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Temporary anchorage devices in orthodontics
Nigel Harradine

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Introduction
Temporary anchorage devices (TADs) have emerged as a major development in orthodontics in recent years. Miniscrews appeared as the subject of encouraging research and case reports in the late 1990s. We have now been using them for several years, during which time they have become established as a very practicable part of orthodontics which is capable of dramatically expanding the scope of orthodontic treatment. Before considering miniscrews in some detail, it is helpful to review the development of the other types of TAD.

Conventional dental implants

In 1945, Gainsforth and Higley first conceived the concept of skeletal orthodontic anchorage using vitallium ramal screws in dogs. This attempt failed, as did almost all implants of that era, chiefly because the metals used were not conducive to the later discovery of osseointegration through titanium. Inflammation around the vitallium screw led to loosening and loss. In the 1960s, Brnemark (1969) and colleagues introduced the concept of osseointegration, using pure titanium implants, defining osseointegration as 'living bone in direct contact with a loaded implant surface. From the outset, Brnemark (1977) was rigorous in reporting long-term rates for success and failure. However, few clinicians envisaged the use of titanium implants in orthodontics at that time. It was not until the 1980s, that several animal studies using titanium implants for orthodontics reported successful results. Roberts et al (1989) studied the effects of orthodontic force on titanium implants in rabbits and dogs with a large majority of the implants remaining stable after 13 weeks of continuous loading with 300 gm force. Conventional osseointegrated implants, as used in restorative dentistry, have since become a standard part of multidisciplinary care involving orthodontics Vince Kokich (1996), but their convenient and appropriate use is limited to a minority of cases because they can only be placed in those positions in a dental arch where there is adequate bone, where orthodontic anchorage is needed and can be used, and where a subsequent implantsupported restoration is required. It should be noted that in 1985, Kokich et al reported a novel source of absolute anchorage when they deliberately induced ankylosis of a deciduous canine tooth which was then used to protract the maxilla in a patient with severe maxillary retrusion. Key summary: Conventional dental implants are only occasionally the option of choice where they will subsequently be needed for supporting a crown or bridge

Midpalatal implants
A next step in adapting implant technology to orthodontics was the development of short but otherwise conventional dental implants to be placed in the midline of the palate. These are now a well-recognized and documented source of anchorage, but are still relatively expensive and complex. They need careful siting anteriorly in the palatal vault to ensure sufficient bone depth and no contact with the roots of adjacent teeth, and are therefore relatively inconveniently situated for a palatal arch to take advantage of them. These implants are typically 34mm in diameter and 6mm in length. Traditionally they have been left to osseointegrate before force application. Tinsley et al (2004) gives an excellent description of the typical current use of these implants and further practical tips can be found in two articles by Cousley and Parberry (2005) and Cousley (2005). The further results of a random controlled clinical trial involving such implants has more recently been published by Sandler et al (2008). A good recent prospective study of palatal miniscrews reported a success rate of 92% (Mannchen and Schatzle 2008) in which the implants were left to osseointegrate for an average of 13 weeks. Interestingly, a recent tomographic study (Gracco et al 2008), concluded that there is sufficient bone posteriorly in and near the palatal midline for insertion of miniscrews. This is frequently a much more convenient place for application of forces to a palatal TAD and shows the versatility of miniscrews. Key summary: Conventional but short dental implants are successful in the palatal midline, but their substantial extra complexity and invasiveness makes miniscrews relatively more attractive.

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Onplants
These are based on the impressive research of Block and Hoffman (1995). These authors used a subperiosteal titanium alloy disk, 2 mm thick and 10 mm wide, coated with hydroxyapatite. This disk-type onplant was inserted subperiosteally and left unloaded for four months to osseointegrate before uncovering and placement of attachments. The large potential advantage of this use of osseointegration is that there is no need for any bone depth, so the onplant can be placed in a much wider range of sites than a conventional implant. Two soft tissue surgical interventions are however still required. It is essentially true that after a further decade of development by Nobel Biocare who developed the Branemark system, they have yet to emerge as a widely available, commercially marketed product and with the emergence of miniscrews, they may no longer have a significant potential place in orthodontics.

Miniplates
These were reported by Umemori et al (1999) and Sherwood (2002), and have been championed by Hugo de Clerck from Belgium amongst others. These are usually T-shaped or L-shaped, with the long arm of the T or L emerging through the mucosa and providing the point of attachment for the traction force. The most common sites for placement are the zygomatic arch and the angle of the mandible. The advocated advantages are twofold: that the fixing screws are above the root apices and therefore much less of a risk to the tooth roots. Secondly, the force application can still be brought close to the occlusal plane and easily avoid unwanted intrusion. These are definite plus points. A minus point is that a flap needs to be raised for insertion and removal and some patients and a few surgeons prefer a general anaesthetic for these procedures. Also the extra space required may render impracticable some applications nearer the front of the mouth. Overall patient acceptability seems good (Cornelis et al 2008) and some impressive results can certainly be achieved. De Clerck has demonstrated consistent distal movement of upper buccal segments in non-growing patients (Cornelis, De Clerck 2007) with the advantage over miniscrews in that application that the teeth can be moved past the TAD, whereas a miniscrew placed between the teeth will need repositioning at some stage. Also impressive has been De Clercks demonstration of substantial protraction of the maxilla and zygomatic arch with 150 gm of elastic traction applied to miniplates. For intrusion of posterior teeth they seem to be a very reliable technique De Clerck et al (2008). Some authors have found slightly higher percentage success rate with minplates than with miniscrews (Kuroda 2007), but also significantly more discomfort associated with their insertion and the necessary flap being raised. A study of the actual surgical technique (Cornelis et al 2008) quantifies the length of the placement procedure (averages ranged from 15 to 30 minutes per plate) and the postoperative discomfort. Fifteen of 200 plates required premature removal. Probably because of the discomfort whilst the mucosal flaps heal, De Clerck recommends starting traction three weeks after the surgery. Cha et al (2011) used a two week interval before starting reverse pull headgear to their plates.

