Temporary Anchorage Devices (TADs) in Orthodontics:

A Comprehensive Scientific Review

1. Introduction

Anchorage control represents the cornerstone of successful orthodontic treatment.

Anchorage is defined as the resistance to unwanted tooth movement during the application
of forces to move other targeted teeth. Historically, orthodontists relied on the teeth
themselves, or on intraoral or extraoral appliances to provide this anchorage. However,
traditional methods often face a significant challenge known as "Anchorage Loss," which is
the unintentional movement of anchorage units, potentially compromising treatment goals
and prolonging its duration. The need for reliable and predictable anchorage became more
pressing with the increasing complexity of some cases, and the rising number of adult
patients seeking orthodontic treatment, who may have fewer teeth or weaker bone support.
The search for anchorage beyond teeth dates back centuries, with early attempts such as
Pierre Fauchard's use of the expansion arch in 1723, and Delabarre's invention of the first
wire crib. However, the qualitative shift towards skeletal anchorage began to take shape with
the development of dental implants and bone fracture fixation. In 1945, Gainsforth and
Higley published the first use of a Vitallium subperiosteal implant for maxillary canine
retraction in dogs. This was followed by Linkow's description in 1969 of perforated blade
implants for orthodontic anchorage. In 1983, Creekmore and Eklund suggested the potential
use of skeletal anchorage in orthodontics. Roberts et al. in the 1990s used conventional
dental implants in the retromolar area to enhance anchorage.
These early implants often relied on Osseointegration, a concept established by Per Ingvar
Branemark using titanium. Despite their effectiveness as "absolute" anchorage, their large
size, the need for a long healing period before loading, and the difficulty of removal limited
their routine use in orthodontics. The concept gradually evolved towards the need for smaller
devices that could be easily placed and removed, and could be loaded with forces
immediately after placement. This development was not linear but resulted from the
cross-pollination of ideas and techniques from the fields of dental implantology, bone fixation
surgery, and orthodontic biomechanics. This multidisciplinary convergence led to the
adaptation and miniaturization of existing technologies to meet the unique needs of
orthodontics.
The late 1990s and early 2000s witnessed the emergence of devices specifically designed
for temporary orthodontic anchorage, known today by various names, most notably
"Temporary Anchorage Devices" (TADs) or "Miniscrews." Kanomi was among the first to
publish their clinical use in 1997, followed by others developing different systems such as
the C-implant system (Chung et al. 2002), the Spider Screw system (Maino et al. 2003), and
the Absoanchor system (Kyung et al.). These devices were characterized by relying primarily
on Primary Mechanical Stability resulting from friction and interlocking between the screw
threads and the surrounding bone, rather than complete biological osseointegration. This
shift in the concept of "absolute anchorage"—from permanent and osseointegrated to
temporary and mechanically stable—is what brought about a true revolution, making skeletal
anchorage effective and practical for daily use in the orthodontic clinic, with ease of
placement and removal suitable for the temporary nature of orthodontic treatment.
Today, orthodontic TADs are considered a Paradigm Shift in the field of orthodontics. They
have fundamentally changed the way specialists think and plan cases, and have expanded
the horizons of treatment in ways previously impossible. This report aims to provide a
comprehensive and detailed scientific review of temporary anchorage devices, covering their
definition, types, materials, diverse clinical uses, advantages compared to traditional
methods, potential risks and complications, placement and removal procedures, clinical
success factors, and their overall impact on modern orthodontic practice, highlighting future
trends in this promising field.
2. Definition and Primary Function of Orthodontic TADs
Temporary Anchorage Devices (TADs), also referred to by terms such as Miniscrews,
Mini-implants, Micro-implants, or Ortho-implants, are small devices temporarily fixed into the
jawbones to enhance or provide a stable and reliable fulcrum for applying orthodontic forces.
They are then removed after their purpose in the treatment plan is fulfilled. These devices
are characterized by their small dimensions compared to traditional dental implants used for
prosthetics.
The primary function of orthodontic TADs is to provide what is known as "Temporary Skeletal
Anchorage." This means they act as fixed and stable anchor points, inserted directly into the
bone, completely independent of adjacent teeth. This independence enables them to provide
"Absolute Anchorage," meaning complete resistance to unwanted movement of the
anchorage unit itself.
TADs rely mainly on mechanical friction and physical interlocking between the implant
surface and the surrounding bone immediately after placement, known as primary or
mechanical stability. Unlike traditional dental implants, biological osseointegration is not
fundamentally required for the function of TADs. In fact, the absence or limitation of
significant osseointegration is considered an advantage, as it facilitates the later removal of
the device without major surgery. This "temporary" nature and non-reliance on full
osseointegration distinguish TADs and make them perfectly suited for the relatively
short-term use in orthodontics.
Anchorage using TADs can be achieved in two main ways:
* Direct Anchorage: In this method, the orthodontic force is applied directly from the TAD
(acting as an independent anchorage unit) to the tooth or group of teeth to be moved. No
other teeth are relied upon as anchor points.
* Indirect Anchorage: Here, the TAD is used to support and stabilize an adjacent tooth or
group of teeth (the traditional anchorage unit), preventing their unwanted movement. The
orthodontic force is then applied from this supported dental unit to the target teeth intended
for movement.
The choice between direct and indirect anchorage depends not only on biomechanical
preference but also reflects a clinical assessment of risks and benefits. Direct anchorage
may simplify biomechanics but can place greater stress on the TAD itself and the
surrounding bone, potentially increasing the risk of failure if forces are not managed
carefully. Indirect anchorage integrates the TAD more conservatively into the mechanical
system, benefiting from its stability without making it the sole resistor of the force, which
might be a safer option in some cases or when using less robust TADs or placing them in
less ideal bone sites. This decision reflects the clinician's assessment of anchorage
requirements, available bone quality, and the desired force system.
In both cases, the primary goal is to overcome the unwanted reactive forces (according to
Newton's Third Law) that inevitably arise when applying any force to move teeth, ensuring
that movement occurs only in the desired direction and to the planned extent, leading to
more precise and efficient treatment outcomes.
3. Types and Materials of Orthodontic TADs
Temporary Anchorage Devices (TADs) are available in a variety of designs, sizes, and
materials, allowing the specialist to choose the most suitable type for each clinical case and
its biomechanical requirements. These devices can be classified based on several criteria:
General Classification:
* Miniscrews/Microimplants: Represent the most common and widely used type in daily
clinical practice. They are characterized by relative ease of placement and removal, multiple
possible insertion sites between tooth roots or in other areas of the jawbone, and lower cost
compared to other alternatives.
