Implant Anchorage and its /certified fixed orthodontic courses by IDA

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats. Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics, Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call 0091-9248678078

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IMPLANT ANCHORAGE AND ITS CLINICAL APPLICATIONS INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com

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1.INTRODUCTION. 2.IMPLANT TERMINOLOGY. 3.PARTS OF IMPLANT. 4.HISTORY OF IMPLANT. 5.CLASIFICATION OF IMPLANT. 6.ORTHODONTIC ANCHORAGE WITH OSSEOINTERGRATION;BONE . 7.PHYSCIOLOGY AND METABOLISUM. 8.IMPLANT-BONE INTERFACE. 9.INDICATION AND CONTRAINDICATIONS OF IMPLANT. 10.TREATMENT PLANNING. 11.TREATMENT CONSIDERATION. 12.RADIOGRAPHIC ANALYSIS. 13.APPLICATION OF IMPLANT IN ORTHODONTICS. 15.OSSEOUS IMPLANT. 16.INTERDENTAL IMPLANTS.. 18.FUTURE OF IMPLANT. 19.CONCLUSION. www.indiandentalacademy.com

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INTRODUCTION : Conservation of anchorage has been a problem to the traditional orthodontist. Conventional means of supporting anchorage have been using either intra-oral sites or relying on extra oral means. Both of these have their limitations – The extra-oral forces cannot be used on a full time basis to the continuous tooth moving forces and are also seeking on the patient's compliance. On the other hand, strict reliance on intra-oral areas does not offer any significant advantages, except the fact that the patient's co-operation is less critical. Due to these constraints therefore, at times, either the treatment options start getting limited or the end result compromised. The advent of osseointegrated implants, due to the pioneering studies of Prof. Branemark has changed this scenario. The implants made of titanium have been widely used by several orthodontists as they offer Absolute Anchorage . www.indiandentalacademy.com

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IMPLANT TERMINOLOGY : Implant : As defined by Boucher Implants are alloplastic devices which are surgically inserted into or onto jaw bone . Osseo-integration : An intimate structural contact at the implant surface and adjacent vital bone , devoid of any intervening fibrous tissue - Branemark(1983) . www.indiandentalacademy.com

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PARTS OF IMPLANT : The commonly used implant screw has two parts, Implant head : The part that serves as the abutment and in the case of an Orthodontic implant, could be source of attachment for elastics/ coil-springs. b) Implant body : The part embedded inside bone. c) Implant tail : The part which drives or navigate implant in to the bone. Head Body Tail www.indiandentalacademy.com

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HISTORY OF IMPLANTS : -DAHL (1945) first published the use of subperiostel vitallium implant to effect tooth movement in dogs. -LINKOW (1966) described endosseous blade implants with perforation for orthodontic anchorage. -KAWAHARA( 1975) developed Bioglass coated ceramic implant for orthodontic anchorage. -THE BRANE MARK (1969, 1977) MENTOR OF MODERN IMPLANT SURGERY described the high compatibility and strong anchorage of titanium in human tissue and coined the term osseointergration. Various bioactive ceramics such as glass ceramic (BROMER ET AL 1977,HENCH ET AL 1973) , tricalcium phosphate ceramic and hydroxyapatite ceramic (LUHR AND RIESS 1984) www.indiandentalacademy.com

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CREEKMORE(1983) reported the possibility of skeletal anchorage in orthodontics . ROBERTS(1989) used conventional two stage implant in the retromolar region to help reinforce anchorage successfully closing first molar extraction site in the mandible . After completion of the orthodontic treatment the implant were removed and histologically analyzed. They found a high level of osseointegration had been maintained despite the orthodontic loading. HIGUCHI and JAMES ( 1991) used titanium fixtures for intraoral anchorage to facilitate orthodontics tooth movement. COSTA ET AL ( 1998) used miniscrew for orthodontic anchorage. UMEMORI ET AL ( 1999) used SAS for open bite correction. GIULIANO MAINO ( 2003) spider screw. www.indiandentalacademy.com

