Temporary anchorage devices in orthodontics


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TAD -skeletal anchorage

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Temporary anchorage devices in orthodontics

  1. 1. Mini implants in Orthodontics. Dr Ravikanth Lakkakula
  2. 2.  Defination of implant.  Introduction.  Historical background.  Parts of implants.  Types of implants.  Bone physiology.  Indications and contraindications.  Treatment planning. Dr Ravikanth Lakkakula
  3. 3.  Treatment considerations.  Sites of implants.  Implant as a absolute anchorage.  Comparision between conventional and implant anchorage.  Surgical procedure.  Comparision of different types of miniimplants.  applications.  Conclusion. Dr Ravikanth Lakkakula
  4. 4. Definition of implant  Implants are defined as alloplastic device (foreign substance i.e.metal,ceramic,plastic) which are surgically inserted into or onto the jaw bone - Boucher  Implantation is transfer of nonliving tissue into biologic system.  Osseointegration: An intimate structural contact at the implant surface and adjacent vital bone, devoid of any intervening fibrous tissue - Branemark (1983). Dr Ravikanth Lakkakula
  5. 5. Introduction  Anchorage control is one of the most important aspects of orthodontic treatment. The success of orthodontic treatment hinges on the anchorage protocol planned for a particular case. Use of extraoral anchorage devices such as headgears requires full patient cooperation, which is sometimes not possible and is unpredictable.  Introduction of implants in orthodontics have solved this problem. Implants have become one of the best sources of reliable anchorage. Mini implants have revolutionized the field of anchorage in orthodontics. Dr Ravikanth Lakkakula
  6. 6. This new modality has been called by several names, some of the popular ones are  Mini implants,  Microimplants,  Skeletal anchorage,  Temporary anchorage Device. Dr Ravikanth Lakkakula
  7. 7.  Use of implants as a source of anchorage has number of advantages as compared to traditional anchorage such as 1. no patient cooperation, 2. easy to use, 3. shortening of treatment time, 4. good control on tooth movements. Branemark and co-workers" (1965) reported the successful osseointegration of titanium implants in bone; many orthodontists began investigating in using implants for the purpose of orthodontic anchorage. Dr Ravikanth Lakkakula
  8. 8. Historical background. • The concept of metal components inserted into maxilla and mandible to enhance the orthodontic anchorage was first published in 1945 by Gainsforth and Higley ,with use of vitallium screws to effect tooth movement in dog ramus. Despite some success ,the resultant tooth movent was limited due to implant loosing within one month of commencing toth movement.  Two decades later, lincow(1969, 1970) used endosseous mandibular blade-vent implants in a patient to apply class II elastics , but did not report on long term stability. Dr Ravikanth Lakkakula
  9. 9.  Vitreous carbon implants showed failure rate of 67% , when undergoing orthodontic loading and atempt at using bioglass coated ceramic implants for orthodontic anchorage were almost as disappointed.  All the above materials are compatible with bone but none of them showed consistent long term attachment of bone to implant surface, which means they did not achieve true osseointegration. Dr Ravikanth Lakkakula
  10. 10.  In 1964, Branemark 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 lightmicroscopic view. Since then, dental implants have been used to reconstruct human jaws or as abutments for dental prostheses.  The first clinical report in the literature on the use of TADs appeared in 1983 when Creekmore and Eklund used a vitallium bone screw to treat a patient with a deep impinging overbite by intruding upper incisors. Dr Ravikanth Lakkakula
  11. 11.  In 1984, Roberts et al corroborated the use of implants in orthodontic anchorage. 6 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. Dr Ravikanth Lakkakula
  12. 12. Idea of absolute anchorage creekmore(1983) Ankylosed tooth Kokich(1985) Dental implants Roberts(1990,2002) Shellhert(1996) onplants Block(1995) Orthoplants(palatal implants) Wehbein(19996) Zygoma ligatures Melsen(1998) miniscrews Costa(1998) Paik(2002) Miniscrews with miniplates Umimori(1999) Chang(2002) Clerck(2002) Kanomi(1997) Park(2001,2002) Lee(2001) Bae(2002) Dr Ravikanth Lakkakula
  13. 13. Parts of implant • Implant head – It serves as the abutment and in the case of an Orthodontic implant, could be the source of attachment for elastics/ coil-springs. • Implant body- It is the part embedded inside bone. This may be a screw type or a plate type . Thescrew and plate design that has been used in Orthodontics as the skeletal anchorage system varies from these conventional plate implants.  Implant Neck- It is the part of the implant which connects the Head and the Body. Implant head Threads in the Implant body Dr Ravikanth Lakkakula
  14. 14. Types of the implants Dr Ravikanth Lakkakula
  15. 15. Implants Endosteal subperiosteal transosseous Root form plate/blade form Dr Ravikanth Lakkakula
  16. 16. Depending upon area of implantation - endosteal -subperiosteal -transosseous Dr Ravikanth Lakkakula
  17. 17. Endosseous implant  These are partially submerged and anchored within bone. These have been the most popular and the widely used ones. Various designs and composition are available for usage in specific conditions. The endosseous implants are most commonly employed types for orthodontic purposes. Dr Ravikanth Lakkakula
  18. 18. Subperiosteal implant  In this design, the implant body lies over the bony ridge. The subperiosteal design currently in use for orthodontic purposes is the “Onplant”. Dr Ravikanth Lakkakula
  19. 19. Transosseous implants  In this particular variety, the implant body penetrates the mandible completely. These have enjoyed good success rate in the past. However they are not widely used because of the possible damage to the intrabony soft tissue structures like the nerves and vessels . Dr Ravikanth Lakkakula
  20. 20.  Depending upon their shape - Screw type. -Bladed type. -Cylindrical. • Based on the configuration design . -Root form implants: These are the screw type endosseous implants and the name has been derived due to their cylindrical structure . - Blade / Plate implants: Dr Ravikanth Lakkakula
  21. 21. Plate / Blade form – As the name suggests the basic shape of plate or blade implant is similar to that of a metal plate or blade in cross section . Some plate blade forms have combination of parallel & tapered sides. Plate / Blade forms are unique among implants in that they can function successfully in either osseointegration or osteopreservation mode of tissue integration. Dr Ravikanth Lakkakula
  22. 22. According to the surface structure. Threaded or Non-threaded: The root form implants are generally threaded as this provides for a greater surface area and stability of the implant. Porous or Non Porous: The screw type implants are usually non porous,whereas the plate or blade implants (non threaded) have vents in the implant body to aid in in growth of bone and thus a better interlocking between the metal structure and the surrounding bone. Dr Ravikanth Lakkakula
  23. 23. Implant materials  Material must be : nontoxic, biocompatible, possess excellent mechanical properties, and provide resistance to stress, strain, and corrosion. 3 categories :  Biotolerant (stainless steel, chromium cobalt alloys)  Bioinert (titanium, carbon)  Bioactive (hydroxyl apatite, ceramic oxidized aluminum) Dr Ravikanth Lakkakula