* Miniplates: These are small metal plates, usually made of titanium, fixed to the bone
surface with two or more screws. They provide very strong anchorage and excellent
resistance to rotational moments, making them suitable for movements requiring large forces
or precise three-dimensional control. However, their placement and removal require a more
invasive surgical procedure, including raising a surgical flap, which may increase patient
discomfort and cost.
* Other Types: Include Palatal implants placed in the palatal vault providing excellent
anchorage, and Onplants placed subperiosteally, but their use is less common compared to
miniscrews.
Classification by Dimensions (Size):
* Diameter: Typically ranges between 1.15 mm and 2.5 mm for miniscrews. Larger
diameters (e.g., 2 mm or more) provide better mechanical stability and higher fracture
resistance but require more interradicular bone space and increase the risk of root contact.
Smaller diameters (less than 1.2 mm) are more prone to fracture during placement or
removal.
* Length: The length of the threaded part of miniscrews usually ranges from 4 mm to 12
mm. The choice of appropriate length depends on the thickness of the cortical bone at the
insertion site, the anatomical location (e.g., the palate or infrazygomatic crest sometimes
requires longer TADs), and the need to avoid vital anatomical structures.
Classification by Head Design:
TAD heads come in various designs to meet different mechanical connection needs and
minimize irritation to surrounding soft tissues. Common types include:
* Small head: Offers better aesthetics and is suitable for areas with limited space.
* Long head: Provides a larger surface area for force distribution and may enhance stability.
* Circle/Sphere head: Offers flexibility in the direction of force application.
* Button head: A common design, can be spherical or hexagonal, providing an attachment
point for elastics or springs.
* Hole head: Contains a hole (usually 0.8 mm) in the head or neck for passing a ligature
wire or applying direct anchorage forces.
* Bracket head: Resembles a traditional orthodontic bracket, allowing direct insertion of the
archwire, facilitating certain mechanics.
* Hook head: Provides a hook for attaching elastics or other accessories.
* Fixation head: Helps in fixing additional components to support complex movements.
Classification by Screw/Body Design:
* Thread Types:
 * Self-drilling: Have a cutting tip similar to a drill bit, allowing them to penetrate bone
without the need for a pilot hole in most cases, especially in less dense bone.
* Self-tapping: Usually require a pilot hole and form the thread path in the bone during
insertion.
* Thread-cutting: Cut the bone during insertion.
* Thread-forming: Compress and condense the bone during insertion.
* Body Shape: Can be Cylindrical or Conical. The conical shape may increase primary
stability by condensing surrounding bone during insertion.
* Neck: The part that passes through the soft tissue (mucosa) and connects the head to the
threaded body. Available in different lengths to match mucosal thickness at various insertion
sites. Its surface should be smooth and well-polished to minimize plaque accumulation and
prevent inflammation, as this transmucosal connection is a potential weak point where
infection or implant failure might start.
Materials:
Orthodontic TADs are primarily made from materials with high biocompatibility and sufficient
mechanical strength to withstand chewing forces and applied orthodontic forces.
* Titanium Alloys: The most common and widely used material. Titanium alloy Grade V
(Ti-6Al-4V) is particularly preferred due to its high strength compared to commercially pure
titanium (CP Ti), which is also used. Titanium is characterized by excellent biocompatibility
and high corrosion resistance due to the protective oxide layer that forms on its surface.
* Stainless Steel (SS): Used as a less expensive alternative to titanium. It possesses good
mechanical properties but may be less biocompatible and corrosion-resistant compared to
titanium. Studies comparing its success rates to titanium vary; some find no statistically
significant difference, while others suggest a slight superiority of titanium.
* Other Materials: Historically, materials like Vitallium (a cobalt-chromium-molybdenum
alloy) have been used. There are also references to the use of ceramics or zirconium in
some applications, although rare in the context of temporary orthodontic TADs.
This wide variety in TAD design (in terms of size, head shape, thread type) reflects not only
differences between manufacturers but primarily indicates the need to meet the diverse
biomechanical requirements of various orthodontic movements and different anatomical
sites within the mouth. For example, molar intrusion might require a strong head and a
longer TAD placed in the palate, whereas incisor retraction might require a smaller diameter
TAD placed interradicularly with a head allowing easy elastic attachment. This means
selecting the appropriate TAD is not a random decision but a crucial part of clinical planning
based on a precise understanding of the required biomechanics and the patient's anatomy,
influencing treatment success.
Regarding materials, while titanium is often preferred for its proven biocompatibility, scientific
evidence for a significant clinical difference in success rates of TADs (where long-term
osseointegration is not targeted) between titanium and stainless steel may not be conclusive
across all studies and applications, especially considering the cost factor. Stainless steel
remains a clinically used option and a potentially cost-effective alternative in some systems.
Table 1: Comparison Between Main Types of Orthodontic TADs (Miniscrews vs. Miniplates)
| Feature | Miniscrews | Miniplates |
|---|---|---|
| Description | Single small screw fixed directly into the bone. | Metal plate fixed to bone by
2-4 small screws. |
| Common Material | Titanium alloys, Stainless steel. | Titanium alloys. |
| Typical Size Range | Diameter: 1.15-2.5 mm, Length: 4-12 mm. | Various shapes and sizes
for plates and accompanying screws. |
| Placement Procedure | Relatively simple, often flapless, can be done chairside under local
LA. | More invasive, usually requires a surgical flap and larger surgical procedure. |
| Removal Procedure | Very simple, usually requires no anesthesia. | Requires a surgical
procedure to remove the plate and screws. |
| Anchorage Strength | Good to excellent, sufficient for most orthodontic movements. | Very
excellent, high resistance to forces and moments. |
| Versatility | Very high, can be placed in many anatomical sites (interradicular, palate, etc.). |
More limited to sites with thick cortical bone (e.g., zygomatic buttress, buccal shelf). |
| Cost (Relative) | Lower cost. | Higher cost. |
| Main Advantages | Ease of placement/removal, versatile sites, lower cost, minimal surgery.
