This document provides an overview of using dental implants for orthodontic anchorage. It discusses the history of implants, defines relevant terminology, and classifies implants based on position, material, size, and shape. The benefits of implants as anchorage devices and various implant designs are described. Acceptable placement sites are outlined as well as surgical procedures and bone-implant interface. Loading protocols, problems encountered, and other applications are summarized. The document concludes by referencing additional sources.

1. PROF (Dr.) SAIBEL FARISHTA

2. • INTRODUCTION
• TERMINOLOGY
• HISTORICAL PERSPECTIVE
• DENTAL IMPLANTS IN ORTHODONTICS
• CLASSIFICATION
• BENEFITS OF IMPLANTS
• IMPLANTS AS ANCHORAGE
• DESIGN OF IMPLANTS
• PLACEMENT SITES
• SURGICAL PROCEDURE
• SURGICAL GUIDES
• BONE- IMPLANT INTERFACE
• IMPLANT MAINTAINENCE
• LOADING PROTOCOLS
• OTHER APPLICATIONS
• MICROSCREW IMPLANT ANCHORAGE SLIDING
MECHANICS
• PROBLEMS ENCOUNTERED
• SKELETAL ANCHORAGE SYSTEM
• CONCLUSION
• REFERENCES

3. Successful orthodontic treatment has always
required intra oral anchorage with a high
resistance to displacement. Extra oral traction
can be an effective reinforcement, but
demands exceptional patient co-operation. The
size, bulk, cost and invasiveness of prosthetic
Osseo integrated implants have limited their
orthodontic application.

4. TERMINOLOGY
• Anchorage : resistance to unwanted tooth movement.
• Temporary anchorage device: device that is temporarily fixed
to the bone for the purpose of enhancing orthodontic
anchorage either by supporting the teeth of the reactive unit
altogether, and is subsequently used.
• Implant : a titanium device placed in the bone that replaces
the root of a tooth and enables the attachment of a
prosthesis.
• Osseo integration : the attachment of bone to the surface of
an implant.
• Immediate loading : a technique in which implants are
restored, and thus, loaded at the time of their placement.

6. 500 B C –Etruscan population
600 A D Mayan population
1700’s John Hunter

7. 1809 Maggiolo
Early 1960 Linkow-
Vent -plant implant
Mid 1960’s – Blade
vent implant

8. Vitallium screw
Flange fixture
Vitreous carbon implants

9. Implants can used in orthodontics ,
with following references
• Implants as a source of absolute
anchorage
• Implants used for anchorage and as
abutments for restorations
• Implant site preparation improved by
orthodontics
• Implants in osteogenic distraction

10. Classification of implants can
be based on :
• Position of the implant can be subperiosteal,
transosseous, or endosseous .
• Titanium is the accepted ideal material for
implant fabrication, but other variants include
gold alloys, vitallium, cobalt-chromium, vitreous
carbon, aluminum oxide ceramics, or nickel-
chromium-vanadium alloys.
• The implant surface maybe rough or smooth,
and may have an additional hydroxyapatite or
titanium-spray coating.

11. 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)

12. Implant sizes
Various sizes of implants:
• Mini implants- 6mm long, 1.2mm in
diameter
• Standard implants- 6-15mm long, 3-5mm
in diameter
• Maximal load is proportional to the bone-
implant contact surface.
• Factors determining the contact area are
length, diameter, shape, and surface
design.

13. Implant shape
• Determines the bone-implant contact area
available for stress transfer and initial
stability.
Commonly used designs are:
• Cylindrical or cylindrical- conical, with a
smooth or threaded surface.
• Degree of surface roughness is related to
the degree of Osseo integration.

14. The main area of dispute focuses on how
an implant gains its support from the
surrounding bone. A screw thread around
the implant surface aids loading of the
surrounding bone in compression,
whereas a smooth cylindrical design
increases implant support when shear
forces are exerted on the bone. Both
these varieties show a more uniform
stress distribution under loading when
compared to other designs.

16. HISTORY
• In 1945, Gainsforth and Higley used vitallium screws and
stainless steel wires in dog mandibles to apply orthodontic
forces.
• 1964, Branemark et al observed a fixed anchorage of
titanium to bone with no adverse tissue response.
• In 1969, Linkow placed blade implants to anchor rubber
bands to retract teeth ,but he never presented long term
results.
• In 1969, titanium implants were stable over 5 years and
Osseo integrated in bone under light microscopy view.
• In 1984, Roberts et al , corroborated the use of implants in
orthodontic anchorage by using titanium screws in rabbit
femur.
• First clinical report in the literature of the use of TADs
appeared in 1983, Creek more and Eklund used a vitallium
bone screw to treat patient with deep impinging overbite.