Bollard Plates in class III patients

We have started to use Bollard miniplates in young class 3 patients as advocated by Hugo de Clerck with some very encouraging success but also with some teething problems. This technique consists of light class 3 elastics worn to miniplates and he describes it as bone-anchored maxillary protraction (BAMP). The technique is described and the effects quantified in a paper by Cervidanes et al (2010). In this analysis of consecutively treated cases, the Wits analysis showed an impressive average 6 mm improvement in the class III skeletal pattern. A more recent paper from the same team by Nguyen et al (2011) has impressively documented enhanced maxillary and zygomatic growth in 24 consecutively treated cases. The average maxillary enhancement is approximately 4 mm with a range from 1.5 to 8.5 mm for the maxilla. This paper is strongly recommended and includes all the essential practical details of the technique. Another paper from the same team ( De Clerck and Swennen 2011) reports on success rates in 25 consecutive class 3 patients treated with Bollard plates. They report a very high 97% success rate for the 100 plates. They attribute this success to a number of details of careful , gentle surgical technique and postoperative care. Our early experience has met with some promising success but two important points have emerged. Firstly it is vital that the orthodontist is present at surgery until the surgeon is fully familiar with the requirements in order to ensure the precise and correct placement of the plates. The hooks must emerge where the applied elastics will not impinge on the soft tissues. The prominence of the hooks must be precise too prominent and the buccal/labial mucosa is traumatised, too close to the bone and the gingivae prevent comfortable placement of elastics. Secondly, we have expereinced a surprising incidence of loose plates. These

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can firm up if the elastics are discontinued for six weeks. Retrospective analysis of our technique has revealed that some of our screws were 1.5mm and not the recommended 2.3 mm and this may have permitted relative movement between screw and plate and hence loosening of the plate. This perhaps illustrates the potential importance of seemingly small details of technique. Key summary: Miniplates slowly grow in popularity in specific sites and applications. They will probably establish a permanent role in these areas where their strong points outweigh the need for a flap to be raised and frequently a general anaesthetic to p lace and remove.

Miniscrews
Miniscrews emerged as a treatment technology from the search for a TAD which fulfilled the following requirements.
Figure 14.1: A self-drilling miniscrew (Ormco VectorTAS) showing the head, transmucosal collar and intraosseous threaded parts. This particular screw has an additional bonecutting groove for sites with dense bone

insertion easily removed following use no patient discomfort at insertion, during use or at removal

quick, easy and comfortable to insert in a wide variety of sites without damage to adjacent teeth convenient for application of orthodontic forces by a variety of means and in a variety of directions available for force application soon or immediately after

As long ago as 1983, Creekmore and Eklund reported a case in which a vitallium implant was placed just below the anterior nasal spine and used for anchorage. A light elastic thread was tied from the head of the screw to the archwire 10 days after placement of the implant to intrude the maxillary incisors. This early loading of an implant, without the usual wait for osseointegration, was to become a major feature of the later use of miniscrews. It was many years before a real emergence of a body of work on miniscrews and most of this originated in the Far East. Kanomi described the use of titanium mini fixation screws in 1997. The problem of accommodating an implant in an intact arch is the subject of papers by authors such as Ohmae et al (2001), Park H-S et al (2001) and Bae and Park H-S (2002). The literature has seen a rapid increase in papers on microscrews many of them case reports. Typical examples are the three contiguous papers in the August 2004 edition of the Angle Orthodontist by authors from South Korea, Taiwan and Japan. The first paper is another by Professor Park and co-workers (Park et al 2004) and focuses on distal movement. The next article by Yao et al describes molar intrusion by a combination of microscrews and miniplates and the third by Kuroda et al also describes molar intrusion in this case by unusually long microscrews. A very good summary of the essentials of miniscrews can be found in the edition of Seminars in Orthodontics edited by Jason Cope in March 2005. NH edited a recent textbook by well-known Korean pioneers of these TADs - Orthodontic Miniscrew Implants by Paik C-H, Park I-K, Woo YJ and Kim T-W (2009). This book is very well illustrated and covers all aspects of technique and a wide range of clinical applications. We initially used the Aarhus system, developed by Professor Birte Melsen and co-workers, and the Dentos AbsoAnchor system developed by Professors Jae-Hyun Sung, Hee-Moon Kyung and Hyo-Sang Park who have carried out foundation research in the placement and immediate loading of such screws. More recently, we have used the IMTEC system, the LOMAS Quattro system from Mondeal and the Ormco VectorTAS system. To date we have used miniscrews for intrusion of molars and incisors, retraction of molars and anterior teeth and protraction of posterior teeth. This clinical experience has coincided with rapidly emerging evidence on many aspects of success and difficulties with miniscrews and this has overlaid our own clinical experience of problems and successes. It is still early days for confident certainties with many aspects of the use of miniscrews, but the following sections summarise the current state of evidence and experience in a rapidly moving field.

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Miniscrew configuration

Miniscrews have been produced with intraosseous diameters between 1.0 mm and 2.0 mm much narrower than the 4 mm of a standard dental implant. Miniscrews are usually described as having three major components, an intraosseous threaded part, a transmucosal collar and a head. Figure 14.1 is of a VectorTAD miniscrew which is representative of these aspects of the design. The intraosseous threaded part of the screw typically ranges between 6 and 11 mm. This particular screw is one of the types which have asymmetric buttressed threads. This pattern of thread facilitates insertion and increases resistance to pullout forces. Above the threaded section is usually a smooth-surface transmucosal section referred to as a neck or collar. Some manufacturers supply miniscrews with a longer collar for use in sites such as the palate or retromolar areas where the gingiva is thicker.

Figure 14.2: A coilspring with a specifically designed eyelet to match the screw head and provide secure, compact retention of the spring (Ormco VectorTAS).