| Superior stability, high resistance to forces/moments, very high success rates. |
| Main Disadvantages | Lower anchorage strength vs. plates, more sensitive to site/bone
quality, risk of root contact interradicularly. | More invasive surgery, higher cost, limited sites,
more post-op discomfort. |
Table 2: Comparison Between TAD Manufacturing Materials (Titanium Alloys vs. Stainless
Steel)
| Feature | Titanium Alloys (Grade V: Ti-6Al-4V) | Stainless Steel (SS) |
|---|---|---|
| Biocompatibility | Very excellent, considered inert. | Good, but less than titanium, may elicit
tissue reactions or allergies rarely. |
| Strength/Fracture Res. | Very high, especially Grade V. | Good, but may be lower than
Grade V Ti-alloy in some conditions. |
| Corrosion Resistance | Very excellent due to oxide layer. | Good, but potentially more prone
to corrosion in the oral environment long-term than Ti. |
| Osseointegration Pot. | Higher than steel, though not highly desired in temporary TADs. |
Much lower, relies primarily on mechanical stability. |
| Cost (Relative) | Higher. | Lower. |
| Reported Success Rates | Very high (often > 80-90%). | Good to high (often > 75-90%),
some studies find no significant difference vs. Ti, one study noted lower success. |
| Main Advantages | Excellent biocompatibility, high strength, superior corrosion resistance,
long & reliable clinical record. | Lower cost, acceptable mechanical properties. |
| Main Disadvantages | Higher cost. | Less ideal biocompatibility vs. Ti, lower corrosion
resistance, potential for allergy (rare). |
4. Clinical Uses of Orthodontic TADs
Temporary Anchorage Devices (TADs) have radically transformed the clinical practice of
orthodontics, not just by providing enhanced anchorage, but by enabling specialists to
achieve a wide range of tooth movements previously considered extremely difficult or even
impossible using traditional methods alone. The ability to obtain a fixed, independent anchor
point in the bone opens the door to diverse clinical applications, including:
* Intrusion: Intrusion, or moving a tooth towards the alveolar bone, is one of the most difficult
traditional orthodontic movements, often accompanied by undesirable side effects like
extrusion of adjacent teeth or tipping. TADs offer an effective solution:
* Anterior Intrusion: Commonly used to treat deep bites where upper incisors cover a large
portion of lower incisors, and to correct gummy smiles resulting from excessive eruption of
upper incisors, revealing a large amount of gum upon smiling. TADs are typically placed in
the bone between or above the incisor roots in the maxilla.
 * Posterior Intrusion: This procedure is very effective in treating anterior open bites caused
by excessive eruption of posterior teeth. Intrusion of molars leads to autorotation of the
mandible (forward and upward), helping to close the open bite and improve the facial profile.
Molar intrusion on one side is also used to correct occlusal plane cant, or to intrude a
supra-erupted tooth or group of teeth due to the loss of the opposing tooth, providing
adequate space for a suitable dental prosthesis. TADs are usually placed in the bone
between molar roots or in adjacent areas like the palate or infrazygomatic crest (IZC). Case
studies, such as those mentioned in [71], [76], and [77], have shown the effectiveness of this
approach in achieving significant clinical and aesthetic results.
* Guided Eruption/Extrusion: TADs can be used to apply precise, guided traction forces to
move impacted or tilted teeth:
* Traction of Impacted Teeth: Especially used for impacted maxillary canines, a relatively
common condition. The TAD provides a fixed anchor point to apply gentle, continuous
traction force to the impacted tooth after surgical exposure, without negatively affecting the
position of adjacent teeth. [40]
* Molar Uprighting: TADs can apply forces to correct the tilting of molars (especially lower
second molars) that may tip forward after the loss of the first molar, facilitating the placement
of a prosthesis or implant in the space of the lost molar. This may involve partial extrusion of
the tilted molar.
* Molar Distalization: Moving molars (usually maxillary) backward is an important procedure
for treating Class II malocclusion resulting from maxillary protrusion or mandibular retrusion,
or to gain space in the dental arch for treating crowding or retracting protrusive anterior
teeth. Traditionally, reliance was heavy on extraoral headgear, requiring high patient
compliance and often being uncomfortable or socially unacceptable. TADs, often placed in
the palate, infrazygomatic crest (IZC), or interradicularly, provide stable skeletal anchorage
allowing efficient molar distalization without patient cooperation and without side effects like
anterior tooth tipping or protrusion. [56, 84] They can be used for en masse distalization of
the entire arch.
* Molar Mesialization/Protraction: Moving molars forward to close spaces resulting from
tooth extractions (like premolars) or congenitally missing teeth is one of the most challenging
traditional orthodontic movements due to molars' significant resistance to forward movement
and anchorage loss in anterior teeth. TADs, typically placed mesial to the molars to be
moved, provide direct or indirect anchorage allowing more effective molar protraction with
better control over anterior tooth position.
* Asymmetry Correction: TADs allow precise control of tooth movement on one side of the
jaw without affecting the other side, facilitating the correction of asymmetries:
* Midline Deviation Correction: TADs can apply asymmetric forces to move teeth and
correct deviations of the upper or lower dental midline.
* Occlusal Cant Correction: As mentioned earlier, this can be achieved by asymmetrically
intruding molars on the supra-erupted side, using TADs as fixed anchorage for this
movement. [76, 79]
* Management of Complex Cases: TADs are an indispensable tool in managing complex
orthodontic cases that exceed the capabilities of traditional methods: [11, 39]
* Maximum Anchorage Cases: Cases requiring significant retraction of anterior teeth (e.g.,
severe dental protrusion) while preventing any forward movement of posterior teeth. [7]
* Extraction Space Closure: Ensuring complete closure of extraction spaces (usually first
premolars) solely by posterior movement of anterior teeth, without anchorage loss in
posterior molars.
 * Adult Cases: Adult patients with tooth loss or reduced periodontal support may lack
sufficient dental anchorage units; TADs provide an effective alternative.
* Alternative to Orthognathic Surgery (Camouflage Treatment): In some borderline skeletal
malocclusion cases (like Class II, Class III, or open bite), TADs can enable acceptable
compensatory dental correction and minor improvement in the facial profile, potentially
avoiding the need for jaw surgery, especially if the patient refuses the surgical option. [85]
However, it must be emphasized that this option may not be entirely comparable to surgical
results in terms of the extent of skeletal correction and long-term stability.
* Other Uses:
* Miniscrew-Assisted Rapid Palatal Expansion (MARPE): Using TADs (usually in the
palate) to support a rapid palatal expander, allowing greater skeletal expansion and reducing
undesirable lateral dental tipping, especially in late adolescents or adults. [86]
* Application of Orthopedic Forces: TADs can apply forces aimed at modifying jaw growth,
as an alternative or adjunct to functional appliances or headgear.
* Stabilization of Other Appliances: Can be used to stabilize functional appliances or as
part of complex systems like the Beneslider or implant-supported Distal Jet. [9]
* Temporary Intermaxillary Fixation: In the context of orthognathic surgery, they can be
used as an alternative to traditional surgical hooks for post-surgical jaw fixation.
