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Dr. RAHUL TIWARI
Post Graduate Student
 Alloplastic device which is surgically
inserted into or onto the jaws.
 Orthodontic anchorage is defined as
“resistance to unwanted tooth movement
 According to Newton’s third law of
motion, every action has an equal and
opposite reaction
 The goal is to maximize desired tooth
movement and minimize undesirable
effects.
 Hence to minimize this undesirable side
effects we need implant.
 As absolute anchorage in maximum retraction requirment such
as high angle bimaxillary protrusion.
 In caseof miisng teeth for example missing molar,mini screw
implant provide anchorage as well as manage space judiciously
.
 To achieve difficult tooh movements such as naterior/posterior
instrusion,en mass distalization of upper nad lower
arches,molar uprightining and molar distalization.
 In adjunctive adult orthodontics for difficult tooth movements.
 In 1945, Gainsforth and Higley used
vitallium screws and stainless steel wires
in dog mandibles to apply orthodontic
forces. However, the initiation of force
resulted in screw loss. In 1969,
 Linkow placed blade implants to anchor
Class II elastics to retract teeth, but he
never presented long-term results.
 In 1964, Brånemark et al observed a firm
anchorage of titanium to bone with no
adverse tissue response.
 In 1969, they demonstrated that titanium
implants were stable over 5 years and
osseointegrated in bone under light
microscopic view.
 Since then, dental implants have been
used to reconstruct human jaws or as
abutments for dental prostheses. The
success has been attributed to the
material, surgical techniques, and the
manner that implants are loaded.
 In 1984, Roberts et al corroborated the
use of implants in orthodontic anchorage.
Six to 12 weeks after placing titanium
screws in rabbit femurs, a 100-g force
was loaded for 4 to 8 weeks by stretching
a spring between the screws. All but 1 of
20 implants remained rigid. Titanium
implants developed osseous contact, and
continuously loaded implants remained
stable. The results indicated that titanium
implants provided firm osseous
anchorage for orthodontics and
dentofacial orthopedics.
 Retromolar implants were described by
Roberts and colleagues (1990) and the
palatal implants were introduced by
Wehrbein and Merz (1998).
 Both are used for indirect anchorage,
meaning they are connected to teeth that
serve as the anchorage units.
 Creekmore and Eklund inserted one
such device below the nasal cavity in
1983, but it was not until 1997 that Kanomi
described a mini-implant specifically
designed for the orthodontic use.
 These are used as direct anchorage.
 In contrast to the osseointegrated
implants, these devices are smaller in
diameter and are designed to be loaded
shortly after insertion
 Based on composition
Biotolerant(stainless steel,chromium-
cobalt alloy
Bioinert (titanium, carbon)
Bioactive(hydroxylapatite,aluminium
oxide
 Based on site of insertion
Palatal/lingual
Buccal
 Based on mode of insertion
Self drilling
Self tapping
 Based on head type
Hook head type
Bracket head type
Circle head type
 Based on shape
Cylindrical
Conical
Jang et al reported cylindrical screw -88% success rate
while with conical screw its 95%
Orthodontic implants
 The head of the mini implant can be
designed for one point contact with a
hole through the neck, as in Dual Top
Anchor System, the Lin/Liou Orthodontic
Mini Anchorage Screw (LOMAS) and the
Spider Screw.
 A hook (LOMAS) or a button (Abso-
Anchor) can also be used.
 A bracket like head design, on the other
hand, offers the advantage of three
dimensional control and allows the screw
to be consolidated with a tooth to serve
as indirect anchorage.
 Examples of this type include Aarhus
Mini Implant, Dual Top Anchor System
and Temporary Mini Orthodontic
Anchorage System.
 Another design factor is the cut of the
threads.With self drilling mini screws
like Aarhus Mini Implant, Dual Top
Anchor System and LOMAS, the apex of
the screw is extremely fine and sharp, so
that the pilot drilling is unnecessary in
most cases.
 The transmucosal portion of the neck
should be smooth. It is also important that
screws be available with different neck
lengths for various implant sites.
Orthodontic implants
 Diameter of the drill has to be smaller than external diameter
of screw
 If drill has same or larger external diameter than mini screw to
be used ,there would be no PRIMARY stabality as the thread
would not anchored in bone,resulting in premature loss of
screw
 GNATHOUS AND PHILIPS-recommend diameter of
drillshould be 70-85% of external diameter of screw.
 This means mini screw with a diameter of 1.6mm, adrill with
diameter of 1.2mm should be used.
 Central drilling means to produce a small crypt or dimple or
depression in surface of bone at intended mini screw
penetration point.
 Its done incases where pre drilling can be difficult eg posterior
access site ,dense bone
 The drill point can slip on dense cortical surface before
actually penetrating the bone
When drill tip slips off ,the bone and adjacent tissue can get
damage
 Producing a DIMPLE or DEPRESSION with central drill
helps to reduce risk.
 After a dimple is created then pilot drill is less likely o slip
Orthodontic implants
 Significant advantage of mini screw is that they can be
loaded immediately after insertion
 Immediate loading is not possible but also it may
positively affect the osseous density around screw
 Degree of immediate loading vary widely depend
upon design of mini screw
Herman and cope recommended-force between 50-30 cN
Melson recommend force not more than 50cN
Buchler et al load not more than 600 cN
Orthodontic implants
 Implant materials. The material must
be
 nontoxic and
 biocompatible,
 possess excellent mechanical properties,
provide resistance to stress, strain, and
corrosion.
Implant Size
Mini implants (6 mm long, 1.2 mm in
diameter)
Standard den tal implants (6-15 mm long,
3-5 mm in diameter
 Since mini screw mostly insert between
roots, amount of interradicular space is
crucial in determining the insertion site
and maximum diameter of screw.
 Poggio et al ,Sung et al,Park et al :has
concluded that ideal diameter should be
from 1.2 -1.5
 Miyawaki et al :All screws with diameter
less than 1.5 were lost prematurely
wherease those with diameter of 1.5mm
or more had 85% succcess rate
 Clinically miniscrew with diameter 1.5
mm or 1.6 mm are recommended
 Depending on region of bone in dental
implant total thickness available range from
4mm-16mm
 Screw longer than 10mm causes iatrogenic
perforation on lingual side of mandible or in
maxillary sinus
 Length is secondary importance,the
thickness of cortical plate through which it is
inserted is more crucial factor
 Thicker corthical plate more reliable
anchorage
Orthodontic implants
 The Spider Screw is a self-tapping
miniscrew available in three lengths—7mm,
9mm, and 11mm—in single-use, sterile
packaging.
 The screw head has an internal .021" × .
025"slot, an external slot of the same
dimensions, and an .025" round vertical slot.
It comes in three heights to fit soft tissues of
different thicknesses: regular, with a thicker
head and an intermediatelength collar; low
profile, with a thinner head and a longer
collar; and low profile flat, with the same thin
head and a shorter collar.
Orthodontic implants
 All three types are small enough to avoid
soft-tissue irritation, but wide enough for
orthodontic loading.
 The biocompatibility of titanium ensures
patient tolerance, and the Spider Screw’s
smooth, self-tapping surface permits
easy removal at the completion of
treatment.
 Because miniscrews rely on mechanical
retention rather than osseointegration for
their anchorage, the orthodontic force
should be perpendicular to the direction
of screw placement.
 Applied forces can range from 50g to
200g, depending on the quality of the
bone and the orthodontic movement
desired. If any mobility is noted
immediately after placement or during
tooth movement, the screw should be
inserted deeper into the bone, or
replaced with a longer screw to engage
the opposite plate of cortical bone.
 The diameter of the mini screw will
depend on the site and the space
available. In the maxilla a narrower
implant can be selected if it is to be
placed between the roots.
 If stability depends on insertion into the
trabecular bone, a longer screw is
needed, but if the cortical bone will
provide enough stability, a shorter screw
can be chosen.
 The length of the transmucosal part of the
neck should be selected after assessing
the mucosal thickness of the implant site.
 Possible insertion site include, in the
Maxilla: the area below the nasal spine,
the palate, the alveolar process, the
infrazygomatic crest, and the retromolar
area.
 In the Mandible: the alveolar process, the
retromolar area and the symphysis.
Orthodontic implants
Orthodontic implants
Orthodontic implants
Orthodontic implants
 Huang, Shotwel,Wang (AJODO 2005)
 One way to evaluate the possibility of
damaging the periodontal ligament
(PDL) is to calculate the safety distance.
 Safety distance: Diameter of the implant
+ PDL space (normal range 0.25 mm ±
50%) minimal distance between implant
and tooth (1.5 mm)
 Example: Safety distance (mm) of mini-
implants when inserted between roots
1.2 (0.25 + 50%) (1.5 +1.5) 4.575.
Therefore, the distance between roots
needs to be at least 4.6 mm to reduce the
risk.
 Gautam P,Valiathan A (AJODO 2006)
 Safety distance: Diameter of the implant
+ 2 X [PDL space (normal range 0.25 mm
± 50%)] minimal distance between
implant and tooth (1.5 mm)
 Example: Safety distance (mm) of mini-
implants when inserted between roots
1.2 2 X(0.25 + 50%) (1.5 +1.5) 4.9.
Therefore, the distance between roots
needs to be at least 5 mm to reduce the
risk.

 After the local anesthetic is applied, the
implant area is washed with .02%
chlorhexidine.
