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USING IMPLANTS FOR GROWING PATIENTS
Arun Sharma and Karin VargervikJ Calif Dent Assoc 2006; 34; 719-724
AAMIR ZAHID GODILFIRST YEAR P.G.
DEPARTMENT OF PROSTHODONTICSM.A.R.D.C.
OUTLINE• INTRODUCTION• GROWTH CONSIDERATIONS
– GROWTH OF MAXILLA– GROWTH OF MANDIBLE– CONCERNS
• EXPERIENCES OF TREATMENT WITH DENTAL IMPLANTS IN YOUNG INDIVIDUALS: CASE REPORTS– BACKGROUND– CASES– TREATMENT SUBSTITUTES– ADVOCATED AGES FOR IMPLANT PLACEMENT
• RECOMMENDED PROTOCOL– OPTIONS– GROUP 1: CHILDREN MISSING A SINGLE PERMANENT TOOTH WITH ADJACENT PERMANENT TEETH– GROUP 2: CHILDREN MISSING MORE THAN A FEW TEETH BUT HAVE PERMANENT TEETH PRESENT
ADJACENT TO THE EDENTULOUS SITE – GROUP 3: CHILDREN WITH COMPLETELY EDENTULOUS ARCH
• CONCLUSION AND CRITIQUE
INTRODUCTION• ‘Hypodontia’ is defined as the congenital missing of <6
permanent teeth, excluding third molars
• ‘Oligodontia’ as the congenital missing of six or more permanent teeth, excluding third molars
• ‘Anodontia’ as the congenital missing of all deciduous and ⁄ or permanent teeth
• In the oral habilitation of children with missing teeth a golden principle is to strive for establishing a good situation from an aesthetic as well as a functional and psycho-social viewpoint with minimal replacement of the missing teeth by prosthetic treatment
GROWTH CONSIDERATIONS
GROWTH OF MAXILLA
Growth of the maxilla is characterized by remodeling in a postero-superior direction while simultaneously being displaced in the
opposite antero-inferior direction
GROWTH OF MANDIBLE
Growth of the mandible is characterized by displacement away from its articulation in the glenoid fossae as the condyles and
rami relocate in a posterosuperior direction
Natural tooth movement occurs as a result of eruption and of being carried along passively with the maxilla and mandible, both of which undergo displacement antero-inferiorly during
craniofacial morphogenesis
Transverse development of the maxilla. (A) Growth at the midpalatal suture is greater posteriorly than anteriorly.
(B) Remodeling allows the dentition to drift horizontally. A dental implant (red circle) will become displaced palatally (in addition to becoming
submerged) in remodeling regions of the alveolar process
Transverse development of the mandible.A) Intercanine growth is minimal and ceases early.
B) Mandibular growth is characterized by an opening hinge movement of its two halves around an axis passing anteroposteriorly through the symphysis.
CONCERNSETIOLOGICAL CONCERNS
• Genetic disorders such as Ectodermal Dysplasia or Down syndrome
• Hypodontia can also been seen in people with cleft lip and palate
• Hormonal defects: Idiopathic Hypoparathyroidism and Pseudohypoparathyroidism
• Environmental causes involving exposure to radiation, anticancer, chemotherapeutic agents, allergy and toxic epidermal necrolysis after drug
• Infectious causes of hypodontia: rubella, candida
• Trauma: accident or sports injury
TREATMENT CONCERNS• Implants inserted into
pediatric patients do not follow the regular growth process of the craniofacial skeleton and are known to behave similar to ankylosed teeth, resulting in both functional and esthetic disadvantages
(OpHeji et al. 2003)
• Additionally, they can interfere with the position and the eruption of adjacent tooth germs, thus resulting in potential severe trauma of the patient
(Rossi & Andreasen2003)
EXPERIENCES OF TREATMENT WITH DENTAL IMPLANTS IN YOUNG INDIVIDUALS: CASE
REPORTS
BACKGROUND• Bjork (1963, 1997):Implanted pins in the jaws of children for longitudinal cephalometric studies and
reported that those in the path of erupting teeth were displaced and those placed in resorptive areas were lost. Pins placed in areas of appositional bone growth became embedded.
• Oesterle (1993): Compared dental implants to ankylosed primary teeth. They wrote that ankylosis
arrests both dental eruption and alveolar bone formation in the affected area..