  24. 24. Based on material of construction  Gold alloys.  Vitallium.  Cobalt-chromium.  Vitreous carbon.  Aluminium oxide ceramics.  Nickel –chromium vanadium.  Titanium alloy.  Titanium alloy with hydroxyappatite coating. Dr Ravikanth Lakkakula
  25. 25. Alloplastic materials Dr Ravikanth Lakkakula
  26. 26.  Based on condition of exposure of the implant. - Open implants-contact with oral cavity - Closed implants- used for skeletal fixation. Dr Ravikanth Lakkakula
  27. 27. CLASSIFICATION OF IMPLANTS FOR ORTHODONTIC ANCHORAGE 1. According to the shape and size: I) Conical (Cylindrical) a) Miniscrew Implants b) Palatal Implants c) Prosthodontic Implants II) Mini plate Implants III) Disc Implants (Onplants) 2. According to Implant bone contact: I) Osteointegrated II) Non-osteointegrated 3. According to the application: I ) Used only for orthodontic purposes. (Orthodontic Implants) or TAD(temporary anchorage devices) I I ) Used for prosthodontic and orthodontic purposes. Dr Ravikanth Lakkakula
  28. 28. Based on the implant morphology: a) Implant discs ------- Onplant b) Screw designs : i. Mini-Implant ii. Orthosystem implant system iii. Aarhus implant iv. Micro-implant v. Newer systems - Spider screw, - OMAS system, - Leone miniimplant, - Imtec screw etc. c) Plate designs i. Skeletal Anchorage system (SAS) ii. Graz implant supported system iii. Zygoma anchorage system Dr Ravikanth Lakkakula
  29. 29. Bone physiology Dr Ravikanth Lakkakula
  30. 30. IMPLANT-BONE INTERFACE The relationship between endosseous implants and bone consists of one of two mechanisms : Osseointegration : when the bone is in intimate contact with the implant, or fibroosseous integration, in which soft tissues, such as fibers and/or cells, are interposed between the two surfaces. The proponents of the fibro-osseous system of implant retention opinon that the presence of a dense collagenous tissue between implant and bone will act as an osteogenic membrane. Dr Ravikanth Lakkakula
  31. 31. The osseointegration concept proposed by Branemark et al and called functional ankylosis by Schroede . it states that there is an absence of connective tissue or any nonbone tissue in the interface between the implant and the bone. A more accurate term, microinterlock, where tissue and implant are juxtaposed , providing a bioinert fixation with surface porositiy grooves, or beads. Osseointegration refers to the direct contact of bone and implant at the light microscope level . Osseointegration never occurs on 100% of the implant surface. Successful cases will have between 30% -95% of the implant. Dr Ravikanth Lakkakula
  32. 32. Bone Tissue : Three distinct types of bone (woven, lamellar, and composite) are involved in postoperative healing and maturation of the osseous tissue supporting an implant . Woven bone : it has high cellularity, a rapid formation rate (30 µ/day or more), relatively low mineral density, high random fiber orientation an poor strength. It serves an important stabilization role in postoperative healing of endosseous implants . During the initial healing process woven bone fills all spaces at the bone-implant interface. Although capable of stabilizing an unloaded implant, woven bone lacks the strength to resist masticatory function. Dr Ravikanth Lakkakula
  33. 33. Lamellar bone is the principal load-bearing tissue of the adult skeleton. It is the predominant component of a mature bone- implant interface. Lamellar bone is formed relatively slowly (less than 1.0 µ/day),has a highly organized matrix, and is densely mineralized. Composite bone is a combination of paravascular lamellar bone deposited on a woven bone matrix.. Formation of composite bone is an important step in achieving stabilization of an implant during the rigid integration process Dr Ravikanth Lakkakula
  34. 34. The healing potential for an implant is determined by three factors: (1) quality of bone at the site of implantation, (2) postoperative stability of the implant, (3) degree of integration of the interface. Dr Ravikanth Lakkakula
  35. 35. If there is good postoperative stability of the implant in cortical bone, the healing response involves six physiological stages: 1. Callus formation (0.5 month)- initial, 2. Callus maturation (0.5 to 1.5 months), 3. Regional acceleratory phenomenon (RAP) - (1.5 to 12 months) remodeling of the non vital interface and supporting bone , 4. Osseous integration of the interface (1.5 to 12 months)completion of the RAP, increased direct contact of living bone at the interface, 5. Maturation of supporting bone (4 to 12 months)completion of the RAP, secondary mineralization of newbone and increased direct contact of living bone at the interface, 6. Long-term maintenance of osseo integration . Dr Ravikanth Lakkakula
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  38. 38. Biology of osseointegration. Hematoma Callus formation Dr Ravikanth Lakkakula
  39. 39. Bone remodeling Fibrous tissue Dr Ravikanth Lakkakula
  40. 40.  Dr .J.B.cope proposed classified othodontic TAD into two types : Dr Ravikanth Lakkakula
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  44. 44. TREATMENT PLANNING Problem List and Patient Desires Initial Evaluation Chief compliant Medical/ Dental History Review Intra /Extraoral Examination Diagnostic Impression /Articulated Casts Radiographs (Panoramic and Periapical ,CT Scan or Tomography Photographs Treatment Options / Informed Consent Dr Ravikanth Lakkakula
  45. 45. TREAMENT CONSIDERATIONS Suitability for implants  Quantity and quality of the bone  Age of the patient  Reason behing their seeking implant placement. Dr Ravikanth Lakkakula
  46. 46. 1)Bone. Bone quantity and extent of ridge resorption are important factors to assess. 2) Age of the patient. Age of the patient is an important consideration, as implants are problematic if inserted in growing children for the following reasons, 1.The use of palatal implants in anterior maxilla contraindicated because of midpalatal suture being open. Dr Ravikanth Lakkakula
  47. 47.  2.Resorption from the posterior part of the maxilla resulting from growth changes, could lead to exposure of implant into sinus.  3.Posterior part of the mandible continues to undergo growth changes in all the planes of space ,and such as definitive implant placement in these area difficult to estimate.  4.Even when growth is complete and teeth appear fully erupted ,infraocclusion of Implants supported crowns may occur. This is result of minimal continued eruption of adjacent teeth, post adolescence, and is most frequently seen with upper lateral incisors. Dr Ravikanth Lakkakula
  48. 48. Teeth- Number & Existing Conditions 1.Size shape & diameter of existing dentition. 2. Tooth & root angulation & proximity. 3.More than 1.5 mm space between implant and natural teeth. Periodontium Bone support : Quality – Best is the thick compact cortical bone with core of dens trabacular cancellous bone . Quantity – 6mm buccal – lingual width with sufficient tissue volume Dr Ravikanth Lakkakula
  49. 49. The predictable use of implants as a source of orthodontic and dentofacial orthopedic anchorage requires a practical understanding of the fundamental principles of bone physiology and biomechanics. However, a careful evaluation of prospective patients is indicated because many candidates for implant-anchored orthodontics are affected by osteopenia, osteoporosis, or other medical problems. Optimal use of osseointegrated implants requires a thorough knowledge of bone biomechanics, particularly when the patient is skeletally and/or periodontally compromised . Dr Ravikanth Lakkakula
