Miniscrews as orthodontic anchorage. Part 2. Retrospective questionnaire study, possible complications.

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KotevnõÂ minisÏrouby v ortodoncii. 2. dõÂl.

DotaznõÂkova studie, mozÏne komplikace

Miniscrews as orthodontic anchorage. Part 2.

Retrospective questionnaire study, possible complications.

MUDr.OndrÏej HajnõÂk, MUDr.Magdalena Kot'ovaÂ, Ph.D.

Ortodonticke oddeÏlenõ Stomatologicke kliniky 3. LF UK a FNKV Praha

Department of Orthodontics, Clinic of Dental Medicine, 3rd Medical Faculty of Charles University, and University Hospital KraÂlovske Vinohrady Praha

Souhrn

Jsou probraÂny mozÏne komplikace prÏi pouzÏitõ kotevnõÂch minisÏroubuÊ v ortodoncii, jejich indikace a kontraindi-kace. Byla provedena dotaznõÂkova studie ke zjisÏteÏnõ postojuÊ pacientuÊ k zavedenõ minisÏroubuÊ z ortodontickyÂch duÊ-voduÊ. Z vyÂsledkuÊ studie vyplyÂvaÂ, zÏe 79 % pacientuÊ necõÂtõ bud'zÏaÂdnou, nebo mõÂrnou bolest po zavedenõ minisÏroubu a 96 % necõÂtõ bud'zÏaÂdnou, nebo mõÂrnou bolest po vyjmutõ a võÂce nezÏ 90 % pacientuÊ by si nechalo minisÏroub v prÏõÂ-padeÏ potrÏeby zaveÂst znovu. ZaÂteÏzÏ pacienta prÏi pouzÏitõ kotevnõÂho minisÏroubu je nepatrnaÂ, terapeuticky efekt velmi dobryÂ. Zavedenõ a zejmeÂna odstraneÏnõ minisÏroubuÊ je instrumentaÂlneÏ, cÏasoveÏ i ekonomicky nenaÂrocÏne a pacienta netraumatizuje(Ortodoncie 2008, 17, cÏ. 3, s. 12-20).

Abstract

Potential complications accompanying the use of miniscrews as orthodontic anchorage are discussed, their indications and contraindications. The questionnaire study records patients' attitudes on miniscrews. The results suggest that 79% of patients have no pains or just moderate discomfort after the insertion of a miniscrew, 96% patients state no pains or just a moderate discomfort after the miniscrew was removed. More than 90% of pa-tients would agree with a new application of the miniscrew if necessary. Demands on a patient with a miniscrew are insignificant; the effect of therapy is very good. The insertion of a miniscrew and its removal is undemanding in terms of armamentarium, time and economic costs and comfortable for a patient(Ortodoncie 2008, 17, No. 3, p. 12-20).

KlõÂcÏova slova:skeletaÂlnõ ortodonticke kotvenõÂ, docÏasna kotevnõ zarÏõÂzenõÂ, kotevnõ minisÏroub.

Key Words:skeletal orthodontic anchorage, temporary anchorage devices, miniscrew as orthodontic anchorage

UÂvod

Komplikace spojene s minisÏrouby a jejich rÏesÏenõÂ

V odborne literaturÏe lze najõÂt mnozÏstvõ kazuistik a studiõÂ, ze kteryÂch je zrÏejmeÂ, zÏe pouzÏitõ minisÏroubuÊ v ortodoncii je metoda spolehliva a takto vytvorÏene kotvenõ je stabilnõÂ. NicmeÂneÏ bez rÏaÂdne erudice a prak-tickeÂho naÂcviku muÊzÏe vyuzÏitõÂtohoto druhu skeletaÂlnõÂho kotvenõ veÂst k ne uÂplneÏ ideaÂlnõÂmvyÂsledkuÊm a neÏkdy muÊzÏe byÂt zdrojemzklamaÂnõ a prÏõÂpadneÏ posÏkozenõÂ

pa-Introduction

Complications accompanying miniscrew appli-cation and their management

In literature we can find many case studies sugge-sting the use of miniscrews in orthodontics is reliable and stable. However, experience and proper training is the prerequisite for successful application of minisc-rews. Therefore, it is a must for an orthodontist to be well informed about potential complications and ways

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cienta. Znalost mozÏnyÂch komplikacõÂ a jejich rÏesÏenõÂ je nezbytnyÂmprÏedpokladempro uÂspeÏch a spokojenost z hlediska osÏetrÏujõÂcõÂho leÂkarÏe i pacienta [8, 25, 26, 28, 29, 43].

NedostatecÏna primaÂrnõ stabilita je patrneÏ nejcÏasteÏji uvaÂdeÏnou komplikacõÂ, jde o stav, kdy je minisÏroub po zavedenõ do kosti nepatrneÏ pohyblivyÂ, cozÏ daÂle vede k jeho zjevne mobiliteÏ s naÂslednyÂmuvolneÏnõÂma selhaÂ-nõÂm.

SoucÏasne poznatky sveÏdcÏõ o tom, zÏe maximum sta-bility minisÏroubu je zajisÏteÏno kompaktou a jen v mensÏõ mõÂrÏe spongiosou. Je trÏeba zvolit takove mõÂsto pro za-vedenõÂ, kde bude kompakty dostatek, poprÏõÂpadeÏ zvolit veÏtsÏõ velikost minisÏroubu. Bylo zjisÏteÏno, zÏe prÏi velkeÂm uÂhlu kraniometrickyÂch basõ cÏelistõ je kompakta v dolnõ cÏelisti tencÏõÂ. U tohoto typu pacientuÊ je proto dobre zvo-lit minisÏroub veÏtsÏõÂch rozmeÏruÊ [25].

DalsÏõÂm duÊvodemnedostatecÏne primaÂrnõ stability muÊzÏe byÂt prÏedvrtaÂnõ prÏõÂlisÏ velke sÏtoly, cozÏ se zpravidla stane v situaci, kdy osÏetrÏujõÂcõÂleÂkarÏ neudrzÏõÂvrtaÂk v jedne rovineÏ a pruÊm eÏr sÏtoly se tak zveÏtsÏõÂ. PouzÏitõÂmsamo-vrtneÂho minisÏroubu se da komplikaci tohoto typu prÏedejõÂt.

OpozÏdeÏna mobilita minisÏroubu muÊzÏe prÏijõÂt v naÂsle-dujõÂcõÂch dnech cÏi m eÏsõÂcõÂch po zavedenõÂ. Tento typ ne-stability je obvykle zpuÊsoben prÏetõÂzÏenõÂmnebo naopak nedostatecÏnyÂmzatõÂzÏenõÂmminisÏroubu. OkamzÏite zatõÂ-zÏenõÂminisÏroubu stimuluje formaci kosti a postupneÏ do-chaÂzõ k jeho upevnÏovaÂnõÂ. Pokud nenõ minisÏroub zatõÂzÏen od zacÏaÂtku, muÊzÏe dojõÂt k vruÊstaÂnõ epiteliõ mezi povrch minisÏroubu a kosti, cozÏ vede k naÂsledne mobiliteÏ. PrÏi iniciaÂlnõÂmzateÏzÏovaÂnõ je trÏeba zmeÏrÏit sõÂlu, kterou ho-dlaÂme minisÏroub zatõÂzÏit - nemeÏla by prÏesaÂhnout 50 g.