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CLASSIFICATION OF IMPLANT   Based on the location Subperiosteal : In this design, the implant body lies over the bony ridge. This type has had the longest history of clinical trials but a decreased long-term success rate; probably due to the fact that the chances of getting it dislodged are high. Also, the complexity of their designs requires a precise casting procedure. The subperiosteal design currently in use for orthodontic purposes is the ‘ ‘Onplant’ www.indiandentalacademy.com

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Transosseous : T he implant body penetrates the mandible completely. These have enjoyed good success rate in the past. However they are not widely used because of the possible damage to the intrabony soft tissue structures like the nerves and vessels. Even in the field of Orthodontics, transosseous implants have not been used. www.indiandentalacademy.com

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Endosseous : These are partially submerged and anchored within bone. These have been the most popular and the widely used ones. Various designs and composition are available for usage in specific conditions. The endosseous implants are most commonly employed types for orthodontic purposes. www.indiandentalacademy.com

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According to the composition : - Stainlesssteel, - Cobalt-Chromium-Molybdenum (Co-Cr-Mo) , - Titanium, - Ceramic Implants, - Miscellaneous such as Vitreouscarbon & Composites. According to the surface structure : - Threaded or Non-threaded . - Porous or Non Porous . www.indiandentalacademy.com

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IMPLANT-BONE INTERFACE : -The relationship between endosseous implants and bone consists of one of two mechanisms: Osseointegration when the bone is in intimate contact with the implant.( tissue and implant are juxtaposed) Integration in which soft tissues, such as fibers and/or cells, are interposed between the two surfaces. The osseointegration concept proposed by Branemark et al and called functional ankylosis by Schroede. it states that there is an absence of connective tissue or any non-bone tissue in the interface between the implant and the bone, providing a bioinert fixation with implant surface. www.indiandentalacademy.com

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The healing potential for an implant is determined by three factors: (1) quality of bone at the site of implantation , (2) postoperative stability of the implant , (3) degree of integration of the interface . www.indiandentalacademy.com

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If there is good postoperative stability of the implant in cortical bone, the healing response involves six physiological stages: 1. Callus formation (0.5 month}-initial. 2. Callus maturation (0.5 to 1.5 months. 3. Regional acceleratory phenomenon (RAP) (1.5 to 12 months) remodeling of the nonvital interface and supporting bone. 4. Osseous integration of the interface (1.5 to 12 months) completion of the RAP, increased direct contact of living bone at the interface. 5. Maturation of supporting bone (4 to 12 months)completion of the RAP, secondary mineralization of new bone and increased direct contact of living bone at the interface. 6. Long-term maintenance of osseointegration www.indiandentalacademy.com

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INDICATIONS AND CONTRAINDICATIONS OF IMPLANTS Indications for implant in orthodontics To retract and align anterior teeth with no posterior support. To close edentulous spaces in first molar extraction cases. To intrude or extrude teeth. To protract or retract teeth of one arch. To stabilize teeth with reduced bone support. For orthopedic traction. Implant for osteogenic distraction. www.indiandentalacademy.com

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Contraindication for implant therapy   Absolute contraindication: Severe systemic disorder, eg: osteoporosis. Psychiatric diseases, eg: psychoses dysmorphobia. Alcoholics drug abusers. Relative contraindications: Insufficient volume of bone Poor bone quality Patients undergoing radiation therapy Insulin dependent diabetes Heavy smokers www.indiandentalacademy.com

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  APPLICATION OF IMPLANT IN ORTHODONTICS As a Source of Anchorage alone (Indirect anchorage) a. Orthopedic Anchorage - Maxillary Expansion Headgear like effects b . Dental Anchorage - Space closure of anterior teeth - Intrusion of posterior teeth - Distalization c. In conjunction with prosthetic rehabilitation (Direct anchorage).   www.indiandentalacademy.com