  50. 50. An evaluation of bone metabolism is a key element of the diagnostic workup. The minimal screening procedure involves a careful medical history, evaluation of signs and symptoms of skeletal disease and an assessment of risk factors associated with negative calcium balance. The most prevalent metabolic bone diseases in middle-aged and older patients are: Renal osteodystrophy-poor bone quality (fibrous dysplasia) that is secondary to inadequate kidney function . Hyperparathyroidism-elevated serum calcium is often associated with high-turnover osteopenia (low bone mass) secondary to a parathyroid adenoma . Thyrotoxicosis-high bone turnover leading to osteopenia, associated with hyperthyroidism or overtreatment of hypothyroidism . Dr Ravikanth Lakkakula
  51. 51. Osteomalacia - poor mineralization of osteoid due to deficiency of the active metabolite of vitamin D (I, 25-dihydroxycholecalciferol) . Osteoporosis-usually defined as symptomatic osteopenia ; most common fractures are of the spine, wrist, and/or hip. Fragility of other weight bearing joints such as the knee and ankle are also common problems. Dr Ravikanth Lakkakula
  52. 52. Mucogingival problems Suffient volume is necessary Soft tissue heights of <2mm or> 4mm may present a challenge Oral hygiene Important pre and post implant placement Systemic manifestations 1.Diabetics are predisposed to delayed healing 2. Destructive habits – smoking is contraindicated to placement of implant as delayed or inadequate tissue healing and osseo intergration is noted Radiographic analysis Periapical pathology Radiopaque/radiolucent regions above the inferior alveolar region or below the maxillary sinus. Adequate space above IAN or below maxillary sinus Implant should be placed at a minimum of 2mm from the inferior alveolar cana or below the maxillary sinus Adequate inter radicular area. Bone quality and quantity. Dr Ravikanth Lakkakula
  53. 53. Sites of the implants Dr Ravikanth Lakkakula
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  55. 55. maxilla BELOW NASAL SPINE PALATE INFRAZYGOMATIC CREST Dr Ravikanth Lakkakula
  57. 57. Blue -- safe zone red -- danger zoneDr Ravikanth Lakkakula
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  59. 59. maxilla Dr Ravikanth Lakkakula
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  74. 74. Implant as a absolute anchorage Dr Ravikanth Lakkakula
  75. 75. Classification of anchorage 1.resiprocal anchorage. 2.muscular anchorage. 3.anchorage preparation : tip back and toe – in 4.splinting anchorage. 5.intermaxillary anchorage. 6.extraoral anchorage. 7.cortical anchorage. 8.extraoral anchorage. 9.absolute anchorage. Dr Ravikanth Lakkakula
  76. 76. 1.Resiprocal anchorage  It is depending upon 1.position,tipping,rotation of tooth 2.radicular size. 3.radicular space(dilacerations etc) 4.periodontal support 5.crown condition 6.root condition 7.it can be – mesiodistal,labiolingual,intrusion or extrusion. Dr Ravikanth Lakkakula
  77. 77. 2. Muscular anchorage  It is depending upon 1.lips and cheek strenght. 2.habits such as lips ,cheek, tongue trust. 3.mandibular elevating muscular strenght type. 4.cusps integrity. 5.presence or absence of antagonist teeth. Dr Ravikanth Lakkakula
  78. 78. 3.Anchorage preparation toe-in and tip back.  Anchorage preparation is achived by incorporation of toe in and tip back bends in archwires. sagittal curve(pronounced curve of spee in the maxilla or inverted curve of spee in the mandible(ovoid shape) Responds to toe-in and tip back respectively.  Anchorage preparation in lingual technique same as Far as saggital curve is concerned,but it is other way around as far as horizontal curve is concerned,also archwire must curve towards the labial.(toe-out curve) Dr Ravikanth Lakkakula
  79. 79. 4.Cortical anchorage It is depends upon 1. radicular position with respect to cortical bone. 2. alveolar border narrowing in edentulous space. 3. It is increase with age due to decrease of blood circulation. Dr Ravikanth Lakkakula
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  81. 81. 5.Splinting anchorage  It is usually done with figure of 8 with ligature wire, Depends upon 1.Number of splinting teeth. 2.Radicular Size and shape of splinting teeth. 3.Periodontal support of splinting teeth. 4.Presence of fixed prosthesis(bridges). It offers only mesio-distal anchorage. Dr Ravikanth Lakkakula
  82. 82. 6.Intermaxillary anchorage  Inter maxillary class 2 ,class 3 oblique , vertical and cross elastics used as inter maxillary anchorage.  There are many appliances(functional appliances, appliances with occlusal guide. etc)and fixed (herbest ,twin force, jasper jumper) also used. Dr Ravikanth Lakkakula
  83. 83. 7.Extraoral anchorage 1.inverse chin cup. 2.facemask. 3.facebow. Dr Ravikanth Lakkakula
  84. 84. 8.Anchorage appliances 1.goshgarian trans palatal arch. 2.Expansion appliances -quad helix -bi-helix -separation appliances etc 3.Distalisation appliances-pendulum 4.Nance appliances 5.Lingual or palatine arch 6.Lip bumper. Dr Ravikanth Lakkakula
  85. 85. 9.Absolute anchorage 1.microimplants 2.miniplates 3.zygomatic ligatures 4.conventional implants 5.ankolysed teeth 6.palatine implants 7.onplants. Dr Ravikanth Lakkakula
  86. 86.  There are two basic forms of absolute anchorage Direct anchorage : when active segment is pulled directly from microimplant. Indirect anchorage : when active segment is pulled from the reactive segment, and this segment is fixed to microimplant to incrase anchorage. Dr Ravikanth Lakkakula
  87. 87. Anchorage is a “resistance to unwanted tooth movement ” --- proffit *Group A :- more than 75% of the extraction space is required for retracting the anterior segment. * Group B :- describes symmetrical space closure with equal movement of the anterior & posterior teeth to close the space. * Group C :- this is a category of non- critical anchorage wherein 75% of the space closure is achieved by mesial movement of the posterior teeth. Dr Ravikanth Lakkakula
  88. 88. Methods of Anchorage control Conventional Extra oral Intra oral Head Gear Dental anchors Dr Ravikanth Lakkakula
  89. 89. Problem with Conventional anchors • Head gears require patient compliance so as to be an effective source of anchorage. If the patient is not co-operative enough with the treatment, anchorage preservation becomes a difficult issue to tackle. & • There are also many reported cases of Head gear injuries. Dr Ravikanth Lakkakula
  90. 90. While problems with dental anchors are that, the anchor units experience a reciprocal effect of the forces applied to move the remaining teeth to their optimal positions – thereby tending to move towards the direction of the force applied. Therefore skeletal anchorage through implants is chosen to limit the extent of detrimental, unwanted tooth movement. The paradigm shift is the usage of implant as skeletal anchors to overcome the problems of conventional anchors. Dr Ravikanth Lakkakula
  91. 91. Differece between conventional and implant anchorage Dr Ravikanth Lakkakula
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  93. 93. Surgical procedure Dr Ravikanth Lakkakula
  94. 94. equipments  General armamentarium Basic set of dental instruments sterile tray cover sterile suction tips anaesthesia : local and topical gel  Instruments for self cutting mini screws mucosal biopsy or soft tissue punch Rotary drill Pilot drill Elbow or contra angle hand piece Hand driver or dental hand piece driver for mini screw. Dr Ravikanth Lakkakula
  95. 95. Direct method Dr Ravikanth Lakkakula
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  97. 97. Anchor pro x-ray guide Pilot drill Short and long screw driverDr Ravikanth Lakkakula