Above the collar is the head which provides the means of attachment of force (elastics, wires and coilsprings). The collar is often separated from the head by a wider area which is designed to help prevent the mucosa from intruding on the head. Variations in miniscrew head design Because the earliest screws were adapted from bone fixation screws, early research and development focussed on the best size and form of the intraosseous threaded part of the screw. Most miniscrews have converged in their design in this respect. However, for orthodontic anchorage, there are potentially important variations in the design of the screw head.

there must be easy and secure attachment for elastic chain, nickel titanium coilsprings and wire ligatures. Most screws will not permit attachment of a conventional coilspring, the head being too large for the eyelet on the coilspring. Some types VectorTAS (Figure 14.2 and 14.3) and DB Infinitas have specifically designed eyelets to fit their screw heads. These are very good. There are coilsprings designed with a specialised but generic eyelet to fit almost all miniscrew heads (Figure 14.4). These eyelets are keyhole shaped and are good but significantly larger. Some screw heads inconveniently require a ligature for almost all secure attachments of coilspring. this first requirement for easy and secure attachments must not weaken the screws ability to withstand the torque forces during insertion and removal the ability to attach a section of archwire to the head is not a big asset. The line of force of any traction must pass directly through the axis of the screw. If a section of archwire is used to cantilever the force, this will rotate the screw within the bone, negating the cantilevered direction of force. If a section of archwire is used in conjunction with a TAD, it is usual to link it to another TAD in tandem to negate this cantilever effect. More commonly, traction rather than pushing forces are applied to a TAD. the head must be rounded and so less likely to irritate adjacent the adjacent cheeks or tongue. Too small a head can be a problem in this respect, whilst some designs which add roundness by a healing cap are consequently too bulky.

Self-tapping, pre-drilling and self-drilling

These terms can cause confusion. Many miniscrews are described as self-drilling or self-tapping. Confusion can arise because all of these terms do not have strictly consistent definitions in the literature, but the terms can be usefully clarified.

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pre-drilling some screws require a pilot hole to be drilled before insertion. This preliminary procedure is sensibly called pre-drilling. It is required for screws that are blunt at their tip and are thus not selfdrilling. The only potential confusion in terminology is when referring to the creation of a very small preliminary indentation in the cortex with a round bur or specialised initiator bur. This very limited pre-drilling is sometimes referred to as pilot drilling. This can be advisable even with selfdrilling screws when the bone is dense or the intended path of insertion is very oblique to the bone surface. self-drilling as the paragraph above infers, these screws have a sharp, pointed end and need no preliminary drilling. Again, there is a potential subdivision of design which may cause confusion of terminology, because some such screws have an additional notch or groove at their tip which adds to the bonecutting capability. These self-drilling screws are sometimes referred to as self-cutting. This additional bone-cutting notch has previously been considered by some authors to increase the chance of fracture of the screw tip, but with current designs this is not a well-supported concern. The additional cutting power is designed to ease screw insertion, particularly in areas of more dense bone in the jaws such as the retromolar area. self-tapping all current miniscrews are self-tapping. Whether or not they are self-drilling, they require no separate tapping of a thread. The potential confusion here is that some authors e.g. (Chen et al 2008), use the term self-tapping to be synonymous with screws which require pre-drilling. Selftapping is therefore not a helpful term in our view.

Pre-drilling or self-drilling? Many early designs took their lead from conventional dental implants and required pre-drilling. There has since been a strong trend to self-drilling. In favour of self-drilling is:

better primary stability (Kim et al 2005) better screw-bone contact after 6 months (Heidemann et al 2001) probable better overall success rate less chance of damage to tooth roots (Barros et al 2011) simpler, quicker and cheaper procedure (no specialised drills required)

Melsen (2005) briefly summarises most of these points. We use self-drilling screws. It is still advisable to make a preliminary cortical indent in a few cases where the bone is especially dense (most commonly the posterior mandible) and especially if the intended path of insertion is significantly oblique to the bony surface this is a

Figure 14.3: Intrusive force application from the spring in Figure Figure 14.4: Generic coilspring with keyhole eyelet fits over 14.2 a 6 mm Ormco Vector TAS most miniscrew heads (Mondeal LOMAS Quattro miniscrew). The keyhole is inconveniently long

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situation where the screw is prone to slip up the cortical surface causing soft-tissue trauma. An alternative strategy to avoid this slipping is to by placing the screw at right angles to the bone surface and then altering to an oblique angle once the first bite in the cortex has occurred. In more dense bone, it sometimes requires 10 or more turns of the screwdriver before an initial bite of the cortex is achieved, so patience can be required.

Success rate of miniscrews

A core aspect of miniscrew success is their stable retention in the bone. Most studies report success rates between 80% and 96% e.g. Park H-S et al (2005). Lim (2009) reported 83% success (and this is the identical success rate as that which NH has to date achieved in all screws inserted). A useful summary table of studies is on page 250 in Orthodontic Miniscrew Implants by Paik C-H et al (2009). A systematic review by Reynders (2009) identified 19 studies of sufficient quality and the success rate was mainly in excess of 80%. Another review Crisman (2010) included 14 studies and reported an overall success rate of 84% in 1519 screws. Key point: When looking at estimations of success, look at the definitions of success. e.g. how long must a screw be in place to be deemed successful? If the screw loosens but is still usable, this is usually but not always counted as a success. Similarly, removal and immediate replacement of a loose screw is sometimes not counted as a failure.

Factors affecting stability of miniscrews

Several factors have been proposed as influencing success (stability of the screw). Individual studies have found correlations between one of these factors and success, but it is important to note that the systematic review by Reynders (2009) found no statistically supported associations with any factor and sometimes contrary correlations in different studies. The main proposed factors affecting success are as follows:

screw diameter (Miyawaki et al 2003) (Park et al 2006). A diameter less than 1.1 mm is associated with a higher failure rate. A diameter greater than about 1.6 mm seems to confer no advantage and clearly wider screws run an extra risk of contact with tooth roots. This consideration is now largely of historic interest because almost all screws are currently between 1.4 and 1.8 mm in maximum diameter. 2.0 mm screws are suitable for sites such as the zygomatic ridge or retromolar pad, where avoidance of roots is not an issue screw length this usually refers to the intraosseous, threaded part of the screw. This length does NOT seem to be a factor in stability if the screw is more than 5 mm long (intraosseous length) (Miyawaki et al 2003) (Park et al 2006), (Kuroda 2007). All manufacturers produce screws of different lengths and longer screws may be advocated if the mucosal thickness is greater e.g. in the palate for alveolar placement. Mortensen et al (2009) found that in Beagle dogs, 3mm was definitely too short, reducing the success rate from 100% to 66% over the 6 week period. We principally use 6mm and some 8 mm screws. peri-implant inflammation (Miyawaki et al 2003), (Park et al 2006). A study by Cheng (2004) found that nonkeratinized mucosa was a risk factor for miniscrew failure. This is a less consistent finding. Owens et al (2007) found no correlation between success and lack of peri-implant inflammation, but most authors report that inflammation is more likely if screws are placed in non-attached mucosa and advise placement in or very close to attached gingiva. This is probably correct, but leaves open the question as to whether the inflammation is a cause of failure. Ure et al (2011) found that in Beagle dogs, resistance to loosening and loss was much lower for screws placed in non-keratinised mucosa. high maxillo-mandibular planes angle and bone density a high MMA was reported as a factor in the mandible by (Miyawaki et al 2003) who attributed this to thinner cortical bone in such subjects, but (Kuroda 2007) found no such association with MMA. Park et al (2008) found generally higher bone density in the mandible than the maxilla the angle of insertion

