Other Skeletal Anchorage

System

Moderator: Dr. Karunakara Presenter: Cyriac John

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Contents:
• Introduction
• History
• Structure of miniplates
• Indications
• Advantages
• Disadvantages
• Sites for placement
• Placement and removal of miniplates
• Biomechanical considerations
• Modifications of miniplates
• Success rates and stability of miniplates
• Complications
• Recent advancements in miniplates
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Introduction

* Anchorage preparation is very important in achieving

successful orthodontic treatment and the desire to have
complete control over anchorage is universal among
orthodontists.

* Often anchorage in an orthodontic appliance attempts to

dissipate the reaction forces over as many teeth as possible
and thus keep pressure in the periodontal ligaments of the
anchor teeth to a minimum.
* Maximum Anchorage - The type of anchorage, in which 1/4th of the 4
extraction space is taken up by the anchor unit itself in the course of the
treatment
* Stationary Anchorage - In certain cases, it is necessary that 100% of
the extraction space is utilized for retraction of the anteriors into the
space so as to reach the treatment goals.

*And in some cases, even the stationary anchorage is not sufficient to

reach the treatment goals and there is requirement of excess space.
Nanda, R., Uribe F., Temporary Anchorage Devices in Orthodontics, Philadelphia, 2009
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Temporary anchorage device
- Use of Miniplates & Miniscrews

* Paradigms have started to shift in the orthodontic world with the

introduction of TAD.
*  Miniscrews not only free orthodontists from anchorage demanding
cases, but they also enable clinicians to have good control over tooth
movement in 3 dimensions.
* Surgeons proposed skeletal anchorage as an adjunct to tooth borne
anchorage.
* Research group of Sugawara in 1992 developed SAS utilising titanium
miniplates and since then SAS
mechanics have been applied to various types of
malocclusion.
Nanda, R., Uribe F., Temporary Anchorage Devices in Orthodontics, Philadelphia, 2009
 6
History & Evolution:
1937- The first implant success was achieved at Harvard University
with cobalt-chromium-molybdenum alloy (vitallium) implants
1945- Gainforth and Higley placed vitallium screws and wires in dog
ramus to achieve distalization

1960 - P. I. Brånemark a Swedish physician and orthopedic surgeon,

found that bone had a high affinity for titanium and coined the term
osseointegration.
1969- Linkow used prosthodontic blade implants to apply class II
elastics Orthodontics in 3 millennia. Chapter 15: Skeletal anchorage.AJODO 2008.Norman Wahl
 7
1983 - Creekmore and Eklund intruded the maxillary
central incisors of a patient using elastic thread and
anchorage from a vitallium screw placed below the
anterior nasal spine.

1985- Ankylosed teeth

as abutments for
maxillary protraction

1990 - Kanomi, Costa , Lee , and Park showed the use of

titanium miniscrews for immediate loading as an
alternative anchorage system

1995 - Block and Hoffman introduced the

onplant to provide orthodontic anchorage.
Orthodontics in 3 millennia.Skeletal anchorage.AJODO 2008
 8
• 1998- Zygoma ligatures were proposed as an option
for maxillary anchorage

• Michele et al first illustrated the miniplate concept, and it was

refined by Champy and associates.

• Jenner and Fitzpatrick first reported on the use of a mandibular

mini-plate in 1985

•In 1992 Sugawara and Umemori used surgical

Miniplate for orthodontic anchorage. They treated an
open bite case with L shaped miniplates.

Orthodontics in 3 millennia. Chapter 15: Skeletal anchorage.AJODO 2008.Norman Wahl

 Temporary Anchorage Device
9

Temporary Anchorage Devices in Orthodontics: A Paradigm Shift

Jason B. Cope; Semin Orthod 11:3-9 © 2005
 Structure of Miniplates 10

* T plate
* Y plate
* I plate
* L plate

• The monocortical screws,

5.0mm in total length and
2.0mm in diameter, are
inserted through the holes in
the miniplate.

