Dental Traumatology. 2020;00:1–6. wileyonlinelibrary.com/journal/edt
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11 | INTRODUCTION
Tooth loss in the growing patient following trauma presents a clinical scenario that is difficult to manage.1 The age of the patient, the
pres-ence of deciduous and permanent teeth, and the incomplete bone growth are important variables that can affect the treatment plan.
In addition to these aspects, it is necessary to take into consid-eration the impact that treatments can have on patients' life qual-ity,2 the discomfort of some interventions both with respect to their
complexity in terms of time and the invasiveness of surgical inter-ventions.3 Until recently, there were three options in the literature to
restore the loss of one or more maxillary incisors following trauma: auto-transplantation, orthodontic space closure, and fixed or mobile prosthetic rehabilitation.4,5,6 The limits of these options, however,
are unfortunately many. The choice of treatment is also influenced by the occlusion and the condition of the adjacent teeth. The treat-ment plan should be as conservative as possible, esthetic, functional, and the most immediate.
It is documented that auto-transplantation of a premolar is the most conservative treatment and that it allows the preservation of bone and soft tissues until growth is completed.5 The
auto-trans-plantation should ideally be performed when the premolar root is at three quarters of its development and requires a complex
operator-dependent technique. After checking the healing of the auto-transplanted tooth, orthodontic treatment may be needed to fill the space created in the donor site and further coronoplasty treatment of the transplanted tooth is necessary to obtain accept-able esthetics. These factors may have unfavoraccept-able repercussions on the patient's quality of life.
An alternative treatment is to orthodontically close the space, but this option is not always feasible, and in the recent literature, there are still doubts regarding the redistribution of the spaces in the arches.7 This technique is related to the patient's age and
occlusion and in some cases will be contraindicated.8 This option
will also require the need to perform coronoplasty at the end of the orthodontic treatment followed by conservative or prosthetic treatments.
Both removable and fixed prosthetic options have significant limitations in the growing patient. In the first case, removable pros-theses are not well tolerated by teenagers who fear the possibility that the prosthesis could move or break. Even more complex is the use of a fixed prosthesis with dental support that requires the sig-nificant reduction in healthy teeth without the possibility of guaran-teeing ideal alveolar and gingival contours. In the mixed dentition, it is almost never indicated and frequently does not guarantee the presence of adequate teeth abutment.9
Received: 5 June 2020
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Revised: 5 August 2020|
Accepted: 5 August 2020 DOI: 10.1111/edt.12604C A S E R E P O R T
Rehabilitation of a patient with mini-implants after avulsion of
the upper incisors: A 13-year follow up
Luca Giannetti
1| Roberto Apponi
1| Alberto Murri Dello Diago
1| Francesco Mintrone
2© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1Department of Dentistry and Oral
Maxillofacial Surgery, University of Modena and Reggio Emilia, Modena, Italy
2Private practice in Sassuolo, Modena, Italy
Correspondence
Roberto Apponi, Department of Dentistry and Oral Maxillofacial Surgery, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41124 Modena, Italy.
Email: roberto.apponi@gmail.com
Abstract
Treatment following avulsion of a tooth in the growing patient requires a complex multidisciplinary therapeutic approach for the clinical team. The literature offers dif-ferent therapeutic solutions following the avulsion of one or more teeth, but unfortu-nately all of them have negative repercussions on the patients' life quality, they involve long treatment plans, they are not always feasible, and they have limits. Alternatively, a new treatment concept that uses mini-implants can be considered and is presented with its rationale, clinical steps and 13 years of follow up of one case.
K E Y W O R D S
One therapeutic option not discussed yet is implant-prosthetic re-habilitation. Historically, it has always been established in the literature that implants were not suitable in the growing patient for many reasons including the possibility that the implant could go into infra-occlusion compared to the physiologically erupted adjacent teeth.9 Prosthetic
management or orthodontic corrections were not considered possible. However, a recent literature review indicated that implant placement in the growing patient can be a valid therapeutic alternative.10
The PRICE guidelines have been followed for this Case Report.
2 | CASE REPORT
The patient is now 24 years old, but he originally presented at the age of 8. He was treated at the Dental Alveolar Trauma Center, which is part of Department of Dentistry and Oral Maxillofacial Surgery, University of Modena and Reggio Emilia, Italy. He had avulsed both of the upper permanent central incisors. Despite the unfavorable extraoral dry time of about 90 minutes, they were replanted. Two years later, due to a second sports injury, a vertical root fracture of the 11 was diagnosed. The tooth was extracted, and the site was subsequently rehabilitated by positioning an immediately loaded mini-implant. The case report was described and published with a 2-year follow up in 2010.11
In the following years, conventional clinical checks were carried out every 6 months. In this phase, it was preferred to wait before re-placing the temporary resin crown with a permanent crown focusing the attention on the jaw growth, the implant stability, and the soft tissue health. Three years later, by means of conventional prosthetic steps, the temporary crown of the 11 was replaced with a permanent ceramic crown (Figure 1).
