Implant dentistry can provide benefits for restoring missing teeth in children, though there are concerns about implant placement during periods of growth. For children with conditions like ectodermal dysplasia that cause extensive tooth agenesis, implants may be considered earlier with certain precautions. Studies have shown implants placed in the anterior mandible of young ectodermal dysplasia patients can integrate successfully with bone and allow for improved oral function and psychology. However, implants placed elsewhere generally require delayed placement until growth is complete to avoid complications from jaw remodeling. Careful evaluation of individual growth is important when considering early implant placement in pediatric patients.

2. BY RACHNA CHAURASIA
PG 1ST YEAR
Dental implants in
growing children
JOURNAL OF INDIAN SOCIETY OF PEDODONTICS
AND PREVENTIVE DENTISTRY | Jan - Mar 2013 |
Issue 1 |Vol 31 | 3

3. INTRODUCTION
IMPLANT DENTISTRY is a boon for restoration
of missing teeth .
It overcomes many disadvantages of other
conventional methods of restorations
i.e.,
with removable prosthesis
with fixed prosthesis .

4. WHAT IS AN IMPLANT ?
 A prosthetic device made of alloplastic material
implanted into the oral tissues beneath the mucosal
or/ & periosteal layer &/or within the bone to
provide retention & support for a fixed or removable
dental prosthesis ;
 a substance that is placed into or / & upon the jaw
bone to support a fixed or removable dental
prosthesis.
 The final restoration looks, feels, &
functions like a natural tooth .

5. CLASSIFICATIONOF DENTALIMPLANT

9. How it works ?
 Taking a titanium post and inserting it
under the gum, or deep within the jaw
bone.
 The bone accepts and osseointegrates
with the titanium rod, merging into the
bone in a similar manner as to how a
natural tooth root is enclosed within
the bone.
 Once the bone has completely fused
with the titanium, an artificial tooth
can be secured into the rod

10. Indications for use of
implants in children
1) Pediatric patients with ectodermal dysplasia
2) Implants combined with bone grafting in patients with
cleft of the alveolus and palate
3) Children and adolescents having anodontia, partial
anodontia, congenitally missing teeth, teeth lost as a
result of trauma
4) Uncooperative children who find it difficult to adjust to
removable appliances.

11. Contra-indications for the
use of dental implants
1) Pre-pubertal age group
2) Individuals with pubertal growth spurt
3) Inadequate mesio-distal space.

12. ADVANTAGES OF IMPLANT
 To overcome the drawbacks of removable prostheses
 Bone maintenance of height and width
 Ideally esthetic tooth positioning
 Improved psychological health
 Increased stability in chewing
 Increased retention
 Eliminates need to involve adjacent teeth

13. DISADVANTAGES OF IMPLANT
 Most expensive
 Time consuming procedure
 Not good for patients who don’t recover quickly
 Adaptation of the bone tissue

14. TILL DATE IT WAS BELIEVED
THAT….
The replacement of teeth by implants is restricted to
patients with completed craniofacial growth.
 Congenital partial anodontia and traumatic tooth loss
are frequently encountered in pediatric patients.
 In such cases, oral rehabilitation is required even before
skeletal and dental maturation has occurred.
 Removable partial denture is the treatment of choice,
but it has certain complications like increased caries
rate, periodontal complications, and increased residual
alveolar resorption.

15. SCANDINAVIAN CONSENSUS CONFERENCE IN
SWEDEN. 1996
 At the consensus conference on oral implants in young patients,
it was agreed that implants should not be placed until growth
and skeletal development is completed or nearly completed. ED
and anodontia were made exceptions.
 Also, back in 1988 according to National Institute of Health
consensus Development Conference on Dental Implants at
Bethesda, pediatric patients with ED could benefit from the use
of dental implants and said that Implants in the mandibular
anterior region can be placed to support an overdenture, from
the age of around 6 years, when the median sutures of the
mandible is closed.

16.  Dental implants for children are a new treatment
modality.There are two primary concerns:
 (i) 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.
 (ii) The second area of concern is the effect of
prosthesis on growth

17.  From a physiologic stand point, the conservation of
bone may be the most important reason for use of
dental implant in a growing patient.
 In case of congenital partial anodontia, little
alveolar bone is present and placement of dental
implant changes the load mechanism on bone and
retards its resorption.
 Other factors that favor implant placement in
children are their excellent local blood supply,
positive immunobiologic resistance, and
uncomplicated osseous healing

18. GROWTH DETERMINATION
 It is an important factor when planning
implant placement in children and adolescents.
 No reliable indicator is available to
determine when growth has ceased.
 Clinician should rely on a reliable evaluation
of growth.

19. DIAGNOSIS OF GROWTH CESSATION
 1) Superimposing tracing of cephalometric radiographs taken
at least 6 months apart
 2) Waiting until no growth changes take place for 1 year.
However ,the time required and the required and the radiation
involved are drawback s.
 3) Evaluating bodily growth in length annually for 2 years to
make sure that annual growth is less than 0.5cm/y.
 4) Observing changes of dental positions within the arch ,such
as the eruption of the second molars

20. Growth Changes as Seen in Maxilla
 Transverse growth in anterior maxilla is
completed before adolescent growth spurt,
but the posterior width increase is in
accordance with increasing jaw
length. Increased maxillary width due to
growth in the median suture is seen more
posteriorly than anteriorly, which results in
transverse rotation of maxilla.
 This change causes lateral segments to
separate posteriorly than anteriorly, and the
result is increased distance between first
molars than canines and decreased length
of the dental arch in the midsagittal plane.

