Temporary Anchorage

Devices in Orthodontics: A Paradigm Shift

Jason B. Cope

Orthodontists are accustomed to using teeth and auxiliary appliances, both intraoral and
extraoral, to control anchorage. These methods are limited in that it is often difficult to
achieve results commensurate with our idealistic goals. Recently, a number of case reports
have appeared in the orthodontic literature documenting the possibility of overcoming
anchorage limitations via the use of temporary anchorage devices— biocompatible devices
fixed to bone for the purpose of moving teeth, with the devices being subsequently removed
after treatment. This article defines and classifies these devices, covers their historical
development, outlines some of the basic biologic parameters for their use, and articulates
questions that need to be addressed with further experiments before broad scale incorpo-
ration into everyday practice.
Semin Orthod 11:3-9 © 2005 Elsevier Inc. All rights reserved.

T raditionally, orthodontists have used teeth, intraoral ap-

pliances, and extraoral appliances, to control anchor-
age—minimizing the movement of certain teeth, while com-
pleting the desired movement of other teeth. However,
because of Newton’s third law, ie, for every action there is an
equal and opposite reaction, there are limitations in our abil-
ity to completely control all aspects of tooth movement. For
example, we often have inadequate mechanical systems with
which to control anchorage, which leads to anchorage loss of
reactive units and often incomplete correction of intra- and
interarch alignment problems. Moreover, in an attempt to
overcome these limitations, clinicians often incorporate
bulky acrylic appliances or extraoral appliances that, when
combined with the ever challenging problem of uncoopera-
tive patients, are often a futile attempt at best.
In the past 5 years, the orthodontic literature has pub-
lished numerous case reports documenting the possibility of
using several different types of temporarily placed anchorage
devices in approximation to bone with the intent of enhanc-
ing or overcoming the limitations of traditional anchorage.
The case report, although important in describing what is
possible clinically, is inadequate for documenting the basic
biologic and biomechanical parameters necessary for the im-
plementation of a new clinical modality on a broad scale. The
literature is just beginning to see the publication of prospec-
From the Department of Orthodontics, Texas A&M University System
Health Science Center, Baylor College of Dentistry, Dallas, TX.
Address correspondence to Jason B. Cope, DDS, PhD, 7015 Snider Plaza,
Suite 200, Dallas, TX 75205; Phone: 214-378-5555; Fax: 214-378-
5552; E-mail: jason@copeorthodontics.com.
tive clinical trials and basic science experiments, which
should begin to answer some of the questions that are impor-
tant. To this end, the purpose of this article is to clearly define
these devices, organize them into a simple but adaptable
classification system, introduce their historical development,
outline the biologic parameters for use, and articulate several
questions that need to be addressed with further experi-
ments.
Orthodontic Anchorage
Although the principle of orthodontic anchorage has been
implicitly understood since the 17th century, it does not
appear to have been clearly articulated until 1923 when Louis
Ottofy1 defined it as “the base against which orthodontic
force or reaction of orthodontic force is applied.” Most re-
cently, Daskalogiannakis2 defined anchorage as “resistance to
unwanted tooth movement.” It can also be defined as the
amount of allowed movement of the reactive unit. Using this
definition requires clarification of the reactive unit (tooth/
teeth acting as anchorage during movement of the active
unit) as well as the active unit (tooth/teeth undergoing move-
ment).
Ottofy1 also summarized the anchorage categories previ-
ously outlined by E.H. Angle and others as simple, stationary,
reciprocal, intraoral, intermaxillary, or extraoral. Since that
time, several noted authors have modified or developed their
own classification. For example, Moyers3 expanded Ottofy’s
classification system by clearly outlining the different subcat-
egories of extraoral anchorage, as well as breaking down sim-

1073-8746/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. 3

doi:10.1053/j.sodo.2004.11.002
4 J.B. Cope
ple anchorage into single, compound, and reinforced subcat-
egories. Later, others developed their own classification
terminology. Gianelly and Goldman4 suggested the terms
maximum, moderate, and minimum to indicate the extent to
which the teeth of the active and reactive units should move
when a force is applied. Marcotte5 and Burstone6 classified
anchorage into three categories—A, B, and C— depending
on how much of the anchorage unit contributes to space
closure. Tweed7 went further to define anchorage prepara-
tion, or the uprighting and even the distal tipping of posterior
teeth to utilize the mechanical advantage of the tent peg be-
fore retracting anterior teeth.
