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Open-Bite Corrections with TADs by Mohammad R. Razavi, DDS, MSD, FRCD (C)

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by Mohammad R. Razavi,
DDS, MSD, FRCD (C)

Since the mid-2000s, temporary anchorage devices (TADs) have given U.S. orthodontists a helpful tool for completing cases faster or for providing an alternative to orthagnathic surgery for open bites. While TADs are most useful for a relatively small number of orthodontic cases, in these cases their advantages are quite significant, and they provide tangible patient benefits and opportunities for differentiating your practice.

TADs can be used to move teeth in ways that were previously impossible—for example, movement in the anteroposterior and vertical directions, distalizing to correct class II molar relations and creating space in the dental arches, or intrusion to aid in correction of anterior open-bite malocclusion, just to name a few. For the maximum benefit, careful case selection for TADs is vital, and when these devices were first gaining traction in the United States I felt they were overused.

Orthodontists were utilizing the devices to save just two or three months in the treatment process by closing extraction spaces more quickly, and to me this small reduction in treatment time did not justify the relatively invasive procedure.

However, as time has gone by, I have seen many cases where the time savings enabled by TADs are much more dramatic. For example, TADs can be extremely effective in moving a first and second molar forward into the space of a premolar. Using traditional orthodontic mechanics this might take up to four years; however with TADs, it can easily be accomplished in less than two years, which is a considerable difference for the patient. As mentioned, TADs can also provide an alternative to surgical intervention in open-bite cases.

While in my practice I limit the use of TADs to a very select list of circumstances, I believe that for the right patients they are an outstanding option, saving years of treatment time or more invasive surgery. I most often place 3M Unitek temporary anchorage devices, which can be placed and removed relatively simply. These mini-implant TADs use a drill-free placement process with topical anesthetic only. Because their surfaces are highly polished, they do not osseointegrate, which makes removal at the end of treatment very simple.

The value of TADs in your practice
In light of the limited group of patients for whom TADs are appropriate, orthodontists may wonder if it is worth learning the procedure and offering the service in their practice. I believe it is worthwhile for two key reasons: First, the benefits of TADs for the right patients are dramatic, and can be a strong differentiator between your practice and another. If you can help a patient avoid jaw surgery or reduce the treatment duration by years, you are providing your patient with an outstanding level of care.

Second, learning to place and effectively use TADS in your office can save your patients the hassle and stress of going to an oral surgeon or periodontist. Some orthodontists are comfortable with using TADs but do not want to perform the placement procedure, and therefore refer their patients to a surgeon for this part of treatment. This can lead to complications if the surgeon does not place the TAD in the ideal site for the treatment plan, and introduces inconvenience for your patient when she has to see an additional doctor with whom she has no relationship. For a 13- or 14-year-old and her parents, this can be a stressful prospect.

By learning the TAD protocol and offering this service to your patients, you maintain control over how the treatment is presented and executed, and you're able to maintain a closer relationship with your patient.

The case shown here will illustrate the use of a TAD to efficiently close an open bite.

Case presentation
The patient was 15 when she first presented to the office with a Class I malocclusion, a posterior crossbite on the right side, a cant in the lower occlusion with the right side being lower than the left, and an open bite from canine to canine. There was also mild crowding on the lower arch. The anterior open bite was of course the issue of most concern for treatment.

Two treatment options were explained to the patient and her mother. The option of surgery was presented, but neither the patient nor her mother wanted to pursue this treatment option. The alternative option was use of a maxillary expansion appliance, a modified transpalatal arch (TPA) and Unitek temporary anchorage device, and braces. This option had the added benefit of being lower in cost than the surgical plan, as orthognathic surgery is not often covered by medical insurances in North America, and presents an out-of-pocket expense to a patient and her or his family. The patient accepted this treatment plan.

Rapid maxillary expansion was undertaken using a Hyrax palatal expander, which was used for active expansion for one month and stabilization for an additional six months. The SmartClip SL3 self-ligating appliance system from 3M Unitek was bonded on the uppers and lowers to level the occlusion during the stabilization stage of maxillary expansion. After the palatal expander had been in place for six months, it was removed and replaced with a TPA, and a TAD was placed 1mm lateral to the midpalatal suture.

Intrusion was maintained for 16 weeks, after which the TAD was removed. No topical or local anesthetic is needed for the removal process; the TAD can simply be unscrewed. No sutures are necessary, and the soft tissue and bone heal within one week. The open bite was closed by this point, so the remainder of the treatment was spent fine-tuning the occlusion. Archwires were sequenced starting with .014 super elastics (Nitinol), to tandem wires (.014 and .016 SE Nitinol), .019 x .025 heat-activated wires, and finally .019 x .025 beta titanium wires during the finishing stage. The entire treatment was completed in 21 months.

Discussion
For any case similar to this one, it is important to note that the orthodontist should wait at least six months after palatal expansion to place the TAD in the midsection of the palate. This allows sufficient time for the cartilage to be replaced by bone, which gives the TAD a more stable base. Additionally, by positioning the TAD approximately 1mm off the midline instead of right into the suture space, you can add to the stability of the TAD.

As seen here, using TADs for molar intrusion can be an appealing option for patients with an open bite. The placement of the TAD in the palate has been demonstrated as effective, as the dense bone provides strong retention.1-4 The straightforward placement protocol used with Unitek TADs makes the learning process realistic, and gives orthodontists a valuable way to expand their offerings for patients.



References
  1. Kang, S.; Lee, S.J.; Ahn, S.J.; Heo, M.S.; and Kim, T.W.: Bone thickness of the palate for orthodontic mini-implant anchorage in adults, Am. J. Orthod. 131:74-80, 2007.
  2. Razavi, M.: Indirect anchorage using the palate: A unique application of the Unitek temporary anchorage device, Orthod. Perspect. 17:6-9, 2010.
  3. Razavi, M.: Applications and benefits of fixed anchorage in the palate, Orthod. Perspect. 16:15-17, 2009.
  4. Razavi, M.: MSIs, TPAs, and SLBs: Combining appliance systems can shorten treatment time and lengthen appointment intervals, Orthod. Prod., Sept. 2011, pp. 30-36.




After receiving his undergraduate degree from the University of Toronto, Dr. Razavi received both his Doctor of Dental Surgery degree and Master's Degree in Orthodontics from Case Western Reserve University in Cleveland, Ohio. He currently teaches as a visiting assistant clinical professor at Case Western. Dr. Razavi attends many national and international orthodontic conferences where he lectures and teaches. Before moving to Toronto, he was the official orthodontist of the Cleveland Browns.


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