Achieving Optimal Esthetics with Palatal Mini-Implants: The Benefit Technique..hawwa shoaib . faculty of dentistry . mansoura university .

3. 

4.  The following factors seem to be relevant for the
premature loss or tipping of a mini-implant
 1. Insufficient bone quality and/or inadequate bone
quantity at the insertion site.
 2. Employment of mini-implants with a small
diameter and/or length.
 3.Inappropriate intra osseous design.
STABLE ANCHORAGE

5. 
 4. Root contact at the time of insertion.
 5. Manipulation with the fingers or tongue.
 6. Insufficient oral hygiene.
 7. Application of high forces or moments.
 8. Use of a large lever arm. This occurs if the mini-
implant is inserted in a region where the gingiva or
mucosa is too thick..
 9. Insertion in the region of the movable mucosa

6. 
 10. Insufficient primary stability.
 11. Bone damage at insertion due to high stress or
bone overheating. This phenomenon is well known
in dental implantology

7. 
 Other regions, such as the anterior palate and the
mental region, provide much better conditions for
temporary anchorage device (TAD) insertion since
the amount and quality of the available bone is
superior. Using TADs in the anterior palate and the
mental region eliminates the risk of root injury and
takes the TADs out of the path of tooth movement..
Mental region Anterior palate

8. 
Benefit Mini-Implants with
Exchangeable Abutments
The Benefit mini-implant has an inner thread on its top . It is made
of titanium alloy . and due to its self-drilling thread design,
insertion can be done without predrilling with a hand piece.
Available dimension are diameter of 2 or 2.3 mm and length of 7,
9, 11, 13, or 15 mm.
Benefit mini-implant with an inner thread.

9. 
 On the top of the mini-implant four different types
of stainless steel abutments can be fixed with a tiny
fixing screw that is integrated into the abutment .
 This small fixing screw can be turned within the
abutment but cannot fall out of it. Different types of
abutments allow the construction of versatile
appliances for a large variety of clinical
applications. The Benefit mini-implants are inserted
primarily in the anterior palate and in edentulous
areas of the alveolar process.
Benefit system. A, Mini-implant. B,
Abutment with wire in place. C, Bracket
abutment. D, Standard abutment. E, Slot
abutment.F, Screwdriver.

10. 
 To improve their stability and to prevent mini-
implant tipping, two Benefit mini-implants can easily
be coupled with the Bene plate . The Bene plate is a
stainless steel plate with a thickness of 1.2 mm. To
cover multiple distances of two mini-implants, it has
a round hole and a long hole. As well, it is available
in two different lengths, resulting in possible
distances of 3.5 to 14 mm measured from the center of
one mini-implant to the center of the other..
The Beneplate: A Mini-Plate for the Easy
Coupling of Two Mini-Implants

11. Bene plate system. A, Short Bene plate. B, Short Bene plate
with wire in place. C, Long Bene plate with bracket in place.
D, Fixation screw

12. 
To enable a stable connection to the orthodontic appliance, Bene
plates with a 1.1-mm-diameter stainless steel wire (for a Bene slider,
Mesial slider, Mesial-Distal-Slider) 0.8-mm-diameter stainless steel
wire (for a Pendulum B or molar intrusion with the Mousetrap
mechanics), and a stainless steel bracket (to ligate in lever arms) are
available.
The Bene plate can be adapted to the Bene fit mini-implants by
bending the plate body as well as the wire.
Small fixing screws are used to fix the Bene plate on top of
the mini-implants..

