The Ortho Implant Using the Cope Placement Protocol: Big Results From a Tiny Implant

by Jason Bryan Cope, D.D.S., Ph.D.

Jason B. Cope received his dental training at Baylor College of Dentistry - DDS (95), orthodontic certificate (97), and PhD (99) in distraction osteogenesis. Upon completion of his orthodontic certificate, he was invited to join the department as an adjunct clinical assistant professor. During his career, Dr. Cope has published 18 refereed journal articles, 34 book chapters, a research handbook, and co-edited a 600-page textbook on distraction osteogenesis. In addition, he has given over 100 lectures nationally and internationally. Dr. Cope is an ad hoc reviewer for the American Journal of Orthodontics, the World Journal of Orthodontics, The Angle Orthodontist, the Journal of Clinical Orthodontics, and was the guest editor for the March 2005 issue of Seminars In Orthodontics on OrthoTADs. Currently, he is writing a textbook OrthoTADs: The Clinical Guide and Atlas. Dr. Copes private practice is located in University Park, Texas, where he treats patients 4 days a week. In March 2002, he passed the American Board of Orthodontics exam, becoming the first person to complete ABO Option 2, and one of the youngest orthodontists ever to become a Diplomate. In July 2004, he presented his scientific paper to become a full member of the SW component of the Edward H. Angle Society of Orthodontists.

INTRODUCTION
Orthodontic temporary anchorage devices (OrthoTADs), and miniscrew implants (MSIs) in particular, have gained acceptance rapidly in the past few years in orthodontics. MSIs provide a cost effective means of overcoming traditional anchorage limitations without sacrificing quality results while providing minimal risk to the patient. Moreover, because of their simplicity and flexibility in use, many orthodontists have begun placing MSIs themselves in their own offices. The Imtec Ortho Implant offers especially unique features making it applicable for most any orthodontic case.

during thread-forming instead of the cutting and removing of bone common with other self-tapping screws. The outer diameter is 1.8 mm with a core diameter of 1.6 mm. Three threaded lengths are available: 6, 8, and 10 mm. The surface is machine-polished to prevent osseointegration but allow bone apposition.

Transmucosal Collar
The transmucosal collar is 1.0 mm tall. The surface is highly polished to allow intimate gingival adaptation, thereby creating a seal between the oral cavity and the underlying bone.

IMTEC ORTHO IMPLANT

The Ortho Implant (IMTEC Corp., Ardmore, Oklahoma) is a recently developed miniscrew implant (MSI) designed for enhancing orthodontic anchorage. Simplicity of use and integration into the daily orthodontic practice were the primary goals when designing the Ortho Implant. With those goals in mind, only one head design and one diameter with three different lengths were chosen. Three different lengths are necessary to facilitate placement in different locations within the oral cavity based on gingival thickness and bony depth. The small dimensions allow placement in a wide variety of intraoral locations, which permits stable anchorage in the treatment of many different malocclusions. Placement and removal of the Ortho Implant is technically easy and can be accomplished by the orthodontist, and in most instances, without injections or pilot holes.

Threaded Body
The threaded body was designed with a sharp tip so that it is drill-free, thereby eliminating the necessity of a pilot hole. In lieu of a thread-cutting cutting flute, the apical 4 mm of the Ortho Implant is tapered from 0.1 mm to the full 1.8 mm (Fig. 1) so that bone is compressed in and around the screw threads

1 Figure 1: IMTEC Ortho Implant

Abutment Head
The abutment head of the Ortho Implant is designed more like a dental implant than a miniscrew and is placed into bone by applying seating force to the square head, which is 1.5 mm tall. The grooved neck and O-Ball combined are 2.4 mm tall. Two 0.75-mm (0.030-inch) holes in the O-Ball are oriented at 90 degrees to each other and perpendicular to the long axis of the screw. The Ortho Implant can be attached to either through the holes in the O-Ball or around the grooved neck. The O-Ball head makes the system universally adaptable; it serves as one component in a ball and socket joint, the other being the Ortho Cap.

