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 Acta Scientific DENTAL SCIENCES (ISSN: 2581-4893)
Volume 4 Issue 10 October 2020
Review Article

Skeletal Anchorage System [Miniplates] - An Orthodontic Perspective - A Review

Amit Bhardwaj1, Ashish Kumar Sharma2*, Kratika Mishra3 and Rahul

Received: August 03, 2020
Jeswani4
1
Published: September 07, 2020
Dean, Professor and Head, Department of Orthodontics, Modern Dental College and
© All rights are reserved by Ashish Kumar
Research Centre, Madhya Pradesh Medical Science University, India
2
Sharma., et al.
Post Graduate Resident, Department of Orthodontics, Modern Dental College and
Research Centre, Madhya Pradesh Medical Science University, India
3
Assistant Professor, Department of Orthodontics, Modern Dental College and
Research Centre, Madhya Pradesh Medical Science University, India
4
Post Graduate Resident, Department of Orthodontics, Maharana Pratap College of
Dentistry and Research Centre, Madhya Pradesh Medical Science University, India
*Corresponding Author: Ashish Kumar Sharma, Post Graduate Resident,
Department of Orthodontics, Modern Dental College and Research Centre, Madhya
Pradesh Medical Science University, Madhya Pradesh India.

Abstract
In the orthodontic world paradigms have started to shift since the invention of mini-plates in the anchorage armamentarium.
Miniplates as bone-borne anchor unit have enabled us with management of wider discrepancies than those with tooth-borne anchor
unit by conventional biomechanics. Miniplate enables clinicians for having good control over tooth movement and anchorage control
in three dimension that is sagittal, vertical and transverse plane. This present literature review will explain about how the skeletal
anchorage system is versatile with usage of miniplates for the correction of malocclusion, emphasising on orthodontic and orthope-
dic movements within three dimensions. Management of impacted teeth and adult orthodontics along with periodontal conditions
is also explained in this review.

Keywords: Miniplate; Anchorage; Skeletal Anchorage Systems (SAS); Molar Distalization

Introduction to be evaluated in three planes of space: anterior-posterior

(AP), transverse, and vertical. Until recently, orthodontists relied
The practice of clinical orthodontics is mainly reliant on the
on intra-and/or extra-oral devices that usually required patient
availability of anchorage. According to Graber, anchorage is de-
compliance to prevent undesired tooth movement. Absolute
fined as nature and degree of resistance to displacement offered
anchorage is required to avoid unwanted tooth movement cause
by an anatomic unit when used for the purpose effecting tooth
by reactive forces. In absolute or infinite anchorage due to force
movement [1]. Its role in orthodontic treatment was appreciated
applied to move teeth there is no movement of anchorage unit [3].
since the 18th century, as prominent orthodontists such as Gun-
Such an anchorage can only be obtained by means of skeletal an-
nell, Desirabode, and Angle realized the limitations of moving
chorage which includes all the devices that are fixed to the bone.
teeth against other teeth used for anchorage, introducing ideas
Miniplates were introduced to offer absolute orthodontic anchor-
such as the use of occipital, stationary, and occlusal anchorage [2].
age a year after the introduction of miniscrews. In 1998, Sugawara.,
Assuming ideal treatment goals, anchorage requirements need

Citation: Ashish Kumar Sharma., et al. “Skeletal Anchorage System [Miniplates] - An Orthodontic Perspective - A Review”. Acta Scientific Dental Sciences
4.10 (2020): 03-10.
Skeletal Anchorage System [Miniplates] - An Orthodontic Perspective - A Review

04

et al. distalize lower molar for rectifying class III malocclusion us- monocortical screws, which are 2.0 mm in diameter X 5.0 mm in
ing titanium miniplates and eventually evolved the skeletal anchor- length. The shape of the screw is square head tapered internally
age system (SAS) [4]. In 1999, Unemori., et al. reported on the use and a body which is self-tapping and threaded.
of miniplates to intrude the posterior segment to correct anterior
open bites [5]. While comparing TADs with mini plates, the mini- The miniplate plate consists of the three components (Figure 1):

plate system is advantageous as they do not interfere with tooth • The head
movement and the more secure anchorage is provided by multiple • The arm
screws, which is especially beneficial in patients with extremely • The body.
thin cortical bone, most often seen in those with excessive verti-
cal facial height [6]. There are two types of head portion according to manner of
tooth movement, which vary with regard to the direction of hooks
Skeletal anchorage systems (SAS) - Miniplates [10].
Skeletal anchorage system (SAS) as devised by Sugawara is an
orthodontic anchorage system that utilize miniplates and mono-
cortical screws made up of titanium that are temporarily fixed in
the maxilla and/or mandible to provide absolute orthodontic an-
chorage [7,8]. The miniplates are the most effective and anticipated
treatment modality option [9,10]. Using miniplate the dentoalveo-
lar complex can be remodeled beyond the limits of contemporary
mechanics. Additionally, bone repositioning and growth modifica-
tion4can be achieved by miniplates they transfer the orthopedic
forces directly to the facial skeleton and reactions of periodontal
anchorage, leading to a reduction in unwanted side effects [8].

