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Temporary replacement of missing maxillary lateral incisors with orthodontic miniscrew implants in growing patients: rationale, clinical technique, and long-term results Jason B. Cope 1,2,3 and David McFadden 4,5,6 1 American Board of Orthodontics; 2 Department of Graduate Orthodontics, St Louis University, St. Louis, MO, USA; 3 Private Practice of Orthodontics, Dallas, TX, USA; 4 American Board of Prosthodontics; 5 American Board of Oral Implantology; 6 Private Practice of Prosthodontics, Dallas, TX, USA The missing maxillary lateral incisor in adolescent patients presents an orthodontic challenge. Historically, there have been three treatment options to address this clinical problem: (1) canine substitution, (2) tooth auto- transplantation, and (3) dental restoration. Unfortunately, these methods are not without limitation. A novel treatment concept, originating in 2003 and utilizing orthodontic miniscrew implants, is presented along with the rationale, clinical technique and 8 years of follow-up. Key words: Temporary anchorage device, miniscrew, miniscrew implant, lateral incisor, restoration Received 14 May 2014; accepted 8 June 2014 Introduction The missing maxillary lateral incisor in adolescent patients, whether due to developmental absence or traumatic injury is a challenge, which the orthodontic profession has struggled to adequately treat since is inception as the first dental specialty. To date, several treatment options have been used for the replacement of absent maxillary lateral incisors (Czochrowska et al., 2000; Zachrisson et al., 2004; Kinzer and Kokich, 2005a; Kinzer and Kokich, 2005b; Kokich and Kinzer, 2005; Priest, 2006; Kavadia et al., 2011; Kokich et al., 2011; Zachrisson et al., 2011; Janakievski, 2012; Liu and Ramp, 2013; Norris and Caesar, 2013). Unfortunately, none ideally addresses the situation and this article will briefly review those options as well as document a relatively new method of treatment first conceived in 2003 and now with long-term follow-up from 2–8 years. Until recently, there have been three treatment options to address a missing maxillary lateral incisor in adoles- cents: (1) canine substitution, (2) tooth auto-transplanta- tion, and (3) dental restoration. Unfortunately, all of the above treatment options have limitations. The removable options are not tolerated well in adolescents, who are typically self-conscious about removing their ‘fake tooth’ and displaying their large edentulous space while eating in front of their friends. They also risk losing or breaking the removable appliance. The fixed options all require enamel reduction of often perfectly healthy teeth. Moreover, they do not guarantee ideal alveolar and gingival contours, or aesthetics. The common limitation to all of the above; however, is the fact that none of them prevent alveolar bone resorption and soft tissue shrinkage over time in the missing tooth location. In fact, all of them promote alveolar bone loss due to a lack of alveolar loading (Packota et al., 1988; Bodic et al., 2005). This bone resorption eventually compromises aesthetics at the pontic site and also makes future restoration with dental implants more difficult. Frequently, these patients require bone and soft tissue grafts if the decision is later made to place a dental implant and restoration, particularly if the patient is young at the onset of orthodontic treatment. One treatment option that has not been mentioned to this point is the placement and restoration of a dental implant. This is because osseointegrated dental implants are not appropriate in growing adolescents. Dental implants, unlike natural teeth, do not continue to erupt, as the adjacent dentition erupts into the inter-maxillary growth space (Cronin and Oesterle, 1998; Percinoto et al., 2001). An arbitrary minimum age of 15 in females MINI-IMPLANT SUPPLEMENT Journal of Orthodontics, Vol. 41, 2014, S62–S74 Address for correspondence: Jason B. Cope, DDS, PhD, 7015 Snider Plaza, Suite 200, Dallas, TX 75205, USA. Email: [email protected] # 2014 British Orthodontic Society DOI 10.1179/1465313314Y.0000000112
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Page 1: Temporary replacement of missing maxillary lateral ... · miniscrew implants (MSIs), miniplate implants, palatal implants, and others (Cope and Owens, 2007). For the purpose of this

Temporary replacement of missing maxillarylateral incisors with orthodontic miniscrewimplants in growing patients: rationale, clinicaltechnique, and long-term resultsJason B. Cope1,2,3 and David McFadden4,5,6

1American Board of Orthodontics; 2Department of Graduate Orthodontics, St Louis University, St. Louis, MO, USA; 3Private Practice ofOrthodontics, Dallas, TX, USA; 4American Board of Prosthodontics; 5American Board of Oral Implantology; 6Private Practice of Prosthodontics,Dallas, TX, USA

The missing maxillary lateral incisor in adolescent patients presents an orthodontic challenge. Historically, there

have been three treatment options to address this clinical problem: (1) canine substitution, (2) tooth auto-

transplantation, and (3) dental restoration. Unfortunately, these methods are not without limitation. A novel

treatment concept, originating in 2003 and utilizing orthodontic miniscrew implants, is presented along with the

rationale, clinical technique and 8 years of follow-up.

