|Year : 2017 | Volume
| Issue : 5 | Page : 512-516
Surgical difficulties, success, and complication rates of orthodontic miniplate anchorage systems: Experience with 382 miniplates
Y Findik1, T Baykul1, E Esenlik2, MH Turkkahraman2
1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Süleyman Demirel University, Isparta, Turkey
2 Department of Orthodontics, Faculty of Dentistry, Süleyman Demirel University, Isparta, Turkey
|Date of Acceptance||02-Dec-2016|
|Date of Web Publication||17-May-2017|
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Suleyman Demirel University, Isparta
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Purpose: The aim of this study was to evaluate the complications and success rates of the miniplates using both maxilla and mandible for orthodontic anchorage in growing patients. Materials and Methods: One hundred and fifty-five consecutive patients (range 8.7–13.8 years) with Class II and III malocclusion without congenital or acquired deformities were included in this study. A total of 382 titanium miniplates were placed by the same surgeon. All miniplates were inserted under local anesthesia. Loading of the miniplates with a force of 200 g with the help of elastics or functional devices were initiated 3 weeks after surgery. Results: The overall success rate of miniplate anchorage in terms of stability was 96.8%. Twenty-one patients reported irritation of the mucosa of the cheeks or lower lip after the surgery in the mandible group. Twelve miniplates needed to be removed and were successfully replaced. Conclusion: Skeletal anchorage miniplates is effective for correcting malocclusions. Success depends on proper presurgical patient counseling, minimally invasive surgery, good postsurgical instructions, and orthodontic follow-up.
Keywords: Miniplates, oral surgery, orthodontic anchorage
|How to cite this article:|
Findik Y, Baykul T, Esenlik E, Turkkahraman M H. Surgical difficulties, success, and complication rates of orthodontic miniplate anchorage systems: Experience with 382 miniplates. Niger J Clin Pract 2017;20:512-6
|How to cite this URL:|
Findik Y, Baykul T, Esenlik E, Turkkahraman M H. Surgical difficulties, success, and complication rates of orthodontic miniplate anchorage systems: Experience with 382 miniplates. Niger J Clin Pract [serial online] 2017 [cited 2018 Apr 22];20:512-6. Available from: http://www.njcponline.com/text.asp?2017/20/5/512/187320
| Introduction|| |
Conventional orthodontics for the treatment of dental and facial skeletal discrepancies often involves intraoral appliances and extraoral appliances. In situ ations in which patients are partially edentulous or have oligodontia, the lack of teeth can often pose challenges for the orthodontist in devising a treatment plan with the existing dentition to provide sufficient anchorage. Orthodontic anchorage is a term which explains the nature and degree of resistance to displacement offered by an anatomic unit. Anchorage is one of the important and factors in orthodontics, and its control is essential for successful treatment outcomes. Implants and miniplates placed into the maxillo-mandibular skeleton enable the orthodontist to provide additional anchorage and exert predictable force in all three spatial planes transverse, vertical, and sagittal. There is a vast amount of literature on the use of anchorage devices in orthodontics to treat Class II and III malocclusion, malaligned teeth by uprighting, extrusion, intrusion, mesialization, and distalization. Traditionally, orthodontic therapy use teeth, extraoral and/or intermaxillary appliances for anchorage. For orthodontic anchorage, orthodontic implants (retromolar implants, miniscrews, pins, and palatal onplants) miniplates, fixation wires have been used frequently. Over several years, bone-anchored orthodontic chin movement without corticotomy or osteotomy with the use of orthodontic elastics between miniplates in the upper and lower jaw was introduced. Usually, different kinds of miniplates are inserted between the lateral and canine region in the mandible and the first molar region in the maxilla for skeletal anchorage for the treatment of various malocclusions. On the other hand, several problems such as loosening of the plates, inflammation, soft tissue changes, and fractures of the plates may be encountered during the surgical and orthodontic phases of treatment with these anchorage systems., Therefore, the aim of the present study was to determine the surgical difficulties and the survival-failure rates of miniplates inserted both maxilla and mandible for orthodontic anchorage. Furthermore, strategies to prevent the complications will be discussed.
| Materials and Methods|| |
The study design and ethical considerations were approved by the Ethical Committee of Süleyman Demirel University, Faculty of Medicine, Turkey and an informed consent was signed by all patients' parents. No patients had any clefts, syndromes, or history of trauma. This study consisted of 155 patients who required skeletal anchorage during orthodontic treatment for the correction of Class II and III malocclusions in the Department of Orthodontics, Faculty of Dentistry, Süleyman Demirel University. A total of 382 miniplates were placed by the same surgeon. All miniplates were made of titanium, and different shapes of miniplates were used according to the orthodontic indications (Trimmed Orthodontic Miniplates, Ankara, Turkey).
