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Mini-Implants in the Anterior Palate:

How to improve Stability in the Long-term

Bjrn Ludwig / Traben-Trarbach / Germany


Benedict Wilmes / University of Dsseldorf / Germany
Stability of Mini-implants
Stability

Phase
of low stability

Primary Secondary
stability stability

1 2 3 4 5 6 7 8 9 Weeks
Stability of Mini-implants
How to measure primary stability:

- Insertion Torque
(in vivo / in vitro)

- Resonance Frequency Analysis (RFA)


(in vivo / in vitro)

- Periotest
(in vivo / in vitro)

- Lateral loading / Pull Out Test


(in vitro)
Stability of Mini-implants
Insertion site?
No difference between median
ISQ and paramedian insertion
40
Resonance
35
median Frequency
30 Analysis
25
ns
paramedian
20 ** * median
ns
*
15

10

0
paramedian 0 2 4 6 Weeks

Nienkemper M, Pauls A, Wilmes B, Drescher D. Development of mini-implant stability


over the initial healing period: A prospective clinical pilot study. Angle Orthod. 2013
Nienkemper M, Pauls A, Wilmes B, Drescher D. Effect of implant length on mini-implant stability
during the initial healing period: A prospective clinical study, Head and Face Med 2013
Nienkemper M, Pauls A, Ludwig B, Drescher D. Stability of paramedian inserted palatal mini-
implants at the initial healing period: a controlled clinical study. Clin Oral Implants Res. 2013
Stability of Mini-implants

Success rate in the anterior palate: 97.9%

Karagkiolidou A, Ludwig B, Pazera P, Gkantidis


N, Pandis N, Katsaros C. Survival of palatal
miniscrews used for orthodontic appliance
anchorage: A retrospective cohort study.
Am J Orthod Dentofacial Orthop. 2013

1. Low failure rate


2. No root damage
3. Tads not in the path
Stability of Mini-implants
Stability of Mini-implants
Optimal -Thick Bone
site -Thin Mucosa

Restricted
site

Ludwig B, Glasl T, Bowman J, Wilmes B, Kinzinger G, Lisson G. Anatomical Guidelines


for Miniscrew Insertion: Palatal Sites. J Clin Orthod. 2011:45(8):433-441
Mini-Implants with Abutments

Mini-implant Abutments

Coupling with the appliance


Mini-Implants with Abutments

Screwed Screwed Bonded Bonded

Spider Screw Benefit Orthoeasy Dual Top


HDC PSM Forestadent Jeil
Mini-Implants with Abutments

Benefit System Beneplate System

Wilmes B, Drescher, D. Wilmes B, Drescher, D. Nienkemper M.


A mini-implant system with A miniplate system for improved
interchangeable abutments. stability of skeletal anchorage.
J Clin Orthod 2008; 42:574-580 J Clin Orthod 2009; 43:494-501
Mini-Implants with Abutments

Pre-drilling in adults

Handpiece

Insertion
Orthodontist could insert
Stability of Mini-implants
Consider angle of insertion!
Mechanics with palatal TADs

Molar distalization

Beneslider Pendulum B

Molar mesialization

T-Bow Mesialslider

RPE / Class III Molar


Hybridhyrax anchorage

Molar Alignment of
Intrusion retained teeth
Beneslider

Beneplate

Benetube
Wilmes B, Drescher, D. Nienkemper M. Beneplate - A miniplate system for
improved stability of skeletal anchorage. J Clin Orthod 2009; 43:494-501
Wilmes B, Drescher D. Application and effectiveness of the Beneslider molar
distalization device. World J Orthod. 11:33134
Combination of distalization mechanics and

conventional braces

lingual braces

Aligners
Beneslider
Beneslider
Beneslider
Beneslider & Aligner

J Clin Orthod 2012:390-8


Beneslider & Aligner
Beneslider & Aligner
Beneslider & Aligner
Beneslider & Aligner
Beneslider & Aligner
Beneslider & Aligner
Beneslider & Aligner
Beneslider & Aligner
Beneslider & Aligner
Beneslider, Efficiency?

Study: N=51

- Moderate implant tipping in 2 cases

- Distalization effect: 3.6 mm (+/- 1.9 mm)

- Distalization speed: 0.6 mm/month

Nienkemper M, Wilmes B, Yamaguchi S, Pauls A, Drescher D.


Treatment efficiency of Mini-implant borne distalization depending on age and eruption of
the second molars. J Orofac Orthop 2014
Pendulum B 0.8 mm TMA

Wilmes B. Clinical management of the Beneslider and the Pendulum B appliances for
maxillary molar distalization. In: Moschos Papadopoulus: Skeletal anchorage in orthodontic
treatment of Class II malocclusion: Contemporary applications of orthodontic implants,
miniscrew implants and mini plates. Amsterdam. Mosby, Elsevier (in press)
Pendulum B
Upper molar mesialization

T-Bow Mesialslider

Indirect Direct
Anchorage Anchorage
Upper molar mesialization

If missing 3,4,5 or 6: no brackets needed


Mesialslider
T-Mesialslider
Hybrid-Hyrax

Wilmes B, Fields of Application of Mini-Implants. In: Ludwig, Baumgaertel,


Bowman: Mini-Implants in orthodontics. Innovative anchorage concepts. London,
Berlin etc. Quintessence. 2008: 91- 122
Wilmes B, Nienkemper M, Drescher D. Application and effectiveness of a new mini-
implant and tooth-borne rapid palatal expansion device. World J Orthod.2010
Hybrid-Hyrax

Force near the CR of the maxilla

Baumgaertel S, Ludwig B, Kinzinger G, Zorkun B, Glasl B, Wilmes B.