13. 
STEP-BY-STEP CLINICAL
PROCEDURE

14. The optimum insertion site
in the maxilla is located in
the anterior palate distally
from the palatal rugae on a
line between the premolars.
Advantages of this region
are a thin soft tissue layer
and sufficient bone height.
Less bone is available in the
areas that are more lateral
and posterior …
Prepared maxilla with two lines showing the optimal insertion
site between the premolars. Less bone is available in the areas that are
more lateral and posterior

15. 
 The first step is local
anesthesia administered
directly in the insertion
site . If the patient is
afraid of a syringe, only
topical anesthesia can be
used.
Local anesthesia administered directly into
the insertion site

16. 
The second step is predrilling (to 3 mm depth) with a 1.4-mm
drill for the 2-mm mini-implants and a 1.7-mm drill for the 2.3-
mm mini-implants. This can be done manually using a special
hand piece equipped with a 1 : 1 contra angle . Due to the low
speed there is no need for cooling. In very young patients ( less
than 12 years of age) pre drilling is not necessary due to the low
mineralization rate of the bone…

17. A, Preparation for predrilling
using a contra angle equipped
with a special hand piece.
B,Predrilling with the contra
angle and the hand piece.

18. 
Once the sites have been
prepared, one or two
Benefit mini-implants are
inserted near the mid
palatal suture, again using
the contra-angle
screwdriver .
A, Preparing a Benefit mini-implant before
insertion.
B, Insertion of a Benefit mini-implant using
the contra-angle screwdriver

19. 
If just one mini-implant is employed (e.g., for molar
anchorage), the dimension 2.3 mm × 11 mm is chosen . if
two mini-implants are employed, usually a 2 mm × 11
mm mini implant is inserted anteriorly and a 2 mm × 9
mm mini implant is inserted posteriorly. As an
alternative, a 2 mm × 9 mm mini-implant is chosen
anteriorly and a 2 mm × 7 mm mini-implant is chosen
posteriorly .

20. One Benefit mini-implant in the
palate (2.3 mm × 11 mm).
Two Benefit mini-
implants inserted in the
palate 2 mm ×11 mm
anterior and 2mm×9 mm
posterior).

21. 
Generally, it is advisable to choose mini-implants with
a big diameter or 2 or 2.3 mm, because they provide
superior stability compared to mini-implants with a
smaller diameter. Usually the Benefit mini-implants are
inserted within a torque range of 10 to 25 Newton
centimeters (Ncm). The maximum insertion torque is 35
Ncm for the mini-implants with a diameter of 2 mm.

22. 
two mini-implants are inserted in a sagittal
line . As an alternative and especially if a
rapid palatal expansion with the Hybrid Hyrax is planned,
the mini-implants are inserted in a transversal lineup
In most cases, two mini-implants
are inserted in a sagittal line
a rapid palatal expansion with the Hybrid
Hyrax is planned, the mini implants
are inserted in a transversal lineup.

24. 
The distance between the two mini-implants
should be at least 4 mm to enable enough space for the
Supra construction (two abutments or one Beneplate).
Additionally, if an impression is planned, there must be
enough space for two impression caps.
The Benefit mini-implants are self-drilling and can be
inserted without predrilling.
there is very high bone density in the anterior palate,
especially in older patients. Soft tissue thickness can
be measured using a dental probe from anterior to
posterior to identify a region with thin mucosa. This is
important in order to achieve a sufficient primary stability
and to avoid large lever arms. The soft tissue in the
anterior region nearby the first and second rugae is very
thick

25. 
Depending on the mechanics, bands with lingual
sheaths are fixed to the upper molars. The appliance
can be bent either directly chair side or after
impression taking in the laboratory. In the latter case,
impression caps are placed on top of the mini-implant
and a silicone impression is taken ..

26. Chair side adaption of the T-bow for front
anchorage during
molar mesialization in the upper arch.

27. Laboratory analog (left) and impression
cap (right)., One Benefit mini-implant after
insertion.

28. An impression cap is placed on top of
the mini-implant…. Impression tray. Note
that the impression cap is visible.

29. 
If desired, the impression caps can be secured by
dental floss. Subsequently, laboratory analogs are inserted
in the impression caps and fixed by wax .
At the end, a plaster model is manufactured. The only
appliance that has to be manufactured in the laboratory is
the Hybrid Hyrax since it requires soldering or welding
connections.
Bands should be adapted on the teeth and later in
the impression if they will be integrated in the appliance..