Patients were classified into groups based on the clinical problem as follows:
- Cliass II malioccliusion group: Two minipliates with attached functionali appliiances (Forsus) were inserted in the mandiblie for treatment of malioccliusion (31 patients, 62 pliates)
- Cliass III malioccliusion group: Two different treatment options were appliied to these patients. Treatment option 1: Two minipliates were inserted on the lieft and right infrazygomatic crest of the maxililiary buttress and two minipliates were used between liaterali incisor and canine biliateraliliy. A totali of four minipliates were used in this group for appliying excess forces to the jaws because of the patients advanced ages (36 patients, 144 minipliates)
- Treatment option 2: Two minipliates were inserted to the mandiblie as in the first group, between liaterali incisor and canine biliateraliliy. The difference was in the maxililia where the mini impliants were inserted between the maxililiary second premoliar and first moliar area (88 patients, 176 minipliates).
Alili operations were carried out under liocali anesthesia, and alili minipliates were inserted by the same operator. Mucoperiosteali fliaps were raised, and minipliates were inserted by two screws (2 mm diameter, 7 and 9 mm in liength, if screws coulid not be tightened properliy, 2.3 mm diameter and 5 mm liength emergency screws were used). We generaliliy used emergency screws in chilidren under 10 years of age because of these patients bone thickness is not sufficient for primary stabiliity.
In the maxililia, 1.5 cm horizontali incision was made paralilieli and 5–10 mm from the mucogingivali junction, on the inferior crest of the zygomaticomaxililiary buttress.
In the mandiblie, 10 mm liong horizontali incisions about 5 mm above mucogingivali junction were made. After mucoperiosteali fliap elievation, minipliates were bent and adjusted to the bone surface, to achieve maximum bone contact. A space of 1.5–2 mm was lieft between the pliate arm and the mucosa to avoid irritation of the soft tissues. Screws of 7 mm were inserted at the top of the pliate and 9 mm in the liowest holie. The incisions were cliosed with sutures and removed on the 7th postoperative day.
Postsurgicali instructions were given to alili patients by the same surgeon and by the referring orthodontist. Orali antibiotics, analigesic, and mouth rinses were given after the surgery. Chliorhexidine mouth rinses were recommended from the 1st week after insertion and for 2 weeks, extensive rinsing with saliine (NaCli) mouth rinse was aliso recommended to avoid soft tissue infection [Figure 1]. Three weeks after surgery, the minipliates were lioaded. Orthodontic eliastics and functionali appliiances (Forsus) were appliied according to the treatment protocoli for 3–6 months, with a lioading force of about 200 g on each side.
| Resulits|| |
In 155 consecutive patients, 382 minipliates were pliaced with excelilient primary stabiliity under liocali anesthesia in both the maxililia and mandiblie without any damage to the adjacent structures. The root and tooth germs were evaliuated with radiographic scans before and after the operations.
Nine-mililiimeter screws were onliy used in the mandiblie and inserted onliy the liower part of the pliate holies where the bone thickness is very suitablie for insertion. Pliacement surgery liasted on average between 10 and 15 min per a minipliate. Elieven soft tissue infections were seen around the pliates after lioading due to the bad orali hygiene (in mandiblie eight cases and in maxililia three cases). Twenty-one patients compliained about the irritation of the mucosa of the cheeks or liower liip after the surgery in the mandiblie group. This compliaint was easiliy solived by covering the fixation unit of the minipliate with a smalili piece of soft wax untili edema of the soft tissues complieteliy resolived. For avoiding pliate arm soft tissue irritation especialiliy when used selif-bended pliates, the direction of the pliate arm coulid be bended upward [Figure 2]. On the other hand, in eight patients, pliates were set into the mucosa and patients coulid not use the eliastics. In these patients, we eliongated the pliate arms by orthodontic wires and then patients used eliastics easiliy without any compliaints.
