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Heymann & Tulloch (2006) Implantable Devices As Orthodontic Anchorage
Heymann & Tulloch (2006) Implantable Devices As Orthodontic Anchorage
ABSTRACT
Recently, there has been a dramatic increase in the use of implantable devices as direct adjuncts
to orthodontic treatment. Whereas the use of conventional dental implants has been researched
extensively, the body of literature associated with the more recent uses of implantable devices in
orthodontics is relatively small. Currently, a limited number of such devices are used to aid in
orthodontic treatment. The options include conventional titanium endosseous dental implants,
palatal implants, titanium miniscrews (also known as micro- or mini-implants), and mini–bone
plates.
Integration of dental implants or implantable devices into contemporary orthodontic practice
has the following possible advantages: serving as a means of increasing orthodontic anchorage,
virtually eliminating patient compliance issues with regard to wearing of appliances, decreas-
ing overall treatment time, and occasionally permitting orthodontic treatments previously
thought to be impossible without surgery.
CLINICAL SIGNIFICANCE
This article is a review of the currently available options for use of implantable devices as sources
of temporary skeletal anchorage in orthodontics.
(J Esthet Restor Dent 18:68–80, 2006)
use of dental implants within the more limited until recently, but the
O ver the past 20 years dentistry
has seen a dramatic increase
in the use of dental implants. What
specialty of orthodontics was lim-
ited to integration of implants into
potential exists for implants to play
an important role in enhancing suc-
was once an “experimental” or treatment plans strictly to facilitate cessful treatment outcomes. Inte-
unproven treatment modality is tooth replacement. The orthodontic gration of dental implants or
now supported by an extensive treatment that has traditionally implantable devices into contempo-
research base. The vast majority of been involved in treatment plans rary orthodontic practice has the
dental implant research is centered including dental implants has been following possible advantages:
around the use of endosseous limited to creating space or aligning serving as a method of increasing
implants for replacement of missing roots for subsequent placement of orthodontic anchorage, virtually
teeth. Recently, the application of implants. The use of dental eliminating patient compliance
implants for use in other specialties implants as a direct adjunct to issues with regard to wearing of
has been explored. Previously, the orthodontic treatment has been appliances, decreasing overall treat-
ment time, and occasionally permit- malocclusions is often limited or The second type of anchorage, as
ting orthodontic treatments previ- defined by the available anchorage. described by Celenza and Hochman,
ously thought to be impossible There are numerous ways in which is known as indirect anchorage,
without surgery. orthodontics has tried to augment which refers to a situation in which
anchorage, including auxiliary a dental implant stabilizes multiple
The practice of clinical orthodon- devices such as headgear, trans- teeth, which then serve as an anchor
tics is largely dependent on the palatal arches, and other appliances. unit. The most common method of
availability of anchorage. Anchor- Many of these appliances are awk- achieving indirect anchorage is by
age, by definition, is a body’s resis- ward or uncomfortable for patients, placing a dental implant, commonly
tance to displacement. Newton’s often leading to less than desired in the midpalatal or retromolar
third law states that for every levels of compliance. Thus, treat- regions, and then linking the
action there is an equal and oppo- ment outcomes can become com- implant to the natural teeth by
site reaction. Thus, orthodontic promised. Only recently has the means of a wire or other rigid fixa-
appliances are designed with this concept of using dental implants as tion device, such as a transpalatal
law in mind, the goal being to resist sources of anchorage been widely arch. The result is a stable anchor-
unwanted tooth movement. accepted as a successful adjunct to age unit composed of multiple teeth
According to Proffit, in treatment orthodontic treatment. that are tethered together by means
planning of orthodontics, of a dental implant that serves as
Dental implants have the ability to additional anchorage. The high
it is simply not possible to consider aid in anchorage either directly or level of stability provided by either
only the teeth whose movement is indirectly. Celenza and Hochman approach makes it promising for
desired. Reciprocal effects through- described two different types of the practice of orthodontics.