The breadth of these applications demonstrates that TADs are no longer just a tool to
"enhance" anchorage but have become an enabler for entirely new patterns of tooth
movement and deformity correction. The ability to apply controlled forces directly from the
bone has allowed movements like true molar intrusion or en-masse arch distalization without
the reactive side effects that limited the effectiveness of traditional mechanics. This
represents a fundamental expansion of the orthodontist's toolbox.
Furthermore, the use of TADs in complex and borderline cases that previously required
orthognathic surgery suggests a potential shift in treatment planning philosophy. The
enhanced control provided by TADs allows for dental and (compensatory) skeletal changes
that might spare the patient the need for surgical intervention in some situations, offering
less invasive treatment options. However, careful case-by-case evaluation remains
essential, as non-surgical correction may not always match surgical outcomes in extent and
stability.
Table 3: Summary of Clinical Uses of Orthodontic TADs and Examples
| Clinical Use | Specific Indication | Typical TAD Placement Sites | Biomechanical Principle
(Brief) | Supporting Refs |
|---|---|---|---|---|
| Intrusion | Deep bite, Gummy smile (Incisors) | Interradicular (upper incisors), Apical to
incisors | Apply vertical force (direct/indirect) to move teeth into bone. | [75] |
| | Anterior open bite, Occlusal cant, Space for prosthetics (Molars) | Interradicular
(buccal/palatal), Palate, IZC | Molar intrusion allows mandibular autorotation or corrects
cant/provides space. | [71, 76, 77] |
| Extrusion/Eruption | Impacted teeth (Canines) | Adjacent to impacted tooth (buccal/palatal) |
Apply gentle, continuous traction from TAD to impacted tooth. | [40] |
| | Molar uprighting | Adjacent to tilted molar | Apply forces to correct tilt, may include
extrusive component. | |
| Molar Distalization | Class II malocclusion, Crowding, Incisor retraction | Palate
(anterior/posterior), IZC, Interradicular (buccal) | Use TAD as fixed anchor to retract molars
or entire arch posteriorly. | [56, 84] |
| Molar Mesialization | Closing extraction/missing tooth spaces | Mesial to molars to be
moved (interradicular/buccal) | Use TAD as fixed anchor to protract molars anteriorly. | |
| Asymmetry Correction | Midline deviation, Occlusal cant | Asymmetrically on side needing
correction (interradicular, palatal, etc.) | Apply asymmetric forces (intrusion, retraction,
protraction) to correct symmetry. | [76, 79] |
| Complex Case Management | Max anchorage needs, Full extraction space closure, Adult
cases, Surgery alternative | According to case needs (often multiple sites) | Provide
absolute, independent anchorage for complex or compensatory movements. | [7, 11, 39, 85]
|
| Other Uses | Maxillary expansion (MARPE), Orthopedic forces, Appliance stabilization |
Palate (MARPE), Various sites for orthopedic forces | Use TAD as direct support for
expander or to apply forces to jaws. | [9, 86] |
5. Advantages and Importance of Using Orthodontic TADs
Temporary Anchorage Devices (TADs) offer a range of fundamental advantages that make
them a valuable and influential tool in modern orthodontic practice, surpassing traditional
anchorage methods in many aspects:
* Absolute or Enhanced Anchorage Control: This is the primary and most significant
advantage of TADs. By being fixed directly into the bone, they provide a completely stable
and fixed anchor point, independent of teeth. This "Absolute Anchorage" significantly
reduces or completely prevents unwanted tooth movement (anchorage loss) that often
occurs with anchorage relying on teeth or traditional appliances. Meta-analysis has shown
that TADs maintain anchorage significantly better (by nearly 2 mm on average) compared to
traditional methods during anterior tooth retraction. [7]
* Increased Treatment Efficiency and Reduced Duration: By providing reliable anchorage,
TADs contribute to simplifying the biomechanics required for complex tooth movements.
Forces can be applied more directly and effectively, potentially leading to faster tooth
movement. Avoiding anchorage loss also reduces the need for additional corrective phases
or complex auxiliary appliances, potentially shortening the overall treatment duration in some
cases. Some studies suggest TAD use can reduce total treatment time, [1] or at least reduce
the time needed for specific movements like intrusion. [75]
* Improved Predictability of Results: Since anchorage no longer heavily depends on the
response of other teeth or patient compliance, the outcomes of tooth movement become
more predictable. The specialist can plan and execute tooth movements with greater
confidence in achieving the desired goals, reducing unpleasant surprises during treatment.
* Reduced Reliance on Patient Compliance: This is one of the most crucial strengths of
TADs. Many traditional anchorage methods, especially extraoral headgear and intermaxillary
elastics, depend entirely on the patient's commitment to wearing them for the recommended
periods, which is a significant challenge, particularly with adolescent or non-compliant
patients. TADs completely eliminate this dependence, providing effective anchorage around
the clock without requiring any effort from the patient. This makes them an ideal choice in
cases where patient cooperation is expected to be poor. The combination of "absolute
anchorage" and "non-reliance on patient compliance" is a powerful mix that makes achieving
maximum anchorage goals more reliable and practical for a wider range of patients. [22, 26]
* Expanded Scope of Treatment and Avoidance of More Invasive Alternatives: TADs have
enabled specialists to treat cases previously considered outside the scope of traditional
orthodontic treatment or requiring more invasive interventions like orthognathic surgery or
tooth extractions. They also offer a less invasive and less costly alternative compared to
using permanent dental implants or large surgical plates as temporary anchorage. In some
cases, they may reduce the need for permanent tooth extractions to achieve treatment
goals. [13, 20]
* Other Advantages: TADs are often more comfortable for the patient compared to bulky
traditional anchorage appliances or extraoral headgear. Their cost is also lower than that of
permanent implants or surgical plates.
The high predictability of outcomes provided by TADs significantly contributes to increased
treatment efficiency and the potential for shorter duration. The time previously wasted
correcting unexpected anchorage loss or dealing with patient non-compliance with auxiliary
appliances can now be saved, allowing tooth movement to progress more directly towards
the planned goal.
6. Risks, Complications, Limitations, and Failure Rates
Despite the numerous advantages of Temporary Anchorage Devices (TADs), their use is not
without potential risks and complications, in addition to certain limitations and failure rates
that must be considered during treatment planning.