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Zhao et al (2011) produced data which suggested that an intermediate angle of insertion relative to the bone surface (50-70 degrees) produced better osseointegration and somewhat higher pullout forces than insertion at right angles or obliquely. Their reasons for these differences are plausible, although the differences, though statistically significant, are not very large. This may prove to be a contributing factor and may influence our angle of insertion if there are no other complicating considerations. time of loading and initial loading force many studies eg (Costa et al 1988) have shown that immediate loading does not reduce the success rate. Whilst success has been reported with a wide range of initial loads, a consensus is emerging that initial forces should err on the side of being light and 200 gm is a frequently suggested maximum. Owens et al (2007) found a good rate of tooth movement of a single premolar in beagle dogs with very light forces (25 and 50 gm) and like many other studies found no difference in the success rate with immediate loading or delayed loading (26 days in that instance). We load all our miniscrews immediately and with a force less than approximately 150 gm. Some of our earlier failures may well have been partially due to applying too high a force with the elastic string which we were advised to use. When using elastic string it is impossible to have an accurate idea of the force being applied. We now use elastic chain or nickel-titanium coils. Cornelis et al (2007) systematically reviewed all the animal experiments relevant to timing and amount of loading and summarizes very nicely the limits of our current knowledge and the areas which need more investigation. Garfinkle et al (2008) found that immediate loading and loading delayed by 5 weeks both had an 80% success rate. This dropped to 60% in non-loaded control miniscrews in the same patients. Interestingly, they also quantified a significant learning curve effect on their success rate. Chen (2009) in a study on Beagle dogs found that completely unloaded screws had a success rate of 75% compared with 90% for screws immediately loaded with a 200 gm force. Zhang et al (2010) have found increasing degrees of osseointegration in beagle dogs if the application of force was delayed for two and then 4 weeks post-insertion. However it is interesting that all their screws were successfully retained over 8 weeks of traction regardless of whether zero, two or four weeks of delay were used.

Clinical message: Immediate loading confers no disadvantage and may actually improve success rates. Overall, our current view is that the factors which influence successful stability of miniscrews remain uncertain iin the light of current evidence

Stability of successful miniscrews

We have had a clinical impression that some miniscrews remain firm but nevertheless drift in response to the applied force. A study by Liu et al (2011) used superimposed CT scans to assess screw movement during retraction of the upper labial segment. They found a small (average 0.23 mm) bodily mesial movement of the miniscrews and rather surprisingly, slightly greater mesial movement of the upper molars which were not receiving any mesially directed orthodontic traction force. The authors recommend allowing for this modest drift if possible when siting miniscrews.

Miniscrew insertion technique

Our initial personal success rates were definitely lower than those in the literature in spite of having attended and hosted courses and masterclasses and followed the best advice. In retrospect, there was a steep learning curve in progress around the world and even the best pioneers did not fully appreciate the importance of several aspects of technique.

pre-drilling or self-drilling: We initially used the pre-drilling method, believing this more likely to give better control of direction. Although good success has been reported with predrilling, this method is now known to be a potential source of: o o heat necrosis of the bone in spite of intentions to use copious irrigation and slow handpiece speed. 500-800 rpm is commonly advocated disruption of the cortex from wobbling of the bur

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greater incidence of root contact { (Barros et al 2011) quotes studies to that effect}

We now therefore only use self-drilling screws and only occasionally make a small indent in the cortex with a drill if the cortex seems very dense and resistance to initial insertion seems high. This is more likely in the posterior mandible Park et al (2008). It is now documented that almost all the primary stability arises from the cortex. This would explain why screw length is less critical than might be thought and also why minimal disruption of the cortex during insertion is important. It is therefore important to ensure smooth wobble-free use of the screwdriver and a slow turning of the screwdriver is also advised with good pauses to allow the cortex to expand rather than fracture. It is also important not to insert until the smooth collar starts engaging the cortex because this may immediately work to provide a loosening force. operator experience: the factors discussed above relate to operator experience and this has been proposed and investigated as a significant factor. In a study by Kim (2010) he reported that the operator who placed all the mid-palatal miniscrews increased his success rate from 75% over the first eighteen months to over 90% thereafter. Garfinkle et al (2008) also found a definite effect of operator experience. Whilst this association seems intuitive and probable, the formal review by Reynders (2009) could only conclude that at present, operator experience probably reduces failure rate. Operator experience again arises as a factor in the study by Cho et al (2010) on root perforation discussed below.

Damage to tooth roots This is clearly a potential hazard. We know of no reports of the clinical incidence of root impingement, but the typodont study by Cho et al (2010) reported a 21% incidence of root contact for inexperienced operators and 13 % for experienced operators. None of the root contacts were serious or caused root perforation. We have only knowingly experienced root contact on one occasion ourselves. Practical steps to minimise the chances of root contact are:

use screws of 1.4 to 1.8 mm maximum thread diameter choose a favourable site. For example, in the maxilla, the inter-radicular space between the roots of the second premolar and first molar tends to be greater than that between the roots of the first and second molars although biomechanical considerations may dictate placement distal to the first molar. The more apical the site, the greater the inter-radicular space, but the need to keep the screws in or close to attached mucosa will limit apical position as may biomechanical considerations and patient soft tissue comfort. A good anatomical study has been published by Hu et al (2009) who reported that the safest interradicular site in the maxilla is between the second premolar and the first molar, from 6 to 8 mm from the cervical margin. The CT study by Fayad et al (2010) found that on average there is 1mm less mesio-distal space distal to the upper first molar than mesial to that tooth (approximately 2.5 mm vs. 3.5mm). These dimensions are in line with those reported by Martinelli et al (2010). However, for upper molar intrusion, we would firmly recommend placing the screws distal to the first molar because this is more effective at intruding the second molar which is crucial in that instance. The safest zone for placement of a miniscrew in the mandible was between the first and second molars, less than 5 mm from the cervical margin. Fayad et al also found variations in cortical thickness at different sites and an increase with age and in males and this may also influence success rate. due to the conical shape of tooth roots, it is obvious that there is more space between them in the apical areas. Theoretically, the more apically the miniscrew is placed, the less is the risk of root damage. However, this is limited by the width of attached gingiva and the depth of the buccal vestibule, as well as by biomechanical considerations. Placing miniscrews at an angle to the bone surface puts the screw tip nearer the wider space between to root apices whilst keeping the screw head in the attached mucosa. However, a large angle between the screw head and the mucosa may hinder attachment of coil springs and elastic chain and a shorter screw at a smaller angle may be a better combination. consider placing screws in the palate. There is more space on the palatal side between posterior teeth and the palatal midline (which is a good site in adults Kim(2010)) eliminates the question of

