower labial segment proclination now presented
that would need to be addressed as part of presurgical
decompensation.
Problem List (After Early Treatment)
Severe mandibular retrognathism
Class II type occlusal relationship
Increased overjet and overbite
Proclined lower incisors
Bony chin deficiency
Considerations
Simultaneous mandibular and genioplasty advancement
surgery was planned, but the lower incisor proclination
would have to be addressed before surgery. The conventional
method to address this issue would be to remove two lower
first premolars to provide space to retract and decompen-
sate the anterior teeth. This would render the upper second
molars nonfunctional after treatment, probably necessitat-
ing extraction.
An option of placing two lower SAS plates at the time
of third molar removal was discussed to act as anchors to
retract the entire lower arch en masse and decompensate
the teeth before simultaneous mandibular surgical advance-
ment and advancement genioplasty. Consideration was also
given to the option of placing all fixed appliances in place
just before performing the jaw surgery, third molar removal,
and placement of SAS plates. Lower arch retraction from
an anterior crossbite relationship would be achieved after
surgery.
Treatment
The unerupted third molars were removed primarily because
of the surgeon’s concerns with simultaneous sagittal split
surgery. T-configuration SAS plates were placed buccal to
the lower first molars with three screws per side with third
molar removal. The plates exited through the gingival tis-
sues at or coronal to the mucogingival junction. When pos-
sible, it is important that the plate exits through attached
keratinized tissue to minimize failure as with most types of
temporary anchors.23
Lower fixed appliances were placed and elastomeric chain
placed from the lower canines to the SAS plates to initiate
the retraction force with a desire to effect greater tipping
forces. Elastomeric chains were replaced every 2 to 3 weeks.
Archwires progressed rapidly from 0.016 Niti through to
0.016 × 0.022 Niti and finally 0.019 × 0.025 β-Titanium
alloys with a crimpable hook to direct the force closer to the
center of resistance and effectively translate the entire lower
arch. The progress photographs and lateral cephalograms
demonstrate the uprighting of the lower anterior teeth from
the SAS plates (Fig. 9.6).
Upper fixed appliances were added toward the end of
lower arch retraction to align and coordinate the arches
following a similar archwire progression to the lower (i.e.,
0.016 Niti through to 0.016 × 0.022 Niti and finally 0.019 ×
0.025 β-Titanium alloy).
 CHAPTER 9
A B
D E
G H
• Fig. 9.4 Facial (A–C) and intraoral (D–H) photos exhibit improvement in the dental relationship but no
significant improvement in chin position. The cephalometric radiograph reveals significant proclination of
the lower incisors (I).
Simultaneous mandibular advancement with a bilateral
sagittal split osteotomy was performed with advancement
genioplasty and removal of the bone plates (Fig. 9.7).
The patient was guided into final occlusal relationships
in 0.017 × 0.025 β-Titanium and seating elastics and the
appliances removed and a combination of a fixed lower
bonded retainer and a removable Hawley type retainer.
Summary
The dental relationships exhibited a most satisfactory occlu-
sal outcome with an esthetic balanced facial form with nor-
mal facial convexity (Fig. 9.8.)
Managing Complex Orthodontic Problems With Skeletal Anchorage 113
C
F
I
Case 2: Decompensation of a Retreatment
Case Presenting With Bimaxillary
Dental Protrusion and Skeletal Class II
Malocclusion
A 24-year-old adult female presented with a primary con-
cern of a perception of a protrusive set of teeth and a weak
chin, following a previous course of orthodontic treatment
involving fixed appliances and upper first premolar extrac-
tions. Facial evaluation revealed a symmetrical face with
increased facial convexity characterized by a retrusive chin
and protrusive lips. The intraoral views exhibited a Class
I type relationship with minimal overjet and overbite, a
114 PA RT I V Skeletal Plates

A B C

D E F

G H

I I

J J
• Fig. 9.5 Facial (A–C) and intraoral (D–H) photos exhibit slight relapse of the dental relationship and signifi-
cant retrusion of the chin. The cephalometric radiograph reveals significant mandibular retrognathism with
proclination of the lower incisors (I). Third molars are visible in the panoramic radiograph and provide bone
volume to consider distal movement of the entire lower arch (J).
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 115

A B C

D E

F
• Fig. 9.6 Intraoral (A–C) photos exhibit fixed appliances, two miniplates lateral to the posterior teeth, and
elastomeric chain placed from extension arms to upright the lower anterior teeth. The cephalometric radio-
graph (D) and superimpositions (E) reveal significant uprighting of the lower incisors. The placement of the
extension arm enables the fore system to lie closer to the center of resistance to facilitate translation of the
lower arch with minimal rotation (F).
116 PA RT I V Skeletal Plates

A B C

D E F

G
H
• Fig. 9.7
Facial (A–C) and intraoral (D–F) photos exhibit excellent immediate postsurgical outcomes with
improvement in chin position. The cephalometric radiograph (G) and superimpositions (H) reveal the out-
come after simultaneous mandibular advancement and genioplasty.

therapeutic Class II molar relationship following extrac- Problem List

tion of the upper fist premolars and mild irregularity in the
upper and lower aches (Fig. 9.9). Protrusive lips
The lateral cephalometric analysis reveals a significant Retrusive chin
Class II skeletal relationship characterized by significant man- Retrognathic mandible and bony chin deficiency
dibular retrognathism, a weak bony chin, proclined upper Proclined upper and severely proclined lower incisors
incisors, and severely proclined lower incisors (see Fig. 9.9). Minimal overbite and overjet
 CHAPTER 9
A B
D E
G H
• Fig. 9.8 Posttreatment facial (A–C) and intraoral (D–H) photos exhibit a balanced profile, excellent smile
esthetics, and a good functional occlusion.
Treatment Goals
Reduction in lip and dental protrusion is the ultimate goal
to satisfy the patient’s request. In addition, the relative and
absolute chin projection must also be improved.
Considerations
Since the upper first premolars had already been extracted,
reduction in upper dental protrusion could be achieved
with the application of skeletal anchors or additional tooth
extraction, such as the healthy first permanent molars. The
lower dental protrusion requires Group A anchorage, and
every mm of extraction space is required to maximally
Managing Complex Orthodontic Problems With Skeletal Anchorage 117
C
F
retract the lower arch and decompensate the lower denti-
tion. A simultaneous mandibular advancement and genio-
plasty could then be performed to idealize the chin and lip
relationship.
Treatment
A plan was outlined to first remove the lower first premo-
lars and all third molars and simultaneously place SAS bone
plates lateral to the upper and lower first molars.
Upper and lower fixed appliances were placed (Fig. 9.10).
Upper and lower fixed appliances were placed and upper
archwires progressed rapidly from 0.016 Niti through to
0.016 × 0.022 Niti and finally 0.019 × 0.025 β-Titanium
118 PA RT I V Skeletal Plates

A B C

D E F

G H

I
• Fig. 9.9Facial (A–C) and intraoral (D–H) photos exhibit a Class I malocclusion with significant bimaxillary
protrusion and a Class II molar relationship from previous upper arch extraction orthodontics, significant lip
protrusion, and chin retrusion. Cephalometric radiograph with Mesh template overlay reveals a significant
skeletal mandibular retrognathism, bony chin deficiency, and proclined upper and lower incisors (I) and
panoramic radiograph (J).
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 119

A B

C D

E F
• Fig. 9.10 Intraoral photos (A and B) exhibit fixed appliances, two miniplates lateral to the upper and lower
posterior teeth and elastomeric chain placed from extension arms on a lower anterior segment to upright
the lower anterior teeth. (C) Elastomeric chain was placed directly to the upper arch to facilitate whole arch
retraction. The placement of the extension arm enables the force system to lie just above the center of
resistance to facilitate controlled tipping of the lower anterior segment (D). The cephalometric radiograph
(E) and superimpositions (F) reveal significant uprighting of the lower incisors.
120 PA RT I V Skeletal Plates
alloys. Elastomeric chain was placed from the upper canines
to the SAS plates to initiate the retraction force with a desire
to effect greater tipping forces. In the lower ach, only the
lower canine-to-canine brackets were bonded with initial
0.016 Niti through to 0.016 × 0.022 Niti and finally 0.019 ×
0.025 stainless steel segment with an extension arm bent gin-
givally distal to the canine to enable the elastomeric chain
from the SAS plate to lie in a position to effect controlled
frictionless tipping of the anterior segment (see Fig. 9.10).
Once space had been closed, continuous archwires of 0.018
Niti through to 0.016 × 0.022 Niti and finally 0.019 × 0.025
β-Titanium alloy were placed to coordinate with the upper.
The lower retraction proceeded rapidly and the whole
ach retraction in the upper somewhat slower. Elastomeric
chains were replaced every 2 to 3 weeks.
The patient wished to finalize a surgical date, but the
upper incisor retraction was incomplete. The use of SAS
plates enabled the surgery to be performed and the plates
retained so that final retraction of the upper arch could be
achieved following the surgery (Fig. 9.11).
Simultaneous mandibular advancement with a bilateral
sagittal split osteotomy was performed with advancement
genioplasty and removal of the lower bone plates only (Figs.
9.12 and 9.13).
Following surgery, elastomeric chains were replaced every
2 to 3 weeks in the upper until ideal upper incisor posi-
tion was achieved and the overjet idealized (Fig. 9.14). The
patient was guided into final occlusal relationships in 0.017
× 0.025 β-Titanium and seating elastics and the appliances
removed and a combination of a fixed upper and lower
bonded retainers and a removable Hawley type retainers.
Summary
The final facial outcome was most impressive, with the
patient thrilled with the overall changes in the dental incli-
nations, the lips flattening, and the chin projection. The
patient exhibits an excellent occlusal outcome with sound
intercuspation, well-aligned arches, and ideal overjet and
overbite. The panoramic radiograph reveals acceptable root
parallelism and minimal root resorption, and the lateral
cephalogram and posttreatment tracing exhibit significant
retraction of both upper and lower teeth on the respective
skeletal bases and a well-balanced skeletal base relationship
(Fig. 9.15).
Case 3: A Complex Interdisciplinary
Challenge Compromised by Previous
Restorative Treatment
A 37-year-old adult female presented with a complex dental
history including childhood trauma to the upper anterior
teeth resulting in devitalization, and ankyloses of the upper
central incisor teeth failed in early adulthood and were
replaced with implant-supported prostheses in their rela-
tively submerged positions. The patient’s primary concerns
related to the esthetics of the smile with the reverse smile
arc, reduce tooth display at rest and when smiling, and a
convex profile with a retrusive chin. A number of posterior
teeth had been heavily restored and the upper second and
third molars have been lost (Fig. 9.16).
Problem List
Reverse smile arc—upper central incisor implant prostheses
in submerged positions
Increased overjet
Mandibular retrognathism
Overerupted lower posterior teeth
Treatment Goals
Increase the vertical projection of the upper anterior teeth
and improve the smile arc and increase the horizontal pro-
jection of the chin to address the chin deficiency and ideal-
ize the overjet.
Considerations
The patient had spent considerable funds on the implant-
supported prostheses but did not want to proceed with
replacement of the implants. It was carefully considered
by the prosthodontist, and if the adjacent teeth could be
extruded, the prosthetic component could be elongated and
pink porcelain added to the gingival margin to improve the
esthetics, as these did not have a high smile line.
The only mechanism by which the overjet could be
addressed would involve surgical mandibular advancement,
but the overerupted second and third molars would interfere
with mandibular advancement in their current positions.
Skeletal anchors could be considered to intrude the lower
posterior teeth before mandibular advancement.
The lower third molars have no strategic role in this plan
so they could be considered for extraction.
Treatment
An interdisciplinary plan was developed as outlined in Fig.
9.17 with an associated diagnostic set up. Full fixed appli-
ances were placed with archwires progressing rapidly from
0.016 Niti through to 0.016 × 0.022 Niti and finally
0.017 × 0.025 and 0.019 × 0.025 β-Titanium alloys in the
upper and lower arches, respectively. Elastomeric chains were
placed vertically from the lower molars to the SAS plates to
initiate the intrusion force (Figs. 9.18 and 9.19). Bonding
of the upper brackets was carefully performed to facilitate
extrusion of the upper lateral incisors and canines relative to
the implanted upper central incisors (see Fig. 9.19).
Additional adjustment bends to extrude the lateral inci-
sors were incorporated into the upper archwire and com-
pressed coils added to create space to facilitate increase in
the mesiodistal dimensions of these teeth (Fig. 9.20).
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 121

A B C

D E F

G H

I
• Fig. 9.11 Facial (A–C) and intraoral (D–H) photos exhibit fixed appliances with a Class II malocclusion
following lower arch decompensation. The upper arch remained slightly proclined at this stage as seen in
the radiograph (I). The panoramic radiograph reveals miniplates in the upper and lower extraction space
closure (J).
122 PA RT I V Skeletal Plates

A B C

D E F

G
• Fig. 9.12 Facial (A–C) and intraoral (D–F) photos exhibit excellent immediate postsurgical outcomes
with improvement in chin position. The cephalometric radiograph (G) and superimpositions (H) reveal the
outcome after simultaneous mandibular advancement and genioplasty. The upper teeth were still in a
slightly protrusive position and the miniplates retained in the upper for ongoing postsurgical maxillary arch
retraction.
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 123

A B
• Fig. 9.13The posttreatment cephalometric radiograph (A) and superimpositions (B) reveal the final out-
come after the upper incisor were retracted and the previous simultaneous mandibular advancement and
genioplasty.

A B C

D E
• Fig. 9.14 The postsurgery intraoral photos (A–E) reveal the final outcome after the upper incisor were
retracted.

Simultaneous mandibular advancement with a bilateral
sagittal split osteotomy was performed with advancement
genioplasty and removal of the lower bone plates (see Fig.
9.20).
The patient was guided into final occlusal relationships
in 0.017 × 0.025 β-Titanium, seating elastics and the
appliances removed, and a combination of a fixed lower
bonded retainer and removable Hawley type retainers
(Fig. 9.21).
The upper central incisor crowns were placed with longer
and wide teeth, and the upper lateral incisors restored with
ceramic restorations.
Summary
The occlusal, esthetic, and functional goals were all achieved
with an excellent occlusal relationship with ideal overjet and
overbite. The heavily restored molars did not appear to suffer
124 PA RT I V Skeletal Plates

A B C

D E F

G H
• Fig. 9.15Posttreatment facial (A–C) and intraoral (D–H) photos exhibit a balanced profile with pleasing
changes in relative lip protrusion, excellent smile esthetics, and a good functional occlusion.
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 125

A B C

D E F

G H

I J
• Fig. 9.16 Facial (A–C) and intraoral (D–H) photos exhibit a Class II malocclusion with increased overjet, a
reverse smile arc, and two implant-supported prostheses placed in an inferior position and chin retrusion.
Cephalometric radiograph with Mesh template overlay reveals a significant skeletal mandibular retrogna-
thism (I), and the panoramic radiograph reveals overeruption of the unopposed lower second and third
molars (J).
126 PA RT I V Skeletal Plates
any significant iatrogenic effects from the intrusive tooth move-
ment. The facial profile was educed in convexity to a balanced
position of the chin, but what really thrilled the patient was the
restoration of normal consonant smile arc (Fig. 9.22).
Sequencing
1. Extraction of the lower third molars and placement of
bone plates to facilitate intrusion of the second molars
BA
2. Full fixed appliances (FFA) to align and coordinate the
teeth within the arches upper lateral incisors will be
extruded to increase the tooth display space opened to
increase the mesiodistal size of the anterior teeth. The
lower molars will intruded by elastomeric chains to the
SAS plates
MG
3. Mandibular orthognathic surgery (remove plates)
BA
4. Post surgical detailing of the occlusion
MG
5. Implant crowns elongated and widened
BGS
6. Final Crowns
BGS
7. Modification of retainer
MG
8. Splint as retainer long term
BGS
• Fig. 9.17 The sequencing plan for the interdisciplinary treatment of
the patient in Fig. 9.16 with the delegated clinicians. BA = Dr. Allan; MG =
Dr. Goonewardene; BGS = Dr. Shepherd.
A B
D E
• Fig. 9.18 Intraoral (A–E) photos exhibit fixed appliances, two miniplates lateral to the lower posterior
teeth, and elastomeric chain to intrude the overerupted lower molars.
Case 4: A Complex Interdisciplinary
Problem Characterized by Tooth Surface
Loss, Dental Asymmetry, and Crowding
A 36-year-old adult male presented with a primary com-
plaint of poor dental esthetics, composite veneers that were
placed to camouflage tooth irregularities, and tooth surface
loss secondary to parafunction that is related to his high-
stress occupation.
On examination, he presented with a symmetrical,
slightly convex profile characterized by mild paranasal flat-
tening and a mildly retrusive chin. Dentally, he exhibited a
Class II subdivision right type malocclusion with an asym-
metrical upper ach and normal overbite and overjet (Fig.
9.23). The right posterior teeth were more mesial than the
left, the upper midline was deviated to the left, and both
upper and low anterior teeth presented with moderate
crowding and mild asymmetry with the posterior teeth on
the left more anteriorly placed. There was significant tooth
surface loss consistent with parafunction, and the Epworth
Sleepiness score did not reflect a value indicative of a signifi-
cant sleep disorder.
The upper anterior teeth were irregular in alignment with
significant discrepancies between the gingival margins that
reflected compensatory eruption secondary to differential
loss of vertical height.
Skeletally, the lateral cephalogram exhibited a Class II skel-
etal pattern characterized by mild maxillary retrognathism
and mandibular retrognathism and retroclined upper incisors.
C
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 127

A B C

D E F

G H

I J
• Fig. 9.19 Facial (A–C) and intraoral (D–H) photos exhibit the presurgical relationships with spaces
being prepared for restoration of the incisors. Note the purposeful extrusion of the upper lateral incisors.
Cephalometric radiograph with superimposition reveals the significant intrusion of the lower posterior teeth
(I and J).
128 PA RT I V Skeletal Plates

A B C

D E F

G H

I J
• Fig. 9.20 Facial (A–C) and intraoral (D–H) photos exhibit excellent immediate postsurgical outcomes
with improvement in chin position. The cephalometric radiograph (I) and superimpositions (J) reveal the
outcome after simultaneous mandibular advancement and genioplasty.
 CHAPTER 9
A B
D E
• Fig. 9.21 The intraoral photos at deband (A–E) reveal an excellent occlusal outcome before restoration of
the incisor teeth. The crowns on the implants will be elongated and the spaces between the incisors will
be used to increase the lateral incisor size.
Problem List
Poor esthetics of compromised restorations
Upper and lower crowding
Tooth surface loss – Bruxism
Asymmetrical upper arch and lower arches
Mildly asymmetrical lower arch
Class II subdivision right
Treatment Goals
Align the upper and lower teeth and address the upper
midline discrepancy by moving teeth around to the right
while simultaneously leveling the teeth vertically by selec-
tive intrusion to facilitate restoration of mesiodistal and
inciso-gingival dimensions. The upper and lower left poste-
rior teeth would be moved distally to simultaneously create
space. The bruxing habit will need ongoing management
with a splint and managing his personal stressors.
A sequencing plan was developed to assist in the
interdisciplinary communication between all parties
(Fig. 9.24).
Considerations
The historical position for addressing a subdivision-
type malocclusion with an upper ach asymmetry would
include consideration for extraction of the upper right
first premolar. There is also a need for space in the lower
arch.
An alternative plan was presented that would include
placement of skeletal anchors in three quadrants, the upper
Managing Complex Orthodontic Problems With Skeletal Anchorage 129
C
right and both lower left and right quadrants. The skeletal
anchors would be used to distal drive the right posterior
teeth to create the necessary space for alignment/restoration
and both lower.
Treatment
Full fixed appliances were placed with archwires progress-
ing rapidly from 0.016 Niti through to 0.016 × 0.022 Niti,
and finally 0.017 × 0.025 β-Titanium alloys in the upper
and lower arches, respectively. SAS plates were inserted
immediately lateral to the left and right upper first molars
and the lower left first molars. No plate was required in the
lower right quadrant soon after banding. Specific attention
was directed toward accurate bracket placement on the
anterior teeth to facilitate leveling of the gingival margins.
Compressed coils were placed to open mesiodistal space and
redistribute space indirectly created by distal driving from
the SAS plates (Fig. 9.25).
When acceptable mesiodistal spaces were created, brack-
ets were removed and the teeth restored by the restorative
dentist with composite resin to ideal form (Fig. 9.26). The
restored teeth were rebracketed, and archwires progressed
through to 0.019 × 0.025 β-Titanium alloys as the SAS
plates were used to finalize the Class II posterior tooth cor-
rection. Following finishing procedures, the brackets were
removed and the patient placed in fixed palatal and lingual
retainers in the upper and lower arches and provisional clear
thermoplastic retainers for full-time wear.
After 6 months of retainer wear, final ceramic restora-
tions were placed to idealize form and color of the anterior
teeth and a splint provided to act as a retainer at night.
130 PA RT I V Skeletal Plates

A B C

D E F

G H

I
• Fig. 9.22 Posttreatment facial (A–C) and intraoral (D–H) photos exhibit a balanced profile, excellent smile
esthetics with pleasing changes in smile arc, and excellent functional occlusion. The cephalometric radio-
graph (I) reveals a balance skeletal and soft tissue outcome after simultaneous mandibular advancement
and genioplasty. The panoramic radiograph reveals acceptable tooth positions with minimal root resorp-
tion of the posterior teeth that were intruded (J).
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 131

A B C

D E F

G H

I
• Fig. 9.23Facial (A–C) and intraoral (D–H) photos exhibit a Class II subdivision right type malocclusion with upper and lower crowding and incisor
tooth wear. Compromise composite restorations have been placed to camouflage the irregular teeth. Note the upper and lower arch asymmetries
(G and H). Cephalometric radiograph and analysis reveal mild skeletal mandibular retrognathism, retroclined upper incisors (I), bony chin deficiency,
and proclined upper and lower incisors (I), and cone-beam computed tomography rendered panoramic radiograph reveals sound root morphology
and third molars in situ (J).
132 PA RT I V Skeletal Plates
A
Sequencing
1. Bone plates for anchorage
2. Full fixed appliances
a. Distal drive to create space
b. Address asymmetry upper and lower
3. Provisional Build-Ups
4. Complete Fixed appliances
5. Final prosthodontics
6. Splint as Retainer
B C
• Fig. 9.24 The sequencing plan for the interdisciplinary treatment of the patient in Fig. 9.23 with the del-
egated clinicians. (A) An occlusogram overlay of the treatment goals for the upper and lower reveals the
need to distal drive the upper right and lower left quadrants to manage the asymmetry (B and C). BA =
Dr. Allan; MG = Dr. Goonewardene; BGS = Dr. Shepherd.
Summary
The upper and lower arch asymmetry was addressed by
the asymmetrical forces systems delivered through the SAS
plates. This corrected the Class II relationship and created
space to restore the teeth to ideal mesiodistal form. In addi-
tion to these anteroposterior changes, selective intrusion of
anterior teeth was performed to idealize the restorative den-
tistry (Fig. 9.27).
Overall a most acceptable occlusal and esthetic outcome
was achieved.
Case 5: A Progressive Condylar Resorption
Case That Developed Into a Class II
Openbite
A 10-year-old female presented for management of incipi-
ent crowding, as the upper right deciduous canine had been
lost prematurely and the dental midline had deviated to the
right.
On examination, the patient presented with a symmetri-
cal face and a slightly convex profile with a mildly retrusive
chin. The characteristics of the smile were within the nor-
mal range. Intraoral examination revealed a Class II sub-
division left malocclusion in the late mixed dentition with
normal overbite and overjet, an upper arch asymmetry with
the left posterior teeth more anteriorly placed, and upper
midline deviation to the right. The skeletal characteristics
reveal a mild Class II skeletal pattern characterized by mild
BA
MG
BGS
MG
BGS
BGS
mandibular retrognathism and slightly retroclined upper
incisors (Fig. 9.28).
An initial stage of treatment was undertaken to move
the upper posterior teeth distally with a pendulum appli-
ance and create space for the anterior teeth. This progressed
uneventfully over a 6-month period, and she was placed in a
Nance holding device to hold the space. During the year that
the Nance button was placed, the patient developed bilat-
eral pain and clicking in both temporomandibular joints
(TMJs). Antiinflammatory medication was prescribed, and
an anterior openbite developed. The patient was referred to
an oral medicine specialist and rheumatologist for routine
diagnostic screening for any systemic contribution to the
degenerative condition. The progress cephalogram revealed
shortening of the ramus and opening of the mandibular
plane consistent with condylar degeneration (Fig. 9.29). A
diagnosis of idiopathic condylar resorption (ICR) was con-
cluded and the patient placed in a mandibular stabilizing
splint to be worn at night to reduce loading on the joints.
The splint was not tolerated by the patient.
Follow-up radiographs revealed ongoing degeneration of
the joints consistent with ICR, a decrease in chin projection
and increase in skeletal convexity, and relative retrognathism
of the mandible with a significant anterior openbite37–40
(Figs. 9.30 and 9.31).
Serial radiographs reflected relative stability of the max-
illo-mandibular relationships and cessation of active degen-
erative stage of ICR.
Facial evaluation revealed a symmetrical face with a con-
vex profile and retrusive chin. The smile analysis revealed
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 133

A B C

D E

F G H

I J

K L
• Fig. 9.25 Intraoral (A–E) photos exhibit fixed appliances, three miniplates lateral to both upper left and
right molars and the lower left posterior teeth, and elastomeric chain to distal drive the posterior teeth from
extension arms to facilitate a more translational tooth movement. As the posterior teeth were moved pos-
teriorly, compressed coils were placed between the anterior teeth to facilitate restoration to their normal
dimensions (F–J). The posterior occlusion was now near Class I and symmetrical (K and L).
A B C

D E
• Fig. 9.26 Intraoral (A–E) photos exhibit fixed appliances with provisional composite restorations to facili-
tate finishing of inciso-gingival positions and mesiodistal dimensions (A–E).

A B C

D E F

G H
• Fig. 9.27 Posttreatment facial (A–C) and intraoral (D–H) photos exhibit pleasing changes to the smile
esthetics after ceramic veneers to the upper anterior teeth and a good functional occlusion with restora-
tion of symmetry.
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 135

A B C

D E F

G H

I
• Fig. 9.28 Facial (A–C) and intraoral (D–H) photos exhibit a Class II type malocclusion in the early mixed dentition with upper midline deviation to
the right resulting from early loss of the upper right deciduous canine. The cephalometric radiograph reveals a mild Class II skeletal pattern with mild
mandibular retrognathism (I), and the panoramic radiograph reveals relatively normal dental development and no apparent temporomandibular joint
pathology (J).
136 PA RT I V Skeletal Plates

A B C

D E F

G H

I
• Fig. 9.29 Progress facial (A–C) and intraoral (D–H) photos exhibit development of a significant Class II
openbite-type malocclusion with the Nance button holding the space created by fixed molar distalizer.
The cephalometric radiograph reveals a mild Class II skeletal openbite pattern with shortening of the pos-
terior vertical ramus dimension (I). The panoramic radiograph reveals significant temporomandibular joint
breakdown (J).
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 137

A B C

D E F

G H

I
• Fig. 9.30 Progress facial (A–C) and intraoral (D–H) photos taken 24 months following initial recognition of
the joint issues exhibit progression of Class II openbite type malocclusion. The cephalometric radiograph
with Mesh template overlay reveals a significant Class II skeletal openbite pattern with shortening of the
posterior vertical ramus dimension (I). The panoramic radiograph reveals significant temporomandibular
joint breakdown (J).
138 PA RT I V Skeletal Plates

A B

C
• Fig. 9.31
The second progress cephalometric radiograph (A) and superimpositions (B) and panoramic
radiograph (C) reveal continued breakdown/remodeling of the condylar head. This has contributed to
worsening of the openbite and mandibular retrognathism.

relatively normal smile characteristics. Intraoral examina-
tion revealed a Class II type malocclusion with increased
overjet, anterior openbite, and moderate crowding in the
upper and lower anterior teeth (Fig. 9.32).
Radiographic evaluation revealed a skeletal openbite
relationship with short ramus height, reduced vertical devel-
opment of the maxillary posterior alveolar heights, and a
retrognathic, backward-rotated mandible. The panoramic
radiograph revealed evidence of previous degenerative
change and significant shortening of the condylar neck (see
Fig. 9.32).
Problem List
Condylar degeneration
Anterior openbite
Short ramus height
Increased mandibular plane
Convex profile
Mandibular retrognathism
Upper and lower crowding
Increased overjet
Treatment Goals
To close the openbite by counterclockwise rotation of the
mandible and address the Class II relationship, chin retru-
sion, and retrognathic mandible by a combination of coun-
terclockwise rotation and horizontal advancement of the
mandible. The upper and lower teeth will be aligned and
the anteroposterior position of the incisors retained on their
respective skeletal bases.
Considerations
Ideally, a surgical plan should be considered from a morpho-
logic perspective to rotate the maxillo-mandibular complex
counterclockwise with simultaneous mandibular advance-
ment. The presence of compromised condyles (ICR) makes
this a relatively unstable procedure with the possibility of
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 139

A B C

D E F

G H
• Fig. 9.32 Progress facial (A–C) and intraoral (D–H) photos reveal relatively stable facial and occlusal
features with facial convexity and Class II openbite with upper and lower crowding that confirmed radio-
graphic evidence of relative stability.

inducing postsurgical changes in the joints that could result
in recurrence of the openbite and mandibular retrogna-
thism.37–40 Simultaneous surgery to reposition the meniscus
has been reported by several investigators to be stable,41,42
but many surgical teams throughout the world do not share
the same optimism for the procedure.
An alternative plan could consider skeletal anchors to
simultaneously intrude and retract upper and lower pos-
terior teeth.43,44 The vertical dimension will be reduced
to close the openbite and rotate the mandible forward
and create space for alignment of the anterior teeth. This
treatment plan would have minimal impact on the load-
ing patterns on the condyles and certainly would be less
invasive than orthognathic surgery with its associated
limitations.
Treatment
Upper and lower third molar extractions scheduled
simultaneously with placement of SAS plates buccal to
140 PA RT I V Skeletal Plates

A B C

D E F

G H
• Fig. 9.33 Progress facial (A–C) and intraoral (D–H) photos following banding and bonding and placement
of four miniplates lateral to the upper and lower molars. Elastomeric chains were placed to intrude and
independently retract the posterior teeth with extension arms on posterior segments to facilitate translatory
distal movement. Note the rectangular lingual arches used to reduce lateral flaring of the posterior teeth
from the intrusive forces (G and H). Incisor contact was achieved within 4 months.

upper and lower first molars. Upper and lower molars
and premolars were banded with Burstone hinge-cap
palatal and lingual attachments with 0.032 × 0.032-inch
square lingual and palatal arches to control the transverse
dimension while intrusive forces were applied from the SAS
plates. Archwires progressed from 0.016 × 0.022 Niti arch-
wires to 0.019 × 0.025-inch titanium molybdenum alloy
(TMA) wires. Simultaneous retraction forces from the bone
plates were applied through extension arms on the upper
wire to place the force as close to the center of resistance of
the upper posterior teeth to minimize tipping on the unit.
Within 4 months, the openbite had improved significantly
(Figs. 9.33 and 9.34). Retraction and intrusion continued
for a total of 9 months before appliances were placed on
the anterior teeth and initial alignment wires of 0.016 Niti
were placed (Fig. 9.35A–E).
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 141

A B C

D E

F G H

I J

• Fig. 9.34 Progress intraoral (A–E) photos with elastomeric chains to continue to retract and intrude
the posterior teeth with extension arms on posterior segments to facilitate translatory distal movement.
Progression of space creation is obvious (F–J). The force systems of independent retraction and intrusion
are represented relative to the center of resistance of the posterior teeth (K).
142 PA RT I V Skeletal Plates

A B C

D E

F G H

I J
• Fig. 9.35
Progress intraoral photos at the time of bonding the remaining anterior teeth (A–E). Alignment
was achieved using flexible nickel titanium archwires (F–J).

Five months after full banding, rectangular 0.016 ×
0.022 Niti archwires were placed (Fig. 9.35F–H) progress-
ing to 0.019 × 0.025-inch TMA wires. Intrusive and retrac-
tion forces were maintained throughout this period with
the need to retract the upper arch to address a mild Class
II tendency using extension arms to control the rotation
(Fig. 9.36A–E).
Finishing and detailing in the lower arch were performed
with a round 0.018 steel archwire (Fig. 9.36F–J) and brackets
removed 16 months after full fixed appliances were placed,
with a total treatment time of 25 months. Bonded upper
and lower retainers and vacuum-formed removable retainers
were constructed with small composite attachments placed
on the labial of the upper anterior teeth to minimize any
tendency for the incisors to relapse (Fig. 9.37).
Summary
The outcome from the treatment is excellent both estheti-
cally and functionally, with several significant benefits from
 CHAPTER 9 Managing Complex Orthodontic Problems With Skeletal Anchorage 143

A B C

D E

F G H

I J
• Fig. 9.36 Intraoral (A–E) photos exhibit fixed appliances in rectangular 19 × 25 titanium-molybdenum
alloy (TMA) wires with elastomeric chain to distal drive the posterior teeth from extension arms to facilitate
a more translational tooth movement. Finishing bends were then placed to complete the correction (F–J).

intruding the posterior teeth with SAS plates. These include
closure of the openbite with counterclockwise rotation of
the mandible, which simultaneously improved the Class II
occlusal relationship and chin projection. The SAS plates
were also able to facilitate space creation for alignment of
the crowded anterior teeth. Moreover, these changes were
able to be achieved with minimal iatrogenic effects and risks
that may have been encountered if a combined surgical plan
was to be considered.
144 PA RT I V Skeletal Plates

A B C

D E F

G H

I J
• Fig. 9.37 Posttreatment facial (A–C) and intraoral (D–H) photos exhibit pleasing changes to the convexity of the facial profile as the mandible rotated
upward and the established alignment and occlusion that were most satisfactory. Cephalometric radiograph with superimposition reveals the signifi-
cant intrusion of the lower posterior teeth and upward and forward rotation of the mandible (I and J).
 CHAPTER 9
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 PART V

Zygomatic Implants

10. Zygomatic Miniplate-Supported Openbite Treatment: An Alternative Method to Orthognathic Surgery

Nejat Erverdi and Çağla Şar
11. Zygomatic Miniplate-Supported Molar Distalization
Nejat Erverdi and Nor Shahab

147147
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10
Zygomatic Miniplate-Supported
Openbite Treatment: An Alternative
Method to Orthognathic Surgery
NEJAT ERVERDI, ÇAĞLA ŞAR
Openbite Malocclusion and Treatment
Anterior openbite is defined as a lack of anterior overlap of
the incisors and can be considered as one of the most chal-
lenging malocclusions to treat. Numerous etiologic factors
contribute to the development of this malocclusion, includ-
ing: heredity, functional disorders, unfavorable growth pat-
terns, functional habits, and trauma. According to Proffit,
tongue thrust swallowing has too short a duration to have
an impact on tooth position.1 During a swallow, tongue
pressure against the teeth only lasts for 1 second. An indi-
vidual swallows 800 to 1000 times in one day, which totals
a few minutes. This duration is not enough to affect the
equilibrium and cause an anterior openbite. Tongue thrust
swallowing is a physiologic adaptation to an anterior open-
bite. On the other hand, a long-term forward or abnormal
tongue posture can exert a continuous light force, prevent-
ing anterior teeth from erupting and may be an etiologic
factor for anterior openbite malocclusion. Furthermore,
if the position of the tongue is not normal, the pattern of
resting pressure is also abnormal. The tongue is generally
positioned above the occlusal surfaces of the lower posterior
teeth and prevents their eruption. Thus the upper posterior
teeth erupt, since they do not have occluding contacts and
the mandible rotates backward.
Anterior openbite can be classified as dental, skeletal, or a
combination of these two. In a dental openbite, the maloc-
clusion is limited to dental changes. Characteristics that have
been found to be associated with skeletal anterior openbite
include: decreased posterior facial height, increased ante-
rior lower facial height, increased mandibular plane angle,
increased maxillary posterior dentoalveolar height, Class II
tendency, and clockwise rotation of the mandible.2,3 Fur-
thermore, inadequate lip seal and weak orofacial muscles
accompany the skeletal openbite malocclusion. Several
treatment approaches have been advocated for the treat-
ment of anterior openbite.4,5 These approaches comprise:
habit breakers, posterior bite blocks, high pull headgears,
anterior vertical elastics with fixed appliance orthodon-
tic treatment, multiloop edgewise archwire technique,6,7
curved arches with vertical elastics, and step-down/step-up
archwire bends. The treatment method should be based on
the malocclusion’s etiologic traits. Dental anterior openbite
treatments focus on eliminating the functional habit, erupt-
ing maxillary and mandibular anterior teeth with fixed orth-
odontic mechanics, and wearing vertical interarch elastics.
If the openbite is caused by the abnormal posture of the
tongue, the treatment modality should focus on increas-
ing the area of the tongue. The size of the tongue can be
considered as actual or relative. Adenoidectomy and tonsil-
lectomy increase the area of the tongue relative the oropha-
ryngeal space, while rapid maxillary expansion and partial
glossectomy actually increase the oropharyngeal space in
relationship to the tongue area. Partial glossectomy should
only be performed if the patient has a macroglossia. Diag-
nostic criteria of macroglossia include the positioning of the
tongue apex outside the dentition, indentations of the teeth
on tongue border and labial/buccal tipping of teeth. If the
tongue size is normal but appears large, it can be caused by a
habitual forward posturing, hypertrophied tonsils/adenoid
tissue, low palatal vault, and small arches.4,8
In a skeletal anterior openbite growth pattern, more
posterior-superior growth of the condyle, lack of forward
internal rotation of the mandible, lack of posterior facial
height development, vertical eruption of maxillary molars,
and more downward position of the maxilla are seen. Most
common morphologic pattern is posterior maxillary den-
toalveolar excess and clockwise rotation of the mandible.4,5
Therefore the aim of the treatment modality should include
intrusion of the maxillary posterior dentoalveolar segments.
This treatment approach leads to a displacement of the
tongue’s root downward, positions the tongue downward
and backward, and corrects the altered functional matrix.
Subsequently, the mandible rotates counterclockwise
149
150 PA RT V Zygomatic Implants

(CCW) and the openbite closes. Many attempts have been

made to intrude maxillary posterior teeth. True intrusion of
the maxillary posterior dentoalveolar segment and the max-
illa can be accomplished with orthognathic surgery, which is
a widespread and proven approach. However, patients who
undergo orthognathic surgery usually have a long and dif-
ficult postoperative healing period. Therefore pros and cons
of surgical treatment should be considered carefully.
With the introduction of temporary anchorage devices in
orthodontics, minimally invasive treatment options became
possible for the treatment of anterior openbite.9 Umemori
et al. placed L-shaped titanium miniplates on the mandibu-
lar corpus area for the intrusion of mandibular posterior seg-
ment in 1999.10 Alternatively, in 2002, Erverdi et al. were
the first researchers who used the zygomatic buttress area as
an anchorage site and placed titanium miniplates to zygo-
matic process of the maxillary bone for the intrusion of the
maxillary dentoalveolar segment.11 The technique requires a
minimally invasive surgery, which can be performed under
local anesthesia. The zygomatic buttress has been proven to
be a safe area, where temporary anchorage devices have been • Fig. 10.1 Multipurpose Implant (MPI) with retentive part and bendable
placed for many years. Erverdi,11–13 Sherwood,14,15 Lentini- part.
Oliveira,5 and Scheffler16 have used zygomatic anchorage
for maxillary posterior teeth intrusion and connected mini- anatomic structures. The extension section or extension arm
plates directly to molars and premolars on segmental fixed is 20 mm long and has a round cross-section made out of
appliances. Having seen the buccal tipping of posterior teeth titanium, which is bendable. Since the desired tooth move-
with the use of these mechanics, Erverdi et al.17 modified ment may vary in many cases, the extension part can be bent
the appliance and the technique. This chapter describes the accordingly to deliver the necessary force vectors.
skeletal openbite treatment with the new generation open- The center of resistance (CR) of the maxillary posterior
bite appliance (OBA) and zygomatic anchorage, which can segment to be intruded passes approximately through the
be an alternative to orthognathic surgery. Moreover, cases mesial root of the upper first molar and zygomatic buttress
treated with this technique are presented. area (Fig. 10.2). Therefore the zygomatic region seems to
be the most suitable place as an anchorage site for maxillary
posterior dentoalveolar intrusion. The force vector provides
Zygomatic Anchorage: Multipurpose parallel intrusion of the segment. In cases where first premo-
Implant lar extractions are performed, CR of the posterior segment
moves slightly distally (Fig. 10.3). Thus a slight distal step is
The zygomatic buttress has been proven to provide sufficient bent on the long extension of the miniplate.
anchorage for significant orthodontic tooth movements,
such as maxillary posterior dentoalveolar intrusion and en- Surgical Method for Multipurpose Implant
masse distalization of the entire maxillary arch. The zygo-
matic process is a safe region, since it has the thickest cortical
Placement
bone in the maxilla. Besides, it is away from the roots of the Surgical placement of MPI is performed under local anesthe-
teeth, and is frequently used for anchorage.18 Complex mal- sia. Following infiltration, a vertical incision is made in the
occlusions, which are challenging to treat with conventional vestibule, by digital palpation along the zygomatic buttress.
orthodontic mechanics, can be predictably treated with the The ideal position has to take into consideration that the
use of titanium miniplates. In the past, miniplates used extension arm of the miniplate should penetrate the soft tis-
for maxillofacial surgery, were also used for orthodontic sue mucosa from the bone through the keratinized attached
anchorage. More recently, titanium miniplates for specific gingiva at the mucogingival junction. Therefore the lower
orthodontic purposes have been introduced to the market border of the incision should be at the intersection of the
with different designs. The Multipurpose Implant (MPI), attached gingiva and mobile mucosa. The mucoperiosteum
developed by Dr. Erverdi (Tasarim Med, Istanbul, Turkey), is released and the area is prepared for fixation. MPI is bent
has two main components: the retentive and the extension precisely according to the shape of the zygomatic buttress.
sections (Fig. 10.1). The retentive section consists of three The extension arm of the miniplate is cut into the proper
holes for fixation of the screws. Diameter of the holes is 2.3 length and bent to form a hook (Fig. 10.4). The miniplate
mm, and screws 5, 7, and 9 mm of length are used to secure has three holes; however, at least two mini-implants should
the plate into the bone according to the thickness of the be placed to avoid rotation.
 CHAPTER 10 Zygomatic Miniplate-Supported Openbite Treatment: An Alternative Method to Orthognathic Surgery
• Fig. 10.2 Center of resistance (CR) of maxillary posterior segment
passes through the mesial root of the first upper molar.
• Fig. 10.3 In cases with first premolar extractions, center of resistance
(CR) of posterior segments shifts slightly posterior to the distal root of
the first molar.
• Fig. 10.4Surgical procedure for Multipurpose Implant (MPI) placement. Vertical incision is done along
the zygomatic buttress. MPI is bent according to the shape of the zygomatic buttress and fixed with three
mini-implants. The extension arm is cut in proper length and bent distally to form a hook.
151
The position of MPI should be as high as possible into
the zygomatic crest for two main reasons: attaining a better
bone quality and increasing the distance between applica-
tion point of skeletal anchorage and the teeth. Since the
desired movement in this case is intrusion, adjusting the
amount of force would be easier when the distance is long.
However, retraction of soft tissues and insertion of upper
screws of MPI may be technically challenging in some
cases. Following the insertion of the miniplates and mini-
implants, the incision is sutured. Following surgery, antiin-
flammatory agents, analgesics, and chlorhexidine gluconate
are prescribed.
Possible Complications
Some complications may be encountered following sur-
gery. If the width of the attached gingiva is too narrow,
the emergence point of the miniplate may be through the
mobile mucosa. In such cases, soft tissue irritation and
postoperative inflammation can be observed, which lead
to mobility of the miniplate. Postsurgical swelling and
pain are the most frequent complications reported by the
patients. The inflammatory symptoms and changes persist
for 5 to 7 days.
Inflammation can be observed in any phase of the treat-
ment. In such cases, force application should be stopped
and antibiotic treatment should be initiated together with
a chlorhexidine mouthwash. Patients should be informed
about maintaining their oral hygiene properly. Healing
period is approximately 15 days. Following healing, force
can be reapplied.
Other complications that may be seen during sur-
gery, postoperatively and during orthodontic treatment,
include: root damage and sinus perforation, soft tissue,
cheek and lip irritation, gingival dehiscence, and anchor
breakage.
Removal of Multipurpose Implant
Removal of the miniplate again requires a mucoperiosteal
incision under local anesthesia. There may be some bone
deposition around the miniplates and screws. Following
removal of the bone, granulation tissues should be removed.
The screws should be loosened with the help of screw driv-
ers, and the incision is sutured.
152 PA RT V Zygomatic Implants

• Fig. 10.5 Fabrication of the openbite appliance. Palatal arches are bent on two layers of wax. The orienta-
tion of the buccal bars should be transversally adjusted in such a way that the vector of force application is
parallel to the long axis of the molars. The right and left acrylic bite blocks are connected with palatal bars
and cover the occlusal surfaces of the teeth.

