An Interim Replacement for Missing Teeth in Children with Temporary Anchorage Device: A Lesser Showcased Aspect
1-6Department of Paediatric, Postgraduate Institute of Dental Sciences, Rohtak, Haryana, India
Corresponding Author: Ruchi Singhal, Department of Paediatric, Postgraduate Institute of Dental Sciences, Rohtak, Haryana, India, Phone: +91 8053452451, e-mail: firstname.lastname@example.org
Received on: 26 April 2022; Accepted on: 29 July 2022; Published on: 26 December 2022
In this modern age, where the appearance and outlook of an individual play such an important role, missing anterior teeth can be very traumatic to the younger generation, both physically and psychologically. Now with the introduction of a temporary anchorage device (TAD), an interim replacement for these teeth without hampering the adjacent teeth or giving the young patient an unpleasant feeling of wearing fake teeth is possible until the growth is completed. Not much data is available in the literature regarding its use; hence, the aim of this case series is to report the cases where orthodontic TADs were successfully used for interim prosthetic rehabilitation in children suffering from partial edentulism due to the avulsion of young permanent teeth. The results obtained showed great success with healthy gingiva, as well as bone around the miniscrew, and there was no loosening or breakage of the miniscrew or the crown during the period of 1-year follow-up.
How to cite this article: Negi S, Singhal R, Namdev R, et al. An Interim Replacement for Missing Teeth in Children with Temporary Anchorage Device: A Lesser Showcased Aspect. J South Asian Assoc Pediatr Dent 2022;5(3):170-175.
Source of support: Nil
Conflict of interest: None
Keywords: Avulsion, Interim replacement, Prosthetic rehabilitation, Temporary anchorage device
A smile has great social value. Not only does it affect others’ perceptions, but also one’s own self-esteem. Loss of anterior teeth at a young age can inflict psychological as well as physical distress on the patient affecting their self-esteem, esthetics, function, speech as well as the development of oral habits.1 Many factors, such as genetics, trauma, or dental caries, can lead to hypodontia in children. Avulsion represents 1–16% of all dental trauma.2 The space created due to the loss of a tooth can either be closed with orthodontic treatment or maintained till the time patient complete their growing stage, depending upon the individual requirements of the patients. The interim prosthetic rehabilitation can either be done by fixed treatment with bonded bridges with or without the preparation of adjacent teeth or removable partial dentures.3 All these treatment options can lead to disuse atrophy of the alveolar bone, which in the future requires bone and soft tissue grafting if a definitive implant and restoration are desired.4
Implants have gained marvelous popularity in recent times for the prosthetic rehabilitation of missing teeth in adults.5 However, its use in growing patients is not much encouraged because studies have suggested that such implants can act as ankylosed teeth. Moreover, the osseointegrated implants fail to adapt to the sagittal, transverse as well as vertical growth of the maxilla leading to their infraocclusion.2 TAD or miniscrews, which were developed for the purpose of proving anchorage for orthodontic movement, have recently been suggested as a temporary replacement for missing teeth.3 It overcomes the drawback of the conventional implants as several studies have reported that mini-implant osseointegrates less than half of what is expected with the conventional implants, and due to its smaller size, it can be easily removed from the bone after completion of the treatment without further hampering the bone.1,6 According to Reddy et al., because of their smooth and polished surfaces, they can be removed easily without anesthesia7. The miniscrew helps to prevent the disuse atrophy of the alveolar ridge as it stimulates the bone and is an economical treatment modality.6
Prosthetic rehabilitation with miniscrew also provides a psychological benefit to the child as it feels like their own teeth, for they do not have to wear a prosthesis all the time only to remove it prior to eating.8 Its smaller diameter allows it to be placed even in the region with transverse loss of alveolar bone.6 The data obtained from the literature regarding the placement of these screws in growing patients for prosthetic rehabilitation is limited; therefore, the aim of this case report was to further add to the literature the benefits of TAD as an interim replacement for missing teeth in children.
