Temporary Anchorage Device (TAD's)

Orthodontic Mini-implants

1. TEMPORARY ANCHORAGE DEVICE By: Dr. Srivani Dept of Orthodontics

2. Introduction Terminology Timeline of dental implant dentistry Physiology of osseointegration Implants structure Classification Indications Contraindications CONTENTS

3. Sites of placement Surgical placement procedure Complications Biomechanical consideration Clinical applications Conclusion References CONTENTS

4. INTRODUCTION

5. 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 non-living 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) Definition Of Implant

6. Gainforth & Higley(1945) first published the use of subperiostel vitallium implant to retract maxillary canines in dog Linkow (1969) described endosseous blade implants with perforation for orthodontic anchorage. Kawahara( 1975) developed Bioglass coated ceramic implant for orthodontic anchorage.

7. Brane Mark ( 1977) Mentor of Modern Implant Surgery described the high compatibility and strong anchorage of titanium in human tissue. Bromer et al 1977, Hench et al 1973 Introduced various bioactive ceramics such as glass ceramic. Sherman' (1978 ) placed the first orthodontic implants.

8. Creekmore(1983) reported the possibility of skeletal anchorage in orthodontics Roberts(1984) used conventional two stage implant in the retromolar region to help reinforce anchorage successfully closing first molar extraction site in the mandible . Turley et al ( 1988) used endo-osseous implants in dogs as anchorage for the application of variety of orthodontic and orthopaedic forces

9. Weherbein and Colleagues (1990’s ) developed palatal implants called “ Straumnn orthosystem ” which was specially designed for orthodontics anchorage Block and Hoffman (1995) introduced the onplant to provide orthodontic anchorage. Kanomi (1997) first reported the clinical use of mini implants for orthodontic anchorage.

10. Physiology of Osseointegration Temporary Anchorage Devices in Orthodontics,Ravindra Nanda

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12. 13 Biology of osseointegration

13. Temporary Anchorage Devices Device that is temporarily fixed to bone for the purpose of enhancing orthodontic anchorage either by supporting the teeth of the reactive unit or by obviating the need for the reactive unit altogether, and which is subsequently removed after use. Jason B. Cope, Shannon E. Owens

14. MINISCREWS: Less surgical procedure and easy installation. Titanium miniscrews are ideal anchorage system well accepted by patients and are simple to insert and remove. The miniscrew can be loaded immediately

15. MINIPLATES: The Miniplate Implants are comprised of bone plates and fixation screws. The plates and screws are made of commercially pure titanium that is biocompatible and suitable for osseointegration. Onplants These are button type implants used in the palatal region. They serve as anchorage source for expansion as well maxillary protraction.

16. osseointegration Application of Orthodontics Mini- Implants Jong Suk Lee, Jung Kook Kim; textbook

17. Implant bone contact osseointegrated Onplants , Orthosystem Advantages Excellent adaptation of the implant to the bone surface Better stability. Disadvantages Two surgical procedures are required – one for placement of the implant & another for removal of the implant. Immediate loading is not possible as adequate time is required for osseointegration.

18. The stability of the implant is by mechanical retention by the threads present in the body of the screw. Eg :- Miniscrews. Advantage Easily placed in the required area with minimum surgical procedure Removed with ease by just unscrewing Non osseointegrated

19. Implant Structure of Implants Head Body (Serves as) Abutment in prosthetic rehabilitation Attachment source for elastics & coil springs in orthodontic treatment

20. Parts of implants The commonly used implant screw/plate has two parts a) Implant head b) Implant body

21. Head The head must be of sufficient dimension. A small diameter and lower profile of the miniscrew head (Lee et al 2009)

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23. Bracket like head design, on the other hand, offers the advantage Eg : Aarhus Mini Implant, Dual Top Anchor System and Temporary Mini Orthodontic Anchorage System

24. Neck Transmucosal portion that passes through the mucosa. • It should be smooth and well polished. • Most miniscrew failure begins with peri-implant inflammation at this site.

