Direct usage of miniscrew anchorage to intrude overerupted maxillary posterior teeth before prosthodontic preparation: a case report
Identifieur interne : 001E49 ( Pmc/Corpus ); précédent : 001E48; suivant : 001E50Direct usage of miniscrew anchorage to intrude overerupted maxillary posterior teeth before prosthodontic preparation: a case report
Auteurs : Yasemin Bahar Acar ; Mustafa AtesSource :
- Journal of Istanbul University Faculty of Dentistry [ 2149-2352 ] ; 2016.
Abstract
Overeruption of maxillary molars due loss of opposing teeth creates occlusal and functional interferences. Before reconstruction can be initiated, intrusion of overerupted molars becomes essential. This report illustrates treatment of overerupted maxillary premolar and molar via direct use of miniscrew anchorage. A 24-year old female had lost first and second left mandibular molars due to pulpal necrotizing agents, resulting with a large alveolar bone defect and overerupted maxillary premolar and molar. She had a history of unsuccessful alveolar distraction of mandibular left premolars to increase the alveolar bone height prior to implant placement. Patient was satisfied with her smile and refused comprehensive orthodontic treatment. Maxillary premolar and molar were intruded segmentally for 4mm in 8 months, using a combination of a mini-implant and partialfixed edgewise appliances. Biological responses of teeth and surrounding bony structures to intrusion appeared normal and acceptable in radiographic and clinical examination.
Url:
DOI: 10.17096/jiufd.24271
PubMed: 28955554
PubMed Central: 5573452
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Direct usage of miniscrew anchorage to intrude overerupted maxillary posterior teeth before prosthodontic preparation: a case report</title><author><name sortKey="Acar, Yasemin Bahar" sort="Acar, Yasemin Bahar" uniqKey="Acar Y" first="Yasemin Bahar" last="Acar">Yasemin Bahar Acar</name><affiliation><nlm:aff id="aff1">Department of Orthodontics Faculty of Dentistry Marmara University<country>Turkey</country></nlm:aff></affiliation></author><author><name sortKey="Ates, Mustafa" sort="Ates, Mustafa" uniqKey="Ates M" first="Mustafa" last="Ates">Mustafa Ates</name><affiliation><nlm:aff id="aff2">Private Practice, Istanbul<country>Turkey</country></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28955554</idno><idno type="pmc">5573452</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573452</idno><idno type="RBID">PMC:5573452</idno><idno type="doi">10.17096/jiufd.24271</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">001E49</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001E49</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Direct usage of miniscrew anchorage to intrude overerupted maxillary posterior teeth before prosthodontic preparation: a case report</title><author><name sortKey="Acar, Yasemin Bahar" sort="Acar, Yasemin Bahar" uniqKey="Acar Y" first="Yasemin Bahar" last="Acar">Yasemin Bahar Acar</name><affiliation><nlm:aff id="aff1">Department of Orthodontics Faculty of Dentistry Marmara University<country>Turkey</country></nlm:aff></affiliation></author><author><name sortKey="Ates, Mustafa" sort="Ates, Mustafa" uniqKey="Ates M" first="Mustafa" last="Ates">Mustafa Ates</name><affiliation><nlm:aff id="aff2">Private Practice, Istanbul<country>Turkey</country></nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Istanbul University Faculty of Dentistry</title><idno type="ISSN">2149-2352</idno><idno type="eISSN">2149-4592</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Overeruption of maxillary molars due loss of
opposing teeth creates occlusal and functional
interferences. Before reconstruction can be initiated,
intrusion of overerupted molars becomes essential.
This report illustrates treatment of overerupted
maxillary premolar and molar via direct use of
miniscrew anchorage. A 24-year old female had lost
first and second left mandibular molars due to pulpal
necrotizing agents, resulting with a large alveolar bone
defect and overerupted maxillary premolar and molar.
