CLINICIAN’S CORNER

Semipermanent replacement of missing

maxillary lateral incisors by mini-implant
retained pontics: A follow-up study
Roberto Ciarlantinia and Birte Melsenb
Recanati, Italy, Hannover, Germany, Perth, Western Australia, Australia, and Lexington, Ky

Agenesis of maxillary lateral incisors can be treated either by closing the space and substituting the canines for
the missing lateral incisors or, in adults, by replacing the missing teeth with fixed prosthetics or implants. This
article illustrates a method that can be used for a semipermanent implant replacement of the missing incisors
in adult patients. An Aarhus mini-implant was inserted perpendicular to the palatal mucosa of the alveolar pro-
cess of the edentulous area. A pontic was made at chair side of composite material around a stainless steel wire
extending from the mini-implant. This replacement approach allowed for the vertical development of the alveolar
process and maintained the bone density and morphology of the alveolar process. Five years after placement,
periapical radiographs showed that the alveolar process was following the vertical development related to the
eruption of the adjacent teeth, and that the morphology and the bone density were maintained, making the later
insertion of a dental implant possible without additional surgical buildup. (Am J Orthod Dentofacial Orthop
2017;151:989-94)

A
genesis of maxillary lateral incisors occurs with a
variable prevalence in different ethnic groups.
According to Bozga et al,1 the range is 2.2% to
10.1%, whereas most analyses report a prevalence be-
tween 6% and 8%. According to a PubMed advanced
search, the first reports dealing with missing maxillary
lateral incisors focused on their prevalence and etiol-
ogy.2,3 The treatment options were limited to space
closure or fixed prosthodontic bridges involving
invasive preparation of abutment teeth. With the
introduction of bonding materials and later of
implants, replacements with less or no preparation of
the neighboring teeth were possible. The introduction
of temporary anchorage devices (TADs) also made
space closure easier, but in some patients the facial
profile indicated that replacement would be the best
treatment. Yet, a problem remained in relation to the
a
Private Practice, Recanati, Italy.
b
Department of Orthodontics, Klinik f€ ur Kieferorthopedie Medizinische Hoch-
shule, Hannover, Germany; Department of Orthodontics, University of Western
Australia, Perth, Western Australia, Australia; Department of Orthodontics, Ken-
tucky University, Lexington, Ky.
The first author has completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported. The second author is a
consultant for American Orthodontics, which sells the screws.
Address correspondence to: Birte Melsen, Holtevej 11, Aarhus C DK-8000,
Denmark; e-mail, birte@melsen.com.
Submitted, May 2016; revised and accepted, December 2016.
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2016.12.012
ongoing growth-related development of the alveolar
process.4,5 The effect of the vertical alveolar
development was at the beginning underestimated;
consequently, the recommended timing for insertion of
permanent replacements has repeatedly been postponed.
Although several attempts have been made, a
consensus regarding space closure or space maintenance
with later replacement has not been reached.6,7 An
explanation may be the interaction of many individual
factors such as facial morphology, tooth morphology,
lip length, and function, each of which has an
important impact on the decision. Although the trend
has been to recommend space closure, in patients
where the replacement solution has been chosen, there
is a need for a temporary replacement until maturity
has been reached.
The options frequently described have been a remov-
able plate with a tooth replacing the missing tooth and a
bonded bridge with or without preparation of adjacent
teeth. The disadvantage of the removable plate is obvi-
ously the required compliance in addition to the contin-
uous coverage of the palatal mucosa. In relation to the
bonded bridge, occlusal contacts on the adjacent teeth
may have a negative influence, hampering the stability
or making invasive preparation necessary. As an alterna-
tive, TADs have recently been suggested as temporary re-
placements. This may, on the other hand, lead to another
problem because TADs, although not surface prepared as
989
990
Table. Patients in the study
Treatment Age at
Patient Sex Age (y) time (mo) insertion (y) Right/left/bilateral
1 F 13.2 13 14.3 Right
2 F 10.10 30 13.4 Bilateral
3 M 11.9 14 13.1 Right
4 M 13.3 18 14.9 Left
5 F 11.2 24 13.3 Left
F, Female; M, male.
dental implants, do osseointegrate. A vertically inserted
