The Case For Microimplants

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The Case For Microimplants

مُساهمة من طرف amr_yadak في 6/10/2008, 3:44 pm

Report about
The Case For Microimplants
by Gaby Bahri, DDS
An orthodontist tells how he came to adopt this new technology, and how it can help your practice

Microimplants
have become part of the standard of care in my practice today. I praise
myself for having made the decision to include this treatment a few
years back after reading an article by Kawamura.1 Since then, my team
and I have offered solutions to a wider variety of orthodontic problems
with more confidence and with a higher degree of certainty.

I
remember the time when I left this technique for others to try on their
patients and make the mistakes at their own expense; I regret every
minute that I spent waiting to start on my first patient. This feeling
repeats itself over and over when I hear that in Europe, like in Korea
and Japan, microimplants and miniscrews are actually being used
routinely by a great number of orthodontists. In fact, those devices
are placed and removed by the orthodontist himself. Have you read the
article by Melson about this subject?2 For me, the reality was hard to
swallow. As Americans, we are not used to taking second place in any
field of endeavor, particularly health care. Generally, when we find
ourselves in this position, we make sure to put forth the necessary
effort to readily change the situation.

Microimplants
are the way of the future. Think of them as you think of stop loops,
expanders, or torquing appliances. Of course, we can sell them to the
patient as an alternative to the most hated of appliances: headgear;
but microimplants offer much more than that. Absolute anchorage is the
name of the game. It allows you to distalize, mesialize, move
individual teeth or groups of teeth, move en masse, move symmetrically
or asymmetrically, intrude, extrude, and move impacted teeth. And if
you do not want to move all that, fine. Microimplants will serve to
just hold everything in place.

Hurdles to Overcome

The
first hurdle to overcome is the fear of the unknown. Keep reading the
scientific literature until you find an appliance you would like to try
on one of your patients. That is how I started. Plan your next
continuing education course or two to be on the subject of
microimplants. Numerous courses are offered to the orthodontist and
other dental specialist about using these devices. An oral-surgery
colleague takes care of all my microimplants. This could be your way to
get started. We met regularly, and often, about the subject when I was
first getting started. Oral surgeons are usually very friendly and will
take the time to show you the pros and cons of placing a screw, a pin,
or a plate in one area of the mouth or another. And by the way, get in
touch with your closest orthodontic school, teaching hospital, or
dental society, and find out what continuing education courses they
offer on the subject.

The
second obstacle is becoming convinced of the usefulness of
microimplants. In other words, make sure to know what types of cases
will yield better results using microimplants. In my experience,
outcomes are at least comparable to the best finished treatments using
conventional methods, but in shorter time frames.

The
third difficulty is in taking the first concrete step toward
transforming your practice. Let us not forget the staff. Remember that
introducing a new mechanotherapy means pushing your team out of its
comfort zone and forcing its members to learn new things. Even though
microimplants require some simple, easy training, our staff is a lot
like us: They fear the unknown. Once you get your staff involved,
though, you will almost certainly be successful in recruiting patients.


As
a testimony to our new conviction, my team and I decided to stop using
headgear as an alternative in our practice. Fortunately, the patients
read right through the message and started trusting the new approach.
It was interesting to note that the feedback from the first few
patients that we treated with the skeletal-anchorage devices all
suggested that we make it available to the rest of our patients.
Patients were actually the ones who helped break down the walls of fear
for many of our new and apprehensive prospects.

The
fourth hurdle is learning about the downsides of this method and trying
to avoid them. Cost and discomfort are the two most commonly known
drawbacks attached to the use of skeletal-anchorage devices. Ensuring
that the microimplants are placedin areas close to, or within, the
attached gingiva will go a long way to solving both of these problems.
Since those areas are very close to the roots of the teeth, the scope
of their use is often limited to extraction cases or special cases.
Clinicians can argue rightfully that a lot of extraction cases can be
treated just as well without the help of the additional anchorage.
Although this is true, we have found that the speed with which we can
complete treatment still argues in favor of choosing microimplants.

Some
extraction cases require more than a conventional anchorage system. As
you start to move away from the gingival attachment in an effort to
avoid the roots, things get more complicated. The placement and removal
of the devices become more involved. Patients will then start to
question your new approach to treatment by asking the following
questions: Is it really necessary? Can things be done in a different,
more comfortable way? What are the expected complications of this
intervention? You need to be ready for those questions. For now, all my
answers end with the following: “The oral surgeon will give you more
accurate details about this procedure.”