25. Screws It embeds into cortical and medullary bone to provide retention. Cutting edge facilitates insertion. Screws are either cylindrical or tapered. Screws are designed as: Self drilling Self tapping types

26. Screw size and diameter Size ranges in – Length : 4-12 mm Diameter : 1.2- 2.7 mm

27. Thread design Self Drilling: It does not require a pilot hole. It has either a sharp or a tapered apex to allow placement or a notch in the tip to drill through the cortex. Self Tapping: These screws are unable to create their own thread as the advance in the bone Two designs are available that are- Thread cutting Thread forming

28. Classification of materials Biotolerant Stainless steel Cobalt chromium alloy Bioinert Titanium Carbon Bioactive Hydroxyapatite Ceramic oxidized aluminium Resorbable Polylactic acid Polyglycolic acid Application of orthodontic miniimplants Jong Suk Lee Jung kook kim Robert vanarasdall

29. Development of microimplants Initially screw were used 1.2 mm in diameter and 5-10 mm in length. Drawback: Lack of superstructure on the head to attach elastics. Ligature wire was tied on neck and bent into hook Hook caused persistant inflammation Now , hooks,button or bracket on head which minimizes inflammation.

30. Design of new mini – implant

31. BIOCOMPATIBLE SMALL AFFORDABLE EASY TO PLACE ROUTINELY RESISTANT TO ORTHODONTIC FORCES ABLE TO LOAD IMMEDIATELY USABLE WITH FAMILIAR ORTHODONTIC MECHANICS EASY TO REMOVE Temporary Anchorage Devices in Orthodontics: Clinical Experimentation or Evidence-Based? Dr. Jason Cope Characteristics of an ideal anchorage device include

32. 1. Length :   2. Diameter: Factors Affecting Success of Mini-Implants- A Review: Dr. Nagarathna KN: The Orthodontic Cyber Journal, Feb 2012

33. 3. Miniscrew head 4. The Trans-gingival Collar:

34. A review of biomarkers in peri- miniscrew implant crevicular fluid (PMICF) Kaur et al;  Progress in orthodontics  2017(18):42-50

35. Factors affecting Primary Stability Primary stability is the mechanical interlocking with the cortical bone when the mini implant is placed. 1. Bone quality

36. 2. Implant design: Length and diameter: Mizrahi E 2007, Mini-implants of 1.4–1.9 mm diameter and 5–8 mm length had the highest success rate Pitch & flutes : Brinley CL et al 2009 analyzed that higher placement torque and pullout strength shown for the 0.75 pitch when compared with 1.0 mm and 1.25 mm pitch

37. c. Self drilling and Self tapping: Chen Y et al in 2008, stated that success rates were higher in the self-drilling group (93%) than in self-tapping group (86%). 3. Material of the screw : Papadopoulos MA et al (2011) reported success rates of 87.7% for both Titanium alloy and Stainless steel. The Stainless steel provides greater mechanical characteristics.

38. 4. Based on the placement site : Martinelli FL et al in 2010 stated that the molars were favorable sites for skeletal anchorage. Placing anchorage in anterior sites requires even more careful planning, 5. Angle of insertion : Park HS et al 2006 Ajodo , suggested that insertion angle of 30°–40° in maxilla and 10°–20° in the mandible

39. Secondary stability occurs due to remodelling of bone. Factors affecting secondary stability: Oral hygiene/ Periodontal health Mucosal type Onset of loading Smoking Secondary Stability

40. Nakagaki  et al 2014 , observed that the bone mineralization of the compression region of cortical bone surrounding immediately loaded miniscrews was significantly higher than that of the tension region. Chaddad et al (2008 Angle orthod ), Elevating a flap for insertion was reported to reduce success rate and resulted in failure of immediate loaded implants and showed screw emergence at the oral mucosa  e.g., palate, retromolar area. Immediate Loading and Delayed Loading

41. Methods of measuring the stability 1. Invasive technique Histological Cutting torque resistance analysis Pullout test 2. Non-invasive technique Radiographs Tapping test/ Percussion test Periotest / Impact hammer method Resonance frequency analysis Finite element analysis

42. Bone density and MISCH classification D 1 Dense cortical bone. Anterior mandible Buccal shelf area midpalatal region D 2 Porous cortical bone with coarse trabeculae Anterior maxilla Midpalatal region Posterior mandible Porous cortical bone with fine trabeculae posterior maxilla Posterior mandible D 3 D 4 Fine trabeculae bone Tuberosity region Misch CE. Contemporary implant dentistry. 2nd ed. Regions frm D 1 to D3 are adequate for TAD insertion. TADS can be placed in D1 to D3 regions with 70-90percent success.

43. Classification of TAD’s 1. Based on the Location: Subperiosteal Transosseous Endosseous 2. Based on the Configuration Design Root form implants Screw designs Blade/Plate Implants Dentos absoanchor implant system Spider screw, OMAS system, Leone mini- implant. Aarhus implant Skeletal anchorage system (SAS) Graz implant-supported system Zygoma anchorage system.  

