orthodontic miniplate with tube as an efficient tool …orthodontic tube and accommodate archwires...

CLINICIAN’S CORNER

Orthodontic miniplate with tube as an efficienttool for borderline cases

Kyu-Rhim Chung,a Seong-Hun Kim,b Yoon-Goo Kang,c and Gerald Nelsond

Seoul, Korea, and San Francisco, Calif

aPresibAssoHee UcFull-UnivedClinicisco.PartlyThe aucts oReprinDenti701, SSubm0889-Copyrdoi:10

An orthodontic miniplate tube device, the C-tube, was designed for use in patients for whom a conventional mini-screw is not suitable, such as those with narrow interradicular spaces, extended maxillary sinuses, dilaceratedroots, or severe alveolar bone loss. After local anesthesia, 2 parallel horizontal incisions are made in the area ofplacement, and the periosteum is elevated. The C-tube is slipped under the mucosal flap and fixed with self-drilling miniscrews (diameter, 1.5 mm; length, 4 mm). Because the screws are short, there is adequate retentionin the alveolar plate, and the clinician can avoid the increased morbidity of anchoring to the zygomatic buttress.This makes placement possible with superficial anesthesia. A small rolled tube at the head part can act as anorthodontic tube and accommodate archwires or as a hook to attach orthodontic elastics. However, in somepatients with pneumatization or systemic diseases, such as diabetes mellitus, or in heavy smokers, cross-type C-tubes with longer miniscrews are recommend for better stability. This new type of orthodontic miniplatecan be an effective alternative to conventional 1-component screws or miniplates in complex situations. (Am JOrthod Dentofacial Orthop 2011;139:551-62)

Recently, a number of case reports with skeletalanchorage as orthodontic anchorage havebeen presented.1-9 Several types of skeletal

anchorage devices, including miniscrews, onplants,and miniplates, have been introduced, and the mostpopular is the miniscrew.5,6 Miniscrews are reasonablycost low, easy to place and remove, and small, and canbe implanted in many locations in the oral cavity.These strong points might be the reasons for theirpopularity. But their placement is usually between thedental roots; this renders them an obstacle to manydesired tooth movements.10-12 To overcome this weakpoint, clinical trials to place miniscrews apart from thedental apparatus—eg, the palatal area—have beenperformed.13,14 But this location complicates the

dent, Korean Society of Speedy Orthodontics, Seoul, Korea.ciate professor, Department of Orthodontics, School of Dentistry, Kyungniversity, Seoul, Korea.time lecturer, Department of Orthodontics, School of Dentistry, Kyung Heersity, Seoul, Koreacal professor, Division of Orthodontics, University of California at San Fran-

supported by the Korean Society of Speedy Orthodontics.uthors report no commercial, proprietary, or financial interest in the prod-r companies described in this article.t requests to: Seong-Hun Kim, Department of Orthodontics, School ofstry, Kyung Hee University #1 Hoegi-dong, Dongdaemun-gu, Seoul 130-outh Korea; e-mail, [email protected], March 2008; revised and accepted, August 2008.5406/$36.00ight � 2011 by the American Association of Orthodontists..1016/j.ajodo.2008.08.041

biomechanical design and is usually limited to themaxilla.

There have been previous reports about surgical min-iplates as orthodontic anchorage.15-17 These miniplatesdo not interfere with tooth movement and canwithstand heavier and more dynamic forces thanminiscrews because of multi-screw retention. However,the surgical miniplate is not ideal for orthodontic pur-poses because its shape is not designed for orthodonticuse, and placement is not easy.

Still, miniplates are useful when the anatomic situa-tion prevents the use of a miniscrew. Several designs aresuitable for orthodontic purposes.7-9 Sugawara et al7

developed a new design of miniplate anchored to the zy-gomatic buttress and named it the “skeletal anchoragesystem.”De Clerck and Cornelis8 showed patients treatedwith miniplates and various additive components. Butthese systems still require relatively longer retentivescrews and are placed in deeper anatomic sites, requiringinvasive surgery. Simpler designs might encourageorthodontists to place the device.

The C-tube was developed exclusively for orthodon-tic purposes with the concept of simple design and smallsize for easy placement.9,18-20 Clinical experiences haveproved that this system can work as a good auxilliaryorthodontic appliance and also as an appliance topartly replace orthodontic brackets. The purposes ofthis article were to introduce the C-tube primarilywhen miniscrews are not applicable and to show thevarious principles of clinical applications.