The authors proposed that implants placed in the posterior maxilla in children might become buried to the point that the apical portion may become exposed as the nasal and antral floor remodel.
They also warned the possibility of loss of implants in the anterior maxilla because of resorption in the infradental fossa and nasal floor.
• Lederman et al (1993):In their 7 year follow up with a mean length of 35.5 months, reported a 90%
success rate on 42 endosseous dental implants placed in 34 patients aged 9 to 18 years.
There was a positive soft and osseous tissue reaction to the implants, and most of the failures occurred because of subsequent traumatic injuries sustained during the healing phase after implant placement.
The major complication reported was the failure of dental implants to respond to the vertical growth of adjacent teeth and alveolus due to ankylosis.
• Brugnolo et al (1996):Noted the infraocclussion of implants placed in patients aged 13 to 14.5 years,
secondary to vertical growth, and prosthesis was redesigned. Anteroposterior and transverse growth seemed not to negatively influence the implants position.
• Smith et al (1993):Implant use in children with ectodermal dysplasia is a treatment of choice, since
its placement in the mandibular anterior region of a 5 year old patient did not affect adjacent tooth buds. Prosthesis remodeling was performed due to implant submergence.
• Guckes et al (1997):Described a case of 3-year-old patient with ectodermal dysplasia in which
dental implants located in the mandible and maxilla have not moved despite growth. During the 5-year follow up, the prosthesis was remodeled to accommodate eruption of the maxillary teeth and facial growth.
• Kearns et al (1999):No evidence of restriction to transverse and sagittal growth due to
implant use in children with ectodermal dysplasia. Prosthesis remodeling was necessary in some patients secondary to implant submergence.
• The youngest child reported was a French boy who had implants placed at the age of 1.5 years
Bonin B, Saffarzadeh A, Picard A, Levy P, Romieux G, Goga D.Early implant treatment of a child with anhidrotic
ectodermal dysplasia. Apropos of a case. Rev Stomatol Chir Maxillofac.2001;102:313–318
• The first published case of placing implants in a boy with hypohidrotic ED and anodontia of the mandible was treated at the Institute in Jo¨nko¨ ping and has been followed for more than 20 years.
• The inter-implant distance has not changed and an overdenture served well until the patient was 19 years old, when two additional implants were placed and the patient was provided with a mandibular fixed implant-supported prosthesis.
Guckes AD, Scurria MS, King TS, McCarthy GR, Brahim JS. Prospective clinical trial of dental
implants in persons with ectodermal dysplasia. J Prosthet Dent. 2002;88:21–25
• Since there is more vertical growth in the posterior regions of the maxilla and mandible during childhood and adolescence, implants placed distal to the canines present more complications.
Bryant SR. The effects of age, jaw site, and bone condition on oral implant outcomes. Int J Prosthodont. 1998;11:470–490.
Enzo Rossi and Jens O. AndreasenMaxillary Bone Growth and Implant Positioning in a Young Patient: A Case Report
The International Journal of Periodontics & Restorative Dentistry Volume 23, Number 2, 2003; 113-119
Panoramic radiograph showing the lost maxillary left central incisor
A 10-year-old Caucasian male lost his maxillary
left central incisor as a result
of a bicycle accident
Surface of the implant at the time of post cementation
Result after 3 years (13 years old), 3-mm incisal discrepancy relative to the adjacent teeth because
of maxillary vertical growth and eruption of the natural teeth.
New crown is again fabricated to create an
even incisal line.
Nine years after implantation (age 19), there is an additional change of 2
mm.Age 21. Now there is a 3-mm
distance.
At age 25, 15 years after implantation, there is a 5-mm
discrepancy
Implant-supported crowns at sites 1.1 and 2.1 in a 23-year-old female demonstrate submergence secondary to residual dentoalveolar growth. The implants were placed at age 16 following avulsion of the
natural teeth
Carmichael RP, Sandor GKB, Habil. Dental Implants, Growth of the Jaws, and Determination of Skeletal Maturity. Atlas Oral Maxillofacial Surg Clin N Am 16 (2008) 1–9
Mutilation of maxillary occlusion in a 21-year-old female caused by
residual dentoalveolar growth subsequent to placement of a dental implant to replace a congenitally missing maxillary left second premolar at age 15.
