Temporary Anchorage Devices in Orthodontics

Temporary Anchorage Devices

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IN

ORTHODONTICS

Temporary Anchorage Devices

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IN

ORTHODONTICS

Ravindra Nanda, BDS, MOS, PhD UConn Orthodomic Alumni Endowed Chair Professor and I-lead Department of Craniofacial Sciences Chair, Division of Onhodontics School of Dental Medicine

University of Connecticut I-Iealth Center Farmington, Connecticut Flavio Andres Uribe, ODS

Assistant Professor Division of Orthodontics Departmem of Craniofacial S<:ienCe$ School of Dental Medicine University of ConnecliuH Health Center Farmington, ConnedinJ(

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Contr ibutors Aim Acar, DDS, PhD Associate ?rofessor Department of Orthodontics Fawlty of Demistry Marmara University Istanbul, Turkey Geoq~e

Anka, DOS, MS Associate Professor Department of Orthodontics Nihon University DenIal College Tokyo, Japan I lead Orthodontist Sekido Onhodomic Office Tama -shL Tokyo, Japan Peler R. Oi~-dri ch, Prof Or Dr Department of Orthodontics University of Aachen Aachen, Germany

Nejat Erw rdi , DDS, PhD !'rofessor Depanmem of Onhodomics Faculty of DentistI)' Marmara University Istanbul, Turkey Ulrike B. Fri tz, Prof Dr Departmem of Orthodomics University of Aachen Aachen. Germany Peter Goellner, Dr moo dent Depanmem of Onhodomics University of Jl.erne Berne, Switzerland Private Onhodomic Practi<:c Bcrne, Switzerland Brilla A. Jun g. Dr med dent Depanmem of Onhodontics lohannes Gutenberg-University .\Iainz Mainz, Germany Ryuzo Kanomi, DDS, PhD Private Praaice. Onhodomics Himeji, Japan

Martin Kunkel, £>Tor Dr mcd, Dr med dem Senior Consuham Departmem of Oral and Maxillofacial SUl);cry Johannes CUlenberg-Unj"crsily Mainz Mainz, Germany

Monen Godtfredscn Laursen, DDS Clinical Assistant Professor Oll,anment of Orthodontics University of Aarhus Aarhus, Denmark Certified Specialist in Orthodontics ('rival!' and Community Orthodontic Prod;ce Aarhus, DenmJrk Ke.Hoon lee, DDS, PhD Assistam Professor Depanmcnt of Onhodonlics College of DentistI)' Yonsei University Seoul, Korea lames Chen g-Yi Lin , DDS Clinical Assistant Professor Depanment of Onhodontics and Pediatric Demistl)' School of DentistI)' National Defense Medkal University Taipei. Taiwan Al1cnding Orthodontist Department of Onhodontics and Craniofacial Demistl)' Chang Gung Memorial Hospital Taipei, Taiwan Dr. lames Lin and Associates' Orthodontic and Implant Ce nter (privale practice) Taipei, Taiwan Eric Jein-Wein Li o u, DDS, MS Associate Professor Depanmen! of Onhodontics Graduate School of Cr;miofacial Medicine Chang Cung University Taoyung. Taiwan Associate Professor and Oirector Depanment of Onhodontics and Craniofacial DentistI)' Chang Gung Memorial Ilospital Taipei, Taiwan

Hiroshi Kawa mura, DDS, DOSc Professor and Chair Depanment of Maxillofacial SurgeI)' To ho ku University Se ndai, Miyagi, Japan vii

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ConlriDulon

Rln e Melsen, Dr Odont, DOS Profasor OepJrunent of Onhodo11lks Univt'nity of AJrhu5 School of Demisuy A.rhus, Denmark

Yo ung·Chd "ark, DDS, rhO Professor alld De~n Dt>panment of Orthod0!11ics College of Dentistry Yonse' lIniwlsilY Seoul. Korea