New-Generation Openbite Appliance
The OBA was first introduced in 2006 by Dr Erverdi.13 It
has been modified over time based on clinical experience.
Fabrication
Wire Bending
The openbite appliance consists two acrylic bite blocks
connected with two palatal bars, made of 1.5-mm round
stainless steel wire. These bars should be away from the
palatal mucosa. To avoid the impingement of the appli-
ance to palatal mucosa during intrusion, two layers of wax
are placed to the palatal side of the model. Buccal bars
are used for force application and are made from 0.8-mm
round stainless steel wire. They extend from first premo-
lar to second molar. Nickel titanium closed coil springs
are attached to the wires before embedding the wires into
the acrylic (Fig. 10.5). The orientation of the buccal bars
should be transversally adjusted in such a way that the vec-
tor of force application is parallel to the long axis of the
molars when the coil springs are attached to the multipur-
pose miniplates. Another advantage is that they can be bent
downward to increase the vertical dimension and allow for
additional activation.
Acrylic Cap
The right and left acrylic bite blocks are connected with
palatal bars. They cover the occlusal surface of the posterior
 CHAPTER 10 Zygomatic Miniplate-Supported Openbite Treatment: An Alternative Method to Orthognathic Surgery 153

• Fig. 10.6 Intraoral application of coil springs from the openbite appliance to the hooks of Multipurpose
Implant.

Cm2 0.70 0.80 0.30 0.30 0.45 0.30 0.40

150-g/cm2 105 120 45 45 65 45 60

100-g/cm2 70 80 30 30 45 30 40

100-g/cm2 75 85 30 30 35 20 20
150-g/cm2 110 130 45 45 50 30 30

Cm2 0.75 0.85 0.30 0.30 0.35 0.20 0.20

• Fig. 10.7 Ricketts’ chart for calculation of force magnitude.

teeth to be intruded. The thickness should be at least 4
mm or greater to impinge into the freeway space. Occlusal
surfaces should contain holes to provide retention during
bonding the appliance to posterior teeth.
Clinical Application
The OBA should be tried in the mouth to check the fit
before bonding. Acrylic bite blocks should contact all pos-
terior teeth equally. Primary contacts are trimmed after
evaluating bite closing and eccentric movements to elimi-
nate occlusal interferences. The appliance is bonded with
glass ionomer cement. Following the removal of sutures
on the seventh day of MPI placement, two 9-mm Niti
coil springs are attached from the buccal bars to the hook
of the miniplate and a total of 400-g (200-g per side) is
applied (Fig. 10.6).
The intrusive force has three components functioning in
the same favorable way to intrude the maxillary posterior
teeth. Niti coil springs using bilateral intrusive force are the
main components of this system. Calculation of the force
magnitude is determined according to the chart developed
by Ricketts (Fig. 10.7). The buccal bars are located on the
same plane as the multipurpose miniplates, allowing the
154 PA RT V Zygomatic Implants
• Fig. 10.8 Schematic illustration of the system. Combination of three intrusive force vectors are present
with the openbite appliance. Small black arrows: intrusive force from the acrylic cap; Large black arrows:
intrusive force from the tongue; Gray arrows: intrusive force from the closed nickel titanium coil springs.
force to be transmitted directly. The acrylic cap is a very
advantageous component to transmit the forces from muscle
tonus and chewing functions directly to the posterior teeth.
Furthermore, the palatal bar in contact with the tongue is
the third component that transmits the intrusive force to the
teeth (Fig. 10.8).
Retention of Openbite Treatment
Retention of the anterior openbite correction can often be
quite difficult. Muscle exercises are recommended together
with canine-to-canine fixed lingual retainers. The easiest
way to improve muscle tone is to chew natural sugar-free
chewing gum 3 to 4 hours daily in the first 3 months of
retention. This type of gum is odorless, tasteless, and hard.
Fixed lingual retainers can prevent recurrence of the crowd-
ing, but they cannot prevent the relapse of anterior openbite
if the abnormal tongue position is still present.
Clinical Experience
This treatment should only be applied to patients with very
good oral hygiene. The areas where the implant is exposed
in the mouth should be cleaned very well, and the patients
must comply with oral hygiene requirements throughout
treatment. Upper third molars should be extracted before
starting the treatment.
The first stage of treatment includes the closure of the
anterior openbite with OBA. It takes approximately 5 to 6
months. The appliance is removed following the openbite
correction and autorotation of the mandible. In some cases,
the position of the incisors may not allow the mandible to
fully autorotate after OBA removal. In such cases, upper
incisors should be leveled and proclined during the intru-
sion phase of treatment. To do this, the acrylic on the buc-
cal side of the first premolar is removed and brackets are
bonded to upper teeth including incisors, canines, and first
premolars.
When the underlying skeletal malocclusion has been
corrected with OBA, fixed orthodontic treatment is started,
which is the second stage of treatment. The first molars
should be ligated to the multipurpose implant to main-
tain the vertical position of the molars until the end of the
treatment.
Case Report 1
Case Summary
A 25-year-old male patient presented with a convex skel-
etal soft tissue profile because of a retrognathic mandible.
He had Class II canine and Class I molar relationships
on both sides, an anterior openbite, increased mandibu-
lar plane angle, and increased lower anterior facial height.
Posterior maxillary dentoalveolar heights were excessive
(Fig. 10.9).
 CHAPTER 10 Zygomatic Miniplate-Supported Openbite Treatment: An Alternative Method to Orthognathic Surgery 155

• Fig. 10.9 Pretreatment facial and intraoral photographs.

Problem List
Dimension Skeletal Dental Soft Tissue
Anteroposterior Convex skeletal profile caused Overjet: 5 mm Retrusive lower lip and
by retrognathic mandible. Class II canine relationship chin
Skeletal Class II
Vertical Increased lower anterior facial Overbite: −4 mm Active mental muscle
height Flat maxillary smile arc while closing the lips
Increased mandibular plane and the mouth
angle Large interlabial gap
Increased maxillary posterior
dentoalveolar heights
Transverse Slight crossbite tendency
on the right buccal
segment
Mandibular midline 1 mm
to the right of facial
midline
156 PA RT V Zygomatic Implants

Treatment Objectives
Dimension Skeletal
Anteroposterior Reduce skeletal convexity with
autorotation of the mandible
in counterclockwise direction
Vertical Reduce lower facial height and
mandibular plane angle by
intruding the maxillary pos-
terior teeth and autorotating
the mandible
Transverse
Dental
Improve overjet by autoro-
tation of the mandible
Improve anterior overbite
and smile arc by intrud-
ing upper posterior
teeth and maintaining
the vertical position of
the anterior teeth.
Correct crossbite ten-
dency on the right
buccal segment
Move mandibular midline
1 mm to the left
Soft Tissue
Improve soft tissue profile
Reduce interlabial gap
Improve the profile by
intruding maxillary
dentoalveolar sites.
Achieve the closure of the
lips without activation of
the mental muscle.

Treatment Plan fixed orthodontic treatment. Following detailing of the

The treatment of a skeletal openbite requires skeletal or
dentoalveolar impaction of maxillary posterior segment to
address the etiology of the malocclusion. Skeletal impaction
could only be obtained by orthognathic surgery. As an alter-
native to orthognathic surgery, zygomatic miniplate–sup-
ported maxillary posterior dentoalveolar impaction could
be used.
Treatment Sequence
Zygomatic miniplates were placed under local anesthe-
sia. The OBA appliance was cemented 1 week after the
surgery. Two 9-mm-length Niti closed coil springs were
ligated bilaterally between the appliance and the tip of the
MPI (Fig. 10.10). The intrusive force was 200-g on each
side. Appointments were scheduled every 4 weeks and the
progress was observed. Following the intrusion of maxil-
lary posterior teeth, fixed orthodontic treatment was initi-
ated (Figs. 10.11 and 10.12). The first molars were ligated
tightly to the implants, to maintain intrusion throughout
occlusion, brackets were removed and fixed lingual retainers
bonded on both arches. The patient was instructed to chew
hard chewing gum 2 hours a day for retention.
Treatment Results
At the end of treatment, Class I canine molar relationships
were achieved. Anterior openbite was corrected by intruding
maxillary posterior dentoalveolar segment, and mandibular
plane angle showed CCW rotation (Fig. 10.13).
Case Report 2
Case Summary
A 21-year-old patient presented with a chief complaint of
anterior openbite. She had a convex skeletal and soft tis-
sue profile with retrognathic mandible. Molar and canine
relationships were Class II on both sides. She exhibited a
5-mm anterior openbite and 4-mm overjet. Mandibular
plane angle and anterior lower facial height were increased.
The smile arch was not in consonance with the lower lip
curve (Fig. 10.14).

• Fig. 10.10 Application of force with closed coil springs from openbite appliance to the hooks of the
zygomatic miniplates.
 • Fig. 10.11 End of intrusion mechanics.

C
• Fig. 10.12 Fixed orthodontic treatment following the intrusion stage.
Upper molars are ligated to zygomatic miniplates throughout the sec-
ond phase of treatment. (A) Intraoral right lateral view; (B) intraoral fron-
tal view; (C) intraoral left lateral view.
158 PA RT V Zygomatic Implants

• Fig. 10.13 Posttreatment facial and intraoral photographs.

CHAPTER 10 Zygomatic Miniplate-Supported Openbite Treatment: An Alternative Method to Orthognathic Surgery 159

• Fig. 10.14 Pretreatment facial and intraoral photographs.

160 PA RT V Zygomatic Implants

Problem List
Dimension Skeletal Dental Soft Tissue
Anteroposterior Convex skeletal profile Overjet: increased Retrusive lower lip and
caused by retrognathic flared maxillary chin
mandible incisors
Class II molar and canine
relationship
Vertical Increased lower anterior Overbite: −5 mm Increased lower anterior
facial height Reverse maxillary smile soft tissue height
Vertical overgrowth of arc Increased gingival maxil-
the maxillary posterior lary display on the
dentoalveolar regions posterior segments
Transverse Narrow maxilla Broad mandibular arch
Dental crossbite on the
right buccal segment
Lower midline 1 mm
to the right of facial
midline

Treatment Objectives
Dimension Skeletal
Anteroposterior Reduce skeletal convexity
with autorotation of the
mandible in counter-
clockwise direction
Vertical Reduce lower facial height
and mandibular plane
angle by intruding the
maxillary posterior teeth
and autorotating the
mandible
Transverse Maintain transverse skel-
etal dimension.
Expand maxillary arch
dentally
Dental Soft Tissue
Reduce excessive overjet Improve soft tissue profile
by autorotation of the
mandible
Improve anterior openbite Improve the profile by
and smile arc by intrud- intruding maxillary den-
ing upper posterior toalveolar sites.
teeth and maintaining
the vertical position of
the anterior teeth.
Correct crossbite on right
buccal segment
Move mandibular midline
to the left

Treatment Plan
The anterior openbite was planned to be corrected by
intruding maxillary posterior teeth, allowing the mandible
to autorotate in a CCW direction. In the present case, the
amount of incisor display was normal. Therefore extrusion
of upper incisors was to be avoided. The intrusion of poste-
rior maxillary dentoalveolar regions was planned to be per-
formed using zygomatic miniplates.
Treatment Sequence
The OBA appliance was cemented following the surgical
insertion of multipurpose miniplates. At day 7, two 9-mm-­
length Niti coil springs were attached bilaterally between
the appliance and the tip of the MPI. Appointments were
scheduled every 4 weeks and the progress was observed.
Following the intrusion of posterior dentoalveolar regions,
fixed orthodontic treatment was initiated. The first molars
were ligated tightly to the miniplates, to maintain intru-
sion throughout the second phase of treatment. Following
detailing of the occlusion, the brackets were debonded and
fixed lingual retainers were bonded on both arches. The
patient was instructed to chew hard chewing gum 2 hours
a day.
Treatment Results
At the end of the treatment, Class I canine molar relation-
ships were achieved (Fig. 10.15). Overjet was reduced to
ideal, and correction of anterior openbite was achieved by
intruding maxillary posterior dentoalveolar segment. Poste-
rior gingival maxillary excess was corrected. Cephalometri-
cally, mandibular plane angle showed CCW rotation (Figs.
10.16 and 10.17).
CHAPTER 10 Zygomatic Miniplate-Supported Openbite Treatment: An Alternative Method to Orthognathic Surgery 161

• Fig. 10.15 Posttreatment facial and intraoral photographs.

162 PA RT V Zygomatic Implants
A B
C D
• Fig. 10.16 Initial and final panoramic and cephalometric radiographs. (A) Pre-treatment cephalometric
radiograph; (B) pre-treatment panoramic radiograph; (C) post-treatment cephalometric radiograph; (D)
post-treatment panoramic radiograph.
• Fig. 10.17
Cephalometric superimposition. Significant autorotation of
the mandible with maxillary posterior segment intrusion.
References
1. Proffit W, Fields H: Contemporary orthodontics, ed 5, St Louis,
2013, Mosby, p 413.
2. Subtelny JD, Sakuda M: Open bite diagnosis and treatment, Am
J Orthod 50:337–358, 1964.
3. Ngan P, Fields H: Open bite: a review of etiology and manage-
ment, Pediatr Dent 19:91–98, 1997.
4. Cozza P, Mucedero M, Baccetti T, Franchi L: Early orthodontic
treatment of skeletal open-bite malocclusion: a systematic review,
Angle Orthod 75(5):707–713, 2005.
5. Lentini-Oliveira DA, Carvalho FR, Rodrigues CG, et al.: Orth-
odontic and orthopaedic treatment for anterior open bite in chil-
dren (Review), Cochrane Database Sys Rev 9:Art No: CD005515,
2014.
6. Kim YH: Anterior openbite and its treatment with multiloop
edgewise archwire, Angle Orthod. 57(4):290–321, 1987.
7. Kucukkeles N, Acar A, Demirkaya A, Evrenol B, Enacar A:
Cephalometric evaluation of open bite treatment with NiTi
archwires and anterior elastics, Am J Orthod Dentofacial Orthop
116:555–562, 1999.
8. Erverdi N. Çağdaş Ortodonti, 1st ed. Istanbul: Quintessence
Yayıncılık;2017; 33–34.
9. Park HS, Kwon OW, Sung JH: Nonextraction treatment of an
open bite with microscrew implant anchorage, Am J Orthod Den-
tofacial Orthop 130(3):391–402, 2006.
10. Umemori M, Sugawara J, Mitani H, Nagasaka H, Kawamura H:
Skeletal anchorage system for open-bite correction, Am J Orthop
115:166–174, 1999.
11. Erverdi N, Tosun T, Keles A: A new anchorage site for the treat-
ment of anterior open bite: zygomatic anchorage case report,
World J Orthod 3:147–153, 2002.
12. Erverdi N, Keles A, Nanda R: The use of skeletal anchorage in
open bite treatment: a cephalometric evaluation, Angle Orthod
74:381–390, 2004.
13. Erverdi N, Üşümez S, Solak A: New generation open-bite treat-
ment with zygomatic anchorage, Angle Orthod 76:519–526,
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 CHAPTER 10 Zygomatic Miniplate-Supported Openbite Treatment: An Alternative Method to Orthognathic Surgery 163

14. Sherwood KH, Burch JG, Thompson WJ: Closing anterior
openbites by intruding molars with titanium miniplate anchor-
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73:597–601, 2003.
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11
Zygomatic Miniplate-Supported Molar
Distalization
NEJAT ERVERDI, NOR SHAHAB
Conventional noncompliance appliances rely exclusively
on intraoral anchorage for molar distalization.1,2 Whereas
these appliances incorporate design components to attempt
to prevent anchorage loss, flaring of the anterior teeth and
increased overjet usually take place to a significant extent.
One negative consequence usually seen with these appli-
ances is the increase of the lower facial height because of
clockwise mandibular autorotation as the posterior teeth
distalize.2–5 In addition, relapse of molar distalization is
commonly seen, since the molars are used as anchorage to
support the second phase of distalization consisting of the
retraction of the premolars and incisors.
To eliminate such complications, various intraoral dis-
talizing mechanics combined with temporary anchorage
devices (TADs) have been used, as it is possible to distalize
the maxillary molars without anchorage loss by using abso-
lute anchorage predictably and efficiently. Many patients
seeking orthodontic treatment have complete dentitions;
therefore no available alveolar bone sites are present for
mini-implant placement to allow uninterrupted molar dis-
talization without TAD replacement for the retraction of
the premolars and incisors. Consequently, several studies
have looked at extra-alveolar alternative sites, such as the
hard palate, the mandibular retromolar area, the inferior
border of the zygomatic buttress, and the mandibular sym-
physial region.6
The inferior border of the zygomatico-maxillary buttress
provides a very suitable anatomic site for TAD placement
as direct access is easy and it is away from critical anatomic
structures. Because it is close to the maxillary molars, the
zygomatic buttress can be used for their anchorage either
Dentaurum stop tube, stop screw
and activator tube assembled
•Fig. 11.1 Representation of the connecting system and miniplates applied. (With permission from
DENTAURUM GmbH & Co. KG.)
directly or indirectly.7,8 Zygomatic miniplates are easily
placed and removed under local anesthesia and can be used
in various clinical situations.
This chapter describes the treatment strategy and out-
comes of zygomatic miniplates and segmented archwires for
maxillary molar distalization.
Method Description
The use of mini-implants-supported zygomatic miniplates
placed on the zygomatic buttress for anchorage is illustrated
in Fig. 11.1. The body of the titanium miniplate (Multipur-
pose Implant, Tasarim Med, Istanbul, Turkey) consists of two
holes made to receive two mini-implants for fixation. After
the miniplates are fixated onto the zygomatic bone, the other
end of the miniplate exits through the attached gingiva on
the furcation level of the first molar. The miniplate placement
surgery is performed under local anesthesia. One week later
the sutures are typically removed after soft tissue healing is
observed. Shortly after, the distalization procedure is started.
Upper first premolars and second molars are bonded (Roth
prescription 0.018-inch slot brackets), while the first molars
are banded on the side of the distalization. The second pre-
molar is usually not bonded during the initial distalization
phase (Fig. 11.2). Following the leveling and alignment of the
segment with nickel-titanium (Niti) archwires, a 0.016-inch
stainless steel segmental wire is used together with 0.036-inch
Niti open coil springs for the sliding mechanics. A stop tube
with a stop screw (Dentaurum, Ispringen, Germany) that are
attached to the extension arm of the miniplate, and an acti-
vator tube that receives the orthodontic wire (Dentaurum,
STD. mini-implants 2x7 mm
Multipurpose implant
165
166 PA RT V Zygomatic Implants

Smile Analysis (Fig. 11.1.2)

Smile arc Nonconsonant
Incisor display Rest: 2 mm
Smile: 9 mm
Lateral tooth First premolar to second
display premolar
Buccal corridor Small
Gingival tissue Margins: irregular
because of crowding
Papilla: present

Dentition Tooth size and proportion:

normal
•Fig. 11.2 Application of the zygomatic miniplate and distalization
Tooth Shape: normal
mechanics.
Axial inclination: maxillary teeth
Ispringen, Germany) are linked together with a loop-shaped inclined lingually
1.1-mm thick stainless steel round wire, soldered at both Connector Space: normal
ends by a dental technician (see Fig. 11.1). The modifiable Incisal embrasure Normal
loop design gives the operator the flexibility to adapt this Midlines Upper dental midline is on with
part between the miniplate arm and teeth according to each the facial midline and lower
patient’s anatomy, extending toward the archwire to transfer dental midline is 1.5 mm to
the point of force application to the level of the archwire. the left.
Maxillary molar distalization process starts 2 to 4 weeks
after miniplate placement surgery. The patients are seen Intraoral Analysis (see Fig. 11.1.2)
every 4 to 5 weeks to monitor progress, while the system is
Teeth present 7654321/1234567 (Unerupted
reactivated when needed by shifting the sliding lock toward
8s)
distal or by placing a longer Niti open coil spring. Distaliza-
7654321/1234567 (Unerupted 8s)
tion is usually completed in approximately 4 to 6 months.
Molar relation Class I on the right, Class II on
the left
Case 11.1 Canine relation Class I on the right, Class II on
the left
A 16-year-old male patient with a chief complaint of upper Overjet 5 mm
and lower arch crowding had a convex profile with compe- Overbite 5 mm
tent lips. Medical and dental history was noncontributory, Maxillary arch U shaped, asymmetric and 2.5
and findings from a temporomandibular joint (TMJ) exam- mm of crowding
ination were normal with adequate range of jaw movements. Mandibular arch U shaped with crowding of
Pretreatment 4 mm and normal curve
Extraoral Analysis (Fig. 11.1.1) of Spee
Oral hygiene Fair
Facial form Mesoprosopic
Facial No gross asymmetry noticed
symmetry Functional Analysis
Chin point Coincidental with facial midline Swallowing Normal adult pattern
Occlusal plane Normal
Temporomandibular joint Normal with ade-
Facial profile Mild convexity because of a
quate range of jaw
prognathic maxilla
movements
Facial height Upper facial height/lower facial
height: normal
Lower facial height/throat depth:
normal Diagnosis and Case Summary
Lips Competent, upper: normal;
lower: normal A 16-year-old male patient with a chief complaint of upper
Nasolabial Increased and lower arch crowding presented with a convex profile
angle with competent lips. He had a normal smiling line; upper
Mentolabial Normal teeth were inharmonious with the lower lip curve. Upper
sulcus dental midline was on with the facial midline and lower
 CHAPTER 11 Zygomatic Miniplate-Supported Molar Distalization 167

• Fig. 11.1.1 Pretreatment extraoral/intraoral photographs and panoramic radiograph.

Parameter Norm Value

SNA (°) 82 84
SNB (°) 80 78
ANB (°) 2 6
FMA (°) 24 29
MP-SN (°) 32 37
U1-NA (mm/°) 4/22 3.8/ 26
L1-NA (mm/°) 4/25 8.4/35
IMPA (°) 95 98
U1-L1 (°) 130 126
OP-SN (°) 14 16
Upper Lip – E Plane (mm) -4 -2

Lower Lip – E Plane (mm) -2 -0.1

Nasolabial Angle (°) 103 125
Soft Tissue Convexity (°) 135 124

• Fig. 11.1.2 Pretreatment lateral cephalogram with tracing and cephalometric analysis.
168 PA RT V Zygomatic Implants

dental midline was 1.5 mm to the left. The patient had vertical growth pattern with decreased upper and increased
Class I molar and canine relationship on the right, Class II lower incisor inclinations. The amount of crowding was 2.5
molar and canine relationship on the left side. Cephalomet- mm and 4 mm in the maxillary and mandibular arches,
ric analysis revealed a Class II skeletal relationship, normal respectively.

Problem List
Pathology/ Irregular gingival margins of anterior teeth
others
Alignment 2.5 mm of crowding present in maxillary arch
4 mm of crowding present in mandibular arch
Dimension Skeletal Dental Soft Tissue
Vertical Increased FMA Increased OB
Anteroposterior Class II Class II molar and canine on left side Increased nasolabial angle
Convex profile caused by Decreased upper and increased lower
prognathic maxilla incisor inclinations
Transverse Upper dental midline is on with the facial
midline and lower dental midline is 1.5
mm to the left.
OB, Overbite; FMA, Frankfurt-Mandibular plane angle.

Treatment Objectives
Pathology/
Others Monitor
Alignment Distalize the upper left posterior segment to create space for alignment and achieve Class I occlusion
Relieve crowding in both arches. Interdental stripping and retraction of mandibular incisors.
Dimension Skeletal Dental Soft Tissue
Vertical Establish ideal overbite
Anteroposterior Correct Class II on the left side
Transverse Match lower midline to facial midline

Treatment Options
In the maxillary arch, unilateral extraction of the left first/
second premolar with distalization of the left canine into
Class I and protraction of the left side first molar into full
cusp Class II could be an option in this case. A disadvantage
of this option is that space closure could result in further ret-
roclination of the maxillary incisors and midline deviation.
A second option is distalization of the left side and buc-
cal segment into Class I. Patient selected a nonextraction
treatment option.
In the mandibular arch, alignment could be performed
by interproximal reduction and retraction of the flared
mandibular incisors.)

• Fig. 11.1.3 Placement of the zygomatic miniplate on the left quadrant.

 CHAPTER 11 Zygomatic Miniplate-Supported Molar Distalization 169

Treatment Sequence and Biomechanical Plan

Maxilla Mandible
Placement of miniplate on left quadrant (Fig. 11.1.3)
Band upper first molars, bond 4s and 7s on the left side
Sectional leveling 4–7 (5 is not bonded) with 0.012, 0.014,
0.016-inch Niti archwires
Sliding mechanics on 0.016-inch SS wires (as described, Fig. 11.1.4)
Continue until overcorrection of distalization is achieved
Bond the rest of maxillary teeth and align with round Niti Bond mandibular teeth and align with Niti
archwires (Fig. 11.1.5) archwires
Continue leveling with 0.016 × 0.016 and Continue leveling with 0.016 × 0.016 and
0.016 × 0.022–inch Niti wires 0.016 × 0.022–inch Niti wires
Continue to full size arch wires and finish Continue to full size arch wires and finish
Debond and place fixed lingual retainer, Essix Debond and place fixed lingual retainer, Essix
6-month recall appointment for retention check 6-month recall appointment for retention check

• Fig. 11.1.4 Progress of segmental distalization treatment.

170 PA RT V Zygomatic Implants
• Fig. 11.1.5 Bonding of maxillary arch for alignment and refinement of the distalization if needed.
Treatment Sequence
Molar distalization with overcorrection was achieved effi-
ciently in 4 months and 2 weeks without any anchorage loss
and the treatment was followed with continuous archwires
in upper and lower jaws.
Final Results
A very good occlusal and esthetic result was achieved while
maintaining apical root integrity of the distalized teeth
(Fig. 11.1.6).
The amount of distalization for the maxillary left first
molar was found to be 6.48 mm (Figs. 11.1.7 and 11.1.8),
showing an amount of 1.44 mm distalization rate per
month. This was accompanied by slight extrusion (0.82
mm), buccal displacement (0.55 mm) and distal tipping
(6 degrees). There were no changes on the right quadrant.
All maxillary teeth on the left side showed significant distal-
ization amounts. The inclination of the maxillary incisors
decreased by 4 degrees (see Fig. 11.1.8 and Fig. 11.1.9).
Some vertical changes were observed on the incisors in
reference to the occlusal plane, which were reflected on the
overbite. The increase in the maxillary intercanine distance
was registered to be 0.13 mm while the increase in the max-
illary intermolar distance was 0.1 mm. The nasolabial angle
was decreased by 1 degree according to soft-tissue cephalo-
metric measurements (see Fig. 11.1.8).
Mesial movement of the anchor teeth did not occur dur-
ing distalization. However, there was 6 degrees of tipping as
well as some distopalatal rotation of the left first molar with
the buccal force application. When uprighting the molar
later in the treatment, this will require some of the space
attained by distalization. Hence an overcorrection is rec-
ommended to compensate in these cases. Nevertheless, this
protocol allowed effective noncompliance maxillary molar
distalization without side effects.
What Was the Cause of This Asymmetrical
Malocclusion in This Patient?
Unilateral full-step Class II correction, with asymmetry in
the maxillary arch, can pose a challenge for the orthodon-
tist. The Class II subdivision malocclusion could be linked
to early loss of a primary molar on the left side. Such situ-
ation can occur because of caries and no prevention plan
regarding space retention in primary/mixed dentition.
Various treatment modalities have been developed and used
successfully over the years. Unilateral premolar extraction is
usually an available treatment option but can cause arch skew-
ing or displacement of the midline. It has been shown that
a unilateral Class II malocclusion can be corrected by head-
gear with asymmetric face-bows but this needs serious coop-
eration from the patient. Moreover, the force delivery system
unavoidably contains a lateral component that can result in a
posterior crossbite. Distalization can also be performed with
noncompliant mechanics, such as TADs with bone anchor-
age, which was our treatment of choice in this patient.
Case 11.2
A 14-year-old female patient with a chief complaint of
protruded upper teeth had a convex profile with compe-
tent lips. Medical and dental history was noncontributory,
and findings from a TMJ examination were normal with
adequate range of jaw movements.
 CHAPTER 11 Zygomatic Miniplate-Supported Molar Distalization 171

• Fig. 11.1.6 Posttreatment extraoral/intraoral photographs and panoramic radiograph.

A B
• Fig. 11.1.7 Distalization magnitudes achieved on the left side (A) and accuracy of superimposition (B).
172 PA RT V Zygomatic Implants

A B
• Fig. 11.1.8 (A) Posttreatment lateral cephalogram; (B) Superimposition. Blue, Pretreatment; red,
posttreatment.

Facial form Mesoprosopic

Facial height Upper facial height/lower facial
height: normal to low angle
Lower facial height/throat
6° depth: normal
4° Lips Competent, upper: normal;
lower: normal
Nasolabial angle Normal
Mentolabial sulcus Normal
0.82 mm
6.48 mm Smile Analysis (see Fig. 11.2.1)
Smile arc Nonconsonant
• Fig. 11.1.9 Schematic illustration of distalization results. Incisor Rest: 3 mm
display Smile: 5 mm of gingival display
starting from lateral incisors and
Pretreatment extending towards posteriorly
Extraoral Analysis (Fig. 11.2.1) Lateral tooth Second premolar to second
display premolar
Facial form Mesoprosopic
Facial symmetry No gross asymmetry noticed Buccal Normal
corridor
Chin point Coincidental with facial midline
Gingival Margins: uneven heights (central
Occlusal plane Normal
tissue margins are apically placed)
Facial profile Mild convexity because of
Papilla: present
prognathic maxilla
 CHAPTER 11 Zygomatic Miniplate-Supported Molar Distalization 173

Dentition Tooth size and proportion: normal Functional Analysis

Maxillary right central incisor has Swallowing Normal adult pattern
incisal edge restoration because Temporomandibular joint Normal with ade-
of a previous trauma quate range of jaw
Tooth Shape: normal movements
Axial inclination: maxillary teeth
inclined lingually
Connector Space: normal
Incisal Normal Diagnosis and Case Summary
embrasure
Midlines Upper dental midline was on with A 14-year-old female patient with a chief complaint of
the facial midline and lower den- protruded upper teeth had a convex profile with compe-
tal midline was 1 mm to the left. tent lips. She had a posterior gummy smile; upper teeth
were nonconsonant with the lower lip curve together with
Intraoral Analysis (see Fig. 11.2.1) lower incisor exposure. Upper dental midline was on with
the facial midline and lower dental midline was 1 mm to
Teeth present 7654321/1234567 (Unerupted 8s) the left. The patient had Class II molar and canine rela-
7654321/1234567 (Unerupted 8s) tionship on both sides. According to cephalometric analy-
Molar relation Class II bilaterally sis, she had a normal to low-angle growth pattern, Class I
Canine relation Class II bilaterally skeletal relationship (slightly prognathic maxilla, big man-
Overjet 8 mm dible) with decreased upper and increased lower incisor
Overbite 0 mm inclinations (Fig. 11.2.2). The amount of crowding was
Maxillary arch U shaped, symmetric, 2.05 mm 2.05 mm and 1.67 mm in the maxillary and mandibular
of crowding arches, respectively.
Mandibular U shaped with crowding of 1.67
arch mm and normal curve of Spee
Oral hygiene Good

Problem List
Pathology/others Irregular gingival margins of anterior teeth
Posterior gummy smile
Upper teeth are nonconsonant with the lower lip curve (reserve smile arc)
Thin biotype of the labial periodontum of the mandibular incisors
Alignment 2.05 mm of crowding present in maxillary arch
1.67 mm of crowding present in mandibular arch
Dimension Skeletal Dental Soft Tissue
Vertical Normal to low-angle Reduced OB
growth pattern
Anterioposterior Class II Class II
Prognathic maxilla Decreased upper and increased lower incisor inclinations
Transverse Upper dental midline on with the facial midline and lower
dental midline 1 mm to the left.
OB, Overbite; FMA, Frankfurt-Mandibular plane angle.

Treatment Objectives
Pathology/others Improve restoration of #11 postorthodontic treatment
Monitor labial periodontum of the mandibular incisors
Alignment Distalize and intrude upper posterior segments to achieve Class I occlusion and correct the posterior
gummy smile
Relieve crowding in both arches
Dimension Skeletal Dental Soft Tissue
Vertical Improve overbite
Anteroposterior Correction of Class II relationship on both sides
Correction of incisal inclinations, interincisal angle
Transverse Correction of midline discrepancy
174 PA RT V Zygomatic Implants

• Fig. 11.2.1 Pretreatment extraoral/intraoral photographs and panoramic radiograph.

Parameter Norm Value

SNA (°) 82 86
SNB (°) 80 80
ANB (°) 2 6
FMA (°) 24 26
MP-SN (°) 32 32
U1-NA (mm/°) 4/22 5.5/ 29
L1-NA (mm/°) 4/25 7.1/30
IMPA (°) 95 98
U1-L1 (°) 130 114
OP-SN (°) 14 17
Upper Lip – E Plane (mm) -4 -3.5

Lower Lip – E Plane (mm) -2 -2.3

Nasolabial Angle (°) 103 113
Soft Tissue Convexity (°) 135 122

• Fig. 11.2.2 Pretreatment lateral cephalogram with tracing and cephalometric analysis.
 CHAPTER 11 Zygomatic Miniplate-Supported Molar Distalization 175

Treatment Options Treatment Sequence

In the present case, anterior and posterior teeth have slightly Molar distalization with overcorrection was achieved efficiently
different occlusal planes that require correction by means of in 6 months without any anchorage loss. Slight buccal rota-
segmental mechanics. Two options are available: tion of the maxillary left segment as distalization ensues (Fig.
• Distalize and intrude upper posterior segment with zygo- 11.2.4). This side effect is corrected by the placement of contin-
matic anchorage allowing some distalization of the whole uous archwires on the maxillary arch (Fig. 11.2.5). Once proper
buccal segment and clockwise rotation of the maxillary archform is achieved with rigid stainless steel archwires, any
occlusal plane with some mandibular autorotation. Align residual distalization is accomplished before the finishing stage.
arches and detail the occlusion.
• Extraction of maxillary premolars could also be an Final Results
option; however, the patient selected a nonextraction
Very good occlusal and esthetic results while maintaining
treatment option.
apical root integrity were achieved through distalization as
observed in the posttreatment photos and panoramic radio-
graph (Fig. 11.2.6).
Treatment Sequence and Biomechanical Plan The amount of distalization for the maxillary right first
molar was found to be 5.61 mm (Figs. 11.2.7 and 11.2.8),
Maxilla Mandible showing an amount of 0.94 mm distalization rate per
Band upper first molars, bond month. This was accompanied by slight intrusion (1.35
4s and 7s. mm), buccal displacement (2.61 mm) and mean distal tip-
Sectional leveling 4–7 (5 is ping for both sides (5 degrees). Distalization of the max-
typically not bonded; was illary left molar was 5.72 mm with intrusion (1.53 mm)
bonded on the right in this and buccal displacement (1.88 mm). All maxillary teeth
case) with 0.012, 0.014, showed significant distalization amounts. The inclination of
0.016-inch Niti archwires the maxillary incisors decreased by 5 degrees, reducing the
(Fig. 11.2.3) overjet. There were some vertical changes observed on the
Sliding mechanics on 0.016 incisors in reference to the occlusal plane, which increased
SS wires (as described) the overbite. The increase in the maxillary intercanine dis-
Continue until overcorrection tance was significant by 3.47 mm, while the increase in the
of distalization is achieved maxillary intermolar distance was significant by 4.49 mm.
(see Fig. 11.2.3) The nasolabial angle was decreased by 4 degrees according
Adjust vertical component to soft-tissue cephalometric measurements (see Fig. 11.2.7).
of the miniplate to achieve Molar distal movement was achieved without active
some posterior intrusion patient compliance and with no undesirable side effects,
Bond the rest of maxillary Bond mandibular such as incisor proclination, clockwise mandibular rotation
teeth and align with round teeth and align with or root resorption.
Niti archwires Niti archwires
Continue leveling with 0.016 Continue leveling with Conclusions
× 0.016 and 0.016 × 0.016 × 0.016 and
Skeletal anchorage protocol is a very efficient treatment option
0.022–inch Niti wires 0.016 × 0.022–inch
for upper molar distalization with no side effects, such as
Niti wires
Continue to full size archwires Continue to full size
anchorage loss and excessive protrusion of the anterior seg-
and finish archwires and finish
ment. This modifiable loop system gives the operator the flex-
Debond and place fixed Debond and place
ibility to adapt the components according to the patient and
lingual retainer, Essix fixed lingual retainer,
adjust the force vector according to planned treatment objec-
Essix
tives, such as some posterior intrusion in addition to distaliza-
6-month recall appointment 6-month recall
tion. Moreover, it offers the patient a treatment option without
for retention check appointment for
tooth extractions.
retention check
176 PA RT V Zygomatic Implants

• Fig. 11.2.3 Distalization sequence with segmental mechanics.

