case report mini-implants: new possibilities in interdisciplinary...

Case ReportMini-Implants New Possibilities in InterdisciplinaryTreatment Approaches

Biju Sebastian

Department of Orthodontics Pushpagiri College of Dental Sciences Thiruvalla Kerala 689107 India

Correspondence should be addressed to Biju Sebastian drbijuseb00gmailcom

Received 5 October 2014 Accepted 17 November 2014 Published 14 December 2014

Academic Editor Khalid H Zawawi

Copyright copy 2014 Biju SebastianThis is an open access article distributed under the Creative CommonsAttribution License whichpermits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

The introduction of mini-implants has broadened the range of tooth movements possible by fixed appliance therapy alone Thelimits of fixed orthodontic treatment have become more a matter of facial appearance than anchorage Many complex cases whichwould previously have required surgery or functional appliances can now be treated with fixed appliance therapy using mini-implants A mutilated dentition case where mini-implants were used to provide anchorage for intrusion of molars and retractionof anterior teeth is reported here to illustrate this point

1 Introduction

For years orthodontic treatment has been limited in scopedue to the range of tooth movements possible [1 2] Evenwithin the limitations imposed as a result of this anchoragewas another issue which had to be tackled The use ofheadgears TPA Nance palatal button to augment anchoragehad its own set of problems These severe restrictions led tothe excessive use of functional appliances and orthognathicsurgical procedures But the introduction of mini-implantsminiplates onplants and so forth has brought about aparadigm shift in the field of orthodontics [3ndash9] Manycases which need maximum anchorage for retraction orneed intrusionextrusion of anterior and posterior teeth canbe treated now by fixed appliances when within reasonablelimits with the help of mini-implantsThis does not diminishthe role played by functional appliances or orthognathicsurgical procedures but the introduction of mini-implantshas revolutionized the field of orthodontics such that manymore complex cases can now be treated with the help of fixedappliances alone This paper is an attempt to illustrate thispoint with help of the following case

2 Case Presentation

A twenty-one-year-old female reported to the hospital forcorrection of protruding front teeth and replacement of

missing lower back teeth She had a Class I incisor relation-ship on a Class III skeletal base with an average maxillary-mandibular plane angle and increased lower face height(Figure 1) Intraoral examination revealed proclined upperanterior teeth and supraerupted upper first molars and upperright second molar due to missing lower first molars andlower right second molar (Figure 2) Bolton analysis showeda mandibular anterior tooth material excess of 18mm

Treatment involved removal of upper first premolars andplacement of mini-implants for lower anterior retractionand upper right second molar intrusion The logic behindusing mini-implants for lower anterior retraction was foranchorage due to missing lower first molars and lower rightsecond molar In addition intrusion of 17 was required forplacement of artificial substitute in the lower arch consideringthe level of extrusion of 17 Mini-implants of 13mm times 8mm(AbsoanchorMini-Implant Dentos Inc Daegu Korea) wereused for this purposeThe implants were positioned palatallybetween 16 and 17 and buccally between 17 and 18 Thepalatal implant was placed 7mm superior to gingival marginwith care taken to avoid Greater Palatine Artery The palatalmucosa was more fibrous and thicker than that on the buccalaspect Figure 3 shows the positioning of mini-implantsplaced for lower anterior retraction Retraction of upper andlower anteriors was done on 001910158401015840 times 002510158401015840 stainless steelwire with hooks Retraction force was derived from 12mm

Hindawi Publishing CorporationCase Reports in DentistryVolume 2014 Article ID 140760 5 pageshttpdxdoiorg1011552014140760

2 Case Reports in Dentistry

Frontal view Frontal smile view

Profile view Three-quarter view

Figure 1 Pretreatment extraoral photographs

Anterior view

Right lateral view Left lateral view

Upper occlusal view Lower occlusal view

Figure 2 Pretreatment intraoral photographs

medium force NiTi close coil springs in lower arch and activetiebacks in upper arch

In the space closure stage a lower removable partialdenture was placedfor space maintenance in the lower

Anterior view



Figure 3 Mid-treatment intraoral photographs alignment stagewith microimplants for lower anterior retraction


Lower occlusal view

Figure 4 Mid-treatment intraoral photographs with lower spacemaintainer

arch (Figure 4) Figure 5 illustrates the mini-implants andmechanics used for 17 intrusion Once intrusion of 17 wasfound to be adequate active intrusive force on 17 was stoppedand passive ligation was done to stabilize the correctionachieved The cephalometric assessment of the treatmentresult is illustrated in Table 1 During the course of thetreatment the upper anterior teethwere intentionally overan-gulated to mask the lower anterior tooth material excessof 18mm This led to unaesthetic appearance of upperincisors and dental midline deviation which was corrected byrepositioning the brackets