Key words: Temporary anchorage device, miniscrew, miniscrew implant, lateral incisor, restoration

Received 14 May 2014; accepted 8 June 2014

IntroductionThe missing maxillary lateral incisor in adolescent patients,

whether due to developmental absence or traumatic injury

is a challenge, which the orthodontic profession has

struggled to adequately treat since is inception as the first

dental specialty. To date, several treatment options have

been used for the replacement of absent maxillary lateral

incisors (Czochrowska et al., 2000; Zachrisson et al.,

2004; Kinzer and Kokich, 2005a; Kinzer and Kokich,

2005b; Kokich and Kinzer, 2005; Priest, 2006; Kavadia

et al., 2011; Kokich et al., 2011; Zachrisson et al., 2011;

Janakievski, 2012; Liu and Ramp, 2013; Norris and

Caesar, 2013). Unfortunately, none ideally addresses the

situation and this article will briefly review those options as

well as document a relatively new method of treatment first

conceived in 2003 and now with long-term follow-up from

2–8 years.

Until recently, there have been three treatment options

to address a missing maxillary lateral incisor in adoles-

cents: (1) canine substitution, (2) tooth auto-transplanta-

tion, and (3) dental restoration. Unfortunately, all of the

above treatment options have limitations. The removable

options are not tolerated well in adolescents, who are

typically self-conscious about removing their ‘fake tooth’

and displaying their large edentulous space while eating in

front of their friends. They also risk losing or breaking the

removable appliance. The fixed options all require enamel

reduction of often perfectly healthy teeth. Moreover, they

do not guarantee ideal alveolar and gingival contours, or

aesthetics.

The common limitation to all of the above; however, is

the fact that none of them prevent alveolar bone resorption

and soft tissue shrinkage over time in the missing tooth

location. In fact, all of them promote alveolar bone loss

due to a lack of alveolar loading (Packota et al., 1988;

Bodic et al., 2005). This bone resorption eventually

compromises aesthetics at the pontic site and also makes

future restoration with dental implants more difficult.

Frequently, these patients require bone and soft tissue

grafts if the decision is later made to place a dental implant

and restoration, particularly if the patient is young at the

onset of orthodontic treatment.

One treatment option that has not been mentioned to

this point is the placement and restoration of a dental

implant. This is because osseointegrated dental implants

are not appropriate in growing adolescents. Dental

implants, unlike natural teeth, do not continue to erupt,

as the adjacent dentition erupts into the inter-maxillary

growth space (Cronin and Oesterle, 1998; Percinoto

et al., 2001). An arbitrary minimum age of 15 in females

MINI-IMPLANT SUPPLEMENT Journal of Orthodontics, Vol. 41, 2014, S62–S74

Address for correspondence: Jason B. Cope, DDS, PhD, 7015

Snider Plaza, Suite 200, Dallas, TX 75205, USA.

Email: [email protected]# 2014 British Orthodontic Society DOI 10.1179/1465313314Y.0000000112

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Comments by Paul L. Ouellette, DDS, MS, AFAAID related to "Proof of Concept" and the viability of the TADplant preserving crestal bone Email> [email protected] Cell> 404 983-2300 Text comments or questions
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Do Nothing >> a Bone and/or Soft Tissue Grafts will be necessary to place an implant. Disuse Atrophy adds cost to future procedures.
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I recently talked with Dr. Cope at an AAO meeting and the patient continues to have the mini implant in place without any complications Still in place 12+ Years = Success!!
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A NEW CONCEPT IN IMPLANT DENTISTRY A "Placeholder" provisional dental implant designed for easy insertion and removal at will. The TADplant preserves crestal bone and implant sites until the patient can afford or has matured to have a standard dental implant placed. Patent Nos. US9629696B2 (4.25.2017) - US9980792b2 (5.29.2018).
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and 18 in males has been suggested for placement of

osseointegrated implants (Cronin et al., 1994). Some

authors recommend an even later implant placement age

(Spear et al., 1997). The aforementioned guidelines;

however, do not account for individual variations in

growth patterns (Behrents, 1985a,b; Fishman, 1987;

