2013 JCO, Inc. My not e distriuted without permission. www.jco-online.com Correction of Upper-Arch Asymmetries Using the Mesil-Distlslider BENEDICT WILMES, DMD, MSD, PHD RAVINDRA NANDA, BDS, MDS, PHD MANUEL NIENKEMPER, DDS, MSC BJÖRN LUDWIG, DMD, MSD DIETER DRESCHER, DMD, PHD Correcting mxillry dentl symmetries without the need for extrctions or spce opening for dentl implnts represents mjor chllenge for the orthodontist, especilly when using conventionl nchorge methods. Although ucclly inserted mini-implnts provide more relile nchorge, the potentil correction is limited to out 1mm ecuse the uccl mini-implnt is plced in the pth of the moving teeth. The plte is more suitle for skeletl nchorge, since ny teeth cn e moved without interference. In ddition, the nterior plte offers good one qulity nd thin ttched mucos, with no risk of root injury, ensuring high rte of success. 1,2 The Mesil-Distlslider 3 (Fig. 1) is miniimplnt-orne pplince tht comines the mechnics of the Beneslider 4,5 nd the Mesilslider, 6 thus llowing simultneous distliztion nd mesiliztion in the sme rch. A common indiction is the upper-rch midline devition resulting from unilterl missing tooth. Clinicl Procedure We use the Benefit* mini-implnt system, 7 in which the selected utment is fixed to the miniimplnt with n inner microscrew. To improve stility nd prevent unwnted rottion, two Benefit mini-implnts re coupled using Beneplte 3 with n integrted.045" stinless steel wire. Fig. 1 Mesil-Distlslider for simultneous unilterl distliztion nd contrlterl mesiliztion. Fig. 2 Benetue inserted from mesil on distliztion side (A) nd from distl on mesiliztion side (B). Tue ody is ent s needed to conform to plte nd void soft-tissue irrittion. 648 2013 JCO, Inc. JCO/NOVEMBER 2013
Dr. Wilmes Dr. Nnd Dr. Nienkemper Dr. Ludwig Dr. Drescher Dr. Wilmes is Professor, Dr. Nienkemper is n Instructor, nd Dr. Drescher is Professor nd Hed, Deprtment of Orthodontics, University of Düsseldorf, Moorenstrsse 5, 40225 Düsseldorf, Germny. Dr. Wilmes is lso Visiting Professor, Deprtment of Orthodontics, University of Alm t Birminghm School of Dentistry, nd the developer of the Benefit system. Dr. Nnd is n Associte Editor of the Journl of Clinicl Orthodontics nd UConn Orthodontic Alumni Endowed Chir, Division of Orthodontics, nd Professor nd Hed, Deprtment of Crniofcil Sciences, University of Connecticut School of Dentl Medicine, Frmington, CT. Dr. Ludwig is Contriuting Editor of the Journl of Clinicl Orthodontics; n Instructor, Deprtment of Orthodontics, University of Homurg, Sr, Germny; nd in the privte prctice of orthodontics in Tren-Trrch, Germny. E-mil Dr. Wilmes t: wilmes@med.uni-duesseldorf.de. *PSM Medicl Solutions, Tuttlingen, Germny; www.psm.ms. Distriuted in the U.S. y Mondel North Americ, Inc., Indio, CA; www.mondel-ortho.com. After dministrtion of topicl or locl nesthetic, 1.4mm drill is used to mke pilot holes to depth of 3mm ner the midpltl suture, posterior to the third ruge. The distnce etween the two mini-implnts should e t lest 5mm nd no more thn 14mm. Drilling cn e done mnully, using 1:1 contr-ngle equipped with supplied mnul driver, which voids the need for cooling. The self-drilling Benefit mini-implnts cn usully e inserted without predrilling. In dult ptients with high one density in the nterior plte, however, the predrilling prevents excessive torquing moments. Predrilling is not necessry in ptients younger thn 12 due to the low level of one minerliztion. Two Benefit mini-implnts (2mm 11mm nterior nd 2mm 9mm posterior) re inserted, gin using the contr-ngle screwdriver. Miniscrews with dimeter of 2mm or 2.3mm will provide superior stility compred to nrrower screws. 8,9 At the sme ppointment, nds with lingul sheths re cemented to the upper molrs. Benetues re inserted from the mesil on the distliztion side (Fig. 2A) nd from the distl on the mesiliztion side (Fig. 2B). In most ptients, the Benetues should e ent wy from the plte to void soft-tissue irrittion; the Beneplte ody cn lso e ent s needed. The Beneplte is ffixed to the mini-implnts with two microscrews. The Mesil-Distlslider cn e instlled with no impressions or lortory work, ut cn lso e dpted on plster cst to sve chirtime. The mesiliztion force is delivered y nickel titnium closing spring (200g), secured y n ctivtion lock pushed mesilly (Fig. 3A), nd the distliztion force y nickel titnium open-coil spring (240g in children, 500g fter eruption of the second molrs) with the ctivtion lock pushed distlly (Fig. 3B). Follow-up ppointments re scheduled every four to six weeks. If friction ppers to e too high on the mesiliztion side fter few months, elstic chins cn e dded. Fig. 3 Activtion of Mesil-Distlslider y pushing ctivtion lock mesilly on mesiliztion side (A) nd distlly on distliztion side (B). VOLUME XLVII NUMBER 11 649