Case Reports in Dentistry 3

Table 1 Pre- and posttreatment cephalometric values

Variable Pretreatment Posttreatment ChangeSNA 86∘ 86∘ 0∘

SNB 86∘ 85∘ minus1∘

ANB 0∘ 1∘ 1∘

N perpendicular to A point 1mm 1mm 0mmN perpendicular to pogonion 2mm 2mm 0mmGo-Po 76mm 76mm 0mmSN to maxillary plane 6∘ 6∘ 0∘

Wits appraisal minus2mm minus1mm 1mmUpper incisor to maxillary plane angle 130∘ 122∘ minus8∘

Lower incisor to mandibular plane angle 95∘ 90∘ minus5∘

Interincisal angle 111∘ 126∘ 15∘

16 to maxillary plane 23mm 21mm minus2mmMM angle 24∘ 24∘ 0∘

Upper anterior face height 44mm 44mm 0mmLower anterior face height 58mm 58mm 0mmFace height ratio 57 57 0Lower incisor to APo line (linear value) 8mm 4mm minus4mmLower lip to Ricketts E Plane 4mm 0mm minus4mm

Upper occlusal view

Buccal view Palatal view

Figure 5Mid-treatment intraoral photographs withmini-implantsfor 17 intrusion Intrusive force on 17 is provided by running an e-chain across the occlusal surface of 17 Further intrusive force on 17from the lingual aspect is provided by an e-chain traction force tothe lingual button on 17

Oral rehabilitationwas completedwith the placement of alower cast partial denture replacing the missing lower molars(Figures 6 7 and 8) Even though implant supported fixedcrownswere suggested as a better option the patient opted fora cast partial denture due to her time constraints and financiallimitations

3 Discussion

The advantages of using mini-implants in orthodontic treat-ment are clearly illustrated in the superimposed pre- and



Figure 6 Posttreatment extraoral photographs

posttreatment cephalometric tracing of the above case report(Figure 9) Earlier treatment of such mutilated cases wouldhave been near impossible with orthodontic therapy aloneOn the lower right posterior segment there is only thirdmolar to provide anchorage for retraction which is not


Anterior view



Figure 7 Posttreatment intraoral photographs without removablecast partial denture

Anterior view


Lower occlusal view

Figure 8 Posttreatment intraoral photographs with removable castpartial denture

adequate in a normal circumstance Also the level of extru-sion of 17 would have meant that intentional RCT and crownwould have to be done for completing the oral rehabilitationOthermethods of intrusion would not have been adequate

PretreatmentPosttreatment

Figure 9 Cephalometric superimposition of pre- and posttreat-ment lateral cephalograms

considering the level of 17 extrusion An added advantageof using mini-implants is that they are temporary anchoragedevices that can be removed after treatment quite easily [10]

Quite a number of recent publications illustrate the useof mini-implants for other types of tooth movements likemolar distalization [11] and protraction [12] and as anchorunits for palatal expansion [13] or extraoral force application[14ndash16] Since the introduction of mini-implants is a recentfeature we have not yet ascertained the extent to whichall these are possible But the guidelines for these willcome with experience in the near future eventually leadingto a broadening of the envelope of discrepancy for toothmovement possible orthodontically [17]

Conflict of Interests

The author declares that there is no conflict of interestsregarding the publication of this paper

References

[1] WR Proffit andR PWhite ldquoTheneed for surgical-orthodontictreatmentrdquo in Surgical-Orthodontic Treatment Mosby YearBook St Louis Mo USA 1999

[2] D Squire A M Best S J Lindauer and D M LaskinldquoDetermining the limits of orthodontic treatment of overbiteoverjet and transverse discrepancy a pilot studyrdquo AmericanJournal of Orthodontics and Dentofacial Orthopedics vol 129no 6 pp 804ndash808 2006

[3] J B Cope ldquoTemporary anchorage devices in orthodontics aparadigm shiftrdquo Seminars in Orthodontics vol 11 no 1 pp 3ndash92005


[4] R Reynders L Ronchi and S Bipat ldquoMini-implants inorthodontics a systematic review of the literaturerdquo The Amer-ican Journal of Orthodontics and Dentofacial Orthopedics vol135 no 5 pp 564e1ndash564e19 2009

[5] C H Chen C S Chang C H Hsieh et al ldquoThe use ofmicroimplants in orthodontic anchoragerdquo Journal of Oral andMaxillofacial Surgery vol 64 no 8 pp 1209ndash1213 2006