Silveira et al., 1992). Dental implants placed in patients,

regardless of their chronological age, but with any facial

growth remaining, run the risk of the implants becoming

Figure 1 Pre-treatment photos: (a) right buccal; (b) anterior; (c) left buccal; (d) maxillary occlusal; (e) lateral overjet; (f)mandibular occlusal (Reprinted with permission from Cope JB: Clinical Case Report 10005. www.CopestheticCE.com)

Figure 2 Pre-treatment panoramic radiograph (Reprintedwith permission from Cope JB: Clinical Case Report10005. www.CopestheticCE.com)

Figure 3 Post-treatment photos: (a) right buccal; (b) anterior; (c) left buccal; (d) maxillary occlusal; (e) lateral overjet; (f)mandibular occlusal (Reprinted with permission from Cope JB: Clinical Case Report 10005. www.CopestheticCE.com)

JO September 2014 Mini-implant Supplement Replacement of lateral incisors with miniscrew implants S63

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Can we now consider placing "Pediatric" provisional dental implants to preserve future receptor sites
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Behrents 1985 published book > his Phd Thesis documents growth changes in the Esthetic Zone past 30 Years of age
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submerged relative to the adjacent erupting permanent

teeth (Spear et al., 1997; Thilander et al., 2001).

Although dental implants designed to osseointegrate

have been shown to be detrimental in growing adoles-cents, what about orthodontic miniscrew implants that

rely on bone-implant contact, but are designed to be

placed and removed at a later date without osseointegra-

tion? This paper will explain the rationale behind that

novel concept first performed on a case that began

treatment in 2003, and now with 99 months of follow-up.

Her sister’s case, with 27 months of follow-up, is also

presented.

RationaleThe detrimental effects of placing dental implants in

growing adolescents have been covered in detail else-

where (Spear et al., 1997; Thilander et al., 2001). Briefly,

the valid concerns are that the dental implants will

osseointegrate, and lead to the following problems:

Figure 4 Intraoperative MSI placement photos: (a) mucoperiosteal flap and initial pilot hole placement; (b)periapical radiograph of pilot drill angulation; (c) MSI at final placement depth; (d) MSI provisional coping inplace; (e) provisional coping after reshaping; (f) polycarbonate crown form selection; (g) pickup of reshapedprovisional coping inside of crown form; (h) provisional crown cemented in place and soft tissues sutured(Reprinted with permission from Cope JB: Clinical Case Report 10005. www.CopestheticCE.com)

S64 Cope and McFadden Mini-implant Supplement JO September 2014

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TADplants can be inserted WITHOUT surgical flaps using a surgical guide. Guides can be made in the Doctor's lab or provided by a surgical guide company such as Anatomage and Blue Sky Bio. A tissue punch and starter pilot hole is recommended. Less invasive surgery significantly reduces crestal bone loss.TADplants "gently" integrate so they can be easily removed months or years later.
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TADplants do not superintegrate so they can be removed and relocated if a growth or aging change makes this necessary. Permanent superintegrated dental implants, if used, are not easily removed. A flap and trephine may be required. An invasive surgery that could damage the implant receptor site. Keep it Simple with TEMPORARY disposable dental implants.
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infraocclusion due to eruption of adjacent teeth, marginal

bone loss around adjacent teeth, buccal bone loss around

the implant, and possible vertical angular defect between

the implant and adjacent teeth (Thilander et al., 2001).

However, in non-growing patients, dental implants have

benefits. For example, they have been shown to stimulate

bone remodelling at a rate significantly higher that of

normal bone remodelling, and this is not a short-term

phenomenon; it is apparently increased for the life of the

implant (Huja, 2007).

If there are bone stimulating benefits of dental implants,

but these are potentially detrimental for growing adoles-

cents, the obvious question becomes ‘Is it possible to

harness the benefits of dental implants while at the same

time minimizing or eliminating the problems experienced

when placing them in growing children?’ It is this question

that the primary author began to contemplate in 2003

when considering the post-treatment options of a patient

with a congenitally missing lateral incisor. Concurrently,

temporary anchorage devices (TADs) were becoming a

popular topic in the pursuit of absolute orthodontic

anchorage. As a point of clarification, the term temporary

anchorage device broadly refers to a group of devices

temporarily fixed to bone for the purpose of enhancing

orthodontic anchorage and which are removed after use

(Cope and Owens, 2007). Included in this group are

miniscrew implants (MSIs), miniplate implants, palatal

implants, and others (Cope and Owens, 2007). For the

purpose of this article, the specific TAD of interest is the

MSI, so this term is used here to prevent confusion with

the other types of TADs.

