Implants in orthodontics / fixed orthodontic courses

IMPLANTS
IN
ORTHODONTICS

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INDIAN DENTAL ACADEMY
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 Introduction
 Classification of Implants
 Materials used for Implants
 Osseointegration
 Use of Implants in Orthodontics


.

 Implants are defined as alloplastic
devices which are surgically inserted into
or onto the jaw bone-Boucher
 Linkow- Father of oral Implantology.


Classification of Implants.
Based on their location: Subperiosteal

 Transosseous

 Endosseous


 Based on their configuration:- Root form Implants

(Threaded or non threaded)

-

Blade/Plate Implants
(Porous or nonporous).


 Based on the biologic adaptation at the
interface:-Implants which osseointegrate.
-Implants which do not osseointegrate.

 Based on the loading characteristics :-Nonlatency implants.
-Latency implants.


 Based on anchorage requirement:-Direct anchorage.
-Indirect anchorage.
 According to composition:-Stainless steel
-Cobalt-Chromium-Molybdenum (Co-Cr-Mo)
-Titanium
-Ceramics.

 Stainless steel:-18% Cr & 8% Ni.
-subjected to crevice & pitting corrosion.

 Cobalt-Chromium-Molybdenum Alloy :-used in fabrication of custom designs such as
subperiosteal frames.


 Titanium:-most widely used metal for implants.
-Highly reactive & readily oxidises to form oxide.
-exist in 3 forms
-Alpha
-Beta
-Alpha-Beta phase (most commonly used).
Ti-6Al-4V


 Ceramics:- two types
Bioactive-Hydroxyapatite
Bioglass- contain oxides of Ca, Na,
P & Si.
 Miscellaneous:-Vitreous carbon, Vitallium, Tantalum, Platinum,
Tungsten, Alumina, Polymers & composites.


Materials used for Implants
 In 16 &17th century –Ivory dental implants .
 20th century-Metal Implant devices.
 1940 &1960’s-CoCrMo subperiosteal & titanium
blade implants.


 1970’s-Non metal biomaterials

 1982-Branemark Implant.


Biocompatibility of Titanium Implants.

 “Passivity”.

 Modulus of elasticity .


Biocompatibility of Titanium Implants: Titanium can be considered as composite
material.
 Chemical process at the Interface:
Types of bonding by which biomolecules stick to the Implant
surface are
-Long range but weak van der waals interaction.
-Short range, strong chemical bonding.
e.g.:-ionic & covalent bonds.

Chemical process that take place at an
Implant-Biotissue interface.


Studies regarding the stability of the
Implant materials.
 Gainesforth & Higley (1945):
-investigated the efficacy of Vitallium screw for orthodontic
anchorage.
-Screws were inserted into the ramus of 6 dogs and immediately
loaded to retract the maxillary cuspids.
-Results:-All the screws were lost within 16 to 31 days.


 Sherman(1978):-

- Inserted Vitreous carbon implants in 6 dogs & allowed to heal for 70
days before applying a force of 175gms.
Results:-After 2wks only two implants were stable.

 Smith(1979):- Investigated bioglass- coated aluminum oxide implants that were
allowed to heal for 12wks before loading them with 425gms of force for
2-9wks.
Results:- All the Implants remained stable except for a slight movement
when the force was doubled.


 Gray(1983):-Tested the bioglass implants & vitallium implants which were placed in
femur of rabbits. After 28 days healing period, loads of 60,120,&180gms
were applied.
Results:-No movement of the implants occurred.

Eugene Roberts(1984):Inserted pure titanium screws shaped implants into the femurs of rabbits &
after a healing period of 6-12wks, the paired implants were loaded with
100gms of force for 12 wks.
Results:-Histologically increase in the bone mass in the area of loaded
implant was seen.


 Eugene Roberts(1988):Examined histologic sections of dog mandibles containing rigid titanium
screws to compare the findings of bright field & polarized light
microscopic illumination to microradiographs of mineralized sections.
Results:-10% direct bone contact is sufficient to resist the implant
movement.

 Linder-Aronson(1990):-tested the effectiveness of Branemark
implants in monkeys.


