Minibone Plates:

The Skeletal Anchorage System

Junji Sugawara and Makoto Nishimura

The skeletal anchorage system (SAS) is a recently developed orthodontic anchorage

modality utilizing titanium miniplates and monocortical screws that are temporarily fixed in
the maxilla and/or mandible for absolute orthodontic anchorage. The most appropriate
application of the SAS is to enable the predictable intrusion and distalization of maxillary
and mandibular molars. Therefore, the SAS offers a nonsurgical orthodontic treatment
option for skeletal (surgical) malocclusions, as well as a nonextraction treatment approach
for some malocclusions characterized by maxillary or mandibular protrusion, and/or ante-
rior crowding.
Semin Orthod 11:47-56 © 2005 Elsevier Inc. All rights reserved.

The Skeletal The maxillary sites where screw fixation is possible are
limited to the zygomatic buttress and the piriform rim. The
Anchorage System (SAS) Y-plate is usually placed in the maxilla at the zygomatic but-

T he SAS is comprised of bone plates and fixation screws

(Fig 1).1-4 The plates and screws are made of commer-
cially pure titanium that is biocompatible and suitable for
osseointegration. The anchor plate consists of the three com-
ponents—the head, the arm, and the body. The head com-
ponent is exposed intraorally and positioned outside of the
dentition so that it does not interfere with tooth movement.
The head component has three continuous hooks for attach-
ment of orthodontic forces. There are two different types of
head components based on the direction of the hooks. The
arm component is transmucosal and is available in three dif-
ferent lengths—short (10.5 mm), medium (13.5 mm), and
long (16.5 mm) to accommodate individual morphological
differences. The body component is positioned subperioste-
ally and is available in three different configurations—the
T-plate, the Y-plate, and the I-plate. The T-plates can be
modified and used as L-plates by cutting off one of the screw
holes. The surgical site requires at least 2 mm of cortical bone
thickness to fix the anchor plate using monocortical screws,
which are 2.0 mm in diameter ⫻ 5.0 mm in length. Each
screw has an internal tapered square head with a self-tapping
threaded body.
Department of Oral Health and Development Sciences, Division of Orth-
odontics and Dentofacial Orthopedics, Graduate School of Dentistry,
Tohoku University, Sendai, Japan.
Address correspondence to Junji Sugawara, DDS, PhD, Division of Orthodon-
tics and Dentofacial Orthopedics, Graduate School of Dentistry, Tohoku
University, 4-1 Seiryo-machi, Aoba-ku Sendai, Japan 980-8575. Phone/
Fax: ⫹81-22-717-8373; E-mail: sugahara@mail.tains.tohoku.ac.jp
tress to intrude or distalize upper molars. Although the lateral
wall of the maxilla is usually too thin for screw fixation, the
bone of the zygomatic buttress is almost always thick enough.
The I-plate is most often placed at the anterior ridge of the
piriform opening for intrusion of upper anterior teeth or
protraction of upper molars.
In the mandible, screw fixation is possible on the lateral
cortex in most locations except adjacent to the mental fora-
men. The T-plate and/or the L-plate is usually placed in the
mandibular body to intrude, protract, or distalize lower mo-
lars, or at the anterior border of the ascending ramus to
extrude impacted molars.
Orthodontic force is usually applied about 3 weeks after
surgical placement of the SAS, waiting only for soft tissue
healing, not for osseointegration. Immediately after orth-
odontic treatment, all of the anchor plates are removed.
Treatment Planning
SAS treatment is performed according to an appropriate di-
agnosis and treatment plan based on the problem oriented
approach. A case treated with the SAS will be used to dem-
onstrate our method of diagnosis, treatment planning, and
mechanotherapy using the SAS.
Problem List
The 19-year-old Japanese male (Fig 2) complained of ante-
rior crowding, open-bite, and difficulty in chewing. He had
mild facial asymmetry, a large interlabial gap, a gummy