 CHAPTER 11 Zygomatic Miniplate-Supported Molar Distalization 177

• Fig. 11.2.4 Superimposition of maxillary arches before (green) and after (white) distalization.

• Fig. 11.2.5 Treatment progress postdistalization with placement of a continuous alignment wire in both
arches.
178 PA RT V Zygomatic Implants

• Fig. 11.2.6 Posttreatment extraoral/intraoral photographs and panoramic radiograph.

A B
• Fig. 11.2.7 (A) Posttreatment lateral cephalogram; (B) Superimposition. Black, Pretreatment; red,
posttreatment.
 CHAPTER 11 Zygomatic Miniplate-Supported Molar Distalization 179

References
1. Bondemark L, Karlsson I: Extraoral vs intraoral appliance for dis-
tal movement of maxillary first molars: a randomized controlled
trial, Angle Orthod 75:699–706, 2005.
2. Bussick TJ, McNamara Jr JA: Dentoalveolar and skeletal changes
associated with the pendulum appliance, Am J Orthod Dentofacial
Orthop 117:333–343, 2000.
5° 3. Chiu PP, McNamara Jr JA, Franchi L: A comparison of two intra-
5° oral molar distalization appliances: distal jet versus pendulum, Am
J Orthod Dentofacial Orthop 128:353–365, 2005.
4. Karlsson I, Bondemark L: Intraoral maxillary molar distalization,
Angle Orthod 76:923–929, 2006.
1.35 mm 5. Gelgör IE, Büyükyilmaz T, Karaman AI, Dolanmaz D, Kalayci
A: Intraosseous screw-supported upper molar distalization, Angle
5.61 mm Orthod 74:838–850, 2004.
6. Polat-Ozsoy O: The use of intraosseous screw for upper molar dis-
talization: a case report, Eur J Dent 2:115–121, 2008.
•Fig. 11.2.8 Schematic illustration of distalization results for the right 7. Nur M, Bayram M, Celikoglu M, Kilkis D, Pampu AA: Effects of
upper quadrant. maxillary molar distalization with Zygoma-Gear Appliance, Angle
Orthod 82:596–602, 2012.
8. Gianelly AA: Distal movement of the maxillary molars, Am J Or-
thod Dentofacial Orthop 114:66–72, 1998.
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 PART VI

Buccal TADs and

Extra-Alveolar TADs

12. Managing Complex Orthodontic Tooth Movement With C-Tube Miniplates

Seong-Hun Kim, Kyu-Rhim Chung and Gerald Nelson
13. Application of Buccal TADs for Distalization of Teeth
Toru Deguchi and Keiichiro Watanabe
14. Application of Extra-Alveolar Mini-Implants to Manage Various Complex Tooth Movements
Marcio Rodrigues de Almeida

181181
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12
Managing Complex Orthodontic Tooth
Movement With C-Tube Miniplates
SEONG-HUN KIM, KYU-RHIM CHUNG, GERALD NELSON
Introduction
The use of orthodontic anchorage devices expands the pos-
sible treatment plan options. Temporary Skeletal Anchorage
Devices (TSAD) have several advantages over more conven-
tional methods, especially the design of simpler mechanics.
We prefer the C-tube miniplates. Midline deviations require
careful and sometimes complex biomechanical planning.1,2
A coincident midline is an important component of den-
tal harmony, esthetics, and functional occlusion.3 If there
is a skeletal component to the midline deviation, treatment
planning becomes more complicated.4,5 When the choice
is to do camouflage treatment for the facial asymmetry
patient, good management of the dental midline is essential
to a good esthetic outcome.6
Good biomechanical design for midline correction starts
with a specific tooth movement goal. The best force sys-
tems provide efficient tooth movement with minimal side
effects. A variety of treatment options has been reported for
correcting dental midline discrepancy: asymmetric extrac-
tion, asymmetric mechanics, Class III elastics on one side
and Class II elastics on the other, anterior diagonal elastics,
or complex wire bending.7–10 The following two cases illus-
trate novel and simpler mechanics, using the C-tube as the
anchorage device to correct a midline deviation.
Methods
In the mandibular arch, we used a C-tube miniplate (Jin
Biomed co., Bucheon, Korea), manufactured from titanium
grade II. This miniplate is smaller than other skeletal anchor-
age plates. The head part can receive a round or rectangular
archwire, or be adapted as an elastic hook. The short I-type
C-tube has a two-hole mounting base to accept screws and a
preformed tube to accept an archwire. It is very useful in the
posterior buccal area of the mandible or in the retromolar
pad. In the cases described here, the I-type C-tube was a
practical device to place on the facial surface of the sym-
physis to apply forces for buccal segment distalization and
control of the vertical position of the lower incisors.
The I-shape design facilitates placement under local anes-
thesia. For example, the procedure for the facial placement is
to retract the lip and make a vertical incision parallel to the
tooth axis in the interdental space (Fig. 12.1A–C). Then the
periosteum is elevated to allow direct contact between the
bone and the mounting plate of the C-tube (Fig. 12.1D).
Next, the C-tube miniplate is fixed with two monocorti-
cal mini-implants, first through the distal hole (1.5-mm
diameter, 4-mm length). A correct position will bring the
tube of the miniplate through the tissue at the mucogingival
junction (Fig. 12.1E and F). Successful fixation to the facial
bone of the symphysis may require bending and manipulat-
ing the mounting plate to adapt to the curves of the bone
surface. Retention of the plate is enhanced by such close
adaptation. The I-type design of the plate enables placement
that avoids teeth roots and the mandibular nerve. Because
the stalk of the head part is malleable, it can be positioned
to enable the best biomechanical advantage. It is neverthe-
less rigid enough to remain stable under force application.
The force application system described here will move
posterior teeth distally on a rectangular wire that emerges
from the miniplate tube. We term this design a C-tube
pushing mechanism (Figs. 12.2 and 12.3). The force is
developed via a compressed open coil spring, and the vector
is parallel to the occlusal plane. The long lever arm that is
inserted in the tube controls tipping very well.
Clinical Report
Case 1
A female patient, 25 years of age, presented with the chief
complaint of mandibular anterior crowding. The man-
dibular third molar on the right was severely horizontally
impacted. The molars and premolars mesial to the impac-
tion were tipped mesially, displacing the canine into a Class
III relationship with the upper canine. The mandibular
anterior teeth were severely crowded. Aligning them would
push all the lower incisors to the left, displacing the mid-
line. Treatment objectives were to align the lower incisors,
183
184 PA RT V I Buccal TADs and Extra-Alveolar TADs

A B C

D E F
• Fig. 12.1 Surgical progress of I-type C-tube miniplate. (A) Checking the estimated position of C-tube
before incision. (B) Making guide indentation with a dental explorer for more accurate placement. (C)
Vertical incision made by a #15 blade with free-end in alveolar mucosa and no crossover in the mucogin-
gival junction. (D) Full thickness of periosteal membrane was stripped with a periosteal elevator. (E) C-tube
positioning and fixation by two 1.5 × 4-mm mini-implants. (F) After stabilizing the C-tube, adjusting the
head according to the desired tooth movement with Weingart plier. (With permission from Jin Biomed co.)

upright and distalize the lower right buccal segment teeth
into Class I, and achieve a lower midline coincident with
the facial midline. Non-asymmetric extraction was avoided
in preference to finishing with a normal occlusion. Four first
premolars and the mandibular third molars were removed.
Applying I-type C-tube on the anterior mandible provided
vertical control of the mandibular incisors during retraction,
and anchorage to distalize the mandibular right buccal seg-
ment (Fig. 12.4). The pretreatment maxillary midline was
coincident with the facial midline, and the pushing mecha-
nism was aided by the C-tube fixed to the facial bone of the
symphysis. Mandibular incisor vertical control during space
closure was achieved by tying a steel ligature wire from the
C-tube head to the archwire (Fig. 12.5).
Case 2
A 30-year-old male patient visited the orthodontic depart-
ment with a chief complaint of edge-to-edge anterior occlu-
sion (Fig. 12.6). There was a lower midline deficiency to
the right combined with anterior and posterior crossbites.
The target approach was distal movement of the right side.
Push-type mechanics were used to the right side to move
the molars distally. An I-type C-tube miniplate was placed
on the buccal alveolar bone between the mandibular sec-
ond premolar and first molar (Fig. 12.7B–E). After gaining
adequate space to resolve the posterior crowding, traction
of anterior teeth started (Fig. 12.7F–I). The mandibular
occlusal view demonstrates a significant amount of distal
movement (Fig. 12.8). Posttreatment examination revealed
a Class I molar and canine relationship on both sides, with
good intercuspation. The midline was congruent with the
facial midline (Figs. 12.9 and 12.10).
Case 3
A female patient had a chief complaint of masticating prob-
lem on the left dentition. The patient had multiple problems
on the left side of the occlusion. The lower left first molar
was extracted a while back, and the lower first, second pre-
molars, and second molar were mesiolingually inclined with
extrusion. The maxillary left second premolar and first and
second molar had extrusion including a collapsed occlusion
with posterior deep bite and a crossbite. She also had ante-
rior crossbite (Fig. 12.11). The treatment objectives were to
correct the left collapsed occlusion while minimizing side
effect movements of the anterior and right teeth. To accom-
plish this treatment goal, a segment archwire technique
was applied (Fig. 12.12B). Fixed appliances were placed
on selective posterior teeth with segmental approaches to
control these independently. The C-tube miniplates were
applied as skeletal anchorage. Two I-type C-tube plates were
placed on the left maxilla buccolingually and one C-tube
was placed in the retromolar area (Fig. 12.13). Each was
A B

C D
• Fig. 12.2 C-tube assisted pushing method: prepare the anchorage against the C-tube to deliver push-
ing forces to the target teeth through open coil springs. (A) Placing C-tube on the mandibular buccal area
and bonding solely target tooth. (B) Holding the rectangular wire passing through the attachment head
hole and posterior bracket slot, first through the attachment head hole to easy placement of an open coil
spring and then onto the bracket slot. (C and D) The lateral and occlusal view of push-type mechanics.
(With permission from Jin Biomed co.)

A B

C D E
• Fig. 12.3 C-tube assisted push-type method for mesially tipped third molar uprighting. (A) 017X025-in
stainless steel segmented archwire between C-tube and single tube on the third molar for uprighting;
(B) open coil spring application for space regaining; (C) pretreatment x-ray; (D) uprighted third molar by
C-tube assisted pushing method; (E) posttreatment x-ray. (With permission from Jin Biomed co.)
186 PA RT V I Buccal TADs and Extra-Alveolar TADs

A B

C D
• Fig. 12.4 Clinical application of this novel method. (A–D) Intraoral photographs demonstrated C-tube
miniplate on the symphysis with achieved midline correction by pushing the right posterior teeth distally.
(With permission from Jin Biomed co.)

A B
• Fig. 12.5 Initial (A) and final (B) panoramic radiographs.

fixed with two drill-free mini-implants. After correction of
the scissors-bite, an edgewise multibracket appliance was
placed, and comprehensive orthodontic treatment was per-
formed in both arches (Fig. 12.12C). Finishing and detail-
ing of the occlusion were then performed to establish a solid
functional occlusion with ideal overbite and overjet while
providing prosthetic space for the lower left first molar. The
collapsed occlusion was corrected without any side effects
on other teeth (Figs. 12.12D and 12.14). The occlusion was
finished in Class II molar and Class I canine relationships
with optimal overjet and overbite. Prosthetic treatment was
continued to replace the lower left first molar (Fig. 12.15C).
Posttreatment records 12 years later showed a stable treat-
ment outcome. Serial panoramic radiographs showed that
collapsed occlusion was improved and maintained well until
12 years later after treatment (Fig. 12.16).
 CHAPTER 12 Managing Complex Orthodontic Tooth Movement With C-Tube Miniplates 187

• Fig. 12.6
A 30-year-old male patient. Intraoral views. Patient reveals mesially positioned posterior teeth
combined with deviation of midline that needs distalization and midline correction.

A B C

D E F

G H I
• Fig. 12.7 (A) Pretreatment. (B–F) I-type C-tube was placed on the buccal alveolar bone between the first
molar and second premolar. Push-type force delivery method started at the right posterior mandible initially
applied to the bonded target teeth and later continued to the whole arch. (G and H) Space developed after
pushing posterior teeth distally; retraction of anterior teeth was carried out by Class III elastics combined
with traction forces anchored by the C-tube miniplate. (I) Final intraoral lateral view demonstrates accept-
able occlusion. (With permission from Jin Biomed co.)
A B

C D
• Fig. 12.8 A 30-year-old male patient. (A) Initial occlusal view displays severe anterior crowding on the right
resulting in a dental Class III occlusion that requires unilateral distalization. (B) Intraoral view depicts that
just the target teeth were bonded. (C) Visually, it is clear to notice greater amount of distal movement of the
second molar. (D) Aligned anterior teeth was observed in the final intraoral photograph.

A B

• Fig. 12.9 A 30-year-old male patient. (A) Initial panoramic radiograph reveals dental Class III occlusion
that requires unilateral distalization. (B) Panoramic radiographs demonstrate that just the target teeth were
bonded. (C) Great amount of distal movement of the second molar is noticed.
 CHAPTER 12 Managing Complex Orthodontic Tooth Movement With C-Tube Miniplates 189

• Fig. 12.10 Intraoral photographs showing stable occlusion of a 30-year-old male patient after 3 years of
retention.

• Fig. 12.11 Pretreatment records; intraoral photographs and cephalometric, panoramic radiographs.

Discussion The advent of TSADs, such as the mini-implants, have

Treatment of dental asymmetry can be very difficult, as it
may require movement of the entire arch. Usually the first
step of our alternative option to treat patients with dental
asymmetry is to make space for the midline correction. It
starts with molar distalization on the nondeviated side. Var-
ious conventional methods have been developed as a tech-
nique for molar distalization. However, those methods are
accompanied by side effects, such as anterior movement of
the premolars and incisors.11–13
made it possible to move molars distally without forward
movement of the anterior teeth.14–16 Although use of
TSADs contributes to make an effective treatment plan,
there are important considerations. To distalize a buccal seg-
ment, TSADs should provide biologically optimum stabil-
ity, offer simple and comfortable hardware, and prevent side
effects to the other teeth in the arch.
The pushing mechanism in Cases 1 and 2 facilitate indi-
vidual molar distalization with simple mechanics using
the C-tube miniplate. Direct application of force from
190 PA RT V I Buccal TADs and Extra-Alveolar TADs

A B

C D
• Fig. 12.12 Treatment progress intraoral photos. (A) Pretreatment. (B) Preparation for target teeth move-
ment. Segmented archwires were applied on to target teeth. I-type C-tubes were used as skeletal anchor-
age on upper and lower buccal side and upper palatal side. Niti spring generates intrusive force on upper
premolars and molar. On the lower arch, Niti spring induce labioversion with intrusion of lower premolars.
(C) After target teeth movement, continuous archwire were applied. (D) Recovery of collapsed occlusion.
(With permission from Jin Biomed co.)

A B C D
• Fig. 12.13
Uprighting of mandibular second molar. (A and B) Installation of C-tube. (C and D) Elastomeric
material was used for intrusive buccal uprighting of second molar using a lingual button and C-tube head.
(With permission from Jin Biomed co.)
 • Fig. 12.14 Posttreatment records; intraoral photographs.

A B

C D
• Fig. 12.15Serial intraoral photographs. (A) Pretreatment. (B) After orthodontic treatment. (C) After restor-
ative treatment. (D) Twelve years of retention.
192 PA RT V I Buccal TADs and Extra-Alveolar TADs
A modified transpalatal arch,21 and cross-arch elastics,22
B each segment separately. The use of limited fixed orthodontic
C the control is limited. To correct the collapsed occlusion,
• Fig. 12.16 Serial panoramic radiographs. (A) Pretreatment. (B) After
orthodontic treatment. (C) Twelve years of retention.
the TSAD to the target tooth eliminates the possibility of
unwanted extraneous movement of other teeth.
A collapsed dental occlusion is a common problem that
is hard to treat for clinicians. A noted cause of the collapsed
occlusion is untreated missing teeth. Patients with missing
teeth tend to have altered tooth positions; typical signs can
include migration of adjacent teeth into the spaces, midline
deviation, loss of vertical dimension, and a multilevel occlu-
sal plane.17 Missing teeth and the tipping of adjacent teeth
lead to infraocclusion of dental components, extrusion of
opposing teeth, and distortion of the occlusal planes.
Another cause of collapsed occlusion is a crossbite or
a scissors-bite. Previous studies have reported that even if
there was no arch-length discrepancy in the posterior seg-
ments, the mandibular second molars can erupt lingually,
producing a buccal crossbite or a scissors-bite.18,19
The primary feature of posterior crossbite is that at least
one tooth in the maxillary arch is ectopically positioned
buccally or lingually with respect to the corresponding man-
dibular tooth or teeth.20
Although there have been some conventional methods
presented in the literature for correction of buccal pos-
terior crossbites in the permanent dentition, such as the
most of them have some unwanted movement on the
anchorage teeth.
Responsive movement of anchorage teeth is unavoidable
because of the principal of action and reaction in conven-
tional orthodontic treatment when using a continuous arch-
wire. If the conventional method is applied in a patient with
collapsed occlusion, the outcome is not an ideal symmet-
ric occlusion but a compromised occlusion, and iatrogenic
asymmetry of the dental arches. Therefore problem-oriented
segmental approaches are preferred to normalize a collapsed
occlusion instead of a continuous archwire technique in the
first treatment stage. A segment treatment strategy essen-
tially aims to resolve the vertical and tipping problems of
appliances in segmental techniques also provides the design
of simplified orthodontic biomechanics. This approach will
reduce adjustment time significantly and improve patient
satisfaction because of the increased comfort as a result of
limited fixed orthodontic appliances.
The development of skeletal anchorage systems has also
made it possible to move specific teeth without involving
other teeth. Skeletal anchorage reduces the side effects that
occur with dental anchorage and simplifies the orthodontic
appliances and the treatment biomechanics.23–25
Yun et al.20 reported application of the TSAD as an indi-
rect skeletal anchorage system to correct the scissors-bite
after bonding the fixed orthodontic appliances. Although
this method helps minimize unwanted tooth movement,
the clinician will prefer more stable anchorage for the con-
trol of several teeth in the segment. The success rates of
mini-implants devices varies from 75.2% to 93.6%, and the
stability can be affected when heavier forces are necessary.26
Orthodontic miniplates were introduced and applied as a
reliable alternative to orthodontic mini-implants.27,28
The C-tube miniplate in Case 3 provided solid skeletal
anchorage to control the badly tipped segment. The C-tube
miniplate can withstand heavier forces, with dependable
stability.
When designing the biomechanics, the C-tube miniplate
also has advantage over a simple mini-implants or other
rigid miniplates, since the neck and head can be manipu-
lated when clinician needs to adjust the amount or direction
of the force.29
 CHAPTER 12 Managing Complex Orthodontic Tooth Movement With C-Tube Miniplates
The body can be bent or adjusted to closely adapt to the
anatomic contour of the bone surface. The plate is securely
away from the roots and the attached gingiva, while the long
neck lets the tube portion exit the tissue through the attached
gingiva.
The anchoring screws that are used to stabilize the C-plate
rarely interfere with roots of the adjacent teeth. It is a cru-
cial property because the correction of collapsed occlusion
requires a large tooth movement to upright and intrude the
tipped teeth. Even though there is considerable orthodon-
tic tooth movement, there is no need for repositioning the
skeletal anchorage.
C-tube miniplates are perfectly efficient devices to use in
push-type force delivery systems to the teeth, all aiding in
the correction of midline deviation and in correcting a col-
lapsed occlusion without undesirable side effects, and there-
fore a shorter treatment period. This technique provided
maximum treatment efficiency and reduced cost with the
least amount of complex hardware.
Conclusion
The I-type C-tube miniplate provides reliable skeletal
anchorage to support a substantial pushing force to trans-
late an entire quadrant of the dentition. The biomechanical
system described provided the necessary tooth movement to
correct dental midline asymmetries efficiently and comfort-
ably with a desirable outcome.
References
1. Lewis PD: The deviated midline, Am J Orthod 70:601–616, 1976.
2. Van Steenbergen E, Nanda R: Biomechanics of orthodontic cor-
rection of dental asymmetries, Am J Orthod Dentofacial Orthop
107:618–624, 1995.
3. Gianelly AA, Paul IA: A procedure for midline correction, Am J
Orthod 58:264–267, 1970.
4. Beyer JW, Lindauer SJ: Evaluation of dental midline position,
Semin Orthod 4:146–152, 1998.
5. Cheng HC, Cheng PC: Factors affecting smile esthetics in adults
with different types of anterior overjet malocclusion, Korean J
Orthod 47:31–38, 2017.
6. Kai R, Umeki D, Sekiya T, Nakamura Y: Defining the location of
the dental midline is critical for oral esthetics in camouflage orth-
odontic treatment of facial asymmetry, Am J Orhtod Dentofacial
Orthop 150:1028–1038, 2016.
7. Bishara SE, Burkey PS, Kharouf JG: Dental and facial asymme-
tries: a review, Angle Orthod 64:89–98, 1994.
8. Nanda R, Margolis MJ: Treatment strategies for midline discrep-
ancies, Semin Orthod 2:84–89, 1996.
9. Tayer BH: The asymmetric extraction decision, Angle Orthod
62:291–297, 1992.
10. Rebellato J: Asymmetric extractions used in the treatment of
patients with asymmetries, Semin Orthod 4:180–188, 1998.
11. Carano A, Testa M: The distal jet for upper molar distalization, J
Clin Orthod 30:374–380, 1996.
12. Byloff FK, Darendeliler MA: Distal molar movement using the
pendulum appliance. Part 1: clinical and radiological evaluation,
Angle Orthod 67:249–260, 1997.
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13. Fuziy A, Rodrigues de Almeida R, Janson G, Angelieri F, Pinzan
A: Sagittal, vertical, and transverse changes consequent to max-
illary molar distalization with the pendulum appliance, Am J
Orthod Dentofacial Orthop 130:502–510, 2006.
14. Sugawara J, Daimaruya T, Umemori M, et al.: Distal movement
of mandibular molars in adult patients with the skeletal anchor-
age system, Am J Orthod Dentofacial Orthop 125:130–138, 2004.
15. Choi YJ, Lee JS, Cha JY, Park YC: Total distalization of the max-
illary arch in a patient with skeletal Class II malocclusion, Am J
Orthod Dentofacial Orthop 139:823–833, 2011.
16. Oh YH, Park HS, Kwon TG: Treatment effects of microimplant
aided sliding mechanics on distal retraction of posterior teeth, Am
J Orthod Dentofacial Orthop 139:470–481, 2011.
17. Chung KR, Kim SH: Correction of collapsed occlusion with
degenerative joint disease focused on the mandibular arch and
timely relocation of a miniplate, Am J Orthod Dentofacial Orthop
141:e53–e63, 2012.
18. Tollaro I, Defraia E, Marinelli A, Alarashi M: Tooth abrasion in
unilateral posterior crossbite in the deciduous dentition, Angle
Orthod 72:426–430, 2002.
19. Pinto AS, Buschang PH, Throckmorton GS, Chen P: Morpho-
logical and positional asymmetries of young children with func-
tional unilateral posterior crossbite, Am J Orthod Dentofacial
Orthop 120:513–520, 2001.
20. Yun SW, Lim WH, Chong DR, Chun YS: Scissors-bite correc-
tion on second molar with a dragon helix appliance, Am J Orthod
Dentofacial Orthop 132:842–847, 2007.
21. Gerhard K, Weiland FJ: Goal-oriented positioning of maxillary
second molars using the palatal intrusion technique, Am J Orthod
Dentofacial Orthop 110:466–468, 1996.
22. Menezes LM, Ritter DE, Locks A: Combining traditional tech-
nique to correct anterior open bite and posterior crossbite, Am J
Orthod Dentofacial Orthop 143:412–420, 2013.
23. Moon CH, Lee JS, Lee HS, Choi JH: Non-surgical treatment
and retention of open bite in adult patients with orthodontic
mini-implants, Korean J Orthod 39:402–419, 2009.
24. Kim MJ, Park SH, Kim HS, Mo SS, Sung SJ, Jang GW, et al.:
Effects of orthodontic mini-implant position in the dragon helix
appliance on tooth displacement and stress distribution: a three-
dimensional finite element analysis, Korean J Orthod 41:191–199,
2011.
25. Lee KJ, Park YC, Hwang WS, Seong EH: Uprighting mandibular
second molars with direct miniscrew anchorage, J Clin Orthod.
41:627–635, 2007.
26. Lee JH: Replacing a failed mini-implant with a miniplate to pre-
vent interruption during orthodontic treatment, Am J Orthod
Dentofacial Orthop 139:849–857, 2011.
27. Chen CH, Hsieh CH, Tseng YC, Huang IY, Shen YS, Chen CM:
The use of mini-plate osteosynthesis for skeletal anchorage, Plast
Reconstr Surg 120:232–237, 2007.
28. Sugawara J, Kanzaki R, Takahashi I, Nagasaka H, Nanda R: Dis-
tal movement of maxillary molars in nongrowing patients with
the skeletal anchorage system, Am J Orthod Dentofacial Orthop
129:723–733, 2006.
29. Ahn HW, Chung KR, Kang SM, Lin L, Nelson G, Kim SH:
Correction of dental Class III with posterior open bite by sim-
ple biomechanics using an anterior C-tube miniplate, Korean J
Orthod 42:270–278, 2012.
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13
Application of Buccal TADs for
Distalization of Teeth
TORU DEGUCHI, KEIICHIRO WATANABE
Temporary anchorage devices (TADs) have been widely
used as one of the most sufficient anchorage devices in
orthodontic field in the last decade. TADs could be used
to control anchorage in all anteroposterior (A-P), vertical,
and transverse dimensions. In this chapter we would like to
provide some information with regard to the effectiveness of
TADs in controlling the anchorage in A-P dimension dur-
ing distalization of entire arch in nonextraction cases.
Methods of Distalizing Molars
Distalizing molars is one of the required tooth movement
in correction of Class II or III molar relationship, and gain-
ing space to eliminate crowding. Especially, when the case
is treated with nonextraction with crowding, distalization
of molars is critical. Conventional methods to distalize
molars are using plate type appliances,1 spring incorporated
appliances,2,3 distal jet,4 intermaxillary elastics, and slid-
ing jigs.5,6 However, if the second molars are present and
already erupted, it is extremely difficult to achieve enough
distalization of the molars. Many Class II mechanics require
patient cooperation and result in reciprocal force to other
teeth, resulting in unwanted tooth movement.
Distalizing Molars by TADs
Recently, the use of dental implant,7 mini-implants,8 and
miniplates9 as orthodontic anchorages has been proven to
be effective in clinical orthodontics. Since there is no loss of
anchorage without patient cooperation with the use of mini-
implants and miniplates these have been used in correction
of Class II or III and distalizing the entire arch. Several types
of temporary anchorage devices (TADs), such as buccal
mini-implants,10 palatal mini-implants,11 and miniplates,12
have been introduced to distalize the teeth. Advantage of
buccal TADs compared to palatal TADs is that they do not
require additional complex laboratory work or appliance and
are easy to place. According to the location where the palatal
TADs are placed, you should be careful to avoid damaging
nerve, blood vessel, and sinus perforation. Miniplates are
also useful and might resist more orthodontic force, par-
ticularly, in the mandible distalization. However, miniplates
require more extensive surgery than buccal TADs and result
in higher cause of inflammation. On the other hand, dis-
advantage of buccal TADs is possible root damage or root
proximity that results in less stability.13–15 Especially dur-
ing distalizing the arch, since buccal TADs are frequently
placed at the premolar or molar area, neighboring teeth
sometimes would be close to the TADs. Thus ideally, buccal
TADs should be as small as possible to avoid root damage
and proximity during treatment.16
Biomechanics in Distalizing Molars With
Buccal TADs
Biomechanical consideration would be less complicated
compared to conventional biomechanics without using
TADs. The most ideal suggested location for TADs is
between the second premolar and the first molar,17 attach-
ing a retraction hook distal or mesial of the canine and
using a power chain or closed coil from the TADs to the
hook (Fig. 13.1A). However, in some cases according to
various factors, such as the morphology of the root, type
of alveolar bone (quality and quantity), difference in the
occlusal force, etc., additional mechanics are required to
efficiently distalize the entire arch with en masse movement.
One simple way is to add an open coil between the molars
and first distalize the second molar and continue the dis-
talization of the other teeth (see Fig. 13.1A). We also use
the Tweed mechanics18 to distalize the second molar by
helical bulbous loop, with open coil between the molars,
and counteract the reciprocal force by using TADs instead
of J-hook head gear (Fig. 13.1B). In addition, crimpable
stop is required distal of the first or the second premolar to
keep the loop active (see Fig. 13.1B). If the patient is coop-
erative, you could add the Class II elastic to reinforce the
anchorage. One of the problems in distalizing molars is the
extrusion from the topping movement. With having TADs,
vertical control is also possible by ligating the TADs to the
195
196 PA RT V I Buccal TADs and Extra-Alveolar TADs
A B
• Fig. 13.1Schema of various methods in distalizing the arch. Distalization by direct anchorage from the
TADs and with the assist from the open coil (A). Distalization similar to Tweed mechanics (B). Distalization
with retracting canine and incisors with loops and with addition of the vertical control in the incisors (C).
molar, while distalizing molars (or premolars according to
the teeth that need to be controlled) (see Fig. 13.1B). If slid-
ing mechanics rather than en masse retraction are required,
a retraction force could be directly applied to the canine
with a closing loop activated by the TADs and simultane-
ously retract the canine and the anteriors (see Fig. 13.1C).
In addition, placing TADs in the anterior results in better
control during the incisor retraction.
Factors that should be considered during distalization
(also anterior retraction) are the position of the TADs, the
location, and the length of the retraction hook. During the
distalization by TADs, generally, alignment and leveling
have been already accomplished, and require bodily move-
ment of the anterior teeth, without extrusion of the poste-
rior teeth. This bodily movement of the entire arch, without
extrusion, is achieved only when the retraction force from
the TADs to the hook passes near or above the center of
the resistance (CR).19,20 Since the CR for six anterior teeth
is known to locate near distal of the canine and about 7
mm above the alveolar bone,21 it is almost impossible to
apply the force above the CR. To apply the retraction force
as close as possible to the CR, TADs must be placed further
above, near the border of attached and removal gingiva.19
However, in most cases, there is limited area of attached gin-
giva, which makes it difficult to place the TADs near CR.
Retraction hooks also need to be as long as possible for the
retraction force to be near the CR.19,20
Treatment Outcome of Distalization
by TADs
There have been several studies that have compared the
treatment outcomes of the conventional and TAD methods
in the past.22–24 Treatment outcome in distalization in Class
II cases have also been reported.10 With the use of TADs,
C
distalization of approximately 2.8 mm to 4.8 degrees of
tipping with 0.6 mm of intrusion was observed. This indi-
cates that Class II end-on molars would be corrected into
Class I molar relationship by simple distalization of molars
(these cases were only distalized, without any additional
appliances). By incorporating the “Tweed” mechanics, we
believe that more distalization, of up to 5.0 mm, is pos-
sible so that full Class II will be corrected into Class I molar
relationship.
Recently, palatal TADs have become of major interest
among the TAD users in the field of orthodontics.25 Palatal
TADs could also be an effective way to distalize molars, since
large lingual roots of the molars could be easily moved. Past
studies indicate that 4.0 mm of distalization of the molars
are possible with the use of palatal TADs.26 However, as
mentioned earlier, palatal TADs require complicated design
and device. Miniplates have also been known to effectively
distalize the molars.27 Average of 4.0 mm of distalization of
molars, without any side effect, was reported; however, it
requires mucoperiosteal incision and flap during placement
and removal, and considerable pain and discomfort dur-
ing the procedure, with higher medical cost. For patients,
we believe that ideal orthodontic treatment should provide
a sufficient treatment effect with the use of a simple and
straightforward device.
Stability of Distalization by TADs
There have been only few studies that reported the stability
of cases treated by using TADs.23,28 Most of the studies have
shown that there is no statistically significant difference in the
stability between the conventional method and cases treated
with TADs. However, since the amount of tooth movement
is significantly more than the conventional method in distal-
ization, there may be a tendency for the TAD-treated cases
to be less stable. In the case of openbite, there was a marginal
 CHAPTER 13
CASE 1
Pre treatment
Age: 12 yrs 10 mo
A C
• Fig. 13.2 Pretreatment facial and intraoral photographs (A), and panoramic (B) and cephalometric (C)
radiographs in Case 1.
tendency for the TAD-treated case to relapse more than the
conventional method.23 In addition, there was a difference in
the pattern of the relapse, namely that TAD-treated openbite
cases had a tendency for the mandibular molar to extrude,
which resulted in significant relapse. From our recent study
that evaluated the stability of the distalization of molars,
after 2 to 3 years of retention, there was approximately 0.8
mm (20%) of relapse in anterior-posterior direction, 0.5
mm (49%) in vertical direction, and 0.6 degrees (118%) of
tipping relapse. In the case of distalization, the amount of
retromolar area is another important factor for the stability.
We found out that less than 18 mm of retromolar area in
pretreatment or less than 15 mm in posttreatment resulted in
significant relapse of the molars (unpublished data).
Case 1. Distalization of Maxillary Molars in
Skeletal II, Angle Class II Case
Diagnosis
A 12-year 10-month-old female had a chief complaint of
protruded upper teeth. She had a convex profile, with lip
incompetent and strain at the mentalis (Fig. 13.2A). From
the intraoral photo, her angle classification was Class II
molar and canine relationship with increased overjet and
overbite. There was also deep curve of spee in the mandible
and a spaced maxillary arch.
Panoramic radiograph showed all permanent teeth (Fig.
13.2B). Cephalometric analysis resulted in Skeletal 2 with
ANB (Point A-Nasion-Point B) of 10 degrees, short man-
dible, and increased axial inclination of mandibular incisors
(Fig. 13.2C; Table 13.1).
Application of Buccal TADs for Distalization of Teeth 197
Treatment Plan
Nonextraction with 0.022 slot edgewise bracket was
planned with the use of TADs between the maxillary sec-
ond premolar and the first molar for the absolute anchorage.
We planned to distalize approximately 3.0 mm of poste-
rior molars with TADs. Increased overjet and overbite were
planned to be corrected by flattening the curve of spee and
intrusion of the maxillary incisors.
Treatment Progress
After 6 months in treatment, leveling and alignment was
mostly achieved, and TADs were placed between the second
premolar and first molar. Immediate loading with 50 rm of
force was performed to distalize the molars (Fig. 13.3A).
During the distalization, the right TAD became loose, and
was replaced between the molars (Fig. 13.3B). After 13
months of treatment, molar relationship was almost Class I;
however, we continued to distalize to correct the Class II
canine (Fig. 13.3C). After removal of the edgewise appli-
ance, a wrap-around retainer was delivered in both maxilla
and in the mandible. Total active orthodontic treatment
time was 19 months.
Treatment Results
On the posttreatment facial photos (Fig. 13.4A), improve-
ment of profile was observed but slight convexity remained.
Strain in mentalis and lip incompetent were improved.
Improvement of occlusion with Class I molar and canine
relationship and ideal overjet and overbite were achieved
from the intraoral photos. However, there was slightly less
intercuspation at the right canine area.
198 PA RT V I Buccal TADs and Extra-Alveolar TADs

TABLE
13.1
  Cephalometric Analysis of Case 1

After 2 yrs
Measurement Norm S. D. Pretreatment Posttreatment Retention
Hard Tissue
SNA (degrees) 82.0 3.5 86.1 83.1 83.6
SNB (degrees) 80.9 3.4 75.7 74.5 75.0
SN - MP (degrees) 32.9 5.2 33.8 35.1 34.4
FMA (MP-FH) (degrees) 23.9 4.5 29.6 31.8 30.4
ANB (degrees) 1.6 1.5 10.4 8.6 8.6
U1 - NA (mm) 4.3 2.7 2.5 –0.8 –1.0
U1 - SN (degrees) 102.8 5.5 102.6 93.2 95.4
L1 - NB (mm) 4.0 1.8 9.9 9.4 8.8
L1 - MP (degrees) 95.0 7.0 103.0 107.3 105.0
Overbite (mm) 2.5 2.0 6.0 1.2 1.6
Overjet (mm) 2.5 2.5 6.5 1.6 2.1
Soft Tissue
Lower Lip to E-Plane (mm) −2.0 2.0 4.1 2.9 3.6
Upper Lip to E-Plane (mm) −6.0 2.0 2.1 0.7 0.2

ANB, Point A-Nasion-Point B; FMA, Frankfort mandibular plane angle; SNA, Sella-Nasion-Point A; SNB, Sella-Nasion-Point B.

C
• Fig. 13.3 Progress intraoral photographs. Six months after the initiation of the orthodontic treatment (A).
Maxillary right TAD was replaced from mesial of the first molar to mesial of the second molar (arrow in B).
Thirteen months after the initiation of the orthodontic treatment (C).
 CHAPTER 13 Application of Buccal TADs for Distalization of Teeth 199

CASE 1
Post treatment
Age:14 yrs 09 mo

A C
• Fig. 13.4
Posttreatment facial and intraoral photographs (A), and panoramic (B) and cephalometric (C)
radiographs in Case 1.

CASE 1
after 2 yrs retention
Age: 16 yrs 09 mo

A B
• Fig. 13.5Postretention (2 years) treatment facial and intraoral photographs (A), and cephalometric (B)
radiograph in Case 1.

From the panoramic radiograph (Fig. 13.4B), proper
root parallelism is shown. Cephalometric analysis resulted in
decreased ANB, but increased axial inclination of mandibular
incisors and an increase in the mandibular plane angle were
observed (Fig. 13.4C; see Table 13.1).
Retention
After 2 years in retention, settling of the occlusion was
observed that resulted in improvement of right canine occlu-
sion (Fig. 13.5A). Also there was a significant improvement
in her profile. Cephalometric analysis resulted in decreased
axial inclination of the mandibular incisors that resulted
in slight increase of overjet (Fig. 13.5B; see Table 13.1).
Soft tissue analysis, such as upper lip to S-line, lower lip to
E-line, and nasolabial angle also improved during the reten-
tion phase.
Superimposition
Overall superimposition showed a clockwise rotation of the
mandible and some improvement in the profile (Fig. 13.6A).
200 PA RT V I Buccal TADs and Extra-Alveolar TADs

A C
• Fig. 13.6Superimposition of the overall (A), maxilla (B), and mandible (C) of pretreatment (black), post-
treatment (red), and 2 years postretention (blue) in Case 1.

