Orthodontic mini implant

Orthodontic Mini-Implant
Under supervision of Dr. Maher A. Fouda
By: Yasmine M. Hammad

What do I want to know about this topic??
o1-History and development
2-Definition
3-Terminology
4-Uses
5-Design features and parts.
6-Concepts and controversies:
7-Armamentarium
8-Steps of Placement and Removal
9- Best mini-implant insertion sites.
10-Case Reports.
A-Method of Insertion
B-Primary Stability
C-Timing of loading
D-Secondary Stability
E-Miniscrew Design: insertion and removal torque
2

History and development
• For a long time, orthodontists struggled to achieve efficient control of anchorage.
{Orthodontic anchorage is defined as resistance to undesired tooth movement.}
Dissatisfaction with conventional methods of anchorage led some pioneer orthodontists to explore the use
of implants as a source of absolute anchorage.
• In 1945, Gainsforth and Higley used vitallium screws in dogs to create absolute anchorage for tooth
movement. A doctor in Sweden accidentally discovered that titanium can bond irreversibly with living bone
tissue.
1952 Per Ingvar Branemark was interested in studying bone healing and regeneration. He screwed a
Titanium Metal Cylinder into a rabbit’s thigh bone as part of an experiment. He attempted to retrieve these
expensive chambers from the rabbits and found that he was unable to remove them. Bone had grown into
such close proximity with the titanium that it effectively adhered to the metal. He named this phenomenon
“osseointegration”.
In 1969 Linkow, described the use of an endosseous blade implant for retraction of anterior teeth.
It was not until the 1980s that the studies on the use of implant in orthodontics reported successful
results.
In 1983, Creekmore and Eklund performed maxillary incisor intrusion with the help of a titanium
osteosynthesis screw.
In 1984, Roberts et al applied these principles for molar movement in an adult patient.
With the invention of the onplant in 1995, Block and Hoffman introduced the palate as an anchorage device
location, and, in 1996, Wehrbein et al used the palate as an implant site.
In 1997 Kanomi used a 1.2-mm diameter mini-implant . After that, many reports have been published on
orthodontic absolute anchorage systems, reflecting their increasing popularity and importance.
3

Later Development
Mid Palatal implant
• its a short but otherwise conventional implants placed in the midline of the palate. These implants are
usually 3-4 mm diameter and 6-10 mm in length.
*Disadvantage:
• 1- require loading after a 10-12 weeks healing period.
• 2- Relatively expensive and complex procedure
Onplants
are osse-ointegrated to the surface of bone. Much simpler than midpalatal implant, based on the research
of Block and Hoffman.
They used a sub-periosteal Ti alloy disk 2 mm thick and 10 mm wide, coated with hydroxyapatite.
*Disadvantages:
1- it is designed to be unloaded for 4 months.
2- Requires an intensive soft tissue surgery.
Mini-screws
• Were originally designed to fix bony segments.
• The late 1990s saw the introduction of miniscrew as temporary anchorage devices.
• The need for osseo-integrated implants in the palate has been greatly diminished by the development of
mini-screws. *Advantages:
• 1-Their small size which permits rapid and a-traumatic placement in almost all sites within the mouth.
• 2- a practical, inexpensive, highly versatile sources of orthodontic anchorage.
4

2-Definition
3-Terminology
4-Uses
o5-Design features and parts.
7-Armamentarium
o10-Case Reports.
B-Primary Stability
C-Timing of loading
5

Definition & Terminology
• Over the years a variety of terms have been used to
discribe the orthodontic implant, such as:miniscrew,
mini-implant, micro-implant and microscrew implant.
micro is short for 'microscopic'; therefore, in some authors' view
'mini' seems to be more appropriate.
'Temporary anchorage device' (TAD) is widely used, but this term
includes bone plates and short osseointegrated implants in the
midline of the palate.
6

7
A temporary anchorage device (TAD)
is a device that is temporarily fixed to
bone for the purpose of enhancing
orthodontic anchorage either by
supporting the teeth of the reactive unit
or by obviating the need for the reactive
unit altogether, and is subsequently
removed after use. They can be located
transosteally, subperiosteally, or
endosteally; and they can be fixed to
bone either mechanically (cortically
stabilized) or biochemically
(osseointegrated).

Uses and Application
Anteroposterior
control
vertical control
Transverse and
asymmetry control
• Mini-implants have replaced other types of fixed appliances for
the delivery of differentiated force systems for posterior tooth
movement or extrusion of impacted canines. Mini-screws have
also been used as anchorage for tooth movements that could not
otherwise have been performed, which are as follows:
8

• In cases to achieve class I molar relationship by molar distalization
[Figure 1].
(a) Implant placed between first molar and
second molar for distalization.
(b) After 4 months
• Cases where the forces on the reactive unit would generate adverse side effects
[Figure2].
(a) Mini-implant inserted in the buccal interproximal
region mesial to the first molar and at an angulation of
approximately 45° to the vertical axis.
(b) A post-insertion radiograph confirms the position
of the mini-implant in the interproximal ...
• Patients with a need for asymmetrical tooth movements in all planes of space
[Figure 3].
(a and b) Implants for cases in which differential
movement in the same arch is required .
• In some cases, as an alternative to orthognathic surgery.
9
Figure 1
Figure 2
Figure 3
A B
A
A
B
B

2-Definition
3-Terminology
4-Uses
7-Armamentarium
10-Case Reports.
B-Primary Stability
C-Timing of loading
10

Parts and Design Features
• A screw is defined as “a simple machine that changes rotational
motion into translation motion while providing a mechanical
advantage”.
The commonly used screw has three parts:
head, core and thread.
The thread is wrapped around the core.
• Core:
it is designed to maximize stability and aid insertion of the mini-
screw into the bone. It’s diameter varies from 1.2mm to 2mm. This
is called the (inner diameter), of the mini-screw
which does not include the thread, or when including the thread it
is called the (outer diameter).
• Head:
Orthodontic mini screw implants differs from the conventional
bone screw as it has a dual head. Which has an additional feature
designed specifically for use in ortho treatment.(e.g: tying a
ligature wire or elastic chain.)The head is also the part that is
engaged in the shaft of the hand screwdriver or rotary inst. The
head design may be hexagonal, octagonal or even ball shaped
according to manufacturer.
12

Pitch:
The vertical distance between two
adjacent screw threads is called the
pitch of the screw. One complete
revolution of the screw will move it
either into or out of an object a distance
equal to the pitch of the screw.
Neck (collar):
Between the head and core is the part
that contacts the gingival tissue (soft
tissue interface) which is often referred
to as the neck or collar. Some mini-
screw may be supplied with longer neck
for use in sites where the overlying
gingiva is thicker, such as: the palate or
the retromolar areas.
13
Threads
Pitch
Core

Ideal Characteristics for micro-implants Nanda-250
*Micro implants should have the following
characteristics:
1. Simple to use (orthodontist should be able
to easily insert and remove the implant)
2. Immediately loadable.
3. Inexpensive.
4. Small dimensions (small enough to place
in any area of alveolar bone, even apical
bone)
5. Withstand orthodontic forces.
6. Stay immobile during treatment.
7. Biocompatible.
8. Not require compliance, i.e:(patient co-
operation)
9. Provide superior results than traditional
anchorage.
15

16
• Few mini-screws require drilling
(preparing a small hole) prior to insertion
and referred to as Pre-drilling mini-
screws.
• On the other hand most of the current
orthodontic mini-screw are of the drill-free
or self-drilling type which have a specially
formed cutting flute that allows insertion
without drilling.
N.B: at the tip of the core
there is a vertical groove
that prevents clogging of
bone debris during
insertion.
*Insertion steps of Self-Drilling mini-screw
Single step: Insertion of Pre-Drilling mini-screw
1
2
Two-steps (1+2): Insertion of Pre-Drilling in case of thick cortical plates

• Threading the fixture site is referred
to as tapping, mini-screw threads are
designed to tap the bone during
insertion. Thus, all orthodontic mini-
screw implants are self tapping and
most of them are self drilling.
• Drill-free mini-screws provide:
1-extensive implant-bone contact.
2-little bone debris and less thermal
damage.
3-less mobility when tested with a
Periotest.
4-show greater bone remodeling and
osseointegration.
17
*The diameter and thread length of the mini-screw are the main
features to consider when selecting a mini-screw

The diameter and thread length of the mini-screw are the main features to
consider when selecting a mini-screw
20
• Regarding diameter, the commonly used 1.6 mm diameter mini-screw is considered
to have sufficient rigidity to be inserted without drilling. Mini-screws with diameter
less than 1.5 mm were inserted using the pre-drilling method to avoid screw
fracture. Recent improvement in materials le to development of self-drilling mini-
screws with small diameters of 1.2-1.4 mm (Dentos and Miangang).
• The drill free mini-screws come in variety of thread lengths
(5-9mm) and are available in two configurations:
• Cylindrical with a diameter
of 1.6mm (OSAS®) and
• tapered with a maximum
diameter of 1.6mm or 1.8 mm
(ORLUS®).

The length to be used depends on the thickness of both the soft tissue and cortical bone at the site
of placement.
• -In mid-palatal area: thin soft tissue , dense cortical bone  use of shorter length screws
(5mm) as contact with dense bone provides adequate retention.
• -Buccal alveolar area: gingival soft tissue tends to be thicker and the cortical bone less dense
(6mm) length mini-screw are used to achieve maximum contact with alveolar bone.
• -Retromolar pad area: usually >or= 8mm
• -Palatal alveolar regions: usually >or= 7mm where gingival tissue is even thicker.
• Some systems provide the option of screws with longer neck or collar for gingival thickness.
21

22
• NOTE that…
If the mini-screw is placed in an area with non-keratinized gingiva,
at the borderline between keratinized and non-keratinized gingiva,
or if gingiva is thick, a stab incision is made before placement of
mini-screw.

