|Year : 2023 | Volume
| Issue : 1 | Page : 14-19
Dental implants in growing children − No longer a myth
D Indrajith, Anil Melath, K Subair, MR Arjun, N Prakash
Department of Periodontics, Mahe Institute of Dental Sciences, Mahe, Kerala, India
|Date of Submission||02-Mar-2023|
|Date of Acceptance||13-Mar-2023|
|Date of Web Publication||31-Mar-2023|
Dr. D Indrajith
Mahe Institute of Dental Sciences, Chalakkara, Pallor Post, Mahe - 673 310, Kerala
Source of Support: None, Conflict of Interest: None
The new era in dentistry is the implant. However, implant placement in the pediatric patient is still a dilemma. Congenital hypodontia, anodontia, and oligodontia are rare in children. However, a variety of treatment options are available and one of the treatment options which can be given to this pediatric patient is the implant. In this review, we focus on implants that can be given to growing children and the effectiveness of the implant in growing children.
Keywords: Implant failures, implants, mini implants in growing children
|How to cite this article:|
Indrajith D, Melath A, Subair K, Arjun M R, Prakash N. Dental implants in growing children − No longer a myth. Int J Prev Clin Dent Res 2023;10:14-9
|How to cite this URL:|
Indrajith D, Melath A, Subair K, Arjun M R, Prakash N. Dental implants in growing children − No longer a myth. Int J Prev Clin Dent Res [serial online] 2023 [cited 2023 Jun 10];10:14-9. Available from: https://www.ijpcdr.org/text.asp?2023/10/1/14/373356
| Introduction|| |
Congenital hypodontia or trauma is the frequent cause of the absence of teeth in children and adolescents. While total anodontia is the congenital absence of all the teeth in the primary dentition and/or the permanent dentition and is a rare condition, Hypodontia or oligodontia is the absence of one or a few teeth that may manifest in several genetic and syndromic conditions.
The most frequently missing teeth are the third molars; however, they do not require prosthetic replacement. Mandibular second premolars (2.8%), maxillary lateral incisors (1.6%), maxillary second premolars, and mandibular incisors (0.23%–0.08%) are the most frequently missing teeth that can be replaced through many treatments modalities.
The absence of teeth negatively affects both the esthetics and function in children. They may suffer from complications such as malocclusion, periodontal damage, lack of alveolar bone growth, inaccurate pronunciation, etc.
In such cases, oral rehabilitation is required even before skeletal and dental maturation has occurred. A removable partial denture is the treatment of choice, but it has certain complications such as increased caries rate, periodontal complications, and increased residual alveolar resorption.
The use of implants in children is less frequent and has been widely discussed because these patients are in the bone development stage. The scarcity of clinical cases reported in the literature and controversies in the use of implants at this stage also increase the discussion.
This article aims to present an in-depth review of pediatric dental implants.
| What are Dental Implants?|| |
Dental implants are prosthetic devices made up of alloplastic materials implanted into the oral tissue under the mucosal or periosteal layer and on or within the bone to provide retention and support for a fixed or removable prosthesis.
| Parts of a Dental Implant|| |
- Titanium implant – Surgically fused with the jaw bone
- Abutment – Fitted over the portion of the implant that protrudes from the gum line
- Crown – Fitted onto the abutment for a natural appearance.
The two essential concerns in pediatric implants are whether, as the child grows, the implants will remain in a position to support a functional prosthesis and whether the implants and/or the prosthesis will affect the child's growth and development in some negative manner. Clinicians considering implant therapy for children must understand the potential for problems associated with craniofacial growth.
| Maxillary Growth|| |
Before the age of 7, maxillary growth is primarily the result of passive displacement. After that, the maxilla grows upward and backward but is translated downward and forward relative to the cranium and cranial base. Some of the growth comes from growth at sutures and displacement caused by growth and flexion of the cranial base. The remainder is due to the remodeling of the maxilla itself. The cranial base in effect pushes the maxilla from behind. As the maxilla moves forward and down, the sutures that attach the maxilla to the cranial base remain the same width and the processes of the maxilla grow to fill the space that has opened. As the maxilla moves forward, the anterior surfaces of the maxilla are remodeled and bone is removed from the anterior surface and nasal floor.
As transverse growth of the cranial base occurs, the midface expands. The mid-palatal suture of the maxilla allows the midface to grow laterally in concert with the cranial base. Transverse growth of the maxilla accelerates at puberty. The average increase in the maxillary bone width varies from 5 to 8 mm. Maxillary width changes occur primarily with the eruption of the permanent teeth. Faster growth during puberty and a longer growth period results in adult males having greater maxillary width than adult females.