The implant had been placed to provide
orthodontic anchorage.
Apparent fenestration of buccal bone and exposure of metal collar are related to surgical placement.
Carmichael RP, Sandor GKB, Habil. Dental Implants, Growth of the Jaws, and Determination of Skeletal Maturity. Atlas Oral Maxillofacial Surg Clin N Am 16 (2008) 1–9
Mandibular growth has led to a separation of the jaws posteriorly and has advanced the mandible into an edge-to-edge incisal relationship.
However, no separation of the proximal surfaces of the right and left sides of the bridge (arrows) is visible,
suggesting no transverse growth across the symphysis has occurred. (A) Facial view. (B) Frontal view of teeth
An 11-year-old boy with hypohidrotic ectodermal dysplasia in whom a two-piece bridge, split at the mandibular midline, on four anterior mandibular implants, had been constructed at age 8
Carmichael RP, Sandor GKB, Habil. Dental Implants, Growth of the Jaws, and Determination of Skeletal Maturity. Atlas Oral Maxillofacial Surg Clin N Am 16 (2008) 1–9
21-year-old male who had been lost to follow-up since implants replacing all his molars had been placed at age 15. In the meantime, he had developed a bilateral posterior open bite following from mandibular growth in the
absence of any posterior dental compensation. (A) Right side view. Note large exophytic, ovoid-shaped, firm, smooth-surfaced, maroon-colored lesion that was found to
be a peripheral giant cell granuloma associated with the dental implant at site 4.6. (B) Left lateral view.
(C) Frontal view. Note splaying of anterior teeth as a result of absent molar support.
Carmichael RP, Sandor GKB, Habil. Dental
Implants, Growth of the Jaws, and Determination
of Skeletal Maturity. Atlas Oral Maxillofacial Surg
Clin N Am 16 (2008) 1–9
Iseri H and Solow B
• No development in the alveolar bone after integration of the implant with bone in a growing alveoli
• But the neighboring tissues continued their 3-dimensional growth
• Therefore artificial teeth upon the osseointegrated implant remained in lower positions in occlusion due to continued eruption of the neighboring teeth
• Recommendation: no implant therapy in either anterior or posterior alveolar segment if there is no intention of modifying the prosthesis
Iseri H, Solow B. Continued eruption of maxillary incisors and first molars in girls from 9 to 25 years, studied by the
implant method. Eur J Orthod. 1996;18:245–256
• Emphasized that the implants did not affect the development of the neighboring tissues.
Iseri H, Solow B. Average surface remodeling of the maxillary base and the orbital floor in female subjects from 8 to 25 years. An implant study. Am J Orthod Dentofacial Orthop.
1995;107:48–57.
• Measured the width between the implants at both sides using posteroanterior radiography and determined a statistically insignificant but important increase.
Iseri H, Solow B. Change in the width of the mandibular body from 6 to 23 years of age: An implant study. Eur J Orthod.
2000;22:229–238.
• Johnston et al advocated the application of short fixed partial dentures to the young patients after the closure of the permanent teeth, even if they have no temporary teeth congenitally
• They stated that the patients should be subjected to routine controls in 3-month periods for accurate balancing of the fixed partial dentures, and monitoring and correction of the occlusion because of the rapidly changing relations in jaws
Johnston JF, Phillips RW, Dykema RW. In: Modern Practice in Crown and Bridge Prosthodontics. Philadelphia, PA:Saunders; 1980:3–
19
• Croll followed the patients with crown restorations for 8 years and observed that the treated molars continued to erupt, and the crown margins came to a supragingival position by that time
• That is why he described stainless steel crowns as intermediate restorations. He asserted that the patients could be treated with noble metal restoration after the termination of the major effect of the physical growth
Croll TP. Restorative dentistry for preschool children. Dent Clin North Am. 1995;39:737–770.
TREATMENT SUBSTITUTES
• Tylman found the application of fixed prostheses to children and youth as being contraindicative due to the fact that the teeth were not fully erupted, and the pulps are very large, which may cause various complications.
• He stated that the age of the application of prosthesis is 17 years.
Tylman SD. In: Theory and Practice of Crown and Fixed Partial Prosthodontics (Bridge). 6th ed. Saint Louis, MO: Mosby;1970:13–51
• Lederman et al stated that the earliest time when the implants could be used was 11 years of age for the girls and 13 years of age for the boys.