Ne vsÏechny pohyblive minisÏrouby musõ byÂt okam-zÏiteÏ vyjmuty. Pokud je mobilita jen nepatrnaÂ, pacient nema zÏaÂdne obtõÂzÏe, nejsou patrne klinicke znaÂmky zaÂ-neÏtu a minisÏroub je stabilnõ natolik, aby odolal ortodon-tickyÂmsilaÂm , m uÊzÏeme jej ponechat na mõÂsteÏ. Pokud je vsÏak mobilita zjevnaÂ, je nutne jej vyjmout a pokusit se zaveÂst novy minisÏroub na jine mõÂsto. Pozdnõ mobilita muÊzÏe byÂt teÂzÏ zpuÊsobena take prÏetocÏenõÂmminisÏroubu prÏi sÏroubovaÂnõ do kosti. Je trÏeba dbaÂt na to, abychom prÏestali sÏroubovat ve chvõÂli, kdy dosaÂhne krcÏek minisÏ-roubu periostu. Pokud nenõ prÏi prÏedvrtaÂnõ zajisÏteÏno do-statecÏne chlazenõ vrtaÂku, muÊzÏe dojõÂt k prÏehrÏaÂtõ kosti a neprÏõÂznivy osud minisÏroubu je tak zpecÏeteÏn.

PrÏi nedodrzÏenõÂ anatomickyÂch zaÂsad muÊzÏe prÏi zavaÂ-deÏnõÂ dojõÂt k porusÏenõÂ anatomickyÂch struktur jako jsou ceÂvy, nervy, zubnõÂ korÏeny a maxilaÂrnõÂ sinus.

Z ceÂv prÏichaÂzõ v uÂvahu arteria palatina maior, z nervuÊ prÏedevsÏõÂmnervus palatinus a nervus mentalis. V prÏõÂpadeÏ, zÏe je osÏetrÏujõÂcõ leÂkarÏ v topograficke anatomii dostatecÏneÏ orientovaÂn, nemeÏlo by k narusÏenõ ceÂv a nervuÊ dojõÂt.

of their management. These are preconditions of suc-cessful results for both a professional and a patient [8, 25, 26, 28, 29, 43].

Insufficient primary stability is probably amongst the most frequent problems. The miniscrew - after the insertion into a bone - moves subtly, which further results in visible mobility of the screw, followed by its loosening and failure.

In the light of current knowledge it is clear that the maximum stability of a miniscrew is facilitated by cor-tical bone and to a lesser degree by trabecular bone. Therefore, it is necessary to choose the place of inser-tion with sufficient amount of compact bone, or to use a bigger miniscrew. ¹High angleª patient is accompa-nied with a thinner cortical bone in the mandible. In such patients it is advisable to use a bigger miniscrew [25].

Insufficient primary stability may be the result of a too large predrilled passageway. This occurs in case an orthodontist fails to keep a drill in one and the same plane, and therefore the passageway diameter is changed. We can avoid the complication when we use a self drilling miniscrew.

Delayed mobility of a miniscrew may occur within days or months after the insertion. This is usually the result of overloading or insufficient loading of a mini-screw. Immediate loading of a miniscrew stimulates bone formation, and thus the miniscrew is gradually fi-xed. In case the miniscrew is not loaded at the very be-ginning, epitheliummay grow between the surface of the miniscrew and the bone, which results in the mobi-lity of the miniscrew. The initial loading should not exceed 50 g.

However, not all mobile miniscrews must be remo-ved immediately. In case the mobility is only moderate, the patient gives no discomfort, there are no symp-toms of inflammation, and the miniscrew is stable enough to resist orthodontic forces, the miniscrew may be left in its place. Nevertheless, in case the mo-bility is visible, the miniscrew must be removed and a new one is inserted in another place. Delayed mobi-lity may be also due to overwind of the miniscrew. We have to stop screwing at the moment when the neck of a miniscrew gets to periosteum. If the drill is not suffi-ciently cooled during predrilling, the bone may over-heat and the treatment results in failure.

Anatomical structures may be damaged during the insertion that does not respect anatomical principles. Veins, nerves, roots, and maxillary sinus are disrupted (especially arteria palatina maior, nervus palatinus, and nervus mentalis).

Another situation arises in case of a randomcontact of a miniscrew and the tooth root or in case antrumis penetrated. During the insertion between the teeth

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Jina je situace prÏi naÂhodneÂmkontaktu minisÏroubu s korÏenemzubu cÏi prÏi narusÏenõ antra. PrÏi zavaÂdeÏnõ minisÏ-roubu mezi korÏeny zubuÊ m uÊzÏe ke kontaktu minisÏminisÏ-roubu s korÏenemzubu dojõÂt i v prÏõÂpadeÏ, zÏe leÂkarÏ postupuje na-prosto exaktneÏ podle nejlepsÏõÂho veÏdomõ a sveÏdom õÂ.

Po zvolenõ mõÂsta pro zavedenõ a jeho rentgenove ve-rifikaci pomocõ mõÂrky ma totizÏ leÂkarÏ k dispozici pouze dvourozmeÏrnou informaci o postavenõ zubuÊ. Pokud nenõ intraoraÂlnõ snõÂmek prÏõÂsneÏ ortoradiaÂlnõÂ, muÊzÏe se vhodne mõÂsto pro inzerci projikovat nespraÂvneÏ. Poru-sÏenõÂperiodoncia cÏi korÏene zubu je pak dõÂlemokamzÏiku. Melsenova a rÏada dalsÏõÂch doporucÏuje rucÏnõ zavaÂ-deÏnõ sÏroubovaÂkem, nebot' jen tak ma leÂkarÏ dostatecÏ-nou taktilnõ kontrolu nad minisÏroubem[28].

V prÏõÂpadeÏ, zÏe dochaÂzõ ke kontaktu se zubem, leÂkarÏ to zpravidla ucõÂtõ a mõÂrnyÂmvychyÂlenõÂmosy minisÏroubu se mu muÊzÏe podarÏit korÏen atraumaticky minout. PrÏi za-vaÂdeÏnõ je trÏeba znecitliveÏnõ pouze mukoperiostu a po-kud je zvolena spraÂvna daÂvka anestetika, pacient prÏõÂ-padny kontakt minisÏroubu s periodonciempocõÂtõ a m uÊzÏe to daÂt leÂkarÏi najevo [10]. Pokud k narusÏenõ pe-riodoncia cÏi korÏene dojde, hrozõ vznik ankyloÂzy zubu. Tsukiboshi ve sve studii vsÏak tvrdõÂ, zÏe narusÏene perio-dontaÂlnõ ligamentum se zhojõ vznikem noveÂho atta-chmentu [41].