2-Definition
3-Terminology
4-Uses
7-Armamentarium
10- Case Reports.
B-Primary Stability
C-Timing of loading
23

*Method of insertion:
drill-free versus predrilling
• In the Drill-free method a self drilling
mini-screw is inserted directly into the
intact cortical bone
• With the drill free method no incision is
needed in the attached mucosa e.g.:
palate or attached gingiva (intact bone)
• The soft tissue in these areas is firm and
does not wrap around the screw threads
• In the buccal alveolar mucosa a small
vertical stab incision through the soft
tissue helps prevent the soft tissue from
wrapping around the screw head.
• In the predrilling method a self tapping
mini-screw is inserted into a guide-hole
made using a drill bit.
• In the predrilling method a slimmer
screw(1.2mm) is usually used thus the
main advantage of it is when the screw
needs to be inserted in a narrow inter-
radicular space.
• * the insertion torque applied to the
screw here is less than that required for a
self drilling screw.(through a guide hole)
24

Upon researches it was found that:
• 1- the contact between the screw and the bone
using self drilling screw was superior to
that with self tapping screws.
• 2- better stability and greater bone density
between the threads of the self drilling mini-screw
• 3- the heat produced when the drill bit was
used could negatively affect the stability of the
screw as well as cause impaired bone remodeling
after insertion of the screw.
• 4- the drill free method is a simpler procedure
and offers greater stability.
• 5- it has been reported that mini-screws with
relatively greater diameter may induce
micro-fractures of the bone.
27
Histological image demonstrating the result of
continous change in direction during insertion; a
number of micro fractures surround the screw.

Primary stability:
Versus
Osseointegration mechanical interlocking
• Osseointegration is defined
as a state in which, under the
optical microscope, there is
direct contact between the
implant and bone without
any intervening soft tissue,
and which enables
transmission of the external
stresses to the bone structure
in a functional manner.
• With regard to orthodontic
mini screw implants,
different views were
expressed. Some suggest
that stability of the
orthodontic mini-screw is
achieved through
mechanical
retention(interlocking of
screw threads and cortical
bone).
28

It was reported that osseo-integration may not be necessary when
titanium screw implants are used for orthodontic anchorage gray et al
Stability of the mini-screws comes from mechanical interlocking
between the screw and bone, and not by osseo-integration. However
some recent reports support the view that a degree of osseo-
integration does occur.
Complete osseo-integration is not mandatory for orthodontic mini-
screw as:
1- The force applied on them is less than that applied to dental
implants.
2- Mini-screw is a temporary device that is removed after treatment.
Osseointegration is a double edged sword as it increase stability
during treatment on one hand but making removal after treatment
more difficult on the other hand.
Removal of a small diameter screw is relatively easy because removal
torque is proportional to the square of the radius of the screw.
29

Timing of loading:
immediate versus delayed loading
• { Waiting for a short period to allow the oral
soft tissue to heal after placement of the
screw comes in the immediate loading
category. }
• It has been reported that the micro-motion
following early loading interferes with
osseo-integration which require a 4-5
months preloading healing period in
humans.
• However, many clinicians have shown that
mini-screw can be successfully loaded
without having to wait for several months.
30

• It was stated that it is possible to apply orthodontic force once the soft
tissues have healed [=1 week to 10 days], starting with relatively light
loads {3-5N (305-510g.} is recommended.
• It is considered important that a low initial
loading force is used, less than 50cN {50g.},
if it is applied soon after mini-screw placement.
• A screw can loosen as a result of application of strain that exceeds the
amount that can cause micro-fractures in the thin cortical bone.
• Studies evaluating the effect of different loads on the osseo-integrated
implants have shown that static loads (constant loads with uniform
levels) stimulate production of more dense cortical lamellar bone and
greater amount of bone implant contact at the interface than no loads or
dynamic loads.
31

Secondary stability:
bone remodeling around the mini-screw implant
• Primary stability of mini-screw implants
comes from mechanical interlocking with
the cortical bone, so the thickness and
integrity of the cortical bone are critical
factors.
• Secondary stability of the mini-screw
implant relies mainly on bone remodeling
or turn over, which not only maintains the
integrity of osseous support, but also
provides a continuous flow of calcium
necessary for bone metabolism.
32

• Bone remodeling differs than bone modeling;
bone modeling refers to the changes
occurring in a bone’s external structure in
response to mechanical loading and/or
trauma which cause changes in shape, size
and/or position of bone.
• Bone remodeling cycle in human takes almost
4 months, and is considered to be responsible
for the integration and maintenance of the
implant in bone. Orthodontic mini-screw
implant seems to be at least partially osseo-
integrated and remains stable through active
bone remodeling.
33

Mini-screw design: insertion and removal torque.
• Orthodontic mini-screw implant has
fewer anatomic limitations than dental
implant and the procedures to insert
and remove the screw are much
simpler.
• Ideal mini-screw require minimal
insertion toque so that the screw does
not fracture and the bone strain is low.
In contrast, the force required to
remove it (removal torque) should be
relatively large, so that it does not
easily loosen under loading.
34

*NOTE: Removal torque is
proportional to the square of the
radius of the mini-screw implant.
 Therefore, orthodontic mini-
screws has lower removal
torque and is much more easily
removed than dental implants.
 Efforts to increase the removal
torque led to development of
the tapered type of mini-screw;
greater diameter near the screw
head. Nevertheless, conical
shape provides better strength
and mechanical stability.
35

A study compared insertion and removal torque of
two types of mini-screw design:
 The tapered type was associated with greater
removal torque values, which is preferable for
mechanical stability, but the insertion torque was
also greater which may be a disadvantage as it
may result in higher strain in the adjacent bony
tissue and mini-screw fracture.
 Also the dual-pitch design has a smaller pitch
which help improve mechanical characteristics, as
it is associated with lower insertion torque and
greater removal torque than the mono-pitch mini-
screw.
36

Path of insertion
versus
Diagonal (oblique) Perpendicular
• Using a diagonal path of insertion will help
to avoid root injury when a micro-implant
is placed between the roots of adjacent
teeth. A comparison of the inter-radicular
space available for micro-implant
placement reveals that, in general, there is
less cause for concern palatally than
buccally.
• From purely mechanical stand point,
however, it is better to place a micro-
implant in a direction perpendicular to the
bone surface. But it can only be used when
there is sufficient space. Thus, when the
micro-implant is inserted in this way, it
should be 1 or 2 mm shorter than the
micro-implant inserted diagonally.
37

2-Definition
3-Terminology
4-Uses
7-Armamentarium
10-Case Reports.
B-Primary Stability
C-Timing of loading
38

Armamentarium
for mini-screw placement
Hand Instruments Motor-driven rotary instruments
• Straight hand driver
• Short hand driver
• Contra-angle hand driver
(torque driver)
• Implant motor with attached
hand-piece.
• Low speed hand-piece with
contra-angle head run at a
reduced speed.
• Connecting bur
• Pilot drills
39

Hand Instruments:
• 1)Straight hand driver has 2 components, the
handle and driver shaft. Indicated in buccal and
labial alveolar area and deep areas with relatively
good access,
including: {infra zygomatic crest, lower
symphyseal area, and mandibular retro-molar
area.}
• 2)Sort hand driver also has 2 components but
used for sites that are difficult to reach with the
straight hand driver
{e.g.: mid palatal area.}
• *Driver tip*: it is the part which delivers the
insertion torque to the mini-screw head. The
short tip is used for palatal slope, anterior rugae
area and mid palatal region in patients with low
palatal vault. The long driver tip is suitable for
mid-palatal and parasagittal areas. An essential
clearance of 6mm at least between the shank of
the screw driver and the upper incisal edge.
40
1
2
1
1 (ORLUS®)
2 (ORLUS®)

• 3)The surgical kit consists of the
instrument organizer, hand drivers, mini-
screws and optionally the connecting burs.
• 4)The contra-angle hand driver (torque
driver) indicated for locations where access
with straight driver is difficult
{e.g.: palatal area: slope and parasagittal
area, lingual slope of the mandibular
alveolar bone, retro-molar pad and
maxillary tuberosity} manually driven, the
driver is held by one hand while the other
hand rotates the wheel at the rear end. The
shaft may rotate with the handle when the
bone is dense or highly resistance.
• *Periodontal Probe* is useful to make an
indentation for the long axis of the roots or to mark
the insertion point. Additional measuring devises
such as *torque gauge and the Periotest* are
helpful in immediately assessing the initial stability
of the mini-screw.
41
3
4
3 (OSAS®)
4

Motor-driven rotary instruments
• Used mainly for sites that are less accessible. Care must be
taken to use controlled, slow speed and to apply light pressure
to the bone when using these instruments, whether for
predrilling or inserting the mini-screw.
• 1) The implant motor is specifically designed for implants and
mini-implants placement with association of speed reduction
contra-angle hand-piece. However such specialized equipment
is expensive.
• 2) The low-speed hand-piece with contra-angle head running at
a reduced speed is used in a micro-motor or implant engine and
can be used for implant placement in all areas of the mouth
especially in the maxillary tuberosity region as well as in the
retro-molar and palatal areas. If an implant motor that can
adjust for torque value is available, it becomes easy to drive the
micro-implant with little risk of implant breakage.
• “Torque is defined as a measure of a force acting on an object
and causing that object to rotate
:. High torque is a disadvantage a thin, weak mini-screw may
fracture when placed in dense bone.”
42
(NSK)

• 3) A connecting bur is mounted on the handpeice with a
frictional grip to connect the hand-piece with the mini-
screw. These burs come in 2 lengths, commonly the
shorter one is used. In cases of mid-palatal screw in a
deep palatal vault the longer connecting bur is used.
• 4) A pilot drill: is useful for penetrating the cortical bone
before the placement of the mini-screw. The pilot drill
used to make the initial tunnel into the bone should be
0.2 to 0.3 mm smaller in diameter than the diameter of
the micro-implant that subsequently is drilled into that
tunnel (self-tapping method)
• *Round Bur*: a low speed, No.2 round bur is commonly
used to make an initial indentation in the cortical bone
surface. This initial indentation prevents slippage of the
pilot drill or micro-implant, especially when they are
inserted in an oblique direction.
43
3
4

Other Surgical Materials
and Supplies
• Topical anesthetic agent.
• Dental syringe for local
anesthesia
• Mirror, cotton forceps, and
explorer.
• No.15 surgical blade.+
Periosteal elevator (in case of
Incision)
44
Sterilization protocol.
Prior to the placement procedure, conventional
sterilization protocols should be followed to
disinfect the dental unit and chair and its
attachments, and the table on which the
instruments for mini-screw placement will be
placed.
The instruments needed for mini-screw
placement are autoclaved. Each instrument is
packed separately, for example contra-angle
drivers and connecting burs. The instrument
organizer is wrapped separately with surgical
drapes and then dry heat
autoclave. The straight
hand driver and the
mini-screws should be
placed in the organizer.
Put a sterilized drape
over the bracket table
before setting the
instruments.