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Fig 1. A, Schematic illustration of I-type C-tube; B and C, preplacement and postplacement of theC-tube retained by 2 drill-free screws 1.5 3 4 mm (width 3 length), recommended for a narrow inter-radicular space; D, cross-type C-tube: E, frontal and F, sagittal cone-beam computed tomographyviews of a C-tube in a patient with an enlarged maxillary sinus.

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C-TUBE AND ORTHODONTIC MECHANICS

C-tubes are titanium miniplates with a 0.036-indiameter hole in the tube. They have 2 to 4 holes (diam-eter, 1.5 mm) and lengths of 4 to 7 mm; they are self-drilling miniscrews (KLS Martin, Tuttlingen, Germany,Jin Biomed Co., Bucheon, Korea) (Fig 1).

The C-tube is anchored to the cortical bone near theposterior teeth, instead of the zygomatic buttress.C-tube placement requires a minimum of dissectioncompared with the buttress site.

Two types of C-tube have developed: I and cross.19

The I-type C-tube is fixed with 2 drill-free miniscrewsand applied in the posterior maxillary area if there arenarrow interradicular spaces or dilacerated roots, or inthe anterior maxilla with a prominent labial frenum(Fig 1, A-C).20 Cross-type C-tubes are used when thereis severe pneumatization of the maxillary sinus orwhen distalization of the dentition is planned. Thecross-type C-tube is fixed with 2 to 4 drill-free 4-mmminiscrews according to the quality of bone and thedirection of the orthodontic force vector. Althougha 4-mm miniscrew might seem short, the use of severalscrews gives good stability to the miniplate even in thincortical bone. Also, these miniscrews are short enoughnot to touch dental roots and not to interfere with tooth

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movement. The C-tube can be placed in various regionof the oral cavity and is valuable where absolute anchor-age is needed (Fig 2).

A C-tube in the posterior maxillary area can beused for intrusion and distalization of posterior teeth(Fig 2, A) and also for intrusion of anterior teeth(Fig 2, B and C). In the maxillary area of the mentalforamen, it can be used for intrusion or distalization ofthe mandibular posterior teeth and intrusion of anteriorteeth (Fig 2, D-F). Also, it is applicable for lingual ortho-dontics and can be placed on the retromolar pad with therolled tube exposed in the oral cavity (Fig 2, G-I).

Usually, the C-tube is placed in alveolar bonebetween the dental roots or in cortical bone above thealveolar bone (Fig 3). These areas are much lower andmore accessible than the zygomatic buttress wherea conventional miniplate is usually placed. The intraoralexposure part of the C-tube is placed at the border be-tween attached and movable mucosa. The head part ofthe C-tube should be adjusted with care so that it willnot be covered by the mucosa.

1. Inject local anesthesia and wait for 10 minutes forcomplete diffusion of the anesthesia.

2. Make a horizontal incision with a number-15 bladewhere the head of C-tube is to be exposed and then

Journal of Orthodontics and Dentofacial Orthopedics

Fig 2. The C-tube can be used whenmini-implants are hard to position. A C-tube provides mechanicalretention with anchorage in the cortical bone away from tooth roots.

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make another 3-mm long horizontal incision 2 mmapical and parallel to the first one (Fig 3, A).

3. Lift the periosteum carefully with a periosteal eleva-tor (Fig 3, B).

4. Conform the C-tube to the exposed bony surfacewith a bending pliers.

5. Place the C-tube on the bone surface through thesecond horizontal incision (Fig 3, C), expose thetube part to the oral cavity, and then fix the C-tubewith self-drilling miniscrews (diameter, 1.5 mm;length, 4 mm) placed through the second horizontalincision (Fig 3, D and E).

6. Suture the incised area with 4-0 silk (Fig 3, F).7. Prescribe nonsteroidal anti-inflammatory drugs and

antibiotics for 3 days. Remove the suture material 1week later.

The removal procedure includes the following steps.

1. After local anesthesia, make a vertical incision onthe miniscrew area with a number 15 blade.

2. Unscrew the miniscrews and remove the C-tubethrough the incision. Sometimes it is necessary to

American Journal of Orthodontics and Dentofacial Orthoped

increase the opening for the head part to slipthrough the tissue.

3. Suture the incision area with 4-0 silk.4. Prescribe nonsteroidal anti-inflammatory drugs and

antibiotics for 3 days. Remove the suture material 1week later.