1073-8746/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. 47

doi:10.1053/j.sodo.2004.11.008
48 J. Sugawara and M. Nishimura

Figure 1 SAS titanium anchor plates. (A) T plate. (B) Y plate. (C) I plate.

smile, and disharmony between the hard and soft tissues. The thognathic surgery, however, because neither his profile, the
posterior-anterior (PA) cephalometric radiograph indicated a large interlabial gap, nor the gummy smile were of concern.
mild facial asymmetry (Fig 3). The lateral cephalometric ra- Instead, he chose SAS camouflage treatment, an alternative
diograph (Fig 4) was taken in natural head position and treatment option.
centric relation with relaxed lip posture. The cephalometric
analysis (craniofacial drawing standard analysis)5 indicated Soft Tissue and Skeletal Profile
● Excessive upper central incisor (U1) to stomion (7.0
that the major skeletal and soft tissue problems were a large
interlabial gap, vertical maxillary excess, and a skeletal Class mm)
● Gummy smiling
III relationship. Clinical examination revealed an anterior
● Large interlabial gap (8.0 mm)
open-bite, upper and lower anterior crowding, anterior
● Mild mandibular asymmetry
crossbite, mandibular dental midline deviation, and a narrow
● Skeletal Class III (large mandible)
upper dental arch (Fig 5). In addition, the lower 3rd molars
● Long face type (high angle, vertical maxillary excess)
were horizontally impacted bilaterally (Fig 6).
Denture
Diagnosis ● Asymmetric dentition
The patient had a fairly complex list of orthodontic problems. ● Deviation of dental midline
A common, and perhaps the most predictable, treatment op- ● Anterior open-bite and crossbite
tion would be surgical orthodontics. The patient refused or- ● Crowding

Figure 2 Pretreatment facial photos. (A) Frontal. (B) Frontal smiling. (C) Lateral.
Titanium miniplates
Figure 3 Pretreatment PA cephalometric radiograph (left) and trac-
ing (right). Note mandibular asymmetry.
Figure 4 Pretreatment lateral cephalometric radiograph (left) and
CDS analysis (right). Hypochromic lines indicate the craniofacial
standard (norm) in Japanese adult male.
49
● L1 lingual inclination
Function
● Incompetence in lip closure
● Mouth breathing
Treatment goals
Although it was impossible to radically correct the skeletal
disharmony and the associated soft tissue profile without
orthognathic surgery, it was possible to improve the dental
and functional problems via three-dimensional movement of
the upper and lower molars with the SAS. To solve the ver-
tical problems, the treatment plan included intrusion of the
upper molars by 2.5 mm. A counterclockwise rotation of the
mandible with intrusion of the upper molars was expected
(Fig 7). This would decrease the excessive lower anterior
facial height and anterior open-bite. One possible negative
sequela of molar intrusion, however, may be exacerbation of
the Class III occlusal relationship.
Based on the occlusogram (Fig 8), the upper incisors
would need to move facially 1.0 to 1.5 mm to compensate
for the mandibular autorotation. The upper molars would
be distalized 1.5 to 2.0 mm to resolve the anterior crowd-
ing. It would also be necessary to distalize the lower right
and left molars by 6.0 mm and 4.0 mm, respectively, to
correct the deviated lower midline.
The final intercuspation was predicted with a diagnostic
setup based on the cephalometric and occlusogram treat-
ment goals (Fig 9). The treatment plan to achieve the treat-
ment goals with the SAS follows.
1. Bonding and banding (upper and lower posterior seg-
ments)
2. Leveling and alignment of posterior segment
3. Maxillary lateral expansion (precision LA: fun type)
4. Implantation of anchor plates to zygomatic buttress
and mandibular body
5. Distalization and intrusion of molars with SAS
Figure 5 Pretreatment intraoral photos. (A)
Right buccal. (B) Anterior. (C) Left buccal.
(D) Maxillary occlusal. (E) Mandibular oc-
clusal.
50 J. Sugawara and M. Nishimura

Figure 6 Pretreatment panoramic radiograph.

