Orthodontic implants /certified fixed orthodontic courses by Indian dental academy


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Orthodontic implants /certified fixed orthodontic courses by Indian dental academy

  1. 1. Orthodontic Implants INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Orthodontic Implants www.indiandentalacademy.com
  3. 3. Introduction  In 1960s, Brånemark et al noticed the biocompatibility of titanium screws in bone tissue. Light microscopic examinations showed bone-to-implant contact; thus, the concept of “osseointegration” developed. www.indiandentalacademy.com
  4. 4.  After this, many studies were conducted to investigate the application of titanium implants in dentistry. An implant success rate of over 90% has been reported in edentulous patients. Decades before, the idea of using dental implants to reinforce orthodontic anchorage showed encouraging results. www.indiandentalacademy.com
  5. 5.  Orthodontic anchorage is defined as “resistance to unwanted tooth movement.” Dentists use appliances to produce desired movements of teeth in the dental arch. According to Newton’s third law of motion, every action has an equal and opposite reaction; this means that, inevitably, other teeth move if the appliance engages them. www.indiandentalacademy.com
  6. 6.  Anchorage is the resistance to the force provided by other teeth or devices. In orthodontic treatment, reciprocal effects must be evaluated and controlled. The goal is to maximize desired tooth movement and minimize undesirable effects. www.indiandentalacademy.com
  7. 7. HISTORICAL PERSPECTIVE  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 rubber bands to retract teeth, but he never presented long-term results. www.indiandentalacademy.com
  8. 8.   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. www.indiandentalacademy.com
  9. 9.  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. www.indiandentalacademy.com
  10. 10.   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. www.indiandentalacademy.com
  11. 11. IMPLANT CRITERIA   Implant materials. The material must be nontoxic and biocompatible, possess excellent mechanical properties, and provide resistance to stress, strain, and corrosion. Commonly used materials can be divided into 3 categories: biotolerant (stainless steel, chromium- cobalt alloy), bioinert (titanium, carbon), and bioactive (hydroxylapatite, ceramic oxidized aluminum). www.indiandentalacademy.com
  12. 12.   Because of titanium’s characteristics (no allergic and immunological reactions and no neoplasm formation), it is considered an ideal material and is widely used. Bone grows along the titanium oxide surface, which is formed after contact with air or tissue fluid. However, pure titanium has less fatigue strength than titanium alloys. A titanium alloy— titanium-6 aluminum-4 vanadium— is used to overcome this disadvantage. www.indiandentalacademy.com
  13. 13.  Implant Size The maximum load is proportional to the total bone-implant contact surface. Factors that determine the contact area are length, diameter, shape, and surface design (rough vs smooth surface, thread configuration). The ideal fixture size for orthodontic anchorage remains to be determined. Various sizes of implants, from “mini implants” (6 mm long, 1.2 mm in diameter) to standard dental implants (615 mm long, 3-5 mm in diameter), have proved to effectively improve anchorage. www.indiandentalacademy.com
  14. 14.  Therefore, the dimension of implants should be congruent with the bone available at the surgical site and the treatment plan. www.indiandentalacademy.com
  15. 15.  Implant shape. This determines the bone-implant contact area available for stress transfer and initial stability. The design must limit surgical trauma and allow good primary stability. It is difficult to identify the “perfect” implant shape. The most commonly used is cylindrical or cylindrical-conical, with a smooth or threaded surface. Studies have shown that the degree of surface roughness is related to the degree of osseointegration. www.indiandentalacademy.com
  16. 16. Mini implants    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. www.indiandentalacademy.com
  17. 17. Materials and Design  Most are made from Titanium alloys. The alloy used for Aarhus Mini Implant is Ti6Al-4V. The Orthodontic Mini Implant (OMI) [Leone, Italy] is made from implant steel 1.4441, which is still used in traumatology. www.indiandentalacademy.com
  18. 18.   The diameter of the threaded portion of the miniscrew varies from 1mm to 2mm. The advantage of thin screw like Abso-Anchor [Dentos, Korea] is the ease of insertion between the roots without the risk of root contact. The drawback is the potential for fracture, which is closely related to the diameter of the screw. (Dalstra M 2004) www.indiandentalacademy.com
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  20. 20.   As the bone density increases, the resistance created by the stress surrounding the screw becomes more important in removal than in insertion of the screw. At removal the stress is concentrated at the neck of the screw. The strength of the screw is optimized by using a slightly tapered conical shape and solid head with a screwdriver slot. www.indiandentalacademy.com
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  22. 22.   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. www.indiandentalacademy.com
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  24. 24.   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. www.indiandentalacademy.com
  25. 25.   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. www.indiandentalacademy.com
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  27. 27. The Spider Screw   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. www.indiandentalacademy.com
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  29. 29.   All three types are small enough to avoid softtissue irritation, but wide enough for orthodontic loading. The biocompatibility of titanium ensures patient tolerance, and the Spider Screw’s smooth, selftapping surface permits easy removal at the completion of treatment. www.indiandentalacademy.com
  30. 30.  Because miniscrews rely on mechanical retention rather than osseointegration for their anchorage, the orthodontic force should be perpendicular to the direction of screw placement. www.indiandentalacademy.com
  31. 31.  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. www.indiandentalacademy.com
  32. 32. Mini Implant Size and Location   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. www.indiandentalacademy.com
  33. 33.  The length of the transmucosal part of the neck should be selected after assessing the mucosal thickness of the implant site. www.indiandentalacademy.com