TAD may therefore prevent the surrounding bone from
following the vertical development related to the erup-
tion of the adjacent teeth. If, on the other hand, the
space opened for a later implant is left untouched, sig-
nificant decreases in both width and height of the alve-
olar ridge may occur while waiting for the dental
implant. Consequently, the necessity is high for a later
bone graft when the implant must be inserted.8,9
The aims of this article were to describe a method for
temporary fixed replacement that allows for the devel-
opment of the alveolar process and to report the changes
occurring clinically and radiographically over 5 years.
MATERIAL AND METHODS
Five patients (from 10 years 10 months to 13 years
3 months) with agenesis of maxillary lateral incisors
received 6 mini-implants that supported temporary re-
placements after orthodontic space opening (Table).
An Aarhus mini-implant (Medicon Instrumente, Tut-
tlingen, Germany) with a bracket-like head and a high
collar was inserted perpendicular to the alveolar process
palatally in the edentulous area, approximately corre-
sponding to the coronal medium third of the length of
the roots of the adjacent teeth.
The pontic was constructed at chair side on the day of
insertion of the mini-implant. A 0.021 3 0.025-in stain-
less steel wire section (American Orthodontics, Sheboy-
gan, Wis) was inserted into the slot of the
mini-implant, and a small loop was bent on the top of
the alveolar process. The wire was adapted with a dis-
tance from the mucosa of 0.5 to 1 mm, with no occlusal
interference and ligated with a tight metal ligature
(American Orthodontics).
The loop was configured so that it could generate
retention for the composite shaped as a crown. A metal
primer (Kuraray America, New York, NY) was applied to
the wire and dried for 2 to 3 seconds, and then a bonding
agent (Adper Scotchbond; 3M ESPE, St. Paul, Minn) was
added and light-cured for 40 seconds. The crown replac-
ing the missing tooth was formed by adding layer after
layer of composite (Filtek Supreme XT Universal
May 2017  Vol 151  Issue 5
Ciarlantini and Melsen
Restorative; 3M ESPE) around the extension of the
wire, polymerized for 20 seconds each time, starting
from the gingival side until the buildup of the lateral
incisor was accomplished.
To complete the gingival and lateral surfaces of the
pontic, the wire with the pontic was loosened from the
miniscrew. Then the pontic was refined with fine dia-
mond burs and silicon points and checked in the mouth
until both esthetics and function were acceptable. Once
the pontic was finished, the wire was ligated tightly to
the bracket-like head of the mini-implant, and the liga-
ture was covered with fluid composite (Filtek Supreme
XT Flowable Restorative; 3M ESPE) for comfort (Fig 1).
Finally, the patients were instructed about flossing daily
between the pontic and the mucosa.
As retention for the orthodontic tooth movement,
performed for the opening of the space for the missing
lateral incisor, the canine and the central incisor were
splinted with the adjacent teeth and not with the pontic
that remained separated from the retention.
The 5 patients in this study were monitored every
6 months for 5 years. The distance between pontic and
mucosa was increased by straightening the wire main-
taining the pontic. Intraoral and radiographic images
were taken immediately after insertion of the mini-
implant (Figs 2 and 3) and at the 2-, 3-, and 5-year
follow-ups (Figs 4 and 5).
RESULTS
The soft tissues adapted well to the pontic over the
years. No inflammation of the soft tissues around the
pontic was detected, most likely due to dental flossing
in this area. The intermittent pressure exerted to the cen-
tral part of the mucosa during function might have
contributed to the generation of papillae between the
pontic and the adjacent teeth.
Inflammation of soft tissues around mini-implants
occurred twice in 1 patient, but it was cured in a few
days by increasing oral hygiene and by daily chlorhexi-
dine mouth rinses.
No bone resorption around the mini-implants was
noticed; on the contrary, the vertical development of
the alveolar process followed the eruption of the adja-
cent teeth. The loading of the pontic during biting
generated a tipping moment to the screw that appeared
to be acceptable, since no mini-implants were lost. The
ligature wire broke twice in 1 patient and was replaced
with a larger wire. Discoloration of the pontic was noted
in 1 patient, most likely caused by strong colors in the
diet. Figure 4, C, shows that the composite in the central
area of the right pontic was replaced to eliminate the
discoloration.
American Journal of Orthodontics and Dentofacial Orthopedics
Ciarlantini and Melsen 991