Kuniaki Miya;imas DOS, MS, PhD Adjunct ProftSSOr Department of Orthodontics 5t. Loui~ University Ce llier for AdvJnced DentJI Ed u('d lion St. Louis. Missouri

A. "orrodi RillO, DDS, Ph D Pri\'at~ Praclice Leiria, Portugal

~lIrO$ h; Nilgil5al.:a, DDS, DDSc Clinical Professor lkpanmfnt of Maxillofacial Surgei)' Tohoku University Sendai, Miyagi, Japan Director Oepannmu of Oral Surgery Miyagi Children's Il ospil~l Scndai, Miyagi, lapall

Ravindra N and;!., 80S, .\IDS, Ph D UConn Onhodontic Alumni Endowtd Chair Pro(~r

J~ffery

A. Rohens, DDS, MSD Privatl" Practice Roben~ Onhodontio. IndialldpoliJ. Indiana

W, Eugene Roben s, D DS, I'h o , DH ClMoo) Jdr.lb,lk Professor and Head Senion or O rth odontics lndi.ln.l Uni"'N~ity School of Dentistry Jndian.lpolis, Indiarm Aswciatc Professol Depanmcnt of Ordl and Maxillofadal hnplanwlogy Unil'l'rsity of Lille JJ 1'3OIhy of Medicine jjll~, 1'r3l\ce

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Departmenl ofCr.mlofilcbl SCiences Chair, Division of Orthodontics SChool of Dclltal Medicine l1niver~ity of Connw iCl.U Jlcahh ('.enter r.rming\On, Connectiwt Makolo Nish im ura. ODS, DOSe:

Pan·Timl' lecturer Division of Oral Dysfunction Sdl'l\CI' Ikpanml'nt of Onll Ileahh and Dt"'o'elopmcnt Sdrncn Graduate School of Dcmisty lohoku University Scndai, lap~n Orthodomk Faruhy liAS Orthodonlic Centre Ichiban..o:ho Dental Offi~ Sfndai, Miragi, Japan

li yo·Sang I'.lfk, DDS, MS, PhD

Junji Sug~ ... ~r~, DDS, DO Se: Visi ting ClinicaJ Ilrofl!SSOr Dil'ision of Onhodontics Depannti'nt ofCrd lliofacia l &iencl' S<:hool of Dental M~didne Uni\'enoity of ConnOClirut Farmington, ConlWClicul

Director SAS Onhodonlic Centn' tchibant of Cr.lniof;x:ial Scil"11«5 Se:hool of 0e0l~1 Medicine lI ni\'~noity of Connl'Clirul ~Icahh Centl'!' Farmingtun, Conn«ticut

tI.$!IOCi~te Prof"sor Dl'p~r1mem of On hod on tics "rungllQok National University School o{ DenTistry Dal'Su, Korca Clininl Director in the Student Clinic Depdnml'nt of Onhodonlia K)'I.Iugpook Uni""nity liosptl.. l O.legu, I{nru

Serda r O ~ iit1ll"~~ DDS, Ph D Asso<'iate [>rofl'5Wr and Chair Dt:panment of Onhodontics Ca.ziantep Unl\'cfljity Faculty of Dl'nti$l/Y GniJntep, l"ur"ty

Contrlbulors Sunil Wadh wa, DDS Assislalll Professor Depanlnelll of Craniofacial Sciences Unive rsity of Conne<:tiUIl School of Dental " tedicine Farmington. Connecticut

Heiner Wehrbeill. Prof Dr lIIed. Dr mOO dent Professor and I lead Depanmen\ of Onhodomics Johannes Gutenberg·University Mainz Mainz. Germany