OSSEOINTEGRATION.
 Term & concept of Osseointegration
-Branemark.
“An intimate structural contact at the implant surface
and adjacent vital bone devoid of any intervening
fibrous tissue.”


Evolution of the concept of
osseointegration
 Vital microscopic studies of the rabbit fibulatitanium chambered microscopes.

 Series of experiments:-Titanium fixtures for immobilization of autologous
bone grafts.
- Tooth implants studies for healing & anchorage
stability.

 Study done on dogs to find out the load bearing
capacity of implants.

 Optical titanium chambers were implanted in
humans-to assess the tissue reactions of
titanium implants.


Biology of osseointegration.
Hematoma

Callus formation


Bone remodeling

Fibrous tissue


Principles of osseointegration
Factors important for reliable bone
anchorage of an Implanted device:Implant biocompatibility:-


Principles of osseointegration.
 Implant Design:-




Implant surface:-


 State of the host bed:-


 Surgical technique:-


 Loading condition:-


Use of Implants in Orthodontics
 Growth Studies
 Anchorage
Orthopaedic

-Expansion
-Protraction

Orthodontic

-Intrusion
-Space closure
-Molar Distalization.


Growth Studies:-

 Implants are the best means of
reference points for studying
the longitudinal growth studies.


 Growth Rotations -Bjork &
skeiller .

 Growth of Cleft lip & palate
patients - Shaw

.


ANCHORAGE:

Orthopeadic correction-

Two methods for obtaining the Skeletal anchorage:

Intentionally Ankylosed teeth.



Endosseous Implants.


 Maxillary Expansion:-

- Guyman(1980)
-Ankylosed teeth acted as abutments for
palatal expansion in rhesus monkeys.
-Transmit the laterally directed forces
across the midpalatal suture.


• After 8wk healing period 1-2 pound force was applied to the
ankylosed teeth.
• Palatal widening was seen due to skeletal expansion that was
periodically assessed during 13, 21, & 23 wks.

Frontonasal suture expansion using titanium screws.
-Kiumars Movassaghi et al(1995)

Pure titanium craniofacial plates were contoured into ‘L’ shape
with a 90 degree angle at the midpoint.
Plates were placed on either sides of the suture.
A distraction force of 55gms was activated across the sutures.


Increase in growth about 6mm was seen across
the frontonasal suture.


Sutural expansion using rigidly integrated
endosseous implants.
Andrew Parr et al(1996)
Evaluated the use of endosseous implants
in the midface region,2 flanged titanium
implants were placed on either side of the
midnasal suture of rabbits.

Divided into two groups:
one group-1N & other group-3N force
was applied.
.


 An open coil spring has been compressed between the
abutments to provide the expansion load.

 Distance between the implants increased significantly in the loaded
groups & higher in the 3N group.


Endosseous Implants for maxillary protraction
-Smalley etal (1988)

Tantalum markers were placed in the cranial base, mandible, zygomatico
Temporal , zygomaticomaxillary, frontomaxillary, premaxillomaxillary
Sutures.


•A traction force of 600gm is used and protraction was done
till 8mm of anterior displacement of maxillary complex occurred.


Implants for Intrusion
Skeletal Anchorage :-Creekmore(1983)
-Vitallium bone screw placed below the
anterior nasal spine is used for intrusion of
Upper anteriors.
-6mm of upper incisor intrusion was seen
after one year.


Implants for space closure.
 Implanto-Orthodontics-Linkow.(1970).
 Implant was used to replace the missing tooth.
 Upper arch was consolidated using a fixed
appliance & in lower arch only premolar and
molar were banded and connected by o.o4o rigid
Elastic
wire.


Use of Endosseous Implant for closure
of extraction-Eugene Roberts (1989)
site
 Endosseous Implants placed in the retromolar
region are used to close the atrophic extraction site.

Pontic

Buccal view after mesial translation
of 2nd & 3rd molars.


Diagnostic models,2.5yrs
Of post retention.


Onplant & Ortho-Implant.
 Onplant:-Block
&Hoffman.(1995)
 It is a flat disk shaped
fixture available in 8 and
10mm in diameter
 It has a HA coated surface
for integration with the
surrounding bone.