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root contact. However, the palate is less comfortable to anaesthetise, usually needs a contra-angle screwdriver and is more awkward to utilise biomechanically. Align the adjacent teeth thoroughly before screw insertion. Err on the side of diverging the roots adjacent to the site of insertion. Upper first and second molars will tend to initially have convergent roots.

Clinical tip: Consider placing brackets to slightly diverge the roots adjacent to the intended insertion site.

check root alignment radiographically before insertion use injected local anaesthetic sparingly (<1 cm of syringe content) or not at all. See the section below on anaesthesia after approximately 1/3 of the screw is in bone, stop turning screwdriver, hold it very lightly and recheck passive orientation. If not satisfactory, remove and re-insert in an adjacent position. The study by Cho et al (2010) revealed that on the right side of the mouth, the insertion tended to err in the direction of slanting too distally, contacts therefore arising in the tooth distal to the embrasure in both jaws. stop insertion if discomfort is reported by the patient or if an increase in resistance - doubling Hembree et al (2009) - occurs after the full diameter of the screw is engaged in bone. Remove and re-insert in an adjacent position. On the one occasion when we (NH) experienced root contact, this was immediately revealed by slight discomfort as the screw neared full insertion. This discomfort was mild and immediately stopped when the screw was screwed out by two turns. The screw was then inserted in a different site with no complications. check radiographically after insertion. Two views from different directions may be needed to give the best view; even then we cannot always be certain that a radiographic indication of root contact is a genuine finding. In the study by Hembree et al (2009) of intentional damage to the roots of Beagle teeth, 26% of cases which indicated damage radiographically were found to have not sustained damage.

Perhaps we should draw no comfort from the ironic fact that Hembree et al (2009) took all measures including stents and radiographs to ensure damage to the Beagle dog roots but failed to achieve damage in 26% of the screws inserted. Consequences of root contact Clearly, it is wise to minimise root contact. However, the literature supports the view that impinging on cementum and dentine is followed by repair in most instances (Asscherickx et al 2005), showed almost total repair twelve weeks after removing screws from beagle dogs. (Melsen 2005), and (Roberts 1989) have also observed good root repair. Penetration of the pulp would be expected to more serious but should be much less likely. Of course, penetration of a root would also be expected to impede movement of that tooth if that is a movement that is intended. An experimental study on ten patients was encouraging that any damage shows rapid repair once the screw contact is removed (Kadioglu et al 2008). Neurovascular damage In the palate, the greater palatine neurovascular bundle consists of a nerve, artery and vein that enter the oral cavity through the greater palatine foramen. The two greater palatine foramina are typically located medial to the third molars. The bluish colour of the vein and softer texture of the gingiva in this region provide clues to the location of the neurovascular bundle in the corner of the palatal vault. The artery is the component of the bundle which is closest to the teeth and this is on average 12 mm from the palatal margin of the buccal teeth. Palatal alveolar miniscrews should be therefore be sited less than 10mm from the cement enamel junction to avoid damaging the greater palatine neurovascular bundle or alternatively they should be sited in or near the midline.

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Maxillary sinus penetration It may not be feasible to place a buccal alveolar miniscrew implant if the floor of the maxillary sinus extends to the alveolar bone between the maxillary posterior teeth. Although minimal complications have been reported following maxillary sinus perforation during orthodontic screw placement, (Costa et al 1988) it may be wise to avoid this area in patients with marked pneumatization.

Fracture of miniscrews This has been reported, but is now largely historical. Several papers (Chen et al 2008), indicate that smaller diameter screws are much more likely to fracture. (Park et al 2006), had a high fracture rate of 10% and all bar one of these was a small diameter (1.2mm) screw. Some designs have also been more prone to screw fracture by having a narrow neck which took the torque force during insertion. To reduce the risk of fracture with thinner screws (1.2 mm or less) these are often designed to require pre-drilling to reduce torque load on such thin screws during insertion. Some authors, eg: Jason Cope, have also reported that early self-drilling designs with a notch or groove to aid bone cutting could be prone to fracture at the tip during insertion. We have personally suffered no screw fracture and it is probable that the better, more recent designs plus a better, slower, smoother insertion technique have made this a very rare potential complication. (Barros et al 2011) analysed forces required to fracture screws ex vivo and recommend screws of diameter greater than 1.3 mm as being suitable for resistance to fracture with self-drilling insertion.

Other potential problems with miniscrews

Anaesthesia for miniscrew placement

Topical anaesthesia is of course indicated whether or not there is a subsequent needle infiltration. Some clinicians find that topical anaesthetic alone is sufficient in all buccal mucosal sites. This may be more likely to be sufficient if a combination of prilocaine 2.5% and lidocaine 2.5% is used (Oraqix). If needle infiltration is then used, the amount should be sparing for the reasons described above in the section on avoidance of root damage. On the thicker palatal mucosa, topical anaesthesia alone is unlikely to be sufficient and completely painless anaesthesia is therefore unlikely.

Miniscrew removal
No problems have been reported in the literature or indeed experienced by ourselves. The miniscrews are simply unscrewed. Even though osseointegration would not be strongly anticipated with immediately-loaded miniscrews, there is some microscopic evidence of osseointegration from an animal study (Kim et al 2005). Zhang et al (2010) have shown increasing degrees of osseointegration in beagle dogs over the first few weeks following insertion. However, small-diameter miniscrews are easy to remove even in the event of some osseointegration as removal torque is proportional to the square of the screw diameter. Anaesthesia is not required (just reassurance to the patient that this is the case).