CLINICAL APPLICATIONS OF THE C-TUBE

The C-tube can be used for en-masse retraction with-out posterior appliances. The C-tube is applied on themaxillary anterior teeth without attached appliances tothe posterior dentition in maximum anchorage cases.It can replace brackets on the posterior dentitionthrough accommodation of the posterior part of thearchwire into its tube without losing control of the ante-rior teeth. It resists heavy and dynamic loads because ofseveral miniscrews. Also, various elastics, power chains,and archwires can be easily applied to the 0.9-mmdiameter hole in the tube.20

A 30-year-old woman visited our orthodontic cliniccomplaining of lip protrusion. After a complete analysis,

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Fig 3. Surgical procedure of cross-typeC-tube placement:A,make a horizontal incisionwith a number-15 blade where the head of the C-tube is to be exposed and then make another 3-mm long horizontalincision 2 mm apical to the first one; B, carefully lift the periosteum with a periosteal elevator; C and D,place theC-tube on the bone surface through the second horizontal incision and expose the tube part tothe oral cavity; E, fix the C-tube with self-drilling miniscrews placed through the second horizontalincision; F, suture the incised area with 4-0 silk.

Fig 4. Patient 1. A C-tube was used for anterior retraction instead of bonded or banded appliances on the maxillary pos-terior dentition.A, Treatment progress panoramic radiograph shows themini-implant on the right side and an I-typeC-tubeon the left side. This patient had a narrow interradicular space and an enlarged maxillary sinus on the maxillary left pos-terior dentition.B,Axial cone-beam computed tomography image of the C-implant between themaxillary right second pre-molar and the first molar.C, Frontal cone-beam computed tomography image (version 4.0, Invivodental, Anatomage, SanJose, Calif) of I-type C-tube in the left posterior maxilla.

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she was diagnosed as having Class II bidentoalveolarprotrusion; the treatment plan included extraction ofthe 4 first premolars and temporary skeletal anchorage


devices TSADs to enable en-masse retraction (Figs 4and 5). A sand-blasted with large grit and acid-etchedsurface-treated mini-implant (C-implant, Cimplant Co.,


Fig 5. Patient 1. A, Anterior retraction initiated; B, after 15 months of retraction; C, after 19 months ofretraction without posterior bonded or banded appliances.

Fig 6. Patient 2. C-tube application for lingual orthodontics: A, initial stage; B, after 2 months of retrac-tion;C, after 5 months of retraction;D, after 8 months of retraction;E, posttreatment occlusal view. Thetotal treatment period was 12 months.

Chung et al 555

Seoul, Korea) was implanted between the maxillary rightsecond premolar and first molar, but, on the left side,a narrow interradicular space and extended maxillarysinus contraindicated the use of the C-implant (Fig 4,A and B). Instead, an I-type C-tube was placed with 2self-drilling miniscrews (Fig 4, C). The miniscrew andthe C-tube eliminated any need for bracketed applianceson the maxillary posterior dentition. The archwire passedthrough the head of the C-tube. After 19 months, reso-lution of anterior protrusion and closure of extractionspace were achieved (Fig 5).


The C-tube can be used in the same way with lingualappliances (Fig 6).

C-tubes can be used for vertical correction. I-typeC-tubes can be used for intrusion of the maxillary inci-sors (Fig 7). A 34-year-old woman with a deep anterioroverbite and a lingually blocked maxillary left lateral in-cisor was treated with an I-type C-tube (Fig 7, A and B).Her blocked lateral incisor was extracted, and the C-tubewas placed between the maxillary right central andlateral incisors. Intrusion force was applied with elasticchain between the C-tube and the archwire. Intrusion


Fig 7. Patient 3. C-tubes can be used for intrusion of the maxillary incisors. Intraoral photographs atA, pretreatment; B, the initial stage of intrusion of the maxillary anterior teeth; C, after 2 months ofintrusion; D, after 4 months of intrusion.

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took 4 months; this allowed bracket to be placed on themandibular anterior teeth (Fig 7, C and D). The totaltreatment period was 15 months.

