Zygomatic anchorage ( mini plates ) in orthodontics SAS skeletal anchorage

1. Zygomatic anchorage
Prof. Maher A. Fouda
Prepared by:- Bilal A.M.
Faculty of dentistry-Mansoura
university - Egypt

2. Zygoma Ligatures: An Alternative
Form of Maxillary Anchorage

3. MELSEN et al (1998) presented a case report of
a patient was 48 years old, with the chief complaint
of increasing maxillary anterior spacing .
Zygoma Ligatures: An Alternative Form of Maxillary
Anchorage

4. She had lost a considerable number of permanent
teeth due to earlier caries and more recent
periodontal problems. Because the only remaining
maxillary teeth were the six anterior teeth and the left
second molar, there was no posterior anchorage for
orthodontic movement.

5. • Surgical Technique
• Under local anesthesia (2% lidocaine with
adrenaline 12.5 micrograms/ml), a 1cm-long
incision is
• made down to the bony surface of the
infrazygomatic crest, opposite the maxillary
first molar, at a
• right angle to the alveolar process

6. The treatment plan involved retraction and intrusion
of the maxillary anterior teeth and closure of the
midline diastema. A force diagram was made to
indicate the point of application from a zygomatic
ligature .

8. After surgery, Sentalloy coil springs were attached
from the zygomatic anchorage to the anterior fixed
appliance, with a central T-loop for space closure. The
anterior spaces were closed, and the clinical crown
height was reduced. The results were maintained with
a 3-3 bonded lingual retainer and a removable unitor.

9. A New Anchorage Site for the
Treatment of Anterior Open Bite:
Zygomatic Anchorage. Case Report

10. Erverdi etal 2002 treated A male patient, 20 years 5 months
of age, with anterior open bite with excessive maxillary
posterior growth. The patient showed100% incisor display
and a posterior gummy smile during smiling .

11. There was a Class II molar relationship on both
sides, 8-mm maxillary crowding, ectopic maxillary
canines and 3-mm anterior open bite (Fig 2a). He
exhibited maxillary constriction and excessive
posterior eruption.

12. An I-shaped titanium miniplate (Leibinger, Mühlheim-
Stelten, Germany) was adjusted to fit the contour of the
lower face of each zygomatic process and fixed by two
bone screws. The long arm of the miniplate was
extended into the oral cavity from the incised wound.
The hole at the tip of the exposed plate served to attach
a coil spring for intrusion.

13. After fixing the plate, the incision site was closed and
sutured. The patient was advised to use antiseptic
mouthwash for 1 week and to use proper oral
hygiene during this healing period.

14. Maxillary first premolars were then extracted. The
maxillary first and second molars were banded and
the first premolars were bonded. Segmental arches
were constructed for the posterior teeth. A
transpalatal arch was constructed from 1.5-mm
stainless steel round wire and bent 3 mm apart from
the palate.

16. Distal force of 100 g was applied at the level of the
center of resistance of the maxillary canines while
intrusion mechanics was proceeding. Rapid bodily
canine distalization was achieved without tipping and
with no anchorage loss.

17. The anterior open bite was corrected and a 1.5-mm
anterior overbite was achieved. Molar intrusion was
retained with wire ligation to the miniplates
throughout the treatment.

18. Full bonded and banded therapy continued for 7
months. The appliances were removed after a
Class I canine relationship and an ideal overbite
and overjet relationship were achieved.

19. At the end of fixed orthodontic treatment, better
interdigitation was achieved with 4 months of positioner
wear.

20. Closing anterior open bites by
intruding molars
with titanium miniplate anchorage.

21. Closing anterior open bites by intruding molars
with titanium miniplate anchorage.
Keith et al (2002) conducted a clinical study to: (1)
validate true intrusion of molars in adults, (2) test the
stabilityof miniplates as anchorage for intruding posterior
teeth in the maxilla, and (3)record the skeletal and dental
changes of open-bite closure.

22. The patients selected for this study were 4 adults (2 men and 2
women) who had long-standing open bites and no habit
history. They had refused orthognathic surgery and elected this
less-invasive, miniplate-assisted orthodontic treatment.

23. All subjects demonstrated some degree of both maxillary and
mandibular vertical excess in the posterior dentoalveolus.
After obtaining appropriate informed consent, Leibinger
titanium miniplates were placed and used as anchorage to
apply orthodontic intrusive forces to the molars.

24. Placing the titanium miniplates began with administering local
anesthesia. A 2-cm incision was made in the vestibule buccal
to the selected maxillary first molars. A full-thickness
mucoperiosteal flap was reflected, and cortical bone was
exposed over the zygomatic strut in the maxilla or the body of
the mandible. An L-, Y-, or T-shaped plate was selected and
contoured to the surface of the bone. Miniplate size and
shape were based on the length of the roots of adjacent
molars, and the contour and
density of underlying bone.

25. The plate was positioned so that only the last loop on the
vertical (most occlusal) leg of the plate projected through the
mucosal incision into the oral cavity. This loop was several
millimeters apical to the brackets on the molars and adjacent
to the teeth requiring the greatest amount of intrusion.

26. Two self-tapping screws were placed to secure the plate to the
bone. Incisions were closed primarily around the miniplate,
insuring that the occlusal loop was cleanly exposed below the
wound margin. Eight weeks was allowed for healing,
integration, and adaptation before applying forces to the
miniplates.

27. During healing and stabilization, orthodontic leveling was
carried out in 3 independent sections of the dental arch. The 2
buccal segments and 1 anterior segment were independently
leveled with light sectional wires, progressing to 0.016
0.022-in sectional stainless steel arch wires placed in the
edgewise slots of the segments. This sectional treatment
prevented the anterior eruption forces that would have
occurred with a continuous arch.

28. Two months after miniplate placement , standard
orthodontic records were gathered—models, photographs,
and lateral cephalometric and panoramic radiographs.
Intrusion was initiated. A coated elastic thread was passed
through the exposed loop of the implanted miniplate and tied
tightly to the bracket of the closest molar or molars to create a
directly vertical intrusive force.

29. To prevent buccal tipping of the molar segments from the
vertical force of the elastic thread, a constricted secondary
.020-in Australian archwire was used. It was inserted only
into the auxilliary tubes of both maxillary first molars and
was lightly ligated to the anterior sectional wire at the dental
midline. It could rotate freely in the posterior vertical plane
as the molars were intruded without affecting the anterior
segment.

30. Intrusion forces were continued for 5.5 months (mean) and
terminated when adequate anterior openbite correction was
visually detected, or the incisors were in contact. Intruded
molars were stabilized by tying a ligature wire from the molar
tube and the bracket to the miniplate loop. Stabilization was
maintained for at least 4 months and removed 2 months before
debanding, debonding, and retaining. Standard orthodontic
retention records were gathered.

31. And the miniplates were removed early in the
retention phase.

32. Keith H. reported two cases of female patient referred
for orthodontic treatment of hypereruptedmolars. The
patients had lost the opposing occluding teeth many years
earlier. The molar(s) to be treated had extruded into the
edentulous space to such an extent that the occlusal surface
was in contact with the opposingalveolar ridge. Without
intervention, an implant
or prosthesiscould not be
placed to
restore the edentulous
area.
Intrusion of Supererupted Molars with Titanium
Miniplate Anchorage.

33. Treatment plan
The treatment plan, with the patient’s informed consent, was
to orthodontically intrude the supererupted teeth with elastic
traction from the band on the affected molar using a miniplate
anchored into cortical bone. The objective was to increase the
interarch space to allow dental restoration of the edentulous
area without damaging the hypererupted teeth.

34. An L-shaped titanium miniplate was contoured over the bone
and the last loop on the plate allowed to project through the
vestibular wound adjacent to the extruded molar. Two self-
tapping screws, three mm each, were placed to secure the plate
to the bone. The mucosal incision was sutured and allowed to
heal around the exposed miniplate loop for approximately
two months.

35. Meanwhile, the other teeth were orthodontically leveled
exclusive of the extruded molars. The hyperextruded teeth
were banded and left unattached to the archwire. Eight weeks
after plate placement, new records were made for dental
cast, photographic, cephalometric, and panoramic
radiographic measures for analysis of progress.

36. Before intrusion mechanics were begun, a continuous
0.016- 3 0.022-inch stainless steel archwire was
placed excluding the supererupted molar(s). In the
maxillary case, buccal crown tipping of the tooth to be
intruded was controlled by an overlay 0.020-inch
round Australian archwire. The wire was moderately
constricted and placed only in the headgear tubes of
the maxillary hyperextruded
molar and the contralateral
normal first molar.

37. This wire was not engaged in the brackets of the other
teeth, allowing it to rotate freely anteriorly and
laterally so that it generated no vertical force on the
molars or on any other teeth. However, it provided an
effective counterbalancing moment to the buccal
tipping moment created by the elastic thread traction.
The normal contralateral molar was stabilized by the
continuous rectangular archwire. In the mandibular
case, an offset, adjustable lingual arch was used to
control tipping.

38. An elastic thread was passed through the exposed loop
on the implanted miniplate and tied tightly over the
buccal tube of the extruded molar to initiate intrusion.
New elastic thread was applied and activated every
month Intrusion mechanics were terminated when
the supererupted tooth was at the plane of occlusion
of the other teeth in the arch (mean active intrusion
time, 6.5 months).

39. The plate was then lightly ligated to the molar tube
with wire ligature and a continuous rectangular
archwire placed. When the orthodontic treatment is
completed, the intruded molars will be retained in
position until the opposing occlusion is restored.

40. Intrusion of the Overerupted Upper Left
First and Second Molars by Mini-implants
with Partial-Fixed Orthodontic
Appliances.

41. Intrusion of the Overerupted Upper Left First and Second
Molars by Mini-implants with Partial-Fixed Orthodontic
Appliances.
Jane Yao et al (2004) presented a case report of
a 31-year-old woman, was seeking restoration of her left
posterior occlusion because of the overerupted left upper
first and second molars.

42. Following the loss of the lower first and second molars. Her
prosthodontist presented a treatment plan to her that
consisted of crown reduction of the overerupted molars and
prosthetic implant replacement of the missing teeth. In
other words, to provide adequate occlusal clearance for the
implant prosthesis, the overerupted upper molars would
receive elective endodontic therapy, occlusal reduction,
crown lengthening, and crown restoration.

