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The Skeletal The maxillary sites where screw fixation is possible are
limited to the zygomatic buttress and the piriform rim. The
Anchorage System (SAS) Y-plate is usually placed in the maxilla at the zygomatic but-
Figure 1 SAS titanium anchor plates. (A) T plate. (B) Y plate. (C) I plate.
smile, and disharmony between the hard and soft tissues. The thognathic surgery, however, because neither his profile, the
posterior-anterior (PA) cephalometric radiograph indicated a large interlabial gap, nor the gummy smile were of concern.
mild facial asymmetry (Fig 3). The lateral cephalometric ra- Instead, he chose SAS camouflage treatment, an alternative
diograph (Fig 4) was taken in natural head position and treatment option.
centric relation with relaxed lip posture. The cephalometric
analysis (craniofacial drawing standard analysis)5 indicated Soft Tissue and Skeletal Profile
● Excessive upper central incisor (U1) to stomion (7.0
that the major skeletal and soft tissue problems were a large
interlabial gap, vertical maxillary excess, and a skeletal Class mm)
● Gummy smiling
III relationship. Clinical examination revealed an anterior
● Large interlabial gap (8.0 mm)
open-bite, upper and lower anterior crowding, anterior
● Mild mandibular asymmetry
crossbite, mandibular dental midline deviation, and a narrow
● Skeletal Class III (large mandible)
upper dental arch (Fig 5). In addition, the lower 3rd molars
● Long face type (high angle, vertical maxillary excess)
were horizontally impacted bilaterally (Fig 6).
Denture
Diagnosis ● Asymmetric dentition
The patient had a fairly complex list of orthodontic problems. ● Deviation of dental midline
A common, and perhaps the most predictable, treatment op- ● Anterior open-bite and crossbite
tion would be surgical orthodontics. The patient refused or- ● Crowding
Figure 2 Pretreatment facial photos. (A) Frontal. (B) Frontal smiling. (C) Lateral.
Titanium miniplates 49
● L1 lingual inclination
Function
● Incompetence in lip closure
● Mouth breathing
Treatment goals
Although it was impossible to radically correct the skeletal
disharmony and the associated soft tissue profile without
orthognathic surgery, it was possible to improve the dental
and functional problems via three-dimensional movement of
the upper and lower molars with the SAS. To solve the ver-
tical problems, the treatment plan included intrusion of the
upper molars by 2.5 mm. A counterclockwise rotation of the
mandible with intrusion of the upper molars was expected
(Fig 7). This would decrease the excessive lower anterior
Figure 3 Pretreatment PA cephalometric radiograph (left) and trac- facial height and anterior open-bite. One possible negative
ing (right). Note mandibular asymmetry. sequela of molar intrusion, however, may be exacerbation of
the Class III occlusal relationship.
Based on the occlusogram (Fig 8), the upper incisors
would need to move facially 1.0 to 1.5 mm to compensate
for the mandibular autorotation. The upper molars would
be distalized 1.5 to 2.0 mm to resolve the anterior crowd-
ing. It would also be necessary to distalize the lower right
and left molars by 6.0 mm and 4.0 mm, respectively, to
correct the deviated lower midline.
The final intercuspation was predicted with a diagnostic
setup based on the cephalometric and occlusogram treat-
ment goals (Fig 9). The treatment plan to achieve the treat-
ment goals with the SAS follows.
1. Bonding and banding (upper and lower posterior seg-
ments)
2. Leveling and alignment of posterior segment
3. Maxillary lateral expansion (precision LA: fun type)
Figure 4 Pretreatment lateral cephalometric radiograph (left) and 4. Implantation of anchor plates to zygomatic buttress
CDS analysis (right). Hypochromic lines indicate the craniofacial and mandibular body
standard (norm) in Japanese adult male. 5. Distalization and intrusion of molars with SAS
6. Upper and lower canine retraction power chain (⬃ 400 g per segment) from the anchor plates
7. Bonding and leveling of upper and lower incisors (Fig 12). Following distalization of the upper and lower
8. Coordination of upper and lower dental arches molars, the remaining teeth were bonded. After leveling
9. Finishing and detailing and aligning of the arches, the asymmetric lower arch and
10. Debonding the open-bite were corrected with the SAS. During finish-
11. Retention (upper: wraparound retainer, lower: lingual ing and detailing, occlusal equilibrium was performed to
bonded retainer) maximize intercuspation.
Treatment Progress
Treatment progress is shown in Fig 10 and Fig 11. A
0.022-inch preadjusted appliance was placed on the buc-
cal segments and the lower incisors. Leveling and aligning
of the posterior teeth and lateral expansion of the upper
arch were initiated using archwires and a transpalatal arch.
About a month before surgical placement of the SAS, all of
3rd molars were extracted. A plate was placed at both the
zygomatic buttress and the apical region of the lower 1st
and 2nd molars, bilaterally. After placing rigid archwires
(0.018 inch ⫻ 0.022 inch stainless steel), en masse intru-
sion and distalization of the molars was initiated with
Figure 9 Diagnostic setup based on cephalometric and occlusogram treatment predictions. (A) Right buccal. (B)
Anterior. (C) Left buccal.
Outcome of SAS Treatment however, the functional occlusion and jaw position re-
An upper wraparound and a lower lingual retainer were mained stable (Fig 17).
placed on completion of treatment, which lasted 1 year
and 9 months (Figs 13 and 14). The anchor plates were
removed 1 month after appliance removal. A functional
occlusion with favorable intercuspation, stable posterior Presurgical Orthodontics
support, and anterior guidance was established. Superim-
Most patients who undergo the SAS surgical placement
position of pre- and posttreatment occlusograms reveals
show mild to moderate facial swelling for several days after
distalization of the lower right and left molars by 6.0 mm
and 3.0 mm, respectively. The upper molars were distal- surgery. Although it is possible to start loading the SAS
ized 3.0 mm, bilaterally. Based on the posttreatment pan- immediately, orthodontic force application is usually de-
oramic radiograph (Fig 15), no significant root resorption layed for 3 weeks to allow for resolution of postoperative
was observed at the molars. Evaluating the cephalometric facial swelling, soft tissue healing, and reinstitution of oral
superimpositions (Fig 16), the predicted mandibular au- hygiene procedures. Therefore, it is advantageous to be in
torotation did not occur, and the open-bite was corrected rigid archwires (ideally, 0.018 inch ⫻ 0.025 inch stainless
mainly by extrusion of anterior teeth. Although upper mo- steel) before surgery. We usually increase the size of arch-
lar intrusion did occur during SAS treatment, upper and wires up to the level of a full-sized archwire. In addition,
lower molar distalization may have caused an increase of the 3rd molars should be extracted either before or during
the lower anterior facial height. After 1 year of retention, SAS placement because they prevent distalization and in-
minor relapse was observed in the upper anterior region; trusion of the 1st and 2nd molars.
Figure 10 Treatment progress (anterior intraoral photos). (A) Leveling and aligning of posterior teeth and expansion of
upper arch. (B) Initial leveling and aligning of upper anteriors. (C) Continued leveling and aligning of upper arch with
continuous wire and distalization of lower molars. (D) Dental midline correction.
Figure 11 Treatment progress (lateral intraoral photos). (A) Leveling and aligning of posterior teeth and expansion of
upper arch. (B) Initial leveling and aligning of upper anteriors. (C) Continued leveling and aligning of upper arch with
continuous wire and distalization of lower molars. (D) Dental midline correction.
52 J. Sugawara and M. Nishimura
Figure 12 Postsurgical photographs. (A) Panoramic radiograph. (B) Right buccal. (C) Left buccal.
SAS Placement Procedure the buccal vestibule (Fig 18A). A vertical incision is usually
made in the maxilla; a horizontal incision in the mandible. The
The surgical procedure is performed under local anesthesia with mucoperiosteal flap is elevated following the subperiosteal dis-
IV sedation. Initially, a mucoperiosteal incision is performed in section to expose the bony cortex (Fig 18B). Based on the dis-
Figure 13 Posttreatment facial photos. (A) Frontal. (B) Frontal smiling. (C) Lateral.
Titanium miniplates 53
tance between the surgical site and the dentition on the pretreat- ization, intrusion, protraction, extrusion, and buccal/lin-
ment panoramic radiograph, the appropriate shape and length gual movement. To date, the SAS has been applied to more
anchor plate is selected. The plate is contoured to the bone than 500 patients in our clinic. Distalization and intrusion
surface and placed in its final position. Then a pilot hole is of maxillary and mandibular molars were performed in
drilled, and a self-tapping monocortical screw is placed. The approximately 85% of all SAS patients.
remaining screws are inserted to firmly attached the anchor It is extremely difficult, if not impossible, to intrude the
plate to the bone surface (Fig 18C). Last, the surgical site is upper and lower molars with traditional orthodontic mech-
closed with resorbable sutures (Fig 18D). The surgery takes anotherapy. SAS mechanics, on the other hand, allow effi-
approximately 10 to 15 minutes for each anchor plate. cient molar intrusion (Figs 19 and 20), making it possible to
correct even severe open-bite cases without orthognathic sur-
gery, thereby minimizing potential risks.
Orthodontic Mechanics Distalization of upper or lower molars is difficult even with
The most significant advantage of the SAS is that it allows the use of a headgear, and more so in adults. By using SAS
the achievement of predictable three-dimensional molar mechanics to achieve molar distalization, it is now possible to
movement. The types of molar movement include distal- correct severe crowding, upper protrusion, anterior cross-
Figure 18 Maxillary anchor plate surgical placement. (A) Mucoperiosteal incision. (B) Flap elevation with subperiosteal
dissection. (C) Anchor plate fixation with titanium screws. (D) Surgical site closed and sutured.
Titanium miniplates 55
Figure 19 Upper molar intrusion mechanics. (A) Leveling and aligning of posterior teeth. (B) Y-plate placed at zygomatic
buttress with elastic intrusive force. Note transpalatal arch to prevent buccal flaring of molars. (C) After intrusion, both
arch are leveled and aligned. (D) Archwire is ligated to anchor plate to prevent relapse.
Figure 20 Lower molar intrusion mechanics. (A) Lower dentition with two occlusal planes. (B) Leveling and aligning of
posterior teeth. (C) L-plate placed at lateral cortex with elastic intrusive force. Note lingual arch to prevent buccal
flaring of molars. (D) After intrusion, both arches are leveled and aligned, then archwire is ligated to anchor plate to
prevent relapse.
Figure 21 Upper molar distalization mechanics. (A) Upper arch. (B) Leveling and aligning of upper arch following 3rd
molar extraction. (C) En masse distalization of upper molars with elastic force from anchor plate. (D) En masse
retraction of anterior teeth.
Figure 22 Lower molar distalization mechanics. (A) Leveling and aligning of lower arch following 3rd molar extraction.
(B) En masse distalization of lower molars with elastic force from anchor plate. (C) En masse retraction of anterior teeth
directly to canine. (D) En masse retraction of anterior teeth using soldered hook.
56 J. Sugawara and M. Nishimura
Figure 23 Maxillary anchor plate surgical removal. (A) Surgical site before soft tissue reflection. (B) Flap elevation with
subperiosteal dissection. (C) Anchor plate removed from bone surface. Note bone growth around plate.
Summary References
The SAS offers several advantages. Since the anchor plates and 1. Sugawara J: JCO interviews Dr Junji Sugawara on the skeletal anchorage
screws are made of commercially pure titanium, they are bio- system. J Clin Orthod 33:689-696, 2000
2. Umemori M, Sugawara J, Mitani H, et al: Skeletal anchorage system for
compatible. Moreover, they are located away from the dentition,
open-bite correction. Am J Orthod Dentofacial Orthop 115:166-174,
and therefore, do not interfere with tooth movement. The SAS 1999
obviates the need for significant patient compliance, particularly 3. Sugawara J, Un Bong Baik, Umemori M et al: Treatment and post-
with regard to extraoral appliances, which allows more predict- treatment dentoalveolar changes following intrusion of mandibular
able treatment results. This also allows an overall decrease in the molars with application of a skeletal anchorage system (SAS) for open
number of nonextraction and orthognathic surgery cases. Be- bite correction. Int J Adult Orthod Orthognath Surg 17:243-253,
cause the SAS is rigidly fixed to bone, molars can be moved in 2002
4. Sugawara J, Daimaruya T, Umemori M, et al: Distal movement of man-
any direction without taxing anchorage and the occlusal plane
dibular molars in adult patients with the skeletal anchorage system. Am J
can be controlled by orthodontists, without the need for sur- Orthod Dentofacial Orthop 125:130-138, 2004
gery. In conclusion, the SAS is quite effective biomechanics for 5. Sugawara J, Soya T, Kawamura H, et al: Analysis of craniofacial morphol-
adult patients, retreatment cases, and patients with complex ogy using craniofacial drawing standards (CDS), application for orthog-
orthodontic problems. nathic surgery. J Jpn Orthod Soc 47:394-408, 1988