Another patient required intrusion of the mandibularanterior teeth. A 32-year old man was diagnosed witha Class II anterior deepbite malocclusion with anteriorspacing. We placed 2 miniscrews on the maxillary teethand an I-type C-tube on the mandibular anterior teeth(Figs 8 and 9). The maxillary miniscrews (C-implants:diameter, 1.8 mm; length, 8.5 mm) were used foranterior retraction, and a C-tube on the mandibularanterior teeth was used for intrusion. The C-tube wasfixed to cortical bone under the mucosa, avoiding theroots of the incisors, and the head of the C-tube wasexposed through the attached gingiva. This minimizedinflammation. Four millimeters of intrusion occurredafter 3 months of active intrusion (Fig 9).

A 16-year-old girl came with a deep anterior overbitecaused by extrusion of the maxillary and mandibular an-terior teeth. We simultaneously intruded both the max-illary and mandibular anterior teeth using maxillary andmandibular anterior I-type C-tubes (Figs 10 and 11).After 2 months of treatment, a significant reductionof anterior overbite was achieved; this allowedplacement of appliances on the mandibular anteriorteeth (Fig 11). As expected, the force vector causedsome incisor flaring.

Intrusion of posterior teeth and resolution of anterioropenbite are also possible with a cross-type C-tubeplaced in the maxillary posterior region (Fig 12). A 25-year-old woman with an anterior open bite visited our


clinic. We planned to intrude her maxillary posteriorteeth against C-tube anchorage. A transpalatal archwas included to prevent buccal tipping of the molarsduring intrusion. Improvement of the anterior overjetwas noted after 7 weeks of intrusion of the maxillarymolars (Fig 12, A-D). After the maxillary posteriorintrusion, distalization of the full maxillary dentitionwas performed simultaneously, and a normal overjetand overbite relationship was achieved after 18 monthsof treatment (Fig 12, E and F).

The C-tube device can endure orthodontic forces ofvarious directions and intensities. We placed an I-typeC-tube in a 27-year-old woman with a Class III inter-maxillary relationship and an anterior open bite. TheC-tube provided anchorage to both intrude the posteriorteeth and retract the mandibular anterior teeth. After 11months of treatment, improved overjet and overbitewere achieved (Fig 13).

Distalization of the full mandibular dentition can beachieved with an I-type C-tube placed on the retromolarpad. If the third molar is not present, there is no risk ofdamaging roots (Fig 14).

A 30-year-old woman with a Class III occlusalrelationship on the left side visited our clinic, anda nonextraction treatment plan including distalizationof the mandibular left dentition was established(Fig 15, A-C). The I-type C-tube was placed on the leftretromolar pad and fixed with 2 self-drilling miniscrews(diameter, 1.5 mm; length, 5 mm). The mandibular leftdentition was distalized with an 0.018 3 0.025-instainless steel sliding jig with force applied with


Fig 8. Patient 4. Intrusion of mandibular anterior teeth: A-C, intraoral photographs and panoramicradiographs at pretreatment; D-F, after 3 months of intrusion, 4 mm of intrusion was obtained.

Fig 9. Patient 4. Lateral cephalograms:A,pretreatment;B,after 3months of intrusion;C, superimposition.

Fig 10. Patient 5. Pretreatment intraoral photographs.

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Fig 11. Patient 5. A and B, Maxillary and mandibular intrusion was started after placement of 2 I-typeC-tubes; C and D, after 2 months of intrusion.

Fig 12. Patient 6. Intrusion of the maxillary molars by elastic thread from a cross-type C-tube: A and B,intraoralphotographsof initial forceapplication;CandD,after7weeksof intrusion;EandF,posttreatment.

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Fig 13. Patient 7. Intrusion of the maxillary posterior teeth and mandibular retraction with I-typeC-tubes:A-C, pretreatment intraoral photographs;D-F, treatment progress;G-I, posttreatment intraoralphotographs. The total treatment period was 11months.

Fig 14. C-tube application for mandibular molar distalization. The arrow shows the retromolar area ofthe mandible.

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a nickel-titanium coil spring (Forestadent Co., Pforz-heim, Germany) (Fig 15, D-I). The total treatment periodwas 10 months, and a Class I occclusal relationship withnormal anterior overjet and overbite was achieved (Fig15, J-L).

DISCUSSION

Various kinds of skeletal anchorage situations havebeen described that permit the orthodontist to treat cer-tain malocclusions that are impossible to manage with


traditional methods.21 Surgical miniplates are the typicaltreatment tool. These plates are used for the treatmentof facial bone fractures and stabilization of osteotomysegments. The materials used for miniplates have provento be stable and biocompatible through long usage.Many authors showed that miniplate systems have fewerfailures compared with orthodontic miniscrews.22-26

Chen et al26 stated that an advantage of miniplates isto keep the anchorage screws out of the way of toothmovement and, thus, to increase the possible range of


Fig 15. Patient 8. C-tube application for mandibular molar distalization: A-C, pretreatment intraoralphotographs; D-F, 2 months after distalization; G-I, 5 months after distalization; J-L, posttreatmentintraoral photographs. Total treatment period was 10 months.