17. TEMPORARY ANCHORAGE DEVICES
Biocompatible Biological
Osseo integration Mechanical retention
Dental implant
Palatal implant
Fixation screws
Fixation wire
Mini screw
Osseo integration
– ankylosed teeth
Mechanical
- Dilacerated teeth

18. Osseo-integrated implants and
orthodontics
• In malocclusions requiring a high level of anchorage control,
Osseo-integrated implants can be used on a temporary
basis to minimize loss of anchorage.
• Roberts et al, used conventional, two-stage titanium
implants in the retro molar region, to help reinforce
anchorage whilst successfully closing first molar extraction
sites in the mandible. After completion of the orthodontic
treatment, the implants were removed using a trephine and
histologically analyzed. They found a high level of Osseo-
integration had been maintained, despite the orthodontic
loading.
• In another study, Turley et al. used tantalum markers and
bone labeling dyes in dogs to illustrate the stability of two-
stage implants in cases of orthodontic or orthopedic traction.
This work also showed that one-stage implants were less
successful in this role.

19. Benefits of implants in treatment of
malocclusions
• Retracting and realigning anterior teeth with no
posterior support.
• Closing edentulous spaces in first molar
extraction sites.
• Centre-line correction when missing posterior
teeth.
• Re-establishing proper transverse and antero-
posterior position of isolated molar abutments.
• Intruding/extruding teeth.
• Protraction or retraction of one arch.
• Stabilization of teeth with reduced bone
support.
• Orthopedic traction.

21. Block and Hoffman addressed the issue of bone height by
developing a disc-like structure called an ‘onplant’ , which is
designed to be placed under local anesthetic. This hydroxyapatite-
coated disc is 10 mm in diameter by 3 mm thick, and is placed
subperiosteally on the posterior aspect of the hard palate, using a
‘tunneling’ surgical procedure

22. Wehrbein and Merz have developed the Straumann Orthosystem
implant (Institute Straumann AG, Walden burg, Switzerland), which can
be up to 6mm in height, based on the potential bone depth available.
The Orthosystem implant is a one-piece device with an 8-week healing
period. It is composed of a screw-type endosseous section of between
4mm and 6mm in length (depending on palatal depth), a cylindrical
transmucosal neck and an abutment, to which a transpalatal arch
attaches.

23. The increasing desire for early loading of implants used for
orthodontic anchorage led Melsen et al to develop the Aarhus
implant. Due to its small dimensions (6 mm length), this titanium
anchorage screw can be located in multiple sites, including between
the roots of teeth. It is said to allow Osseo-integration to occur even
in the presence of immediate orthodontic loading, providing the
orthodontic forces (25–50 g from Sentalloy springs) pass through the
screw. The strain that develops in the bone surrounding the loaded
screw leads to a local environment in which increased bone formation
results. Due to the size of the screw it can be used in a number of
different locations and can be easily removed when no longer
required.

24. This is a self tapping , commercially pure titanium miniscrew. The
screw can be immediately loaded with forces in the range of 50 to
300g. available in either 1.5mm or 2.0mm diameter. The 1.5mm
comes in lengths of 6, 8, or 10mm. The 2.0mm comes as 7, 9, or
11mm lengths.
The placement of screw requires sufficient bone depth of at least
2.5mm to protect the anatomic structures.

25. Kanomi has described a mini-implant, which is 6 mm in length and 1.2
mm in diameter. This was developed from a mini-bone screw used for
fixing bone plates, is screwed into the alveolus under local anesthetic,
to within 3 mm of the apices of the teeth. Subsequent to healing and
Osseo-integration, a titanium bone plate is fixed to the screw, and acts
as a hook for the attachment of an orthodontic ligature wire to aid
intrusion of the respective teeth. Due to potential oral hygiene
problems, the ligature is not attached directly to the implant.