Correction of Upper-Arch Asymmetries Using the Mesil-Distlslider Fig. 4 Cse 1. 32-yer-old mle ptient with missing upper right lterl incisor, excessive overjet, nd Clss II reltionship on left side efore tretment. Fig. 5 A. Cse 1. Mesil-Distlslider plced for mesiliztion of upper right qudrnt nd distliztion of upper left qudrnt. B. Prtil closure of upper right lterl-incisor spce fter five months of tretment. 650 JCO/NOVEMBER 2013
Wilmes, Nnd, Nienkemper, Ludwig, nd Drescher Fig. 6 Cse 1. Sgittl movements completed nd Mesil-Distlslider removed fter seven months of tretment. The premolrs nd cnines will egin to migrte distlly on the distliztion side, resulting in the ppernce of smll spces, while the premolrs re pushed mesilly on the opposite side. After completion of these sgittl tooth movements, which require high degree of nchorge, the cse cn e finished with lil or lingul fixed pplinces or, when fesile, with ligners. In some ptients, the Mesil-Distlslider cn e used t the sme time s onded rckets. The following cses demonstrte oth methods. Cse 1 A 32-yer-old mle presented with missing upper right lterl incisor, excessive overjet, nd Clss II reltionship (one-third of the premolr) on the left side (Fig. 4). He hd previously undergone tretment with ligners to open spce for dentl implnt, ut the right centrl incisor nd cnine hd tipped into the lterl-incisor site, leving even less spce for n implnt. We recommended mesiliztion nd cnine sustitution on the right side nd distliztion to correct the Clss II mlocclusion on the left, using the Mesil-Distlslider nd lil rckets. An dditionl lever rm mde of.020" stinless steel ws welded to the nterior section of the Mesil- Distlslider to pply uccl mesiliztion force to the centrl incisor (Fig. 5A). In our experience, this simultneous ppliction of uccl nd lingul force increses the speed of mesil movement. After five months of tretment, the lterlincisor spce ws much smller, nd the right posterior dentition hd moved slightly distlly (Fig. 5B). Two months lter, the sgittl corrections hd een completed, nd the Mesil-Distlslider ws removed to llow molr movement during the finishing stge (Fig. 6). Another two months lter, tretment ws completed. Figure 7 shows the ptient two yers fter deonding. Cse 2 A 15-yer-old mle trnsfer ptient ws referred to our clinic with Clss III mlocclusion (Wits pprisl = 3.4mm), crossite on the left side, nd mild centric occlusion-centric reltion discrepncy. The upper right cnine ws sent, resulting in midline devition to the right (Fig. 8). The lower left first premolr hd een removed previously. Our tretment pln ws to mesilize the upper right qudrnt for closure of the cnine VOLUME XLVII NUMBER 11 651
Correction of Upper-Arch Asymmetries Using the Mesil-Distlslider Fig. 7 Cse 1. Ptient two yers fter deonding. spce nd to distlize the upper left qudrnt for midline correction, using the Mesil-Distlslider (Fig. 9A). In the lower rch, the remining first premolr would lso e extrcted to compenste for the skeletl Clss III. After seven months of tretment with the Mesil-Distlslider, the upper right cnine spce ws closed, nd smll spces hd ppered in the upper left qudrnt. The force pplied to the molr lso pushed the premolrs mesilly, resulting in minor tipping (Fig. 9B) tht ws corrected in the susequent leveling phse (Fig. 9C). After reciprocl spce closure in the lower rch nd finishing, the rckets were removed (Fig. 10). Totl tretment time ws four yers. Discussion The insertion moments of mini-implnts in the midpltl region hve een mesured t 8-25Ncm, which cn e regrded s dequte for primry stility. 3 These mini-implnts cn e inserted close to the suture, 2,10 where sufficient one volume is ville s fr s out 3mm to either side. 11 The Mesil-Distlslider cn e used either 652 JCO/NOVEMBER 2013
