Failure Rate

Simple for Buccal

Mechanics for Shelf
ToughScrews
Cases
Paris
3 Small Screws 10-5-2015

Angle
Society
1-26-2015

AAO
4–24-2017
(30 min)

Chris Chang, DDS, PhD., ABO, Angle Midwest Conflict of interest statement:

Beethoven Orthodontic Center, Taiwan 10:45~11:15 I am the President of the company that develops and manufactures the screws used in this research.

1 2

that dramatically impact my practice that dramatically impact my practice

3 small Screws 3 Screws

that dramatically simplify my practice that dramatically simplify my practice

1. BS Screws 1. BS Screws
2. Ramus Screws 2. Ramus Screws
3. IZC Screws 3. IZC Screws
The Indiana University Institutional Review Board approved the protocol, assigning the number 1408974880. The Indiana University Institutional Review Board approved the protocol, assigning the number 1408974880.

3 4

1 Honda Y., 20y8m

5 6
 11 mm 11 mm

Honda Y., 20y8m Honda Y., 20y8m

7 8

11 mm He was told that only surgery could solve his problem.

11 mm OJ = - 5 mm

9 10

Neither surgery nor extraction

22
22

11 12
Neither surgery nor extraction Whole Arch distalization w BS Screw

22 22
People say, it seems photoshopped. BS: Buccal Shelf
13 14

9 13
Chris,
one case
doesn’t mean anything!

OJ = - 5 mm
4 OJ = + 1 mm

12:00
15 16

I am profoundly stubborn with evidence-based dentistry.

AJODO, 148: 943-55, Dec. 2015
CENTENNIAL SPECIAL ARTICLE 944 Roberts et al Roberts et al 945

Biology of biomechanics: Finite element analysis nents, representing the normal and shear stresses
in each plane (Fig 4, B). A pascal is a very small

Rodrigo Viecilli of a statically determinate system to rotate the value, so most relevant physiologic stresses are ex-
pressed in kilo (k), mega (M), or giga (G) pascals,
which are 103, 106, or 109, respectively.9-11
occlusal plane for correction of a skeletal Class III 5. Pressure is a scalar quantity, so the stresses
(compressive or tensile) are the same in all directions
open-bite malocclusion 6.
(isotropic).
Strain is deformation per unit of length. The term is
dimensionless because it is a relative reference,
W. Eugene Roberts,a Rodrigo F. Viecilli,b Chris Chang,c Thomas R. Katona,d and Nasser H. Paydare similar to a percentage. For example, a 100-mm
Indianapolis, Ind, Loma Linda, Calif, and Hsinchu, Taiwan length of bone flexed (bent) or elongated by
1 mm is exposed to a 1% deformation or a 0.01

A step further
strain. Bone will typically fracture when bent by
Introduction: In the absence of adequate animal or in-vitro models, the biomechanics of human malocclusion Fig 3. In mechanics, there are 4 fundamental loads,
which elicit a distinct response in a loaded material: ten-
about 2.5%, so a full “unit” of strain (ε) is a large
must be studied indirectly. Finite element analysis (FEA) is emerging as a clinical technology to assist in distortion that considerably exceeds the ultimate
diagnosis, treatment planning, and retrospective analysis. The hypothesis tested is that instantaneous FEA sion, compression, shear, and torsion. According to Pois-
son's ratio, loading in tension and compression results in strength of the bone. It follows that the physiologic
can retrospectively simulate long-term mandibular arch retraction and occlusal plane rotation for the correction
narrowing or widening of the loaded structure as its length influence of strain on a living bone is at the micro-
of a skeletal Class III malocclusion. Methods: Seventeen published case reports were selected of patients
treated with statically determinate mechanics using posterior mandible or infrazygomatic crest bone screw changes. See text for details. strain (mε) level, which is 10!6 strain or 10,000 mε.
anchorage to retract the mandibular arch. Two-dimensional measurements were made for incisor and molar Frost's mechanostat (Fig 5) summarizes the differ-
movements, mandibular arch rotation, and retraction relative to the maxillary arch. A patient with cone-beam ential bone response to varying levels of strain.4
computed tomography imaging was selected for a retrospective FEA. Results: The mean age for the sample more complex (higher-order) tensors provide the 7. FEA is a numeric method (Fig 6) for calculating the
was 23.3 6 3.3 years; there were 7 men and 10 women. Mean incisor movements were 3.35 6 1.55 mm of retrac- mathematical relationships between stresses and levels of stress in a homogeneous or composite
tion and 2.18 6 2.51 mm of extrusion. Corresponding molar movements were retractions of 4.85 6 1.78 mm and Fig 1. A force (white arrow) applied at the buccal surface Fig 2. When the tooth is restrained by bone (white texture strains. Young's modulus of elasticity (material stiff- structure, based on the material properties of each
intrusions of 0.85 6 2.22 mm. Retraction of the mandibular arch relative to the maxillary arch was 4.88 6 1.41 mm. of a mandibular molar in space produces moments in the overlay), the same force (Fig 1) results in a complex bio- ness) and Poisson's ratio (ratio of deformation, in of its components.5,6
Mean posterior rotation of the mandibular arch was –5.76! 6 4.77! (counterclockwise). The mean treatment time axial (red) and sagittal (blue) planes, relative to the center logic response in 3 dimensions, relative to the center of the perpendicular dimension, as a material is
(n 5 16) was 36.2 6 15.3 months. Bone screws in the posterior mandibular region were more efficient for intruding of mass for the tooth (intersection of the x, y, and z resistance, which is the intersection of the x, y, and z stretched or compressed in the axial direction) are
molars and decreasing the vertical dimension of the occlusion to close an open bite. The full-cusp, skeletal Class planes). planes. Note that this “restrained body effect” displaces Statically determinate mechanics
specific constants for each material (Fig 3). In the
III patient selected for FEA was treated to an American Board of Orthodontics Cast-Radiograph Evaluation score the y-axis for tipping in the sagittal plane (x-axis) to the
most general state, the number of independent The term “biomechanics” is usually applied to the
of 24 points in about 36 months by en-masse retraction and posterior rotation of the mandibular arch: the bilateral center of resistance, which is about a third of the distance
actually the science of how applied loads affect biologic stresses is reduced to 6 (Fig 4, C). Fortunately, static equilibrium of applied loads, but statically deter-
load on the mandibular segment was about 200 cN. The mandibular arch was retracted by about 5 mm, posterior from the alveolar crest to the apex of the tooth. The tooth
structures, such as the supporting periodontium (Fig 2). simultaneously tips around the y-axis and rotates around with respect to controlling the complexity of calcu- minate mechanics are typically restricted to simple
rotation was about 16.5! , and molar intrusion was about 3 mm. There was a 4! decrease in the mandibular plane
Rather than relating to the center of mass, as for a tooth the z-axis in response to a force (white arrow) applied at lations, there is an orientation where the shear collinear forces or 2 parallel force-1 couple, 2-
angle to close the skeletal open bite. Retrospective sequential iterations (FEA animation) simulated the clinical
response, as documented with longitudinal cephalometrics. The level of periodontal ligament stress was in space (Fig 1), the response to an applied force is rela- the buccal surface. Little is known about the 3D biome- stresses equal zero, and then the associated normal dimensional (2D) systems. For 3D statically determinate
relatively uniform (\5 kPa) for all teeth in the mandibular arch segment. Conclusions: En-masse retraction of tive to the center of resistance of the supported root (Fig chanics of the tissue response, which is called the “bio- stresses are referred to as principal stresses (sn). s1 is systems, there can be 3 force components and 3 moment
the mandibular arch is efficient for conservatively treating a skeletal Class III malocclusion. Posterior mandibular 2). Forces and moments can be measured or calculated logic black box.” maximal, s2 is intermediate, and s3 is minimal prin- components. In the absence of true 3D mechanics, or-
Gene Roberts Rodrigo Viecilli Chris Chang thodontists typically apply 2D mechanics in the sagittal

17
anchorage causes intrusion of the molars to close the vertical dimension of the occlusion and the mandibular for individual teeth along an archwire, but the boundary cipal stress. All principal stresses may exist in
plane angle. Instantaneous FEA as modeled here could be used to reasonably predict the clinical results of conditions, such as bracket engagement, effects of adja- compression or tension, but s1 is the most tensile and frontal planes, but that approach falls short of a true
an applied load. (Am J Orthod Dentofacial Orthop 2015;148:943-55) of the PDL and other supporting tissues, is required to 3D statically determinate system. Movement of multiple
cent teeth, and the variance of the load delivered over (or least compressive), and s3 is the most compres-
convey the clinical significance of the finite element
time, are difficult to control.2,3 Typical archwires sive (or least tensile). s3 is particularly important in teeth with a flexible archwire is indeterminate (Fig 7, A
analysis (FEA) reported. The following terms are defined. and B), but en-masse movement of an entire dental arch
deliver unknown loads to the supporting tissues in an orthodontics because it is directly related to PDL ne-
undefined manner: the biologic black box. 1. Tension, compression, shear, and torsion are illus- crosis and the path of tooth movement.5-7 Common as a segment may be determinate (Fig 8) if there is negli-

I
n orthodontics, the term “biomechanics” is often statically determinate mechanics: those that can be Unfortunately, there are no appropriate bench or trated in Figure 3. but less mathematically precise designations for s1, gible change in the relative positions of individual teeth
restricted to the physics of mechanics.1 Forces and calculated using the principles of static equilibrium animal models for comprehensive clinical orthodontics. 2. Tensors are a continuous mathematical framework s2, and s3 are P1, P2, and P3, respectively (Fig 4, D). as the segment is moved. A rigid wire completely filling
moments can be calculated in 3 dimensions for (Newton's laws) (Fig 1). However, biomechanics is Realistic studies must be performed on the clinical in physics. Scalars are the base of the scale: zero- 3. Force is an interaction that tends to change the mo- the slot on every tooth is not required, but the archwire
records of specific patients.4 order tensors with magnitudes but no directionality. tion of an object; in the current context, forces must provide sufficient torque control to prevent
a e
Professor emeritus of orthodontics and adjunct professor of mechanical engineer- Chancellor, Indiana University and Purdue University at Indianapolis; executive changes in the axial inclination of the teeth in the
This article assesses a novel clinical method for con- Vectors, first-order tensors, possess magnitude and deform structures. It is a vector with direction,
ing, Indiana University and Purdue University at Indianapolis, Indianapolis, Ind, vice president, and professor of mechanical engineering and informatics and
and visiting professor, Department of Orthodontics, School of Dentistry, Loma computing, Indiana University, Indianapolis, Ind. servative treatment of a skeletal malocclusion and eval- direction (Fig 4, A). In addition, a force vector has a magnitude, line of action, and frequency (if inter- segment.

skeletal C III cases w BS screws

Linda University, Loma Linda, Calif. Address correspondence to: W. Eugene Roberts, Indiana University and Purdue uates the biomechanical predictability of the clinical point of application and a line of action. Within mittent). Its unit of measurement is the newton Accurate determination of the applied load is critical
b
Associate professor, Center for Dental Research and Department of Orthodontics, University at Indianapolis, 1121 W Michigan St, Indianapolis, IN 46202;
School of Dentistry, Loma Linda University, Loma Linda, Calif. e-mail, werobert@iu.edu.
response at the level of the periodontal ligament a loaded structure, external loads (forces and (N), about 102 g at Earth's gravity.4,8 for reliably calculating stress in supporting structures.
c
Founder and director, Beethoven Orthodontic Center, and Newton's A, Hsinchu, Submitted, revised and accepted, October 2015. (PDL), with advanced engineering technology. Since moments) are expressed as stresses (second-order 4. Stress is the internal force per unit of area, and its Unfortunately, appliances conforming to the restraints
Taiwan. 0889-5406/$36.00 this information is intended for clinicians, a succinct tensors) (Fig 4, B). Stress is a higher-order term unit of measurement is the pascal (Pa): 1 N per of statics and equilibrium are rare in the clinic because
d
Associate professor, Departments of Orthodontics and Oral Facial Genetics, and Copyright ! 2015 by the American Association of Orthodontists. review of some fundamental principles of mechanical the term “determinate mechanics” is typically applicable
Mechanical Engineering, Indiana University and Purdue University at Indianapolis, http://dx.doi.org/10.1016/j.ajodo.2015.10.002
than a vector (force) because it is more complex square meter. As previously explained, stress is a
Indianapolis, Ind. engineering, relative to the unique material properties (force/unit area). The mechanical properties of the second-order tensor with 6 independent compo- to 2 teeth or dental segments.7 A common exception is

943

December 2015 ! Vol 148 ! Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics American Journal of Orthodontics and Dentofacial Orthopedics December 2015 " Vol 148 " Issue 6

17 18
 levels in the PDL is uncertain, unless all boundary
conditions are controlled.

Mechanical properties
The “memory shape” of flexible archwires is the basis
for most fixed appliance therapy. This indeterminate
approach (Fig 7) may be effective, but it can (and often
does) produce a clinical surprise.1 If a deformed archwire
is not physically altered, it tends to recover its original
conformation but at an unknown 3D planar orientation,
delivering constantly changing loads to the periodon-
tium over time. In effect, the teeth align to the archwire
in an unpredictable manner, and as Dr Charles Burstone1
Fig 5. Frost's mechanostat describes the relationship of so aptly concluded, “The wire does the thinking!” He

I am profoundly stubborn with evidence-based dentistry. maintenance, stubborn

bone strain to the progressive hierarchy of bone atrophy,
I am profoundlyhypertrophy, fatigue failure, and sponta- with
4
evidence
subsequently developed the segmented arch technique
-based systems
to take advantage of determinate dentistry.
for en-
neous fracture. The relative effects on bone resorption masse tooth movement.1 He later preferred to refer to
AJODO, 148: 943-55, Dec. 2015 AJODO,
(R) and formation (F) are illustrated. See 148: 943-55,
text for details. Dec. 2015
his principles as “scientific biomechanics,” because
948 Roberts et al

946 Roberts et al Roberts et al 947 948 Roberts et al

most “techniques” are a cookbook approach. The
is typically less predictable because the load delivered to
segmented arch approach uses scientific principles that
the supporting tissues is unknown. Measuring moments
and forces at the archwire level may be helpful for under-
standing the loads applied,2,3 but extrapolation to stress
are universal, and not unique to orthodontics. Bur-
levels in the PDL is uncertain, unless all boundary
conditions are controlled.

Mechanical properties
stone's determinate mechanics are the basis for the pre-
The “memory shape” of flexible archwires is the basis
for most fixed appliance therapy. This indeterminate
approach (Fig 7) may be effective, but it can (and often
Fig 7. A, Indeterminate mechanics, an elastomeric chain anchored with mandibular buccal shelf bone
screws bilaterally, are illustrated for correction of a skeletal Class III malocclusion, with traction begin-
ning at 9 months into treatment. B, At 20 months into treatment (11 months later), the mechanics are
sent FEA.1
does) produce a clinical surprise.1 If a deformed archwire effective but indeterminate, so they cannot reliably estimate PDL stress with the current FEA method.
See text for details.
is not physically altered, it tends to recover its original
conformation but at an unknown 3D planar orientation,
delivering constantly changing loads to the periodon- significant limitation for calculating stress in the PDL.
tium over time. In effect, the teeth align to the archwire It can only be an approximation, so PDL stress results
Fig 7. A, Indeterminate mechanics, an elastomeric chain anchored with mandibular buccal shelf bone
Periodontal ligament
in an unpredictable manner, and as Dr Charles Burstone1 should be consistent with experimental or clinical
Fig 5. Frost's mechanostat describes the relationship of so aptly concluded, “The wire does the thinking!” He data.8-10
bone strain to the progressive hierarchy of bone atrophy, subsequently developed the segmented arch technique The hypothesis tested is that instantaneous FEA can screws bilaterally, are illustrated for correction of a skeletal Class III malocclusion, with traction begin-
maintenance, hypertrophy, fatigue failure, and sponta- retrospectively predict long-term mandibular occlusal
neous fracture.4 The relative effects on bone resorption
to take advantage of determinate systems for en-
masse tooth movement.1 He later preferred to refer to plane rotation for the correction of a skeletal Class III ning at 9 months into treatment. B, At 20 months into treatment (11 months later), the mechanics are
(R) and formation (F) are illustrated. See text for details. his principles as “scientific biomechanics,” because
most “techniques” are a cookbook approach. The
malocclusion.
The thin
effective soft tissue
but indeterminate, interface
so they cannot reliablybetween the with
estimate PDL stress root of aFEA method.
the current
segmented arch approach uses scientific principles that MATERIAL AND METHODS
See text for details.
tooth and its supporting bone is a stress riser with a rela-
are universal, and not unique to orthodontics. Bur- A PubMed advanced search of the literature was per-
stone's determinate mechanics are the basis for the pre- formed in September 2015 with these search items: (1)
sent FEA.1 skeletal Class III malocclusion, (2) bone screws, and (3)

tively low modulus of elasticity (stiffness). It serves as a stress in the PDL.