* Gripping the straight hand driver*:
45
• Holding the handle with the palm and the fingers
• provides a stable grip on the driver and prevents the
• Mini-screw from wobbling around its axis. The hand
driver is rotated slowly at a speed of 15–30 rpm to
minimize damage to the cortical bone.

• .
46
Steps of
Diagnosis
Sterilization and
preparation for
placement
procedure
Steps of mini-
screw removal

A-Steps of Diagnosis
• Patient history
47
Photography
Panoramic X-ray
Disinfection of
working feild
Positioning the x-ray guide
Axial C.T scan to view
inter-radicular spaces
Cephalometric X-ray
tracing
X-ray guide
Periapical x-ray with x-ray guide

*Notes:
• Once a decision has been made to use mini-screw
implants during orthodontic treatment, informed
consent should be obtained from the patient. A full
explanation is given to the patient about the benefits
and side effects of having mini-screws incorporated in
the treatment procedure.
• Computed topography (CT) is a valuable tool for
3-D evaluation of the root configuration, cortical bone
thickness, and location of anatomical structures such
as maxillary sinus and inferior alveolar canal.
• X-ray guides are placed on the micro-implant
insertion site and they are fixed to orthodontic arch
using Fermit.
• X-rays are taken to confirm the correct position.
• In case that the position is not correct, it must be
modified and the X-rays are repeated.
48

SURGICAL TECHNIQUE
• Depending on the author, there are various techniques
for micro-implant insertion.
• - With or without previous incision:
The incision using scalpel and separation of mucosa and
periosteum is
a must when the work is done on free gingiva, but some
authors assure that it is not necessary when micro-implant is
inserted in attached gingiva or in palatal mucosa.
Some authors recommend previous incision using scalpel in all
cases to avoid the impulsion of soft tissues inside the bone
which would be
an instability center for micro-implant
• - With or without previous drilling:
A technique with previous drilling is called indirect technique,
and without previous drilling, a direct technique. Direct
technique insertion offers more retention to micro-implant and
therefore it would be the first choice.
49

B- Sterilization and preparation for placement
procedure
1. The patient is instructed to rinse with a
chlorhexidine solution.
2. Wipe the patient’s mouth area with an oral
disinfectant. The authors use a disinfectant with
hypochlorous acid (30 ppm) as the active
substance. Chlorhexidine may also be used.
3. Place a sterile drape over the patient’s face to
isolate the field.
4. Wipe the recipient area with an oral
disinfectant
5. Apply a topical anesthetic gel.
51

6. Infiltrative anesthesia is given with 2% lidocaine with
epinephrine 1:50 000. Usually injection of a quarter of a single
1.8 mL ampule is sufficient for alveolar mini-screw placement.
The small amount of local anesthetic will probably not
completely anesthetize the periodontal ligaments so the patient
will feel discomfort if the mini-screw touches a root.
The anesthetic is given through X-ray guides. An endodontic
buffer is placed on the needle. It is important to make bone
contact with the needle to measure correctly the muco-periostic
thickness.
The muco-periostic layer thickness should be
measured to determine the length of micro-implant which
should be equal to the soft tissues thickness plus 4-5mm, because
it is important that micro-implant penetrates at least 4-5mm the
bone.
A buccal alveolar mini-screw requires buccal anesthesia only,
and the palatal alveolar mini-screw requires palatal anesthesia
only.
52

7. Determine the site before insertion by placing a probe
parallel to the long axis of the teeth and keeping in mind
the position of the tip of the miniscrew (Fig. 5.23). For
the buccal alveolar mini-screw, the site of insertion is
occlusal to the final position of the tip of the mini-screw.
Appropriate height is determined by viewing the
panoramic radiograph and an effort is made to place the
mini-screw in the attached gingiva.
8. A pinpoint mark is made at the planned insertion site
with an explorer. This is checked with a mouth mirror. If
the mini-screw is to be placed in non-keratinized,
unattached gingiva, such as in the posterior buccal
alveolar region, where there is little attached gingiva, an
additional step is required at this stage. A vertical stab
incision up to the bone surface is made in the gingiva
with #12 blade to prevent wrapping of the soft tissue
around the mini-screw. Gingival undermining is not
necessary.
53

**Mini-screw pick up**
• When mounting a mini-screw on the tip of
the shaft of the hand driver (A) or on the
connecting bur of a hand-piece (B), the
core of the mini-screw should not come in
contact with anything other than sterilized
instruments. The mini-screw should be
picked up directly from the instrument
organizer tray, and the fit between the
mini-screw head and the shaft tip or
connecting bur should be checked.
54
A
B

9. The mini-screw is mounted on a hand driver
and secured on the cortical bone surface, before
driving through the bone . The patient should be
instructed not to open the mouth too wide, so
that lips are relaxed and retraction is readily
possible. Check the orientation and location of
the mini-screw with the mouth mirror .
Looking through a mirror from the occlusal side
helps to confirm the mini-screw location.
Checking the mini-screw’s position with a naked
eye from the chairside may lead to errors because
the operator's line of view is usually oblique to
the placement site, especially in the posterior
alveolar area. A mini-screw that seems to
penetrate a dental root when checked with the
naked eye may actually be well positioned when
checked with an x-ray.
55

10. Drive in the screw by rotating the hand driver clockwise at less than 30
rpm (1/4 rotation per-second). No saline irrigation is required, unless the
speed exceeds the recommended rate. However, it is possible to exceed this
rate even when the mini-screw is manually driven into the bone. Thus the
authors routinely use saline irrigation.
11. Stop driving when the head of the screw lies at the level of the surface of
the gingiva. Detach the driver from the mini-screw by pulling the driver
exactly in line with the axis of the screw.
56

Mini-screw placement using rotary instruments
• 1-Determine the site and mark the soft tissue at
the planned location.
• 2- Mount the mini-screw on the handpiece.
Secure the mini-screw at the insertion site and
check the orientation of the mini-screw with the
mouth mirror.
• 3- Drive the screw into the bone using a low-
speed handpiece, with light pressure at a speed of
less than 30 rpm. No saline irrigation is required,
unless the speed exceeds the recommended rate.
• 4- After placement detach the handpiece from the
inserted mini-screw. This may not be easy
because owing to the tight contact between the
connecting bur and the minis-crew head, and the
confined space at the back of the oral cavity.
Detach the connecting bur first from the
handpiece and then the bur from the minis-crew.
57

Post-placement instruction for patients
58
After the mini-screw is placed, the precautions are
explained to the patient. Written instructions are also
given. The patient is informed that they may have pain
but it will not last for more than 1–2 days. They can
take simple, over-the-counter analgesics if required.
Aspirin is not recommended as its anti-inflammatory
properties have been reported to inhibit tooth
movement. The patient can brush their teeth as usual,
but they should be cautious not to tap the screw with
the plastic part of the toothbrush. A toothbrush with
very soft bristles should be recommended.

C- Steps of mini-screw removal
Removal using hand instrument Removal using rotary instrument.
The buccal alveolar mini-screw is removed
with a hand driver. Topical anesthesia is
applied and the patient is asked to rinse their
mouth with chlorhexidine. The hand driver is
fitted on the mini-screw head and rotated
counterclockwise. Anesthesia is not needed
for removal because the bone does not have
sensory nerve endings.
A handpiece is required to remove a mini-
screw from the maxillary tuberosity. The
connecting bur is used to grab the mini-
screw head and rotated counterclockwise. No
anesthesia is required.
59

2-Definition
3-Terminology
4-Uses
7-Armamentarium
10- Case Reports.
B-Primary Stability
C-Timing of loading
60

Best mini-implant INSERTION SITES
In order to discuss the suitable sites for mini-implant
placement, the SIZE of mini-implant is of prime importance
in regard to placement site.
.

Micro-implant SIZE guideline
Length Diameter
®

• Infra-zygomatic crest area.
• Maxillary tuberosity area.
• Buccally:
- Between maxillary first and second
molar.
- Between maxillary first molar and
second premolar.
- Between maxillary canine and premolar.
- Between maxillary incisors facially.
• Palatally: Between maxillary second
premolar and first molar and between
first and second molar
• Mid-palatal area.
*According to: Absoanchor ® mini-implants.

• Infra-zygomatic Crest area
Purpose: retracting the entire maxillary
dentition to correct class II canine and molar
relationships. Also can be used for intrusion
of maxillary molars.
Surgical considerations: require larger
incision and the surgery is more extensive
compared to mini-implants inserted in
mucogingival area. However, it is impossible
to keep the implant’s head exposed, so a
ligature wire is extended to the attached
gingival area.
Recommended micro-implant size: diameter
of 1.3 – 1.4 mm and length of 5 – 6mm.
Insertion sites in the

• Maxillary tuberosity area:
Purpose: retraction of the maxillary
posterior teeth.
Surgical consideration: this location
is used when third molars are
missing. This location poses a
surgical challenge in placement of
mini-implant and the quality of
cortical bone may be compromised.
Longer mini-implants are used and
no incision is needed.
Recommended micro-implant size:
Diameter of 1.3 to 1.5 mm and a
length of 7 to 8mm.