  34. 34.   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. www.indiandentalacademy.com
  35. 35. Below the ANS, Palate www.indiandentalacademy.com
  36. 36. Infrazygomatic crest www.indiandentalacademy.com
  37. 37. Retromolar region www.indiandentalacademy.com
  38. 38. Alveolar process, Smphysis www.indiandentalacademy.com
  39. 39.   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. www.indiandentalacademy.com
  40. 40. Safety Distance    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) www.indiandentalacademy.com
  41. 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. www.indiandentalacademy.com
  42. 42. Safety Distance Modified    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.  www.indiandentalacademy.com
  43. 43. Insertion   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. www.indiandentalacademy.com
  44. 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. www.indiandentalacademy.com
  45. 45. Zygoma Anchorage System (ZAS)  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. www.indiandentalacademy.com
  46. 46.  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. www.indiandentalacademy.com
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  48. 48.  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. www.indiandentalacademy.com
  49. 49.  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. www.indiandentalacademy.com
  50. 50.   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. www.indiandentalacademy.com
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  52. 52.   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. www.indiandentalacademy.com
  53. 53.  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. www.indiandentalacademy.com
  54. 54. Biomechanics: Extraction www.indiandentalacademy.com
  55. 55.  In conventional sliding mechanics, the frictional forces along the canine and the molar region tend to neutralize each other which may explain why the overjet is not reduced when the first molars are used for the posterior anchorage. www.indiandentalacademy.com
  56. 56.   On the other hand, when the elastics are attached from the canine bracket to the miniscrew or a miniplate in the first molar region, the distal traction on the archwire created by friction in the canine bracket is not counterbalanced by mesial traction from friction in the molar tube. The incisors spontaneously follow the movement of the canine. www.indiandentalacademy.com
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  59. 59.   The remainder of the overjet and overbite can easily be corrected with a T- loop arch once the canines have reached Class I relationship. The intrusive forces required for bite opening in the anterior region generate reactive forces, distal to the T- loops, which tend to cause canine extrusion. www.indiandentalacademy.com
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  61. 61.  The Class I relationship in the buccal segment is maintained by elastic traction between the canine and the bone anchor, which adds a small intrusive component of the force to the canines. www.indiandentalacademy.com
  62. 62. Transverse dimension  In conventional biomechanics, canine and first molar tend to rotate in opposite directions when an elastic traction is applied. www.indiandentalacademy.com
  63. 63.  In skeletal anchorage there is no rotation of the first molar, but the initial canine rotation tends to push the distal end of the archwire towards the midline, leading to crossbite during distal movement of canine. www.indiandentalacademy.com
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  65. 65. Biomechanics: Non Extraction   If anterior teeth are crowded, only a few of the incisors are bonded to support the anterior portion of the archwire. Both upper canines are bonded but the premolars are not. www.indiandentalacademy.com
  66. 66.  After leveling, a sliding jig or a closed coil spring with a sliding hook is placed on an .016” round or .016 X .016” SS archwire between each molar tube and the canine bracket. www.indiandentalacademy.com
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  69. 69.  With skeletal anchorage, the canines are distalized along with the molars, helping to reduce the overjet. This can be explained by the ‘friction hypothesis’. www.indiandentalacademy.com
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  71. 71.  To avoid rotation of the first molar around the palatal root, the second molars should always be bonded. www.indiandentalacademy.com
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  73. 73.   Once the first molars are in Class I relationship, the premolars and remaining incisors are bonded. After a short leveling stage, elastics are attached from the canines to the bone anchors to close the remaining space between the canines and the molars. www.indiandentalacademy.com
  74. 74.  Molars are kept in place with ‘molar holding springs’- .016 X .022” SS inserted in the vertical slot of the bone anchors. www.indiandentalacademy.com
  75. 75.  Once spaces in the buccal segments have been closed, the remaining overjet is corrected and bite is opened with .016 X . 022 SS T- loop archwire. www.indiandentalacademy.com
  76. 76. PALATAL 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. www.indiandentalacademy.com
  77. 77.  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. www.indiandentalacademy.com
  78. 78.  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. www.indiandentalacademy.com
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  80. 80.  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. www.indiandentalacademy.com
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  82. 82. Optimal site for Palatal 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. www.indiandentalacademy.com
  83. 83. Acceptance rate of palatal implants   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. www.indiandentalacademy.com
  84. 84.  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. www.indiandentalacademy.com
  85. 85. Anchorage effect of various shape palatal osseointegrated implants   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. www.indiandentalacademy.com
  86. 86.  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 bone was calculated. www.indiandentalacademy.com
  87. 87.  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 little advantage in increasing the anchorage effect. www.indiandentalacademy.com
  88. 88. Anchorage Effect of Osseointegrated vs Nonosseointegrated Palatal Implants.   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 basis of the clinical situation. www.indiandentalacademy.com
  89. 89.  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. www.indiandentalacademy.com
  90. 90.  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. www.indiandentalacademy.com