Fig 4. A, An imaginary, infinitesimally small cube, cut out from within any loaded structure (beam, nonsurgical treatment. One case report was found:
truss, bone, PDL, root), experiences internal forces. Two such force components are shown acting
on 2 of the 6 cube faces. On the top surface, Fz is the “normal” (perpendicular) force. Fy is a “shear”
Periodontal ligament Fig 8. Determinate mechanics are produced by approxi-
mately 200 cN of superelastic nickel-titanium force gener-
Jing et al (2013).12 The entire mandibular arch of a
20-year-old woman with a skeletal Class III malocclusion
significant limitation for calculating
The thin soft tissue interface between the root of a
force because it acts within that plane. On the right surface, Fy becomes the normal force, and Fz be-
tooth and its supporting bone is a stress riser with a rela- ated from mandibular buccal shelf bone screws. The was retracted by 4 mm. The anchorage was provided by
It can only be an approximation, so PDL stress results
biologic transducer for osseous adaptation, permitting
comes a shear force. Similar relationships apply to the other 4 faces of the cube. The Fz and Fy normal force is applied bilaterally to a full-size archwire. Under miniscrews placed in the external oblique ridges of the
forces are shown in tension (arrow pointing away from the surface), but they can also be in compression tively low modulus of elasticity (stiffness). It serves as a
(arrow pointing into the surface). B, When a force component is divided by the area of the surface on
which it acts, it becomes a stress component (second-order tensor). The first subscript indicates the
biologic transducer for osseous adaptation, permitting
a tooth to move relative to its apical base of bone.4
these conditions, the mandibular arch is a segment.
This 3D graphic is a revised original illustration by Dr
mandible. Progressive, flexible copper-nickel-titanium
archwires were used in the mandibular arch while it
should be consistent with experimental or clinical
base of bone.4
Rungsi Thaharungkul. 8-10
data.
a tooth to move relative to its apical
plane, and the second subscript indicates the direction of the component. Thus, the normal stresses The viscoelastic component of PDL displacement has was retracted, so the mechanics were indeterminate.
are typically denoted as sxx, syy, and szz, but they can be expressed as sx, sy, and sz without the been modeled in vitro,5 but the vascular reflex to resist Two unpublished skeletal Class III case reports were
redundancy of the double subscripts. Compressive normal stresses are negative, whereas tensile
stresses are positive. The shear stresses are generally written as txy, txz, tyz, tyx, tzx, and tzy. Again,
compression has only been documented in animals.4 It
is widely assumed that all continuous orthodontic loads
optimal because it induces and maintains bone
modeling reactions (formation and resorption) in the
sourced from the records of an author (C.C.) to distin-
guish indeterminate (Fig 7) from determinate (Fig 8) me- The hypothesis tested is that instantaneous FEA can
the drawing shows only 2 planes, but the same relationship applies to the other 4 faces of the cube. C,
The most general state of stress is illustrated for 3 faces of the cube. Equilibrium dictates that some
(opposing) stresses are equal, so txy 5 tyx, txz 5 tzx, and tyz 5 tzy, thus reducing the number of inde-
result in at least some transient PDL necrosis, the “lag-
phase” of tooth movement, but the PDL-level biome-
plane of tooth movement, without necrosis and
increased risk of root resorption. These rodent data are
chanics. The statics for the 2 force systems appear
similar, but there are several critical factors for achieving
determinate mechanics that are amenable to the FEA: (1)
The viscoelastic component of PDLretrospectively displacement has mandibular occlusal
predict long-term
pendent components to 6. D, It is possible to calculate an orientation of the imaginary cube where all
Fig 6. A color illustration of an early finite element model chanics for en-masse tooth movement have never been intriguing but require confirmation in humans.
5 plane rotation for the correction of a skeletal Class III
been modeled in vitro, but the vascular reflex to resist
of the human mandible, originally published in black and rigorously tested.4,8 If we assume that the dental load The PDL is a unique tissue with a variable modulus of full-size archwire (engaging anterior torque) in the
shear stresses equal 0. That orientation is the principal direction (x0 -y0 -z0 ), and the associated normal mandibular arch segment was present during the entire
elasticity because of its viscoelastic properties and char-
malocclusion.
white, shows the stress distribution in megapascals, rela- is known (determinate or reliably measured), an FEA
stresses are then principal stresses, sx0 , sy0 , and sz0 . All principal stresses can be in compression or
tive to a 1-N load applied to the left first premolar area can calculate the stress throughout the supporting acteristic vascular response, which transiently resists retraction phase, (2) relatively constant force of supere-
tension, but the relative order is fixed. The most tensile (least compressive) of the 3 (sx0 , as drawn)
(arrow). The mandible is a cantilever exposed to substan- compression in support of masticatory function.4 It is lastic nickel-titanium springs can be effectively modeled
is the maximum principal stress, which is designated as P1. The most compressive (least tensile) structures, including the PDL. The critical factor in
4
compression has only been documented MATERIAL AND METHODS It
in animals.
tial bending and torsion, particularly in the posterior body, challenging to model the PDL with FEA because it over time, and (3) the force is applied directly to the arch-
(sy0 ) is P3, the minimum principal stress. The second (intermediate) principal stress, P2, is in between
mandibular ramus, and coronoid process, as designated
eliciting desirable tooth movement is the level of stress
(sz0 ). in the PDL. In rodents, stress greater than 8 to 10 kPa does not have a fixed modulus of elasticity. Fortunately, wire (Fig 8). For this study, the concept of a “segment” in
by the yellow, orange, and red areas. See the study of the sagittal plane was defined as a block of teeth with a
usually compresses the PDL to the point of necrosis, this has not been a major problem, probably because the
Paydar et al6 for details.
the symmetrical molar anchorage for an intrusive base restraint such as friction also occurs. It follows that

is widely assumed that all continuous Aorthodontic loads

thereby at least transiently inhibiting tooth PDL modulus is so much less than those of adjacent rigid “full-size archwire,” which means that it engaged torque
arch. These mechanics are determinate for the incisors most clinical mechanics are indeterminate, including structures (teeth and bone). Little change is noted in the in the brackets on the anterior teeth, so that the entire
and the bilateral molars if there is no cinch-back8; how- typical archwires, engaged in multiple brackets. Reliable
(determinate) loads that are reasonably constant. On the
other hand, indeterminate mechanics can be effective
movement.4,8,10 PDL necrosis is also associated with
the expression of root resorption.8,10 In these studies, overall FEA results for even an order of magnitude vari- arch was retracted en masse with no significant dental PubMed advanced search of the literature was per-
ever, some form of tie-back or other less predictable FEA to determine PDL stress requires known ance in the PDL modulus.7 However, there is still a tipping. In general, any variance from a segment with

result in at least some transient PDLformed in September 2015 with these search items: (1)
for precise alignment of teeth (Fig 7), but that approach the data show that PDL stress less than 8 kPa is

necrosis, the “lag-

skeletal Class III malocclusion, (2) bone screws, and (3)
December 2015 ! Vol 148 ! Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics American Journal of Orthodontics and Dentofacial Orthopedics December 2015 ! Vol 148 ! Issue 6 December 2015 ! Vol 148 ! Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics

phase” of tooth movement, but thenonsurgical PDL-level treatment.

12 biome-
One case report was found:
Jing et al (2013). The entire mandibular arch of a
Fig 8. Determinate mechanics are produced by approxi-
Fig 6. A color illustration of an early finite element model chanics
mately 200 cN offor en-masse
superelastic tooth
nickel-titanium forcemovement
gener- havewoman
20-year-old never with abeen
skeletal Class III malocclusion
ated from mandibular buccal 4,8 shelf bone screws. The was retracted by 4 mm. The anchorage was provided by
of the human mandible, originally published in black and rigorously
force tested.
is applied bilaterally If archwire.
to a full-size we assumeUnder that theplaced
miniscrews dental load oblique ridges of the
in the external
white, shows the stress distribution in megapascals, rela- these conditions, the mandibular arch is a segment.
is 3Dknown
graphic is (determinate or reliably measured), an FEA
19 20 mandible. Progressive, flexible copper-nickel-titanium
This a revised original illustration by Dr archwires were used in the mandibular arch while it
tive to a 1-N load applied to the left first premolar area can calculate the stress throughout
Rungsi Thaharungkul.
the sosupporting
was retracted, the mechanics were indeterminate.
(arrow). The mandible is a cantilever exposed to substan- Two unpublished skeletal Class III case reports were
structures,
optimal because it including the PDL.
induces and maintains bone The critical
sourced from the factor
records of an inauthor (C.C.) to distin-
tial bending and torsion, particularly in the posterior body,
mandibular ramus, and coronoid process, as designated
eliciting desirable tooth movement
modeling reactions (formation and resorption) in the
plane of tooth movement, without necrosis and
is the level of stress
guish indeterminate (Fig 7) from determinate (Fig 8) me-
chanics. The statics for the 2 force systems appear

by the yellow, orange, and red areas. See the study of in theriskPDL.
increased In rodents,
of root resorption. stress
These rodent data greater
are than
similar, 8 to
but there 10 kPa
are several critical factors for achieving
intriguing but require confirmation in humans. determinate mechanics that are amenable to the FEA: (1)
Paydar et al6 for details. usually
The PDL is acompresses
unique tissue with a the
variablePDL
modulusto of thefull-size
point of necrosis,
archwire (engaging anterior torque) in the
mandibular arch segment was present during the entire
thereby at least transiently retraction
elasticity because of its viscoelastic properties and char-
acteristic vascular response, which transiently resists
inhibiting tooth
phase, (2) relatively constant force of supere-
4,8,10
(determinate) loads that are reasonably constant. On the movement.
compression in support of PDL necrosis is also
masticatory function. 4
It is associated
lastic nickel-titanium with
springs can be effectively modeled
challenging to model the PDL with FEA because it over
8,10 time, and (3) the force is applied directly to the arch-
other hand, indeterminate mechanics can be effective thenotexpression
does have a fixed modulus ofofroot resorption.
elasticity. Fortunately, In 8).these
wire (Fig studies,
For this study, the concept of a “segment” in
the sagittal plane was defined as a block of teeth with a
for precise alignment of teeth (Fig 7), but that approach this has not been a major problem, probably because the
the data show that PDL stress less
PDL modulus is so much less than those of adjacent rigid
than
“full-size archwire,”8 whichkPameansisthat it engaged torque
structures (teeth and bone). Little change is noted in the in the brackets on the anterior teeth, so that the entire
overall FEA results for even an order of magnitude vari- arch was retracted en masse with no significant dental
ance in the PDL modulus.7 However, there is still a tipping. In general, any variance from a segment with

American Journal of Orthodontics and Dentofacial Orthopedics December 2015 ! Vol 148 ! Issue 6
December 2015 ! Vol 148 ! Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics

I am profoundly stubborn with evidence-based dentistry. I am profoundly stubborn with evidence-based dentistry.
AJODO, 148: 943-55, Dec. 2015 AJODO, 148: 943-55, Dec. 2015
952 Roberts et al Roberts et al 953 954 Roberts et al
P&W esthetics

(12 to 17)
4.7
2.1

Use
(111 to 137)
ABO CRE
24.1
9.5

10
Treatment time (mo)

Finite Element
(118 to 162)

AP, Anteroposterior; ABO CRE, American Board of Orthodontics Cast-Radiograph Evaluation; P&W esthetics, pink and white dental esthetics score.
36.2
15.3

16
("16.5 to 13.5)
Rotation (! )

Analysis to calculate
Fig 12. More detailed cephalometric tracings of the
"5.76
4.77

mandible are superimposed on the inferior alveolar canal

17

Fig 13. A retrospective FEA was used to calculate the center of rotation (blue) for mandibular arch Fig 15. PDL stress associated with the posterior rotation of the mandible appears to be less than
and the internal symphysis. Blue represents the start of
retraction with determinate mechanics, as described by Shih et al.16 See text for details. 1 kPa, but the error of the method suggests that less than 5 kPa is a more reliable estimate. See
treatment (age, 21 years), and red represents the finish
text for details.
Table. Mandibular arch retraction and rotation with extra-alveolar bone screw anchorage

(age, 24 years). Note that the entire mandibular arch

To maxillary arch

was retracted and rotated counterclockwise as a “rigid”

segment. The intrusion of the molars and the extrusion
("8 to "3)

placed in the posterior maxilla to continue the mandib- CONCLUSIONS

AP (mm)
"4.88
1.41

of the incisors reversed the etiology of the developing ular arch retraction and close the anterior open bite. A skeletal Class III malocclusion was conservatively
17

malocclusion documented in Figure 9. Fortunately, a CBCT image was obtained to assess root corrected (without extractions or orthognathic surgery)
contact with the interradicular miniscrews, and this 3D by applying statically determinate mechanics to retract
of the malocclusion, thereby simultaneously decreasing radiographic image marked the end of posterior mandib- and posteriorly rotate the entire mandibular arch. In
ular anchorage and the start of posterior maxillary (in-
Vertical (mm)

the mandibular plane angle, the vertical dimension of less than 5 minutes, a desktop computer simulated the
("5 to 12.5)

the occlusion, and the open bite (Fig 11).16 frazygomatic crest) anchorage (Fig 10). That scenario
"0.85
2.22

efficient clinical result with FEA animation and esti-

allowed a comparison of mandibular arch retraction
17

The patient selected for FEA experienced molar intru- mated the level of PDL stress associated with the applied
sion and a decrease in facial height when the mandibular with posterior mandibular or infrazygomatic

CRe vs CRo
mechanics. As orthodontics and dentofacial orthopedics
Molars

arch was retracted with posterior anchorage (Figs 8 and anchorage.16 Since the CBCT image was available, it enter the 3D age, this method can be used to design effi-
10). The open bite continued to close when a retraction was then possible to study the most favorable mechanics cient mechanics, with a low risk of root resorption, for
("10 to "3)
AP (mm)

with FEA.
"4.85
1.78

force was anchored in the infrazygomatic crest region the conservative management of malocclusions.
Recently, the soft tissue irritation problem for
17

(Fig 7, B), but there was no further improvement in

the vertical dimension of the occlusion.16 In effect, the mandibular buccal shelf bone screws has been solved ACKNOWLEDGMENTS
more inferior direction of traction (Figs 8 and 10) by placing longer screws that have at least 5 mm of
clearance between the soft tissue insertion point and This research was the product of a 25-year coopera-
Vertical (mm)

reversed the etiology of the open-bite malocclusion, as

("6 to "1)

documented with the pretreatment cephalometric im- the head of the screw.17 With the latter method, there tive effort at Indiana University and Purdue University at
2.18
2.51

was no significant difference in the success rate for Indianapolis between the School of Engineering and
17

ages from 18 to 21 years (Fig 9), and decreased both

more than 1600 mandibular buccal shelf bone Technology at Purdue University and the School of
Incisors

the open bite and the facial height to achieve lip compe-
tence (Fig 11). screws, placed in either attached gingiva or moveable Dentistry at Indiana University. We acknowledge the
Fig 14. The posterior rotation of the mandibular arch relative to the original position (white mesh) is
The published case selected for the FEA had a unique mucosa. insightful leadership of Chancellor Gerald Bepko, Dental
("6 to "1)

determined by iterations of the FEA. Note that the results are almost identical to the actual mandibular
AP (mm)
"3.35
1.55

scenario. The initial mandibular buccal shelf bone screws arch rotation documented with the cephalometric images (Figs 11 and 12). Unfortunately, there are no CBCT records for the Dean H. William Gilmore, and Engineering Dean Bruce
17

failed because they were placed deep in the buccal other 16 case reports, so they cannot be analyzed Renda in creating this interactive biomechanics program
fold.16 Despite an apically repositioned flap of attached with the current FEA method. As CBCT imaging in 1990. Dr John Lin, Dr Irene Shih, and Bella Chu pro-
provided approximately the same posterior mandibular mandibular first molars did contact the interradicular becomes more routine in clinical practice, FEA is a vided original records as needed for the published case,
gingiva, soft tissue irritation prevented their use for
Subjects (n)

anchorage as expected for mandibular buccal shelf miniscrews after about 14 months of mandibular retrac- promising approach for testing different types of force and Professor Jie Chen provided valuable advice for
anchorage. The mandibular buccal shelf bone screws
bone screws (Fig 10), but they could potentially block tion. The mandibular interradicular miniscrews were systems. the preparation of the article.
Range

were removed, and interradicular miniscrews were

Mean

the path of tooth movement. The roots of the removed, and infrazygomatic crest bone screws were
SD

placed distally to the roots of the first molars. The latter

December 2015 # Vol 148 # Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics American Journal of Orthodontics and Dentofacial Orthopedics December 2015 ! Vol 148 ! Issue 6 December 2015 ! Vol 148 ! Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics

21 22

What else?
Severe Post. Buccal X-bite

2 33y6m

23 24
 10 months ago, she was told by 4 Drs. that
only surgery could solve her problem. ? BS Screw

10
No band, no surgery, no extraction No band, no surgery, no extraction

25 26

3 BS Screw
Why is that so
special?
6mm 0mm
This was 2011. This was 2011.

27 28

Severe Post. Buccal X-bite Severe Post. Buccal X-bite

33y6m This was 2011.

33y6m This was 2011.

29 30
Angle Orthodontics, P 374-379, Mar. 2014

26y2m Mar. 2014 33y6m Mar. 2011

31 32

Taiwan Taiwan

26y2m Mar. 2014 33y6m Mar. 2011 26y2m Mar. 2014 33y6m Mar. 2011

33 34

Taiwan Taiwan

26y2m Mar. 2014 33y6m Mar. 2011 26y2m Mar. 2014 33y6m Mar. 2011

35 36
 Taiwan Taiwan
Ver y LeFort 1 Osteotomy
 What do U thin k
BSSRO 2-Jaw abou t thes e kind s
simi lar Surgery of Surger ies?