Risks and Complications During Placement or Use:
* Adjacent Tooth Root Injury/Contact: This is the most significant and concerning risk,
especially when placing TADs in narrow interradicular spaces. Root contact or perforation
can lead to pain, loss of tooth vitality, root resorption, or the development of a periapical
lesion. To avoid this, careful radiographic assessment (preferably CBCT in difficult cases)
and maintaining sufficient safety distance (usually 1-2 mm) between the TAD and the root
surface are strongly recommended. [83]
* Soft Tissue Injury/Irritation: The protruding TAD head or associated orthodontic
attachments (like springs or elastics) can cause irritation or ulceration of the buccal, lingual,
or labial mucosa. Mucosal overgrowth around the TAD may also occur, especially if placed in
mobile, non-attached mucosa.
* Inflammation and Infection (Peri-implantitis): Inflammation of the soft tissues surrounding
the TAD (peri-implantitis) can occur, potentially progressing to infection if not managed
properly. Plaque accumulation due to poor oral hygiene is the primary cause of this issue,
which in turn can lead to loss of TAD stability and failure. [69]
* Pain/Discomfort: Pain is usually mild and temporary, occurring mainly immediately after
TAD placement, and controllable with simple analgesics.
* Loosening/Mobility: This is the most common cause of TAD failure. It can occur due to
insufficient primary stability (due to poor bone quality or placement technique error),
peri-implant tissue inflammation, or the application of excessive or inappropriate forces. [38,
97]
* Screw Fracture: An undesirable but relatively rare complication. It can happen during
placement (due to excessive torque or very dense bone) or removal (due to partial
osseointegration or weak TAD design, especially at the neck or when using very small
diameters). [62, 83]
* Injury to Other Anatomical Structures: Extreme caution must be exercised to avoid injuring
vital anatomical structures such as the inferior alveolar nerve in the mandible, the mental
foramen, blood vessels, or perforation of the nasal floor or maxillary sinus in the maxilla.
Careful radiographic planning is essential to prevent these complications.
* Post-Removal Complications: May include minor temporary bleeding, fracture of a small
TAD fragment remaining in the bone (usually causing no issues if small and sterile), soft
tissue scarring, or excessive bone growth (Exostosis) at the insertion site.
Failure Rates: Various studies show a wide range of failure rates for TADs, with reported
percentages typically ranging from 5% to 30%. [58, 97] However, most recent studies
indicate relatively high overall success rates, often exceeding 80% or even 90% when
appropriate protocols are followed. [38, 45]
* Variation by TAD Type: Some systematic reviews and meta-analyses suggest that
Miniplates and Palatal implants have higher success rates (i.e., lower failure rates)
compared to Miniscrews placed interradicularly. [60] This may be attributed to their
placement in areas with better bone quality and less susceptibility to mechanical or
inflammatory influences.
* Variation by Site: Insertion site also appears to influence success rates. Sites
characterized by thick cortical bone and good quality, such as the palate, retromolar area, or
buccal shelf, often show higher success rates than interradicular sites in cancellous bone.
[65]
Limitations and Contraindications:
* Absolute Contraindications: Include conditions preventing any oral surgical procedure,
such as severe uncontrolled systemic disorders (e.g., very advanced osteoporosis),
psychiatric conditions preventing cooperation, or alcohol/drug addiction.
* Relative Contraindications: Require careful risk-benefit assessment before deciding on
treatment. These include:
* Bone-related factors: Insufficient bone volume (especially interradicular distance or
vertical height), or very poor bone quality (e.g., D4 or D5).
* Systemic factors: Systemic diseases affecting bone healing or infection resistance (e.g.,
uncontrolled diabetes, immunodeficiency disorders), bleeding disorders, or treatment with
anticoagulant medications.
* Previous radiation therapy: In the jaw region.
* Medications affecting bone: Long-term bisphosphonate use (risk of osteonecrosis) or
other drugs affecting bone metabolism.
* Oral factors: Active, untreated gingivitis or periodontitis, or severe, unmanageable poor
oral hygiene.
* Smoking: Heavy smoking is considered a risk factor for TAD failure and increased
inflammation. [45]
* Parafunctional habits: Such as severe, uncontrolled bruxism.
* Anatomical limitations: Proximity of vital anatomical structures (nerves, vessels, sinuses),
or very thin cortical bone providing insufficient primary stability.
* Age-related limitations: Placing TADs directly into the mid-palatal suture should be
avoided in growing children and adolescents to prevent hindering normal maxillary growth.
The relatively high success of TADs (over 80% in most studies) is encouraging, but does not
mean they are problem-free. The significant variability in reported failure rates (from 5% to
30% or more), [38, 58, 97] along with the long list of potential complications, [83] underscore
that TAD placement and management require high skill and precision, heavily relying on
careful case selection, meticulous planning, skillful execution, and close monitoring. Success
is not guaranteed and depends on controlling a range of patient-, implant-, and
operator-related variables.
Furthermore, the comparison between different TAD types suggests a trade-off between
ease of use and reliability. While miniscrews offer great flexibility in placement sites and
procedural simplicity, miniplates or palatal implants, despite being more invasive, may offer
higher success rates and better stability in cases requiring very strong anchorage, often due
to their placement in areas with better bone quality and distance from root proximity risks.
[60] This highlights the importance of selecting the TAD type and site based on specific case
requirements and a thorough risk-benefit assessment for each option.
Table 4: Summary of Common Risks, Complications, and Approximate Failure Rates for
Orthodontic TADs
| Complication/Risk | Description | Potential Consequences | Frequency/Failure Range (%) |
Key Contributing Factors | Prevention/Management Strategies |
|---|---|---|---|---|---|
| Root Injury | Contact or perforation of adjacent tooth root during placement. | Pain, vitality
loss, root resorption, periapical lesion. | Not precisely defined, but a major risk factor for
failure. | Narrow interradicular space, inaccurate planning, incorrect insertion angle. | Precise
radiographic planning (CBCT), use of surgical guides, safety margin (1-2 mm), appropriate
insertion angle. |
| Soft Tissue Inflammation/Irritation | Inflammation, ulceration, or mucosal overgrowth around
TAD head. | Pain, discomfort, difficult hygiene, may lead to failure. | Relatively common (esp.