Application of a new visco-elastic FEM-Model and analysis of miniscrew
supported Hybrid-Hyrax treatment. Am J Orthod Dentofacial Orthop 2013
Hybrid-Hyrax

Goal 1:
No load on the bicuspids/
deciduous molars
No/less tipping of the teeth
Wilmes B. Fields of Application of Mini-Implants. In: Ludwig B, Baumgaertel S, Bowman JS, editor.
Mini-Implants in Orthodontics Innovative Anchorage Concepts. London: Quintessence Publishing
Co Ltd;2008. p. 91-122
Maxillary advancement using a Facemask
Goal 2:
Mesial migration of the dentition
Avoid mesial migration
of the teeth

Just skeletal maxillary


advancement

Transfer of the force F


to the bone
Ngan P, Yiu C, Hu A, Hagg U, Wei SH, Gunel E. Cephalometric and occlusal changes following
maxillary expansion and protraction. Eur J Orthod 1998;20:237-254.
Williams MD, Sarver DM, Sadowsky PL, Bradley E. Combined rapid maxillary expansion and
011351

protraction facemask in the treatment of Class III malocclusions in growing children: a prospective long-
term study. Semin Orthod 1997;3:265-274.
Hybrid-Hyrax

Mini-Implants with abutments

Hyrax Expander
Hybrid-Hyrax / Facemask
Hybrid-Hyrax / Facemask

Nienkemper M, Wilmes B, Pauls A, Drescher D. Maxillary protraction using a


hybrid hyrax - facemask combination. Prog Orthod 2013
Hybrid-Hyrax / Facemask
Hybrid-Hyrax / Facemask + Alt-Ramec

Wilmes B, Ngan P, Liou E, Franchi L, Drescher B,


Early Class III Facemask Treatment with the Hybrid Hyrax and Alt-RAMEC Protocol
J Clin Orthod 2014
Hybrid-Hyrax / Facemask Alt-Ramec

WITS -8.2 mm WITS -1.1 mm


Hybrid-Hyrax / Facemask Alt-Ramec

Clinical Studies needed.


Hybrid-Hyrax / Facemask

Hybridhyrax

Mentoplate
Wilmes B, Kau CH, Ludwig B, Drescher D. Early Class III
Treatment with a Hybrid Hyrax-Mentoplate Combination,
J Clin Orthod 2011
Hybridhyrax and Mentoplate
Hybridhyrax and Mentoplate

Peter Ngan, Hong He, and Benedict Wilmes.


Early Treatment of Class III Malocclusion.
In: Peter Ngan, Class III Malocclusion: Craniofacial Biology and Treatment
Strategies" Oak Park. Bentham eBooks (in press)
Hybridhyrax and Mentoplate

Before 8 months After

WITS: -8.3 mm WITS: -2.8 mm


Hybridhyrax and Mentoplate

17 years
Overview early class III treatment
Conv.RPE + Hybrid Hyrax Hybrid Hyrax 4 Bollard
Facemask + Facemask + Mentoplate Plates

2 mini-implants 4 miniplates
Surgery? No 2 mini-implants 1 miniplate

Skeletal
Efficiency?
Molar anchorage
Molar anchorage
Molar intrusion

J Clin Orthod 2013


Molar intrusion
Forced eruption of retained teeth
Forced eruption of impacted teeth
Outlook: Multipurpose appliances

Wilmes B, Ludwig, B, Katyal V, Nienkemper M, Rein A, Drescher D.


The Hybrid Hyrax Distaliser, a new all-in-one appliance for rapid palatal expansion, early
class III treatment and upper molar distalisation. J Orthod (in press)
Conclusions: 1. Anterior palate is the best insertion site

Ludwig B, Glasl T, Bowman J, Wilmes B, Kinzinger G, Lisson G. Anatomical Guidelines


for Miniscrew Insertion: Palatal Sites. J Clin Orthod. 2011:45(8):433-441
Conclusions: 2. Tads with abutments for the palate

Molar distalization

Beneslider Pendulum B

Molar mesialization

T-Bow Mesialslider

RPE / Class III Molar


Hybridhyrax anchorage

Molar Alignment of
Intrusion retained teeth
Conclusions: 3. No difference between median and lateral
Conclusions: 4. Just do it !

Insertion of mini-implants in the palate is very easy!!!


Orthdontists can do it

Courage!
Palatal Mini-implants

wilmes@med.uni-duesseldorf.de
www.uniklinik-duesseldorf.de/kieferorthopaedie

Thank you very much for your attention!