Background: Management of skeletal Class III malocclusion of maxillary origin in late adolescence remains challenging, as conventional tooth-borne orthopedic approaches show reduced effectiveness at advanced stages of skeletal maturation. Minimally invasive, bone-anchored alternatives supported by digital workflows may improve clinical feasibility and patient acceptance. Objective: To describe a digitally guided clinical protocol combining a hybrid maxillary expander and supragingival mandibular miniplates, and to explore skeletal and dentoalveolar outcomes in late adolescents. Methods: This retrospective pilot clinical study included ten late adolescents (mean age 16.0 ± 1.3 years; range 13.8-17.7) in advanced skeletal maturation stages (CS4-CS6) with skeletal Class III malocclusion of maxillary origin. Treatment consisted of a hybrid maxillary expander anchored to palatal miniscrews and custom supragingival mandibular miniplates, placed using a fully digital workflow. Maxillary protraction was performed using a modified Alt-RAMEC protocol followed by continuous intermaxillary elastic traction for 12 months. Pre- and post-treatment cephalometric analyses were conducted. Results: A significant increase in SNA was observed (mean +6.1°, p < 0.001), indicating forward maxillary displacement. The Wits appraisal improved by 3.3 mm (p = 0.007), and the SeMax increased by 2.9 mm (p = 0.0013). No significant changes were found in the SNB or mandibular plane angle. Dentoalveolar effects were limited. Conclusions: Within the limitations of this pilot clinical study, the proposed digitally guided protocol demonstrated clinically relevant maxillary advancement with minimal dentoalveolar side effects and preserved vertical control. This relatively minimally invasive approach compared to conventional subgingival miniplates and orthognathic surgery may represent a feasible treatment option for selected late adolescent patients. Further controlled studies are required to confirm these findings.

Background: Conventional Herbst appliances are effective for the correction of skeletal Class II malocclusion, but they are frequently associated with dentoalveolar side effects, particularly lower incisor proclination. Skeletal anchorage systems may improve orthopedic outcomes; however, submucosal miniplates require invasive surgical procedures that may reduce patient acceptance. This pilot clinical study evaluated the feasibility, safety, and skeletal effects of a minimally invasive digitally guided protocol using supragingival miniplates for bone-supported Herbst therapy in late adolescents. Methods: Eleven late-adolescent patients (14-17 years; cervical vertebral maturation stages CS4-CS5) with skeletal Class II malocclusion due to mandibular retrusion were prospectively treated using a bone-supported Herbst appliance anchored to digitally planned supragingival stainless-steel miniplates fixed with bicortical miniscrews. Miniscrew placement was planned by merging CBCT and intraoral scan data and performed using 3D-printed surgical guides. Cephalometric variables, including SNA, SNB, Wits appraisal, mandibular plane angle, and incisor inclinations, were assessed before treatment and after a 10-month Herbst phase. Mandibular advancement was additionally explored using a complementary linear measurement (SeMndb-line). Results: All patients completed treatment without anchorage loss, appliance failure, or surgical complications. Significant skeletal improvements were observed, including an increase in SNB (+3.36°, p < 0.001) and a reduction in Wits appraisal (-2.65 mm, p < 0.001). The SeMndb-line increased by +3.49 mm (p < 0.001), supporting effective mandibular advancement. Lower incisor inclination remained stable (Δ = -0.18°, p = 0.909), indicating effective dentoalveolar control. No clinically relevant changes in vertical skeletal pattern were observed. Conclusions: Digitally guided supragingival miniplates for bone-supported Herbst therapy appear to be a feasible and minimally invasive approach for the treatment of skeletal Class II malocclusion in late adolescents. This protocol achieved clinically meaningful mandibular advancement while minimizing dentoalveolar side effects. Given the pilot design, small sample size, and lack of a control group, further controlled studies with larger samples and long-term follow-up are required.

BACKGROUND:Miniscrew-assisted palatal expansion techniques such as MARPE (Miniscrew-Assisted Rapid Palatal Expansion) and MASPE (Miniscrew-Assisted Slow Palatal Expansion) represents non-surgical alternatives for the correction of transverse maxillary deficiencies in adults. However, concerns have arisen regarding their potential to cause craniofacial complications due to the high forces applied for midpalatal suture opening in skeletally mature patients. METHODOLOGY:This article aims to present and describe isolated clinical cases of cranialfacial complications observed in adult patients following MARPE and MASPE procedures, and to discuss the potential biomechanical mechanisms behind these events. Eleven clinical cases involving adult patients who underwent skeletal midface expansion with miniscrew-assisted devices are presented. All cases exhibited craniofacial unwanted dislocations identified through CBCT imaging, including zygomatic fractures, parasutural bone fractures, and asymmetrical disjunction of craniofacial sutures. These events were retrospectively documented through clinical follow-up and radiographic analysis. RESULTS:Among the eleven cases presented, complications included seven asymmetric fractures of the frontonasal process, two orbital fractures, one zygomatic bone fracture, and one parasagittal fracture of the palatine bone. These complications were primarily observed in patients who underwent MARPE with rapid activation protocols. One minor complication occurred in a MASPE case, where the patient followed the prescribed slow activation schedule. CONCLUSION:Non surgical mid facial expansion is a potential source of unwanted and unpredicted dislocations in the craneofacial complex. According to this report the observed complications do not seem to be age related and are difficult to predict from the CBCT. A close clinical follow up including force monitoring and force limitation should be mandatory when performing MARPE. MASPE and minimally invasive SARPE could be alternatives to minimise the incidence of creaniofacial complications.