• Buccally between the first and
second molar:
• Purpose: it is considered the second
choice for micro-implant placement to
retract the maxillary anterior teeth
when a micro-implant placed between
2nd premolar and 1st molar fails. Its also
used in applying intrusive forces to
maxillary molars.
• Surgical considerations: sometimes
there is no enough space as roots of 2nd
molar tend to tip mesially. Placement
in attached gingiva does not require
incision where placement in movable
soft tissue will require a small vertical
incision.
• Recommended size: Diameter of 1.2 to
1.3 mm and a length of 7 to 8mm.

 Purpose: it is the best area for retraction of the
maxillary anterior teeth as well as for intrusion of
maxillary molars.
 Surgical considerations: when micro-implants are
placed at higher level it is advisable to drill at an
angle approximately perpendicular to he roots of
teeth which is helpful in avoiding sinus injury.
Again, placement in attached gingiva does not
require incision where placement in movable soft
tissue will require a small vertical incision.
In order to avoid root injury, it is better to place
the micro-implant diagonally and somewhat mesial to
the contact point. Or else, create enough space by
orthodontic leveling of teeth.
*Higher positioned micro-implants provide more
of a vertical component and less of a horizontal
component of force for retracting anterior teeth.
 Recommended size: Diameter of 1.2 to 1.3mm and
a length of 7 to 8mm.

• Purpose: This position is useful for
moving the maxillary molars distally or
mesially and for intrusion of the buccal
segments.
• Surgical Consideration: The quality of
attached gingiva is very good in this area,
easy region to access, and no incision is
required prior to drilling.
• If the implants are used for molars
distalization its better placed closer to
gingival margin, while it is better to place
them slightly in a higher position if
intrusion of posterior teeth is required.
• Recommended Micro-implant Size:
Diameters of 1.2 to 1.3mm and a length of
7 to 8mm.

Between maxillary incisors facially:
Purpose: this site is used for intrusive forces and
torque control of the maxillary incisors.
Surgical Consideration: this area has very good
quality cortical bone and attached gingiva. Micro
implants should be placed in a higher position to
produce intrusion of the incisors.
In younger patient a larger gap between the 2
centrals is available and the midline suture area is
open so a larger diameter micro-implant may be
required.
Soft tissue over growth is common in this
frenum area so a ligature wire extension hook from
mini-implant head to the attached gingiva is
required.
If the micro-implants is placed between the
central and lateral incisors bilaterally it can be
helpful in correcting canted occlusal plane.
Recommended Micro-implant Size: Diameters of
1.3 to 1.6mm and a length of 6 to 7mm.

Palatally: Between maxillary second
premolar and first molar and between
first and second molar:
• Purpose: used for intrusion of maxillary molars in
open-bite treatment and for anchorage in lingual
orthodontics.
• Surgical Consideration: before placement of micro-
implant, thickness of palatal mucosa should be
measured. A micro-implant must be long enough to
penetrate thick soft tissue (3-6mm) and at least 6mm
into bone. No incision is needed, only a pilot hole.
Positions of greater palatine artery and nerve should be
reviewed to avoid injuring them. also., the slope of the
palatal shelves varies from steep to obtuse, and therefore
the angulation used during micro-implant placement
should be modified accordingly.
In case of steep alveolar bone, the angulation of
placement relative to the long axis of teeth may be
increased from an oblique direction to a more
perpendicular direction.
• Recommended Micro-implant Size: diameters of
Lingual ortho dontics

• Mid-palatal area:
• Purpose: Used for any kind of tooth movement of
maxillary posterior teeth, including unilateral
constriction of the arch. Can be attached to a TPA
for improving anchorage and distalizing molars.
• Surgical Consideration: No incision is needed
before drilling. This region offers a good quality
cortical bone. Thicker diameter micro-implant is
used in patent sutures. Care must be taken not to
penetrate the nasal cavity during placement
because the thickness of the mid-palatal area is
different from site to site and from patient to
patient.
If the TPA and micro-implant are connected, the
posterior teeth can be moved mesially and distally be
applying force from the micro implant to the TPA.
• Recommended Micro-implant Size: diameters of

• Retromolar area.
• Bucally:
- Between the mandibular
first and second molar.
- Between the mandibular first
. molar and second premolar
- Between the mandibular
canine and premolar
• Mandibular symphysis
facially.
• Edentulous areas.

Retro-molar area:
• Purpose: The uprighting of tilted
mandibular molars, retraction of
mandibular teeth or the whole mandibular
dentition.
• Surgical Consideration: This area offers
adequate thickness and high quality cortical
bone. The mucosa is as thick as that of the
palate, a proper length must be selected
provided that, the insertion is at least 4mm
into the bone. micro-implants can be placed
during the same surgical procedure used to
extract the third molar.
Occlusal contact between micro-implants and
maxillary teeth may occur in patients with
small interocclusal clearance. This must be
checked and prevented.
• Recommended Micro-implant Size:
Diameters of 1.4 to 1.6mm and a length of 5
to 10mm.

Buccally: between the first and second mandibular molars.
Purpose:
Retracting mandibular anterior teeth also for
intrusion and distal movement of mandibular molars.
Surgical consideration:
• Area of placement in attached gingiva is considered
hygienic.
• The quality of cortical bone is excellent (+/- 3mm)
offering enough thickness to allow a diagonal
placement of the micro-implant, so care is required
to prevent heat generation.
• The mini-screw could be placed in a perpendicular
direction when positioned slightly apically.
Recommended Micro-implant size:
Diameter of 1.3 to 1.6mm and a length of 5 to 7 mm.
75

Buccally: between the Mandibular Canine and
premolar
Purpose:
This site is used for protraction of mandibular
molars.
Area of placement in attached gingiva is considered
hygienic.
The distance between the canine and first premolar
roots is almost 2.2mm. The volume of buccal
alveolar bone in this area is not as thick as it is in
the post. Mandibular.
Diameter of 1.3 to 1.6mm and a length of 5 to 7
mm.
76

Mandibular Symphysis Facially.
Purpose:
This site is used for intrusion of
mandibular incisors.
The bone in this area is usually of good
quality. Its better to place micro-implants
diagonally due to narrow distance between
the roots in this area.
Diameter of 1.3 to 1.4mm and a length of 5
to 6 mm.
77

Edentuolous area.
Purpose:
This site is used for controlling teeth
adjacent to an edentulous space to achieve
movement s such as molar up-righting.
An excellent location because the cortical
bone in this area is of good quality. There
is no risk of root injury.
Diameter of 1.3 to 1.6mm and a length of 7
to 8 mm.
78

2-Definition
3-Terminology
4-Uses
7-Armamentarium
o10- Case Reports.
B-Primary Stability
C-Timing of loading
79

Mini-implant anchorage is applied in many clinical orthodontic conditions successfully, including:
Maximal retraction in protrusion cases,
 Class II correction,
 Class III correction,
 molar distalization in crowding cases,
 mesial movement of posterior teeth,
 molar intrusion in molar elongation cases,
 deep-bite correction, open bite correction,
 midline correction,
 correction of occlusal plane canting
 and posterior cross-bite.
80

Case#1:Maximum anchorage in a patient with bi-
maxillary protrusion
A 22-year-old Korean woman
presented with bi-maxillary
protrusion. She had a convex
profile with severe lip protrusion
and incompetence, and mentalis
strain was noted on closure of the
lips. The face was asymmetric with
the left side appearing longer. Her
smile line was also asymmetric
(Figs 6.1–6.4). She was a mouth
breather. There was clicking in
both temporomandibular joints,
but there was no pain.
81
Complain and clinical examination

Intraoral examination showed good oral hygiene, Class I canine and
molar relationships on both sides with an Over-jet of 3.0 mm, and
mild upper and lower anterior crowding. The teeth were generally
large in size and the dental and facial midlines were coincident.
82

Radiographic Evaluation
The panoramic revealed all the teeth were present except the third
molars.
83

Cephalometric
analysis revealed
skeletal Class I
bi-maxillary protrusion.
Both the upper and the
lower incisors were
proclined. The lower lip
was protrusive relative
to the E (esthetic) line.
The maxillo-
mandibular planes
angle and GoMn/SN
angle were increased.
84

Treatment objectives and plan.
Treatment objective:
was maximum retraction of the upper and lower anterior teeth and reduction of
lip protrusion.
Treatment plan:
1-Extract the four first premolars and reduce the dento-alveolar protrusion.
2-Maximum anchorage would be provided with four mini-screw implants placed
in the inter-radicular buccal alveolar bone in each quadrant to avoid mesial
movement of the posterior teeth.
3-The extraction space would be closed mostly by retraction of the anterior teeth
to maximize reduction in lip protrusion.
Treatment:
After extraction of the four first premolars, the upper and lower arches were
bonded with .022/.028 pre-adjusted fixed appliances. A transpalatal arch was
fitted on the upper first molars. Following leveling and aligning, .019/.025
stainless steel working archwires were inserted in both arches.
85

Mini-screw implant anchorage and
space closure.
86

Six months into treatment, two
Martin® mini-screw implants (diameter
1.6 mm, length 6.0 mm) were placed in
the upper arch between the second
premolar and first molar on the right
side and between the first and second
molars on the left side.
The position of the mini-screw implant
was determined by assessing the inter-
radicular distances in the panoramic
radiograph.
87