Considering the above classification systems, it becomes
apparent that a lack of consensus exists on the terminology
for describing anchorage. Moreover, these systems are out-
dated and do not currently provide clear guidelines with
which the orthodontist can clearly and concisely communi-
cate. For example, these classification systems only account
for anteroposterior dental relationships and do not really ac-
count for vertical or transverse relationships. They also only
account for the anteroposterior extent of the dental bases and
do not account for distalizing the dentition to create a Class I
dental relationship without the need for extractions or sur-
gery. Moreover, they only account for groups of teeth; they
do not account for individual teeth, nor do they account for
the entire occlusal plane. The reason for the latter is most
likely because at the time these classification systems were
developed, the possibility of, for example, intruding poste-
rior teeth to correct a skeletal anterior openbite without sur-
gery was unimaginable. Given the recent advances in biology,
materials, and clinical treatment, this movement is not only a
possibility, but also a reality; it thus becomes apparent that a
new anchorage classification system is needed.
Temporary Anchorage Devices
A temporary anchorage device (TAD) is a device that is tem-
porarily fixed to bone for the purpose of enhancing orth-
odontic anchorage either by supporting the teeth of the reac-
tive unit or by obviating the need for the reactive unit
altogether, and which is subsequently removed after use.
They can be located transosteally, subperiosteally, or en-
dosteally; and they can be fixed to bone either mechanically
(cortically stabilized) or biochemically (osseointegrated). It
should also be pointed out that dental implants placed for the
ultimate purpose of supporting a prosthesis, regardless of the
fact that they may be used for orthodontic anchorage, are not
considered temporary anchorage devices since they are not
removed and discarded after orthodontic treatment. Impor-
tantly, the incorporation of dental implants and TADs into
orthodontic treatment made possible infinite anchorage,
which has been defined in terms of implants as showing no
movement (zero anchorage loss) as a consequence of reaction
forces.2
Historical Development
The evolution of temporary anchorage devices was based on
the development and improvement of traditional orthodon-
tic anchorage, dental implants, and orthognathic fixation
methods. Later, modifications of these techniques were uni-
fied with basic biologic and biomechanical principles of os-
seointegration into orthodontic mechanics that were finally
improved based on experiences with interdisciplinary den-
tistry.
Orthodontic Anchorage
Very early in our history, orthodontists realized the limita-
tions of using teeth as anchorage to move other teeth. As early
as 1728, Fauchard8 described the use of the expansion arch
that, by ligating the teeth to an ideally shaped rigid metal
plate, broadened the crowded dentition to a more normal
form. About 100 years later, Gunnell9 claimed to have used
occipital anchorage in 1822, but did not describe its use until
1841. In 1841, J.M.A. Schange9 perfected the “crib” of Dela-
barre and utilized it for attaching the palatal plate as anchor-
age, which allowed the use of a labial arch and ligatures of silk
or gold wires to accomplish various tooth movements. Oc-
cipital anchorage was later perfected by Angle9 in 1891. De-
sirabode,9 in 1843, is reported to have used teeth with longer
and stronger roots as anchorage to move other teeth. Of
course, no discussion of orthodontic anchorage would be
complete without the contributions of E.H. Angle, who also
introduced the idea of stationary anchorage in 1887 and oc-
clusal anchorage in 1891.9
Dental Implants
Despite the fact that Brånemark and colleagues10,11 pioneered
the original experimental work that established the principle
of osseointegration, he was well behind those who originally
imagined the possibility of using biocompatible materials to
replace missing teeth. This has been been overlooked, how-
ever, since much of the background information is not avail-
able in the clinical literature, but primarily in patent docu-
ments. In addition, the lack of online accessibility of our
original dated journals limits their use to those who are will-
ing to venture into the library.
Greenfield,12 in a patent of 1909 entitled “Mounting for
Artificial Teeth,” envisioned a replacement for teeth, the basis
of which was a metal frame that would be inserted into a
cavity drilled into the jaw bone. This predecessor of the hol-
low basket implant concept would allow bone to grow into
the cage followed by cementation of a crown onto the frame.
However, according to Strock,13 the iridioplatinum mesh-
work of Greenfield was not strong enough to withstand the
forces placed on it. Moreover, the cage was frequently placed
in both the molar and canine region with a gold bridge sus-
pended between the two cages. Strock13 implied that the
bridge was placed and loaded without sufficient time for
osseointegration.