44. Depending upon the area of implantation Subperiosteal Endosteal Transosseous

45. Screw type Disc type Blade type ii) Depending on shape

46. 3. According to the Composition Stainless steel Cobalt-chromium-molybdenum(Co-Cr-Mo) Titanium Ceramic implants Miscellaneous vitreous carbon & composites Alpha Beta Alpha-Beta phase Ti-6Al-4V 4. According to the Surface Structure Threaded or Nonthreaded Porous or Nonporous Role of Mini-implants in Orthodontics, International Journal of Oral Implantology and Clinical Research, Sep-Dec 2011

47. 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 )

48. 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) II) Used for prosthodontic and orthodontic purposes Temporary anchorage devices in orthodontics, Gowri sankar.Singaraju , Annals and Essences of Dentistry , July – September 2009

49. Temporary anchorage devices in orthodontics, Gowri sankar.Singaraju , Annals and Essences of Dentistry , July – September 2009

50. Temporary anchorage devices in orthodontics, Gowri sankar.Singaraju , Annals and Essences of Dentistry , July – September 2009

51. Indications for placement of implants Maximum anchorage cases Patient with several missing teeth making it difficult to engage posterior units Intrusion of anterior and posterior segments and distalization Where asymmetrical tooth movement is needed To treat borderline cases with non extraction method When patient is not willing to undergo orthognathic surgery

52. Contraindication for Implant Therapy Absolute Contraindications Bleeding Disorders Bone Metabolism Disorders Immuno-compromised Diabetes Mellitus Anti-coagulant treatment Pregnancy Xerostomia Titanium allergy

53. 57 Relative Contraindications Insufficient volume of bone Poor bone quality Patients undergoing radiation therapy Insulin dependent diabetes Heavy smokers.

54. SAFE ZONES 58

55. In green are the zones with a mesiodistal measure over 3.1 mm . In blue are the zones with a mesiodistal measure between 2.9 and 3.1 mm. ‘‘ Safe Zones’’: A Guide for Miniscrew Positioning in the Maxillary and Mandibular Arch, Paola Maria Poggioa ; Cristina Incorvatib ; Stefano Velob ; Aldo Carano†b (Angle Orthod 2006;76:191–197.)

56. 60 Poggio PM, Incorvati C, Velo S, Carano A. ‘‘Safe Zones’’: A Guide for Miniscrew Positioning in the Maxillary and Mandibular Arch. Angle Orthod 2006;76:191–197

57. Safety distance = Diameter of the implant PDL space + 2  + Minimum distance between implant and tooth, i.e 1.5 mm 4.95 mm. 1.2 . 375 1.5 Am J Orthod Dentofacial Orthop .  2005 Jun;127(6):713-22. Dental implants for orthodontic anchorage. Huang LH ,  Shotwell JL ,  Wang HL

58. 63 Insertion Angle Angled insertion either to the long tooth axis or the occlusal plane has been suggested to increase bone-to-implant contact and reduce anatomic structures injury risk. Angled insertion to the long tooth axis of 30°–40° in the maxilla and 10°–20° in the mandible has been suggested. Park HS, Jeong SH, Kwon OW. Factors affecting the clinical success of screw implants used as orthodontic anchorage. Am J Orthod Dentofacial Orthop 2006;130:18-25

59. 64 Angulation to the occlusal plane was suggested to be 30°–45° for the posterior maxilla and mandible  whereas approximately 90° for the anterior maxilla and posterior edentulous maxilla Steeper angulation (<30°) increases miniscrew slippage risk. Lim SA, Cha JY, Hwang CJ. Insertion torque of orthodontic miniscrews according to changes in shape, diameter and length. Angle Orthod 2008;78:234-40

60. Anatomic Regions of Implant Placement & Clinical Applications

61. SITES OF PLACEMENT: MAXILLA Infrazygomatic crest area. Tuberosity area. Between 1st and 2nd molars buccally. Mid palatal Area. Between 1st molar and 2nd premolar buccally. Between canine and premolar buccally. Between incisors facially. MANDIBLE Retromolar Area. Between 1st and 2nd molars buccally. Between 1st molar and 2nd premolar buccally. Between canine and premolar buccally.