Solving Day-to-Day Problems
Once
it became established that we use microimplants in my practice, the
first growing pains seemed to become more and more remote with time.
Now we need to look into solving the day-to-day problems that we all
know come with anything in life. Aside from scheduling and mechanics,
my personal feeling is that microimplants in orthodontics have two or
three major practical problems.

First
is the fact that they can loosen up. Failure to hold can happen at the
time of placement or at some future time. The second problem is bolting
a miniscrew down too close to the bony surface, which means that the
head of the screw will be imbedded in soft tissue—which in turn leads
to the use of connection devices like chains and plates that emerge
from the soft tissues. What normally follows is an inflammatory
response around the screws or the connection devices, most commonly
around the gold chains we use for traction. Blame it on the patient’s
hygiene if you will; but you still have the problem. The third
potential problem is the discomfort involved in the activation
procedures of the devices. The mechanics are just like those used for
impacted teeth; thus, one should pay special attention to the highly
sensitive soft tissues surrounding the emerging chain or plate.

Start Small

In
any case, your first microimplant patient should not be the very
special case that seems impossible to do orthodontically. A challenging
case will still be challenging even though you are using microimplants.
Pick an easier or more straightforward case that would be made easier
or faster by using microimplants. You will avoid most of the problems
by placing the screws in a superficial area that is easy to access.
After all, the goal is to make the new devices a fully integrated part
of your daily practice and not a specific tool for a specific occasion.
Choosing the case is not very difficult. Any anchorage requirement can
be met with the use of microimplants.

Offer
one or two freebies if that will make you feel better at the beginning.
You can do that with a friend on whom you really want to exhibit your
best performance. It could be a family member or a referring dentist’s
son or daughter. For the rest, it should be clear that the new, added
appliances come with a price that is affordable but not cheap. We
usually use two screws on the average case. My oral surgeon’s fees are
anywhere between $450 and $700 per implant. We can do it for $300
apiece for microscrews and $500 if we are using a bone plate.
Orthodontists that place their own implants in the mouth can structure
their fees accordingly.

This
paper is too short to reveal all the “secrets of the trade,” so to
speak, but one can quickly review some of the choices for implants and
plates available on the market today. Try to define what exactly it is
that you want to accomplish with this new method of anchorage prior to
choosing a favorite device. Remember, experience helps.

Here are some general guidelines. Cases in the same category can be treated somewhat similarly:

1) Class I cases requiring upper and/or lower posterior anchorage (most with spacing or extraction spaces):
a)
For the maxilla, choose a zygomatic attachment (miniplate or miniscrew)
or a microimplant at the level of the gingival attachment.

b) For the mandible, the implant can be placed in the ramus or between the posterior roots (microscrew).
2) Class II cases requiring maxillary molar distalization: Use a zygomatic attachment.
3) Class II cases requiring lower molar protraction: Place microscrews between the anterior/canine roots.
4) Class III cases requiring maximum anchorage for the lower posterior and maxillary protraction forces:
a) Attachments can be placed in the ramus or between the posterior roots in the mandible.
b) Attachments can be placed between the roots of the upper laterals and canines in the maxilla.
Special
placement patterns exist for all cases with anterior open bite, deep
overbite, asymmetry, mutilated arches and edentulous sections, or
impacted teeth.

Common Uses of Microimplants
The
most common procedure I do is the Class II case with zygomatic
implants, followed by bimaxillary protrusive cases using four
microimplants at the four corners of the mouth posteriorly. In third
position comes the mesial protraction of lower molars.

Retraction
cases often exhibit a substantial vertical component that we always
have to keep in check. Micro- and mini-implants offer a convenient
solution for that problem. Their placement almost always puts them
apical to the plane of the archwire; thus, there is always an intrusive
component with their use.

In
conclusion, the intent of this paper is to bring to the table a hot
subject that everyone talks about—yet very little is being done to walk
the walk as opposed to talking the talk. I offer these thoughts as an
open invitation to American orthodontists to think about the matter. In
brief, it will be far better for our patients if we do not drag our
feet regarding stepping up and using this new and exciting treatment
modality. Future papers will show results and will discuss protocols
and mechanics.

Gaby Bahri, DDS, has a private practice in Jacksonville, Fla.

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رد: The Case For Microimplants

مُساهمة من طرف amalgam في 8/10/2008, 8:49 pm

It allows you to distalize, mesialize, move
individual teeth or groups of teeth, move en masse, move symmetrically
or asymmetrically, intrude, extrude, and move impacted teeth.

thxxx

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