The most useful application of the SAS is to permit the predict-

able and anticipated intrusion and distalization of maxillary and
Figure 1: Design of a T-type miniplate [16].
mandibular molars. SAS offers a non-extraction treatment ap-
proach for some severe malocclusions characterized by maxillary
The miniplate consists of a specially designed head with two
or mandibular protrusion, as well as a non-surgical orthodontic
segments:
treatment option to correct skeletal malocclusions(surgical), an-
terior crowding in adult patients, retreatment cases, patients with • Hooks to attach elastics, coil springs, elastomeric modules;
complex orthodontic problems, reduce total treatment time, cor-
• Reamed oblong apertures with a maximum cross-section of
rect minor surgical inaccuracies and relapse tendencies after or-
.022 - .028” for insertion of auxiliaries (cantilever or stabi-
thognathic surgery [11-13].
lization auxiliary).
Appliance design
There are three basic types (Figure 2):
Bone plates and fixation screws are the components of the
skeletal anchorage system [7]. The plates and screws are made of • The T-plate,
commercially pure titanium that is biocompatible and suitable for • The Y-plate and
osseo-integration; which is strong enough to withstand and resist
• The I-plate.
the optimal orthodontic forces but it can also be bent with ease
for fitting into the bone contour of the implantation site. The mini- The choice of miniplate (T-, I-, Y- or L-shaped) and the length of
plate is shaped according to bone morphology and is fixed in the the stem (5, 7 or 10 mm) will depend upon the chosen placement
cortical bone area above roots using fixating screws; two or three site, bone density (two or three screws), the depth of the buccal
screw according to plate used [14,15]. The surgical site requires at sulcus and the facial typology (Figure 3).
least 2 mm of cortical bone thickness to fix the anchor plate using

Citation: Ashish Kumar Sharma., et al. “Skeletal Anchorage System [Miniplates] - An Orthodontic Perspective - A Review”. Acta Scientific Dental Sciences
4.10 (2020): 03-10.
Skeletal Anchorage System [Miniplates] - An Orthodontic Perspective - A Review

05

radiograph and the oral surgeon must assess anatomical limita-

tions or any pathology at the miniplate placement sites through
radiographic and clinical examinations [17]. General status of the
patient is also considered.

Indications
Skeletal orthodontic anchorage devices are indicated when sta-
tionary anchorage is required involving diverse anchorage tasks
[12,18]. In particular, these can include:
Figure 2: Miniplate. A) T-type, B) Y-type, C) I-type [8]. • Complete retraction of the arch (symmetrical or asymmet-
rical, maxillary or mandibular)

• Space closure from mesial

• Space closure from distal

• Intrusion and extrusion (anterior and posterior teeth)

• Distalization, mesialization, and midline corrections

• Molar uprighting.

In cases requiring absolute anchorage, miniplates are compara-

tively superior to miniscrews. The miniplate does not interfere with
the roots of moving teeth and as the head of miniplate is closer to
centre of rotation of arch, the force applied will induce controlled
and continues movement. Thus miniplates are more reliable and
Figure 3: Position of miniplates. A) I-type, B) Y-type, C) L-type, no patient cooperation is required [9]. Miniplates offer supreme ef-
D) T-type [4]. fectiveness even with conditions like asymmetrical retraction, full
arch distalization [19].