6. Upper and lower canine retraction power chain (⬃ 400 g per segment) from the anchor plates
7. Bonding and leveling of upper and lower incisors (Fig 12). Following distalization of the upper and lower
8. Coordination of upper and lower dental arches molars, the remaining teeth were bonded. After leveling
9. Finishing and detailing and aligning of the arches, the asymmetric lower arch and
10. Debonding the open-bite were corrected with the SAS. During finish-
11. Retention (upper: wraparound retainer, lower: lingual ing and detailing, occlusal equilibrium was performed to
bonded retainer) maximize intercuspation.

Treatment Progress
Treatment progress is shown in Fig 10 and Fig 11. A
0.022-inch preadjusted appliance was placed on the buc-
cal segments and the lower incisors. Leveling and aligning
of the posterior teeth and lateral expansion of the upper
arch were initiated using archwires and a transpalatal arch.
About a month before surgical placement of the SAS, all of
3rd molars were extracted. A plate was placed at both the
zygomatic buttress and the apical region of the lower 1st
and 2nd molars, bilaterally. After placing rigid archwires
(0.018 inch ⫻ 0.022 inch stainless steel), en masse intru-
sion and distalization of the molars was initiated with

Figure 7 Cephalometric treatment prediction. Solid line: pretreat-

ment; dotted line: posttreatment. Figure 8 Occlusogram treatment prediction.
Titanium miniplates 51

Figure 9 Diagnostic setup based on cephalometric and occlusogram treatment predictions. (A) Right buccal. (B)
Anterior. (C) Left buccal.

Outcome of SAS Treatment
An upper wraparound and a lower lingual retainer were
placed on completion of treatment, which lasted 1 year
and 9 months (Figs 13 and 14). The anchor plates were
removed 1 month after appliance removal. A functional
occlusion with favorable intercuspation, stable posterior
support, and anterior guidance was established. Superim-
position of pre- and posttreatment occlusograms reveals
distalization of the lower right and left molars by 6.0 mm
and 3.0 mm, respectively. The upper molars were distal-
ized 3.0 mm, bilaterally. Based on the posttreatment pan-
oramic radiograph (Fig 15), no significant root resorption
was observed at the molars. Evaluating the cephalometric
superimpositions (Fig 16), the predicted mandibular au-
torotation did not occur, and the open-bite was corrected
mainly by extrusion of anterior teeth. Although upper mo-
lar intrusion did occur during SAS treatment, upper and
lower molar distalization may have caused an increase of
the lower anterior facial height. After 1 year of retention,
minor relapse was observed in the upper anterior region;
however, the functional occlusion and jaw position re-
mained stable (Fig 17).
Presurgical Orthodontics
Most patients who undergo the SAS surgical placement
show mild to moderate facial swelling for several days after
surgery. Although it is possible to start loading the SAS
immediately, orthodontic force application is usually de-
layed for 3 weeks to allow for resolution of postoperative
facial swelling, soft tissue healing, and reinstitution of oral
hygiene procedures. Therefore, it is advantageous to be in
rigid archwires (ideally, 0.018 inch ⫻ 0.025 inch stainless
steel) before surgery. We usually increase the size of arch-
wires up to the level of a full-sized archwire. In addition,
the 3rd molars should be extracted either before or during
SAS placement because they prevent distalization and in-
trusion of the 1st and 2nd molars.

Figure 10 Treatment progress (anterior intraoral photos). (A) Leveling and aligning of posterior teeth and expansion of
upper arch. (B) Initial leveling and aligning of upper anteriors. (C) Continued leveling and aligning of upper arch with
continuous wire and distalization of lower molars. (D) Dental midline correction.