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OSSEOUS IMPLANT   Osseous implants are those that are placed in dense bone such as the zygoma, the body and ramus area or the mid-palatal areas. The implant systems under this category are the   Skeletal Anchorage system , The Grazimplant supported system   The Zygoma anchorage system www.indiandentalacademy.com

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INTERDENTAL IMPLANTS :     These implants are endosseous implants but of smaller diameter, which allows placement in interdental areas. They rely more on mechanical retention than complete osseointegration. Placement is very simple and can be done under L.A. b) They seem to be equally effective in resisting forces as the larger root form implants. c) They can be used for bringing about all types of tooth movement. d) Removal is an uneventful procedure www.indiandentalacademy.com

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MINIIMPLANT :   Ryuzo Kanomi introduced the Mini-implant in 1997   Method of Placement After reflection of mucoperiosteal flap and denuding of bone, 2mm round bur used to make 1.5mm pit. Pilot drill used to enter bone same distance as length of mini-implant. Mini-implant inserted with accompanying screwdriver. Implant site sutured over. Gingival tissue exposed over head of mini-implant. Mucosal punch used to remove soft tissue surrounding head of mini-implant. Two-hole titanium bone plate attached to head of mini-implant and tied to bracket with ligature wire. After four months the implant is loaded.   www.indiandentalacademy.com

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Implant site sutured over. Gingival tissue exposed over head of mini-implant. Mucosal punch used to remove soft tissue surrounding head of mini-implant Two-hole titanium bone plate attached to head of mini-implant and tied to bracket with ligature wire www.indiandentalacademy.com

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Placement of mini-implants for cuspid retraction. Placement of mini-implants for molar intrusion www.indiandentalacademy.com

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ADVANTAGE OF MINIIMPLANT : It is small enough to place in any area of alveolar bone, even apical bone. The surgical procedure is easy enough for an orthodontist to perform and healing is rapid. The implant can be easily removable after orthodontic traction www.indiandentalacademy.com

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Another location is in the Infrazygomatic crest . Level and direction may vary depending on the individual anatomy. From this position the zygoma wire and the implant can deliver anchorage for retraction and intrusion of anterior teeth. In addition, the screws can be placed so that they serve as anchorage for intrusion of molars that have over erupted secondarily to extraction of the occluding teeth. The force delivered with a micro implant anchorage will result in intrusion and buccal tipping, although the latter can be avoided with use of a lingual appliance with a one point. www.indiandentalacademy.com

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In Mandible ; Three different locations are suggested for use in the mandible. Roberts et al routinely placed micro implant in the retromolar position and established a satisfactory anchorage for mesial movement of molars, thereby avoiding retraction of thc anterior teeth in thc case of space closure following extraction of first molar. Roberts et al also used this position to neutralize the eruptive force generated in uprighting mesially tipped molars www.indiandentalacademy.com

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Determination of screw placement site   Nature of tooth movement required Direction of force to be at right angle to implant-non axial Bone depth at selected site Proximity of roots anatomical structures. Usaually a clinical estimate is adequate In doubt it is possible to plan on IOPA X ray Radiographic Index Crestal bone height Root Length Angulation of the teeth www.indiandentalacademy.com

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Surgical implant Index   Prepare an acrylic jig in cold cure acrylic to fit the occlusal surfaces of adjacent teth 0.9mm ss orthodontic wires Mark likely spot on soft tissue with methylene blue indeliable marker or bleeding point Align tip of jig wire to this point IOPA X-ray with jig to determine suitability of site   ACRYLIC SURGICAL INDEX RADIOGRAPHIC EVALUTION www.indiandentalacademy.com

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Measure Soft Tissue Thickness at Implant Site If loose tissue present then a need for incision . In firm tissue its possible to drill through the tissue Amount of tissue in palate will help you decide the implant length Procedure For Microimplant Placement   Aneasthesia for implant placement Soft local Infilitration usually adequate Soft tissue aneasthesia required Pain only if drill approximate roots Can be immediately redirected Palatal mucosa thickness can be checked with needle www.indiandentalacademy.com