This consecutive retrospective study compared Mini-implant Assisted Slow Palatal Expansion (MASPE) with rapid palatal expansion (MARPE) using a bone-borne skeletal expander in adults with a narrow maxilla. CBCT scans analyzed transverse changes and potential pterygoid process deformation before (T1) and after expansion (T2). The Force Controlled PolyCyclic (FCPC) SLOW palatal expansion group (FCPC-MASPE-G) comprised 35 adults aged 18–54 years and received a skeletal expander limiting expansive force only allowing 500 cN at the activation wrench (force control). Discontinuous, polycyclic activations according to the FCPC-protocol were applied. The MARPE-group (n = 6) underwent continuous RAPID activation without FCPC until the desired width was reached. CBCT scans were taken pre and post-expansion. Inclusion criteria for both groups were successful outcomes without surgical assistance. The maxilla opened transversally in both groups mildly V-shaped, with a pyramidal shape in the coronal plane, impacting the zygomatic bone. Width measurements at T2 indicated superior mechanical response in FCPC-MASPE-G. Response of zygomaticomaxillary sutures was similar in both groups (p < 0.001 to 0.025). Pterygoid process deformations were notably less in FCPC-MASPE-G (0.87–1.35 mm, p < 0.001) compared to MARPE-G (2.70–3.04 mm, p < 0.001 to 0.009). Dental measurements were similar (p < 0.001 to 0.023), but the ratio “Mid-palatal suture Opening Related to Expander opening” (M.O.R.E.-factor) was better with 84

Aim: This in vitro study investigates the limit of expansion forces and torque wrench forces developed by five skeletal bone expander designs (MICRO 2/4 expanders™) for clinical application. Material and Methods: A total of 30 skeletal expanders were placed in artificial bone blocks and mechanically tested, simulating maxillary expansion. Differences in jackscrew (Dentaurum™ [D], Superscrew™ [S] and Powerscrew™ [P]), number of orthodontic mini-implants (OMIs; two or four) and their placement inclinations (parallel 0° or 10° inclination) form five designs (D4/10°, S4/0°, S4/10°, P4/10° and P2/10°). Expansion forces and torque wrench values were registered, and radiographs were made initially and after 4 mm of expansion. Stress-strain curves were obtained after successive activations and the statistical analysis was performed as appropriate. Results: Plastic deformations in the OMIs and jackscrew occurred around the activation numbers 11–13, with torque wrench values in the range of 500–700 cN. The maximum expansion forces in expanders with four OMIs varied from 93.0 (D4/10°) to 166.6 N (P4/10°) whereas two OMI expanders (P2/10°) registered forces of 79.4 N. Radiographs revealed during loads bending forces (S4/00°, S4/10°) with jackscrew and OMIs deformation in a convex shape, and shear forces (P4/10°, P2/10°) demonstrated only OMIs deformation in a concave shape, providing 15% more expansive force. The jackscrew D4/10° did not have any deformation, but its wire key did not allow reliable activations from activation number 10 and compared to S4/10° and P4/10°, these expanders provided greater expansion forces ( P = 0.000 and P = 0.032, respectively). Conclusion: The different results obtained in stability and expansion forces indicate that if the activations are carried out under extreme conditions, they may have clinical importance with deformations and non-working expansion mechanics. Jackscrew designs play an important role in expansive forces and expander stability. Torque wrench values can be used clinically as a tool to asses the expansion forces and to avoid deformations.

When using clear aligners, if distalization greater than 3 mm is required, there is no real predictable procedure to follow. The aim of this article is to show with two clinical cases the biomechanics of distalizing lower molars with mini-implant anchorage and aligners.