Andreasen a Kristerson zjistili, zÏe pokud je defekt v periodonciu mensÏõ nezÏ 2 mm, dochaÂzõ ke zhojenõ ad integrumbez vzniku ankyloÂzy [42]. Asscherickxova a kol. ve sveÂmexperimentu na psech podrobili analyÂze trÏi zuby, jejichzÏ korÏeny byly porusÏeny zavedenyÂmi mi-nisÏrouby. U vsÏech dosÏlo beÏhem18 tyÂdnuÊ po vyjmutõ minisÏroubuÊ k teÂm eÏrÏ kompletnõÂmu zahojenõ defektuÊ [43]. ZaveÂst nesÏt'astnou naÂhodou minisÏroub prÏõÂmo do korÏene je teÂm eÏrÏ nemozÏneÂ. Pokud je zavaÂdeÏnõ ma-nuaÂlnõÂ, taktilnõ vjemprÏi kontaktu s korÏenemje natolik zrÏejmyÂ, zÏe k penetraci do korÏene dojõÂt nemuÊzÏe.

Riziko zavedenõÂminisÏroubu do antra vzruÊsta s pneu-matizacõ maxilaÂrnõÂho sinu, ktera je zpravidla dobrÏe pa-trna na ortopantomogramu. NejveÏtsÏõÂmrizikempo vzniku oroantraÂlnõ komunikace je maxilaÂrnõ sinusitis a chronicka oroantraÂlnõ põÂsÏteÏl. PorusÏenõ integrity an-traÂlnõ dutiny nemusõ byÂt diagnostikovaÂno. SÏroub zave-deny do antra muÊzÏe totizÏ fungovat v perforaci jako ¹zaÂ-tkaª, prÏes nõÂzÏ prÏeroste antraÂlnõ sliznice a po vyjmutõ leÂ-karÏ opeÏt nemusõ prÏedesÏlou komunikaci vuÊbec diagnostikovat.

Periimplantitis se projevuje pouze v prÏõÂpadeÏ osteointegrovaneÂho protetickeÂho implantaÂtu, proto je prÏi zaÂneÏtu kolemminisÏroubu vhodneÏjsÏõ pouzÏõÂvat pojmu ¹periimplantitis okolo docÏasneÂho kotvenõª (TAP - Tem-porary Anchorage Periimplantitis), jejõÂzÏ prÏõÂcÏinou byÂvaÂ, jako u prave periimplantitis, anaerobnõ infekce. Mobi-lita minisÏroubu se rozvõÂjõ rychle a je doprovaÂzena bo-lestõÂ. MinisÏroub je nutne vyjmout.

roots the contact between a miniscrew and a root may occur even if an orthodontist proceeds exactly. The orthodontist has at his disposal only two-dimensional information about the teeth position. In case the intrao-ral X-ray is not precisely directed, the appropriate place for the insertion may project incorrectly. Perio-dontal ligament or a root may be disturbed very easily. Melsen and others recommend manual insertion with a screwdriver as this allows for a good tactile con-trol over the miniscrew [28].

The orthodontist usually feels when the contact occurs, he can moderately deflect the miniscrew axis and avoid the root. Only mucoperiosteum is anestheti-zed, and the patient may notice the contact of the mi-niscrew with a periodontal ligament and let the ortho-dontist know [10]. Disruption of periodontal ligament or a root may lead to ankylosis of the tooth. However, Tsukiboshi [41] states that a disturbed periodontal li-gament heals with a creation of a new attachment.

Andreasen and Kristerson recorded that in case the defect in periodontium does not exceed 2 mm, it is healed ad integrumwithout the thread of ankylosis [42]. Asscherickx et al. [43] experimented with dogs and made the analysis of three teeth that were distur-bed by the inserted miniscrews. Within 18 weeks after the miniscrews were removed, all defects healed com-pletely. To insert a miniscrew directly into the root by accident is virtually impossible. In manual insertion the tactile perception of the contact with a root is so clear that the penetration is impossible.

The risk of inserting the miniscrew into antrum in-creases with pneumatization of maxillary sinus. This is rather obvious in OPG. After the oroantral communica-tion occurs, the greatest risk is the maxillary sinusitis and a chronic oroantral fistula. However, disruption of the antrumintegrity may not be diagnosed. The screw introduced into the antrummay function in the perfora-tion as a sort of a tap. Mucosa may overgrow the screw and an orthodontist may not notice the perforation at all. Periimplantitis occurs only with osseointegrated prosthetic implants, therefore it is better to use the term Temporary Anchorage Periimplantitis (TAP). The cause is usually, as with periimplantitis proper, anaero-bic infection. Mobility of the miniscrew occurs very soon and is painful. In such a case the miniscrew must be removed.

Lesion of soft tissues due to the insertion is not very frequent. There is no need to manipulate in any way with soft tissue during the insertion of miniscrews, be-cause the place of insertion is in the area of marginal gingiva. If the insertion must be performed in the area of mucosa, mucous membrane tends to wind around the body of the screw. Therefore, we have to use a round mucotom or cut the mucosa with a scalpel

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-Trauma meÏkkyÂch tkaÂnõ prÏi zavaÂdeÏnõ byÂva kompli-kacõÂneprÏõÂlisÏ cÏastou. PrÏi zavaÂdeÏnõÂminisÏroubuÊ nenõÂtrÏeba jakkoli manipulovat s meÏkkyÂmi tkaÂneÏmi, nebot' zavaÂ-deÏnõ je lokalizovaÂno v oblasti prÏipojene gingivy. Pokud je nutne minisÏroub zaveÂst v oblasti sliznice, ma tato tendenci se omotaÂvat okolo teÏla minisÏroubu. Je nutne pouzÏõÂt kruhovy mukotom nebo naÂrÏez skalpelem, kte-ryÂmse vytvorÏõ otvor v mukoperiostu a tõÂmto tunelem je pote m ozÏne minisÏroub zaveÂst. K traumatizaci meÏk-kyÂch tkaÂnõ m uÊzÏe dojõÂt nejen prÏi zavaÂdeÏnõÂ. I beÏhemorto-donticke terapie je nutne pecÏliveÏ kontrolovat, zda hla-vicÏka minisÏroubu cÏi prÏõÂdavna zarÏõÂzenõÂ, jako jsou tazÏne pruzÏinky cÏi elasticke rÏetõÂzky, neinterferujõ s meÏkkyÂmi tkaÂneÏmi. NejmeÂneÏ vhodnyÂm mõÂstem pro zavedenõ mi-nisÏroubu se zda byÂt v teÂto souvislosti fornix vestibula. KromeÏ traumatizace se muÊzÏe objevit i zaÂneÏt.

Infekce meÏkkyÂch tkaÂnõ spojena se zavedenõÂmmini-sÏroubu se projevuje lehkyÂmeryteÂmem. Tuto kompli-kaci zpravidla vyrÏesÏõ zlepsÏena uÂstnõ hygiena a vyÂplachy 0,12 % chlorhexidinempo dobu 1 tyÂdne; je trÏeba vcÏasna diferenciaÂlnõ diagnostika periimplantitis.

Interference minisÏroubu a zubu beÏhemterapie je meÂneÏ cÏastou komplikacõÂ.