43. Accordingly, treatment had been started by inserting two
lower implants into the missing molar positions six months
ago and the caps on the implants were exposed recently
. At that juncture, the patient requested an alternative
treatment to preserve her upper two vital molars. She
was then referred to us for management of the overerupted
left upper first and second molars.

44. This patient presented with a Class I malocclusion
characterized by bimaxillary dentoalveolar protrusion. Her
dental conditions revealed a normal overjet and overbite, mild
maxillary and mandibular anterior crowding, overerupted
maxillary left first and second molars, and implants in the
mandibular left first and second molar area.

45. Her dental conditions revealed a normal overjet and overbite,
mild maxillary and mandibular anterior crowding, overerupted
maxillary left first and second molars, and implants in the
mandibular left first and second molar area. Judging by the
marginal ridge discrepancy, the maxillary first molar had
overerupted three mm occlusally, encroaching upon the
antagonistic missing dental space and leading to the occlusal
interference upon mastication.

46. A partial-fixed 0.018-inch slot edgewise appliance was
placed on the upper left first premolar and second molar.
Subsequently, an ‘‘L’’ shaped miniplate and a miniscrew
(Leibinger, Freiburg, Germany), 2.0 mm in diameter and 15
mm long were implanted onto the buccal and palatal alveolar
ridges, respectively, above and between the left maxillary
first and second molars.
Positions of the miniplate and miniscrew. (A) Buccal side, an ‘‘L’’ shaped miniplate
was inserted. (B) Buccal side and (C) palatal side, after initial healing. Note that the
positions of the mini-implants were high and between two molars.

47. The distance between the root apices and the mini-implants
was calculated on the basis of the amount of intrusion needed .
Two weeks of initial wound healing was allowed, and the
molar intrusion was scheduled thereafter.

49. To provide adequate space for the first molar upon intrusion, a
0.016 3 0.022-inch segmental stainless steel archwire was
engaged into the bracket slots and an open coil spring inserted
between the first and the second molars to push the second
molar distally.

50. The implant prostheses were installed the following
month. Afterward, the teeth were laced together with ligature
wire to allow for settling and then debonded. In the
meantime, the miniplate and the miniscrew were removed
under local anesthesia.

51. No retainer was required because the posterior vertical
dimension had been reconstructed.
The patient’s occlusion has now been stable and functional
for more than one year after the implant prosthesis was
Installed.

52. The Use of Skeletal Anchorage in
Open Bite Treatment:

53. The Use of Skeletal Anchorage in Open Bite Treatment:
ERVERDI et al (2004), published a clinical study involved
10 patients 17 to 23 years of age. Five of the patients had
Class I occlusion, and the other five patients had a Class II
malocclusion. Six patients were treated with upper first
premolar extractions,and the other four patients were treated
with a nonextraction treatment approach. A mean of 20.6 mm
anterior open bite was present. Lateral cephalograms and
posteroanteriorradiographs were taken before and after the
treatment.

54. An I-shaped titanium miniplate
(Leibinger, Mu¨hlheim-Stelten,
Germany) was adjusted to fit
the contour of the lower
face of each zygomatic process
and fixed by two bone screws
(length seven mm), with the
long arm exposed to the oral
cavity from the incised wound.
Initially, we intended to use
long screws (seven mm) to
stabilize the plates. Presently,
however, we use five-mm
screws, which are long enough
to keep the plate in place.

55. All patients received a transpalatal arch constructed
from 0.9 mm stainless steel round wire and adapted three
mm away from the palate. The anterior and posterior teeth
were aligned with the help of two posterior and one anterior
segmental wire. After the initial alignment, nine-mm
Ni-Ti coil springs were placed bilaterally between the hole
of the mini plate and the first molar buccal tube. The anterior
open bite was corrected in a mean of 5.1 months.

56. Molar intrusion was
retained with vertical wire
ligation between the tube of
the molar bands and the
miniplates throughout the
subsequent orthodontic
treatment. One month
before debonding, the
plates were removed. The
total treatment duration
was a mean of 18.3
months.

57. (a) Initial extraoral frontal view of the patient. (b) Initial extraoral
smiling view of the patient. (c) Initial extraoral profile view of the
patient.

59. (a) Final extraoral frontal view of the patient. (b) Final
extraoral smiling view of the patient. (c) Final extraoral
profile view of the
patient.

60. (a) Final intraoral frontal view
of the patient at the end of
the treatment. (b) Final
intraoral right view of the
patient. (c) Final intraoral left
view of the patient.

61. Apical Root Resorption of Maxillary
First Molars after Intrusion with
Zygomatic Skeletal Anchorage

62. ERVERDI et al (2005), discussed the apical root resorption
through a clinical study That aimed to evaluate
radiographically the apical root resorption of maxillary first
molars after their intrusion was done using zygomatic
miniplates as skeletal anchorage in open-bite cases. The study
group comprised 16 consecutively treated open-bite cases
who had received special titanium miniplates in their
zygomatic bones for use as anchorage to apply orthodontic
intrusive forces to the maxillary posterior region.
Apical Root Resorption of Maxillary First Molars
after Intrusion with Zygomatic Skeletal Anchorage

63. For the study group (group 1), 16 consecutively
treated open-bite cases (13 females and three males)
were selected, who had received special titanium
miniplates in their zygomatic bones to use as anchorage
to apply orthodontic intrusive forces to the maxillary
posterior region.

64. The intrusion of the upper posterior segments including
the first molars was accomplished using closed Ni-Ti coil
springs from the intraoral extensions of the zygomatic
miniplates to extensions on the capsplints.

65. Further orthodontic treatment after the intrusion was
completed consisted of a standard 0.018 3 0.025–inch
slot Edgewise technique with the maxillary molars tied
passively to the zygomatic miniplates.

66. A) On-screen identification
of the most occlusal point
of the cusp and most
apical point of the root. (B)
Computer-generated
measurement of the
distance between two
identification points (root
length).

67. The control group (group 2) consisted of 16 patients,
who were matched regarding age, sex, and treatment
duration but who had undergone standard 0.018 3
0.025–inch slot Edgewise treatment without intrusion
mechanics for molars. The mean age in group 1 was 19.25
years (range 14–26 years). The mean age in group 2 was
19.43 years (range 14–25 years).

68. Within the limitations of this study, apical root resorption
of maxillary first molars after intrusion was done using
zygomatic miniplates as skeletal anchorage was not
clinically significantly different from apical root resorption
associated with fixed orthodontic treatment without
intrusion mechanics.

69. Maxillary Molar Intrusion with Fixed
Appliances and Mini-implant Anchorage
Studied in Three Dimensions

70. Jane Yao et al (2005) demonstrated a tree dimensional
study of maxillary molar intrusion with miniplates.
Data were obtained from the records of 22 patients who had
undergone orthodontic treatment to intrude overerupted
maxillary molars. Their ages ranged from 15 to 42 years, with
a mean of 27.6 years. There were 12 Class I and 10 Class II
molar relationships, and nine cases were hyperdivergent
(SN-MP . 378), with only two cases being hypodivergent
(SN-MP , 288). Six of the 22 patients had local treatment with
partial fixed orthodontic appliances.

71. The other 16 patients initially had partial appliances to
intrude the overerupted teeth, followed by full-mouth
fixed appliances to correct the malocclusion.
Eighteen of the 22 patients received implantation of both
a buccal miniplate and palatal miniscrew. The other four
patients had buccal and palatal miniscrews inserted. The
average treatment duration of active intrusion was 7.6
months with a range of five to 12 months. A pretreatment
and postintrusion maxillary dental cast was collected for
each patient.

72. To prepare bony anchorage for maxillary molar intrusion,
a titanium L-shaped miniplate and a miniscrew
were implanted onto the buccal and palatal sides of
the overerupted molars. Miniscrews were implanted
without flap elevation or with just a stab incision. To
implant a miniplate, a mucoperiosteal flap was elevated
under local anesthesia.

73. The miniplate was adjusted to fit the contour of the
cortical bony surface and was fixed by bone screws with
the intention to expose the free fixation hole to the oral
cavity from the incised wound, which was located in the
zone of attached gingiva. Sufficient distance was left
between root apex and mini-implant to avoid
interference with the intended intrusive tooth movement.

74. After initial healing of the soft tissue around the mini-
implants, a medium intrusive force (150–200 g) was
applied with the elastic chains between the buccal
miniplate and the attachment on the first molar band,
and also between the palatal miniscrew and the cleat of
the molar attachment.

75. When adjacent teeth need to be intruded, those teeth
were bonded and a sectional archwire was inserted with
the intrusive force primarily applied only on the maxillary
first molar. After sufficient intrusion was attained, their
vertical position was maintained by ligating the molars to
the miniscrew and the miniplate.
Intrusion of left maxillary first
molar. (a) Elastic chain between
miniscrew and palatal cleat of
first molar. (b) Elastic chain
between miniplate and buccal
attachment. (c) Initial
radiographic image.
(d) Postintrusion radiographic
image

76. In those cases where posterior occlusion could be restored
immediately after the overerupted tooth was leveled, no
retainer was required . Otherwise, full-coverage retention was
used if no subsequent full-mouth comprehensive therapy was
performed.

77. Desktop mechanical 3D digitizer.

78. The maxillary molars were successfully intruded
with the mini-implant system in all the patients. The
intrusion was also noted at the maxillary teeth adjacent
to the first molar, ie, at the second molar and at the
first and the second premolars.

79. The maximum amount of intrusion (8.67 mm at
mesiobuccal cusp of right maxillary first molar and 8.04
mm at second premolar) was noted in a case of a 23-
year-old female patient with all her right mandibular
molars missing and the teeth of the opposing arch (15 to
17) overerupted.

80. A positive value denoted buccal tipping of maxillary
posterior teeth.
The difference between the buccal and palatal cusps
and either the mesial or distal position of the crown
was generally small compared with the total intrusion
achieved. Similar to the negligible tipping of the maxillary
molar, the difference between the buccal and palatal
cusps of the maxillary premolar was generally little.
None of the differences in
intrusion between the buccal
and palatal cusps reached the
level of significance

81. They concluded that the average intrusion of
maxillary molars was more than three to four mm. A
combination of mini-implants and fixed appliances is a
predictable and effective procedure to achieve maxillary
molar intrusion.

82. Minibone Plates: The Skeletal
Anchorage System

83. Junji Sugawara and Makoto Nishimura (2005) presented
a case report of 19-year-old Japanese male complained of
anterior crowding, open-bite, and difficulty in chewing. He
had mild facial asymmetry, a large interlabial gap, a gummy
smile, and disharmony between the hard and soft tissues.
The posterior-anterior (PA) cephalometric radiograph
indicated a mild facial asymmetry.