 Even when self drilling screws are used,
pilot drilling may be required where the
cortex is thicker than 2mm, as in the
retromolar area or the symphysis, because
dense bone can bend the fine tip of the
screw.The pilot drill should be .2-.3 mm
thinner than the screw and should be
inserted to a depth of no more than 2-3mm.
 If a manual screwdriver is used for insertion,
it is immediately evident when the a root
has been contacted, and any damage will
be minimum. In tests where notches were
intentionally created, histological analysis
showed spontaneous repair by the
formation of cellular cementum.
 If the screw is inserted with a low speed
drill, there is a greater chance of not
detecting a root due to lack of tactile
sensation.
 Whenever possible, the mini implant
should be inserted through attached
gingiva. If this is not possible, the screw
can be buried beneath the mucosa so
that only a wire, a coil spring, or a
ligature passes through the mucosa.
 In the maxilla, the insertion should be at
an oblique angle, in an apical direction;
in the mandible, the screw should be
inserted as parallel to the roots as
possible if teeth are present.
 The alignment of roots can be assessed by extendingthe height
of conttour from buccal cusp tip of clinical crown
 Additionally the depression between the nebighouring root
contourcan be palapated which represent the configuration of
root alignment and is major indicator in insertion site
 The safe linterdental areais estimated by making linear
indention with a periodontalprobe
 When clinical crown exhibit considerable mesiodistal
inclination the interdental area should be assessed accordingly.
Orthodontic implants
 A coronally placed miniscrew is to be on
firm attached gingiva but the risk of root
damage increases because of conical shape
of roots
 In constrast subapical or periapical insetion
may cause soft tissue impengement.
 Therfore MUCOGINGIVAL junction is the
insertion point which minimize possible root
damage while preventing root damage.
Orthodontic implants
 Insertion angle(Occlusogingival)
A 45 degree angulation relative to occlusal
plane is considered acceptable.
 Insertion path (Mesiodistal)
A good clinical guideline is direction of
proximal contact area,since configuration of
interradicular space reflect direction of contact
surface viewed from occlusal surface.
 Zygoma Anchorage System (ZAS) has
been developed, in which the miniscrews
are placed at a safe distance from the
roots of the upper molars. Because of its
location and its solid bone structure, the
inferior border of the
zygomaticomaxillary buttress, between
the first and second molars, is chosen as
the implant site. Combining three
miniscrews with a titanium miniplate can
bring the point of force application near
the center of resistance of the first
permanent molar.
 The upper part of the Zygoma Anchor is
a titanium miniplate with three holes,
slightly curved to fit against the inferior
edge of the zygomaticomaxillary
buttress. A round bar, 1.5mm in diameter,
connects the miniplate and the fixation
unit. A cylinder at the end of the bar has a
vertical slot, where an auxiliary wire with
a maximum size of .032" × .032" can be
fixed with a locking screw.
Orthodontic implants
 The plate is attached above the molar roots
by three self-tapping titanium miniscrews,
each with a diameter of 2.3mm and a length
of 5mm or 7mm.The miniscrews do not
need to be sandblasted, etched, or coated.
Square holes in the center of the screw
heads accommodate a screw- driver for
initial placement, while pentagonal outer
holes are used to remove the screws at the
end of treatment.
 To place the anchor, an L-shaped
incision, consisting of a vertical incision
mesial to the inferior crest of the
zygomaticomaxillary buttress and a small
horizontal incision at the border between
the mobile and attached gingiva, is made
under local anesthesia.The
mucoperiosteum is elevated, and the
upper part of the anchor is adapted to
the curvature of the bone crest.
 Three holes with a diameter of 1.6mm
each are drilled, and the Zygoma Anchor
is affixed with the three miniscrews.The
cylinder should penetrate the attached
gingiva in front of the furcation of the first
molar roots at a 90° angle to the alveolar
bone surface.
 Orthodontic forces can be applied to the
anchor immediately after implantation.
Orthodontic implants
 The ZAS uses three miniscrews,
increasing total anchorage over other
types of implants.
 Because the miniscrews and miniplate
have excellent mechanical retention,
immediate loading is possible.The point
of application of the orthodontic forces is
brought down to the level of the furcation
of the upper first molar roots.
 The vertical slot with the locking screw
makes it possible to attach an auxiliary wire,
which can move the point of force
application some distance from the anchor.
The connection between the anchor and the
conventional fixed appliance can easily be
adapted to changing anchorage needs
throughout treatment.Therefore, the ZAS
seems to be an effective alternative to
conventional extraoral anchorage.
 Anterior retraction with sliding mechanics is usually
accomplished by placing elastomeric chain or nickel
titanium springs between hooks on the anterior teeth
and the second molars.
 The anterior and posterior segments rotate around the
center of rotation, which causes bowing of the
archwire.
 A precurved archwire can be used to prevent this side
effect.
 The use of miniscrews for anchorage reinforcement produces
somewhat different mechanics.
 Because the force used during retraction is not reciprocal,
either the entire arch will rotate around the center of rotation.
 In cases of severe protrusion, where absolute anchorage is
required in both arches, these mechanics can produce posterior
open bite and deep overbite
 The use of precurved archwires will result in an even stronger
intrusive
force on the posterior segment. Following are several possible
solutions to these problems
Orthodontic implants
Orthodontic implants
Orthodontic implants
 In occlusal plane-mini screw causes distal in
movement in posterior region.Thus molar
tor-in often incorporated in conventional
sliding archwire is eliminated with
miniscrew appliance design
 In frontal plane:-the level of mini screw site
should be predetermined at same height on
either side of the arch.Mini screw placed at
different level on two side of the same arch
causes rotation/canting of occlusal plane.
 Intrusion of single molar-
 Extruted molar requires pure molar intrusion along its long axis without
extrusion of adjacent teeth.
 For this line of force should pass through C resistance both on lateral and
frontal view to prevent possible bucco lingual and mesio distal tipping
during intrusion.
 Cresi of upper first molar is expected to be at center of occlusal table
,close to palatal root.
 The lineof force should pass through C resistance.
 So mini screw inserted on- mesial interdental area on buccal surface and
distal interdental area on palatal surface or vice versa
 tn this way combined bilateral force from buccaland palatal side wil
produce line of force passing through C resis of molar including pure
intrusion without tipping
 When molar on both sides need to be symmerically
intruted on the midpalate.
 The intrusive force is delivered through transpalatal
bar connecting both molars.
 TPA needs to be slightly expanded to prevent molar
from tipping palatally.
 Anterior-posterior position ,miniscrew should be on
line connecting the central fossa of both molars
Orthodontic implants
 Implant placed between canine and premolar.
 Move one molar at a time to obtain controlled mvement.
 Initially ,force to protract the first molar is generted using coil
spring from TSAD.
 With mesial movement of molar there will also be
accompanying moment to tip molar forward.
 After most of the protraction of first molar ,a tip back bend is
given to upright this molar(with a ligature wire consolidation
from premolar to molar)and coil spring is attached to second
molar.
 This tip back bend helps in uprighting the root of first molar
while second molar is been protracted
Orthodontic implants
 Mini screw inserted between first and second molar
and elastic engaged to protract molar.
 Without lever arm,line of force generate mesial tipping
of molar and may lead to bowing of archwire in
premolar area.
 To achieve constant translation of molar in maintaining
arch shape-a lever arm made of rigid SS wire is placed
on molar so that line of force from miniscrew will go
through C resistance of molar.
Orthodontic implants
 Place screw in retromolar region distal to
molar that needs to be uprightining
 On mesial side of tooth ,a button is
bonded and a elastic e chain attached
from button to screw.
Orthodontic implants
 In 1995, a 2-stage hydroxylapatite-coated
titanium subperiosteal implant (Onplant,
Nobel Biocare, Göteburg, Sweden) was
developed.This system has several
characteristics: disc shaped, 10 mm in
diameter, 2 mm thick, coated with
hydroxyapatite on the side against bone,
and smooth titanium facing soft tissue
with a threaded hole where abutments
will be placed.
 After biointegration with tissue, the disc
is exposed by punch technique (removal
of a patch of tissue at the center). A ball-
shaped abutment is connected, to which
orthodontic devices will be attached.
Onplants have been shown, to provide
sufficient anchorage to move and anchor
teeth.
 In 1996, a 1-stage endosseous
orthodontic implant for palatal
anchorage was presented (Orthosystem,
Straumann).This system has a diameter
of 3.3 mm and endosseous length of 4 or
6 mm.The self-tapping design provides
good initial stability with fewer
procedures and less instrumentation
during surgery.
Orthodontic implants
 A groove above the transmucosal part
can hold a transpalatal bar (square wire,
0.032 0.032 in, stainless steel), which can
be clamped by a cover and screwed
tightly to the implant. Many studies have
demonstrated its success in maxillary
tooth retraction and stabilization of
anchorage teeth.
Orthodontic implants
 The midsagittal area has relatively low
vertical bone height, and complete
ossification of the suture is rare before 23
years of age (Schlegel et al 2002). For
most adults, osseointegration is
uneventful. However, the paramedian
region might be more optimal for
adolescents to avoid connective tissue of
the suture and interaction of its growth.
 Gunduz E et al AJODO 2004
 In this study, 85 patients who received
orthodontic treatment with palatal
implants in 2 clinics in Austria completed
questionnaires.The results show that
most patients got used to their implants
in about 2 weeks; 95% were satisfied with
the treatment, and 86% would
recommend the treatment to other
patients.