Lederman P, Hassell T, Hefti A. Osseointegrated dental implants as alternative therapy to bridge construction or orthodontics in young patients. Seven years of clinical experience. Pediatr Dent. 1993;15:327–333
ADVOCATED AGES FOR IMPLANT PLACEMENT
Placement of dental implants can not be recommended before the age of 6 years, since it is well established that children can and should take part in decisions on elective surgery from the age of around 5 years
Bradbury ET, Kay SP, Tighe C, Hewison J. Decision-making by parents and children in paediatric hand
surgery. Br J Plast Surg. 1994;47:324–330
• At the Consensus Conference ‘Oral Implants in Young Patients’ it was agreed in a consensus statement that implants should not be placed until growth and skeletal development is completed or nearly completed
Bergendal B, Koch G, Kurol J, Wa¨nndahl G, eds. Consensus Conference on Ectodermal Dysplasia with special
reference to dental treatment. Stockholm, Sweden: Fo¨ rlagshuset Gothia AB; 1998.
• This was illustrated in a figure based on the curve of growth velocity from infant to adult where the colours allude to a traffic light
• Anodontia and severe oligodontia were mentioned as exceptions to this rule
Bergendal B, Olgart K. Congenitally missing teeth. In: Koch G, Bergendal T, Kvint S, Johansson UB, eds. Consensus
Conference on Oral Implants in Young Patients. Stockholm, Sweden: Fo¨ rlagshuset Gothia AB; 1996:16–27.
RECOMMENDED PROTOCOL
OPTIONSCONVENTION
ALDENTURES
FIXED PROSTHESES
CAST PARTIAL DENTURES
SPACE MAINTAINERS
/ KIDDY DENTURES
IMPLANTS WAIT
Maroulakos G, Artopoulou II, Angelopoulou MV, Emmanouil D. Removable partial dentures vs overdentures in children with ectodermal dysplasia: two
case reports. European Archives of Paediatric Dentistry. 2016 Jun:1-6.
GROUP 1• Children
missing a single permanent tooth with adjacent permanent teeth
GROUP 2• Children
missing more than a few teeth but have permanent teeth present adjacent to the edentulous site
GROUP 3• Children with
completely edentulous arch
Sharma A, Vargervik K. Using Implants for the Growing Child. J Calif Dent Assoc 2006; 34; 719-724
1 Children missing a single permanent tooth with adjacent permanent teeth
• Do not place implants until two annual cephalograms show no change in the portion of the adjacent teeth and alveolus
• Completion of dentoalveolar growth can be seen as early as 16 in girls and as late as 22 in boys
Kearns G, Sharma AB et al. Placement of implants in children and adolescents with heriditary ectodermal dysplasia. Oral Surg Oral Med Oral Path Oral Radiol Endod 88:5-10,1999
2 Children missing more than a few teeth but have permanent teeth present adjacent to the edentulous site
• Most complex to manage• Initial objective: Orthodontically optimise the position
of the teeth present• Removable prostheses can be given until dentoalveolar
development is complete• Consider: psychological and esthetic factors• Safest approach: wait until dentoalveolar growth is
complete (no change in lateral cephalogram at one year interval)
• If implants are placed before growth completion, segmental osteotomy or distraction osteogenesis can be done for surgical repositioning
• Alternative: Remake the prosthesis using pink porcelain
3 Children with completely edentulous arch
• Concern: Downward and forward growth of mandible- jaw discrepancy and change in implant position
• Physical and psychological considerations• Implant placement before 7 years of age is
not advocated- unsatisfactory oral hygiene• Surgery may be necessary when growth is
complete to correct jaw size discrepancy• Prosthesis may have to be remade
Sharma A, Vargervik K. Using Implants for the Growing Child. J Calif Dent Assoc 2006; 34; 719-724
CONCLUSION AND CRITIQUE• NO TREATMENT ALTERNATIVES SUGGESTED FOR
REHABILITATION OF GROWING EDENTULOUS PATIENTS
• INSUFFICIENT GUIDELINES ON MANAGEMENT OF A CHILD DURING IMPLANT PLACEMENT- ROLE OF PAEDIATRIC DENTIST
Thank You
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