[6] Y C Tseng C H Hsieh C H Chen et al ldquoThe applicationof mini-implants for orthodontic anchoragerdquo InternationalJournal of Oral and Maxillofacial Surgery vol 35 pp 704ndash7072006

[7] M Motoyoshi M Matsuoka and N Shimizu ldquoApplicationof orthodontic mini-implants in adolescentsrdquo InternationalJournal of Oral and Maxillofacial Surgery vol 36 pp 695ndash6992007

[8] H-S Park S-K Lee andO-W Kwon ldquoGroup distal movementof teeth using microscrew implant anchoragerdquo The AngleOrthodontist vol 75 no 4 pp 602ndash609 2005

[9] K H Sherwood J G Burch and W J Thompson ldquoClosinganterior open bites by intrudingmolars with titaniumminiplateanchoragerdquo American Journal of Orthodontics and DentofacialOrthopedics vol 122 no 6 pp 593ndash600 2002

[10] B Vande Vannet M M Sabzevar H Wehrbein and K Assch-erickx ldquoOsseointegration of miniscrews a histomorphometricevaluationrdquoTheEuropean Journal of Orthodontics vol 29 no 5pp 437ndash442 2007

[11] G S M Kinzinger N Gulden F Yildizhan and P R DiedrichldquoEfficiency of a skeletonized distal jet appliance supportedby miniscrew anchorage for noncompliance maxillary molardistalizationrdquoTheAmerican Journal of Orthodontics and Dento-facial Orthopedics vol 136 no 4 pp 578ndash586 2009

[12] W E Roberts G R Arbuckle and M Analoui ldquoRate of mesialtranslation of mandibular molars using implant-anchoredmechanicsrdquoAngle Orthodontist vol 66 no 5 pp 331ndash338 1996

[13] K J Lee Y C Park J Y Park and W S Hwang ldquoMiniscrew-assisted nonsurgical palatal expansion before orthognathicsurgery for a patient with severe mandibular prognathismrdquoTheAmerican Journal of Orthodontics and Dentofacial Orthopedicsvol 137 no 6 pp 830ndash839 2010

[14] A Enacar B Giray M Pehlivanoglu and H IplikciogluldquoFacemask therapy with rigid anchorage in a patient withmaxillary hypoplasia and severe oligodontiardquoAmerican Journalof Orthodontics and Dentofacial Orthopedics vol 123 no 5 pp571ndash577 2003

[15] B Wilmes M Nienkemper and D Drescher ldquoApplicationand effectiveness of a mini-implant- and tooth-borne rapidpalatal expansion device the hybrid hyraxrdquo World Journal ofOrthodontics vol 11 no 4 pp 323ndash330 2010

[16] B Wilmes B Ludwig V Katyal M Nienkemper A Rein andD Drescher ldquoThe Hybrid Hyrax Distalizer a new all-in-oneappliance for rapid palatal expansion early class III treatmentand upper molar distalizationrdquo Journal of Orthodontics vol 41supplement 1 pp S47ndashS53 2014

[17] W R Proffit H W Fields D M L Sarver and J L AckermanContemporary Orthodontics Mosby Elsevier St Louis MissUSA 5th edition 2013

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Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

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Figure 1 Pretreatment extraoral photographs

Anterior view



Figure 2 Pretreatment intraoral photographs

medium force NiTi close coil springs in lower arch and activetiebacks in upper arch

In the space closure stage a lower removable partialdenture was placedfor space maintenance in the lower

Anterior view



Figure 3 Mid-treatment intraoral photographs alignment stagewith microimplants for lower anterior retraction


Lower occlusal view

Figure 4 Mid-treatment intraoral photographs with lower spacemaintainer

arch (Figure 4) Figure 5 illustrates the mini-implants andmechanics used for 17 intrusion Once intrusion of 17 wasfound to be adequate active intrusive force on 17 was stoppedand passive ligation was done to stabilize the correctionachieved The cephalometric assessment of the treatmentresult is illustrated in Table 1 During the course of thetreatment the upper anterior teethwere intentionally overan-gulated to mask the lower anterior tooth material excessof 18mm This led to unaesthetic appearance of upperincisors and dental midline deviation which was corrected byrepositioning the brackets





ANB 0∘ 1∘ 1∘







Upper occlusal view




3 Discussion







Anterior view




Anterior view


Lower occlusal view









References


























Biomaterials












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ANB 0∘ 1∘ 1∘







Upper occlusal view




3 Discussion







Anterior view




Anterior view


Lower occlusal view









References


























Biomaterials












Journal of




















Anterior view




Anterior view


Lower occlusal view









References


























Biomaterials












Journal of









































Biomaterials












Journal of



















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