 In addition, 75% of the patients found the
orthodontic construction between the
anchor teeth and the palatal implant less
comfortable than the implant itself,
whereas 7% found the palatal implant
less comfortable. Approximately 24
months of treatment with the palatal
implant is tolerable for patients; this is
the average orthodontic treatment time.
 Chen F, Terada K, Handa K.
 The purpose of this study was to compare
the anchorage effects of different palatal
osseointegrated implants using a finite
element analysis.Three types of cylinder
implants (simple implant, step implant,
screw implant) were investigated.Three
finite element models were constructed.
 Each consisted of two maxillary second
premolars, their associated periodontal
ligament (PDL) and alveolar bones,
palatal bone, palatal implant, and a
transpalatal arch. Another model without
an implant was used for comparison.The
horizontal force (mesial 5N, palatal 1N)
was loaded at the buccal bracket of each
second premolar, and the stress in the
PDL, implant, and implant surrounding
 The results showed that the palatal
implant could significantly reduce von
Mises stress in the PDL (maximum von
Mises stress was reduced 24.3-27.7%).
The von Mises stress magnitude in the
PDL was almost same in the three models
with implants.The stress in the implant
surrounding bone was very low.These
results suggested that the implant is a
useful tool for increasing anchorage.
Adding a step is useful to lower the stress
in the implant and surrounding bone, but
adding a screw to a cylinder implant had
 Chen F, Terada K, Hanada K, Saito I.
Angle Orthod. 2006
 The purpose of this study was to compare
the anchorage effects of an
osseointegrated palatal implant (OPI)
with a nonosseointegrated palatal
implant (NOPI), using finite element
analysis. One model, which was
composed of two maxillary premolars,
periodontal ligament (PDL), alveolar
bone, a palatal implant, palatal bone, a
bracket, band, and TPA, was created on
 The palatal implant was treated as either
NOPI or OPI.The force on the premolars
was investigated under three conditions:
a mesiodistal horizontal force, a
buccolingual horizontal force, and a
vertical intrusive force.The PDL stress
was calculated and compared with a
model without an implant.
 The result showed that OPI could reduce
PDL stress significantly. (The average
stress was reduced by 14.44% for the
mesiodistal horizontal force, 60.28% for
the buccolingual horizontal force, and
17.31% for the vertical intrusive force.)
The NOPI showed almost the same
anchorage effect as OPI.
 The stress on the NOPI surface was
higher than that on the OPI surface, but
the stress was not high enough to result
in failure of the implant.These results
suggested that waiting for
osseointegration might be unnecessary
for an orthodontic implant.
 Thiruvenkatachari B, Pavithranand A,
Rajasigamani K, Kyung HM.(AJODO
2006)
 The purpose of this study was to compare
and measure the amount of anchorage
loss with titanium microimplants and
conventional molar anchorage during
canine retraction. METHODS: Subjects for
this study comprised 10 orthodontic
patients (7 women, 3 men) with a mean
age of 19.6 years (range, 18 to 25 years),
who had therapeutic extraction of all first
 After leveling and aligning, titanium
microimplants 1.3 mm in diameter and 9
mm in length were placed between the
roots of the second premolars and the
first molars. Implants were placed in the
maxillary and mandibular arches on 1
side in 8 patients and in the maxilla only
in 2 patients.
 After 15 days, the implants and the
molars were loaded with closed-coil
springs for canine retraction. Lateral
cephalograms were taken before and
after retraction, and the tracings were
superimposed to assess anchorage loss.
 The amount of molar anchorage loss was
measured from pterygoid vertical in the
maxilla and sella-nasion perpendicular
in the mandible. RESULTS: Mean
anchorage losses were 1.60 mm in the
maxilla and 1.70 mm in the mandible on
the molar anchorage side; no anchorage
loss occurred on the implant side.
CONCLUSIONS:Titanium microimplants
can function as simple and efficient
anchors for canine retraction when
 Oyonarte R, Pilliar RM, Deporter D,
Woodside DG
 Bone response to orthodontic loading
was compared around 2 different types of
osseointegrated implants (porous
surfaced and machined threaded) to
determine the effect of implant surface
geometry on regional bone remodeling.
 METHODS: Five beagles each received 3
implants of each design in contralateral
mandibular extraction sites. After a 6-week
initial healing period, abutments were placed,
and, 1 week later, the 2 mesial implants on each
side were orthodontically loaded for 22 weeks.
All implants remained osseointegrated
throughout orthodontic loading except for 1
threaded implant that loosened. Back-scattered
scanning electron microscopy and
fluorochrome bone labeling techniques were
used to compare responses around the 2 types
 RESULTS:The loaded, porous-surfaced
implants had significantly higher
marginal bone levels and greater bone-
to-implant contact than did the
machined-threaded implants.
CONCLUSIONS: Significant differences in
peri-implant bone remodeling and bone
formation in response to controlled
orthodontic loading were observed for
the 2 implant designs. Short, porous-
surfaced implants might be more
effective for orthodontic applications
than machine-threaded implants
 If implants are planned for future
prosthetic abutments, a standard healing
protocol should be followed.
 Direct orthodontic forces generate less
stress on implants due to limited force
imposed ( 3N, about 300 g).The stress is
far less for indirect anchorage because
implants are used to stabilize teeth.
 During surgery, assessment of bone
quality and initial implant stability are
important.With dense bone and
satisfactory stability, immediate loading
might be feasible.
 Threaded implants provide superior
mechanical interlock as compared with
cylindrical designs.Thus, waiting time
should be longer for nonthreaded
implants.
 Complete osseointegration is favorable
but not essential for effective orthodontic
anchorage implants. However, stable
mechanical retention or partial
osseointegration is required, and
implants should not be overloaded
during healing.
 Ohmae et al, 2001 reported a study on
Dog jaws in which Titanium mini-implant
were loaded using 150g force for12-18
wks after 6 wks healing period. All
implants remained stable. Periimplant
bone at loaded implants was equal to or
slightly greater than unloaded ones.
 Trisi and Rebaudi, 2002 reported on
Human Titanium (Biaggini, Ormco)
implants.
 Force of 80-120g/8-48 wks was applied
after 8 wks healing period.
 All implants remained stable and
osseointegrated. Bone remodeling
around implants was observed.
 Akin-Nergiz et al,1998
 Orthopedic force (2 N/12 wks- 5N/24)
after healing period of 12wks was
applied on Dog jaws using Titanium (ITI)
implants). Implants had no displacement
for any force level.
 Deguchi T, et al (J Dent Res. 2003)
quantified the histomorphometric
properties of the bone-implant interface
to analyze the use of small titanium
screws as an orthodontic anchorage and
to establish an adequate healing period.
Overall, successful rigid osseous fixation
was achieved by 97% of the 96 implants
placed in 8 dogs and 100% of the
elastomeric chain-loaded implants.
 All of the loaded implants remained
integrated. Mandibular implants had
significantly higher bone-implant contact
than maxillary implants.Within each
arch, the significant histomorphometric
indices noted for the "three-week
unloaded" healing group were: increased
labeling incidence, higher woven-to-
lamellar-bone ratio, and increased
osseous contact.
 Analysis of these data indicates that
small titanium screws were able to
function as rigid osseous anchorage
against orthodontic load for 3
months with a minimal (under 3
weeks) healing period.
 Disadvantages include longer treatment
time, financial concerns, and anatomical
limitations. However, the benefit from
superior anchorage and time saved by
using implant anchorage often exceeds
the healing time after surgery.
 Implant surgery does cost more than
other treatments. If implants will be used
in the prosthetic treatment plan, the fee is
offset. In addition, implant anchorage
reduces the risk of jeopardizing existing
dentition. Application of implants might
be limited by the amount and quality of
bone.Therefore, thorough evaluation is
critical before treatment.
 Intrude/extrude teeth. It is difficult to
intrude or extrude teeth, particularly
molars. Implant anchorage greatly
facilitates these movements. Mini-
implants (1.2 mm in diameter, 6 mm in
length), which can be placed between
roots or apical to a tooth, are more
feasible. Pure intrusion or extrusion
cannot be achieved. If the implant is at
the facial side for intrusion, only intrusion
plus protrusion can be accomplished.
Also, care should be taken not to involve
the periodontal ligament and prevent
Orthodontic implants
Orthodontic implants
Orthodontic implants
Orthodontic implants
 Close edentulous spaces. Missing first
molars or congenital missing teeth are
common. Because of reduced anchorage,
implants in retromolar areas have been
used to translate teeth into edentulous
areas.
 Titanium screws can be placed to
protract molars and close the spaces of
congenital missing premolars.
Orthodontic implants
Orthodontic implants
Orthodontic implants
 This treatment is superior to others when
adjacent teeth are intact or have large
pulp chambers, making preparation
undesirable. Plaque control is more
complicated with fixed partial dentures,
which increase the risk of caries and
endodontic or periodontal disease.
 If the translated tooth is tipped, it should
be uprighted to prevent a mesial angular
bony defect.
 Reposition malposed teeth.
Preprosthetic corrections of tilted
abutments are not unusual. Adequate
anchorage for tooth movement is often
impossible when there are several
missing teeth. Realignment of molars by
using the remaining teeth is complicated
because of limited support. Implants
facilitate uprighting the abutment teeth
at the end of a long edentulous ridge. If
carefully planned, dental implants used
to upright teeth can be restored as
implant-supported prostheses in
Orthodontic implants
Orthodontic implants
Orthodontic implants
 Reinforce anchorage. Palatal implants
have been developed to reinforce
anchorage. An endosseous orthodontic
implant anchor system (Orthosystem,
Straumann,Waldenburg, Switzerland) has
been designed and can be used in Class
II malocclusion patients in whom no
extraction or extraction of maxillary first
premolars and retraction of anterior teeth
are planned.