CASE 2
Pre treatment
Age: 21 yrs 08 mo

A C
• Fig. 13.7 Pretreatment facial and intraoral photographs (A), and panoramic (B) and cephalometric (C)
radiographs in Case 2.

Reginal tracing showed in the maxilla, approximately 2.5

mm of distalization of molars with no vertical change and
approximately 7 degrees of retraction and 2.0 mm of intru-
sion was observed (Fig. 13.6B). In the mandible, approxi-
mately 3.0 mm of mesial movement and slight extrusion
(that resulted in clockwise rotation of the mandible), as well
as some labial flaring and 3.0 mm of intrusion of incisors,
were observed (Fig. 13.6C).
Case 2: Distalization of Mandibular Molars
in Skeletal III, Angle Class III Case
Diagnosis
A male patient of 21 years and 8 months had chief com-
plaint of anterior crossbite. He had a concave profile, with
increased anterior facial height, with slight asymmetry of
the mandible (Fig. 13.7A). Intraoral photograph showed
 CHAPTER 13 Application of Buccal TADs for Distalization of Teeth 201

TABLE
13.2
  Cephalometric Analysis of Case 2

After 2 yrs
Measurement Norm S. D. Pretreatment Posttreatment Retention
Hard Tissue
SNA (degrees) 82.0 3.5 84.9 85.1 84.7
SNB (degrees) 80.9 3.4 85.9 86.2 86.0
SN - MP (degrees) 32.9 5.2 35.0 34.7 33.9
FMA (MP-FH) (degrees) 26.9 4.5 28.1 28.0 27.5
ANB (degrees) 1.6 1.5 −1.0 −1.1 −1.3
U1 - NA (mm) 4.3 2.7 6.6 9.3 8.4
U1 - SN (degrees) 102.1 5.5 115.9 120.2 120.5
L1 - NB (mm) 4.0 1.8 7.2 4.9 4.5
L1 - MP (degrees) 95.0 7.0 78.9 76.8 75.1
Overbite (mm) 2.3 2.0 0.1 1.8 1.1
Overjet (mm) 3.2 2.5 –2.4 2.9 2.0
Soft Tissue
Lower Lip to E-Plane (mm) 2.0 2.0 4.6 1.7 1.2
Upper Lip to E-Plane (mm) −1.0 2.0 0.2 −0.7 0.1

ANB, Point A-Nasion-Point B; FMA, Frankfort mandibular plane angle; SNA, Sella-Nasion-Point A; SNB, Sella-Nasion-Point B.

Class III molar and right canine and Class I canine relation-
ship on the left (full Class III molar) with anterior crossbite.
The mandible was shifted 2.5 mm to the left. He had oral
hygiene problem, which was addressed at the beginning of
the orthodontic treatment.
From panoramic radiograph (Fig. 13.7B), mandibu-
lar left third molar was missing. Cephalometric analysis
resulted in Skeletal III with ANB of −1.0 degrees, increased
anterior facial height, increased axial inclination of max-
illary incisors, and protruded mandibular incisors (Fig.
13.7C; Table 13.2).
Treatment Plan
Nonextraction with 0.018 slot edgewise bracket was
planned with the use of TADs, between the mandibular sec-
ond premolar and the first molar for the absolute anchor-
age. Class I molar and canine and ideal overjet and overbite
were planned to be corrected by retracting the entire man-
dibular arch.
Treatment Progress
Before initiating active treatment, mandibular right third
molar was extracted. After 3 months in treatment, TADs
were placed between the mandibular second premolar and
first molar. We first ligated the canine and the TADs to lace
back until leveling and alignment of the mandibular arch
were achieved. (Fig. 13.8A). After 10 months of leveling,
we started to retract the mandibular by closed coil from the
TADs to the hook attached to the distal of the canine (Fig.
13.8B). We used a long hook so that the retraction force
would be close to the CR. After 21 months, we replaced
the TAD on the right side, since we needed further retrac-
tion (Fig. 13.8C). After removal of the edgewise appliance,
a wraparound retainer was delivered in both maxilla and
in the mandible, and also bonded retainer was used in the
mandible. Total active orthodontic treatment time was 33
months.
Treatment Results
On the posttreatment facial photos (Fig. 13.9A),
improvement of anterior facial height and lower lip was
observed but still had a concave profile. From the intra-
oral photographs, Class I canine was achieved, but the
molar was finished in Class III (super-Class I) relation-
ship. Crossbite was corrected and ideal overjet and over-
bite were achieved. However, because of patient’s poor
oral hygiene maintenance, white spots in the incisors and
gingival recession were observed in canine and premolar
region.
From the panoramic radiograph (Fig. 13.9B), proper
root paralleling was achieved, but some external root resorp-
tion was observed at the maxillary incisors. Cephalometric
analysis resulted in a slight decrease in ANB by the late
growth of the mandible and increased axial inclination of
maxillary incisors (Fig. 13.9C; see Table 13.2).
202 PA RT V I Buccal TADs and Extra-Alveolar TADs

• Fig. 13.8Progress intraoral photographs. Three (A), 10 (B), and 21 (C) months after the initiation of
the orthodontic treatment. After 10 months, TAD on the right side was replaced for further retraction
(arrow in B).

CASE 2
Post treatment
Age: 23 yrs 05 mo

A C
• Fig. 13.9
Posttreatment facial and intraoral photographs (A), and panoramic (B) and cephalometric (C)
radiographs in Case 2.

Retention
After 2 years in retention (Fig. 13.10A), there was no sig-
nificant change in his profile. Oral photographs showed
stable occlusion, but a slightly decreased overjet was
observed at the right maxillary lateral incisor. There was
also no significant change from the panoramic radiograph
(Fig. 13.10B) and cephalometric analysis (Fig. 13.10C; see
Table 13.2).
Superimposition
Overall superimposition (Fig. 13.11A) showed a 2.0 to 3.0
mm of horizontal growth of the mandible. Maxillary super-
imposition resulted in 1.5 to 2.0 mm of mesial movement
and some buccal flaring of the incisors (Fig. 13.11B). Man-
dibular tracing resulted in 2.0 to 3.0 mm distal movement
and tip back of molars without any extrusion, and bodily
incisors retraction of 3.0 mm was observed (Fig. 13.11C).
 CHAPTER 13 Application of Buccal TADs for Distalization of Teeth 203

CASE 2
AFTER 2 Yrs retention
Age:25 yrs 05 m0

A C
• Fig. 13.10
Postretention (2 years) treatment facial and intraoral photographs (A), and panoramic (B) and
cephalometric (C) radiograph in Case 2.

A C
• Fig. 13.11Superimposition of the overall (A), maxilla (B), and mandible (C) of pretreatment (black), post-
treatment (red), and 2 years postretention (blue) in Case 2.

Case 3: Distalization of Maxillary and
Mandibular Molars in Skeletal II, Angle
Class II Bimaxillary Case
Diagnosis
A female patient of 21 years and 7 months had chief com-
plaint of protrusion and crowding. She had a convex profile
(Fig. 13.12A). Intraoral photograph showed Class I molar
and canine relationship with scissors-bite on maxillary and
mandibular left second molar.
Panoramic radiograph (Fig. 13.12B) showed short root
on the mandibular incisors, and the maxillary right central
had history of trauma with root canal treatment. Cepha-
lometric analysis resulted in Skeletal II with ANB of 4.2
degrees, increased mandibular plane angle, and increased
axial inclination of mandibular incisors (Fig. 13.12C;
Table 13.3).
204 PA RT V I Buccal TADs and Extra-Alveolar TADs

CASE 3
Pre treatment
Age: 21yrs 7 mo

A C
• Fig. 13.12
Pretreatment facial and intraoral photographs (A), and panoramic (B) and cephalometric (C)
radiographs in Case 3.

TABLE
13.3
  Cephalometric Analysis of Case 3

Measurement Norm S. D. Pretreatment Posttreatment After 3 yrs Retention

Hard Tissue
SNA (degrees) 82.0 3.5 78.2 78.0 77.5

SNB (degrees) 80.9 3.4 74.0 73.7 73.5

SN - MP (degrees) 32.9 5.2 45.1 41.4 38.0

FMA (MP-FH) (degrees) 27.9 4.5 36.5 37.4 34.8

ANB (degrees) 1.6 1.5 4.2 4.3 4.0

U1 - NA (mm) 4.3 2.7 9.1 4.6 5.8

U1 - SN (degrees) 101.8 5.5 110.5 98.5 99.3

L1 - NB (mm) 4.0 1.8 12.5 9.4 10.4

L1 - MP (degrees) 95.0 7.0 102.3 100.4 101.6

Overbite (mm) 2.3 2.0 0.5 1.5 1.7

Overjet (mm) 3.2 2.5 3.9 1.8 2.2

Soft Tissue
Lower Lip to E-Plane (mm) −2.0 2.0 4.0 2.6 2.5
Upper Lip to E-Plane (mm) −1.8 2.5 0.5 −1.5 −2.5

ANB, Point A-Nasion-Point B; FMA, Frankfort mandibular plane angle; SNA, Sella-Nasion-Point A; SNB, Sella-Nasion-Point B.
 CHAPTER 13 Application of Buccal TADs for Distalization of Teeth 205

B
• Fig. 13.13 Progress intraoral photographs. Two (A) and 5 (C) months after the initiation of the orthodontic
treatment.

CASE 3
Posttreatment
Age:24 yrs 4 mo

A C
• Fig. 13.14
Posttreatment facial and intraoral photographs (A), and panoramic (B) and cephalometric (C)
radiographs in Case 3.

Treatment Plan
Extraction of maxillary right third molar, left second molar,
and mandibular right and left third molar was decided, and
0.018 slot edgewise bracket was planned with the use of
TADs, between the mandibular second premolar and the
first molar, and between maxillary first and second molar,
for the absolute anchorage. Class I molar and canine and
ideal overjet and overbite were planned to be corrected by
retracting both maxillary and mandibular arch.
Treatment Progress
After 2 months in treatment, TADs were placed between
the mandibular second premolar and first molar. We first
ligated the mandibular left first molar, to prevent lingual
tipping during aligning the mandibular left second molar
(Fig. 13.13A). Five month later, TADs were placed between
maxillary first and second molar and started retracting the
entire arch (Fig. 13.13B). After removal of the edgewise
appliance, a wraparound retainer was delivered for the max-
illa, and bonded retainer was used in the mandible. Total
active orthodontic treatment time was 33 months.
Treatment Results
On the posttreatment facial photos (Fig. 13.14A), straight
profile was achieved. From the intraoral photographs, Class
I canine and molar relationship was achieved. Scissors-bite
was corrected and ideal overjet and overbite were achieved.
From the panoramic radiograph (Fig. 13.14B), proper
root paralleling was achieved, but some external root
206 PA RT V I Buccal TADs and Extra-Alveolar TADs

resorption was observed at the maxillary incisors. Cepha-
lometric analysis resulted in a slight increase in ANB by
clockwise rotation of the mandible, and decreased axial
inclination of maxillary and mandibular incisors was
observed (Fig. 13.14C; see Table 13.3).
Retention
After 3 years in retention (Fig. 13.15A), there was no sig-
nificant change in the client's profile. Intraoral photographs
showed stable occlusion, without any significant change.
There was also no significant change from the panoramic
(Fig. 13.15B) or cephalometric analysis (Fig. 13.15C; see
Table 13.3).
Superimposition
Overall superimposition (Fig. 13.16A) showed a clockwise
rotation of the mandible, and retraction of the upper and
lower lips was observed. Maxillary superimposition resulted

CASE 3
After 3 yrs retention
Age: 27 yrs 4 mo

A C
• Fig. 13.15
Postretention (3 years) treatment facial and intraoral photographs (A), and panoramic (B) and
cephalometric (C) radiograph in Case 3.

A
C
• Fig. 13.16Superimposition of the overall (A), maxilla (B), and mandible (C) of pretreatment (black), post-
treatment (red), and 3 years postretention (blue) in Case 3.
 CHAPTER 13
in approximately 4.5 mm of distalization of molars, and 5.0
mm retraction of the incisors (Fig. 13.16B). Mandibular
tracing resulted in approximately 3.0 mm of distalization
and tip back of molars, and 3.0 mm of incisor retraction was
observed (Fig. 13.16C).
Acknowledgement
We thank Dr. Hiroshi Kamioka of Okayama University and Dr. Eiji
Tanaka of Tokushima University for the advice and assistance. The
authors dedicate this chapter to celebrate of the life of Dr. Shingo
Kuroda—excellent clinician, scholar, and friend.
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14
Application of Extra-Alveolar
Mini-Implants to Manage Various
Complex Tooth Movements
MARCIO RODRIGUES DE ALMEIDA

Introduction towards the molars. It is a palpable bony protuberance

Mini-implants or mini-implants are absolute anchorage sys-
tems that are highly useful in orthodontic clinics. Although
they are frequently fixed at sites in the alveolar process,
between the roots of contiguous teeth, new extra-alveolar
(E-A) sites have been suggested by Chang,1 Park,2 Almeida,3
and others. These authors recommended sites in the infra-
zygomatic crest (IZC) and the buccal shelf (BS) regions for
many orthodontic therapies that require an efficient and
secure anchorage system (Fig. 14.1).
Anatomically, the IZC, or infrazygomatic crest, is a
reinforced bone area, with greater thickening of the corti-
cal layer, which extends along the maxilla from the zygoma
that is located anteriorly to the maxillary tuberosity. Sev-
eral authors4–7 recognize that the IZC is an appropriate
site for mini-implant placement and can be used to pro-
vide anchorage in cases of canine retraction, and en masse
retraction of the anterior teeth (of the whole upper den-
toalveolar process), and intrusion of the posterior teeth, as
we will see later (Fig. 14.2).
The buccal shelf region corresponds to the bone plateau
that lies between the buccal face of the lower molars and the
mandibular external oblique line. This plateau widens, as it
approaches the second and third molar. According to Chang
et al.8 and Almeida,9 the ideal area for the positioning of a
mini-implant is between the first and second lower molars

A B
• Fig. 14.1
(A and B) Extra-alveolar sites, such as infrazygomatic crest and buccal shelf, are nowadays very
common areas for absolute anchorage, to provide whole maxilla and mandibular dentoalveolar retraction.

209
210 PA RT V I Buccal TADs and Extra-Alveolar TADs
because of the thickness of the cortical bone and the reason-
able amount of attached gingiva (which decreases toward
the distal teeth). These considerations are valid for the place-
ment of mini-implants both at an angle and perpendicularly
to the bone, that is, almost parallel to the long axis of the
molars (Fig. 14.3).
• Fig. 14.2 Anatomic localization of an infrazygomatic crest (IZC) area:
upper arrow showing zygomatic process, middle arrow showing the
medial part of IZC, and lower arrow showing the inferior portion of the IZC.
• Fig. 14.3 Buccal shelf area (red area), with the ideal site for the posi-
tioning of a mini-implant between the first and second lower molars.
A B
• Fig. 14.4 (A and B) Individual canine retraction with infrazygomatic crest screw to provide room for the
anterior teeth in patient treated without extractions.
Indications
Unlike intraalveolar mini-implants, E-A mini-implants
placed in the infrazygomatic and BS regions have a precise
indication, as described later. E-A screws are widely used
in en masse distalization of the teeth of the upper and
lower arches. This is because they allow greater anchorage,
immediately after placement (primary stability), when
introduced into maxillary and mandibular reinforced
bone areas.
IZC mini-implants are recommended in cases of en-
masse anterior teeth retraction, en masse retraction of the
dentoalveolar arch of the maxilla, intrusion of the posterior
teeth, individual canine, premolar and molar retraction in
patients with biprotrusion, distalization of canines and pre-
molars to obtain anterior space (Fig. 14.4), and in case of
patients requiring correction of the midline with en masse
distalization of the teeth (Fig. 14.5).
Other indications for the use of mini-implants in IZC
are: anchorage for retraction of an anterior dental block in
cases of superior extraction, correction of asymmetries of
the occlusal plane, anchorage for the use of a cantilever in
traction of impacted canines, early treatment of Class III,
and for Class III orthognathic surgical planning.
The indications for the use of mini-implants placed in
the BS region are similar to those for mini-implants in IZC;
that is, they can be used in Class III conservative treatment
(camouflage), as well as for retraction and/or distalization of
molars, in treatment of cases with excessive crowding of the
lower teeth, mesialization of molars, anchorage for retrac-
tion of the anterior block, in cases of inferior extraction,
intrusion of posterior teeth, corrections of asymmetries of
the occlusal plane, deviations from the midline, anchor-
age for the use of a cantilever in traction of impacted lower
canines, and in preparation for orthognathic surgery.
Cases of bimaxillary protrusion can be treated using mini-
implants placed in the BS and IZC, as seen in Fig. 14.6.
A comprehensive study on the subject was conducted
by the author9 in his book Extra-Alveolar mini-implants
in Orthodontics. This book emphasizes the biomechanical
 CHAPTER 14 Application of Extra-Alveolar Mini-Implants to Manage Various Complex Tooth Movements 211

principles and clinical applications of this recent and effec-
tive method of anchorage.
Characteristics of Mini-Implants
The mini-implants placed in the IZC and BS regions are
made of a titanium alloy (Ti-6 AI-4 V) or stainless steel
(SS), since neither of these promote osseointegration and
can be easily removed when necessary.
Nevertheless, there is a certain controversy over the
use of one or the other type. While some authors, such
as Park et al.10 recommend the use of titanium alloys,
Chang et al.7,8 recommend the use of surgical stainless steel
because of its greater modulus of elasticity, providing resis-
tance to fracture.
Currently, several mini-implants with different shapes,
diameters, lengths, and surface treatments are commer-
cially available. Whether made of steel or titanium, they
may have self-tapping or self-drilling properties. Self-
tapping screws require initial milling (perforation of the
mucosa and cortical bone using a spear tip or clinical
probe), because they have a rounded apex and no cut-
ting capacity. Self-drilling screws, in turn, do not require
prior drilling, since these screws are extremely thin and
sharp, creating their own path inside the bone during
placement, and facilitating simple placement. The thread
length of the screws may vary from 4 to 12 mm, and
the diameter may vary from 1.2 to 2 mm. Interradicular
mini-implants are usually smaller and of reduced cali-
ber, because of the possibility of injuring adjacent noble
structures, such as the roots of the teeth. Conversely,
E-A mini-implants are larger, both in length (10, 12, 14,
17 mm) and diameter (1.5–2 mm). Placement torque is
influenced by the diameter of the mini-implants; that is,
the larger the diameter, the greater the torque required
for placement, and consequently, the greater the pri-
mary stability. Primary stability refers to the mechani-
cal stability that mini-implants show, shortly after their
apposition. It is a prerequisite for healing, and one of the
most important characteristics of temporary anchorage
devices. It depends on various factors, such as the mor-
phology of the mini-implants, number of threads, length,
shape of the active thread, diameter, thickness, and den-
sity of the cortical bone, as well as the placement tech-
nique. Lemieux et al.11 reported that mini-implants with
longer lengths allow excellent anchorage. However, they
are associated with an increased risk of damage to neigh-
boring structures, especially maxillary sinus perforation.
The depth of fit and bone density at the mini-implants
placement site are the best predictors of primary stabil-
ity. Chen et al.12 state that using an 8-mm instead of a
6-mm mini-implants increases the success rate from 72%
to 90%. Other authors also reported a higher success rate
with the use of longer mini-implants.
The resistance to torsional fracture of the mini-
implants is directly related to their diameter, as already
mentioned; that is, the larger the diameter, the greater the
fracture torque. Thus it seems to be advantageous to use
mini-implants with a larger diameter and longer length,
such as the steel mini-implants described by Chang,7 in
E-A sites.
• Fig. 14.6
Extra-alveolar mini-implants used as for the retraction of the
whole dentition to correct a bimaxillary protrusion.

A B
• Fig. 14.5 (A and B) Unilateral Class II malocclusion treated with the infrazygomatic crest screw
installed in the right side, where the case requires correction of the midline and also the molar
relationship.
212 PA RT V I Buccal TADs and Extra-Alveolar TADs
Since, in a clinical context, the E-A mini-implants are
placed in a site with high bone density (cortical bone), ini-
tial perforation with a spear-tip or clinical probe is indicated
in certain cases, even when using self-drilling orthodontic
steel mini-implants. The aim of this procedure is to mini-
mize the risk of fracture during placement.
Motoyoshi et al.13 reported that one of the ways to
increase the primary stability of mini-implants in adoles-
cents is to drill a small hole, a pilot hole, into the cortical
bone before implant placement. Although there is a world-
wide trend toward the use of surgical steel mini-implants
for E-A placement, Almeida9 has successfully used a Bra-
zilian kit (Morelli, Sorocaba, SP, Brazil), which is made of
titanium. It should be noted that the placement technique
differs according to whether the mini-implants are made of
SS or titanium, as we will see later.
The basic kit used by Almeida9 (Fig. 14.7), consisting of
a hand-driver, long blade, and spear-tip, is the preferred kit
because it contains all the material necessary for the place-
ment of E-A mini-implants. Mini-implants have different
lengths and diameters. Our suggestion is to use a longer
A B
C
• Fig. 14.7 (A to C) Basic kit used by the author consisting of a hand-driver, a long blade, and a punch.
mini-implant, 10 mm in length, 1.5/2.0 mm in diameter,
and with a 2-mm collar (transmucosal profile9).
Despite having a small head and a round hole that pre-
vents the correct activation of an inserted cantilever, rub-
ber bands and springs made of nickel–titanium alloy can be
placed simultaneously in the head of the screw, as shown in
Fig. 14.8.
The Peclab screw kit developed by Almeida9 is another
option available in the Brazilian market (Peclab, Belo Hori-
zonte, MG, Brazil). It is also made of titanium, with dimen-
sions of 2 × 12 mm or 14 mm; it has a rectangular hole
that allows correct adaptation and activation of a cantilever
in situations of impacted canine traction. With a diameter
of 2 mm and good placement torque, this mini-implants
has been considered as a substitute for steel because of the
encouraging results obtained with its use (Fig. 14.9).
However, using SS mini-implants, in sites where bone
density is typically high, may be useful. In this situation, a
higher placement torque will occur, and thus a steel screw,
as mentioned previously, having greater resistance to frac-
ture, would be ideal.
 CHAPTER 14 Application of Extra-Alveolar Mini-Implants to Manage Various Complex Tooth Movements
In these cases, Chang et al.14 advocated the use of a steel
mini-implant of 12 mm in length and 2 mm in diameter,
with specific characteristics and the appropriate design for
placement in IZC and BS areas.
Placement Technique
The mini-implant placement techniques in question
(IZC and BS) depend on the material out of which the
implants are made (steel or titanium), to increase the suc-
cess rate (stability). In this regard, Chang and Roberts15
highlighted three key factors: (1) bone quality, (2) mini-
implants design, and (3) placement technique, which are
interrelated.
• Fig. 14.8 Despite having a small head and a round hole that pre-
vents the correct activation of an inserted cantilever, rubber bands and
springs made of nickel–titanium alloy can be placed simultaneously in
the head of the screw.
• Fig. 14.9 The Peclab screw developed by Almeida9 is another option
available in the Brazilian market (Peclab, Belo Horizonte, MG, Brazil). It is
made of titanium, with dimensions of 2 × 12 or 14 mm; it has a rectangu-
lar hole that allows correct adaptation and activation of a cantilever, in sit-
uations of impacted canine traction. With a diameter of 2 mm and good
placement torque, this mini-implants has been considered as a substitute
for steel, because of the encouraging results obtained with its use.
213
Placement in the Infrazygomatic Crest
The principles of biosafety must be strictly observed before
the placement of the mini-implants. The angle of place-
ment of the mini-implant in the IZC is fundamental. Park
et al.10 evaluated the angle between the axis of the mini-
implants and the cortical bone. They concluded that plac-
ing it almost parallel to the long root axis of the molars
increases its contact surface with the cortical bone, guar-
anteeing greater stability. A more upright position of the
mini-implant reduces the chance of reaching the root. Hsu
et al.16 suggested the following steps for secure placement
in the IZC:
1. Anesthetize the surgical area.
2. Initially, place the tip of the mini-implants at a 90-degree
angle to the bone surface at the region of the IZC, after
piercing the cortical bone at the mucogingival junction,
using an endodontic explorer.
3. Penetrate the tip 1 mm into the cortical bone, at the
height of the buccal roots, between the first and second
upper molars in adults and in the region between the
second premolar and the first molar in young people,
since the zygomatic–maxillary crest in these individuals
is located more anteriorly, as can be determined by local
palpation.
4. Then, turn the hand wrench between 60 and 70 degrees
to the occlusal plane, while rotating it clockwise, thread-
ing the mini-implants, as shown in Fig. 14.10.
5. The patient’s age, bone morphology, and the type of bio-
mechanics to be performed should be considered. In the
sagittal plane, that is, in the anteroposterior direction,
position the head of the mini-implants, with a slight
incline to the mesial direction. Fig. 14.11 demonstrates
a correctly placed mini-implant for mesialization of the
upper teeth.
Placement in the Buccal Shelf
Careful evaluation of the BS area should be performed
before the placement of a mini-implants; the amount of
bone present and the extent of gingiva, through which the
mini-implants needs to be inserted, should be considered.
Nucera et al.17 and Elshebiny et al.18 described a point
located buccal to the distal root of the second lower molar,
between 4 and 8 mm from the cementoenamel junction,
as the best anatomic location for fixation. It is necessary to
emphasize, however, that this area shows significant mor-
phologic variation, and that some patients may have a well-
demarcated bone plateau, while others do not, and have a
bone profile that is practically straight. This difference can
be clinically diagnosed by palpation or by cone-beam com-
puted tomography (CBCT).
One point to consider is the topography of the man-
dibular canal through which the inferior alveolar nerve
travels. Because of its more lingual position relative to
the apex of the roots of the lower molars, the chance of
214 PA RT V I Buccal TADs and Extra-Alveolar TADs
A B
C
• Fig. 14.10 (A to C) Steps for secure placement of mini-implants in the infrazygomatic crest area.
• Fig. 14.11Position of the head of the mini-implants with a slight incli-
nation to the mesial direction to provide mesialization of the maxillary
teeth.
reaching such a canal is remote, even with 2 × 12 mm
mini-implants.
For patients with a well-defined plateau and well-
attached gingiva, placement of the mini-implant is much
simpler; a sizeable BS allows the positioning of the mini-
implants in a nearly vertical position, almost parallel to
the root of the lower molars. The placement becomes more
difficult if the BS area is less favorable to placement, as the
mini-implants should be placed at a higher angle and in a
free mucosal site.
Authors have argued for the use of the mini-implants in
the BS, both in the attached gingiva and in free gingiva,14
depending, in the latter case, on more careful hygiene, to
avoid possible inflammation and periimplant mucositis,
with consequent anchorage instability.
It should be emphasized that the attached gingiva range
is larger in the region of the first lower molar, and decreases
to the distal ends of the dental arch. Although the lower
second molar region has more pronounced bone density,
it is necessary to assess the best positioning of the mini-
implants adequately, considering not only the bone density,
but also other factors that will ensure greater stability to the
mini-implant.
Placement Technique
As previously seen, the placement technique depends
not only on the material from which the mini-implants
are made but also on their design and the patient’s bone
structure.
 CHAPTER 14 Application of Extra-Alveolar Mini-Implants to Manage Various Complex Tooth Movements
• Fig. 14.12 Modification of the installation of the buccal shelf screw. In
some situations, depending on the biomechanics, the mini-implants
is inclined to the mesial plane to provide a mesialization of whole
dentition.
Placement in the Buccal Shelf Region
The placement technique follows the same procedures men-
tioned for the mini-implants placed in the IZC; that is, after
following the principles of biosafety, it is necessary to per-
form local anesthesia and drill the cortical bone. Then the
mini-implant is placed at the desired angle (70 degrees) rela-
tive to the occlusal plane.
In some situations, depending on the biomechanics, the
mini-implants is inclined to the mesial plane, as shown in
Fig. 14.12.
Magnitude of the Force Applied
The magnitude of the mechanical force with which E-A
mini-implants are placed is an important factor for the
success of the therapy because it influences the stability of
the anchorage, as many authors have pointed out.9,14,16,19
The recommended weight for orthodontic mechanics using
mini-implants, in the region of the IZC, ranges from 220
to 340-g (8 to 12 oz) and from 340 to 450-g, when mini-
implants are used in the BS area.
Benefits
Contemporary orthodontics has used E-A mini-implants,
located in areas far from the insertion points of the roots of
the teeth, to extend the limits of this treatment, in view of
the benefits of this approach, such as:
1. Reduced risk of traumatizing roots.
2. Larger amount of cortical bone at the points of place-
ment, which allows the use of more flexible mini-
implants (2 mm).
3. Lack of interference with the mesiodistal movement of
the teeth.
4. Adequate anchorage for the retraction of the dental arch
as a whole, reducing protrusion.
215
5. Low percentage of failure.
6. Use of fewer mini-implants in complex cases.
Precautions
1. Preferably place the mini-implants in the attached gingiva.
2. Respect general principles of biosafety.
3. Maintain strict hygiene at the site of implantation, espe-
cially in cases where the mini-implants are placed, in the
area of transition, from attached gingiva towards mov-
able mucosa.
4. Maintain the correct angle when placing the mini-
implant, to avoid injuring the roots, in both the upper
and lower teeth.
5. When the implanted region is that of the zygomatic–
alveolar crest, avoid the possibility of reaching the maxil-
lary sinus (although this seems not to be a problem).
6. In cases of distalization of lower second molars, use pan-
oramic x-ray or CBCT to verify that there is sufficient
space for this movement.
7. In young people, mini-implants are placed more anteriorly
(in the region of the first molar, IZC 6) and higher (vertical),
to prevent the possibility of lesioning the root of the tooth.
Often the positioning is done in the free gingiva (mobile
mucosa), taking the above-mentioned precautions.
8. Clinically, in cases of doubt, preevaluate the placement
of the mini-implant, both in the IZC region and the BS
region, using CBCT.
The clinical case presented subsequently is that of a patient
with Class III malocclusion, anterior openbite, and crowd-
ing of the incisors, which was treated by extracting the lower
third molars and by bilateral placement of mini-implants in
the BS region, between the first and second lower molars, as
for the retraction of whole mandibular dentition (Fig. 14.13).
Final Considerations
Given that the technique for placing mini-implants in the
IZC and BS regions involves surgery, the practitioner respon-
sible for this maneuver must thoroughly investigate all the
risk factors of this process to ensure the safety of the patient.
Although this absolute anchorage is efficient, it involves
risk to nearby anatomic structures, especially the maxil-
lary sinus and inferior alveolar nerve. Recent studies20
have shown that the success rate of long mini-implants
placed in the IZC is 96.7%, with 78.3% of them pen-
etrating the maxillary sinus. However, the authors draw
attention to the fact that it is recommended that this
penetration does not exceed 1 mm. Similarly, Elshebiny
et al.18 has indicated that the most favorable site for the
correct positioning of the mini-implant in the BS area,
to avoid trauma to the alveolar trigeminal branch, is the
site corresponding to the distobuccal portion of the lower
second molar.
216 PA RT V I Buccal TADs and Extra-Alveolar TADs

A B C

D E F

G
• Fig. 14.13 (A to H) Male patient of 16 years of age, Class III malocclusion, concave profile, anterior
openbite, and crowding in both arches. (I to K): The resolution of the malocclusion occurs with a buccal
shelf mechanics to distalize the whole dentition backward. A power-chain was hooked to the titanium-
molybdenium alloy (TMA) 0.017 × 0.025-inch mandibular arch with a long hook and 350-g of force each
side. The duration of the distalization of mandibular arch was 7 months. Total treatment time was 17
months. (L to S): At the completion of the case, we can see a good intercuspation of posterior teeth and
also a good facial profile.
 CHAPTER 14 Application of Extra-Alveolar Mini-Implants to Manage Various Complex Tooth Movements 217

H I

J K

L M N
• Fig. 14.13 cont’d
218 PA RT V I Buccal TADs and Extra-Alveolar TADs

O P

Q R

S
• Fig. 14.13 cont’d

References
1. Cheng SJ, Tseng IY, Lee JJ, Kok SH: A prospective study of the
risk factors associated with failure of mini implants used for orth-
odontic anchorage, Int J Oral Maxillofac Implants 19(1):100–
106, 2004.
2. Park HS, Lee SK, Kwon OW: Group distal movement of teeth
using microscrew implant anchorage, Angle Orthod 75(4):602–
609, 2005.
3. Almeida MR, Almeida PR, Chang C: Biomecânica do trata-
mento compensatório da má-oclusão de Classe III utilizando
ancoragem esquelética extra-alveolar, Rev Clín Ortod Dental Press
15(2):74–76, 2016.
4. Almeida MR, Almeida PR, Nanda R: Biomecânica dos mini-
implantes inseridos na região de crista infrazigomática para
correção de má-oclusão de Classe II subdivisão, Rev Clin Ortod
Dental Press 15(6):90–105, 2017.
 CHAPTER 14 Application of Extra-Alveolar Mini-Implants to Manage Various Complex Tooth Movements
5. Almeida MR: Biomecânica de distalização dentoalveolar com
mini-implantes extra-alveolares em paciente Classe I com bipro-
trusão, Rev Clin Ortod Dental Press 16(6):61–76, 2017.
6. Costa A, Raffainl M, Melsen B: Mini-screws as orthodontic
anchorage: a preliminary report, Int J Adult Orthodon Orthognath
Surg 13(3):201–209, 1998.
7. Chang CH: Clinical applications of orthodontic bone screw in
Beethoven orthodontic center, Int J Orthod Implantol 23:50–51,
2011.
8. Chang C, Huang C, Roberts E: 3D cortical bone anatomy of the
mandibular buccal shelf: a CBCT study to define sites for extra-
alveolar bone screws to treat Class III malocclusion, Int J Orthod
Implantol 41(1):74–82, 2016.
9. Almeida MR: Mini-implantes extra-alveolares em Orrtodontia, ed 1,
Maringá, 2018, Dental Press.
10. Park HS, Jeong SH, Kwon OW: Factors affecting the clinical
success of screw implants used as orthodontic anchorage, Am J
Orthod Dentofacial Orthop 130(1):18–25, 2006.
11. Lemieux G, et al.: Computed tomographic characterization of
mini-implant placement pattern and maximum anchorage force
in human cadavers, Am J Orthod Dentofacial Orthop 140(3):356–
365, 2011.
12. Chen CH, Chang CS, Hsieh CH, Tseng YC, Shen YS, Huang
IY, et al.: The use of microimplants in orthodontic anchorage, J
Oral Maxillofac Surg 64(8):1209–1213, 2006.
13. Motoyoshi M, Matsuoka M, Shimizu N: Application of orth-
odontic mini-implants in adolescents, Int J Oral Maxillofac Surg
36(8):695–699, 2007.
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14. Chang C, Liu SS, Roberts WE: Primary failure rate for 1680
extra-alveolar mandibular buccal shelf mini-screws placed in
movable mucosa or attached gingiva, Angle Orthod 85(6):905–
910, 2015.
15. Chang CH, Roberts WE: A retrospective study of the extra-alve-
olar screw placement on buccal shelves, Int J Orthod Implantol
32:80–89, 2013.
16. Hsu E, Lin JSY, Yeh HY, Chang C, Robert E: Comparison of the
failure rate for infra-zygomatic bone screws placed in movable
mucosa or attached gingiva, Int J Orthod Implantol 47(1):96–
106, 2017.
17. Nucera R, Lo Giudice A, Bellocchio AM, Spinuzza P, Caprioglio
A, Perillo L, et al.: Bone and cortical bone thickness of mandibu-
lar buccal shelf for mini-screw insertion in adults, Angle Orthod
87(5):745–751, 2017.
18. Elshebiny T, Palomo JM, Baumgaertel S: Anatomic assessment
of the mandibular buccal shelf for mini-screw and insertion in
white patients, Am J Orthod Dentofacial Orthop 153:505–511,
2018.
19. Hsieh YD, Su CM, Yang YH, Fu E, Chen HL, Kung S: Evalu-
ation on the movement of endosseous titanium implants under
continuous orthodontic forces: an experimental study in the dog,
Clin Oral Implants Res 19(6):618–623, 2008.
20. Jiay, Chen X, Huang X: Influence of orthodontic mini-implant
penetration of the maxillary sinus in the infrazygomatic crest
region, Am J Orthod Dentofacial Orthop 153(5):656–661, 2018.
This page intentionally left blank

     
 PART VII

Management of
Multidisciplinary and Complex
Problems
15. Management of Skeletal Openbites With TADs
Flavio Uribe and Ravindra Nanda
16. Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion
Eric JW. Liou
17. Management of Multidisciplinary Patients With TADs
Flavio Uribe and Ravindra Nanda
18. Second Molar Protraction and Third Molar Uprighting
Un-bong Baik
19. Class II Nonextraction Treatment With MGBM System and Dual Distal System
B. Giuliano Maino, Giovanna Maino, Luca Lombardo, John Bednar and Giuseppe Siciliani
20. Anchorage of TADs Using Aligner Orthodontics Treatment for Lower Molars Distalization
Kenji Ojima, Junji Sugawara and Ravindra Nanda

221221
This page intentionally left blank

     
15
Management of Skeletal Openbites
With TADs
FLAVIO URIBE, RAVINDRA NANDA
A
nterior openbite is perhaps the type of malocclusion in
which the use of temporary anchorage devices (TADs)
has been advocated more frequently. The great suc-
cess outcomes reported in the early years of this new century
drew clinicians to consider the application of TADs for the
correction of skeletal openbite malocclusions, where tradi-
tionally, surgery had been the only option. These remarkable
results showed for the first time that predictable molar intru-
sion was attainable. Before TADs, molar intrusion had been
described as relatively difficult to achieve or limited at best.
The approaches for molar intrusion to control the vertical
dimension before the advent of skeletal anchorage relied on
appliances that prevented the eruption of posterior teeth dur-
ing growth. Some of these appliances were bite plates,1,2 mag-
nets,3 chin cups,4,5 high pull headgears,6 and combination of
these appliances.7 Although positive effects were observed in
the correction of the anterior openbite, these were primar-
ily dentoalveolar, consisting in the eruption of the incisors as
main driver of the positive occlusal change.5
Prior to the TADs era, the adult patient with a skeletal
openbite requiring intrusion of the posterior teeth to control
the vertical dimension had to resort to orthognathic surgery.
The Multiloop Edgewise Archwire (MEAW) technique was
one of the first techniques that was proposed as a nonsurgi-
cal method to correct skeletal openbites.8 Unfortunately, the
true effects of this appliance primarily effected the incisors
with extrusion, instead of the expected molar intrusion.9
Later, the use of skeletal anchorage through miniplates on all
quadrants was published and the significant results evoked
the attention of orthodontic clinicians.10,11 Mini-implants
were later introduced to achieve buccal segment intrusion
with a simplified insertion protocol12 and thus allowed the
orthodontist the placement of these temporary anchorage
devices, instead of relying on a surgeon.
More than 20 years have transpired since the advent of
skeletal anchorage, and many different approaches have been
advocated for the correction of the anterior openbite maloc-
clusion and control of the vertical dimension. The primary
target of these appliances has been the maxillary molars.13 Two
basic systems have been described to achieve molar intrusion:
mini-implants and miniplates. Although miniplates have
been reported to have slightly better success rates compared to
mini-implants,14 these have limited locations for placement.
Specifically, for the control of the vertical dimension, mini-
plates are placed in the infrazygomatic (IZ) crest in the maxilla
and in the buccal crest of the corpus of the mandible. On the
other hand, mini-implants can be placed in the same sites,
and also include interradicular and palatal anatomic locations
to deliver the desired intrusive force system to the molars.
Mini-implants are certainly more popular than miniplates
because of the ease of placement, ease of replacement, no
need for elevating a flap during placement and removal, and
overall reduced costs. Furthermore, as described earlier, more
locations are available for placement of mini-implants. Since
many anatomic locations are available, which one is the best
suited when molar intrusion is required to reduce the lower
facial height and correct an anterior openbite malocclusion?
Certainly, the answer to this question lies in the clinician’s
preference, but perhaps more important, the biomechanical
considerations are key to determine the best mini-implants
location and thus the most effective force system to be applied.
Biomechanics of Molar Intrusion in
Skeletal Openbites
It is common knowledge in orthodontics that we are typi-
cally unable to apply a force at the center of resistance of
a tooth. This is the case when we are describing force sys-
tems that are applied in anteroposterior direction along the
arch. On the other hand, when the force system, such as an
intrusive force, is applied from a sagittal point of view, it
is possible to apply this force through the estimated center
of resistance of a tooth or a group of teeth, at least when
analyzed from a sagittal plane. However, when this applied
force is analyzed from a frontal plane, this force generates a
moment, since it is not through the center of resistance. If
we consider maxillary first and second molars to be intruded
bilaterally, it is clear, from a sagittal plane perspective, that
a force applied at the bracket level of the first and second
223
224 PA RT V I I Management of Multidisciplinary and Complex Problems

A B C

D E F
• Fig. 15.1 Buccal rolling of posterior segments with intrusion from infrazygomatic (IZ) mini-implants. (A–C)
Intraoral photos of an anterior openbite, where the occlusal planes diverge anteriorly from the first premo-
lars. (D–F) Buccal force from the IZ mini-implants created a premature contact of the molar cusps of the
molars, preventing openbite closure. A buccal crossbite tendency also developed.