84. The cephalometric analysis (craniofacial drawing
standard analysis)5 indicated that the major skeletal and
soft tissue problems were a large interlabial gap, vertical
maxillary excess, and a skeletal Class III relationship.
Clinical examination revealed an anterior open-bite,
upper and lower anterior crowding, anterior crossbite,
mandibular dental midline deviation, and a narrow upper
dental arch.

85. In addition, the lower 3rd molars were horizontally
impacted bilaterally.

87. Treatment progress:-
A 0.022-inch preadjusted appliance was placed on the
buccal segments and the lower incisors. Leveling and
aligning of the posterior teeth and lateral expansion of
the upper arch were initiated using archwires and a
transpalatal arch.
Treatment progress
(anterior intraoral
photos). (A) Leveling and
aligning of posterior
teeth and expansion of
upper arch. (B) Initial
leveling and aligning of
upper anteriors. (C)
Continued leveling and
aligning of upper arch
with continuous wire and
distalization of lower
molars. (D) Dental
midline correction.

88. Treatment progress (lateral intraoral photos). (A) Leveling and aligning of
posterior teeth and expansion of upper arch. (B) Initial leveling and aligning of
upper anteriors. (C) Continued leveling and aligning of upper arch with
continuous wire and distalization of lower molars. (D) Dental midline correction.

89. About a month before surgical placement of the SAS, all
of 3rd molars were extracted. A plate was placed at both
the zygomatic buttress and the apical region of the lower
1st and 2nd molars, bilaterally. After placing rigid
archwires (0.018 inch 0.022 inch stainless steel), en
masse intrusion and distalization of the molars was
initiated with power chain ( 400 g per segment) from the
anchor plates.

90. Following distalization of the upper and lower molars,
the remaining teeth were bonded. After leveling and
aligning of the arches, the asymmetric lower arch and
the open-bite were corrected with the SAS. During
finishing and detailing, occlusal equilibrium was
performed to maximize intercuspation.

91. Upper molar intrusion mechanics. (A) Leveling and aligning of posterior teeth.
(B) Y-plate placed at zygomatic buttress with elastic intrusive force. Note
transpalatal arch to prevent buccal flaring of molars. (C) After intrusion, both
arch are leveled and aligned. (D) Archwire is ligated to anchor plate to prevent
relapse.

92. Posttreatment intraoral photos. (A) Right buccal. (B)
Anterior. (C) Left buccal. (D) Maxillary occlusal. (E)
Mandibular occlusal.

93. Posttreatment facial photos. (A) Frontal. (B) Frontal
smiling. (C) Lateral.

94. One year posttreatment intraoral photos. (A) Right
buccal. (B) Anterior. (C) Left buccal. (D) Maxillary
occlusal. (E) Mandibular occlusal.

95. Zygomatic Anchorage for En Masse
Retraction in the Treatment of Severe
Class II Division 1

96. Zygomatic Anchorage for En Masse Retraction in the
Treatment of Severe Class II Division 1
Nejat Erverdi (2005) presented a case report of a 24-year-old
female who presented with a Class II division 1 malocclusion. Her chief
complaints were an unaesthetic facial appearance and a gummy smile.
Her anamnesis showed no contraindication to orthodontic treatment.

97. The patient was characterized by an excessively convex
facial profile resulting from a retrognathic mandible. Her
facial appearance was characterized by a short mandibular
corpus length, excessive lip strain in the closed lip position,
and an insufficient chin prominence.

98. She had a gummy smile, with an excessive gingival showing
both in the an terior and posterior parts of the dentition and
a slight open bite. She also had a tongue thrust swallow
associated with the presence of an open bite.
She presented with a Class II molar and canine relationship
on both sides, along with a 12-mm overjet and two mm
anterior open bite.

99. She presented with a Class II molar and canine relationship
on both sides, along with a 12-mm overjet and twomm
anterior open bite. She had a maxillary midline diastema and
undersized upper laterals, too.

101. Surgical method
Under local infiltrative anesthesia, a one-cm-long vertical
incision was carried along the crest of the zygomatic buttress,
ending at the intersection of the attached and mobile gingiva.
A mucoperiosteal flap was elevated, and by blunt dissection,
the lower aspect of the zygomatic process of the maxilla was
totally exposed.

102. A zygomatic implant manufactured by Surgi-Tec (Brugge,
Belgium) was adjusted to fit the contour of the inferior border
of each zygomatic process and fixed with four bone screws.
The ball end of the zygomatic implant was exposed to the oral
cavity from the incision area. Care was taken to adjust the
position of the ball end in such a manner that its horizontal
tube would be parallel to the buccal surface of the first molar
crowns.

103. The orientation of the horizontal tube was a critical step during
the surgical procedure because this tube would be used instead
of a molar tube during retraction of the anterior teeth. The
incision site was closed and sutured. The patient was advised
to use antiseptic mouthwash for one week and practice good
oral hygiene during the healing period. The bone anchor was
loaded immediately after removal of the sutures.

104. Treatment progress
The maxillary first premolars were extracted as part of the
orthodontic treatment plan. Roth prescription brackets (0.018
inch) were bonded to the upper six anterior teeth. Because
there was only a slight misalignment in the incisor region,
leveling was postponed until the end of en masse retraction.

105. A 0.017 3 0.25–inch stainless steel archwire with slight
steps, insets, and offsets was placed passive in the upper
bracket slots. The archwire was bent vertically in the apical
direction after the canine bracket on each side and after the
formation of a helix, bent distally at the same vertical level
as the tube on the ball end. It was adjusted to pass through
the tubes in the ball ends and two-mm wire extensions were
left distal to the ball ends. The archwire was engaged in
the brackets and the tubes and ligated tightly.

106. NiTi closed coil springs exerting 150 g of force were
attached bilaterally to the helices on the archwire. The point
of force application. Activation was completed by engaging
the free ends of the coil springs to the extensions of the arch
wire distal to the tubes on both sides.

107. To prevent soft tissue impingement, the helices and the ends of
the coil springs were covered with adhesive material. The
patient was requested to return to the clinic each month for
control visits. No activation of the coil springs was necessary
during these visits. Wire extensions distal to the tubes were
shortened at each visit.

108. After correction of the overjet, molar bands and premolar
brackets were applied and a round 0.016-inch NiTi archwire
was engaged for leveling, followed by rectangular stainless
steel archwires for finishing. No orthodontic treatment was
performed in the lower arch. At debonding, slight diastemata
were left mesial and distal to the undersized upper laterals,
which were filled later during a composite buildup of these
teeth. For retention, a fixed lingual canine-tocanine retainer
was placed in the upper arch.

110. The overjet was reduced to normal limits in six months, and
the overall treatment lasted 17 months. No movement in the
molar area was observed. The superimposition shows that the
incisor movement was controlled tipping rather than bodily
movement as originally planned. A side effect observed during
treatment was palatal tipping of the canines.

112. En masse retraction of the six anterior teeth by using
zygomatic bone anchorage is an efficient method for the
correction of a severe overjet problem.

113. Distal movement of maxillary
molars in non growing patients
with the skeletal anchorage
system

114. Sugawara et al (2006) discussed a clinical study Twenty-five
nongrowing patients (22 female, 3 male) who had undergone
SAS treatment at Tohoku University, Japan, Twenty-two
patients were treated by 1 clinician (J.S.), and 3 patients were
managed by residents under his supervision. All subjects met
the following criteria for case selection: (1) it was
cephalometrically confirmed that they were nongrowing at
least in terms of the maxillary growth before treatment, (2)
there was sufficient space behind the first molar for the
second and third molars after distalization, (3) individualized
treatment goals were feasible according to the cephalometric
and occlusogram predictions, and (4) treatment could be
performed by using symmetrical distalization mechanics.

115. The third molars were bilaterally extracted in 12 patients
and bilaterally missing in 5. The bilateral second molars
were extracted in 6 patients because of anticipated
difficulty in extracting the maxillary third molars. The
average SAS treatment period was about 19 months
(range, 8 to 36 months).

116. weeks after the implantation surgery, after postsurgical
management, but it was not necessary to wait for the
osseointegration of the titanium screws and plates. All
anchor plates were removed immediately after
debonding. Two representative SAS mechanics for
distalization of the maxillary molars. One is single molar
distalization, and the other is en-masse molar distalization
with sliding mechanics. All subjects were bonded with
preadjusted multi-bracketed appliances with 0.022-in slots.
Heat-treated 0.018 x 0.025-in blue Elgiloy (Rocky Mountain
Orthodontics, Denver, Colo) wires were used as the main
archwires for distalization of the maxillary molars.

117. The orthodontic forces were
approximately 200 g for
single molar distalization and
approximately 500 gf for en-
masse molar distalization.
Orthodontic forces were
mostly provided by nickel-
titanium open-coil springs
(Tomy International, Tokyo,
Japan) or elastic chain modules
(Pro-Chain, Dentsply-Sankin).

118. This patient presented with an
anterior crossbite. After
receiving the first phase of
treatment with a maxillary
protracting facial mask for 1.5
years, she remained under
observation for growth related
changes. Immediately before
the second phase of treatment.

119. she had the following orthodontic problems: skeletal
Class III tendency, severe crowding in the maxillary
dentition, an edge-to-edge bite, a lack of anterior
guidance, and Class III dentition. To solve those
problems, Y-shaped and L-shaped anchor plates were
bilaterally implanted at the zygomatic buttresses and the
mandibular body, respectively, after extracting all third
molars. SAS mechanics were applied to move the
maxillary and mandibular molars distally.

120. After SAS treatment for approximately 13 months, the
brackets were debonded, and a wraparound type of
retainer for the maxillary dentition and a lingual bonded
retainer in the mandibular anterior dentition were used.
The severe crowding in the maxillary dentition was
completely corrected by using SAS with no outward
flaring of the maxillary incisors. The maxillary first molars
were distalized in the manner of bodily translation. The
amounts of posterior displacement of the crown and root
were 4.7 and 4.5 mm, respectively. The mandibular first
molars were also distalized and uprighted with SAS.