Animal studies:

In the dog, the onplant has been exposed & connected to the contra lateral
2nd premolar with a stainless steel spring activated to deliver 110z of force
.
5months later tooth moved towards the onplant by 8mm from its original
position.

An expansion device soldered to a traspalatal bar & secured to the
expansion device to control molar distalization.
The 2nd molars were bodily distalized 6mm in 11 months.


Ortho-Implant
- Celenza

& Hochman

•Similar to onplant but it is an endosseous Implant.
•Its surface is sandblasted and etched to
increase the adhesion to the surrounding bone


Uses of Onplant & Ortho-Implant
 Space closure.
 Molar distalization.


Palatal Bone Support for placement of an
Orthodontic Implant is sufficient enough without
causing any damage to the Nasal floor.
-Heinrich et al (1999)


Impacted Titanium Post for
Anchorage

-Frederic Bousquet etal(1996)

•35-yr old female before treatment, showing
anterior crowding.

Titanium post

Titanium post & head of
Mechanical impactor.


Post impacted in interdental
septum between 1st molar &
extraction site.

Rigid .040 wire connecting 1st molar
tube to post.


Upper right posterior segment after 2 months
of retraction showing distal movement of
Premolar & no mesial movement of molar.


Cast models after 18 months of treatment.


Mini-Implant for Orthodontic Anchorage:-Ryuzo Kanomi(1997)

 Mini-Implant is 1.2mm in diameter and
6mm in length.


After raising of mucoperiosteal flap
and denuding of bone, 2mm of round bur
is used.

Pilot drill used to enter bone same
Distance as the length of mini-implant.

Mini-Implant inserted with accompanying screw driver.

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.

Patient at start of incisor intrusion.


Mini-Implants for space closure.


Mini-Implants for molar intrusion


Skeletal Anchorage system for Open bite correction
-Umemori , Sugawara etal (1999)

• Control of vertical dimension is

very important in correction of
anterior open bite
•‘L’ shaped titanium miniplates are used as a
Source of anchorage for intruding the molars.


 Procedure for miniplate
insertion:-


Pretreatment facial photographs

Pretreatment intraoral photographs

Post treatment intraoral photographs


‘Y’ Titanium miniplate for intrusion &
distalization of maxillary molars.
(key ridge)

Straight titanium miniplate for
Intrusion of maxillary incisors.
(anterior ridge of piriform opening).


Intrusion of maxillary anterior teeth using SAS

Before treatment

Intrusion of maxillary anteriors

After treatment

Microimplant (Absoanchor)
Kyung, Park et al

Recent among the implants – Microimplant.
To overcome disadvantages of conventional Osseointegrated implants like
-size, procedure of insertion, cost, & bulkiness.
Diameter is 1.2mm but available in different sizes.


Usually 4-5mm length of implant with 1.2-1.3mm diameter will
provide adequate retention, but in maxilla a microimplant of
6-8mm is used.
Microimplant insertion:-


Periapical radiograph to see the
root approximation.

• NiTi coil spring applied to maxillary buccal & lingual and
mandibular buccal microimplants.

Micro Implant
-Park et al

 Dimension of micro implant are 1.2mm in diameter & 6mm
in length.

28yr old female with CL-I bialveolar protrusion before treatment.

Placed in the buccal alveolar bone between 2nd premolar &1st
molar in the upper arch & between 1st molar & 2nd molar in the
lower arch.

Placement of maxillary microscrew.

Mandibular microscrew.


Initial maxillary canine retraction force applied with
tieback between micro-implant & canine.

After 2 months of treatment, maxillary
anterior retraction force applied with
nickel titanium coil spring.


Mandibular micro-implants between 1st & 2nd molars. Force
applied with elastic thread between microscrews & mandibular
archwire.


Mechanism of bodily retraction of anterior segment, with force
applied against microimplant passing near center of resistance
of six anterior teeth.
Mandibular microimplant uprights & intrudes the molars.


.
Patient after 18 months of treatment


Superimposition of pre & post- treatment cephalometric tracings.

Micro-Implant for anchorage
in Lingual orthodontics

19yr old female with skeletal CL-II malocclusion before treatment.