mild inflammation). | Poor hygiene, placement in mobile mucosa, head design, friction from
attachments. | Excellent oral hygiene, placement in attached gingiva, chlorhexidine rinse,
modifying/covering TAD head. |
| Loosening/Mobility | Movement of TAD under applied forces or spontaneously. | Failure to
provide anchorage, need for removal/repositioning. | Most common cause of failure (5-30%
overall failure). [38, 97] | Poor bone quality/quantity, insufficient primary stability,
inflammation, excessive force, root contact. | Proper site selection, correct insertion
technique (adequate torque), good hygiene, appropriate forces, delayed loading in some
cases. |
| Screw Fracture | Breakage of part of the TAD (usually neck or tip) during placement or
removal. | Difficulty removing remaining fragment, may require surgery. | Rare (usually
<1-2%). [62, 83] | Using too small diameter, excessive torque, very dense bone, poor TAD
design, partial osseointegration on removal. | Select appropriate diameter, use torque
wrench, careful insertion/removal technique. |
| Infection | Development of purulent infection around the TAD. | Pain, swelling, TAD failure,
potential spread of infection. | Uncommon with good sterilization. | Severe poor hygiene,
patient immunocompromise, contamination during placement. | Strict sterilization, excellent
oral hygiene, antibiotics if necessary. |
| Anatomical Structure Injury | Injury to IAN, maxillary sinus, nasal floor, blood vessels. |
Numbness, paresthesia, sinusitis, bleeding. | Very rare with good planning. | Inadequate
radiographic planning, error in site or depth of insertion. | 3D radiographic planning (CBCT)
in risky areas, selecting safe site, angle, and depth of insertion. |
Note: Failure ranges are approximate and depend on the definition of failure and the studies
included.
7. Procedures for Placing and Removing Orthodontic TADs
Successful use of Temporary Anchorage Devices (TADs) requires meticulous planning,
appropriate site selection, skillful application of the placement technique, and proper removal
once they are no longer needed.
Planning and Site Selection: This stage is crucial for ensuring primary stability, long-term
success of the TAD, and avoiding complications.
* Clinical and Radiographic Assessment: Begins with a comprehensive evaluation of the
patient's medical and dental history, and examination of soft and hard tissues in the potential
implant area. Radiographic assessment is necessary to determine the quantity and quality of
available bone, measure the distance between adjacent tooth roots, and identify the
locations of vital anatomical structures to be avoided. Periapical and panoramic radiographs
are useful, but Cone-Beam Computed Tomography (CBCT) provides a more accurate 3D
view of bone thickness and root morphology, and is highly recommended in cases requiring
high precision or in complex anatomical areas. [29]
* Site Selection Criteria: The ideal site should meet several conditions:
* Bone: Sufficient bone quantity (especially thick cortical bone) to provide good primary
mechanical stability. Bone quality of D2 or D3 according to Lekholm & Zarb classification is
preferred. Areas with very little bone or poor quality (D4, D5) should be avoided.
* Soft Tissue: Placement within the Attached Gingiva is strongly preferred over mobile
Alveolar Mucosa. Attached gingiva is less prone to movement, inflammation, and covering
the TAD head. If placement in mobile mucosa is necessary, a TAD neck of appropriate
length should be chosen, and special attention paid to hygiene.
* Roots and Vital Structures: The site must provide sufficient safety distance (at least 1-2
mm) from adjacent tooth roots and important anatomical structures like nerves, vessels, and
sinuses.
* Biomechanical Requirements: The site must allow the application of orthodontic force in
the desired direction and vector to achieve the targeted tooth movement.
* Common Sites: Based on the above criteria, common insertion sites include: interradicular
spaces (buccal, palatal, lingual), the palate (midline or paramedian), maxillary tuberosity,
retromolar area, buccal shelf of the mandible, infrazygomatic crest (IZC) in the maxilla, and
the anterior chin area. [30] The palate, IZC, and buccal shelf are considered extra-radicular
sites that reduce the risk of root contact and allow freer tooth movement.
Placement Technique: After selecting the site and determining the appropriate TAD type and
size, placement is usually performed chairside:
* Anesthesia: Local anesthetic (injection, gel, or spray) is typically sufficient to numb the soft
tissues and periosteum at the insertion site.
* Sterilization: Standard surgical sterilization procedures must be followed for instruments,
materials, and the insertion site.
* Pilot Drilling (If Necessary): For self-tapping TADs or when placing in very dense cortical
bone, a small pilot hole may be required using a special drill at low speed with irrigation.
Self-drilling TADs usually do not require this step.
* Insertion: The TAD is inserted into the bone using a special manual driver or a low-speed
mechanical handpiece (around 25 rpm).
* Insertion Angle: As mentioned, the angle is often oblique to the long axis of the teeth
(30-45° in the maxilla, 10-20° in the mandible) to increase contact with cortical bone and
avoid roots. Insertion starts at a steeper angle to create a purchase point, then the angle is
adjusted for final insertion. [61]
* Torque: The applied insertion torque must be controlled. Too low torque results in
insufficient primary stability, while too high torque can cause excessive pressure on the
bone, leading to localized necrosis or TAD fracture. A range of 5-10 Ncm is often considered
ideal, and using a torque wrench is preferred for precise control. [65]
* Surgical Guides and Navigation: To increase placement accuracy and reduce the risk of
injuring roots or anatomical structures, pre-designed surgical guides (acrylic templates or
CAD/CAM designed and 3D printed) can be used to guide the drill or TAD to the
predetermined site and angle accurately. [64] Dynamic Navigation techniques, similar to
those used in dental implantology, are also emerging as a promising tool for real-time
guidance of TAD placement. [50]
Loading Considerations:
* Immediate Loading: Since TADs rely on primary mechanical stability, orthodontic forces
can, in most cases, be applied immediately after placement or within a very short period. [54]
 * Delayed Loading: In some situations, such as less dense bone, younger patients, or when
high forces are needed, some clinicians prefer to wait for a period of two to four weeks (or
even longer in rare cases) before starting loading, to allow for some initial tissue healing or
potential secondary stability increase. The debate on optimal loading time continues, and the
decision seems to depend on a clinical assessment of multiple factors including bone quality,
TAD design, patient age, and the required force. [1]
Removal Technique: Removal of TADs is generally a simple and quick procedure:
* Anesthesia is usually not required, or a topical anesthetic may be used if needed.
* The appropriate manual driver for the TAD head is used to simply unscrew it by rotating
counter-clockwise.
* Soft and hard tissues at the insertion site typically heal quickly after removal without
leaving any permanent trace.
* In rare cases where removal is difficult (due to partial osseointegration or TAD fracture),
the clinician may need to wait a few days to allow some loosening or may resort to a minor
surgical procedure to remove the remaining fragment.
The increasing emphasis on site selection criteria and meticulous planning confirms that
TAD success begins before the placement procedure itself. Proper planning and site
selection based on accurate assessment of bone, soft tissues, adjacent structures, and
biomechanical needs may be more critical to success than the placement technique itself,
assuming basic operator competency.