She had a history of unsuccessful alveolar distraction
of mandibular left premolars to increase the alveolar
bone height prior to implant placement. Patient was
satisfied with her smile and refused comprehensive
orthodontic treatment. Maxillary premolar and molar
were intruded segmentally for 4mm in 8 months,
using a combination of a mini-implant and partialfixed
edgewise appliances. Biological responses of
teeth and surrounding bony structures to intrusion
appeared normal and acceptable in radiographic
and clinical examination.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Jakhi, Sa" uniqKey="Jakhi S">SA Jakhi</name></author><author><name sortKey="Parekh, Bk" uniqKey="Parekh B">BK Parekh</name></author><author><name sortKey="Gupta, S" uniqKey="Gupta S">S Gupta</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nagle, G" uniqKey="Nagle G">G Nagle</name></author><author><name sortKey="Woodbury, Ma" uniqKey="Woodbury M">MA Woodbury</name></author><author><name sortKey="Zenz, C" uniqKey="Zenz C">C Zenz</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Yakata, H" uniqKey="Yakata H">H Yakata</name></author><author><name sortKey="Azumi, T" uniqKey="Azumi T">T Azumi</name></author><author><name sortKey="Kawasaki, T" uniqKey="Kawasaki T">T Kawasaki</name></author><author><name sortKey="Nakajima, T" uniqKey="Nakajima T">T 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Mk" uniqKey="Eklund M">MK Eklund</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Umemori, M" uniqKey="Umemori M">M Umemori</name></author><author><name sortKey="Sugawara, J" uniqKey="Sugawara J">J Sugawara</name></author><author><name sortKey="Mitani, H" uniqKey="Mitani H">H Mitani</name></author><author><name sortKey="Nagasaka, H" uniqKey="Nagasaka H">H Nagasaka</name></author><author><name sortKey="Kawamura, H" uniqKey="Kawamura H">H Kawamura</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kuroda, S" uniqKey="Kuroda S">S Kuroda</name></author><author><name sortKey="Katayama, A" uniqKey="Katayama A">A Katayama</name></author><author><name sortKey="Takano Yamamoto, T" uniqKey="Takano Yamamoto T">T Takano-Yamamoto</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Favero, L" uniqKey="Favero L">L Favero</name></author><author><name sortKey="Brollo, P" uniqKey="Brollo P">P 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Istanb Univ Fac Dent</journal-id><journal-id journal-id-type="iso-abbrev">J Istanb Univ Fac Dent</journal-id><journal-id journal-id-type="publisher-id">J. Istanbul Univ. Fac. Dent.</journal-id><journal-id journal-id-type="hwp">jiufd</journal-id><journal-id journal-id-type="pmc">jiufd</journal-id><journal-id journal-id-type="publisher-id">IUFD</journal-id><journal-title-group><journal-title>Journal of Istanbul University Faculty of Dentistry</journal-title></journal-title-group><issn pub-type="ppub">2149-2352</issn><issn pub-type="epub">2149-4592</issn><issn-l>2149-2352</issn-l><publisher><publisher-name>Istanbul University Faculty of Dentisty</publisher-name><publisher-loc>Istanbul, Turkey</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28955554</article-id><article-id pub-id-type="pmc">5573452</article-id><article-id pub-id-type="doi">10.17096/jiufd.24271</article-id><article-id pub-id-type="publisher-id">jiufd-50-1-345</article-id><article-categories><subj-group subj-group-type="heading"><subject>Articles</subject><subj-group subj-group-type="heading"><subject>Biological Sciences</subject><subj-group subj-group-type="heading"><subject>Dentistry</subject></subj-group></subj-group></subj-group></article-categories><title-group><article-title>Direct usage of miniscrew anchorage to intrude overerupted maxillary posterior teeth before prosthodontic preparation: a case report</article-title><alt-title alt-title-type="short">Direct miniscrew anchorage for intrusion</alt-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Acar</surname><given-names>Yasemin Bahar</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref rid="cor" ref-type="corresp"><sup>*</sup></xref></contrib><contrib contrib-type="author"><name><surname>Ates</surname><given-names>Mustafa</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><aff id="aff1"><label>1</label>Department of Orthodontics Faculty of Dentistry Marmara University<country>Turkey</country></aff><aff id="aff2"><label>2</label>Private Practice, Istanbul<country>Turkey</country></aff></contrib-group><author-notes><corresp