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Who places miniscrews? Options · View
WendyO@jco-online.com
Posted: Friday, June 6, 2008 8:35:08 PM
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JCO recently asked several editors, authors, and colleagues whether they are using miniscrews in their practices for skeletal anchorage and, if so, who is placing them. Respondents had compelling reasons both for orthodontists to place their own miniscrews and for having them placed by oral surgeons or periodontists.

We would like to hear other opinions on this topic. Do you use miniscrews for skeletal anchorage? Do you place them yourself? If not, who places them and how do you prescribe placement location?
jamesmah@usc.edu
Posted: Friday, June 6, 2008 8:56:29 PM

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Maybe it is a generation issue, but I have observed that orthodontists that have been out for approximately 15 years or more generally prefer to have an oral surgeon place their TADs. More recent graduates, less than 5 years, are generally placing their own. Very new grads and residents are placing ALL their own TADs. Many programs have integrated TAD placement in their curriculum and the residents are still accustomed to providing anaesthetic and performing dental procedures. With this training and confidence, they feel this is a "no brainer" for them to place.

Our JCO article in March 2005 (Mah and Bergstrand) covered the issue of having an oral surgeon place the TADs. Our consensus group for that article felt strongly that the orthodontist with a knowledge of biomechanics AND proposed directions of tooth movement was in the best position to place TADs. This information may be somewhat complicated to explain on a written instruction form to the oral surgeon. Nevertheless, a variety of options should exist for the diversity of orthodontists out there.

--James Mah, DDS, MS, DMS
orth65flag538@msn.com
Posted: Friday, June 6, 2008 9:03:51 PM

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I am not placing TADs. I have had some issues introducing laser tissue removal into my practice with some reservations from the patients/parents about “cutting” tissue. Screwing a screw into the bone requires a better sales job than I am ready to do.

I have taken about 5 courses on TADs but I am not ready to do them yet. This is my problem, i.e., not a treatment problem. It takes some education in the office for the parents and patients to understand about this issue-–and it takes some experience for the Doctor putting them in. Since I have the Ortho Clinic at the dental school available, I will put some in there to build my confidence before I do them in the office---but it will become a routine part of treatment in the future because orthodontics needs a better anchorage system than we have now.

In my understanding, the problem with referring them out is that the oral surgeon may place a TAD that doesn’t have the correct head for connecting wires or springs to it. Plus the patient has to pay for the procedure. Also, TADs can come loose, which means that the patient has to go back to the OS to replace it – at an additional charge in most cases. This causes some trepidation on the part of the parents/patients about the wisdom of doing this “experimental” procedure and puts the orthodontist in a real bind about his recommendation to do this.

I think some bad experiences of these types will force the orthodontist to become the controlling person in this process.

--Randy Womack, DDS
kcomppas@coral.ocn.ne.jp
Posted: Friday, June 6, 2008 9:17:43 PM

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I think, in general, Japanese orthodontists place mini-screws by themselves. This is because we, the orthodontists, can control the timing and location, consider mechanics, feel the bone density sometimes, and discuss patient concerns, more easily. I, however, send a patient to oral surgeon or periodontist if the patient needs to have plate-type anchorage or has general problems. Basically, putting mini-screw into bone is not so difficult treatment but we need a constant, systematic methodology for placing mini-screw anchorage. I feel there are some confusions of methodology for placing mini-screws. This is important for educational standpoint in orthodontic department at this era.

--Masatada Koga, DDS, PHD
Tokyo, Japan
rboyd@pacific.edu
Posted: Friday, June 6, 2008 9:21:09 PM

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We have taught microimplant placement as a basic clinical skill for our residents in our ortho program for about 4 years, but my impression is that less than 10% of private practice docs actually do it. Everybody agrees that it is critically useful in many cases to use them. But on a day-to-day basis this may still be a bit of an academic area because in private practice a lot of docs just do not want to place them and then there is a cost issue when referring them out, as some oral surgeons and periodontists charge what seems like a lot to place them (around $400 to 600 per microimplant). If they are presented as an add-on to treatment, patients may well decline. We believe it is better to just tell patients who we think need them that they are a part of the treatment and not an option (thus contained in the initial cost when placed by the orthodontist).

--Robert Boyd, DDS, MEd
clarkortho@aol.com
Posted: Friday, June 6, 2008 9:26:31 PM

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We have made arrangements with an oral surgeon to place our TAD's for the same cost he would charge to remove a tooth. I mark on the patient photos where to place the TAD's and he places them and then charges the patient for the cost of the TAD and the equivalent cost of an extraction. This process has worked well for us, the patients, and the oral surgeon.