•Pilot drill 1.5mm Monocortical screws:

Nanda, R., Uribe F., Temporary Anchorage Devices in Orthodontics, Philadelphia, 2009
 11
* Head

* Arm

* Body

Surface property of Miniplate

* Sand blasted surface

* Mirror like surface

Nanda, R., Uribe F., Temporary Anchorage Devices in Orthodontics, Philadelphia, 2009
 12
•Miniplates and screws are classified based on the diameters of the
fixation miniscrews, such as 1.0, 1.5, 2.0 or 2.3 mm systems.

•The surface areas of 2.0 mm or 2.3 mm screws are considerably

larger than that of the 1.5 mm screw and they have greater
mechanical strength.

•When the diameter is smaller than 2 mm, mechanical stability of the

screw may not be sufficient for orthodontic anchorage.

•Both self-tapping and self-drilling screws can be used for fixation of

miniplates.
Skeletal anchorage in orthodontic treatment of class II malocclusion .Moschos APapdopoulos,2015
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Modifications in Miniplate System

The Bollard miniplate

(Surgitec, Brussels,
Belgium)
Skeletal anchorage in orthodontic treatment of class II malocclusion .Moschos APapdopoulos,2015
* The C-tube (0.036” diameter tube formed by curving the end
of the miniplate; (Martin, Tuttlingen, Germany)
* Miniplates designed for the zygoma, apertura
piriformis & symphysis regions.
(Tasarım Med, İstanbul, Turkey)

Skeletal anchorage in orthodontic treatment of class II malocclusion .Moschos APapdopoulos,2015 14

 Indications: 15
•Non surgical camouflage treatment of skeletal malocclusions ,
such as Class II, Class III, open bite, deep bite, and facial
asymmetry.

•Non extraction treatment of various types of malocclusion

characterized by incisor protrusion or anterior crowding.

•Traction of deeply impacted teeth

•Second phase treatment of growing patients who need molar

movement

•Pre surgical and postsurgical orthodontic treatment of surgical

cases

•Re – treatment of failed cases with complex orthodontic problems.

Nanda, R., Uribe F., Temporary Anchorage Devices in Orthodontics, Mosby., Philadelphia, PA. 2009
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Advantages
• Higher stability, owing to lower incidence of screw loosening and
solid frame construction of the miniplate and miniscrews

• Faster wound healing and resistance to infection, owing to

supraperiosteal placement of the plate

• Wider range of indications for use.

• Long standing and more reliable.

• Screws lie away from the roots.

Nanda, R., Uribe F., Temporary Anchorage Devices in Orthodontics, Mosby., Philadelphia, PA. 2009
 17
Disadvantages

• Placement and removal of miniplates require minor surgical

procedure

• Comparitively less patient acceptance

• Expensive

• Post operative oedema and discomfort

Nanda, R., Uribe F., Temporary Anchorage Devices in Orthodontics, Mosby., Philadelphia, PA. 2009
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Sites For Placement

Skeletal anchorage in orthodontic treatment of class II malocclusion .Moschos APapdopoulos,2015

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Safe zones for Miniplate placement

Mandible:

Suitable areas: Symphysis and

basal bone of the mandible
corpus
Attention to IAN and mental
foramen

Quantitative CBCT evaluation of maxillary and mandibular cortical bone thickness and density variability
for orthodontic miniplate placement. Rossi et al, International orthodontics, November 2017
 20
Maxilla

Suitable areas:
Zygomatic buttress
Nasal buttress
Basal bone between canine and
first molar

Quantitative CBCT evaluation of maxillary and mandibular cortical bone thickness and density variability
for orthodontic miniplate placement. Rossi et al, International orthodontics, November 2017
 21
Zygomatic Anchorage
•The zygomatic area may be used for molar distalization, posterior en
masse distalization, incisor retraction and en masse retraction in Class
II malocclusion as well as for molar intrusion in patients with open bite.

•This area may even be used for the correction of Class III
malocclusion by using Class III elastics.