V pruÊbeÏhu ortodonticke terapie se muÊzÏe posuno-vany zub prÏiblõÂzÏit k minisÏroubu natolik, zÏe vznikne ne-bezpecÏõ resorpce korÏene. Melsenova ale tvrdõÂ, zÏe po-kud se zub postupneÏ k minisÏroubu prÏiblizÏuje, dojde drÏõÂve nezÏ k resorpci korÏene k uvolnÏovaÂnõ minisÏroubu.

Fraktura minisÏroubu prÏi zavaÂdeÏnõ cÏi vyjmutõ nenõ cÏa-staÂ, ale je trÏeba ji uveÂst. Ke zlomenõ dochaÂzõÂ, pokud je minisÏroub prÏõÂlisÏ tenky v oblasti krcÏku. PrÏi vyÂbeÏru mini-sÏroubu je nutne pecÏliveÏ zvaÂzÏit kvalitu kosti v mõÂsteÏ za-vedenõ a adekvaÂtneÏ tomu vybrat spraÂvnou velikost mi-nisÏroubu. Pokud k zalomenõ dojde hloubeÏji v kosti, stojõ za zvaÂzÏenõÂ, zda fragment v kosti neponechat. Pokud je vsÏak fragment v uÂzkeÂmvztahu k periodonciu zubu, cÏi je blõÂzÏe k povrchu, je nutne jej chirurgicky odstranit. Po-kud je vyvõÂjen prÏi zavaÂdeÏnõ samovrtneÂho minisÏroubu prÏõÂlisÏ velky tlak, nebo je vrstva kompakty prÏõÂlisÏ silnaÂ, muÊzÏe dojõÂt ke zlomenõ gracilnõÂho hrotu, ktery zajisÏt'uje samovrtnost kotevnõÂho zarÏõÂzenõÂ. V tomto prÏõÂpadeÏ je nutne minisÏroub vymeÏnit za novy a o zavedenõ se po-kusit znovu pomocõ mensÏõÂho tlaku, poprÏõÂpadeÏ proveÂst lehky naÂvrt kompakty [28].

NeÏkdy byÂva komplikovane odstraneÏnõ minisÏroubu. Pokud je minisÏroub po vyuzÏitõ v ortodonticke terapii osteointegrovaÂn, je prÏõÂlisÏ pevny a nenõ mozÏne jej prÏi prvnõ naÂvsÏteÏveÏ vyjmout, doporucÏuje se neÏkolik dnõ prÏed plaÂnovanyÂmodstraneÏnõÂm sÏroubu s nõÂmopako-vaneÏ pootocÏit. JizÏ samotny prvnõ pokus o vyjmutõ sÏroubu zpuÊsobõ v kosti mikrofraktury a dõÂky vyvolanyÂm tkaÂnÏovyÂmzmeÏnaÂmdojde za neÏkolik dnõ k samovol-neÂmu uvolneÏnõ minisÏroubu a pote jizÏ nebyÂva probleÂm jej z kosti beÏhem3-7 dnõ vysÏroubovat [13].

to make a hole in mucoperiosteum through which the miniscrew is then inserted. Soft tissues may be injured not only during the insertion. It is necessary to check during orthodontic treatment whether the miniscrew head or additional devices, e.g. traction springs or ela-stic chains, do not interfere with soft tissues. Fornix of oral vestibule seems to be the least appropriate place for the insertion of a miniscrew. Apart from lesions, an inflammation may arise.

Infection of soft tissues due to the miniscrew inser-tion manifests itself as a mild erythema. The problem is usually solved with improved hygiene of the oral cavity and irrigations with 0.12% chlorhexidine applied for one week. Differential diagnostics for periimplantitis is required.

Interference of a miniscrew and a tooth during the the-rapy is less frequent. The tooth which is moved may get so close to the miniscrew that the danger of a root re-sorption arises. However, Melsen states that in case the tooth approaches a miniscrew gradually, the minisc-rew loosens before the resorption may appear.

Fracture of a miniscrew during its insertion or remo-val is rather rare. The miniscrew that is too thin in the neck area may break. We have to consider the quality of the bone in the place of insertion, and choose an ap-propriate size of a miniscrew accordingly. In case the miniscrew breaks deeper in the bone, it may be possi-ble to leave the fragment there. If the fragment is close to periodontal ligament, or close to the surface, it must be surgically removed. If there is an enormous pres-sure during the insertion of a self drilling miniscrew, or the compact bone layer is too thick, the delicate tip of the screw may break. In such a situation we have to use a new miniscrew and try to insert it using less pressure, or to predrill the compact bone [28].

Sometimes the problems may occur in removal of the miniscrew. In case a miniscrew is osseointegrated (after orthodontic therapy), it is too rigid, and we can-not remove it, it is recommended to screw or wobble the miniscrew repeatedly several days before the plan-ned removal. The first attempt to remove the minisc-rew results in minifractures of a bone. Thus the chan-ges in tissues are elicited, and within a few days the mi-niscrew loosens itself. After 3-7 days the mimi-niscrew may be screwed off without any problem [13].

However, complications may occur immediately af-ter the miniscrew was removed. If there is pain, oedema or exudation near the wound, irrigations with 0.12% chlorhexidine are recommended.

Late complications following the miniscrew removal are rather rare, and include ankylosis of the tooth close to the place of insertion. The tooth must be regularly controlled to avoid inner or outer resorption.

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I bezprostrÏedneÏ po vyjmutõ minisÏroubu se muÊzÏeme setkat s komplikacemi. Pokud po vyjmutõ prÏetrvaÂva bolest, otok nebo exsudace v okolõ raÂny, doporucÏujõ se vyÂplachy 0,12% chlorhexidinempo dobu neÏkolika naÂsledujõÂcõÂch dnuÊ.

Pozdnõ komplikace po odstraneÏnõ ortodontickeÂho kotevnõÂho minisÏroubu jsou vzaÂcne a patrÏõ mezi neÏ an-kyloÂza zubu, v jehozÏ blõÂzkosti byl zaveden minisÏroub. Pokud toto podezrÏenõ vznikne, je nutne zub pravidelneÏ kontrolovat, nebot'hrozõÂriziko vnitrÏnõÂcÏi vneÏjsÏõÂresorpce.

Indikace a kontraindikace

KotvenõÂ s pomocõÂ minisÏroubuÊ m uÊzÏeme vyuzÏõÂt vsÏude tam, kde nejsme schopni dosaÂhnout kotvenõÂ bez sÏko-dliveÂho uÂcÏinku reciprocÏnõÂch sil.

Dle Melsenove jsou minisÏrouby kontraindikovaÂny u pacientuÊ se systeÂmovou poruchou kostnõÂho meta-bolismu,zpuÊsobenoubud'nemocõÂneboleÂkyausilnyÂch kurÏaÂkuÊ [28]. DaÂle jsou kontraindikovaÂny u ozubeneÂho alveolaÂrnõÂho vyÂbeÏzÏku ve smõÂsÏeneÂmchrupu z duÊvodu nebezpecÏõ posÏkozenõ zaÂrodkuÊ staÂlyÂch zubuÊ.