id="cor"><label>*</label>To whom correspondence should be addressed: Dr. Yasemin Bahar Acar <institution content-type="edu"> Department of Orthodontics Faculty of Dentistry Marmara University </institution><country>Turkey</country> Phone: +90 216 421 16 21 <email>yaseminbaharciftci@gmail.com</email></corresp></author-notes><pub-date pub-type="collection"><year>2016</year></pub-date><pub-date pub-type="epub"><day>12</day><month>1</month><year>2016</year></pub-date><volume>50</volume><issue>1</issue><fpage>43</fpage><lpage>50</lpage><history><date date-type="received"><day>20</day><month>10</month><year>2014</year></date><date date-type="accepted"><day>11</day><month>3</month><year>2015</year></date></history><permissions><copyright-statement>Copyright © 2016 Journal of Istanbul University Faculty of Dentistry</copyright-statement><copyright-year>2016</copyright-year><copyright-holder>Journal of Istanbul University Faculty of Dentistry</copyright-holder><license license-type="open-access"><license-p>This article is licensed under Creative Commons License Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) license (<ext-link ext-link-type="uri" xlink:href="https://creativecommons.org/licenses/by-nc-nd/4.0/" xlink:show="new"></ext-link>). Users must give appropriate credit, provide a link to the license, and indicate if changes were made. Users may do so in any reasonable manner, but not in any way that suggests the journal endorses its use. The material cannot be used for commercial purposes. If the user remixes, transforms, or builds upon the material, he/she may not distribute the modified material. No warranties are given. The license may not give the user all of the permissions necessary for his/her intended use. For example, other rights such as publicity, privacy, or moral rights may limit how the material can be used.</license-p></license></permissions><abstract><p>Overeruption of maxillary molars due loss of
opposing teeth creates occlusal and functional
interferences. Before reconstruction can be initiated,
intrusion of overerupted molars becomes essential.
This report illustrates treatment of overerupted
maxillary premolar and molar via direct use of
miniscrew anchorage. A 24-year old female had lost
first and second left mandibular molars due to pulpal
necrotizing agents, resulting with a large alveolar bone
defect and overerupted maxillary premolar and molar.
She had a history of unsuccessful alveolar distraction
of mandibular left premolars to increase the alveolar
bone height prior to implant placement. Patient was
satisfied with her smile and refused comprehensive
orthodontic treatment. Maxillary premolar and molar
were intruded segmentally for 4mm in 8 months,
using a combination of a mini-implant and partialfixed
edgewise appliances. Biological responses of
teeth and surrounding bony structures to intrusion
appeared normal and acceptable in radiographic
and clinical examination.</p></abstract><kwd-group><kwd>Miniscrew</kwd><kwd>interdisciplinary treatment</kwd><kwd>orthodontic intrusion</kwd><kwd>direct anchorage</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="s1"><title>Introduction</title><sec id="s1a"><title>Case Presentation</title><p>A 24-year old female patient was seeking
restoration of her left mandibular posterior
edentulous area and was referred to our clinic by
the prosthodontics department. She had overerupted
maxillary left second premolar and first molar teeth
due to the loss of lower left molars (<xref ref-type="fig" rid="fig1">Figure 1</xref>) At the age of 18, the patient consulted a dentist
for the pain in her lower left first molar tooth. After
application of pulpal necrotizing agent into the dental
cavity, the patient returned to the dentist months
later despite doctor’s instructions to return 2 days
later. In the meantime, the necrotizing agent leaked
from the dental cavity and damaged the neighboring
periodontium and second molar teeth. Eventually the
patient lost first and second left mandibular molars,
resulting with a large alveolar bone defect (<xref ref-type="fig" rid="fig2">Figure 2a</xref>). She was presented a treatment plan that consisted of
alveolar distraction of left premolars posteriorly until
third molar to increase the alveolar bone height prior to
implant placement, orthodontic intrusion of overeruped
upper teeth and finally prosthetic implant replacement of
the missing teeth (<xref ref-type="fig" rid="fig2">Figure 2b, 2c</xref>).