Furthermore, the continuous development of digital tools, such as using CBCT for 3D
planning, designing and manufacturing surgical guides using CAD/CAM and 3D printing, and
dynamic navigation systems, indicates a clear trend towards increasing precision and
predictability in the TAD placement process. [50, 64] These technologies are expected to
help reduce complications associated with freehand placement, such as root injury, and
enhance clinician and patient confidence in using this powerful tool.
8. Clinical Success Factors for Orthodontic TADs
Clinical success of a Temporary Anchorage Device (TAD) is defined by its ability to remain
stable in its position throughout the clinically required period, withstand applied orthodontic
forces without excessive mobility, and not cause persistent inflammation or unacceptable
pain to the patient. Achieving this success depends on a complex interplay of various factors
that can be categorized into patient-related, implant-related, and
operator/management-related factors.
Patient Factors:
* Age: Study results on the effect of age are conflicting. Some suggest higher success rates
in younger patients (<20 years), possibly due to better bone healing capacity, [65] while
others find higher success in older patients, perhaps due to increased bone density, [45] or
find no statistically significant difference. Waiting longer before loading might be beneficial in
adolescents.
* Sex: Patient sex does not appear to be a significant factor in most studies, [45] although
some reports have indicated minor and inconsistent differences.
* Oral Hygiene: Considered one of the most important patient-controlled factors. Poor oral
hygiene leads to plaque accumulation around the TAD, causing soft tissue inflammation
(peri-implantitis), which is a major cause of TAD loosening and failure. Maintaining excellent
oral hygiene is crucial. [69]
* Bone Density/Quality: A critical factor for the primary and mechanical stability of the TAD.
Thick, dense cortical bone (like quality D1 and D2) provides the best stability. Less dense
bone (D3 and D4) is associated with higher failure rates. Bone quality at the planned
insertion site must be assessed radiographically and clinically. [65]
* Systemic Health/Smoking: Certain systemic health conditions affecting bone metabolism
or wound healing, such as severe osteoporosis or uncontrolled diabetes mellitus, can
increase the risk of TAD failure. Heavy smoking is also considered a risk factor that
increases the likelihood of inflammation and failure. [45]
* Soft Tissue Type: Placing the TAD in stable attached gingiva provides a better
environment and reduces the risk of inflammation and overgrowth compared to placement in
mobile alveolar mucosa.
Implant Factors:
* Design:
* Diameter: Larger diameter TADs tend to be more stable and fracture-resistant but require
more space and increase the risk of root contact. [19]
* Length: Longer TADs may provide better stability, especially in less dense bone where
stability relies more on cancellous bone. However, length must be balanced against the risk
of injuring anatomical structures. [19]
* Thread Shape: Thread design (e.g., pitch, depth, cutting tip shape) affects ease of
insertion, required torque, stress distribution on bone, and thus primary stability. [66]
* Material: As previously discussed, titanium alloys are the preferred material for their
biocompatibility and strength. There is no conclusive evidence that stainless steel leads to
significantly higher failure rates in short-term TAD use, but titanium remains the most
common choice. [14, 54]
Management/Operator Factors:
* Site Selection: Considered one of the most critical operator-controlled factors. Choosing a
site with good bone quality, sufficient quantity, attached gingiva, and distance from roots and
vital structures significantly increases the probability of success. [44]
* Insertion Technique:
* Insertion Angle: Inserting the TAD at an appropriate oblique angle can increase contact
with cortical bone and reduce the risk of root contact.
* Torque: Applying appropriate torque (not too low, not too high; optimal range often 5-10
Ncm) is necessary for good primary stability without damaging the bone. [65]
* Avoiding Root Contact: Close proximity or contact with a root during insertion is a major
factor for failure. Precision in placement and using surgical guides when needed are crucial.
[44]
* Loading:
* Force Magnitude: Applying excessive orthodontic forces to the TAD can lead to
increased stress on the surrounding bone and loss of stability. Gentle, continuous forces
appropriate for the type of movement required should be used. Some studies suggest
moderate forces (e.g., 250g) may be more successful than very light forces (100g). [37]
* Force Direction: The direction of force should be appropriate to achieve the desired
movement without generating unwanted rotational moments on the TAD that could lead to
loosening.
* Timing of Loading: As discussed, immediate versus delayed loading may impact success
rates, especially under specific conditions.
* Operator Experience/Skill: The clinician's experience in case assessment, selecting the
appropriate site and TAD, performing the placement procedure accurately, and managing
applied forces plays a significant role in achieving success. [44]
 * Inflammation Control: Close monitoring of soft tissue health around the TAD and early
intervention to treat any inflammation are essential for maintaining its stability.
It is clear from these factors that TAD success is not merely a matter of luck but the result of
careful planning, meticulous execution, and diligent follow-up. While some factors (like the
patient's baseline bone quality) may be beyond the direct control of the clinician, many other
critical factors, such as oral hygiene, site selection, insertion technique, force management,
and inflammation control, fall within the influence of the patient and the clinician. Focusing on
these modifiable factors is key to maximizing the benefit of this valuable technique. Primary
stability, which depends heavily on bone quality, TAD design, and insertion technique, is
considered the cornerstone upon which subsequent TAD success is built.
9. Impact of Orthodontic TADs on Modern Orthodontic Practice and Future Trends
The introduction and use of Temporary Anchorage Devices (TADs) have had a profound and
transformative impact on orthodontic practice in recent decades, to the extent that it can be
described as a true "Paradigm Shift" in the field. [13, 22, 23, 24, 25, 26] This impact is
evident in several key aspects:
* Revolution in Anchorage Concept: Shifting from near-total reliance on dental or extraoral
anchorage (with their known limitations) to the possibility of achieving absolute, reliable
skeletal anchorage intraorally, independent of teeth and patient compliance.
* Massive Expansion of Treatment Scope: Enabling specialists to treat complex
malocclusions and dentofacial deformities previously considered extremely difficult or
inevitably requiring surgical intervention. This includes the ability to achieve precise and
complex 3D movements like significant intrusion, en-masse arch movement, and correction
of severe asymmetry.
* Increased Efficiency and Predictability: Simplifying biomechanics, reducing unwanted side
effects, and making treatment outcomes more predictable and less dependent on
uncontrolled factors like patient cooperation.
* Improved Patient Experience: Reducing the need for uncomfortable and unaesthetic
extraoral appliances, potentially shortening treatment duration in some cases, and achieving
better results that may increase patient satisfaction.