ORTHODONTIC MECHANICS
After placement, the Ortho Implant can be loaded immediately. There is no need to wait days or even weeks to load for soft tissue or bony healing. Attachment mechanics can be placed directly through the 0.030-inch holes (Fig. 3A), around the Ortho Implant neck (Fig. 3B), around a cotter pin placed through the 0.030-inch holes (Fig. 3C), around the groove in the O-Cap if placed (Fig. 3D), or to attachments soldered to the O-Cap (Fig. 3E). Postoperative pain is negligible, and at most 400-800 mg of ibuprofen is administered. Postoperative antibiotics for prophylactic reasons are not necessary unless the patient otherwise would be covered under the American Heart Association guidelines. Ortho Implants can be used to overcome anchorage limitations in several different case categories. Moreover, they can also be used to increase treatment efficiency (decrease total treatment

Ortho Cap
The Ortho Cap (O-Cap) is a stainless steel abutment component with an internal O-ring that locks in place around the O-Ball (Fig. 2). The O-Cap can be placed and removed with little effort but is stable enough that a patient cannot inadvertently dislodge it. If the clinical situation warrants, the O-Cap can be placed to suppress the soft tissues and prevent mucosal overgrowth, a situation not uncommon with other MSI systems. A groove is located around the circumference of the O-Cap so that ligatures, elastics, or power chain can be attached directly to the O-Cap. And because the O-Cap is made of stainless steel, it can be soldered to, thereby allowing different attachments to be fabricated.

2 Figure 2: Ortho Cap for placement around the O-Ball head.

SURGICAL PROCEDURE
The surgical procedure is as follows (Cope Placement Protocol): 1. Patient brushes teeth without fluoridated toothpaste. 2. Patient rinses with 15 mL of 0.12% chlorhexidine gluconate for 30 seconds. 3. Apply Oraqix anesthetic topically. 4. Apply local anesthetic (optional). 5. Determine the Ortho Implant insertion site. 6. Perform bone sounding with periodontal probe to measure soft tissue thickness. 7. Determine Ortho Implant length based on both soft tissue and bone thicknesses. 8. Place punch incision with 1.5-mm soft tissue biopsy punch (alveolar mucosa only). 9. Place pilot notch with No. 2 round bur or pilot hole with 1.1-mm pilot drill bit (optional). 10. Insert Ortho Implant with O-Driver or contra-angle LT-Driver. 11. Place O-Cap to prevent soft tissue overgrowth (optional). 12. Load Ortho Implant immediately either by attaching to O-Cap or directly to implant head.
3D 3E Figures 3A-E: Methods of attachment. A, Directly through the 0.030-inch holes. B, Around the implant neck. C, Around a cotter pin placed through the 0.030-inch holes. D, Around the groove in O-Cap. E, To soldered O-Caps. 3B 3C 3A

time) in cases that can be treated by traditional orthodontic mechanics. Several different examples of OrthoTADs treatment mechanics are illustrated below.

Anterior Retraction
Maximum anchorage is a primary indication of MSIs in premolar extraction cases. When maximum retraction of the anterior segment is desired, the Ortho Implant can be placed laterally in the alveolar ridge mesial to the first molar (Fig. 4). Locking closed coil springs are placed around the head of the OBall so that it does not have to be ligated and the patient cannot inadvertently dislodge it.
4A 4B

Figure 4A-B: Anterior en masse retraction. A, Buccal photograph at initial placement and loading. B, Buccal photograph after 6 months of loading. Note the new locking closed coil spring that does not require ligation and locks in place over the Ortho Implant so that it cannot be dislodged by the patient. (Courtesy Dr. Jason B. Cope, Dallas, Tex. Patent pending.)

Arch Distalization
Mechanics to distalize the entire arch for avoiding extractions and/or correcting buccal segment relationships can be designed either to pull or push the arch distally. In pulling mechanics the implants must be placed posteriorly so that ample distance exists for active mechanics (Fig. 5A). In pushing mechanics the implants must be placed more anteriorly (Fig. 5B).

Posterior Protraction
Ortho Implants used for protraction require additional consideration. In these situations, a full-sized rectangular stainless steel arch wire (rounded posteriorly to ease sliding mechanics) is used. In addition, the force should pass through the center of resistance on the facial, and a light force should also be applied on the lingual (Fig. 6). The lingual force is not necessarily for protraction but simply to minimize any rotational tendency and decrease friction.