out the dental arches must be care- anchorage as pertaining to the use
fully analyzed, evaluated, and of implants in orthodontics.2 Direct There are numerous situations in
controlled. An important aspect of anchorage refers to any situation in which additional anchorage would
treatment is maximizing the tooth which forces that originate from the enhance treatment success. Exam-
movement that is desired, while min- actual implant itself are used to ples of orthodontic treatment of
imizing undesirable side effects.1 augment anchorage. An example malocclusions that would particu-
would be a restored dental implant larly benefit from dental implant use
In orthodontic movement of teeth, with an orthodontic bracket are as follows: closing edentulous
segments of teeth that resist move- bonded to the restoration. If con- spaces in first molar extraction sites,
ment and serve as “anchors” are ventional orthodontic appliances midline correction when no poste-
used to pull against other segments are used in conjunction with the rior teeth are present, retracting and
that are intended to be moved. Usu- surrounding teeth and the restored realigning anterior teeth with no
ally, the anchor segment will contain implant, the implant will serve as a posterior teeth present, intruding or
more teeth or teeth with greater stable “anchor.” That is, the extruding teeth, stabilization of
root surface area than the segment implant will not respond to the teeth with reduced bone support,
of teeth that are to be moved. This forces generated by the orthodontic reestablishing the proper transverse
concept of differential anchorage is wires in the same way that the nat- and anterior or posterior position of
important in most orthodontic ural teeth do. The implant simply isolated molar abutments, protrac-
cases, especially more complex situ- remains stationary while surround- tion or retraction of one arch, and
ations. In fact, treatment of certain ing teeth move. perhaps many more applications.3
The high level of stability gained implants indicated that they had include conventional titanium
from the types of implants placed in been well integrated, again despite endosseous dental implants, palatal
retromolar or midpalatal regions is orthodontic loading. It seems implants (such as onplants and the
derived largely from the fact that apparent that when subjected to the Straumann Orthosystem [Andover,
the implants are osseointegrated. relatively low continuous forces MA, USA]), titanium miniscrews
Initial concerns about disruption of that are used in orthodontic ther- (also known as micro- or mini-
osseointegration by orthodontic apy, implants have little difficulty implants), and mini–bone plates.
loading were proven to be maintaining osseointegration.
unfounded by several studies. Therefore, the question must be Conventional Implants
Roberts and colleagues reported raised: is osseointegration desirable Conventional titanium endosseous
using two-stage conventional tita- or even necessary for orthodontic dental implants can be used as
nium implants in the retromolar anchorage? In a review of studies sources of absolute or direct
region to help augment anchorage exploring implantable orthodontic anchorage for orthodontic treat-
while protracting molars to close anchorage, Favero and colleagues ment. This approach can be used
extraction sites.4 The implants were asked a similar question: when edentulous spaces exist
removed using a trephine following within an arch and adjacent or
the conclusion of orthodontic treat- Some studies have shown that opposing teeth are not positioned
ment and were subsequently histo- implants loaded early on, ideally. In such cases when the
logically analyzed. Roberts and although not presenting intimate restorative treatment plan involves
colleagues found that approxi- bone-to-bone contact [osseointe- a dental implant, it may be benefi-
mately 80% of the endosseous por- gration] because of the formation cial to use the implant itself as
tions of the implants were in direct of a pseudo-peri-implant fibrous anchorage for treating concomitant
contact with mature bone. Thus, ligament, appeared to be suffi- orthodontic problems (Figure 1). In
this case study indicated that a rela- ciently stable and capable of sus- 1991 Higuchi and Slack reported
tively high level of osseointegration taining the function of anchorage correcting malocclusions in seven
was maintained despite loading the with normal orthodontic forces. adults using Brånemark implants as
implant with orthodontic forces. Did these represent failures, sources of direct anchorage.8 Later