A B
• Fig. 15.2 Control of the molars in a buccolingual direction. (A) Two palatal mini-implants and two extension
arms, fabricated from a framework, were placed to deliver an intrusive and lingual force vector to the maxillary
molars. (B) Molar lingual cusps have intruded with these mechanics, allowing for anterior openbite reduction.

molar would be very close to the estimated center of resis-
tance of these four teeth, and thus would intrude without
expressing a rotational moment in this plane. On the other
hand, when this force is analyzed from the frontal plane, the
intrusive force at the level of the molar tubes would generate
a moment on these teeth that will tend to erupt the palatal
cusps, preventing the correction of the openbite (Fig. 15.1).
To counteract this rotational moment, two options are
available. The first one is the application of the same force
magnitude in the same anteroposterior location, but from
the palatal side (Fig. 15.2). The other alternative is the
placement of a transpalatal arch, which requires to be placed
away from the palatal vault, to allow space for the apical dis-
placement of the transpalatal bar, as the molars are intruded.
To deliver this described intrusive force to the first and
second molars, the IZ crest area provides the best location.
Typically, the crest is located slightly mesial to the second
molar, therefore a slight mesial component of the force is
expected if the force is delivered only to the second molars.
An alternative is to place an interradicular mini-implant
between the first and second molar, if enough space is avail-
able between these two teeth for placement. If the force is to
be delivered from the palatal side only, the mini-implant can
be also placed mesial to the palatal root of the second molar.
This location has the advantage of increased space for place-
ment of the mini-implant. In addition, the clinician must
be aware that the palatal foramen is in the vicinity of the
second molar in some individuals,15 and therefore caution
is required when placing a mini-implant in this location.
An advantage of delivering a force from the lingual side of
the molars is that the palatal cusp can be controlled easier
with this point of force application. Furthermore, if palatal
constriction is evident, a palatal expansion screw could be
placed to expand, as needed, to control the lingual tip ten-
dencies, with the intrusive forces.
The anatomy of the openbite is an important consider-
ation when intrusion of the buccal segment is desired in
patients with skeletal openbites. If the occlusal plane of
the maxillary and mandibular arches diverge from the first/
second molars anteriorly, the application of a force vector
 CHAPTER 15 Management of Skeletal Openbites With TADs 225

B C D

F G H
• Fig. 15.3 Palatal molar intrusion on an openbite, with anteriorly diverging occlusal planes from the pre-
molars. Lateral cephalogram (A) and intraoral photographs (B–D) depicting moderate to severe anterior
openbite, with occlusal contacts on the molars and second premolars. (E) Two palatal mini-implants were
placed between the first and second molars. A palatal expansion screw with occlusal rests on the second
molars was cemented on the first molars to control the transverse dimension. (F–H) Reduction of the ante-
rior openbite, after maxillary molar intrusion and placement of continuous arches.
226 PA RT V I I Management of Multidisciplinary and Complex Problems
I J
L
Fig. 15.3, cont’d (I–K) Final occlusal result. (L) Although molar intrusion was achieved, significant extrusion
of the incisors is noticed on the maxillary superimposition.
• Fig. 15.4 Horizontal vector with intrusive force from infrazygomatic
(IZ) mini-implant. As molars are intruded from an IZ mini-implant, the
force vector can become more horizontal than vertical, resulting in less
molar intrusion and more buccal expansion on the maxillary arch.
to these two teeth bilaterally is advantageous, as a wedge
effect is expected with the intrusion of these terminal teeth
in the arch. However, when the occlusal planes diverge
anteriorly from the first premolar, the biomechanics of this
correction is more complex. In this scenario, a single labial
or lingual vertical force applied to the second/first molar
region would tend to rotate the posterior segment in a
clockwise direction along the sagittal plane, with the intru-
sion of the first and second molars, creating a posterior
openbite in this location, while the premolars remain in
contact. A way to prevent this from happening is through
a force applied to the second molar and another separate
force applied to the second or first premolar (from the IZ
region). This force system can control better the rotation
of the segment from a sagittal perspective; however, a net
force vector with a distal direction is generated, which may
K
be advantageous in a Class II malocclusion, but not in a
Class III malocclusion. Furthermore, since the premolars
typically do not receive a transpalatal arch, a stiff full arch-
wire needs to be placed to counteract the labial rotational
moment on these teeth.
The same problem can be observed if the vertical force
is applied from the palate at the level of the second molar.
The patient in Fig. 15.3 presented with a significant anterior
openbite that diverged anteriorly from the second premo-
lars. Two Lomas mini-implants (Mondeal Medical Systems,
Donau, Germany) were placed in the palate between the
first and second molars. A palatal arch with an expan-
sion screw was delivered to the maxilla to counteract the
moment of the intrusive force to the molars. In addition, an
occlusal rest was added to the second maxillary molars to aid
with the intrusion of these teeth as the force was applied to a
hook in the appliance between the two molars. Molar intru-
sion and anterior openbite closure were obtained until the
first premolars and the canine started to contact occlusally.
At this point, more intrusion was not possible and extru-
sion of the incisors had to be effected. Although closure of
the openbite was achieved, the maxillary superimposition
shows that the molar intrusion was approximately 1 to 2
mm. Nonetheless, despite these molar intrusion, majority
of the correction was achieved by eruption of the maxillary
central incisors.
Another problem may be also encountered when intrud-
ing maxillary molars from IZ mini-implants. As intrusion is
obtained, the vector of the force becomes more horizontal
and thus less effective. This is more obvious if the attach-
ment head of the mini-implant is placed somewhat labial
 CHAPTER 15
A B
D E
• Fig. 15.5Distalization from infrazygomatic (IZ) mini-implants. (A–C) Distalization force vector from IZ mini-
implants to correct the Class II buccal occlusion. (D–F) Reduction of overjet and improvement of the
anterior openbite observed.
from the buccal surface of the molars as shown in Fig.
15.4. The solution to this problem is to place the IZ mini-
implants in more apical position; however, there is anatomic
limitations in doing so, and often a better force vector may
be obtained from the palatal side.
There is, however, one advantage to the IZ mini-implant
for molar intrusion. If a distalization force vector is desired
in conjunction with the maxillary intrusion, it is much
easier to deliver this force from the labial aspect than from
the lingual aspect. Fig. 15.5 shows the same patient in Fig.
15.1, where the occlusion is Class II on the canine, requir-
ing distalization. A labial power arm is placed on the arch-
wire distal of the canine to achieve this distal movement of
the buccal segment.
Case Report One
To account for all these potential pitfalls with buccal seg-
ment intrusion in patients with occlusal planes diverging
anteriorly from the premolars, we have designed an appli-
ance that provides versatility in the application of the
required force vectors. The appliance is fabricated from two
1.8 × 8-mm IMTEC Ortho mini-implants (3M Unitek,
Ardmore, Okla) placed at the level of the second premolars
and first molars, from which four extension arms project
with hooks that allow the delivery of specific targeted forces
depending on the biomechanical needs. A 13-year-old male
patient, displayed in Fig. 15.6, shows a significant convex
profile, with an openbite that diverges anteriorly from the
first premolars. The incisor display at rest was adequate, so
intrusion of the maxillary buccal segment was required to
correct the openbite while maintaining the incisor position
vertically. Because of the significant amount of crowding,
Management of Skeletal Openbites With TADs 227
C
F
the first premolars were also extracted. Intrusive forces were
delivered to the molars from the four extension arms in the
palate. The versality of this appliance relies on the possibil-
ity to intrude both the molars and/or premolars, as needed,
with a vertical force vector. In addition, anteroposterior
forces for mesialization or distalization of the buccal seg-
ments may be delivered unilaterally or bilaterally.
During the intrusion process of the molars, the palatal
forces being delivered generate a moment to rotate the teeth
buccolingually, which can create a crossbite. To account for
this, two options are available. The first one is to place a full
engagement base, stainless steel archwire, on the labial aspect
(0.021 × 0.025-inch stainless steel), with slight expansion.
The second option involves the placement of a palatal arch
or palatal expander appliance, which was the option used in
the following case.
A palatal expander screw is designed with bands in the
first molars. The expansion screw needs to rest approxi-
mately 5 mm from the palatal vault to allow displacement
of the molars in a superior direction. The appliance can also
incorporate wire extensions to the occlusal surface of the
second molars, to intrude these teeth in synchrony with
the first molars, without having to bond them. In the same
manner, extension arms projecting anteriorly are extended
along the lingual surfaces of premolars and an occlusal stop
is also added to the first premolars. Although a bondable
metal mesh base pad could be added to the second premo-
lars to be able to intrude the whole buccal segment without
labial appliances, the bonding of this tooth to the appli-
ance is problematic and often fails. In this instance, a labial
full arch may be engaged to the buccal segments, bypassing
the anterior teeth, engaging the second premolars. Fig. 15.7
shows these precise mechanics.
228 PA RT V I I Management of Multidisciplinary and Complex Problems

A B C

D E F

H
G

J
• Fig. 15.6Versatile palatal temporary anchorage device (TAD) supported mini-implant device for intrusion
of the buccal segments and delivery of anteroposterior forces. Pretreatment extraoral (A–C) and intraoral
(D–H) photographs. (I) Pretreatment cephalogram. (J) Palatal supported framework with four extension
arms derived from two palatal mini-implants. Parallel intrusion of the buccal segment can be achieved with
this mechanics.
 CHAPTER 15 Management of Skeletal Openbites With TADs 229

L M N

O P Q

R
Fig. 15.6, cont’d (L–N) Preintrusion occlusion, after four premolar extractions and placement of continuous
archwires. (O–Q) Postintrusion occlusion, after the delivery of intrusive forces. (R) Anteroposterior force
delivered to the left premolar from the lingual side for Class II correction.
230 PA RT V I I Management of Multidisciplinary and Complex Problems

S T U

V W X

Y
Fig. 15.6, cont’d (S–X) Posttreatment extraoral and intraoral photos and lateral cephalogram (Y).
 CHAPTER 15 Management of Skeletal Openbites With TADs 231

B C D

F G H
• Fig. 15.7 Palatal TADs-supported appliance with full control of the buccal segments for parallel intrusion.
(A) Palatal TADs-supported appliance (from two mini-implants) with four extension arms for control of the
force vector delivery. Palatal expansion screw with occlusal stops on the second molars and first premo-
lars. Second premolars could be bonded to the palatal expander framework; however, this bond tends
to fail. Labial brackets can help to control the position of these teeth when bonding fails. (B–D) Intraoral
photos showing significant anterior openbite, with occlusal planes diverging anteriorly from the second
premolars. (E) Intrusion both at the level of the first premolars and molars. (F–H) Significant reduction of the
anterior openbite, with levelling of the maxillary occlusal plane.
232 PA RT V I I Management of Multidisciplinary and Complex Problems

Vertical Control With Palatal TADs in the
Growing Patient
An interesting approach, in the vertical dimension control,
is the intrusion of the buccal segments in growing patients,
with skeletal openbite features. These patients present with
a convex profile tendency, long lower facial height, a Class II
malocclusion, and a tendency to an anterior openbite. It has
been reported that adequate vertical control can be achieved
in these patients, who can benefit from the resulting
anteroposterior projection of the mandible.16 The molar
intrusion forces can also prevent further clockwise rotation
of the facial complex. The positive vertical effects would also
aid in the correction of the Class II malocclusion, as a more
favorable horizontal growth pattern is achieved.
Case Report Two
Fig. 15.8 shows a 13-year-old boy with a slightly convex
profile, long lower facial height, Class II malocclusion, with

A B C

D E F

G
• Fig. 15.8
Vertical control of the maxillary molars in a growing patient with a long face skeletal pattern.
Pretreatment extraoral (A–C) and intraoral (D–F) photographs (G) Pretreatment lateral cephalogram.
 CHAPTER 15 Management of Skeletal Openbites With TADs 233

J K L

M N O
Fig. 15.8, cont’d (H) Palatal TADs-supported appliance for parallel intrusion of the buccal segment. Arms
extended anteriorly and bonded to both premolars bilaterally. (J–L) Openbite after inserting the appliance
related to the occlusal rest on the second molars. (M–O) Intraoral photos showing positive overbite and an
improved anteroposterior relationship of the buccal segments.
234 PA RT V I I Management of Multidisciplinary and Complex Problems

R U
Fig. 15.8, cont’d (P) Profile photo showing the progress in profile change, with the molar intrusion. (Q) TAD
appliance holding the first molars vertically while the finishing stage is being completed. (R–T) Occlusal
relationship in the finishing phase. (U) Progress of the facial profile change.
 CHAPTER 15 Management of Skeletal Openbites With TADs 235

V W X

Z ZA ZB

ZC
Fig. 15.8, cont’d Posttreatment extraoral (V–X) and intraoral (Y–Zc) photographs.
 ZD ZE
Fig. 15.8, cont’d Posttreatment lateral cephalogram (Zd) and superimposition (Ze).

B C

D E F
• Fig. 15.9 Mandibular molar intrusion. (A) Lateral cephalogram showing significant anterior openbite,
with occlusal planes diverging anteriorly from second molars. (B–C) Mandibular molar intrusion delivered
from TADs in the molar region. (D–F) Final intraoral photographs depicting the correction of the anterior
openbite.
 CHAPTER 15
H
Fig. 15.9, cont’d Cranial base (H), maxillary (I) and mandibular (J) superimpositions, showing the intrusion
of the mandibular molars and the significant autorotation of the mandible.
anterior openbite tendency, and approximately 6 mm of
overjet. A maxillary intrusion appliance targeting the pos-
terior buccal segment was prescribed for vertical translatory
movement of the posterior teeth, with the intent of obtain-
ing more horizontal mandibular growth. The positive effect
of the appliance in the correction of the malocclusion and
favorable facial change is evident. It should be noted that
although there was adequate control of the eruption of the
maxillary molars, the mandibular molars erupted signifi-
cantly with growth. Nonetheless, favorable growth direction
was observed with this approach, which facilitated obtaining
a good occlusal result.
Mandibular Molar Intrusion in Openbite
Correction
Majority of the efforts in the correction of the anterior
openbite, through molar intrusion, has been achieved by
targeting the maxillary molars. Sole intrusion of the man-
dibular molars to correct an anterior openbite has been sel-
domly reported.17 It appears that this intrusive movement
of the mandibular molars could be difficult to achieve.
However, in a patient with a significant divergent occlu-
sal planes, it may be possible to effect significant changes
with minor molar intrusion. Fig. 15.9 shows an adult
male patient with occlusal plane diverging from the sec-
ond molars. Third molars were extracted and intrusion of
the second molar was achieved, with the placement of an
Management of Skeletal Openbites With TADs 237
J
interradicular mini-implants on the labial aspect between
the left first and second molar and a miniplate in a similar
anteroposterior location on the right side, after the failure
of two consecutively placed mini-implants. The final result
shows the significant anterior openbite correction shown
in the superimposition. This result, however, took a signifi-
cantly long time to achieve (over a 3-year period), and the
panoramic radiograph shows moderate root resorption in
the distal roots of both second molars.
It has been suggested that when intruding the maxillary
molars, it may be necessary to hold vertically the supraeruption
of the lower molars, by placing mini-implants or miniplates
in the mandible.18 Mini-implants can be placed between the
first and second molars and a light force applied to control the
eruption of the lower teeth. This approach is recommended if
significant mandibular projection is desired, as the maxillary
molar intrusion is being achieved, since full vertical control can
be obtained.
Correction of Anterior Openbites Through
Incisor Extrusion With TADs
Although the primary target of skeletal anchorage in
the treatment of the openbite malocclusion has been the
molars, TADs could also be used as a tool to control the side
effects of incisor extrusion arch mechanics in these patients,
especially in the noncompliant patient that does not wear
intermaxillary elastics.19
238 PA RT V I I Management of Multidisciplinary and Complex Problems

Case Report Three
Fig. 15.10 shows a patient with excellent buccal occlusion
and anterior openbite. Interradicular mini-implants were
placed in all the quadrants and a sectional wire was placed
from these TADs to the first molars for indirect anchorage.
An extrusion arch was delivered to extrude the maxillary
and mandibular incisors. The mesial tip moment on the
maxillary and mandibular first molars that resulted from
the extrusive force of the extrusion arch was controlled by
indirect anchorage, drawn from the mini-implant in each
quadrant.

A B C

D E F

G
• Fig. 15.10 Temporary anchorage devices (TADs) for incisor extrusion and correction of the anterior open-
bite. Pretreatment extraoral (A–C) and intraoral (D–F) photographs. (G) Pretreatment cephalogram showing
good buccal occlusion and anterior openbite diverging from the first premolars anteriorly.
 CHAPTER 15 Management of Skeletal Openbites With TADs 239

H I J

K L M
Fig. 15.10, cont’d Progress intraoral photographs showing extrusion arches applied from all the first molars
which are being anchored indirectly by interradicular mini-implants. (H–J) Initiation of incisor extrusion;
(K–M) 3 months of active incisor extrusion.
240 PA RT V I I Management of Multidisciplinary and Complex Problems

N O P

Q R S

T
Fig. 15.10, cont’d Posttreatment extraoral (N–P) and intraoral (Q–S) photographs and lateral cephalogram (T).
(From: Librizzi ZT, Janakiraman N, Rangiani A, Nanda R, Uribe FA. Targeted mechanics for limited poste-
rior treatment with mini-implant anchorage. J Clin Orthod. 2015;49(12):777-783.)
 CHAPTER 15 Management of Skeletal Openbites With TADs 241

B C D

E F G
• Fig. 15.11 Temporary anchorage devices (TADs) to control the mesial tip moment on the maxillary molar
with incisor extrusion. (A) Maxillary TADs-supported habit appliance delivering indirect anchorage to the
first molar. (B–D) Extrusion arch extended to the incisors from the first molars. (E–G) Mesial tip observed on
the maxillary molars, premolars and canines, when a buccal segment was extended from the first molars
to the canines. The molar mesial tip tendency from the extrusive force to the incisors was not counteracted
by the cemented palatal appliance.

bar was delivered, engaging these mini-implants and the

• Fig. 15.12Three mini-implant Palatal Appliance. Three mini-implants
placed in the maxilla, as an example of an option to control the mesial
tipping moment on the molars, with the extrusive force applied to the
incisors, when using temporary anchorage devices (TADs) with round
attachment heads.
It is important to highlight that indirect anchorage may
not suffice in the control of the mesial moment on the
molars. Patient in Fig. 15.11 shows an extrusion arch deliv-
ered from the first molars. When the mesial tip of the molars
was observed, two palatal IMTEC Ortho mini-implants
(3M Unitek, Ardmore, Okla) were placed and a transpalatal
molars. Since the attachment head of these mini-implants
was round, the cemented attachment cap of the appliance
was not able to resist the moment generated at the molar
level, from the extrusion arch, and the TADs were ineffec-
tive to counteract the mesial tip. Perhaps an attachment
head with a vertical wall or a screw retained attachment head
could better resist these rotational tendencies observed with
extrusion of the incisors, when mini-implants are placed in
the palate and indirect anchorage is prescribed in this man-
ner. A final option could be adding a third mini-implant in
the palate, to counteract this mesial moment (Fig. 15.12).
Conclusion
Maxillary molar control, through intrusive force vectors
from TADs, have been the main strategy to control the ver-
tical dimension and correct skeletal openbites. The anatomy
of the openbite should be considered to apply the proper
force vectors. Although many skeletal anchorage options are
available, the required force vector should be matched to
242 PA RT V I I Management of Multidisciplinary and Complex Problems
the appropriate TAD delivery system for each clinical situ-
ation. Mandibular molar intrusion may be a useful strategy
to complement maxillary molar intrusion if a significant
facial change is desired. Finally, TADs could be also used for
incisor extrusion, by means of an extrusion arch, in patients
with anterior openbites, with a small skeletal vertical com-
ponent, who are noncompliant patients and adequate inter-
maxillary elastic wear is lacking.
Acknowledgments
We would like to acknowledge all the residents and faculty
who participated in the treatment of these cases.
References
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2. Kuster R, Ingervall B: The effect of treatment of skeletal open bite
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10. Sherwood KH, Burch JG, Thompson WJ: Closing anterior open
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Skeletal anchorage system for open-bite correction, Am J Orthod
Dentofacial Orthop 115:166–174, 1999.
12. Kuroda S, Katayama A, Takano-Yamamoto T: Severe anterior
open-bite case treated using titanium screw anchorage, Angle
Orthod 74:558–567, 2004.
13. Alsafadi AS, Alabdullah MM, Saltaji H, Abdo A, Youssef M:
Effect of molar intrusion with temporary anchorage devices in
patients with anterior open bite: a systematic review, Prog Orthod
17:9, 2016.
14. Yao CC, Chang HH, Chang JZ, Lai HH, Lu SC, Chen YJ:
Revisiting the stability of mini-implants used for orthodontic
anchorage, J Formos Med Assoc 114:1122–1128, 2015.
15. Tomaszewska IM, Tomaszewski KA, Kmiotek EK, Pena IZ,
Urbanik A, Nowakowski M, et al.: Anatomical landmarks for
the localization of the greater palatine foramen—a study of 1200
head CTs, 150 dry skulls, systematic review of literature and
meta-analysis, J Anat 225:419–435, 2014.
16. Buschang PH, Carrillo R, Rossouw PE: Orthopedic correction
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17. Freitas BV, Abas Frazao MC, Dias L, Fernandes Dos Santos PC,
Freitas HV, Bosio JA: Nonsurgical correction of a severe anterior
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Dentofacial Orthop 153:577–587, 2018.
18. Hart TR, Cousley RR, Fishman LS, Tallents RH: Dentoskeletal
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16
Orthognathic Camouflage With TADs
for Improving Facial Profile in Class III
Malocclusion
ERIC JW. LIOU
T
he treatment of Class III malocclusion includes sur-
gical orthodontics,1–4 or orthodontic camouflage
treatment.5–7 Orthodontic camouflage treatments,
such as protraction of upper dentition and/or retraction of
lower dentition through extraction or nonextraction ther-
apy, improve the anterior crossbite in patients with Class III
malocclusion.8–11 The scope of Class III orthodontic cam-
ouflage treatment expands after the temporary anchorage
devices (TADs) have been included.9–11
Orthodontic retraction of lower dentition also retracts
lower lip and relatively worsens chin projection and man-
dibular prognathism.12 The goal of Class III orthodontic
camouflage treatment should be to improve both occlu-
sion and facial profile. However, mandibular prognathism
is difficult to camouflage orthodontically.
An innovative concept of “orthognathic camou-
flage”13 by orthodontic backward rotation of mandible,
to decrease chin projection, in treating either growing
or adult patients with Class III malocclusion has been
proposed. This concept is not new. It originated from
the clockwise rotation of maxillomandibular complex
by orthognathic surgery, for the improvement of Class
III facial profile,14–16 as well as from the opposite, the
orthodontic intrusion of posterior teeth with TADs,
for the correction of anterior openbite and improve-
ment of mandibular retrognathism in Class II openbite
patients.17,18
Orthognathic camouflage, by backward rotation of
mandible, for patients with Class III malocclusion, is to
extrude the upper and/or lower dentitions, for improv-
ing upper incisor show and smile arc, and subsequently
to backward rotate the mandible to decrease chin pro-
jection and mandibular prognathism. Three techniques,
including bimaxillary or single-dentition extrusion with
or without TADs, have been developed. They could be
used in either nonextraction or extraction, growing or
adult patients.
Bimaxillary Extrusion Without TADs
This is a technique of orthodontic backward rotation of
mandible, with bite raisers and vertical elastics. The strategy
is to place bite raisers/blocks on posterior teeth to open the
bite and backward rotate the mandible to the planned posi-
tion, and then the anterior openbite is closed, via bimaxil-
lary extrusion of the upper and lower dentitions, by using
intermaxillary vertical elastics (Figs. 16.1 and 16.2).
Preparation
A segmental maxillary archwire from second premolar to
second premolar with anterior labial crown torque is placed,
and another two segmental archwires are placed on both
sides of the maxillary first and second molars. A transpalatal
arch (TPA) is placed to consolidate the maxillary posterior
teeth. A continuous archwire and a lingual holding arch are
then placed in the mandibular dentition.
Placement of Bite Raisers to Backward Rotate
Mandible
The material for bite raisers could be a light-cured compos-
ited resin or glass ionomer (GI) band cement. For the ease
of saliva control, bite raisers placement, and their removal,
it is recommended to use light-cured GI band cement and
bond them on both sides of upper posterior teeth.
The occlusal surfaces of upper molars on both sides are
first cleaned with pumice powder, and then the central fos-
sae of the upper molars, but not the entire occlusal surface,
are conditioned with etching agent. The etching process at
the central fossae ensures retention of the bite raisers, with-
out dislodgement during treatment, and ease of removal
after treatment. The GI band cement is then added incre-
mentally on the occlusal surfaces of the upper molars until
2 to 3 mm bite opening at the anterior teeth.
243
244 PA RT V I I Management of Multidisciplinary and Complex Problems

Extrusion of Anterior Teeth to Close Anterior
Openbite
After placing the bite raisers, intermaxillary vertical elas-
tics are then applied between the upper and lower anterior
teeth. Patients are instructed to wear the intermaxillary
vertical elastics 14 to 20 hours per day, and arranged to
return to the clinic on a monthly basis. Increment of GI
band cement is added on the bite raisers to keep the bite
opened 2 to 3 mm, at each monthly visit, so that the man-
dible rotates backward incrementally to the planned posi-
tion or facial profile.

A
• Fig. 16.1 The clinical procedure and case report of bimaxillary extrusion without TADs for backward
rotation of mandible and redirecting the mandibular growth in a 13-year-old female client with Class III
malocclusion. (A) The pretreatment extraoral, cone beam computed tomography (CBCT) images, and
intraoral photographs revealed inadequate upper incisor show, excessive lower incisor display, maxillary
hypoplasia, mandibular prognathism, and anterior crossbite;
(Continued on next page)
 CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion 245

Extrusion of Posterior Teeth
After the mandible has incrementally backward rotated
to the planned position or facial profile and the upper
and lower anterior teeth have been brought into occlu-
sion, the bite raisers are removed. Intermaxillary poste-
rior vertical elastics, together with TPA lateral expansion,
are then applied to extrude the upper molars, without
palatal tipping and decreasing maxillary intermolar
width.
After the upper and lower posterior teeth have occluded,
a continuous maxillary archwire is then placed to replace the
segmental archwires in the maxillary dentition.

C
• Fig. 16.1, cont’d(B) The anterior crossbite was first corrected by maxillary orthopedic protraction through
7-week of Alternate Rapid Maxillary Expansions and Constriction (Alt-RAMEC) with a double-hinged
expander and then a pair of intraoral protraction springs for 3 months. The expander was maintained for
another 3 months after the maxillary protraction; (C) The overall skeletal superimposition on cranial base
(pretreatment: silver color, postprotraction: green color) revealed the maxilla was protracted 3.0 mm, and
the mandible was displaced downward 4.0 mm and backward 2.0 mm.
(Continued on next page)
 D

F
• Fig. 16.1, cont’d (D) Bite raisers were placed incrementally on the upper posterior teeth at each appointment
to open the bite 2 mm at the anterior teeth and to redirect the mandible downward and backward, and anterior
vertical elastics were applied for bimaxillary extrusion of the anterior teeth and premolars after the upper and
lower dentitions were aligned; (E) The bite raisers were removed and posterior vertical elastics were applied for
extruding the posterior teeth, after 4 months of redirecting the mandibular growth; (F) The posterior teeth of both
upper and lower dentitions were brought into occlusion after 5 months of posterior vertical elastics;
(Continued on next page)
 CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion 247

G
• Fig. 16.1, cont’d(G) The posttreatment extraoral, CBCT images, and intraoral photos at the age of 15
years revealed a full smile arc and good amount of upper incisor show, without excessive lower incisor
display, and a Class I facial profile;
(Continued on next page)
248 PA RT V I I Management of Multidisciplinary and Complex Problems

I
• Fig. 16.1, cont’d
(H) The overall skeletal superimposition on cranial base (postprotraction: green color,
posttreatment: red color) revealed the maxilla remained stable, the maxillary posterior teeth were extruded
5.0 to 6.0 mm, the maxillary anterior teeth were extruded 2.0 to 3.0 mm, and the mandible was further
redirected downward 5.0 mm and backward 3.0 mm. (I) The 1-year posttreatment extraoral and intraoral
photos at the age of 16 years revealed stable clinical results, without obvious changes of facial profile and
occlusion.
 CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion 249

D
• Fig. 16.2 The overall effects of maxillary protraction and redirection of mandibular growth of the case
reported in Fig. 16.1. (A) The overall skeletal superimposition on cranial base (pretreatment: silver color,
posttreatment: red color) revealed the maxilla was protracted 3.0 mm, and the mandible was redirected
and grew downward 9.0 mm and backward 5.0 mm, rather than downward and forward; (B) The overall
soft tissue superimposition based on overall skeletal superimposition on cranial base revealed the soft
tissue at the midface and paranasal area was 1.5 mm fuller, and the chin projection reduced 5.0 mm back-
ward and 8.0 mm downward; (C) The cranial base superimposition without mandible revealed the maxillary
was protracted 3.0 mm, the maxillary molars were extruded 5.0 to 6.0 mm, and the maxillary anterior teeth
were extruded 3.0 mm; (D) The mandibular superimposition illustrated the lower dentition was extruded
5.0 to 6.0 mm, and the mandibular condyles grew 4.0 mm.
250 PA RT V I I Management of Multidisciplinary and Complex Problems

Single-Dentition Extrusion With TADs in Insertion of TADs

Mandible The preparation procedure of this technique is the same
as the bimaxillary extrusion without TADs. To rotate the
This is a technique of orthodontic backward rotation of
mandible without extruding the lower dentition, TADs
mandible with bite raisers, TADs in mandible, and verti-
are placed in the anterior of mandible. The TADs could be
cal elastics. The strategy is to achieve backward rotation of
inserted interdentally between mandibular canine and first
mandible, without extruding lower anterior teeth, by using
premolar on both sides.
TADs in the mandible (Figs. 16.3 and 16.4).

A
• Fig. 16.3 The clinical procedure and case report of single-dentition extrusion with TADs in mandible for
backward rotation of mandible and redirecting mandibular growth in a 14-year 3-month-old male client
with Class III malocclusion and bilateral cleft lip and palate. (A) The pretreatment extraoral, cone beam com-
puted tomography (CBCT) images, and intraoral photographs revealed depressed midface and paranasal
area, excessive chin throat length, maxillary hypoplasia, mandibular prognathism, and anterior crossbite;

(Continued on next page)

 CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion 251

C
• Fig. 16.3, cont’d (B) The anterior crossbite was first corrected by maxillary orthopedic protraction
through 7-week Alternate Rapid Maxillary Expansions and Constriction (Alt-RAMEC) with a double-hinged
expander and then a pair of intraoral protraction springs for 3 months. The expander was maintained for
another 3 months after the maxillary protraction; (C) The overall skeletal superimposition on cranial base
(pretreatment: silver color, postprotraction: green color) revealed the maxilla was protracted 3.0 mm, and
the mandible was displaced downward 7.0 mm and backward 1.5 mm;

(Continued on next page)

 D

F
• Fig. 16.3, cont’d (D) The TADs were inserted between the lower canine and first premolar at both sides,
bite raisers were placed incrementally on the upper posterior teeth at each appointment to open the bite 2
mm at the anterior teeth, and vertical elastics were applied between the lower TADs and upper dentition to
extrude the upper dentition and redirect mandibular growth; (E) The bite 6 months after redirecting man-
dibular growth; (F) The bite raisers were removed and posterior vertical elastics were applied for extruding
the posterior teeth for 15 months;
(Continued on next page)
 CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion 253

G
• Fig. 16.3, cont’d
(G) The posttreatment extraoral, CBCT images, and intraoral photos at the age of 16
years and 9 months revealed a better smile arc, and upper incisor show and improvement of facial profile;
(Continued on next page)
254 PA RT V I I Management of Multidisciplinary and Complex Problems

H
• Fig. 16.3, cont’d(H) The overall skeletal superimposition on cranial base (postprotraction: green color,
posttreatment: red color) revealed the maxilla grew 1.0 mm forward further, although there were anterior
teeth dental relapse. The maxillary dentition was extruded 4.0 to 5.0 mm at the anterior and 6.0 to 7.0
mm at the posterior, and the mandible was further redirected downward 4.0 mm and backward 1.0 mm.

Placement of Bite Raisers and Extrusion of
Upper Anterior Teeth
The placement of the bite raisers is the same as the procedure
of bimaxillary extrusion without TADs. After insertion of the
TADs in mandible and placement of bite raisers on the occlu-
sal surfaces of maxillary posterior teeth, intermaxillary vertical
elastics are then applied between the upper anterior teeth and
the lower TADs for extruding the upper dentition.
Extrusion of Posterior Teeth
This procedure is the same as the extrusion of posterior teeth
in procedure of bimaxillary extrusion without TADs.
Single-Dentition Extrusion With TADs in
Maxilla
This is a technique of orthodontic backward rotation of
mandible, with TADs in maxilla, without bite raisers and
vertical elastics. The strategy is to achieve backward rota-
tion of mandible, without extruding lower anterior teeth by
using TADs and extruding springs in the maxilla (Figs. 16.5
and 16.6).
Insertion of TADs
To rotate the mandible without extruding the lower denti-
tion and without bite raisers, TADs are placed in the buccal
side of maxilla. The TADs could be inserted interdentally
between the maxillary canine and first premolar, between
the premolars, or between the first molar and premolar on
both sides in extraction cases.
After insertion of the TADs, a pair of extruding springs
(0.019 × 0.025 titanium molybdenum alloy [TMA]) is
placed in the TADs, for extruding the entire maxillary
dentition. The extruding spring is composed of two arms.
One arm is for the extrusion of maxillary anterior, and it is
hooked on the main archwire, between the central incisors,
to avoid occlusal cant caused by unbalancing force, from
each side of the extruding springs. The other arm is for the
extrusion of maxillary posterior teeth, and it is hooked on
the main archwire between the first and second maxillary
molars.
The TADs insertion sites are better symmetrically at the
same position, on each side, so that the extruding springs
are equal in length and force to avoid causing occlusal cant.
A removable and adjustable TPA (0.032 TMA) should be
used to avoid palatal tipping of posterior teeth during molar
extrusion. Buccal crown torque and lateral expansion are
added on the TPA.
Maxillary Vertical Development in Class III
Patients
Either bimaxillary or single-dentition extrusion extrudes
maxillary dentition and also develops maxillary vertical
height, which improves the smile and upper incisor show
A

D
• Fig. 16.4 The overall effects of maxillary protraction and redirection of mandibular growth with lower
TADs of the case reported in Fig. 16.3. (A) The overall skeletal superimposition on cranial base (pretreat-
ment: silver color, posttreatment: red color) revealed the maxilla was protracted and grew forward 4.0
mm, and the mandible was redirected and grew downward 11.0 mm and backward 2.5 mm, rather than
downward and forward; (B) The overall soft tissue superimposition based on overall skeletal superimposi-
tion on cranial base revealed the soft tissue at the midface and paranasal area was 2.5 mm fuller, and the
chin projection reduced 6.0 mm backward and 11.0 mm downward; (C) The cranial base superimposition
without mandible revealed the maxillary was protracted and grew 4.0 mm forward, the maxillary posterior
teeth were extruded 8.0 mm, and the maxillary anterior teeth were extruded 5.0 mm; (D) The mandibular
superimposition illustrated the lower posterior teeth were extruded and erupted 5.0 to 6.0 mm, the lower
anterior teeth were extruded and erupted 2.0 mm, and the mandibular condyles grew 8.0 mm on the right
and 6.0 mm on the left.
256 PA RT V I I Management of Multidisciplinary and Complex Problems

in patients with Class III malocclusion. Maxillary hypo-
plasia and/or mandibular prognathism are the most two
common features in patients with Class III malocclusion.
The maxillary hypoplasia includes sagittal and/or vertical
deficiency. Unfortunately, the Class III orthodontic camou-
flage treatment usually focuses on the sagittal improvement
of anterior crossbite,5–7 but seldom on the improvement of
maxillary vertical deficiency.
Orthodontic extrusion or force eruption has been
used successfully for implant site development in alveo-
lar vertical bone height.19–21 Similarly, the extrusion of
maxillary dentition could develop the maxillary alveolar
vertical bone height and subsequently improve the max-
illary incisors show and smile arc, backward rotate the
mandible, reduce chin prominence, and shorten the chin
throat length.