30. A laboratory analog is inserted in the
impression cap. , Impression for a
Hybrid Hyrax with replaced bands and
laboratory analogs.

32. 
Principle: Direct versus Indirect Anchorage
 Class II malocclusions are very common. For patients
with a dental Class II malocclusion with increased
over jet and/or anterior crowding, upper molar
distalization is a frequently chosen treatment
alternative. Molar distalization with a headgear is
unpleasant for many patients for esthetic reasons
and because of the length of time the headgear needs
to be worn..
DISTALIZATION IN THE UPPER
ARCH

33. 
 To minimize or eliminate anchorage loss of the
anterior dentition, skeletal anchorage devices have
been integrated into distalization appliances.
Although indirect anchorage can be used to support
the premolars during maxillary molar distalization,
mini-screw tipping and wire deformation may result
in anchorage loss and mesial premolar migration.
Moreover, after molar distalization the appliance
must be reconstructed in order to distalize the
premolars and anterior teeth. Therefore direct
anchorage is preferable..

35. 
 The Beneslider is a distalization appliance that uses
direct anchorage and is based on one or two mini-
implants in the anterior palate. Through the use of
the Benefit mini-implants with exchangeable
abutments, a stable and safe connection between the
mini implants and the distalization mechanics is
achieved. To couple the Beneslider with the molars,
bands with lingual sheaths are fixed to the upper
molars.
Direct Anchorage with the
Beneslider

37. 
 Benetubes are plugged into the sheaths from the
mesial side .To avoid irritation of the soft tissues, the
Benetube must be bent slightly in most cases. If one
mini-implant was inserted, an abutment with a wire
in place is adapted to the curvature of the palate. If
two mini-implants were inserted, a Bene plate with a
1.1-mm stainless steel wire in place is now adapted .
Depending on the axis and the location of the two
mini implants, the Bene plate body must be bent.

40. 
 By changing the angulation of the 1.1-mm stainless
steel wire, it is possible to achieve a simultaneous
intrusion or extrusion of the molars . The adapted
abutment is now fixed on the mini-implant by the
inner fixing screw. If two mini-implants were
inserted, the Bene plate is fixed by two fixing screws

43. 
 the distalization force is applied by springs that are
activated by pushing the activation locks distally .
the use of nickel-titanium (Ni-Ti) springs (240 g in
children and 500 g in adults). It seems advantageous
that the Beneslider mechanics can be installed
without need for any laboratory work in terms of
welding or soldering. In other words, the Bene slider
mechanics can be applied directly in the oral cavity
without taking an impression. To save chair time,
however, the Bene slider can also be adapted on a
plaster model .

45. 
 Follow-up should be scheduled every 4 to 6 weeks.
Usually the premolars and canines migrate distally
toward the molars due to stretching of the
interdental fibers. After distalization of the molars
with the Bene slider, the Bene slider stays in place as
an anchorage device during retraction of the anterior
dentition. The treatment can be finished with buccal
brackets, lingual brackets, or aligners..

46. 
 The patient was a 13-year-old male with a Class II
relationship and severe bialveolar protrusion. In the
canine region, half of a Class II occlusion was found .
The treatment plan was distalization and correction
of the protrusion in the upper arch with a Beneslider
and distalization with a lip bumper and retrusion of
the incisors in the lower arch…...
Clinical Example Using the
Bene slider

49. 
After insertion of two Benefit mini-implants
in the anterior palate, the Beneslider mechanics were
applied and activated .. After 6.5 months the upper
molars were distalized approximately 4 mm and
brackets were bonded . The radiographs show a bodily
distalization of the molars ...