Another study by Turley and col- because osseointegration did not Schweizer and colleagues reported
leagues also pointed to the stability occur, or successes, because the the use of conventional endosseous
of two-stage titanium implants used anchorage was achieved anyway?7 implants in orthodontic therapy in
for orthodontic traction in dogs.5 A 1996.9 The authors stressed the
later study by Wehrbein and col- It seems that the question does not importance of double use (com-
leagues used the Straumann have a definitive answer, and until bined orthodontic and prosthodon-
Orthosystem (Straumann Holding specific parameters of success are tic treatment modalities) of the
AG, Basel, Switzerland) in mid- defined, it would be prudent to use implant system because once the
palatal and retromolar areas in the existing body of research to implant has been placed, no move-
humans for anchorage purposes.6 determine success. ment will occur owing to osseointe-
The implants were subjected to gration. In 1995 Smalley noted the
continuous orthodontic loading and AVAILABLE IMPLANT SYSTEMS importance of using a pretreatment
were removed and analyzed follow- Currently, only a limited number of diagnostic wax-up to aid in the pre-
ing treatment. The findings from implantable devices may be used in cise placement of implant(s) prior
the histologic evaluation of the orthodontic treatment. The options to orthodontic treatment.10 This
healing period, a small amount of indicated that the onplants did not contralateral side. The bands were
tissue is removed over the healing move in relation to the incisors or connected to the onplant abutment
screw, which is replaced by an abut- molars. The premolars attached to with either wire or a cast bar. Both
ment (Figure 2B). the onplant abutment exhibited premolars were extracted bilater-
movement ranging from 4 to 8 mm. ally, and stainless steel springs were
Block and Hoffman conducted two Histologic examination showed extended from each canine to the
studies using their Onplant system. that bone directly opposed the tex- ipsilateral first molar. Measure-
The first study was performed with tured, hydroxyapatite-coated sur- ments at the conclusion of this
mongrel dogs and the second with face. Onplants were also placed in study yielded an average of
monkeys. In the canine study, the mandible to examine the shear 1.2 ± 0.2 mm movement of the
springs were extended from the force required for removal. The anchored molars toward the central
onplant abutment to the first pre- results indicated that 160 to incisors. The nonanchored molars,
molar and activated to exert 162 pounds of “push-off” force however, moved an average of
11 ounces of force. Measurements was required to dislodge the 4.1 ± 1.4 mm toward the central
of tooth movement were made peri- onplants from the mandible. incisors. The canines on both the
odically, and after 5 months the anchored and nonanchored sides
dogs were euthanized. The maxillas The monkey study examined the moved an average of 1.9 mm away
were retrieved and sectioned, and effectiveness of the Onplant system from the central incisors. Soft tissue
osseointegration was assessed. A to anchor molars during anterior dehiscences were observed over the
soft tissue dehiscence developed dental retraction. In addition, this original onplant design but were
over one of the onplants at the study introduced onplants with not observed in the tapered margin
sharp margin, causing failure of the tapered margins and compared design. This study concluded that
onplant to integrate. The other them with the original sharp- “the onplant can provide sufficient
onplants did integrate and were margined onplants. Bands were anchorage to molars to prevent
loaded with the springs. At the con- placed on the first molar on one anterior migration in situations
clusion of the study, measurements side and the second molar on the requiring maximum anchorage.”
A B
Figure 2. A, Illustration of an onplant (Nobel Biocare, Göteborg, Sweden) as described by Block and Hoffman. B, Diagram of
placement of the onplant connected to a transpalatal arch.
In addition to requiring less bone The surface of the Orthosystem placed for the next 10 to 12 weeks,
depth for placement compared with implant is Straumann’s sand- after which time the impression is
endosseous implants, onplants can blasted, large-grit, acid-etched sur- made. The impression is sent to a
be loaded after a shorter healing face (Figure 3). laboratory for fabrication of the
period. The onplant system cuts prescribed orthodontic appliance.