Vertical growth of the maxilla occurs primarily by apposition on the occlusal surface of the alveolus. As the alveolus is enlarged by apposition on the occlusal aspect, it is decreased by resorption on the nasal floor. Approximately one-third of the increase in alveolar height is lost by this resorption. Actual vertical growth of the maxilla from infancy to puberty is in the range of 1–2 cm but net vertical growth of the maxilla is 5–6 mm. The majority of that increase is due to the increased vertical size of the permanent teeth. In terms of implant placement in children, the important consideration is that teeth and unerupted buds follow the downward migration of the maxilla while ankylosed teeth and dental implants do not.
| Mandibular Growth|| |
The mandible is projected downward and forward during growth and the chin becomes more pronounced, although it is actually a site of net resorption. The ramus is remodeled as a result of lingual and buccal cortical plate drift and permanent tooth eruption. The mandible lengthens primarily by the growth of the condyle and posterior growth of the ascending ramus. Mandibular width increases mainly in the posterior. There is little change in the anterior mandibular arch after the onset of the adolescent growth spurt. The mandible grows vertically by apposition at the dentoalveolar complex and growth at the condyle. In normal growth and development, the mandible rotates minimally on a sagittal plane to maintain a normal inter-arch relationship. However, mandibles in individuals with long-face or short-face syndrome rotate considerably more. When more pronounced rotation occurs, eruption patterns are affected. An implant placed adjacent to one of the teeth in an abnormally rotating mandible would not move in concert with the mandible, inevitably leading to a negative relationship between the teeth and the implant. For example, in children with considerable rotation, the posterior teeth will continue to erupt to maintain the occlusal plane, but implants would not erupt and would be buried in the alveolar process. In the developing jaw, osseointegrated implants react in much the same manner as an ankylosed primary tooth. Because they lack periodontal ligament, they do not erupt or adapt to dental alveolar or facial growth. As the development of the maxilla and mandible progresses, implants can become loose due to normal facial remodeling. They can also be vertically buried due to alveolar apposition. In addition, implants may not remain in an appropriate and functional position relative to other teeth or oral structures as changes in the mandible and maxilla occur.
The consensus in the dental community seems to be that implant therapy should be recommended only in extraordinary cases for the treatment of normally developing children who are missing teeth. For normally developing children, other treatment options should be employed until skeletal craniofacial growth is complete. Chronological age is not a reliable measure of growth as there are huge differences in growth not only between the sexes but also from one individual to another. Historically, several methods have been used to determine that growth has ceased. Cephalometric radiographs taken at least 6 months apart, eruption of second molars, radiographic analysis of the wrist, and the onset of menses have been used to determine whether growth has ceased. Assessment of mandibular growth based on cervical vertebrae maturation has gained acceptance. Results from the analysis of cervical vertebrae maturation are consistent with the results from radiographic studies of the ossification of the bones of the hand and wrist, for many years, the standard for measurement of skeletal growth. Growth is considered to be complete when a radiograph shows that the second, third, and fourth cervical vertebrae have reached stage 4 of the 5-stage cervical growth maturation index.
| Implant Placement Sites|| |
Maxillary anterior region
It is an important area of consideration due to higher chances of traumatic tooth loss and frequent congenital tooth absence. Substantial growth is seen in vertical and anteroposterior dimensions. The vertical growth is maximum in this quadrant, as compared to all other quadrants. Hence, premature placement of implants can lead to growth cessation and the requirement for lengthening transmucosal implant connection. Hence, the placement of implants should be delayed up to the age of 15 years in girls and 17 years in boys.
Maxillary posterior region
Maxillary posterior quadrant has similar growth factors as described for the maxillary anterior-posterior area. An additional growth factor transfers maxillary growth at mid palatal suture, which produces rotational growth that anteriorizes the position of maxillary molars. Placement of osseointegrated dental implants in the maxillary posterior quadrant is best delayed until the age of 15 years and 17 years of age in females and males, respectively.
Mandibular anterior region
It is the best site for the placement of an osseointegrated implant before skeletal maturation. The mandibular anterior quadrant presents fewer growth variables. The closure of the mandibular symphyseal suture occurs during the first 2 years of life. Prosthesis supported by dental implants in the anterior mandibular region should be retrievable and designed to allow for an average increase of dental height of 5–6 mm as well as anteroposterior growth.
