THE USE OF IMPLANTS FOR ORTHODONTIC ANCHORAGE

Implant Dentistry
Charles J. Goodacre, DDS, MSD Professor, Restorative Dentistry Loma Linda University Loma Linda, California

INTRODUCTION
A wide variety of orthodontic tooth movements and orthopedic bone movements have been accomplished using dental implants.1-39 Successful orthodontic tooth movement requires adequate anchorage which is usually provided by other teeth.8,9 The anchorage teeth are used to effect movements in other teeth. Dental implants, because of their stability in bone, serve as excellent anchorage units. Dental implants are particularly helpful in partially edentulous patients where an adequate number of natural teeth may not be available to use for anchorage. The idea of using implants for orthodontic anchorage is not new.10,11 In 1945,10 base metal screws were placed in the ramus of dogs in an attempt to move teeth. The implants began to move the teeth but the implants failed before the desired movement was complete. Since the introduction of endosseous root form implants, this treatment modality has been successfully used to create a variety of movements. The following information is designed to provide foundational knowledge regarding the possibilities available when implants are used for anchorage.

ANIMAL RESEARCH FINDINGS

A number of animal studies1,2,10-27 provide valuable information that serves as a foundation upon which clinical applications of this concept are based. These studies determined that endosseous root form implants are capable of withstanding the orthodontic forces required to move teeth. It was determined1 that implants which lack the ideal amount of direct bone contact (see reference #1) were still capable of resisting orthodontic forces. It was also determined2 that titanium implants are capable of resisting the forces required to produce orthopedic bone movement (see reference #2).

CLINICALLY ADVANTAGEOUS USES OF IMPLANTS FOR ORTHODONTIC ANCHORAGE

There have been several papers that discussed the clinical use of implants for orthodontic anchorage.28-39 Retracting Teeth When There Is Inadequate Posterior Anchorage Partially edentulous patients can present with only a few remaining anterior teeth that are proclined facially and need realignment (figure 1A).9,25.29,30,32 Without any posterior teeth, as occurs with patients wearing a Kennedy Class I removable partial denture, orthodontic realignment of the anterior teeth is very challenging and may not produce the desired result. However, if posterior implants are placed (figure 1B), provisional prostheses can be attached to the implants (figure 1C), and then the prostheses used for orthodontic anchorage to realign the anterior teeth and change their relationship relative to the opposing arch (figure 1D). If the implants are skillfully positioned with interdisciplinary coordination between the surgeon, orthodontist, and restoring dentist, then the implants can also be used for support and retention of definitive prostheses3 after the anterior teeth are realigned (see reference #3). Eliminating The Need For A Prosthesis By Closing Spaces When a mandibular first molar is missing, it can be an orthodontic challenge to completely close the space by moving the second and third molars forward (about 10 millimeters or more). This movement is particularly challenging without creating reciprocal movement of the anterior teeth and premolars that would be used for the anterior anchorage. Implants have been located distal to the last molar (in the ramus of the mandible) and effectively used8,37,38 to create anterior movement of the molars (figure 2A & figure 2B). This procedure4 closes the space and eliminates the need for a prosthesis. The implant can subsequently be removed or left in position (see reference #4). Realigning Malposed Molars (Uprighting) When there is a missing second premolar or first molar, the molar(s) distal to the edentulous space can move out of their normal position and into the edentulous space. Mandibular molars are particularly prone to tipping mesially and sometimes lingually into the space. If space closure is not the treatment of choice, then realignment of the tipped molar may be necessary prior to replacing the missing tooth (teeth). Orthodontic realignment of the tipped teeth allows them to be retentively prepared for a fixed partial denture and creates an alignment that facilitates proper hygiene and periodontal health. Orthodontic movement may also be required to realign the teeth and/or open the space for placement of an implant in the edentulous area. Orthodontic realignment of a molar can be a challenge, particularly when the molar is located at the end of a long edentulous span. The distance from the anteriorly located anchorage teeth to the tipped molar can present challenges in achieving the desired molar movement and in preventing its eruption as it is realigned.

When an implant is placed in the edentulous space (figure 3), it can be used9,34 as anchorage to move the tipped molar and the implant can also be used to support a definitive restoration after the molar is realigned. Other Tooth Movements Implants have been used to simultaneously intrude and extrude teeth,24,32,34 to correct a reverse occlusal relationship (crossbite),33,35 to correct an anterior open occlusal relationship36 (open bite) (figure 4A & figure 4B), and complete an unlimited number of other applications32,35 where additional anchorage is needed or there is no available natural tooth anchorage. Orthopedic (Bone) Movement Implants can be used to effect positional changes in the bone and accompanying teeth, perhaps even eliminating or reducing the magnitude of surgical procedures required to correct significant craniofacial anomalies (figure 5A, 5B, 5C, & 5D).