Pokud jsou dodrzÏeny kontraindikace, nenõ pouzÏitõ kotevnõÂch minisÏroubuÊ veÏkoveÏ omezeno. U starsÏõÂch veÏ-kovyÂch kategoriõ pacientuÊ je vsÏak nutno dbaÂt na fakt, zÏe kostnõÂmetabolismus jizÏ nenõÂtak aktivnõÂjako u mladi-stvyÂch, rovneÏzÏ u zÏen po menopauze lze prÏedpoklaÂdat, zÏe z duÊvodu mozÏne osteoporoÂzy bude riziko selhaÂnõ minisÏroubu zvyÂsÏeneÂ.

CõÂlemstudie bylo zjistit, jak pacienti akceptujõÂ osÏe-trÏenõÂ ortodontickyÂmkotevnõÂmminisÏroubem.

MateriaÂl a metodika

Do souboru bylo vybraÂno 55 pacientuÊ a byl jimprÏed-lozÏen dotaznõÂk. KriteÂriempro vybraÂnõ do souboru bylo pouzÏitõ kotevnõÂch minisÏroubuÊ cÏi palatinaÂlnõÂch implan-taÂtuÊ beÏhemortodonticke terapie fixnõÂmaparaÂtem. Do-tazovanõ pacienti byli leÂcÏeni na OrtodontickeÂmoddeÏ-lenõ Stomatologicke kliniky 3. LFUK FNKV Praha, na OrtodontickeÂmoddeÏlenõ Stomatologicke kliniky LFUK v Plzni, v soukrome ortodonticke praxi MUDr. Marka, MUDr. Vandase, MUDr. Petra, MUDr. SÏrytra a MUDr. HofmanoveÂ.

Byl zjisÏt'ovaÂn typ implantaÂtu a otaÂzky byly

OtaÂzka cÏ. 1.CõÂtili jste po zavedenõÂ implantaÂtu bo-lest? (po odezneÏnõÂ anestesie)

(zÏaÂdnou/mõÂrnou/strÏednõÂ/velkou/krutou - jak dlouho?).

OtaÂzka cÏ. 2.CõÂtili jste po vyjmutõÂ implantaÂtu bolest? (po odezneÏnõÂ anestesie)

(zÏaÂdnou/mõÂrnou/strÏednõÂ/velkou/krutou - jak dlouho?).

OtaÂzka cÏ. 3.MeÏli jste v souvislosti se zavedenõÂm im-plantaÂtu neÏjake jine obtõÂzÏe?

OtaÂzka cÏ. 5.Bylo-li by nezbytneÂ, nechali byste si v prÏõÂpadeÏ dalsÏõÂ terapie fixnõÂm aparaÂtem implantaÂt znovu zaveÂst?(ano/ne)

Indications and contraindications

Miniscrews as orthodontic anchorage may be used whenever we are not able to establish anchorage wi-thout a harmful effect of reciprocal forces.

According to Melsen, miniscrews are contraindica-ted in patients with systemic alterations in the bone metabolism due to disease, medication, or heavy smo-king (28). They are also contraindicated in toothed al-veolar process in mixed dentition - there is a risk of da-mage to permanent dentition buds.

The use of miniscrews as orthodontic anchorage does not depend on the patient's age, and is not limi-ted by the age. However, in older patients the bone metabolism is not as active as in adolescents; in post-menopausal women the risk of a miniscrew failure can be higher due to potential osteoporosis.

The aimof our study was to find out about how pa-tients accept the treatment with an orthodontic minisc-rew anchorage.

Material and methods

The sample included 55 patients who were asked to answer the questionnaire. In all patients miniscrews or palatal implants were applied during the orthodontic treatment with fixed appliance. The patients were trea-ted at the Department of Orthodontics, Clinic of Dental Medicine, 3rd Medical Faculty of Charles University in Prague; Department of Orthodontics, Clinic of Dental Medicine, Medical Faculty in PlzenÏ, in the private prac-tices of MUDr. Marek, MUDr. Vandas, MUDr. Petr, MUDr. SÏrytr, and MUDr. HofmanovaÂ.

First, the type of implant was determined. The que-stionnaire included the following questions:

Q1.Did you experience any pain after the insertion of the miniscrew? (after anesthesia subsided)

(no/minor/moderate/major/severe - how long?)

Q2.Did you experience any pain after the miniscrew was removed? (after anesthesia subsided)

(no/minor/moderate/major/severe - how long?)

Q3.Did you experience any discomfort due to the inserted miniscrew?

Q5.In case it is inevitable, during another therapy with fixed appliance - would you agree to have the mi-niscrew inserted again?(yes/no)

Results

Type of TAD (palatal implant or miniscrew)

Out of 55 patients 52 had a miniscrew, 3 a palatal implant. At the time of questionnaire distribution, 42 patients were already without the miniscrew.

The sample of patients with palatal implants is small, so we cannot give detailed results. However,

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VyÂsledky

Typ implantaÂtu (patrovy implantaÂt nebo miniimplan-taÂt)

Z celkoveÂho pocÏtu 55 pacientuÊ m eÏlo 52 zavedeno kotevnõÂ minisÏroub a 3 palatinaÂlnõÂ implantaÂt. PrÏi sbeÏru dat meÏlo 42 pacientuÊ kotevnõÂ minisÏroub jizÏ vyjmut.

Vzhledemk maleÂmu souboru pacientuÊ s palatinaÂl-nõÂmi implantaÂty nejsou u teÏchto pacientuÊ podaÂny de-tailnõ vyÂsledky, nicmeÂneÏ bolest se u nich pohybovala spõÂsÏe v rozmezõ charakteristik mõÂrna cÏi strÏednõ a vsÏichni 3 pacienti by si nechali zaveÂst v prÏõÂpadeÏ potrÏeby pa-trovy implantaÂt znovu.

DotaznõÂk:

OtaÂzka cÏ. 1.CõÂtili jste po zavedenõÂ implantaÂtu bo-lest? (po odezneÏnõÂ anestesie)

(zÏaÂdnou/mõÂrnou/strÏednõÂ/velkou/krutou - jak dlouho?). ZÏaÂdnou bolest udalo 21 pacientuÊ (41 %), mõÂrnou bo-lest oznacÏilo 20 pacientuÊ (38 %). ZÏaÂdnou nebo mõÂrnou bolest udaÂvalo tedy 79 % pacientuÊ (Obr. 1). StrÏednõÂbo-lest pocit'ovalo 8 pacientuÊ (15 %), velkou 2 pacienti (4 %) a krutou 1 pacient (2 %).

Na dobu bolesti po zavedenõÂminisÏroubu neodpoveÏ-deÏlo 36 pacientuÊ, proto nenõÂ tato cÏaÂst otaÂzky prÏi zpra-covaÂnõÂ dat hodnocena

OtaÂzka cÏ. 2.CõÂtili jste po vyjmutõÂ implantaÂtu bolest? (po odezneÏnõÂ anestesie)

(zÏaÂdnou/mõÂrnou/strÏednõÂ/velkou/krutou - jak dlouho?). Pacienti popsali mõÂru bolestivosti po vyjmutõÂ mini-sÏroubu (Obr. 2). ZÏaÂdnou bolest udalo 26 pacientuÊ (63 %), mõÂrnou bolest oznacÏilo 14 pacientuÊ (33 %). 96 % pacientuÊ tedy prakticky nemeÏlo obtõÂzÏe v souvi-slosti s odstraneÏnõÂmimplantaÂtu.