A 13-year-old female patient reported to the department with a complaint of an unesthetic appearance due to missing central incisors (Fig. 1A). Patient gave a history of trauma 2 years back that led to the avulsion of both teeth. According to the patient, both teeth were reimplanted at a private dental clinic but did not respond well to the treatment and were later on extracted. On clinical examination, the edentulous ridge had adequate bone height and width with firm overlying mucosa. As the patient was still in the growing phase, so interim prosthetic rehabilitation with TAD was planned. But some space loss was evident, and the space was not adequate enough to receive two pontics over the miniscrews, so the space was gained orthodontically using an open coil spring (Fig. 1B). Preoperatively (pre-op), the edentulous space between the right and the left lateral incisors measured approximately 12 mm. After giving the open coil spring, the space was increased up to 18 mm, giving a net gain of 6 mm before the placement of TAD. Before planning the surgery, the bone width was measured using cone beam computed tomography (CBCT). Two self-drilling TAD miniscrews made up of titanium grade 5 (SK Surgicals, Pune, Maharashtra, India), both measuring 1.5 × 12 mm, were selected. Local anesthesia was administered, a small incision was given over the alveolar ridge, and the flap was raised. Two small ditches, approximately 0.5 mm in depth, were made at the center of the ridge Bucco-palatally with a round bur attached to a slow-speed micromotor. The miniscrews were then driven vertically perpendicular to the bone one by one in occlusogingival position endosteally using a manual hand screwdriver. The head of the miniscrew was kept outside the gingiva, and the flap was sutured back in position. Good stability and retention were achieved after the insertion of the miniscrew postoperatively (post-op). The patient was then recalled after 1 week for suture removal (Fig. 1C).
After a period of 15 days, when gingival healing was complete, an alginate impression was taken of the complete arch along with the screw heads in the edentulous space. The cast was obtained and sent to the lab for porcelain fused to metal (PFM) crown fabrication directly over the screw head. The crowns were then luted over the miniscrew head with the help of luting glass ionomer cement (GC Fuji Gold Label Type 1 Luting Cement) (Fig. 1D). Patient, as well as her parents, were instructed regarding oral hygiene maintenance, including flossing around the implants especially. The patient was also instructed to avoid biting on food items with hard consistency directly from the TAD-supported crowns. The patient was kept on regular follow-ups. No inflammation of the gingiva or mobility of the crown was observed on follow-up visits.
Radiographically no bone resorption was noticed around the TADs (Fig. 1E). Patient, as well as her parents, were highly satisfied with the results both esthetically as well as in terms of psychological well-being as the rehabilitation removed social awkwardness that prevented her from smiling in public and these implants felt like her own teeth. Phonetics was also improved after the rehabilitation.
A 14-year-old male patient reported to the department with a history of trauma and avulsion of a central incisor in the right maxillary quadrant 9 months back (Fig. 2A). The tooth was lost at the site of the accident. The parents complained about the lack of social confidence in the child due to his missing tooth and hesitated to smile in public. Prosthetic rehabilitation with TAD was planned for this patient. On clinical examination, a slight overgrowth of gingiva over the ridge was noticed. CBCT was done to measure the adequacy of the bone. The parents were informed about the procedure and its merits and demerits. Depending upon the dimensions of the bone, a self-drilling TAD miniscrew of dimension 1.5 × 12 mm was selected (Fig. 2B). Prosthetic rehabilitation was followed as mentioned in the previous case (Fig. 2C). Due to the presence of slight growth of the gingiva over the ridge, gingivectomy was performed during the surgery to esthetically recontour the shape of the gingiva. Post-op instructions were given to the patient as well as his parents.
The patient reported inflammation of the gingiva around the implant at 3 months follow-up because of lack of oral hygiene maintenance. The patient was motivated, and oral hygiene instructions were reinforced. The patient did not complain about any such symptoms in the subsequent visits.
Several treatment modalities are available for the rehabilitation of patients with missing teeth, such as orthodontic closure of the space, implants, prosthetic rehabilitation, and autotransplantation.9 However, the selection of the most appropriate treatment option for an individual depends upon several factors, such as the age of the patient, patient compliance, occlusion, adequacy of the alveolar bone, amount of the edentulous space, systemic condition of the patient as well as the cost factor.