121. New Generation Open-bite
Treatment with
Zygomatic Anchorage

122. Erverdi et al (2006) presented a case report A 14-year-old,
female Class II patient with an anterior open bite was treated
with a new generation posterior intrusion appliance. At the
end of treatment, a Class I canine and molar relationship and
a correction of the anterior open bite were achieved. The
molars were impacted 3.6 mm, and this impaction was
maintained throughout the treatment. The mandibular plane
showed a counterclockwise autorotation of 48. This case
report demonstrates that zygomatic anchorage can be used
effectively for molar intrusion and anchorage maintenance.

123. Open-bite Treatment with Zygomatic Anchorage
The Angle Orthodontist: Vol. 76, No. 3, pp. 519–526.

124. This technical note aims to present the fabrication and application
of a new generation of posterior intrusion appliances using zygomatic
anchorage. The use of zygomatic anchorage enables en masse
impaction of the posterior segment without any side effects such
as labial flaring. A 14-year-old, female Class II patient with an anterior
open bite was treated with a new generation posterior intrusion
appliance. At the end of treatment, a Class I canine and molar
relationship and a correction of the anterior open bite were achieved.
The molars were impacted 3.6 mm, and this impaction was maintained
throughout the treatment.
Open-bite Treatment with Zygomatic Anchorage
The mandibular plane showed a counterclockwise autorotation of 4°.
This case report demonstrates that zygomatic anchorage can be
used effectively for molar intrusion and anchorage maintenance.
However, further clinical studies with larger samples are required to
confirm its effectiveness.
The appliance consists of two shallow acrylic bite blocks connected with
two heavy palatal arches (1.4-mm round stainless steel) and wire
attachments on each buccal side, which are used for force application.

125. APPLIANCE DESIGN AND FABRICATION
Open-bite Treatment with Zygomatic Anchorage
Palatal arches are bent over two layers of wax to avoid impingement on
the palatal mucosa during intrusion. Bite blocks cover all of the teeth that
need to be intruded, ie, generally all teeth distal to the upper canines.
The outer wire attachments are made from 0.9-mm stainless steel wire,
and two 200-g NiTi open-coil springs are attached before the ends of the
wire are embedded in the acrylic resin. The offset of this wire is adjusted
so that the vector of force application will be parallel to the long axis of the
first molars when the NiTi coils are attached.
After allowing 7 to 10 days for wound healing and after removal of the
sutures, the appliance is first tried in the mouth to check for even occlusal
contact. The cusp tips of the appliance segments are trimmed flat to contro
bite opening during expansion and generation of eccentric and unilateral
contact points. Glass ionomer cement is used to bond the appliance. This
material will usually remain interfaced on the teeth when the appliance is
removed, and it may take more time to clean the teeth. However,
a successful treatment requires a good retention of the appliance.

126. Open-bite Treatment with Zygomatic Anchorage
Two 9-mm NiTi coil springs (Masel, Bristol, Pa) were placed bilaterally
between the tip of the implant and the outer wire creating an intrusive
force of 400 g.
The anterior open bite is usually corrected in 5 to 6 months. Intrusion of
the posterior segment is retained with wire ligation between the molar
tube and the implant throughout the subsequent orthodontic treatment.
The implants are removed about 1 month before debonding.
FIGURE 2. Zygomatic buttress area is exposed

127. Open-bite Treatment with Zygomatic Anchorage
After implant placement surgery and
suture removal at day 7, the appliance
was cemented, and force application
was initiated. The patient was observed
at 4-week intervals, and progress was
observed. No fixed appliances were
placed until the completion of the
posterior dentoalveolar intrusion in
7 months. After completion of the
impaction, orthodontic therapy was
started, and the impaction was
maintained with wire ligation between
the implant and the molar tubes
throughout the treatment .
FIGURE 1. Vertical incision completed

128. Open-bite Treatment with Zygomatic Anchorage
At the end of treatment, a Class I canine and molar relationship and
correction of the anterior open bite were achieved through the impaction
of maxillary posterior dentoalveolar segment and eruption and uprighting
of the upper incisors. The incisors were erupted when the accentuated
curve of Spee in the upper arch was aligned with straight wires. No other
particular extrusion mechanics were involved in the treatment.
FIGURE 3. Implant is fixed with three screws

129. Open-bite Treatment with Zygomatic Anchorage
The molars were impacted 3.6 mm, and this impaction was maintained
throughout the treatment. The mandibular plane showed 4° of counter
clockwise autorotation.
FIGURE 4. Surgery site is closed and sutured. Note the
placement of the implant tip exposed at the
mucogingival junction

130. Open-bite Treatment with Zygomatic Anchorage
FIGURE 5. Fabrication of intraoral appliance
for posterior intrusion.

131. Open-bite Treatment with Zygomatic Anchorage
FIGURE 6. Extraoral and intraoral photographs
of the patient before treatment

132. Open-bite Treatment with Zygomatic Anchorage
FIGURE 6. Extraoral and intraoral photographs
of the patient after treatment

133. Orthopedic Protraction with Skeletal
Anchorage in a Patient with
Maxillary Hypoplasia and
Hypodontia

134. Kircelli et al (2006) presented a case report of
a 11-year-old girl was referred with a complaint of‘‘small
and separated teeth’’ and ‘‘lower jaw projection.’’ Medical
history of the patient was noncontributory other than her
parents were cousins. Furthermore, her elder brother
presented with similar complaints of maxillary hypoplasia
and hypodontia. Clinical and radiological examination
revealed severe hypodontia and microdontia. Twenty-one
of her permanent teeth were missing, whereas number 11,
21, 36, 46 existed in the dental arch and germs of the
number 15, 37, and 47 could be detected on the panoramic
radiograph.

136. Furthermore, microdontia existed both in her
primary and permanent dentition. The maxillary
arch was deficient sagittally and transversally, so
that there was an eight mm negative overjet and
a bilateral buccal crossbite relationship with the
lower jaw.

137. A depression of the midfacial structures included the
maxillary and infraorbital regions with a relative
prominence of the mandible, inadequate projection of
the nasal tip and an old face appearance with an
unesthetic smile constituted general features of the
patient . She also had nasal respiratory problems
causing mouth opening during sleep.

139. Three treatment options were considered for maxillary
advancement. The first option was to delay treatment
until growth has ceased and to correct the jaw
relationship by orthognathic surgery. The second option
was to apply rigid external distraction together with
complete Le Fort I osteotomy. The third option was to
try to take advantage of the sutural growth potential by
applying extraoral force with a face mask via rigid
skeletal anchors placed to the maxillary bone.
Treatment options

140. A titanium miniplate designed by Erverdi16 (MPI,
Tasarımmed, Istanbul, Turkey) was used as a rigid
skeletal anchor to attach the elastic orthopedic forces to
the maxilla. Multipurpose miniplates were to be placed
on both sides of the apertura piriformis and on the lateral
nasal wall of maxilla. Rapid maxillary expansion was also
planned to correct the transversal maxillary deficiency
and to disturb the circummaxillary sutures.

141. Because the maxillary dentition was insufficient, it was
decided to place intraosseous titanium screws (two 3 eight
mm IMF screws, Leibinger, Germany) on the palatal
bone, near the alveolar crests, to provide anchorage for the
expansion appliance. After routine surgical preparations,
patient received general anesthesia. Bilateral mucosal
incisions were made on labial sulcus between lateral incisor
and first cuspid region.

142. Then, mucosal flaps were carried inferiorly, the muscles
and periosteum were incised and reflected
superomedially, exposing the apertura piriformis and the
lateral nasal wall of maxilla on both sides. Once an
adequate space was achieved for miniplate placement, the
nasal mucoperiosteum was elevated. Multipurpose
miniplates were meticulously contoured to the bilateral
lateral nasal wall, and straight extensions were bent to
hook shape providing retention for face mask elastics and
projected into the oral cavity through three mm
mucoperiosteal incisions made inferiorly on the attached
gingiva.).

143. Subsequently, for final stabilization of the bone plates
three, 2.0 mm screws (five mm length) were placed with a
1.3 mm diameter drill under copious irrigation
Simultaneously, four intraosseous bone screws were
placed in the anterior and posterior palatal region, close to
the alveolar crests, bilaterally .After soft tissue healing,
orthopedic forces were applied.
IMF screws placed in anterior and
posterior palatal region.

144. Impressions and stone casts were obtained with th IMF
screws in place. The screws were blocked out with wax on the
stone model, and an acrylic plate was prepared with an
expansion screw in the midline. Appliance adaptation was
checked intraorally and then connected to the IMF screw
heads using cold curing methyl methacrylate–free acrylic
resin (Ufi Gel hard, Voco GmbH, Cuxhaven, Germany). One of
the parents was asked to activate the screw a quarter turn
once a day.
Construction of the intraosseous screw– supported
expansion appliance
Intraosseous screw–supported
maxillary expansion appliance.

145. An elastic force of approximately 150 g was applied
bilaterally to the miniplate extensions after the adaptation
of face mask (Leone spa, Firenze, Italy). After being sure of
the stability, the force was increased gradually to 350 g.
The direction of the force was adjusted approximately 308
to the occlusal plane, and the patient was asked to wear
the face mask full time except during meals.

146. The application of the orthopedic forces via elastics directly
to the anterior part of the maxillary bone by using miniplate
anchorage resulted in a remarkable improvement in the
middle face. Together with the maxillary bone advancement,
significant enhancement in the soft tissue profile revealed
improved facial esthetics. The maxilla was expanded from the
median palatal suture, and seven mm of expansion was
achieved across the buccal segments. Coordination of the
dental arches both in the sagittal and transversal planes
created improved physiological functions.

148. Post treatment intraoral
photographs.

149. Skeletal Anchorage for Orthodontic
Correction of Maxillary Protrusion
with Adult Periodontitis.

150. Fukunaga (2006) reported a case report of A female
patient
aged 50 years seven months came to the outpatient clinic of
our university dental hospital, with a chief complaint of
spacing between the maxillary incisors and dental protrusion.
Clinical examination demonstrated an acute nasolabial angle,
straining of the circumoral musculature on lip closure, Class II
malocclusion, and increased overjet (7.5 mm) and overbite
(four mm).

152. The upper incisors showed migration and rotation,
resulting in five mm of spacing, whereas the lower
anterior segment demonstrated mild crowding (0.5 mm).
The upper left first molar was missing, and a temporary
bridge had been set. The lower right second premolar
and first molar were under prosthetic treatment. The
third molars were absent.

153. Periodontal charting demonstrated that probing depths
ranging from three to 10 mm and bleeding on probing
was present in almost all teeth except for the upper and
lower left lateral incisors, upper first premolar, and lower
second premolars. Radiographic examination
demonstrated generalized horizontal bone loss in both
arches, with vertical bone loss in the upper right first
premolar and molars, lower right first premolar, and
second molars. In particular, severe bone loss around
three-fourths of the root was noted in the upper left
posterior region.