  98. 98. Surgical implant Index Prepare an acrylic jig in cold cure acrylic to fit the occlusal surfaces of adjacent teth 0.9mm ss orthodontic wires. Mark likely spot on soft tissue with methylene blue indeliable marker or bleeding point. Align tip of jig wire to this point . IOPA X-ray with jig to determine suitability of site. ACRYLIC SURGICAL INDEX RADIOGRAPHIC EVALUTION Dr Ravikanth Lakkakula
  99. 99. Indirect method Dr Ravikanth Lakkakula
  100. 100.  Surgical procedure for orthodontic implants should be placed on following principles, 1)aseptic principle. 2)atraumatic principle. 3)thorough preoperative examination and precise implant positioning. 4)premedication for pain control. 5)standerised procedure. Dr Ravikanth Lakkakula
  101. 101. Aseptic principle Dr Ravikanth Lakkakula
  102. 102. Dr Ravikanth Lakkakula
  103. 103. Atraumatic procedure  Necrotic bone should be removed to promote the healing of the bone tissue. it is essential to minimize trauma during implant placement to allow favorable healing ,because the necrosis of the osseous tissue inevitable. Dr Ravikanth Lakkakula
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  107. 107.  To promote standardized process, the surgical procedure divided into 1) preoperative examine stage. 2) marking stage. 3) perforating stage. 4) guiding stage. 5) finishing stage. Dr Ravikanth Lakkakula
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  111. 111. Perporating stage There are two ways by which perporate through cortical bone : 1. use of surgical drill. 2.use of an implant. Implant is inserted perpendicular to the surface is recommended to prevent slippage on the surface. The slope of osseuoss tissue should be determined by palpation at earlier stage. Dr Ravikanth Lakkakula
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  133. 133. Possible causes of implant failure 1.infection : the surface of microimplant should be contaminated. 2. hygiene of the patient : tooth brushing and illutories. 3.avoid overload, the pull direction should be perpendicular as possible to the axial direction of implant. 4. microimplants are designed to support 450grams but it is better to use forces under 300grams. Dr Ravikanth Lakkakula
  134. 134. 5.Microimplant mobility provokes inflammatory response to adjacent teeth. If mobility appears, remove and reinsert again same other site. 6.insufficient penetration into bone. (not less than 4-5mm not counting the soft tissue thickness) 7.Oblique insertion angle offers more retention than perpendicular insertion angle, but because it offers a wide contact angle between micro implant and cortical bone. it should be taken account osseo integration should not take place. Dr Ravikanth Lakkakula
  135. 135. 8.Failure to disinfect the area before insertion. 9.Too much heat during insertion due to high velosity. excessive pressure or abscence of irrigation. 10.poor quality of bone and poor density. 11.dry mouth and inflammation. 12.smoker. 13.poor oral hygiene. 14.contact of implants with adjacent roots. Dr Ravikanth Lakkakula
  136. 136. prevention of complications and failures 1.use tapered microimplants. 2.Use a large diameter as possible ,but not smaller than 1mm 3.try to insert micro implants through attached gingiva. 4.Do not press micro implants while inserting them to avoid its fracture. 5.Usually,a long screwdriver will be used in labial zone and a short screwdriver in palatine zone. it is recommendable to tie up the short screwdriver to avoid accidents such as its swallowing. Dr Ravikanth Lakkakula
  137. 137. 6.Avoid oscillatory movements when inserting microimplants to avoid perforating larger diameter into the bone than needed,which than would not serve to retain microimplant. special attention should be paid when perforating palatine surface due to tongue pressure or in labial distal zone ,due to labial commissure tension. 7.check inter radicular space before insertion of micro implant. 8. if there is too much resistance offered when trying to insert micro implant ,repeat drilling using thicker bur. 9.measure adequately the mucosa thickness to determine microimplant’s lenght. microimplant should penetrate into the bone 4-5mm as minimum. Dr Ravikanth Lakkakula
  138. 138. 10.use bur that has a diameter of 0.3-1mm smaller than diameter of microimplant which will depend on the quality of the bone, to perforate the cortical bone, especially in zones where cortical bone is very thick. 11.if closed coil spring or elastic chain is used, check if they do not press the mucosa and if necessary, insert a buffer to avoid its invagination into mucosa. Dr Ravikanth Lakkakula
  139. 139. Prevention of microimplant deformation and fracture.  In case that a significant resistant is encountered when screwing microimplant ,it is recommendable to perforate the cortical bone with a bur that has smaller diameter than microimplant . Special screwdriver have been designed with force controllers which avoids microimplant fracture. Dr Ravikanth Lakkakula
  140. 140. Prevention of peri microimplantitis  By avoiding the infection and avoiding the to overload of microimplant. It is important to take following precautions  Surgical technique : disinfection of surgical field sterilisation of instruments and microimplants ,maitainance of sterilisation according to aseptic norms, not contaminating microimplants during insertion.  Hygiene of the patient : recommended buccal irrigators ,careful teethbrushing.etc. Dr Ravikanth Lakkakula
  141. 141.  The risk is increased in smokers and mouthbreathers.  Force intensity : it should be less than 300grams buy force used in orthodontics is less than 200 grams.  Force should be as perpendicular perpendicular to microimplant direction as possible.at least it should be tried not to exert axial force. Dr Ravikanth Lakkakula
  142. 142. Dr Ravikanth Lakkakula
  143. 143. Dr Ravikanth Lakkakula
  144. 144. DIFFERENT TYPES OF MICROIMPLANTS Dr Ravikanth Lakkakula
  145. 145. Dr Ravikanth Lakkakula
  146. 146. Different companies of miniscrews Dr Ravikanth Lakkakula
  147. 147. Number of miniscrews in the delivery program of different companies. Dr Ravikanth Lakkakula
  148. 148. Different head designs Dr Ravikanth Lakkakula
  149. 149. Dr Ravikanth Lakkakula
  150. 150. The diameter of the trans gingival collar in relation to diameter of the head. To avoid inflammation around the screw (perimucositiis), it is recommended that the diameter of the head should be smaller(A) or equal (B) to the diameter of the head. The gingiva around the screw is difficult to clean if the gingiva is covered by part of the miniscrew(c). Dr Ravikanth Lakkakula
  151. 151. Dr Ravikanth Lakkakula
  152. 152. Dr Ravikanth Lakkakula
  153. 153. Dr Ravikanth Lakkakula
  154. 154. Dr Ravikanth Lakkakula
  155. 155. Screw with design type indication Coupling elements advantage ball or triangular head Mesial and distal translations with restrictions, space closure and intrusion. Elastic chain, tension and coil springs, round wires. Most coupling elements can be easily applied. Orientation of ball head in contrast to screw with hooks is not necessary. Eyelets or holes Mesial and distal translations with restrictions, space closure and intrusion. Round wires,tension springs and elastic chains. No advantage compare to either hook or ball head. Dr Ravikanth Lakkakula