26y2m Mar. 2014 33y6m Mar. 2011 26y2m Mar. 2014 33y6m Mar. 2011

37 38

When somebody screws you, screw them back in spades. Ready for publication AJODO (Apr. 2, 2017)
Trumpology, P48. Unilateral Scissor Bite IJOI IJOI CASE REPORT
IJOI CASE REPORT

Severe unilateral scissor bite and occlusal canting Dr. Angle Lee,
Editor, International Journal of Orthodontics & Implantology(Left)

treated by infra-zygomatic crest and buccal shelf Dr. Chris Chang,

Founder, Beethoven Orthodontic Center
Publisher, International Journal of Orthodontics & Implantology (Center)

mini-screws without surgery Dr. W. Eugene Roberts,

Editor-in-chief, International Journal of Orthodontics & Implantology (Right)

IYou’re
don’t like it!
fired!
Abstract
This case report describes the conservative treatment of a 29-year-old woman with skeletal Class III
malocclusion associated with anterior crossbite and atrophic mandibular first molar extraction sites. A
fixed appliance in combination with anterior bite turbos and light force Class III elastics was indicated to
correct the anterior crossbite. The closure of mandibular first molars extraction sites would retract
mandibular incisors, reduce the lower lip protrusion, and eliminate the need for prothesis. After 38
months of treatment, normal overjet and overbite were achieved and the profile with protrusive lower lip
had been improved. Complete closure of atrophic mandibular first molars extraction sites had been

It is essential to make differential diagnosis of skeletal Class III malocclusion with anterior
cross-bite before execute a treatment plan. Particularity for adults, many patients are told
that orthognathic surgery is the only option. However, for those Class III patients with a
good profile, most of them are over treated. The diagnosis of skeletal Class III can not only
rely on cephalometric analysis, instead, clinical examination is more reliable.1-3 Functional
assessment is able to determine whether there is a centric relation (CR) and centric
occlusion (CO) discrepancy, and evaluates true Class III malocclusion and pseudo Class III
malocclusion.4 Pseudo Class III patients who have orthognathic profile in CR usually have
good prognosis for conservative treatment.1

In adults, closing an old extraction site over mandibular first molar area is a big challenge
to orthodontists. Typically, bone remodeling with vertical and buccolingual narrowing of
Fig. 12: Post-treatment facial and intraoral photographs.
Fig. 1: Pre-treatment facial and intraoral photographs.
alveolar ridges occurred after extractions.5,6 Therefore, remodeling of cortical bone is
required when wider tooth roots are pushed through narrow alveolar ridges. It takes time

39 40

Ready
Readyfor
forpublication
publicationAJODO
AJODO(Apr.
? AO ?
2, 2017) Ready
Readyfor
forpublication
publicationAJODO
AJODO(Apr.
? AO ?
2, 2017)
IBOI Cast-Radiograph Evaluation Occlusal Contacts
Unilateral Scissor Bite IJOI
IJOI CASE REPORT Unilateral Scissor Bite IJOI
Case # Patient
iJOI 25 IAOI CASE REPORT

Discrepancy Index Worksheet Total Score: Occlusal Contacts

DISCREPANCY INDEX WORKSHEET EXAM YEAR2009
Cast-Radiograph Evaluation IBOI Pink & White Esthetic Score
DISCREPANCY INDEX WORKSHEET EXAM YEAR      2009
    
CASE ABOABO
ID# ID#9611296112 2
CASE # # 1 1 P(Rev. P(Rev.
ATIENT
ATIENT   CHAO-YUEN
  CHAO-YUEN
9/22/08) CHIU 
CHIU 
TOTAL
TOTAL D.I. D.I.
SCORE
9/22/08)
SCORE 25 25 23 Alignment/Rotations
Total Score: = 3
OVERJET
OVERJET LINGUAL
LINGUAL POSTERIOR
POSTERIOR X-BITE
X-BITE
Total Score: 20 1. Pink Esthetic Score Total = 0
0 mm.0 mm. (edge-to-edge)
(edge-to-edge) = = 1 pt. 1 pt.
1 – 31mm.
– 3 mm. = = 0 pts.0 pts. 1 pt.tooth
1 pt. per per tooth Total Total
= = 0 10
maxillary left central incisor for dental correction of the mandibular protrusive lip. 3.1 –3.1 – 5 mm.
5 mm. = = 2 pts.2 pts. ! ! ! ! ! Alignment/Rotations 1. M-D Papilla 0 1 2
5.1 –5.1 – 7 mm.
7 mm. = = 3 pts.3 pts. BUCCAL POSTERIOR X-BITE
midline correction(Fig. 10). Two months The smile has been improved remarkably 7.1 –7.1 – 9 mm.
9 mm. = = 4 pts.4 pts. BUCCAL POSTERIOR X-BITE
5 2 6 2. Keratinized Gingiva 0 1 2
> 9 mm.
> 9 mm. = = 5 pts.5 pts. 5
prior to debond, the upper archwire was (Fig. 12). The ABO Cast-Radiograph 2 pts.2per
pts.tooth
per tooth Total Total
= = 2 02 4 3. Curvature of Gingival Margin 0 1 2
Negative
Negative OJ (x-bite)
OJ (x-bite) 1 pt.mm.
1 pt. per per per
mm.tooth = 7=
per tooth 1
sectioned distally to the canines and all Evaluation (CRE) score was 23 points 2 3 1
CEPHALOMETRICS
CEPHALOMETRICS (See Instructions)
(See Instructions)
4. Level of Gingival Margin 0 1 2

upper teeth except second molars were (Worksheet 2). The major CRE discrepancy TotalTotal = = 75 5 2 5. Root Convexity ( Torque ) 0 1 2
ANBANB
≥ 6° ≥or6°≤or-2°≤ -2° = 4=pts. 4 pts. 2
tied together with stainless steel ligature was the position of mandibular left second OVERBITE
OVERBITE Marginal Ridges 6. Scar Formation 0 1 2
Each Each degree
degree -2°      
< -2° <      =      
x2 1 pt.x 1= pt.      2
0 – 30mm.
– 3 mm. = = 0 pts.0 pts.
wire to prevent space opening. The lower molar and maxillary right second molar. 3.1 –3.1 – 5 mm.
5 mm. = = 2 pts.2 pts. Occlusal Relationships
Each Each degree
degree 6°      
> 6° >      =      
x 1 pt.x 1= pt.     
5.1 –5.1 – 7 mm.
7 mm. = = 3 pts.3 pts. Marginal Ridges
archwire was sectioned distally to the first The position of mandibular left second Impinging
Impinging (100%) =
(100%) = 5 pts.5 pts. 1. M&D Papilla 0 1 2
SN-MP
SN-MP Occlusal Relationships
The posttreatment photograghs showed molar was substituted by third molar. The 3
≥ 38°≥ 38° = 2=pts. 2 pts.
11

Fig 18. 2. Keratinized Gingiva 0 1 2

TotalTotal = = 35 5 5
The maxillary occlusal view of the treatment sequence is shown in clockwise order from pretreatment (upper Each Each degree
degree > 38°> 38° x 2=pts. =
x 2 pts.
that facial esthetics was improved due to distal cusp of mandibular left third molar 3. Curvature of Gingival Margin 0 1 2
left) to post-treatment (lower left). The months of treatment is shown in the black box in the upper right
corner of each photograph. ≤ 26°≤ 26° = 1=pt. 1 pt. 4. Level of Gingival Margin 0 1 2
ANTERIOR
ANTERIOR OPEN
OPEN BITE
BITE 1 1
Fig 20. Each Each degree
degree < 26°< 26°4 4x 1 pt.x 1= pt. =4 4 1 1 5. Root Convexity ( Torque ) 0 1 2
The mandibular occlusal view of the treatment sequence is shown in clockwise order from pretreatment 0 mm.0 mm. (edge-to-edge),
(edge-to-edge), 1 pt. 1per
pt.tooth
per tooth 1
(upper left) to post-treatment (lower left). The months of treatment is shown in the black box in the upper then then
1 pt.1per
pt.additional
per additional full mm.
full mm. per tooth
per tooth 1 to ≥MP
1 to MP 99°≥ 99° = 1=pt. 1 pt. Buccolingual Inclination 6. Scar Formation 0 1 2
right corner of each photograph. Interproximal
1 Contacts2 2
Each Each degree
degree > 99°> 99°2 2x 1 pt.x 1= pt. =2 2
TotalTotal = = 00 0 Interproximal Contacts
Buccolingual Inclination 2. White Esthetic Score ( for Micro-esthetics )
Discussion severe prognathic patient with a concave Total = 4
LATERAL OPEN BITE Total Total = =8 68 0
profile, orthognathic surgery is the best LATERAL OPEN BITE
The treatment of Class III malocclusion is 3 1. Midline 0 1 2
2 pts.2 per
pts.mm. per tooth
per mm. per tooth OTHER
OTHER
(See Instructions)
(See Instructions)
challenging primarily due to inadequate treatment option. 2. Incisor Curve 0 1 2
Supernumerary
Supernumeraryteeth teeth                 
x 1 pt.x =1 pt. =      
diagnosis. The 3-Ring Diagnosis is an TotalTotal = = 0
0 0 Ankylosis of perm.
Ankylosis teeth teeth           
of perm. x 2 pts.      
x 2= pts. =       1 3. Axial Inclination(5°, 8°,10°) 0 1 2
Class: Evaluate canine and first molar Anomalous morphology           
morphology
Anomalous x 2 pts.      
x 2= pts. =       1 2
effective method for identifying Class III CROWDING (only(only
CROWDING one arch)
one arch) Impaction (except
Impaction 3rd molars)
(except 3rd molars) x 2 pts.
x 2= pts. = 4. Contact Area(50%,40%,30%) 0 1 2
occlusal classification in CO. An anterior Midline discrepancy
Midline (≥3mm)
discrepancy (≥3mm) @ 2 pts. 02 pts. =     
@ =      3
malocclusion.1,2 The 3-Ring includes: 1 – 31mm. = = 1 pt. 1 pt.

DI = 23 CRE = 20
– 3 mm. Missing teeth (except 3rd molars)           
x21 pts.
x 1= pts. = 4 5
3.1 –3.1
5 mm. =
Missing teeth (except 3rd molars) 2 6 5. Tooth Proportion(1:0.8) 0 1 2
crossbite is easier to treat when the – 5 mm. = 2 pts.2 pts. Missing teeth, teeth,
Missing congenital           
congenital x 2 pts.      
x 2= pts. =      
5.1 –5.1
7 mm.
– 7 mm. = = 4 pts.4 pts. Overjet
Spacing (4 or more,
Spacing per arch)
(4 or more, per arch)           x 2= pts. =2
x 2 pts. 2 Root Angulation 6. Tooth to Tooth Proportion 0 1 2
molars are Class I in CO (pseudo Class III) > 7 mm. = = 7 pts.7 pts. 2
Profile: Assess orthognathic or prognathic > 7 mm. Spacing
Spacing
(Mx cent.
(Mxdiastema ≥ 2mm)≥ 2mm)
cent. diastema @ 2 pts.
@= 2 pts. 2= 2 Overjet
Fig 19. ToothTooth
transposition
transposition           
x 2 pts.      
x 2= pts. =      
than molars are Class III in CO (true Class TotalTotal = = 1 1
The mandibular occlusal view of the treatment sequence is shown in clockwise order from pretreatment CR profile. The majority of pseudo Class III 7 Skeletal asymmetry
Skeletal (nonsurgical
asymmetry tx)
(nonsurgical tx) @ 3 pts.
@= 3 pts. = 1 4
                 1 1. Midline 0 1 2
(upper left) to post-treatment (lower left). The months of treatment is shown in the black box in the upper Addl.Addl.
treatment complexities
treatment complexities x22 pts.
x 2= pts. 4
=       1 1
right corner of each photograph. profiles in CR are orthognathic, and these III).
OCCLUSION
OCCLUSION Identify:
Identify:
2. Incisor Curve 0 1 2
Atrophic ridges (both sides)
patients have good response to ClassClass
I to end
I to on
end on = = 0 pts.0 pts. 1 1 3. Axial Inclination(5°, 8°,10°) 0 1 2
Fig 17. Superimposed tracings indicate that the maxillary incisors had been protracted, the maxillary molar had
been distalized, the mandibular incisors had been retracted, mandibular second molars had been uprighted and
Functional Shift: Diagnosis the presence End End
on Class II or IIIIIor III
on Class = = 2 pts.2per per      
pts.side pts. pts.
side       Total Total = =4 64
dentoalveolar treatment. However, for a Full Full
ClassClass
II or IIIIIor III = = 4 pts.4per per      
pts.side pts. pts.
side      
4. Contact Area(50%,40%,30%) 0 1 2
extruded, mandible had been rotated clockwise, and lower lip had been retracted. Beyond ClassClass
II or IIIIIor III
=
Beyond = 1 pt. 1per
pt.mm.per mm. pts. pts.
          
5. Tooth Proportion(1:0.8) 0 1 2
additional
additional
TotalTotal = 0
0 2 6. Tooth to Tooth Proportion 0 1 2
= 0
INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter
in the white Place
INSTRUCTIONS: box. Mark extracted
score teeth deficient
beside each with “X”. tooth
Second molars
and should
enter total be in occlusion.
score for each parameter
in the white box. Mark extracted teeth with “X”. Second molars should be in occlusion.

41 42
 3
Amazing Dilacerated
Impaction

➟
OS plan ???
1. Remove all

17mm Dilacerated
root
2. Two implants

OMG!

43 44

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25 IJOI
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Hori onta y Im acted Lower anine wit ucca S e f Screw IJOI 46

Dr. Szu Rou Yeh,

Lecturer, Beethoven Orthodontic Course (Left)

Dr. Chris Chang,

Founder, Beethoven Orthodontic Center
Publisher, International Journal of Orthodontics & Implantology (Center)

Dr. W. Eugene Roberts,

Editor-in-chief, International Journal of Orthodontics & Implantology (Right)

tract
A 10yr 6m female presented with an unerupted mandibular left canine and crowding of the maxillary incisors. Cone-beam computer
tomography (CBCT) revealed the unerupted cuspid was a deep transalveolar impaction, positioned lingual to the roots of the left
mandibular incisors and buccal to the root of the adjacent first premolar. Extraction posed serious surgical risks to the mental nerve,
sublingual artery, and periodontium. So a carefully sequenced treatment plan was devised to reverse the etiology of the aberrant
development, and recover the cuspid by uprighting it in an oblique plane corresponding to the long axis of the impaction. Two stages
█ Fig. 1: Pre-treatment facial photographs of a 10yr 6mo female █ Fig. 4: Post-treatment facial photographs at 13yr 6mo of age
of conservative surgery exposed and progressively bonded the impaction as it was uprighted. To help avoid root resorption, the
adjacent lateral incisor was not bonded and engaged on the archwire. The precise mechanics to upright the cuspid in the prepared
oblique plane was provided by a rectangular lever arm anchored by a mandibular buccal shelf miniscrew (OrthoBoneScrew®). This
very difficult malocclusion with a Discrepancy Index (DI) of 30 was treated to an excellent result in 36 months, as documented a Cast-
Radiograph Evaluation (CRE) of 20 and Pink & White esthetic score of 2. (Int J Orthod Implantol 2017;46:40-56)

Key words:
Sublingual trans-alveolar impacted cuspid, 3-D lever arm, minimally invasive surgery, progressive bracket bonding, moment to force
ratio, buccal shelf screw, horizontal cuspid impaction

istor and tiolog █ Fig. 2: Pre-treatment intraoral photographs █ Fig. 5: Post-treatment intraoral photographs

This 10y6m female was in good general health. The initial clinical examination revealed Class I molars and
an edge to edge incisal relationship. The mandibular midline was 3mm to the left of the facial and maxillary
midlines. The mandibular left canine was unerupted and there was space between the left premolars (Figs.

Dilacerated
1-3). The apparent etiology for the impaction was an aberrant path of eruption. An innovative treatment
plan was devised to reverse the aberrant development by: 1. creating an oblique space in the arch form that
corresponded to the plane of the aberrant path of eruption (long axis of the impaction), and 2. uprighting the
cuspid in the prepared oblique plane with mechanics designed to rotate the tooth at its apex. The patient

root was treated to an excellent outcome as documented in Figs. 4-6. A pre-treatment cone beam computed
tomography (CBCT) documented the position of the impacted canine (Fig. 7). Panoramic and cephalometric
radiographs before and after treatment are illustrated in Figs. 8 and 9, respectively. Superimposed

Free IJOI hard copies at ORMCO/Newton’s A Booth

cephalometric tracings are show in Fig. 10.
█ Fig. 3: Pre-treatment study models (casts) █ Fig. 6: Post-treatment study models (casts)

40 41

45 46

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Free download IJOI-46-2017 at Hori onta y Im acted Lower anine wit ucca S e f Screw IJOI 46 IJOI 46 iAOI ASE RE ORT IJOI 46 iAOI ASE RE ORT
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7
0.019x0.025-in auxiliary hole (OrthoBoneScrew® (OBS)
Newton's A Ltd., Hsinchu City, Taiwan), was inserted in canines to the lower first molars to correct the Class
the mandibular buccal shelf, lateral to the mesial root #
ll relationship. An open bite in the area of teeth 23
#
of the lower left first molar ( 19). An elastomeric power and 24 was noted.
chain, anchored by the OBS, was used to retract tooth
#
21, to help open space for the impaction (Fig. 12). In the twenty-third month, the maxillary arch wire
was changed to 0.019x0.025-in SS, the mandibular
#
Three months later, the upper dentition (except tooth 10) 1M 0M arch wire was changed to 0.017x0.025-in TMA,
was bonded with low torque brackets on the anterior and both arches were secured with figure-eight
teeth. An 0.014-in CuNiTi wire was engaged with an █ Fig. 12: █ Fig. 7: Pre-treatment CBCT imaging reveals the unfavorable location of the impacted lower left cuspid.
A 2x12mm OBS with a rectangular hole through the head SS ligatures. The patient received myofunctional
#
open coil spring between teeth 9 to 11 to open space,