However, distraction protocol was unsuccessful and the premolar teeth lost
vitality. After endodontic treatment of premolars, the
patient was referred to department of orthodontics.</p><fig id="fig1" orientation="portrait" position="float"><label>Figure 1.</label><caption><p>Pretreatment facial and intraoral photographs.</p></caption><graphic xlink:href="jiufd-050-043-e001"></graphic></fig><fig id="fig2" orientation="portrait" position="float"><label>Figure 2.</label><caption><p>a) Pretreatment panoramic radiograph, b) Panoramic radiograph with alveolar distractor, c) Lateral cephaometric radiograph showing alveolar distractor.</p></caption><graphic xlink:href="jiufd-050-043-e002"></graphic></fig></sec><sec id="s1b"><title>Diagnosis and Etiology</title><p>This patient presented with a skeletal Class II
relationship due to retrognatic mandible and she had a
slightly convex profile (<xref ref-type="fig" rid="fig3">Figure 3</xref>).
Her dental condition
revealed Class II canine and molar relationships,
retroclined maxillary incisors and proclined
mandibular incisors, normal overjet and overbite,
mild maxillary crowding, overerupted maxillary left second premolar and first molar and missing
lower left first and second molar teeth. Judging by
the marginal ridge of maxillary left first premolar on
the dental casts, it was measured that maxillary left second premolar and first molar have overerupted by
4 mm, disturbing the occlusal plane continuity and
resulting in inadequate occlusal clearance for esthetic
and functional mandibular restorations.</p><fig id="fig3" orientation="portrait" position="float"><label>Figure 3.</label><caption><p>Pretreatment cephalometric radiograph.</p></caption><graphic xlink:href="jiufd-050-043-e003"></graphic></fig></sec><sec id="s1c"><title>Treatment Objectives</title><p>We presented a treatment plan that included
comprehensive orthodontic treatment with intrusion of overerupted teeth and distalization of posterior
dentition in the maxillary arch and leveling and
alignment in the mandibular arch. Treatment
objectives were to correct posterior interdigitation,
resolve anterior crowding, provide enough clearance
for lower posterior restorations and improve smile
esthetics. Patient was satisfied with her smile and
occlusion.Her main concern was reconstruction of lower
edentulous area and she wanted to solve her dental
problems as soon as possible. Therefore, she refused
comprehensive orthodontic treatment. An alternative
treatment plan that focused on intrusion of maxillary
left premolar and molar with segmental mechanics
and direct miniscrew anchorage was proposed. This
plan was adopted by the patient for esthetics and
shorter treatment duration.</p></sec><sec id="s1d"><title>Progress</title><p>Pretreatment orthodontic records (intraoral and
extraoral photographs, maxillary and mandibular dental casts, lateral cephalometric and panoramic
radiographs) were collected. After separation, an
alginate impression with molar bands on maxillary
first molars was taken. A transpalatal arch (TPA)
with acrylic button was constructed and soldered
to molar bands. This was then bonded with a dualcure
glass ionomer cement to bilateral molar teeth.
A partial-fixed 0.018-inch slot edgewise appliance
was placed on the upper left second premolar
and first molar, levelled sequentially with 0.016-
in and 0.016x0.022-in segmental nickel-titanium
archwires (<xref ref-type="fig" rid="fig4">Figure 4a</xref>).
After leveling and alignment,
0.016x0.022-in stainless-steel segmental archwire
was placed. At the same session, a non-osteointegrated
miniscrew (length, 7mm; diameter, 1.6 mm; Turkuaz,
Medikodental, Turkey) was placed through the
keratinized gingiva into the buccal alveolar bone
between the roots of second premolar and first molar under infiltrative local anesthesia. Miniscrew was
inserted high on the attached gingiva, slightly below
the mucogingival junction; taking into consideration
the amount of intrusion. Care was taken to apply the
anesthesia deep into the sulcus in order not to cause
swollen mucosa, which can be deceiving about the
height of mucogingival junction. A light intrusive
force of (100-150 gr) was loaded immediately by
power-chains between the archwire and the miniscrew.