62. Selection of Microimplant Sites and Sizes Microimplants with diameters ranging from 1.2 to 1.6 mm are small enough to be placed anywhere in the mouth. Microimplant lengths of more than 6 mm in the maxilla, and 5 mm in the mandible are recommended. Role of Mini-implants in Orthodontics, International Journal of Oral Implantology and Clinical Research, Sep-Dec 2011

63. Uses of orthodontic mini-implants Used for retraction of anterior teeth , Uprighting of molars, Open bite correction. Deep bite correction Molar mesialization Molar distalization

64. Place your screenshot here Maxilla Infrazygomatic Crest Area : Recommended micro-implant size: Diameters of 1.3 and 1.4 mm and a length of 5 to 6 mm.

65. 70 Maxillary Tuberosity Area: Recommended micro-implant size: Diameters of 1.3 and 1.5 mm Length of 7 to 8 mm.

66. Place your screenshot here Between the Maxillary First Molar and Second Premolar Buccally: Recommended micro-implant size: Diameters of 1.2 and 1.3 mm Length of 7 to 8 mm.

67. Between the Incisors Facially Recommended micro-implant size: Diameters of 1.3 and 1.6 mm and a Length of 6 to 7 mm.

68. Place your screenshot here Between the Maxillary First Molar and Second Premolar Palatally : Recommended microimplant size: Diameters of 1.3 and 1.6 mm and a Length of 10 to 12 mm.

69. 74 Mid-Palatal Area Recommended microimplant size: Diameters of 1.5 and 1.8 mm Length of 5 to 6 mm.

70. Between the maxillary 1 st molar and 2 nd molars bucally Recommended microimplants : Diameter of 1.2 and 3mm Length of 7-8mm

71. Between canine and premolar buccally Recommended microimplants Diameter of 1.2 and 1.3mm Length of 7-8mm

72. Retromolar Area Recommended micro-implant size: Diameters of 1.4 and 1.6 mm and a length of 5 to 10 mm. Mandible

73. 78 Between the Mandibular First Molar and Second Premolar Bucally Recommended micro-implant size: Diameters of 1.3 and 1.6 mm Length of 5 to 7 mm.

74. Between mandibular first and second molar buccally Recommended microimplants : Diameter of 1.2-1.4mm Length of 5-7mm

75. Place your screenshot here Mandibular Symphysis Facially Recommended micro-implant size: Diameters of 1.3 and 1.4 mm and a length of 5 to 6 mm.

76. Cleaning and Sterilization 1. Conventional cleaning 2. Ultrasonic cleaning 3. Rinsing and drying 4. Sterilization Microimplant ( AbsoAnchor system)catalogue_ Korean 9th ed jan 2014

77. 5. Step by step sterilization procedures including Microimplants using the kit case

78. 6. Microimplant installation procedures into driver 7. Sterilized Package - No need sterilization

79. Surgical procedure for implant placement

80. Surgical Procedures A. One-Step Self Drilling (Drill-Free) Method (Attached Gingival Area) B. Two-Step Self Drilling (Drill-Free) Method (Attached Gingival Area)

81. C. Self-Tapping (Pre-Drilling) Method (Attached Gingival Area) D. Self-Tapping (Pre-Drilling) Method (Movable Mucosal Area)

82. Standardized procedures Preoperative examination stage Marking stage Perforating stage Guiding stage Finishing stage Application of orthodontic miniimplants textbook; Jong Suk Lee Jung kook kim Robert vanarasdall

83. 1) Preoperative examination stage Insertion site is selected according to the anatomic conditions and biomechanical requirements Confirmation should be done by both clinical and radiographic examinations. Administration of LA.

84. Mucosal patch Topical Infiltration

85. Periodontal probe is used to mark horizontal and vertical reference lines on the gingiva 2. Marking stage

86. A brass wire used to determine proper anteroposterior and vertical placement of a microimplant

87. X RAY is used to determine the place of insertion Mark the planned location with pen on working cast. Drill a hole in the cast, 5mm deep, at the prescribed insertion site, angulations, and inclination Miniimplant analogue is inserted manually using the screwdriver Abutment if fitted over the analogue Guide cylinder is placed over abutment Plaster separating media is applied over it and it is pressure formed using a thermoforming baseplate . Surgical stents for accurate miniscrew insertion. Richard R J Cousley ,  David J Parberry , J Clin Orthod .  2006 Jul;40(7):412-7; quiz 419

88. Micro-implant Positioning Guide , Hemanth, Sudhanshu Verma, Technique Clinic 2012

89. 3 ) Perforating stage CORTICAL BONE ORLUS SURGICAL DRILL IMPLANT Orthodontic Micro-Implants- Technology and Clinical Applicaions , Georgeta Zegan,Romanian Journal of Oral Rehabilitation, April 2009

90. 4) Guiding stage Engaged screw is inserted at a planned angle Rotation of the screw with minimal vertical force

91. Palm grip is recommended for Perforating and guiding stage Pen grip is not recommended

92. 5) Finishing stage Implant inserted to the planned depth Head exposed to an adequate extent Finishing solely with rotational force is crucial to maximize contact with the cortical bone

93. For the finishing stage, it is better to use the finger grip because rotation should be applied very cautiously. The handle should be grasped gently with only 3 fingers.