Fig 1. Technique step by step: A, inserting the screw; B, bending the wire. Note that the wire must be
bent where it is inserted into the bracket head of the mini-implant because this bend reduces the forces
acting on the ligature; C and D, buildup of the pontic; E, polishing; F, ligating the sectional wire to the
screw.

Fig 2. Postorthodontic treatment intraoral photographs: A and B, patient 1; C and D, patient 2.

Gingival impingement can occur when the adjacent
teeth erupt more than the distance between the pontic
and the mucosa; this was seen at visits of 2 patients.
Moving the pontic more occlusally by straightening
the wire connecting the pontic with the mini-implant
alleviated this impingement. A small V-bend on the
wire when constructing the pontic allowed for the
adjustment without removal of the wire from the bracket
head of the mini-implant. Without a bend in the wire al-
lowing for adjustment, a new pontic may be necessary.
An example of gingival impingement is seen in
Figure 4, D, on the right side.
DISCUSSION
In patients with agenesis of maxillary incisors, 1 solu-
tion is to open space orthodontically for a later

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992 Ciarlantini and Melsen

Fig 3. Postorthodontic treatment intraoral radiographs: A, patient 1; B and C, patient 2, right and left
sides.

Fig 4. Intraoral images at 5-year follow-up: A and B, patient 1; C and D, patient 2.

replacement with an implant. However, the maintenance
of this space is not without problems, one being to allow
for the vertical development of the alveolar process when
the adjacent teeth are erupting, and another to maintain
the width necessary for the planned dental implant.
Several studies have demonstrated significant decreases
in the width and height of the alveolar ridge in patients
with congenitally missing maxillary lateral incisors who
had orthodontic treatment to create space for a dental
implant.8,9 In this clinical report, a method for a
semipermanent replacement of a missing maxillary
lateral incisor has been described. A TAD placed
parallel to the occlusal plane has been suggested. In
contrast to TADs placed perpendicular to the occlusal
plane, this position does not prevent the vertical
development of the alveolar process. The idea was
born when a TAD that had served as anchorage for
mesialization of a molar in a patient with agenesis of
all mandibular premolars was unintentionally left
behind on 1 side in the edentulous area corresponding
to the first premolar.10 An additional observation was
made in a patient with agenesis of both maxillary lateral
incisors, where a horizontally placed mini-implant had
served as anchorage only on 1 side. The hypothesis
was further supported by a dog experiment demon-
strating that a horizontally placed TAD could prevent
alveolar atrophy of an extraction space.10
The mini-implants inserted from the palatal side
serving as support for the pontics were not used as
anchorage for tooth movement but were loaded

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Ciarlantini and Melsen 993

Fig 5. Intraoral radiographs at the 5-year follow-up: A, patient 1; B and C, patient 2, right and left sides.

intermittently when the patient occluded on the pontic.

It is likely that the strain generated between the mini-
implant and the surrounding bone resulted in increased
bone turnover adjacent to the mini-implants. This hy-
pothesis was corroborated by the fact that in relation
to the bicortical TADs, the clinical examination
confirmed that the buccolingual width of the alveolar
process had been preserved during healing.
In 2 patients, 5-year evaluations were performed also
on CBCT images. The sections made through the pontic
area supported the clinical finding and indicated the best
results with bicortical screws (Fig 6). The CBCT images
facilitated the assessment of the buccolingual dimension
that determines the appropriate length, position, and
inclination of the screw. According to Hourfar et al,11
the first palatal ruga corresponds to 30% to 40% of
the root length of the central incisors; this reference
could be used to indicate the height where the TAD
should be inserted.
The use of TADS placed vertically as a basis for a tran-
sitional replacement of a lateral incisor was previously pro-
posed.12-15 The statement by Graham13 that “the insertion
of a mini-implant in the edentulous space conducts bone-
preserving forces during mastication” has however not
been supported by any evidence. Graham claimed that
“alveolar bone height could be preserved as TADs are
different from dental implants and do not osseointegrate.”
Osseointegration is defined as bone-to-implant contact, Fig 6. Cone-beam computed tomograms at the 5-year
but although the surface of TADs is smooth and not follow-up: A, patient 1; B, patient 2, left.
specially treated or coated, the bone-to-implant contact
has been described in several animal experiments. TADs
exhibit 60% to 80% bone-to-screw contact.16 The os- process. A clinical report published in the same year
seointegration will, as in the case of a dental implant, pre- demonstrated inhibition of alveolar growth.14 Wilmes
vent the vertical development of the alveolar process et al,18 on the other hand, stated that they rarely observed
related to growth; Kokich and Swift17 consequently alveolar growth inhibition, “probably because of the
warned against placing TADs on the top of the alveolar smaller dimensions of mini-implants compared to the

American Journal of Orthodontics and Dentofacial Orthopedics May 2017  Vol 151  Issue 5
994
dental implants.” Cope and McFadden12 supported the
same statement when they presented 2 cases in which
they found no infraocclusion at the follow-up observation.
However, in 1 case, in the follow-up x-rays, a minor lack of
vertical development of the bone in the area where the
screw was inserted can be noticed.
The discrepancy between those who observe arrested
vertical development and those who do not is explained
by the difference in growth pattern and the short obser-
vation period, since the rate of vertical development is
both small and variable.
Mini-implants with a small diameter may, on the
other hand, not be able to withstand occlusal forces,
and the risk of miniscrew fracture can increase or
decrease according to the diameter of the mini-
implants used. Ludwig19 reported recently on 2 patients
in whom there had been fracture of the mini-implants
inserted on the top of the alveolar process; because of
this complication, he suggested not to use mini-
implants inserted vertically.
CONCLUSIONS
A method for a semipermanent replacement of a
missing lateral incisor has been described, and mainte-
nance over 5 years has been demonstrated. A composite
pontic was placed on a stainless steel wire segment ex-
tending from a lingually placed TAD with a bracket-
like head (Aarhus mini-implant). The bicortically placed
TADs were able to preserve or even increase bone density
and morphology of the alveolar process, whereas the
maintenance of distance between the pontic and the
alveolar mucosa allowed for continuous vertical devel-
opment.
ACKNOWLEDGMENT
We thank Alberto Laino for collaboration in the treat-
ment of 1 patient.
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American Journal of Orthodontics and Dentofacial Orthopedics