Palatal microscrew should be implanted into the alveolar bone
at 30-40 degree between 1st & 2nd molar to avoid root damage.


Lingual Sliding mechanics using nickel titanium coil springs
to microimplants.


Patient after 16 months of treatment.

Superimpositions of cephalometric tracings before & after treatment.

28yr old female CL-II patient with lip protrusion & gummy smile
before treatment.

Insertion site measured from guide bar on bite-wing x-ray

Stab incision for flap reflection
Drilling through cortical bone only.

Microimplant insertion.


Maxillary .017x.o25 ss closing loop archwire & .016x.016ss overlay
intrusion archwire used to retract anterior teeth upward & backward.


Schematic of retraction wire.


Improvement in profile & gummy smile after treatment.


Use of Osseointegrated Implants in
unilateral cleft lip & palate pts.
Hiroaki et al (1999)

 Unilateral cleft pts who needed maxillary lateral bony
defect in the alveolar region restricts orthodontic
accomplishment.
 Late secondary bone grafting to the cleft region followed by
the insertion of the Osseointegrated implants provides
good retention to the maxillary arch.


Bibliography.





Implants in dentistry-Hobkirk.
Block & Kent- Oral Implantology.
Science of dental materials- Skinner.
Orthodontic principles & practice-Graber &
Vanarsdall.


 Bone responses to orthodontic forces on vitreous carbon
dental implants –Alan Sherman AJO:JULY 78.
 Bone dynamics associated with the controlled loading of
bioglass coated aluminum oxide endosteal implants-John
Smith AJO:DEC 79.
 Ankylosed teeth as abutments for palatal expansion in
rhesus monkeys. Guyman et al AJO :sep 83.
 Osseous adaptation to continuous loading of rigid
endosseous implants. AJO :AUG 84.
 Osseointegrated titanium implants for maxillofacial
protraction-Smalley et al AJO:OCT 88.

 Implant-Orthodontics-Linkow JCO MAY 70.
 Possibility of skeletal anchorage- Creekmore JCO APR 83.
 Absolute anchorage device-Hoffman & block AJO MAR 95.
 Rigid implant anchorage to close a mandibular first molar
extraction site –Roberts et al JCO:DEC 94.
 Osseointegration and its experimental background.J.Prosth. dent sep 83.
 Biocompatibility of titanium implants –kasemo.
J.Prosth.dent jun 83.
 Endosseous implants as anchorage to protract molars and
close an atrophic extraction site.-Roberts, Marshall AO sep
89.

 Frontonasal suture expansion in rabbits using titanium
screws.-Movassaghi et al J. of oral max. surg 95.
 Sutural expansion in using endosseous implants –Rabbit
study-Parr AO may 96.
 Use of impacted titanium post for orthodontic anchorage –
Bousquet et al JCO AUG 96.
 Mini-Implant-Ryuzo kanomi. JCO 97.
 Skeletal Anchorage System-Sugawara JCO DEC 99.

 Micro-Implant anchorage for treatment of skeletal
class-I Bialveolar protrusion-Hyo-Sang Park.2001
JUL JCO.


MAGNETS
IN
ORTHODONTICS


 Introduction
 Types of magnetic materials
 Properties of magnets
 Application of magnets in orthodontics.

 In 1953, magnets were first used for denture
retention by BEHRAN & EGAN.

 Use of magnets in orthodontic- BLECHMAN &
SMILEY.


PROPERTIES OF MAGNETS

 Flux Density


 In dentistry, ferromagnetic materials with
static field are used.
 Magnetocrystalline Anisotropy.
 Coercivity.


 Coulombs law:-This law states that force between
two magnetic poles is directly proportional to
magnitude & inversely proportional to square of
the distance between them.
 Curie point:-Pierre Curie(1859-1906)


 High force to volume ratio.

 Maximal force at shorter distances.


 No interruption of magnetic force lines by
intermediate media.

 No energy loss.


TYPES OF MAGNETIC
MATERIALS







Platinum-cobalt (Pt-co)
Aluminium-Nickel-Cobalt(Al-Ni-Co)
Ferrite
Chromium-cobalt-Iron
Samarium Cobalt(SmCo)
Neodymium-Iron-Boron(Nd2Fe B)
14


 Advantages:-Continuous force is exerted.
- Eliminates the patient co-operation.
-No friction.
 Disadvantages:-Tarnish & corrosion products are cytotoxic.
-Cost factor.