Introduction Bone-borne miniscrew assisted palatal expansion (MAPE) is a common technique to improve maxillary transverse deficiency in young adolescents. Adult patients usually present a challenge, as they often require additional surgical assisted maxillary expansion (SARPE). There is still no clear statement about non-surgical expansion in adult patients using this technique. The aim of this study was to evaluate the success and complication rate of non-surgical palatal expansion in adults utilizing MAPE with a novel force-controlled polycyclic expansion protocol (FCPC). Methods This consecutive study consisted of 33 adult patients with an average age of 29.1 ± 10.2 years (min. 18 years, max. 58 years), including one dropout patient. First, four miniscrews were inserted and after 12-weeks latency, the expander was placed and the FCPC protocol was applied (MAPE group). In case of missing expansion, a SARPE was performed (SARPE group). After maximum expansion, a cone beam CT was made and widening of the midpalatal suture was measured. The outcome variables were successful non-surgical expansion and, with sample size power above 80%, the odds of failed non-surgical expansion and associated complications were evaluated. The primary predictor variable was age. Statistical analysis was performed using R (Version 3.1) to calculate power, to construct various models for measuring the odds of requiring surgical intervention/complications, and others. Results Successful non-surgical expansion was achieved in 27 patients (84.4%), ranging from 18 to 49 years. Mean age differed significantly between both groups (26.8 ± 8.2 years vs. 41.3 ± 9.9 years; p < 0.001). Mean expansion at the anterior and posterior palate for the MAPE group was 5.4 ± 1.5 mm and 2.5 ± 1.1 mm, respectively. Among these subjects’ complications were observed in 18.5%. Age significantly increased the odds of complications ( p = 0.019). Conclusions 1. The success rate of MAPE among individuals aged 18 to 49 years was 84.4%. 2. A V-shaped expansion pattern in the antero-posterior dimension was mostly observed. 3. Complications were significantly associated with age. 4. A careful expansion protocol seems to be beneficial to prevent unfavorable results in adult patients. Trial registration Consecutive cohort study, Review Board No. EK-2-2014/0016.

Evaluate the quality of finishing and degree of contamination before and after handling and surface treatment of titanium (Ti) orthodontic mini-implants (OMIs). A scanning electron microscope (SEM) study on ninety-six titanium OMIs was done. Energy-Dispersive X-ray Analysis (EDX) identified the present particles on manufactured OMIs surfaces. Then, OMIs were manipulated with gauze (dry sterile, soaked in chlorhexidine) and gloves (latex, nitrile) to evaluate the contamination of these handling materials. Finally, OMIs underwent surface treatments and were placed in bone to observe the contaminants they released. Roughness (Ra) and wettability with contact angle parameter (CA) were measured on these treated OMIs. Machined OMIs presented surface irregularities and were contaminated with manufacturing-process particles (carbon, plastic Polyvinyl Chloride PVC, aluminum). Hand-manipulated OMIs were also contaminated by the handling materials. OMIs surface characteristics were as follows: acid-etched (Ra ≈ 1.3 μm, CA ≈ 66°), machined (Ra ≈ 0.3 μm, CA ≈ 68°), SB (Ra ≈ 3.3 μm, CA ≈ 78°), and SBAO (Ra ≈ 3.1 μm, CA ≈ 92°). Bone was contaminated by OMIs surface defects and extra particles. Manufactured OMIs have surface contaminants that increase with clinical handling. Surface treatments (SBAO, a combination of sandblasting and anodic oxidation) increase the roughness and contact angle, which play an important role in osseointegration. Surface-treated OMIs leave titanium particles in the bone during their insertion-removal. The use of a gauze soaked in chlorhexidine is recommended when handling OMIs. Further investigations would be interesting to study more variables and confirm the present results.

Objective: To compare the periodontal condition and the microbiological status between the vestibular group (VG), lingual group (LG) and control group (CG).Mataerial and Methods: 18 patients(mean age: experimental group: 32 years old; and control group: 25 years old): 6 treated with vestibular fixed appliance, 6 with lingual appliance and 6 subjects in the control groupwho did not receive orthodontic treatment. A periodontal exam was performed before placing braces (T0) and after 4 weeks (T1). The gingival index (GI), plaque index (PI), Bleeding on probing (BOP) and periodontal pocket depth (PPD) was evaluated. Through PCR was detected the presence or absence ofEikenellacorrodens (Ec), Fusobacterium nucleatum (Fn), Agregati bacteractinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Tannerella forsythensis (Tf), Terponema denticolla (Td), and Prevotella intermedia (Pi).Results: It was found a significant increased in the plaque index and gingival index. No significant changes were found according to BOP and PPD. The microbiological results show significant differences between the control group and the experimental groups in Aa, Tf, Pi, Fn and a tendency to an increase of Pg, Td in both experimental groups. Conclusions: There’s a direct relation between the placement of fixed appliance (vestibular and lingual) and the increase of plaque index and gingival index. Also, the growth of periodonto pathogens in subgingival plaque is promoted. Clinical relevance : This study stresses the importance of monitoring orthodontic patients. Vestibular orthodontic appliance seems to be better than the lingual in terms of less worsening condition during time.

Facial asymmetry is a common complaint in patients with facial concerns. Some patients have mandibular asymmetries that have light maxillary cant compensation due to a reduced gingival exposure. A common treatment in facial asymmetries is bimaxillary surgery treatment. However, there are no cases of non-severe occlusal plane canting (OPC) with mandibular asymmetry treated with mandibular surgery and miniscrews for the extrusion of the maxillary molars. The aim of this article is to show how to correct mandibular asymmetries combined with OPC by making a single mandibular "early surgery" combined with the extrusion of the maxilla with miniscrews to correct the occlusal plane in order to avoid a Le Fort I surgery. This type of treatment provides lower medical costs, shorter surgeries, and less postoperative discomfort and invasion for patients.