this healing period approximately Lateral cephalometric analysis is After completion of orthodontic
in half. Despite these advantages, required prior to placement to treatment, the implant is removed
one area of concern with this sys- determine the ideal site for place- by drilling down two-thirds of the
tem is removal of the onplant. ment and the appropriate length of implant length with the exploration
Block and Hoffman described using implant. Under palatal local anes- trephine and pulling out the
osteotomes for removal of the thesia, the palatal mucosa at the implant with extraction forceps
devices.12 Although this technique implant site is removed. The site is and gentle rotation.13 Currently,
is obviously atraumatic to a eutha- prepared using a series of drills use of this system is approved by
nized dog, performing it on a rotated at no more than 750 rpm the US Food and Drug Administra-
human could be uncomfortable to under saline irrigation. The implant tion (FDA) for midpalatal place-
the patient. Removal of the onplant is hand-turned as far as possible, ment in adults only owing to
also requires removal of a large and a ratchet is used to tighten the concerns about the effects on the
portion of soft tissue, which could implant into its final position. A midpalatal suture in younger
be uncomfortable postoperatively healing cap or healing screw is patients (Figure 4).
for a patient.
In 1998 Wehrbein and colleagues anchor the posterior teeth for ante- Miniscrews
published a study examining bone- rior dental retraction after premolar An alternative approach to achiev-
to-implant contact of implants fol- extraction. In one patient, the mid- ing anchorage is the use of titanium
lowing orthodontic loading in palatal implant was used for both miniscrews. These devices are very
patients.6 In this study, four anterior and posterior anchorage in small and can be placed in areas
patients were treated for Class II premolar mesialization. The retro- where other implantable devices
malocclusion using Straumann molar implants were used for bilat- cannot. For example, some minis-
Orthosystem implants for anchor- eral molar distalization. crews are so small that they can
age instead of conventional extrao- actually be placed in bone between
ral anchorage aids. Orthosystem After completion of orthodontic the roots of individual teeth. The
implants were placed in the mid- treatment, the implants were screws themselves are similar or
palatal area of the maxilla and the removed in a bony core using a identical to those used for
retromolar areas of the mandible. trephine. These cores were then osteotomy fixation following
Midpalatal implants were used to preserved and sectioned through orthognathic surgery. These mini-
screws are unique because unlike palatal suture, infrazygomatic crest tem uses a self-drilling titanium
restorative endosseous implants of the maxilla, retromolar area of screw, and the surgical process and
they do not require osseointegra- the mandible, and mandibular sym- clinical applications are not unlike
tion. Instead, these devices rely on physis and within edentulous areas the previously mentioned systems.
mechanical retention to maintain of the alveolar process. After taking This system is FDA approved.
rigidity, which also makes their into account what tooth move-
removal relatively simple and non- ments were desired, the location In 2003 Kyung and colleagues
invasive. They may be loaded was decided upon, and the screws reported the development of a
immediately, but biomechanical fac- were placed with specific angula- microimplant for orthodontic
tors must be taken into considera- tions to accommodate existing anchorage.18 This implant is a
tion owing to the increased chance anatomy and deliver forces in the small titanium screw known as the
of loosening associated with the desired directions. Prior to insertion Absoanchor and is manufactured
lack of integration and torquing or of the screws, a 1.5 mm diameter by a Korean company called
rotational forces that may occur hole was drilled into the bone with Dentos Inc. (Taegu, Korea).