Alvin Strock,13 a dentist from Boston, began to search for
his own methods of tooth replacement. At that point in time,
implants were frequently made of lead and iron, which
eroded intraorally and also caused bone resorption. Since
Greenfield’s cage was not suitable, Strock began to use the
screw principle of fixation combined with a recently devel-
Temporary anchorage devices
oped alloy called vitallium, which Venable and Stuck14 had
determined to be completely inert in bone. Strock began to
use a 5/8-inch vitallium Venable screw for immediate re-
placement of incisors lost as a result of trauma or endodontic
failure. Of interest is the fact that in the 1940s he discussed
several salient points that remain critical even today—imme-
diate placement is feasible if enough bone remains for the
implant to be secure from the start, and that the occlusion
must be favorable to prevent occlusal trauma to the implant.
For example, he routinely left the celluloid (temporary)
crown out of occlusion for a period of 4 to 6 months until it
was replaced by a porcelain jacket crown.
It was not until the late 1950s that Per Ingvar Brånemark11
came onto the scene. It was then that this young researcher
was using specially designed optical titanium chambers to
study the intravascular dynamics of bone marrow circulation
by transillumination in vivo. At this point in time, the tita-
nium chambers were custom made and extremely expensive,
therefore they were to be removed and reused. However,
bone grew into the thin spaces in the titanium and could not
be easily removed. It was this finding that prompted the
detailed experimentation that ensued. Based on these and
other findings by the Brånemark’s group,10,11,15 he advocated
a healing time of 4 to 6 months before functional loading
because function allowed micromotion, which permitted fi-
brous tissue growth and subsequent failure.
Orthognathic Fixation
Although current fixation techniques for orthognathic sur-
gery are performed primarily using bone plates and screws,
most fractures before the 1800s were treated with splints,
bandages, and combinations of intraoral/extraoral appli-
ances. Gordon Buck is credited with being the first to place an
interosseous wire in a mandibular fracture in 1847.16 How-
ever, it was Milton Adams17 who popularized the practice. In
the late 1800s, Thomas Gilmer18 was the first American to
utilize the dentition for use in securing maxillomandibular
fixation (wires) in the treatment of jaw fractures.
Bone plates were originally introduced to oral surgery by
Christiansen19 in 1945. However, it was not until the late
1960s that enough experimental data and the biomechanical
understanding of long bone fracture healing was applied to
the mandible.20 Hans Luhr21 is credited with introducing the
compression plate to maxillofacial surgery in the late 1960s.
His vitallium compression plate used the gliding screw prin-
ciple to achieve compression across the fractured segments,
thereby allowing the possibility of fracture healing without
the need for maxillomandiublar fixation.
Screw fixation, using the lag screw technique, was first
introduced to maxillofacial surgery in 1970 by Brons and
Boering,22 who demonstrated the possibility of fracture re-
duction with screws only 2.7 mm in diameter. Finally, in
1973, Michelet and colleagues23 began a small revolution by
reporting on the treatment of mandibular fractures using
miniaturized plates and screws placed intraorally. Champy
and colleagues24-26 substantiated that the technique was sci-
entifically sound. Miniaturized bone screws, as the sole
5
source of fixation, was first reported by Jeter and colleagues27
in 1984. Their group placed three 2.0-mm-diameter bone
screws bilaterally through a transoral approach to fix the
mandible after osteotomy.
First TAD Experience
Although the concept of temporary implant anchorage has
only recently been described, it was envisioned as early as
1945. Gainsforth and Higley,28 understanding that “. . . the
teeth selected for the anchorage often move simultaneously
with those in which movement is desired,” sought “. . . a
method of basal bone anchorage.” Using a 2.4-mm pilot hole,
a 3.4-mm-diameter ⫻ 13-mm-long vitallium screw was
placed in the ascending ramus of 6 dogs (Fig 1). A rubber
band delivering between 140 and 200 g of force was attached
from the screw head to a 0.040-inch wire that slid through a
tube on the upper molar band and was soldered to the upper
canine band. The system was designed to distally tip/retract
the canine by immediately loading the screws with the rubber
bands. Unfortunately, all of the screws were lost within 16 to
31 days. The authors do not describe frank infection; how-
ever, the failures may have been due to the lack of well-
developed antibiotics at the time, as well as the dynamic
loading of the screws.
The first clinical report in the literature of the use of TADs
appeared in 1983 when Creekmore and Eklund29 used a
vitallium bone screw to treat a patient with a deep impinging
overbite. The screw was inserted in the anterior nasal spine to
intrude and root and correct the upper incisors using an
elastic from the screw to the incisors 10 days after the screw
was placed.