ABSTRACT Introduction: The force applied to the teeth by fixed orthopaedic expanders has previously been studied, but not the force applied to the orthodontic mini-implant (OMI) used to expand the maxilla with Hyrax hybrid expanders (HHE). Objective: The aim of this article was to evaluate the clinical safety of the components (OMI, abutment and double wire arms) of three different force-transmitting systems (FTS) for conducting orthopaedic maxillary expansion: Jeil Medical & Tiger Dental™, Microdent™ and Ortholox™. Methods: For the realization of this in vitro study of the resistance to mechanical load, three different abutment types (bonded, screwed on, and coupling) and three different OMIs’ diameters (Jeil™ 2.5 mm, Microdent™ 1.6 mm and Ortholox™ 2.2 mm) were used. Ten tests for each of these three FTS were carried out in a static lateral load in artificial bone blocks (Sawbones™) by a Galdabini universal testing machine, then comparing its performance. Comparisons of loads, deformations and fractures were carried out by means of radiographs of FTS components in each case. Results: At 1- mm load and within the elastic deformation, FTS values ranged from 67 ± 13 N to 183 ± 48 N. Under great deformations, Jeil & Tiger™ was the one who withstood the greatest loads, with an average 378 ± 22 N; followed by Microdent™, with 201 ± 18 N, and Ortholox™, with 103 ± 10 N. At 3 mm load, the OMIs shaft bends and deforms when the diameter is smaller than 2.5 mm. The abutment fixation is crucial to transmit forces and moments. Conclusions: The present study shows the importance of a rigid design of the different components of HHEs, and also that HHEs would be suitable for maxillary expansion in adolescents and young adults, since its mean expansion forces exceed 120N. Furthermore, early abutment detachment or smaller mini-implants diameter would only be appropriate for children.

ZusammenfassungEine Behandlung transversaler Oberkieferdefizite im Erwachsenenalter mit herkömmlichen Expansionsgeräten ist aufgrund der möglichen parodontalen Schädigung oft schwer durchführbar. Chirurgische Verfahren (SARME=surgically assisted rapid maxillary expansion oder Segment-LeFort-I-Operationen) werden bei abgeschlossenem Wachstum erfolgreich eingesetzt. Einige Patienten lehnen aber eine Operation in Allgemeinnarkose ab. Alternativ gibt es Möglichkeiten auch im Erwachsenenalter mit weniger invasivem Vorgehen eine transversale Oberkieferkorrektur durchzuführen. Dies wird anhand zweier Patientenbeispiele demonstriert.

Despite recommendations for early treatment of hereditary Angle Class III syndrome, late pubertal growth may cause a relapse requiring surgical intervention. This study was performed to identify predictors of successful Class III treatment.Thirty-eight Class III patients treated with a chincup were retrospectively analyzed. Data were collected from the data archive, cephalograms, and casts, including pretreatment (T0) and posttreatment (T1) data, as well as long-term follow-up data collected approximately 25 years after treatment (T2). Each patient was assigned to a success or a failure group. Data were analyzed based on time (T0, T1, T2), deviations from normal (Class I), and prognathism types (true mandibular prognathism, maxillary retrognathism, combined pro- and retrognathism).Compared to Class I normal values, the data obtained in both groups yielded 11 significant parameters. The success group showed values closer to normal at all times (T0, T1, T2) and vertical parameters decreased from T0 to T2. The failure group showed higher values for vertical and horizontal mandibular growth, as well as dentally more protrusion of the lower anterior teeth and more negative overjet at all times. In adittion, total gonial and upper gonial angle were higher at T0 and T1. A prognostic score-yet to be evaluated in clinical practice-was developed from the results. The failure group showed greater amounts of horizontal development during the years between T1 and T2. Treatment of true mandibular prognathism achieved better outcomes in female patients. Cases of maxillary retrognathism were treated very successfully without gender difference. Failure was clearly more prevalent, again without gender difference, among the patients with combined mandibular prognathism and maxillary retrognathism. Crossbite situations were observed in 44% of cases at T0. Even though this finding had been resolved by T1, it relapsed in 16% of the cases by T2.The failure rate increased in cases of combined mandibular prognathism and maxillary retrognathism. Precisely in these combined Class III situations, it should be useful to apply the diagnostic and prognostic parameters identified in the present study and to provide the patients with specific information about the increased risk of failure.

To investigate the skeletal and dental changes during chincup versus facemask treatment, to compare the long-term effects of the two appliances, and to document the impact of each on treatment success.