Considering that MSIs used for orthodontic ancho-

rage are generally 1.5 to 2.0 mm diameter and designed

to prevent osseointegration, and that dental implants

placed in the maxillary lateral incisor position are on

Figure 5 Comparison photos from before and after restorative procedure: (a) post-orthodontic occlusal; (b) post-orthodontic facial; (c) post-restorative occlusal; (d) post-restorative facial (Reprinted with permission from Cope JB:Clinical Case Report 10005. www.CopestheticCE.com)

Figure 6 Post-treatment panoramic radiograph (Reprintedwith permission from Cope JB: Clinical Case Report 10005.www.CopestheticCE.com)

JO September 2014 Mini-implant Supplement Replacement of lateral incisors with miniscrew implants S65

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We should all thank Dr. Jason Cope for his "Proof of Concept" evidenced by the cases presented in this article. Orthodontists and Pediatric Dentists can now provide a better evidenced-based solution for congenitally missing teeth.
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average 3.5 mm in diameter and designed to encourage

osseointegration, might there be a possible application

of MSIs as a temporary dental implant during the

adolescent years, and then replaced by a ‘permanent’

dental implant after the cessation of growth? The

literature was searched in 2003, but there was no report

that anyone had utilised this apparently novel concept.

Clinical case 1The patient presented at 9 years 8 months of age with the

diagnosis of skeletal class II, class II right and class I left

buccal relationships, congenitally missing maxillary right

lateral incisor, peg maxillary left lateral incisor, and

buccally impacted maxillary left canine. All deciduous

second molars were present clinically and the permanent

second molars had not yet erupted (Figures 1 and 2). Thetreatment plan was to initiate an early phase of treatment

in the maxillary arch due to the location of the maxillary

left canine over the adjacent lateral incisor root and the

anticipated duration of time to bring the impacted canine

into the arch. The canine would be uncovered and slowly

moved postero-inferiorly into its normal position in the

arch. The lower arch would be bonded later to minimize

the duration of full appliances. Cervical-pull headgearwith the possible addition of right side Class II elastics

would be worn nightly for approximately six months

to correct the right Class II dental relationship. Upon

completion of treatment, all appliances would be removed.

An MSI would be placed in the missing maxillary right

lateral incisor position and restored with a provisional

polycarbonate crown. The maxillary left peg lateral

incisor would be restored at the same time. The MSI

would remain in place until the cessation of growth,

followed by replacement of the MSI with a permanent

dental implant.

Treatment proceeded as prescribed. The canine was

uncovered and brought into position. An ideal occlusion

was established followed by orthodontic appliance

removal. Diagnostic records were acquired at 12 years 6

months of age (Figure 3). The patient proceeded to the

prosthodontist for placement of the MSI and restoration.

The procedure was as follows (Figure 4):

1. Under local anaesthesia a mid-crestal incision was

made in the edentulous site with sulcular incisions

at the proximal teeth.

2. A full thickness soft tissue flap was elevated to

expose the underlying ridge crest to enable:

a. Direct visualization of the bony crest, as pre-

ferred in cases where bone volume and thickness

is poor,

b. Cement removal prior to soft tissue re-approx-

imation and closure.

3. Minor alveoplasty, or bony recontouring, of the

edentulous ridge was completed to simulate naturaltooth bony architecture.

4. A 2.2 mm diameter MSI (IMTEC Sendax MDI

MAX, 3M Unitek, St. Paul, MN, USA, www.

3MUnitek.com) was placed in the centre of the site,

equidistance from the adjacent roots.

Figure 7 99-month retention photos: (a) right buccal; (b) anterior; (c) left buccal; (d) maxillary occlusal; (e) lateral overjet; (f)mandibular occlusal (Reprinted with permission from Cope JB: Clinical Case Report 10005. www.CopestheticCE.com)

S66 Cope and McFadden Mini-implant Supplement JO September 2014

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TADplant dimension at crestal bone level is 3.4mm. It tapers to 1.5mm to safely fit between adjacent tooth roots.
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My son, Dr. Jonathan Ouellette, is an Implant Dentist. The alveoplasty is a routine procedure for him. However, Orthodontists are not generally trained to perform alveoplasties. A referral to a Prosthodontist or Implant specialist may be considered for some cases.
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a. Use of a surgical guide was preferable, but

difficult due to the 1.0 mm single-drill protocol.

b. Visualization and palpation of the adjacent root

eminences was performed to assist with initial

1.0 mm diameter drill placement and angulation

(Figure 4a).

c. Intraoperative periapical radiographs were taken

– a shallow 3.0 mm penetration depth using the

1.0 mm diameter drill as a radiographic guide pin

(Figure 4b). The shallower drill depths allowed

easier angular corrections, when necessary.

d. The MSI was placed to the final depth (Figure 4c).