The Zygoma Anchorage System. Hugo de Clerk. Jco/August 2002.

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Surgical Placement

Skeletal anchorage in orthodontic treatment of class II malocclusion .Moschos APapdopoulos,2015

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Miniplates on Piriform aperture
• Indications for this site include Class II elastics, maxillary
protraction using face masks in patients with Class III malocclusion
and intrusion of maxillary incisors in patients with deep bite.

Skeletal anchorage in orthodontic treatment of class II malocclusion .Moschos APapdopoulos,2015

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Surgical Placement

Skeletal anchorage in orthodontic treatment of class II malocclusion .Moschos APapdopoulos,2015

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Symphyseal Anchorage
Miniplates are inserted into the symphysis region to anchor fixed
functional appliances in growing patients with skeletal Class II
malocclusion, and also for Class III elastics and intrusion of
mandibular incisors in patients with deep bite.

Skeletal anchorage in orthodontic treatment of class II malocclusion .Moschos APapdopoulos,2015

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Surgical Placement
 27
Retromolar (Angulus) Anchorage
Miniplates inserted at this area are used for anchorage to obtain

skeletal correction in growing patients with Class II malocclusion using

Class II elastics and for mandibular molar intrusion in open bite.

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Post Operative Instructions

•Following surgery, pain killers (acetominophen 500 mg three times a

day), chlorhexidine gluconate (mouthwash three times daily) and

amoxicillin trihydrate (500 mg three times a day) for 4 days are

prescribed.

•Patients should follow the instructions regarding maintenance of

oral hygiene.

•Miniplates should be cleaned daily to prevent inflammation.

 29
•Moderate postoperative facial swelling generally occurs and may
remain a few days after surgery.

•Applying ice packs every 15 minutes in the early postoperative period

may reduce the edema.

•There may be moderate levels of discomfort and pain associated with

the placement surgery.

•Patients should be clearly informed of the pain that they might

experience during miniplate insertion and removal and of possible
complications that might occur.
 30
Timing of force application

• Orthodontic force is usually applied about 3 weeks after surgical

placement of the SAS, waiting only for soft tissue healing, not for
osseointegration.

• Immediately after orthodontic treatment, all of the anchor plates are

removed.

• Orthopedic forces of 400-500 grams per side can be applied on the

miniplates
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Removal of Mini plates:
Fully Customized Placement Of Orthodontic Miniplates:
A Novel Clinical Technique. Hourfar Et Al. Head & Face Medicine 2014

32
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Biomechanical Considerations

• Treatment of Class II Malocclusion

• Treatment of Class III Malocclusion

• Intrusion of Molars

• Protraction of Molars

• Disimpaction of teeth
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Treatment of Class II Malocclusion

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Distalization
 38
Amount of Molar Distalization:

• The average amount of the maxillary molar distalization was averge of

3.8 mm crown and 3.2 mm root, respectively.

• This suggests that it might be possible to correct arch space deficiency

of approximately 7 mm without the need for bicuspid extraction.

• In other words, the SAS biomechanics has significantly expanded the

range of non extraction treatment.

Skeletal anchorage in orthodontic treatment of class II malocclusion .Moschos APapdopoulos,2015

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Canine Retraction In Extraction Protocol
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Fixed functional appliance
 43
Class II Elastics

Effects of skeletally anchored Class II elastics: A pilot study and new approach for treating Class
II malocclusion; Angle Orthod. 2017
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Effects of skeletally anchored Class II elastics: A pilot study and new approach for treating Class
II malocclusion; Angle Orthod. 2017
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Correction of Class III Malocclusion

46
 47
Bone Anchored Maxillary Protraction

Zygomatic miniplates for skeletal anchorage

in orthopedic correction of Class III malocclusion:
A controlled clinical trial; KJO 2017
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Pre

Post
 49
Mandibular Distalization:

Orthodontic camouflage of skeletal Class III malocclusion with miniplate: a case

report. Dental Press J Orthod. 2016 July-Aug;21(4):89-98
50
52
 Open bite
appliance 53

Temporary anchorage devices in

orthodontics; Ravindra Nanda, 2009
54
 55

Temporary anchorage devices in orthodontics; Ravindra Nanda, 2009

 Disimpaction of teeth 56

Targeted Traction of Impacted Teeth With C-Tube Miniplates

Chung et al; The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
57
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Modifications
 60
Multi purpose implants (MPI):

•Designed by Erverdi, Turkey

Temporary anchorage devices in orthodontics; Ravindra Nanda, 2009

A Miniplate System for Improved Stability of Skeletal 61
Anchorage. JCO 2009

• Beneplate system:

A. Long plate (18mm) with metal

bracket.
B. Short plate (12mm) with palatal
screw.
C. Short plate.
D. Fixing screw.
E. Short plate with .032" TMA wire
F. Short plate with .045" stainless
steel wire.
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Distalization:

RME
 63
Bioresorbable Plates and Screws for Clinical Applications.
A Review. Journal of Healthcare Engineering · Vol. 3 · No. 2 · 2012

Calcium Phosphates
 Polyglycolide (PGA)
 Polylactide (PLA)
 Polydioxanone (PDS)
 Polysulphone (PS)
 Propylene (PP)
 Polycarbonate (PC)
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Resorbable Vs Titanium Plates For
Orthognathic Surgery. Cochrane Database Of Systematic Reviews
2017

• Recognition of some of the limitations of titanium plates and screws

used for the fixation of bones has led to the development of plates
manufactured from bioresorbable materials.

• Resorbable plates appear to offer clinical advantages over metal

plates in orthognathic surgery, concerns remain about the stability of
fixation and the length of time required for their degradation and the
possibility of foreign body reactions.
 65
• This review included two trials, involving 103 participants, one
compared titanium with resorbable plates and screws and the other
titanium with resorbable screws.

• All patients in one trial suffered mild to moderate postoperative

discomfort with no statistically significant difference between the
two plating groups at different follow up times.

• Mean scores of patient satisfaction were 7.43 to 8.63 (range 0 to

10) with no statistically significant difference between the two
groups throughout follow up.

• Adverse effects reported in one study were two plate exposures in

each group occurring between the third and ninth months. Plate
exposures occurred mainly in the posterior maxillary region,
except for one titanium plate exposure in the mandibular premolar
region.
Resorbable Vs Titanium Plates For Orthognathic Surgery. Cochrane Database Of Systematic Reviews 2017
 66

• Known causes of infection were associated with loosened screws and

wound dehiscence with no statistically significant difference in the
infection rate between titanium (3/196), and resorbable (3/165) plates.

• This review provides some evidence to show that there is no

statistically significant difference in postoperative discomfort, level of
patient satisfaction, plate exposure or infection for plate and screw
fixation using either titanium or resorbable materials in orthognathic
surgery

Resorbable Vs Titanium Plates For Orthognathic Surgery. Cochrane Database Of Systematic Reviews 2017
 67
Success rates and stability of Miniplates
• Case series report success rates varying from 85 to 98%.

• A meta-analysis of temporary anchorage devices estimated the

failure rate of miniplates at 7.3% and concluded that miniplates
and palatal implants, when grouped together, showed a 1.9-fold
lower failure rate than Mini implants.

• Success rates are usually higher in the maxilla than in the

mandible, and in adults than in growing patients

Skeletal anchorage in orthodontic treatment of class II malocclusion Moschos A Papdopoulos,2015

 68

Success rate of miniplates

Time of Magnitude
Loading of force

Skeletal anchorage in orthodontic treatment of class II malocclusion .Moschos APapdopoulos,2015

 69
Risk Factors

• Insertion location

• Lack of primary stability of the screws

• Screw to root contact

• Soft tissue inflammation

• Patient’s age

• Occlusal interferences
Skeletal anchorage in orthodontic treatment of class II malocclusion .Moschos APapdopoulos,2015
 70
Complications