50. After 6.5 months the upper molars were distalized approximately 4
mm and brackets were bonded.

52. 
 Steel ligature were inserted between the Benetubes and
the activation locks to deactivate the Beneslider. As an
alternative, the Ni-Ti springs can be removed. In other
words, the Beneslider was modified from a distalization
device to a molar anchorage device. An elastic chain was
inserted from the first molar to the contralateral first
molar to retract the anterior dentition. After 5 months of
retraction the spaces were almost closed to the distal. To
avoid contact of the Bene plate wire and the soft tissues it
is important to anticipate the amount of front retraction at
the time of bending the wire.

54. 
After the finishing phase the brackets were de bonded.
The Beneslider and the Benefit mini-implants were
removed without anesthesia . End of treatment was
reached after 18 months ..

58. 
Principle: Direct versus Indirect Anchorage
 Congenitally missing lateral incisors or second premolars,
extremely displaced canines, or a severe trauma of a central
incisor are potential complaints that result in a reduced upper
dentition. The two major treatment approaches are space
closure or space opening to allow prosthodontic replacements
with either a fixed prosthesis or a single-tooth implant. Both of
these treatment approaches can potentially compromise
esthetics, periodontal health, and function. In many cases
space closure to the mesial (front teeth should stay where they
are, when posterior teeth are moving mesially) seems to be the
favorable treatment goal, since treatment can be completed as
soon as the dentition is complete. Canine substitutions can be
accomplished with good esthetic outcomes by tooth reshaping
and positioning, bleaching, and porcelain veneers.
MESIALIZATION IN THE UPPER ARCH

59. 
The more mesial the missing tooth is, the higher will be
the demands for anchorage quality, especially in
asymmetrical cases with a midline deviation. If the central
incisors are in the correct position (midline, torque, and
angulation is correct), a T-bow can be bonded to the
lingual surfaces of the central incisors to apply an indirect
anchorage, with the goal being to avoid lingual tipping of
the central incisors during space closure.

60. 
As an alternative to the T-bow(indirect anchorage), the
Mesialslider can be used as a direct anchorage device.
The Mesialslider enables clinicians to mesialize upper
molars unilaterally or bilaterally. Since the incisors are
not fixed, a midline deviation can be corrected at the
same time. The Mesial slider can also be used for
protrusion of the whole upper dentition to compensate
a mild Class III occlusion.

61. 
The T-bow is an arch wire that is connected from one
or two mini-implants in the anterior palate to the
lingual surfaces of the upper central incisors. Using the
T-bow avoids an undesired lingual tipping of the
incisors during mesialization in the upper arch..
Clinical Application of the T-Bow

63. 
 Typical indications are unilateral or bilateral agenesis
of the lateral incisors or missing canines. The incisors
should already be well aligned and in the correct
position when the T-bow is applied. After insertion
of the mini-implants, a Bene plate with a 1.1-mm
stainless steel wire in place is bent and adapted to fit
between the mini-implants and the central incisors.
 Depending on the insertion axis and the position of
the mini-implants, the Bene plate body must be
adapted as well.
 After fixation of the Bene plate on top of the mini-
implants by tiny fixing screws, the wire is bonded to
the lingual surfaces of the central incisors ...

65. 
The patient was a 14-year-old female with missing
upper lateral incisors and second molars. The treatment
plan was mesialization in the upper arch without
anchorage loss of the incisors by using a T-bow. After
leveling, one Benefit mini implant was inserted in the
anterior palate ..
Clinical Example Using the T-Bow

66. An abutment with a 1.1-mm stainless steel wire in
place .was adapted to fit between the mini-implant
and the incisors .. Following bonding of the T-bow an
elastic chain was used to apply mesialization forces to
the lateral dentition. After 17 months the upper
dentition was mesialized ..

68. 
 The treatment result showed a well-preserved over
jet and a proper occlusion.
 it seems recommendable to use two mini implants to
achieve a high anchorage quality.