  91. 91.  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. www.indiandentalacademy.com
  92. 92. Anchorage loss of the molars with and without the use of implant anchorage  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 premolars. www.indiandentalacademy.com
  93. 93.  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. www.indiandentalacademy.com
  94. 94.  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. www.indiandentalacademy.com
  95. 95.  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 maximum anchorage is desired. www.indiandentalacademy.com
  96. 96. Implant surface geometry and its effect on regional bone remodeling.   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. www.indiandentalacademy.com
  97. 97.  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 of implants. www.indiandentalacademy.com
  98. 98.  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 www.indiandentalacademy.com
  99. 99. SURGERY AND HEALING TIME   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. www.indiandentalacademy.com
  100. 100.   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. www.indiandentalacademy.com
  101. 101.  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. www.indiandentalacademy.com
  102. 102.  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. www.indiandentalacademy.com
  103. 103.    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. www.indiandentalacademy.com
  104. 104.   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. www.indiandentalacademy.com
  105. 105.  Deguchi T, et al (J Dent Res. 2003) quantified the histomorphometric properties of the boneimplant 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. www.indiandentalacademy.com
  106. 106.  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 "threeweek unloaded" healing group were: increased labeling incidence, higher woven-to-lamellarbone ratio, and increased osseous contact. www.indiandentalacademy.com
  107. 107.  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. www.indiandentalacademy.com
  108. 108. DISADVANTAGES OF USING DENTAL IMPLANTS  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. www.indiandentalacademy.com
  109. 109.  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. www.indiandentalacademy.com
  110. 110. INDICATIONS  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 postoperative peri-implant mucositis, www.indiandentalacademy.com
  111. 111. Miniscrews for Molar Intrusion www.indiandentalacademy.com
  112. 112. www.indiandentalacademy.com
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  115. 115. 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.  www.indiandentalacademy.com
  116. 116. Miniscrews for Molar Protraction www.indiandentalacademy.com
  117. 117. www.indiandentalacademy.com
  118. 118. www.indiandentalacademy.com
  119. 119.   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. www.indiandentalacademy.com
  120. 120.  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 edentulous areas. www.indiandentalacademy.com
  121. 121. Uprighting tipped Molars www.indiandentalacademy.com
  122. 122. www.indiandentalacademy.com
  123. 123. www.indiandentalacademy.com
  124. 124.  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. www.indiandentalacademy.com
  125. 125. www.indiandentalacademy.com
  126. 126. www.indiandentalacademy.com
  127. 127. www.indiandentalacademy.com
  128. 128. Group distal movement of teeth using microscrew implant anchorage   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. www.indiandentalacademy.com
  129. 129.  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. www.indiandentalacademy.com
  130. 130.  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. www.indiandentalacademy.com
  131. 131. 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.  www.indiandentalacademy.com
  132. 132.  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. www.indiandentalacademy.com
  133. 133.  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. www.indiandentalacademy.com
  134. 134. IMPLANTS AS ANCHORS FOR ORTHOPEDIC APPLICATIONS    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. www.indiandentalacademy.com
  135. 135.   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. www.indiandentalacademy.com
  136. 136.   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. www.indiandentalacademy.com
  137. 137.  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. www.indiandentalacademy.com
  138. 138. Transitional Implants  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. www.indiandentalacademy.com
  139. 139. The titanium Modular Transitional Implant www.indiandentalacademy.com
  140. 140.  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. www.indiandentalacademy.com
  141. 141. www.indiandentalacademy.com
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  144. 144. Conclusion   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. www.indiandentalacademy.com
  145. 145.  In the future, as developments occur in the implant technology, they may have a significant role as anchorage reinforcement aids. www.indiandentalacademy.com
  146. 146. References   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. www.indiandentalacademy.com
  147. 147.    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;18:14954. Roberts WE, Smith RK, Zilberman Y, Mozsary PG, Smith RS. Osseous adaptation to continuous loading of rigid endosseous implants. Am J Orthod 1984;86:95-111. www.indiandentalacademy.com
  148. 148.    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. www.indiandentalacademy.com
  149. 149.   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;32:53950. www.indiandentalacademy.com
  150. 150.    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. www.indiandentalacademy.com
  151. 151.    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 anchorage. Angle Orthod 1989;59:247-56 www.indiandentalacademy.com
  152. 152.   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. www.indiandentalacademy.com
  153. 153.   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. www.indiandentalacademy.com
  154. 154.   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. www.indiandentalacademy.com
  155. 155.   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. www.indiandentalacademy.com
  156. 156.   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 www.indiandentalacademy.com
  157. 157.    De Clerck H, Geerinckx V, 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. www.indiandentalacademy.com
  158. 158.   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. www.indiandentalacademy.com
  159. 159.    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 www.indiandentalacademy.com
  160. 160. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com