Medical contraindications or relative contraindications to miniscrew placement generalised bone pathology: severe osteoporosis, intravenous or high dose biphosphonate
treatment local bone pathology: radionecrosis at risk for bacterial endocarditis immune deficiency bleeding disorder heavy smoking poor oral hygiene

Biomechanics with TADs

It is very important to appreciate the biomechanical consequences of applying forces from a site at a distance from the occlusal plane. If the force is in a mesial and intruding direction, then the teeth will move in both of those directions. This can significantly derange the occlusal plane if left for a period of time. It can also increase the

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Figure 14.5: A long crimp-on hook (Ortho Organisers) enabling distal traction without incisor intrusion.

Figure 14.6: An Ormco Vector post enabling mesial sliding of the premolar with force parallel to the occlusal plane. These hooks or posts can be crimped or can slide along the archwire. However, the binding when used uncrimped as in this figure is extremely high and the coilspring here principally acts by moving the entire upper arch.

friction during sliding mechanics. It is essential to have long crimp-on hooks available to enable forces to applied from TADs parallel to the occlusal plane if that is required. (Figures 14.5 and 14.6).

Stability of molar intrusion

In the past, molar intrusion through orthodontic force application proved almost impossible to achieve to a clinically significant extent. The introduction of TADs offered a clear opportunity for successful molar intrusion and they have been widely employed to that end in cases with anterior open bites. A natural question is the stability of this novel tooth movement. A recent paper by Baek et al (2010) measured molar intrusion and overbite during treatment of nine adults and for three years post-treatment. Upper molars were intruded using miniscrews with palatal arches to limit buccal flaring of the molars. Adults are an excellent group for such a study because the complications of cephalometrics in the presence of significant facial growth are avoided. They found a good treatment response and good overall stability. Only 23% of the molar intrusion and 17% of the overbite improvement relapsed. Most of that relapse occurred in the first year post treatment. This is an encouraging report as is the paper by Deguchi et al (2011) which compared orthodontic treatment for AOB with and without miniscrew assisted intrusion of molars. They found that miniscrews indeed succeeded in achieving molar intrusion and reduction in the MMA and linear face height with very little incisor extrusion. All of these changes were the opposite in the groups treated without miniscrews. Two years after treatment, the upper molar intrusion and almost all the overbite had remained stable, with relapse of the approximately 1 mm of mandibular molar intrusion.

NICE guidance and further reading

In November 2007, the National Institute for Clinical Excellence issued guidance on Miniscrews, stating that there are no safety concerns which should deter clinicians from using this technique. This guidance approves of their use, provides references for the basis for their use and comments from the consulted clinicians. The April 2007 AJO-DO supplement Number 4 supplement 1 is devoted to miniscrew-related topics and is a good concentrated source of articles. The systematic review by Cornelis et al (2007) referred to previously is part of this supplement.

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References
Asscherickx K, Vannet BV, Wehrbein BV and Sabzevar MM (2005) Root repair after injury from mini-screw Clinical Oral Implantology Research 16: 575-578 Barros SE, Janson G, Chiqueto K, Garib DG, Janson M (2011) Effect of mini-implant diameter on fracture risk and self-drilling efficacy American Journal of Orthodontics and Dentofacial Orthopaedics 140:e181-e192 Bae S-M and Park H-S (2002) Clinical application of micro-implant anchorage Journal of Clinical Orthodontics 36: 298-302 Baek M-S, Choi Y-J, Yu H-S, Kwak J, Park Y-C (2010) Long-term stability of anterior open-bite treatment by intrusion of maxillary posterior teeth American Journal of Orthodontics and Dentofacial Orthopaedics 138: 396.e1-396.e9 Brnemark P I, Adell R, Breine U et al. (1969) Intra-osseous anchorage of dental prostheses. I. Experimental studies Scandinavian Journal of Plastic and Reconstructive Surgery 3: 81100 Brnemark P I, Hansson B O, Adell R et al. (1977) Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period Scandinavian Journal of Plastic and Reconstructive Surgery Supplement 16: 1132 Block MS, Hoffman DR (1995) A new device for absolute anchorage for orthodontics. American Journal of Orthodontics and Dentofacial Orthopaedics 107: 251-258 Cevidanes L, Baccetti T, Franchi B, McNamara JA and De Clerck H (2010) Comparison of two protocols for maxillary protraction bone anchors versus face mask with rapid maxillary expansion Angle Orthodontist 80: 799-806 Cha B-K, Choi D-S, Ngan P, Jost-Brinkmann P-G, Kim S-M, Jang I-S (2011) Maxillary protraction with miniplates providing skeletal anchorage in a growing Class III patient American Journal of Orthodontics and Dentofacial Orthopaedics 139: 99-112 Chen Y, Shin H-I, Kyung H-M (2008) Biomechanical and histological comparison of self-drilling and self-tapping orthodontic microimplants in dogs American Journal of Orthodontics and Dentofacial Orthopaedics 133: 44-50 Chen Y, Kang ST, Bae S-M, Kyung H-M (2009) Clinical and histologic analysis of the stability of microimplants with immediate orthodontic loading in dogs American Journal of Orthodontics and Dentofacial Orthopaedics 136: 260-267 Cheng SJ, Tseng IY, Lee JJ, Kok SH (2004) A prospective study of the risk factors associated with failure of mini-implants used for orthodontic anchorage. International journal of Oral Maxillofacial Implants 19: 100-106 Cho U-H, Yu W and Kyung H-M (2010) Root contact during drilling for microimplant placement. Angle Orthodontist 80:130-136 Cope JB (2005) Temporary anchorage devices in orthodontics: paradigm shift Seminars in Orthodontics11: 39 Cornelis MA, Scheffler NR, De Clerck HJ, Tulloch JFC and Nyssen-Behets C (2007) Systematic review of the experimental base of temporary skeletal anchorage devices in orthodontics American Journal of Orthodontics and Dentofacial Orthopaedics 131supp 1: 52-58 Cornelis MA, De Clerck HJ (2007) Maxillary molar distalization with miniplates assessed on digital models: a prospective clinical trial American journal of Orthodontics and Dentofacial Orthopaedics 132: 373-377 Cornelis MA, Scheffler NR, Nyssen-Behets C, De Clerck HJ and Tulloch CT (2008) Patients and orthodontists perceptions of miniplates used for temporary skeletal anchorage: A prospective study American Journal of Orthodontics and Dentofacial Orthopaedics 133: 18-24 Cornelis MA, Scheffler NR, Mahy P, Siciliano S, De Clerck HJ and Tulloch JF (2008) Modified miniplates for temporary skeletal anchorage in orthodontics: placement and removal surgeries. Journal of Oral Maxillofacial Surgery 66: 1439-1445