  156. 156. Single slot Uprighting,intrusion ,extrusion, Mesial and distal translations Square and rectangular wires , tension springs and elastic chains. Square and rectangular wires can be used. Cross slot Uprighting, intrusion, extrusion, Mesial and distal translations Square and rectangular wires , round wires,tension springs and elastic chains. The head design has added advantage of permitting the in corporation of Square and rectangular wires for indirect applications that open new horizon in biomechanics for Advanced users of miniscrews. hooks Mesial and distal translations with restrictions, space closure and intrusion. Elastic chain, tension and coil springs, round wires. Most coupling elements can be easily appiled. Dr Ravikanth Lakkakula
  157. 157. Different head designs--companies Dr Ravikanth Lakkakula
  158. 158. Comparision of shanks Dr Ravikanth Lakkakula
  159. 159. Comparision of self drilling and self tapping thread. Dr Ravikanth Lakkakula
  160. 160. APPLICATIONS Dr Ravikanth Lakkakula
  161. 161. APPLICATION OF IMPLANT IN ORTHODONTICS As a Source of Anchorage alone (Indirect anchorage) a. Orthopedic Anchorage - Maxillary Expansion - Headgear like effects b. Dental Anchorage -Space closure of anterior teeth -Intrusion of posterior teeth -Distalization c. In conjunction with prosthetic rehabilitation (Direct anchorage). Dr Ravikanth Lakkakula
  162. 162. ORTHOPEDIC CORRECTION WITH IMPLANTS i) Maxillary Protraction ii) Maxillary Expansion. However, these have been in experimental studies. i) Maxillary Protraction. Smalley et al in 1988 used Branemark implants into the maxilla, zygoma, orbital and occipital bones of monkeys. A force of 600 gm was delivered to maxillary and zygomatic bones . A 12mm widening at the zygomaticomaxillary suture was seen and 16mm widening at zygomaticotemporal suture was observed. The dental changes seen were a 5-7mm change in overjet . However dental tipping also occurred along with skeletal protraction. Dr Ravikanth Lakkakula
  163. 163. ii) Implants for skeletal expansion In 1995 - Movassaghi et al tested fronto nasal suture expansion in rabbits from an implanted titanium screw device. The plates were placed in frontal and nasal bones. After 4 weeks of healing, 55 gm force was applied . Force was applied for 5 weeks and a significant increase in growth to the tune of 6 mm across frontonasal suture was seen. Dr Ravikanth Lakkakula
  164. 164. In 1997 Andrew Parr et al conducted experiments on Midnasalexpansion using endosseous titanium screws. They divided the sample into 3 groups- 1 control and 2 experimental groups. 1 Nand 3N loading forces were applied in the two experimental groups. Their results showed a 92% stability of implants. Sutural expansion of 5.2mm and 6.8 mm respectively was seen in the 1N and 3N load categories. Mineral apposition and bone formation rates were significantly higher in the experimental group. The 3N group showed more expansion but this did not affect the rate of bone formation across the suture Dr Ravikanth Lakkakula
  165. 165. ENDOSSEOUS IMPLANT Implants for dental anchorage a) Implants for intrusion of teeth Creekmore in 1983 published a case report of usage of a vitallium implant for anchorage, while intruding the upper anterior teeth. The vitallium srew was inserted just below the anterior nasal spine . After an unloading period of 10 days, an elastic thread was tied from head of the screw to the arch wire. Within one year, 6mm intrusion was demonstrated along with lingual torque . Dr Ravikanth Lakkakula
  166. 166. Another study by Southard in 1995 compared the intrusion 'potential of implants with that of teeth (denta1 anchors). Titanium implants were placed in extracted 4th premolar area in dogs, followed by an unloading period of three months. Then, an intrusive force of 50-60 gm via 'V' bend was effected. This was compared with intrusive potential of teeth on the other side using the same mechanics. No movement of implant was seen at the end of the experiment whereas, on the other side, the tooth acting as the anchor units tipped severely. Therefore, implants are definitely superior to the teeth acting as anchor units. Dr Ravikanth Lakkakula
  167. 167. b) Implants for space closure Extensive research relating to usage of retromolar implants for orthodontic anchorage has been done by Eugene Roberts. The first clinical trial was on an adult wherein an atrophic extraction site had to be closed. A special implant was developed of size 3.8mm width and 6.9 mm length, which was placed in the retromolar area. A 0.021" X .025" SSwire was used for used for anchorage from the screw around the premolar bracket . The extraction spaces were closed using forces from buccal as well as the lingual sides by activating the lingual arch. The premolar was prevented from moving distally with the help of 0.021 X .025" wire acting as an anchorage. The modification in this technique as suggested by him in 1994 includes the usage of a .019" X.025" TMAwire ---This wire is termed as the anchorage wire. Dr Ravikanth Lakkakula
  168. 168. Dr Ravikanth Lakkakula
  169. 169. A Patient before treatment, showing missing mandibular first molar with mesial tipping of second and third molars into extraction site. B. Beginning of active treatment, with anchorage wire In place. C. Molars translated mesially with no appreciable distal movement of premolars. D. Five months after active treatment, 9 mm of mesial translation of mandibular molar root apices. Dr Ravikanth Lakkakula
  170. 170. Although the retromolar implants popularised by Eugene Roberts are very efficient in preserving anchorage, they suffer from certain drawbacks, which in turn has hindered their acceptance in routine clinical practice. DISADVANTAGE OF RETROMOLAR (ENDOSSEOUS) IMPLANT. The important limitations are : a) Bulkiness of the implant and therefore the non suitability of placement in the inter-dental areas. b) It involves a two stage procedure and therefore a long waiting time before loading the implant. c) Anatomical limitations - such as erupting teeth, nerve canal etc. also add to their minimal usage. d) Cost of the implants - These are the root form implants used for tooth replacement and therefore, very expensive. . Dr Ravikanth Lakkakula
  171. 171. SUBPERIOSTEL IMPLANT THE ONPLANT This is a classic example of a sub periosteal implant in Orthodontics , Developed by Block and Hoffman in 1995, this system consists of a circular disc 8-10 mm in diameter with a provision for abutments in the center of the superficial surface . These abutments would enable the Orthodontist to carry out tooth movement against the Onplant. The undersurface of this Titanium disc is textured and coated with Hydroxyapatite (HA). The Hydroxyapetite ,being bioactive helps in stabilisation of the implant by improving integration with bone. The average thickness (height) of the implant is 3 mm . Lateral view Different shapes Internal surfaceDr Ravikanth Lakkakula
  172. 172. Method of Placement: The onplant is placed by a surgeon through a specialised procedure known as Tunneling. After making an incision in the posterior region of the palate, a sub- periosteal tunnel flap is created extending till the desired location, using an elevator. Care is taken to position the onplant as close to the midline as possible. The onplant is not disturbed for a period of 3-4 months to allow bio-integration. Later, the superficial surface of the onplant is exposed using a trephine and the desired abutment is then threaded on. Various head designs Dr Ravikanth Lakkakula
  173. 173. Dr Ravikanth Lakkakula