Figure 11 Treatment progress (lateral intraoral photos). (A) Leveling and aligning of posterior teeth and expansion of
upper arch. (B) Initial leveling and aligning of upper anteriors. (C) Continued leveling and aligning of upper arch with
continuous wire and distalization of lower molars. (D) Dental midline correction.
52 J. Sugawara and M. Nishimura

Figure 12 Postsurgical photographs. (A) Panoramic radiograph. (B) Right buccal. (C) Left buccal.

SAS Placement Procedure the buccal vestibule (Fig 18A). A vertical incision is usually
made in the maxilla; a horizontal incision in the mandible. The
The surgical procedure is performed under local anesthesia with mucoperiosteal flap is elevated following the subperiosteal dis-
IV sedation. Initially, a mucoperiosteal incision is performed in section to expose the bony cortex (Fig 18B). Based on the dis-

Figure 13 Posttreatment facial photos. (A) Frontal. (B) Frontal smiling. (C) Lateral.
Titanium miniplates
tance between the surgical site and the dentition on the pretreat-
ment panoramic radiograph, the appropriate shape and length
anchor plate is selected. The plate is contoured to the bone
surface and placed in its final position. Then a pilot hole is
drilled, and a self-tapping monocortical screw is placed. The
remaining screws are inserted to firmly attached the anchor
plate to the bone surface (Fig 18C). Last, the surgical site is
closed with resorbable sutures (Fig 18D). The surgery takes
approximately 10 to 15 minutes for each anchor plate.
Orthodontic Mechanics
The most significant advantage of the SAS is that it allows
the achievement of predictable three-dimensional molar
movement. The types of molar movement include distal-
Figure 15 Posttreatment panoramic radiograph.
53
Figure 14 Posttreatment intraoral photos. (A)
Right buccal. (B) Anterior. (C) Left buccal.
(D) Maxillary occlusal. (E) Mandibular oc-
clusal.
ization, intrusion, protraction, extrusion, and buccal/lin-
gual movement. To date, the SAS has been applied to more
than 500 patients in our clinic. Distalization and intrusion
of maxillary and mandibular molars were performed in
approximately 85% of all SAS patients.
It is extremely difficult, if not impossible, to intrude the
upper and lower molars with traditional orthodontic mech-
anotherapy. SAS mechanics, on the other hand, allow effi-
cient molar intrusion (Figs 19 and 20), making it possible to
correct even severe open-bite cases without orthognathic sur-
gery, thereby minimizing potential risks.
Distalization of upper or lower molars is difficult even with
the use of a headgear, and more so in adults. By using SAS
mechanics to achieve molar distalization, it is now possible to
correct severe crowding, upper protrusion, anterior cross-
54 J. Sugawara and M. Nishimura

bite, and asymmetries without the need for premolar extrac-

tion or significant patient cooperation. Initially, individual
molar distalization followed by anterior retraction was the
common method used in early SAS cases. Currently, how-
ever, en masse distalization is more common since it allows
decreased treatment time (Figs 21 and 22).

SAS Removal Procedure

Immediately after orthodontic treatment, all anchor plates are
removed. The surgical procedure for removing the anchor plates
in the maxilla is shown in Fig 23A. Initially, a mucoperiosteal
incision and subperiosteal dissection are performed to expose
the anchor plate. Although the monocortical bone screws have
been removed, the anchor plate is still firmly attached to the
bone surface because of the thin layer of newly deposited bone,
which is frequently observed covering the anchor plates (Fig
23B). After removing the anchor plate, new bone formation is
often observed surrounding the plate as well (Fig 23C). The
Figure 16 Cephalometric superimposition. Dotted line: pretreat-
surgical site is then closed and sutured.
ment; solid line: posttreatment.

Figure 17 One year posttreatment intraoral

photos. (A) Right buccal. (B) Anterior. (C)
Left buccal. (D) Maxillary occlusal. (E) Man-
dibular occlusal.