A TAD is basically meant for the purpose of providing zero anchorage loss in the field of orthodontics, but for its properties of “no or minimum” osseointegration, it can be used as a miniscrew that can be inserted into the edentulous region and provide an interim prosthetic rehabilitation till the child attains age to receive a conventional implant. These miniscrews differ from conventional implants in various ways. The size of conventional dental implants is 6–15 mm long and 3–5 mm in diameter, whereas TAD is smaller in size, with lengths varying from 6 to 12 mm and widths of 1.2–2 mm. Standard dental implants come in parts that have to be placed subsequently into the bone, whereas miniscrew or TAD comes as a single screw. Insertion of TAD is way simpler, less time-consuming, and well-accepted by children, and it is way more affordable than conventional implants. The success of a conventional implant depends upon its ability to osseointegrates or fix to the bone, but in these devices, there is no such property seen, and its stability in the bone results from the mechanical interlocking, which is determined by the amount of contact of bone to the screw and length of the screw. The strength of miniscrews or these anchorage devices is lesser as compared to standard implants. Thus, it can only provide a temporary esthetic benefit, act as a space maintainer, and also maintains the level of alveolar bone and soft tissue as it stimulates the bone and prevents bone atrophy until the child is ready for permanent rehabilitation.
The use of implants in children and adolescents is a controversial topic. Some authors advocate its usage, whereas others contradict it. According to a systematic review done on the adverse effect of implants in children, six out of 11 studies reported infraocclusion within a follow-up period of 1–13 years.5 Both patients in the present case series were still in their growing period; therefore, a conventional implant could have resulted in infraocclusion because of osseointegration. However, few studies do claim that some osseointegration occurs with TAD miniscrew also, but this should be weighed against the consequences of a decrease in the height and width of the alveolar ridge if the space is left untouched while waiting for a conventional implant to be inserted later on.3,7 According to Giannetti et al., fibro integration is seen with the mini-implants when it is subjected to immediate load.2
For the longevity of the TAD miniscrew, primary stability is very important, which basically refers to the degree of mechanical interlocking following its insertion.6 The implant must acquire the primary stability to withstand the mechanical forces. The capability of the miniscrew to bear the mechanical load is proportional to the total implant-bone interface, which is determined by the physical properties of the miniscrew, such as its length, diameter, shape, and surface design (rough or smooth) of the implant. Singh et al. stated that miniscrew length was one of the factors affecting successful placement.11 Keeping it in mind, 12 mm long miniscrews were inserted in both patients, which resulted in the clinical success of the treatment as no unfortunate loosing of the screw was encountered in the follow-ups.
The direction of insertion of the miniscrew also has its take on the success of the treatment. The miniscrews were inserted directly on the alveolar ridge in occlusogingival direction perpendicular to the ridge at a site of good bone density, which might have contributed to the treatment’s success. The same direction of insertion was adopted by previous studies, where success was also achieved with no infraocclusion at the follow-up observations.1 However, in the literature, TAD was also placed parallel to the occlusal plane, and studies claimed that a perpendicular position prevents the vertical development of the alveolar process and one study reported the fracture of the mini-implant placed directly on the alveolar process.3
Space was gained orthodontically in the first case, which resulted in better esthetics as well as the success of the treatment, as studies have shown that the distance between the implant and the adjacent teeth affects the bone around the implant. The greater the distance, the lesser will be the bone loss around the implant.5 One patient reported inflammation of the gingiva around the implant after 3 months of TAD placement which was mainly because of a lack of oral hygiene maintenance. Plaque accumulation near the gingival margin can lead to inflammation of the gingiva, and prolonged inflammation can further lead to the breakdown of bone around the implant and, consequently, implant failure.11 Apart from this, no other drawback of the TAD miniscrew placement was observed in the 1-year follow-up of both cases (Fig. 3).
Despite its promising benefits, it must be kept in mind that TAD is a transitional or interim type of rehabilitation, and its success is based majorly on mechanical retention and not osseointegration. As the patient completes his/her growth or reaches 18 years of age, it must be replaced with some other permanent intervention. Other limitations of TAD can be loosening or breakage of the miniscrew under the occlusal forces, periimplantitis, and bone resorption around the miniscrew. However, more prospective studies with large sample sizes and longer follow-ups should be conducted so that the benefits, as well as long-term drawbacks of TAD used for prosthetic rehabilitation in growing patients, can be well documented.
The vast horizon of benefits it provides, including esthetics, function, and patient satisfaction with a simple and cost-effective procedure, is good enough to encourage its use as an interim option for prosthetic rehabilitation in children. Despite the limitation of conventional implants in pediatric dentistry, TAD miniscrew has opened up the doors to more or less similar benefits of the implant to children as a better option for the management of partial edentulism due to any unfortunate cause.
Shefali Negi https://orcid.org/0000-0003-0891-0829
Ruchi Singhal https://orcid.org/0000-0002-5514-2482
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