Using implants for growing patients

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.


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


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

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Using implants for growing patients