Figure 18 Maxillary anchor plate surgical placement. (A) Mucoperiosteal incision. (B) Flap elevation with subperiosteal
dissection. (C) Anchor plate fixation with titanium screws. (D) Surgical site closed and sutured.
Titanium miniplates 55

Figure 19 Upper molar intrusion mechanics. (A) Leveling and aligning of posterior teeth. (B) Y-plate placed at zygomatic
buttress with elastic intrusive force. Note transpalatal arch to prevent buccal flaring of molars. (C) After intrusion, both
arch are leveled and aligned. (D) Archwire is ligated to anchor plate to prevent relapse.

Figure 20 Lower molar intrusion mechanics. (A) Lower dentition with two occlusal planes. (B) Leveling and aligning of
posterior teeth. (C) L-plate placed at lateral cortex with elastic intrusive force. Note lingual arch to prevent buccal
flaring of molars. (D) After intrusion, both arches are leveled and aligned, then archwire is ligated to anchor plate to
prevent relapse.

Complications patients in oral home care; it is also advisable to professionally

Most patients who undergo SAS placement show mild to mod-
erate facial swelling for several days after surgery, which is ex-
pected. Although infrequent, infection occurs in about 10% of
patients. Mild infections can be controlled by antiseptic mouth-
wash and careful brushing techniques. In more severe cases,
antibiotics are required. It is important to thoroughly educate
clean the orally exposed part of the anchor plate at all routine
orthodontic appointments, which greatly reduces postoperative
infection. Plate loosening has occurred in only 1% of our cases.
Other potential complications include plate fracture and muco-
sal dehiscence around the plate, neither of which has occurred
during SAS treatment to date.

Figure 21 Upper molar distalization mechanics. (A) Upper arch. (B) Leveling and aligning of upper arch following 3rd
molar extraction. (C) En masse distalization of upper molars with elastic force from anchor plate. (D) En masse
retraction of anterior teeth.

Figure 22 Lower molar distalization mechanics. (A) Leveling and aligning of lower arch following 3rd molar extraction.
(B) En masse distalization of lower molars with elastic force from anchor plate. (C) En masse retraction of anterior teeth
directly to canine. (D) En masse retraction of anterior teeth using soldered hook.
56
Figure 23 Maxillary anchor plate surgical removal. (A) Surgical site before soft tissue reflection. (B) Flap elevation with
subperiosteal dissection. (C) Anchor plate removed from bone surface. Note bone growth around plate.
Summary
The SAS offers several advantages. Since the anchor plates and
screws are made of commercially pure titanium, they are bio-
compatible. Moreover, they are located away from the dentition,
and therefore, do not interfere with tooth movement. The SAS
obviates the need for significant patient compliance, particularly
with regard to extraoral appliances, which allows more predict-
able treatment results. This also allows an overall decrease in the
number of nonextraction and orthognathic surgery cases. Be-
cause the SAS is rigidly fixed to bone, molars can be moved in
any direction without taxing anchorage and the occlusal plane
can be controlled by orthodontists, without the need for sur-
gery. In conclusion, the SAS is quite effective biomechanics for
adult patients, retreatment cases, and patients with complex
orthodontic problems.
J. Sugawara and M. Nishimura
References
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1999
3. Sugawara J, Un Bong Baik, Umemori M et al: Treatment and post-
treatment dentoalveolar changes following intrusion of mandibular
molars with application of a skeletal anchorage system (SAS) for open
bite correction. Int J Adult Orthod Orthognath Surg 17:243-253,
2002
4. Sugawara J, Daimaruya T, Umemori M, et al: Distal movement of man-
dibular molars in adult patients with the skeletal anchorage system. Am J
Orthod Dentofacial Orthop 125:130-138, 2004
5. Sugawara J, Soya T, Kawamura H, et al: Analysis of craniofacial morphol-
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nathic surgery. J Jpn Orthod Soc 47:394-408, 1988