A
• Fig. 16.5 The clinical procedure and case report of single-dentition extrusion with TADs in maxilla for
backward rotation of mandible and orthognathic camouflage in a 27-year-old female with Class III maloc-
clusion. (A) The pretreatment extraoral, cone beam computed tomography (CBCT) images, and intraoral
photographs revealed excessive chin throat length, mandibular prognathism, inadequate upper incisors
show, excessive lower incisors display, flat smile arc, and anterior cross bite;

(Continued on next page)

 CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion 257

Comparisons and Indications of
Bimaxillary Extrusion and Single-Dentition
Extrusion
The bimaxillary extrusion extrudes both the maxillary
and mandibular dentitions. On the other hand, the sin-
gle-dentition with TADs in mandible or maxilla extrudes
mostly maxillary dentition, but not the mandibular den-
tition. Bimaxillary extrusion has been reported to be
more efficient and effective than single-dentition extru-
sion in rotating the mandible downward and backward
in growing Class III patients.13 It has more mandibular
backward rotation and orthognathic camouflage than the
single-dentition extrusion. Single-dentition extrusion
might spend more time in rotating the mandible clock-
wise to the same extent the bimaxillary extrusion does.
Bimaxillary extrusion extrudes lower incisors and may
unfavorably increase lower incisor show, especially in adult

C
• Fig. 16.5, cont’d (B) The anterior crossbite was first improved by alignment and leveling of the upper
and lower dentitions with bite raisers at the upper posterior teeth for jumping the bite. Then, TADs were
inserted between the upper canine and first premolar at both sides; (C) pairs of extruding springs (0.019
× 0.025 TMA) were placed in the TADs for extruding upper dentition. The upper archwire was built in with
anterior teeth labial torque, for avoiding palatal tipping during extrusion, and a transpalatal arch (TPA) was
built in with lateral expansion and parallel molar torque for avoiding palatal tipping and decreasing buccal
overjet during extrusion;
(Continued on next page)
D

E
• Fig. 16.5, cont’d
(D) The extruding springs and the TPA lateral expansion were applied for 8 months; (E)
The posttreatment extraoral, CBCT images, and intraoral photos revealed a better smile arc, upper incisor
show, and improvement of facial profile.
 CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion 259

D
• Fig. 16.6 The overall effects of orthognathic camouflage of the case reported in Fig. 16.5. (A) The overall
skeletal superimposition on cranial base (pretreatment: silver color, posttreatment: red color) revealed the
maxillary dentition was extruded 4.0 to 5.0 mm, and the mandible was rotated downward 5.0 mm and
backward 4.0 mm; (B) The overall soft tissue superimposition based on overall skeletal superimposition
on cranial base revealed the chin projection reduced 3.0 mm backward and 3.0 mm downward. The chin
throat length decreased 3.0 mm; (C) The cranial base superimposition without mandible revealed the
maxillary dentition was extruded 4.0 to 5.0 mm; (D) The mandibular superimposition illustrated the lower
second molars were intruded 1.5 mm, lower premolars were extruded 1.5 mm, and the lower anterior
teeth were intruded 1.5 mm. The lower curve spee was leveled.
260 PA RT V I I Management of Multidisciplinary and Complex Problems
patients. Interestingly, we have observed clinically that
the lower incisor show remained similar or even was less
in growing patients treated with bimaxillary extrusion (see
Fig. 16.1). This could be caused by the growth of soft tis-
sue compensating for the extrusion of lower incisors. Thus,
due to the mandibular growth, growing patients are better
treated by bimaxillary extrusion. For the adult patients with
excessive lower incisor show, bimaxillary extrusion could be
contraindicated.
On the other hand, bite raisers open the bite but also
interfere with eating. This might be not a big problem for
growing patient but could be a problem for adult patients.
The single-dentition extrusion with TADs in maxilla would
be friendlier for adult patients.
Backward rotation of mandible also increases anterior
facial height and might lead to lip incompetence. There-
fore backward rotation of mandible should be stopped
when lip incompetence is developing. Orthodontic back-
ward rotation of mandible is indicated in Class III patients
with short face, low angle, maxillary vertical deficiency,
or overclosure, and it might not be indicated in Class III
patients with long face, high angle, openbite, or lip incom-
petence. Class III patients with lip incompetence caused
by dentoalveolar protrusion could still be candidates for
extraction therapy.
The Stability of Orthodontic Extrusion
Although the long-term stability of orthodontic extru-
sion has yet to be well revealed, the 1 to 3 years post-
treatment results were reported stable in some case
reports.22–24 In contrast, the stability of orthodontic
intrusion has been documented and the 3 to 4 years post-
treatment relapse of orthodontic intrusion of posterior
teeth was 13.37% to 22.88%.25,26 The long-term stabil-
ity of orthodontic extrusion could be similar to that of
orthodontic intrusion, and overcorrection is commended
for the backward rotation of mandible in patients with
Class III malocclusion.
References
1. Patel PK, Novia MV: The surgical tools: the LeFort I, bilateral
sagittal split osteotomy of the mandible, and the osseous genio-
plasty, Clin Plast Surg 34:447–475, 2007.
2. Drommer RB: The history of the “Le Fort I osteotomy”, J Maxil-
lofac Surg 14:119–122, 1986.
3. Epker BN: Modifications in the sagittal osteotomy of the man-
dible, J Oral Surg 35:157–159, 1977.
4. Chen YR, Yeow VK: Multiple-segment osteotomy in maxillofa-
cial surgery, Plast Reconstr Surg 104:381, 1999.
5. Baik HS: Limitations in orthopedic and camouflage treatment
for Class III malocclusion, Semin Orthod 13:158–174, 2007.
6. Burns NR, Musich DR, Martin C, Razmus T, Gunel E, Ngan P:
Class III camouflage treatment: what are the limits? Am J Orthod
Dentofacial Orthop 137: 9.e1-9.e13, 2010.
7. Tekale PD, Vakil KK, Parhad SM: Orthodontic camouflage in
skeletal class III malocclusion: a contemporary review, J Orofac
Res 4:98–102, 2014.
8. Ning F, Duan YZ: Camouflage treatment in adult skeletal Class
III cases by extraction of two lower premolars, Korean J Orthod
40:349–357, 2010.
9. Yanagita T, Kuroda S, Takano-Yamamoto T, Yamashiro T: Class
III malocclusion with complex problems of lateral open bite
and severe crowding successfully treated with miniscrew anchor-
age and lingual orthodontic brackets, Am J Orthod Dentofacial
Orthop 139:679–689, 2011.
10. He S, Gao J, Wamalwa P, Wang Y, Zou S, Chen S: Camou-
flage treatment of skeletal Class III malocclusion with mul-
tiloop edgewise arch wire and modified Class III elastics by
maxillary mini-implant anchorage, Angle Orthod 83:630–640,
2013.
11. Nakamura M, Kawanabe N, Kataoka T, Murakami T, Yamashiro
T, Kamioka H: Comparative evaluation of treatment outcomes
between temporary anchorage devices and Class III elastics
in Class III malocclusions, Am J Orthod Dentofacial Orthop
151:1116–1124, 2017.
12. Modarai F, Donaldson JC, Naini FB: The influence of lower
lip position on the perceived attractiveness of chin prominence,
Angle Orthod 83:795–800, 2013.
13. Liou EJ, Wang YC: Orthodontic clockwise rotation of maxillo-
mandibular complex for improving facial pro le in late teenagers
with Class III malocclusion: a preliminary report, APOS Trends in
Orthod 8:3–9, 2018.
14. Tsai IM, Lin CH, Wang YC: Correction of skeletal Class III
malocclusion with clockwise rotation of the maxillomandibu-
lar complex, Am J Orthod Dentofacial Orthop 141:219–227,
2012.
15. Villegas C, Janakiraman N, Uribe F, Nanda R: Rotation of
the maxillomandibular complex to enhance esthetics using
a “surgery first” approach, J Clin Orthod 46:85–91, 2012.
quiz 123.
16. Choi JWMD, Park YJ, Lee CY: Posterior pharyngeal airway in
clockwise rotation of maxillomandibular complex using sur-
gery-first orthognathic approach, Plast Reconst Surg Glob Open
3(8):e485, 2015.
17. Tanaka E, Yamano E, Inubushi T, Kuroda S: Management of
acquired open bite associated with temporomandibular joint
osteoarthritis using miniscrew anchorage, Korean J Orthod
42:144–154, 2012.
18. Alsafadi AS, Alabdullah MM, Saltaji H, Abdo A, Youssef M:
Effect of molar intrusion with temporary anchorage devices in
patients with anterior open bite: a systematic review, Prog Orthod
179-136, 2016.
19. Salama H, Salama M: The role of orthodontic extrusive remodel-
ing in the enhancement of soft and hard tissue profiles before
implant placement: a systematic approach to the management of
extraction site defects, Int J Periodontics Restorative Dent 13:312–
333, 1993.
20. Rokn AR, Saffarpour A, Sadrimanesh R, et al.: Implant site devel-
opment by orthodontic forced eruption of nontreatable teeth: a
case report, Open Dent J 6:99–104, 2012.
21. Kwon EY, Lee JY, Choi J: Effect of slow forced eruption on
the vertical levels of the interproximal bone and papilla and
the width of the alveolar ridge, Korean J Orthod 46:379–385,
2016.
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22. Atsawasuwan P, Hohlt W, Evans CA: Nonsurgical approach
to Class I open-bite malocclusion with extrusion mechanics: a
3-year retention case report, Am J Orthod Dentofacial Orthop
147:499–508, 2015.
23. Küçükkeleş N, Acar A, Demirkaya AA, Evrenol B, Enacar A:
Cephalometric evaluation of open bite treatment with NiTi
arch wires and anterior elastics, Am J Orthod Dentofacial Orthop
116:555–562, 1999.
24. Lo FM, Shapiro PA: Effect of presurgical incisor extrusion on sta-
bility of anterior open bite malocclusion treated with orthognathic
surgery, Int J Adult Orthodon Orthognath Surg 13:23–34, 1998.
261
25. Baek MS, Choi YJ, Yu HS, Lee KJ, Kwak J, Park YC: Long-term
stability of anterior open-bite treatment by intrusion of maxillary
posterior teeth, Am J Orthod Dentofacial Orthop 138:396, e1-9,
2010; discussion 396-398.
26. Marzouk ES, Kassem HE: Evaluation of long-term stability of
skeletal anterior open bite correction in adults treated with maxil-
lary posterior segment intrusion using zygomatic miniplates, Am
J Orthod Dentofacial Orthop 150:78–88, 2016.
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17
Management of Multidisciplinary
Patients With TADs
FLAVIO URIBE, RAVINDRA NANDA
M
ultidisciplinary treatment encompasses the care of
a patient where two or more specialties overlap to
work synergistically, to obtain the best outcome.
In orthodontics, this interaction is often found with the
restorative dentist or prosthodontist. The problems usually
addressed as a team include the preprosthetic work, for the
placement of dental implants, or other dental restorations.
Another common interaction is also evidenced in patients
undergoing orthognathic surgery, where the orthodontist and
oral surgeon work as a team in the treatment of patients with
dentofacial deformity.
Adults seeking orthodontic treatment are the patient demo-
graphic that more often require interdisciplinary care. Further-
more, the number of adult patients in orthodontic treatment
has increased in the United States in recent years.1 Often these
patients present with a whole range of occlusal problems,
which many of them stem from the missing teeth. The delete-
rious occlusal effects of missing teeth may compound with an
already present malocclusion, which adds to the complexity of
treatment. A significant malocclusion, with few anchor teeth
for demanding orthodontic movements, require careful treat-
ment planning and often the aid of skeletal anchorage units.
Temporary Anchorage Devices (TADs)
for Space Development for Implant in
Congenitally Missing Lateral Incisor
The most common type of multidisciplinary treatment in
orthodontics involves the space appropriation required for pros-
thetic work to be performed, after orthodontics. Ridge space
development for patients, congenitally missing lateral incisors,
is one such clinical situation that may require the use of skeletal
anchorage, if a nonextraction treatment approach is planned.
Case Report One
Fig. 17.1 shows a 33-year-old female patient congeni-
tally missing the permanent maxillary left lateral incisor.
The primary left lateral incisor was supraerupted and was
squeezed out of the arch, leaving only approximately 3
mm of space between the left permanent central incisor
and the canine. With time, the maxillary primary lateral
incisor had become symptomatic, as evidenced by a fis-
tula in the labial mucosa, which required to take action.
Only minimal space was available for the placement
of an implant in the lateral incisor site, after the even-
tual extraction of the primary lateral incisor. A canine
substitution option required the buccal segment to be
protracted from an end-on Class II relationship to a full-
cusp Class II occlusion. The patient was adamant of get-
ting an endosseous dental implant placed on the lateral
incisor site, which required the distalization of the buccal
segment for the development of adequate space for this
missing tooth. The patient was opposed to the extraction
of the left first premolar to obtain the required space for
the lateral incisor. To distalize the left buccal segment,
including the canine, two 1.8 × 8 mm IMTEC Ortho
mini-implants (3M Unitek, Ardmore, Okla) were placed
in the palate, at the level of the second premolar. An algi-
nate impression was taken of the maxilla, and two ana-
logue mini-implants were placed on the impression, and
stone was poured to obtain a working model. Two O-caps
(IMTEC Ortho, 3M Unitek, Ardmore, Okla) were used
as framework to fabricate a distalization appliance, con-
sisting of a tracking bar parallel to the left buccal seg-
ment, at a height close to the furcation of the first molar.
A band with a lingual 0.032-inch Burstone bracket
(Ormco, Glendora, Calif ) with a hinge cap was cemented
on the first molars. From the lingual bracket, an exten-
sion arm with a head gear tube engaged the tracking bar
of the appliance. An open coil spring along the tracking
bar was placed to drive the first molar distal. Once distal-
ization was achieved, natural drift of the premolars was
monitored until labial conventional orthodontic appli-
ances were added to detail the occlusion and achieve the
proper dimensions for the endosseous dental implant in
the lateral incisor site.
263
264 PA RT V I I Management of Multidisciplinary and Complex Problems

A B C

D E F

G H I

J K L
• Fig. 17.1 TAD-supported maxillary distalization for implant site development. (A) Pretreatment extra-
oral (A–C) and intraoral (D–F) photographs. (G) Two palatal IMTEC Ortho mini-implants supporting a
framework with tracking arms, extending posteriorly to the first molars. Space opening mesial to the
left maxillary first molar after distalization force delivered directly form the TADs. (H) Class I molar
achieved on the left side. (I) Space developed for a lateral incisor dental implant after the extraction
of the primary tooth. (J) Class I canine achieved with distalization. (K–N) Final intraoral photographs,
after final restoration with the endosseous dental implant. (O) Smile photograph depicting the excel-
lent esthetic result. (P) Close-up view of the lateral incisor implant crown.
 CHAPTER 17
N P
• Fig. 17.1, cont’d
TADs for Preprosthetic Space
Appropriation
Another situation where TADs are important, in multidisci-
plinary treatment, is in the space appropriation for esthetic
prosthetic restorations in the anterior maxillary segment.
Case Report Two
Fig. 17.2 displays a patient who was seeking better smile
esthetics. The maxillary incisors were worn on the incisal
edges, the maxillary dental midline was significantly devi-
ated to the right, and the patient displayed a Class II molar
occlusion on the left side, with a significant overbite. On
the lower arch, the patient had only two mandibular inci-
sors. The plan consisted of centering the maxillary midline,
overbite correction, and space appropriation for maxillary
anterior veneers, which was to be obtained through the
correction of the Class II canine and molar relationship on
the left side. In the lower arch, space was to be developed
mesial to the right canine, for one single dental implant. To
achieve the objectives in the maxilla, an infrazygomatic (IZ)
Lomas mini-implant (Mondeal Medical Systems, Donau,
Germany) was placed on the left side and distalization of the
maxillary left buccal segment was achieved. At the end of the
orthodontic and prosthodontic treatments, Class I occlu-
sion and matched dental and facial midlines were observed.
Management of Multidisciplinary Patients With TADs 265
Endosseous Dental Implants for
Anchorage in Patients With Missing
Posterior Teeth
Skeletal anchorage for orthodontic movement in multidisci-
plinary patients can also be achieved through the placement
of endosseous dental implants, during orthodontic treat-
ment. This is a cost-effective use of skeletal anchorage, as the
dental implant would serve a dual purpose, for orthodontic
anchorage and restoration of an edentulous site.
Case Report Three
Fig. 17.3 displays a 66-year-old male with a heavily restored
dentition, a Class II malocclusion, and significant overjet
and overbite. The treatment plan for this patient included
the correction of the overbite, using an intrusion arch in
the mandibular dentition. The overjet was to be corrected
through the extractions of the maxillary right first premolar,
which had a periapical lesion and the left second premolar
that had a coronal cusp facture. The maxillary left first molar
had a root fracture, making it unrestorable, requiring also
the extraction of this tooth. An endosseous dental implant
was to be placed, once the site healed, after the extraction.
This implant was to be used during orthodontic treatment
to maximize the retraction of the canine, without any mesial
movement of the posterior segment or anchorage loss.
266 PA RT V I I Management of Multidisciplinary and Complex Problems

A B C

D E F

G H

I J K
• Fig. 17.2 Preprosthetic space appropriation and midline correction with unilateral infrazygomatic (IZ)
temporary anchorage device (TAD). Pretreatment extraoral (A–C) and intraoral photographs (D–H).
(I–K), IZ TAD on the left side to distalize the buccal segment and center the maxillary dental midline.
 CHAPTER 17 Management of Multidisciplinary Patients With TADs 267

L M

N
• Fig. 17.2, cont’d(L) Improvement on the maxillary dental midline in relation to the facial midline. (M)
Final smiling photograph, with maxillary veneers. (N) Intraoral photo of the final maxillary and man-
dibular restorations.

Ridge Mini-implants for Orthodontic
Anchorage
Although endosseous dental implants provide a dual advan-
tage when placed (anchorage during orthodontic treatment
and restorative prosthetic solution at the end of treat-
ment),2,3 there are certain limitations and problems that
may arise when placing dental implants, before or during
the early phases of orthodontic treatment. Often the final
predicted location of the endosseous dental implant after
orthodontic treatment is not precise, requiring the restor-
ative dentist to make adjustments to the restoration that
may compromise the esthetics of the outcome.
One option that still allows to draw skeletal anchor-
age from edentulous areas, without the rigor of perfect
insertion location of the fixture, is the placement of mini-
implants vertically into the alveolar ridge, mimicking the
position of a conventional endosseous dental implant.
These mini-implants can then be used for anchorage pur-
poses and even replaced in other locations, as needed, dur-
ing orthodontic treatment. In fact, this approach has the
advantage of enabling the clinician to apply conventional
orthodontic biomechanics while using skeletal anchorage
as the mini-implant is placed along the arch. A bracket is
bonded to the attachment head of the mini-implant, after
adding a temporary crown made out of flowable compos-
ite, thereby allowing the mini-implant to receive the main
archwire through the bracket slot. The only limitation of
this type of TAD placement is that it does not allow an
easy approach for significant intrusion of the adjacent
teeth, when using direct anchorage. However, by means
of cantilever arms, vertical forces can be delivered to the
anterior teeth. Overall, the main role of this mini-implant
is the aid in anchorage in the anteroposterior dimension.
There are various advantages in these ridge mini-implants.
Firstly, this mini-implant is easy to place, as there is typically
ample room for insertion. Secondly, it is easy to apply con-
ventional biomechanics, as it can be added to the archwire
to deliver the necessary forces. Thirdly, compared to endos-
seous dental implants, the insertion site can be changed,
depending on the specific needs during treatment. In other
words, there is versatility also for changes in the treatment
plan, based on the progress of treatment. Finally, it allows to
deliver a push-type force mechanism, a force delivery type
that is not typically delivered directly from mini-implants,
where pull-type mechanics is the norm.
268 PA RT V I I Management of Multidisciplinary and Complex Problems

A B C

D E F

G H

I J
• Fig. 17.3Endosseous dental implant for orthodontic anchorage. Pretreatment extraoral (A–C) and intra-
oral photographs (D–H). Lateral cephalogram (I) and panoramic radiograph (J). (K–M) Segmental man-
dibular incisor intrusion. (N–Q) Extraction of maxillary right first premolar and left second premolar for
orthodontic reasons. Endosseous dental implant placement on the maxillary left molar region. This tooth
required extraction because of root fracture. (R–U) Maxillary canine retraction from endosseous dental
implant on the left side for maximum anchorage. Posttreatment intraoral (V–Y) and extraoral (Z–ZB) photo-
graphs. Posttreatment lateral cephalogram (ZC) and panoramic (ZD) radiographs. (ZE) Final dental implant
restoration on the left maxillary first molar.
 CHAPTER 17 Management of Multidisciplinary Patients With TADs 269

K L M

N O P

Q R S

T U V

W X Y
• Fig. 17.3, cont’d

The specific technique for ridge mini-implant placement
is as follows:
1. A mini-implant with a rectangular or square attachment
head with enough retention areas, such as bracket wings,
is preferred, as composite material will mechanically
interlock. The Lomas Quattro mini-implant (Mondeal
Medical Systems, Donau, Germany) complies with this
characteristic. Typically, the dimension used is a 2 ×
9-mm or 2.3 × 9-mm mini-implants.
2. The mini-implant is inserted with a contraangle driver
on the ridge. A pilot hole is placed if the alveolar ridge
morphology is that of a knife edge.
270 PA RT V I I Management of Multidisciplinary and Complex Problems
Z ZA
ZC ZD
ZE
• Fig. 17.3, cont’d
3. Once the mini-implant is placed, it is important to visu-
alize the location of the attachment head, as it should
be in close proximity to the line connecting the labial
surfaces of the adjacent teeth.
4. Occlusogingivally, the attachment head should not be in
contact with the teeth in the opposing arch and should
be close to the height of the bracket level of the adjacent
teeth.
5. Flowable composite is applied around the attachment
head, and a bracket is bonded trying to allow a passive
wire engagement in occlusogingival and buccolingual
direction, in relation to the adjacent teeth.
6. A wire is placed to start tooth movement.
ZB
7. If failure of the ridge mini-implant is observed, two mini-
implants are placed adjacent to each other and splinted,
with flowable composite to increase stability.
Another one of the advantages of placing mini-implants
in the ridge is observed in patients with large edentulous
spans, where the terminal tooth needs to be orthodontically
moved.
Case Report Four
Fig. 17.4 shows a 29-year-old female patient with multiple
missing teeth, especially in the lower arch. A large edentu-
lous span is observed from the right first premolar through
A B C

D E F

G H

I J
• Fig. 17.4 Anchorage derived from ridge mini-implants. Pretreatment extraoral (A–C) and intraoral pho-
tographs (D–H). Pretreatment lateral cephalogram (I) and full mouth periapical radiographs (J). (K–O)
Progress after placement of two ridge mini-implants in the mandibular molar region bilaterally. (P–T)
Progress showing the protraction of mandibular molars and midline correction, with anchorage derived
from the ridge mini-implants. (U–Y) Posttreatment intraoral photographs. (Z) Lower thermoplastic retainer,
with pontics, showing the adequate spacing for dental implants on the mandibular arch. Note that the right
third molar erupted after protraction of the second molar. (ZA–ZC) Posttreatment extraoral photographs.
Posttreatment lateral cephalogram (ZD) and panoramic (ZE) radiographs.
272 PA RT V I I Management of Multidisciplinary and Complex Problems

K L M

N O

P Q R

S T

U V W
• Fig. 17.4, cont’d
 CHAPTER 17 Management of Multidisciplinary Patients With TADs 273

X Y Z

ZA ZB ZC

ZD ZE
• Fig. 17.4, cont’d

the right second molar. The right mandibular third molar
was impacted distal to the second molar. The plan for this
patient included the extraction of the maxillary right first
premolar to retract the incisors, reducing the proclination of
these teeth and the overjet, and to protract the lower right
second molar to reduce the edentulous space to a single
endosseous dental implant. On the mandibular left side, the
buccal segment was to be protracted to match the maxillary
midline while maintaining the edentulous sites.
Two ridge 2 × 9-mm Lomas mini-implants were placed
mesial to both mandibular second molars. These mini-
implants allowed for better stiffness of the archwire in the
edentulous spans as the interbracket distance was reduced.
The result was better control of the adjacent teeth to be
moved. On the right side, the first molar was moved anteri-
orly, allowing for the eruption of the third molar into occlu-
sion and reduction of the edentulous span to the space of a
single restoration with an endosseous dental implant. On
274 PA RT V I I Management of Multidisciplinary and Complex Problems

the left side, the ridge mini-implant was used to correct the
mandibular yaw. The left buccal segment was protracted
to correct the lower midline deviation and the mesiodistal
width of the edentulous sites was maintained, preserving the
space for two endosseous dental implants.
TADs in Patients With Compromised
Maxillary Incisors
Another specific clinical situation, where mini-implants are
appropriate in multidisciplinary care, is evident when some
of the teeth in the arch have poor prognosis and anchorage
cannot be drawn from them. Fig. 17.5 illustrates a 24-year-
old male patient with significant root resorption of the
maxillary central incisors and congenitally missing the right
maxillary incisor. The buccal occlusion was Class I bilater-
ally and the maxillary incisor anteroposterior position and
lip support was normal. The treatment plan for this patient
included either the substitution of the canine for the lateral
incisor, and the replacement of the two significantly resorbed
incisors, with two endosseous dental implants placed next
to each other; or the placement of two dental implants in
the sites of the right lateral incisor, and left central incisor,

A B C

D E

F G H

I J K
• Fig. 17.5 Infrazygomatic temporary anchorage device (TAD) for anchorage to retract a canine on a patient
with severely resorbed maxillary central incisors. (A–D) Pretreatment intraoral photographs and panoramic
radiograph (E). (F–H) Progress of treatment showing the distalization of the maxillary right canine, bypass-
ing the severely resorbed incisors. (I–L) Progress showing space development for the congenitally missing
right lateral incisor. (M–P) Bonding of central incisors to achieve proper anterior spacing for an implant
supported bridge, from the right lateral to the left central incisor, after distalization of the canine.
 CHAPTER 17
L M
N O
• Fig. 17.5, cont’d
and a pontic on the right central incisor supported by the
two implants. This last option was selected as the restor-
ative prosthodontist believed that the soft tissue, especially
the papillary heights, would have a better esthetic outcome
if the implants were separated by a pontic. To achieve this
objective, it was required to maintain perfect anchorage on
the right side while retracting the canine. This was achieved
by placing a 2 × 9-mm Lomas IZ mini-implant (Mondeal
Medical Systems, Donau, Germany) from which a retrac-
tion force was applied. A 0.019 × 0.025-inch stainless steel
archwire bypassing the anterior teeth was placed and a
bracket with an extension arm bonded to the canine. The
canine was retracted to a Class I canine relationship and a
then the anterior teeth were bonded for proper space appro-
priation and placement of a temporary esthetic pontic.
Skeletal Anchorage in Orthognathic
Surgery
Another example where skeletal anchorage is useful in mul-
tidisciplinary treatment occurs in orthognathic surgery. Of
recent, the surgery first approach has become a popular
treatment method in orthognathic surgery, for patients with
dentofacial deformity, with some advantages over the con-
ventional three-stage approach.4,5 Some of these patients
may present with congenitally missing lateral incisors that
could be treated with canine substitution, as a presurgical
phase, while the patient is still growing. The protraction
of the posterior segment into the site of the missing lateral
incisor can be achieved in a very inconspicuous manner, if
addressed from the palate.
Management of Multidisciplinary Patients With TADs 275
P
Case Report Five
Fig. 17.6 illustrates a 17-year-old male patient with a moder-
ately concave profile, midface deficiency, and a Class III maloc-
clusion with anterior and posterior crossbites. The patient was
congenitally missing the maxillary left lateral incisor. Based on
his age, it was decided to monitor his growth through serial
cephalograms to properly determine if the skeletal growth had
ceased. During this time, it was prescribed for the patient to
receive a very limited presurgical orthodontic phase consisting
of a protraction appliance to the left buccal segment for the
canine substitution. Two maxillary 1.8 × 8-mm IMTEC Ortho
mini-implants (3M Unitek, Ardmore, Okla) were placed on
both sides of the palate, slightly lateral to the midpalatal raphe.
An appliance that connected two O-caps (IMTEC Ortho, 3M
Unitek, Ardmore, Okla) was fabricated, which consisted of a
tracking bar that extended parallel to the left buccal segment. A
molar band was attached to the tracking bar, through an exten-
sion arm from the lingual side, with a soldered headgear tube
that engaged the tracking bar as described in the patient in Fig.
17.1. A coil spring, delivering 200-g of force, was used from
the extension arm to a hook in the appliance to close the space
mesial to the premolars. After 7 months of molar protraction
and with the determination of skeletal growth completion,
the patient was bonded with full labial orthodontic appliances
for a modified surgery first approach. With this protocol, no
alignment or leveling of the arches was done before surgery.
Passive wires were inserted before the surgical procedure. Two
weeks after surgery, the orthodontic treatment was started to
align and level the arches and refine the occlusal result. The
postsurgical orthodontic treatment lasted for 16 months with
very good esthetic and occlusal results.
276 PA RT V I I Management of Multidisciplinary and Complex Problems

A B C

E F G
• Fig. 17.6 Protraction of the buccal segment into congenitally missing lateral incisor from palatal tem-
porary anchorage devices (TADs) before orthognathic surgery. Pretreatment extraoral (A–C) and intraoral
photographs (D–G). Pretreatment lateral cephalogram (H) and panoramic (I) radiographs. (J) Left molar
protraction device from two palatal IMTEC Ortho mini-implants. (K–N) Progress of molar protraction with
all anterior spaces closed. Patient with brackets bonded and ready for a modified surgery first approach.
Postsurgical extraoral (O–Q) and intraoral (R–T) photographs. Posttreatment extraoral (U–W) and intraoral
(X–ZA) photographs. (ZB) Posttreatment lateral cephalogram.
 CHAPTER 17 Management of Multidisciplinary Patients With TADs 277

H I

J K

L M N
• Fig. 17.6, cont’d
278 PA RT V I I Management of Multidisciplinary and Complex Problems
O P
R S
• Fig. 17.6, cont’d
Mini-implants in Vertical Alveolar Ridge
Development
Finally, skeletal anchorage is also a good tool for the vertical
alveolar bone development, in patients with compromised
periodontal support and esthetics in the anterior region. Ver-
tical alveolar bone development can be performed in a local-
ized manner, with anchorage derived from a mini-implant.6
Case Report Six
Fig. 17.7 shows a 53-year-old female patient with reduced
periodontal attachment in the anterior maxillary region.
Specifically, the right lateral and central incisors were affected
by bone loss and had supraerutped, resulting in unesthetic
consequences that included recession and significant open
gingival embrasures in this region. The patient wanted to
address her smile esthetics in the anterior region of the
maxilla. A treatment plan was prescribed that included the
forced eruption of both the right central and lateral incisors,
until adequate vertical alveolar bone height was obtained.
This vertical alveolar bone displacement also resulted in
better gingival architecture, before the placement of an
endosseous dental implant. Because of limited finances, a
single implant in the central incisor site was placed after the
extraction of both right incisors. A cantilever ovate pontic
from the central incisor implant was to be placed to mimic
the gingival contours of the contralateral lateral incisor.
Q
T
A 2 × 9-mm Lomas mini-implant (Mondeal Medical
Systems, Donau, Germany), with a slot in the attachment
head, was placed between the right incisors. Brackets were
bonded to both incisors and connected with a 0.019 ×
0.025-inch stainless steel wire segment, inserted in the slot
of these brackets passively. A double tube, one in a verti-
cal and the other in a horizonal direction, was welded to
this archwire. Another 0.019 × 0.025-inch stainless steel
archwire was inserted through the slot of the mini-implant
and the vertical tube of the double tube. The wire was left
long and bent on the gingival portion and a coil spring
delivering an extrusion force was placed. The lower por-
tion of the wire was cut to prevent any discomfort of the
patient. The final esthetic result shows the significant smile
esthetics enhancement through the coronal migration of
the gingival margin levels, with the reduction of the open
gingival embrasures.
Conclusion
Skeletal anchorage is a powerful aid in multidisciplinary
treatment. Patients undergoing preprosthetic orthodontics
and orthognathic surgery benefit from the use of mini-
implants and miniplates. Multiple options for skeletal
anchorage are available that include preprosthetic space
appropriation, vertical alveolar ridge development, increased
archwire stiffness in edentulous sites and protraction of seg-
ments, before orthognathic surgery.
 CHAPTER 17 Management of Multidisciplinary Patients With TADs 279

U V W

Y Z ZA

ZB
• Fig. 17.6, cont’d
280 PA RT V I I Management of Multidisciplinary and Complex Problems

A C

B D E

F G
• Fig. 17.7 Vertical alveolar bone development from a mini-implant in the anterior maxillary region. (A) Smile
photograph showing the affected anterior esthetics, with periodontal attachment loss. (B) Supraerupted
maxillary right central and lateral incisors creating an unesthetic black triangle. (C) Panoramic radiograph
showing the reduced vertical bone levels on the right maxillary incisors. (D–G) Progress of the eruption of
the two right incisors from a temporary anchorage device (TAD) placed in the interradicular bone between
these two teeth.
 CHAPTER 17 Management of Multidisciplinary Patients With TADs 281

H
K

J M
• Fig. 17.7, cont’d (H) Periapical radiograph showing the progress and vertical ridge development. (I)
Retention wire to hold the vertical alveolar development. Note the favorable coronal migration of the soft
tissue. Radiograph with wire retainer showing the vertical alveolar bone development (J) and after implant
placement in the right central incisor site (K). (L) Smile photo with the temporary restoration of a canti-
levered lateral incisor pontic from the central incisor implant. (M) Close up of the temporary restoration
showing the drastic reduction in the black triangle and the natural interface between the pontic and the
gingiva on the right lateral incisor site.
282 PA RT V I I Management of Multidisciplinary and Complex Problems
Acknowledgments
We would like to acknowledge all the residents and faculty who par-
ticipated in the treatment of these cases.
References
1. Keim RG, Gottlieb EL, Vogels DS, Vogels PB: 2017 JCO Orth-
odontic practice study, J Clin Orthod 51:639–656, 2017.
2. Huang LH, Shotwell JL, Wang HL: Dental implants for orth-
odontic anchorage, Am J Orthod Dentofacial Orthop 127:713–
722, 2005.
3. Weber D, Handel S, Dunham D: Use of osseointegrated implants
for orthodontic anchorage, J Clin Orthod 51:406–410, 2017.
4. Nagasaka H, Sugawara J, Kawamura H, Nanda R: “Surgery first”
skeletal Class III correction using the skeletal anchorage System, J
Clin Orthod 43:97–105, 2009.
5. Yang L, Xiao YD, Liang YJ, Wang X, Li JY, Liao GQ: Does the
surgery-first approach produce better outcomes in orthognathic
surgery? A systematic review and meta-analysis, J Oral Maxillofac
Surg 75:2422–2429, 2017.
6. Fritz UB, Diedrich PR: Clinical suitability of titanium miniscrews
for orthodontic anchorage. In: R N, editor: Temporary anchorage de-
vices in orthodontics, St. Louis, Missouri, 2009, Elsevier, pp 287–294.
18
Second Molar Protraction and Third
Molar Uprighting
UN-BONG BAIK
Introduction
Recently, with the help of temporary anchorage devices
(TADs), substantial mandibular second molar protraction
into the space created by a missing mandibular first molar
(L-6) or retained deciduous mandibular second molar
(L-E), without the succedaneous premolar, has become
possible.1–9
When patients have impacted third molars, second molar
protraction into the space of the missing tooth may pro-
mote the eruption of impacted third molars. Although the
mechanics of second molar protraction may be challeng-
ing in some cases, most horizontally impacted third molars
can be uprighted and serve as a substitute for implants or
prostheses.
The specific changes of impacted third molars following
second molar protraction, such as spontaneous vertical erup-
tion, horizontal movement, angular change, and others, are
not yet known. Previous studies on the eruption or move-
ment of third molars have mostly focused on their natural
eruptive pattern, on patients who underwent extraction of
premolars or second molars for orthodontic purposes.10–17
This chapter describes the movement of impacted third
molars after second molar protraction.
• Fig. 18.1 U-NE + L-6: Final occlusion should be molar Class I relationship. (Canine relation: Class I)
Currently, 212 cases of second molar protraction into
the space of a missing first molar or second premolar have
been completed. Among them, there was agenesis of the
third molars in 30 cases, 75 cases already had erupted third
molars, and 107 had impacted third molars. This chapter
describes the specific type of displacement observed in these
107 impacted third molars after second molar protraction.
Various types of posterior occlusion may be observed
when protracting mandibular molars. These types depend
specifically on the site of the missing posterior teeth. Among
them, the mandibular second molar can conform to one
of the following four occlusal relationships. In this chapter,
the term “Class I molar relationship” is used to describe the
position of the second molars that have been moved into the
first molar location. In addition, the term “U-6” signifies a
missing maxillary first molar, “NE” means nonextraction,
and “U-4” means upper bicuspid extraction.
1. U-NE (maxillary nonextraction treatment) + L-6: Class I
molar relation (Fig. 18.1)
2. U-6 (missing maxillary first molar) + L-6: Class I molar
relation (Fig. 18.2)
3. U-NE + L-E: Class III molar relation (Fig. 18.3)
4. U-4 (maxillary first premolar extraction treatment) +
L-6: Class II molar relation (Fig. 18.4)
283
284 PA RT V I I Management of Multidisciplinary and Complex Problems

• Fig. 18.2 U-6 + L-6: Final occlusion should be molar Class I relationship. (Canine relation: Class I)

• Fig. 18.3 U-NE + L-E: Final occlusion should be molar Class III relationship. (Canine relation: Class I)

• Fig. 18.4 U-4 + L-6: Final occlusion should be molar Class II relationship. (Canine relation: Class I)

Third Molar Changes With Second Molar
Protraction
There have been many reports regarding the normal devel-
opment or movement of the third molar after second molar
extraction.10–17 Meanwhile, sufficient research has not been
conducted on the eruption of an impacted third molar,
after second molar protraction. The reason for this paucity
in research has been that predictable molar protraction has
been only available until recently, with the advent of TADs.
The spontaneous movement of an impacted third molar
is multidimensional. Therefore analysis should be performed
separately in each direction. Moreover, the studies on spon-
taneous angular changes and alveolar bone level are needed.
Studies on the vertical eruption patterns of impacted man-
dibular third molars, after protraction of second molars, were
performed and were recently published.18 This study was able
to show that even the most severely impacted mandibular
third molars may spontaneously erupt after second molar
protraction, without the aid of any appliances. Even in such
cases, where the root formation was slightly insufficient in the
initial stage, the root eventually fully developed and the third
molar erupted (Fig. 18.5). Furthermore, in adults whose
third molar root was completely developed, proper eruption
 CHAPTER 18 Second Molar Protraction and Third Molar Uprighting 285

A B C D
• Fig. 18.5 Spontaneous vertical eruption of an impacted third molar in a 17-year-old female. (A) Initial; (B)
Treatment progress; (C) Posttreatment; (D) 5 years and 8 months after debond. The missing mandibular
left first molar space closed completely. The root was fully translated with no evidence of tipping. Although
this was an adult and the third molar root was well developed, the third molar still erupted into the oral
cavity, without the aid of any appliance.

A B C D
• Fig. 18.6Spontaneous eruption and uprighting of the third molar on a 15-year-old male. (A) Radiograph
depicting extraction of left mandibular first molar. (B) Treatment progress showing space closure with erup-
tion and uprighting of the third molar. (C) Posttreatment radiograph showing the missing first molar space
closed completely; the impacted third molar followed spontaneously the second molar, without using any
orthodontic appliances. (D) Three years and 6 months after debond.

A B C D
• Fig. 18.7Unresponsive mandibular third molar to significant second molar protraction. (A) Pretreatment.
(B) Treatment progress of the protraction of the second molar. (C) Treatment progress with complete of
space closure mesial to the second molar. (D) Treatment progress after the uprighting of the third molar.
Surgical access and traction were necessary.

A B C D
• Fig. 18.8 No change in third molar angulation after considerable second molar protraction. (A)
Pretreatment; (B) Treatment progress during initial protraction of the second molar; (C) Space closure
almost complete; (D) No distinct movement of the third molar observed although appropriate space was
available.

followed in most of the cases. In this respect, age, gender,
Nolla stage, and angle of the third molars did not show sig-
nificant correlations with the vertical change of the impacted
third molars, whereas, the depth of third molar impaction
and available space showed significant correlations.
In general, an impacted mandibular third molar follows
the movement of the second molar during the protrac-
tion (Fig. 18.6). However, in some cases, the third molar
does not follow the second molar (Fig. 18.7). Preliminary
studies reveal that the mesial movement of the third molar
increases, as second molar protraction and Nolla stage of the
third molar increase, and when the molar is located close to
the occlusal plane.
The spontaneous angular changes of an impacted man-
dibular third molar vary significantly. The angle remained
constant (Fig. 18.8); uprighted without using any appli-
ances (Fig. 18.9); while in some other cases, the third molar
tipped more (Fig. 18.10). Preliminary findings evaluating the
286 PA RT V I I Management of Multidisciplinary and Complex Problems

A B C D
• Fig. 18.9 Spontaneous third molar uprighting on a 27-year-old male with poor prognosis of the left man-
dibular first molar. (A) Pretreatment showing complete horizontal impaction of the third molar. (B) Treatment
progress immediately after extraction of the first molar. (C) Treatment progress during protraction of the
second molar. (D) Considerable space closure achieved with partial uprighting and eruption of the third molar.

A B C D
• Fig. 18.10 Spontaneous mesioangular tipping of the third molar on a 22-year-old female. (A) Third molar
deeply impacted at pretreatment. (B) Treatment progress during protraction of the second molar. (C) Space
closure almost complete and third molar erupting. (D) Posttreatment showing increased third molar mesio-
angular tip, as the second molar was protracted.

predictability in the changes suggest that: (1) older patients
with more developed third molars tend to have these sponta-
neously upright; (2) available space for third molar eruption
before and after second molar protraction is not associated
with the angular change; (3) increased rate in the eruption
process of third molars is associated with third molar upright-
ing; and (4) an increased rate of movement of the second
molar may result in mesial tipping of the third molars.
Alveolar bone changes of the second and third molars
are of interest, since this approach is prolonged and orth-
odontic appliances are needed for longer periods of time.
Our experience shows that the posttreatment alveolar bone
level of fully impacted third molars are good; however, those
of the second molars vary. In particular, the distal alveolar
bone level shows a large variation. It is not known what fac-
tors influence these phenomena. Currently, we are conduct-
ing three-dimensional computed tomography scans studies
to evaluate these specific changes.
Cases of Horizontally Impacted Third
Molars
The following case reports illustrate the displacement
changes observed on horizontally impacted third molars,
resulting from second molar protraction. Partial uprighting
with anterior movement and eruption of the crown allowed
for placement of the third molars in proper occlusion.
Case One
A 29-year-old female, with chief complaint of protrusion
and crowding, presented for orthodontic treatment. Her
skeletal pattern was Class II. The right mandibular first
molar had a periapical lesion for which the prognosis was
deemed to be poor (Fig. 18.11). Treatment involved extrac-
tion of both maxillary first premolars and the right man-
dibular first molar. The space from the missing lower first
molar was closed through second molar protraction. Signifi-
cant molar protraction was necessary, which typically results
in more side effects during the orthodontic movement.12
The mandibular third molar was horizontally impacted and
had an antagonist (Fig. 18.12).
An 0.018-inch slot and a straight wire appliance was
used. In the upper arch, canine retraction was performed,
while in the lower arch, second molar protraction was
performed using sliding mechanics. A TAD was inserted
in the lower right bicuspid area for protraction of the sec-
ond molar (Fig. 18.13). After certain amount of canine
retraction, brackets were bonded on the anterior maxil-
lary teeth. The mandibular second molar was protracted
considerably without tipping, and the impacted third
molar erupted and partially uprighted, without orth-
odontic appliances (Fig. 18.14).
During the space closure phase, long vertical hooks were
attached for maximum retraction of the anterior teeth from
the mini-implants. In the lower arch, midline correction
was performed using the mini-implants for anchorage. A
bracket was bonded to the impacted right third molar for
root control (Fig. 18.15).
The final occlusion showed good intercuspation, with an
improvement on the facial profile. In the lower arch, the
right second and third molars were uprighted completely.
The molar occlusion was Class II on both sides. The alveo-
lar bone condition and the periodontal status of the third
molar were adequate. The distal alveolar bone of the man-
dibular right second molar showed a vertical bone defect.
Since the third molar was impacted horizontally behind the
 CHAPTER 18
• Fig. 18.11
Pretreatment records. (A-E) Intraoral photographs; (F) initial lateral cephalogram; (G) initial pan-
oramic radiograph.
second molar before treatment, the alveolar bone in that
area may have been absent from the beginning (Fig. 18.16).
The superimposition shows that the mandibular right
second molar was purely protracted to the space of the miss-
ing mandibular first molar. The horizontally impacted third
molar was uprighted. The upper anterior teeth and lip were
retracted significantly (Fig. 18.17).
Three years and 8 months later, the occlusion was stable.
The uprighted third molar was in good condition. The distal
alveolar bone level of the mandibular right second molar
had not worsen. The lamina dura was clearly defined. The
mandibular left second molar was recently extracted because
of an endodontic problem (Fig. 18.18).
Case Two
A 22-year-old female with the mandibular left second molars
presented with a scissors-bite, and the left first molar was
absent. Initially, the scissors-bite was corrected and the sec-
ond molar protracted. The left missing first molar space was
closed completely, through full protraction of the second
Second Molar Protraction and Third Molar Uprighting 287
molar. The third molar that was initially deeply impacted
was uprighted (Fig. 18.19).
Case Three
A 22-year-old female presented with a chief complaint of
upper anterior teeth protrusion. Her lower anterior teeth did
not protrude, and the lower left first molar was not in good
condition. After the extraction of the lower left first molar,
the missing molar space had to be closed by full protraction
of the second molar. After treatment, the missing mandibu-
lar left first molar space was closed completely. Although the
third molar was initially deeply impacted, it was uprighted
completely after second molar protraction. The periodontal
condition was adequate, the lamina dura was intact, and the
alveolar bone levels were appropriate (Fig. 18.20).
Conclusion
Mandibular second molar protraction into the space of
missing first molars or second premolars is a predictable
288 PA RT V I I Management of Multidisciplinary and Complex Problems

• Fig. 18.12 Treatment progress after extraction of teeth. (A-E) Progress intraoral photographs; (F) progress
panoramic radiograph. Note the horizontal impaction of the right mandibular third molar.

• Fig. 18.13 Treatment progress, initial space closure.

 CHAPTER 18 Second Molar Protraction and Third Molar Uprighting 289

• Fig. 18.14Treatment progress, full bonding of the maxillary teeth. (A-E) Progress intraoral photographs;
(F) progress panoramic radiograph. Note some degree of uprighting of the right mandibular third molar.
290 PA RT V I I Management of Multidisciplinary and Complex Problems

• Fig. 18.15 Treatment progress, final space closure and mandibular midline correction. (A-E) Progress
intraoral photographs. Mini-implant placed on the left side for midline correction; (F) progress panoramic
radiograph showing the right mandibular third molar uprighted after a tube was bonded.
• Fig. 18.16 Final records. (A-E) Final intraoral photographs; (F) final lateral cephalogram; (G) final pan-
oramic radiograph. Note the proper angulation of the right mandibular third molar.

• Fig. 18.17
Superimposition depicting full translatory movement of the
mandibular second molar.
292 PA RT V I I Management of Multidisciplinary and Complex Problems

• Fig. 18.18 Records after 3 years and 8 months follow-up. (A-E) Retention follow-up intraoral photo-
graphs; (F) retention follow-up panoramic radiograph.

A B C D
• Fig. 18.19(A) Initial; (B) treatment progress; (C) posttreatment; and (D) 3 years and 7 months after debond-
ing. (Reproduced with permission from Baik UB, Kim MR, Yoon KH, Kook YA, Park JH. Orthodontic
uprighting of a horizontally impacted third molar and protraction of mandibular second and third molars
into the missing first molar space for a patient with posterior crossbites. Am J Orthod Dentofacial Orthop.
2017;151[3]:572-582.8)
 CHAPTER 18
A B
• Fig. 18.20 Mandibular left second molar protraction after extraction of hopeless first molar. (A) Initial after
extraction of left fist molar; (B) treatment progress; (C) posttreatment; and (D) 2 years and 7 months after
debonding.
procedure, when TADs are incorporated to the biomechan-
ical approach. Currently, 212 cases of second molar pro-
traction have been completed, of which four have failed,
mainly because of periodontal problems. The failed cases
were related to protraction into the first molar site. In the
future, perhaps more meticulous case selection and simulta-
neous periodontal therapy may be able to decrease the rate
of failure.
In spite of the few failures, this approach has also favor-
able effects on impacted third molars. Dentists and other
specialists should be aware of this approach, as it may reduce
dental health costs and preserve the natural dentition.
References
1. Robert WE, Nelson CL, Goodacre CJ: Rigid implant anchorage
to close a mandibular first molar extraction site, J Clin Orthod
28:693–704, 1994.
2. Kyung SH, Choi JH, Park YC: Miniscrew anchorage to pro-
tract lower second molars into first molar extraction sites, J Clin
Orthod 37:575–579, 2003.
3. Nararaj K, Upadhyay M, Yadav S: Titanum screw anchorage for
protraction of mandibular second molars into first molar extrac-
tion site, Am J Orthod Dentofacial Orthop 134:583–591, 2008.
4. Kravitz ND, Jolley T: Mandibular molar protraction with tem-
porary anchorage devices, J Clin Orthod 42:351–355, 2008.
5. Baik UB, Chun YS, Jung MH, Sugawara J: Protraction of man-
dibular second and third molars into missing first molar spaces
for a patient with an anterior open bite and anterior spacing, Am
J Orthod Dentofacial Orthop 141(6):783–795, 2012.
6. Baik UB, Park JH: Molar protraction: orthodontic substitution
of missing posterior teeth, Create Space, 2013.
7. Kim KB: Temporary skeletal anchorage devices: a guide to design and
evidence-based solution, Heidelberg, Germany, 2014, Springer.
Second Molar Protraction and Third Molar Uprighting 293
C D
8. Baik UB, Kim MR, Yoon KH, Kook YA, Park JH: Orthodontic
uprighting of a horizontally impacted third molar and protrac-
tion of mandibular second and third molars into the missing first
molar space for a patient with posterior crossbites, Am J Orthod
Dentofacial Orthop 151(3):572–582, 2017.
9. Baik UB, Park JH, Kook YA: Correction of bimaxillary protru-
sion after extraction of hopeless mandibular posterior teeth and
molar protraction, J Clin Orthod 51(6):353–359, 2017.
10. Liddle DW: Second molar extraction in orthodontic treatment,
Am J Orthod 72:599–616, 1977.
11. Rindler A: Effects on lower third molars after extraction of sec-
ond molars, Angle Orthod 47:55–58, 1977.
12. Slodov I, Behrents RG, Dobrowski DP: Clinical experience with
third molar orthodontics, Am J Orthod Dentofac Orthop 96:453–
461, 1989.
13. Richardson ME, Mills K: Late lower arch crowding: the effect of
second molar extraction, Am J Orthod Dentofac Orthop 98:242–
246, 1990.
14. Richardson ME, Richardson A: Lower third molar development
subsequent to second molar extraction, Am J Orthod Orthop
104:566–574, 1993.
15. Orton-Gibbs Sharon, et al.: Eruption of third permanent molars
after the extraction of second permanent molars. Part 2: func-
tional occlusion. and periodontal status, Am J Orthod Dentofac
Orthop 119:239–244, 2001.
16. De-Ia-Rosa-Gay Cristina, et al.: Spontaneous third molar erup-
tion after second molar extraction in orthodontic patients, Am J
Orthod Dentofac Orthop 129:337–344, 2006.
17. De-la-Rosa-Gay C, Valmaseda-Castello´n E, Gay-Escoda C: Pre-
dictive model of third molar eruption after second molar extrac-
tion, Am J Orthod DentoFacial Orthop 137:346–353, 2010.
18. Baik UB, Kook YA, Bayome M, Park JU, Park JH: Vertical erup-
tion patterns of impacted mandibular third molars after the
mesialization of second molars using miniscrews, Angle Orthod
86(4):565–570, 2016.
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19
Class II Nonextraction Treatment With
MGBM System and Dual Distal System
B. GIULIANO MAINO, GIOVANNA MAINO, LUCA LOMBARDO, JOHN BEDNAR,
GIUSEPPE SICILIANI
In this chapter we describe a protocol for the treatment of
Class II, without compliance, that meets with predictability
the aesthetic and functional requirements of the patient.
In the nonextraction orthodontic therapy of Class II
malocclusion we use the principle of Bidimensional Tech-
nique that divides the treatment into three well-defined
phases. This enables the practitioner to readily identify
unforeseen problems by careful monitoring treatment
progress during each phase.1
The three phases of Bidimensional Technique include:
Phase 1: distalization of upper molars into a “super Class I”
relationship with the lower molars.
Phase 2: retraction of the upper canines and premolars, con-
solidation of spacing between the upper incisors, and cre-
ating three groups of teeth in the maxillary arch.
Phase 3: consolidation of the three groups of teeth by re-
tracting the upper incisors.
Phase 1: Upper Molar Distalization
The MGBM System2 is comprised of a passive anchorage
system and an active distalization system.
The passive anchorage system uses two mini-implants 10
mm in length and 1.5 mm in diameter (Spider Screw K1
HDC, Thiene, Italy) connected to a transpalatal bar.
The mini-implants can be safely inserted palatally,
between the second premolars and the first molars, because
of the anatomic space resulting from the upper first molar
single palatal root.3 Mini-implants are inserted at an angle
approximately 30 to 40 degrees with respect to palatal vault
inclination.
In some cases, the mini-implant can be inserted
between the upper first and second premolars, in the pres-
ence of wide interproximal space between these teeth. This
would permit distal drifting of the upper second premo-
lars as a result of interproximal fiber tension, during molar
distalization.
A transpalatal bar (stainless steel 0.036-inch diameter)
is bonded with composite on the occlusal surfaces of the
upper first premolars and connected to the mini-implants
by a thoroughly tightened 0.014-inch stainless steel ligature
(Fig. 19.1).
The palatal bar will prevent loss of anchorage and unde-
sirable rotation, inclination, and torsion effects on the first
premolars.
The active distalization system is comprised of sectional
0.018 × 0.022-inch SS wires and open 200-g nickel tita-
nium (Niti) coils, which extend 10 mm longer than the dis-
tance from the distal of the upper first premolar brackets to
the mesial of the first molar tubes, on each side. The second
premolars are not bracketed at this time to allow insertion
of the coils.
In the event that the maxillary second molars have
erupted, a Simultaneous Upper Molar Distalizing System
(SUMODIS) component is added to the system to distal-
ize the second molars. This component is comprised of a
double tube, a small section of 0.018 × 0.025-inch Niti
wire, and two sliding crimpable stops. Before inserting
and ligating the sectional 0.018 × 0.022-inch SS wire into
the first premolar bracket, the lower portion of the double
tube is inserted on the sectional SS wire and then an open
200-g Niti coil is inserted on the sectional SS wire, forcing
the double tube against the premolar bracket. A distogin-
givally inclined direct bonded tube is placed on the second
molar (Fig. 19.2). Two stops are crimped on the ends of
a sectional 0.018 × 0.025-inch 200-g Niti wire, which is
9 mm longer than the distance from the distal of the first
premolar bracket to the mesial of the second molar tube,
creating an arc as it is inserted into the upper portion of
the double tube, at the first premolar and the tube on the
second molar (see Fig. 19.2). The active Niti wire in excess
of 9 mm will distalize the upper second molar, while the
compressed coil will distalize the first molar simultane-
ously. The distogingival inclination of the second molar
tube is critical to minimize distal inclination of the second
295
296 PA RT V I I Management of Multidisciplinary and Complex Problems
molar crown that would result from the elasticity of the
Niti wire.
When in presence of a severe deep bite, a removable bite
plane from 3 to 3, to be used during night time, can be
delivered to the patient to facilitate lower molars extrusion,
open the bite, and decrease the occlusal forces on the first
premolars (Fig. 19.3).
• Fig. 19.1 The MGBM System. The mini-implants are inserted on the
palatal side with an inclination of 30 to 40 degrees with respect to the
palatal vault. A traspalatal bar is attached with composite to the occlu-
sal surface of the first premolars and connected to the mini-implants
with a tightened stainless steel legature.
+ 6 mm + 3 mm
• Fig. 19.2 The MGBM System with SUMODIS (Simultaneous Upper Molars Distalization System).
• Fig. 19.3 Removable bite plane from canine to canine.
Clinical Tips for Phase 1
• The tube on the second molar should be placed with a
distogingival inclination, to compensate the crown-distal
tipping effect, from the use of a superelastic Niti sec-
tional wire.
• Avoid using excessive length (greater than 9 mm excess)
of Niti sectional wire in the SUMODIS system to avoid
soft tissue damage in the vestibule of the maxilla.
• When the distalization to “super Class I” is completed
on one side before the other side, a closed coil should
replace the open coil and serve as a space maintainer on
the “super Class I” molar side, while distalization is con-
tinued on the other side.
Phase 2: Retraction of the Upper Premolars
and Canines
When the upper molars have been distalized into “super
Class I” relationship with the lower molars, two mini-
implants, 1.5 mm in diameter and 8 to 10 mm in length
(Spider Screw K1, HDC, Thiene, Italy) are inserted mesial
to the upper first molars on the buccal surfaces, with a per-
pendicular or oblique insertion angle. The palatal mini-
implants and the transpalatal bar are subsequently removed.
 CHAPTER 19 Class II Nonextraction Treatment With MGBM System and Dual Distal System
The maxillary arch is bracketed and aligned by placing
a superelastic wire (0.016 × 0.022-inch Niti) with stops,
mesial to the upper first molars and crimpable hooks, mesial
to the upper canines. A 0.012-inch steel ligature wire is
attached from the mini-implants to the archwire hooks pre-
venting molar mesial migration and loss of the Class I molar
positions (Fig. 19.4). In cases with significant crowding, the
maxillary molar stops can be positioned slightly mesial to
the upper molar tubes to permit slight mesial molar migra-
tion from the “super Class I” positions, thereby expediting
the alignment of the upper arch.
Premolar and canine distalization can be initiated imme-
diately by placing elastic chains or 50-g retraction NiTi coils
from the mini-implants to the teeth.
When alignment is complete, a 0.016 × 0.022-inch
SS archwire with stops, mesial to the upper molars, and
crimped hooks, mesial to the canines is placed. Steel liga-
tures (0.012-inch) are placed from the mini-implants to the
hooks on the archwire and the simultaneous retraction of
the upper canines and first premolars is continued using
100 to 150-g forces from the teeth to the mini-implants,
which provide direct anchorage.
• Fig. 19.4 Alignment phase using a 0.016 × 0.022-inch nickel titanium
(Niti) wire, with stop crimped mesial to the maxillary first molar, and
a steel ligature extending from the mini-implant to the hook crimped
mesial to the maxillary canine. Simultaneous distalization of the canine
and first premolar is initiated using light forces.
• Fig. 19.5 Phase 2. Simultaneous retraction of the first premolar and canine using coils from the mini-
implants to the teeth (direct anchorage). Retraction of the second premolar placing elastic chain from the
first molar to second premolar is necessary.
297
In the event that the upper molars have been distalized
into “super Class I” positions, the majority of the upper sec-
ond premolars will migrate distally, while passing buccally
to the mini-implants, under the influence of transseptal
fiber pull.
If additional distal movement of the upper second pre-
molars is required, Class I forces are applied from the first
molars to the second premolars, using indirect anchorage.
The Class I forces can be applied from the buccal or palatal
aspects to control undesirable rotations (Fig. 19.5).
The simultaneous retraction of both premolars and
canines allows a significant reduction of the treatment time.
Also, lower arch treatment can be delayed until the com-
pletion of Phase II, reducing the risk of caries and chair-
time for possible lower arch bracket replacement emergency
visits.
Clinical Tips for Phase 2
• The stops on the 0.016 × 0.022-inch SS archwire must
be in contact with the first molars, and the metal liga-
tures between the mini-implants and the hooks must be
thoroughly tight.
Phase 3: Incisors Retraction
In the Bidimensional Technique, the incisor brackets are
0.018 × 0.025-inch and the canine, premolar, and molar
brackets are 0.022 × 0.028-inch. The maximum archwire
dimension for incisor retraction is 0.018 × 0.022-inch,
thereby maintaining a complete couple in the anterior seg-
ment and allowing sliding through the posterior segment as
incisors are retracted.
When the three groups of teeth have been created and
the upper canines are in Class I relationship with the lower
canines, the retraction of the upper incisors is initiated
using sliding mechanics, by inserting a 0.018 × 0.022-inch
upper SS archwire, with hooks crimped distal to the lateral
incisors, into the pretorqued 0.018 × 0.025-inch incisor
298 PA RT V I I Management of Multidisciplinary and Complex Problems

brackets. This forms a complete couple between the incisor Clinical Tips for Phase 3
pretorqued brackets and the archwire, thereby retracting the
incisors bodily for proper incisor inclination (Fig. 19.6). • In cases where the root length is longer than average or
The three groups of maxillary teeth are combined whenever it is necessary to implement the torque control
together and the overjet is reduced. of the anterior region, a thicker SS wire 0.018 × 0.025-
A small section of closed coil is placed between the sec- inch can be used.
ond premolar brackets and first molar tubes to prevent A significant number of Class II malocclusions have a
contact of the mesial roots of the first molars with the mini- deep overbite necessitating bite opening, as the incisors are
implants and avoid root damage.4–5 retracted.
A 0.012-inch metal ligature is placed from the mini-
implants to the canines to maintain the canines and premo-
lars in Class I relationships, with the lower arch. On each
side, 300-g coils are placed from the mini-implants to the
maxillary archwire hooks to retract the upper incisors (Figs.
19.7–19.15).

LATERAL SEGMENT FRONTAL AREA:

UPPER INCISORS

0.028 0.025 0.022

0.022
0.022 0.018 0.018 0.018

• Fig. 19.6 Bidimensional brackets allows complete coupling of the full -
thickness 0.018 × 0.022-inch SS wire in the pretorqued slots of the
anterior brackets, for bodily incisor retraction and the accompanying
sliding of the lateral segments.
• Fig. 19.7Phase 3. The canines are tied back to the mini-implants with
metal ligatures. Incisor retraction is initiated with coils from the mini-
implants to the hooks crimped on the archwire. A section of closed coil
is placed between the first molars and second premolars to prevent
root contact with the mini-implants.

• Fig. 19.8 A male patient treated with the MGBM system without extractions: pretreatment extraoral
photographs.
 CHAPTER 19 Class II Nonextraction Treatment With MGBM System and Dual Distal System 299

• Fig. 19.9 Pretreatment intraoral photographs.

• Fig. 19.10 Phase 1 (molars distalization): beginning of distalization with SUMODIS (Simultaneous Upper
Molar Distalizing System) and end of distalization, with closed coils as space maintainers.
300 PA RT V I I Management of Multidisciplinary and Complex Problems

• Fig. 19.11
Phase 2: simultaneous retraction of the premolars and canines using buccally inserted mini-
implants as anchorage, 0.016 × 0.022-inch SS wire, with stops against the molars, metal ligature from
the mini-implants and the hooks crimped on the archwire and elastic chains to retract simultaneously
premolars and canines.

• Fig. 19.12 Phase III: retraction of the incisors.

• Fig. 19.13 End of treatment.

Bite opening can be achieved by upper or lower inci-
sor intrusion, molar extrusion, or a combination of these
methods, often dependent upon smile esthetics and growth
patterns.6
In the use of mini-implants as anchorage, the center of
resistance of the maxilla is almost coincident with the ver-
tical height of the mini-implant. When forces are applied
from the mini-implant to the anterior teeth, the resultant
force retracting the incisors passes below the center of
resistance of the incisors, causing mandibular plane rotation
in a clockwise direction, with molar intrusion and incisor
extrusion.7–9 Power arms can be used to prevent undesirable
rotation; however, they slow tooth movement, they are dif-
ficult to clean, and often cause soft tissue damage.10,11
Fortunately, the Bidimensional Technique allows a full
couple of pretorqued anterior brackets and archwire, and
these adverse reactions can be controlled without power
arms in the majority of cases.
 CHAPTER 19
If an exaggerated curve of Spee is placed in the upper
archwire and a reverse curve of Spee is placed in the lower
archwire, combined with vertical elastics from upper to
lower molars, the molar intrusion is eliminated and the
rotation of the occlusal plane is controlled.
The extrusion of the incisors resulting from the forces
from the mini-implants to the incisors will be controlled
• Fig. 19.14 Panoramic radiograph before and after treatment.
• Fig. 19.15 Lateral cephalometric radiograph before and after treatment.
Class II Nonextraction Treatment With MGBM System and Dual Distal System 301
by the intrusive force of the modified curves of Spee in the
upper and lower archwires (Fig. 19.16).
The use of power arms therefore could be restricted to
the very severe deep bite cases (Fig. 19.17).
In cases where second premolars are unerupted and sec-
ond molars are erupting, before or simultaneously, with the
second premolars, the mini-implants can be applied pala-
tally to avoid interradicular insertion. Through the use of
the MAPA System guide,12,13 two mini-implants 2 mm
in diameter and length dependent upon the palatal bone
thickness can be inserted palatally. In the same appoint-
ment, a bar connecting the palatal mini-implants and
bonded on the palatal or occlusal surfaces of the premolars
can be inserted in the same appointment, according to the
“one visit” protocol.14 The bar bonded to the first premolars
forms the passive anchorage component of MGBM system.
The active distalization component placed on the vestibular
side has been previously described (Fig. 19.18).
Dual Distal System
The palatal vault is many times preferred for the mini-
implant insertion because there are no roots interferences.
When using this location, the MGBM system is often
used in combination with distalization systems, which use
only palatal mechanotherapy.15,16 In fact, these palatal dis-
talization systems often have an undesirable mesial rotation
of the upper molars, causing a negative effect on the Class I
relationship, which they are trying to achieve (Fig. 19.19).
Furthermore, when the second molars have erupted,
these palatal distalization systems become less efficient in
302 PA RT V I I Management of Multidisciplinary and Complex Problems
• Fig. 19.16 Phase 3: exaggerated curve of Spee on the upper arch
and a reverse curve of Spee on the lower prevent incisor extrusion.
Vertical elastics in the posterior part of the mouth are inserted to pre-
vent intrusion of the molars.
• Fig. 19.17 Phase III: retraction of the incisors in a severe deep bite
case using power arm hooks.
• Fig. 19.18 MGBM system and SUMODIS (Simultaneous Upper Molar
Distalizing System) with mini-implants inserted in the palatal vault.
B
• Fig. 19.19 (A) Mesial rotation of the molars using the palatal mecha-
notherapy. (B) Distal rotation using the MGBM system.
achieving the desired distalization in a reasonable amount
of treatment time.
In a comparative distalization study,17 the MGBM sys-
tem produced 0.90 mm molar distalization per month,
compared to a palatal system producing only 0.33 mm per
month of molar distal movement. Consequently, adding the
MGBM system on the buccal side renders the DUAL sys-
tem far more efficient, as a result of the positive effects of the
two systems, when combined (Fig. 19.20).
Conclusion
The MGBM system represents a rational approach to the
treatment of Class II malocclusions.
It is a fact that the placement of mini-implants on the
palatal aspect is easier because of ample interradicular space.
However, the upper molars, which must be distalized, are
often rotated mesially, and MGBM distalization mechano-
therapy, applied to the buccal aspect, provides derotation of
the molars and continued rotation control throughout the
distalization process. The application of mini-implants to
the palatal vault can be used solely or can be combined with
other types of mechanotherapy, such as the MGBM system
to increase efficiency and molar control.
 CHAPTER 19 Class II Nonextraction Treatment With MGBM System and Dual Distal System
• Fig. 19.20 Dual distal system: in presence of the erupted second
molar, an MGBM system with SUMODIS (Simultaneous Upper Molar
Distalizing System) is added on the buccal aspect to facilitate molar
distalization.
The application of the SUMODIS system is an efficient
time saving approach to the distalization of upper first and
second molars simultaneously.
The use of the mini-implants as direct anchorage on
the buccal aspects in Phase II and Phase III, to retract the
canines, premolars, and incisors, minimizes the risk of any
molar anchorage loss. In the event of failure of the direct
mini-implants anchorage, the molar Class I position will
not be compromised.
The Bidimensional Technique uses two dimensions of
brackets 0.018 × 0.025-inch on the incisors and 0.022 ×
0.028-inch for the canines, premolars, and molars. This pro-
vides for a complete anterior couple of the wire and bracket
slot resulting in torque control of the incisors as they are
retracted and facilitates the biomechanics in deep bite cases.
An undersized posterior wire relative to the slot size per-
mits sliding mechanics, as teeth are moved posteriorly into
groups and as spaces are closed.
References
1. Gianelly AA: Bidimensional technique. Theory and practice, New
York, 2000, GAC Int.
2. Maino BG, Gianelly AA, Bednar J, Mura P, Maino G: MGBM
System: new protocol for Class II non extraction treatment
without cooperation, Prog Orthod 8(1):130–143, 2007.
3. Poggio PM, Incorvati C: “Safe zones”: a guide for miniscrew
positioning in the maxillary and mandibular arch, Angle Orthod
76(2):191–197, 2006.
303
4. Maino BG, Weiland F, Attanasi A, Zachrisson BU, Buyuky-
ilmaz T: Root damage and repair after contact with miniscrews,
J Clin Orthod XLI(12):762–766, 2007.
5. Kadioglu O, Buyukyilmaz T, Zachrisson BU, Maino BG: Con-
tact damage to root surfaces of premolars touching miniscrews
during orthodontic treatment, Am J Orthod Dentofacial Orthop
134:353–360, 2008.
6. Zachrisson BU: Esthetic factors involved in anterior tooth dis-
play and the smile: vertical dimension, J Clin Orthod 32:432–
445, 1998.
7. Jung M, Kim T: Biomechanical considerations in treatment
with miniscrew anchorage, Part I: the sagittal plane, J Clin
Orthod 42(2):79–83, 2008.
8. Tominaga Jun-ya, Ozaki Hiroya: Effect of bracket slot and arch-
wire dimensions on anterior tooth movement during space clo-
sure in sliding mechanics: a 3-dimensional Finite element study,
Am J Orthod Dentofacial Orthop 146:166–174, 2014.
9. Ozaki Hiroya, Tominaga Jun-ya, Hamanaka Ryo, et al.: Biome-
chanical aspects of segmented arch mechanics combined with
power arm for controlled anterior tooth movement: a three-
dimensional finite element study, J Dent Biomech 6:1–6, 2015.
10. Tominaga J, Tanaka M, Koga Y, Gonzales C, Kobayashi M,
Yoshida N: Optimal loading conditions for controlled move-
ment of anterior teeth in sliding mechanics, Angle Orthod
79(7):1102, 2009.
11. Rokutanda Hiromi, Koga Yoshiyuki, Yanagida Hiroko, Tomi-
naga Jun-ya, Fujimura Yuji, Yoshida Noriaki: Effect of power
arm on anterior tooth movement in sliding mechanics analyzed
using a three-dimensional digital mode, Orthod Waves 74:93–
98, 2015.
12. Maino BG, Paoletto E, Lombardo L, Siciliano G: MAPA: a new
high-precision 3D method of palatal miniscrew placement, Eur
J Clin Orthod 3(2):41–47, 2015.
13. Maino BG, Paoletto E, Lombardo L, Siciliani G: A three-dimen-
sional digital insertion guide for palatal miniscrew placement, J
Clin Orthod 50(1):12–22, 2016.
14. Maino BG, Paoletto E, Lombardo L, Siciliani G: From planning
to delivery of a bone-borne rapid maxillary expander in one visit,
J Clin Orthod LI(4):198–207, 2017.
15. Cozzani M, Zallio F, Lombardo L, Gracco A: Efficiency of the
distal screw in the distal movement of maxillary molars, World J
Orthod 11(4):341–345, 2010.
16. Wilmes B, Drecher D: Application and effectiveness of the
Beneslider: a device to move molar distally, World J Orthod
11(4):331–340, 2010.
17. Cozzani M, Fontana M, Maino BG, Maino G, Palpacelli L,
Caprioglio A: Comparision between direct vs indirect anchorage
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86:399–406, 2016.
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20
Anchorage of TADs Using Aligner
Orthodontics Treatment for Lower
Molars Distalization
KENJI OJIMA, JUNJI SUGAWARA, RAVINDRA NANDA
Introduction
In recent years, challenging aligner treatments, which require
molar control, have become a possibility.1–12 There have
been several reports of positive results of aligner treatments
with maxillary molar distalization. We would like to share
with you two cases that we treated with Invisalign in which
we performed mandibular molar distalization using mini-
implants on the lower molars as anchorage for elastics.
Case One
The patient was a 27-year-old female whose chief complaint
was lateral openbite, leading to impaired mastication and lower
anterior crowding, as well as desire to improve the facial profile.
The patients’ facial configuration displayed frontal sym-
metry, with a slight protrusion of the lower lip. Intraorally,
the upper and lower midline were approximately in line,
central incisors displayed edge-to-edge bite, the upper and
lower canines and first molars were in Class III relationship
with anterior crowding, and an excessive curve of Spee, with
a pronounced lateral openbite. Furthermore, compared to
the lower dentition, the upper dental arch was contracted.
Occlusion was unstable. Results of the cephalometric analy-
sis showed that the ANB was −1.1 degrees, Wits −10.0, com-
pared to the maxilla, the mandible was further forward, the
mandibular plane was open in a skeletal Class III relationship.
With regards to the incisor tooth axis, both upper and lower
incisors displayed lingual inclination. A panoramic x-ray
showed no pathologies, the upper and lower third-molars on
both sides had been extracted and there were no locations of
pathologic root resorption identified (Figs. 20.1–20.3).
Treatment Goals
We planned lower molars distalization to achieve Class
I relationship and improve the facial profile through
improvement of the molar relation, edge-to-edge bite of the
incisors, and the lateral openbite.
Treatment Alternatives
There were three possible treatments to achieve the treat-
ment goals. The first option was a combined orthodontic
treatment option, including a sagittal split ramus osteotomy
(BSSO). Treatment time would be 24 months. The second
option, while nonsurgical, included extraction of all four
upper and lower premolars (treatment time 24 months).
The third option was more ambitious than the other two:
nonextraction distalization of the posterior and lateral lower
teeth, using a removable aligner (predicted treatment time
between 30 and 36 months). After receiving an explanation
of the benefits and drawbacks of each option, the patient
expressed interest in the option that was least conspicuous,
nonsurgical, nonextraction, with the lowest expectation of
a large change in the facial profile and potential to finish
in 2 years’ time. Following a comprehensive examination
of patient needs and treatment options, the third option,
treatment with aligner technology Invisalign System,13–28
was chosen.
Treatment Progression
The aligner treatment began with a three-dimensional intra-
oral scan of the teeth and occlusion, followed by a treat-
ment simulation using ClinCheck. The treatment plan was
decided based on this simulation (Fig. 20.4).
The main tooth movements were as follows:
1. Distalization of the lower molars (approx. 4 mm) to
achieve a Class I relation.
2. Intrusion of the lower molars to produce an appropriate
overbite.
3. Lateral expansion of the upper dental arch (approx.
7 mm).
305
306 PA RT V I I Management of Multidisciplinary and Complex Problems

A B C

D E

F G
• Fig. 20.1 (A–E) Pretreatment intraoral photos. (F–G) Pretreatment extraoral photos.

• Fig. 20.2 Pretreatment panoramic radiograph.

Attachments were not used from initial insertion of the

aligner and attached after 1 month into treatment. Rectan-
gular attachments were affixed to the lower teeth from the
molars to the canines (Fig. 20.5). After the second month,
we began distalization of the lower molars, planned to
move one tooth at a time in sequence, beginning with
the rear-most molars. Following the completion of molar
distalization, we began distalization of the premolars (Fig.
20.6). To prevent mesial drift and create an anchor for the • Fig. 20.3 Pretreatment lateral cephalogram.
distalization of teeth, from the canines forward, temporary
anchorage devices (TADs) were installed between the lower and incisors and finished with an optimal overbite of the
first molar and second molar and elastics were used (Figs. anterior teeth.
20.7–20.9). Following the completion of molar and pre- During treatment, after the first 10 months of aligner use,
molar distalization, we began distalization of the canines minor imperfections were detected such as slight torsion of
 CHAPTER 20 Anchorage of TADs Using Aligner Orthodontics Treatment for Lower Molars Distalization 307

B C

D E
• Fig. 20.4 (A–E) Initial situation in the ClinCheck software.

• Fig. 20.5 Attachment on.

 • Fig. 20.6 Start mandibular molar distalization and intrusion maxillary molars.

• Fig. 20.7
Sequential distalization of mandibular molars. Then place temporary anchorage devices
(TADs) between #36,37 and #46,47 for retraction #34,44.

• Fig. 20.8After finished distalization premolar then retraction #33,43 using temporary anchorage
devices (TADs).

• Fig. 20.9 Mandibular anterior retraction.

 CHAPTER 20 Anchorage of TADs Using Aligner Orthodontics Treatment for Lower Molars Distalization 309

B C

D E

F G H
• Fig. 20.10 (A–E) Posttreatment intraoral photo. (F–H) Posttreatment extraoral photo.

the lower canines and lower incisors, and we planned for
extra aligners for refinement and finishing (Fig. 20.10). Fol-
lowing the completion of treatment, Vivera retainers were
used to retain the position.
Treatment Results
Examination of the posttreatment facial profile photographs
show that tension in the lips had been relaxed and the lower
lip had retracted slightly. The patient was satisfied with this
result. Intraoral pictures showed that an appropriate overjet-
bite had been achieved, upper and lower canines and molars
had achieved Class I relation, and lateral openbite had been
perfectly improved. Posttreatment, dental arch width had
greatly increased, but molars achieved good occlusion. The
final situation is in line with the final ClinCheck simulation
results (Fig. 20.11).
Crowding in the lower anterior teeth had been relieved
and, while there was slight retraction in the interdental
papilla, it was barely noticeable and no periodontal pockets
had formed. Posttreatment panoramic x-rays showed main-
tained dental parallelism, with no obvious root resorption
in the alveolar bone (Fig. 20.12). Superimposed pre- and
posttreatment cephalometric analyses show no anterior-
posterior shift of the mandible and a slight counterclock-
wise rotation (Fig. 20.13) and cephalometric analysis data.
Upper incisors exhibited a slight labial inclination and
extrusion and lower incisors exhibited labial inclination
and extrusion. The upper first molars exhibited almost no
change (Fig. 20.14).
At the end of treatment, 20 stages of upper aligners and
61 stages of lower aligners were used over 10 months. In
refinement, an additional 6 months were added to treat-
ment with 10 additional upper stages and 34 lower stages
for a total of 16 total months of treatment. One-year post-
treatment and occlusion was stable with no change (Figs.
20.15 and 20.16).
Case Two
The patient was an 18-year-old male with a chief complaint
of anterior openbite. In his facial appearance, an intraoral
and radiography findings on the first examination, exten-
sion of the lower face, crowding and dental compensation
of the upper and lower dentitions, and openbite between
the premolars were observed. In the skeletal findings,
310 PA RT V I I Management of Multidisciplinary and Complex Problems

B C

D E
• Fig. 20.11 (A–E) Posttreatment ClinCheck software simulation.

• Fig. 20.12 Posttreatment panoramic radiograph.

mandibular overgrowth-associated mandibular protrusion

was noted (Figs. 20.17 and 20.18). Based on these observa-
tions, the patient was diagnosed with skeletal mandibular
protrusion and surgical orthodontic treatment was indi-
cated; orthodontic treatment using an aligner and TADs
was selected. Before the initiation of treatment, tooth move-
ment was predicted by computer simulation software (Clin-
Check) and attachments were set as shown (Fig. 20.19).
When this patient came to our clinic, we determined they
were a skeletal Class III and a candidate for orthognathic • Fig. 20.13 Posttreatment lateral cephalogram.
 CHAPTER 20 Anchorage of TADs Using Aligner Orthodontics Treatment for Lower Molars Distalization
surgery. However, both the patient and their mother had
strong feelings against orthognathic surgery, but still sought
a significant aesthetic improvement. Our treatment plan
for this patient included attachment of TADs on the lower
molars, as anchorage for aligners with elastics, a camouflage
treatment.
Treatment Progression
Treatment plan combined with distalization of the man-
dibular molars and concomitant use of TADs was planned.
Considering the biomechanics of the teeth, distalization
of the mandibular molars by elastic rubber traction using
TADs, counterclockwise rotation of the mandible setting
the rotation center at the mandibular premolars by intru-
sion of the upper and lower molars, and extrusion of the
maxillary anterior tooth region were planned (Fig. 20.20).
Treatment Results
Sequential distalization of the mandibular molars using TADs
and counterclockwise rotation of the mandibular body by
intrusion of the molars were simultaneously performed over
the treatment period, and not only improvement of the ante-
rior tooth overbite, but also construction of a functional Class
I occlusion in the molar region were achieved (Figs. 20.21
Palatal Plane at
anterior nasal spine (ANS)
Black: Pre Treatment Mandibular Plane at Me
Red: Post Treatment
• Fig. 20.14 Lateral cephalometric superimpositions between the pre-
treatment and posttreatment stages: overall, maxilla, and mandible.
Maxillary incisors exhibited a slight labial inclination and extrusion and
mandibular incisors exhibited labial inclination and extrusion. The max-
illary fist molars exhibited almost no change.
• Fig. 20.15 ClinCheck software superimposition.
311
and 20.22). The duration of treatment was 43 months, and
the occlusal state improved as simulated by ClinCheck (Fig.
20.23). As of 2 months after completion of orthodontic treat-
ment, the occlusal state has been stable. When cephalograms
were superimposed, forward movement of the mandible by
counterclockwise rotation of the mandibular body predicted
before treatment was observed, and the anterior tooth over-
bite had significantly improved (Fig. 20.24).
Discussion
When planning a treatment using a digital planning infrastruc-
ture, such as that with the Invisalign system, you must consider
not only the ClinCheck, but if TADs are used for anchorage,
you must also consider biomechanics and reactionary force in
your treatment plan. Furthermore, when planning mandibular
molar distalization, you must also consider the condition of the
jaw bone and roots. It has been suggested in the literature that,
by using TADs to secure anchorage, molar distalization pro-
cedures in an aligner treatment have indeed become possible.
However, the most effective movement plan is not simultane-
ous, but sequential staging.
Since its release, the modern aligner system has gone
through various improvements, evolving to expand the
range of possible treatments to a wider variety of com-
plicated malocclusion. Compared to the long history of
edgewise methods, however, to predict the safe and accu-
rate completion of this treatment, with a high degree of
certainty, would be challenging. Furthermore, with molar
distalization in cases of openbite, to avoid the molar rais-
ing wedge effect, what we considered to be the key to the
success of this treatment, we decided that rather than an en
masse movement using TADs and extraoral force, would
opt for a more time consuming, but safer treatment plan,
with individual tooth movements, which would allow a
greater degree of control. We explained to the patient that
treatment with aligners could take up to 3 years and that
she should not expect a drastic improvement in facial pro-
file. The patient agreed to use assistive TADs to prevent
mesial movement of the distalized teeth. We were espe-
cially concerned with the distalization of the first and
second lower molars and, after distalization of the second
molar, half of the total movement distance, we began dis-
talization of the first molar. When we began retraction of
the premolars, to prevent mesial movement of the molars
moved thus far, we had implanted TADs between the first
and second molars, which had unfortunately come loose
midtreatment and we reattached them to the distal side of
the second molar.
312 PA RT V I I Management of Multidisciplinary and Complex Problems

B C

D E
• Fig. 20.16 (A–E) Intraoral situation after 1-year retention.