The treatment continued with scheduled visits to monitor the physiological replacement of the deciduous teeth with the perma-nent teeth. However, radiographs revealed external replacement
resorption of tooth 21 without mobility and signs of periodontal defects.
Unfortunately in 2010, the patient suffered another sports acci-dent. On this occasion, tooth 21 underwent lateral luxation. It was immediately treated by a private dentist who stabilized it with a com-posite splint. Further radiographic and clinical investigation was con-ducted to define the diagnosis, and it was decided to extract the tooth. The patient and his parents were informed about the therapeutic alternatives and the risks related to each of them. According to the patient and his parents, it was decided to replace the tooth 21 by a immediate-loaded mini-implant in the post-extraction socket. The parents of the patient, who was a minor, signed the informed con-sent following the indications of the Helsinki Declaration.
Under local anesthesia, the residual root was extracted and a grade 5 titanium alloy fixture of 2.5 mm diameter and 13 mm length with sandblasted surface was placed. The implant was manually po-sitioned and then screwed using a dynamometric torque wrench. In the same session, a temporary crown was placed to stabilize the soft tissues and restore the 21. Twelve months after implant placement, the temporary resin crown was replaced with a permanent ceramic crown by means of conventional prosthetic steps (Figure 2).
From 2011 to 2013, the patient underwent functional ortho-dontic treatment using Sn2 to promote correct mandibular growth (Figure 3). Following the conventional monthly checks and adjust-ments, the orthodontic discrepancy between the dental arches was corrected. As the patient continued his sporting activity, he was asked to wear a mouthguard to protect the teeth from further trauma.
In 2015, it was necessary to correct the mandibular incisor crowding by performing orthodontic treatment with removable aligners (Figure 4). No further prosthetic treatment of the implant abutments 11 and 21 was indicated at that time.
Eleven years after the first implant placement, the first pros-thetic crowns were replaced with new crowns to better adapt to the gingival contour. In addition, the prosthetic crowns were periodically
F I G U R E 1 A, Front view 3 y after
implant placement in position of the #11 with the permanent ceramic crown. B, Front view of the implant abutment in position of the #11 without ceramic crown. C, Side view of the permanent ceramic crown in place. D, Radiograph of the mini-implant placed in position of the #11. External replacement resorption of tooth #21 is evident
(A) (B)
modified in order to adapt to the gingival contour and to ensure es-thetic improvement (Figure 5). A new mouthguard to be worn during sports was provided.
After 13 years of follow up, an orthopantomography and a max-illary CT scan were performed. These revealed osseointegration of both implants with the maintenance of bone volumes. Labial bone resorption was evident adjacent to the implant for the 21. Clinically, the occlusion and the implants were stable although some tissue lev-eling was evident (Figure 6).
The following options were discussed with the patient as alterna-tives if the implants were removed:
1. Connective tissue graft to develop the pontic zone and sub-sequent a lithium disilicate Maryland with palatal supports on 12 or 22;
2. Connective tissue graft followed by an all-ceramic prosthetic bridge between 12 and 22;
3. Prosthetic implant rehabilitation with conventional implants placement, contextual bone regeneration, and soft tissue grafting to optimize the gingival contour improving the esthetic.
4. After discussing the different therapeutic options, the patient preferred to postpone any further treatment.
3 | DISCUSSION
It is known that following avulsion of a tooth, the clinician must care-fully evaluate many parameters12 before finalizing the treatment
plan. The assessments must include functional and esthetic aspects, and they must consider the patient's expectations.
F I G U R E 2 A, In 2010, the patient
suffered another sports accident. Tooth #21 was laterally luxated. It was urgently treated by a private dentist who stabilized it with a composite splint. B, The socket after the extraction of tooth #21. C, Tooth #21 was replaced with an immediate-loaded mini-implant. D, Provisional resin crown on the implant in the position of the #21 (A) (C) (B) (D) F I G U R E 3 A-C, From 2011 to 2013,
the patient underwent functional orthodontic treatment to promote correct mandibular growth. Right side, left side, and bottom view during the treatment. D, Radiograph at 6 y after implant placement in the position of tooth #11 and 3 y after implant placement in the position of tooth #21
(A)
(C)
(B)
Different treatment options are described in the literature, which are feasible under certain conditions or which require long treatment times with negative repercussions on the quality of life of young patients.
The literature describes two principal treatment options to re-solve this problem.13
The first is maintenance of the space followed by auto-transplan-tation or prosthetic replacement of the missing teeth. The second option consists of orthodontic space closure followed by prostho-dontic treatment of the teeth to simulate the missing tooth.
Tooth auto-transplantation14,15 preserves the dentition using a
natural tooth rather than a mechanical prosthesis, and it is useful in many aspects. It is a procedure in which teeth have the potential capacity to induce alveolar bone growth and can be applied in pa-tients before puberty growth is complete. Immature teeth with an
open apex are the best teeth to be transplanted. Another import-ant aspect is that the transplimport-anted tooth allows a normal interdental papilla to develop and a correct emergence profile, both of which are fundamental aspects for esthetics. Further orthodontic correction can be made later if necessary.