  174. 174. Studies on Onplants: Extensive animal studies have been carried out on onplants. They point out to the fact that onplants bio-integrate and can tolerate a maximum force of 16 Ibs(1 pound = 450 grams). Block and Hoffman further suggest that these onplants could be used not only for dental anchorage; for eg: retraction of anteriors or distalising posteriors, but also for orthopedic traction. Human trials are however, limited. Disadvantages of Onplants: a) A long waiting period prior to orthodontic force application.(3 months - osseointegration) b) Excessive surgical intervention - Two surgeries are necessary after onplant placement; one to uncover the onplant cover screw and the other to remove the onplant itself following Orthodontic treatment. c) Cost factor. Dr Ravikanth Lakkakula
  175. 175. OSSEOUS IMPLANT Osseous implants are those that are placed in dense bone such as the zygoma ,the body and ramus area or the mid-palatal areas. The implant systems under this category are the 1.Skeletal Anchorage system, 2. Graz implant supported system , 3. Zygoma anchorage system . Dr Ravikanth Lakkakula
  176. 176. SKELETAL ANCHORAGE SYSTEM The skeletal anchorage system was developed by Umemori and Sugawara. Appliance design It essentially consists of titanium miniplates, which are stabilised in the maxilla or the mandible using screws. The earlier of these miniplates were the conventional surgical mini plates, which are used by Oral Surgeons for rigid fixation. The recent versions of these miniplates have been modified for attaching orthodontic elastomeric or coil springs. Different designs of miniplates are available and this fact offers some versatility in placing the implants in different sites. The 'L' shaped miniplates have been the most commonly used ones, while the 'T' shaped ones have been proposed for usage while intruding anterior teeth . The screws used for fixing the miniplate are usually 2-2.5mm in diameter Dr Ravikanth Lakkakula
  177. 177. Dr Ravikanth Lakkakula
  178. 178. Method of Placement Titanium miniplates were implanted after a local anesthesia with intravenous sedation. First, a mucoperiosteal incision was made at the buccal vestibule directly under the first or second lower molars. The mucoperiosteal flap was then elevated, and the surface of the cortical bone at the apical region of the molar was exposed. An L-shaped miniplate was adjusted to fit the contour of each cortical bone surface and was fixed by bone screws (length, 5 mm or 7 mm) with the long arm exposed to the oral cavity from the incised wound (there are two holes in the long arm of the miniplate; the exposed hole will be used to directly receive the intrusive force). The implant was placed such that it did not interfer with mandibular movement.. All of the miniplates were transfixed at the region of the buccal vestibule. Loading was done after wound is healed. Dr Ravikanth Lakkakula
  179. 179. Dr Ravikanth Lakkakula
  180. 180. Advantage of miniplates The shape of the miniplate can be adjusted to the type of tooth movement: i.e, intrusion of molars, intrusion of incisors, distalization or protraction of teeth, etc., and the thickness of the patient’s bone. Position of the plate can be adjusted during the treatment . It can be placed without destroying the teeth or bone The anchor plates are monocortically placed at the piriform opening rim, the zygomatic buttresses, and any regions of the mandibular cortical bone. The anchor plates work as the onplant and the screws function as the implant, SAS enables the rigid anchorage that results from the osseointegration effects in both the anchor plates and screws All portions of the anchor plates and screws are placed outside the maxillary and mandibular dentition, so the SAS does not interfere with tooth movement Dr Ravikanth Lakkakula
  181. 181. Distalization of molars It is possible to distalize the mandibular molars with anchor plates placed at the anterior border of the mandibular ramus or mandibular body. Distalization of the mandibular molars enables the clinician to correct anterior crossbites, mandibular incisor crowding, and mandibular dental asymmetry without extracting premolars. single molar distalization Extraction of the third molars is done to create the space for the molar distalization. After the buccal segments are leveled and aligned, stiff archwires . L-shaped anchor plates are placed at the anterior border of the mandibular ramus. Then the bands or brackets of the first molars are taken off, and a retractive force is applied to the second molars with an open coil spring. To avoid the side effects of the reciprocal coil spring, the first premolars must be firmly ligated with anchor plates . After the distalization of the second molars, distalization of the first molars is done with the same procedure. Dr Ravikanth Lakkakula
  182. 182. Dr Ravikanth Lakkakula
  183. 183. En masse distalization of the entire buccal segments. Direct retractive force is applied from the anchor plates to the first premolars to perform en masse distalization of the buccal segments. Elastic chains or nickeltitanium closed coil springs usually provide the retractive orthodontic force. Dr Ravikanth Lakkakula
  184. 184. Intusion of lower molar for correction of open bite. Intrusion of the lower molars was achieved with the application of elastic orthodontic force on the SAS , Lingual crown torque was applied to the lower molars with Burstone’s precision lingual arch to avoid buccal flaring during intrusion . Dr Ravikanth Lakkakula
  185. 185. A) L-shaped miniplate for intrusion of molars B) L-shaped for distal movement of molars C) Y-shaped intrusion and distalizaton of maxillary molars D) Straight miniplate for intrusion of molars Dr Ravikanth Lakkakula
  186. 186. ADVANTAGE OF SAS The SAS enables tooth movement to be controlled 3-dimensionally, so that treatment goals can be accomplished, even when the amount of tooth movement required is more than the mesiodistal width of the premolars. SAS, it is not always necessary to extract the mandibular first or second premolars, even in patients with moderate to severe crowding. The molar relationship in patients with symmetric or asymmetric Class III molar relationships can be corrected without having to extract mandibular premolars Dr Ravikanth Lakkakula
  187. 187. ZYGOMA ANCHORAGE SYSTEM( ZAS ) Hugo De Clerck and Geerinckx of Belgium introduced this system in 2002. Appliance design 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 .020 can be fixed with a locking screw. 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. Dr Ravikanth Lakkakula
  188. 188. Method of Placement To place the anchor, an L-shaped incision, consisting of a vertical incision mesial to theinferior 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. The miniplate is covered by the mucoperiosteum and sutured with resorbable stitches. Dr Ravikanth Lakkakula
  189. 189. CLINICAL APPLICATION Orthodontic forces can be applied to the anchor immediately after implantation. To connect the Zygoma Anchor with the anterior teeth, a rigid power arm was designed to fit in the large vertical slot of a canine bracket .The hook at the end of the power arm is situated at the level of the canine’s center of resistance. A nickel titanium closed-coil spring with a force of 50-100g is attached between the power arm on the canine and the Zygoma Anchor, so that the direction of force is parallel to the main archwire Dr Ravikanth Lakkakula
  190. 190. ADVANTAGE 1. Miniscrews are small enough to be placed between the roots of the teeth in the alveolar bone.By connecting two or more miniscrews, the orthodontic reaction forces can be neutralized. 2.The surgical procedure is uncomplicated because the screws are placed directly through the gingiva, without a mucoperiosteal flap, and can be loaded immediately after insertion. 3.Miniscrews can be used in the anterior or posterior region and attached with elastics or coil springs to the fixed appliance for direct anchorage. 4.Anchorage can be adapted to changing treatment needs in different parts of the dental arches. Dr Ravikanth Lakkakula