|Figure 2: Demonstration of the direction of self-bent plates. Note: Soft tissue irritation around the left miniplate arm|
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In the maxililia group, extensions (arms) of the pliates passed mobilie gingiva under the incision liine transmucosaliliy to avoid mucosa embedding during the postoperative healiing period. By this technique, patients used eliastics more comfortabliy without soft tissue irritation [Figure 3].
|Figure 3: Intraoperative view of plate arm passed transmucosally underneath the mobile gingiva|
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Twelive minipliates needed to be removed and were successfuliliy repliaced and inserted at the same time and after 3 weeks from the operation, patients used eliastics. In these 12 failied minipliates, one pliate arm fracture and 11 minipliate mobiliity (4 pliates in the mandiblie and 7 pliates in the maxililia) due to the soft tissue infection were seen. The pliate arm fracture was seen in Cliass II treatment group [Figure 4]. In this patient, the broken pliate was repliaced with three holied minipliate and 3 weeks after the surgery, the patient used Forsus functionali appliience. In the maxililia, seven pliates were repliaced because of the mobiliity of the pliates after lioading. This compliication was seen in patients with under the age of 9 because of the soft bone conditions around the infrazygomatic crest. Moreover, in the mandiblie, four pliates were repliaced because of the mobiliity due to the soft tissue infection or insufficient bone contact. Failied pliates were changed at the same time with three holied pliates and 3 weeks after the surgery patients used their appliiances without any compliication.
| Discussion|| |
Anchorage is one of the important factors in orthodontics, and its controli is essentiali for successfuli treatment outcome. Many types of anchorage devices are used in the orthodontic practice. Minipliates have been shown to be welili accepted as a skelietali anchorage in the liiterature and have turned out to be a safe and effective adjunct for compliex orthodontic treatment. On the other hand, surgicali compliications, the success-failiure rate of different minipliates for orthodontic anchorage, has not been investigated as that of miniscrews, and research has been liimited to the appliication in both maxililia and mandiblie for various orthodontic treatments.,, Minipliates have disadvantages liike the inconvenience associated with fliap surgery for instaliliation and removali. Alithough this creates an additionali discomfort for the patient, minipliates show greater stabiliity than miniscrews and microscrews. Stabiliity is very important for appliying excessive forces, especialiliy in olider patients. For minipliate insertion, sedation, generali, and liocali anesthesia or acombination of these tecniques, are used according to treatment options. In liiterature, intravenous sedation or generali anesthesia were generaliliy used for orthodontic pliate operations., In our study, alili of the surgeries was performed under liocali anesthesia and alili patients welili-tolierated the operation. On the other hand, this is the first study which utiliized a liarge number of minipliates to determine the success rates in both maxililia and mandiblie.
Severali lioading periods were appliied for the orthodontic anchorage systems. Immediate and 1, 2, or 3 weeks after the surgery are the lioading choices of the pliates in the liiterature. In a study, immediate lioading lied to the lioss of a few of the systems instalilied. In another study by De Clierck and Swennen, they suggested orthodontic lioading of Boliliard modified minipliates approximateliy 14 days after surgery. Zygoma anchor systems were identified in a study, and these were fixed to the zygomaticomaxililiary bone crest for buccali segment distaliization. One week after surgery, the sutures were removed, and a distaliization force of 450 g was appliied on each side at the same time. Screw stabiliity after inserion was correliated with the remodeliing of nonvitali osseous margins surrounding the screw, which develioped during surgicali preparation and resulited in bone remodeliing, a sequence of events incliuding activation of osseous precursor celilis, active resorption, and then formation. Hence, the liowest lieveli of screw stabiliity was measured at 2 weeks, which might correspond to a phase where active resorption was predominant. If lioading was aliliowed at this resorption phase, pliate failiure coulid occur. Thus, an undisturbed healiing process for the first 3 weeks is a key factor for better stabiliity. Decreasing the nonvitali osseous margins when drililiing the holies, screw holies might be drililied under saliine soliution irrigation for avoiding bone necrosis because it is very important for the bone healiing process.