Orthodontic implants
Orthodontic implants
Orthodontic implants
 Park HS, Lee SK, Kwon OW Angle
Orthod. 2005
 The purpose of this study was to quantify
the treatment effects of distalization of
the maxillary and mandibular molars
using microscrew implants.The success
rate and clinical considerations in the use
of the microscrew implants were also
evaluated.Thirteen patients who had
undergone distalization of the posterior
teeth using forces applied against
microscrew implants were selected.
 Among them, 11 patients had mandibular
microscrew implants and four patients
had maxillary implants, including two
patients who had both maxillary and
mandibular ones at the same time.The
maxillary first premolar and first molars
showed significant distal movement, with
no significant distal movement of the
anterior teeth.
 The mandibular first premolar and first
and second molars showed significant
distal movement, but no significant
movement of the mandibular incisor was
observed.The microscrew implant
success rate was 90% over a mean
application period of 12.3 +/- 5.7 months.
The results might support the use of the
microscrew implants as an anchorage for
group distal movement of the teeth.
 Treat partial edentulism. Treatment is
complicated in patients with
malocclusion and many missing and
periodontally compromised teeth.
Fortunately, implants in edentulous areas
to provide orthodontic anchorage and
later serve as prosthetic abutments have
been considered a proper
interdisciplinary approach.
 Transitional implants have been applied
in these situations.
 Correct undesirable occlusion.
Correcting Class III anterior crossbite
with conventional methods is not always
satisfactory. Retracting the entire
mandibular arch with dental implants is
possible. Localized crossbite can be
treated by bonding implants and teeth to
avoid full-mouth treatment. Protracting
maxillary arches can be achieved by
using implant anchorage.
 Provide orthopedic anchorage. Palatal
implants can be used to elicit palatal
expansion.This applies to partially
edentulous patients or children with
congenital diseases that result in facial
developmental defects or missing teeth.
Implants in congenital anomalies can
promote orthodontic and orthopedic
therapy and accelerate jaw movement by
sutural distraction.
 In orthopedic treatment the forces are
transmitted to the bones by a tooth; this
implies skeletal as well as dental effects.
 Tooth splinting or controlling force
vectors can minimize undesirable
movement, but it cannot be avoided.
Skeletal movement can be accomplished
by using teeth as anchorage, but dental
side effects often limit the amount of
movement.
 Implants can overcome the limitations by
guiding forces directly to the bones.
 Facial skeletal movement by implant
anchorage has also been evaluated.
(Smalley et al 1988)
 A 600-g force was applied until 8 mm of
maxillary displacement occurred. All
implants remained stable over 12 to 18
weeks.The findings also showed the
possibility of controlling the direction of
protraction.
 To evaluate the application of implants in
sutural expansion, animal studies have
been conducted. (Parr JA et al 1997)
 Two titanium implants were placed on
either side of the internasal suture in 18
rabbits, which were divided into an
unloaded control group and 2 test
groups. After 8 weeks, each test group
was loaded with a force of 1 Newton (N)
or 3 N. All implants remained stable for
12 weeks.
 Several congenital facial anomalies and
developmental defects present
anchorage challenges. Case reports
using dental implants for orthopedic
movement and acceleration of jaw
movement by sutural distraction have
been reported. Nonetheless, the optimal
load, which has not been determined yet,
for sutural expansion is the lowest above
the woven bone threshold that effectively
separates it.Therefore, further studies are
needed to determine the optimal load.
• While endosseous dental implants
are intended to resist the heavy,
intermittent forces of occlusion,
orthodontic forces are
considerably lower and more
sustained.Therefore, the
requirements of an orthodontic
anchor implant may be quite
different.
Orthodontic implants
 The Modular Transitional Implant, 1.8mm
in diameter, is available in lengths of
14mm, 17mm, and 21mm. It was designed
to support a temporary fixed prosthesis
during the healing phase associated with
placement of permanent implants, and to
be removed when the permanent
implants are restored.
Orthodontic implants
Orthodontic implants
Orthodontic implants
 Currently, dental implants have become
predictable and reliable adjuncts for oral
rehabilitation.
 Osseointegrated/ Non osseointegrated
implants can be used to provide rigid
orthodontic or orthopedic anchorage.
Although initial results are encouraging,
the risks and benefits must be thoroughly
evaluated.
 In the future, as developments occur in
the implant technology, they may have a
significant role as anchorage
reinforcement aids.
 Irfan Dawoodbhoy,Valiathan Ashima:
Implants as anchors in Orthodontics.
Journal of Indian Orthodontic Society.
1994; 25(4): 124-127.
 Gautam P,Valiathan A. Implants for
anchorage. Am J Orthod Dentofacial
Orthop. 2006 Feb;129(2):174; author
reply 174.
 Lien-Hui Huang, Jeffrey Lynn Shotwell,
and Hom-Lay Wang. Dental implants for
orthodontic anchorage Am J Orthod
Dentofacial Orthop 2005;127:713-22
 Linkow LI.The endosseous blade implant
and its use in orthodontics. Int J Ortho
1969;18:149-54.
 Roberts WE, Smith RK, ZilbermanY,
Mozsary PG, Smith RS. Osseous
adaptation to continuous loading of rigid
endosseous implants. Am J Orthod
1984;86:95-111.
 Gainsforth BL, Higley LB. A study of
orthodontic anchorage possibilities in
basal bone. Am J Orthod Oral Surg
1945;31:406-17.
 Kanomi R. Mini-implant for orthodontic
anchorage. J Clin Orthod 1997;31:763-7.
 Roberts WE, Marshall KJ, Mozsary PG.
Rigid endosseous implant utilized as
anchorage to protract molars and close
an atrophic extraction site. Angle Orthod
1990;60::135-52.
 Drago CJ. Use of osseointegrated
implants in adult orthodontic treatment: a
clinical report. J Prosthet Dent
1999;82:504-9.
 Shapiro PA, Kokich VG. Uses of implants
in orthodontics. Dent Clin North Am
1988;32:539-50.
 Wehrbein H. Feifel H. Diedrich P. Palatal
implant anchorage reinforcement of
posterior teeth: a prospective study. Am J
Orthod Dentofacial Orthop 1999;116:678-
86.
 Gray JB, Smith R.Transitional implants for
orthodontic anchorage. J Clin Orthod
2000;34:659-66.
 Prosterman B, Prosterman L, Fisher R,
Gornitsky M.The use of implants for
orthodontic correction of an open bite.
Am J Orthod Dentofacial Orthop
1995;107:245-50.
 Parr JA, Garetto LP,Wohlford ME,
Arbuckle GR, Roberts WE. Sutural
expansion using rigidly integrated
endosseous implants: an experimental
study in rabbits. Angle Orthod
1997;67:283-90.
 Gray JB, Steen ME, King GJ, Clark AE.
Studies on the efficacy of implants as
orthodontic anchorage. Am J Orthod
1983;83: 311-7.
 Roberts WE, Helm FR, Marshall KJ,
Gongloff RK. Rigid endosseous implants
for orthodontic and orthopedic
 Deguchi T,Takano-Yamamoto T, Kanomi
R, Hartsfield JK Jr, Roberts WE, Garetto LP.
The use of small titanium screws for
orthodontic anchorage. J Dent Res
2003;82:377-81.
 Akin-Nergiz N, Nergiz I, Schulz A, Arpak
N, Niedermeier W. Reactions of peri-
implant tissues to continuous loading of
osseointegrated implants. Am J Orthod
Dentofacial Orthop 1998; 114:292-8.
 Chen F, Terada K, Hanada K, Saito I.
Anchorage Effect of Osseointegrated vs
Nonosseointegrated Palatal Implants. Angle
Orthod. 2006 Jul;76(4):660-5.
 Thiruvenkatachari B, Pavithranand A,
Rajasigamani K, Kyung HM. Comparison
and measurement of the amount of
anchorage loss of the molars with and
without the use of implant anchorage during
canine retraction. Am J Orthod Dentofacial
Orthop. 2006 Apr;129(4):551-4.
 Oyonarte R, Pilliar RM, Deporter D,
Woodside DG. Peri-implant bone response
to orthodontic loading: Part 2. Implant
surface geometry and its effect on regional
bone remodeling.Am J Orthod Dentofacial
Orthop. 2005 Aug;128(2):182-9.
 Oyonarte R, Pilliar RM, Deporter D,
Woodside DG. Peri-implant bone response
to orthodontic loading: Part 1. A
histomorphometric study of the effects of
implant surface design. Am J Orthod
Dentofacial Orthop. 2005 Aug;128(2):173-81.
 Chen F, Terada K, Handa K. Anchorage
effect of various shape palatal
osseointegrated implants: a finite
element study.Angle Orthod. 2005
May;75(3):378-85.
 Gunduz E, Schneider-Del Savio TT,
Kucher G, Schneider B, Bantleon HP.
Acceptance rate of palatal implants: a
questionnaire study. Am J Orthod
Dentofacial Orthop. 2004 Nov;126(5):623-
6.
