this seminar explains why and when should we use dental implants in growing children

1. Dental Implants in Pediatric
Dentistry
Dr. Alvi Fatima
Jr II
Dept. of Pedodontics and Preventive
Dentistry1

2. Definition
Dental implant is defined as a
prosthetic device made up of
alloplastic material(s) 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.
2

3. Introduction
• Children and adolescents are
seen to manifest anodontia,
congenitally missing teeth as
well as teeth loss due to
trauma.
3

4. • The conservation of bone may be the
most important reason for the use of
dental implants in growing patients.
• In some cases to stimulate alveolar
bone development in cases of
congenital partial anodontia and
traumatic tooth loss where oral
rehabilitation is required even before
skeletal and dental maturation has
occurred.
4

5. Other factors that favor implant
placement in children are their
excellent local blood supply,
positive immunobiologic resistance,
and uncomplicated
osseous healing.
5

6. The issue of timing of placement of
implant in children is still under critical
evaluation as there are two major concerns:
1. First, if implants are present during
several years of facial growth, there is a
danger of them becoming embedded,
relocated, or displaced as the jaw grows.
2. Second area of concern is the effect of
prosthesis on growth.
6

7. GROWTH AND IMPLANT
PLACEMENT 7

8. • Growth in the maxilla and mandible does not
happen uniformly in one plane.
• It is multidirectional,
occurring in
sagittal,
 vertical, and
transverse planes..
8

9. • Growth does not happen at a fixed pace,
slow periods of growth are followed by
phase of growth spurts.
• The teeth maintain their position in the
arches by following this pace of growth
through remodeling and drifting within the
alveolar bone.
9

10. MAXILLARY GROWTH
• Early childhood, the transverse growth of the maxilla
is influenced by the increasing width of the cranial
base and growth at the median suture.
10

11. • This sutural growth accelerates at puberty and is the
earliest of the three dimensions to be completed in
adolescence.
11

12. Transverse Growth
• Early placement of implant can give rise to a
diastema with the adjacent teeth as transverse
growth occurs.
• Transverse problems are not reported in
implants placed in the anterior maxilla even as
early as 9 years of age.
12

13. • Moorrees et al. suggested that a decrease of incisor
canine circumference noted from 13 to 18 years of
age was associated with a decrease in arch length,
rather than a narrowing in arch width. Overall, the
changes are those that would contribute to crowding
in the dental arches.
Moorrees CF, Lebret LM, Kent RL. Changes in the natural dentition after
second molar emergence 13-18 years. Int Assoc Dent Res. 1979;58:276.
13

14. • Bishara et al. observed that tooth size-arch length
discrepancy increases significantly from early
adolescence to mid-adulthood in both maxillary and
mandibular arches.
Bishara SE, Jakobsen JR, Treder JE, Stasi MJ. Changes in the maxillary and
mandibular tooth size-arch length relationship from early adolescence to early
adulthood. A longitudinal study. Am J Orthod Dentofacial Orthop. 1989;95:46–59.
14

15. • Increased crowding during the period of
maximum growth can result in an implant
crown that is out of alignment with adjacent
natural teeth.
15

16. Sagittal growth
• Resorption occurs at the anterior
surface of maxilla that brings it
downward and forward.
• Early placement of implant could
result in a loss of labial cortical bone
for the implant.
• There is a spontaneous mesial drift
in the teeth in which the implants do
not participate
16

17. Vertical growth
• Vertical growth of the maxilla occurs by sutural
lowering
• There is growth in the orbits, increase in the size of
the nasal cavity and maxillary sinuses by resorption
on the nasal surface and deposition on the palatal and
alveolar surface.
• The vertical growth of the face is the last to complete.
17

18. • Adult levels of vertical growth are
near complete by 17–18 years in
girls and even later in boys and
are further influenced by the facial
growth type.
• Hence, an early placement of an
implant can lead to its presence in
the nasal floor after puberty while
the permanent teeth have moved
down.
18

19. • Westwood reported the case of a boy aged 15 years and 4
months in whom an implant was inserted to replace the
congenitally missing maxillary left second premolar
immediately after removal of the retained primary molar.
• A radiograph taken 48 months following implant
placement revealed bone resorption due to skeletal growth
in the floor of the antrum that exposed the apical end of the
implant in the sinus.
Westwood RM, Duncan JM. Implants in adolescents: A
literature review and case reports. Int J Oral Maxillofac
Implants. 1996;11:750–5.
19

20. 20

21. Mandibular growth
The mandible being more closely associated with the
cranial structures shows a differential growth as
compared to the maxilla. This is more in the sagittal
plane which is responsible for converting the more
convex facial profile of the child to a straighter adult
profile. The sagittal growth of the mandible is
through endochondral growth in the condyle that
extends the length but has no
impact on the shape of the
mandible as such. 21