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movement. They found that placement and removal ofminiplates are minimally invasive, with mild postopera-tive discomfort and few risks.21 We are orthodontistswho are not practiced in surgical procedures. Neverthe-less, we place and remove C-tubes by ourselves withoutthe help of surgeons.

Most orthodontic miniplates described in the inter-national journals are placed on the zygomatic buttressor the basal bone area after a 2-cm vestibular inci-sion.25,26 To support the rather long arm that extendsinto the oral cavity, several miniscrews (diameter, 2mm; length, 5-10) are usually used.

C-tubes also can be placed on the zygomatic buttresslike other miniplates, but, for most patients, the alveolarcortical bone adjacent to the interradicular space is pre-ferred, since it is a simpler and less invasive procedure.18

Not much surgical training is needed for these proce-dures. Although C-tubes are fixed with several screws,


these screws are of 4 mm in length to minimize the pos-sibility of dental root damage. They are placed withouta pilot hole. Using several screws to fixate the device pro-vides good stabililty against the application of heavy anddynamic forces.

The tube part of the fixture offers improved biome-chanical options. Specifically, it can accommodate arch-wires, and so the device can replace posterior bracketsand tubes. Surgical procedures for C-tube placementare easier than for conventional miniplates but morecomplicated than miniscrews. However, the C-tubedoes not interfere with tooth roots during molar distal-ization or intrusion. C-tubes can be successfully used inyoung growing patients.

The patients presented in this article had 6 treatmentsituations: (1) interradicular spaces too narrow for con-ventional miniscrews, (2) severe pneumatization of themaxillary sinuses, (3) dilacerated roots that made


Chung et al 561

interradicular spaces unavailable for miniscrews, (4) nar-row interradicular spaces and distalization of the entiredentition, (5) need for a TSAD on the retromolar pad,and (6) severe loss of alveolar bone that compromisedthe placement of miniscrews.

In the case of severe pneumatization, when themaxillary buccal cortical bone is usually too thin, theuse of a cross-type C-tube fixed with more than 3miniscrews (diameter, 1.5 mm; length, 4 mm) isrecommended.

Although minor sinus perforations can occur, theymight not be a concern. Reports suggest that perforationof the sinus membrane is the most common complica-tion during the sinus floor elevation procedures for pros-thetic implants.27,28 Research showed that perforationswere not related to increased loss of implants, andonly 5% of patients showed signs of sinusitis.27 Thesinus mucosa will usually regenerate across the immobi-lized bone graft during normal healing. Berengo et al28

showed that small membrane perforations during theosteotomy are compatible with clinically healthy postop-erative sinus conditions.

Even though the C-tube has numerous advantagescompared with mini-implants and orthodontic mini-plates, there are some details to consider. When applyingorthdontic elastics to the C-tube, open the rolled tubewith a pliers to provide a hook. The C-tube is made ofcommercially pure titanium; therefore, it is easily bent.If a patient has excess sinus pneumatization, the clini-cian should take care not to screw the miniscrew toofirmly into the cortical wall. Because the cortical bonein the pneumatization area can be thin, it is prone tofracture during miniscrew placement.

In a patient with a systemic disease patient (especiallydiabetes mellitus), a longer miniscrew should be used forbetter mechanical retention of the C-tube. Even thoughthe 4-mm long miniscrew is short compared withconventional miniscrews, clinicians should neverthelesstake care to avoid contact with tooth roots duringplacement.

CONCLUSIONS

The typical anatomic site for the placement of a C-tube is in the anterior or posterior facial alveolar bone.Whereas placement of a C-tube miniplate involves screwplacement closer to roots than a miniplate attached tothe zygomatic buttress, the use of short screws moder-ates the risk of root contact. Further study will developadditional biomechanic protocols for the C-tube,discover any risk factors, including effects on the neigh-boring roots andmaxillary sinuses, and establish the bestanatomic sites for placement.


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orthodontic miniplate with tube as an efficient tool …orthodontic tube and accommodate archwires...

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