Even though the first clinical TAD procedure documented
the successful application of TADs, this technique did not
gain immediate acceptance. This was most likely due to the
lack of the widespread acceptance of surgical procedures, the
still unaccepted field of implant dentistry, the lack of scien-
tific data on the use of implantable materials, and the fear of
complications. Instead, traditional anchorage mechanics re-
mained the principal treatment modality for managing orth-
odontic problems.
Interdisciplinary Dentistry
Apparently, the first report concerning the use of osseointe-
grated implants for both restorative and orthodontic pur-
poses appeared in 1969 when Linkow30 used a blade implant
in the mandibular 1st molar region as a partial abutment for
a bridge that was restored before orthodontics. Class II elas-
tics were worn from the implant-supported bridge to the
upper arch to facilitate tooth movement. Since this initial
application, the use of osseointegrated dental implants for
orthodontic anchorage has been well documented. Kokich31
and Smalley32 and Smalley and Blanco33 have developed pro-
tocols for determining how to accurately place dental im-
plants in the final desired location for restorative procedures
before orthodontic therapy such that the implants can be
used for both orthodontic anchorage as well as the subse-
quent restorative therapy.
6 J.B. Cope

Figure 1 Orthodontic appliance for vitallium screw anchorage. Redrawn from: Gainsforth BL, Higley LB. A study of
orthodontic anchorage possibilities in basal bone. Am J Orthod Oral Surg 31:406-416, 1945.

Current Devices anchorage control without the intention of osseointegration

but only for mechanical stability.
Some of the characteristics of an ideal anchorage device in- It is important for orthodontists to be able to communicate
clude the following: simple to use, inexpensive, immediately with each other clearly and concisely. Previously, several dif-
loadable, small dimensions, can withstand orthodontic ferent terms have been used to refer to the same entity. To
forces, immobile, does not require compliance, biocompat- explain, what has heretofore been referred to as a miniscrew
ible, and provides clinically equivalent or superior results implant has been referred to, in the literature, as a microim-
when compared with traditional anchorage systems. At a plant,35 microscrew implant,36 mini-implant,37 minidental
minimum, when initially placed, TADs must have primary implant,38 miniscrew,39 and screw-type implant.40 “Mini” is
stability and be able to withstand orthodontic force levels. simply the shortened form of “miniature,” which traditional
For integrated implants, the maximum load is proportional dictionaries refer to as something small compared with other
to the quantity of osseointegration, whereas for noninte- things of its type, or small in relation to others of the same
grated implants the maximum load is proportional to the
surface area contact of the bone to the implant.
The currently available temporary anchorage devices can
be classified as either biocompatible34 (Fig 2) or biological in
nature (Fig 3). Both groups can be subclassified based on the
manner in which they are attached to bone, either biochem-
ical (osseointegrated) or mechanical. For instance, an anky-
losed tooth temporarily used for orthodontic anchorage and
subsequently replaced would be considered a biological TAD
that is fixed to bone biochemically. Likewise, a significantly
dilacerated tooth can be used as a biological TAD that is
essentially fixed to bone mechanically.
The biocompatible TADs are either 1) a modification of a
dental implant, or 2) a surgical fixation method. For example,
a palatal implant is a miniaturized dental implant placed in
the palate with the intention of osseointegration and subse- Figure 2 Biocompatible temporary anchorage devices. Redrawn with
quent use for orthodontic anchorage. On the other hand, a permission from: Cope JB, Classification of temporary anchorage
miniscrew is a fixation device placed in many locations for devices. www.orthoTADs.com, 2005.
Temporary anchorage devices
Figure 3 Biological temporary anchorage devices. Redrawn with per-
mission from: Cope JB, Classification of temporary anchorage de-
vices. www.orthoTADs.com, 2005.
kind. “Micro,” on the other hand, is the shortened form of the
word “microscopic,” which traditional dictionaries refer to as
requiring magnification, or revealed by or having the struc-
ture discernible only by microscopic examination. By defini-
tion then, it follows that something microscopic conceivably
has no viable use in orthodontic mechanics at present; there-
fore, the term mini is more correct and is preferable.
The difference between a screw and an implant can also be
debated. Both can be defined based on function or design.
