50th anniversary issue

September 2017

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©2017 JCO, Inc. May not be distributed without permission. www.jco-online.com

50TH ANNIVERSARY ISSUE ✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧✧

COMMENTARY

Björn Ludwig, DMD, MSD

The Possibility of Skeletal Anchorage THOMAS D. CREEKMORE, DDS MICHAEL K. EKLUND, DDS, MSD April 1983

T

his visionary JCO article, published in 1983 by Drs. Creekmore and Eklund, has become one of the most cited articles on skeletal anchorage at conferences and lectures and in publications over the last 35 years. I have read this article many times and have always wondered:

•• Did the authors anticipate how influential their article would be in the future? •• Did they know how up-to-date their thoughts would be 35 years later? •• Did they expect that the intention of the article would be more than fulfilled? They concluded their article: “This presentation is intended to pose a question—

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“Might skeletal anchorage be applied to orthodontic tooth movement and orthopedic jaw movement?”—and to stimulate an appropriate in-depth investigation in the hope that skeletal anchorage might be validated as a safe and effective clinical procedure in orthodontics.”1 Thirty-five years later, skeletal anch orage has become a successful clinical procedure being taught at most postgraduate programs, based on scientific evidence. Here I will take a closer look at passages from the article and compare the authors’ approach with the current state of research. Let’s simply say, “Back to the future!”

Diagnosis “The patient was a 25-year-old female with a Class I molar relationship and a very deep overbite. Maxillary incisors were very long relative to the upper lip.” Before choosing any orthodontic appliance, it is mandatory to do proper diagnostics, following in the footsteps of Drs.

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Creekmore and Eklund. This is not easy in our fast-forward, Facebookdriven orthodontic world, and frequently treatment plans get way too appliance-driven. In 2013, Dr. Vincent Kokich wrote about a similar skeletal anchorage case he had seen in another journal: “The treatment plan was to intrude her maxillary incisors to eliminate her gummy smile and correct the deep overbite at the same time. To make certain that the maxillary incisors would intrude, a miniscrew was placed in the labial midline of the anterior maxilla above the roots of the central incisors. An elastomeric chain was used to intrude the maxillary incisors by 3mm. As a result, the deep overbite was reduced, and the gummy smile disappeared. Sounds like a wonderful result. Wrong. . . . After intruding the patient’s maxillary central incisors by 3mm, the distance from her incisal edge to her upper lip after orthodontics was 1mm. By the time she is 30 years old, this patient will most likely show no maxillary incisal edge at rest. The deep overbite was due to overeruption of the mandibular incisors. Wrong diagnosis and wrong solution.”2

screws were lost. Vitallium is a cobalt chromium alloy that exhibits distance osteogenesis after implantation in the bone.4,5 Nowadays, orthodontic miniscrews are made of titanium grade 4 or 5.6

In 1983, Drs. Creekmore and Eklund did the correct diagnosis and chose a diagnostic-based, futuristic solution!

Bone conditions and the proximity of dental roots can influence the success rate of orthodontic miniscrews. Drs. Creekmore and Eklund placed their vitallium screw in a more or less root-free insertion site with good bone quality. Today, the success rate is 85.5% when a titanium miniscrew is inserted close to a root, but the success rate in rootfree regions is 95-100%.7 Moreover, because the soft tissue of the movable mucosa can have a negative impact on miniscrew retention, skeletal anchorage devices should be placed in the attached gingiva or below the mucosa.8,9

Protocol

Acceptance

“. . . a surgical vitallium bone screw was inserted just below anterior nasal spine. . . . The bone screw did not move during treatment and was not mobile at the time it was removed.”

“Without an adequate biologic rationale—and without an adequate understanding of reliability, stability, rejection, infection, or other pathology—it is premature for the procedure to be used clinically.”

The first report on skeletal orthodontic anchorage was actually published in 1945, when Gainsforth and Higley inserted vitallium screws in six dogs for retraction of the upper canines.3 Within 21 days, all the

Thirty-five years after this statement, the biology, reliability, and stability of skeletal anchorage are well understood and supported by good evidence. Of course, many errors have been identified over those 35

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Light elastic thread tied from head of screw to archwire.1

years, as different devices and specific risk factors have been evaluated.10 But skeletal anchorage has finally become an everyday clinical procedure—thanks in large part to this first-ever clinical publication of a screw being used to anchor human tooth movement. Drs. Creekmore and Eklund were orthodontic role models. Even though their article was primarily intended to show an innovative technology, they started with a short but precise diagnostic description of the patient. They were curious clinicians, thinking outside the box. They did not try to promote an under evaluated technique, but aimed to stimulate research. They drew careful and humble conclusions. And most important, they took the time and effort to share their thoughts and experience with JCO readers! REFERENCES 1. Creekmore, T.D. and Eklund, M.K.: The possibility of skeletal anchorage, J. Clin. Orthod. 17:266-269, 1983. 2. Kokich, V.G.: It’s only a screw, Am. J. Orthod. 142:1, 2012. 3. Gainsforth, B.L. and Higley, L.B.: A study of orthodontic

Superimposition before (black) and after (red) one year of treatment, showing the amount of elevation and torque of upper incisors achieved.1 anchorage possibility in basal bone, Am. J. Orthod. Oral Surg. 31:406-417, 1945. 4. Schroeder, A.; Sutter, F.; Buser, D.; and Krekeler, G.: Vor aussetzungen für einen implantologischen Dauererfolg, in Orale Implantologie: Allgemeine Grundlagen und ITISystem, ed. A. Schroeder, F. Sutter, D. Buser, and G. Krekeler, Georg Thieme Verlag, Stuttgart, Germany, 1994, pp. 2-10. 5. Gray, J.B.; Steen, M.E.; King, G.J.; and Clark, A.E.: Studies on the efficacy of implants as orthodontic anchorage, Am. J. Orthod. 83:311-317, 1983. 6. Ludwig, B.; Baumgaertel, S.; and Bowman, J.S.: MiniImplants in Orthodontics: Innovative Anchorage Concepts, 1st ed., Quintessence Publishing Co., London, 2008. 7. Hourfar, J.; Bister, D.; Kanavakis, G.; Lisson, J.A.; and Ludwig, B.: Influence of interradicular and palatal placement of orthodontic mini-implants on the success (survival) rate, Head Face Med. 13:14, 2017. 8. Ludwig, B.; Glasl, B.; Bowman, S.J.; Wilmes, B.; Kinzinger, G.S.M.; and Lisson, J.A.: Anatomical guidelines for miniscrew insertion: Palatal sites, J. Clin. Orthod. 45:433441, 2011. 9. Ludwig, B.; Glasl, B.; Kinzinger, G.S.M.; Lietz, T.; and Lisson, J.A.: Anatomical guidelines for miniscrew insertion: Vestibular interradicular sites, J. Clin. Orthod. 45:165-173, 2011. 10. Hourfar, J.; Bister, D.; Lisson, J.A.; and Ludwig, B.: Incidence of pulp sensibility loss of anterior teeth after paramedian insertion of orthodontic mini-implants in the anterior maxilla, Head Face Med. 13:1, 2017.

BJÖRN LUDWIG, DMD, MSD Dr. Ludwig is a Contributing Editor of the Journal of Clinical Orthodontics; an instructor, Department of Orthodontics, University of Homburg, Saar, Germany; and in the private practice of orthodontics at Am Bahnhof 54, 56841 TrabenTrarbach, Germany; e-mail: [email protected].

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