under loading. Kanomi published a slow-speed handpiece using irri- According to Kyung and Dentos,
one of the preliminary reports of gation. The miniscrews were the Absoanchor is a particularly
this technique in which he referred inserted by hand with a screw- attractive member of the family of
to the devices as mini-implants.15 driver. To apply the desired force, mini-implants because it “has been
Although he referred to the devices the heads of the screws were joined designed specifically for orthodon-
by a different name, his results were to the dental arch or tooth with a tic use and has a button-like head
essentially similar to those of other wire. In cases involving one-dimen- with a small hole that accepts liga-
case reports on the use of mini- sional force, the head of the screw tures and elastomers. The Absoan-
screws, such as the one published was placed so that mucosa would chor’s small diameter allows its
by Costa and colleagues.16 Their cover it and the attached wire insertion into many areas of the
article is a case report in which the would emerge from the mucosa. In maxilla and mandible previously
authors observed 14 patients with cases that involved the use of multi- unavailable—even between roots
16 screws. The titanium screws that dimensional forces, the heads of the of adjacent teeth” (Figure 5).18
they used were manufactured by a screws were kept above the mucosa
company called Cizeta (Rome, so that edgewise wires could be The stated advantages of minis-
Italy) and had a diameter of 2 mm inserted into the specially designed crews for use in orthodontic treat-
and a length of 9 mm. The place- head of the screw. In this article, the ment are primarily the ease of
ment technique involved inserting miniscrews were loaded immedi- insertion and removal. Compared
the screws under local anesthesia ately, and after treatment they were with other systems the surgical pro-
directly through mucosa without a removed under local anesthesia cedure for placing and removing
mucoperiosteal flap. The screws using the same screwdriver that was miniscrews is very simple and non-
were placed in several different used during initial placement. invasive. This can allow the proce-
locations depending on the desired dures to be performed by an
treatment and available bone. They In 2000 Melsen and Costa report- orthodontist, thereby eliminating
were reported to be useful in both ed the use of a similar device called the need for a surgical referral.
the maxilla and the mandible, the Aarhus Achorage screw, which Additional advantages are that
specifically, on the inferior surface is manufactured by Medicon loading can occur immediately,
of the anterior nasal spine, mid- (Tuttlingen, Germany).17 This sys- which has the potential to shorten
Miniplates
A further approach to the use of
implantable devices in conjunction
with orthodontic treatment has
been the use of titanium miniplates.
Miniplates are frequently used in
B
orthognathic surgery for osteotomy
Figure 5. A, An example of a minis- fixation or in the fixation of frac-
crew, the Absoanchor (courtesy of tures. An early case report by
Dentos Inc., Taegu, Korea). B, Dia-
gram of a possible placement loca- Sherwood and colleagues described
tion of a miniscrew (courtesy of two adult patients referred for
A Dentos Inc.).
orthodontic treatment of super-
erupted molars.20 The extruded
teeth were in contact with the
treatment time, and local soft tissue unscrews the screw. If the screw is opposing alveolar ridge. Without
irritation is reported to be limited loaded such that the force is ori- orthodontic intervention the
compared with other transmucosal ented in the direction that tightens supererupted teeth would need to
types of anchorage and, when pre- the screw, then loosening does not be reduced occlusally by a consider-
sent, is easily controlled with local occur as quickly. This supposition able amount, which would have
application of chlorhexidine. The helps reinforce the conjecture that required endodontic therapy and
stated disadvantages of the minis- lateral shearing forces are more subsequent restoration. The implant
crews as used in the Costa and col- detrimental to the stability of placement involved a surgical proce-
leagues article were the potential implantable devices than are other dure with a 1.5 cm incision under
for infection or local soft tissue irri- forces. Miyawaki and colleagues local anesthesia in the buccal
tation, the potential for maxillary retrospectively examined the suc- vestibule adjacent to the extruded
sinus perforation, infringement cess rates of titanium screws placed molars. A full-thickness mucope-
upon tooth roots, especially when for orthodontic anchorage in the riosteal flap was reflected, and bone
placed in the infrazygomatic crest buccal alveolar bone in the poste- was exposed. An L-shaped titanium
region, and, perhaps most impor- rior region.19 They concluded that a Leibinger (Stryker Leibinger GmbH
tantly, loosening of the miniscrew.16 screw diameter of 1.0 mm or less, & Co. KG, Freiburg, Germany)
During the trial reported by Costa inflammation of periimplant tissue, miniplate was contoured over the
and colleagues 2 of the 16 screws and a high mandibular plane angle exposed bone and fixed with two
were loosened and lost prior to the were associated with the mobility self-tapping screws of 3 mm length.
completion of treatment. Loosening (failure) of the screws. Interestingly, The last loop of the miniplate was
is suggested to be a problem only they detected no association allowed to project through the
when the screws are loaded in a between the success rate and length vestibular wound adjacent to the
manner that results in a force that of the screw. Miniscrews are avail- supraerupted molars. The incision
is oriented in a direction that able from manufacturers other than was closed via sutures, and soft
tissue was allowed to heal around second molars. The C-tubes were correction of Class II malocclusion.