ix

Preface I'aliem (OmpliaJlc~, anchorage preservation, and I
ORGANIZAnON Part I, 6iologial Perspettive, addresses the use of endosseous rnini.screws and the biOlogical rnponse to TAOs. Chapter I leviews the historical p.."rspE"Clivf of implant development relative 10 the current (oncepts of bone physiology, surgery, healing. a nd integration. It i$ written to help clinidans develop a Kientilk perspecliv~ (or the effective use of miniKI"eWS. Chapter 2 looks at bone biology and the factors that predict stabi lit)' behi nd m«han icaliy retained ,lI1d 05scous·integrated o rthodontic TAI>$. P~ rt II , Diagnosis ~nd Treatmen t Planning. looks at thl'$l' aspCCI5 for orthodontic rasa that require skeletal ancho rage Chapter J reviews idea) sites for the placement of mini-implants and how to apply orth· odontic fo"... using three·dimensional finite ~)~ment

models (3D I'F.M). Chapter 4 provides a unique ~r. spective of !h~ I{. ] system, since the chapter au th or designed the I{· I System. Chapter 5 det,llls what factol"!i should be add ressed when deciding to usc skeletal anchorage, including the indications (or when skeletal anchorage shou ld be used ~nd the possible failu~ and advi'T"So.' dftcts. p~" Ill , "i"mecha nlcs Consi der.ltion s, offers prag. matic d iscussions r
Chapler 17 revi~s the analomic·.. 1 consider,uion~ in PJlalal implam placement. r~diogr~phic evalualion of bone height aI Ihe implJnI Sill', prt'pannion oflhl' surgical lemplate for posi tioning the implant, Ihe surgical nll'thod, "",a lu.llion o f lhe impl'lIl1 pl" c.emem method, and voHious orthodontic mcchanio used wi th p,llat,ll implallls. Chaplcr 18 looks at a.unmotl ly used 5kelclal ort hodonti c anchot:lge deviO"S and discusses their dini{";I i uSt' and polemial benefits. Sp<.'Cifi{";llly, the chaplet" focuw:s on the USt' of pal~lal implants for orthodontic t'UUllerll l.lsks.

CONTRIBUTORS Thl'" amhOTs who ha,·coontributed to th is book are dini("lll>' 3aivl': many of them are engJgt.-d in ciini{";ll and labomlory reS<'arch ill bone biology, tooth move ml'"lll ,

dinical onhodunllcs. and biomechanics. Thl'"re{o,,~, mos, of the argurnents pUI forw...d in this textbook are based on currenl research finding:;. I lowever, wrn-n con _ dusillC evidence W;t$ nOI available, we presented 3 conS<'nsus founded on 3 significant dCPlh of Cl
NOTE FROM THE EDITOR I was fonun,lIe to work with 3 group of 3U1hol'!l who are among the mOst prominent in the field of orthodontia. We hope Ihal ourdfor15 will St'IVC as a stimulus for further r~3rd1 in Ih ;~ incll:.tsingly impott3nt ~""~ of clinical onhodomia and also provide the much· ne«led impetus loward gt'nual acceptabililY ofTADs in day-Io-day onhodontics.

Acknowledgments lowe a heanfelt thanks 10 my contribUlOrs. Without

I also express my gratitude both 10 Caby Hrkko, who

their cooperation, this effor! could not have come to

during her residency did exhaustive literature resear(h that was instmmental in helping me decide on potemial contributors. and Madhur Upadhyay. who help<.'<1 me in the fin al stages of preparing the manUKript, especially with proofreading o(various chapters. A book like this is nOI possible without the cn(Our· ageme1l1 o( the publisher. I express my sincere thanks to Senior Editor John Dolan (or laking up this project and h~lping me at every step, and my deep grati!Ud~ 10 Counney Sprehe. my developmental editor, (or being the driving fOf((' for Ihis book (,om day one.

fruition. They are innovators. scientists. and super clinicians in the trucst sense, and they haw helped 10 pioncrT a new way 10 address the correction of malocdusions_ I hope they will appreciate the final result and will forget

about my constant pleas to meet deadlines, Flavio Uribe deserves special Te
advice and comments. which were easy to incorporate in development of the book

Ravindra Nanda

lIiii

Contents Part I

BIOLOGICAL PERSPECTIVE

Chapter I

EndO$seot)s Mlniscrews: Historical, Vascular. aM Imegration Perspectives, 3 W. Eugene ROOms and Jeffery A. Roben$