27. maxilla
BELOW NASAL SPINE
PALATE
INFRAZYGOMATIC
CREST

28. RETROMOLAR AREA
AND MOLAR AREA
ALVEOLAR PROCESS SYMPHYSIS
Mandible

30. Surgical guide for optimal
positioning of mini implant

31. Pre- surgical evaluation

32. Acrylisation

35. Self drilling method

36. Self tapping method- attached
gingival area

37. Self tapping method –
movable mucosal area

38. Bone – implant interaction
• Endosseous implantation in to cortical bone elicits a
unique sequence of modeling and remodeling events
that are critical to healing, adaptation, and long term
maintenance of the bone implant interface.
• Callus formed at the endosteal and periosteal surfaces
is the first vital bone to contact the implant.
• Initial healing response is driven by release of local
chemical factors such as PDGF, TGF-ß and PGs.
• Remodeling of bone- implant interface is of
importance because it is the mechanism for forming a
vital interface between the implant and host bone.

39. Peri implant bone response to orthodontic
loading - Oyonarte et al :AJO august 2005.
• Smaller amounts and less variability in crestal bone loss were
seen in porous surface implants compared with machine
threaded implants in both control and orthodontically loaded
subjects.
• Orthodontic loading does not seem to affect the amount of
direct bone-to-implant contact with Osseo integrated implants.
• Implant surface design appears to be an important determinant
of peri implant bone remodeling with dental implants used as
orthodontic anchorage units.
• Sintered , porous surface implants show more favorable
patterns of bone remodeling under orthodontic loading
compared with machine threaded implants, suggesting that
shorter implant lengths still maintain Osseo integration.

40. Drill free Vs Drill type implants
Drill free advantages:
• Reduce operative time
• Lower morbidity
• Less invasive
• DF had more bone –to-implant contact
and a larger bone area than D type.
• DF had increased level of bone remodeling
and Osseo integration.

41. • For easy removal, low torque is needed
which is proportional to the square of
screw radius.
• Removal torque is directly proportional to
screw radius and bone contact area, which
is proportional to screw radius under same
bone contact ratio.
• When screw radius reduces to one-third/
one-fourth, the removal torque is
decreased by one-ninth / one-sixteenth.

42. As bone density increases, the resistance created by the stress surrounding
the screw becomes important in removal than in insertion of the screw. At
removal, the stress is concentrated in neck, which may lead to fracture.

43. CLINICAL APPLICATIONS OF
THE MINISCREW IMPLANT

44. Intermaxillary
anchorage
Molar intrusion
Molar distalisation
Molar mesialisation
Extrusion
of impacted
canines
Alignment
of dental
midlinesCorrection
of cant
occlusal plane
Symmetrical
incisor
intrusion
Closure of
extraction
spaces

45. Closure of extraction spaces
If both intrusive and distalizing forces are needed ,
miniscrew should be positioned above the mucogingival
line.

46. If the primary movement is to be a distalising
vector, the miniscrew should be placed at
mucogingival line.

47. •Miniscrew placed high in maxilla must be more
perpendicular to bone to avoid damaging maxillary
sinus
•If screw head is at mucogingival level, it should be
inclined a 30- 450 to interradicular bone

48. Symmetrical incisor intrusion

49. Correction of canted occlusal plane
The screws inserted between upper lateral incisor and
canines, upper canines and premolars, or lower lateral
incisor and canines

50. Miniscrew must be centered between roots of
teeth to be intruded to avoid interference
between teeth and screw

51. Alignment of dental midlines

52. Extrusion of impacted canines

53. Molar intrusion

54. Molar distalisation

55. Molar mesialisation

56. Inter maxillary anchorage

57. Upper third molar alignment

58. IMPLANT MAINTENANCE
• After surgery, the surrounding soft tissues
must be maintained to ensure longevity
of implant. Plaque accumulation near the
gingival margin can cause perimucositis.
Prolonged inflammation leads to
breakdown of bone around implants and
peri implantitis. Therefore , patient is
instructed to follow daily plaque control at
home and have periodic professional
care.

59. SCREW LOADING PROTOCOLS
• Implants fulfill the criteria for primary stability, but also
withstand the stress and strain applied. There are
substantial differences between orthodontic and occlusal
forces.
• Orthodontic loads are continuous, horizontal, and usually
20 to 300g.
• Occlusal loads are discontinuous, vertical and are up to
some kilograms.
• To discuss the maximal load, evaluating the design of the
fixtures, the biomechanical requirements, the anatomic
limitations and , the degree of Osseo integration is
needed.

60. HOW LONG SHOULD WE WAIT
BEFORE LOADING?
• If the 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
impose (300gm).
• 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 non
threaded implants.