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Surgical Incision   If tissue soft and mobile a 5mm surgical incision to prevent rolling up of tissue Drill can be used to penetrate mucosa attached gingival and bone directly in firm tissue   Surgical site preparation Use a 1.5 mm drill Check for wooble /tight fit essential for mechanical retention Water coolant to prevent thermal bone cello trauma Speed 30-200 rpm www.indiandentalacademy.com

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Insertion of Micro implant   Use slow speed pick up driver to engage screw into site Angulation of implant critical to success Maxillary implant need 30- 40 angulation to long axis of teeth buccally and palatally Increase the surface contact between screw and bone Improve retention Reduce risk of striking root Mandibular implant need 10 – 20 angulation More cortical density Final positioning of implant Use long manual screw driver Clinical sensitivity to any resistance You may need to withdraw the implant and change direction in the event of encountering roots www.indiandentalacademy.com

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Immediate loading of implant Prevents micro motion Stabilises implant   Micro implant Biomechanical considerations Non axial loading Direction of force at right angle Head to facilitate attachment Longer than convention Bone screw Larger moments at the implant head   Stability of microimplants No perimplant bone loss due to mechanical loading Lateral loading – increases in density of periimplant bone Nonaxial loading of upto 500gms- osseointergration www.indiandentalacademy.com

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SURGICAL PROCEDURE IN MAXLLARY ARCH www.indiandentalacademy.com

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A)L.AB)3-4mm incisionC)Reflection of flap with periostal elevatorsD)Hole made with pilot drillE) Micro implant in screw driverF)Micro implant screwed into placeG) After placement www.indiandentalacademy.com

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Molar uprighting A micro-implant (1.2mm in diameter, 12mm in length) was placed in the maxillary tuberosity. A longer microscrew was used than in the lower retromolar area because the cortical bone is much thinner in the maxillary arch than in the mandibular arch. After two weeks of healing, 70g of force was applied with between the microscrew and lingual cleats on the buccal and lingual surfaces of the second molar . Four months later, the second molar showed considerable uprighting www.indiandentalacademy.com

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A micro-implant (1.2mm in diameter, 8mm in length) was placed in the retromolar area distal to the second molar, and a ligature wire was extended outward for elastomeric force application . To avoid root damage, only 50g of orthodontic force was applied . The molar was uprighted after eight months of treatment, and a bracket was bonded to it for further movement www.indiandentalacademy.com

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SPIDER SCREW   The Spider Screw is a self-tapping miniscrew available in three lengths--7mm, 9mm, and11mm--in single-use, sterile packaging. The screw head has an internal .021" × .025" slot, an external slot of the same dimensions, and an .025" round vertical slot.   www.indiandentalacademy.com

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It comes in three heights to fit soft tissues of different thicknesses: regular , with a thicker head and an intermediate-length collar; low profile , with a thinner head and a longer collar; and low profile flat , with the same thin head and a shorter collar .All three types are small enough to avoid soft-tissue irritation, but wide enough for orthodontic loading. The biocompatibility of titanium ensures patient tolerance, and the Spider Screw's smooth, self-tapping surface permits easy removal at the completion of treatment. www.indiandentalacademy.com

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Method of Placement The placement site should have enough bone depth to accommodate the screw length and at least 2.5-3mm of bone width to protect adjacent dental roots and anatomic structures such as the maxillary sinus or the inferior alveolar nerve. Typical insertion areas include the maxillary tuberosity, the retromolar areas, edentulous ridges, interradicular septi, the palate, and the anterior alveolar processes above the apices. A water-cooled 1.5mm pilot drill with a stop corresponding to the length of the Spider Screw is used to perforate the soft tissue and cortical bone . A low-speed hand piece should be used straight for anterior locations or contra-angular for buccal or posterior locations.. www.indiandentalacademy.com