22. Transverse growth
• The transverse growth in the mandible completes
very early because of the closure of the symphysis in
the 1st year of life, and only limited changes occur
afterward through remodeling.
22

23. • There is resorption of the bone lingually and
deposition buccally that leads to remodeling.
• This pattern of bone growth
may bring about lingual
positioning of the implant in
case it is placed early
23

24. Vertical growth
• The apposition at the dentoalveolar complex and
rotation of the condyle that appears to displace the
mandible downward and forward from the cranium.
• The vertical dimension is maintained through the
dentoalveolar compensatory mechanism.
24

25. 25

26. • Endosseous implants (two in the maxilla and four in the
mandible) were placed in a 3-year-old child with
ectodermal dysplasia (ED). After a 5-year follow-up,
implants placed in the anterior mandible moved with the
mandible as growth occurred in the condyles and rami. The
rotation of the mandible, which accompanies growth, did
not cause a significant problem relative to the angulation of
the implants and the prosthodontic occlusal plane. The
maxillary implant however, was close to the nasal floor
Guckes AD, McCarthy GR, Brahim J. Use of endosseous implants in a 3-year-old child
with ectodermal dysplasia: Case report and 5-year follow-up. Pediatr
Dent. 1997;19:282–5. 26

27. • Montanari et al. reported a case of a child affected with ED
accompanied with anodontia. At 2 years of age,
conventional upper and lower prosthesis were made to
allow for mastication and normal physiological
development. At 11 years and 11 months, fabrication of
lower implant supported dentures, and an upper
conventional denture was indicated. Mandibular growth in
sagittal and transverse direction showed no adverse effects
on implant position. After a 3-year follow-up, the implant
supported overdenture was well accepted by the patient.
Montanari M, Battelli F, Callea M, Corinaldesi G, Sapigni L, Marchetti C, et al. Oral
rehabilitation with implant-supported overdenture in a child with hypohidrotic
ectodermal dysplasia. Ann Oral Maxillofac Surg. 2013;1:26. 27

28. GROWTH ASSESSMENT
• Chronologic age is not a true indicator of growth
cessation.
• There is a wide range of pubertal growth spurt in boys
(11–17 years) and girls (9–15 years).
• There is no accurate indicator as to when growth has
ceased.
• A reliable assessment of growth is based on
cephalometric radiographic examination.
28

29. • Serial cephalometric radiographs are taken 6 months
apart, and their tracings are superimposed to ensure
that no growth has taken place.
• Although it is the most reliable method, but it takes a
lot of time and delays
implant insertion.
29

30. • Another accurate way of determining skeletal age is to
take a hand wrist radiograph and compare it to a
standardized atlas.
30
Capping of the epiphysis
Adductor sesamoid
Epiphysis and diaphysis

31. • Three quick indicators of growth completion are the
appearance of adductor sesamoid of the thumb, capping
of the epiphysis of the middle phalanx of the third finger
and fusion of the epiphysis and diaphysis of the radius.
• As the skeletal growth of the long bones is complete,
facial growth too stops, or it is safe to assume that it is
near completion and implants can be safely placed.
31

32. FACTORS TO BE CONSIDERED FOR IMPLANT
PLACEMENT IN GROWING PATIENTS 32
Skeletal Maturity
Level/Age of the
Patient
Implants placed after 15
years in girls and 18
years in boys or
when two annual
cephalograms show no
change in position of
adjacent teeth and
alveolus are said to be
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
adolescent
girls to allow growth
completion.
Number and Location of
Missing Teeth
In patients with complete
anodontia, implants can be
planned 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 prosthesis
may have to be modified. It
is advisable to restore a
larger edentulous area with
implants than to place a
single implant supported
crown.

33. SCOPE OF DENTAL IMPLANTS IN
PEDIATRIC DENTISTRY
33
• Implant popularity as a treatment modality in
adults is tremendous.
• However, the treatment planning and execution of
implant placement in children and adolescents is
still in its infancy.
• In partially edentulous cases, long-term success of
dental implants has been responsible for other
clinicians to broaden the use of implants to
adolescents.

34. • In the absence of maxillary teeth, the maxilla will
remain underdeveloped both sagittally and vertically
as the alveolar ridges will not develop.
• In contrast, the mandibular growth is not dependent on
the presence of teeth.
• Therefore, disproportionate relationship between two
jaws will tend to occur in the presence of hypodontia
or anodontia resulting in class III development.
• Furthermore, physiological and psychological factors
increase the pressure to start early treatment.
34

35. 35
Indication
Pediatric patients with ectodermal
dysplasia
Implants combined with bone
grafting in patients with cleft
of the alveolus and palate
Children and adolescents having
anodontia, partial anodontia, congenitally
missing teeth, teeth lost as a
result of trauma
Uncooperative children who find it
difficult to adjust to removable appliances