Site of miniplate placement Absolute contraindications include patients with titanium ele-
In the maxillary sites screw fixation is possible but they are lim- ment allergies, any local active infection, blood-borne diseases,
ited to the zygomatic buttress and the piriform rim. The Y-plate is cardio-vascular diseases, metabolic bone disorders or any bone
used to intrude or distalize upper molars which are usually placed pathologies, ongoing bone radiation therapy, psycho-somatic dis-
in the maxilla at the zygomatic buttress. I-plate is routinely placed orders and current/previous bisphosphonate therapy. Relative
at the anterior ridge of the piriform opening for intrusion of upper contraindications are inadequate patient compliance, poor oral
anterior teeth or protraction of upper molars. The L-plate and/or hygiene, parafunctional habits, and the use of drugs, alcohol, or to-
the T-plate are usually placed at the anterior border of the ascend- bacco; depending on whether the condition can be eliminated or
ing ramus for extrusion of impacted molars or in the mandibular resolved before surgical placement of miniplate [17].
body for intrusion, protraction, or distalization of lower molars.
Miniplate placement procedure
Preparation for surgery
The surgical procedure is routinely accomplished under local
anesthesia. A mucoperiosteal incision is made at the buccal ves-
A team of oral surgeon and orthodontist is needed for placement
tibular of the implantation site -vertical incision in maxilla, -hori-
of miniplates. Combined efforts of an orthodontist and oral sur-
zontal incision in mandible. As the mucoperiosteal flap is elevated
geon where, the orthodontist selects the type and length of mini-
the cortical bone surface is exposed and the Suitable type of mini-
plate and plans on the exact position of the head over panoramic

Citation: Ashish Kumar Sharma., et al. “Skeletal Anchorage System [Miniplates] - An Orthodontic Perspective - A Review”. Acta Scientific Dental Sciences
4.10 (2020): 03-10.
Skeletal Anchorage System [Miniplates] - An Orthodontic Perspective - A Review

06

plate is selected and contoured to fit the surface of cortical bone Miniplate removal procedure
[17]. Miniplate is nicely secured to bone with monocortical screw All miniplates and screws are routinely removed after the com-
(if self tapping type pilot hole is to be drilled first). In maxilla, for pletion of orthodontic treatment, under local anesthesia. Initially a
securing miniplates self-drilling screws are more pertinent [20]. At short mucoperiosteal incision is made and subperiosteal ablation
this moment it is important to ensure that: All of the miniplates are is performed at the implantation site to expose miniplate body and
transfixed at the region of the buccal vestibule, does not disturb fixation screw. Any remaining inflammatory tissue is curettage to
mandibular movement or adjacent soft tissues, emergence of the accelerate healing of soft tissue and the mucoperiosteal flap is su-
miniplate at the mucogingival junction or within the attached gin- tured with resorbable suture [17]. Medication like Analgesics, anti-
gival is essential for good soft tissue healing and management, ex- biotics are prescribed to control postoperative swelling and infec-
posure of the miniplates through the mobile mucosa may result in tion. Oral hygiene is reestablished with oral rinse solutions.
increased irritation, inflammation, infection, and soft tissue over-
growth around the miniplates. Finally with resorbable suture the Orthodontic biomechanics with SAS (miniplates)
mucoperiosteal flab is sutured. The surgical placement of miniplate Presently the most significant advantage of SAS is its achieve-
usually requires 10 to 15 minutes individually. ment of predictable 3D molar movement without the need for
patient compliance [4,7,21]. Miniplates have greater stability and
Miniplates with two or three screws have good mechanical are away from dental component of arch, allowing for three dimen-
stability at time of placement so immediate loading of orthodon- sional movement of molar (intrusion, extrusion, mesial or distal
tic force is possible. It is usually applied about 3 weeks after im- movement). With the adjuvant of SAS mechanics envelop of tooth
plantation surgery. In general orthodontic force is usually applied movement has enhanced dramatically and also patients with den-
3 weeks following miniplate placement surgery to allow soft tissue tal and skeletal malocclusions are offered with more treatment Op-
healing and to subside facial swelling post-operatively [14]. Mea- tions (Figure 4).
sures are to be taken to re-establish oral hygiene procedures.

Figure 4: Miniplate position and biomechanics [4].

Molar distalization for molar distalization. For molar distalization the amplitude of
While molar distalization has always been considered difficult, orthodontic force up to 400-500 gram can be implicated on each
with the development of SAS mechanics, en-mass movement of the side [19]. Distalization of upper molar is indicated for relieving
posterior molars can be achieved, considerably reducing treatment anterior crowding in maxillary arch, Class II cases, a symmetrical
time. Third molars if present are usually extracted to build space maxillary dentition, and in skeletal Class III cases for dental de-

Citation: Ashish Kumar Sharma., et al. “Skeletal Anchorage System [Miniplates] - An Orthodontic Perspective - A Review”. Acta Scientific Dental Sciences
4.10 (2020): 03-10.
Skeletal Anchorage System [Miniplates] - An Orthodontic Perspective - A Review