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5B

Figure 5A-B: Arch distalization. A, Occlusal photograph of pulling mechanics. B, Occlusal photograph of pushing mechanics.

6A

6B

Molar Uprighting
Traditional orthodontic mechanics for uprighting mesially tipped molars usually cause relative extrusion of molars and placing them in traumatic occlusion with the opposing molars. In these cases, the Ortho Implant is placed distal to the tipped molar and in line with the central fossa (Fig. 7). The molar is pulled distally and intruded simultaneously, thereby preventing extrusion.

6C

6D

Molar Intrusion
For supererupted teeth, molar intrusion is relatively simple. An Ortho Implant can be placed on both the facial and palatal surfaces or just on the facial surface (Fig. 8). The reason it is possible to place an Ortho Implant on the facial surface only is because of the additional root surface area of the molars.

Figure 6A-D: Posterior protraction. A, Buccal photograph at initial Ortho Implant placement and loading. B, Buccal photograph after 2 months of loading. C, Occlusal photograph at initial Ortho Implant placement and loading. D, Occlusal photograph after 2 months of loading.

Incisor Intrusion
Although anterior bite opening is possible with traditional mechanics using reverse curve of Spee wires, bite opening usually takes upward of 8-12 months, unless bite opening auxiliaries are bonded to the molars or incisors. The Ortho Implant can be used in these cases to open the bite in less than half the time, thereby allowing lower bonding sooner (Fig. 9).
7A 7B 7C

Figure 7A-7C: Molar uprighting. A, Pretreatment occlusal photograph. Note third molars were extracted. B, Ortho Implant location in line with central fossa. C, Progress occlusal photograph after 5 months of molar uprighting.

Posterior Intrusion
Perhaps the best location for MSI placement in hyperdivergent skeletal open bite case being treated by dental intrusion is in the palatal bone, but only if the patient does not have a narrow intermolar width. These patients characteristically have a high palatal vault such that placement of an MSI at the junction of the palatal bone and palatal alveolar ridge is high enough for intrusion mechanics (Fig. 10). Moreover, these patients usually have hanging lingual cusps that need more intrusion than the facial cusps.

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REMOVAL PROCEDURE
Ortho Implant removal is indicated after its use for anchorage and tooth movement is complete. Ortho Implant removal occurs without topical or local anesthetic by simply unscrewing the Ortho Implant. No pain is associated with the Ortho Implant removal; therefore, analgesics are not indicated.

10E

10F

8A

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Figure 10: Posterior intrusion using palatal mechanics. A, Anterior photograph at initial Ortho Implant placement and loading. B, Anterolateral photograph at initial Ortho Implant placement and loading. C, Occlusal photograph of Ortho Implant location and attachment mechanics. D, Close-up photograph of Ortho Implant location and attachment mechanics (Courtesy Dr. Jason B. Cope, Dallas, Tex. Patent pending). E, Anterior photograph after 3 months of loading. F Anterolateral photograph after 3 , months of loading. Note that the overbite has closed and overjet decreased due to autorotation.

Figure 8A-B: Molar intrusion. A, Buccal photograph of Ortho Implant at initial loading. B, Buccal photograph of Ortho Implant after 7 months of loading. Note overintrusion of first and second molars (Photographs taken in maximum intercuspation).

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9B

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9D

Figure 9A-D: Incisor intrusion. A, Anterior photograph at initial Ortho Implant placement and loading. B, Anterolateral photograph at initial Ortho Implant placement and loading. C, Anterior photograph after 5 months of loading allowing lower bracket placement. D, Anterolateral photograph after 5 months of loading.

Excerpted from Cope JB, Herman RJ. The Ortho Implant System. In: Cope JB, ed. OrthoTADs: The Clinical Guide and Atlas. Under Dog Media, LP Dallas, In Press, April 2006, with permission from , Under Dog Media, LP www.orthotads.com. ,

Reprinted from Orthodontic Perspectives Vol. XIII No. 1. 2006 3M. All rights reserved.