Buccolingual implant trajectory was of minimal

concern since the abutment head was only

4.0 mm tall. The implant was facially inclined

due to typical bony anatomy.

5. The provisional coping was placed on the implant

(Figure 4d). The coping was reshaped extraorally

to fit within the confines of the provisional crown

(Figure 4e).

6. An appropriate sized polycarbonate crown was

selected and modified in length and width

(Figure 4f).

7. Intraorally, the polycarbonate crown was used

to pick up the provisional coping using crown

and bridge resin (Figure 4g). Only minimal

acrylic resin was used for initial coping pick

up.

8. In the laboratory, additional acrylic was added to

thicken the gingival margins. The crown was then

placed on a lab analogue to adjust and create the

ideal emergence profile.

Figure 8 Comparison photos from porcelain crown cementation at 12 months in retention to 99 months in retention:(a) 12 months retention facial; (b) 12 months retention anterior; (c) 99 months retention facial; (d) 99 months retentionanterior (Reprinted with permission from Cope JB: Clinical Case Report 10005. www.CopestheticCE.com)

JO September 2014 Mini-implant Supplement Replacement of lateral incisors with miniscrew implants S67

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9. The provisional crown was placed intraorally and

adjusted. It fitted snugly with interproximal contactsand was free of functional occlusal and excursive

contacts. Most adjustments were performed extrao-

rally, when possible, to reduce contamination of the

surgical site with acrylic shavings.

10. Final crown modifications were made followed by

laboratory polishing.

11. The crown was cemented with temporary cement.

The lateral walls of the abutment head were parallel

to the body of the MSI, and so provided improved

resistance and retention form. In addition, the

abutment head had a circumferential undercut, andso provided improved retention form. Therefore,

very little cement was necessary. Contrary to popular

belief, definitive cementation is not necessary.

12. Cement was cleaned while the flap was open. The

surgical site was irrigated with sterile saline.

13. The soft tissues were closed with resorbable sutures

(Figure 4h). Although not necessary in this case,

some tissue sculpting can be performed if a large

band of keratinized tissue exists.

14. The patient was instructed to brush, floss and eat

normally, but refrain from eating anything hard in

the area of the MSI crown.

Upon completion of the procedure, a maxillary retainer

was fabricated, and post-operative photographs (Figure 5)

and radiographs taken (Figure 6). The plan at that point

was to continue to observe the patient every six months

during her school years to insure that infra-occlusion

did not develop. After approximately nine months, the

provisional crowns began to discolour. Since the MSI was

anticipated to be in place for approximately 6–8 years, a

‘temporary’ porcelain crown was placed until the final

implant and restorations were placed. The porcelain crown

was cemented at 12 months of retention.

As the clinical photographs (Figures 7 and 8) and

periapical radiographs (Figure 9) demonstrate, no infra-

occlusion has developed after eight years, nor has any

bone defects been created around the MSI or adjacent

teeth. Although the original plan was to remove and

replace the MSI with a ‘permanent’ dental implant, it is

hard to justify the additional procedure considering the

Figure 9 Periapical radiographs: (a) day of MSI placement; (b) 99 months of retention. Note that superimpositionof the periapical radiographs indicates approximately 1.0 mm of bone grown coronally down the distal MSIthreads (Reprinted with permission from Cope JB: Clinical Case Report 10005. www.CopestheticCE.com)

S68 Cope and McFadden Mini-implant Supplement JO September 2014

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**Rule of Dental Implant Dentistry: Always design and place crowns in infraocclusion free of functional occlusal and excursive contacts.
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The image to the left illustrates an ideal receptor site with the mini implants placed exactly in the middle of the site. This can be easily achieved with guided surgery. Surgical guide companies provide virtual planning sessions using CBCT and a digital model superimposed. You will be able to see "where the bone is". If using TADplants they should be placed with a palatal versus facial position. Stay away from the buccal plate. The maxillary can grow 6mm downward and 2 mm palatal. Plan for it!
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lack of problems while the ‘temporary’ MSI and restora-

tion have been in place.