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The Spider Screw is mounted on the pick-up device of a low speed contra-angle for insertion at about 30rpm . A manual screwdriver is then used for final turning until the screw collar reaches its ideal position.If the screw location is surrounded by mucosa, a small, 5mm vertical incision can be made and the flaps separated without removing tissue or denuding alveolar bone. In areas where the bone is extremely compact, initial placement can be facilitated by using a 1.8mm bur to drill deeper and reach less compact bone. www.indiandentalacademy.com

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Once the screw has been inserted-especially in sites with poor bone quality it must be loaded immediately to promote mechanical stability. Because miniscrews rely on mechanical retention rather than osseointegration for their anchorage, the orthodontic force should be perpendicular to the direction of screw placement. Applied forces can range from 50g to 200g, depending on the quality of the bone and the orthodontic movement desired.If any mobility is noted immediately after placement or during tooth movement, the screw should be inserted deeper into the bone, or replaced with a longer screw to engage the opposite plate of cortical bone. For the first seven days, the patient should rinse with a 12% chlorhexadine solution. The Spider Screw is easily removed with a manual screwdriver, without local anesthetic in most cases www.indiandentalacademy.com

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MINISCREW ANCHORAGE SYSTEM(M.A.S) Developed by Incorvati ,Carano and et al Appliance design The screws used in the M.A.S. system are made of medical grade 5 titanium, they have a conical profile and are available in three diameters. Type A has a 1.3 mm diameter at the height of the neck of the implant, and 1.1 mm at the tip. Type B has a 1.5 mm diameter at the neck and 1.3 mm at the tip. The overall length for both Type A and Type B is 11.0 mm. Type C has a 1.5 mm at the neck and 1.3 mm at the tip with 9mm of total length. www.indiandentalacademy.com

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The head has a shape of two spheres ( 2.0 mm the lower sphere and 2.2mm the upper) that are fused together, with an internal hexagon for the insertion of the screw driver. There is a 0.6 mm aperture placed perpendicular to the length of the screw where a ligature wire or auxiliary monkey hook can be attached. In the junction point between the two circles, a slot is present for the attachment of elastics, chains or coil springs www.indiandentalacademy.com

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ADVANTAGE OF MINISCREW ANCHORAGE SYSTEM: . Independency from the number or position of the present teeth . Optimal use of the pulling forces . Independency from patient cooperation . Patient comfort . Shorter treatment time (not need to prepare dental anchorage) . Easyand fast screw insertion . Possible application even in interceptive therapy Advantages when compared with other osteointegrated systems: . VersatiIity in the insertion sites . Easy insertion and removal . Immediate loading . Application in growing patients . Low cost www.indiandentalacademy.com

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Some potential complications common to other implant procedure are : . Lesions of some anatomic structures like nerves, vessels, dental roots. . Loss of the screw during the placement or during loading were lost during loading) . Inflammation around the implant site . Breakage of the screw within the bone during insertion or removal. This complication has probably be due to the use of screws with a small diameter www.indiandentalacademy.com

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CLINICAL APPLICATION Closure of Space For posterior space closure the anterior-posterior location of the miniscrew is between roots of the first molars and the second bicuspids roots. Vertically the miniscrew should be located at or above the mucogingival line depending on the desired line of action. For intrusion and distalization –above the mucogingival line For distal movement –at level of the mucogingival line Higher the screw in the maxilla the more perpendicular it is in order to avoid damage to the maxillary sinus .Ideally it is 30- 40 degrees . In case the alveolar process is to prominent an auxillary attachment (monkey hook) is used it avoids discomfort and possible ulceration of the gums. In the mandibular arch care should be done to avoid the mental foramen. www.indiandentalacademy.com

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Symmetric intrusion of the incisors To intrude the upper incisors the screw is placed between the upper lateral incisors and the canines. The placement of the mini-screws should be done after leveling and alignment, in order to maximize the interadicular space at the placement site. In order to avoid tipping the upper incisors buccally during the intrusion, the end of thearchwire should be cinched back www.indiandentalacademy.com