The present study evaluated the temporal release of Co Cr, Mn, and Ni from the components of a typical orthodontic appliance during simulated orthodontic treatment. Several commercially available types of bands, brackets, and wires were exposed to an artificial saliva solution for at least 44 days and the metals released were quantified in regular intervals using inductively coupled plasma quadrupole mass spectrometry (ICP-MS, Elan DRC+, Perkin Elmer, USA). Corrosion products encountered on some products were investigated by a scanning electron microscope equipped with an energy dispersive X-ray microanalyzer (EDX). Bands released the largest quantities of Co, Cr, Mn, and Ni, followed by brackets and wires. Three different temporal metal release profiles were observed: (1) constant, though not necessarily linear release, (2) saturation (metal release stopped after a certain time), and (3) an intermediate release profile that showed signs of saturation without reaching saturation. These temporal metal liberation profiles were found to be strongly dependent on the individual test pieces. The corrosion products which developed on some of the bands after a 6-month immersion in artificial saliva and the different metal release profiles of the investigated bands were traced back to different attachments welded onto the bands. The use of constant release rates will clearly underestimate metal intake by the patient during the first couple of days and overestimate exposure during the remainder of the treatment which is usually several months long. While our data are consistent with heavy metal release by orthodontic materials at levels well below typical dietary intake, we nevertheless recommend the use of titanium brackets and replacement of the band with a tube in cases of severe Ni or Cr allergy.

In a case report in the May 2016 issue, Carlson et al reported the use of a microimplant-assisted rapid palatal expansion (MARPE) appliance to correct transverse maxillary deficiency in an adult (Carlson C, Sung J, McComb RW, Machado AW, Moon W. Microimplant-assisted rapid palatal expansion appliance to orthopedically correct transverse maxillary deficiency in an adult. Am J Orthod Dentofacial Orthop 2016;149:716-28). The report was interesting and very systematic, but it was missing some important details. As the authors stated in their introduction, true skeletal expansion is free of dental and alveolar side effects, and only pure skeletally anchored expanders can achieve this. However, the appliance used in this case report, a MARPE appliance, is a dentally and skeletally anchored expander with evident dental (molar) side effects. MARPE means mini-implant "assisted" rapid maxillary expansion, which expresses skeletal anchorage in additional to dental anchorage. These appliances are subsumed under the "hybrid" type of expanders as reported by Wilmes and Drescher1Wilmes B. Drescher D. A miniscrew system with interchangeable abutments.J Clin Orthod. 2008; 42: 574-580PubMed Google Scholar and Ludwig et al.2Ludwig B.G. B Zorkun B. Wilmes B. Kinzinger G. Lisson J. Forcierte Gaumennahterweiterung mit skelettalem Kraftansatz: die Hybrid-GNE.Kieferorthop. 2009; 23: 267-274Google Scholar Hybrid expanders use mini-implants in the lateral anterior palate and the maxillary first molars as anchorage. The MARPE is a hybrid expander because it is anchored on 4 mini-implants in the lateral posterior palatal region and the maxillary first molars. To clarify anchorage definitions, a term such as BAME should be used, for pure "bone-anchored maxillary expanders." The letter R, for "rapid," should be omitted, because thanks to solid anchorage, these expansions can also be performed in a slow way. This technique was presented with the Micro6-expander in 2013 (Fig).3Winsauer H. Vlachojannis J. Winsauer C. Ludwig B. Walter A. A bone-borne appliance for rapid maxillary expansion.J Clin Orthod. 2013; 47: 375-381PubMed Google Scholar Explaining the outcomes of their rapid palatal expansion, the authors described "uprighting" of the maxillary first molars. The change in degrees indicates buccal tipping of those molars, a highly undesirable side effect with a high risk for periodontal harm or root damage. Pure bone-borne expanders3Winsauer H. Vlachojannis J. Winsauer C. Ludwig B. Walter A. A bone-borne appliance for rapid maxillary expansion.J Clin Orthod. 2013; 47: 375-381PubMed Google Scholar, 4Walter A. Wendl B. Ploder O. Mojal S. Puigdollers A. Stability determinants of bone-borne force-transmitting components in three RME hybrid expanders—an in vitro study.Eur J Orthod. 2016 Apr 1; ([Epub ahead of print])Google Scholar do not show any translational dental movements or buccal tipping5Winsauer H, Ploder O, Katsaros C, Puigdollers A, Walter A. Skeletal changes after polycyclic maxillary expansion with a pure bone-borne device without SARPE in adult patients. Poster presentation at the 91st Congress of The European Orthodontic Society in Stockholm, Sweden; June 11, 2016.Google Scholar because no teeth are involved. After the expansion, they even show minor spontaneous palatal tipping5Winsauer H, Ploder O, Katsaros C, Puigdollers A, Walter A. Skeletal changes after polycyclic maxillary expansion with a pure bone-borne device without SARPE in adult patients. Poster presentation at the 91st Congress of The European Orthodontic Society in Stockholm, Sweden; June 11, 2016.Google Scholar of the buccal teeth, as Carlson et al described for the maxillary canines only. In this case report, the mini-implant- and molar-anchored expander was opened 10 mm, achieving an overall palatal widening of 6 mm between the first molars. Now the question arises, what has happened to the missing 4 mm? Four millimeters of anchorage loss (2 mm per side) in this young adult would mean either that the implants have moved through the bone, or the implants have tipped or deformed, or even both. A cone-beam computed tomography cross-section image of this region could have answered this question and given visual information about the bone height and the situation around the mini-implants, although as stated in the Treatment progress section, an image with the appliance in place had been taken. Why was it not presented in this case report? Why is there is not a single photo of the appliance before or after expansion in this presentation? The estimated average bone height in this region (16 mm behind the incisive foramen and 7 mm lateral of the midline) is around 3 mm.6Winsauer H. Vlachojannis C. Bumann A. Vlachojannis J. Chrubasik S. Paramedian vertical palatal bone height for mini-implant insertion: a systematic review.Eur J Orthod. 2014; 36: 541-549Crossref PubMed Scopus (35) Google Scholar How much higher is the anchorage loss in older adults (>25 y) with more resistance against expansion due to more mature bone?7Knaup B. Yildizhan F. Wehrbein H. Age-related changes in the midpalatal suture. A histomorphometric study.J Orofacial Orthop. 2004; 65: 467-474Crossref PubMed Scopus (94) Google Scholar According to the examinations by Walter et al,4Walter A. Wendl B. Ploder O. Mojal S. Puigdollers A. Stability determinants of bone-borne force-transmitting components in three RME hybrid expanders—an in vitro study.Eur J Orthod. 2016 Apr 1; ([Epub ahead of print])Google Scholar directly loaded titanium mini-implants with a diameter of 1.5 mm under these circumstances will undergo major deformations with the risk of breakage. According to this study, hybrid expanders with dental anchorage and the assistance of 2 to 4 mini-implants should be used only in adolescent patients, not in adults.4Walter A. Wendl B. Ploder O. Mojal S. Puigdollers A. Stability determinants of bone-borne force-transmitting components in three RME hybrid expanders—an in vitro study.Eur J Orthod. 2016 Apr 1; ([Epub ahead of print])Google Scholar In a study of 33 adults with pure BAME, 90% of the patients between 23 and 33 years (n = 11) had successful palatal widening without SARPE and no dental side effects.8Winsauer H, Walter A, Muchitsch AP, Winsauer C, Jaeschke D, Katsaros C, et al. Pure bone borne maxillary expansion with 4 mini-implants in adults with and without SARPE: a consecutive study of 35 patients. Oral presentation at the 91st Congress of The European Orthodontic Society in Venice, Italy; June 13, 2015.Google Scholar In this letter, we have focused on different types of anchorage for palatal expanders. Thorough treatment decisions should be made according to the patients age in regard to appliance design and opening protocol (rapid vs slow vs polycyclic). The challenges, however, are to prevent dental side effects and to enable palatal widening in even mature adult patients without SARPE. Authors' responseAmerican Journal of Orthodontics and Dentofacial OrthopedicsVol. 151Issue 1PreviewWe agree that the term "hybrid" is appropriate if the dentition is used with the implants for anchorage for the expansion force. However, this does not mean that incorporating the dentition in an appliance design always makes it a hybrid or dental expander. If the purpose of the dentition in the appliance is not anchorage for the expansion force but something else, then the term "true skeletal anchorage" can be applied to the appliance. The expander we used, which we now officially call the "maxillary skeletal expander" (MSE), was originally designed to deliver the expansion force to 4 implants inserted deeply, engaging both layers of the cortical bone (palatal and nasal layers); the first molars were used to stabilize the position of the jackscrew during the expansion rather than for anchorage. Full-Text PDF