Na dobu bolesti po vyjmutõÂ minisÏroubu neodpoveÏ-deÏlo 38 pacientuÊ, proto nenõÂ tato cÏaÂst otaÂzky prÏi zpra-covaÂnõÂ dat hodnocena.

the pain was characterized as minor or moderate. All three patients would agree with a new implant.

Questionnaire:

Q1.Did you experience any pain after the insertion of the miniscrew? (after anesthesia subsided)

(no/minor/moderate/major/severe - how long?) No pain was reported by 21 patients (41 %), minor pain was reported from20 patients (38 %). No or minor pain reported 79 % of patients ( Fig. 1). Eight patients had moderate pain (15 %), major 2 patients (4 %) and severe 1 patient (2 %).

36 patients did not specify the time/duration of pain, therefore this part of the question is not evaluated.

Q2.Did you experience any pain after the miniscrew was removed? (after anesthesia subsided)

(no/minor/moderate/major/severe - how long?) No pain was reported from26 patients (63 %), 14 patients (33 %) had minor pain. So 96% of patients re-ported no problems after the miniscrew was removed (Fig. 2).

Obr.1.Bolest, kterou pacienti cõÂtili po zavedenõÂ kotevnõÂho mini-sÏroubu. PocÏty pacientuÊ a procenta.

Fig.1.Pain after the insertion of the miniscrew. Number of patients and percentage.

Obr.2.Bolest, kterou pacienti cõÂtili po vyjmutõÂ kotevnõÂho minisÏroubu. PocÏty pacientuÊ a procenta.

Fig.2.Pain after the miniscrew was removed. Number of patients and percentage.

Obr.3.SubjektivnõÂ pocity pacientuÊ se zavedenyÂmkotevnõÂmmini-sÏroubem. PocÏty pacientuÊ.

Fig.3.Discomfort due to the inserted miniscrew. Number of pa-tients.

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Literatura/References:

1. Cope, J. B.: Temporary Anchorage Devices in Orthodon-tics : A ParadigmShift. Semin. Orthodont. 2005, cÏ. 11, s. 3-9.

2. Melsen, B.: Is the intraoral - extradental anchorage chan-ging the spectrumof orthodontics? PoznaÂmky ke kurzu. IOS, Praha, 2006.

3. Linkow, L. I.: Implanto-Orthodontics. J. clin. Orthodont. 1970, 4, cÏ.12, s. 685-705.

4. Melsen, B.; Petersen, J. K.; Costa, A.: Zygoma ligatures: an alternative formof maxillary anchorage. J. clin. Ortho-dont. 1998, 32, cÏ.3, s. 154-158.

OtaÂzka cÏ. 3.MeÏli jste v souvislosti se zavedenõÂm im-plantaÂtu neÏjake jine obtõÂzÏe?

38 pacientuÊ bylo bez obtõÂzÏõÂ, 14 meÏlo subjektivnõ ob-tõÂzÏe. Byly to zejmeÂna gingivitis (3 pacienti), prÏeruÊstaÂnõ sliznice (4 pac.), vzaÂcneÏji jine (viz obr. 3).

OtaÂzka cÏ. 4.Bylo-li by nezbytneÂ, nechali byste si v prÏõÂpadeÏ dalsÏõÂ terapie fixnõÂm aparaÂtem implantaÂt znovu zaveÂst?(ano/ne)

V prÏõÂpadeÏ potrÏeby by si minisÏroub nechalo opeÏt za-veÂst 92 % pacientuÊ a 8 % pacientuÊ nikoliv.

Diskuse

PlaÂnovaÂnõ dentoalveolaÂrnõÂch, prÏõÂpadneÏ skeletaÂlnõÂch zmeÏn v raÂmci ortodonticke leÂcÏby dostaÂva s mozÏnostõ vyuzÏitõ teÏchto zarÏõÂzenõ novy rozmeÏr. Dle Kurody je nej-veÏtsÏõ starostõ pacienta prÏi ortodonticke terapii praÂveÏ bolest. Ve sve praÂci uvaÂdõÂ, zÏe pro pacienty jsou komfort-neÏjsÏõÂminisÏrouby zavaÂdeÏne bez odklaÂpeÏnõÂmukoperistaÂl-nõÂho laloku [27]. Kotevnõ zarÏõÂzenõ s jednoduchou faÂzõ za-vaÂdeÏnõ jsou pro pacienty mnohem snesitelneÏjsÏõ nezÏ ta, u kteryÂch se musõ odklaÂpeÏt mukoperiostaÂlnõ lalok.

ZaÂveÏr

Vzhledemk obavaÂmpacientuÊ, zda je osÏetrÏenõÂ, spo-jene s pouzÏitõÂmminisÏroubuÊ bolestiveÂ, jsou prezento-vaÂny naÂzory pacientuÊ na tento zpuÊsob osÏetrÏenõÂ. Z vyÂ-sledkuÊ dotaznõÂkove studie vyplyÂvaÂ, zÏe 79 % pacientuÊ necõÂtõÂbud'zÏaÂdnou, nebo mõÂrnou bolest po zavedenõÂmi-nisÏroubu a 96 % necõÂtõ bud' zÏaÂdnou, nebo mõÂrnou bo-lest po vyjmutõ a võÂce nezÏ 90 % pacientuÊ by si nechalo minisÏroub v prÏõÂpadeÏ potrÏeby zaveÂst znovu. Tyto vyÂ-sledky jsou pro uvedenõ kotevnõÂch minisÏroubuÊ do beÏzÏne ortodonticke praxe velice povzbudive pro leÂkarÏe i pacienty.

PrÏi vyÂbeÏru nejvhodneÏjsÏõÂho kotevnõÂho systeÂmu do-porucÏujeme rÏõÂdit se slozÏitostõ manipulace s kotevnõÂm systeÂmem. Pokud jsou zvoleny kotevnõ minisÏrouby, je nutne pecÏliveÏ zvaÂzÏit spraÂvnou kombinaci minisÏroubu a kvality kosti, dostupne v mõÂsteÏ plaÂnovane inzerce. ZaÂteÏzÏ pacienta prÏi pouzÏitõ kotevnõÂho minisÏroubu je ne-patrnaÂ, terapeuticky efekt velmi dobryÂ. Zavedenõ a ze-jmeÂna odstraneÏnõ minisÏroubuÊ je instrumentaÂlneÏ, cÏa-soveÏ i ekonomicky nenaÂrocÏne a pacienta netraumati-zuje.

38 patients did not specify the time/duration of pain, therefore this part of the question is not evaluated.

Q3.Did you experience any discomfort due to the inserted miniscrew?

38 patients reported no problems; 14 patients re-ported subjective problems. They were mostly gingivi-tis (3 patients), mucosa overgrowth (4 patients), others were rare (see Fig. 3).