%
was inserted in the mandibular left buccal shelf, and a power therapy to correct her tongue-thrust swallowing
#
and tooth 10, was bonded with a low torque bracket chain from the OBS was used to retract tooth #21 along the iagnosis and interdental soft tissue posturing habits. In the
archwire. Note that the lateral incisor (#23) was not bonded
one month later. At the following appointment an and engaged on the archwire, so that it can act as a “free CBCT imaging ( Fig. 7 ) revealed that the trans- Skeletal: twenty-eighth month of active treatment, progress
body” to avoid root resorption, as the arch is aligned and
0.014x0.025-in CuNiTi was placed, and in the sixth space is opened. alveolar impaction of the left mandibular canine was records were collected, including panoramic and
1. Skeletal Class I (SNA 81º, SNB 78º, ANB 3º)
oriented lingual to the roots of the left lower incisors, M cephalometric radiographs. All teeth judged to
2. High mandibular plane angle (SN-MP 41º, FMA
and facial to the root of the adjacent first premolar. have incorrect axial inclinations were rebonded
32º)
The cephalometric measurements are presented in and a more flexible 0.014x0.025-in CuNiTi maxillary
Table 1. Dental: archwire was engaged. The mandibular archwire
was progressively changed to 0.018-in CuNiTi and
A O I 1. Class I occlusal relationships bilaterally
0.017x0.025-in TMA. After 36 months of active
A A A I 2. Anterior edge to edge occlusion of the incisors
treatment, the appliances were removed.
PRE-Tx POST-Tx DIFF. 3. 7mm of crowding in the upper anterior region
10M
7M 7M SNA° (82°) 81° 80° 1° 4. Multiple spaces were noted in the lower arch

Failure Rate for

SNB° (80°) 78° 78° 0° etention

5. Impacted lower left canine
ANB° (2°) 3° 2° 1°
6. Lower midline was 3mm left of the facial and A fixed retainer was bonded on all maxillary incisors.
SN-MP° (32°) 41° 40° 1°
maxillary midlines Clear overlay retainers were delivered for both
FMA° (25°) 32° 31° 1°
arches. The patient was instructed to wear them
A A A I Facial: full time for the first 6 months and nights only
U1 TO NA mm (4 mm) 3 mm 6 mm 3 mm
• Orthognathic profile with acceptable nose and 11M thereafter. Instructions were provided for home care
U1 TO SN° (104°) 104° 109° 5°
lip esthetics and maintenance of the retainers.
7M M L1 TO NB mm (4 mm) 4 mm 7 mm 3 mm █ Fig. 21:
L1 TO MP° (90°) 83° 91° 8° A progressive series of panoramic x-rays illustrate the

Buccal Shelf Screws

█ Fig. 13: ABO Discrepancy Index (DI) was 30 as shown in the uprighting of the impaction over an 11 month period
In the seventh month (7M), CBCT images from the labial (a) and lingual (b) show the 3D morphology. A 7M panoramic
A IA A A I compared to pre-treatment (0M). The first surgery to bond inal aluation o reatment
subsequent worksheet. an eyelet was performed at eight months (8M). The eyelet
radiograph (c) and eighth month (8M) intraoral photograph (d) show that there is adequate arch length to upright the tooth, E-LINE UL (-1 mm) 0 mm -1 mm 1 mm
but no information is provided on the 3D relationship of tooth roots to the impaction, mental foramen or sublingual area. was bonded on the root because the crown was too close to The molar and canine relationships were both
The CBCT scans (a and b) show that an oblique transalveolar space has been created that corresponds to the long axis of the E-LINE LL (0 mm) 2 mm 1 mm 1 mm the incisor roots and sublingual artery. The second surgery
impaction. NOTE: red arrows mark the structures that present the greatest surgical risk: the mental foramen position (a) and was performed at eleven months (11M) to reposition the Class I. The upper incisor to the SN angle
sublingual foramen (b).
█ Table 1: Cephalometric summary eyelet onto the clinical crown.

Free IJOI hard copies at ORMCO/Newton’s A Booth 45 42 48

47 48
 Failure rate for Md screws Attached Gingiva or Movable Mucosa

19%
7 %

~4 %
Chang C, AO, 2015 Dr. Park, YC, PCSO, 2004 MGJ: Muco-Gingival Junction

49 50

2 CHANG, LIU, ROBERTS MANDIBULAR BUCCAL SHELF MINISCREWS 3 4 CHANG, LIU, ROBERTS

Original Article

Primary failure rate for 1680 extra-alveolar mandibular buccal shelf

miniscrews placed in movable mucosa or attached gingiva
Chris Changa; Sean S.-Y. Liub; W. Eugene Robertsc

ABSTRACT
Figure 1. A 2 3 12-mm stainless steel bone screw is designed to be inserted in the mandibular buccal shelf as a self-drilling fixture.
Objective: To compare the initial failure rate (#4 months) for extra-alveolar mandibular buccal Figure 2. An occlusal view of a human mandible shows the available
shelf (MBS) miniscrews placed in movable mucosa (MM) or attached gingiva (AG). Figure 4. The mucogingival junction (MGJ) separates the attached Figure 8. For the right-handed surgeon in this study, the failure rate
bone in the buccal shelf area (arrow).
thickness may be the most important stability factor 6).43–46 After installation, the screw head was at least gingiva (AG) from the movable mucosa (MM). Figure 6. A drawing superimposed on a radiograph shows that a for buccal shelf miniscrews was significantly greater (P , .001) on
Materials and Methods: A total of 1680 consecutive stainless steel (SS) 2 3 12-mm MBS the patient’s left than on the right.
overall.20 Placement technique focuses on minimal root 5 mm above the level of the soft tissue (Figure 5) and screws involved only 105 patients: 89 patients had properly positioned screw is buccal to the molars roots.
miniscrews were placed in 840 patients (405 males and 435 females; mean age, 16 6 5 years). All
screws were placed lateral to the alveolar process and buccal to the lower first and second molar damage during screw placement. Park et al. 15,17 the endosseous portion had approximately 5 mm of single-screw failure and the other 16 lost screws on Many patients have a minimal width of attached
roots. The screw heads were at least 5 mm superior to the soft tissue. Loads from 8 oz–14 oz suggested placing the screws at an obtuse angle to bone engagement (contact) (Figure 6).46 All minis- both sides. The bilateral failures suggest a predispo- gingiva buccal to the molars, so .75% of optimally skeleton may be advantageous for buccal shelf
(227 g–397 g, 231–405 cN) were used to retract the mandibular buccal segments for at least the bone surface to increase bone contact and lower the crews were immediately loaded using prestretched sition to failure in a small portion of the patients (16/ positioned buccal shelf screws penetrated MM.43 miniscrews.52 In addition, there were 16 patients who N Overall, the method is highly successful for most
4 months. risk of root damage. Placing the devices in an E-A site elastomeric modules (power chains) to deliver a 840 5 1.9%). Attached gingiva can be moved to the buccal shelf site had bilateral failures, suggesting a predisposition to (93%) patients, but a small fraction of patients (1.9%)
Results: Overall, 121 miniscrews out of 1680 (7.2%) failed: 7.31% were in MM and 6.85% were in like the MSB permits the use of larger-diameter screws relatively uniform force.45–50 The mandibular retraction with an apically repositioned flap, but the present data failure in some patients. This result is not surprising appears to be predisposed to failure.
AG (statistically insignificant difference). Failures were unilateral in 89 patients and bilateral in 16. that can be inserted parallel to the axial inclination of force varied from 8 oz–14 oz (227 g–397 g, 231– DISCUSSION suggest that the expense and discomfort associated because ‘‘clustered failures’’ are well known both for
Left side (9.29%) failures was significantly greater (P , .001) compared with those on the right molars and not interfere with tooth roots.1,2 405 cN), being proportional to the perceived density of with that additional surgical procedure is unnecessary. dental implants53 and orthodontic miniscrews.54 A follow- ACKNOWLEDGMENT
Within the restraints of this study, placing MBS up study of all failures in the sample is indicated to
(5.12%). Average age for failure patients was 14 6 3 years. A pull-out study on both arches of dogs showed the bone when screwing in the miniscrew. The patients However, the elevated position of the screw head is
miniscrews in MM is an acceptable clinical procedure. investigate predisposition based on patient age, genetic This article is a research study presented to the Midwest
Conclusion: MBS miniscrews were highly successful (approximately 93%), but there was no greater strength for miniscrews placed in the mandible30 were instructed in oral hygiene procedures to control probably an important factor in successfully maintaining

7
The 4-month assessment interval was selected be- Component of the Edward H. Angle Society of Orthodontists in
significant difference between placement in MM or AG. Failures were more common on the but in human studies, maxillary sites were more inflammation. The prestretched power chains47–49 were the screws in MM, because oral hygiene is facilitated to factors, and bone characteristics. Some patients may partial fulfillment of the requirements for active membership.
cause all patients in the study required at least
patient’s left side and in younger adolescent patients. Having 16 patients with bilateral failures successful than those in the mandible in all26,37–40 but replaced every 4 weeks. The stability of the buccal control peri-screw inflammation. have an enhanced regional acceleratory phenomenon55
4 months of mandibular buccal segment retraction.
suggests that a small fraction of patients (1.9%) are predisposed to failure with this method. (Angle one study.23 More recent research confirmed the maxilla shelf screws was tested at every appointment for The significant difference in primary failures on the when bone is wounded with a miniscrew. This exagger- REFERENCES
Additional study of the sample is indicated to deter-
Orthod. 0000;00:000–000.) as a superior site for miniscrews,12,17,24 but inadequate 4 months. Percent failure data was tested by chi- left side (9.29%) vs the right (5.12%) reflects the ated hyperinflammatory response may be genetic, such
mine the long-term failure rate relative to the anchor- 1. Chang C, Roberts WE. Orthodontics. Taipei: Yong Chieh;
AG continues to be a concern.1,2 These results suggest square. The Indiana University Institutional Review technical sensitivity of the procedure and possibly as homozygosity for allele 2 of interleukins 1-beta,
KEY WORDS: Mandibular buccal shelf; Miniscrews; Skeletal anchorage; Attached gingiva; age needs of each patient. 2012:285–298.
there may be a problem if E-A miniscrews are inserted Board approved the protocol, assigning the other uncontrolled biological factors such as chewing predisposing a patient to periodontitis.56
Alveolar mucosa; Extra-alveolar orthodontic anchorage Most studies of I-R miniscrews have shown a higher 2. Lin J, Liaw J, Chang C, Roberts WE. Orthodontics: Class III

Sandra
in MM, but soft tissue considerations have not been number 1408974880. failure rate in the mandible (19.3%) than in the maxilla and brushing habits. It is more difficult for a right- Correction. Taipei: Yong Chieh; 2013.
specifically addressed.41–44 handed clinician to ideally position buccal shelf CONCLUSIONS 3. Creekmore TD, Eklund MK. The possibility of skeletal
(12.0%).24,51,53 Furthermore, the physical stability of
The hypothesis tested is that MBS miniscrews are RESULTS miniscrews on the opposite side. Additional refinement anchorage. J Clin Orthod. 1983;17:266–269.
INTRODUCTION application, but they are often problematic in the miniscrews tends to decrease for the first 3 weeks.31 N To provide optimal anchorage for retracting the 4. Roberts WE, Smith RK, Zilberman Y, Mozsary PG, Smith
less successful short-term (,4 months) if they are of the clinical technique is indicated to help control this
Skeletal anchorage is a broad-based experimental
posterior mandible.11,12,15,17–26 Miniscrews in the mandib- Retrospective analysis of the 1680 miniscrews With a primary failure rate of approximately 7%, MBS mandibular arch, MBS miniscrews must be posi- RS. Osseous adaptation to continuous loading of rigid
placed in MM. variable.
and clinical concept.1–7 Kanomi8 introduced surgical
ular buccal shelf (MBS) are proposed as a reliable revealed that 1286 (76.5%) were placed in MM and miniscrews are an attractive option for retraction of the tioned precisely relative to tooth roots, soft tissue, endosseous implants. Am J Orthod. 1984;86:95–111.
Predisposition to MBS miniscrew failures is an
miniscrews for orthodontic anchorage, and more
source of extra-alveolar (E-A) anchorage for retracting 394 (23.5%) were in AG. Overall, 121 of 1680 (7.2%) mandibular buccal segments or the entire lower arch. and available bone. 5. Roberts WE, Helm RF, Marshall JK, Gongloff RK. Rigid
MATERIALS AND METHODS important area for future research. Miniscrew studies endosseous implants for orthodontic and orthopedic an-
specific devices soon followed.9,10 Currently there is a
the entire mandibular arch to correct severe crowding, miniscrews failed within 4 months, and the average Furthermore, the risk of root damage is remote when N Assuming adequate soft tissue clearance (approxi-
chorage. Angle Orthod. 1989;59:247–256.
of other sites have found no significant relationship
large range of miniscrews varying in diameter from
protrusion, and skeletal malocclusion, without extrac- MBS miniscrews were installed in a consecutive time of failure was 3.3 months. In the MM group, 94 out buccal shelf miniscrews are applied as described mately 5 mm), screws can be positioned in attached 6. Roberts WE, Marshall KJ, Mozsary PG. Rigid endosseous
between failure rate and age.11,16,17,21 However, in the
1.0 mm–2.3 mm and in length from 4 mm–21 mm.11–19
tions or orthognathic surgery.1,2 series of 840 patients (405 males, 435 females; age 16 of 1286 (7.31%) failed, and 27 out of 394 (6.85%) Figures 2–6. or movable mucosa. implant utilized as anchorage to protract molars and close
Success rates for I-R miniscrews range from 57%– current study, younger patients tended to have a an atrophic extraction site. Angle Orthod. 1990;60:135–152.
Interradicular (I-R) miniscrews are the most common 6 5 years), inserted in private practice by the same failed in AG (Figure 7). A chi-square test failed to show
95%, with a mean of approximately 84%.26–28 Failure is higher failure rate, suggesting that a more mature 7. Lee KJ, Park YC, Hwang CJ, et al. Displacement pattern of
orthodontist (senior author) from 2009 to 2012. A total a statistical significance (P . .05) between the groups,

Dr. Damon
common in the posterior mandible, typically occurring the maxillary arch depending on miniscrew position in sliding
of 1680 SS miniscrews (2 3 12-mm, Newton’s A, so the hypothesis was rejected.

3D
a
Private Practice, Beethoven Orthodontic Center, Hsinchu in the first few weeks, so primary stability is the critical mechanics. Am J Orthod Dentofacial Orthop. 2011;140:
Hsinchu City, Taiwan) (Figure 1) were placed without On the other hand, there were interesting failure 224–232.
City, Taiwan. factor for clinical success.29–31 Attempts to improve

%
b
Assistant Professor, Department of Orthodontics and Oro- flap elevation under local anesthesia (Figures 2 and relationships among other variables: age, side (right vs 8. Kanomi R. Mini-implant for orthodontic anchorage. J Clin
primary stability include smaller diameter pilot holes,23 3); 1286 were in MM and 394 penetrated the AG left), and predisposition. The average age of the 121 Orthod. 1997;31:763–767.
facial Genetics, Indiana University School of Dentistry, India-
napolis, Ind. sites with increased cortical bone thickness and (Figures 4 and 5). All miniscrews were placed as failure patients was 14 6 3 years, which is consider- 9. Costa A, Raffainl M, Melsen B. Miniscrews as orthodontic
c
Professor Emeritus of Orthodontics and Adjunct Professor of density,29–32 and a self-drilling protocol.33,34 Bone quality nearly parallel as possible to the mandibular first and ably lower than the average age of all patients (16 6 anchorage: a preliminary report. Int J Adult Orthod Orthog-
Mechanical Engineering, Indiana University and Purdue Univer- is particularly important for orthodontic miniscrews nath Surg. 1998;13:201–209.
sity, Indianapolis, Ind.
second molar roots (extra-alveolar approach). The 5 years). These data suggest that the failures were 10. Bechtold TE, Kim JW, Choi TH, Park YC, Lee KJ.
because they are retained by mechanical locking rather surgical procedure began with a sharp dental explorer more common among the younger patients who

Dr.
Dr. John Dr.Gene
Gene
Corresponding author: Dr W. Eugene Roberts, 8260 Skipjack Distalization pattern of the maxillary arch depending on the
than osseointegration.35,36 Screw design studies show a

John Dr.
Dr, Indianapolis, IN 46236 sounding through the soft tissue to bone at the desired tended to have less dense cortical bone in the MBS. number of orthodontic miniscrews. Angle Orthod. 2013;83:
(e-mail: werobert@iu.edu) .70% success rate for I-R miniscrews with a diameter skeletal site (Figures 2 and 3). The most anatomically Regarding side of patient, 78/121 (64.5%) of the 266–273.
of $1.2 mm, and multiple studies show success is favorable site for the miniscrew is usually at or near the failures were on the left side and 43/121 (35.5%) were 11. Miyawaki S, Koyama I, Inoue M, Mishima K, Sugahara T,
Accepted: December 2014. Submitted: September 2014.
Published Online: January 20, 2015 directly related to screw length.17–21 However, increased Takano-Yamamoto T. Factors associated with the stability
mucogingival junction (Figure 4). A self-drilling bone on the right (Figure 8). Overall, the failure rate on the Figure 5. Screw insertion point may penetrate AG or MM but the Figure 7. There was a slight tendency for more failures when screws of titanium screws placed in the posterior region for
G 0000 by The EH Angle Education and Research Foundation, screw size increases the probability of root damage,21
screw was inserted and screwed into the bone right (9.29%), compared with the left (5.12%) side, was Figure 3. A lateral cutaway view of a human mandible shows the head of the screw must be at least 5 mm above the level of the were in MM rather AG, but the difference was not statistically orthodontic anchorage. Am J Orthod Dentofacial Orthop.
Inc. and a recent review suggests that cortical bone
perpendicular to the occlusal plane (Figures 5 and statistically significant (P , .001). The 121 failed area of available bone (arrow) for placing a buccal shelf bone screw. soft tissue. significant. 2003;124:373–378.