The second treatment option is orthodontic space closure which limits the prosthodontic treatment to the insertion of a laminate ve-neer with conservative reduction in enamel or to direct reshaping with composite resin. This approach needs assessment of the space for the final restoration.
Both of these options are based on different major factors: age of the patient, type of occlusion, space conditions, and the crown and root shape.
In cases where it is not possible to perform either of these two treatments, an alternative involves the use of implants.
F I G U R E 4 A and B, In 2015, it was
necessary to correct the mandibular incisor crowding by performing orthodontic treatment with removable aligners. Upper and lower occlusal situation before dental alignment treatment. C and D, Upper and lower occlusal view of the teeth after the dental alignment treatment. At the end of the alignment, the patient was 16 y old (A) (C) (B) (D) F I G U R E 5 A, In 2018, 11 y after the
first implant placement, the prosthetic crowns were replaced with new resin crowns to better adapt to the gingival contour. B, The prosthetic crowns were periodically modified in order to adapt to the gingival contour and to ensure esthetic improvement. C, The low smile-line guaranteed an excellent esthetic result. D, Occlusal view of the implant abutments without the prosthetic crowns
(A)
(C)
(B)
Osseointegrated implants are an alternative when replacing a lost tooth, despite some technical difficulties. The prognosis is sup-ported by scientific evidence (more than 95% implant survival at 10 years16 compared with a transplant success rate of over 90% at
17-41 years in long-term studies).17
The use of dental implants in the growing patient has been widely evaluated, but studies have considered almost exclusively the use of conventional diameter implants. From these studies, it emerges that the only problem is infra-occlusion which creates difficult prosthetic management in the adult patient.18 This led to their use being
con-traindicated in growing patients.
A recent analysis of the literature shows that many authors have evaluated the possibility of using mini-implants in growing patients following avulsion.12,19,20 A 2019 review concluded that there is not
enough evidence to contraindicate the use of implants in the grow-ing patient and the only adverse event described is infra-occlusion.19
Another review outlined how similar advantages and disadvantages exist between the use of implants and the orthodontic closure of spaces when teeth are missing.21
A correct treatment plan should reduce the discomfort caused by tooth loss, resolve the loss suffered as quickly as possible, and ensure easy case management in the following years.22 The rationale
for the use of mini-implants could be to use them as a temporary support and then replace them, if necessary, with conventional di-ameter implants at the end of bone growth. It is interesting to eval-uate the definitive resolution in adulthood. It is necessary to define whether the use of mini-implants in the initial phase can lead to a more difficult resolution of the case or if the condition when re-moving the mini-implants is similar to that of using other temporary solutions such as removable partial prostheses or Maryland bridges. The tooth replacement in a few sessions through a fixed prosthe-sis represents a significant advantage for both the clinician and the growing patient.
Infra-occlusion, the only negative sequence, will be a conse-quence known to the clinician who will evaluate how to resolve it at the time of definitive rehabilitation in adulthood.
At this point, the treatment options will be many. It will be possible to produce new prosthetic crowns or remove implants and plan a new fixed rehabilitation on implants or on natural teeth.23,24
The result of this clinical case indicates that the use of mini-im-plants following tooth avulsion in the growing patient can be a viable and manageable therapeutic option over time. The use of protection systems during sports is strongly encouraged.25
4 | CONCLUSION
The loss of one or more teeth in the esthetic area is perceived by patients as a serious esthetic compromise and represents a difficult challenge for the clinician.
The use of mini-implants in growing patients as a temporary and definitive treatment option is very promising. This technique ex-ploits the advantages of conventional diameter implants and those of reduced diameter implants both during the positioning phases of the fixtures and during the prosthetic phases.
A fixed rehabilitation compared to a mobile one or a short thera-peutic course determines an obvious psychosocial benefit especially during the complex adolescent age.
The crestal bone atrophy resulting from the loss of teeth and the use of other temporary rehabilitation options during growth and development does not provide a more favorable framework for the definitive rehabilitation in adulthood.
Therefore, the possibility of carrying out post-traumatic reha-bilitation using mini-implants and cemented prosthetic crowns be-comes an interesting alternative for the growing patient.
F I G U R E 6 A, Frontal view of the
resin crowns modified to adapt to the gingival contour. B, Palatal view of the resin crowns on implant placed in the positions of the #11 and the #21. C, Orthopantomography in 2020, at 13 y after mini-implant placement in the position of the #11 and 10 y after mini-implant placement in the position of the #21. D, CT imaging in 2020, when the patient was 21 y old
(A) (B)
There is a need for randomized clinical trials to be able to confirm this technique even if no adverse effects on the other surrounding teeth are reported in the literature.
CONFLIC T OF INTEREST
The authors confirm that they have no conflict of interest.
ORCID
Roberto Apponi https://orcid.org/0000-0001-7039-3506
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How to cite this article: Giannetti L, Apponi R, Murri Dello
Diago A, Mintrone F. Rehabilitation of a patient with mini-implants after avulsion of the upper incisors: A 13-year follow up. Dent Traumatol. 2020;00:1–6. https://doi. org/10.1111/edt.12604