69. 
 After insertion of two Benefit mini-implants, bands
with lingual sheaths are fixed to the upper molars.
Subsequently, two Bene tubes and a Bene plate with
a 1.1-mm stainless steel wire in place are adapted to
the curvature of the palate. To avoid irritation of the
soft tissues, the Bene tubes must be bent in most
cases.
Clinical Application of the
Mesialslider

70. 
 Depending on the axis and the location of the two
mini-implants, the Bene plate body also must be
bent. The mesialization force is delivered by two Ni-
Ti closing springs (200 g) that are attached to the
activation locks. The Bene plate is fixed by two fixing
screws using a screwdriver or the contra angle and
the hand piece, which is more comfortable. Finally,
the Mesial slider is activated by pushing the
activation locks mesially ..

72. 
 In cases with missing second premolars or first
molars, the Mesial slider can be inserted without
putting brackets on the other teeth. Similar to the
Bene slider, the Mesial slider can be installed without
the need for laboratory work in terms of welding or
soldering. In other words, the Mesial slider device
can be applied directly in the oral cavity without an
impression but can also be fabricated indirectly to
save chair time...

73. 
 A 13-year-old female patient with missing upper
second premolars was treated with a Mesial slider .
The spaces were closed in the mesial direction after
12 months .
Clinical Example Using the
Mesialslider

76. 
When second premolars or first molars are missing, the
Mesial slider can be installed without brackets on the
other teeth. If a more anterior tooth is missing, such as a
lateral incisor or a canine, it is recommended to apply
an additional mesialization force anterior by using :
Additional Tips for Using the
Mesial slider

77. 
 1. An additional lever arm that is soldered to the
Mesial slider. Using this lever arm, buccal and
lingual forces can be applied

78. 
 2. An additional Bene tube that is
bonded to a canine or bicuspid

79. 
 3. A combination of the Mesial slider and a T-
bow: the T-Mesial slider. Forces can be
applied buccally and lingually

80. 
 The treatment protocol for a 14-year-old female
patient with a missing upper right lateral incisor .
 The canine erupted palatally, resulting in a cross
bite.
 The treatment plan was canine substitution,
mesialization in the first quadrant, and distalization
in the second quadrant to correct the shifted midline.
After extraction of the deciduous canine a Mesial-
Distal-Slider was installed and activated..
Clinical Example Using the
Mesial-Distal-Slider

83. 
 To reduce the time in full braces, an additional
spring was soldered to push the canine buccally .
 After 8 months, brackets were bonded. The spaces in
the first quadrant were closed on the mesialization
side after 16 months and many small spaces were
established on the distalization side . Debonding and
reshaping of the canine was performed after a total
treatment time of 24 Months.

87. 
Clinical Considerations for Maximum
Anchorage of the Molars
Conventional appliances designed to provide molar
anchorage are the headgear, Class II elastics, the
transpalatal arch (TPA), the Nance button, and the
incorporation of additional bends in the arch wire such
as tip-back and buccal root torque..
EN MASSE RETRACTION

88. 
 anchorage mechanics are limited in their efficiency,
which depends in part on patient compliance. A mean
of 1.6 to 4 mm anchorage loss can be anticipated during
conventional anchorage. As a consequence, mini-
implants prove to be very useful if the molar mesial
migration should be avoided during en masse
retraction . to avoid the risk of root damage and mini-
implant fracture and the high failure rate of mini-
implants in the alveolar process, bigger mini-implants
in the anterior palate instead of small mini-implants
between the second bicuspids and the first molars
seems advantageous. It is feasible to anchor the molars
with a Beneslider appliance . To establish this posterior
anchorage, the Beneslider is left in place and
deactivated by two steel ligatures after distalization for
molar anchorage during anterior retraction.

90. 
 The second alternative is to adapt a Beneplate or
similar abutment with a 1.1-mm stainless steel wire
in place and bond it to the lingual surfaces of the
molars . these two mechanics tend to expand the
molars if they are loaded with the force delivered for
the en mass retraction. To avoid side effects in the
transverse dimension found advisable to carry out
corresponding additional posterior transversal
reinforcement, resulting in the Triangle-TPA..