292

TEMPORARY ANCHORAGE DEVICES IN ORTHODONTICS EXCELLENCE IN ORTHODONTICS 2012

Costa A, Raffainl M and Melsen B (1998) Miniscrews as orthodontic anchorage: a preliminary report International Journal of Adult Orthodontics and Orthognathic Surgery 13: 201209 Cousley RRJ (2005) Critical aspects in the use of orthodontic palatal implants American Journal of Orthodontics and Dentofacial Orthopaedics 127: 723-729 Cousley R RJ and Parberry DJ (2005) Combined cephalometric and stent planning for palatal implants Journal of Orthodontics 32: 20-25 Creekmore T D, Eklund M K (1983) The possibility of skeletal anchorage Journal of Clinical Orthodontics 17: 266269 Crisman AG, Bertl MH, Celar AG, Bantleon H-P and Burstone CJ (2010) Miniscrews in orthodontic treatment: Review and analysis of published clinical trials American Journal of Orthodontics and Dentofacial Orthopaedics 137:108-113 DB Infinitas Clinical Manual De Clerck HJ, Timmerman HM and Cornelis MA (2008) Biomechanics of skeletal anchorage. Part 3. Intrusion Journal of Clinical Orthodontics 42: 270-278 De Clerck EEG and Swennen GRJ (2011) Success rate of miniplate anchorage for bone anchored maxillary protraction. Angle Orthodontist 81:1010-1013 Deguchi T, Kurosaka H, Oikawa H, Kuroda S, Takahashi I, Yamashiro T, Takano-Yamamoto T (2011) Comparison of orthodontic treatment outcomes in adults with skeletal open bite between conventional edgewise treatment and implant-anchored orthodontics American Journal of Orthodontics and Dentofacial Orthopaedics 139:S60-S68 Fayad MMS, Pazera P and Katsaros C (2010) Optimal sites for orthodontic mini-implant placement assessed by cone beam computed tomography Angle Orthodontist 80: 939-951 Gainsforth BL and Higley LB (1945) A study of orthodontic anchorage possibilities in basal bone American Journal of Orthodontics and Oral Surgery 31: 406416 Garfinkle JS, Cunningham LL, Beeman CS, Kluemper GT, Hicks EP and Kim M-O (2008) Evaluation of orthodontic mini-implant anchorage in premolar extraction therapy in adolescents American Journal of Orthodontics and Dentofacial Orthopaedics 133: 642-653 Gracco A, Lombardo L, Cozzani M and Siciliani G (2008) Quantitative cone-beam computed tomography evaluation of palatal bone thickness for orthodontic miniscrew placement American Journal of Orthodontics and Dentofacial Orthopaedics 134: 361-369 Heidemann W, Terheyden H and Gerlach GL (2001) Analysis of the osseous/metal interface of drill free screws and self-tapping screws Journal of Craniomaxillofacial Surgery 29: 69-74 Hembree M, Buschang PH, Carrillo R, Spears R and Rossouw PE (2009) Effects of intentional damage of the roots and surrounding structures with miniscrew implants American Journal of Orthodontics and Dentofacial Orthopaedics 135:280.e1-280.e9 Herman R and Cope JB (2005) Miniscrew implants: IMTEC Mini Ortho Implants Seminars in Orthodontics11: 3239 Hu K-S, Kang M-K, Kim T-W, Kim K-H, Kim H-J (2009) Relationships between Dental Roots and Surrounding Tissues for Orthodontic Miniscrew Installation Angle Orthodontist 79:37-45 Kadioglu O, Buyukyilmaz T, Zachrisson BU, Maine BG (2008) Contact Damage To Root Surfaces Of Premolars Touching Miniscrews During Orthodontic Treatment American Journal of Orthodontics and Dentofacial Orthopaedics 134:353-360

TEMPORARY ANCHORAGE DEVICES IN ORTHODONTICS EXCELLENCE IN ORTHODONTICS 2012

293

Kanomi R (1997) Mini implant for orthodontic anchorage Journal of Clinical Orthodontics 31: 763-767 Kim JW, Ahn SJ and Chang YI (2005) Histomorphometric and mechanical analyses of the drill-free screw as orthodontic anchorage American Journal of Orthodontics and Dentofacial Orthopaedics128: 190-4 Kim YK, Yang S-M, Kim S, Lee JY, Kim KE, Gianelly AA and Kyung S-H (2010) Midpalatal miniscrews for orthodontic anchorage: Factors affecting clinical success American Journal of Orthodontics and Dentofacial Orthopaedics 137:66-72 Kokich V G, Shapiro P A, Oswald R et al. (1985) Ankylosed teeth as abutments for maxillary protraction: a case report American Journal of Orthodontics 88: 303307 Kokich VG (1996) Managing complex orthodontic problems: the use of implants for anchorage Seminars in Orthodontics 2: 153-160 Kuroda S, Katayama A and Takano-Yamamoto T (2004) Severe anterior open-bite case treated using titanium screw anchorage Angle Orthodontist 74: 558567 Kuroda S, Sugawara Y, Deguchi T, Kyung H-M and Takano-Yamamoto T (2007) Clinical use of miniscrew implants as orthodontic anchorage: Success rates and postoperative discomfort American Journal of Orthodontics and Dentofacial Orthopaedics 131: 9-15 Kyung H-M, Park H-S, Bae S-M, Kwon O-W and Sung J-H (2004) Handbook for the Absoanchor Orthodontic Implant Taegu Korea, Dentos Inc Liu H, Lv T, Wang N-n, Zhao F, Wang K-l, Liu D-x (2011) Drift characteristics of miniscrews and molars for anchorage under orthodontic force: 3-dimensional computed tomography registration evaluation American Journal of Orthodontics and Dentofacial Orthopaedics 139: e83-e89 Mannchen R and Schazle M (2008) Success rate of palatal implants: a prospective longitudinal study Clinical Oral Implants Research 19: 665-669 Martinelli FL, Luiz RR, Faria M, Nojima LI (2010) Anatomic variability in alveolar sites for skeletal anchorage American Journal of Orthodontics and Dentofacial Orthopaedics 138: 252el-259 Melsen B and Lang NP (2001) Biological reactions of alveolar bone to orthodontic loading of oral implants. Clinical Oral Implants Research 12: 144-152 Melsen B (2005) Overview - Mini-Implants: Where are we? Journal of Clinical Orthodontics 39: 539-547 Melsen B and Verna C (2005) Miniscrew implants: the Aarhus anchorage system Seminars in Orthodontics 11: 2431 Miyawaki S, Koyama I, Inoue M, Mishima K, Sugahara T and Takano-Yamamoto T (2003) ,Factors associated with the stability of titanium screws placed in the posterior region for orthodontic anchorage American Journal of Orthodontics and Dentofacial Orthopaedics 124: 373-378 Mortensen MG, Buschang PH, Oliver DR, Kyung H-M and Behrents R (2009) Stability of immediately loaded 3- and 6-mm miniscrew implants in beagle dogsa pilot study American Journal of Orthodontics and Dentofacial Orthopaedics 136:251-259 Nguyen T, Cevidanes L, Cornelis MA, Heymann G, de Paula LK and De Clerck H (2011) Three-dimensional assessment of maxillary changes associated with bone anchored maxillary protraction American Journal of Orthodontics and Dentofacial Orthopedics140: 790-798 NICE guidance on Mini/micro screw implantation for orthodontic anchorage (2007) IPG 238