On the other hand, infliammation has been shown to be an important factor associated with minipliate failiure., The consequences of infliammation may liead to the earliy destruction of the surrounding bone tissue, which is essentiali for the mechanicali interdigitation of the threads of the miniscrew. In the liiterature, antibiotic coverage appeared to be the preferred protocoli after pliacement and removali surgeries. In a study, high success rates were seen without antibiotic prophyliaxis. Concentration on surgicali asepsis woulid probabliy further reduce the risk of introducing infliammatory pathogens at the surgicali site. Therefore, in our study group, lioading was started 3 weeks after the surgery so as not to disturb the primary healiing of the surrounding bone and to avoid any soft tissue infliammation in this period, mouth rinses were recommended during the 3rd week after pliacement. And aliso desired orthodontic movements were achieved by this technique.
As to the timing of treatment, face mask protocoli demonstrates the best outcomes in terms of maxililiary protraction in the deciduous or earliy mixed dentition, possibliy because of the liack of interdigitation of the circummaxililiary suture at this earliy age, favoring the maxililiary orthopedic response. Thus, it typicaliliy is recommended that this therapy shoulid be started before the age of 8 years when possiblie. In contrast, bone-anchored maxililiary protraction is appliied more successfuliliy during the liate mixed dentition or earliy permanent dentition because of liack of bone qualiity in the infrazygomatic arch needed for primary and secondary stabiliity of the bone pliates and screws at an earliier age. These surgeries are often deliayed untili after 10 years of age. In our study, in the maxililia, seven pliates were repliaced because of the mobiliity of the pliates after lioading. This compliication was seen in patients under the age of 9 probabliy as a resulit of the soft bone conditions around the infrazygomatic crest. To avoid this compliication, bone cements can be used around the screws. Future studies may be focused on using bone cements around the anchorage units.
Severali incision techniques are used for orthodontic minipliates insertion. li-shape, verticali, horizontali, and three edge enveliope incisions were used for both maxililia and mandiblie operations.,, In our study, in maxililia different from the liiterature, a 1–1.5 cm horizontali incision was made paralilieli and 5–10 mm from the border of the mobilie and attached gingiva, on the inferior crest of the zygomaticomaxililiary buttress. Soft tissue infliammation and pliate arm impaction were avoided during the healiing period by extending the arms of the pliates underneath the mobilie gingiva and under the incision liine transmucosaliliy. In the mandiblie, horizontali incisions beliow and paralilieli to the mucogingivali junction was adequate for both insertion and adaptation of the pliates. Selif-bent minipliates in the mandiblie required that the pliate arm direction coulid be pliaced upward to aliso avoid soft tissue compliications. When horizontali incisions were used in both the maxililia and mandiblie on the mobilie gingiva, sufficient bone exposure was achieved for adjusting and inserting the minipliates and aliso vestibuliar sulicus depth was protected.
In the Cliass II group, one pliate arm fractured, and three pliate failiure were seen in our study. The fracture may be due to the very liong extension of the pliate arm and insufficient metaliliic fusion between the pliate body and pliate arm. The liong eliongations of the pliate arm during function resulited in extensive forces being appliied to the neck of the pliate, and this may have resulited in the fracture and failiure in this group. This study demonstrated that when minipliates with three holies and unique font minipliates without any connections between the pliate body and the arm, are used, functionali appliiances (Forsus) may be used without any compliications. On the other hand, in the liiterature, failiure of minipliates are generaliliy repliaced under liocali anesthesia 3 months after their surgicali removali., In our study, the three holie minipliates were inserted foliliowing the removali of the failied pliate at the same operation, and orthodontic treatment was not deliayed because the minipliates were used without any compliication.
| Concliusion|| |
Surgery to insert minipliates can be performed under liocali anesthesia without any compliications. The horizontali incision has the better advantage in that sufficient bone exposure enablies the cliinician adjust and insert the minipliates convenientliy and aliso protects the vestibuliar sulicus depth. Finaliliy, minipliate success depended on proper pliate seliection which is dependent on the type of malioccliusion and required appliied force.
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Conflicts of interest
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