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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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.
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).
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
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
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.
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
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.
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.
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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**
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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!
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.
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
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)
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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:
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.
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..
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-
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.
ReferencesBehrents RG. Growth in the aging craniofacial skeleton. Monograph 17.
Craniofacial Growth Series. Ann Arbor, MI: Center for human growth
and development, University of Michigan. 1985.
Behrents RG. An atlas of growth in the aging craniofacial complex. Monograph
18. Craniofacial Growth Series. Ann Arbor, MI: Center for human growth
and development, University of Michigan. 1985.
Figure 14 Comparison of surface areas of dental implantand miniscrew implant (Reprinted with permission fromCope JB: Clinical Case Report 14001. www.CopestheticCE.com)
JO September 2014 Mini-implant Supplement Replacement of lateral incisors with miniscrew implants S73
Bidra AS, Almas K. Min implants for definitive prosthodontics treatment: A