93. 
 The treatment protocol for an 18-year-old female
patient with a severe skeletal Class III malocclusion
The goal was dento alveolar de compensation in
terms of retrusion of the upper incisors and
protrusion of the lower incisors ahead of bi maxillary
osteotomy. To facilitate upper front retrusion,
distalization of the molars or extraction must be
done..
Clinical Example Using the Triangle-TPA for
Upper Molar Anchorage

96. 
In this case, two premolars were extracted due to a
dysplastic upper right second bicuspid.
After insertion of one Benefit mini-implant (2.3 mm ×
11 mm) the Triangle-TPA was manufactured on a
plaster model..

97. 
The abutment with a wire in place and an additional
posterior stainless steel wire were soldered to the molar
bands. After fixation of the Triangle-TPA the second
premolars were extracted and retraction of the first
premolars was initiated . A cephalogram was made
after closure of half of the extraction space…

100. 
 After 14 months the en masse retraction was
achieved without mesial migration of the molars,
resulting in a sufficient negative over jet . After bi
maxillary osteotomy , the last steps in terms of
finishing of the occlusion and de bonding were
conducted . Due to the large amount of de
compensation that was enabled by the skeletal
anchorage, an enormous improvement of the profile
was obtained ..

104. 
Principle: Direct versus Indirect Anchorage
The treatment of impacted teeth usually comprises
three phases:
ALIGNMENT OF IMPACTED
TEETH

105. 
 (1) surgical exposure and bonding of an attachment.
 (2) eruption of the impacted tooth by application of
an extrusive force.
 (3) three-dimensional orthodontic alignment.

106. 
 The force needed to extrude an impacted tooth very
often produces side effects on the dentition .
Intrusion of the adjacent teeth or even a cant of the
occlusal plane may be encountered. Consequently,
stable anchorage is essential to minimize the stated
side effects. Adjustment of the line of force during
the extrusion phase is crucial to prevent root
damage.

107. 
 By employing indirect anchorage mechanics,
unwanted side effects such as tipping of teeth used
for anchorage for extrusion of impacted teeth should
be avoided. Depending on the requirements of the
particular situation, the mechanics for distalization,
mesialization, and molar anchorage described earlier
can be used to avoid unwanted side effects on the
molars. This principle can be applied when the
molars are being used as an anchorage unit for
extrusion of incisors or canines..
Indirect Anchorage Mechanics for
Alignment of Impacted Teeth

108. 
 10-year-old female patient with a horizontally
impacted upper left central incisor. After surgical
exposure, a Bene slider with an additional soldered
tube was installed and a 0.016-inch × 0.022-inch β-
Titanium segmental arch wire was inserted in the
tube. After 3 months the incisor erupted successfully

111. 
After 6 months the incisor was almost fully erupted and
the bracket was removed . After 8 months the incisor
was at its final position; the molars were distalized to
gain enough space in the upper arch ..

114. 
 Especially if molars are impacted, direct anchorage
mechanics is appropriate to extrude them. In this case, the
alignment of an impacted upper second left molar
Direct Anchorage Mechanics for Alignment
of Impacted Teeth

116. 
 After insertion of two Benefit mini-implants and
bonding of an attachment to the second molar, a Bene
plate with a 0.8-mm stainless steel wire in place is
adapted to the curvature of the palate. One side of the
wire is activated as an extrusion lever arm; the other
side of the wire is cut . The molar was fully erupted after
4 months . and the attachment was removed.