As an alternative to an orthodontic palatal implant this project evaluated two sagittally in the midline of the palate positioned titanium mini-screws as indirect anchorage elements. Over the whole treatment period no complications were observed. The orthodontic treatment was successfully completed. The measurements of lengths and widths carried out on 3D scanned models confirmed the stability of the molar anchorage reinforced by this kind of modified palatal implant. Wendl B1*, Muchitsch AP1, Winsauer H2, Walter A3, Droschl H1, Jakse N1, Wendl M4 and Wendl T4 1Clinical Department of Oral Surgery and Orthodontics Medical University Graz, Austria, Billrothgasse 4, A-8010 Graz, Austria 2Private Practice Bregenz 3Departamento de Ortodoncia y Ortopedia dento-facial, Universitat Internacional de Catalunya, Barcelona, Spain 4Institute of Software Development and Biomedical Engineering, Technical University Graz, Austria Wendl B, et al., Journal of Dentistry and Oral Biology Remedy Publications LLC. 2017 | Volume 2 | Issue 14 | Article 1089 2 and vertical overbite and overjet were evident. Treatment goals: Alignment and Distalization of the teeth 13, 14, and 15 using overlay mechanics (super elastic wires, elastic chains) and anchorage support of the first molars (Figure 4 and 5). Anchorage was planned by micro implants, for this two implantation screws (Dual top micro anchorage screws: Type G with slot 0.022" by 0.025", 1.6 by 10 mm with gingiva protection -TIGER DENTAL, Bahnhofstrasse 59, A6900 Bregenz (Figure 1)), 10 mm long and 1.6 mm in diameter, were placed behind the nasopalatine canal, bilaterally to the palatal suture. An acrylic splint was used to guide the implantation in the presurgically planed correct position (Figure 6 and 7). For insertion the area was selected according to the recommendations of high bone support by Bernhart et al. [2]. This means 6 mm to 9 mm posterior to the nasopalatine foramen and 3 mm to 6 mm paramedian to avoid the mid-palatal suture. The supraconstruction was a tanspalatinal 1, 1 mm steel wire which was soldered to the molar bands. In detail the transpalatinal steel wire were moulded as counterpart of the miniscrew to establish contact. This was followed by fastening the transpalatinal steel wire to the head of the screw by means of a stainless steel ligature. Finally, a light-curing composite adhesive was used to get a rigid link between the screw head and the transpalatinal steel wire (Figures 5, 8 and 9). To evaluate the maximal molar anchorage, the initial and final models were scanned three dimensionally. The object was scanned from above with a laser ray, in steps of 0.6 μm. The reflection of the laser off the object is recorded by an optical measuring unit and electronically processed, so the model can be presented digitally. Figure 1: Mini Screw. Figure 2: Enoral pre-treatment photograph. Figure 3: Panoramic X-ray (pre-treatment). Figure 4: Clinical treatment photograph. Figure 5: Clinical treatment photograph. Figure 6: Acrylic Splint for Insertion. Figure 7: Surgical Insertion. Figure 8: Schematic and clinical set up of the supra construction. Wendl B, et al., Journal of Dentistry and Oral Biology Remedy Publications LLC. 2017 | Volume 2 | Issue 14 | Article 1089 3 This scanning process was carried out independently by two people, each doing it twice, to facilitate a comparison of measurements and detection of any scanning irregularities. The models scanned in 3D mode are shown in Figure 10 and 11. The last step was measuring the distances from 3 different points on the occlusal molar surfaces (molars 16, 26) to the most mesial point of the tip of the papilla, and the measurement of the transverse constant (molars 16-26). This was carried out from several points on the occlusive surfaces of the implant supported molars. Results The clinical treatment goals were achieved (Figures 9, 12 and 13). Teeth 13 and 15 were successfully aligned and maximal molar anchorage has remained clinically stable. As for the skeletal conditions, there was even some improvement of the ANBdifference through increased growth of the maxilla (SNA: 79°, SNB: 79°). The measurements of length (upper molars to papilla incisiva) and transverse width of the 3D scans of the models are summed up in Table 1. The maximal difference recorded in both measurements (length and tranverse) was 0.5 mm, and there was also good correspondence between the two separately conducted scans, which showed a maximal difference of 0.1 mm. Discussion The measurements conducted showed differences of only up to 0.5 mm. The figures recorded by two separately undertaken scans corresponded well, showing up a maximal difference of 0.1 mm. This is proof of the good positional stability of the inserted miniscrews. By placing two miniscrews parasagittally, rotation control was achieved. Dual top screws are self-drilling and -cutting. They can be implanted into the upper jaw without pre-drilling, which takes only a few minutes. For