LinLin Roberts
Roberts
DOI: 10.2319/092714.695.1 1 Angle Orthodontist, Vol 00, No 0, 0000
Angle Orthodontist, Vol 00, No 0, 0000 Angle Orthodontist, Vol 00, No 0, 0000 Angle Orthodontist, Vol 00, No 0, 0000

Real Pro in
Biomechanics Tha nks
The Angle Orthodontist, Nov. 2015 Class III

51 52

that dramatically impact my practice

3 small Screws
that dramatically simplify my practice How to fix this
1. BS Screws
impaction?
10:55 2. Ramus Screws
3. IZC Screws
Dr. Case Dr. Burstone

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Tx Plan ?

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Why
14 mm?

Buccal Shelf Screw

Ramus Screw
(2x12 SS)
(2x14 SS)

69 70

Why Ramus Screw Ramus Screw

14 mm? (2x14 SS) (2x14 SS)

Why
14 mm?

71 72
 Ramus Screw
(2x14 SS) Ramus Screw: 2x14 SS

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Covered with
14 mm? thick Medial
Pterygoid M.

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Make a dent on BONE w an explorer

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Ramus Screw: 2x14 SS Jobs’ 3 levels of Pro.

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Failure Rate of Ramus Screws
What is the

5
20.0%

Failure Rate for

15.0%

Ramus Screws?
19.5%

10.0%

5.0%
12% %
From 2013~15 (4 months observation)
7.2%
5.0%

0%
I-R miniscrew, I-R miniscrew, E-A miniscrew, E-A miniscrew,
Mandible Maxilla MBS Ramus

77 78
 Free download IJOI-41-2016 at ijoi.pro Free download IJOI-41-2016 at ijoi.pro

I J OI
Class II Division 1 Malocclusion with 5mm of Crowding IJOI 41 RE EAR RE IE IJOI 41 RE EAR RE IE R I IJOI 41 R I IJOI 41 IJOI 41 RE EAR RE IE
Treated Non-Extraction with IZC Miniscrews Anchorage
Drs. Irene Yi-Hung Shih, John Jin-Jong Lin & W. Eugene Roberts

Class II, Excessive Overjet and Deep Bite with a Congenitally

Missing Lower Incisor
Drs. Yi-Yang Su, Chris Chang & W. Eugene Roberts
Dr. Chris Chang,
Forty Consecutive Ramus Bone Screws Used to Correct Founder, Beethoven Orthodontic Center
Horizontally Impacted Mandibular Molars International Journal of Publisher, International Journal of Orthodontics& Implantology (Left)
Drs. Chris Chang, Shih-Yung Lin & W. Eugene Roberts Orthodontics & Implantology ort on c ti am on cr Dr. Shih-Yung Lin, DDS,
Editor, International Journal of Orthodontics & Implantology (Middle)
3D Cortical Bone Anatomy of the Mandibular Buccal Shelf:
a CBCT study to define sites for extra-alveolar bone screws to Vol. 41 Jan 1, 2016 to orr ct ori onta mpact 20.0%
Dr. W. Eugene Roberts,
report the clinical experience as a success rate from Despite the obvious mechanical advantage of a design ( Fig. 1 ) was based on a careful study of plane (Fig. 5). A relatively long (14 mm) SS miniscrew
57-95%, with an average of about 84%. 15-17 E-A SS ramus screw for uprighting a horizontally impacted anatomy of the anterior ramus ( Figs. 2 and 3 ). The was selected because of the need to penetrate thick
treat Class III malocclusion
Drs. Chris Chang, Chi Huang & W. Eugene Roberts
an i ar o ar Chief consultant, International Journal of Orthodontics & Implantology (Right)
miniscrews are used in the MBS and infrazygomatic molar, there are numerous concerns about this optimal site for a direct line of traction without unkeratinized mucosa, with an underlying layer of
crest ( IZC ) for retracting or protracting individual region as an E-A TAD site: 1. highly mobile alveolar occlusal interference was midway between the masticatory muscle. For hygiene access, the TADs
15.0% teeth or entire arches, to correct a wide variety of mucosa, 2. relatively thick layer of unattached soft external and internal oblique ridges (Fig. 4) of the were screwed in until the head of the TAD was 5
malocclusions.18,19 A large study of 1,680 consecutive tissue, 3. underlying layer of active muscle some ascending ramus, about 5-8 mm above the occlusal mm above the level of the soft tissue (Fig. 5).
19.5% same location as horizontally impacted molars, so rigid (moved within the bone), and often interfered MBS miniscrews reported a failure rate of only 7.2%,5 of which is attached to bone, and 4. difficult area

tract they were unsuitable anchorage for their recovery. with the path of tooth movement, so they were not which is considerably lower than for I-R miniscrews in for maintaining oral hygiene to control soft tissue
10.0%
Failure of temporary anchorage devices (TADs) is a serious limitation when treating complex problems like horizontal impactions of Subsequently, Kanomi 2 and others 3,4 introduced suitable for managing deep horizontal impactions. the mandible (19.3%) or the maxilla (12.0%) (Table 1).20-21 hyperplasia.31 A 2x14 mm SS screw was designed a
mandibular molars, because there are few other viable options. From a biomechanics perspective, the anterior ramus of the mandible multiple types of titanium alloy (Ti) miniscrews that as the best fit for the anatomical features of the
is an ideal location for a TAD. However, this area appears to be a high risk site because it is covered with thick, mobile soft tissue. 12% Failure of multiple osseointegrated implants in anterior ramus region ( Fig. 1 ). The objective for
were placed in the alveolar process between the Realizing that the first two generations of TADs
Objective: Assess the failure rate and efficacy of ramus bone screws used as anchorage to upright horizontal impactions of 5.0% roots of teeth. These interradicular (I-R) devices were (retromolar and I-R) lacked the versatility to manage the maxilla of individual patients are associated testing this screw was to assess its failure for any
mandibular molars within four months. not well suited for complex problems like horizontal horizontal impactions. Chang et al.5 expanded the with parafunction and psychologic factors, 22 but reason, in serving as adequate anchorage to recover
7.2%
Materials and Methods: The sample (n = 37) was thirty-seven consecutive patients (20 males, 17 females, mean age 18±6 yr) 5.0% impactions, and they often had a high failure rate E-A TAD concept by developing a 2 mm diameter those parameters have not been systematically a horizontal impaction(s). The null hypothesis is that
with horizontal impactions distal to the functioning lower arch. Three patients had bilateral horizontal impactions, for a total of 40 particularly in the posterior mandible ( Table I ). studied relative to TADs. However, Chang et al. 5 ramus screws will have a high failure rate and low
stainless steel ( SS ) bone screw ( Fig. 1 ) that was
consecutive ramus bone screws. The crowns of the impactions were uncovered and bone was removed down to the cementoenamel 0% Furthermore, the I-R TADs had other limitations5-8 suitable for dense cortical bone sites, such as the did note bilateral failures of MBS bone screws in efficiency in recovering horizontal impactions of
junction, if needed. All screws were placed perpendicular to the ascending ramus, about 5 mm superior to the occlusal plane of the
I-R miniscrew, I-R miniscrew, E-A miniscrew, E-A miniscrew, including damaging the roots of teeth, were not mandibular buccal shelf (MBS). The MBS bone screw multiple patients, suggesting that some patients are mandibular molars.
mandible. For oral hygiene access, the head of the screw was at least 5 mm above the soft tissue. The load applied to upright the
molars ranged from 2-4 oz (57 g-113 g, 56 cN-112 cN). Mandible Maxilla MBS Ramus predisposed to TAD failure. Miniscrew failure may be

Results: Ramus screw anchorage was very effective for uprighting horizontal impactions. Two of the 40 screws failed (2/40 = 5%) due █ Table 1: due to a loss of stability, or to soft tissue inflammation, █ Fig. 3:
The failure rates for four types of TADs are illustrated in a bar graph. Interradicular (I-R) miniscrews are placed in the alveolar so primary stability is the critical factor for clinical aterial and et ods b After administering local anesthesia, the clinician locates the
to soft tissue hypertrophy that covered the head of the screw, but none were loose relative to supporting bone. Both failing screws external oblique ridge with the left thumb, and then marks
process between the roots of teeth. Extra-alveolar (E-A) are place outside the alveolar process. I-R miniscrew in the mandible Smooth Mushroom Head 4-way Rectangular Holes 23-25
were repositioned with additional soft tissue clearance, and then they were then successful for the purpose intended. (blue) and the maxilla (royal blue) are compared to E-A (extra-alveolar) bone screws in the MBS (mandibular buccal shelf, green) For lever arm to solve impacted
success. The latter is enhanced by a larger In this study, the ramus screws were inserted in 37 the site for the ramus screw by sounding through the soft
For comfort & retention of elastic chain tissue to bone with a sharp explorer.
and anterior ramus of the mandible (red). tooth
Conclusion: Ramus screws were highly successful (38/40 = 95%) as anchorage units to upright horizontal impactions in the posterior diameter screw, smaller diameter pilot hole, and consecutive patients (20 males, 17 females, mean age
mandible. When the two failed screws were repositioned, they were successful as planned, so the overall success rate for ramus screw thicker cortical bone.23-26 Furthermore, the self-drilling 18±6 yr ), presenting for treatment of horizontally
anchorage was 100%. (Int J Orthod Implantol 2016;41:60-72) was placed lateral to the first and second molars, challenging intraoral site like the anterior ramus of protocol can also play a role. 27,28
Screw design studies impacted mandibular molars. Three of the patients
Key words: so it did not interfere with the retromolar location the mandible. A detailed review of TAD failure was in show a >70% success rate for I-R miniscrews with a had bilateral impactions, so a total of 40 stainless
Horizontally impacted second molars, molar up-righting, ramus screws, TAD failure rate, soft tissue hypertrophy, TAD repositioning Double Neck Design 14 mm in Length
of horizontal impactions, or the path of tooth order to design a reliable bone screw for recovering diameter of ≥1.2 mm, and multiple studies show that steel, self-drilling miniscrews ( 2x14 mm, Newton’s
Easy hygiene control & extra attachment Penetrate thicker soft and hard
movement within the alveolar process. However, horizontal molar impactions. tissue, more stability success is directly related to the screw length.12-14,29 A Ltd, Hsinchu City, Taiwan) were installed in the
active mechanics to recover horizontal impactions However, the probability of root damage is increased anterior ramus to upright the uncovered impactions.
with MBS bone screws were complex and difficult to Retromolar osseointegrated implants,1 the original when a wider diameter I-R miniscrew screw is All the patients were treated over a three year period
Introduction control. To better address the mechanical problems, E-A TADs, have about the same failure rate as other used.29 A recent review30 indicated that cortical bone █ Fig. 2:
(2013-15 ) in a single private practice by the same
Stainless Steel Sharp Cutting Edge Anatomy of the mandibular ramus is viewed from the
Horizontally impacted mandibular molars are complex problems that are refractory to routine orthodontic bone screws were needed in the anterior ramus osseointegrated fixtures (<5%), but the risk of failure High flexibility & resistance to fracture Easy to penetrate cortical bone, thickness appears to be the most important factor orthodontist. The ramus screws were installed under superior (a) and mesial (b) perspective. The insertion site for
of the mandible to provide a more superior and for I-R miniscrews is much greater, which may relate a ramus screw (red arrows) is between external and internal
treatment. An efficient treatment strategy required the development of anchorage devices that were suitable no pre-drilling for primary stability. The overall experience with I-R local anesthesia, without flap elevation or pilot oblique ridges, about 5-8 mm superior to the occlusal plane.
for challenging intraoral sites outside the alveolar process. Roberts et al.1 utilized osseointegrated implants as posterior direction of traction, along the plane to their highly variable shape, diameter (1.0-2.3 mm), miniscrews indicated they were high risk TADs with drilling. From the occlusal perspective, note the relatively smooth,
Bust and portrait of the father of orthodontic biomechanics, Charles J. Burstone (1928-2015). Permanent collection in Beethoven 6-14 broad area between the internal and external oblique ridges

Free IJOI hard copies at ORMCO/Newton’s A Booth Free IJOI hard copies at ORMCO/Newton’s A Booth
extra-alveolar (E-A) temporary anchorage devices (TADs) for closing edentulous spaces in mandibular arch. of the impaction. The major concern from the and length (4-21 mm). Since the failure rate for little potential for managing complex problems like (a). In the lateral view (b) note that the insertion point for █ Fig. 4:
Orthodontic Center, Taiwan.
onset was the risk of failure when using TADs in a many I-R devices is relatively high, many authors horizontal impactions in the posterior mandible. The selection of the anatomical site and the screw the bone screw (red arrow) is distant from the mandibular The insertion site for the bone screw is about 5-8 mm above
These retromolar devices were reliable and efficient, but the site for the osseointegrated fixtures was in the █ Fig. 1: A 2x14-mm stainless steel bone screw was designed to be inserted in the ramus as a self-drilling fixture.
foramen and inferior alveolar canal. the mandibular occlusal plane.
International Journal of Orthodontics & Implantology is an experience sharing magazine for worldwide orthodontists and
Implantologists. Download it at http://iaoi.pro. 《僅供牙科專業人士參閱》

60 62 61 63 64

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R I IJOI 41 IJOI 41 RE EAR RE IE R I IJOI 41

a b

a b technique. 41 A fractured screw is worrisome for am le i e and Inclusion riteria

the patient, may result in injury of adjacent tissue,
5 mm In collecting a group of patients to assess a clinical
is the third molar, followed by the maxillary canine and It is usually desirable to recover horizontally amus as a A ite
or block the desired site for a TAD. Risk of screw
problem, it is important to avoid sampling bias. c d e
fracture is decreased by increasing the diameter of
mandibular second molars.36 The current study of 37 impacted mandibular second molars. Impacted The patients selected may be a random or inclusive
An efficient, yet simple mechanism is required to hand, a ramus screw must penetrate much thicker the screw to at least 2 mm, using a tougher material
3 mm patients with a total of 40 horizontal molar impactions third molars may also be valuable dental units if the sample of all patients meeting the inclusion criteria
recover deeply impacted or mesially tipped molars. soft tissue before engaging the dense cortical bone such as stainless steel (SS), and drilling a pilot hole for
appears to be the largest orthodontic sample of adjacent first or second molars are compromised within a given time frame.42,43 The current study is
Lin37 reviewed six different methods for recovering of the mandible. Thus, a 14 mm screw is necessary to the screw. The latter is not practical because of the
horizontal mandibular molar impactions reported. or missing. Uprighting horizontally impacted third an inclusive sample of patients with a relatively rare
deeply impacted molars, and concluded that the provide at least 5 mm of soft tissue clearance, after thick soft tissue covering the bone, but using 2 mm
These dental anomalies are complex problems that molars prior to extraction may be a wise measure condition, that was treated with 40 ramus bone
most reliable and efficient approach was to surgically the bone has been penetrated 3 mm or more (Fig. 8).40 diameter screws made of SS is a practical approach

You Tube
are difficult to treat to an optimal outcome. The most to avoid damaging the second molar and its screws in 37 patients, over a 3 year time frame. One
expose the deeply impacted molars and upright █ Fig. 8:
for decreasing fracture risk. On the contrary,
problematic aspect of the treatment is the initial periodontium and inferior alveolar nerve during a The muscle in the retromolar area is composed of the traversing fibers of the medial pterygoid (a) and the anterior fibers of the patient was rejected because the impacted molar 0M 0M 0M
them with traction via a ramus bone screw.38,39 The temporals that are inserting into the ramus surface (b). increasing the length of a screw to 14 mm renders
uprighting, which this study demonstrates can be surgical extraction procedure. This approach may om lications was periodontally compromised. Randomization is
current study validates that concept. it more susceptible to a flexure-related fracture. All f g h
routinely accomplished with ramus screw anchorage be wise, even if no other orthodontic treatment is inappropriate for such a small number of patients.
The anatomical structure near the ramus, presenting things considered, the 2x14 mm SS bone screw
in 4 months or less (Fig. 6). needed. Although there were 40 ramus screw sites, the total
█ Fig. 5: the most serious risk for complications, is the appears well suited as a ramus TAD, because to date
mm crews sample size for the current study is only 37. The
Left: after TAD placement, the screw head is about 5 mm above the soft tissue. neurovascular bundle in the inferior alveolar none of the screws have fractured.
Right: The average bone engagement for a ramus screw is ~3 mm. 0M 1M remaining three cases were bilateral applications of
Previous studies with mandibular buccal shelf bone (mandibular) canal (Fig. 2b). Under normal
the same treatment, so they are not independent
screws,1,6,19 utilized 2x12 mm stainless steel screws circumstances, the ramus TAD site is about 15 to 20
samples. However, bilateral samples are important in
All miniscrews were immediately loaded using pre- there was soft tissue overgrowth and severe (SS), because soft tissue was less than 3 mm thick. A mm away from the neurovascular bundle. Once the amus crew ailure
a clinical series because they provide information on
stretched elastomeric modules ( power chains ) 32-34 inflammation around the TAD head. The failures 12 mm screw length was adequate to leave 5 mm screws are inserted, postoperative panoramic films Based on the previous experience with buccal shelf 1M 1M 1M
patient predisposition to failure.
attached to the button or eyelet bonded on the occurred in different patients; one was on the right of clearance between soft tissue and the head of revealed that the screw tip may be within 5 to 8 mm bone screws,5 it's surprising that none of the ramus
impacted teeth (Fig. 5). The patients were instructed side of a 12 year-old boy and the other was on the the screw after installation (Figs. 5 & 7). On the other of the mandibular canal (Figs. 7 - 9). Fig. 10 is a series screws loosened during 4 months of traction. Only 2 i j k
Although the sample size is small (n = 37), this study
in oral hygiene procedures to control soft tissue left side of a 13 year-old girl. Both failed screws were
of 40 screws failed to serve as adequate anchorage

