Wilmes 2019

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CLINICIAN'S CORNER

Maxillary molar mesialization with the


use of palatal mini-implants for direct
anchorage in an adolescent patient
Benedict Wilmes,a Sivabalan Vasudavan,b and Dieter Dreschera
Duesseldorf, Germany, and Perth, Australia

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

for the maxillary arch as a source of direct anchorage


(Fig 2). Other mini-implant systems with abutments
may be used as well (eg, OrthoEasy Pal, Forestadent).21
Treatment commenced with the insertion of the 2
palatal mini-implants, under local anesthesia, distal to
the third palatal rugae (T-zone).22 Stainless steel circum-
ferential bands were cemented to the maxillary
second molars, and an impression was recorded at the
same appointment for laboratory fabrication of the Me-
sialslider. For this purpose, impression caps and labora-
tory analogs were used. Several days later, the
Mesialslider appliance was fitted and engaged to the
maxillary second molars (Fig 3). No brackets were
bonded. Mesialization of maxillary molars commenced
bilaterally with the application of a nickel-titanium clos-
ing coil spring (200 g). Over the next 6 months, approx-
imately one-half of the first permanent molars space was
closed, and elastic chains were then added to maintain
the necessary mesialization force to facilitate continued
space closure (Fig 4). Twelve months after the
commencement of treatment, the bilateral spaces were
closed and the planned mesial tooth movement of the
Fig 2. Parts for the Mesialslider. maxillary left second molars was achieved (Fig 5), and
the Mesialslider was removed (Figs 6 and 7). A
vacuum-formed stent was prescribed for retention.
osseointegrated implants, and autotransplantation of
the third molars. Although such alternative treatment
approaches may be readily delivered with relatively TREATMENT RESULTS
shorter treatment times, they involve invasive surgical The planned treatment objective of maxillary space
procedures (dental implants, autotransplantation) or closure without concomitant anchorage loss was
are potentially biologically costly, often involving signif- achieved. The maxillary third molars moved forward
icant tooth preparation (fixed prosthesis). Variable long- autonomously secondary to the pull of the interdental
term survival rates and complications of the alternate periosteal fibers. The chosen biomechanical approach
prosthetic and surgical options have been reported.14,15 enabled the line of force action to be applied closer to
The patient made an informed decision to proceed with a the center of resistance of the maxillary second molars,
treatment program involving closure of the residual thereby achieving space closure predominantly through
maxillary arch spacing through the advancement of translation, or bodily tooth movement. The posttreat-
the maxillary second molars. Further consideration was ment panoramic radiograph (Fig 7) showed bodily mesi-
given for the potential favorable eruption of the alization of the maxillary second and third molars into
maxillary third molars into the original second molar the first molar spaces and sound alveolar bone levels.
position. The superimposition of pre- and posttreatment 3D scans
(superimposed on the palatal rugae23) showed the mesi-
INSTALLATION OF THE MESIALIZATION alization of both second and third molars (Fig 8). The
APPLIANCE AND TREATMENT PROGRESS posttreatment retention review was completed 3 years
The treatment objectives consisted of type C after the treatment was finished, and records demon-
anchorage requirements, in which more than 75% of strated good stability of the dental movements. The
the residual space needed to be closed by the forward small space between the maxillary right second and third
movement of the posterior segments through the mesi- molar disappeared owing to a final mesial drift of the
alization of the maxillary second molars. A Mesialslider third molar (Figs 9 and 10).
(1.1 mm stainless steel wire) connected to 2 median
palatal mini-implants (anterior 2 3 11 mm, posterior DISCUSSION
2 3 9 mm; Benefit System, PSM North America), as There has been a plethora of published cases and
reported previously by Wilmes et al,16-20 was planned clinical studies recently describing the mesialization of

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.

previous bone loss. Both nonhuman29 and human30 ex-


periments have shown that when a tooth is mesialized
into a reduced bony ridge, the periodontal apparatus
of the newly moved tooth undergoes minimal peri-
odontal alterations. In addition, there can be a positive
change in the width of the alveolar ridge,30 as was
observed in the present case. Moving teeth through
the maxillary sinus is considered to be one of the
most challenging treatment tasks in orthodontics,
because it requires compensatory new bone apposition
in the direction of tooth movement. Some papers re-
ported root resorption, loss of pulp vitality, and perfo-
ration of the sinus membrane as possible complications
after moving molars through a lowered maxillary si-
nus.31,32 However, it is well known that orthodontic
tooth movement may also cause bone apposition at
border structures, such as the sinus floor, as was
Fig 9. Superimposition of the pretreatment and posttreat- demonstrated by Oh et al.33 In a nonhuman animal
ment lateral cephalograms. experiment it was shown that the sinus wall may main-
tain a consistent thickness.34
support and its associated costs. However, depending The total treatment time was 12 months, which
on the experience of the operator, chairside adjust- is relatively short compared with the reported
ments may require additional clinical time. Alterna- average of 24–48 months for cases requiring
tively, an impression or scan and adaptation of the molar mesialization.35 Active mesialization of the
Mesialslider on a plaster model might prove to be second molar was commenced shortly after the re-
more practical. Figure 2 illustrates the mesialization ported loss of the maxillary first permanent molar.
system and its constituent parts for individualization Most conventional straight-wire approaches involve
in differing anchorage requirements. Although in our a preliminary phase of alignment and leveling,
case we soldered part K directly to the maxillary molar which serve to delay the commencement of active
bands, as shown in Figure 3, A, part L can be inserted space closure.
directly into a standard molar band sheath chairside The patient was particularly pleased about the lack
and does not require a laboratory soldering procedure. of visibility of the appliance, maximizing the smile
Our clinical experience has revealed that associated esthetics during treatment and reducing the risks of
molar tipping can be prevented absolutely if the enamel decalcification and root resorption. There
connection is as rigid as possible through the use of were no significant complications noted or reported
a soldered connector (Fig 2, K). during and after orthodontic treatment. The patient
In our case, the maxillary second and third molars was highly motivated and maintained good oral
were moved anteriorly into alveolar ridges with hygiene.

May 2019  Vol 155  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Wilmes, Vasudavan, and Drescher 731

Fig 10. Intraoral photographs after 3 years in retention.

CONCLUSIONS 6. Costa A, Raffainl M, Melsen B. Miniscrews as orthodontic


anchorage: a preliminary report. Int J Adult Orthodon Orthognath
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May 2019  Vol 155  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics

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