Clinical case 2This patient, the younger sister of Case 1, presented at

11 years 6 months of age with a skeletal class III

relationship, dental class I with a class III tendency,

congenitally missing maxillary right lateral incisor, peg

maxillary left lateral incisor, and retroclined lower

anterior teeth. Nine deciduous teeth were present. A

lingual arch was placed to maintain the mandibular

second deciduous molar spaces until active treatment

commenced 14 months later when all of the permanent

teeth were present.

The treatment plan was to accept the class III skeletal

relationship and to achieve a class I dental relationship

by retracting the mandibular premolars into the

deciduous molar spaces followed by retraction of the

mandibular anterior teeth. Class III elastics would be

worn 22 hours per day as needed once full-sized

archwires were placed. Upon completion of treatment

an MSI would be placed in the missing maxillary right

lateral incisor position and restored with a provisionalpolycarbonate crown. The maxillary left peg lateral

would be restored at the same time. The MSI would

remain in place until the cessation of growth and then

replaced by a permanent dental implant, if necessary.

Orthodontic treatment proceeded as prescribed for

15.5 months, then the patient was referred to the

prosthodontist for placement of the MSI and restora-

tion. The same MSI procedure was followed as in Case 1

(Figures 10 and 11). Based on the sibling’s previousexperience with the polycarbonate crown, a ‘temporary’

porcelain crown was planned in this case until the final

implant and restoration stage. The porcelain crown was

cemented after bleaching at 6 months of retention.

As the clinical photographs (Figure 12) and periapical

radiographs (Figure 13) demonstrate, no infraocclusion has

developed after 27 months. Interestingly, superimposition

Figure 10 Intraoperative MSI placement photos: (a) mucoperiosteal flap; (b) minor alveolar crest recontouring foremergence profile; (c) initial pilot hole placement; (d) initial MSI placement; (e) final MSI placement; (f) impressioncoping in place; (g) MSI O-Ball Immediate Temporization Cap in place; (h) MSI O-Ball Immediate Temporization Capfrom occlusal (Reprinted with permission from Cope JB: Clinical Case Report 14001. In Press, www.CopestheticCE.com)

JO September 2014 Mini-implant Supplement Replacement of lateral incisors with miniscrew implants S69

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The images on this page illustrate implant surgery using a full thickness flap. This was what I wanted to avoid in a orthodontic clinical setting. We routinely place TADplants without flaps in the open orthodontic bay. TADplants can be placed in 60 seconds and removed in under 30 seconds.
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TADplants can be placed DURING orthodontic treatment in lateral agenesis cases. TADplants can be used with the Orthoveneer/Orthocrown system. A crown or veneer with a computer designed integrated (monolithic) orthodontic attachment can be 3D printed or milled. Additional information is available upon a TEXT request.
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of periapical radiographs taken the day of MSI place-

ment and 27 months later demonstrate that approxi-

mately 1.2 mm of bone growth occurred coronally along

the threads of the MSI.

DiscussionThe results of these two cases indicate that the placement

of MSIs with provisional restorations may be a viable

treatment option in certain growing individuals. Three

other adolescents have been treated in a similar manner

by the author. None of these five patients have shown any

type of deleterious effect, such as infraocclusion or bony

defects, as would be expected for osseointegrating dental

implants in growing individuals after 2 to 8 years of

follow-up. However, it is accepted that properly con-

ducted cohort studies are required to fully validate this

approach.

The potential benefits of temporary MSI lateral incisor

replacement include: prevention of bone resorption, sti-

mulation of bone remodelling, prevention of adjacent

tooth migration vertically and/or horizontally, prevention

of root migration into the edentulous area, minimization

or elimination of bony and/or soft tissue grafts, less

demanding orthodontic retention, little risk of orthodontic

MSI osseointegration, and the dark collar seen through

the gingiva around dental implants should not occur

because the smaller diameter MSI is placed more lingually

towards the centre of the alveolar crest.

Initially, the desired clinical technique was a modification

of the Cope Placement ProtocolTM (Cope and Herman,

2007), i.e. a minimally invasive technique using topical

anaesthetic, no incision/flap, and no pilot hole followed by

placement of an untreated, self-drilling machine polished

1.8 mm Unitek TADTM. However, the prosthodontist,

who routinely places dental implants surgically, saw little

need for a minimally invasive protocol. In particular, his

rationale for elevating a mucoperiosteal flap was for better

surgical visualization of the knife-edged alveolar ridge.