Newtonsa0301
has provided a reliable initial estimate for the failure
inflammation. For reactivation at monthly intervals, removed, the hypertrophic soft tissue was removed,
for uprighting molars, but those problems were
rate of ramus screws. None of the devices loosened
the traction force was increased by advancing one the bone screw was cleaned with alcohol, and then
a b because of soft tissue hyperplasia in adolescents
from bone during the 4 month test interval, and
loop on the elastic chain and cutting it off every 4 repositioned in an adjacent location, leaving at
2M 4M with relatively poor oral hygiene. Both patients
Fig. 9: the only failures were due to reversible soft tissue
weeks (Figs. 6 & 10). The stability of the ramus screws least 5 mm exposure for the screw head. Both of █

Panoramic films was taken immediately after 3 ramus screw insertions to evaluate the angulation of the screws, and estimate with the initial failures were successfully treated by
problems. It can be concluded the the ramus
was regularly hand tested at 4 week intervals for 4 the initial failures were then clinically successful, so their proximity to the neurovascular bundle. None of the screws were closer than 5 mm to the inferior alveolar canal. removing the screws, resecting the hyperplastic
screw is a reliable option for recovering horizontal
months, which was the maximum duration of the all 40 horizontally impacted molars were recovered 2M 3M 4M
tissue, and replacing it in an adjacent location.
impactions, that have an adequate periodontium.
molar uprighting phase of treatment. At 5 months and aligned except for one impaction, that had no
of drawings that illustrate the details for utilizing crew ractures From these results it is clear that the success of █ Fig. 10:
the previously impacted molars were bonded with a bone on the distal surface of the root when it was
a ramus screw to upright a horizontally impacted in t e Absence o re drilling ramus screws depends on appropriate hygiene A series eleven drawings illustrates the details for ramus screw placement. a. an occlusal semitransparent view illustrates the
It is important to remember that one of the lower
routine buccal bracket. uncovered. position for a horizontally impacted molar. b. a similar drawing shows the position of the ramus screw superior to the impaction.
molar. If a clinician carefully follows the detailed measures. So it is very important to provide hygiene
Fracture is a significant risk for small ( <2 mm molar impactions, from a patient treatment planned c-e. Three progressive drawings reveal the position of the ramus screw, bonding of an attachment with an elastic chain attached
instructions provided, the risk of complications is instructions and monitor soft tissue inflammation at to the crown of the impaction, and applying traction to the impaction by attaching the elastic chain to the ramus screw. f-h.
diameter), brittle screws (Titanium or Titanium alloy) for a ramus screw, was not recovered because it similar drawings illustrate reactivation of the elastic chain and trimming it after one month of traction (1M). i-k. The progressive
minimal. each appointment.31 uprighting and extrusion of the impaction is shown after two (2M), three (3M) and four (4M) months of traction. See text for
esults iscussion inserted into dense cortical bone with a self drilling was periodontally compromised. That was the only
█ Fig. 7: details.
Only 2 out of 40 ramus screws (5%) failed to serve as Extra-alveolar (E-A) bone screws are very effective for The insertion sites for E-A bone screws are compared.
█ Fig. 6:

Free IJOI hard copies at ORMCO/Newton’s A Booth Free IJOI hard copies at ORMCO/Newton’s A Booth
a. A 2x12 mm screw is well secured in the bone (at least 3 mm) of the mandibular buccal shelf and there is still adequate
adequate anchorage for uprighting the horizontal managing a variety of malocclusions including deeply Panoramic films were exposed immediately after surgery (0M), as well as one (1M), two (2M) and four (4M) months later. clearance (~5 mm) above the soft tissue for hygienic maintenance.
The horizontally impacted second molar was up-righted with 4 months of traction, and a routine molar tube was bonded one 68 69 70
impaction. Neither failed screws were loose, but impacted teeth.35 The most common impacted tooth month later. b. The ramus screw must penetrate much thicker soft tissue to engage bone so a 2x14 mm SS screw is required.

65 66 67

81 82

that dramatically impact my practice

Tip: Bone engagement: 3 mm
3 small Screws
that dramatically simplify my practice
over
Insertion
Torque: 30 Ncm 1. BS Screws
????
2. Ramus Screws
3. IZC Screws 11:00
The Indiana University Institutional Review Board approved the protocol, assigning the number 1607517021.
Chris Ch

83 84
Chris, please wash IZC Screw: Outside the roots
Dr.
your brain. John Lin

Learn from
the PRO!

Dr. John Lin Chris IZC: Infra-Zygomatic Crest

85 86

Z ygomatic

I ZC miniscrew
process

87 88

I nfra I nfra

Z ygomatic Z ygomatic

C rest C rest

89 90
 MGJ IZC Screws
I
nfra

Z ygomatic
> 5 mm
C rest

Extra-Alveolar Insertion

91 92

1
Occlusion

IZC Screws
for Mx arch distalization 0 point

93 94

IZC Screw Full cusp C II w 14 mm OJ

Class III
End on
Class I End on Class II
> Class III Class III
less than end on
Class III or Class II
Class II > Class II 0 19

4 points 2 points 0 point 2 points 4 points

1 point/mm 1 point/mm
Ethen 15y7m

95 96
 Full cusp C II w 14 mm OJ CII correction

0 19 IZC Screws + CII elastics + Bite Turbo

1 8

Ethen 15y7m

97 98

CII correction Early IZC screw insertion (1st month) is the KEY.

IZC Screws + CII elastics + Bite Turbo 0 0 1

7 8

5 7 11
2 oz

99 100

Early IZC screw insertion (1st month) is the KEY. 0 12

14 17 19

1FU 1FU 3FU

OJ =14 mm

101 102
0 0 19
19

OJ =14 mm OJ =14 mm

103 104

0 19

OJ =14 mm OJ =14 mm

105 106

Pre-Tx Post-Tx Diff

1. SNA (82˚) 84.5˚ 84˚ 0.5
2. SNB (80˚) 80.5˚ 80˚ 0.5
3. ANB (2˚) 4˚ 4˚ 0
4. SN-MP (32˚) 28˚ 28˚ 0
5. FMA (25˚) 21˚ 21˚ 0

6. U1→NA (4mm) 12 mm 3 mm 9

7. U1→SN (104˚) 128˚ 99˚ 29

8. L1 →NB (4mm) 4 mm 6 mm 2
9. L1 →MP (90˚) 96˚ 101˚ 5

10. UL→E-line (-1mm) 4 mm 2 mm 2

11. LL →E-line (0 mm) 5 mm 2 mm 3
OJ =14 mm

107 108
 How IZC= Infra Zygomatic Crest

to retract the whole Mx dentition in such a

huge scale w only 2 IZC screws?

Dr. Rungsi OJ =14 mm Chris

3:15
109 110

IZC= Infra Zygomatic Crest

IZC

Placement

111 112

IZC Placement

Inter-radicular
Placement

113 114
Outside the roots

In-between 

the roots

115 116

1
IZC Screws
for Mx arch distalization
Easy to adjust Gingival
the position of
What else?
irritation caused
PC by impinged
Power Chain.

117 118

4 major 4 major
applications applications
of of
IZC screws IZC screws
1. Mx arch distalization
1. Mx arch distalization
2. Molar intrusion 2. Molar intrusion
3. Molar mesialization
3. Molar mesialization
4. Impaction or transposition
4. Impaction or transposition

119 120
 4 major 4 major
applications applications
of of
IZC screws IZC screws

1. Mx arch distalization 1. Mx arch distalization

2. Molar intrusion 2. Molar intrusion
3. Molar mesialization 3. Molar mesialization
4. Impaction or transposition 4. Impaction or transposition

121 122

4 major 4 major
applications applications
of of
IZC screws IZC screws

1. Mx arch distalization 1. Mx arch distalization

2. Molar intrusion 2. Molar intrusion
3. Molar mesialization 3. Molar mesialization
4. Impaction or transposition 4. Impaction or transposition

123 124

4 major 4 major
applications applications
of of
IZC screws IZC screws

1. Mx arch distalization 1. Mx arch distalization

2. Molar intrusion 2. Molar intrusion
3. Molar mesialization 3. Molar mesialization
4. Impaction or transposition 4. Impaction or transposition
IZC screw + 3D lever arm

125 126
 4 major 4 major
applications applications
of of
IZC screws IZC screws

1. Mx arch distalization 1. Mx arch distalization

2. Molar intrusion 2. Molar intrusion
3. Molar mesialization 3. Molar mesialization
4. Impaction or transposition 4. Impaction or transposition
IZC screw + 3D lever arm IZC screw + 3D lever arm

127 128

4 major
applications
of
IZC screws
0
3
3
Transposition 2
2

129 130

Open coil spring

T-loop

(to create space)

for retraction

(19x25 TMA)

Stop
Screw

(mesial to w square hole

crowding) (Anchorage; 2x14H)

Don’t bond lateral

Power chain to S.

(free body) (prevent flaring)

131 132
 Once you have control, get creative.

0 0 3 5 0 0 3 5

7 8 9 9 7 8 9 9
2 KEYS
1. Don’t bond the lateral
to solve the
transposed 2. Keep the transposed tooth as high as possible
teeth:

133 134

I prefer to write or read AJODO

case reports that contain
every single step - esp, KEY steps. Dec. 2016 edition
CASE REPORT 2 Hsu, Chang, and Roberts Hsu, Chang, and Roberts 34 Hsu, Chang, and Roberts

Hsu, Chang, and Roberts 5 6 Hsu, Chang, and Roberts Hsu, Chang, and Roberts 710 Hsu, Chang, and Roberts
1
2
3
Canine-lateral incisor transposition: 121
122
123
61
62
63
241
242
243
181
182
183
361
362
363
301
302
303
421
422
423
4
5
Controlling root resorption with a 124
125
64
65
244
245
184
185
364
365
304
305
424
425
481
482
601
602
541
542
721
722
661
662
1081
1082
781
782
1141
1142
6
7
8
bone-anchored T-loop retraction 126
127
128
66
67
68
246
247
248
186
187
188
366
367
368
306
307
308
426
427
428
483
484
603
604
543
544
723
724
663
664
1083
1084
1085
783
784
1143
1144
1145
485 605 545 725 665 785
9 129 69 249 189 369 309 429 486 606 546 726 666 1086 786 1146
10 a
130 70 250 190 370 310 430 487 607 547 727 667 1087 787 1147
Q8
Q1
Yu
Lin
Hsu,Chris
H.
Chang,b
and
W.
Eugene
Robertsc
11 131 71 251 191 371 311 431 488 608 548 728 668 1088 788 1148
HsinChu, Taiwan, and Indianapolis, Ind
12 132 72 252 192 372 312 432 489 609 549 729 669 1089 789 1149
13 133 73 253 193 373 313 Fig
7.
After
extraction
of
the
deciduous
canine,
Damon
433 490 610 550 730 670 1090 790 1150
14 134 74 254 194 374 314 3mx
(Ormco,
Glendora,
Calif)
brackets
were
bonded
to
434 491 611 551 731 671 1091 791 1151
A 12-year-old girl presented with a Class II Division 1 malocclusion, complicated by a complete transposition of
15 135 75 255 195 375 315 435 492 612 552 732 672 1092 792 1152
the maxillary left canine into the position normally occupied by the left lateral incisor. Dental and medical histories the
entire
maxillary
arch
with
the
exception
of
the
left

16 136 76 256 196 376 316 436 493 613 553 733 673 1093 793 1153
were noncontributory. Brackets were bonded on all maxillary teeth, from first molar to first molar, except for lateral
incisor;
this
allowed
it
to
react
as
a
free
body
during
Fig 10. In month 8, a low-torque bracket was bonded to Fig 13. At 11 months, light Class II elastics were worn bilat-
17 137 77 257 197 377 317 437 494 1094 1154
18
the left lateral incisor. Because the lateral incisor was not engaged on the archwire, the tooth was free to
138 78 258 198 378 318
retraction
of
the
transposed
canine.
An
open-coil
spring

438
the left lateral incisor. A power chain moved it mesially erally 24 hours a day to correct the buccal relationships.614 554 734 674 794
495 615 555 735 675 1095 795 1155
19
physiologically move out of the path of canine root movement. To prepare the site for canine retraction, 139
a coil 79 259 199 379 Fig 6. Pretreatment
319 lateral cephalometric radiograph was
placed
between
the
central
incisor
and
first
premolar
439 and also assisted in delivering a distal force on the first
to
create
space.
Two
OrthoBoneScrews
(Newton's
A,
496 616 556 736 676 1096 796 1156
20 spring was used to open space between the left central incisor and the first premolar. A 2 3 12-mm stainless 140 80 260 200 380 shows a Class
320 II skeletal pattern. 440 premolar without excessive flaring of the central incisor. 1097 1157
HsinDhu,
Taiwan)
were
inserted
in
the
bilateral
infrazygo- 497 617 557 737 677 797
21 steel miniscrew was placed in the infrazygomatic crest, labial to the mesiodistal cusp of the maxillary 141 left first 81 261 201 381 321 441 1098 1158
matic
crest
to
provide
anchorage
for
retraction.
An
498 618 558 738 678 798
22 molar. A 0.019 3 0.025-in titanium-molybdenum alloy T-loop, anchored by the miniscrew, was used to142 retract 82 262 202 382 322 442 1099 1159
activated
T-loop
spring
made
of
0.019
3
0.025-in
499 619 559 739 679 799
23 the canine root over the labial surface of the root of the distally positioned lateral incisor. In 24 months, this143 difficult 83 263 203 383 323 443 1100 1160
Table. Cephalometric summary titanium-molybdenum
alloy
was
connected
between
the
500 620 560 740 680 800
24 malocclusion, with a Discrepancy Index score of 18, was treated to a Cast-Radiograph Evaluation score 144 of 26. 84 264 204 384 324 444 501 621 561 741 681 1101 801 1161
25 (Am J Orthod Dentofacial Orthop 2016;-:---) 145 85 265 205 385 325 Pretreatment Posttreatment Difference transposed
canine
and
the
OrthoBoneScrews
to
retract
445 1102 1162
502 622 562 742 682 802
26 146 86 266 206 386 326
Skeletal analysis the
canine
without
extruding
it. 446 1103 1163
503 623 563 743 683 803
27 147 87 267 207 387 SNA (! ) 327 81 80 1 447 504 624 564 744 684 1104 804 1164
28 148 88 268 208 388 SNB (! ) 328 77 76 1 448 1105 1165

T
505 625 565 745 685 805
29 missing maxillary lateral incisors, retention of
149 deciduous 89 269 209 389 ANB (! ) 329 4 4 0 449 1106 1166
ooth
transposition
is
defined
as
a
change
in
posi- Fig 2. Pretreatment study models (casts). 506 626 566 746 686 806
30 150 2,4,6-9 90 270 210 390 SN-MP 330(! ) 36 36 0 450
tion
of
UXP
adjacent
teeth
in
the
same
quadrant,
canines, malposed adjacent teeth, and rotations. 507 627 567 747 687 1107 807 1167
31 FMA (! )331 24 23 1
but
the
clinical
presentation
may
be
quite
Several etiologic factors have been151proposed: 91 271 211 391
Dental analysis
451 508 Fig 14. Bite turbos were bonded on the lingual surfaces 628 568 748 688 1108 808 1168
32 152 92 272 212 392 332 452 509 629 569 749 689 1109 809 1169
variable.1-5 genetics,2,4,6,12,13 interchange in the position of U1 to NA (mm) 5 1 4 of the central incisors to disarticulate the occlusion and
33 153 3,10,15,16 93 273 213 393 333 453 510 630 570 750 690 Fig 18. Posttreatment study models (casts). 1110 810 1170
34 the developing tooth buds,11,14 trauma, 154 94 274 214 394 U1 to SN
334( !
) 113 104 9 454
provide an intrusive load on the incisors.
1111 1171
It
is
identified
as
a
complete
transposition
when
the 511 631 571 751 691 811
35 mechanical interferences,2,8,9,11 early loss of155 deciduous 95 275 215 395
L1 to NB (mm)
335
6 5 1
455 512
Fig 11. The previously transposed canine was engaged
632 572 752 692 1112 812 1172
crowns
and
the
roots
of
the
involved
teeth
exchange Fig 1. Pretreatment facial and intraoral photographs. L1 to MP (! ) 101 98 3 with a 0.014-in copper-nickel-titanium wire at 9 months
36 teeth,3,16,17 and prolonged retention of156 deciduous 96 276 216 396 336 456 513 633 573 753 693maintained, and a pleasant facial profile was achieved Figure 23 gives a comparison of the before, 1113 after, and [F23-4/C]. 813 1173
places
in
the
dental
arch,
and
as
an
incomplete 8 Facial analysis into treatment.
37 teeth. However, the latter is more often a157 sequela of 97 277 217 397 337
E-line to UL (mm) 1
457 514 634 574 754 694after 24 months of orthodontic treatment. The canine 3-year follow-up images. Gingival tissue1114 and occlusal 814 1174
38 transposition
when
the
crowns
are
transposed
but
the "1 "2
transposition rather than an etiologic factor.158 deciduous 98 canine, so the chief complaint was crowding create ideal overbite and overjet, (4) correct incisor 278
incli- 218 398 338
E-line to LL (mm) 1 0 1
458 515 635 575 Fig 17. Posttreatment facial photographs and intraoral photographs show excellent alignment. The pa- 755 695
and molar relationships were corrected to Class I, and relationships remained healthy and stable.
1115 815 1175
39 roots
remain
in
their
normal
positions.1
The
prevalence
6
Peck et al3 classified transpositions as 159 follows: (1) of the maxillary99
arch. The asymmetric overjet had a nations and root angulations, and (5) improve
279
facial es-
219 399 E-line to339
LL (mm) "0.5 "2 1.5 459 516 636 576 tient's lateral profile was improved. 756 696
the upper, lower, and facial midlines were coincident
1116 816 1176
40 of
transposition
is
about
0.4%. Tooth
transpositions 160 100 280 220 400 340 Fig 8. The activated T-loop spring placed in the bracket 460 517 637 577 757 697 1117 817 1177
maxillary canine-first premolar, (2) maxillary canine- maximum of 5 mm, but the lateral facial profile was thetics. DISCUSSION
41 occur
more
commonly
in
the
maxilla
than
in
the
161 101 281 221 401 341 of the canine provided a clockwise moment. 461 518 638 578 758 [F17-4/C]. 698(Fig 17). A functional occlusion was established with sta- 1118 818 1178
lateral incisor, (3) maxillary canine to first162 molar site, acceptable. 102A mild mandibular tooth size-arch length
42 mandible,6,7
and
the
maxillary
permanent
canine
is
the 282 222 402 342 462 519 639 579No bracket was bonded on the maxillary left lateral surfaces of the central incisors to open the bite and759 699ble posterior support and proper anterior guidance A successful orthodontic result is often1119
predicated on 819 1179
(4) maxillary lateral incisor-central incisor, (5)
163maxillary discrepancy 103 was noted. The intraoral examination TREATMENT ALTERNATIVES Fig223
3. Buccal view of the maxillary left canine shows that TREATMENT 343 PROGRESS incisor, so it could react as a free body and move out intrude the incisors (Fig 14). the design of the force system.18 The IZC is1120
43
most
frequently
involved
tooth.6,8 283 403 463 520 640 580 760 700(Fig 18).
[F14-4/C].½F18": a convenient 820 1180
44 canine to central incisor site, and (6) mandibular
164 lateral showed that 104 the maxillary right second molar was 284 it was
224 displaced facially. 404 344 464 1121miniscrews 1181
Tooth
transpositions
are
more
commonly
observed
in Compared with the mandibular arch, there are more Treatment was started in the maxillary arch, with a 521 641 of
581the path of canine retraction. As the canine moved In month 19, a torquing spring was attached to the761 701 The superimposition of the cephalometric tracings placement site in the maxilla for orthodontic 821
45 2-4,7-9
incisor-canine. 165 partially 105
erupted, but the other 3 second molars were un- 285 225 Fig 5. Pretreatment panoramic radiograph 405shows a 345 465 522 642 582
distally, the crown of the adjacent lateral incisor was maxillary 0.014 3 0.025-in copper-nickel-titanium762 702before and after treatment showed that the treatment 1122to provide
or miniplates.19 It has been used successfully 822 1182
46 female
patients and
may
occur
unilaterally
or 166 of the therapeutic options for the maxillary dentition because 0.022-in 346 passive self-ligation system (Damon 3mx; 466
bilaterally.10
There
is
a
greater
frequency
of
unilateral
This patient had a complete transposition erupted. 106 286
the supporting bone is less dense. Esthetically and func-
226 406
completely transposed left canine in the maxilla.
Ormco, Glendora, Calif); low-torque brackets were
523 643 583
physiologically tipped in a distal and palatal direction, archwire for delivering labial root torque to the left763 [F19-4/C]. 703
goals were achieved (Fig 19). The retraction of the whole skeletal anchorage for retraction of canines1123
and incisors, 823 1183
47 maxillary left canine and lateral incisor. 167 107 287 227 407 347 467 524 644 584 764 704 1124 824 1184
48 transpositions
on
the
left
side.2,3,6-8,11
Transpositions 168
A panoramic
108
radiograph documented that all perma- tionally, it is generally preferable to move transposed288 228 408 placed on348 the incisors. An open-coil spring was placed 468 Fig 15. At 19 months, a torquing spring was placed645 on as the canine root passed over the labial surface of its lateral
incisor
(Fig
15).
Triangular
elastics
(Monkey
3/
765
[F15-4/C]. maxillary arch resulted in near ideal overjet and Class I both individually and en masse, as well as intrusion of
525 585 705 1125 825 1185
49 are
often
associated
with
peg-shaped
or
congenitally 169 nent teeth, 109 including the third molars, were present teeth to their normal positions in the arch.1 289 229 technically, there are multiple compromises 409
in outcomes between 349 the left central incisor and the first premolar 469 526 the left lateral incisor to tip the crown palatally. 646 root.
586 This free body effect decreased the chance of
8-in,
3.5
oz;
0SNDP)
were
applied
in
month
23
to
seat766 706molar relationship. The panoramic radiograph obtained the maxillary posterior teeth.20-25 For our 1126patient, an 826 1186
50 DIAGNOSIS AND ETIOLOGY 170 ½F5" (Fig 5). The110cephalometric analysis was consistent with Consistent with the treatment objectives, the 290 most 230 410
associated with retaining Class II buccal segments: es- to create 350space. One week later, the deciduous canine 470 527 647 root
587 resorption, compared with engaging the lateral (settle
in)
the
occlusion
(Fig
16).
After
24
months
of
767
[F16-4/C]. 707 at debonding showed that the entire dentition had OrthoBoneScrews in each IZC was used 1127 to retract the 827 1187
active
treatment,
all
appliances
were
removed,
and
ante-768
51
The clinical examination of this 12-year-old171
girl in a Class II skeletal
111 pattern and a mild tooth size arch width conservative treatment plan was nonextraction align- 291 231
thetics, periodontal, and functional. 411 351
was extracted, and 2 OrthoBoneScrews (2 3 12 mm) 471 528 648 incisor
588 on the archwire. 708proper root parallelism, including the root of the trans- entire maxillary arch to correct the Class II relationship,
1128 828 1188
52 172 ½F6" discrepancy 112(Fig 6). There was increased axial inclination 292 232 412 352 472 529 649 589In month 8, a low-torque bracket was bonded on the rior
fixed
retainers
were
bonded:
maxillary
MBUFSBM
JODJTPS
UP 769 709posed canine (Figs 20 and 21). There was some as well as to provide anchorage to1129 retract the 829 1189
a
%JSFDUPS,
Andersen
Dental
Clinic,
HsinChu,
Taiwan. the permanent dentition showed an Angle Class II molar ment of the malposed teeth. Bilateral infrazygomatic The third treatment option was to extract413 per- with
0
the leftQ2 .022
3
0 .028-in
rectangular
o penings
(Newton's
A,
MBUFSBM
JODJTPS
½F20":
53 173 of both the 113
maxillary and mandibular incisors. The ceph- 293 233 353 473 530 650 590 770 710 1130 830 1190
crest (IZC) bone-screw anchorage was indicated left
lateral
incisor,
and
a
power
chain
was
applied
to
the
½F21": distortion in the maxillary and mandibular left canine transposed left canine.
malocclusion with a complete transposition 174 of the 294to manent and deciduous canines and restore414 the canine HsinDhu,
354 5aiwan)
were
inserted
bilaterally
in
the
IZCs,

b
Director,
Beethoven
Orthodontic
Center,
HsinChu,
Taiwan.
54 114 234 474 531 Fig 12. After 11 months of treatment, the panoramic 651 1131 1191
c
Professor
Emeritus
of
orthodontics;
adjunct
professor
of
mechanical
engineer- ½T1" alometric measurements are summarized in the Table. retract the transposed canine and correct the Class adjacent
591 central
incisor
to
close
the
anterior
space
[F10-4/C]. and
mandibular
DBOJOF
UP
DBOJOF.
A
clear
overlay
retainer
was
771 711
areas, but the posttreatment records (Figs 17 and 18) A 2 3 12-mm stainless steel OrthoBoneScrew was 831
55 ing,
Indiana
University
&
Purdue
University,
Indianapolis,
Ind. maxillary left canine and lateral incisor (Figs 1751 and 2). [F1-4/C] 115 295 II Fig2354. Labial view shows that the maxillary left canine
with a dental implant. Considering the growth415potential buccal
to
355 the
m olars.
Low-tension
(2
o
axillary
first
m z)
p
ower
Fig 9. After 3 months of treatment, the transposed canine 475 532 radiograph shows that the completely transposed canine 652 592 772 712 1132 832 1192
56 The ectopic eruption of the maxillary 176 left canine ½F2" 116 malocclusion. To prevent root interference or resorption
296 236 of this young patient, an osseointegrated implant
416 was an chains
were
attached
from
the
first
p
356 476 (Fig
10).
One
month
later,
the
left
canine
was
engaged
with
a
deliv-
Q4
ered
for
the
maxillary
arch,
and
the
patient
was
in- document the near ideal alignment of the entire selected. Setting the screw head at the level of the arch-
1133 1193
All
authors
have
completed
and
submitted
the
ICMJE
Form
for
Disclosure
of
was fully erupted but displaced high in the vestibular fold. remolars
to was translated distally about 4 mm. 533 was moved to its normal position. 653 593 773 713 833
57 Potential
Conflicts
of
Interest,
and
none
were
reported. positioned it high in the vestibular fold between
177 the TREATMENT 117 OBJECTIVES during the retraction process, the transposed canine297 was 237 undesirable choice. After carefully considering all the the screws357
417 [F7-4/C] bilaterally (Fig 7). 477 534 654 0.014-in
594 copper-nickel-titanium
continuous
[F11-4/C].
archwire
structed
to
wear
it
full
time
for
the
first
6
months
and
nights
774 714dentition. wire helped to prevent a vertical component 1134of force on 834 1194
58 Address
correspondence
to:
W.
Eugene
Roberts,
8260
Skipjack
Dr,
Indianapolis,
655 (Fig
11). 595
only thereafter. 715 The cast-radiograph evaluation score was 26, as the maxillary molars. The left OrthoBoneScrews had a
IN
46236;
e-mail,
werobert@iu.edu;
werobert@me.com.
central and lateral incisors (Figs 3 and 4). 178 118
The treatment
[F3-4/C] objectives were to (1) establish func- maintained in a high position as it was retracted to298 take 238
A second treatment plan was to extract the trans- 418 correct
options, the first treatment plan was selected: A T-loop 358of 0.019 3 0.025-in titanium-molybdenum T-loop retracted the transposed canine while maintain- 478 535 775 1135 835 1195
59
From the patient's perspective, the anomaly 179
was tional 119I molar and canine relationships, (2) correct
[F4-4/C]Class advantage of the tapered root structure of adjacent 299 239
posed canine and substitute the first premolar for the 419
the canine transposition and the Class II buccal relation- alloy was 359inserted in the hole of the left OrthoBoneScrew ing its position high in the vestibular fold. After 1 month, 479 536 656 596 In
month
11,
a
panoramic
radiograph
was
exposed TREATMENT
RESULTS 776 716shown in the subsequent work sheet. Most of the points specially designed 0.022 3 0.028-in rectangular
1136 open- 836 1196
Submitted,
August
2015;
revised
and
accepted,
October
2015.
60 180 120 300 240 420 360 480 537 the canine. When activated, the T-loop produced a root 657 597to
check
the
root
angulation
of
the
transposed
canine 777 717deducted were due to the malposed second molars, ing just beneath the screw head that allowed1137 insertion 83724. Sequential buccal and occlusal views of the transposed canine show its progressive retraction 1197
0889-5406/$36.00 camouflaged by normal midlines and a functional the transposition and restore natural tooth order, (3) teeth. canine. Although this approach is less challenging ship with IZC bone-screw anchorage. and activated to retract the left canine. As designed, the a power tube was activated from the left first premolar to Fig
!
2016
by
the
American
Association
of
Orthodontists.
All
rights
reserved.
538 [F8-4/C] distal moment on the canine (Fig 8). After 3 months of 658 [F12-4/C].
598
(Fig
12).
The
mandibular
arch
was
bonded,
and
Class
Q3
The
transposed
canine
was
successfully
retracted
to
778the
718which had not been bonded and aligned. The 3-year of a T-loop made with 0.019 3 0.025-in 1138 titanium- 838alignment from 1 to 9 months.
and 1198
1139 1199
http://dx.doi.org/10.1016/j.ajodo.2015.10.036 1 539
traction, the transposed canine was translated about Fig
16.
At
23
months,
the
occlusion
was
seated
with
Q7

659 599
II
elastics
(Parrot,
5/16in,
2
oz;
0SNDP
(MFOEPSB
$BMJG)
ideal
position
in
5
months.
The
keratinized
gingival
tissue
on
779 719
[F22-4/C]. follow-up records show a stable result (Fig 22). molybdenum alloy. 839
540 660 600 the
canine
was
normal;
there
was
no
gingival
recession
780 or
720 1140 840 1200
[F9-4/C] 4 mm distally (Fig 9). finishing
elastics
(Monkey,
3/8,
3.5
oz;
0SNDP). were
applied
- 2016 # Vol - # Issue - American Journal of Orthodontics and Dentofacial Orthopedics American Journal of Orthodontics and Dentofacial Orthopedics - 2016 ! Vol - ! Issue - - 2016 # Vol - # Issue - American Journal of Orthodontics and Dentofacial Orthopedics [F13-4/C].
(Fig
13).
Bite
turbos
were
bonded
on
the
lingual dehiscence.
The
nasolabial
angle
was
CRP 5.4.0 DTD ! YMOD5477_proof ! 28 September 2016 ! 8:40 pm

American Journal of Orthodontics and Dentofacial Orthopedics - 2016 ! Vol - ! Issue - - 2016 ! Vol - ! Issue - American Journal of Orthodontics and Dentofacial Orthopedics American Journal of Orthodontics and Dentofacial Orthopedics - 2016 # Vol - # Issue -- 2016 ! Vol - ! Issue - American Journal of Orthodontics and Dentofacial Orthopedics

135 136

that dramatically impact my practice

If you plan to treat a patient with a transposed maxillary canine, I
strongly encourage you to review the treatment of the patient
presented in this excellent case report. John Casko
3 small Screws
that dramatically simplify my practice

1. BS Screws
SS
2. Ramus Screws
3. IZC Screws
Dr. John Casko The Indiana University Institutional Review Board approved the protocol, assigning the number 1607517021.
Chris Ch

137 138
 that dramatically impact my practice

3 small Screws Why SS?

that dramatically simplify my practice

SS
1. BS Screws
2. Ramus Screws
Ti SS vs

Ti? 3. IZC Screws 11:05 What’s the failure rate?

The Indiana University Institutional Review Board approved the protocol, assigning the number 1607517021. 386 patients
Chris Chang

139 140

Randomized Double Blind

IZC screws
Clinical Trial
Materials
&
Methods
P’t 386 patients Dr 386 patients
Joshua Lin Chris Chang
141 142

Maxillary sinus
Only Mx arch distalization HOW
to put

Only one Dr. an IZC screw?

only one technique Muco-Gingival

Junction

386 patients 386 patients Dr. Rungsi

143 144
 Maxillary sinus Maxillary sinus
HOW HOW
to put to put
an IZC screw? an IZC screw?

90o

386 patients Dr. Rungsi 386 patients Dr. Rungsi

145 146

Maxillary sinus Thicker bone

HOW HOW
to put to put
an IZC screw? an IZC screw?
60˚-70˚

1 mm Dr. Rungsi

147 148

HOW HOW
to put to put
an IZC screw? an IZC screw?

149 150
 386 patients
Believe me, it is EASY!
Chris,

can I do it ?

Believe me when I say it - believe me !!! Trumpology P220

151 152

Believe me, it is EASY! Believe me, it is EASY!

30 sec
IZC: 2 X 12 mm SS (outside the roots) IZC: 2 X 12 mm SS (outside the roots)

153 154

386 patients Summary

Total failure rate for IZC screws : 6.3%
SS (7 %) > Ti (5.7 %)

Summary But Not Statistically Significant

SS Ti
✔
vs.

155 156
IJOI RESEARCH PREVIEW
Free download at ijoi.pro IJOI RESEARCH PREVIEW
soon Free download at ijoi.pro soon

6
Randomized Double Blind Clinical Trial Comparing TADs have been broadly applied as orthodontics
anchorage for over 20 years, but there has been little
were used to retract the maxilla to correct Class II
malocclusion, and/or to intrude the dentition to
the Failure Rate for Stainless Steel and Titanium investigation of the materials best suited for the manage excessive gingival exposure (“gummy
miniscrews. Stainless steel (SS) is well established for smile”).11 The hypothesis tested was that SS
Alloy Infrazygomatic Crest Miniscrews orthopedic devices, and both Ti and Ti alloy are miniscrews will have a higher overall failure rate
biocompatible materials for constructing compared to Ti alloy.
osseointegrated implants. TADs are not usually
designed to integrate,7 so SS is the materials choice, Material and Methods
Abstract
but titanium (Ti) may be preferred to avoid nickel
Objective: Compare the 6 month failure rates for stainless steel (SS) and titanium alloy (Ti) miniscrews placed in the infra- sensitivity. Ti is more brittle than surgical stainless A total of 772 consecutive 2x12-mm (OrthoBoneScrew®,
zygomatic crest (IZC). The hypothesis was that SS miniscrews will have a higher failure rate. Newton’s A Ltd, Hsinchu City, Taiwan) were placed
steel (SS), so small diameter Ti TADs may be subject
bilaterally in each IZC in 386 consecutive patients
Materials and Methods: A total sample of 386 consecutive patients was composed of 76 males and 310 females with a mean to fracture when they are installed with a self-

%
age 24.3 yr, range 10 to 59 yr. Each subject was recruited from a patient pool, previously treatment-planned for supplemental (76 males and 310 females, mean age 24.3 yr, range
drilling approach into dense cortical bone.
anchorage with bilateral IZC miniscrews (OrthoBoneScrew® Newton’s A Ltd, Hsinchu City, Taiwan). Each patient who agreed 10-59 yr). All the screws were placed by the same
to participate received a 2x12-mm SS miniscrew on one side and a Ti miniscrew in the other. The 386 pairs of screws were Infrazygomatic crest (IZC) bone screws are a orthodontist in the lateral aspect of the posterior
coded for an equal distribution of material type and side of placement. For each patient a coded pair of screws was randomly
promising new approach for an E-A TAD anchorage alveolar process, on the buccal surface of the upper
drawn, and then placed in the right or left side as specified (double blind, split mouth design). Miniscrews were placed by the
same orthodontist buccal to the upper first and second molar roots, which is defined as an extra-alveolar (E-A) anchorage site. in the posterior maxilla (Fig. 1). In investigating this first and second molar roots. To facilitate oral
The screw heads were at least 5-mm superior to the soft tissue, which was either attached gingiva (AG) or moveable mucosa challenging site, it was deemed important to hygiene and control soft tissue irritation, the head of
(MM). The surgeon chose the same anatomic location for the miniscrew without regard to the the type of soft tissue. each screw was positioned at least 5-mm superior
compare the failure rate for miniscrews made with
Retrospectively, the soft tissue type was scored relative to the mucogingival junction (MGJ). All miniscrews were immediately
loaded with pre-stretched elastomeric modules. The force ranged from 8-oz to 14-oz (227–397g, 223–389 cN) depending on the Ti alloy and SS (Fig. 2). Both types of IZC miniscrews to the level of the soft tissue (Figs. 1 and 3).
surgeon’s perception of bone density at the miniscrew site. Maxillary buccal segments were retracted for at least 6 months.
Failure was defined as any miniscrew that failed to provide continuous anchorage.

