Wilmes 2019
Wilmes 2019
Wilmes 2019
A unique clinical challenge presents when dealing with a compromised first permanent molar. A compelling treat-
ment option for consideration is the removal of a nonrestorable first permanent molar, with the subsequent
“replacement” through controlled mesial tooth movement of viable second and third molars. To reinforce the
anchorage support associated with such a planned movement, indirect or direct implant-supported mechanics
may be used. With the use of direct anchorage, orthodontic brackets are not required and space closure can be
commenced immediately. In this article, we report the clinical procedure and design of direct-anchorage me-
chanics used for the successful closure of a maxillary first permanent molar space with the use of an implant-
supported appliance (Mesialslider). Treatment was completed in just under 12 months, with successful mesial
movement of the maxillary second and third molars without the need for the bonding of orthodontic brackets on
the anterior dentition. The result was determined to be stable over a 3-year period. (Am J Orthod Dentofacial
Orthop 2019;155:725-32)
T
he first permanent molar is the tooth most effective, and more convenient to use than endosseous
frequently lost to dental caries or periodontal dis- implants.6-10 The most frequently reported site for
ease.1 Although there are a number of prosthetic insertion and placement of these mini-implants is the
options readily available for tooth replacement, ortho- buccal dentoalveolar region which can potentially be
dontic space closure by controlled mesial movement of in the path of moving teeth. Therefore, particularly in
the second and third permanent molars may be prefer- the maxilla, the anterior palatal area seems advanta-
able and mitigates the need for ongoing restorative geous, because all of the teeth can be moved without
maintenance.2-5 A complex biomechanical challenge any interference from the mini-implants.11 Other con-
exists when protraction of the molars is required siderations that make the anterior palate a preferred
without retraction of the anterior teeth and premolars. site for implant placement includes good bone quality,
Anchorage control is crucial in the treatment of such a thin attached mucosa, minimal risk of tooth injury,
patients because lingual tipping of the incisors must and a high associated success rate.12,13
be prevented while protracting the second and third To reinforce anchorage with the use of mini-
molars. implants, direct or indirect mechanics can be applied.
Titanium mini-implants are commonly used as a In indirect anchorage treatment strategies, one tooth
source of absolute anchorage during various types of or many teeth are stabilized with the use of a rigid ortho-
tooth movement, because they are simpler, more cost- dontic wire, with an adjunctive full multibracket appli-
ance needed. In contrast, the use of mini-implants
a
with direct anchorage concepts involve forces being
Department of Orthodontics, University of Duesseldorf, Duesseldorf, Germany.
b
Private practice, Perth, Australia. directly applied to the teeth that are to be moved.
All authors have completed and submitted the ICMJE Form for Disclosure of Po- Considerations that may favor direct over indirect
tential Conflicts of Interest, and none were reported. anchorage approaches include a possible esthetic advan-
Address correspondence to: Benedict Wilmes, Department for Orthodontics, Uni-
versity of D€usseldorf, Moorenstr. 5, D-40225 D€ usseldorf, Germany; e-mail, tage if concomitant orthodontic bracket placement is
wilmes@med.uni-dueseldorf.de. not required. A further corollary of such an approach is
Submitted, August 2018; revised and accepted, January 2019. the reduced friction within the system, leading to treat-
0889-5406/$36.00
Ó 2019 by the American Association of Orthodontists. All rights reserved. ment objectives being achieved over a shorter period of
https://doi.org/10.1016/j.ajodo.2019.01.011 time. Furthermore, direct anchorage bypasses the initial
725
726 Wilmes, Vasudavan, and Drescher
Fig 1. Pretreatment facial and intraoral photographs and panoramic radiograph. (Patient was treated
in cooperation with Dr Bahareh Wymar, Cologne, Germany.)
alignment and leveling period associated with most con- intercuspidation. Her malocclusion was characterized by
ventional straight-wire systems, with the immediate minor incisor irregularity, and mild mandibular arch-
commencement of space closure. In the present paper, length insufficiency was noted. The panoramic radio-
the clinical procedure and design of direct anchorage graph confirmed the presence of the unerupted
mechanics for maxillary space closure with the use of 2 maxillary third molars, the periapical periodontitis of
palatal mini-implants (Mesialslider) are described. the upper right first molar, and a mucous retention
cyst noted in the maxillary left sinus. The functional
assessment of the occlusion did not show a discrepancy
CLINICAL EXAMPLE between centric occlusion and centric relation. There
A 17-year-old adolescent female patient presented were no signs or symptoms of temporomandibular
with the absence of the maxillary first permanent molars. dysfunction.
She was seeking orthodontic treatment to facilitate After extensive discussion with the patient and her
mesial movement of the maxillary second and third mo- parents, informed consent was obtained to proceed
lars (Fig 1). Both maxillary first molars were lost because with a program of orthodontic care to protract the
of periodontitis and nonrestorable decay. The patient maxillary second molars and close the residual extraction
reported that she had previously undergone a compre- spaces in the first permanent molar site. Alternative
hensive course of orthodontic treatment, and she treatment approaches that were also considered were
presented with an Angle Class I occlusion sound buccal the use of removable or fixed prosthesis options,
May 2019 Vol 155 Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Wilmes, Vasudavan, and Drescher 727
American Journal of Orthodontics and Dentofacial Orthopedics May 2019 Vol 155 Issue 5
728 Wilmes, Vasudavan, and Drescher
Fig 3. A, Mesialslider adapted on a plaster model. B, Intraoral photograph after placement of palatal
mini-implants and the Mesialslider. C, D, radiographs after placement.
