height of the tooth may be achieved. This reduction in height will then permit the vertical elastic from the plate to the mandibular second molar to erupt the tooth to its ideal height in relation to the occlusal plane, without the need to involve conventional multibracketed orthodontics in the eruption process.
It has been shown that titanium screws have a success rate in excess of 80% [20], although this author is unable to reach that level of success. Notwithstanding the fact that the screws are easily and rapidly replaced in the event of failure, the very failure itself creates a nuisance in the smooth running of the treatment. Accordingly, in cases where considerable movement is needed on a fairly long‐term basis, a good alternative is the use of a malleable titanium plate onlay. This may be adapted to the shape of an area of bone surface, such as in the palate or the inferior surface of the zygomatic process of the maxilla [21]. Titanium screws are then used to secure the plate to the strategically selected area, and the flap sutured to leave only the extremity of the plate exposed at one end, for use as an elastic attachment device. The zygomatic plate TAD appears to be much more successful in terms of its reasonably long‐term usefulness and has been shown to have a much lower failure rate than screws [22].
Fig. 2.8 An indirect anchorage system. (a) Extra‐oral view to show tipped occlusal plane due to anchorage loss during the attempted active eruption of the non‐responsive left maxillary canine. (b) Intra‐oral view of the same case shows the exposed canine ligated with elastic ligature to the first premolar. The space was held open by a steel tube tied between the incisor and premolar brackets. The extrusive force had resulted in the lateral open bite and cant of the occlusal plane. (c) Vertical intermaxillary bite‐closing (blue) elastics were used to support the anchorage of the maxillary arch. The mandibular canine bracket was ligated to a titanium screw temporary anchorage device with an elastic chain, to prevent unwanted reactive eruption of the lower teeth.
Zygomatic plate
Zygomatic plates (Figure 2.9a–c) may be used as the direct source of anchorage for intermaxillary and intramaxillary elastic attachment. Their placement is surgically more demanding than the bone anchor screw and they are generally inserted by an oral and maxillofacial surgeon. Notwithstanding this disadvantage, the zygomatic plate has several inherent advantages over screw TADs. In the first place, since it is not placed on the alveolar ridge, it can be used as the base from which to apply traction to move teeth in the mesio‐distal plane over long distances, without impediment and without the need to alter their positions in the light of progress. Thus, if placed bilaterally in a young adult patient, they may be employed in place of the much‐hated, user‐contentious and under‐worn extra‐oral headgear for efficient horizontal distal movement of all the posterior teeth, en bloc, in the treatment of a class II case.
Fig. 2.9 Zygomatic plate. (a) An onplant plate. (b) The plate is held in place by three screws into the inferior surface of the zygomatic arch. (c) The extension portion is drawn through the edges of the fully replaced and resutured surgical flap.
Zygomatic plates also have excellent application in the vertical plane, as in the treatment of open bite cases that are due to or in association with forward tongue posture and abnormal swallowing behaviour. In these patients there is an increase in the height of the lower third of the face and the maxillary posterior teeth are over‐erupted, with elongated alveolar processes. To close the anterior open bite by extrusion of the incisor teeth is both counterproductive in terms of the face height and highly unstable. On the other hand, it is easy to apply vertically intrusive force to the posterior teeth and achieve a significant reduction in the lower facial height. It should be remembered that 1 mm of molar intrusion is reflected as 3 mm of anterior open bite closure, simply because the incisors are that much further away from the temporomandibular joint centre of the mandibular rotation. The plate should be supported by placing a transpalatal bar between the molars, to prevent buccal ‘rolling’ of these teeth that would occur by applying the intrusive force from the zygomatic onplant plate to an unsupported single molar. The intrusively directed force is then distributed to the bracketed posterior teeth through the agency of an archwire that must reach all the way to the last erupted molar on each side. Intrusion of posterior teeth, rather than extrusion of anterior teeth, may produce more stable results in what seems to offer a greater chance for correction of the abnormal tongue and swallowing anomalies. It should be understood that the prognosis is still in doubt but, if considerable clinical experience (in the declared absence of solid evidence) is anything to go by, probably improved.
In the immediate context of the treatment of impacted teeth, however, this procedure offers advantages for problems that are difficult to overcome by other means, and nowhere is its efficacy easier to demonstrate than in relation to the resolution of an impacted second mandibular molar. If an attempt is made to elevate an impacted mandibular molar, particular one with a distinct mesial inclination beneath the distal bulbosity of the first molar, a great deal of anchorage potential may be expended in its alignment. To use the remaining teeth as the base from which the extrusive force is to be applied will rapidly cause marked intrusion of these teeth and a strong cant in the occlusal plane. In time, this may then secondarily cause an asymmetrical deterioration in the maxillary occlusal plane.
Had the opposing teeth been used as the anchorage base, rapid extrusion of these teeth and a cant in the upper occlusal plane would be generated. Furthermore, the maxillary second molar may already have over‐erupted a priori, in the absence of the unerupted mandibular second molar, and may even be impinging on the soft tissue overlying this impacted tooth. Clearly, therefore, intra‐arch or inter‐arch tooth‐borne mechanics are completely inappropriate unless backed up by some form of skeletal anchorage.
The over‐eruption of an unopposed maxillary second molar is usually recognized by its vertically prominent mesial marginal ridge in relation to the occlusal plane, as represented by the distal marginal ridge of the first molar. This needs to be corrected concurrently with orthodontic eruption of an impacted mandibular molar, to bring it into occlusion at the level of the occlusal plane. To this end, an elastic chain may be drawn across the occlusal surface of the over‐erupted maxillary molar from a palatal screw TAD to the intra‐oral extremity of the zygomatic plate implant.
At the same time, a vertical intermaxillary elastic may be placed by the patient from the same intra‐oral extremity of the zygomatic plate, to an attachment on the impacted tooth in the mandible. In this manner, it is easy to balance the degree of extrusion of the one with the degree of intrusion of the other, in relation to the occlusal plane. For these movements to be completed, no brackets or other appliances need to be placed on any of the other teeth. Furthermore, no retainer appliances need to be placed at the end of this phase of the treatment.
It will be appreciated that the zygomatic plate is an important device that may be used as a support to move a tooth mesially or distally and to extrude or to intrude a tooth. It may also be employed as an anchor base to safeguard against movement of a block of teeth and to move a large number of teeth at one and the same time. It may be used for intermaxillary up‐and‐down stability in the correction of vertical discrepancies and, antero‐posteriorly, for class II or class III correction.
Ankylotic, infra‐occluded, implanted or otherwise non‐movable teeth as bone anchors