THE USE OF IMPLANTS IN GROWING PATIENTS

Adolescents are affected by trauma, congenital anomalies, and surgical procedures that produce edentulous spaces. The use of implants could greatly facilitate function, comfort, esthetics, and a variety of psychosocial factors that may not be effectively addressed by other types of prostheses. However, continued dental and skeletal growth can present challenges to the early use of dental implants. If implants are placed before growth is completed, continued bone growth will leave the implant in its initial position, perhaps deeply submerged relative to the surrounding bone and natural teeth. Growth in the maxilla is initially associated with early childhood growth of the cranial base in a downward and forward direction and subsequently occurs primarily by maxillary enlargement (figure 6A & figure 6B). Substantial changes occur5 as the maxilla grows (see reference #5). Mandibular growth6 (figure 7A & figure 7B) is also multidirectional and results in substantial changes in shape. There are also considerable variations when compared to the growth changes that occur in the maxilla (see reference #6). It is best to wait until growth is completed7 before placing endosseous root form implants (see reference #7).

REFERENCES
1. Roberts WE, Helm FR, Marshall KJ, Gongloff RK. Rigid endosseous implants for orthodontic and orthopedic anchorage. Angle Orthod 1989;59:247-56.

This animal research study involved both rabbits and dogs. In the dog study, young beagle dogs had pairs of implants placed 18 millimeters apart. The implants were subsequently loaded in compression using a 3 Newton (3N) closed coil, stainless steel spring. All the implants remained stationary. It was determined that implants with less than 10% of their surfaces in direct contact with the bone successfully resisted the 3N force. It was concluded that implants are capable of resisting orthodontic forces and minimal direct osseous contact is required. 2. Turley PK, Kean C, Schur J. Stefanac J., Gray J, Hennes J, Poon LC. Orthodontic force application to titanium endosseous implants. Angle Orthod 1988 Apr;58:15162. Implants were placed into 5 sites (mandibular alveolar ridge, mandibular lingual cortical plate, palatal to the maxillary alveolar ridge, the temporal buttress, and the zygoma) of six young adult mongrel dogs. Bands and orthodontic appliances were positioned so 300 grams of force (about 3 Newtons) was applied from the implant to the teeth. One thousand grams of force (about 10 Newtons) was applied between the zygoma implants and the temporal buttress implants to create orthopedic movement. All of the implants that integrated into the bone anchorage resisted both the orthodontic and orthopedic forces. 3. Goodacre CJ, Brown DT, Roberts WE, Jeiroudi MT. Prosthodontic considerations when using implants for orthodontic anchorage. J Prosthet Dent 1997;77:160-70. The literature was reviewd relative to animal and clinical studies that evaluated the use of implants for orthodontic anchorage. The following 10 prosthodontically advantageous uses of orthodontic anchorage were presented and illustrated: 1) retracting and realigning teeth; 2) closing edentulous spaces so prostheses are not required; 3) correcting midline and anterior tooth spacing problems; 4) reestablishing proper anteroposterior and mediolateral positions for malposed molar abutments; 5) intruding and/or extruding teeth; 6) correcting a reverse occlusal relationship; 7) correcting an anterior open occlusal relationship; 8) protracting/retracting one arch on the entire dentition; 9) providing stabilization for teeth with reduced bone support; and 10) providing anchorage for orthopedic movement. 4. Roberts WE, Hohlt WF, Analoui M. Implant-anchored space closure as a viable alternative to fixed prostheses. Biological Mechanisms of Tooth Movement and Craniofacial Adaptation, Edited by Z. Davidovitch and LA Norton, page 617-21, 1996, Harvard Society for the Advancement of Orthodontics, Boston, Massachusetts, USA.