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95. Post operative instructions

96. Emergency situations MARKED MOBILITY MEANS A FAILURE IF EXTRUDED REIMPLANTATION REQUIRED CONTINUOUS PAIN SWELLING DRAINAGE OF PUS

97. Removal

98. Risks & Complications Miniscrew slippage Nerve involvement Trauma to the periodontal ligament or the dental root during insertion can lead to ankylosis. Air subcutaneous emphysema

99. Nasal and maxillary sinus perforation Miniscrew bending and fracture during insertion Aphthous ulceration due to tissue irritation Soft tissue inflammation, infection and peri-implantitis Miniscrew fracture during removal.

100. Causes of Orthodontic Mini- Implant failure and ways to avoid them Maintenance Factor Avoid Overload

101. Insertion Torque 107

102. 108 The rotational axis of the torque tester was rotated clockwise at a speed of 3 rotations per minute, and the torque values were recorded every 0.1 second using a computer program ( QuickDataAcq , SDK Developer, London, UK).

103. Surface Roughness of Miniscrews 109

104. 110 Surface Roughness of Miniscrews To increase surface roughness: Lasers Machined surface Acid etched surface Resorbable blasting media (RBM) Coatings of hydroxyapatite powder RBM+ Machined (Hybrid) Anodized surface Influence of surface treatment on the insertion pattern of self-drilling orthodontic mini-implants

105. 111 SEM image of orthodontic mini implants (× 10).  A , Machined surface;  B , acid etched surface;  C , RBM surface;  D , hybrid surface. The surface difference between C and D is observed. SEM, Scanning electron microscope; RBM, resorbable blasting media.

106. Recycling of Mini-Implants 112

107. 113 Effects of recycling on the biomechanical characteristics of retrieved orthodontic miniscrews ; Soon-Dong Yuna,Sung -Hwan Choia,Jung -Yul ChaKorean J Orthod 2017;47(4):238-247]

108. Recent Advances In TADS

109. SUMMARY

110. CONCLUSION Implants have revolutionized the field of anchorage in orthodontics. The presently available implant systems are bound to change and evolve into more patient friendly and operator convenient designs. So by choosing a proper selection mini implant insertion site, angle, length and diameter we can get good results in orthodontic treatment

111. REFERENCES

112. Seminars in Orthodontics Volume 11, Issue 1 , Pages 47-56, March 2005 Minibone plates: The skeletal anchorage system Seminars in Orthodontics Volume 11, Issue 1  , Pages 40-46, March 2005 miniscrew implants: The Spider Screw anchorage system Temporary Anchorage Devices in Orthodontics,Ravindra Nanda Application of orthodontic miniimplants Jong Suk Lee Jung kook kim Robert vanarasdall Temporary Anchorage Devices in Orthodontics: Clinical Experimentation or Evidence-Based? Dr. Jason Cope A review of biomarkers in peri- miniscrew implant crevicular fluid (PMICF) Kaur et al;  Progress in orthodontics  2017(18):42-50

113. Role of Mini-implants in Orthodontics, International Journal of Oral Implantology and Clinical Research, Sep-Dec 2011 Misch CE. Contemporary implant dentistry. 2nd ed Temporary anchorage devices in orthodontics, Gowri sankar.Singaraju , Annals and Essences of Dentistry , July – September 2009 Safe Zones’’: A Guide for Miniscrew Positioning in the Maxillary and Mandibular Arch, Paola Maria Poggioa ; Cristina Incorvatib ; Stefano Velob ; Aldo Carano†b (Angle Orthod 2006;76:191–197.) Micro-implant Positioning Guide , Hemanth, Sudhanshu Verma, Technique Clinic 2012 Orthodontic Micro-Implants- Technology and Clinical Applicaions , Georgeta Zegan,Romanian Journal of Oral Rehabilitation, April 2009 Surgical stents for accurate miniscrew insertion. Richard R J Cousley ,  David J Parberry , J Clin Orthod .  2006 Jul;40(7):412-7; quiz 419

114. It's not how far you fall but how high you bounce that really matters.“ ~ Zig Ziglar. THANK YOU!