154. Treatment progress
Before starting orthodontic treatment, the patient
received periodontal treatment from a periodontist for 14
months. Periodontal treatment involved oral hygiene
instructions, curettage, scaling, root planing, and flap
operations. The upper left second molar was extracted
because of poor response to periodontal treatment. After
periodontal treatment, the patient acquired good plaque
control and clinically healthy gingiva

155. Probing depths were less than three mm, except at the
mesial palatal aspects of upper left premolars and right
first molar, mesial lingual aspect of the lower left second
molar, and distal buccal aspec of the lower right second
molar, where the probin depths were four mm. The
upper right molars and lowe left molars were fixed with
an A-splint, and temporar continuous crowns were set in
the lower right secon premolar and molars.

156. Six months after finishing the initial periodontal
treatment, a 0.018-inch slot, preadjusted edgewise
appliance was placed on the lower anterior teeth and
first molars, and leveling and alignment with a round
archwire was initiated. Stripping of the lower incisors
was performed for the retraction and intrusion of lower
incisors. The anchorage consisted of two bilateral
segments connecting the posterior teeth.

157. Y-shaped miniplates (Dentsply-Sankin, Tokyo, Japan)
were implanted into the zygomatic process of the
maxilla through the buccal mucosa after local anesthesia
had been administered.

158. Analgesics and antibiotics were prescribed to the
patient for three days after the implantation. After eight
weeks for healing, integration, and adaptation, a 0.018-
inch slot, preadjusted edgewise appliance was placed
on the upper anterior teeth. Then, leveling and
alignment were initiated with light sectional wires.

159. (B) Four months after the start of the retraction of the upper
incisors. (C) Eight months later.

160. At the beginning of leveling, a 0.010 inch ligature wire was
tied from the miniplates to the anterior segment
to prevent the flaring the upper incisors. After a 0.016 3
0.022–inch sectional stainless steel archwire was placed,
retraction and intrusion of the anterior teeth was started with
elastic chains between the miniplate and the hook.

161. Eight months after the start of loading, the space in the
upper anterior segment was closed. After 21 months of
edgewise treatment, ideal overjet and overbite were
achieved. Three months before removal of the edgewise
appliances, the miniplates were removed. After the
removal of the edgewise appliances, the maxillary teeth
were stabilized by a six-unit bonded lingual retainer with
a Begg-type retainer, and the mandibular teeth were
stabilized by a nine-unit bonded lingual retainer. During
orthodontic treatment, the periodontist carried out
periodontal maintenance at one-month intervals and home
care was emphasized.

163. The space in the upper dentition was closed, and
maxillary dental midline coincided with the mandibular
midline. The upper incisors were inclined 9.58 lingually,
and the vertical perpendicular distance from the upper
central incisal edge to the nasal floor was maintained.
The upper incisors were intruded two mm at the apex.
The lower incisors were intruded and lingually inclined.

164. There was no remarkable apical root resorption
observed in the upper and lower incisors, and ideal
overbite and overjet with a Class I canine relationship
was established. After two years of retention, acceptable
occlusion and facial profile were also maintained. During
retention, the lower incisors were labially inclined 8.58,
and the lower right second molar was extracted because
of severe vertical bone loss around the apex of the root.

165. Use of Zygomatic Anchors
during Rapid Canine
Distalization

166. Karacay et al (2006) presented a case report A 16-year-old,
female who had a Class II division I malocclusion was
referred to the Department of Orthodontics for treatment. Her
chief complaint was the malalignment of the upper anterior
teeth. Intraoral examination revealed a bilateral Class II
canine and molar relationship, excessive overjet, a tendency
to open bite, and a mild malalignment, especially in upper
right lateral incisor and canine region. It was also observed
that the maxillary dental arch was deviated to the left side,
creating a midline shift.

168. The extraoral examination revealed a convex profile with
a slightly prominent chin, indistinct subnasal sulcus, and
a symmetrical face.

170. Treatment objective
The clinical, radiographic, and study model examination
revealed that the patient had a skeletal Class I and
dental Class II division I malocclusion. Because the
patient was an adult, camouflage treatment was planned
with extraction of the upper first premolars to eliminate
the overjet and correct the midline shift. The molar
relationship was Class II before treatment, so maximum
anchorage was required for protection. Because the
patient did not agree to the use of a headgear, surgical
procedures would inevitably be necessary to provide
maximum anchorage. However, to reduce the treatment
period, rapid canine distalization through distraction of the
periodontal ligament was planned, and tooth-borne intraoral
distraction devices were constructed.

171. Distraction device
The device consisted of three sections modified from a
conventional Hyrax screw. The anterior section included
a retention arm (with a rectangular tip) for the canine
tube and two non grooved slots for the sliding rod and
screw. The posterior section consisted of a round sliding
rod (1.5 mm), a retention arm (with a rectangular tip) for
the first molar tube, and a grooved screw socket. The
third section was the screw (2.5 mm), produced in a
military establishment.
A 360 degree activation of
the screw caused one mm
of distal movement in the
canine tooth.

172. Surgical procedure for periodontal distraction
After the first premolar extraction, a vertical osteotomy
was performed in the buccal and lingual interseptal
bone between the canine and first premolar teeth.
The two vertical osteotomies were connected with an
oblique osteotomy extending toward the base of the
interseptal bone to weaken the resistance. Osteotomies
were performed inside the socket.

173. Distraction protocol
The distractor was activated 908, three times a day
with eight-hour intervals. Activation was begun just after
the extractions and surgical procedures. The canine
teeth were distracted into their desired position within
three weeks, and a Class I canine relationship
was attained. The distractor is presented in Figure 5.
The patient was closely monitored by periapical
radiographs taken weekly
during the distraction
period, and no apical root
resorption was observed
on apex of canines.

176. Surgical procedure for the placement of zygoma anchor
Zygoma anchors (Surgi-Tec, Bruges, Belgium) were
implanted under local anesthesia after the distractors
were cemented and brackets were attached on the
incisors. A mucoperiosteal flap was elevated after an L
shaped incision, consisting of a vertical incision at the
mesial of the inferior crest of zygomaticomaxillary
buttress, was performed.
The upper part of the zygoma
anchor was adjusted to fit the
curvature of the bone crest,
and three holes were drilled
at the appropriate points.
The appliance was fixed to
the bone by miniscrews.

177. The cylindrical fixation unit of the zygoma anchor was
exposed to the oral cavity between the roots of molar
and second premolar teeth at a 908 angle to the alveolar
bone. The wounds were closed with 3.0 suture material
(Polyglactin 910, Ethicon, Johnson- Johnson, Brussels,
Belgium), and one week later the sutures were taken.

178. Incisor retraction
Immediately after implantation of the anchors, a 0.016-
inch archwire was bent to level and retract the incisors
and was attached in the brackets and anchors. At the
end of the three-week distraction period, the distractors
and the archwire were extracted. A hook was
constructed from a 0.9-inch laboratory wire and fixed to
the vertical slot of the anchor by a locking screw. A 0.016
3 0.016–inch stainless steel archwire, consisting of a
crimpable hook at the mesial of the lateral incisor, was
inserted in the brackets. Intraoral Class I elastics were
attached between the hooks on the anchors and the
crimpable hook. The patient was instructed in how to apply
the elastics, and she was advised to use them at all times
except when eating.

180. The incisors were retracted efficiently in an average of three
weeks, and the ZAS were removed under local anesthesia. At
the last stage of the treatment, intermaxillary elastics were
used to correct the midline and 0.016 3 0.022–inch and 0.017
3 0.025–inch blue Elgiloy finishing archwires were inserted.
The patient wore a Hawley retainer for one year after fixed
appliances were removed.

183. CONCLUSIONS
X- Rapid canine distalization and zygoma anchors are
two new orthodontic approaches that can be used
together.
X- Combined use of these techniques shortens
orthodontic
treatment period and provides absolute anchorage
for canine distalization and incisor retraction
without patient compliance.
X- Early intraoral improvement motivated the patient
and increased cooperation.
X- Combined use of these two new concepts seems
promising for the reduction of orthodontic treatment
time.

184. Sia et al (2007) published An In Vivo Study to To determine
the location of center of resistance and the relationship
between height of retraction force on power arm (power-arm
length) and movement of anterior teeth (degree of
rotation) during sliding mechanics retraction.
Determining the Center of Resistance of Maxillary
Anterior TeethSubjected to Retraction Forces in Sliding
Mechanics.

186. Subjects were one male and two female adult patients
who were randomly chosen and diagnosed with
maxillary protrusion. Subjects were given informed
consent forms, and the research protocol was examined
and approved by the related authorities. The selection
criteria for those patients were as follows:
• Diagnosed as Angle Class II division 1 malocclusion;
• Availability of good and normal periodontal condition;
• Underwent orthodontic treatments with maxillary first
premolars extractions and anterior crowding relieved
(if any); and the target tooth was set to be the maxillary
right central incisor, with absence of root resorption
(determined by periapical radiographs).

187. A magnetic sensor device used here was described
previously,and therefore will be only summarized in
this paper. The main part of the system was composed
of two magnets and 16 magnetic sensors for
measuring motion in five degrees of freedom.

188. Hall elements (HW-302B, Asahi Kasei Electronics Co,
Tokyo, Japan) were used as magnetic sensors because
they are small enough to be placed in the oral cavity and
sensitive enough to detect a small displacement.
Dimensions of the sensor were 2.7 mm 2.35 mm 0.95
mm. Neodymium magnets (NE412, IBS Magnet Ing,
Berlin, Germany) were used for target points as they are
small and powerful.

189. The magnet was cylindrical and 4.0 mm in diameter and
1.2 mm in length. Eight sensors were arranged in a
cubic array around a magnet to measure three
dimensional displacement. Two sensor units were
placed labially and palatally to the maxillary central
incisor and rigidly fixed to the posterior teeth by a splint.
Two magnets were placed in the center of each sensor
unit and attached to the maxillary central incisor by
aluminum rods.

190. An appliance with 0.018-in slot brackets with 0.016
0.022-in Elgiloy archwire was used. Two titanium
miniplate implants (Orthoanchor SMAP system,
Dentsply-Sankin, Tokyo, Japan) were inserted at both
sides of the buccal region of the maxillary first molars
as a source of anchorage for retracting the anterior
teeth.