118. 
 Over erupted upper molars due to missing lower
antagonists are a common finding, especially in
adult patients. To facilitate prosthodontic restoration
in the mandible, these over erupted molars must be
intruded.
PREPROSTHODONTIC MECHANICS
FOR MOLAR INTRUSION

119. 
 To avoid tipping of the molars that are to be
intruded, forces must be applied both buccally and
lingually. If the intrusive force is applied only at one
side, a TPA can be inserted to avoid buccal or palatal
tipping. Mini-plates inserted in the area of the
zygomatic buttress can be employed to apply a
buccal intrusive force for upper molar intrusion

121. 
 In many cases there is not enough space on the
buccal side to insert a mini-implant safely between
the roots especially in the region of the upper molars
 On the palatal side of the alveolar process the soft
tissue often happens to be very thick.
there are some disadvantages
regarding the insertion between the roots of
the upper molars :

122. 
 If the mini-implant comes into contact with a root,
periodontal structures may be damaged and the risk
of failure of the mini-implant will be higher.
 small implant diameters also mean a higher risk of
fracture and a higher risk of failure.

123. 
 The intrusion may be stopped and the root surface
may be damaged when the molar is moved against a
mini implant during intrusion..
 There is a risk of penetration of the maxillary sinus
when a mini-implant is inserted in the posterior area
of the upper alveolar process

124. 
 The Mousetrap appliance comprises one or two lever
arms connected to two Benefit mini-implants
inserted in the anterior palate, depending on the
need for either unilateral or bilateral molar
intrusion..
 By using a skeletally anchored lever arm, an
intrusive force of approximately 100 g is applied
palatally to the molar. Due to the point of force
application, palatal tipping can be significant and
should be controlled with the use of a TPA.

125. 
 1. A Bene plate with a bracket in place is used . After
wards, a 0.017-inch × 0.025-inch stainless steel lever
arm is bent and ligated to the bracket of the Bene
plate.
 2. A Bene plate with a 0.8-mm stainless steel wire in
place is adapted to the curvature of the palate.
There are two different options to
construct the palatal lever arm for molar
intrusion :

127. 
 1. Using a steel ligature..
 2. Soldering a hook on the TPA that is used as a stop
for the lever arm..
In the posterior region, the intrusive force
can be applied using two different
approaches

129. 
 At first glance its sophisticated design appears to be
more complex and a bit more bulky compared to
other TAD-based appliances.
The Mousetrap is a reliable appliance for
the intrusion of over erupted molars

141. 
• Low surgical invasiveness
• No risk of penetration of the maxillary sinus
• No risk of root damage at the time of insertion of the
mini-implant or during molar intrusion
• TADs can be inserted in an optimum insertion site; the
anterior palate ensures low failure rates and no risk of
mini-implant fracture
• Constant force delivery that is easy to measure and adjust
intraorally
Mousetrap It provides the
following advantages:

142. 
 Treatment of young Class III patients with maxillary
deficiency is mostly conducted with a facemask. Since the
force is applied to the teeth, mesial migration of the
dentition is inevitable and may result in severe anterior
crowding. On the other hand, the desired skeletal effect of
this commonly used approach often turns out to be less
than expected. To overcome these drawbacks and to
minimize mesial migration of the molars, sagittal skeletal
support by the Hybrid Hyrax is very useful. Second, to
facilitate the advancement of the maxilla, opening of the
mid face sutures by RPE is recommended.
RAPID PALATAL EXPANSION AND
EARLY CLASS III TREATMENT

143. 
 Second, to facilitate the advancement of the maxilla,
opening of the mid face sutures by RPE is
recommended. With the goal being to avoid an extra
oral device (facemask) and to apply the forces
directly to the skeletal structures, De Clerck
introduced the use of four mini-plates (two anterior
in the lower jaw and two posterior in the upper jaw)
in combination with Class III elastics. This represents
a new purely skeletal approach to correct the skeletal
discrepancy..