the lower jaw, cantering of about 1mm is recommended because of the greater bone density. This minimally invasive procedure means only little strain for the patient. The hexagonal screw facilitates axial drilling, avoiding slipping and tilting. The practical design of the screwdriver handle also contributes to the secure placement of the screw, and the desired high primary stability. This means simple and safe application for the orthodontist. Positioning the screw is carried out under local anesthetic and its removal is possible without any anesthetic. This can be explained by the absence of osseointegration, which is prevented by the quality of the material and the smooth surface of the implant. Additionally no dental computerized tomography to avoid nasal cavity perforation (which can be caused by inserting palatal implants) or difficult surgical procedure (like on plants or zygomatic plates placement) is necessary. Wehrbein et al. [29] compared 1.2 mm by 1.2 mm steel wire transpalatal braces with ones dimensioned 0.8 mm by 0.8 mm and found that the deflection rate with the weaker dimensioned wire was up by a factor of 4.5. As there was also an increase of tilt that was proportional to the increase of load, the application of a palatal implant as distalizing anchorage Figure 9: Clinical treatment photograph. Figure 10: Scanned 3D-Modell pre-treatment. Figure 11: Scanned 3D-Modell post-treatment. N Min. Max. Mean Standard Deviation Transversal Scan 1 5 -0.522 0.518 0.027 0.373 Transversal Scan 2 5 -0.478 0.378 -0.015 0.314 Transversal Difference 5 -0.044 0.140 0.041 0.070 Molar Papilla Incisiva Scan 1 6 0.0114 0.533 0.323 0.165 Molar Papilla Incisiva Scan 2 6 0.116 0.506 0.328 0.125 Difference Molar Papilla Incisiva 6 -0.172 0.189 -0.006 0.131 Table 1: Descriptive statistics. Figure 12: Panoramic X-ray post-treatment. Figure 13: Enoral post-treatment clinical. Wendl B, et al., Journal of Dentistry and Oral Biology Remedy Publications LLC. 2017 | Volume 2 | Issue 14 | Article 1089 4 should be carried out with a steel wire of 1.1 mm in diameter, as demonstrated in our case study. Gelgör et al. [30] found that a 14 mm implantation screw increases stability significantly. However, only one screw of 14 mm length and 1.8 diameters was used to distalize upper jaw molars on both sides. 88% of the distalizing force resulted in molar distalization and only 12% in reciprocal anchorage loss, which was reflected in a 1° protrusion of the incisors and an overjet increase of 0.5 mm. In this clinical case study, two parasagittal mini screws, 10 mm in length and 1.6 mm in diameter, were placed to achieve rotation stability, too. Schnelle et al. [31] demonstrated that adequate bone material for placing implants is available only in the lower half of the root. This area, however, is mainly covered by mobile gingiva, which would again mean a greater risk of loss. In the lower jaw, the buccal surfaces and the retromolar region provide adequate width and sufficient cortical bone to allow the use of implantation screws with a 1.2 mm to 1.3 mm diameter and 4 mm to 5 mm length. The buccal cortical surfaces in the upper jaw are thinner and less compact, so micro-implants of 6 mm to 8 mm in length and 1.2 mm to 1.3 mm in diameter should be used here. For palatal implants the thickness of the mucosa should be measured first. To achieve at least 6mm of bone insertion, screws of 10 mm to 12 mm length and 1.2 mm to 1.3 mm in diameter are required [32]. According to Yun et al. [33], the soft tissue on the palatal incline is two to three times as thick as on the buccal side, but the central palatal region 4mm behind the papilla incisiva is covered by only 1mm of mucosa. In addition, this area offers much high value cortical bone [34,35]. There are different accounts of the success rates of these mini implants. A success rate of 97% is contrasted by studies that show a loss of 30%, with the failure rate in the lower jaw higher than in the upper jaw. Factors with a negative impact, like the age of patients being over 40, the design of the implant, the material, low bone density, placement in posterior areas, and inflammatory reactions in the neighboring areas can lead to implant mobility [36-38]. Miyawaki et al. [39] recommend the use of screws with a diameter larger than 1mm in their study. Apart from this, 2.3 mm diameter screws or even mini plates, which even have a success rate of 100%, should be used for patients with large mandibular plane angles, which so often go together with thin cortical bone. The prevention of inflammations and the restriction of load to less than 2N also promise success. Thus, taking into account surgical aspects, including implant placement, the general health of the patients and perfect hygiene (chlorohexidine rinse), successful application can be expected. Conclusion Titanium micro screws are compliance independent and stable direct or indirect (using supra-constructions) elements of orthodontic anchor