 Park HS, Lee SK, Kwon OW. Group
distal movement of teeth using
microscrew implant anchorage. Angle
Orthod. 2005 Jul;75(4):602-9.
 Deguchi T, Takano-Yamamoto T,
Kanomi R, Hartsfield JK Jr, Roberts
WE, Garetto LP. The use of small
titanium screws for orthodontic
anchorage. J Dent Res. 2003
May;82(5):377-81
 De Clerck H, GeerinckxV, Siciliano S. The
Zygoma Anchorage System. J Clin Orthod.
2002 Aug;36(8):455-9
 Celenza F, Hochman MN. Absolute
anchorage in orthodontics: direct and
indirect implant-assisted modalities. J Clin
Orthod. 2000 Jul;34(7):397-402
 Kanomi R. Mini-implant for orthodontic
anchorage. J Clin Orthod. 1997
Nov;31(11):763-7.
 Park HS, Jeong SH, Kwon OW. Factors
affecting the clinical success of screw
implants used as orthodontic anchorage.
Am J Orthod Dentofacial Orthop. 2006
Jul;130(1):18-25.
 Ohashi E, Pecho OE, Moron M, Lagravere
MO. Implant vs screw loading protocols
in orthodontics.
Angle Orthod. 2006 Jul;76(4):721-7.
 Cornelis M A, Clerck H J. Biomechanics of
Skeletal anchorage. Part 1 Class II
Extraction treatment. 2006;60 (4); 261-269
 Clerck H J, Cornelis M A. Biomechanics of
Skeletal anchorage. Part 1 Class II Non
Extraction treatment. 2006;60 (5); 290-298
 Melsen B. Mini-implants:Where are we?
J Clin Orthod. 2005 Sep;39(9):539-47

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Orthodontic implants

  • 1. Dr. RAHUL TIWARI Post Graduate Student
  • 2.  Alloplastic device which is surgically inserted into or onto the jaws.
  • 3.  Orthodontic anchorage is defined as “resistance to unwanted tooth movement  According to Newton’s third law of motion, every action has an equal and opposite reaction  The goal is to maximize desired tooth movement and minimize undesirable effects.  Hence to minimize this undesirable side effects we need implant.
  • 4.  As absolute anchorage in maximum retraction requirment such as high angle bimaxillary protrusion.  In caseof miisng teeth for example missing molar,mini screw implant provide anchorage as well as manage space judiciously .  To achieve difficult tooh movements such as naterior/posterior instrusion,en mass distalization of upper nad lower arches,molar uprightining and molar distalization.  In adjunctive adult orthodontics for difficult tooth movements.
  • 5.  In 1945, Gainsforth and Higley used vitallium screws and stainless steel wires in dog mandibles to apply orthodontic forces. However, the initiation of force resulted in screw loss. In 1969,  Linkow placed blade implants to anchor Class II elastics to retract teeth, but he never presented long-term results.
  • 6.  In 1964, Brånemark et al observed a firm anchorage of titanium to bone with no adverse tissue response.  In 1969, they demonstrated that titanium implants were stable over 5 years and osseointegrated in bone under light microscopic view.  Since then, dental implants have been used to reconstruct human jaws or as abutments for dental prostheses. The success has been attributed to the material, surgical techniques, and the manner that implants are loaded.
  • 7.  In 1984, Roberts et al corroborated the use of implants in orthodontic anchorage. Six to 12 weeks after placing titanium screws in rabbit femurs, a 100-g force was loaded for 4 to 8 weeks by stretching a spring between the screws. All but 1 of 20 implants remained rigid. Titanium implants developed osseous contact, and continuously loaded implants remained stable. The results indicated that titanium implants provided firm osseous anchorage for orthodontics and dentofacial orthopedics.
  • 8.  Retromolar implants were described by Roberts and colleagues (1990) and the palatal implants were introduced by Wehrbein and Merz (1998).  Both are used for indirect anchorage, meaning they are connected to teeth that serve as the anchorage units.
  • 9.  Creekmore and Eklund inserted one such device below the nasal cavity in 1983, but it was not until 1997 that Kanomi described a mini-implant specifically designed for the orthodontic use.  These are used as direct anchorage.  In contrast to the osseointegrated implants, these devices are smaller in diameter and are designed to be loaded shortly after insertion
  • 10.  Based on composition Biotolerant(stainless steel,chromium- cobalt alloy Bioinert (titanium, carbon) Bioactive(hydroxylapatite,aluminium oxide  Based on site of insertion Palatal/lingual Buccal
  • 11.  Based on mode of insertion Self drilling Self tapping  Based on head type Hook head type Bracket head type Circle head type
  • 12.  Based on shape Cylindrical Conical Jang et al reported cylindrical screw -88% success rate while with conical screw its 95%
  • 14.  The head of the mini implant can be designed for one point contact with a hole through the neck, as in Dual Top Anchor System, the Lin/Liou Orthodontic Mini Anchorage Screw (LOMAS) and the Spider Screw.  A hook (LOMAS) or a button (Abso- Anchor) can also be used.
  • 15.  A bracket like head design, on the other hand, offers the advantage of three dimensional control and allows the screw to be consolidated with a tooth to serve as indirect anchorage.  Examples of this type include Aarhus Mini Implant, Dual Top Anchor System and Temporary Mini Orthodontic Anchorage System.
  • 16.  Another design factor is the cut of the threads.With self drilling mini screws like Aarhus Mini Implant, Dual Top Anchor System and LOMAS, the apex of the screw is extremely fine and sharp, so that the pilot drilling is unnecessary in most cases.  The transmucosal portion of the neck should be smooth. It is also important that screws be available with different neck lengths for various implant sites.
  • 18.  Diameter of the drill has to be smaller than external diameter of screw  If drill has same or larger external diameter than mini screw to be used ,there would be no PRIMARY stabality as the thread would not anchored in bone,resulting in premature loss of screw  GNATHOUS AND PHILIPS-recommend diameter of drillshould be 70-85% of external diameter of screw.  This means mini screw with a diameter of 1.6mm, adrill with diameter of 1.2mm should be used.
  • 19.  Central drilling means to produce a small crypt or dimple or depression in surface of bone at intended mini screw penetration point.  Its done incases where pre drilling can be difficult eg posterior access site ,dense bone  The drill point can slip on dense cortical surface before actually penetrating the bone When drill tip slips off ,the bone and adjacent tissue can get damage  Producing a DIMPLE or DEPRESSION with central drill helps to reduce risk.  After a dimple is created then pilot drill is less likely o slip
  • 21.  Significant advantage of mini screw is that they can be loaded immediately after insertion  Immediate loading is not possible but also it may positively affect the osseous density around screw  Degree of immediate loading vary widely depend upon design of mini screw Herman and cope recommended-force between 50-30 cN Melson recommend force not more than 50cN Buchler et al load not more than 600 cN
  • 23.  Implant materials. The material must be  nontoxic and  biocompatible,  possess excellent mechanical properties, provide resistance to stress, strain, and corrosion.
  • 24. Implant Size Mini implants (6 mm long, 1.2 mm in diameter) Standard den tal implants (6-15 mm long, 3-5 mm in diameter  Since mini screw mostly insert between roots, amount of interradicular space is crucial in determining the insertion site and maximum diameter of screw.
  • 25.  Poggio et al ,Sung et al,Park et al :has concluded that ideal diameter should be from 1.2 -1.5  Miyawaki et al :All screws with diameter less than 1.5 were lost prematurely wherease those with diameter of 1.5mm or more had 85% succcess rate  Clinically miniscrew with diameter 1.5 mm or 1.6 mm are recommended
  • 26.  Depending on region of bone in dental implant total thickness available range from 4mm-16mm  Screw longer than 10mm causes iatrogenic perforation on lingual side of mandible or in maxillary sinus  Length is secondary importance,the thickness of cortical plate through which it is inserted is more crucial factor  Thicker corthical plate more reliable anchorage
  • 28.  The Spider Screw is a self-tapping miniscrew available in three lengths—7mm, 9mm, and 11mm—in single-use, sterile packaging.  The screw head has an internal .021" × . 025"slot, an external slot of the same dimensions, and an .025" round vertical slot. It comes in three heights to fit soft tissues of different thicknesses: regular, with a thicker head and an intermediatelength collar; low profile, with a thinner head and a longer collar; and low profile flat, with the same thin head and a shorter collar.
  • 30.  All three types are small enough to avoid soft-tissue irritation, but wide enough for orthodontic loading.  The biocompatibility of titanium ensures patient tolerance, and the Spider Screw’s smooth, self-tapping surface permits easy removal at the completion of treatment.
  • 31.  Because miniscrews rely on mechanical retention rather than osseointegration for their anchorage, the orthodontic force should be perpendicular to the direction of screw placement.
  • 32.  Applied forces can range from 50g to 200g, depending on the quality of the bone and the orthodontic movement desired. If any mobility is noted immediately after placement or during tooth movement, the screw should be inserted deeper into the bone, or replaced with a longer screw to engage the opposite plate of cortical bone.
  • 33.  The diameter of the mini screw will depend on the site and the space available. In the maxilla a narrower implant can be selected if it is to be placed between the roots.  If stability depends on insertion into the trabecular bone, a longer screw is needed, but if the cortical bone will provide enough stability, a shorter screw can be chosen.
  • 34.  The length of the transmucosal part of the neck should be selected after assessing the mucosal thickness of the implant site.