These mini-screw implants served as
direct anchorage units for retraction of the
proclined incisors. A manual screwdriver
(hand driver) was used for insertion. The
length was selected on the basis of the
thickness of the mucosa at the insertion site.
An incision was not necessary because the
soft tissue was very thin.
Periapical radiographs taken after
insertion verified the absence of contact
between the screw and the neighboring
tooth roots.
88

The patient was given the usual post-
insertion oral hygiene and care
instructions.
The head of the mini-screw was left
exposed in the oral cavity to facilitate
force application, which was started 1
week after insertion to allow the soft
tissues to heal. Space closure in the
upper arch was started with
{150–200 g} of force delivered by
active tiebacks from the pre-soldered
anterior hooks on the archwire to the
mini-screw implants.
89

When the treatment plan requires
miniscrew placement in the inter-radicular
space, it is recommended to place the
miniscrews after leveling and aligning of the
teeth is complete. This aids in determining
the best possible location for the miniscrew
and avoids root damage during and after
placement.
Depending on the initial alignment of the
teeth, the timing of miniscrew placement in
the upper and lower arches may vary, and
some anchorage loss is inevitable during
this initial stage of treatment.
90

At 8 months, another similar two Martin®
mini-screw implants were placed in the
lower arch, in the inter-radicular alveolar
bone between the second premolar and first
molar on both sides. On the right side
another periapical view was taken with the
cone of the x-ray machine placed more
distally and directed toward the mesial to
verify that the tip of the mini-screw was not
in contact with the neighboring root. Again
active tiebacks were placed between the
hooks on the lower archwire and the mini-
screws on both sides to retract the
mandibular anterior teeth.
91

At the same visit, the upper left mini-screw
became loose and was replaced with an OsteoMed®
mini-screw (diameter 1.6 mm, length 6.0 mm). As
the tieback ligature wire was impinging on the soft
tissue it was covered with a plastic sleeve to reduce
the gingival irritation.
92
For bodily retraction of the
upper anterior teeth, the
hooks on the upper archwire
were extended gingivally so
that the traction force passed
through the center of
resistance of the anterior
teeth.

The total treatment time was 27
months. After bracket removal, an
upper palatal retainer and a lower
lingual retainer were bonded and the
patient was also given wraparound
removable retainers.
The lip protrusion was greatly reduced.
Facial esthetics were satisfactory, and
good dental occlusion was obtained
93

There was minimal root resorption despite the significant amount
of anterior tooth movement.
96

The cephalometric
superimpositions show
considerable change in the position
of the anterior teeth. The upper
incisors were retracted by 10.0 mm
with a 17.0° reduction in labial
inclination.
The lower incisors were retracted
by 10.0 mm with a 16.0° reduction
in labial inclination. The upper and
lower molars moved forward by 1.5
mm and 2.0 mm, respectively.
There was little overlap between
the pre- and post-treatment incisor
position in the superimposition.
Considerable amount of alveolar
bone remodeling was seen. The
mentalis strain on lip closure had
disappeared.
Vertically, there were minimal
changes.
97

Follow up:
At a review visit 2 years 10 months into retention,
there were no remarkable changes. The soft tissue of
lower face appeared more natural. However, there
was a slight opening of the upper left extraction site
because the patient had not been compliant with
retainer wear.
99

100
Fig: 6.49
Fig: 6.50b
Fig: 6.50
Fig: 6.51 Fig: 6.51b

Case#2: Maxillary molar distalization with
MGBM*-system in class II malocclusion
A 13-year-old boy presented for treatment in
the permanent dentition stage. Patient showed a
bilateral Class II molar relationship. There was
no transverse discrepancy. No signs or
symptoms of temporomandibular joint
problems were observed. There was a significant
crowding in the upper arch with a severe
irregularity index.
102
*MGBM-System:(G.B Maino, A. Giannelly, R. Bernard, P. Mura),
introduced in 2007, is a new intraoral device for the upper first and second molar distalization used to treat Class II
malocclusions without patient cooperation by unilateral or bilateral molar distalization.

Panoramic radiographs showed the presence of all of the teeth
included the lower and upper wisdom teeth.
103

Patient had
-SNA angle of 81°
-SNB angle of 78°
-ANB angle of 3°.
-The mandibular plane (Sn-GoMe)
angle was 35°
-the lower incisors had a 92° angle
relative to the mandibular plane
-the upper incisors had a 105° angle
relative to the palatal plane.
104

Treatment Plan
Patient and his family choose the non-extraction alternative and a
distal movement of the upper first and second molar was planned.
Treatment objectives
It included achieving a Class I molar relationship with distalization of both upper first
and second molars using the MGBM-system.
Treatment
The first phase of Class II treatment by MGBM-System involves the distalization of the
maxillary molars to an overcorrected Class I relationship.
Anchorage is provided by a transpalatal bar, bonded on the occlusal surfaces, of the
maxillary first premolars and connected to two palatal mini-screws (Spider Screw,[16]
HDC, Sarcedo, Italy) inserted directly between the first molar and the second premolar.
To distalize the first molar before the eruption of the second molar, we use a sectional SS
wire extended from the first premolar to the first molar and a compressed 200 g Sentalloy
coil spring activated of 10 mm.
When the second molars are erupted, the simultaneous upper molar distalizing system
was applied. It consist of two different distalizing components: One activated against the
first molar as previously described and the other against the second molar
105

In the initial phase of distalization, we applied light forces that do not
interfere with the stabilization of the palatal mini-screws.
We started the simultaneous distalization with a 160 g Neo
Sentalloy wire and a superelastic coil of 100 g. After 2 months,
the coil was replaced with one of 200 g.
After a treatment period of 5 months, the first and second maxillary
molars had been moved 5 mm distally and at the end of distalization
phase we achieved an overcorrected bilateral Class I molar relationship.
106

The palatal mini-screws and the transpalatal bar were removed
and 2 mini-screws (K1, 10 mm) are placed in the buccal site mesial
to the first molars, perpendicular to the cortical bone. The mini-
screws were placed low in the attached gingival because was not
necessary to intrude the incisor segment.
A 50-100 g load was immediately applied using elastics stretched
from the mini-screws to retract the premolars and canines at the
same time.
107

After the first 2 months, during which time we could judge the
trustworthiness of the mini-screws, we increased the elastic force. After
the first premolars and canines have attained a Class I position, the
retraction of the incisors by means of sliding mechanics started.
108

At the end of the treatment an ideal Class I molar and canine
relationship, an ideal overbite, and an ideal overjet were all achieved
109

Case#3: Retraction of upper and lower dentitions in
a patient undergoing non-extraction treatment.
111
A 13-year-old Korean boy presented with severe upper
anterior crowding and upper lip protrusion. Both upper
canines were blocked buccally and the molar relationship
was Class II bilaterally. The upper incisors were retroclined
and the lower incisors were proclined with an overjet of 3.0
mm and overbite of 3.5 mm.
There was a midline discrepancy.
Note: Patient refused to publish
his extraoral photos.

Treatment objectives and plan
Treatment plan
The patient’s parents requested non-extraction
treatment. Molar distalization was planned to gain
space for relief of anterior crowding.
Treatment
Two OSAS® mini-screws (diameter 1.6 mm, length
6.0 mm) were placed in the buccal alveolar inter-
radicular bone between the upper second premolars
and first molars. Root proximity was checked on a
panoramic radiograph prior to placement. A manual
screwdriver (hand driver) was used for placement.
Periapical radiographs were taken after placement to
verify the absence of mini-screw–root contact.
113

In the following week, a palatal arch was cemented
to the upper first premolars. The mini-screw
implants were connected passively to this with steel
ligature wires to negate the reciprocal forces
produced by the push coil springs placed between
the first premolars and first molars.
Segmental .016/.022 stainless steel wires were
engaged in the brackets and nickel-titanium open
coil springs were placed to distalize the first molars.
114

A panoramic radiograph was taken to check any mini-
screw contact with second premolars.
Molar distalization was continued and the second
premolars drifted distally as well.
115

After 12 months, sufficient arch length was gained with minimal change in
the anterior dentition.
116
Another panoramic
radiograph was taken. The
second premolars were near
the mini-screws and so
molar distalization was
stopped.

The lingual arch was removed and a trans-
palatal arch, with a hook soldered in the
center to facilitate elastic chain application,
was fitted on the first molars. The buccal
alveolar mini-screw implants were
removed under topical anesthesia.
Under infiltrative anesthesia, another
OSAS® mini-screw implant (diameter 1.6
mm, length 6.0 mm) was placed in the
midpalatal region level with first molars
anteroposteriorly. The upper anterior teeth
and all lower teeth were bonded with
.022/.028 pre-adjusted fixed appliances.
Distal traction was applied between the
transpalatal bar and the mini-screw to
prevent the molars from moving mesially.
The archwires were engaged in the canines
from the start of this phase.
117

Archwire size was progressively increased and the chain between
the transpalatal arch hook and the mini-screw implant was replaced
regularly to continuously refresh the intrusive and retractive force
on the molars.
118

Post Treatment Evaluation
An ‘over-corrected’ Class I molar relationship was attained. Superimposition of the
pre- and post-treatment cephalometric tracings showed 2.5 mm bodily distal
movement and 1.0 mm intrusion of the upper molars. Eruption of lower molars was
seen.
119

There was favorable downward and forward mandibular growth
during the treatment with proclination of the upper and lower incisors.
120

Intraoral photographs taken 2 years after treatment showed
minimal post-treatment changes.
122

NOTE:
Mini-screw implant Anchorage for anterior
movement of posterior teeth.
Mesial movement of teeth is generally easier than distal movement.
However, mesial movement of posterior teeth without reciprocal
retraction of anterior teeth is not so easy. There are several methods for
reinforcing the anchorage unit – the anterior teeth.
One way is to incorporate as many teeth as possible in the anterior
anchor unit. Other ways include applying lingual/ palatal root torque to
the incisor teeth and extraoral traction using a facemask to apply a
mesially directed force.
With miniscrew implants, such methods of anchorage reinforcement are
unnecessary. Treatment mechanics are simplified and the treatment is not
dependent on patient compliance.
124