Chapter 2

Biological Response to OrthodOntiC Temporary Anchorage Devices. 14 Sunil WadhwII ""d Ramndm Nand"

Part II

DIAGNOSIS AND TREATMENT PLANNING

Chapter 3

Radiographic EvalUiltion of Bone Sites for Mini-lmplant Placement 25 Kuniaki Mi,'a jima

Chapter 4

Miniature Osseorntegrated Implants for Orthodontics Anchorage, 49 Ryuw Kanllm; and IV. Euge"e Rolwm

Ch apter 5

FaclOr'> in the Decision to Use Sl:eletal Anchorage, 73 /line Mei5ell and Monell Godtfrl'dsen tauf$I!r1

Part III

BIOMECHANICS CONSIDERATIONS

Chapler 6

Biomecnanical Principles in Mmi5Crew-Dr1ven OrthodOntio. 93

Chapter 7

Skeletal Anchorage Based on BiorTle
Part IV

ANCHORAGE DEVICE SYSTEMS AND CLINICAL APPLICATIONS

Chapter 8

Appliances, Mechanics, and Treatment Strategies Toward Orthognathic-Like Treatment Results, 167

Chapter 9

Controlled Occlusal Plane Changes Using Temporary Anchorage Devices, 198

Young-Chel ['ark all(/ Kee·/oon I.£e

Eric Jein-lVein Liou mul I"mes Cheng-Yi Un Gcorge Alibi Chapter TO

Man
George A li bi Chapter 1 I

Skeletal AnchO(age: Different Approaches. 238

Chapter 12

Clinical Application of Microimpjants, 260

Chapter 13

Clinical Suitability of Titan ium Mrcroscrews Ulrike B. fritz ami PCler R. Diedrich

Chapter 14

Treaunem Planning With Endosseous Implants RestO(atiom, 295

A.

Ko.,-odi Rino

H)'o-Snng I'ark fO(

Oithodontic Anchorage, 287 fO(

Orthodontic Anchorage and ProsthodontiC

1'1"'10 Amlre5 Uribe Ilml R"r'indra Nan/iii

Part V

SKELETAL ANCHORAGE

Chapter 1 5

Skeletal Anchorage System Using Orthodontic Miniplates, 317 Junji $uga",ara, MakOID Nishimura, /-lirwhi Nagruaka, ",,,I Hiroshi Ka",amura

Chapter 16

Bone Anchorage: a New Concept in OrthodontICS, 342

Nejat £rverdi mid Serdar OJ",,m<'Z Chapter 17

Palatal Anchorage. 374 Nejlll En-erdi ""d Ahu A(
Chapter 18

Sl:eietal Anchorage in OrthodOntiCS USing Palatal Implants. 392 Heiner lVehrbein, Brilra A. lung, Martin Kunkel, ami Peler GOellner

PART

I

BIOLOGICAL PERSPECTIVE

"

CHAPTER

1

Endosseous Miniscrews: Historical, Vascular, and Integration Perspectives W. Eugene I?obens and Jeffery A. I?oberts

T he explosive development of temporary anchorage devices (TAUs) presents a professional dilemma for onhodomists. Ahhough a large body of evidence suppons oSSRoimegmrl'd anchorage, mOSt miniscrew and microscrew systems currently are HOI d..sjgn~'() for osseous integrution (osscointegration) and were mar· keted with liu le or no fundamcnwl scientific verifica lion. Clinical applications have superseded the scientific rationale for their effective use. In the :lbscnce of adequate (evidence-based) research, dinicians must rely on a limited number of beause of the nature of the malocdusion, the hosl response to the inv,\siwdevice( s), and the biomechan ical approaches favored by the cl inician,