  • 35.  Possible insertion site include, in the Maxilla: the area below the nasal spine, the palate, the alveolar process, the infrazygomatic crest, and the retromolar area.  In the Mandible: the alveolar process, the retromolar area and the symphysis.
  • 40.  Huang, Shotwel,Wang (AJODO 2005)  One way to evaluate the possibility of damaging the periodontal ligament (PDL) is to calculate the safety distance.  Safety distance: Diameter of the implant + PDL space (normal range 0.25 mm ± 50%) minimal distance between implant and tooth (1.5 mm)
  • 41.  Example: Safety distance (mm) of mini- implants when inserted between roots 1.2 (0.25 + 50%) (1.5 +1.5) 4.575. Therefore, the distance between roots needs to be at least 4.6 mm to reduce the risk.
  • 42.  Gautam P,Valiathan A (AJODO 2006)  Safety distance: Diameter of the implant + 2 X [PDL space (normal range 0.25 mm ± 50%)] minimal distance between implant and tooth (1.5 mm)  Example: Safety distance (mm) of mini- implants when inserted between roots 1.2 2 X(0.25 + 50%) (1.5 +1.5) 4.9. Therefore, the distance between roots needs to be at least 5 mm to reduce the risk. 
  • 43.  After the local anesthetic is applied, the implant area is washed with .02% chlorhexidine.  Even when self drilling screws are used, pilot drilling may be required where the cortex is thicker than 2mm, as in the retromolar area or the symphysis, because dense bone can bend the fine tip of the screw.The pilot drill should be .2-.3 mm thinner than the screw and should be inserted to a depth of no more than 2-3mm.
  • 44.  If a manual screwdriver is used for insertion, it is immediately evident when the a root has been contacted, and any damage will be minimum. In tests where notches were intentionally created, histological analysis showed spontaneous repair by the formation of cellular cementum.  If the screw is inserted with a low speed drill, there is a greater chance of not detecting a root due to lack of tactile sensation.
  • 45.  Whenever possible, the mini implant should be inserted through attached gingiva. If this is not possible, the screw can be buried beneath the mucosa so that only a wire, a coil spring, or a ligature passes through the mucosa.  In the maxilla, the insertion should be at an oblique angle, in an apical direction; in the mandible, the screw should be inserted as parallel to the roots as possible if teeth are present.
  • 46.  The alignment of roots can be assessed by extendingthe height of conttour from buccal cusp tip of clinical crown  Additionally the depression between the nebighouring root contourcan be palapated which represent the configuration of root alignment and is major indicator in insertion site  The safe linterdental areais estimated by making linear indention with a periodontalprobe  When clinical crown exhibit considerable mesiodistal inclination the interdental area should be assessed accordingly.
  • 48.  A coronally placed miniscrew is to be on firm attached gingiva but the risk of root damage increases because of conical shape of roots  In constrast subapical or periapical insetion may cause soft tissue impengement.  Therfore MUCOGINGIVAL junction is the insertion point which minimize possible root damage while preventing root damage.
  • 50.  Insertion angle(Occlusogingival) A 45 degree angulation relative to occlusal plane is considered acceptable.  Insertion path (Mesiodistal) A good clinical guideline is direction of proximal contact area,since configuration of interradicular space reflect direction of contact surface viewed from occlusal surface.
  • 51.  Zygoma Anchorage System (ZAS) has been developed, in which the miniscrews are placed at a safe distance from the roots of the upper molars. Because of its location and its solid bone structure, the inferior border of the zygomaticomaxillary buttress, between the first and second molars, is chosen as the implant site. Combining three miniscrews with a titanium miniplate can bring the point of force application near the center of resistance of the first permanent molar.
  • 52.  The upper part of the Zygoma Anchor is a titanium miniplate with three holes, slightly curved to fit against the inferior edge of the zygomaticomaxillary buttress. A round bar, 1.5mm in diameter, connects the miniplate and the fixation unit. A cylinder at the end of the bar has a vertical slot, where an auxiliary wire with a maximum size of .032" × .032" can be fixed with a locking screw.
  • 54.  The plate is attached above the molar roots by three self-tapping titanium miniscrews, each with a diameter of 2.3mm and a length of 5mm or 7mm.The miniscrews do not need to be sandblasted, etched, or coated. Square holes in the center of the screw heads accommodate a screw- driver for initial placement, while pentagonal outer holes are used to remove the screws at the end of treatment.
  • 55.  To place the anchor, an L-shaped incision, consisting of a vertical incision mesial to the inferior crest of the zygomaticomaxillary buttress and a small horizontal incision at the border between the mobile and attached gingiva, is made under local anesthesia.The mucoperiosteum is elevated, and the upper part of the anchor is adapted to the curvature of the bone crest.
  • 56.  Three holes with a diameter of 1.6mm each are drilled, and the Zygoma Anchor is affixed with the three miniscrews.The cylinder should penetrate the attached gingiva in front of the furcation of the first molar roots at a 90° angle to the alveolar bone surface.  Orthodontic forces can be applied to the anchor immediately after implantation.
  • 58.  The ZAS uses three miniscrews, increasing total anchorage over other types of implants.  Because the miniscrews and miniplate have excellent mechanical retention, immediate loading is possible.The point of application of the orthodontic forces is brought down to the level of the furcation of the upper first molar roots.
  • 59.  The vertical slot with the locking screw makes it possible to attach an auxiliary wire, which can move the point of force application some distance from the anchor. The connection between the anchor and the conventional fixed appliance can easily be adapted to changing anchorage needs throughout treatment.Therefore, the ZAS seems to be an effective alternative to conventional extraoral anchorage.
  • 60.  Anterior retraction with sliding mechanics is usually accomplished by placing elastomeric chain or nickel titanium springs between hooks on the anterior teeth and the second molars.  The anterior and posterior segments rotate around the center of rotation, which causes bowing of the archwire.  A precurved archwire can be used to prevent this side effect.
  • 61.  The use of miniscrews for anchorage reinforcement produces somewhat different mechanics.  Because the force used during retraction is not reciprocal, either the entire arch will rotate around the center of rotation.  In cases of severe protrusion, where absolute anchorage is required in both arches, these mechanics can produce posterior open bite and deep overbite  The use of precurved archwires will result in an even stronger intrusive force on the posterior segment. Following are several possible solutions to these problems
  • 65.  In occlusal plane-mini screw causes distal in movement in posterior region.Thus molar tor-in often incorporated in conventional sliding archwire is eliminated with miniscrew appliance design  In frontal plane:-the level of mini screw site should be predetermined at same height on either side of the arch.Mini screw placed at different level on two side of the same arch causes rotation/canting of occlusal plane.
  • 66.  Intrusion of single molar-  Extruted molar requires pure molar intrusion along its long axis without extrusion of adjacent teeth.  For this line of force should pass through C resistance both on lateral and frontal view to prevent possible bucco lingual and mesio distal tipping during intrusion.  Cresi of upper first molar is expected to be at center of occlusal table ,close to palatal root.  The lineof force should pass through C resistance.  So mini screw inserted on- mesial interdental area on buccal surface and distal interdental area on palatal surface or vice versa  tn this way combined bilateral force from buccaland palatal side wil produce line of force passing through C resis of molar including pure intrusion without tipping
  • 67.  When molar on both sides need to be symmerically intruted on the midpalate.  The intrusive force is delivered through transpalatal bar connecting both molars.  TPA needs to be slightly expanded to prevent molar from tipping palatally.  Anterior-posterior position ,miniscrew should be on line connecting the central fossa of both molars
  • 69.  Implant placed between canine and premolar.  Move one molar at a time to obtain controlled mvement.  Initially ,force to protract the first molar is generted using coil spring from TSAD.  With mesial movement of molar there will also be accompanying moment to tip molar forward.  After most of the protraction of first molar ,a tip back bend is given to upright this molar(with a ligature wire consolidation from premolar to molar)and coil spring is attached to second molar.  This tip back bend helps in uprighting the root of first molar while second molar is been protracted
  • 71.  Mini screw inserted between first and second molar and elastic engaged to protract molar.  Without lever arm,line of force generate mesial tipping of molar and may lead to bowing of archwire in premolar area.  To achieve constant translation of molar in maintaining arch shape-a lever arm made of rigid SS wire is placed on molar so that line of force from miniscrew will go through C resistance of molar.
  • 73.  Place screw in retromolar region distal to molar that needs to be uprightining  On mesial side of tooth ,a button is bonded and a elastic e chain attached from button to screw.
  • 75.  In 1995, a 2-stage hydroxylapatite-coated titanium subperiosteal implant (Onplant, Nobel Biocare, Göteburg, Sweden) was developed.This system has several characteristics: disc shaped, 10 mm in diameter, 2 mm thick, coated with hydroxyapatite on the side against bone, and smooth titanium facing soft tissue with a threaded hole where abutments will be placed.
  • 76.  After biointegration with tissue, the disc is exposed by punch technique (removal of a patch of tissue at the center). A ball- shaped abutment is connected, to which orthodontic devices will be attached. Onplants have been shown, to provide sufficient anchorage to move and anchor teeth.
  • 77.  In 1996, a 1-stage endosseous orthodontic implant for palatal anchorage was presented (Orthosystem, Straumann).This system has a diameter of 3.3 mm and endosseous length of 4 or 6 mm.The self-tapping design provides good initial stability with fewer procedures and less instrumentation during surgery.