  191. 191. DISADVANTAGE The main disadvantage of these screws is their proximity to the roots, which may be damaged during placement of the screws or when the adjacent teeth are displaced 5.The ZAS uses three miniscrews, increasing total anchorage over other types of implants. 6.The point of application of the orthodontic forces is brought down to the level of the furcation of the upper first molar roots. 7.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. Dr Ravikanth Lakkakula
  192. 192. ORTHOSYSTEM IMPLANT Developed by Wehrbein, this is a titanium screw implant with a diameter of 3.3 mm inserted into the median palate or the retromolar regions of the mandible or the maxilla . The implants are surface treated with sand blasting and acid etching for reducing to improve integration. They are available in two sizes of 4 mm and 6 mm length. An 8 week waiting period has been suggested before applying forces onto this implant. Dr Ravikanth Lakkakula
  193. 193. GRAZ IMPLANT SUPPORTED PENDULUM Graz implant supported system introduced by Karcher and Byloff, this anchorage system consists of a modified titanium miniplate, with provision for four miniscrews, and two oval shaped cylinders. This was used mainly as a support for the Nance button of a pendulum appliance in the palate . This system can be loaded within 2 weeks to distalize and anchor maxillary first and second molars .. Dr Ravikanth Lakkakula
  194. 194. Appliance Design It consists of a simple surgical plate (15 X 10 mm) . Two cylinders (10 mm long and 3.5 mm in diameter) are soldered at right angles to the center of the plate. The plate is fixed to the palatal bone via four 5-mm-long titanium miniscrews.The 2 cylinders perforate the palatal mucosa to enter the oral cavity .The entire anchorage device is constructed of 100% titanium. No auxiliary wires are bonded to the premolars, making the GISP removable . In the palatal portion of the resin body are 2 cylindric slots that correspond to the 2 cylinders . The system is based on a telescopic principle:the 2 slots of the removable pendulum (RP) are placed over the 2 fixed cylinders of the implant . Dr Ravikanth Lakkakula
  195. 195. CLINICAL APPLICATIONS Surgical placement and orthodontic procedure The surgeon exposes the anterior part of the palate for insertion of the anchorage plate by preparing a mucoperiosteal flap . If third molars are removed at the same time, the procedure is carried out under general anesthesia. The titanium plate with the 2 cylinders is fixed via four 5-mm-long titanium miniscrews to the bony palate in the median palatal area. Dr Ravikanth Lakkakula
  196. 196. The plate can be positioned so that the cylinders are positioned either mesiodistally along the palatal suture, or one to the right and one to the left (i.e, rotated 90degrees). The area is then covered again with the flap, which has been incised to let the 2 cylinders pass through. After 1 to 2 weeks of healing, an impression is made of the maxillary arch and the palate , and a plaster model is made of the maxilla and titanium cylinders. The removable Pendulam Appliance is fabricated in the laboratory and then placed onto the 2 cylinders in the patient's mouth. Dr Ravikanth Lakkakula
  197. 197. The TMA springs are extraorally activated prior to insertion to generate approximately 250 g of force at a 45-degreeangle . The Removable Pendulum is then slid onto the 2 cylinders , and the 2 TMA springs are introduced into lingual sheaths on the maxillary first molars. At the same time a 0.020- inch stainless steel round sectional wire is inserted into the tubes on the first and second molars. A nickel-titanium alloy (Ni-Ti) push-coil distalizes the second molar with approximately 100 g of force. Once the second molar is sufficiently distalized, the force of the push-coil is reduced to be barely active. The TMA spring of the Removable Pendulum is then stronger than the passive push-coil between the first and second molar. In this way the first molar is more effectively moved distally, since the force of the distalizing force is focused primarily on it, while the second molar is kept in the desired position. Dr Ravikanth Lakkakula
  198. 198. Advantages of Osseous implants: The osseous implants, specially the mini plate designs offer the Orthodontist a fair chance of success in effecting complex tooth movements such as molar intrusion. True intrusion of upper and lower molars in moderate anterior open bite cases converts a borderline orthognathic case into an orthodontic one. This emerging new area of implant application has been termed as 'Orthognathic Orthodontics limitations of Osseous implants: Disadvantage 1. They need a fairly complex surgery and therefore have to be placed by a surgeon. 2. The chances of infection are greater than the screw implants. 3. Their removal is as difficult as the placement . Dr Ravikanth Lakkakula
  199. 199. INTERDENTAL IMPLANTS These implants are endosseous implants but of smaller diameter, which allows placement in interdental areas. They rely more on mechanical retention than complete osseointegration .They are favored over the retro molar implants due to the following reasons: a) Placement is very simple and can be done under L.A. b) They seem to be equally effective in resisting forces as the larger root form implants. c) They can be used for bringing about all types of tooth movement . d) Removal is an uneventful procedure . Dr Ravikanth Lakkakula
  200. 200. Molar uprighting A micro-implant (1.2mm in diameter, 12mm in length) was placed in the maxillary tuberosity. A longer microscrew was used than in the lower retromolar area because the cortical bone is much thinner in the maxillary arch than in the mandibular arch. After two weeks of healing, 70g of force was applied with between the microscrew and lingual cleats on the buccal and lingual surfaces of the second molar . Four months later, the second molar showed considerable uprighting Dr Ravikanth Lakkakula
  201. 201. A micro-implant (1.2mm in diameter, 8mm in length) was placed in the retromolar area distal to the second molar, and a ligature wire was extended outward for elastomeric force application . To avoid root damage, only 50g of orthodontic force was applied . The molar was uprighted after eight months of treatment, and bracket was bonded to it for further movement. Dr Ravikanth Lakkakula
  202. 202. SPIDER SCREW The Spider Screw is a self-tapping miniscrew available in three lengths--7mm, 9mm, and11mm--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. Dr Ravikanth Lakkakula
  203. 203. It comes in three heights to fit soft tissues of different thicknesses: A . regular, with a thicker head and an intermediate-length collar; B . low profile, with a thinner head and a longer collar; and C . low profile flat, with the same thin head and a shorter collar . 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. Applied forces can range from 50g to 200g, depending on the quality of the bone and the orthodontic movement desired Dr Ravikanth Lakkakula
  204. 204. MINISCREW ANCHORAGE SYSTEM(M.A.S) Developed by Incorvati ,Carano and et al Appliance design The screws used in the M.A.S. system are made of medical grade 5 titanium, they have a conical profile and are available in three diameters. Type A ----- has a 1.3 mm diameter at the height of the neck of the implant, and 1.1 mm at the tip. Type B ------has a 1.5 mm diameter at the neck and 1.3 mm at the tip. The overall length for both Type A and Type B is 11.0 mm. Type C ---------has a 1.5 mm at the neck and 1.3 mm at the tip with 9mm of total length. Dr Ravikanth Lakkakula