For instance, the screw’s original function was to utilize the
mechanical advantage of the inclined plane wrapped around
a central body to lift objects. It was later used to join two
objects together. Its design is defined by its length, diameter,
thread width, thread pitch, and head/end configuration. The
implant’s original function was to replace or augment a body
part. It was later used as a modification of a screw for initial
mechanical stability with anticipated osseointegration. Its de-
sign is also defined by its length, diameter, thread width,
thread pitch, and head/end configuration. An implant, how-
ever, is usually shorter in relation to its diameter, whereas a
screw is usually longer in relation to its diameter. Because
there does not appear to be a clear-cut defining distinction,
the term miniscrew implant will be used. Furthermore, “mi-
niscrew implant” will be defined as having a diameter of less
than 2.5 mm. Simple, yet distinct, acronyms for all of the
currently available TADs are listed below.34 For example,
shorthand terminology for a palatal implant would be TAD-PI.
TAD - Temporary Anchorage Device
PI - Palatal Implant
RMI - RetroMolar Implant
PO - Palatal Onplant
MSI - Mini Screw Implant
MBP - Mini Bone Plate
FW - Fixation Wire
ATR - Ankylosed Tooth Root
DTR - Dilacerated Tooth Root
Important Factors To Consider
To date, most of the scientific data on osseointegrated im-
plants have been published in journals related to restorative
7
dentistry, with considerably less in orthodontic journals. It
follows, therefore, that a discussion of the basic biology must
also begin with the original dental implant research. Several
of the controversies for orthodontic TADs today are not new,
but originated in implant dentistry.
Delayed Versus Immediate Loading
Currently, temporary anchorage devices can be fixed to bone
in one of two ways— either biochemically (osseointegrated)
or mechanically (cortically stabilized). Originally, however,
based on Brånemark’s work,10,11,15 it was thought that all
implants should undergo a 4- to 6-month healing period
before functional loading. This was because the authors,
based on both clinical and experimental evidence, felt that
premature loading caused micromotion of the implants,
which allowed the invasion of fibrous tissue, and implant
failure. This was supported by the findings of Roberts and
colleagues,41 using a rabbit model to study static orthodon-
tic-type implant loading of 100 g after 6, 8, or 12 weeks of
healing. Based on his findings, Roberts considered that 6
weeks (in rabbits) was the earliest an implant should be
loaded after placement. Since sigma, or the duration of re-
modeling, in humans is approximately 3 times longer than in
rabbits, he considered that the same duration equaled 18
weeks in humans.
In the early 1990s several groups began to publish their
findings of immediately loading dental implants after initial
surgical placement. Lum and colleagues,42 comparing hy-
droxylapatite coated to uncoated blade-type implants in rhe-
sus monkeys, found that immediately loaded implants were
comparable clinically and histologically to delayed loaded
implants, ie, both were stable and had direct bone contact
without fibrous tissue invasion. Importantly, all implants
were stabilized by a fixed prosthesis, thereby minimizing
micromotion of the implant.
Several years later, Tarnow and colleagues43 reported sim-
ilar findings in human patients. Their study used a minimum
of 10 mandibular implants—5 of which were loaded imme-
diately via a multi-implant retained single-unit prosthesis,
the other 5 remained buried/unloaded in case any of the
immediately loaded implants failed. Only 2 of 69 immedi-
ately loaded implants failed, both of which were placed into
an immediate extraction site. The findings of Tarnow and
colleagues43 suggested that immediate loading of implants
may also be possible clinically as long as the implants are
splinted together, thereby minimizing local micromotion.
Dynamic Versus Static Loading
Duyck’s group44 recently evaluated the differences in load
type on osseointegrated implants. After 10-mm-long Bråne-
mark implants were allowed to heal for 6 weeks, the implants
were loaded for 14 days either statically (constant loads of
uniform force levels), dynamically (cyclic loads of variable
force levels), or left unloaded. Interestingly, similar bone:
implant contact was seen for all implants, but a difference
was seen in the marginal bone around the implant. The stat-
ically loaded and unloaded controls showed a more dense cor-
8 J.B. Cope
tical lamellar bone at the neck and apex of the implants, whereas
the dynamically loaded implants revealed bony craters and
Howship’s lacunae around the implants necks, indicating a
higher level of bony resorption. Gotfredsen and colleagues45
found similar results in laterally loaded experimental im-
plants— higher bone density and bone:implant contact for
the statically loaded implant compared with unloaded con-
trols.
Based on some of the more relevant studies, it appears that
for implants designed to be osseointegrated, they can be
loaded earlier than previously thought as long as the implants
are splinted together (ie, micromotion is minimized). Ac-
cording to Szmukler-Moncler and colleagues,46 micromotion
should be less than approximately 100 ␮m. Statically loaded
implants have more dense cortical lamellar bone and higher
bone:implant contact on the loaded surface than dynamically
loaded or unloaded control implants. Statically loaded im-
plants are similar to orthodontically loaded implants, in that
they are usually loaded in one direction only, with a relatively
uniform force over an extended period of time.