 Biological effect of magnetic forces:-

Aronson:-thinning of epithelium under
attracting & repelling magnets.
McDonald - proliferative activity of fibroblasts
in presence of static magnetic field
Lars Bondemark & Kurol studied changes in
human dental pulp and gingival tissue.

Clinical Applications of Magnets.
Orthopaedic

- Expansion
-Growth modulation

Orthodontic

-Tooth Intrusion
-Space closure
-Molar Distalization.
-Retainer.




EXPANSION:-Vardimon et al(1987) demonstrated
palatal expansion using two types of magnetic devices in
Macaca fascicularis monkeys.
-Tooth borne appliance


 Tissue borne appliance (attached directly to
palate by endosseous pins).


Change in the Inter incisal relationship

Maxillary Protraction was related to A-P activity of the premaxillary suture
(primarily) & the transverse palatine suture (secondarily).


Transverse change as measured from before and
after treatment models.

Intercanine change vs. Intermolar change


 Functional Orthopaedic Magnetic Appliances:Vardimon(1989)
-for correction of CL-II


4 types of functional magnetic system:-


 Magnetic Twin Block:Clark(1996)
-Samarium cobalt magnets
were embedded in the
inclined surface of the
twin block in attractive
mode.


 Magnetic Activator Device(MAD):-Darendilier (1993) developed this magnetically active
functional appliance.
-MAD I-mandibular deviations
-MAD II-CLII malocclusion
-MADIII-CLIII malocclusion
-MADIV-skeletal open bite correction.


MAD-II

MAD II is used for correction of CL-II malocclusion.
It consists of upper& lower removable appliance , carrying magnets
in both buccal segments.


A 30 degree inclination of the occlusal surface of the magnet to the
basal surface produces an oblique force vector to correct a
CL-II malocclusion.


Mechanical retention of the appliance against the magnetic forces is by
clasps on the posterior teeth & in the anterior area by adding small amount
of composite on the labial surface so that the labial bow rests on it.


• A 10yr old pt with a skeletal & dental CL-II Div 1 malocclusion.
Overjet-6mm & Overbite-3mm.


After 4 months of night time wear


MAD-II FOR CORRECTION OF CL-II,DIVISION 1
MALOCCLUSION.

Deep Bite

open Bite


MAD II appliance with transverse screw & two sagittal screws
incorporated in lingual side of the lower appliance to permit the
sagittal reactivation.


Early CL-III treatment with Magnetic appliance.

Patient before treatment.


Combined MED & MAD III appliance

 MAD III

Bonded upper plate ,with two
midpalatal Samarium cobalt magnets.

Removable lower plate with buccal
magnets.


Patient after 14 months of treatment.


 MAD - IV
Magnetic activator device IV uses anterior attracting &
posterior repelling magnets.


•MAD IV consists of removable upper &
lower plates each of which contains
three cylindrical neodymium magnets
coated with stainless steel.


MAD IV(a)

MAD IV( b)

MAD IV( c)


 Tooth Intrusion:Active Vertical Corrector-Dellinger(1986)
-Samarium cobalt magnets in the repelling mode
are used.


Pre-Treatment


Post-Treatment

 Fixed Magnetic Appliance:-introduced by VARUN KALRA & CHARLES BURSTONE.

Appliance consists of an upper &lower acrylic splints with
samarium cobalt magnets in stainless steel casting
embedded in a repelling mode.


Results:-Length of the mandibular condyle increased significantly in the treated group.
-the entire upper and lower arches intruded during the treatment.


 Tooth Impaction:- Vardimon,Graber,Drescher
-Neodymium Iron Boron magnets can be used
to assist eruption of an impacted canine.


Vertical &Horizontal magnetic brackets were designed with the
magnetic axis magnetized parallel and perpendicular to the base of the
edge wise bracket.
•Vertical type –Impacted canines & incisors
.
•Horizontal type –Impacted premolars &molars.