Likewise, a minimal 1.0 mm diameter by 3.0 mm deep

pilot hole prevented the miniscrew from ‘slipping’ to the

buccal or lingual upon placement, and also allowed intrao-

perative radiographs for proper angulation. Considering

placement in a growing individual, the only unacceptable

deviation of the proposed protocol was the placement of a

‘treated’ miniscrew, i.e. the miniscrew was surface treated

like a traditional dental implant (sandblasted and acid

etched [SLA treatment] to roughen the surface and

encourage osseointegration). This type of implant was

placed in Case 1 due to a lack of communication, but has

Figure 11 Comparison photographs from before and after restorative procedure: (a) post-orthodontic occlusal; (b)post-orthodontic facial; (c) post-restorative occlusal; (d) post-restorative facial (Reprinted with permission fromCope JB: Clinical Case Report 14001. In Press, www.CopestheticCE.com)

S70 Cope and McFadden Mini-implant Supplement JO September 2014

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Orthodontists do not usually use sutures. The TADplant system is a flapless procedure and sutures are not required.
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Evidence of 1.2mm of bone growth after 8 years in the mouth demonstrates the benefit of Dr. Cope's use of mini implants
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TADplants are place palatally as well.
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TADplants are placed PALATALLY!
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Significant Finding described below:
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since been replaced with a standard machine polished MSI

in subsequent cases. The rationale for using a machine

polished, rather than an SLA treated, MSI is that the latter

would have a significantly greater risk of osseointegrating,

and hence submerging during continued adolescent facial

growth.

Holmes (2013) reported that ‘Some authors have

suggested use of miniscrews with a temporary restoration;

there is a theoretic concern (emphasis added) that the

screw could impair vertical development of the alveolus

and result in a vertical defect, which will require further

site development. Here he refers to an article by Kokich

and Swift (2011) which stated ‘I would not recommend

placing a miniscrew in an adolescent orthodontic patient

who will eventually receive an implant restoration to

replace a missing maxillary lateral incisor. Two primary

reasons supported this perspective: (1) If a miniscrew

perforates the periosteum, as the teeth erupt, the implant

is left behind and vertical angular defects are created in the

implant site. (2) Miniscrews lack versatility for restorative

purposes and most do not have the ability to receive

standard abutments. Further, miniscrew diameters aver-

age 1.5 mm, which compromise the emergence profile,

and therefore, the esthetic appearance of the crown.

Unfortunately, no reference was given to support Dr

Kokich’s points. To date, no animal or clinical research

Figure 12 Comparison photos from porcelain crown cementation at 6 months in retention to 27 months in retention:(a) 6 months retention facial; (b) 6 months retention anterior; (c) 27 months retention facial; (d) 27 months retentionanterior (Reprinted with permission from Cope JB: Clinical Case Report 14001. In Press, www.CopestheticCE.com)

JO September 2014 Mini-implant Supplement Replacement of lateral incisors with miniscrew implants S71

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The TADplant has a 3.4mm wide platform-switched prosthetic platform that supports a screw retained provisional or permanent crown. A tissue sculpting abutment creates a normal emergence profile. TADplants, is not a narrow diameter TAD, but it was designed with similar features of temporary anchor devices. ie Easily Removal!
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TADplants are "Two-piece" hybrid dental implants that have tissue sculpting abutments. Note the difference in gingival anatomy between the two maxillary laterals. This can be improved with the TADplant abutment.
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has been published documenting that a small diameter

miniscrew implant causes vertical angular defects when

placed in a growing individual. Although, this does not

mean that an MSI cannot cause a vertical defect, no

evidence currently exists. Moreover, at the time of

publication of Dr Kokich’s article, there were, in fact, at

least two, commercially available MSI systems that had

the necessary versatility to allow for prosthetic restoration

without a compromised emergence profile (Cope and

Herman, 2007; Jeong et al., 2011).

What appears to be overlooked by those opposed to the

temporary use of MSIs for the replacement of maxillary

lateral incisors is that while both a small diameter MSI

and a larger diameter dental implant are technically both

dental implants, their characteristics are distinctly differ-

ent, especially the total surface area and surface rough-

ness. For example, comparing a 10 mm long61.8 mm

diameter Unitek TADTM and a 10 mm long63.5 mm

diameter dental implant (Figure 14), the surface area of

the dental implant is 142.5% greater than the TAD. This

does not even consider the surface roughness of the MSI

and dental implant. Except for the Korean C-implant

(Jeong et al., 2011) all other commercially available MSIs

are machine polished or smooth. Dental implants, on

the other hand, are surface roughened to substantially

increase surface area and osseointegration by several

hundred percent (Thomas et al., 1987; Buser et al., 1991).

This is a key concept to understand. Several definitions

of osseointegration have been put forward, which is

beyond the scope of this article. At a basic level, osseoin-

tegration is related to the amount or percentage of bone in

contact with the implant (Huja, 2007). It logically follows

that the greater amount of surface area, the greater the

chance of osseointegration. In light of several scientific

studies that report a lack of MSI osseointegration(Deguchi et al., 2003; Huja et al., 2006; Roberts and

Roberts, 2007), the primary author’s 15-year TAD clinical

experience without a single MSI osseointegrating, and the

significantly greater surface area of a dental implant

compared to an MSI, it is highly unlikely that a smooth-

surfaced, machine-polished MSI will osseointegrate.

Considering the possible negative sequellae in advance,

what could go wrong, and if so, what measures would benecessary to adequately treat the situation?

1. The MSI could osseointegrate and submerge relative

to the adjacent teeth – even if an MSI does

submerge, it should not do so to a significant extent

in any six month observation period and so could beaddressed by two means: backing the MSI out and

re-restoring the clinical crown or by simply additive

restoration of the clinical crown. Another option for

a submerged MSI would be to trephine and remove

it altogether. At a diameter of 1.8 mm, the trephined

hole would be a maximum of 2.2 mm, which is still

Figure 13 Periapical radiographs: (a) day of MSI placement; (b) 27 months of retention. Note that superimpositionof the periapical radiographs indicates approximately 1.2 mm of bone grown coronally down the MSI threads(Reprinted with permission from Cope JB: Clinical Case Report 14001. In Press, www.CopestheticCE.com)

S72 Cope and McFadden Mini-implant Supplement JO September 2014

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The TADplant was designed with a prosthetic platform. Abutments from 3,6 and 12 mm are available for any changes in the receptor site..
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smaller than the pilot hole of a 3.5 mm diameter

dental implant.

2. The crown could fracture or come loose: refabrica-

tion and/or recementation of the clinical crown.

3. The MSI could fracture in a traumatic event:

removal and/or replacement of the fractured MSI.

A more likely event, assuming ideal initial placement, is

that the resulting MSI hole upon removal years later willbe smaller than the pilot hole for the definitive dental

implant, and so additional bone removal will be required

prior to final dental implant placement.

A final concern that some clinicians have expressed is

that a 2.0 mm implant is not sufficient to withstand the

functional forces of occlusion. In the past seven years, the

second author has placed approximately 15 mini-dental

implants in adults unwilling to undergo orthodontic

treatment to either parallel roots or make adequate space

for an ideal restoration. All of those implants were placed

in the maxillary lateral incisor or lower incisor posi-

tions with no failures to date. Other authors have alsodemonstrated that mini-dental implants are capable of

sustaining long-term function when placed under ideal

conditions for both adults (Mazor et al., 2004; Dilek et al.,

2007; Flanagan, 2008; Flanagan and Mascolo, 2011;

Gleiznys et al., 2012; Shatkin and Petrotto, 2012; Sohrabi

et al., 2012; Bidra et al., 2013) and children (Graham,

2007; Jeong et al., 2011; Kalia, 2014; Wilmes, 2014).

ConclusionsThe absence of anterior teeth in the growing individual has

historically presented a difficult clinical treatment challenge.

The use of a miniscrew implant as a temporary treatment

option holds considerable promise. The benefits of using a

miniscrew implant and a crown as an interim restoration are

significant. For the patient, the obvious psychosocial benefit

is not having to wear a retainer 24 h a day only to remove it

immediately prior to eating; the crestal and buccolingualalveolar bone and soft tissue volume is preserved during and

through the completion of facial growth. All other

treatment options doom the alveolar bone to disuse

atrophy, necessitating future bone and soft tissue grafting

in the event a definitive implant and restoration is desired

(Spear et al., 1997). Therefore, the possibility of a miniscrew

implant and a cemented crown become an attractive

alternative for the growing patient. Since the initial conceptin 2003, several authors have implemented similar techni-

ques (Ciarlantini 2012; Giannetti 2010; Graham, 2007;

Jeong et al., 2011; Kalia, 2014; Wilmes, 2014). Ciarlantini

2012, Giannetti 2010. Although to date no long-term

randomized clinical trial has been published, no deleterious

effects have been reported elsewhere.

Disclaimer statements

Contributors No statement made.

Funding None.

Conflicts of interest The primary author has a financial

interest in the Unitek TAD system.

Ethics approval None.

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