Results: 49 out of 772 miniscrews failed (6.3%); failures were divided into 27 SS (7.0%) and 22 Ti alloy (5.7%). The 1.3% difference
between SS and Ti failures was not statistically significant (p=.07). Failures were unilateral in 21 patients (5.4%) and bilateral in
14 patients (3.6%). The collective failure rates were similar on the right and left sides, 6.5% and 6.2%, respectively. The age of Smooth Mushroom Head Double Neck Design
patients with a failed IZC miniscrews, 12-43 yr, with a mean of 24.2 yr, was similar to that for the entire sample. Compared to For comfort & retention of Easy hygiene control &
Ti, SS miniscrews had a significantly (p<.05) higher failure rate when placed in AG (7.4%) and on the right side (7.9%). elastic chain extra attachment

Conclusion: Overall, IZC miniscrews were about 94% successful for at least 6 months. SS miniscrews had a slightly higher, but
statistically significant failure rate when placed in AG and on the right side. Failure was not related to patient age, but a
predisposition to failure was noted in 3.6% who had bilateral failures. From a clinical perspective, all IZC miniscrews were at
least 92% successful, so the slight difference between SS and Ti at some sites was not clinically significant. Since SS is less prone
to screw fracture and tends to hold a sharper edge at the tip, it continues to be the preferred material for self-drilling 2-mm in Diameter Sharp Cutting Edge
Resistance to fracture Easy to penetrate cortical bone,
miniscrews placed in dense cortical bone.
no pre-drilling
KEY WORDS:
Infra-zygomatic crest, miniscrews, skeletal anchorage, stainless steel, titanium alloy, extra-alveolar orthodontic anchorage,
randomized clinical trial, double blind, split mouth, predisposition to failure Fig. 2:
A 2x12-mm miniscrew is designed to be inserted in the infra-zygomatic crest (IZC) with a self-drilling technique.

Free IJOI hard copies at ORMCO/Newton’s A Booth Free IJOI hard copies at ORMCO/Newton’s A Booth

157 158

% Failure Rate Dr. Park, YC, PCSO, 2004

Conclusion
Between
19 the roots
% Outside SS
the roots

Conclusion 12
%
7
%
5 %
6
%

E-A E-A
E-A IZC
I-R Ramus
I-R MBS
Maxilla
Mandible Angle Orthod 2015 Nov;85(6):905-10
Int J Orthod Implantol 2015;40:84-92

159 160

11:10 How to fix this Gummy Smile?

One More SS Screw alone can fix it.

161 162
 No OGS
Screw alone can fix it.

Only Screw! WOW

163 164

11:12
No OGS
The secret is
Screw alone can fix it.

Mechanics
f
Huge
Dr. Case
Chris Chang Ortho

165 166

Incisor Screw IZC Screw

➟

1.5 X 8 mm SS 2 X 12 mm SS 1.5 X 8 mm SS 2 X 12 mm SS
➟

➟
2~3 OZ

8~12 OZ

Mx Impaction & Retraction Mx Impaction & Retraction

167 168
 Free download IJOI-35-2014 at ijoi.pro Free download IJOI-35-2014 at ijoi.pro
I J OI
CBCT Imaging to Diagnose and Correct the Failure of
Dr. Chris Lin,
Maxillary Arch Retraction with IZC Screw Anchorage Director, Morita dental clinic,
Dr. John Jin-Jong Lin Board eligible, International Association for Orthodontists & Implantologists (Left)
Dr. Yvonne Wu,
Board eligible, International Association for Orthodontists & Implantologists (middle)
Bimaxillary Protrusion and Gummy Smile Corrected
Dr. Chris Chang,
with Extractions, Bone Screws and Crown Lengthening Founder, Beethoven Orthodontic Center a a
Drs. Chris Lin, Yvonne Wu, Chris Chang & W. Eugene Roberts Publisher, International Journal of Orthodontics& Implantology (middle)
International Journal of W. Eugene Roberts, Periodontal probe
Crowded Class II Division 2 Malocclusion with Class I Orthodontics & Implantology Consultant, International Journal of Orthodontics & Implantology (right)

Molars Due to Blocked In Lower Second Premolars Gingival Margin

Drs. Pei-Wen Shu, Hsin Yin Yeh, Chris Chang & W. Eugene Roberts Vol. 35 July. 1, 2014 10 mm
Dento-
Gingival
Complex
This case report describes the interdisciplinary treatment of a 25-year-old woman presenting with chief complaints of bimaxillary
b Osseous Crest
protrusion and excessive gingival display (“gummy smile”). She was dissatisfled with her previous non-extraction orthodontic
treatment, rendered at age 10. The Discrepancy index (DI) for this severe malocclusion was 21. Orthodontic treatment involved
extraction of four premolars to correct protrusion, and skeletal anchorage via four minisscrews (2 anterior and 2 posterior) to intrude
b █ Fig. 14:
the entire maxillary arch. Space closure utilizing maxillary extra-alveolar (E-A) bone screws reduced lip protrusion and the anterior
As extraction space closed, the right buccal segment tend
miniscrews were used to intrude the maxillary incisors. Following orthodontics, surgical crown lengthening was performed in the
toward crossbite, so the archwire was expanded. Bone Sounding
maxillary anterior segment. 32 months of interdisciplinary treatment resulted in a near ideal result as evidenced by a Cast-Radiograph
█ Fig. 1: Pre-treatment facial photographs █ Fig. 4: Post-treatment facial photographs 7 mm
Score (CRE) of 15 and Pink & White (dental esthetic) score of 3. (Int I Ortho Implantol 2014;35:40-60) rectangular shaped Fox (1/4” 3.5 oz ) elastics were
Key words: utilized to settle the posterior occlusion. █ Fig. 19:
Class I malocclusion, bimaxillary protrusion, surgical crown lengthening, self-ligating appliance, gummy smile c The dentogingival complex can be measured by bone
sounding with a periodontal probe. The dimensions of the
After orthodontic appliances was complete, surgical normal dento-gingival complex are approximately
crown lengthening ( Figs. 17-19 ) was performed to 3.0 mm buccally and lingually, with a mean of 4.5 to 5.0 mm
interproximally.3
█ Fig. 16:
establish proper crown heights and proportions. The
The distance of 3 mm between the screws and main arch
total active treatment time 32 months. wire from 16th to 23rd month have been reduced.
c
A 25-year-old woman presented with a history Skeletal:
of non-extraction orthodontic treatment, and a 1. Slightly retrusive mandible (SNA 78o, SNB 75o, █ Fig. 18:
labial frenectomy to close the diastema between █ Fig. 2: Pre-treatment intraoral photographs █ Fig. 5: Post-treatment intraoral photographs Yellow lines represent the CEJs and black lines are the
ANB 3o) alveolar bone level before osteoplasty (a). The white arrow
the upper central incisors, at age 10. The current (a) shows that the biologic width of #10 was only ~1 mm (b).
2. High mandibular plane angle (SN-MP 41o, After osteoplasty (b) the biologic width was corrected to
concerns were bimaxillary protrusion and a gummy 2.5 mm, and the gingiva was sutured with #4 Gore-Tex®
FMA 32o)
smile ( Fig. 1 ). A functional exam documented lip (Gore Medical Products, Flagstaff, AZ).

incompetence with a hyperactive mentalis muscle Dental:

to achieve lip closure. Clinical examination revealed Extra-oral causes:
1. Class I molar relationship, midlines were
a severe bimaxillary protrusion, gummy smile,
coincident 1. Short Upper Lip: Lip length is normally about
lip incompetence and short clinical crowns. Mild
2. Short clinical crowns due to altered passive one third of lower facial height. Clinically, lip
crowding was noted in the lower dentition (Figs. 2 █ Fig. 13:
eruption, type I, B length is measured from subnasale to the inferior
Diagrams and corresponding photographs illustrate the mechanics employed at progressive stages of treatment: █ Fig. 15:
and 3). Comprehensive orthodontics treatment and
a. At 16 months the occlusal plane was gradually steepening. The force systems provided by the four OBSs and their overall effect on the maxillary arch are complex. The yellow arrow on border of the upper lip (Fig. 21). Individuals with █ Fig. 20:
surgical crown lengthening resulted in a pleasing 3. Overjet ( 5 mm ) the left indicates the intrusive force applied to the incisors. The large red arrow is the retraction force anchored by the IZC OBS. Photos taken at 14th months of treatment show the maxillary
b. At 23 months anterior bite turbos were bonded on the palatal surfaces of the maxillary central incisors.
The small red arrow is the intrusive component on the posterior maxillary segment. The large blue arrow is the net resultant
less than 20 mm of lip length are usually classified
molars are tilted mesially because of inaccurate brackets
The 2014 Beethoven International Damon, OBS & VISTA Workshop. Participants took photo with Dr. Chris Chang (center) outcome as documented in Figs. 4-9. c. In the 27th month, retraction force from the IZC miniscrews closes upper space but also provide lingual crown torque to the
Fig. 6: Post-treatment study models (casts)
force on the maxilla, and the blue circular arrow represents the moment of the retraction force around the center of resistance as having a short lip.6 positioning.
and instructors after VISTA workshop in Beethoven Orthodontic Center.
█ Fig. 3: Pre-treatment study models (casts) █ upper incisors. of the maxilla (red dot with a cross).

International Journal of Orthodontics & Implantology is an experience sharing magazine for worldwide orthodontists and

Free IJOI hard copies at ORMCO/Newton’s A Booth Free IJOI hard copies at ORMCO/Newton’s A Booth
Implantologists. Download it at http://iaoi.pro. 40 41 45 46 49

169 170

Free download IJOI-35-2014 at ijoi.pro

Chris,
what’s wrong w you?
CRE
15
Fig. 23:

It’s too easy!

█

Classification of altered passive eruption is important for determining the most appropriate surgical procedure(s) to correct it.15

CRE < 26
Lip line : Low (0 pt), Medium (1 pt), High (2 pts) =
Gingival biotype : Low-scalloped, thick (0 pt), Medium-scalloped, medium-thick (1 pt),
High-scalloped, thin (2 pts) =
Shape of tooth crowns : Rectangular (0 pt), Triangular (2 pts) =
Bone level at adjacent teeth : 5 mm to contact point (0 pt), 5.5 to 6.5 mm to
contact point (1 pt), 7mm to contact point (2 pts) =
Bone anatomy of alveolar crest : H&V sufficient (0 pt), Deficient H, allow
simultaneous augment (1 pt), Deficient H, require prior grafting (2 pts), Deficient V or Both
H&V (3 pts) =
█ Fig. 24: Soft tissue anatomy : Intact (0 pt), Defective ( 2 pts) =
The decision tree is a flow chart for assessing excessive gingival display to determine the most appropriate clinical Infection at implant site : None (0 pt), Chronic (1 pt), Acute( 2 pts) =
management for a specific problem. The five determinants for decision making are: extent of the excessive gingival display,
clinical crown length, incisal wear, incisor exposure at rest, and the crown-root ratio.5

Free IJOI hard copies at ORMCO/Newton’s A Booth 53 57 58

171 172

Gummy smile due to

Ext. Not

Retro-inclined Incisors
w Protrusion
Ext. Not

173 174
 Ext. Not Ext. Not

Decision 1. Profile Protrusive Straight Decision 1. Profile Protrusive Straight

Making Table 2. Md. angle High Low Making Table 2. Md. angle High Low
for Ext. for Ext.
3. Bite Open Deep 3. Bite Open Deep
4. Ant. inclination Flaring Flat 4. Ant. inclination Flaring Flat
5. Crowding > 7mm None

6. Decay/missing Present ????

7. P’t perception OK No
8. Etc...

9:30 9:30
175 176

How to treat this Severe Protrusion & Gummy Smile? How to treat this Severe Protrusion & Gummy Smile?

No No No No
Ext. OGS Ext. OGS
Pre-Tx Post-Tx Pre-Tx Post-Tx

177 178

0 ? No OGS: No fixation plates 0 ?

No No No No
Ext. OGS Ext. OGS

179 180
 0 ? The secret is:
A large scale of lingual root torque & intrusion

How ?

No No No No
Ext. OGS Ext. OGS

181 182

9:40
Gummy smile correction
will be discussed next year

How? in full detail.

183 184

11:15

Thanks Gummy smile correction will be

discussed next year in full detail.
I J OI
Probable Airway Etiology for a Severe Class III Openbite
Malocclusion: Conservative Treatment with Extra-Alveolar
Bone Screws and Intermaxillary Elastics
Drs. Ming-Jen Chang, John Jin-Jong Lin & W. Eugene Roberts

Protrusive Partially Edentulous Malocclusion: Early Loss of a

Lower First Molar, Implant Site Development and VISTA Soft
Tissue Augmentation
Drs. Chris Lin, Chris Chang & W. Eugene Roberts
International Journal of
Convex, Class II, Deepbite, Gummy Smile and Lingually Tipped
Orthodontics & Implantology
Incisors: Conservative Correction with Bone Screws and a
Crown Lengthening Procedure

I J OI I J OI
Drs. Chang-Kai Chen, Angle Lee, Chris Chang & W. Eugene Roberts Vol. 45 Jan 1, 2017
In memory
Class IIof Charles
Division Burstone:with
1 Malocclusion He 5mm
has been missing almost
of Crowding
two years, but
Treated the void is with
Non-Extraction still IZC
fresh.
Miniscrews Anchorage Class II Division 1 Malocclusion with 5mm of Crowding
Treated Non-Extraction with IZC Miniscrews Anchorage
Dr. BirteDrs.
Melsen
Irene Yi-Hung Shih, John Jin-Jong Lin & W. Eugene Roberts
Drs. Irene Yi-Hung Shih, John Jin-Jong Lin & W. Eugene Roberts
Class II, Excessive Overjet and Deep Bite with a Congenitally
Missing Lower Incisor Class II, Excessive Overjet and Deep Bite with a Congenitally
Drs. Yi-Yang Su, Chris Chang & W. Eugene Roberts Missing Lower Incisor
Drs. Yi-Yang Su, Chris Chang & W. Eugene Roberts
Forty Consecutive Ramus Bone Screws Used to Correct
Horizontally Impacted Mandibular Molars International Journal of Forty Consecutive Ramus Bone Screws Used to Correct
Drs. Chris Chang, Shih-Yung Lin & W. Eugene Roberts Orthodontics & Implantology Horizontally Impacted Mandibular Molars International Journal of
Drs. Chris Chang, Shih-Yung Lin & W. Eugene Roberts Orthodontics & Implantology
3D Cortical Bone Anatomy of the Mandibular Buccal Shelf:
a CBCT study to define sites for extra-alveolar bone screws to Vol. 41 Jan 1, 2016 3D Cortical Bone Anatomy of the Mandibular Buccal Shelf:
treat Class III malocclusion a CBCT study to define sites for extra-alveolar bone screws to Vol. 42 Apr 1, 2016
Drs. Chris Chang, Chi Huang & W. Eugene Roberts treat Class III malocclusion
Drs. Chris Chang, Chi Huang & W. Eugene Roberts

Oct. 18-21, 2016

Oct. 22-24, 2016

Dec. 8-9, 2016

Photo collage (from left, clockwise) of Dr. Birte Melsen giving a haircut for Charles Burstone; the Beethoven international workshop;
Advanced Keynote workshop; Damon Bonding workshop. Participants take photos with Drs. John Lin, Chris Chang and Rungsi
3D
Thavarungkul at Newton's A, Hsinchu, Taiwan.
Bust and portrait of the father of orthodontic biomechanics, Charles J. Burstone (1928-2015). Permanent collection in Beethoven
International Journal of Orthodontics & Implantology is an experience sharing magazine for worldwide orthodontists and David Sarver(center left, back) and Dan Gauer(center right, back) sneaked in the background and spoiled a supposed-to-be secret
Orthodontic Center, Taiwan.
Implantologists. Download it at http://iaoi.pro. meeting of (from left to right, front) Kyoto Takemoto, Chris Chang, Giuseppe Scuzzo and Koichi Kobayashi during the Damon Forum on
International Journal of Orthodontics & Implantology is an experience sharing magazine for worldwide orthodontists and
《僅供牙科專業人士參閱》 February 12, 2016.
Implantologists. Download it at http://iaoi.pro. 《僅供牙科專業人士參閱》
International Journal of Orthodontics & Implantology is an experience sharing magazine for worldwide orthodontists and
Implantologists. Download it at http://iaoi.pro. 《僅供牙科專業人士參閱》

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