Recently, I was chatting with a resident and he stated that he had recently lost 60% of the TADs he had placed and was wondering what he was doing wrong. Not just residents relate these kinds of frustrations. An experienced orthodontist was also telling me that he could not understand the hoopla about TADs since he has lost 80% of the ones he has inserted. He then answered my next question on who was placing the screws and he told me an OS and a periodontist. That is a mistake. You must place your own.
I've placed 800 TADs but certainly I lost a lot of them in the beginning. On the other hand, I’ve lost only one since September in my office. Here is a short list of things to be aware of when you’re doing TADs:
1. Generally, TADs work best if you use them as part of your original treatment plan and not as a bail out when something goes wrong. They can be used for that but generally they don’t work as well
2. before inserting a TAD, have the patient rinse with Peridex for one minute
3. you should insert the TAD slowly. Some people have said that it should take you a minute to fully insert a single TAD 4. if I am inserting a TAD between the roots of the maxillary second bicuspid and maxillary first molars, I almost always diverge the roots first using a Z bend on a 14 steel (Australian) wire. Depending on the case, I might not even worry about levelling the rest of the teeth until the second bicuspid root is diverged.
5. I may also do this in the mandible but it seems less necessary as a routine recommendation. It’s generally always a good idea in the maxilla
6. there are certain locations in which TADs work best and I almost always use those locations. If you choose to use a different location you can expect to have a higher failure rate. Those locations are as follows: (1) The only real location that is predictably successful on the buccal of the maxilla is the surface between the five and the six.
(2) There are four locations on the palate. (2a) inter-radicular between the 5 & 6. (2b) inter-radciular between the 6 & 7 (2c) mid palatal at the level of the mesial of the first molar and (2d) mid palatal at the level of the mesial of the first bicuspid. This is also just about where the third rugae if located.
Anyplace else you can expect a higher failure rate. Learn to adapt your mechanics to these predictably successful insertion areas.
Finally, I use three TAD systems in my office. On the buccal surface in the maxilla or mandible, I only use C-implants unless there is some special reason not to. What I really like is the C-Implant comes in two pieces and it is designed to partially osseointegrate. You insert the first part of the C-implant flush with the gingiva and allow it to rest unloaded for 6 weeks. It partially integrates during those six weeks. And since nothing protrudes from the gingiva, there are no occlusal forces on the TAD during those initial six weeks. After six weeks, you attach the second piece and load it. I rarely lose these TADs.
On the palate, I really like the IMTEC implant system from Unitek. I use the 6mm anteriorly in the palatal midline and the 8 mm between the roots of the 5-6 area. The 10mm goes between the 6-7 roots. The IMTEC comes with a stainless steel cap that allows me to solder an auxiliary. This auxiliary typically is used to stabilize the adjacent tooth for indirect anchorage. You can do the same thing by bonding a wire from the adjacent tooth to say a Vector TAD but my staff does not like me “fiddling” with that and using valuable chair time. Using the IMTEC system requires an alginate impression and then some lab work. When the patient returns, the DA can bond the wire to the tooth and therefore I am not tied up at one chair for an extended time perio.
Finally, to close open bites, I place the OrthoTechnology Spider screw in the mid palatal area at the level of the mesial of the first molar and connect a niti spring from a TPA to the TAD. Have the TPA made first and then you can use it as a guide where to place the TAD. I like the 1.9mm diameter and 5mm long screw . Bigger is better as we all know and the larger diamter really seems to stabilize things. Using a length of 5 mm prevents inadvertent insertion into the nasal floor.