Background: The aim was to test which component [wire arm, connecting abutment attachment, and orthodontic mini-implant (OMI)] of the force-transmitting system (FTS) in the anterior palate of three commonly used hybrid expanders (HEs; WILMES-HE, LUDWIG-HE, and WINSAUER-HE) deforms under increasing load.Materials and methods: Crude single and double wire arms were tested individually. Non-opening of the maxillae halves was simulated in artificial bone blocks with single wire and double wire FTS specimens. OMIs were inserted 8 mm and underwent 6 mm of continuous static lateral loading. Deformation angles were measured (X-ray, n = 6) at 0, 3 and 6 mm feed. OMIs and abutments were scan electron microscope (SEM) evaluated.Results: After 1.0 mm of loading, the single wire arm of all FTS deformed between 63.4 (16.5) N and 76.2 (18.4) N, and the double wire arm of reinforced FTS (wires positioned 'side by side') deformed after 1.0 mm between 110.0 (18.4) N and 134.8 (22.3) N. The crude single wire resisted 89 (5.1) N until plastic deformation, whereas the crude double wire positioned 'on top of each other' resisted 438 (21.3) N. At 6 mm loading, the reinforced WINSAUER-HE FTS withstood a maximum load of 320.9 (31.1) N and the reinforced LUDWIG-HE FTS 19% less, both under great deformation of double wires and OMIs. The screw-fixated WILMES-HE FTS abutment attachment (overlapping OMI head 34%) detached around 250 N. The bonded WINSAUER-HE and LUDWIG-HE abutment attachments did not detach. Nor did the modified bonded plus the modified screw-fixated WILMESHE abutment attachment when overlapping 100%.Conclusion: Early OMI and single wire arm deformation in HEs are crucial for unsuccessful RME in more mature maxillae. Double wire arms should be obligatory. OMIs with inner diameter greater 1.36 mm are recommended. One hundred per cent overlapping abutment attachments do not detach.

A single treatment of transversal deficits in the upper jaw at the adult age with conventional expansion devices is difficult due to possible periodontal injury. Surgical procedures (SARME=surgically assisted rapid maxillary expansion or multi-segment Fe Fort I surgery) are successfully used when growth is completed. However, some patients reject surgery in general anesthesia. Nevertheless, there are possibilities to perform a transversal upper jaw correction with a less invasive procedure also in the adulthood. This is demonstrated by 2 patient treatment protocols.