  • 79.  A groove above the transmucosal part can hold a transpalatal bar (square wire, 0.032 0.032 in, stainless steel), which can be clamped by a cover and screwed tightly to the implant. Many studies have demonstrated its success in maxillary tooth retraction and stabilization of anchorage teeth.
  • 81.  The midsagittal area has relatively low vertical bone height, and complete ossification of the suture is rare before 23 years of age (Schlegel et al 2002). For most adults, osseointegration is uneventful. However, the paramedian region might be more optimal for adolescents to avoid connective tissue of the suture and interaction of its growth.
  • 82.  Gunduz E et al AJODO 2004  In this study, 85 patients who received orthodontic treatment with palatal implants in 2 clinics in Austria completed questionnaires.The results show that most patients got used to their implants in about 2 weeks; 95% were satisfied with the treatment, and 86% would recommend the treatment to other patients.
  • 83.  In addition, 75% of the patients found the orthodontic construction between the anchor teeth and the palatal implant less comfortable than the implant itself, whereas 7% found the palatal implant less comfortable. Approximately 24 months of treatment with the palatal implant is tolerable for patients; this is the average orthodontic treatment time.
  • 84.  Chen F, Terada K, Handa K.  The purpose of this study was to compare the anchorage effects of different palatal osseointegrated implants using a finite element analysis.Three types of cylinder implants (simple implant, step implant, screw implant) were investigated.Three finite element models were constructed.
  • 85.  Each consisted of two maxillary second premolars, their associated periodontal ligament (PDL) and alveolar bones, palatal bone, palatal implant, and a transpalatal arch. Another model without an implant was used for comparison.The horizontal force (mesial 5N, palatal 1N) was loaded at the buccal bracket of each second premolar, and the stress in the PDL, implant, and implant surrounding
  • 86.  The results showed that the palatal implant could significantly reduce von Mises stress in the PDL (maximum von Mises stress was reduced 24.3-27.7%). The von Mises stress magnitude in the PDL was almost same in the three models with implants.The stress in the implant surrounding bone was very low.These results suggested that the implant is a useful tool for increasing anchorage. Adding a step is useful to lower the stress in the implant and surrounding bone, but adding a screw to a cylinder implant had
  • 87.  Chen F, Terada K, Hanada K, Saito I. Angle Orthod. 2006  The purpose of this study was to compare the anchorage effects of an osseointegrated palatal implant (OPI) with a nonosseointegrated palatal implant (NOPI), using finite element analysis. One model, which was composed of two maxillary premolars, periodontal ligament (PDL), alveolar bone, a palatal implant, palatal bone, a bracket, band, and TPA, was created on
  • 88.  The palatal implant was treated as either NOPI or OPI.The force on the premolars was investigated under three conditions: a mesiodistal horizontal force, a buccolingual horizontal force, and a vertical intrusive force.The PDL stress was calculated and compared with a model without an implant.
  • 89.  The result showed that OPI could reduce PDL stress significantly. (The average stress was reduced by 14.44% for the mesiodistal horizontal force, 60.28% for the buccolingual horizontal force, and 17.31% for the vertical intrusive force.) The NOPI showed almost the same anchorage effect as OPI.
  • 90.  The stress on the NOPI surface was higher than that on the OPI surface, but the stress was not high enough to result in failure of the implant.These results suggested that waiting for osseointegration might be unnecessary for an orthodontic implant.
  • 91.  Thiruvenkatachari B, Pavithranand A, Rajasigamani K, Kyung HM.(AJODO 2006)  The purpose of this study was to compare and measure the amount of anchorage loss with titanium microimplants and conventional molar anchorage during canine retraction. METHODS: Subjects for this study comprised 10 orthodontic patients (7 women, 3 men) with a mean age of 19.6 years (range, 18 to 25 years), who had therapeutic extraction of all first
  • 92.  After leveling and aligning, titanium microimplants 1.3 mm in diameter and 9 mm in length were placed between the roots of the second premolars and the first molars. Implants were placed in the maxillary and mandibular arches on 1 side in 8 patients and in the maxilla only in 2 patients.
  • 93.  After 15 days, the implants and the molars were loaded with closed-coil springs for canine retraction. Lateral cephalograms were taken before and after retraction, and the tracings were superimposed to assess anchorage loss.
  • 94.  The amount of molar anchorage loss was measured from pterygoid vertical in the maxilla and sella-nasion perpendicular in the mandible. RESULTS: Mean anchorage losses were 1.60 mm in the maxilla and 1.70 mm in the mandible on the molar anchorage side; no anchorage loss occurred on the implant side. CONCLUSIONS:Titanium microimplants can function as simple and efficient anchors for canine retraction when
  • 95.  Oyonarte R, Pilliar RM, Deporter D, Woodside DG  Bone response to orthodontic loading was compared around 2 different types of osseointegrated implants (porous surfaced and machined threaded) to determine the effect of implant surface geometry on regional bone remodeling.
  • 96.  METHODS: Five beagles each received 3 implants of each design in contralateral mandibular extraction sites. After a 6-week initial healing period, abutments were placed, and, 1 week later, the 2 mesial implants on each side were orthodontically loaded for 22 weeks. All implants remained osseointegrated throughout orthodontic loading except for 1 threaded implant that loosened. Back-scattered scanning electron microscopy and fluorochrome bone labeling techniques were used to compare responses around the 2 types
  • 97.  RESULTS:The loaded, porous-surfaced implants had significantly higher marginal bone levels and greater bone- to-implant contact than did the machined-threaded implants. CONCLUSIONS: Significant differences in peri-implant bone remodeling and bone formation in response to controlled orthodontic loading were observed for the 2 implant designs. Short, porous- surfaced implants might be more effective for orthodontic applications than machine-threaded implants
  • 98.  If implants are planned for future prosthetic abutments, a standard healing protocol should be followed.  Direct orthodontic forces generate less stress on implants due to limited force imposed ( 3N, about 300 g).The stress is far less for indirect anchorage because implants are used to stabilize teeth.
  • 99.  During surgery, assessment of bone quality and initial implant stability are important.With dense bone and satisfactory stability, immediate loading might be feasible.  Threaded implants provide superior mechanical interlock as compared with cylindrical designs.Thus, waiting time should be longer for nonthreaded implants.
  • 100.  Complete osseointegration is favorable but not essential for effective orthodontic anchorage implants. However, stable mechanical retention or partial osseointegration is required, and implants should not be overloaded during healing.
  • 101.  Ohmae et al, 2001 reported a study on Dog jaws in which Titanium mini-implant were loaded using 150g force for12-18 wks after 6 wks healing period. All implants remained stable. Periimplant bone at loaded implants was equal to or slightly greater than unloaded ones.
  • 102.  Trisi and Rebaudi, 2002 reported on Human Titanium (Biaggini, Ormco) implants.  Force of 80-120g/8-48 wks was applied after 8 wks healing period.  All implants remained stable and osseointegrated. Bone remodeling around implants was observed.
  • 103.  Akin-Nergiz et al,1998  Orthopedic force (2 N/12 wks- 5N/24) after healing period of 12wks was applied on Dog jaws using Titanium (ITI) implants). Implants had no displacement for any force level.
  • 104.  Deguchi T, et al (J Dent Res. 2003) quantified the histomorphometric properties of the bone-implant interface to analyze the use of small titanium screws as an orthodontic anchorage and to establish an adequate healing period. Overall, successful rigid osseous fixation was achieved by 97% of the 96 implants placed in 8 dogs and 100% of the elastomeric chain-loaded implants.
  • 105.  All of the loaded implants remained integrated. Mandibular implants had significantly higher bone-implant contact than maxillary implants.Within each arch, the significant histomorphometric indices noted for the "three-week unloaded" healing group were: increased labeling incidence, higher woven-to- lamellar-bone ratio, and increased osseous contact.
  • 106.  Analysis of these data indicates that small titanium screws were able to function as rigid osseous anchorage against orthodontic load for 3 months with a minimal (under 3 weeks) healing period.
  • 107.  Disadvantages include longer treatment time, financial concerns, and anatomical limitations. However, the benefit from superior anchorage and time saved by using implant anchorage often exceeds the healing time after surgery.
  • 108.  Implant surgery does cost more than other treatments. If implants will be used in the prosthetic treatment plan, the fee is offset. In addition, implant anchorage reduces the risk of jeopardizing existing dentition. Application of implants might be limited by the amount and quality of bone.Therefore, thorough evaluation is critical before treatment.
  • 109.  Intrude/extrude teeth. It is difficult to intrude or extrude teeth, particularly molars. Implant anchorage greatly facilitates these movements. Mini- implants (1.2 mm in diameter, 6 mm in length), which can be placed between roots or apical to a tooth, are more feasible. Pure intrusion or extrusion cannot be achieved. If the implant is at the facial side for intrusion, only intrusion plus protrusion can be accomplished. Also, care should be taken not to involve the periodontal ligament and prevent
  • 114.  Close edentulous spaces. Missing first molars or congenital missing teeth are common. Because of reduced anchorage, implants in retromolar areas have been used to translate teeth into edentulous areas.  Titanium screws can be placed to protract molars and close the spaces of congenital missing premolars.
  • 118.  This treatment is superior to others when adjacent teeth are intact or have large pulp chambers, making preparation undesirable. Plaque control is more complicated with fixed partial dentures, which increase the risk of caries and endodontic or periodontal disease.  If the translated tooth is tipped, it should be uprighted to prevent a mesial angular bony defect.