Orthodontic Immediate Loading
Although Creekmore and Eklund29 used a miniscrew in
1983, the screw was not loaded for 10 days. More recently,
Costa and colleagues47 reported the use of miniscrews for
orthodontic anchorage in 14 patients. Without a soft tissue
flap, a 1.5-mm-diameter pilot hole was placed under local
anesthesia followed by placement of a 2.0-mm miniscrew,
which was immediately loaded orthodontically. Importantly,
only 2 of 16 miniscrews loosened and were lost before com-
pletion of orthodontic treatment. Several years later, Melsen
and Costa48 reported comparable findings on four monkeys
using a similar protocol as their human study. The histologic
data suggested that the bone surrounding the miniscrew was
similar in nature to the local host bone, that is the mandibular
symphysis was dense cortical, whereas the zygoma was tra-
becular. In the two screws that failed, the local soft tissue
never adequately healed, suggesting that gingival health may
be an important factor in TAD success. Moreover, the authors
suggested that overheating of bone during pilot hole place-
ment may have compromised local bone viability.
Freudenthaler and colleagues49 used immediately loaded
fixation screws for mandibular molar protraction. These au-
thors suggested, however, that bicortical fixation is critical.
Perhaps the rationale lies in their surgical protocol, which
includes a soft tissue incision, flap reflection, and a 2.0-mm
pilot hole for a 2.0-mm fixation screw. When using a pilot
hole equal in diameter to the screw, it may be prudent to
obtain screw fixation from both the medial and lateral corti-
ces. Moreover, since a flap is elevated, the potential for soft
tissue inflammation or infection is increased relative to a
nonflap technique. The technique obviously works, how-
ever, as only one screw was lost. The authors explained that
primary stability was not achieved at the time of placement
for this screw, resulting in premature failure.
When considering the factors associated with success or
failure, Miyawaki and colleagues50 published the only report
to date comparing multiple systems. They evaluated the sta-
bility of three different miniscrew systems as well as a
miniplate system, comparing the systems to determine what
factors negatively affected TAD success. Interestingly, the fac-
tors statistically associated with decreased success were 1) an
increased mandibular plane angle, 2) increased gingival in-
flammation, and 3) decreased screw diameter. Surprisingly,
screw length was not negatively associated with success.
Based on the above studies, it appears that implants de-
signed for mechanical retention (and not osseointegration)
can also be loaded earlier. Since the more stable osseointe-
grated implants require static loading, it can be assumed that
mechanically retained implants must also be statically
loaded. The individual TADs should be at least 1.5 mm in
diameter and gingival inflammation should be addressed
with appropriate measures as soon as possible.
Future Directions
The concept of temporary anchorage devices is a relatively
new application of more established clinical methodologies.
Although the clinician can look to the literature for many
answers, much is unknown and will only be answered by
well-designed prospective basic science and clinical trials.
The future development of temporary anchorage devices for
orthodontic anchorage will establish a more complete under-
standing of the biology and biomechanics associated with
both osseointegrated and nonintegrated TADs.
Major questions that need to be evaluated include: Should
the miniscrew implant be self-tapping or drill-free? While the
latter does not require a pilot hole, will it be more difficult to
control the angle of placement? If a pilot hole is placed, what
is the chance of overheating the bone? What are the ideal
characteristics of miniscrew implants—length, diameter,
head design, thread design, body design, end design, mate-
rial? What is the ideal orientation of the TAD relative to the
surface of the bone and the force vector? Should only a pol-
ished implant be used for nonintegrated purposes, or does it
matter? Are microorganisms more attracted to one surface
design than the other? What is the maximum force that a
TAD can withstand? Presumably, osseointegrated implants
can withstand more force than nonintegrated TADs, but is
this presumption correct? Can TADs be used for the applica-
tion of orthopedic forces? If so, what is the force limit? Pre-
sumably the major complications involved with TAD appli-
cations are tooth root damage, local bony or soft tissue
infections, or maxillary sinus perforation. If so, how are these
managed? Although the stability of tooth movement is well
documented, TADs are now being used to dentally correct
musculoskeletal malocclusions that would ideally be treated
by orthognathic surgery. What is the long-term stability of
skeletal openbite cases treated by posterior dental intrusion?
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3. Moyers R: Handbook of Orthodontics for the Student and General
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