191. Two power arms were soldered at both sides of the
mesial canine region of the archwire to simulate en-
masse retraction of anterior teeth in the clinical situation.
The power arms were perpendicular and apical to the
occlusal plane. Each power arm contained six small
hooks with 2 mm distance per hook. Hence, the first
hook in each power arm was set to be level 1 at 0 mm
(corresponding to the bracket position, or 4.5 mm apical
to the incisal edge), followed by second
hook at level 2 (2 mm from bracket position) until the
sixth hook at level 6 (10 mm from the bracket position).

192. A horizontal retraction force of 150 g was applied
bilaterally parallel to the archwire. Precalibrated
closed-coil springs were hooked between the posterior
attachments with six hooks (capped onto titanium
miniplate implants) and the anterior power arms
bilaterally at the same height of the hook level and
parallel to the archwire.

193. The vertical heights of the hooks on the posterior
attachments were similar to the vertical heights of the
hooks on the anterior power arms. Height of the
posterior attachments was changed in tandem with the
height of the anterior power arms. Vertical distances
from the closed-coil spring to the archwire were
measured at a few reference points throughout the
experiment to keep the force vector parallel to the
archwire for every height level of force application.

194. Three measurements were performed for each of the
three subjects and averaged. Tooth movements
projected on the midsagittal plane were analyzed from
the displacements of the two magnets, as these
movements are clinically important when anterior teeth
are retracted. By calculating the angle of rotation from
the displacements measured, the location of the center
of resistance was determined.

195. CONCLUSIONS
• The location of the center of resistance of the maxillary
central incisor was shown to be approximately
0.77 of the root length from the apex
• During anterior tooth retraction with sliding mechanics,
controlled crown-lingual tipping and controlled
crown-labial movement can be achieved by attaching
a power-arm length that is lower or higher than
the level of center of resistance, respectively.

196. Chair-side simple estimation of location of center of resistance
of maxillary central incisor (by lateral cephalogram tracing)
and the required height of retraction force on power arm in
order to produce preprogrammed tooth movement during
anterior retraction with sliding mechanics.

197. Bodily translation movement (lingual movement) can be
achieved by attaching a power-arm length that lies
on the same level of the center of resistance.

198. Intrusion of Overerupted Molars by
Corticotomy and Orthodontic
Skeletal Anchorage.

199. Moon et al (2007) presented a case report of 26-year-old
female patient with overerupted left maxillary molar teeth.
Her chief complaint was that the maxillary left first and the
second molar intruded into the space required for the
mandibular left first and the second molars, preventing
prosthodontic treatment.

200. Corticotomy Procedure
The surgical procedure was performed with local
anesthesia. Mucogingival flaps were elevated on both
the palatal and buccal sides of the overerupted molars
to expose the cortical bone completely beyond the
apex. Then vertical bone cuts were made with a fissure
bur (#701) extending from 3 to 4 mm above the
alveolar crest between the second premolar and the
first molar to 3.0 mm beyond the apices. The cant of
these vertical bone cuts should coincide with the desired
direction of intrusion of the posterior segment.

201. A horizontal bone cut was made 3.0 mm above the
apices of the teeth to the maxillary tuberosity with a
round bur (#4), and the pterygomaxillary junction was
separated with an osteotome. This resection was 3 to 4
mm wide to facilitate molar intrusion.

202. The depth of the bone cuts should be limited to the
cortical bone, barely reaching the medullary bone. After
completing the corticotomy, the incisions were closed by
sutures. Antibiotics and anti-inflammatory drugs were
prescribed for 3 days after the surgery.

203. OSAS Implant Procedure
An L-shaped miniplate (Meditech Co, Boston, Mass)
was fixed in the buccal vestibule using two bone
screws with the short arm exposed to the oral cavity
from the incised wound.

204. Two orthodontic miniscrews (Jeil Medical Co, Seoul,
Korea), 1.6 mm in diameter and 8 mm in length, were
implanted in the palatal area. One was 3.0 mm and the
other was 8.0 mm from the midpalatal area. The
miniplate was fixed during the corticotomy procedure,
and the orthodontic miniscrews were implanted 2 weeks
after the corticotomy.

205. Hook Fabrication
Just after insertion of the screw type OSAS, an impression
was obtained to make a hook. For the working model, two
orthodontic miniscrews (analogous to an implant) were put
inside the impression material and poured with yellow stone.

206. The hook was made with 0.7-mm stainless steel wire, and the
force direction that allows suitable intrusion of overerupted
molars was considered. Orthodontic miniscrews and the hook
were attached using a metal primer, bonding agent, and resin
after each was sandblasted.

207. Treatment Progress and
Results
The same day the screw
type OSAS was inserted,
a specially designed hook
was bonded on the palatal
side. After that, brackets
were bonded on the center
of the buccal and lingual
faces of the molar, and
elastics were used to apply a
force of 100 to 150 g on each
side.

208. In this case, the amount of intrusion of the first and second
molars should be different, so we used a different force
between the two teeth. One month after the application of
elastic force, considerable intrusion had occurred. The mesial
marginal ridge of the maxillary left first molar was level with
the distal marginal ridge of the maxillary left second premolar.
However, for correction of the curve of Spee, we continued
the force on the maxillary left second molar and reduced the
force on the maxillary left first molar tooth.

209. Two months after surgery, the molars were adequately
intruded, and a suitable curve of Spee was present. The
overerupted molars were successfully intruded without
movement of the adjacent teeth, and the intruded teeth
remained vital.

210. Intraoral photographs of the patient. (a) Pretreatment.
(b) Posttreatment. (c, d) The miniplate and one of two
orthodontic miniscrews were used as a retainer during
the retention period. (e) After retainer removal.

211. The patient experienced minimum discomfort and a
slight soft tissue inflammation around the hook on the
palatal side. The miniplate and one of the two
orthodontic miniscrews were used as a retainer. During
retention, oral hygiene education was given to the
patients, and no complications occurred.

212. Seven months into retention, implant treatment for prosthetic
replacements started. After 1 month of prosthodontic
treatment, we stopped the retention and removed the miniplate
and miniscrew. Three months after stopping the retention, the
patient had a satisfactory occlusion.

213. Cephalometric superimposition showed that the maxillary left
first molar had intruded 3.0 mm and the second molar had
intruded 3.5 mm. The teeth were tipped about 1 to 3. The
posttreatment radiograph demonstrated that the overerupted
molars were successfully intruded without root resorption.

214. Miniplates allow efficient and
effective treatment of anterior open
bites

215. Faber et al (2008) evaluated the effectiveness of mini plate
anchorage for treatment of anterior open bites.
Miniplates allow efficient and effective treatment
of anterior open bites
BIOMECHANICS TO CORRECT ANTERIOR OPEN BITE USING
MINIPLATES:-
Intrusive vertical force is produced by
Means of a chain elastic or nickel-
titanium spring attached to the
miniplate’s exposed link and to the
molar tube. Segmented as well as
straight arch wires can be used.

216. Intrusion-related mechanical issues. A) Both continuous arch
wires and segmented arch wires can be utilized. Segmented arch
wires (blue arrow) are best suited for open bites restricted to the
anterior region. B) When continuous arch wires are used, incisor
extrusion does not occur (X on the yellow arrow), as previously
suggested18, but not demonstrated in the literature.

217. Although the possibility has been raised that the use of straight
arch wires might cause incisor overeruption due to occlusal
plane rotation19, the authors’ experience has shown that such
effect does never occur, as already published elsewhere.

218. To avoid molar buccal rotation while applying intrusive
force, the use of a contracted rectangular arch wire is
indicated or, preferably, a transpalatal bar or lingual
arch.

219. Diagrams representing cross-sections of the maxilla in the first upper molar
region. A) Prior to placing the appliance. B) Miniplate insertion (green arrow)
and application of intrusion forces (blue arrows). C) Intrusive forces
decomposed into an expansive component (a) and an intrusive component (b).
Expansive components cancel out one another in the presence of a palatal bar
or (D) lingual arch (red arrow).

220. Should any undesirable alteration occur in the cross-sectional
plane, this can be solved by bonding a tube directly onto the
miniplate while concurrently activating a power arm in the
same orientation as the corrective force.
In order to correct any cross-sectional alterations in the upper and
lower dental arches, a bracket or tube can be bonded directly onto
the miniplate and be used as anchorage for arch wires, springs
and other devices. To this end, two small grooves should be made
in the miniplate link to retain the bonding resin.

221. Molar intrusion in only one of the maxillas can be
accomplished by correcting open bites of up to 3mm. Open
bites of more significant sizes should be corrected with the aid
of miniplates in both arches. The simultaneous intrusion of
upper and lower molars allows a greater counterclockwise
mandible rotation and more significant skeletal changes14.

222. CLINICAL CASE:- miniplates in maxilla and mandible, placed
unilaterally
Male patient, 21 years and 9 months old, exhibited
a Class I malocclusion with severe open bite, which
caused only the right second molars to occlude. There
was vertical asymmetry featuring inclined maxilla, lower
on the right hand side.

223. TMJ radiographs and scintigraphic images were
requested to check for possible left condyle
morphological alterations and hypercaptation. An
analysis of these exams ruled condyle hyperplasia or
neoplasia.

224. Treatment progress
After aligning and leveling lower and upper teeth, surgical
guides were fashioned to provide orientation for the surgeon
as to the desired miniplate position. Prior to surgery, a palatal
bar and lingual arch wire were inserted with the purpose
of preventing posterior teeth buccal rotation during the
intrusion process. These appliances had their arch wires
untempered on the left hand side to attain greater flexibility
and allow for adequate movement.

225. Two weeks after miniplate insertion on the right hand
side of the mandible and maxilla chain elastics were
placed between the miniplates and the first molars with
the aim of intruding the
posterior teeth.

226. Subsequently, intrusion elastics were also extended the
second molars. As soon as an adequate overbite was
achieved, a speech therapy treatment was launched
which lasted throughout the entire orthodontic treatment.

227. Results
The upper and lower molars were intruded and the
mandible underwent a counterclockwise rotation. At the
end of the orthodontic treatment, proper dental
relationships were established.

229. A 3 x 3 lower retainer was put in place. Additionally, for the
upper arch, wraparound style removable retainers were
produced. One conventional, for day time use, and one with
a palatal grid in the right hand side region, for night time use.
After six months of orthodontic treatment had elapsed, only
the night time retainer was maintained.