125
Be the light..
that
Enlightens
other peoples’
World!

Case#4: Retraction of lower teeth in a patient with
skeletal Class III malocclusion with facial asymmetry
A 30-year-old
Korean man presented
with an edge to edge
bite. He had a concave
profile with upper lip
retrusion. His upper
incisors were not
visible in lip repose
126

Intraoral examination showed a midline discrepancy. The upper dental midline was
aligned with the facial midline but the lower dental midline was deviated to the left. The
canine and molar relationships were Class III on right side, but the canines were in Class II
and the molars in Class I relationship on the left side.
The maxillary lateral incisors were peg shaped, a cross-bite was noted on the left from the
incisors through to the premolars. Both arch forms were broad and teeth were well aligned.
127

The panoramic radiograph revealed a full complement of teeth except
the maxillary left third molar, which was missing. Slight generalized
horizontal alveolar bone loss was evident.
128

Cephalometric
analysis revealed a
skeletal Class III
relationship with the
maxilla retrusive
relative to the cranial
base.
The upper and lower
incisors were well
positioned over the
basal bone. The upper
lip was retrusive
relative to the E line.
129

The PA cephalogram
showed the mandible
deviated to the left with an
asymmetric mandibular
border. The lower dental
midline deviation was also
seen.
130

Treatment Objectives and Plan
Treatment with extraction of the three third molars
and mini-screw implant anchorage in the right retro-
molar area was planned to retract the lower teeth and at
the same time correct the dental midline discrepancy.
Treatment
After extraction of the three third molars, the upper
and lower arches were bonded with .022/.028 pre-
adjusted fixed appliances. The arches were leveled and
aligned and the archwires progressively increased up
to .019/.025 stainless steel working archwires.
At 4 months into treatment, an ORLUS® mini-screw
implant (diameter 1.6 mm, length 10.0 mm) was
placed in the lower right retro-molar area. The non-
threaded part of the screw was 2.0 mm long and
threaded part was 8.0 mm long. The length was
selected on the basis of the thickness of the mucosa at
the insertion site. The head of the mini-screw was
exposed intraorally to facilitate open-pull force
application.
131

One week after mini-screw insertion, a 200 g orthodontic force
was applied by using medium force Sentalloy® coil springs.
Total treatment time was 19 months.
132

Post Treatment Evaluation
Lower lip protrusion reduced as the lower dentition had been
retracted. The dental midlines were aligned. Super Class I canine
and molar relationships were attained on both sides. The crossbite
was corrected.
133

Uprighting of the molars was noted on the post treatment panoramic
radiograph. The horizontal alveolar bone level was maintained.
135

The pre- and post-treatment cephalometric superimpositions show retraction of
the lower teeth. The difference in the antero-posterior position of the right and left
molar teeth decreased following treatment as the lower right molar, which had been
more anteriorly positioned initially, was retracted. The lower incisors were retracted
by 3.0 mm and retroclined 8.5°.
136
Pre-ttt Post-ttt

Intrusion of the lower
incisor and molars, 0.7
mm and 1.7 mm,
respectively, was noted
because the retraction
force on the lower teeth
was applied from retro-
molar mini-screws at
the level of the gingiva.
Minimal movement
was seen in the upper
teeth. A slight increase
in upper incisor
proclination and slight
decrease in the facial
height was noted.
137

Notes:
The retromolar pad is covered with thick keratinized gingiva, and an incision is
required before placement of the mini-screw.
The mini-screw head could be exposed in the oral cavity (open-pull method;) This
method offers superior patient comfort than the (closed-pull method), in which the
mini-screw is embedded in the soft tissue and a braided wire extension exits through
the gingiva. This often irritates the mucosa. A mini-screw with a longer soft tissue
interface or ‘neck’ is useful for this purpose when using a retromolar pad mini-screw.
138
Open-pull force applied from mini-screw in the retro-molar area Close-pull force applied from mini-screw in the retro-molar area

139
Know something about
every thing and every
thing about one thing!

Case#5: Non compliance space closure in case of
missing maxillary lateral incisor
An adult male presented with bilateral agenesis of the maxillary
lateral incisors and a deep overbite in a Class II, division 2
malocclusion with retroclined central incisors.
140

Treatment objective:
was to move the entire maxillary dentition
mesially to close all spaces and simultaneously
correct the deep bite by upper-incisor torque
correction and lower-incisor intrusion.
Treatment plan:
divided into first stage of space closure and
anchorage control, using the T-Mesialslider, and
a second stage for finishing and esthetic
detailing after removal of the palatal appliance.
141

After insertion of two 2mm × 9mm palatal
miniscrews (Fig.A), laboratory caps were placed
over the screwheads and secured with red
flowable composite resin** (Fig.B). Before the
impression was poured, two analog miniscrews
were inserted into the laboratory caps.
The T-Mesialslider was fabricated with a
soldered single-arm T-bar, and two hooks were
soldered to the U-shaped wire (Fig.C).
The first-molar bands were provided with
lingual sheaths to accommodate the sliding
molar tubes.
142
**Triad Gel, Dentsply
A
B
C

Mesial molar activation was performed with
superelastic coil springs at a force level of
about 250g; light palatal power chains were
placed alongside the springs to improve
tongue comfort (Fig.D).
Elastic traction with a force of about 100g
was used between the canines and central
incisors.
143
Appliance during space closure with coil springs
(elastic chain added for patient comfort).
D

The spaces were closed after nine months, at
which point the T-Mesialslider was removed and
finishing was begun (Fig.E).
High-torque brackets (+22°) were used on the
canines to improve palatal root torque; the
premolars were uprighted using untorqued
standard edgewise brackets. Natural “high-low-
high” gingival leveling was achieved with step-
bends—step-downs for the canines and step-ups
for the first premolars (Fig.F).
144
E
F
Fig. F: Archwire bends made for marginal
gingival leveling (extrusion bend for canine
and intrusion bend for first premolar).

After cuspal grinding of the extruded
canines, six porcelain laminate
veneers were bonded for esthetic
finishing (Fig.G). Superimposition of
the pretreatment and post-space-
closure lateral cephalograms
demonstrated improved incisor
positions and inclinations (Fig.H).
145
Fig.H: Pre-treatment and post-space-closure
cephalograms superimposed on facial profiles.
Fig.G: Patient two years after completion of
treatment and placement of six porcelain veneers;
note natural gingival contours.
H
G

Case#6: Bodily Molar Distalization using TopJet
A 15-year-old female
presented with a Class II
dental relationship, an open-
bite from first molar to first
molar, and a maxillary anterior
space deficiency of about 3mm.
147

Treatment Plan
She had recently been treated with a chin cup
and rapid maxillary expander for skeletal Class III
malocclusion involving mandibular prognathism
and inadequate maxillary transverse dimension.
Because ClassII elastics would have exacerbated
the open bite and head gear therapy could have
worsened the skeletal Class III, molar
distalization with a TopJet prototype was planned
(uncovered open-coil springs with no reactivation
mechanisms.)
150

Tongue spikes were bonded to the
upper right canine and upper left
lateral incisor in an attempt to
improve the open bite. The four
impacted third molars were extracted
in preparation for upper molar
distalization. The TopJet prototype
was placed and activated with 250cN
of force per side.(Fig.A)
151

Three months later, it was
replaced with the current TopJet.
After 10 months of treatment, a
slight molar overcorrection of
about half a premolar width had
been achieved, while the upper
canines and pre molars had
drifted distally about the same
distance.(Fig. B, C & D)
152

After 18 months of
treatment, including
finishing with a positioner,
the patient showed a ClassI
occlusion, well-formed
arches, and a normal over-
bite.
154

Case#7-a: Molar Uprighting
A 45-year-old female presented
with a mesially tipped lower left
second molar following previous
extraction of the first molar and
second premolar. A Benefit mini-
implant was inserted into the
alveolar ridge, and an uprighting
spring was placed and activated.
(Fig. A)
157
A
A

*PSM Medical Solutions, Tuttlingen, Germany
**Registered trademark of Ormco Corporation, Orange
A Benefit* mini-implant (2mm × 11mm) is
inserted along the dental axis. The head of the
Benefit screw has a special inner thread that
allows
different kinds of abutments to be attached for
various mechanics.5 In this case, an abutment
with
an .018" bracket is used.
The uprighting spring is bent from .016" ×
.022" TMA** wire and inserted between the
bracket abutment of the mini-implant and the
second-molar band. Activation with a mesial
eccentric V-bend applies an uprighting
moment and an intrusive force to the second
molar.
158

B
Five months later, the lower second
molar had been uprighted without any
extrusion (Fig.B). The mini-implant
remained stable throughout
treatment and was subsequently used to
anchor a temporary crown that would
prevent overeruption of the upper
dentition.
159
B

Case#7-b: Molar Uprighting
A 51-year-old female was referred by her general
dentist for preprosthetic treatment. Her lower
right first molar had been extracted several years
earlier, and the second molar was tipped mesially
into its space.
Although the patient had a severe Class II
malocclusion with a deep bite, she refused
comprehensive orthodontic treatment. After
insertion of a Benefit mini-implant in the alveolar
ridge, a sectional wire was inserted and activated
as in Case#7-a.
160

Because the lower right first premolar
was lingually displaced, the mesial
segment of the sectional wire was
extended to the bracketed first premolar
and activated to produce buccal
movement.
Seven months later, the second molar
had been uprighted without extrusion,
and the occlusion of the first premolar
had been improved. A fixed retainer was
placed to stabilize the buccal segment
until prosthetic treatment was finished.
161

Case#8: Correction of Severe Class IIII Division 1 Mal-
occlusion with Mini-screw Anchorage.
A 28-year-old woman presented
with chief complaints of protrusive
lips and upper front teeth. The
clinical examination showed a
convex facial profile, retrognathic
mandible, excessively proclined
upper and lower incisors, large
overbite and overjet and a Class II
division 1 malocclusion.
163