DEFINITION AND DESIGN The TADs (Ompose a broad array of implants used to suppon onhodontic treaune1l1, As presently defined. all TADs are invasive devices and are b-e5t resented for problems that cannOI be effectively managed with

convemional mech anics (Figure \-1, A) . 11Ie anchorage componem may be a biocompatible wire allached 10 the en,tosseous base of an implant design~'d for pros· thetic use. Funhermore, a nonfunctional osseoimegrated implant may serve as an abutment for surgically assisted. rapid palatal expan~ion (I'igure \ . 1. 8) . ·I'h.., products with the longest clinical histOJY of efficacy are os~oimegra ted fixture~ originally designed for pros· thetic purposes. '·' Most current mini5Cl'eW5 are titanium (1i) or titanium aHoy and are manufadured with a smooth. machined surface that is nOI designed 10 osscoilllegratc. By definition. TAOs are temporary devices; no long·(;>ITn functiona l or esthetic role is planned. Thus. most TADs are removed a(ter orthodontic treatment Howe\'er. some osscointegrated TADs may be covered with saft tissue (· put 10 sleep") or retained for sustained I)ros· thetic funnion (see Fi gure I-I. B) . At present, Ihe mOSI common TADs include miniscrews. microsocws, min· ia ture implallts (mini·implants). pal'lml implan ts. modified bone plates. and retromolar im plants, as well ~s functionally loaded prosthetic implanlS. In addition, a TAD may be a temporary prosthetic component (e.g.. bracket allae,hed 10 gold crown) that is removed after treatment (Fib'\lre 1-2). '111erefore. TADs can range from nonintegrated miniscrews 10 implant·$upponed prostheses (ISPs) wilh lemporary onhodontic altlchments.

BACKGROUND At the Bone Research Laboratory at the UniveJ1'iily of Padlic in San Francisco, the authors performed a series of experiments 10 develop onhodontic anchorage devices.'·· .. Titanium miniscrt'ws. 2 mm in diameter with an acid·el(hed surface, were tested in rabbils. dogs. and monkeys from 1980 to 1988. "I'h .. de"ices were very predictable when pla(ed in exlraoral sites such as rab· bit femur a nd nasa l bones. ~""" but the intraoral use of Ihe miniscrews in dogs and monkeys was less successful (failure ratc. - 25%·50%). Failure was defined as 3

4

PART I

BioIogic.. 1 P.-np«live

Figure I-I

A. ~~. a.", III. p~ni~lIY~~'l\ulous nuJocdusion in 4J-Y" ••.()Id WOmdn compliuted by

in ... lin-depe-ndml di.loon n,dlilU' ,....d end-51• •nul d; ... ~ ... II. I.di .t'lfOmolu Impl.nI (TAD) was used 10 ~I;gn and I1l(lW 1M [hird molu maially to "'f\~ .as an arn.umem for 3 6nd pro:Olhn,s; it will 1M' rt'ITIO'-U fkQ,,, ... of!h~ P.l,iml', tw.llh probl~ onhogrmhi<" 5Uf8I'f}' ..-u rIOI a vi.ble option. The rompromi ... trl"ltmtnl in dlt m""iII~f}' arch wal pfrprostlletic alignmemlo opm 'pM~ oow«n tht l1'flh md mcn~ IIw Idl segment maially. The riglll mAXiIl~f)· implam In th~ lubefosiry region wn origin~lly " Icmpordf)' ancho",~ device (TAD), but il w,1I ft'tainw 10 5<:"'" "s a posterior abutment for a removable pania) denmfr.