The concept of using retromolar implants for orthodontic anchorage is presented as an alternative to a fixed partial denture in terms of cost, prognosis, and patient comfort over a lifetime of service/replacement. Serial radiographs and histomorphometric analysis of retromolar implants demonstrated that the forces used during orthodontic treatment did not move the implants. Thirty-eight patients were treated using this modality to close molar spaces using retromolar implants for orthodontic anchorage. It was found to be a successful method of treatment. The rate of molar movement was about 0.6 millimeters per month for the first 8 months and then it decreased to about 0.3 millimeters per month when the distal root of the mandibular molar(s) encountered the dense bone formed by the movement of the mesial root. 5. Oesterle U, Cronin RJ, Ranly DM. Maxillary implants and the growing patient. Int J Oral Maxillofac Implants. 1993;8:377-87. Maxillary growth can be vertical, transverse, and anteroposterior. The transverse growth occurs primarily at the midpalatal suture area and any implants/prostheses that traverse this area could limit proper maxillary growth. The placement of implants in a growing patient can result in the implants becoming submerged below the definitive occlusal plane after growth has ceased. Vertical bone growth is what can produce submersion of an implant when it is placed during a period of active growth. Implants placed during the prepubertal or early pubertal periods should be avoided since they may restrict transverse palatal growth. Implants placed during the pubertal period have less of chance of interfering with growth but the safest time for implant placement is after growth has stopped. 6. Cronin RJ, Oesterle U, Ranly DM. Mandibular implants and the growing patient. Int J Oral Maxillofac Implants. 1994;9:55-62. The mandible lengthens by posterior growth of the ramus and posterosuperior growth of the condyle. The ramus length increases, the body of the mandible increases anteroposteriorly and the mandible increases in width. Implants placed in the posterior mandible often become submerged relative to surrounding teeth, depending on the direction of condylar growth. Children with strong patterns of rotational growth will experience greater posterior implant submersion. While mandibular anterior implants are not as affected by submersion because the growth in this area is completed earlier than other areas of the mandible, they are unable to change angulations to compensate for rotational growth changes in the mandible. Width and height changes in the mandible are identified to help clinicians understand the dynamic growth changes that occur in the mandible. It is proposed that implants placed after age 15 in girls and after age 18 in boys have the most predicable prognosis. It is noted that submerged implants (ones placed when growth changes are actively occurring) act like ankylosed teeth and could interfere with tooth-to-tooth esthetic relationships, occlusal relationships, force distribution, and jaw growth patterns.

7. Cronin RJ, Oesterle U. Implant use in growing patients-treatment planning concerns. Dent Clin N Am 1998;42:1-33. This paper provides a comprehensive review of both maxillary and mandibular growth. It also discusses the variability of growth factors and describes the following techniques that are used to determine if growth is complete: 1) appearance of the adductor sesamoid of the thumb; 2) capping of the epiphysis of the middle phalanx of the third finger; and 3) fusion of the epiphysis and diaphysis of the radius. Recommendations are made for implant placement in each quadrant of the mouth.

REFERENCE LIST
1. Roberts WE, Helm FR, Marshall KJ, Gongloff RK. Rigid endosseous implants for orthodontic and orthopedic anchorage. Angle Orthod 1989;59:247-256. 2. Turley PK, Kean C, Schur J, Stefanac J, Gray J, Hennes J, Poon LC. Orthodontic force application to titanium endosseous implants. Angle Orthod 1988 Apr;58:151162. 3. Goodacre CJ, Brown DT, Roberts WE, Jeiroudi MT. Prosthodontic considerations when using implants for orthodontic anchorage. J Prosthet Dent 1997;77:160-170. 4. Roberts WE, Hohlt WF, Analoui M. Implant-anchored space closure as a viable alternative to fixed prostheses. Biological Mechanisms of Tooth Movement and Craniofacial Adaptation, edited by Z Davidovitch and LA Norton, page 617-621, 1996, Harvard Society for the Advancement of Orthodontics, Boston, Massachusetts, USA. 5. Oesterle U, Cronin RJ, Ranly DM. Maxillary implants and the growing patient. Int J Oral Maxillofac Implants. 1993;8:377-387. 6. Cronin RJ, Oesterle U, Ranly DM. Mandibular implants and the growing patient. Int J Oral Maxillofac Implants. 1994;9:55-62. 7. Cronin RJ, Oesterle U. Implant use in growing patients treatment planning concerns. Dent Clin N Am 1998;42:1-33. 8. Shapiro PA, Kokich VG. Uses of implants in orthodontics. Dent Clin North Am 1988;32:539-550. 9. Arbuckle GR, Nelson CL, Roberts WE. Osseointegrated implants and orthodontics. Oral Maxillofac Surg Clin North Am 1991;3:903-919. 10. Gainsforth BL, Higley LB. A study of orthodontic anchorage possibilities in basal bone. Am J Orthod Oral Surg 1945;31:406-417. 11. Sherman AJ. Bone reaction to orthodontic forces on vitreous carbon dental implants. Am J Orthod 1978;74:79-87. 12. Oliver S, Mendez-Villamil C, Evans C, Schnitman P, Shulman L. Change in position of vitreous carbon implants subjected to orthodontic forces [Abstract]. J Dent Res 1980;59(Suppl):280. 13. Smith JR. Bone dynamics associated with the controlled loading of bioglass-coated aluminum oxide endosteal implants. Am J Orthod 1979;76:618-636. 14. Paige S, Clark AK, Costa P, King GL, Waldron JM. Orthodontic stress application to bioglass implants in rabbit femurs [Abstract]. J Dent Res 1980;59(Suppl):445.