Mandibular posterior region
The dynamic growth and development of the posterior mandible in the transverse and anteroposterior dimensions coupled with its rotational growth presents multiple treatment concerns. The placement of osseointegrated implants in the posterior mandibular quadrant is best delayed until skeletal maturation.
| Recommendations for Implant Placement According to the Length of the Edentulous Span|| |
Sharma and Vargervik stated that the use of implants for the growing child is not routinely recommended due to concerns regarding jaw growth. However, there are certain cases where implant placement can be considered. They have classified patients into three distinct groups that follow specific anatomic criteria:
- Group I: children who are congenitally missing a single tooth and have adjacent permanent teeth
- Group II: Children who are missing more than a few teeth but have permanent teeth present adjacent to edentulous sites
- Group III: Children who are completely edentulous in one arch or have one or two teeth in poor positions in the arch.
In Group I patients if the implant is placed before completion of growth, the implant will become submerged relative to adjacent teeth. This would lead to an esthetic complication and may result in a poor implant-to-crown ratio if the restoration was remade to its appropriate length to camouflage the submergence.
In Group II patients, removable prostheses are used to orthodontically optimize teeth positions and consolidate edentulous spaces. However, in some patients, implants may be placed before growth is completed, for the psychological benefits of having a more functional, stable, and esthetic solution. However, when the growth is completed, there will be a need for surgically repositioning the implant segment with segmental osteotomy or distraction osteogenesis to a more favorable position. Another alternative would be a replacement of the prosthesis with pink porcelain to improve the esthetic symmetry of tooth proportion and gingival position.
Group III patients usually have the diagnosis of ectodermal dysplasia (ED). As the teeth are absent, the dentoalveolar growth and subsequent submergence of the implant are not a concern. Here, the downward and forward growth of the mandible and subsequent jaw size discrepancy is a problem.
| Scope of Dental Implants in Pediatric Dentistry|| |
Dental implants are popularly a treatment modality in adults. Its scope in pediatrics is still in its infancy. In partially edentulous cases, the long-term success of dental implants has been responsible for other clinicians to broaden the use of implants to adolescents in whom teeth are missing due to trauma or agenesis. There is no sufficient evidence to either indicate or contradict the usage of implants in growing children. The failure of implants in the form of pain/paresthesia, mobility, or peri-implant radiolucency has not been reported which indicates the best possible osseointegration in growing children The infra occlusion is the only reported problem and can be managed by using treatment modalities such as new prosthetic restoration, orthodontic treatment, or distraction osteogenesis.
| Indications for Use of Implants in Adolescents|| |
- Children with ED
- Patients with cleft lip and palate combined with bone grafting
- Children with partial or complete anadontia
- Teeth lost due to trauma.
| Contraindication|| |
- Children in prepubertal age group due to pence of growth spurt.
- Condition with inadequate mesiodistal space for implant placement.
| Factors Considered for Implant Placement in Growing Children|| |
Skeletal maturity level/age of the patient
Dental implants placed after 15 years in girls and 18 years in boys or when two annual cephalograms show no change in the position of adjacent teeth and alveolus are said to be having most predictable prognosis.
Sex of the patient
As males grow for a longer time period than females, implants in adolescent boys must be delayed longer than in girls to allow growth completion.
Number and location of missing teeth
In patients with complete anodontia, implants can be planted in the maxilla and anterior mandible as early as 7 years. However, it must be kept in mind that the implants may have to be replaced or the prosthesis may have to be modified. It is advised to restore a larger edentulous area with implants than to place a single implant-supported crown.
Osseointegration with dental implants is well-documented as a safe and predictable method of tooth replacement. However, all scientific studies about this have been performed in adults, when the dynamics of growth and development is not an issue.
Ledermann et al. conducted a study on 34 patients with a mean age of 15.1 years and had a success rate of 90%. The majority of failures were found to be due to traumatic injuries during the healing phase after implant placement. Ankylosis of the dental implant was seen with failure to respond to the vertical growth of adjacent teeth and alveolus.
Escobar and Epker conducted a study placing endosseous mandibular implants in edentulous children who had congenitally missing successors. It was observed that alveolar bone growth occurred in the absence of natural teeth. They concluded that growth and preservation are dependent upon biomechanical factors rather than the presence of teeth.
Iseri and Solow studied the eruption of maxillary incisors and first molars in girls from 9 to 25 years by the implant method. They concluded that due to the continued eruption of the natural teeth, the use of an osseointegrated implant with artificial teeth should not be recommended in childhood, adolescence, and early adulthood. If placed, special provisions should be made for later revision or replacement of the artificial teeth to compensate for the lack of continued eruption of such implants.
