Mini-Implants in the Anterior Palate: How to improve Stability in the Long-term

Björn Ludwig / Traben-Trarbach / Germany Benedict Wilmes / University of Düsseldorf / Germany Stability of Mini-implants

Phase

of low stability 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 ns median * 15

10

5

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 : A retrospective cohort study. Am J Orthod Dentofacial Orthop. 2013

1. Low failure rate 2. No root damage 3. Tad´s 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 TAD´s

Molar distalization

Beneslider Pendulum B

Molar mesialization

T-Bow Mesialslider

RPE / Class III Molar Hybridhyrax anchorage

Molar Alignment of 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. 11:331–34 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 : 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 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 011351 term study.term long aprospective children: growingin Class of III treatment the in facemask protraction DM, Sarver Williams MD, maxillary Ngan Maxillary Transfer Mesialmigration the of dentition P, Yiu to expansion Semin C, Hu C, A, the of Orthod advancement and bone Hagg the protraction Sadowsky 1997;3:265 U, WeiU, SH, force . PL, Bradley E. Combined rapid maxillary expansion and expansion maxillary rapid E. Combined PL, Bradley Eur - 274. Gunel J Orthod E. using Cephalometric 1998;20:237 a Goal 2:  - of the teeth 254. and Facemask  Avoid migration mesial advancement F Just occlusal skeletal

changes

following maxillary - 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. Tad´s 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

[email protected] www.uniklinik-duesseldorf.de/kieferorthopaedie

Thank you very much for your attention!