Surgical procedure:Palatal approach was used to expose the
maxillary canine.

Vertical magnetic bracket bonded on the palatal
crown surface of the impacted canine.


• A spacer of 2.5mm is positioned between the magnetic bracket &
loose intraoral magnet.
•Fixation of the intraoral magnet to the Hawley type retainer with self
curing acrylic followed by removal of spacer , to apply an attraction force
of 0.3N.


•Treatment progression of the magnetic attraction
after 3 months.

• Fixed appliance treatment stage.


An attractive solution to unerupted tooth.
-Sandler(1991)


•Upper left canine erupting through the mucosa.

•Larger magnet repositioned to allow further
movement.

•Sufficient eruption to allow attachment to be
placed.


Detailing with fixed Appliance.

Post -treatment

Mancini(1996)-force levels are sufficient enough to induce the
cellular & biochemical changes required to produce orthodontic
tooth movement.


space closure:-Complex Intra & Interarch Mechanics:-Blechman(1985)

CL-II mechanics with a magnetic force
system in a CL-I extraction case


3 magnet configuration to enhance
CL-II mechanics

3 magnet configuration
used to simultaneously
move all 4 canines distally

Intramaxillary magnetic force to move
Canine distally.


Upper canine retraction

Pre-treatment.

Lower canine retraction

Post-treatment

 Molar Distalization:-Gianelly et al(1989):-repelling magnets in conjunction
with a modified Nance appliance was used.

Lateral view of magnets in position.

-A 11yr/F with a CL-II DIV I malocclusion in the late mixed

dentition period.
-Nance appliance was seated on the second deciduous molar.
Results:-Molar movement in distal direction-3.2mm
Deciduous molar movement in mesial direction-0.6mm

Molar distalization with repelling magnets
-Takami etal(1991)

The Molar distalization system uses two
opposing magnets for each maxillary quadrant.
.
• Nance appliance is placed to reinforce the anchorage.
• Constant magnetic force of 80z is applied.
• Magnets are reactivated for every 2wks


Case from the present study before & after rapid molar
distalization.


Repelling magnets vs. superelastic Ni-Ti coils.
Bondemark & Kurol (1992).

 In simultaneous distal movement of maxillary first & second
molars
-Mean distal movement for supercoils is 3.2mm.
-for magnets is 2.2mm.


 Magnetic Edgewise Brackets:-Kawata(1987)
-Samarium cobalt magnet with an edgewise bracket
(o.018slot) .


Clinical application of magnetic brackets in crowded dental arch.

Cast models before & after treatment.

Autonomous fixed magnetic appliance.
-Darendeliler & Joho

 Treatment of CL-II bimaxillary protrusion with
magnets:.

A13yr old female patient before treatment

•Ideal arch form using Bonwill-Hawleys method.

•Calculation of mesial & distal magnet cuts needed
to create proper arch form.

•Upper & lower magnetic arches before coating.


Lower magnets temporarily affixed to cast
for Indirect bonding.


Magnetic arches in place.


Additional magnet bonded to close median diastema

Patient after 6 months of treatment with AFA

 Propellant Unilateral Magnetic Appliance (PUMA)
- Chate(1995)


Magnets are use to stimulate costo-chondral bone graft in
Hemi facial microsomia.


 Retainers:-Springate &
Sandler(1991)
-micro magnets made
of neodymium iron boron
magnets as a fixed
retainer in a patient with
persistent diastema.


 Bibliography:-

-Dentofacial Orthopedics with functional appliances-T.M Graber,
Rakosi,Petrovic.
-Magnetic force systems in orthodontics-Blechman AJO 78.
-Rare earth magnets and Impaction-Vardimon AJO 91.
-Use of magnets to move the molars distally-Gainelly AJO 89.
-Magnetic vs Mechanical expansion with different thresholds and
points of force application. Vardimon.AJO 87.
-Effects of fixed magnetic appliance on the dentofacial complex.
Kalra.AJO 89.
-A new orthodontic force system of magnetic brackets. Kawata AJO
87.
-An open bite correction with MAD IV. JCO 95. Darendeliler.


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Leader in continuing dental education


Implants in orthodontics / fixed orthodontic courses

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