As I travel around the country doing my lectures and speaking with orthodontists, I note that more and more TAD's are being used by orthodontists. Many of the TAD's are being placed by younger orthodontists, while some are being placed by older orthodontists, but many of these doctors are referring the procedure of placing the TADS out to oral surgeons or periodontists. Many doctors don't want to give injections. I feel in the future more and more orthodontists will be placing TAD's themselves, but it will be an evolution.

--Jerry Clark, DDS
drnat@fantasticsmiles.com
Posted: Friday, June 6, 2008 9:33:49 PM

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We use TADs extensively in our office, but we do not place them ourselves. We send them to the oral surgeon.

For us, it is a financial issue. We don’t want to charge our patients any more than we currently do, and we believe that patients view it differently if the fee for the TADs is being paid to someone else. If we lived in a different socio-economic area, I would probably place them myself.

We send a recent pano and a plaster model with marks indicating ideal placement. If the surgeons are unable to place it where indicated, they must call our office before placement. Also, we indicate to the surgeon what our treatment plan is and exactly how we will be using the TAD(s).

--Dr. Natalie Parisi
Wyomissing, PA
sshoaf@wfubmc.edu
Posted: Monday, June 9, 2008 1:06:39 PM

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I do not do TADs right now, as haven’t figured out how to put them in the financials of the treatment plan. Have not heard of local guys who are placing their own screws. Mostly oral surgeons and periodontists in this area that do the placement of TADs.

--Sarah Shoaf, DDS, MED, MS
rhaeger@seanet.com
Posted: Monday, June 9, 2008 1:11:43 PM

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I have been placing my own TAD’s from the beginning, almost three years now. I think it’s a huge waste of money and the patient’s time to have an oral surgeon or periodontist place the implants. After all, we are the ones who know exactly where we want the TAD’s and the desired direction of force needed. From what I hear, the orthodontists who are using TAD’s regularly are putting them in themselves.

--Robert Haeger, DDS, MS
DrBruce@DrMcFarlane.com
Posted: Monday, June 9, 2008 2:12:25 PM

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Here's my experience:
--NO to placing them myself: I prefer to stay away from anaesthetic, blood, invasive procedures, etc.
--NO to having an oral surgeon place them. They seem to think of them as "implants:" and charge accordingly (too much!)
--YES to a GP down the way who places them all for me. I'll send him a model or a photo and show him exactly where I want it placed: and he does so: accurately, efficiently, and inexpensively.

--R. Bruce McFarlane, DMD, BSCD, MCLD
Winnipeg, MB
drmehan@drmehan.com
Posted: Monday, June 9, 2008 10:19:37 PM

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I haven’t placed TADS myself, but wish to...I’m presently taking the necessary courses. Surgeons now place mine. We should.

--William Mehan, DMD, MS
Manchester, NH
mark@greatersmiles.com
Posted: Monday, June 9, 2008 10:27:48 PM

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My associate and I have given some seminars on the use of TADs for RMO. We, of course, place our own, but there does appear to be a reluctance by orthodontists to place these. In addition to orthodontists, pediatric dentists, oral surgeons and periodontists have also taken our seminars, primarily for the purpose of placing them for the orthodontists with whom they work.

Placing TADs is more of a paradigm shift than Invisalign for most orthodontists. This is strictly my opinion, though a survey could confirm this, but I believe the younger orthodontist who is fewer years removed from practicing dentistry or from dental school will be more likely to place his or her own TADs. Moreso, the orthodontist who placed them in his or her residency program will more likely be placing them. Orthodontists with more years in practice will be less likely to try something requiring new skills, as I have found while giving Invisalign seminars.

I surveyed members of my study club: I had 7 out of 16 responses, with 6 replying that they place their own. I feel like those that do place their own would respond, so it may very well be 6 out of 16. Not scientific, but representative of our group.

--Mark Perelmuter, DMD, MS
Louisville, KY
binderre@umdnj.edu
Posted: Monday, June 9, 2008 10:34:26 PM

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As of this time there seems to be a split between self placement and those placed by oral surgeons or periodontists. It seems that younger, less established orthodontists are placing their own TADS because it is less expensive than referring and they tend to be more comfortable doing so.

--Robert E. Binder, DMD
orthologan@aol.com
Posted: Friday, June 13, 2008 12:29:10 PM

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The grapevine of the orthodontist in the San Fernando Valley of Southern California tells me that they prefer oral surgeons or periodontists to place the TAD's.

The reasoning is that: (1) The oral surgeon or periodontist has the knowledge of the oral anatomy to best insert and position the TAD's and (2) The oral surgeon or periodontist is skilled to resolve any TAD morbidity problems during and after orthodontic treatment.