* Widespread Adoption and Growing Use: TADs have become an integral part of clinical
practice for many orthodontists worldwide, with a continuous increase in research and
scientific publications related to them. [32, 55]
Future Trends: The future of orthodontic TADs looks promising, with continued development
and innovation in this field. Expected future trends include:
* Advanced Digital Integration:
* 3D Planning: Routine use of CBCT to precisely determine the optimal implant site in 3D,
considering bone density, root anatomy, and adjacent vital structures.
* Customized Surgical Guides: Designing and manufacturing accurate surgical guides
using CAD/CAM and 3D printing technologies to guide TAD placement with utmost
precision, minimizing human error and the risk of root injury. [64]
* Dynamic Navigation: Using optical or electromagnetic tracking systems to guide the
clinician's hand in real-time during TAD placement, offering high accuracy and greater
flexibility compared to static guides. Preliminary studies have shown acceptable accuracy for
this technology in TAD placement. [50]
* Full Digital Workflow: Integrating TAD planning and placement into a comprehensive
digital workflow including intraoral scanning, smile design, virtual treatment planning, and
manufacturing of customized appliances.
* Material Science and Design Evolution:
 * Improved Designs: Development of new TAD designs to enhance primary stability,
facilitate placement and removal, reduce tissue irritation, and provide more versatile
mechanical connection options (e.g., interchangeable head systems like the Benefit system).
[9]
* New Materials and Surface Coatings: Research into new materials that may offer higher
strength or better biocompatibility. Development of bioactive surface coatings aimed at
improving the surrounding tissue response or reducing bacterial adhesion. [15, 34, 35]
* Nanotechnology Applications: Exploring the potential use of nanotechnology to modify
TAD surfaces to enhance their antibacterial properties, reduce inflammation, and possibly
influence surrounding bone remodeling positively, while being cautious about potential
long-term effects.
* Technique and Protocol Refinement:
* Standardization of Protocols: Need for further research to establish optimal protocols for
site selection, placement technique, and timing/magnitude of loading for various clinical
situations.
* Deeper Understanding of Biomechanics: Conducting more studies (e.g., Finite Element
Analysis - FEM) to understand stress distribution around TADs under different forces and to
optimize the design of applied mechanics. [37]
* Better Management of Complications: Developing more effective strategies for
preventing common complications (like root injury and inflammation) and managing them
when they occur.
* Broader Adoption and Training:
* Increased Use in Multidisciplinary Treatments: Enhancing the role of TADs in cases
requiring collaboration between orthodontics and other specialties like prosthodontics
(Ortho-Prostho) or maxillofacial surgery. [41, 49]
* Need for Better Training and Guidelines: As TAD use increases, the need arises for
comprehensive and standardized training programs for clinicians, and the development of
clear clinical guidelines to ensure the safe and effective use of this technology. [29, 33, 52,
63, 89]
The "paradigm shift" brought about by orthodontic TADs is ongoing, as practice trends
towards more precise procedures, digital planning, and technologically guided interventions.
The future holds promises of further improvements in materials, designs, and techniques,
which will enhance the safety, efficacy, and predictability of TAD use. Orthodontic TADs are
expected to remain a pivotal tool in the orthodontist's armamentarium, enabling them to
achieve better treatment outcomes and meet the increasing patient expectations for
effective, comfortable, and aesthetic treatments.
10. Conclusion
Temporary Anchorage Devices (TADs) represent a highly significant development and a
revolutionary addition to the field of modern orthodontics. These small devices, temporarily
fixed in bone, have successfully overcome many limitations associated with traditional
anchorage methods, offering a reliable and effective solution for obtaining "absolute" or
skeletal anchorage.
The importance of TADs lies in their ability to provide a fixed anchor point independent of
teeth, preventing unwanted reactive dental movements and allowing precise control over the
direction and magnitude of applied forces. This has led to a significant expansion in the
scope of possible orthodontic movements, including complex movements like intrusion,
en-masse arch movement, and asymmetry correction, which were previously difficult or
impossible. They have also contributed to increased treatment efficiency, improved
predictability of outcomes, and importantly, significantly reduced reliance on patient
cooperation, especially regarding the wear of extraoral appliances.
TADs are available in various types, designs, and materials, most notably miniscrews, often
made from titanium alloys. The selection of the appropriate TAD and its placement site
depends on a careful assessment of the clinical situation, bone quality, adjacent anatomical
structures, and the biomechanical requirements of the planned treatment.
Despite high success rates exceeding 80-90% in most studies when used correctly, TADs
are not without potential risks and complications, such as root injury, peri-implant tissue
inflammation, loss of stability, and fracture. Clinical success depends on an interacting set of
patient-related factors (especially oral hygiene and bone quality), implant-related factors
(design and material), and operator-controlled factors (most importantly site selection,
precise insertion technique, management of applied forces, and inflammation control).
The continuous evolution in this field points towards a promising future for TADs, driven by
technological advancements, particularly integration with digital tools like CBCT, CAD/CAM,
3D printing, and dynamic navigation, which will enhance the precision and safety of their
placement. Ongoing research in material sciences and implant design may lead to further
improvements in their effectiveness and stability.
In conclusion, temporary anchorage devices have truly brought about a paradigm shift in
orthodontics, transforming it from reliance on often relative and uncertain anchorage to an
era of absolute and controlled skeletal anchorage. They have become an indispensable tool
for treating complex cases and will continue to play a pivotal role in shaping the future of
orthodontics, enabling specialists to achieve better, more efficient treatment results and
better meet patient aspirations.
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D8%A3%D8%B3%D9%86%D8%A7%D9%86-%D8%B9%D9%84%D9%89-%D8%AA%D9%
82%D9%88%D9%8A%D9%85-%D8%A7%D9%84%D8%B3%D9%86-%D8%A7%D9%84%
D9%85%D8%AA%D8%B7%D8%A7%D9%88%D9%84-%D9%88%D8%A5%D8%B1%D8%
AC%D8%A7%D8%B9%D9%87-%D8%B7%D8%A8%D9%8A%D8%B9%D9%8A%D8%A7
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%B1%D8%A7%D8%BA%D9%8A-%D9%81%D9%8A-%D8%A7%D9%84%D9%81%D9%83
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[Link]%2Fhlthscnc%2Fsearch%2Fauthors%2Fview%3FfirstName%3D%25D9%2585%25D
8%25B1%25D9%258A%25D9%2585%26middleName%3D%26lastName%3D%25D9%258
7%25D8%25AF%25D9%258A%25D9%2588%25D8%25A9%26affiliation%3D%26country%
3D (Note: Original Arabic title/text)