Intraorally, she had full Class II
molar and canine relationships on
both sides, with proclined upper and
lower incisors, excessive overjet (13
mm), deep anterior overbite (5 mm,
100%), and crowding of both arches
The space deficiencies of upper and
lower arches are both 5 mm. Deep
curve of Spee with 5 mm at both sides
was noted. The lower dental midline
was deviated to her right by 1 mm.
164

Upon panoramic examination, no remarkable findings regarding
the condylar shape and the status of maxillary sinus were noted.
The presence of upper third molars was shown (Figure 4)..
166

The lateral
cephalometric analysis
(Figure 5 and Table 1)
revealed a Class II
skeletal relationship with
mandibular
retrognathism (SNA,
80.0, SNB, 72.0, and
ANB, 8.0 ) and an
average mandibular
plane angle
(SN-MP) of 35.0.
The upper and lower
incisors were proclined
with an acute interincisal
angle (interincisal angle,
88.0 ). Soft tissue
analysis revealed an
acute nasolabial angle
and protrusive upper and
lower lips.
167

Upper and lower 0.018-inch stainless steel archwires were used for canine
retraction, and (0.016 × 0.022-inch) stainless steel archwires were placed
for incisor retraction. Anterior retraction of the upper arch was conducted
by using nickel-titanium closed-coil springs attached from the heads of
miniscrews to either canines or anterior crimpable hooks of arch wires.
Vertical control and intrusion of upper and lower incisors were
accomplished by placing upper and lower utility arches and intrusive lever
arms (Figure 6).
168

Treatment Plan:
Was to correct the facial profile, lip protrusion, large overjet, space
deficiency and approximately full Class II relationship, distal movement of
the maxillary first molars using mini-screw anchorage along with
extraction of the maxillary and mandibular first premolars.
169
Treatment Objectives:
1. Improve the facial profile and smile arc;
2. reduce protrusion of the upper and lower lips and harmonize lip posture;
3. increase the nasolabial angle and decrease the deep labiomental fold and
mentalis muscle strain;
4. retract the upper anterior teeth, relieve dental crowding, and level the deep
curve of Spee; and ,
5. achieve Class I molar and canine relationships, normal overbite and
overjet, and solid interdigitation

The 0.022 slot pre-adjusted edgewise appliance brackets were bonded,
and bands were placed on all first molars. The first premolar was
removed in each quadrant. The upper and lower 0.016-inch nickel-
titanium wires were used for initial leveling and alignment..
170

Two miniscrews (9.0 mm in leng × 2.0 mm in diameter; hook-type, LOMAS®,
Mondeal, Tuttlingen, Germany) were inserted into the maxillary alveolar buccal
bone between the first and second molars on both sides. Upper and lower
canines were retracted using sliding mechanics followed by anterior retraction
of the upper and lower incisors.
171

Class I molar relationships with space closure were achieved after
24 months of treatment course. Another 6 months were spent for
finishing and detailing. At the 30th months, the orthodontic
treatment was finished. Good Class I molar and canine
relationships were achieved.
172

Lingual fixed retainers were bonded to both arches, and removable
wraparound retainers were placed in both arches for retention. The upper
wrap-around retainer was constructed with a baseplate to prevent lower
incisors from over-erupting. The patient was instructed to wear the retainers
full time for six months and then night time.
173

The patients' facial profile and esthetic features were effectively
improved after orthodontic treatment
174

Intraorally, a Class I canine and molar relationship was achieved
with adequate interdigitation of the teeth. Normal overbite and
overjet were established.
175

The post-treatment panoramic radiograph revealed adequate root
parallelism in both arches.
176

Cephalometric
superimposition and analysis
revealed remarkable
retraction of the upper
incisors. The protruded upper
incisors were retracted by 12
mm while maintaining their
vertical position. The lower
incisors were retracted by 1
mm and intruded by 6 mm.
177

To compensate for the severe
Class II skeletal relationship, the
lower incisors were slightly
proclined. The maxillary molars
moved distally by 2 mm and
intruded by 1.5 mm, whereas the
mandibular molars moved
mesially movement by 1 mm
while maintaining their vertical
position. The ANB angle slightly
decreased from 8.0 to 7.0 by
mild retraction of points A and
B. In addition, the mandibular
plane exhibited
counterclockwise rotation (1
degree) due to the 1.5-mm
intrusion of the maxillary
molars
178

Case#9: Correction of deep-bite by intrusion.
A patient was presented with a molar Class I malocclusion and
anterior deep bite. Alignment and leveling were carried out using
.016" NiTi arches, and then torque correction was done using .016"
x.022" NiTi arch .
180

Microimplants were inserted between the roots of upper
central and lateral incisors on both sides.
183

The head of micro-implant was covered with Fermit to
avoid lip lesions.
184
®

The elastic chain pull was carried out from micro-implants
to fixed orthodontic arch.
185

The treatment progress can be seen on the
following figures.
186

This is very
important in
anterior
deep bite
treatment
187

196
‫أخذ‬ ‫ما‬ ‫هلل‬..‫أعطى‬ ‫ما‬ ‫وهلل‬..
‫لك‬ ‫هللا‬ ‫قسم‬ ‫بما‬ ‫فارض‬..
‫الناس‬ ‫أغنى‬ ‫تكن‬..

Case#10: Paradigm Shift in Class III Treatment* with
Mini-implant
197
This 24 y/o female patient asked for
orthodontic treatment with the chief
complaint of mandibular prognathism and
anterior crossbite. Her extraoral frontal
photograph showed no obvious asymmetry.
Her vertical proportion was within normal
limit. Upper anterior malalignment was very
obvious in smiling view. The lateral view
showed concave profile because of
mandibular prognathism.
* Class III
malocclusions
are quite
common in
Asian
population

Anterior crossbite and deepbite can be seen in intraoral frontal photograph.
Dental midline discrepancy was also noted. Arch length discrepancy in the
upper arch was 6.5mm, and the upper right second molar was missing. Arch
length discrepancy in the lower arch was 1.5mm. Molar Class III and canine
Class III relationships were noted in the right side. Molar Class I and canine
Class III were noted in the left side.
198

The panoramic X-ray showed horizontal impaction in the two lower
wisdom teeth, upper right central incisor and upper right second
premolar were endodontically treated.
199

Cephalometric X-ray
revealed Skeletal Class III
relationship. (ANB:-2 )
Mandibular plane angle
was within normal range.
(SN-MP: 32 ) Dental
compensation for skeletal
Class III was noted.
(U1-SN:113, L1-MP:83 )
200

Treatment Plan
Two options were proposed:
Option1: upper second premolars, lower first premolars and lower wisdom teeth extraction.
The treatment goal for upper second premolar extraction is to relieve upper anterior
crowding. The purpose of lower first premolar extraction is to correct anterior crossbite.
The proposed extraction pattern was for the anchorage consideration of molar Class III
correction.
Option2: lower wisdom teeth extraction. Mini-implant anchorage will be used to retract the
whole lower dentition. After the correction of anterior crossbite, mini-implant anchorage
will be used to retract upper and lower dentition simultaneously.
After thorough discussion and communication, treatment plan option 2 was accepted
and reevaluation will be made after occlusion corrected. If the profile were too protrusive,
then four bicuspids extraction will be considered as the back-up treatment plan.
As for the missing upper right second molar, implant prosthesis was proposed and the patient
will consider it during the orthodontic treatment.
201

Upper arch was bonded
with Damon 2 brackets
and a .014inch. Cu-NiTi
archwire was inserted as
the initial archwire. A
custom-made bite turbo
was bonded on the
lingual surface of lower
left central incisor to
avoid interference of the
upper brackets with the
lower dentition.
202
14/05/2004

Two months later, lower arch
was bonded with Damon 2
brackets and a .014inch. Cu-
NiTi archwire was inserted.
Two J-screws ( Bio-Ray Biotech
Corporation, Taiwan ), 2mm in
diameter and 12mm in length,
were inserted at the buccal
shelves of mandible on both
sides. Two NiTi coil springs of
150gm were attached from the
head of the J-screws to the
brackets of lower canines.
203
09/07/2004

Upper and lower archwires
were both changed
to .016 × .025 inch.
Cu-NiTi one month later.
One more month, the
anterior crossbite was
corrected to edge-to-edge
relationship. The elastic
chains from lower canine to
canine, combined with the
coil springs from the
miniscrews, retracted the
whole lower dentitions.
204
04/09/2004

Provisional crowns were
fabricated on four upper
incisors because of severe
incisal wear from previous
malocclusion. Although
positive overjet was
obtained, the canine
relationship is still Class III.
205
25/09/2004

Molar and canine
Class I relationship
were both achieved
after four months
retraction with
Mini-screw
anchorage.
206
16/11/2004

Bi-dentoalveolar
protrusion was
obvious after
cross-bite
correction.
207

The mini-screws were
inserted at the
infrazygomatic crest at
both sides to distalize
the whole upper
dentition.
208
16/02/2005

Two months later,
the archwires were
sectioned and the
posterior segments
of the archwires
were removed . Up-
and-down elastics
were prescribed.
(Ostrich, Ormco
Co.)
209
13/04/2005

After settling, all the brackets, bands and miniscrews were removed.
The treatment duration was 12 months. One .014inch Cu-NiTi and one
.016inch × .025inchCu-NiTi were used throughout the treatment for both
upper and lower arches. The anterior crossbite was corrected, and the
molar and canine Class I relationship was achieved.
210

The lateral profile became more orthognathic.
212

Post-treatment panoramic X-ray shows normal root parallelism and the
lower second molars were obviously distalized.
213

The post-treatment
cephalogram looks more
orthognathic profile, but
the ANB angle is still -2º .
The mandibular plane
angle was increased from
32º to 33º .
214