Q4.In case it is inevitable, during another therapy with fixed appliance - would you agree to have the mi-niscrew inserted again? (yes/no)

92% of patients answered Yes, 8% No.

Discussion

Planning of dentoalveolar or skeletal changes within orthodontic therapy has a new dimension thanks to the new devices. According to Kuroda the fear of pain is the main patients concern in orthodontic therapy. In his study, Kuroda states that miniscrews placed wi-thout flap surgery are more comfortable for patients [27]. Thus the anchorage devices which are inserted with ¹simple surgical stageª are better tolerated.

Conclusion

Our study presents the views of patients with regard to the application of miniscrews. Results of the retro-spective questionnaire study suggest that 79% of pa-tients experience no or moderate pains after the inser-tion of a miniscrew, 96% experience no or moderate pains after the removal of the miniscrew, and over 90% of patients would agree with repeated placement of a miniscrew if necessary. The results are therefore encouraging for both orthodontists and patients.

Difficulty in manipulation should play the main role in choice of an appropriate anchorage system. If we decide for miniscrews, we have to consider in detail the right combination of a miniscrew with regard to the quality of a bone in the place of the planned inser-tion. In case of a miniscrew as orthodontic anchorage, patients experience only minor discomfort, while the effect of the therapy is very good. Placement of a mi-niscrew and its removal is undemanding in terms of ar-mamentarium, time and economic costs, and it is com-fortable for a patient.

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5. Creekmore, T. D.; Eklund, M. K.: The possibility of skeletal anchorage. J. clin. Orthodont. 1983, 17, cÏ. 4, s. 266-269. 6. Kanomi, R.: Mini-implant for orthodontic anchorage. J.

clin. Orthodont. 1997, 31, cÏ. 11, s. 763-767.

7. Costa, A.; Raffaini, M.; Melsen, B.: Miniscrews as ortho-dontic anchorage: A preliminary report. Int. J. Adult Orthodont. Orthognath. Surg. 1998, 13, cÏ. 3, s. 201-209. 8. Mah, J.; Bergstrand, F.; Graham, J. W.: Temporary an-chorage devices: A status report. J. clin. Orthodont. 2005, 39, cÏ. 3, s. 132-136.

9. P-I Branemark Institute Bauru Brazil [online]. Dostupne z: http://us.branemark.org.br.

10. Melsen, B. - osobnõÂ sdeÏlenõÂ 2006, Praha.

11. Wilmes, B.; Rademacher, C.; Olthoff, G.; Drescher, D.: Parameters Affecting Primary Stability of Orthodontic Mini-implants. J. Orofac. Orthop. 2006, 67, cÏ. 3, s. 162-174.

12. Bumann, A - osobnõÂ sdeÏlenõÂ 2006, Praha.

13. Melsen, B.; Verna, C.: Miniscrew Implants: The Aarhus Anchorage System. Semin. Orthodont. 2005, cÏ. 11, s. 24-31.

14. Kyung, H. M.; Park, H. S.; Bae, S. M.; Sung, J. H. ; KimI. B.: OVERVIEW Development of Orthodontic Micro-Im-plants for Intraoral Anchorage. J. clin. Orthodont. 2003, 37, cÏ. 6, s. 321-328 .

15. Park, H. S.; Kwon, T. G.: Sliding Mechanics with Mic-roscrew Implant Anchorage. Angle Orthodont. 2004, 74, cÏ. 5, s. 703-710.

16. Roth, A.; Yildrim, M.; Diedrich, P.: Forced eruption with microscrew anchorage for preprosthetic leveling of the gingival margin. J. orofac. Orthop. 2004, 65, s. 513-519. 17. Ohnishi, H.; Yagi, T.; Yasuda, Y.; Takada, K.: A Mini-Im-plant for orthodontic anchorage in a deep overbite case. Angle Orthodont. 2005, 75, cÏ. 3,s. 444-452.

18. Kuroda, S.; Sugawara, Y.; Yamashita, K.; Mano, T.; Ta-kano-Yamamoto, T.: Skeletal Class III oligodontia pa-tient treated with titaniumscrew anchorage and ortho-gnathic surgery. Amer. J. Orthodont. dentofacial Orthop. 2005, 127, cÏ. 6, s. 730-738.

19. Gray, J. B.; Smith R.: Transitional implants for orthodon-tic anchorage. J. clin. Orthodont. 2000, 34, cÏ. 11, s. 659-666.

20. Park, H. S.; Jeong, S. H.; Kwon, O. W.: Factors affecting the clinical success of screw implants used as orthodon-tic anchorage. Amer. J. Orthodont. dentofacial Orthop. 2006, 130, cÏ. 1, s. 18-25.

21. Absolon, K. et al.: VsÏeobecna encyklopedie Diderot, Praha, Diderot, 1999. ISBN 80-902555-7-4.

22. Bumann, A.: Latest advancements in temporary ortho-dontic anchorage devices. PoznaÂmky ke kurzu. IOS, Praha, 2006

23. Carano, A.; Velo, S.; Leone, P.; Siciliani, G.: Clinical appli-cations of the miniscrew anchorage system. J. clin.Or-thodont. 2005, 39, cÏ. 1, s. 9-24.

24. Titan a slitiny titanu [online]. Dostupne z: http://www.bi-bus.cz/cz/?pg=vypis-produktu&id=276.

25. Miyawaki, S.; Koyama, I.; Inoue, M.; Mishima, K.; Suga-hara, T.; Takano-Yamamoto, T.: Factors associated with the stability of titaniumscrews placed in the posterior

re-gion for orthodontic anchorage. Amer. J. Orthodont. dentofacial Orthop. 2003, 124, s. 373-378.

26. Motoyoshi, M.; Hirabayashi, M.; Uemura, M.; Shimizu, N.: Recommended placement torque when tightening an orthodontic mini-implant. Clin. Oral Impl. Res. 2006, 17, cÏ. 1, s. 109-114.

27. Kuroda, S.; Sugawara, Y.; Deguchi, T.; Kyung, H. M.; Ta-kano-Yamamoto, T.: Clinical use of miniscrew implants as orthodontic anchorage: Success rates and postope-rative discomfort. Amer. J. Orthodont. dentofacial Orthop. 2007, 131, cÏ. 1, s. 9-15.

28. Melsen, B.: OVERVIEW Mini-Implants: Where Are We? J. Clin. Orthod. 2005, 39, cÏ. 9, s. 539-547.

29. Graham, J. W.; Cope, J. B.: Miniscrew Troubleshooting. Orthodontic Products. 2006, April 2006, s. 1-6 [online]. Dostupne z: http://www.orthodonticproductsonline.com/ issues/articles/2006-04_04.asp.

30. Dalstra, M.; Cattaneo, P. M.; Melsen, B.: Load transfer of miniscrews for orthodontic anchorage. Orthodontics 2004, cÏ. 1, s. 53-62.