In addition, local anesthetics are being used more to minimize discomfort during the TAD placement. An informed consent for anesthetics would be indicated. Many of the orthodontic practices have a needle free environment. The placemtnt of the TAD's would also be best done in a private treatment room.

Lee Logan, DDS, MS
Northridge, California
gayleglenn@earthlink.net
Posted: Friday, June 13, 2008 12:34:05 PM

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More and more of my orthodontic colleagues are placing their own TADs, especially new graduates who have been taught the technique in school. To date, I have not taken a course or workshop on TAD placement and have not purchased the equipment/kit. Currently, I am having an oral surgeon place the TADs for me, after reviewing the patient's diagnostic records to determine the optimal location. It appears that more and more orthodontists will place their own TADs in the future."

-Gayle Glenn, DDS, MSD
-Dallas, TX
johnwgraham@cox.net
Posted: Friday, June 13, 2008 12:49:06 PM

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My experience as I have traveled around the world has been quite the opposite from the recent JCO Readers' Corner survey (May 2007) that indicates a low use of miniscrews by orthodontists. It doesn't surprise me, by the way, as I know the majority of those who responded to the survey, and they are not representative of the vast majority of orthodontic practitioners in the U.S.

In the past several months I have lectured in St. Petersburg Russia, Paris, London, Munich, Madrid, Montreal, Singapore, Auckland, Melbourne, and Sydney, not to mention traveling all over the U.S. (nearly every major city in the last 12 months) lecturing to thousands of orthodontists about miniscrews. My observations are a stark contrast to that of the readers' survey. The majority of orthodontists in the U.S. will be placing their OWN miniscrews in their offices within the next 3 years. They will have to of necessity because it is becoming the standard of care, much like Dr. Keim observed in a recent editorial (JCO, December 2007).

Orthodontists in the U.S. and around the world are not afraid to place miniscrews, they merely need to be taught the techniques involved. When I begin a lecture to a group of orthodontists, I always ask how many are actually placing the miniscrews themselves. It is usually around 15-20%. I then follow up at the end of the lectures by asking the same question, and almost without exception the number is 100%.

Orthodontists see the distinct disadvantages to having other specialists place miniscrews, and would much rather place them themselves. This evolution is moving at light speed, and miniscrew placement is being adopted by orthodontists in the U.S. and around the world faster than any new technique in recent memory. I'm out here in the trenches, and I see it every day.

John W. Graham, DDS, MD
Litchfield Park, Arizona
nanda@nso.uchc.edu
Posted: Friday, June 13, 2008 12:59:06 PM

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As far as orthodontists I know, place TAD's themselves and do not refer patients out. My feeling is 'younger' age group likes to do themselves. Referrals are primarily by orthodontists who have been in practice 15 years or more.

Ravindra Nanda, BDS, MDS, PHD
DrRDHelmholdt@aol.com
Posted: Friday, June 13, 2008 1:07:34 PM

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I do all my own TAD's, and quite a few of them. I find them a valuable source of anchorage to enhance mechano-therapy; but like all treatment modalities, it requires a degree of discretion and skill in their placement; but if done with in the parameters of prescribed use, I've found them to be rather trouble free!

Robert D. Helmholdt, DDS
Fort Lauderdale, FL

drjwyred@aol.com
Posted: Friday, June 13, 2008 1:13:30 PM

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Here is a paragraph from the book chapter that I had published in the latest Moyer's Symposium book:

Procedure Orders: Location, Location, Location
"Who should place mini-screws? Ninety-five percent of mini-screw acolytes currently prefer to refer, but N.F.L. (Not For Long). Like many recent converts, they will likely find that convenience, control, and cost are compelling factors to D.I.Y. If, however, the decision is made to refer the patient to a periodontist or oral surgeon for placement of the TAD, then a narrative description of the exact position of the implant is critical. These instructions should include details of the position of the mini-screw relative to the mucogingival junction and marginal gingival, the insertion angle relative to the alveolar bone, and the orientation of the hole, slot, or bracket that may be featured in the head design of the screw. In addition, do you want the screw driven until the transmucosal collar touches bone or is partially embedded in the tissue and do you want the head of the screw compressing, just touching, or slightly above the tissues? 'Plan for the best, expect the worst, and be prepared to be surprised,' Denis Waitley."

I had 300 screws placed by others before doing the next 260 screws myself. We can do this and should do this ourselves.

S. Jay Bowman, DMD, MSD
Kalamazoo, MI
drameetr@yahoo.co.in
Posted: Thursday, July 3, 2008 10:21:53 AM

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I do my TADs myself. I just finished my post graduation. I agree that it is a generation issue because most of my colleagues in graduate school too do their own TADs.

Dr Ameet Revankar BDS, MDS
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