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 anchorage: 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 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. 11:331–34 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 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 protraction facemask in the treatment of Class III malocclusions in growing children: a prospective long- 011351 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. 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!.