Fig 4. Progress occlusal photographs after 6 months; Fig 5. Occlusal photograph after 12 months, at the end of
elastic chains were added. treatment.
second and third molars into the space of missing first posteriorly. Recently published cone-beam computed
molars.2-4,19,24-26 However, our treatment mechanics tomographic studies revealed that a length of 9 mm
was unique from previously reported cases, because is sufficient to serve as anchorage in the anterior pal-
there is no need for brackets if a direct anchorage– ate.27,28 The framework for the Mesialslider appliance
based mechanism is used. (Fig 2, H) is readily available and allows for the Me-
In this case, the mini-implants used had dimen- sialslider to be adapted and manipulated at chairside.
sions of 2 3 11 mm anteriorly and 2 3 9 mm This potentially removes the need for laboratory
May 2019 Vol 155 Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Wilmes, Vasudavan, and Drescher 729
Fig 6. Posttreatment extraoral and intraoral photographs, after removal of the Mesialslider.
Fig 7. Posttreatment lateral cephalogram and panoramic radiograph after removal of the Mesialslider.
American Journal of Orthodontics and Dentofacial Orthopedics May 2019 Vol 155 Issue 5
730 Wilmes, Vasudavan, and Drescher
Fig 8. 3D scans of the maxilla: A, before treatment, B, after treatment, and C, superimposition of before
and after scans.
May 2019 Vol 155 Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Wilmes, Vasudavan, and Drescher 731
American Journal of Orthodontics and Dentofacial Orthopedics May 2019 Vol 155 Issue 5
732 Wilmes, Vasudavan, and Drescher
18. Wilmes B, Drescher D, Nienkemper M. A miniplate system for 27. Hourfar J, Ludwig B, Bister D, Braun A, Kanavakis G. The most
improved stability of skeletal anchorage. J Clin Orthod 2009;43: distal palatal ruga for placement of orthodontic mini-implants.
494-501. Eur J Orthod 2015;37:373-8.
19. Wilmes B, Nienkemper M, Nanda R, Lubberink G, Drescher D. Pala- 28. Hourfar J, Kanavakis G, Bister D, Schatzle M, Awad L,
tally anchored maxillary molar mesialization using the mesial- Nienkemper M, et al. Three dimensional anatomical exploration
slider. J Clin Orthod 2013;47:172-9. of the anterior hard palate at the level of the third ruga for the
20. Wilmes B, Katyal V, Willmann J, Stocker B, Drescher D. Mini- placement of mini-implants—a cone-beam CT study. Eur J Orthod
implant-anchored Mesialslider for simultaneous mesialisation 2015;37:589-95.
and intrusion of upper molars in an anterior open bite case: a 29. Lindskog-Stokland B, Wennstr€ om JL, Nyman S, Thilander B. Or-
three-year follow-up. Aust Orthod J 2015;31:87-97. thodontic tooth movement into edentulous areas with reduced
21. Ludwig B, Zachrisson BU, Rosa M. Noncompliance space closure in bone height. An experimental study in the dog. Eur J Orthod
patients with missing lateral incisors. J Clin Orthod 2013;47: 1993;15:89-96.
180-7. 30. Lindskog-Stokland B, Hansen K, Ekestubbe A, Wennstr€om JL. Or-
22. Wilmes B, Ludwig B, Vasudavan S, Nienkemper M, Drescher D. The thodontic tooth movement into edentulous ridge areas—a case se-
T-zone: median vs paramedian insertion of palatal mini-implants. ries. Eur J Orthod 2013;35:277-85.
J Clin Orthod 2016;50:543-51. 31. Wainwright WM. Faciolingual tooth movement: its influence on
23. Becker K, Wilmes B, Grandjean C, Vasudavan S, Drescher D. Skel- the root and cortical plate. Am J Orthod 1973;64:278-302.
etally anchored mesialization of molars using digitized casts and 32. Daimaruya T, Takahashi I, Nagasaka H, Umemori M, Sugawara J,
two surface-matching approaches: analysis of treatment effects. Mitani H. Effects of maxillary molar intrusion on the nasal floor
J Orofac Orthop 2018;79:11-8. and tooth root using the skeletal anchorage system in dogs. Angle
24. Holberg C, Winterhalder P, Holberg N, Wichelhaus A, Rudzki- Orthod 2003;73:158-66.
Janson I. Indirect miniscrew anchorage: biomechanical loading 33. Oh H, Herchold K, Hannon S, Heetland K, Ashraf G, Nguyen V,
of the dental anchorage during mandibular molar protraction— et al. Orthodontic tooth movement through the maxillary sinus
an FEM analysis. J Orofac Orthop 2014;75:16-24. in an adult with multiple missing teeth. Am J Orthod Dentofacial
25. Uribe F, Janakiraman N, Fattal AN, Schincaglia GP, Nanda R. Cor- Orthop 2014;146:493-505.
ticotomy-assisted molar protraction with the aid of temporary 34. Kuroda S, Wazen R, Moffatt P, Tanaka E, Nanci A. Mechanical
anchorage device. Angle Orthod 2013;83:1083-92. stress induces bone formation in the maxillary sinus in a short-
26. Jacobs C, Jacobs-M€ uller C, Luley C, Erbe C, Wehrbein H. Ortho- term mouse model. Clin Oral Investig 2013;17:131-7.
dontic space closure after first molar extraction without skeletal 35. Hom BM, Turley PK. The effects of space closure of the mandibular
anchorage. J Orofac Orthop 2011;72:51-60. first molar area in adults. Am J Orthod 1984;85:457-69.
May 2019 Vol 155 Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics