Achieving Optimal Esthetics with Palatal Mini-Implants: The Benefit Technique

Achieving Optimal Esthetics with Palatal Mini-Implants: The Benefit Technique

The following factors seem to be relevant for the premature loss or tipping of a mini-implant

1. Insufficient bone quality and/or inadequate bone quantity at the insertion site.

2. Employment of mini-implants with a small diameter and/or length.

3.Inappropriate intra osseous design.STABLE ANCHORAGE

4. Root contact at the time of insertion.5. Manipulation with the fingers or tongue.6. Insufficient oral hygiene.7. Application of high forces or moments.8. Use of a large lever arm. This occurs if the mini-implant is inserted in a region where the gingiva or mucosa is too thick..9. Insertion in the region of the movable mucosa

10. Insufficient primary stability.11. Bone damage at insertion due to high stress or bone overheating. This phenomenon is well known in dental implantology

Other regions, such as the anterior palate and the mental region, provide much better conditions for temporary anchorage device (TAD) insertion since the amount and quality of the available bone is superior. Using TADs in the anterior palate and the mental region eliminates the risk of root injury and takes the TADs out of the path of tooth movement..

Mental regionAnterior palate

Benefit Mini-Implants withExchangeable AbutmentsThe Benefit mini-implant has an inner thread on its top . It is made of titanium alloy . and due to its self-drilling thread design, insertion can be done without predrilling with a hand piece. Available dimension are diameter of 2 or 2.3 mm and length of 7, 9, 11, 13, or 15 mm.

Benefit mini-implant with an inner thread.

On the top of the mini-implant four different types of stainless steel abutments can be fixed with a tiny fixing screw that is integrated into the abutment .This small fixing screw can be turned within the abutment but cannot fall out of it. Different types of abutments allow the construction of versatile appliances for a large variety of clinical applications. The Benefit mini-implants are inserted primarily in the anterior palate and in edentulous areas of the alveolar process.

Benefit system. A, Mini-implant. B, Abutment with wire in place. C, Bracket abutment. D, Standard abutment. E, Slot abutment.F, Screwdriver.

To improve their stability and to prevent mini-implant tipping, two Benefit mini-implants can easily be coupled with the Bene plate . The Bene plate is a stainless steel plate with a thickness of 1.2 mm. To cover multiple distances of two mini-implants, it has a round hole and a long hole. As well, it is available in two different lengths, resulting in possible distances of 3.5 to 14 mm measured from the center of one mini-implant to the center of the other..The Beneplate: A Mini-Plate for the EasyCoupling of Two Mini-Implants

Bene plate system. A, Short Bene plate. B, Short Bene platewith wire in place. C, Long Bene plate with bracket in place. D, Fixation screw

To enable a stable connection to the orthodontic appliance, Bene plates with a 1.1-mm-diameter stainless steel wire (for a Bene slider, Mesial slider, Mesial-Distal-Slider) 0.8-mm-diameter stainless steel wire (for a Pendulum B or molar intrusion with the Mousetrap mechanics), and a stainless steel bracket (to ligate in lever arms) are available. The Bene plate can be adapted to the Bene fit mini-implants by bending the plate body as well as the wire.Small fixing screws are used to fix the Bene plate on top ofthe mini-implants..

STEP-BY-STEP CLINICAL PROCEDURE

The optimum insertion site in the maxilla is located in the anterior palate distally from the palatal rugae on a line between the premolars. Advantages of this region are a thin soft tissue layer and sufficient bone height. Less bone is available in the areas that are more lateral and posterior

Prepared maxilla with two lines showing the optimal insertionsite between the premolars. Less bone is available in the areas that aremore lateral and posterior

The first step is local anesthesia administered directly in the insertion site . If the patient is afraid of a syringe, only topical anesthesia can be used.

Local anesthesia administered directly into the insertion site

The second step is predrilling (to 3 mm depth) with a 1.4-mm drill for the 2-mm mini-implants and a 1.7-mm drill for the 2.3-mm mini-implants. This can be done manually using a special hand piece equipped with a 1 : 1 contra angle . Due to the low speed there is no need for cooling. In very young patients ( less than 12 years of age) pre drilling is not necessary due to the low mineralization rate of the bone

A, Preparation for predrilling using a contra angle equippedwith a special hand piece. B,Predrilling with the contra angle and the hand piece.

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Once the sites have been prepared, one or two Benefit mini-implants are inserted near the mid palatal suture, again using the contra-angle screwdriver .

A, Preparing a Benefit mini-implant before insertion.B, Insertion of a Benefit mini-implant using the contra-angle screwdriver

If just one mini-implant is employed (e.g., for molar anchorage), the dimension 2.3 mm 11 mm is chosen . if two mini-implants are employed, usually a 2 mm 11 mm mini implant is inserted anteriorly and a 2 mm 9 mm mini implant is inserted posteriorly. As an alternative, a 2 mm 9 mm mini-implant is chosen anteriorly and a 2 mm 7 mm mini-implant is chosen posteriorly .

One Benefit mini-implant in the palate (2.3 mm 11 mm).Two Benefit mini-implants inserted in the palate 2 mm 11 mm anterior and 2mm9 mm posterior).

Generally, it is advisable to choose mini-implants with a big diameter or 2 or 2.3 mm, because they provide superior stability compared to mini-implants with a smaller diameter. Usually the Benefit mini-implants are inserted within a torque range of 10 to 25 Newton centimeters (Ncm). The maximum insertion torque is 35 Ncm for the mini-implants with a diameter of 2 mm.

two mini-implants are inserted in a sagittalline . As an alternative and especially if arapid palatal expansion with the Hybrid Hyrax is planned, the mini-implants are inserted in a transversal lineup

In most cases, two mini-implants are inserted in a sagittal line a rapid palatal expansion with the Hybrid Hyrax is planned, the mini implantsare inserted in a transversal lineup.

The distance between the two mini-implantsshould be at least 4 mm to enable enough space for the Supra construction (two abutments or one Beneplate). Additionally, if an impression is planned, there must be enough space for two impression caps.The Benefit mini-implants are self-drilling and can be inserted without predrilling. there is very high bone density in the anterior palate, especially in older patients. Soft tissue thickness canbe measured using a dental probe from anterior to posterior to identify a region with thin mucosa. This is important in order to achieve a sufficient primary stability and to avoid large lever arms. The soft tissue in the anterior region nearby the first and second rugae is very thick

Depending on the mechanics, bands with lingual sheaths are fixed to the upper molars. The appliance can be bent either directly chair side or after impression taking in the laboratory. In the latter case, impression caps are placed on top of the mini-implant and a silicone impression is taken ..

Chair side adaption of the T-bow for front anchorage duringmolar mesialization in the upper arch.

Laboratory analog (left) and impression cap (right)., One Benefit mini-implant after insertion.

An impression cap is placed on top ofthe mini-implant. Impression tray. Note that the impression cap is visible.

If desired, the impression caps can be secured bydental floss. Subsequently, laboratory analogs are insertedin the impression caps and fixed by wax .At the end, a plaster model is manufactured. The only appliance that has to be manufactured in the laboratory is the Hybrid Hyrax since it requires soldering or welding connections.Bands should be adapted on the teeth and later inthe impression if they will be integrated in the appliance..

A laboratory analog is inserted in the impression cap. , Impression for aHybrid Hyrax with replaced bands and laboratory analogs.

Principle: Direct versus Indirect Anchorage

Class II malocclusions are very common. For patients with a dental Class II malocclusion with increased over jet and/or anterior crowding, upper molar distalization is a frequently chosen treatment alternative. Molar distalization with a headgear is unpleasant for many patients for esthetic reasons and because of the length of time the headgear needs to be worn..DISTALIZATION IN THE UPPER ARCH

To minimize or eliminate anchorage loss of the anterior dentition, skeletal anchorage devices have been integrated into distalization appliances. Although indirect anchorage can be used to support the premolars during maxillary molar distalization, mini-screw tipping and wire deformation may result in anchorage loss and mesial premolar migration. Moreover, after molar distalization the appliance must be reconstructed in order to distalize the premolars and anterior teeth. Therefore direct anchorage is preferable..

The Beneslider is a distalization appliance that uses direct anchorage and is based on one or two mini-implants in the anterior palate. Through the use of the Benefit mini-implants with exchangeable abutments, a stable and safe connection between the mini implants and the distalization mechanics is achieved. To couple the Beneslider with the molars, bands with lingual sheaths are fixed to the upper molars.Direct Anchorage with the Beneslider

Benetubes are plugged into the sheaths from the mesial side .To avoid irritation of the soft tissues, the Benetube must be bent slightly in most cases. If one mini-implant was inserted, an abutment with a wire in place is adapted to the curvature of the palate. If two mini-implants were inserted, a Bene plate with a 1.1-mm stainless steel wire in place is now adapted . Depending on the axis and the location of the two mini implants, the Bene plate body must be bent.

By changing the angulation of the 1.1-mm stainless steel wire, it is possible to achieve a simultaneous intrusion or extrusion of the molars . The adapted abutment is now fixed on the mini-implant by the inner fixing screw. If two mini-implants were inserted, the Bene plate is fixed by two fixing screws

the distalization force is applied by springs that are activated by pushing the activation locks distally . the use of nickel-titanium (Ni-Ti) springs (240 g in children and 500 g in adults). It seems advantageous that the Beneslider mechanics can be installed without need for any laboratory work in terms of welding or soldering. In other words, the Bene slider mechanics can be applied directly in the oral cavity without taking an impression. To save chair time, however, the Bene slider can also be adapted on a plaster model .

Follow-up should be scheduled every 4 to 6 weeks. Usually the premolars and canines migrate distally toward the molars due to stretching of the interdental fibers. After distalization of the molars with the Bene slider, the Bene slider stays in place as an anchorage device during retraction of the anterior dentition. The treatment can be finished with buccal brackets, lingual brackets, or aligners..

The patient was a 13-year-old male with a Class II relationship and severe bialveolar protrusion. In the canine region, half of a Class II occlusion was found . The treatment plan was distalization and correction of the protrusion in the upper arch with a Beneslider and distalization with a lip bumper and retrusion of the incisors in the lower arch...Clinical Example Using the Bene slider

After insertion of two Benefit mini-implantsin the anterior palate, the Beneslider mechanics were applied and activated .. After 6.5 months the upper molars were distalized approximately 4 mm and brackets were bonded . The radiographs show a bodily distalization of the molars ...

After 6.5 months the upper molars were distalized approximately 4 mm and brackets were bonded.

Steel ligature were inserted between the Benetubes and the activation locks to deactivate the Beneslider. As an alternative, the Ni-Ti springs can be removed. In other words, the Beneslider was modified from a distalization device to a molar anchorage device. An elastic chain was inserted from the first molar to the contralateral first molar to retract the anterior dentition. After 5 months of retraction the spaces were almost closed to the distal. To avoid contact of the Bene plate wire and the soft tissues it is important to anticipate the amount of front retraction at the time of bending the wire.

After the finishing phase the brackets were de bonded. The Beneslider and the Benefit mini-implants were removed without anesthesia . End of treatment was reached after 18 months ..

Principle: Direct versus Indirect Anchorage

Congenitally missing lateral incisors or second premolars, extremely displaced canines, or a severe trauma of a central incisor are potential complaints that result in a reduced upper dentition. The two major treatment approaches are space closure or space opening to allow prosthodontic replacements with either a fixed prosthesis or a single-tooth implant. Both of these treatment approaches can potentially compromise esthetics, periodontal health, and function. In many cases space closure to the mesial (front teeth should stay where they are, when posterior teeth are moving mesially) seems to be the favorable treatment goal, since treatment can be completed as soon as the dentition is complete. Canine substitutions can be accomplished with good esthetic outcomes by tooth reshaping and positioning, bleaching, and porcelain veneers.MESIALIZATION IN THE UPPER ARCH

The more mesial the missing tooth is, the higher will be the demands for anchorage quality, especially in asymmetrical cases with a midline deviation. If the central incisors are in the correct position (midline, torque, and angulation is correct), a T-bow can be bonded to the lingual surfaces of the central incisors to apply an indirect anchorage, with the goal being to avoid lingual tipping of the central incisors during space closure.

As an alternative to the T-bow(indirect anchorage), the Mesialslider can be used as a direct anchorage device. The Mesialslider enables clinicians to mesialize upper molars unilaterally or bilaterally. Since the incisors are not fixed, a midline deviation can be corrected at the same time. The Mesial slider can also be used for protrusion of the whole upper dentition to compensate a mild Class III occlusion.

The T-bow is an arch wire that is connected from one or two mini-implants in the anterior palate to the lingual surfaces of the upper central incisors. Using the T-bow avoids an undesired lingual tipping of the incisors during mesialization in the upper arch..Clinical Application of the T-Bow

Typical indications are unilateral or bilateral agenesis of the lateral incisors or missing canines. The incisors should already be well aligned and in the correct position when the T-bow is applied. After insertion of the mini-implants, a Bene plate with a 1.1-mm stainless steel wire in place is bent and adapted to fit between the mini-implants and the central incisors.Depending on the insertion axis and the position of the mini-implants, the Bene plate body must be adapted as well.After fixation of the Bene plate on top of the mini-implants by tiny fixing screws, the wire is bonded to the lingual surfaces of the central incisors ...

The patient was a 14-year-old female with missing upper lateral incisors and second molars. The treatment plan was mesialization in the upper arch without anchorage loss of the incisors by using a T-bow. After leveling, one Benefit mini implant was inserted in the anterior palate ..Clinical Example Using the T-Bow

An abutment with a 1.1-mm stainless steel wire in place .was adapted to fit between the mini-implant and the incisors .. Following bonding of the T-bow an elastic chain was used to apply mesialization forces to the lateral dentition. After 17 months the upper dentition was mesialized ..

The treatment result showed a well-preserved over jet and a proper occlusion. it seems recommendable to use two mini implants to achieve a high anchorage quality.

After insertion of two Benefit mini-implants, bands with lingual sheaths are fixed to the upper molars. Subsequently, two Bene tubes and a Bene plate with a 1.1-mm stainless steel wire in place are adapted to the curvature of the palate. To avoid irritation of the soft tissues, the Bene tubes must be bent in most cases.Clinical Application of the Mesialslider

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Depending on the axis and the location of the two mini-implants, the Bene plate body also must be bent. The mesialization force is delivered by two Ni-Ti closing springs (200 g) that are attached to the activation locks. The Bene plate is fixed by two fixing screws using a screwdriver or the contra angle and the hand piece, which is more comfortable. Finally, the Mesial slider is activated by pushing the activation locks mesially ..

In cases with missing second premolars or first molars, the Mesial slider can be inserted without putting brackets on the other teeth. Similar to the Bene slider, the Mesial slider can be installed without the need for laboratory work in terms of welding or soldering. In other words, the Mesial slider device can be applied directly in the oral cavity without an impression but can also be fabricated indirectly to save chair time...

A 13-year-old female patient with missing upper second premolars was treated with a Mesial slider . The spaces were closed in the mesial direction after 12 months .Clinical Example Using the Mesialslider

When second premolars or first molars are missing, theMesial slider can be installed without brackets on the other teeth. If a more anterior tooth is missing, such as a lateral incisor or a canine, it is recommended to apply an additional mesialization force anterior by using : Additional Tips for Using the Mesial slider

1. An additional lever arm that is soldered to the Mesial slider. Using this lever arm, buccal and lingual forces can be applied

2. An additional Bene tube that is bonded to a canine or bicuspid

3. A combination of the Mesial slider and a T-bow: the T-Mesial slider. Forces can be applied buccally and lingually

The treatment protocol for a 14-year-old female patient with a missing upper right lateral incisor . The canine erupted palatally, resulting in a cross bite. The treatment plan was canine substitution, mesialization in the first quadrant, and distalization in the second quadrant to correct the shifted midline. After extraction of the deciduous canine a Mesial-Distal-Slider was installed and activated..Clinical Example Using the Mesial-Distal-Slider

To reduce the time in full braces, an additional spring was soldered to push the canine buccally .After 8 months, brackets were bonded. The spaces in the first quadrant were closed on the mesialization side after 16 months and many small spaces were established on the distalization side . Debonding and reshaping of the canine was performed after a total treatment time of 24 Months.

Clinical Considerations for MaximumAnchorage of the Molars

Conventional appliances designed to provide molar anchorage are the headgear, Class II elastics, the transpalatal arch (TPA), the Nance button, and the incorporation of additional bends in the arch wire such as tip-back and buccal root torque..EN MASSE RETRACTION

anchorage mechanics are limited in their efficiency, which depends in part on patient compliance. A mean of 1.6 to 4 mm anchorage loss can be anticipated during conventional anchorage. As a consequence, mini-implants prove to be very useful if the molar mesial migration should be avoided during en masse retraction . to avoid the risk of root damage and mini-implant fracture and the high failure rate of mini-implants in the alveolar process, bigger mini-implants in the anterior palate instead of small mini-implants between the second bicuspids and the first molars seems advantageous. It is feasible to anchor the molars with a Beneslider appliance . To establish this posterior anchorage, the Beneslider is left in place and deactivated by two steel ligatures after distalization for molar anchorage during anterior retraction.

The second alternative is to adapt a Beneplate or similar abutment with a 1.1-mm stainless steel wire in place and bond it to the lingual surfaces of the molars . these two mechanics tend to expand the molars if they are loaded with the force delivered for the en mass retraction. To avoid side effects in the transverse dimension found advisable to carry out corresponding additional posterior transversal reinforcement, resulting in the Triangle-TPA..

The treatment protocol for an 18-year-old female patient with a severe skeletal Class III malocclusion The goal was dento alveolar de compensation in terms of retrusion of the upper incisors and protrusion of the lower incisors ahead of bi maxillary osteotomy. To facilitate upper front retrusion, distalization of the molars or extraction must be done..Clinical Example Using the Triangle-TPA forUpper Molar Anchorage

In this case, two premolars were extracted due to a dysplastic upper right second bicuspid.After insertion of one Benefit mini-implant (2.3 mm 11 mm) the Triangle-TPA was manufactured on a plaster model..

The abutment with a wire in place and an additionalposterior stainless steel wire were soldered to the molarbands. After fixation of the Triangle-TPA the second premolars were extracted and retraction of the first premolars was initiated . A cephalogram was made after closure of half of the extraction space

After 14 months the en masse retraction was achieved without mesial migration of the molars, resulting in a sufficient negative over jet . After bi maxillary osteotomy , the last steps in terms of finishing of the occlusion and de bonding were conducted . Due to the large amount of de compensation that was enabled by the skeletal anchorage, an enormous improvement of the profile was obtained ..

Principle: Direct versus Indirect Anchorage

The treatment of impacted teeth usually comprises three phases:ALIGNMENT OF IMPACTED TEETH

(1) surgical exposure and bonding of an attachment.(2) eruption of the impacted tooth by application of an extrusive force.(3) three-dimensional orthodontic alignment.

The force needed to extrude an impacted tooth very often produces side effects on the dentition . Intrusion of the adjacent teeth or even a cant of the occlusal plane may be encountered. Consequently, stable anchorage is essential to minimize the stated side effects. Adjustment of the line of force during the extrusion phase is crucial to prevent root damage.

By employing indirect anchorage mechanics, unwanted side effects such as tipping of teeth used for anchorage for extrusion of impacted teeth should be avoided. Depending on the requirements of the particular situation, the mechanics for distalization, mesialization, and molar anchorage described earlier can be used to avoid unwanted side effects on the molars. This principle can be applied when the molars are being used as an anchorage unit for extrusion of incisors or canines..Indirect Anchorage Mechanics for Alignment of Impacted Teeth

10-year-old female patient with a horizontally impacted upper left central incisor. After surgical exposure, a Bene slider with an additional soldered tube was installed and a 0.016-inch 0.022-inch -Titanium segmental arch wire was inserted in the tube. After 3 months the incisor erupted successfully

After 6 months the incisor was almost fully erupted and the bracket was removed . After 8 months the incisor was at its final position; the molars were distalized to gain enough space in the upper arch ..

Especially if molars are impacted, direct anchorage mechanics is appropriate to extrude them. In this case, the alignment of an impacted upper second left molar Direct Anchorage Mechanics for Alignmentof Impacted Teeth

After insertion of two Benefit mini-implants and bonding of an attachment to the second molar, a Bene plate with a 0.8-mm stainless steel wire in place is adapted to the curvature of the palate. One side of the wire is activated as an extrusion lever arm; the other side of the wire is cut . The molar was fully erupted after 4 months . and the attachment was removed.

Over erupted upper molars due to missing lower antagonists are a common finding, especially in adult patients. To facilitate prosthodontic restoration in the mandible, these over erupted molars must be intruded.PREPROSTHODONTIC MECHANICS FOR MOLAR INTRUSION

To avoid tipping of the molars that are to be intruded, forces must be applied both buccally and lingually. If the intrusive force is applied only at one side, a TPA can be inserted to avoid buccal or palatal tipping. Mini-plates inserted in the area of the zygomatic buttress can be employed to apply a buccal intrusive force for upper molar intrusion

In many cases there is not enough space on the buccal side to insert a mini-implant safely between the roots especially in the region of the upper molars

On the palatal side of the alveolar process the soft tissue often happens to be very thick.there are some disadvantagesregarding the insertion between the roots of the upper molars :

If the mini-implant comes into contact with a root, periodontal structures may be damaged and the risk of failure of the mini-implant will be higher.

small implant diameters also mean a higher risk of fracture and a higher risk of failure.

The intrusion may be stopped and the root surface may be damaged when the molar is moved against a mini implant during intrusion..

There is a risk of penetration of the maxillary sinus when a mini-implant is inserted in the posterior area of the upper alveolar process

The Mousetrap appliance comprises one or two lever arms connected to two Benefit mini-implants inserted in the anterior palate, depending on the need for either unilateral or bilateral molar intrusion..By using a skeletally anchored lever arm, an intrusive force of approximately 100 g is applied palatally to the molar. Due to the point of force application, palatal tipping can be significant and should be controlled with the use of a TPA.

1. A Bene plate with a bracket in place is used . After wards, a 0.017-inch 0.025-inch stainless steel lever arm is bent and ligated to the bracket of the Bene plate.2. A Bene plate with a 0.8-mm stainless steel wire in place is adapted to the curvature of the palate.There are two different options to construct the palatal lever arm for molar intrusion :

1. Using a steel ligature..2. Soldering a hook on the TPA that is used as a stop for the lever arm..In the posterior region, the intrusive force can be applied using two different approaches

At first glance its sophisticated design appears to be more complex and a bit more bulky compared to other TAD-based appliances.The Mousetrap is a reliable appliance for the intrusion of over erupted molars

Low surgical invasiveness No risk of penetration of the maxillary sinus No risk of root damage at the time of insertion of themini-implant or during molar intrusion TADs can be inserted in an optimum insertion site; theanterior palate ensures low failure rates and no risk ofmini-implant fracture Constant force delivery that is easy to measure and adjustintraorallyMousetrap It provides thefollowing advantages:

Treatment of young Class III patients with maxillary deficiency is mostly conducted with a facemask. Since the force is applied to the teeth, mesial migration of the dentition is inevitable and may result in severe anterior crowding. On the other hand, the desired skeletal effect of this commonly used approach often turns out to be less than expected. To overcome these drawbacks and to minimize mesial migration of the molars, sagittal skeletal support by the Hybrid Hyrax is very useful. Second, to facilitate the advancement of the maxilla, opening of the mid face sutures by RPE is recommended.RAPID PALATAL EXPANSION AND EARLY CLASS III TREATMENT

Second, to facilitate the advancement of the maxilla, opening of the mid face sutures by RPE is recommended. With the goal being to avoid an extra oral device (facemask) and to apply the forces directly to the skeletal structures, De Clerck introduced the use of four mini-plates (two anterior in the lower jaw and two posterior in the upper jaw) in combination with Class III elastics. This represents a new purely skeletal approach to correct the skeletal discrepancy..

To enhance the skeletal effect by opening the mid face sutures, employs the Hybrid Hyrax appliance in the upper jaw, allowing simultaneous rapid maxillary expansion and skeletally borne maxillary protraction. In the lower jaw the Bollard mini-plates by De Clerck are usually inserted after eruption of the canines. To allow earlier insertion of the mini-plate in the mandible,

Dr. Drescher developed the Mento plate. Since the Mento plate is inserted sub apically to the lower incisors, it typically can be used as early as age 8 to 9 years. By means of the Hybrid Hyrax in combination with a facemask or a Mento plate, forces are applied to skeletal structures only with the goal of achieving an optimum skeletal effect.

The early treatment of an 8-year-old male patient with a skeletal Class III malocclusion (Wits appraisal 7.6 mm) is demonstrated and Major complaints were the sagittal and transversal deficiency of the maxilla. Two Benefit mini-implants (2 mm 7 mm) were inserted after topical anesthesiaClinical Example Using the Hybrid Hyrax in Combination with a Facemask

Predrilling was not performed due to the low mineralization of the bone in young patients. The Hybrid Hyrax with two additional lateral wires was manufactured in a laboratory and inserted after 4 days . RPE was started immediately in combination with application of a facemask. To facilitate the correction of the negative over jet, a removable plate was made for the lower arch . RPE was finished after 10 days . After 5 months the Wits appraisal improved significantly to 0.1 mm . This early treatment was finished after 11 months..

As an alternative to the facemask, a purely intraoral treatmentapproach can be offered to patients by using theMentoplate.

The Mentoplate is a titanium mini-plate , that is inserted in the mental region. After preparation of a muco periosteal flap, the two extensions are shortened and adapted. The extensions should penetrate the soft tissue in the region of attached mucosa . After fixation of the Mentoplate by four screws, the flap is flipped back and fixed by stitches. The Class III elastics (3.5 oz, 3/16 inch) are worn immediately after expansion of the maxilla for 24 hours per day.Introduction of the Mentoplate

1. Forces are applied directly to (Mentoplate) or aretransferred to (Hybrid Hyrax) skeletal structures 2. Almost invisible mechanics with no extra oral devices3. The RPE effect with opening of mid face sutures foreasier maxillary protraction4. Stable anchorage with a high reliability5. Insertion before complete eruption of the lower caninesis possible6. Low surgical invasiveness7. Upper and lower arches remain fully accessible for orthodonticcorrectionsAdvantages of the Hybrid HyraxMentoplate approach for early Class III treatment are:

The combination of the Hybrid Hyrax and the Mentoplateseems to be a very promising approach for early treatmentof Class III patients.Based on the clinical experiences, the Mentoplatehas the potential to be used not only for orthopedic but alsofor orthodontics purposes (e.g., lower molar protraction),since the mini-implant failure rates in the alveolar processare still too high. As a consequence, the mental region seemsto be the best site for skeletal anchorage in the mandible; itis the anterior palate of the lower jaw.

The clinical example presents a 9-year-old girl with a skeletal class III malocclusion (Wits appraisal 6.7 mm; and Two Benefit mini-implants (2 mm 7 mm) were inserted and an impression was taken to manufacture the Hybrid Hyrax . Since the patient preferred an intraoral approach, the Hybrid Hyrax was combined with a Mentoplate instead of a facemask .Clinical Example Using the Hybrid Hyrax inCombination with a Mentoplate

Due to a lack of space for the canines, the Hybrid Hyrax was removed after the early class III treatment (7 months) and a Beneslider was inserted for molar distalization in the upper arch. For this purpose the same mini-implants were used and a Beneplate with a wire at the long site was employed . This multipurpose use is one of the advantages when mini-implants with exchangeable abutments are used. Six months later bodily distalization of the molars was recognizable.At the end of the phase I treatment, the Class III dysgnathia has been improved (Wits appraisal 2.6 mm) and space has been generated by distalization of the molars.