230. Miniplates anchorage on open-
bite treatment

231. Ramos et al (2008) evaluated the effectiveness of mini plate
anchorage for treatment of anterior open bites. of an adult
female patient who presented severe anterior openbite,
clockwise rotation of the mandible, biprotrusion and the
absence of labial sealing.
Miniplates anchorage on open-bite treatment

232. The patient showed SAOB with its typical characteristics
(negative vertical trespass, high anterior facial height, a
high mandible plane angle, absence of passive labial
sealing) associated to an excessive biprotrusion, Class III
relation and absence of the maxillary first molars and
maxillary left third molar.

233. Two treatment proposals where shown. The first
included the association with orthognatic surgery for
effective skeletal correction, allowing posterior maxillary
impaction and correction of the maxillary incisors
inclination. In the mandible, would be accomplished a
sagital reduction osteotomy, as an advance genioplasty,
with vertical reduction. Previously to the surgery an
orthodontic fixed appliance would be utilized for lower
discompensation (with previous indication of extraction
of lower first molars) and segmented maxillary leveling.
The second treatment option included the compensatory
correction, through help of four anchorage miniplates (to
allow suitable biprotrusion correction and vertical
control), and also the indication of extraction of lower
first molars.

234. In front of the options offered, the patient preferred the
treatment without orthognatic surgery, authorizing the
treatment with clear consent. The titanium plates design
used were drawn originally for orthognatic surgery
osteosynthesis and modified into anchorage dispositives.

237. It can be observed that in the upper quarters the most
occlusal chain unit of the miniplate was not correctly
vertically distant from the orthodontic wire line, therefore
later it was eliminated. the most occlusal chain unit
should be positioned 6 to 8mm far from the orthodontic
wire line, emerging in alveolar mucosa. The tissue repair
after miniplates placement was suitable, with tolerable
symptoms, being the suture removed after five days.
the last chain unit from the upper plates were removed,
allowing a suitable distance to the orthodontic wire. In the
lower arch, the retraction of seconds pre-molars was began,
anchored on the miniplates.

238. The alignment and leveling was conducted until rectangular
wire, when hooks were joint for anterior retraction,
associated to vertical control (especially maxillary), through
the positioning of elastomeric chains in the miniplates.
As an auxiliary upper anchorage, with the purpose of avoiding
arch expansion (due to vertical vector), a palatal bar with
0.8mm was inserted on maxillary second molars.
Leveling and alignment phase, starting lower premolars retractions. Observe that last chain unit
from the upper miniplates were removed. As an auxiliary upper anchorage, with the purpose of
avoiding arch expansion (due to vertical vector), a palatal bar was used.

239. The arches in anterior region were in good anterior
posterior relation; however the mesialization of lower
first molars was less evident than the upper ones. For
that reason, upper retraction was stopped momentarily
(stabilized with a 0,10mm twisted steel wire) and the
lower molars movement was accelerated with an
elastomeric chain that passed through the miniplate and
the hook until the molars.

240. however with an increase on gingival exposure. The
upper incisor protrusion correction, even with vertical
control, needled this situation, as pointed out by Sarver.
As the level of open bite correction was suitable, and with
over correction, it was decided to include an auxiliary
intrusion arch in the anterior segment, concomitant to the
ongoing mechanic.

242. Ending treatment phase interiorly photos.

247. Osteotomy Assisted Maxillary
Posterior Impaction with Miniplate
Anchorage.

248. Tuncer et al (2008) presented a case report of a 14-year-
old girl with a severe anterior open bite was treated by
intrusion of the maxillary posterior teeth with miniplate
anchorage accelerated by osteotomy- assisted maxillary
posterior impaction.
Osteotomy Assisted Maxillary Posterior Impaction with
Miniplate Anchorage.

249. Clinical examination revealed a convex profile due
to a retrognathic mandible. A severe anterior open bite
with an overbite of 5 mm and an overjet of 5 mm
were present. Both sides revealed a Class I molar and
canine relationship. Mild crowding was present in both
arches. Dental hygiene was proper.

250. the cephalometric analyses showed a skeletal Class II
relationship (ANB angle, 8; norms, 2.65 1.63) with
mandibular retrusion (SNB angle, 68; norms, 79.92
3.44). The mandibular plane angle was steep (SN-MP
angle, 53; norms, 31.66 5.25). The inclination of
maxillary and mandibular incisors was normal (U1-SN,
98; norms, 102.07 9.73; and L1-MP, 95; norms, 96.50
7.50). The maxillary molars were extruded (U6-PP, 25
mm; norm, 23 mm).

251. Treatment Progress
The treatment plan included impaction of the maxillary
posterior segment using a zygomatic bone anchorage.
Surgical assistance was considered to accelerate
the treatment and minimize the adverse effects of
orthodontic treatment. The patient was fully informed about
the procedures. The first and second upper molars were
banded, and a transpalatal arch appliance was prepared to
prevent buccoversion of the posterior teeth during the
intrusive force application.

253. The surgical procedure was performed under local
anesthesia with Ultracain DS-forte (Aventis Pharma,
Istanbul, Turkey). A horizontal incision was performed
above the attached gingiva from the canines towards
the tuber maxilla. Full-thickness mucoperiosteal flaps
were elevated, taking care not to expose the buccal
fat pad. The principle of osteotomy was to create
adequate bone gap that would avoid frictions between
bone edges during impaction. The horizontal osteotomy
was performed 5 mm above the apices of molars
with a 2-mm diameter tungsten round bur under saline
irrigation.

255. The resulting gap was 2.5 mm. Initial guide bone cuts for
anterior and posterior vertical osteotomies were
performed with a diamond disk (FRIOS MicroSaw
Diamond disk, Friadent, Mannheim, Germany) with a
cutting depth of 3.2 mm and a width of 1 mm. An anterior
vertical bone cut was performed between the first molars
and second premolars 3 mm above the interdental
alveolar margin. A posterior vertical bone cut was
prepared on the lateral side of the upper third molar
extraction gap, which was removed during the operation.
The horizontal palatal bone cuts were carried out
through the buccal osteotomy gaps. To weaken the
resistance of palatal bone, an initial guide corticotomy
was achieved using round bur.

257. This helped prevent the possible damage of palatal
mucosa and vascular bundle. The osteotomies were
completed by horizontal and vertical palatal osteotomies
with a thin custommade spatula osteotome. All of the
bone gaps were 1–1.5 mm, except the buccal horizontal
osteotomy. The miniplates were mounted on the
zygomatic buttresses.

258. After bleeding control, the incision sites were closed with
resorbable sutures. No surgical complications were
observed in the follow-up period. The miniplate was
loaded 1 week after the surgery to reposition the
corticotomized posterior segment with a force of 250 g
by nickel-titanium (Ni-Ti) closed coil springs. The force
was applied from the miniplate to the upper first and
second molar buccal tubes.
The intrusion was completed
2.5 months after the surgery.

259. Afterward, the fixed appliances (0.018-in slots) were
placed, and a 0.014-in Ni-Ti archwire was also placed.
The posterior segments were attached to the miniplates
by ligature wire throughout the treatment to prevent
possible relapse. After the alignment of anterior teeth,
0.016 0.022-in Ni-Ti archwire was placed, and anterior
elastics were used for the stability of the overbite. The
orthodontic treatment was finished with 0.017 0.025-in
stainless steel archwires. The whole treatment lasted 12
months, and optimal occlusion was obtained. At the end
of the treatment, the patient was instructed to wear Hawley
retainers. The bone anchors were removed under local
anesthesia, and complete bone healing was observed at the
operation sites without any bone gap remaining.

260. RESULTS
The anterior open bite was closed after intrusion of
the maxillary posterior teeth, and a well-aligned
dentition was obtained.

262. Dental Changes
A 1-mm overbite was obtained after the treatment.
The maxillary and mandibular incisors showed extrusion,
which was beneficial for open-bite closure (1.5 mm,
respectively). The maxillary incisors showed a
protrusion of 1, and the mandibular incisors showed
protrusion of 3. As a result, the interincisal angle
decreased 3. The maxillary molars were impacted 4.0
mm, and the mandibular molars showed 1.0 mm of
extrusion.

263. Skeletal Changes
Both the SNA and SNB angles were increased by
1 and 2, respectively. The mandible showed
counterclockwise autorotation; accordingly, the SN-MP
angle was reduced from 53 to 50. The inclination of the
palatal plane increased only 1, whereas the angle of
palatal plane to MP decreased from 39 to 36. The
occlusal plane angle showed an increase of 1. No
change was observed with the gonial angle (ArGoMe).
The posterior facial height–anterior facial height ratio
was increased from 50.7% to 52.2%.

264. Total anterior facial height (N-Me) decreased by 2 mm.
Lower anterior facial height (Ans-Me) decreased by 3
mm. Posterior facial height (S-Go) increased slightly,
from 68 mm to 69 mm.
Soft Tissue Changes
A decrease of 1 was found in the angle of Ns-Sn-
Pos, reflecting the slight improvement in the convex
profile. Accordingly, the Z angle showed an increase
of 1.5. The upper lip-E plane was decreased slightly
from 0 mm to 1 mm. The lower lip-E plane was
decreased 0.5 mm.

265. Pretreatment and posttreatment cephalometric
superimpositions revealed intrusion of the maxillary
posterior teeth, labioversion of the maxillary and
mandibular incisors, slight extrusion of the mandibular
molars, and a closing autorotation of the mandible. No
dental or periodontal problems and complications related
to surgery were detected during the overall treatment.

267. Skeletal Anchorage for Orthodontic
Correction of Severe Maxillary
Protrusion after Previous
Orthodontic Treatment.

268. Tanaka et al (2008) presented a case report of a patient
was a 22-year 3-month-old woman who presented a
maxillary protrusion with a Class II molar relationship.

269. She complained about the difficulty of lip closure due to
severe maxillary protrusion with a gummy smile. Her facial
profile was convex with a protrusive upper lip and no facial
asymmetry. Overjet and overbite were 7.6 mm and 0.9 mm,
respectively. Occlusal contacts were recognized only at the
premolar and molar regions at maximum intercuspation.

270. When she was a student in elementary school, she
submitted to an orthodontic treatment with a multibracket
appliance in which her maxillary first premolars were
extracted. The model analysis showed an arch length
discrepancy of 14.5 mm on the upper and 4.5 mm on the
lower arch. The panoramic radiograph showed mesial tipping
of the upper and lower molars.