(<xref ref-type="fig" rid="fig4">Figure 4b</xref>) After intrusion was completed, miniscrew
and appliances were retained in place to prevent reeruption
until the prosthesis were installed (<xref ref-type="fig" rid="fig5">Figure 5a</xref>)
After cementation of lower restorations, the
miniscrew and other appliances were removed without
the need for local anesthesia (<xref ref-type="fig" rid="fig5">Figure 5b</xref>) No retainer
was required because the posterior vertical dimension
had been reconstructed. The patient’s occlusion now
became stable and functional.</p><fig id="fig4" orientation="portrait" position="float"><label>Figure 4.</label><caption><p>a) Levelling with segmental 0.016-in nickel-titanium archwire b) power-chains between 0.016x0.022-in stainless-steel
archwire and miniscrew.</p></caption><graphic xlink:href="jiufd-050-043-e004"></graphic></fig><fig id="fig5" orientation="portrait" position="float"><label>Figure 5.</label><caption><p>a) Appliances retained in place until final restoration of lower teeth b) Immediately after removal
of miniscrew and appliances c) Post-treatment facial photographs.</p></caption><graphic xlink:href="jiufd-050-043-e005"></graphic></fig></sec></sec><sec sec-type="results" id="s2"><title>Results</title><p>Maxillary premolar and molar teeth were intruded
segmentally by using a combination of a mini-implants
and partial-fixed edgewise appliances without disturbing
the occlusion and the other dentition in a short period.
Total orthodontic treatment time was 8 months.
Pretreatment and post treatment records were compared
to evaluate treatment results.</p><p>In order to measure the amount of intrusion; firstly
a vertical line that passes from the intermaxillary suture
was drawn (Line A). Vertical lines (Line B and C) that
extends downwards from the buccal cusp tip of 2nd
premolar (Point 1) and mesiobuccal cusp tip of 1st molar (Point 2) to was drawn parallel to Line A. The points
where Lines B and C intersect the superior border of
the mandibular corpus were marked (Point 3 and 4).
Distances between points 1-3 and 2-4 were measured
in pretreatment and posttreatment OPTGs. The increase in the posttreatment OPTG was recorded
as the amount of intrusion. In pretreatment OPTG, the maxillary sinus floor
showed pneumatization due to over-eruption of the
teeth. Post treatment panoramic radiograph and clinical
examination showed that roots of the intruded teeth
remained intact (<xref ref-type="fig" rid="fig6">Figure 6</xref>)
Bicuspid was intruded effectively without tipping but some mesial tipping of the
molar tooth was seen despite the segmental 0.016x0.022-
in stainless-steel archwire. Tipping of the molar can be a
result of the larger root mass of the tooth and therefore
the higher cortical resistance of the sinus floor, repressing
parallel intrusion of the tooth. <xref ref-type="fig" rid="fig7">Figure 7</xref> shows the pre and post-treatment cast
models of the patient. The line that connects the
mesial cusp tip of upper second molar and the cuspid
emphasize the change in the level of marginal gingiva
and the change in the occlusal level of intruded teeth.
<fig id="fig6" orientation="portrait" position="float"><label>Figure 6.</label><caption><p>Diagram explaining the method of measurements on post treatment panoramic radiograph.</p></caption><graphic xlink:href="jiufd-050-043-e006"></graphic></fig><fig id="fig7" orientation="portrait" position="float"><label>Figure 7.</label><caption><p>Pre and post-treatment cast models.</p></caption><graphic xlink:href="jiufd-050-043-e007"></graphic></fig></p></sec><sec sec-type="discussion" id="s3"><title>Discussion</title><p>Chemotherapeutic agents such as arsenic trioxide
and paraformaldehyde were commonly employed
as pulp-necrotizing agents in the past to devitalize
inflamed pulpal tissue. In dentistry, arsenic trioxide,
a water-soluble compound, has been used in a dental
paste form. Due to its dissolving capacity, this agent
has a potential for leakage not only from the dental
cavity into the gingiva, but also through the apical
foramen and accessory canals to the periodontal
tissues (<xref rid="b1" ref-type="bibr">1</xref>, <xref rid="b2" ref-type="bibr">2</xref>, <xref rid="b3" ref-type="bibr">3</xref>).</p><p>Arsenic and its compounds are reported to have
extreme cytotoxic and carcinogenic potential on hard
and soft tissues, which eliminated them from clinical
dental practice especially after the development of