  205. 205. The head has a shape of two spheres ( 2.0 mm the lower sphere and 2.2mm the upper) that are fused together, with an internal hexagon for the insertion of the screw driver. There is a 0.6 mm aperture placed perpendicular to the length of the screw where a ligature wire or auxiliary monkey hook can be attached. In the junction point between the two circles, a slot is present for the attachment of elastics, chains or coil springs . Dr Ravikanth Lakkakula
  206. 206. ADVANTAGE OF MINISCREW ANCHORAGE SYSTEM: . Independency from the number or position of the present teeth . Optimal use of the pulling forces. . Independency from patient cooperation. . Patient comfort. . Shorter treatment time .(not need to prepare dental anchorage). . Easy and fast screw insertion. . Possible application even in interceptive therapy . Advantages when compared with other osteointegrated systems: . VersatiIity in the insertion sites . Easy insertion and removal . Immediate loading . Application in growing patients . Lowcost Dr Ravikanth Lakkakula
  207. 207. CLINICAL APPLICATION Closure of Space For posterior space closure the anterior-posterior location of the miniscrew is between roots of the first molars and the second bicuspids roots. Vertically the miniscrew should be located at or above the mucogingival line depending on the desired line of action. For intrusion and distalization –above the mucogingival line. For retration movement –at level of the mucogingival line. Higher the screw in the maxilla the more perpendicular ,it is inorder to avoid damage to the maxillary sinus .Ideally it is 30- 40 degrees . In case the alveolar process is to prominent an auxillary attachment (monkey hook) is used it avoids discomfort and possible ulceration of the gums. In the mandibular arch care should be done to avoid the mental foramen. Dr Ravikanth Lakkakula
  208. 208. Dr Ravikanth Lakkakula
  209. 209. Dr Ravikanth Lakkakula
  210. 210. Symmetric intrusion of the incisors To intrude the upper incisors the screw is placed between the upper lateral incisors and the canines. The placement of the mini-screws should be done after leveling and alignment, in order to maximize the inter radicular space at the placement site. In order to avoid tipping the upper incisors buccally during the intrusion, the end of the archwire should be cinched back . Dr Ravikanth Lakkakula
  211. 211. Correction of cant of occlusal plane  The facial asymmetry is often associated with canting of occlusal plane. the cant in the occlusal plane may compromise the beauty, facial profile, with concurrent canting the lip line.  The canted occlusal plane can be corrected with extrusion of teeth on the side with more superiorly placed teeth, using vertical elastics.  The intrusion of the extruded side, however cannot be achived with coventional orthodontic mechanics. Dr Ravikanth Lakkakula
  212. 212.  The microimplant can be placed in buccal alveolar bone can apply intrude force to the posterior teeth, and can be used to correct the canted occlusal plane.  During the intrusive movements, it is very important to center the mini-screws in between the roots of the teeth that need to be intruded in order to avoid the interferences between the teeth and the screw. Dr Ravikanth Lakkakula
  213. 213. Molar intrusion  The extruded molar required pure molar intrusion along the long axis the tooth without extrusion of the adjacent teeth.  The c-res of the upper molar is expected to be at the center of the occlusal table , close to the palatal root. Dr Ravikanth Lakkakula
  214. 214. The recommended insertion points are mesial interdental area of the buccal surface and distal interdental area on the palatal side, or viceversa. Dr Ravikanth Lakkakula
  215. 215.  In this way a combined buccal and palatal force can pass throught the c-res .  Additional miniscrews are placed either side of the alveolar slope to increase the adjustability of the force direction.  three or four miniimplants are useful to prevent or correct the tipping of the molars . Dr Ravikanth Lakkakula
  216. 216. Dr Ravikanth Lakkakula
  217. 217. Enmass anchorage loss(molar mesialisation)  To avoid mesioinclination of posterior teeth and retroinclination of anterior teeth during molar mesialisation ,mechanics are followed  A long hook is welded to the first molar band and microimplant is inserted from distal from the canine in the c-res ,in this way molar can be moved mesially without side effects. Dr Ravikanth Lakkakula
  218. 218. Intermaxillary anchorage Class II correctionis done by elastics or anterior repositioning appliances (i.e. Jasper Jumper, Bite Fixer, etc. There are numerous unwanted side effects of those kinds of mechanics, such as excessive anterior movement (proclination and protrusion) . To address the above problems one alternative may be to place MAS between the roots of the first and second lower molars or between the root of the second bicuspids and lower first molars, in this way the upper arch can be retracted without any unwanted dental effects on the lower teeth. The placement of the MAS mesial to the lower molar may also prevent the mesial movement of the entire lower arch because the MAS, when in contact with the lower molar, may not allow it to move anteriorly. More research is needed to verify the clinical results. Dr Ravikanth Lakkakula
  219. 219. Lingual orthodontics  To facilitate and minimize the appliance.  Minimize the friction.  Minimize the requirements of patient co-operation.  Minimize the force.  Maximize the anchorage. Dr Ravikanth Lakkakula
  220. 220. Asymmetric expansion Dr Ravikanth Lakkakula
  221. 221. FUTURE OF IMPLANT(BIOS). The ideal implant design would be one that would be simple to place as well as remove, causing minimum discomfort to the patient. At the same time, they should be optimum in resisting the conventional Orthodontic forces. One would be looking at newer designs, which could be placed by an Orthodontist himself. Also, since the implants need not last for a very long time, biodegradable implants may be a lucrative option. Biodegradable screws made of L-polylactide have been introduced by Glatzmaier et al and are currentlyundergoing clinical trials. The system, termed as theBIOS (Bioresorbabale implant for Orthodontic systems)consists of resorbable polylactide with a metal abutment. Dr Ravikanth Lakkakula
  222. 222.  The bio resorbable implant anchor for orthodontics system (BIOS) implant is designed to provide orthodontic anchoring functions in adolescents and adult patients, and to then be resorbed without a foreign body reaction or signs of clinical inflammation.  Shear strength and maximum vertical strength have been measured in biomechanical in vitro tests. BIOS fixtures can be loaded with horizontal shearing forces of 50 N with a mean deflection of 0.26+0.13 mm and mean vertical removal forces of 155+80 N.  Clinical studies are currently being undertaken to evaluate clinical practicability and biocompatibility of the BIOS implants. Dr Ravikanth Lakkakula
  223. 223. CONCLUSION Implants for the purpose of conserving anchorage are welcome additions to the armamentarium of a clinical Orthodontist. They help the Orthodontist to overcome the challenge of unwanted reciprocal tooth movement. The presently available implant systems are bound to change and evolve into more patient friendly and operator convenient designs. Long-term clinical trials are awaited to establish clinical guidelines in using implants for both orthodontic and orthopedic anchorage. Dr Ravikanth Lakkakula