36. Contraindication
36
Pre-pubertal age group
Individuals with
pubertal growth spurt
Inadequate
mesiodistal space

37. Parts of dental implant
37

38. 38

39. Recommendations by area for placing
an implant
• Anterior maxilla
It is the most risky site for early implantation due
to the unpredictability of growth in the area,
especially in the presence of natural teeth.
Premature implant placement can necessitate a
repeated lengthening of the transgingival or
transmucosal part of the implant, resulting in a
poor implant - prosthesis ratio and adverse load
magnification. It is advised to delay implant
insertion until after skeletal growth is completed.
39

40. • Posterior maxilla
An early inserted implant can become
submerged occlusally and exposed apically
because of resorption of bone in the maxillary
sinus/floor of the nose. It is recommended to
delay an implant placement until after cessation
of growth.
40

41. • Anterior mandible
This site seems to hold the greatest potential for
early use of an implant supported prosthesis.
However use of early implants in combination
with teeth is not advisable due to the significant
compensatory change in the dentition in this area
during growth.
41

42. • Posterior mandible
It is recommended to delay implant placement
until skeletal growth is completed as progressive
infraocclusion of the implant and harm to
adjacent teeth preclude the early placement of
implant in this site.
42

43. 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.
• Though from all the studies it is evident that implant
placement should be delayed till the completion of
growth, there are certain cases where we can
consider the placement of implants.
43

44. • Sharma and Vargervik have classified these
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.
44

45. 45
• 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 poor implant to crown ratio.

46. • In Group II patients removable prostheses are used so as to
orthodontically optimize teeth positions and consolidate
edentulous spaces. In some patients implants may be placed
before growth is completed, for psychological benefits of having a
more functional, stable and esthetic solution.
• When the growth is completed, there will be a need for surgically
repositioning of the implant segment with segmental osteotomy or
distraction osteogenesis to a more favorable position.
• Another alternative would be a replacement of prosthesis with
pink porcelain to improve esthetic symmetry of tooth proportion
and gingival position.
46

47. 47
Pink porcelain Distraction
osteogenesis
Segmental osteotomy

48. • Group III patients usually have the diagnosis of
ectodermal dysplasia. As the teeth are absent, the
dentoalveolar growth and subsequent submergence
of the implant is not a concern. Here, the
downward and forward growth of the mandible
and subsequent jaw size discrepancy is a problem.
However, owing to poor oral hygiene, placement
of implants in patients younger than the age of 7 is
not indicated. In a study by Kearns, Perrott and
Sharma, in patients with ectodermal dysplasia,
implants have been successfully placed in the
maxillary arch and in the mandible anterior to the
mental foramen. However, surgery may be
necessary when growth is complete to correct the
jaw size discrepancy. The prosthesis may have to
be remade.
48

49. Recent advances
• Mini implants
◉Mini dental implants (MDIs) are small diameter dental
implants.
◉Are sometimes referred to as SDIs (small diameter
implants), as well as NDIs (narrow body implants).
◉Diameter: 1.8mm to 2.9mm (less than 3mm)
◉Various lengths: 10, 13, 15 & 18 mm’s
49

50. • The MDI are available with either an O-ball head for
use with removable or fixed dentures, or a square head
for fixed prostheses or retrofitting a poorly adapted
partial denture
• A small pilot bit is used to create the opening for the
implant to be threaded into the bone.
• The definitive implant supported crowns are usually
delivered within 2 weeks of surgery
50

51. Advantages
• Immediate loading,
• Can be inserted in minimal tissues without relying on
grafting techniques
• Minimally invasive procedure
• One-stage denture stabilization
• Does not require osteotomy
• Cost-effective
• Can be placed with a simple technique in patients with ridge
too narrow for conventional implants
51

52. 52
TRANSITIONAL IMPLANTS
• Diameter ranges -1.8 to 2.8 mm
• Length -7mm to 14mm.
• Fabricated with pure titanium in a single body with
treated surface.
• Primary function is to absorb masticatory stress during
healing phase

53. • The abutment head generally has a 5 degree taper,
which makes it optimal for retention of cement
retained prostheses.
• Only one drill, a 1.5 mm or 2 mm twist drill is
required for placement of the implants.
53

54. • Advantages
• Provisionalisation of fully and partially edentulous
jaws
• Undisturbed healing of bone grafts Effective way
to generate aesthetic transitional appliances
• Allows evaluation of phonetics and function.
• Cost effective.
54

55. Conclusion
Mini-implant is becoming promising alternative to crown
anchorage in the anterior region, especially in oral
rehabilitation of patients under development due to its
simple ways to use, versatility and great biocompatibility
55
Despite limitations; it is a simple, single
appointment and superior technically. As it
provides good aesthetic and functional results
which improves the patient’s quality of life,
social integration and increases the self-esteem.