effective local anesthesia techniques. However, some
cases are still encountered where patients suffer large
tissue damage due to the use of pulp-necrotizing
pastes (<xref rid="b4" ref-type="bibr">4</xref>, <xref rid="b5" ref-type="bibr">5</xref>, <xref rid="b6" ref-type="bibr">6</xref>, <xref rid="b7" ref-type="bibr">7</xref>). This report presents the orthodontic
treatment of a case, where the leakage of the arsenic
trioxide caused wide periodontal tissue damage in the
mandible and this has led to the loss of mandibular
teeth, extrusion of antagonist teeth and prosthodontic
problems consecutively. The patient had to undergo
complex dental treatment procedures while she could
have only received endodontic treatment for the molar
tooth. Overerupted maxillary molar teeth had to be
intruded in order to restore the upper occlusal plane and a functional occlusion. For this purpose, one
minicrew was placed on the buccal alveolar bone and
used as the direct anchorage unit. Miniscrew implants
are available in different lengths and diameters to
accommodate placement at different sites in both
jaws and they have been reported to be biocompatible
(<xref rid="b8" ref-type="bibr">8</xref>, <xref rid="b9" ref-type="bibr">9</xref>, <xref rid="b10" ref-type="bibr">10</xref>).</p><p>Miniscrew anchorage is reported to be used in many
cases, such as the correction of deep overbites, closure
of extraction spaces, correction of a canted occlusal
plane, alignment of dental midlines, extrusion of
impacted canines, extrusion and uprighting of impacted
molars, molar intrusion, maxillary molar distalization,
distalization of mandibular teeth, en-masse retraction
of anterior teeth, molar mesialization, upper third
molar alignment, intermaxillary anchorage for the
correction of sagittal discrepancies, and correction of
vertical skeletal discrepancies that would otherwise
require orthognathic surgical procedure (<xref rid="b11" ref-type="bibr">11</xref>).
Miniscrew anchorage is especially useful for tooth
intrusion, because it can apply a low, continuous force
without causing reciprocal movements of other teeth
(<xref rid="b12" ref-type="bibr">12</xref>, <xref rid="b13" ref-type="bibr">13</xref>, <xref rid="b14" ref-type="bibr">14</xref>). Under constant loading with medium forces
of 150 to 200 g from elastic modules, the molars
intrude, whereas the implants remain stable (<xref rid="b15" ref-type="bibr">15</xref>).</p><p>An intrusion force, directed upwards, was applied
with elastic power chains between the archwire and the miniscrew. The orientation of the intrusive force
from the implants to the molar attachments determines
the direction of the tooth movements. In this case, the
point of force application was more buccal than the
center of rotation of the teeth; which would cause the
teeth to tip buccally during intrusion. Buccal tipping
of the teeth was not desired and had to be prevented.
The TPA was used to fix the intermolar width and it
was rigid enough to prevent buccal tipping of teeth.
Additionally, the TPA was constructed 5 mm away
from the palatal tissue and an acrylic button was
included. This was used to decrease the space of the
tongue to obtain an intrusive force from the palatal
side at the same time, with the pressure of the tongue.
It is accepted that if the transpalatal arch crosses the
palate 2 to 3 mm away from the mucosa, tongue
forces during swallowing will assist the molars and
they will be intruded by vertical tongue forces during
swallowing (<xref rid="b16" ref-type="bibr">16</xref>).</p><p>In a study by Chiba et al, the maximum tongue
pressure value on the loop of TPA was obtained when
the loop was at the level of 2nd molars and a distance
of 6 mm from the palatal mucosa (<xref rid="b17" ref-type="bibr">17</xref>). The finding
that the bicuspid intruded more and parallel than the
molar might suggest that the rate of intrusion was
dictated by the number of the roots. The bony resistance from the three roots of a molar
may exceed that of a single root bicuspid. However,
the intruded teeth and the affected bone responded
well to the intrusive loading while the force applied
was mild and constant.</p></sec><sec sec-type="conclusion" id="s4"><title>Conclusion</title><p>Direct anchorage from a miniscrew is useful
for tooth intrusion to apply a low, continuous force
without causing reciprocal movements of other teeth,
especially in cases where segmental orthodontic
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