the exposed loop for 2 months. placed so that the tube end pro- The specific points addressed by
During healing the other teeth were truded through the mucosa. The De Clerck and colleagues were
orthodontically leveled, excluding authors reported good results in the design of the extension arm,
the extruded molars. Elastic threads retraction of anterior teeth and lev- the exit of the extension arm at the
were attached to the exposed loop eling of the occlusal plane following mucogingival junction, and the ver-
of the miniplate and tied tightly connection of C-tubes to the rest of satility of the attachment apparatus.
over the buccal tube of the extruded the arches via rectangular wires.
molar, which was now banded. This case was cut short owing to The apparent advantages for using
New elastics were applied and acti- the patient moving away, but the a miniplate system as declared by
vated every month. This process results nevertheless seem to indicate the above authors are as follows: a
was continued until the molars a potential method of achieving long history of biocompatibility, a
were at the plane of occlusion of the skeletal anchorage. variety of shapes and sizes, a mini-
adjacent teeth. This process took mally invasive surgical procedure,
approximately 6.5 months, and In 2002 De Clerck and colleagues and little risk of damaging nerves
afterward the molars were ligated introduced and reported success in or tooth roots. This approach is
to the miniplate loops for retention. the treatment of Class II malocclu- indicated by various authors as
sion using the Zygoma Anchorage being valuable in aiding patients
In another case report by Chung and System.22 The authors adapted a needing intrusion of individual or
colleagues the investigators used the Surgitec zygoma anchor miniplate groups of teeth, correction of
miniplate system by Martin Medizin (Surgitec, Bruges, Belgium) secured severe crowding, correction of
Technik (Gebruder Martin GmbH with three screws that had a round skeletal Class II malocclusion, and
& Co KG, Tuttlingen, Germany), extension arm carrying an attach- management of an anterior open
but they soldered a round 0.036-inch ment mechanism (Figure 7). These bite.23 The disadvantages are that
tube with a hook to one end of devices were placed in the inferior placement of miniplates is more
the miniplate.21 The authors called surface of the zygomaticomaxillary invasive than the placement of
this device the C-tube, and it was buttress. The surgical procedure miniscrews and requires a surgeon
designed to use the tube with a for placement was similar to that for the procedure. In the reports
hook instead of an exposed loop discussed for the other miniplate of miniplate use as temporary
or rectangular slot to minimize systems; however, in this case the skeletal anchorage, patients
torque forces (Figure 6). This spe- devices were loaded immediately experience loosening of the plates
cific report involved the treatment after placement. The tooth move- secondary to inflammation or
of a 10-year-old female with severe ments reported in this case were excessive shearing or torsional
crowding and a Class II skeletal retraction and intrusion for forces from the archwire.
discrepancy. The surgical process
was similar to that described by
Sherwood and colleagues. One
C-tube was placed in each quad-
rant. In the maxilla they were
placed between the second premo-
lars and first molars and in the
mandible between the first and Figure 6. The C-tube miniplate (KLS Martin, Tuttlingen, Germany).
of dentistry. With the increased DISCLOSURE AND 12. Block MS, Hoffman DR. A new device
ACKNOWLEDGMENTS for absolute anchorage for orthodontics.
interest in the area of implantology Am J Orthod Dentofacial Orthop
has come a great deal of credible The authors do not have any finan- 1995;107:251–8.
research exploring the use of dental cial interest in the companies whose 13. ITI/Straumann Orthosystem [product
implants. Indeed, evidence-based materials are discussed in this article. brochure].
dentistry is the basis for sound clini- 14. Wehrbein H, Glatzmaier J, Mundwiller U,
We thank Dr. Nicole Scheffler for Diedrich P. The Orthosystem—a new
cal decision making and treatment- implant system for orthodontic anchorage
stimulating interest in this subject.
planning modalities. Whereas the in the palate. J Orofac Orthop
1996;57:142–53.
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