271. The mandibular second premolars had received restorative
treatment and the left one had been under endodontic treatment.
Cephalometric analysis indicated a tendency toward a skeletal
Class II malocclusion. The mandibular plane and gonial angles
were larger than those of the Japanese average control group.8 The
mandible exhibited a backward and downward rotation and,
consequently, the lower anterior facial height was larger than
normal. The maxillary and mandibular incisors were tipped more
labially.

272. From these findings, this patient’s diagnosis was maxillary
protrusion with a mandibular retrusion, and a large overjet.
The treatment plan for this patient was:
— Placement of anchor plates in the zygomatic process
as an absolute anchorage.
— Extraction of the maxillary third molars and the mandibular
second premolars. The bilateral lower second premolars were
chosen to be extracted because they were in poorer condition
than the first premolars.

273. Placements of a transpalatal arch on the upper and a
lingual arch on the lower arch to avoid the buccal flare-
out and mesial movement of the upper and lower
molars, respectively.
— Distal movement of the maxillary second and first
molars.
— Retraction and intrusion of the maxillary incisors by
use of a multi-bracket appliance.
— Retention using lingual bonded retainers in both
dentitions.

274. Treatment Progress
Y-shaped anchor plates (Orthoanchor SMAP, Dentsply-
Sankin, Tokyo, Japan) were implanted onto the
zygomatic process of the maxilla through the buccal
mucosa under local anesthesia.

275. The plates were contoured to fit the bone surface. The
head portion was intraorally exposed and positioned
outside the dentition. After a month for healing,
integration, and adaptation, a 0.018 0.025 inch slot multi-
bracket appliance was placed on the maxillary dentitions.

276. After the leveling of the posterior teeth, stiff segmental
0.016 0.022 inch wires were applied on the both canine-
to-molar regions, and an open-coil spring was placed
between the first and second molars to move the second
molars distally. A 0.016-inch NiTi wire was overlaid for
leveling of the anterior teeth.

277. During distal movement, an elastic chain was applied
from the hook of the anchor plate to the upper canine to
prevent the flaring the anterior teeth. After distal
movement of the maxillary second molars, a plain
stainless steel 0.016 0.022 inch wire was placed and en
masse distal molar movement with sliding mechanics
was performed.

278. In the lower arch a lingual arch and a multibracket appliance
were placed 7 months after initiating treatment of the upper
arch. The initial arch was a 0.016 x 0.016 inch wire, and the
retraction of the first premolars and the mesial movements of
molars were started simultaneously with labial elastics. At 11
months after initiating treatment, incisal intrusion was
performed using a utility arch in both arches.

279. After en masse distal movement, a transpalatal arch was
placed on the upper arch to maintain the position of the
molars . After 2 years of orthodontic treatment, a well-
balanced face and an acceptable occlusion were
achieved, and the multibracket appliances were
removed.

280. Immediately after removal, lingual bonded retainers
were placed on both dentitions.
In addition, labial bonded wires were applied from the
lower first premolar to the first molar.

281. Treatment Results
Facial photographs showed that overall facial balance
was improved. Although the lower an terior facial height
was not changed, the lips showed less tension on closure.
Acceptable occlusion was achieved and the overbite was
improved to 1.2 mm
and the overjet to 1.0 mm.

284. The molar relationships were changed to Class I on the
both sides. Cephalometric analysis indicated a slight
clockwise rotation of the mandible. The inclinations of
the upper and lower central incisors were improved
within the normal range. The upper incisors were
intruded 2.2 mm at the root apex.

285. There was a slight apical root resorption observed in the
upper and lower anterior teeth. From the
superimposition of the maxilla, the average amount of
distal movement of the upper first molars was 7.2 mm at
the crown and 5.3 mm at the root level.
Two years after retention, an acceptable occlusion

286. was maintained without recurrence of the maxillary
protrusion, indicating a stability of the occlusion.

287. Comparison of the zygoma
anchorage system with cervical
headgear in buccal segment
distalization

288. Kaya et al (2009) compared between the effect of the
zygoma anchorage system with cervical headgear in buccal
segment distalization.
This prospective study consisted of 60 lateral cephalometric
radiographs of 30 patients who received orthodontic
treatment in the Department of Orthodontics, Faculty of
Dentistry, Ba ş kent University. The records were obtained at
the beginning (T1) and end (T2) of buccal segment
distalization. The patients were included in the study
according to the following criteria:

289. 1. In the post-peak pubertal growth stage or non-growing
[at CV4 or later stages according to the cervical
vertebrae growth and maturation index ( Hassel and
Farman, 1995 )]
2. Skeletal Class I or Class II but with a dental Class II
relationship (buccal segments at least a half unit
bilaterally)
3. Low-angle or normal vertical growth pattern
(S.N/GoGn < 40 degrees)
4. All permanent teeth present and erupted (excluding
third molars)
5. Anterior crowding in the maxillary dental arch and/or
increased overjet

290. 6. Mild or no crowding in the mandibular dental arch
7. Normal or increased overbite
8. Treatment on a non-extraction basis.
Thirty patients fulfi lling these inclusion criteria were
allocated to one of the two study groups. The fi rst group
consisted of 15 patients (10 females and 5 males, mean
age 14.74 years at T1) who underwent buccal segment
distalization with the ZAS and the second group 15
patients (8 females and 7 males, average age 15.26
years at T1) received buccal segment distalization with
CH.

291. All orthodontic treatment was carried out by the same
operator (BK). All patients had 0.018 inch slot brackets
(Roth Omni C-PM/ Hook, GAC International Inc.,
Bohemia, New York, USA) bonded on the maxillary
premolars and triple tube molar bands (Ideal Molar
Bands, GAC International Inc.) on their maxillary molars.

292. on their maxillary molars. After levelling, the posterior
teeth in both groups were distalized segmentally on a
0.016 × 0.022 inch stainless steel archwire . A vertical
step was bent into the archwire to allow easier tooth
cleaning.

293. The ZAS (Bollard Zygoma Anchor, Surgi-Tec, Bruges,
Belgium), which was introduced as anchorage for canine
retraction ( De Clerck et al. , 2002 ), was used for
distalization of premolars and molars as one unit in the fi
rst group. The zygoma anchor is a titanium miniplate
with three holes, which continues with a round bar and a
cylindrical unit at the end.

294. A 1.5 cm vertical incision was made under local
anaesthesia on the inferior crest of the zygomatico-
maxillary buttress which extended to the border of the
mobile and attached gingivae. A mucoperiosteal fl ap
was elevated and the cortical bone surface at the
implantat site was exposed.

295. After the zygoma anchor was adapted to the curvature
of the bone crest, the cylindrical unit was bent distally,
the anchorwas fi xed with miniscrews, covered with
mucoperiosteum, and sutured.

296. One week after surgery, the sutures were removed and
a distalization force of 450 g was applied on each side
with nickel-titanium closed coil springs from the zygoma
anchors to crimpable hooks placed mesial to the first
premolar brackets.

297. The CH was used with the outer bow parallel to the
occlusal plane. All posterior teeth were ligated together
and a distalization force of 450 g per side was applied.
The patients were instructed to wear their headgear at
least 20 hours a day and to write down the duration of
wear each day.

298. The outer bows were bent 10 – 15 degrees upwards
after spaces developed in the buccal segment, similar to
Kloehn’s prescription ( Hubbard et al. , 1994 ).
Distalization was considered complete when a Class I
buccal relationship was obtained in all patients.

299. Standardized lateral cephalometric radiographs of each
subject were taken at T1 and T2 with the same
cephalostat (Planmeca EC Proline, Helsinki, Finland).
The subjects were positioned in the cephalostat with the
sagittal plane at a right angle to the path of the X-rays,
the Frankfort plane parallel to the horizontal, the teeth in
centric occlusion, and the lips in a relaxed position.

300. Results
Throughout the distalization period, there was no
obvious clinical mobility of the zygoma anchors and the
positions of the miniscrews and zygoma anchors
remained unchanged on the superimposed radiographs.
However, gingival inflammation occurred in two patients
and infection in one, due to poor oral hygiene. Mild
gingival infl ammation was managed using antiseptic
mouthwash and improving the oral hygiene status of the
patients. The patient with the more severe infection was
successfully treated with drainage and an amoxicillin
protocol for 1 week.

301. In the CH group, the majority of patients complied with
the request to wear their headgear for 20 hours a day.
The total (N – Me), upper (N – ANS), and lower (ANS – Me)
anterior face heights increased in both groups. SNA and A –
VR (representing the sagittal position of the maxilla)
decreased in both groups and confi rmed the retrusion of
point A.

302. Signifi cant retrusion and distalization ( P < 0.001) were
observed at the maxillary incisors, premolars, and
molars in both groups. However, differences were found
between the groups for second premolar and fi rst molar
distalization ( P < 0.05), and these were more significant
in the ZAS group. The maxillary incisors and molars
showed lingual and distal tipping in both groups ( P <
0.001).

303. While the maxillary premolars in the ZAS group showed
no tipping, in the CH group they were tipped distally ( P
< 0.001). The maxillary incisors extruded ( P < 0.001)
and the maxillary second molars intruded ( P < 0.01) in
both groups. The maxillary premolars did not show
signifi cant vertical movement in the ZAS group,
although signifi cant extrusion was observed in the CH
group.
Overjet decreased signifi cantly in both groups. Overbite
did not change signifi cantly in the ZAS group, but
decreased signifi cantly in the CH group ( P < 0.05).
Evaluation of the soft tissue changes showed that the
upper and lower lips (Ls – VR and Li – VR) retruded
significantly in both groups.

304. Conclusions
1. The buccal segment was effi ciently distalized and the
incisors, point A, and the lips retruded in both the ZAS
and CH groups.
2. The ZAS provided absolute anchorage to apply the
same distalization force and to obtain similar effects as
with CH.
3. More signifi cant vertical change and extrusion
occurred in the CH group.
4. The ZAS is an aesthetic and non-compliant alternative
to extraoral traction.

305. Skeletal Anchorage for Class
II Correction in a Growing
Patient.

306. Skeletal Anchorage for Class II Correction in a Growing
Patient.
MAINO et at (2009) A 12-year-old male in the late mixed
dentition was referred by his dentist for orthodontic
treatment. Initial examination revealed a skeletal and dental
Class II malocclusion with a retrognathic mandible, a severe
overbite, moderate overjet, and mild malalignment of both
arches, including rotations and generalized spaces in the
mandibular arch.