15. Gray JB, Steen ME, King GJ, Clark AK. Studies on the efficacy of implants as orthodontic anchorage. Am J Orthod 1983;83:311-317. 16. Lubberts R, Turley PK. Force application to bioglass coated alumina implants of various sizes [Abstract]. J Dent Res 1982;61(Suppl):339. 17. Turley PK, Roth P. Orthodontic force application to vitallium subperiosteal implants [Abstract]. J Dent Res 1983;62A:681. 18. Turley PK, Gray JW, Kean CJ, Roberts WE. Titanium endosseous and vitallium subperiosteal implants as orthodontic anchors for tooth movement in dogs [Abstract]. J Dent Res 1984;63A:344. 19. Douglass JB, Killiany DM. Dental implants used as orthodontic anchorage. J Oral Implantol 1987;13:28-38. 20. Roberts WE, Smith RK, Zilberman Y, Mozsary PG, Smith RS. Osseous adaptation to continuous loading of rigid endosseous implants. Am J Orthod 1984;86:95-111. 21. Linder-Aronson S, Nordenram A, Anneroth G. Titanium implant anchorage in orthodontic treatment: an experimental investigation in monkeys. Eur J Orthod 1990;12:414-419. 22. Wehrbein H, Diedrich P. Endosseous titanium implants during and after orthodontic load an experimental study in the dog. Clin Oral Implants Res 1993;4:76-82. 23. Kluemper GT, Marciano RD, Smith KJ. Biologic response to an intraoral extraosseous implant system: a pilot study. Implant Dent 1995;4:46-49. 24. Southard TE, Buckley MJ, Spivey JD, Krizan KE, Casko JS. Intrusion anchorage potential of teeth versus rigid endosseous implants: a clinical and radiographic evaluation. Am J Orthod Dentofacial Orthop 1995;107:115-120. 25. Block MS, Hoffman DR. A new device for absolute anchorage for orthodontics. Am J Orthod Dentofacial Orthop 1995;107:251-258. 26. Turley PK, Shapiro PA, Moffett BC. The loading of bioglass-coated aluminum oxide implants to produce sutural expansion of the maxillary complex in the pigtail monkey (Macaca nemestrina). Arch Oral Biol 1980;25:459-469. 27. Smalley WM, Shapiro PA, Hohl TH, Kokich VG, Brnemark P-I. Osseointegrated titanium implants for maxillofacial protraction in monkeys. Am J Orthod Dentofacial Orthop 1988;94:285-295. 28. Wigglesworth SW. The orthodontic movement of a metal implant. Br J Orthod 1977;4:2057. 29. Linkow LI. The endosseous blade implant and its use in orthodontics. Int J Ortho 1969;17:149-154. 30. Linkow LI. Implanto-orthodontics. J Clin Orthod 1970;4:685-705. 31. Creekmore TD, Eklund MK. The possibility of skeletal anchorage. J Clin Orthod 1983;17:266-269. 32. Odman J, Lekholm U, Jemt T, Brnemark P-I, Thilander B. Osseointegrated titanium implants a new approach in orthodontic treatment. Eur J Orthod 1988;10:98-105. 33. Van Roekel NB. Use of Brnemark system implants for orthodontic anchorage: report of a case. Int J Oral Maxillofac Implants 1989;4:341-344. 34. Haanaes HR, Stenvik A, Beyer-Olsen ES, Tryti T, Faehn O. The efficacy of twostage titanium implants as orthodontic anchorage in the preprosthodontic correction of third molars in adults a report of three cases. Eur J Orthod 1991;13:287-292.

35. Higuchi KW, Slack JM. The use of titanium fixtures for intraoral anchorage to facilitate orthodontic tooth movement. Int J Oral Maxillofac Implants 1991;6:338344. 36. Prosterman B, Prosterman L, Fisher R, Gornitsky M. The use of implants for orthodontic correction of an open bite. Am J Orthod Dentofacial Orthop 1995;107:245-250. 37. Roberts WE, Marshall KJ, Mozsary PG. Rigid endosseous implant utilized as anchorage to protract molars and close an atrophic extraction site. Angle Orthod 1990;60:135-152. 38. Roberts WE, Nelson CL, Goodacre CJ. Rigid implant anchorage to close a mandibular first molar extraction site. J Clin Orthod 1994;28:693-704. 39. Smalley WM. Implants for tooth movement: determining implant location and orientation. J Esthetic Dent 1995;7:62-72.