294

TEMPORARY ANCHORAGE DEVICES IN ORTHODONTICS EXCELLENCE IN ORTHODONTICS 2012

Ohmae M, Saito S, Morohashi T, Seki K, Qu H, Kanoni R, Yamasaki K, Okano T, Yamada S, and Shibasaki Y (2001) A clinical and histological evaluation of titanium mini-implants as anchors for orthodontic intrusion in the beagle dog American Journal of Orthodontics and Dentofacial Orthopaedics 119: 489-97 Owens SE, Buschang PH, Cope JB, Franco PF and Rossouw PE (2007) Experimental evaluation of tooth movement in the beagle dog with the mini-screw implant for orthodontic anchorage American Journal of Orthodontics and Dentofacial Orthopaedics 132: 639-646 Paik CH, Woo YJ, Kim JS and Park JU (2002) Use of miniscrew for intermaxillary fixation of lingual-orthodontic surgery patients Journal of Clinical Orthodontics 36: 132-6 Paik C-H, Park I-K, Woo YJ, Kim T-W (2009) Orthodontic miniscrew implants. Clinical applications. Consulting editor Harradine N Mosby Elsevier ISBN 978-0-7234-3402-3 Park H-S, Bae S-M et al (2001) Micro-implant anchorage for treatment of skeletal class 1 bialveolar protrusion Journal of Clinical Orthodontics 35: 417-422 Park H-S, Kwon T-G and Sung J-H (2004) Nonextraction treatment with microscrew implants The Angle Orthodontist 74: 539549 Park H-S Lee S-K and Kwon O-W (2005) Group distal movement of teeth using microscrew implant anchorage American Journal of Orthodontics and Dentofacial Orthopaedics 75: 602-609 Park H-S, Jeong S-H and Kwon O-W (2006) Factors affecting the clinical success of screw implants used as orthodontic anchorage American Journal of Orthodontics and Dentofacial Orthopaedics 130: 18-25 Park H-S, Lee Y-J, Jeong S-H and Kwon T-G (2008) Density of the alveolar and basal bone s of the maxilla and the mandible American Journal of Orthodontics and Dentofacial Orthopaedics 133: 30-37 Park Y-C, Lee S-Y, Kim D-H and Jee S-H (2003) Intrusion of posterior teeth using mini-screw implants American Journal of Orthodontics and Dentofacial Orthopaedics 123: 690-694 Ren Y, Maltha JC, and Kuijpers-Jagtman A-M (2003) American Journal of Orthodontics and Dentofacial Orthopaedics Angle Orthodontist 13: 86-92 Reynders R, Ronchi L and Bipat S (2009) Mini-implants in orthodontics: A systematic review of the literature American Journal of Orthodontics and Dentofacial Orthopaedics 135: 564.e1-564.e19 Roberts WE, Helm FR, Marshall KJ and Gongloff RK (1989) Rigid endosseous implants for orthodontic and orthopedic anchorage Angle Orthodontist 59: 247256 Sandler J, Benson P, Doyle P, Majumder A, ODwyer J, Speight P, Thiruvenkatachari B and Tinsley D (2008) Palatal implants are a good alternative to headgear: A randomised trial American Journal of Orthodontics and Dentofacial Orthopaedics 133: 51-57 Tinsley D, ODwyer JJ, Benson PE, Doyle PT and Sandler J (2004) Orthodontic palatal implants: clinical technique Journal of Orthodontics 31: 3-8 Umemori M, Sugawara J, Mitani H, Nagasaka N and Kawamura H (1999) Skeletal anchorage system for open-bite correction American Journal of Orthodontics and Dentofacial Orthopaedics 124: 373-378 Ure,DS,, Oliver D, Kim KB, Melo,AC, BuschangPH (2011) Stability changes of miniscrew implants over time The Angle Orthodontist 81: 994-1000 VectorTAS website

TEMPORARY ANCHORAGE DEVICES IN ORTHODONTICS EXCELLENCE IN ORTHODONTICS 2012

295

Yao C-CJ, Wu H-Y, Kok S-H, Chang H-FF and Chen Y-J (2004) Intrusion of the overerupted upper left first and second molars by mini-implants with partial-fixed orthodontic appliances: a case report Angle Orthodontist 74: 550557 Zhang L, Zhao Z, Lia Y, Wua J, Zheng L and Tang T (2010) Anatomic variability in alveolar sites for skeletal anchorage Angle Orthodontist 80: 354-360 Zhao L, Xu Z, Zhao Z, Yang Z, Zhang L, Li Jand Tang T (2011) Effect of placement angle on the stability of loaded titanium microscrews: A microcomputed tomographic and biomechanical analysis American Journal of Orthodontics and Dentofacial Orthopaedics 139: 628-635

296

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