144. 
 To enhance the skeletal effect by opening the mid
face sutures, employs the Hybrid Hyrax appliance in
the upper jaw, allowing simultaneous rapid
maxillary expansion and skeletally borne maxillary
protraction. In the lower jaw the Bollard mini-plates
by De Clerck are usually inserted after eruption of
the canines. To allow earlier insertion of the mini-
plate in the mandible,

145. 
 Dr. Drescher developed the Mento plate. Since the
Mento plate is inserted sub apically to the lower
incisors, it typically can be used as early as age 8 to 9
years. By means of the Hybrid Hyrax in combination
with a facemask or a Mento plate, forces are applied
to skeletal structures only with the goal of achieving
an optimum skeletal effect.

148. 
 The early treatment of an 8-year-old male patient
with a skeletal Class III malocclusion (Wits appraisal
−7.6 mm) is demonstrated and Major complaints
were the sagittal and transversal deficiency of the
maxilla. Two Benefit mini-implants (2 mm × 7 mm)
were inserted after topical anesthesia
Clinical Example Using the Hybrid
Hyrax in Combination with a Facemask

149. 
 Predrilling was not performed due to the low
mineralization of the bone in young patients. The Hybrid
Hyrax with two additional lateral wires was
manufactured in a laboratory and inserted after 4 days .
RPE was started immediately in combination with
application of a facemask. To facilitate the correction of
the negative over jet, a removable plate was made for the
lower arch . RPE was finished after 10 days . After 5
months the Wits appraisal improved significantly to 0.1
mm . This early treatment was finished after 11 months..

156. 
As an alternative to the
facemask, a purely
intraoral treatment
approach can be offered
to patients by using the
Mentoplate.

157. 
 The Mentoplate is a titanium mini-plate , that is
inserted in the mental region. After preparation of a
muco periosteal flap, the two extensions are
shortened and adapted. The extensions should
penetrate the soft tissue in the region of attached
mucosa . After fixation of the Mentoplate by four
screws, the flap is flipped back and fixed by stitches.
The Class III elastics (3.5 oz, 3/16 inch) are worn
immediately after expansion of the maxilla for 24
hours per day.
Introduction of the Mentoplate

158. 
1. Forces are applied directly to (Mentoplate) or are
transferred to (Hybrid Hyrax) skeletal structures
2. Almost invisible mechanics with no extra oral devices
3. The “RPE effect” with opening of mid face sutures for
easier maxillary protraction
4. Stable anchorage with a high reliability
5. Insertion before complete eruption of the lower canines
is possible
6. Low surgical invasiveness
7. Upper and lower arches remain fully accessible for orthodontic
corrections
Advantages of the Hybrid Hyrax–Mentoplate
approach for early Class III treatment are:

159. 
 The combination of the Hybrid Hyrax and the Mentoplate
seems to be a very promising approach for early treatment
of Class III patients.
 Based on the clinical experiences, the Mentoplate
has the potential to be used not only for orthopedic but also
for orthodontics purposes (e.g., lower molar protraction),
since the mini-implant failure rates in the alveolar process
are still too high. As a consequence, the mental region seems
to be the best site for skeletal anchorage in the mandible; it
is the “anterior palate of the lower jaw.”

160. 
 The clinical example presents a 9-year-old girl with a
skeletal class III malocclusion (Wits appraisal −6.7
mm; and Two Benefit mini-implants (2 mm × 7
mm) were inserted and an impression was taken to
manufacture the Hybrid Hyrax . Since the patient
preferred an intraoral approach, the Hybrid Hyrax
was combined with a Mentoplate instead of a
facemask .
Clinical Example Using the Hybrid Hyrax in
Combination with a Mentoplate

161. 
Due to a lack of space for the canines, the Hybrid Hyrax was
removed after the early class III treatment (7 months) and a
Beneslider was inserted for molar distalization in the upper
arch. For this purpose the same mini-implants were used
and a Beneplate with a wire at the long site was employed .
This multipurpose use is one of the advantages when mini-
implants with exchangeable abutments are used. Six months
later bodily distalization of the molars was recognizable.
At the end of the phase I treatment, the Class III dysgnathia
has been improved (Wits appraisal −2.6 mm) and space has
been generated by distalization of the molars.