Alcan et al. conducted a study on a 4-year-old ED patient by placing endogenous implants. After loading, the vertical growth pattern changed to a low angle due to a lack of alveolar growth in time. Correction by changing the vertical heights of the abutment and prosthesis was done. They concluded that early implant placement and fixed prosthesis could be good treatment options for ED patients.
Smith et al. placed an implant in the mandibular anterior region in an ED patient considering it as a treatment of choice since it did not affect tooth buds. He concluded that prosthesis remodeling due to implant submergence was required from time to time. Osseointegrated implants in children with ED seemed to be a feasible treatment.
| Management of Failure|| |
Methods for the management of infra-occluded implants have been mentioned in the literature which includes new implant-borne prosthetic restoration, orthodontic pretreatment with the intrusion of adjacent teeth and extrusion of opposing teeth, and distraction osteogenesis.,,
New implant-borne prosthetic restoration has been successfully considered in the management of infra-occlusion. The factor that might influence the prognosis of the new implant-borne prosthetic restoration is the crown-root ratio. In a study, with a retrospective cohort design, crown-root ratios of single-tooth implant restorations were determined and compared with the guidelines on crown-root ratios established for the ratios of natural teeth. The results suggested that the guidelines associated with natural teeth should not be applied for the potential implant site or existing implant restoration, as the crown-root ratios of implants in function were similar to those that failed. This factor has been substantiated in studies conducted on the same topic, which proved that this factor was not as important to the success of implants as previously thought, though the ideal ratio for the replacement has not yet been determined.
Another procedure that allows better predictable management of osseous and gingival tissues is distraction osteogenesis. The successful use of this technique in the management of infra-occluded implants has been reported. This procedure elongates bones by creating gaps and filling them with newly formed bone without the need for soft or hard tissue grafting. The positive outcome of this procedure has made this treatment a reliable option, as it saves time and improves esthetics by changing the implant-crown ratio. However, there are certain limitations with this technique, such as infection, premature consolidation, incomplete osteotomy, delayed consolidation leading to nonunion, undesirable shape, and undesirable inclination of the transported bony segment, either lingually or palatally relative to the basal bone.
| Mini Implants in Pediatric Patients for Orthodontic Treatment|| |
For a child in an active growth phase, mini implants are another treatment protocol that gives esthetic and functional success. Mini dental implants are small-diameter dental implants. Mini implants were first developed by Dr. Victor I Sendax of Newyork in early 1985. Bulard added a single one-piece Oball design. They have a diameter of <3 mm (1.8–2.9 mm). They are available in various lengths –10, 13, 15 and 18 mm. a small pilot bit is used to create the opening for the implant to be threaded into the bone.
Mini implants are made of one part whereas conventional implants consist of two parts (the implant and the abutment). Mini implants have one piece of titanium screw with a ball-shaped head for denture stabilization or a square prosthetic head for fixed applications instead of the classic abutment. Mini implants protruded over the gingival surface when they are placed into the bone where as conventional implants are placed under the gingival.
The advantages of using miniimplants are immediate loading, minimally invasive procedure, minimal osseointegration, and consequently, allowing the volumes of soft and bone tissues to be maintained until growth is complete, cost-effective, etc.,,,, If infraoccluded, they can be easily unscrewed, enabling a conservation approach and are effective in the growth phase.
| Conclusion|| |
The literature contains several anecdotal reports of the use of dental implants in children, many with anodontia or severe hypodontia, often associated with ED, or trauma. There is no sufficient evidence to either indicate or contradict the usage of implants in growing children. However, dentists should not contraindicate the usage of dental implants in young individuals, just to avoid infra occlusion, as the studies of craniofacial dimensions have demonstrated significant changes during adulthood too. Thus, the advantage of implants should always be weighed against the complications. Reduced bone loss, improved esthetics, function, and dental hygiene are the major advantages in addition to the psychological comfort of the child. Rehabilitation with implant improves the self-esteem of children or adolescents, which is an important factor to suggest the usage of implants. The lack of relevant long-term clinical studies should not prevent clinicians from using implant-assisted prostheses in pediatric patients, especially in children with ED in whom it is a viable treatment option.
Financial support and sponsorship
This study was financially supported by Mahe Institute of Dental Sciences.
Conflicts of interest
There are no conflicts of interest.
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