61. Implant vs. Screw Loading Protocols in
Orthodontics
A Systematic Review
Elizabeth Ohashi; Oscar E. Pecho; Milagros Moron; Manuel O. Lagravere
The Angle Orthodontist: Vol. 76, No. 4, pp. 721–727.
• Eleven articles fulfilled the selection criteria
established. Five studies involved the use of
implants while six involved the use of screws for
orthodontic purposes.
• Conclusions: Loading protocols for implants
involve a minimum waiting period of 2 months
before applying orthodontic forces while loading
protocols for screws involve immediate loading or a
waiting period of 2 weeks to apply forces. Success
rates for implants were on average higher than for
screws.

62. • The short waiting period for healing and Osseo
integration after screw insertion is because of
mechanical retention that is initially obtained.
This gives the screws a sufficient primary
stability to resist orthodontic loading forces,
ranging between 30 and 250 g used in
different orthodontic movements.
• This short waiting period is sufficient for
healing but not for Osseo integration, which is
an important factor in maintaining a rigid
anchorage unit.

63. • Histologically, it has been demonstrated that
the premature load generates the formation
of fibrous tissue between the bone and the
screw. This layer of tissue gives the
mechanical retention for the screw to not
displace in the direction of the applied force.
• In some cases, this layer of tissue can
become granulation tissue because of the
short time given for the formation of a
correct Osseo integration.

64. • Forces applied to implants or screws,should
be proportional to the amount of Osseo
integration, which at the same time
depends on the surface contact between
material and osseous tissue.
• Factors that are involved : increase in
surface are length, diameter, and shape of
the appliance.
• According to Favero et al, there is an
inverse relationship between length and
diameter where if the length decreases, the
diameter should increase.

65. • Liou et al demonstrated that the screws
are clinically stable but not absolutely
stationary when forces are loaded on
them.
• The screws mostly move toward the
direction of the applied force, ranging
from −1 to 1.5 mm displacement.
• For this reason, it is recommended that
they should be placed 2 mm away from
any vital anatomical structure (roots,
nerves).

66. The following conclusions should be
considered with caution because
only a secondary level of evidence
was found.
• Loading protocols for implants involve a
waiting period of a minimum of 2 months
before applying orthodontic forces.
• Loading protocols for screws involve
immediate loading or a waiting period of 2
weeks to apply orthodontic forces.
• The success rates for implants were, on
average, higher than for screws.

67. Implants used for anchorage and as
abutments for restorations
• Cases requiring implants for both restorative management
and orthodontic anchorage require extensive planning
involving the orthodontist, restorative specialist, oral
surgeon, and periodontist.
• There are cost and time implications, and the potential
surgical difficulties of access and local anatomy that may
prejudice against the ideal positioning of a conventional
implant should be borne in mind.
• The dimensions of the implant should conform closely to
the desired emergence profile of the final restoration
without compromising the inter-dental bone. For optimal
aesthetics of the emergence profile, the implant head
should be 2 mm below the cemento-enamel junction of
the adjacent teeth.

68. Implant site preparation improved
by orthodontics
• When there has been bone loss associated with
periodontal disease, which can significantly affect
the aesthetic outcome and prognosis of implant
treatment.
• Teeth that are compromised beyond the scope of
periodontal treatment can be used to develop the
alveolar bone in that region, through orthodontic
traction, to allow the subsequent use of implants.
This ‘forced orthodontic eruption’ of such a
hopeless tooth causes an alteration in the soft
tissue architecture of the periodontium as well as
improving the amount and quality of bone
available for implant placement.

69. Implants in osteogenic
distraction
• Pilot studies on the maxilla and mandible,
undertaken by Ueda et al have illustrated
the use of Osseo-integrated implants to
transfer continuous distraction forces
through the full width of the distraction site.
This has been successfully completed in
mandibular lengthening, maxillary
advancement, and alveolar ridge
augmentation but requires further research
prior to becoming an established technique

71. Step-by-step procedure
MAXILLARY ARCH:
• Placement of microscrew implant into the alveolar bone
between II premolar and I molar on both sides.
• Bonding of 0.022 PEA and transpalatal bar for
maintaining arch form.
• Partial canine retraction; a canine tied back to the
microscrew implant.
• En masse retraction of 6 anterior teeth via 0.016×0.022
archwire hooks ; NiTi closing coil spring conncts the
anterior hooks to the microscrew implant and applies
150g of force on each side.
• Finishing; occlusal settling with vertical elastics.