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Correction of the cant of the plane of occlusion and of the dental midline The miniscrew is used to intrude the extruded canines and the laterals on the side of the cant, and to center the dental midline . During the intrusive movements, it is very important to center the mini-screws in between the roots of the teeth that need to be intruded in order to avoid the interferences between the teeth and the screw. www.indiandentalacademy.com

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Molar intrusion It is very hard to place the micro-screws precisely between the roots of first and second molars without interfering with the roots of the teeth either during implantation or during the intrusive movements. Moreover, sometimes the intrusion force need to be relatively high and more than one screw might be necessary in places where there is insufficient space available for the screw placement. For the above reasons it is suggested to limit the use of the miniscrews to cases where simple molar intrusion of one or two teeth www.indiandentalacademy.com

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Molar mesialization MAS is placed mesial to the space to be closed, at a height that facilitates a vector of force approximating the center or resistance of the molar, dental tipping can be avoided. The MAS can be placed after the initial leveling and aligning phase has been completed, so to use a full size arch wire that will prevent the mesial crown tipping of the molar during the space closure. The mesial movements are usually very slow especially in the lower arch so not more than 2-3 mm of mesial molar movement should be attempted . www.indiandentalacademy.com

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Intermaxillary anchorage Class II correctionis done by elastics or anterior repositioning appliances (i.e. Jasper Jumper, Bite Fixer, etc. There are numerous unwanted side effects of those kinds of mechanics, such as excessive anterior movement (proclination and protrusion) of the lower incisors and opening of the bite, . To address the above problems one alternative may be to place MAS between the roots of the first and second lower molars or between the root of the second bicuspids and lower first molars, in this way the upper arch can be retracted without any unwanted dental effects on the lower teeth. The placement of the MAS mesial to the lower molar may also prevent the mesial movement of the entire lower arch because the MAS, when in contact with the lower molar, may not allow it to move anteriorly. More research is needed to verify the clinical results www.indiandentalacademy.com

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LONG TERM STABILITY OF IMPLANT Miyawaki et.al analysed the success rate of three different screw sizes and a miniplate design. Their sample consisted of 51 patients who had 134 different implants used for conserving anchorage. The implants were in the form of screws(134 in number) of 1.0, 1.5 and 2.3 mm diameter as well as 17 miniplates.On one year after placement, they drew the following conclusions:  a) The implant screws of 1 mm diameter had a high failure rate and are not recommended for clinical use as Orthodontic anchors. b) Implant screws of 1.5 and 2.3 mm diameter had reasonable success rates - 84 and 86 % respectively and therefore could be used in majority of the cases.  c) The miniplates had the best stability (96%), but the surgical intervention and patient discomfort was greater with these compared to miniscrews. Miniplates have beenrecommended in high angle patients. d) Peri-implant hygiene is one of the major factors, which could affect the stability of these implants. www.indiandentalacademy.com

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FUTURE OF IMPLANT   The ideal implant design would be one that would be simple to place as well as remove, causing minimum discomfort to the patient. At the same time, they should be optimum in resisting the conventional Orthodontic forces. One would be looking at newer designs, which could be placed by an Orthodontist himself. Also, since the implants need not last for a very long time, biodegradable implants may be a lucrative option.Biodegradable screws made of L-polylactide have been introduced by Glatzmaier et al and are currently undergoing clinical trials. The system, termed as the BIOS (Bioresorbabale implant for Orthodontic systems)consists of resorbable polylactide with a metal abutment. www.indiandentalacademy.com

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CONCLUSION   Implants for the purpose of conserving anchorage are welcome additions to the armamentarium of a clinical Orthodontist. They help the Orthodontist to overcome the challenge of unwanted reciprocal tooth movement. The presently available implant systems are bound to change and evolve into more patient friendly and operator convenient designs.Long-term clinical trials are awaited to establish clinical guidelines in using implants for both orthodontic and orthopedic anchorage. www.indiandentalacademy.com

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