• Post operative complications

• Soft tissue complications

• Damage to teeth and adjacent structures

• Miniplate mobility

• Practical complications

• Complications during removal

Skeletal anchorage in orthodontic treatment of class II malocclusion .Moschos APapdopoulos,2015

 71
Post operative
complications
• Swelling
• Pain
Soft tissue complications
• Soft tissue irritation
• Gingival dehiscence
 72
Damage to teeth and adjacent structures:
• Root damage

• Sinus perforation

Miniplate mobility:
 73
Practical complications
• Anchor breakage

• Interference to tooth movement

 74
Complications during removal
• Bone overgrowth
 75
Success rate of miniplate anchorage for bone anchored
maxillary protraction; Angle Orthod. 2011
76
 77
Effect of molar intrusion with temporary anchorage
devices in patients with anterior open bite: a systematic
review; Alsafadi et al. Progress in Orthodontics (2016) 17:9
 Treatment of severe anterior open bite with skeletal 78
anchorage in adults: Comparison with orthognathic
surgery outcomes.Am J Orthod Dentofacial Orthop 2007
•Twenty-three subjects with overbite less than –3.0 mm were treated
with skeletal anchorage (n 10) or with LeFort I osteotomy combined
with mandibular osteotomy (n 13).

•Pretreatment and posttreatment lateral cephalograms were compared.

•Incisors were significantly elongated in the surgically treated subjects

4.6 mm. There were no significant differences in the treatment results
between skeletal anchorage and surgery, with reduced facial heights of
4.0 and 3.8 mm, and increased overbites of 6.8 and 7.0 mm,
respectively.

•These results suggest that molar intrusion with skeletal anchorage is

simpler and more useful than 2-jaw surgery in the treatment of patients
with severe anterior open bite.
79
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82
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Patients and orthodontists perceptions of miniplates used
for temporary skeletal anchorage: A prospective study
AJODO 2008
85
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References
1.Nanda, R., Uribe F., Temporary Anchorage Devices in Orthodontics, Mosby Co.,
Philadelphia, PA. 2009.
2. Nanda, R. Kapila S., Current Therapy in Orthodontics, Mosby Co. Philadelphia,
PA 2010.
3.Nanda,R Biomechanic and Esthetic Strategies in Clinical Orthodontics. WB
Saunders Co, Philadelphia, PA 2005.
4. Skeletal anchorage in orthodontic treatment of class II malocclusion
Moschos A Papdopoulos,2015
5. Umemori M, Sugawara J, Mitani H, et al: Skeletal anchorage system for open-bite
correction. Am J Orthod Dentofacial Orthop 115:166-174, 1999
6. Sugawara, J., et al. (2002) Treatment and posttreatment dentoalveolar
changes following intrusion of mandibular molars with application of a skeletal
anchorage system (SAS) for open bite correction. The International Journal of Adult
7. Fully customized placement of orthodontic miniplates: a novel clinical technique87
Jan Hourfar, Georgios Kanavakis, Peter Goellner and Björn Ludwig Head & Face
Medicine 2014, 10:14
8. Microradiographic and histological evaluation of the bone-screw and bone-plate
interface of orthodontic miniplates in patients
9. Patients and orthodontists perceptions of miniplates used for temporary skeletal
anchorage: A prospective study.AJODO 2008
10. A Miniplate System for Improved Stability of Skeletal Anchorage.JCO.Aug 2009
11. Three-dimensional dental model analysis of treatment outcomes for protrusive
maxillary dentition: Comparison of headgear, miniscrew, and miniplate skeletal
anchorage AJODO 2008 ;134:636-645
12. New approach of maxillary protraction using modified C-palatal plates in Class
III patients. KJOD 2015;45.4.209-214
13. A retrospective analysis of the failure rate of three different orthodontic skeletal
anchorage systems Clin. Oral Impl. Res. 18, 2007 / 768–775