Clockwise mandibular
rotation was noted in
cephalometric
superimposition. The
upper incisors were
proclined a little bit
without too much
advancement.
(U1-SN: from 113 to 118 )
The lower dentition were
en masse distalized. The
lower incisors became
more retroclined
inevitably.
(L1-MP: from 83 to 77 )
215

Corresponding serial cephalometrics.
217

Case#11: Palatal-Implant Anchorage
in an Adult Class II Patient using modified Hilgers
Pendulum appliance
A 25-year-old female presented
with moderate crowding in
both arches. Photography
revealed a balanced profile, and a
pleasant facial appearance.
219

Clinical examination revealed Class II skeletal and dental
relationships
220

Radiographic examinations:
221

Treatment Plan
Three treatment options were discussed with the patient:
#1: extraction of the upper first and lower second premolars to correct the
Class II malocclusion;
#2: extraction of the upper first premolars to compensate for the
malocclusion;
#3: non-extraction treatment involving distalization of the maxillary molars.
The patient declined extractions and the 2ndoption was chosen. The
treatment plan involved anchorage from a temporary midpalatal implant.
223

*Registered trademark of Institut Straumann,
Waldenburg, Switzerland; www.straumann.com
After some interproximal reduction to
reduce crowding, the lower arch was
bonded. A self-threading Orthosystem
mini-implant* (6mm × 3mm) was
inserted at an angle of about 60° to the
occlusal plane, and a healing cap was
placed. After 12 weeks, a polyvinyl
siloxane impression of the maxillary
arch was taken, using a transfer analog
connected to the implant to reproduce
the exact position of the implant on the
cast.
224

**Registered trademark of Ormco,
Orange, CA; www.ormco.com
The distalizing device was a
modified version of the Hilgers
Pendulum, which has the
advantages of flexibility and ease
of activation due to its removable
springs. Two arms ending in
lingual sheaths were soldered to
a stainless steel octagonal cap
designed to fit over the mini-
implant. Distalizing springs were
fabricated from .032" TMA**
wire, and the mesially oriented
loops were inserted into the
lingual sheaths.
225

Following Hilgers’s recommended procedure
for bodily distal movement of the maxillary
molars, the two distalizing springs were initially
activated at 60° to the horizontal plane,
producing 200g of distalizing force. A second
activation was performed 12 weeks later to
correct the root inclination by bending the two
spring ends at 30° to the sagittal plane.
226

Lower brackets
were removed
and lingual
retainer
bonded.(Radiogr
aphs taken
before removal
of lower
brackets)
The distalization phase was
completed in six months, with the
right side reaching a Class I
position first. The lower brackets
were debonded, and a lingual
retainer was bonded.
227

A rigid .051“ transpalatal
bar was then connected to
the palatal mini-implant
to maintain the molar
positions
228

As expected, the upper premolars drifted distally over the
next five months of this molar retention phase.
229

Additional space closure and alignment were carried out in the
upper arch using the Bidimensional technique18 with an
.018" × .022“ stainless steel archwire. Nickel titanium closed-coil
springs (300g) were attached to crimped hooks distal to the lateral
incisor brackets for anterior retraction.
230

***Registered
trademark of
A.J. Wilcock
Pty. Ltd.,
Whittlesea,
Victoria,
Australia;
www.ghwire.
com.
The lower canines through first molars were re-bonded for the finishing
phase. An .018" Australian wire*** was placed in the upper arch from
second premolar to second premolar, and an .018“ Australian overlay
archwire with an asymmetrical intrusion loop was inserted in the first-
molar tubes to align the gingival margins.
231

Post-treatment evaluation showed
Class I molar and canine
relationships with proper overbite
and overjet.
232

Cephalometric data and superimpositions indicated no change in the skeletal
pattern, except for some important variations in incisor inclination. The upper
incisors were retruded 18°, compatible with the amount of space opening
during molar distalization. The 4° improvement in lower incisor inclination was
attributable to the interproximal stripping for relief of crowding and to the
avoidance of Class II elastics, made possible by the use of implant anchorage.
233

Case#12: Distalization of molars using two stage
mini-implants
A 15-year-old girl was referred for an
orthodontic consultation. Her chief complaint
was crooked upper canines. Her medical history
was unremarkable.
She presented with a class I skeletal pattern
with average vertical proportions and no
asymmetry.
Soft tissue assessment revealed competent lips
but both lips were slightly ahead of S- and E-
lines. There was 3 mm of upper incisor tooth
shown at rest and 1 mm of gingival shown on
smiling. There were no signs or symptoms of
TMD.
235

Intra-orally she had all the teeth
erupted, except the third molars.
There was a class I incisor
relationship (2 mm overjet and 3.5
mm overbite) and bilateral class II
molar relationships.
The overjet and overbite were 2 and
3 mm respectively. There were 6.5
and 1.8 mm arch length
discrepancies in the upper and
lower arches, respectively, and both
upper canines were buccally
positioned and short of space.
The upper and lower midlines were
coincident.
236

The Panoramic x-ray confirmed the presence of all permanent teeth
including the unerupted third molars. The upper third molars were
smaller in size.
237

A pre-treatment
cephalometric radiograph
was taken in centric
occlusion. The pre-
treatment cephalometric
values compared to
population norms are given
in Table 1. This confirmed
that the patient had a class
I skeletal relationship and
average vertical pattern.
Upper and lower incisor
angulations were
acceptable with a
satisfactory soft tissue
profile.
238

:Treatment Aims and Objectives.
• Relief of crowding and alignment of the upper canines;
• To achieve class I incisor, canine and molar relationships;
• Maintenance of the facial profile and soft tissue
pattern.
1- extraction of the upper first premolars and finish with a class II molar
relationship. But moderate space is required so, this could lead to excess
space remaining distal to canines at the end of the treatment;
2- distalization of the upper first molars after extraction of the upper second
molars. But as seen on the panorama, the size and shape of the unerupted
third molars were abnormal. In addition, the patient and her parents were
against the extraction of healthy teeth for orthodontic purposes;
3- distalization of the upper first molars without any extractions, to gain the
required space.
240
Treatment Options:

Since the size, shape and position of the unerupted third molars were
abnormal and the patient refused any extractions the agreed treatment
plan was as follows:
A} upper molar distalization using buccally placed NiTi open coils, and
mini-implants for an indirect anchorage;
B} after completion of molar distalization, since the mini-implants placed
to achieve this would prevent further tooth retraction, it was planned that a
second pair of mini-implant be placed just mesial to the distalized first
molars during premolar retraction;
C} this approach would also minimize the adverse soft tissue effects caused
by a Nance button, and reduce the time needed with brackets on the
anterior teeth
241
Treatment Plan:

Bands were placed on the maxillary first premolars,
second premolars and first molars with 0.022-inch
bracket slots and a MBT prescription. The initial
alignment was carried out using a 0.018-inch Nitinol
archwire.
After 4 weeks, the mini-implants were placed. These
were a titanium alloy Ti–6Al–4V (medical grade V)
one piece device (Denticon India Ltd) with a 1.4 mm
long and 10 mm diameter endosseous body. The body
had a self-tapping thread with a tapered shape. The
mini-implant head had a 2 mm diameter eyelet hole
to thread ligature wires and elastic thread.
The mini-implants were inserted under local
anaesthesia, bilaterally between the maxillary second
premolar and first molar teeth, without a
mucoperiosteal incision or raising a flap.
242

Loading began 2 weeks after placement.
NiTi coil springs were placed bilaterally on a
straight length of 0.018-inch diameter
stainless steel sectional archwire. Round
wire was preferred over rectangular wire to
decrease the friction between archwire and
molar tube. The sectional wire with NiTi coil
spring was inserted in the first molar tube,
compressed and ligated to the second
premolar.
The compressed NiTi coil spring delivered
a continuous force of 240 g per side, as
measured with a force dynamometer. A
0.010-inch ligature wire was pre-stretched
and threaded through the mini-implant
head and firmly ligated around the first
premolar bracket. The ligature wire was
encased in a plastic sleeve.
243

After initial activation, the patient was
monitored at 4- week intervals for further
adjustments and reactivation of the
appliance. At each appointment, the
miniimplants were checked for stability
and mesial movement. The maxillary first
molars were distalized until in a super class
I molar relationship accomplished after 6
months. Further radiographs were taken.
244

After distalization, to decrease the treatment time, an active force was
applied to retract the premolars instead of waiting for them to drift
distally. After removal of the first implant, a similar second mini-implant
was placed at an angle of approximately 30º just mesial to the distalized
first molar.
245

This allowed retraction of the premolars and also prevented the molars
moving mesially again. The previously used bands were recemented on the
molars. Initial alignment was started with a 0.014-inch NiTi archwire.
The upper canines were not engaged. No palatal appliance was used for
stabilization of the distalized molars. After 2 months, a 0.020-inch stainless
steel archwire was placed. The upper premolars were retracted using a
stretched elastomeric module from the mini-implants, which took 2 months.
246

When space had been created, brackets were bonded to
the upper canines, which were aligned with a 0.016-inch
NiTi archwire. The stability of the second pair of mini-
implants was evaluated during treatment and were
removed after canine alignment. The lower fixed
appliance was placed and full alignment was completed
in a further 5 months.
Before debonding, a panoramic and lateral
cephalometric radiograph were taken.
247

At the completion of treatment, the patient was
fitted with a lower fixed retainer and upper Begg
retainer. The patient was instructed to wear the
Begg retainer for 24 hours for the initial 3 months
and at night only for a further 6 months. The total
treatment time was 17 months.
249

Cephalometric superimpositions of:
(a) overall pre-treatment (black) and post-treatment (red) changes,
(b) maxillary pretreatment (black) and post-treatment (red) changes, and
(c) maxillary post-distalization (blue) and post-treatment (red) changes
250

Orthodontic mini implant

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