Wilmes, Nnd, Nienkemper, Ludwig, nd Drescher with (Cse 1) or without (Cse 2) simultneously onded rckets. Although the reduced friction cn mke it dvntgeous to egin tretment without fixed pplinces, the premolrs nd cnines on the mesiliztion side my ecome mesilly tipped nd thus require lter correction, s in Cse 2. To prevent this prolem, in procedure descried y Dr. Thoms Bnch, Benetues cn e onded directly to the lingul surfces of one or more teeth for extr nterior guidnce (Cse 3, Fig. 11). Unlike intermxillry elstics or interrch Fig. 8 Cse 2. 15-yer-old mle trnsfer ptient with left crossite nd missing upper right cnine, resulting in midline devition to right. c Fig. 9 Cse 2. A. Mesil-Distlslider plced to close upper right cnine spce nd distlize upper left qudrnt for midline correction. B. Cnine spce closed, with smll spces ppering on left side, fter seven months of tretment. Note mesil tipping of unonded premolrs during mesiliztion of upper right first molr. C. Initition of leveling in upper rch. VOLUME XLVII NUMBER 11 653
Correction of Upper-Arch Asymmetries Using the Mesil-Distlslider **Registered trdemrk of Denturum, Inc., Newtown, PA; www. denturum.com. ***Trdemrk of Americn Orthodontics, Sheoygn, WI; www. mericnortho.com. devices such s the Herst** pplince or Jsper Jumper,*** the Mesil-Distlslider cn correct dentl symmetry in the upper rch without producing ny movements of the lower teeth tht my cuse ptient to finish with discrepncy etween the dentl nd fcil midlines, even if the occlusion seems perfect. It lso voids the need for unilterl Clss II or contrlterl Clss III elstics, which require ptient complince nd cn cuse TMJ discomfort. Conclusion The Mesil-Distlslider hs proven relile in delivering unilterl mesiliztion nd contrlterl distliztion of the upper dentition for correction of dentolveolr symmetry or midline devition. In pproprite cses, it thus reduces the need for compenstory extrctions on the distliztion side nd for dentl implnts on the mesiliztion side. Fig. 10 Cse 2. Ptient fter four yers of tretment. 654 JCO/NOVEMBER 2013
Wilmes, Nnd, Nienkemper, Ludwig, nd Drescher c c Fig. 11 Cse 3. A. Mesil-Distlslider used for tretment of 11-yer-old femle ptient with congenitlly missing upper lterl incisors nd severe midline devition to right. Note Benetue onded to upper right first premolr for guidnce of mesilized teeth. B. After five months of tretment. C. After seven months of tretment with Mesil-Distlslider pplying forces only to upper first molrs nd upper right first premolr. Additionl Benetue nd effects of interdentl fiers on distliztion side llowed midline correction nd odily mesiliztion of right premolrs without rckets. REFERENCES 1. Lim, H.J.; Choi, Y.J.; Evns, C.A.; nd Hwng, H.S.: Predictors of initil stility of orthodontic miniscrew implnts, Eur. J. Orthod. 33:528-532, 2011. 2. Ludwig, B.; Glsl, B.; Bowmn, S.J.; Wilmes, B.; Kinzinger, G.S.; nd Lisson, J.A.: Antomicl guidelines for miniscrew insertion: Pltl sites, J. Clin. Orthod. 45:433-441, 2011. 3. Wilmes, B.; Drescher, D.; nd Nienkemper, M.: A miniplte system for improved stility of skeletl nchorge, J. Clin. Orthod. 43:494-501, 2009. 4. Wilmes, B.; Nienkemper, M.; Ludwig, B.; Ku, C.H.; Puls, A.; nd Drescher, D.: Esthetic Clss II tretment with the Beneslider nd ligners, J. Clin. Orthod. 46:390-398, 2012. 5. Wilmes, B. nd Drescher, D.: Appliction nd effectiveness of the Beneslider: A device to move molrs distlly, World J. Orthod. 11:331-340, 2010. 6. Wilmes, B.; Nienkemper, M.; Nnd, R.; Lüerink, G.; nd Drescher, D.: Pltlly nchored mxillry molr mesiliztion using the Mesilslider, J. Clin. Orthod. 47:172-179, 2013. 7. Wilmes, B. nd Drescher, D.: A miniscrew system with interchngele utments, J. Clin. Orthod. 42:574-580, 2008. 8. Wilmes, B.; Rdemcher, C.; Olthoff, G.; nd Drescher, D.: Prmeters ffecting primry stility of orthodontic miniimplnts, J. Orofc. Orthop. 67:162-174, 2006. 9. Wilmes, B. nd Drescher, D.: Impct of insertion depth nd predrilling dimeter on primry stility of orthodontic miniimplnts, Angle Orthod. 79:609-614, 2009. 10. Kng, S.; Lee, S.J.; Ahn, S.J.; Heo, M.S.; nd Kim, T.W.: Bone thickness of the plte for orthodontic mini-implnt nchorge in dults, Am. J. Orthod. 131:S74-81, 2007. 11. Bernhrt, T.; Freudenthler, J.; Dörtudk, O.; Bntleon, H.P.; nd Wtzek, G.: Short epithetic implnts for orthodontic nchorge in the prmedin region of the plte: A clinicl study, Clin. Orl Impl. Res. 12:624-631, 2001. VOLUME XLVII NUMBER 11 655