When treating overbite, our main goal is to increase the
depth of the anterior occlusal bite. Schupp has reported
that, in his aligner treatments, he has used attachments
to achieve not relative, but absolute extrusion. With KIM
using the edgewise method (MEAW), he reported that it is
necessary to change the occlusion plane.28–32 Results from
the present study also indicate absolute extrusion of the
anterior teeth and inclination of the occlusal plane.
In our plan to move teeth with aligners, movements can
be roughly divided into distalization of the lower posterior
teeth, followed by retraction of the incisors. During each
clinical visit, we checked to see whether or not tooth move-
ment was consistent with the ClinCheck to ensure sufficient
adaptation of each aligner.33–38 As a result, the number of
aligners and the overall treatment time naturally increased.
The original treatment plan called for 61 stages, with maxi-
mum movement of a single stage of 0.25 mm over a 2-week
period, this equated to treatment time exceeding 30 months.
To reduce the period of treatment, we including the use
of OrthoAccel’s AcceleDent, an accelerated orthodontic
device, which we have used repeatedly to achieve effective
results39–44 (see intraoral picture 1 year after retention).
There is controversy about the effectiveness of this device.
It is thought that effectiveness with multi-bracket system
(MBS) depends on a number of factors, including the type
of brackets, wire size and shape, method of wire ligation. It
is difficult to say that aligners, a wireless option that instead
covers the teeth to move them, is not affected by similar
 CHAPTER 20 Anchorage of TADs Using Aligner Orthodontics Treatment for Lower Molars Distalization 313

A B C

D E F

G H
• Fig. 20.17 (A–C) Pretreatment extraoral photo. (D–H) Pretreatment intraoral photo.

A B
• Fig. 20.18 (A) Pretreatment lateral cephalogram. (B) Pretreatment panoramic radiograph.
314 PA RT V I I Management of Multidisciplinary and Complex Problems

A B C
• Fig. 20.19 (A–C) Initial situation in the ClinCheck software with attachment.

A B

C D

E F
• Fig. 20.20 (A and B) Upper and lower molars intrusion and anterior extrusion first. (C and D) Upper molar
intrusion and anterior extrusion. Molar molars distalization sequentially using temporary anchorage devices
(TADs). (E and F) Posttreatment, #33,43 retraction using TADs, then lower anterior retraction.
 CHAPTER 20 Anchorage of TADs Using Aligner Orthodontics Treatment for Lower Molars Distalization 315

G H

I J

K L
Fig. 20.20, cont’d

restrictions, and thus it is impossible to say that aligners are
the best fit for the device. Still, by using an accelerated orth-
odontic device, not only is treatment time decreased and
aligner fit improved, but the pain and discomfort that usu-
ally accompanies the initial insertion of a new aligner stage
is also decreased. The benefits of accelerated orthodontics
extend beyond the orthodontist to the patient as well.
Conclusion
In this study, favorable occlusion was achieved in a Class III
patient using aligners to perform a nonextraction distaliza-
tion treatment in the mandible. Furthermore, the use of an
accelerated orthodontic device enabled drastic reduction of
the overall treatment time, but also an aligner change of
every 7 days seems to be working well, allowing a short-
ening of the former treatment time of 50%. I believe that
aligner treatments require their own special brand of treat-
ment planning and approach, which considers the unique
biomechanics in play.
It is my belief that one of the unique advantages of
aligners over traditional MBS treatments is the ability
to effectively harness bite force for treatment, because of
the aligners complete coverage of the teeth. In addition
to being able to easily perform molar intrusion, the sim-
plicity and elegance of the device and its mechanics make
316 PA RT V I I Management of Multidisciplinary and Complex Problems
A B
D E
H
• Fig. 20.21 (A–F) Posttreatment intraoral photo. (G–H) Posttreatment extraoral photo.
aligners a less threatening orthodontic option for patients.
Furthermore, compared to a similarly clean-looking and
invisible orthodontic system, like lingual brackets, the
patient’s mouth is kept in a far more hygienic state and
there is a lower risk of inflammation. The appeal of aligners
is compounded by the fact that, other than the TADs, they
are fully removable for dining, which places less pressure
C
F
on patients and ultimately is a factor in higher treatment
motivation. Treatment possibilities with aligners have
moved beyond simple anterior crowding cases and now
can be effectively used to treat a wide variety of malocclu-
sion treatments, such as four-premolar extraction, nonex-
traction maxillary molar distalization, openbite, and deep
bite.
 CHAPTER 20 Anchorage of TADs Using Aligner Orthodontics Treatment for Lower Molars Distalization 317

A B
• Fig. 20.22 (A) Posttreatment lateral cephalogram. (B) Posttreatment panoramic radiograph.

A B C
• Fig. 20.23 (A–C) Posttreatment ClinCheck software simulation.

Initial
Final

• Fig. 20.24 Lateral cephalometric superimpositions between the pretreatment and posttreatment stages.
318 PA RT V I I Management of Multidisciplinary and Complex Problems
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Index

A Anterior openbite (Continued)

Acrylic cap, 152–153 treatment results of, 160, 161f–162f
Aligner, start during distalization, 74–80, 76t, 78f–83f, 80t treatment sequence of, 160
Alveolar ridge development, vertical, mini-implants in, Anterior teeth
278, 280f–281f bimaxillary extrusion without TADs, 244
Anchor loss, 29 crowding, 89–98
Anchorage devices, temporary, management of case summary of, 98–99, 100f
multidisciplinary patients with, 263–282 diagnosis of, 98–99, 100f
in compromised maxillary incisors, 274–275, extraoral analysis of, 98t
274f–275f intraoral analysis and functional analysis, 99t
endosseous dental implants, for missing posterior teeth, problem list, 99t
265, 268f–270f smile analysis of, 98t
mini-implants in vertical alveolar ridge development, treatment objectives of, 101t
278, 280f–281f treatment options of, 99, 102f–107f
for preprosthetic space appropriation, 265, 266f–267f treatment sequence and biomechanical
ridge mini-implants for orthodontic anchorage, 267– plan of, 101t
274, 271f–273f Appliance fabrication, 62, 64f–65f
skeletal anchorage in orthognathic surgery, 275, Arch asymmetry, upper and lower, 126, 132, 134f
276f–279f Asymmetrical malocclusion, cause of, 170
for space development for implant in congenitally
missing lateral incisor, 263, 264f–265f B
Angle class II Division I subdivision right Beneslider appliance, 73f
hand, 73–74 with aligners, 71–86
Angle class II malocclusion, 71 clinical considerations of, 80–83
Anterior crossbite, 89, 244f–248f clinical procedure and rationale of, 72–80
case summary of, 89, 91f during distalization, 74–80, 76t, 78f–83f, 80t
diagnosis of, 89 simultaneous start of, 73–74, 75f–77f
extraoral analysis of, 89t strategies and clinical tips, 72–73, 74f
intraoral analysis and functional analysis of, 90t Bilateral mandibular i-station, 48–51
problem list for, 90t Bilateral sagittal split osteotomy, simultaneous mandibular
smile analysis of, 90t advancement with, 113, 116f
treatment objectives of, 92t Bimaxillary anterior crowding, with bioefficient skeletal
treatment options of, 89, 93f–98f anchorage, nonextraction treatment of, 87–108
treatment sequence and biomechanical plan, 92t Bimaxillary dental protrusion, decompensation of a
Anterior crowding, mandibular, 183–184, 186f retreatment case presenting with, 113–120, 118f
Anterior occlusion, edge to edge, 184, 187f–189f considerations of, 117
Anterior openbite, 149, 156, 159f final facial outcome of, 120, 124f
classification of, 149 problem list, 116–117
lower molars distalization for, 309–311, 313f–314f treatment goals of, 117
treatment progression for, 311, 314f–315f treatment of, 117–120, 119f, 122f–123f
treatment results for, 311, 316f–317f Bimaxillary extrusion
problem list of, 160 and single-dentition extrusion, 257–260
treatment objectives of, 160 without TADs, 243–245, 244f–249f
treatment plan of, 160 bite raisers to backward rotate mandible, 243

Note: Page numbers followed by “f ” indicate figures, “t” indicate tables, and “b” indicate boxes.

321
322 Index

Bimaxillary extrusion (Continued) Conventional techniques, in mini-implants, 12

extrusion of anterior teeth to close anterior openbite, Couple, defined, 7–8, 7f–8f
244 CROT. see Center of rotation
extrusion of posterior teeth, 245 Crowding
preparation for, 243 in upper and lower anterior teeth, 89–98
Bioefficient skeletal anchorage, nonextraction treatment of case summary of, 98–99, 100f
bimaxillary anterior crowding with, 87–108 diagnosis of, 98–99, 100f
Biomechanics, 3 extraoral analysis of, 98t
in distalizing molars with buccal TADs, 195–196, 196f intraoral analysis and functional analysis, 99t
Bite raisers problem list, 99t
in bimaxillary extrusion without TADs, 243 smile analysis of, 98t
in single-dentition extrusion with TADs in mandible, 254 treatment objectives of, 101t
Bodily movement, 11 treatment options of, 99, 102f–107f
Brazilian kit, 212 treatment sequence and biomechanical plan of, 101t
Buccal alveolar mini-implants, 29–30 upper and lower arch, 166
Buccal bars, 152 diagnosis and case summary of, 166–168
Buccal segment, protraction of, 276f–279f extraoral analysis for, 166, 167f
Buccal shelf area final result of, 170, 171f–172f
mini-implants in, placement of, 209f, 213–215 functional analysis for, 166
TAD site in, 25–26, 26f intraoral analysis for, 166
Buccal temporary anchorage devices problem list of, 168
biomechanics in distalizing molars with, 195–196, 196f smile analysis for, 166, 167f
for distalization of teeth, 195–208 treatment objectives of, 168
distalizing molars by, 195 treatment options of, 168
stability of distalization by, 196–197 treatment sequence and biomechanical plan for,
treatment outcome of distalization by, 196 168f–170f, 169
Burstone bracket, 263 treatment sequence of, 170
in upper and lower teeth, 89
C case summary of, 89, 91f
CBCT. see Cone-beam computed tomography diagnosis of, 89
Center of gravity, 6, 6f extraoral analysis of, 89t
Center of mass, 6 intraoral analysis and functional analysis of, 90t
Center of resistance (CR), 6, 6f problem list for, 90t
of maxillary posterior segment, 150, 151f smile analysis of, 90t
Center of rotation (CROT), 9, 10f treatment objectives of, 92t
estimating, 10–12, 10f treatment options of, 89, 93f–98f
moment-to-force (M/F) ratios in, 11–12 treatment sequence and biomechanical plan of, 92t
types of tooth movement in, 10–11, 10f C-tube microplates, managing complex orthodontic tooth
Centric force, 6 movement with, 181–194
Cephalogram, lateral, 50f, 52f, 55f, 58f clinical report of, 183–186, 186f–192f
Cephalometric analysis, 45, 47, 50f, 55f methods of, 183, 184f–185f
Class I molar relationship, 283, 283f–284f C-tube pushing mechanism, 183, 185f
Coincident midline, 183
Collapsed dental occlusion, 192 D
Cone-beam computed tomography (CBCT), 61–62, 61f Dental asymmetry, treatment of, 189
for partial anterior crossbite, 89, 93f Dental openbite, 149
for upper and lower anterior teeth, 98f, 102f, 107f Dentition extrusion, single, with TADs
Congenitally missing lateral incisor, space development in mandible, 250–254, 250f–255f
for implant in, temporary anchorage devices for, 263, bite raisers and extrusion of upper anterior teeth, 254
264f–265f extrusion of posterior teeth, 254
Controlled tipping, 11 insertion of TADs, 250
Conventional noncompliance appliances, 165 in maxilla, 254, 256f–259f
 Index 323

Distalization Equivalent force systems, 8–9, 9f

of dentition using loop mechanics, 44, 48f Extraalveolar anchorage, with i-station device, 43–44,
and intrusion using loop mechanics, 56f 44f–45f
of mandibular molars, in skeletal III, angle class III case, light and efficient force systems, 43–44, 46f–48f
200–202 Extraalveolar implants, 209–220
diagnosis of, 200–201, 200f, 201t benefits of, 215
retention of, 202, 203f in buccal shelf area, 210f
superimposition of, 202, 203f characteristics of, 211–213, 214f–218f
treatment plan of, 201 in extraalveolar site, 209f–210f
treatment progress of, 201, 202f final considerations for, 215
treatment results of, 201, 202f indications for, 210–211, 211f–213f
of maxillary and mandibular molars in skeletal II, angle infrazygomatic crest (IZC) area, 210f
class II bimaxillary case, 203–207 magnitude of the force applied, 215
diagnosis of, 203, 204f, 204t placement techniques for, 213
retention of, 206, 206f buccal shelf, 213–214
superimposition of, 206–207, 206f buccal shelf region, 209f, 215
treatment plan of, 205 infrazygomatic crest, 208f, 213
treatment progress of, 205, 205f precautions of, 215
treatment results of, 205–206, 205f Extraalveolar mini-implants, 30
of maxillary molars in skeletal II, angle class II case, Extraalveolar sites, for implants, 209f–210f
197–200 Extraoral photographs, of mandibular deviation, 45, 49f,
diagnosis of, 197, 197f, 198t 52f
retention of, 199, 199f postretention, 46–47, 53f
superimposition of, 199–200, 200f posttreatment, 58f
treatment plan of, 197–199, 198f pretreatment, 47, 54f
treatment progress of, 197 Extrusion, 38
treatment results of, 197–199, 199f bimaxillary
in mini-implant assisted retraction, 16–17, 17f and single-dentition extrusion, 257–260
retention of without TADs, 243–245, 244f–249f
of mandibular molars, 202, 203f single-dentition, with TADs
of maxillary molars, 197–200, 199f in mandible, 250–254, 250f–255f
using i-stations, 57f in maxilla, 254, 256f–259f
Distalizing molars
biomechanics in, with buccal TADs, F
195–196, 196f Fabrication, of openbite appliance, 152–153
methods of, 195 Facial profile improvement, in class III malocclusion,
by TADs, 195 orthognathic camouflage with temporary anchorage
stability of, 196–197 devices for, 243–262
treatment outcome of, 196 bimaxillary extrusion
Dual distal system, 301–302, 302f–303f and single-dentition extrusion, 257–260
Dynamics, 3 without TADs, 243–245, 244f–249f
maxillary vertical development, 254–256
E orthodontic extrusion stability, 260
Eccentric force, 6 single-dentition extrusion with TADs
Edentulous span, 270–273 in mandible, 250–254, 250f–255f
Edge to edge anterior occlusion, 184, 187f–189f in maxilla, 254, 256f–259f
Efficient force systems, 43–44, 46f–48f Failed growth modification/camouflage in skeletal class II,
Elastomeric chain, 112, 120 reversing effects of, 110–112, 113f–115f
Endosseous dental implants, for missing posterior teeth, considerations of, 112
temporary anchorage devices in, 265, 268f–270f problem list, 110
Equilibrium, 8 treatment goals, 112
in orthodontics, 8, 8f treatment of, 112
324 Index
FHP. see Frankfort horizontal plane
Fixed lingual retainers, 154
Force, 3, 4f
directional effects of, 4–6, 5f
effects on system, 4, 5f
Force arm, 6
Force diagrams, 4–6
Force system through time, 14, 16f
Force vectors, 4–6, 4f
Frankfort horizontal plane (FHP), 4–5
Free vector, 7
G pretreatment, 47, 54f
Gingivectomy, 38
H extraalveolar anchorage through, 43–44, 44f–45f
Hawley type retainers, 120
Horizontally impacted third molars, 286–287, 287f–293f
Hybrid model, with mini-implant anchorage,
17–19, 18f–19f
I for, 33–42
Idiopathic condylar resorption (ICR), 132
Impacted third molars, horizontally, 286–287,
287f–293f
Implants
extraalveolar, 209–220
benefits of, 215
in buccal shelf area, 210f
characteristics of, 211–213, 214f–218f
in extraalveolar site, 209f–210f
final considerations for, 215
indications for, 210–211, 211f–213f
infrazygomatic crest (IZC) area, 210f
magnitude of the force applied, 215
placement techniques for, 213
buccal shelf, 213–214
buccal shelf region, 209f, 215
infrazygomatic crest, 208f, 213
precautions of, 215
multipurpose, 150–151, 150f–151f
possible complications of, 151
removal of, 151
surgical method for, 150–151, 151f
IMTEC Ortho mini-implants, 263, 264f–265f, 275
Incisors
mechanics to apply labial crown torque,
45–51, 49f
retraction
mechanical factors, 17–19, 17t, 18f
in MGBM system, for class II nonextraction, 297–
301, 298f–302f
Inflammation, multipurpose implant and, 151
Infrazygomatic crest, mini-implants in, placement
of, 208f, 213
Infrazygomatic (IZ) Lomas mini-implant, 265, 266f–267f
Infrazygomatic temporary anchorage device, for anchorage,
274f–275f
Interdisciplinary plan, 120
Interradicular mini-implants, 29–30
Intraoral photographs, of mandibular deviation, 45, 49f,
52f
postretention, 46–47, 53f
posttreatment, 58f
Intrusion, 38
I-station, predictable management with, 43–60
light and efficient force systems, 43–44
mechanics to apply labial crown torques, 45–51, 49f
L
Lateral incisors, upper, missing, space closure
interdisciplinary aspects of, 38
canine, 38
first premolar, 38
orthodontic space closure for, 35, 37f
palatal screw selection and insertion for, 35–38
prosthetic-implantologic solution for, 35, 36f
therapy options to replace, 35, 36f
Lateral openbite, with anterior crowding, lower molars
distalization for, 305–309, 306f
treatment alternatives for, 305
treatment goals for, 305
treatment progression for, 305–309, 307f–309f
treatment results for, 309, 310f
Left dentition, masticating problem with, 184–186,
189f–192f
Light force systems, 43–44, 46f–48f
Line of action, 6
Lomas mini-implant, 273–274, 278
Lomas Quattro mini-implant, 269
Loop mechanics
comparison of sliding mechanics and, 44, 47f
distalization of dentition, 44, 48f
maxillary bilateral molar distalization, 56f
range of movement, 44, 48f
Lower arch crowding, 166
diagnosis and case summary of, 166–168
extraoral analysis for, 166, 167f
final result of, 170, 171f–172f
functional analysis for, 166
intraoral analysis for, 166

Lower arch crowding (Continued)
problem list of, 168
smile analysis for, 166, 167f
treatment objectives of, 168
treatment options of, 168
treatment sequence and biomechanical plan for,
168f–170f, 169
treatment sequence of, 170
Lower fixed appliances, 112
Lower molars distalization, anchorage of TADs for,
305–320
anterior openbite, 309–311, 313f–314f
treatment progression for, 311, 314f–315f
treatment results for, 311, 316f–317f
lateral openbite, with anterior crowding,
305–309, 306f
treatment alternatives for, 305
treatment goals for, 305
treatment progression for, 305–309, 307f–309f
treatment results for, 309, 310f–312f
patient, discussion in, 309–311
M devices in, 274–275, 274f–275f
Macroglossia, diagnostic criteria of, 149
Malocclusion
class II, 71, 265, 266f–267f
decompensation of a retreatment case presenting
with, 113–120, 118f
considerations of, 117
division 1 type, 110, 111f, 121f
problem list, 116–117
treatment goals of, 117
treatment of, 117–120, 119f, 122f–123f
class III, orthognathic camouflage with temporary
anchorage devices for, 243–262
bimaxillary extrusion
and single-dentition extrusion, 257–260
without TADs, 243–245, 244f–249f
maxillary vertical development, 254–256
orthodontic extrusion stability, 260
single-dentition extrusion with TADs
in mandible, 250–254, 250f–255f
in maxilla, 254, 256f–259f
Mandible
i-station in, 43, 44f
single-dentition extrusion with TADs in, 250–254,
250f–255f
bite raisers and extrusion of upper anterior
teeth, 254
extrusion of posterior teeth, 254
insertion of TADs, 250
Mandibular anterior crowding, 183–184, 186f
Index 325
Mandibular buccal shelf screw, 29
Mandibular dentition intrusion, 57f
Mandibular left second molar protraction, 293f
Mandibular midline correction, 290f
Mandibular molars
distalization of, 200–202
diagnosis of, 200–201, 200f, 201t
retention of, 202, 203f
superimposition of, 202, 203f
treatment plan of, 201
treatment progress of, 201, 202f
treatment results of, 201, 202f
intrusion, in openbite, 236f–237f, 237
MAPA. see Mini-implants assisted palatal appliances
Maxilla
i-station in, 43, 44f
narrow, 65–67, 67f–68f
single-dentition extrusion with TADs in, 254,
256f–259f
vertical development, in class III malocclusion, 254–256
Maxillary bilateral molar distalization, 46, 50f, 56f
Maxillary incisors, compromised, temporary anchorage
Maxillary i-station, 46, 51f
Maxillary molars, distalization of, 197–200
diagnosis of, 197, 197f, 198t
retention of, 199, 199f
superimposition of, 199–200, 200f
treatment plan of, 197–199, 198f
treatment progress of, 197
treatment results of, 197–199, 199f
Maxillary posterior area, TAD sites in, 25, 25f
Mechanics, defined, 3
Mesial sliding appliance, 37–38, 37f–38f
MGBM system, for class II nonextraction, 295–304
dual distal system and, 301–302, 302f–303f
incisor retraction in, 297–301, 298f–302f
upper molar distalization in, 295–296, 296f
upper premolars and canines, retraction of, 296–297,
297f
Midline deviations, 183
Mini-implant assisted retraction, distalization effect of,
16–17, 17f
Mini-implant diameter, 31
Mini-implants
anchorage, hybrid model with, 17–19, 18f–19f
benefits of, 215
in buccal shelf area, 210f
characteristics of, 211–213, 214f–218f
in extraalveolar site, 209f–210f
final considerations for, 215
indications for, 210–211, 211f–213f
326 Index

Mini-implants (Continued) Molars distalization, lower, anchorage of TADs for

infrazygomatic crest (IZC) area, 210f (Continued)
magnitude of the force applied, 215 treatment alternatives for, 305
optimal insertion sites for, 71–72 treatment goals for, 305
placement techniques for, 213 treatment progression for, 305–309, 307f–309f
bone sites for, 21–28 treatment results for, 309, 310f–312f
buccal shelf, 213–214 patient, discussion in, 309–311
buccal shelf region, 209f, 215 Moment of the couple (MC), 7
infrazygomatic crest, 208f, 213 Moment of the force (MF), 6–7
three-dimensional evaluation of, 21–28 Moment (torque), 6–7, 7f
precautions of, 215 Moment-to-force (M/F) ratios, 11–12
space closure mechanics with, 12, 13f altering, 11–12, 12f
Miniplates, 109, 110f point of force application, 11, 11f
Mini-implant-driven orthodontics, biomechanics Multidisciplinary patients, with temporary anchorage
principles in, 1–20 devices, management of, 263–282
approaches for studying tooth movement in, 3 in compromised maxillary incisors, 274–275, 274f–275f
basic mechanical concepts in, 3–8 endosseous dental implants, for missing posterior teeth,
concept of equilibrium as, 8 265, 268f–270f
couple as, 7–8, 7f–8f mini-implants in vertical alveolar ridge development,
force as, 3, 4f 278, 280f–281f
force diagrams and vectors as, 4–6, 4f for preprosthetic space appropriation, 265, 266f–267f
moment (torque) as, 6–7, 7f ridge mini-implants for orthodontic anchorage, 267–
basic model for space closure in, 12–17, 13f–15f 274, 271f–273f
center of rotation in, 9, 10f skeletal anchorage in orthognathic surgery, 275,
equilibrium in orthodontics in, 8 276f–279f
estimating the center of rotation in, 10–12 for space development for implant in congenitally
mechanical factors affecting incisor retraction in, 17–19, missing lateral incisor, 263, 264f–265f
17t, 18f Multipurpose implant (MPI), 150–151, 150f–151f
principle of equivalent force systems in, 8–9, 9f possible complications of, 151
space closure mechanics with mini-implants, 12, 13f removal of, 151
Mini-implants surgical method for, 150–151, 151f
application of, 62, 64f Muscle exercises, openbite treatment and, 154
ridge, for orthodontic anchorage, 267–274,
271f–273f N
in vertical alveolar ridge development, 278, 280f–281f Nance button, 71
Mini-implants assisted palatal appliances (MAPA), 61–70 Nickel-titanium (NiTi) springs, 73–74
appliance fabrication of, 62, 64f–65f Nonextraction, 197
clinical cases of, 62–67
asymmetrical cases, 67, 68f O
class II patient, 63–65, 66f O-caps, 275
class III growing patients, 62–63, 65f Occlusion, after space closure, 38, 39f
narrow maxilla, 65–67, 67f–68f Openbites, 149
mini-implant application of, 62, 64f anterior, 149, 156, 159f
surgical guide fabrication in, 61–62, 61f–63f classification of, 149
Mini-implant-supported zygomatic miniplates, use of, problem list of, 160
165–166, 165f treatment objectives of, 160
Molars distalization, lower, anchorage of TADs for, treatment plan of, 160
305–320 treatment results of, 160, 161f–162f
anterior openbite, 309–311, 313f–314f treatment sequence of, 160
treatment progression for, 311, 314f–315f class II, progressive condylar resorption case, 132–142,
treatment results for, 311, 316f–317f 135f–139f
lateral openbite, with anterior crowding, 305–309, 306f considerations of, 138–139

Openbites (Continued)
problem list, 138
treatment goals, 138
treatment of, 139–142, 140f–144f
skeletal, 221–242
biomechanics of molar intrusion in, 223–227,
224f–227f
case report on, 227, 228f–231f
mandibular molar intrusion in, 236f–237f, 237
through incisor extrusion with TADs, 237–241
case report on, 238–241, 238f–241f
vertical control with palatal TADs, 232–237
case report on, 232–237, 232f–237f
treatment, retention of, 154
Openbite appliance (OBA), new generation,
152–160
clinical application of, 153–154, 153f–154f
clinical experience of, 154
fabrication of, 152–153
acrylic cap, 152–153
wire bending, 152, 152f
retention of, 154
Openbite malocclusion, treatment
and, 149–150
Orthodontic anchorage, ridge mini-implants for, 267–274,
271f–273f
Orthodontic extrusion stability, 260
Orthodontic space closure, 35, 37f
Orthognathic camouflage, with temporary anchorage
devices, for class III malocclusion, 243–262
bimaxillary extrusion
and single-dentition extrusion, 257–260
without TADs, 243–245, 244f–249f
maxillary vertical development, 254–256
orthodontic extrusion stability, 260
single-dentition extrusion with TADs
in mandible, 250–254, 250f–255f
in maxilla, 254, 256f–259f
Orthognathic surgery, skeletal anchorage in, temporary
anchorage devices in, 275, 276f–279f
Overbite, correction of, 265
Overjet, correction of, 265
P diagnosis and case summary of, 173, 174f
Pain, multipurpose implant and, 151
Palatal acrylic pad, 71
Palatal mini-implants, 30–31
extraalveolar mini-implants and, 30
risk factors for, 30–31, 30t
Palatal screw
insertion of, 35–38
selection of, 35–38
Index 327
Palatal temporary anchorage devices, 196
aligner treatment using, 71–86
with Beneslider, strategies and clinical tips for, 72–73,
74f
clinical considerations of, 80–83
clinical procedure and rationale of, 72–80
during distalization, 74–80, 76t, 78f–83f, 80t
distalization and, simultaneous start of, 73–74,
75f–77f
site of, 25, 25f
Panoramic photographs, of mandibular deviation, 45, 49f,
52f, 55f
posttreatment, 58f
Partial anterior crossbite, 89
case summary of, 89, 91f
diagnosis of, 89
extraoral analysis of, 89t
intraoral analysis and functional analysis of, 90t
problem list for, 90t
smile analysis of, 90t
treatment objectives of, 92t
treatment options of, 89, 93f–98f
treatment sequence and biomechanical plan, 92t
Peclab screw kit, 207f, 212
Positron emission tomography (PET)-G bite, 61–62
Posterior teeth
in bimaxillary extrusion without TADs, 245
missing, endosseous dental implants for, temporary
anchorage devices in, 265, 268f–270f
single-dentition extrusion with TADs in
mandible, 254
Postsurgical swelling, multipurpose implant and, 151
Power arm–based space closure, 15f
Preprosthetic space appropriation, temporary anchorage
devices for, 265, 266f–267f
Progressive condylar resorption case, class II openbite
development, 132–142, 135f–139f
considerations of, 138–139
problem list, 138
treatment goals, 138
treatment of, 139–142, 140f–144f
Prosthetic-implantologic solution, 35, 36f
Protruded upper teeth, 170, 197
extraoral analysis for, 172, 174f
final results of, 175, 178f–179f
functional analysis for, 173
intraoral analysis for, 173
problem list of, 173
smile analysis for, 172–173
treatment objectives of, 173
treatment options of, 175
328 Index

Protruded upper teeth (Continued) Skeletal Anchor System (SAS) plates, 109
treatment sequence and biomechanical plan for, 175, 176f Skeletal anchorage
treatment sequence of, 175, 177f complex orthodontic problems managing with,
Push-type mechanics, for edge to edge anterior occlusion, 109–146
184 bimaxillary dental protrusion, decompensation of
treatment case, 113–120, 118f
Q considerations of, 117
Qualitative approach, for studying tooth movement, 3 final facial outcome of, 120, 124f
Quantitative approach, for studying tooth movement, 3 problem list, 116–117
Quasi-static system, 8, 8f treatment goals of, 117
treatment of, 117–120, 119f, 122f–123f
R previous restorative treatment, 120–123, 123f, 125f
Rapid palatal expansion (RPE), 62–63 considerations of, 120
Restorative treatment, previous, complex interdisciplinary problem list, 120
challenge compromised by, 120–123, 123f, 125f treatment goals, 120
considerations of, 120 treatment of, 120–123, 126f–130f
problem list, 120 progressive condylar resorption case class II openbite
treatment goals, 120 development, 132–142, 135f–139f
treatment of, 120–123, 126f–130f considerations of, 138–139
Resultant, 4 problem list, 138
Retrognathic mandible, 154, 155f treatment goals, 138
problem list of, 155 treatment of, 139–142, 140f–144f
treatment objectives of, 156 reversing effects of failed growth modification/
treatment plan of, 156 camouflage in skeletal class II, 110–112,
treatment results of, 156, 158f 113f–115f
treatment sequence of, 156, 156f–157f considerations of, 112
Ricketts’ Chart for Calculation of Force Magnitude, problem list, 110
153–154, 153f treatment goals, 112
Ridge mini-implants treatment of, 112
for orthodontic anchorage, 267–274, 271f–273f tooth surface loss, dental asymmetry and crowding,
placement techniques, 269 126–129, 131f
Rugae, T-Zone palatal posterior from, 72f considerations of, 129
problem list, 129
S
treatment goals of, 129, 132f
Sagittal split osteotomy, simultaneous mandibular
treatment of, 129, 133f–134f
advancement with, 113, 116f
group A, mechanics, maximum, 110f
Second molar protraction, 283–294
in orthognathic surgery, temporary anchorage devices
Self-drilling screws, 211
in, 275, 276f–279f
Self-tapping screws, 211
palatal mini-implants and, 30–31
Sequential plastic aligners, 72
protocol of, 175
Simple tipping, 10–11
risk factors associated with, 29–32
Simultaneous mandibular advancement, 123
site of placement, 29–30
Simultaneous Upper Molar Distalizing System
buccal alveolar mini-implants/interradicular mini-
(SUMODIS) component, 295–296, 296f
implants, 29–30
Single-dentition extrusion
success rates with, 29–32
bimaxillary extrusion and, 257–260
Skeletal anterior openbite, 149
with TADs
Skeletal mandibular retrognathism, magnitude of, 112
in mandible, 250–254, 250f–255f
Skeletal openbites, 221–242
bite raisers and extrusion of upper anterior teeth,
biomechanics of molar intrusion in, 223–227,
254
224f–227f
extrusion of posterior teeth, 254
case report on, 227, 228f–231f
insertion of TADs, 250
mandibular molar intrusion in, 236f–237f, 237
in maxilla, 254, 256f–259f

Skeletal openbites (Continued)
through incisor extrusion with TADs, 237–241
case report on, 238–241, 238f–241f
vertical control with palatal TADs, 232–237
case report on, 232–237, 232f–237f
Sliding mechanics, and loop mechanics, 44, 47f
Space closure
basic model for, 12–17, 13f–15f
mechanics with mini-implants, 12, 13f
Space development, for implant in congenitally missing
lateral incisor, temporary anchorage devices for, 263,
264f–265f
Spontaneous vertical eruption, of impacted third molar,
284–285, 285f
Statics, 3
SUMODIS component. see Simultaneous Upper Molar
Distalizing System (SUMODIS) component
Superimposition, 51, 52f, 58f, 291f
of distalization
of mandibular molars, 202, 203f
of maxillary molars, 199–200, 200f
Surgical guide fabrication, 61–62, 61f–63f
Surgically assisted rapid palatal expansion (SARPE), 65
T Tipping
TADs. see Temporary anchorage devices
Temporary anchorage devices (TADs), 23, 150, 283
application of, 109
in compromised maxillary incisors, 274–275, 274f–275f
endosseous dental implants, for missing posterior teeth,
265, 268f–270f
management of multidisciplinary patients with, 263–282
mini-implants in vertical alveolar ridge development,
278, 280f–281f
orthognathic camouflage with, for class III
malocclusion, 243–262
bimaxillary extrusion
and single-dentition extrusion, 257–260
without TADs, 243–245, 244f–249f
maxillary vertical development, 254–256
orthodontic extrusion stability, 260
single-dentition extrusion with TADs
in mandible, 250–254, 250f–255f
in maxilla, 254, 256f–259f
in orthognathic surgery, 275, 276f–279f
preoperative treatment planning of, 24–26
in buccal shelf area, 25–26, 26f
in maxillary posterior area, 25, 25f
in palate, 25, 25f
for preprosthetic space appropriation, 265, 266f–267f
ridge mini-implants for orthodontic anchorage, 267–
274, 271f–273f
Index 329
Temporary anchorage devices (TADs) (Continued)
root damage of, 23, 24f
“safe zones” for, 23, 24f
sites, 23, 24f
for skeletal openbites, 221–242
biomechanics of molar intrusion in, 223–227,
224f–227f
case report on, 227, 228f–231f
mandibular molar intrusion in, 236f–237f, 237
through incisor extrusion with, 237–241
case report on, 238–241, 238f–241f
vertical control with palatal, 232–237
case report on, 232–237, 232f–237f
for space development for implant in congenitally
missing lateral incisor, 263, 264f–265f
Temporary Skeletal Anchorage Devices (TSAD), 183
Temporo-mandibular joint radiographs, 55f
Third molar
angulation, 285–286, 285f
changes with second molar protraction, 284–286,
285f–286f
horizontally impacted, 286–287, 287f–293f
spontaneous mesioangular tipping of, 285–286, 286f
uprighting, 283–294, 285f–286f
controlled, 11
simple, 10–11
uncontrolled, 10–11
β-Titanium alloy, 120, 129
Tongue thrust swallowing, 149
Tooth movement
approaches for studying, 3
managing of, with C-tube microplates, 181–194
clinical report of, 183–186, 186f–192f
methods of, 183, 184f–185f
types of, 10–11, 10f
Transmissibility, principle of, 4
Transpalatal bar, in upper molar distalization, 295, 296f
TSAD. see Temporary Skeletal Anchorage Devices
U
Uncontrolled tipping, 10–11
Unilateral premolar extraction, for asymmetrical
malocclusion, 170
Unresponsive mandibular third molar, 285, 285f
Upper anterior teeth, extrusion of, placement of bite raisers
and, 254
Upper arch crowding, 166
diagnosis and case summary of, 166–168
extraoral analysis for, 166, 167f
final result of, 170, 171f–172f
functional analysis for, 166
330 Index

Upper arch crowding (Continued) Upper teeth, protruded (Continued)

intraoral analysis for, 166 functional analysis for, 173
problem list of, 168 intraoral analysis for, 173
smile analysis for, 166, 167f problem list of, 173
treatment objectives of, 168 smile analysis for, 172–173
treatment options of, 168 treatment objectives of, 173
treatment sequence and biomechanical plan for, treatment options of, 175
168f–170f, 169 treatment sequence and biomechanical plan for, 175,
treatment sequence of, 170 176f
Upper central incisor crowns, 123 treatment sequence of, 175, 177f
Upper fixed appliances, 112, 117f
Upper lateral incisors, missing, space closure for, 33–42 V
interdisciplinary aspects of, 38 Vector addition, 4, 5f
canine, 38 Vector composition, 4
first premolar, 38 Vector resolution, 4–6, 5f
orthodontic space closure for, 35, 37f Vertical alveolar ridge development, mini-implants in, 278,
palatal screw selection and insertion for, 35–38 280f–281f
prosthetic-implantologic solution for, 35, 36f Vertical eruption patterns, of impacted third molar,
therapy options to replace, 35, 36f 284–285
Upper molar distalization, 295–296
asymmetric noncompliance, 71–86 W
in aligner treatment, 71 Wire bending, 152, 152f
clinical considerations of, 80–83
Z
clinical procedure and rationale of, 72–80
Zygomatic anchorage, 150–151
aligner start during distalization, 74–80, 76t,
Zygomatic buttress, 150
78f–83f, 80t
Zygomatic miniplate
combine Beneslider and aligners, strategies and
supported molar distalization, 165–180
clinical tips, 72–73, 74f
method description of, 165–166, 165f–166f
simultaneous start of aligner and distalization,
supported openbite treatment, 147–164
73–74, 75f–77f
multipurpose implant, 150–151, 150f–151f
Upper teeth, protruded, 170
new generation openbite appliance, 152–160
diagnosis and case summary of, 173, 174f
openbite malocclusion and, 149–150
extraoral analysis for, 172, 174f
final results of, 175, 178f–179f
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