07

compensation of the upper incisors before orthognathic surgery. • Orthopedic movement: A new orthopedic treatment for
And distalization of lower molar is indicated for relieving anterior maxillary protraction using pure bone-borne orthopedic force
crowding in mandibular arch, a symmetrical mandibular dentition, between the maxilla and the mandible has been reported by
anterior crossbite, and in skeletal Class II cases for dental decom- De Clerck., et al. and Heymann., et al. orthopedic force is gen-
pensation of the lower incisors before orthognathic surgery [21]. erated by Class III elastics connected with miniplates which
are inserted into the infra-zygomatic crests and bilaterally
Molar intrusion between the mandibular canines and first premolar [30,31].
With traditional orthodontic mechanics intrusion of molars is Since this intraoral appliance is invisible, long-time use (24
extremely difficult but orthodontic intrusion using a miniplates hours per day), prevent dentoalveolar compensation. Wilmes.,
anchorage placed at the zygomatic buttress for maxillary molar, et al. reported a technique of skeletally borne maxillary pro-
or at the posterior mandibular body for mandibular molar is now traction by using miniplates combined with bone-borne rapid
achievable [21]. After the placement of a rigid rectangular archwire maxillary expansion [32].
in the buccal side and a transpalatal arch (TPA) in the maxilla or a • Speedy orthodontics: Chung., et al. reported ‘corticotomy-
lingual arch (LA) in the mandible, an elastic intrusive force will be assisted orthodontic treatment called speedy orthodontics’
provided from the miniplates anchorage [22]. Intrusion of maxil- [10]. Peri-segmental corticotomy is carry out in two steps;
lary molar is indicated for cases with anterior open bite cases, pos- first labial coricotomy and then two weeks later palatal co-
terior vertical maxillary excess and moderate Class II relation. And ricotomy ; to outline the anterior or posterior teeth bearing
intrusion for mandibular molar is indicated for cases with anterior segment. Orthopedic force of 500-900 gm per side is applied
open bite, lower molar height excess and mild Class III relation. In- to the corticotomized segment which derives anchorage from
trusion of molar result in counterclockwise movement of mandible miniplates to bring about faster space closure.
following correction of open bite [23,24].
• “Surgery First” orthognathics: Nagasaka., et al. for the treat-
Molar protraction ment of skeletal Class III malocclusion describe “Surgery
With miniplate placed at the anterior mandibular body or at the First” orthognathics with the rigid fixation with miniplates
piriform rim, orthodontic protraction of molar is effortless [25,26]. [4]. The principle of “Surgery First” is to correct the skeletal
Protractive force of about 200-400 gram can be applied unilater- discrepancy first and then correct the dental relation. This
ally. Protraction of maxillary molar is indicated for cases with Class surgery first orthodontics has two significant advantages: a
III molar relationship, asymmetrical maxillary dentition, anterior shorter treatment time and rapid improvement of the facial
crossbite caused by maxillary deficiency, congenitally missing lat- profile. The SAS is vitally important for intermaxillary fixation,
eral incisor or second premolar. And protraction of mandibular a stable and functional occlusion is very likely obtained with-
molar is indicated in cases with Class II molar relationship, a sym- out extraction of bicuspid or segmental maxillary osteotomy.
This technique represents a potential paradigm shift in field of
metrical mandibular dentition, congenitally missing second pre-
molar, diastemas of mandibular dentition [27,28]. surgical orthodontics.

Clinical application of SAS (miniplates) Miniplate advantages, failure and complications

Non-surgical camouflage treatment: Majority of skeletal prob- Advantages

lems like anterior open bite, class II and class III deformity can • Bio-compatible.
be treated with camouflage or compensation methods using SAS
• Miniplates are most rigid of the skeletal anchorage available.
(miniplate) that conventionally needed orthognathic surgery. As
compared to other orthodontic TADs miniplates have more stabil- • Located away from the dentition, and therefore, do not in-

ity, high success rate, offer more controlled tooth movement and terfere with tooth movement.

do not interfere tooth movement. Consequently, goal oriented ap- • Reduces the need for significant patient compliance, with
proach and foreseen treatment outcomes can be executed [29,30]. regard to extraoral appliances.

• Allows more predictable treatment results.

Citation: Ashish Kumar Sharma., et al. “Skeletal Anchorage System [Miniplates] - An Orthodontic Perspective - A Review”. Acta Scientific Dental Sciences
4.10 (2020): 03-10.
Skeletal Anchorage System [Miniplates] - An Orthodontic Perspective - A Review

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