72. Mandibular arch
• Placement of microscrew implant between the first and
second molars on both sides.
• Partial canine retraction; the canine is tied back to the
second premolar.
• En masse retraction of 6 anterior teeth via 0.019×0.025
inch archwire.
• Application of an intrusive force to upright and intrude
the mandibular molars by ligating an elastic thread from
implant to mandibular archwire.
• Finishing

74. Controlling the mode of anterior tooth
retraction are:
• Occlusogingival position of the implant,
the height of the anterior hooks, and the
amount of torquing curve given on the
arch wire.
• Implant placed low position -4mm gingival
to arch wire distalizing force in non
extraction cases
• Position at 8-10mm gingival to arch wire
retraction of anteriors in extraction cases

75. Characteristics of MIA sliding mechanics
• Allows bodily retraction of 6 anteriors,
while utilizing the force near the center of
resistance.
• Induce early changes of profile.
• Uprighting and intrusion of mandibular
molars induce autorotation of mandible.
• Reduces treatment time.

76. COMMON PROBLEMS ASSOCIATED
WITH MINI IMPLANTS
1.Screw related problems
2.Operator related problems
3.Patient related problems

77. Screw related problems
1. Screw can fracture if it is too narrow or the
neck area is not strong enough to withstand
the stress of removal. The solution is to
choose a conical screw with a solid neck and
a diameter appropriate to the quality of
bone.
2. Infection can develop around the screw if
the transmucosal portion is not entirely
smooth.

78. Operator related problems
• Application of excessive pressure during
insertion of a self drilling screw can fracture
the tip of the screw.
• Over tightening can cause it to loosen. It is
crucial to stop turning the screw as soon as
the smooth part of the neck has reached
periosteum.
• With a bracket like screw head , the ligature
should be placed on top of the screw in the
slot perpendicular to the wire.
• It is important not to wiggle the screw driver
when removing it from screw head.

79. Patient related problems
• The prognosis for primary stability of a mini implant is
poor ,in cases where the cortex is thinner than 0.5mm
and the density of trabecular bone is low.
• In patients with thick mucosa, the distance between the
point of force application and the center of resistance of
the screw will be greater than usual, thus generating a
large moment when a force is applied.
• Loosening can occur , even after primary stability has
been achieved, if a screw is inserted in an area with
considerable bone remodeling because of either
resorption of a deciduous tooth or post extraction
healing.
• Mini implants are contra indicated in patients with
systemic alteration in the bone metabolism due to
disease, medication , or heavy smoking

81. MINIBONE PLATES: THE SKELETAL ANCHORAGE
SYSTEM
• The SAS comprises of bone plates and fixation
screws. They are made of commercially pure
titanium that is biocompatible and suitable for
Osseo integration.
• The anchor plate consists of 3 components – the
head, the arm and the body.
• The head component is exposed intra orally and
positioned outside of the dentition so that it does
not interfere with tooth movement. The head
has 3 continuous hooks for attachment of
orthodontic forces. Two different types of head
based on direction of hooks.
• The arm is transmucosal and in 3 lengths- short
(10.5mm), medium(13.5mm), long(16.5mm).

82. The body is positioned sub- periosteally
and in 3 configurations- T plate, Y- plate
and I plate

83. • Maxillary sites : zygomatic buttress and
piriform rim
• Mandible: lateral cortex in most locations
except adjacent to mental foramen.
• Y plate maxilla at zygomatic buttress to
intrude and distalise upper molars
• I plate in piriform opening for intrusion of
upper anteriors or protraction of upper
molars.
• T or L plate placed in body of mandible to
intrude , protract or distalise lower molars. At
anterior border of ascending ramus to
extrude impacted molars.

84. Advantages
• Made of pure titanium , its safe and stable.
• Do not disturb any kind of tooth system as placed
outside dentition.
• Easy control of occlusal plane.
• Patient compliance not needed
• Significant advantage it allows the achievement of
predictable three dimensional molar movements.
• Timing of orthodontic treatment: orthodontic force is
applied about 3 weeks after implantation procedure,
but before the Osseo integration of the titanium
screws are implants.
• Immediately after orthodontic treatment , all anchor
plates are removed.

85. The concept of temporary anchorage device is a
relatively new application of more established
clinical methodologies. Although the clinician
can look to the literature for many answers,
much is unknown and will only be answered by
well designed prospective basic science and
clinical trials. The future development of
temporary anchorage devices for orthodontic
anchorage will establish a more complete
understanding of biology and biomechanics
associated with both Osseo integrated and non
integrated devices.

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89. THANK YOU