mobililY or exfolialion of Jhe anchora~ filnure. Similar 10 current reports."" there were 5ignificMlI anatomical limitations rd3tive to where min;screws could be- plaud. Funhennore. sofl ti$SlU' irritalion of cheek. tongue. and alveolar mUC0$3 was a significant problem. The biomechanical possibilities "·ere wmpromised bec:ause of a lack of torsio,,~1 resistan«-. panicularly when immediately loaded. Unlt5s m;niscrews are os5tOimcgrated, Ihe m,»t reliable mechanics are for the line of force to pass through the implam, nOI ideal for treaUnenl of mo§t malocclusions, The use of lever am,s 10 improve Ihe line of force may result in unfavor.lblc mO!llen~' on the implant. It Is impomnt to nOll' that the limitalions of Ihe miniscrews tested more than 20yearsago in Ih~ authors' laboratory are similar to Ihe omenl predictability for these devicts."" ThUs. it is apparent that Ihe biological efficaq of miniscrews is lagging th~ rapid increasc in their dinical usc. This s<:.mario is ~imilar 10 Ih~ initial d('\·elopmem of denial implanl$ befOTe Ihe welldocumenled introduction of "osseoinlegralion" in Ihe early 19805." The 2· mm, acid·et(hed Ti minis<:rt..'W$ develop·ed in Ihe alllhors' laboralory were never used in patients b«ause th e intraoral animal data were considered inad_ equale 10 secure institutional review board (tRill approv~1 for a clinicallrial. Because of the long history of clinical su(c~ without any serious complicatioru (e.g., osteomyelitis. neoplasms), siandard 8ranemark (Swedish) prosthetic fu:lura wer~ adapted for orthodontic anchora~. These relatively large implants (3.75 x 7 mm) could not be- placed in the alveolar ridge if space closure and arch consolidation were Ih~ objectl\le$ of Iftatment (S« Fig. \.]). I'or malldibular anchorage.

Ihe retromolar area was selected as the optimal si ll'. Indirect anchorage evolved as the mosl effectiw mecha. nism for mOSI applications. ' To a lesser exlent, the luberosity region oflhe m"t.

PERSPEcnVES Dental impla1l1 ancllora~ has progressed from non· imegraled screws (19405)' 10 osseointegraled devkts (1972 10 presenl). The firsl documemed UM: of osseo;n· legraled unhodontic anchorage apparently W~i in a patient trEated from 1912 to 1975 by Dr. Tom Iionon (Columbus, Gwrgia) and Dr. lIilt Tatum (Opelika, Alabama). Dr. Iionon corrected a buccal cr055b;lc (scissors·bi te) with a bite plate and crOS$-claslics anchored by an ossrotntegrated 11 blade implant. cmtom·made and plaud by Dr. Hilt Tatum, a pioneer in the field of implant dentiSlry. In addilion 10 pl~c­ ing the firsl osseointegrated implall\ fat orthodontic

E"dosseous M,,,,u,ews: Historical. VaKu'ar. arid I"trq,atio" Perspectives

5

Il'lapse ofClus II. Division I malocclusion in 47·Y"'ar·old brach),<<'Phalic woman. A malocclusion w.s (feat<"d 35 yean earlier wilh o."",ion of (OUf fin. pll'molaf$. A. T",atment fequiml o~ning SJ)KG 10 replaa th~ mandibulu p",molUll with implants. 8. Onhooomic brackn.....,re att.KhW to the wu ""Il~m for the crowIl1 brio", inVGtirt3 and ClS,ing in gold. C. TIlt crowns "'Ith allach«l brackeu sen>ed :as TAOs for kwling and finMirt3 the mandibul.r ,"th. O. Afte. uea,men, 'he gold crowns ~ mvonnl and the brackm rem
deep·bi!~

anchorage. Dr. Tatum was the developer of the maxil· lary sinus bone graft procedure" and numerou~ other dental implant innOvations'»'" TIlt: field of dental implamology originally embraced what was actually all osseointegratioll "failure" (fibrous implant interface) with the semiphysiologkal tl'nn "pseudoperiodomium.""'''' Ilowever. subsequent research demonstrated that Ihl' fibrous interfa<e W
(Vitallium) blade dental implants have had many years o f (un(lio'131 ~JVice. Most favorable repons involve blades ,hal achieved ossrointegrntion despite being immediately loaded!'" The mOS! reliable dental implant devices currently in use are osseoin(e· grated systems. based directly or indirectly on the biological concept introduced by Brlnemark and his (oliegul'S.'L" l"i~ developmenlal progression likely will repeal ilself with Il!$pea to miniscrew$ because osseoimegralion is a mature technology wilh high reliability. Extension of the biol«h nology of