  • 119.  Reposition malposed teeth. Preprosthetic corrections of tilted abutments are not unusual. Adequate anchorage for tooth movement is often impossible when there are several missing teeth. Realignment of molars by using the remaining teeth is complicated because of limited support. Implants facilitate uprighting the abutment teeth at the end of a long edentulous ridge. If carefully planned, dental implants used to upright teeth can be restored as implant-supported prostheses in
  • 123.  Reinforce anchorage. Palatal implants have been developed to reinforce anchorage. An endosseous orthodontic implant anchor system (Orthosystem, Straumann,Waldenburg, Switzerland) has been designed and can be used in Class II malocclusion patients in whom no extraction or extraction of maxillary first premolars and retraction of anterior teeth are planned.
  • 127.  Park HS, Lee SK, Kwon OW Angle Orthod. 2005  The purpose of this study was to quantify the treatment effects of distalization of the maxillary and mandibular molars using microscrew implants.The success rate and clinical considerations in the use of the microscrew implants were also evaluated.Thirteen patients who had undergone distalization of the posterior teeth using forces applied against microscrew implants were selected.
  • 128.  Among them, 11 patients had mandibular microscrew implants and four patients had maxillary implants, including two patients who had both maxillary and mandibular ones at the same time.The maxillary first premolar and first molars showed significant distal movement, with no significant distal movement of the anterior teeth.
  • 129.  The mandibular first premolar and first and second molars showed significant distal movement, but no significant movement of the mandibular incisor was observed.The microscrew implant success rate was 90% over a mean application period of 12.3 +/- 5.7 months. The results might support the use of the microscrew implants as an anchorage for group distal movement of the teeth.
  • 130.  Treat partial edentulism. Treatment is complicated in patients with malocclusion and many missing and periodontally compromised teeth. Fortunately, implants in edentulous areas to provide orthodontic anchorage and later serve as prosthetic abutments have been considered a proper interdisciplinary approach.  Transitional implants have been applied in these situations.
  • 131.  Correct undesirable occlusion. Correcting Class III anterior crossbite with conventional methods is not always satisfactory. Retracting the entire mandibular arch with dental implants is possible. Localized crossbite can be treated by bonding implants and teeth to avoid full-mouth treatment. Protracting maxillary arches can be achieved by using implant anchorage.
  • 132.  Provide orthopedic anchorage. Palatal implants can be used to elicit palatal expansion.This applies to partially edentulous patients or children with congenital diseases that result in facial developmental defects or missing teeth. Implants in congenital anomalies can promote orthodontic and orthopedic therapy and accelerate jaw movement by sutural distraction.
  • 133.  In orthopedic treatment the forces are transmitted to the bones by a tooth; this implies skeletal as well as dental effects.  Tooth splinting or controlling force vectors can minimize undesirable movement, but it cannot be avoided. Skeletal movement can be accomplished by using teeth as anchorage, but dental side effects often limit the amount of movement.  Implants can overcome the limitations by guiding forces directly to the bones.
  • 134.  Facial skeletal movement by implant anchorage has also been evaluated. (Smalley et al 1988)  A 600-g force was applied until 8 mm of maxillary displacement occurred. All implants remained stable over 12 to 18 weeks.The findings also showed the possibility of controlling the direction of protraction.
  • 135.  To evaluate the application of implants in sutural expansion, animal studies have been conducted. (Parr JA et al 1997)  Two titanium implants were placed on either side of the internasal suture in 18 rabbits, which were divided into an unloaded control group and 2 test groups. After 8 weeks, each test group was loaded with a force of 1 Newton (N) or 3 N. All implants remained stable for 12 weeks.
  • 136.  Several congenital facial anomalies and developmental defects present anchorage challenges. Case reports using dental implants for orthopedic movement and acceleration of jaw movement by sutural distraction have been reported. Nonetheless, the optimal load, which has not been determined yet, for sutural expansion is the lowest above the woven bone threshold that effectively separates it.Therefore, further studies are needed to determine the optimal load.
  • 137. • While endosseous dental implants are intended to resist the heavy, intermittent forces of occlusion, orthodontic forces are considerably lower and more sustained.Therefore, the requirements of an orthodontic anchor implant may be quite different.
  • 139.  The Modular Transitional Implant, 1.8mm in diameter, is available in lengths of 14mm, 17mm, and 21mm. It was designed to support a temporary fixed prosthesis during the healing phase associated with placement of permanent implants, and to be removed when the permanent implants are restored.
  • 143.  Currently, dental implants have become predictable and reliable adjuncts for oral rehabilitation.  Osseointegrated/ Non osseointegrated implants can be used to provide rigid orthodontic or orthopedic anchorage. Although initial results are encouraging, the risks and benefits must be thoroughly evaluated.
  • 144.  In the future, as developments occur in the implant technology, they may have a significant role as anchorage reinforcement aids.
  • 145.  Irfan Dawoodbhoy,Valiathan Ashima: Implants as anchors in Orthodontics. Journal of Indian Orthodontic Society. 1994; 25(4): 124-127.  Gautam P,Valiathan A. Implants for anchorage. Am J Orthod Dentofacial Orthop. 2006 Feb;129(2):174; author reply 174.
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  • 148.  Drago CJ. Use of osseointegrated implants in adult orthodontic treatment: a clinical report. J Prosthet Dent 1999;82:504-9.  Shapiro PA, Kokich VG. Uses of implants in orthodontics. Dent Clin North Am 1988;32:539-50.
  • 149.  Wehrbein H. Feifel H. Diedrich P. Palatal implant anchorage reinforcement of posterior teeth: a prospective study. Am J Orthod Dentofacial Orthop 1999;116:678- 86.  Gray JB, Smith R.Transitional implants for orthodontic anchorage. J Clin Orthod 2000;34:659-66.  Prosterman B, Prosterman L, Fisher R, Gornitsky M.The use of implants for orthodontic correction of an open bite. Am J Orthod Dentofacial Orthop 1995;107:245-50.
  • 150.  Parr JA, Garetto LP,Wohlford ME, Arbuckle GR, Roberts WE. Sutural expansion using rigidly integrated endosseous implants: an experimental study in rabbits. Angle Orthod 1997;67:283-90.  Gray JB, Steen ME, King GJ, Clark AE. Studies on the efficacy of implants as orthodontic anchorage. Am J Orthod 1983;83: 311-7.  Roberts WE, Helm FR, Marshall KJ, Gongloff RK. Rigid endosseous implants for orthodontic and orthopedic
  • 151.  Deguchi T,Takano-Yamamoto T, Kanomi R, Hartsfield JK Jr, Roberts WE, Garetto LP. The use of small titanium screws for orthodontic anchorage. J Dent Res 2003;82:377-81.  Akin-Nergiz N, Nergiz I, Schulz A, Arpak N, Niedermeier W. Reactions of peri- implant tissues to continuous loading of osseointegrated implants. Am J Orthod Dentofacial Orthop 1998; 114:292-8.
  • 152.  Chen F, Terada K, Hanada K, Saito I. Anchorage Effect of Osseointegrated vs Nonosseointegrated Palatal Implants. Angle Orthod. 2006 Jul;76(4):660-5.  Thiruvenkatachari B, Pavithranand A, Rajasigamani K, Kyung HM. Comparison and measurement of the amount of anchorage loss of the molars with and without the use of implant anchorage during canine retraction. Am J Orthod Dentofacial Orthop. 2006 Apr;129(4):551-4.
  • 153.  Oyonarte R, Pilliar RM, Deporter D, Woodside DG. Peri-implant bone response to orthodontic loading: Part 2. Implant surface geometry and its effect on regional bone remodeling.Am J Orthod Dentofacial Orthop. 2005 Aug;128(2):182-9.  Oyonarte R, Pilliar RM, Deporter D, Woodside DG. Peri-implant bone response to orthodontic loading: Part 1. A histomorphometric study of the effects of implant surface design. Am J Orthod Dentofacial Orthop. 2005 Aug;128(2):173-81.
  • 154.  Chen F, Terada K, Handa K. Anchorage effect of various shape palatal osseointegrated implants: a finite element study.Angle Orthod. 2005 May;75(3):378-85.  Gunduz E, Schneider-Del Savio TT, Kucher G, Schneider B, Bantleon HP. Acceptance rate of palatal implants: a questionnaire study. Am J Orthod Dentofacial Orthop. 2004 Nov;126(5):623- 6.
  • 155.  Park HS, Lee SK, Kwon OW. Group distal movement of teeth using microscrew implant anchorage. Angle Orthod. 2005 Jul;75(4):602-9.  Deguchi T, Takano-Yamamoto T, Kanomi R, Hartsfield JK Jr, Roberts WE, Garetto LP. The use of small titanium screws for orthodontic anchorage. J Dent Res. 2003 May;82(5):377-81
  • 156.  De Clerck H, GeerinckxV, Siciliano S. The Zygoma Anchorage System. J Clin Orthod. 2002 Aug;36(8):455-9  Celenza F, Hochman MN. Absolute anchorage in orthodontics: direct and indirect implant-assisted modalities. J Clin Orthod. 2000 Jul;34(7):397-402  Kanomi R. Mini-implant for orthodontic anchorage. J Clin Orthod. 1997 Nov;31(11):763-7.
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Editor's Notes

  1. Explain high grade stainless steel –biocompatible but connective tissue and mri so currently leone Why use titanium-direct contact Cp titanium vs titanium alloy ti 6al 4 vandium strenght surface contact strss strain yeild strength wear resistance