31. Chen, Y. J.; Chen, Y. H.; Lin, L. D.; Yao, C. C.: Removal torque of miniscrews used for orthodontic anchorage -a prelimin-ary report. Int. J. Or-al M-axillof-ac. Impl-ants 2006, 21, cÏ. 2, s. 283-289.

32. Deguchi, T.; Takano-Yamamoto, T.; Kanomi, R.; Harts-field, J. K.; Roberts, W. E.; Garetto, L. P.: The Use of Small Titanium Screws for Orthodontic Anchorage. J. Dent. Res. 2003, 82, cÏ. 5, s. 377-381.

33. Ohmae, M.; Saito, S.; Morohashi, T.; Seki, K.; Qu, H.; Ka-nomi, R.; Yamasaki, K.; Okano, T.; Yamada, S.; Shiba-saki, Y.: A clinical and histological evaluation of titanium mini - implants as anchors for orthodontic intrusion in the beagle dog . Amer. J. Orthodont. dentofacial Orthop. 2001, 119, cÏ. 5, s. 489-497.

34. Motoyoshi, M.; Yano, S.; Tsuruoka, T.; Shimizu, N.: Bio-mechanical effect of abutment on stability of orthodontic mini-implant . A finite element analysis. Clin. Oral Impl. Res. 2005, 16, s. 480-485.

35. Heidemann, W.; Gerlach, K. L.; Grobel K. H.; Kollner, H. G.: Drill Free Screws: a new formof osteosynthesis screw. J. Craniomaxillofac. Surg. 1998, 26, cÏ. 3, s. 163-168. 36. Tracey, S.: The Nuts And Bolts of Miniscrews.

Orthodon-tic Products. 2006, February 2006, s. 1-6 [online]. Do-stupne z: www.orthodonticproductsonline.com/issues/ articles/2006-02_12.asp.

37. Kim, J. W.; Ahn, S. J.; Chang, Y. I : Histomorphometric and mechanical analyses of the drill-free screw as ortho-dontic anchorage. Amer. J. Orthodont. dentofacial Orthop. 2005, 128, cÏ. 2, s .190-194.

38. Melsen, B.; Costa, A.: Immediate loading of implants used for orthodontic anchorage Clin. Orthodont. Res. 2000, cÏ. 3, s. 23-28.

39. Maino, B. G.; Mura, P.; Bednar, J.: Miniscrew implants: The Spider Screw Anchorage System, Semin. Ortho-dont. 2005, cÏ. 11, s. 40-46.

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41. Tsukiboshi, M.; Asai, Y.; Nakagawa, K.: Wound healing in transplantation and replantation. In: Tsukiboshi, M. : Autotransplantation of Teeth. Tokyo, Japan: Quintes-sence, 2001, s. 21-56. (Cit. in: [29])

42. Andreasen, J. O.; Kristerson, L.: The effect of limited drying or removal of the periodontal ligament:

Periodon-tal healing after replantation of mature permanent inci-sors in monkeys. Acta Odontol. Scand. 1981, 29, s.1-13. (Cit. in:[29])

43. Asscherickx, K.; Vannet, B. V.; Wehrbein, H.; Sabzevar, M. M.: Root repair after injury frommini - screw. Clin. Oral Impl. Res. 2005, 16, cÏ. 5, s. 575-578.

MUDr.OndrÏej HajnõÂk

Stomatologicka klinika 3.LF UK Praha SÏrobaÂrova 50, 100 34 Praha 10

Altis Group, spol. s r. o.

± vyÂhradnõÂ zastoupenõÂ pro CÏeskou republiku a Slovensko

RaÂdi bychom VaÂs pozvali na pokracÏovaÂnõÂ dvoudennõÂho kurzu

Prof. Dr. Bjorn U. Zachrissona DDS, MSD, PhD., Norsko

TermõÂn: 7.±8. listopadu 2008

MõÂsto konaÂnõÂ kurzu:

ANDEL'S HOTEL PRAGUE

(StroupezÏnickeÂho 21, 150 00 Praha 5)

TeÂmata kurzu:

1. PrÏestavba alveolaÂrnõÂch tkaÂnõÂ a kosti ortodontickyÂm posunem zubu pro zlepsÏenõÂ estetiky implantaÂtu

2. LeÂcÏebny plaÂn a kefalometrie - skeletaÂlnõ analyÂza a analyÂza meÏkkyÂch tkaÂnõÂ. VyuzÏitõ VTO.

3. DuÊlezÏite aspekty dlouhodobe stability vyÂsledkuÊ ortodonticke leÂcÏby.

4. Extrakce jednoho dolnõÂho rÏezaÂku v ortodoncii.

5. Klinicke novinky u fixnõÂch lepenyÂch retianeruÊ.

6. Lepenõ na atypicke povrchy (porcelaÂn, amalgaÂm, zlato, kompozitum atd.) v klinicke praxi -

ne-srovnalosti mezi laboratornõÂmi a klinickyÂmi fakty.

7. SpolupraÂce s estetickou stomatologiõÂ a uzavõÂraÂnõÂ mezer u pacientuÊ s chybeÏjõÂcõÂmi hornõÂmi

lateraÂl-nõÂmi rÏezaÂky.

ÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐ

6. 9. 2008

Praha, hotel ILF

± jednodennõÂ seminaÂrÏ

TeÂma:

KotevnõÂ mikrosÏrouby v praxi

KlõÂcÏova prÏednaÂsÏka:

MUDr. JirÏõÂ Baumruk

DalsÏõÂ prÏednaÂsÏejõÂcõÂ:

MUDr. I. Marek, MUDr. K. Iha, MUDr. B. Chadim, MUDr. O. HajnõÂk,

MUDr. J. KucÏera, MUDr. S. NovaÂcÏkovaÂ, MUDr. O. Suchy a dalsÏõÂ

PrÏijd'te se s kolegy podeÏlit o zkusÏenosti z praxe!

Altis Group, s. r. o., 17. listopadu 5, 690 00 BrÏeclav, provozovna: Husova 25, 690 02 BrÏeclav

Tel./fax: 519 325 414, e-mail: orthoorganizer.cz@email.cz, Petra Karafova - 731 476 456, Marie PõÂsarÏõÂkova ± 606 746 716

Zelena linka: 800 100 535

Slovakia Altis Group, s. r. o., K. SÏmidkeho 2424/20, 911 08 TrencÏõÂn,

mobil: 905 297 483, tel./fax: +42132 65 80 287, e-mail: orthoorganizer@slovanet.sk

CÏlensky poplatek pro rok 2008 cÏinõ 1500,- KcÏ nebo 45,- EUR. CÏlenove v zameÏstnaneckeÂm vztahu 800,- KcÏ nebo 25,- EUR.

Postgraduanti, duÊchodci a zÏeny na materÏske dovolene 300,- KcÏ nebo 10,- EUR. RegistracÏnõ polatek cÏinõ 500,- KcÏ.

PrÏedplatne cÏasopisu Ortodoncie pro necÏleny CÏOS je 1000,- KcÏ za rok nebo 35,- EUR. UÂhrada poplatku do 28.2.2008,

cÏ. uÂ.: 32932-021/0100, konst. symbol: 0558, variab. symbol: rodne cÏõÂslo.

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