21.  Obvious changes are seen in width of the arch with
advancing age. Increase in inter-canine width can
occur up to 13 years of age and this distance
decreases gradually by a small amount of 0.5-1 mm up
to 20 years of age; as a result, in such patients, the
implant crown will be out of alignment with the
neighbouring tooth.
 Early and late decrease in arch length exceeds the
increase in arch length due to emergence of incisor
and transverse rotation of the maxilla, resulting in an
arch length which is shorter at age 18 years as
compared to arch length at 4 years of age. Therefore,
caution is to be taken while placing implants in maxilla
before the eruption of permanent teeth

22. Maxilla
Anterior region
completed prior to
adolescent growth
Spurt
Sutural widening
greater in posterior
Closely associated
with
skeletal growth;
when it
follows the
mandibular
growth, loss of
Sutural
growth via
resorption
results
Maxilla displaced
downward
via Sutural growth,
remodeling
and eruption; adult
levels of
vertical growth
usually reached
at age 17—18 in
girls and later
in boys
Implication • Can lead to
diastema and
shifting of midline
to the implant side
• Anterior
resorption
could result in loss
of
bone on labial side
of
implant
• Leads to
infraocclusal;
•unfavorable
Endosseous-
supraosseous
ratio
Transverse growth Sagittal growth Vertical growth
Implications of early implant placement by location and type of growth

23. Studies related to maxillary
implants….
 According to studies by Ranly et al., implants placed in
the maxillary anterior region at the age of 7 years will
become 10 mm apical to the neighboring tooth.
Movement of the tooth in maxilla with short facial types
is usually in the horizontal direction. This makes the
implants placed in the anterior segment to be more
palatal to the adjacent teeth.
 Thilander and Odman in their study have suggested
that implant placement in anterior maxilla should be
delayed until the cessation of growth is observed.
 Kokich said that stabilization of shoe and garment size,
arrest of growth in height, shaving in males, and
absence of change in serial cephalometric radiographs
taken 1 year apart can be used as a measure of growth
arrest.

24. Growth Changes as Seen in mandible
• In the posterior mandible, growth changes occur
predominantly in late childhood with large
amounts of anteroposterior, transverse and
vertical growth (Enlow 1990).
• Additionally, the mandible undergoes rotational
growth, resulting particularly in vertical
alterations (Skieller et al. 1984; Enlow 1990).
•When several teeth are present, vertical growth
is a major aspect of dental height increase and
results in anteroposterior compensatory changes
in the dentition.

25. Mandible
Anterior growth
ceases early; limited
remodeling causes
least problems
Posterior growth
continues longer
through remodeling
and bone apposition
Endochondral
growth at
condyle and
remodeling
of ramus
Height increase bv
condylar
growth and bone
apposition
Implication • Premolar or molar
implant could be
shifted into a
lingual position
• No impact on
implant
placement
• Rotation in sagittal
plane must be
considered
• Affects
antereoposterior and
vertical eruption
patterns
• Affects relationship
between
implant and adjacent
tooth
in vertical and
labiolingual
direction
Transverse growth Sagittal growth Vertical growth
Implications of early implant placement by location and type of growth

26. Studies related to mandible
implants….
 Danny Heij in 2000 found that patients with
1) Normal facial type -show mandibular rotation in sagittal plane.
2) long face type- frontally placed implants in the mandible tend
to become more vestibularly placed due to growth changes.
3)short facial type- there is an increased mesial drift such that
implants in the front become lingual to natural dentition and the
vertical growth in the premolar and molar areas lead to infra-
occlusion of implants.
 Cronin et al., suggested that successful implants in the
mandible are favored by the lack of a complicating suture.
Therefore, mandibular midline implants have a better prognosis
in a young patient than those placed in other areas of the
mandible or maxilla.

27. Suggestions for implant placement in
unaffected patients
Extreme caution must be used in placing implants in children
because of growth changes in jaw and the dentition.
1. Whenever possible, implant placement must be delayed until
the age of 15 years for girls and 18 years for boys.
2. Growing patient treated with dental implant should have
adequate follow-up.
3. Further research is needed in the areas of implants in growing
children.
4. Implant location, the sex of the patient, and the skeletal
maturation level are the most important factors in the final
decision of when to place implant.
5. It is still recommended to wait for the completion of dental
and skeletal growth, except for severe cases of ED.

28. REASONS FOR THIS EXCEPTION
 However, there are exceptions, for instance, children
who suffer from extended hypodontia or even
anodontia and congenital syndromes such as
ectodermal dysplasia .
 In affected patients, the extensive lack of both
deciduous and permanent teeth results in atrophy and
a reduced growth rate of the affected alveolar
processes.
 Recent reports suggest that these pediatric patients
can benefit remarkably from an implant-supported oral
rehabilitation.
 Psychological support

29. ECTODERMAL DYSPLASIA
 The ectodermal dysplasia represent a group of inherited
disorders characterized by defects in tissues that are derived from
ectoderm.
 The classic form of ectodermal dysplasia (Christ-Siemens-
Touraine syndrome) is thought to be X-linked and involves
hypodontia, hypohidrosis, hypotrichosis, and a characteristic
facies. Because these individuals don't sweat, this condition is
sometimes referred to as X-linked- hypohidrotic ectodermal
dysplasia (XLHED).

30. Oral findings of ectodermal
dysplasia
 It includes multiple tooth abnormalities
such as anodontia, hypodontia, and
tapered, malformed, and widely spaced
teeth.
 Abnormal alveolar ridge development also
may be present.
 Other physical signs can involve the sweat
glands, scalp, hair, nails, skin pigmentation,
and craniofacial structures (e.g. cleft lip and
cleft palate).

31. Congenital anodontia
 Congenital anodontia is a rare condition and is seen mostly
as a feature in heritable syndromes.
 Anodontia of the mandible is most commonly found in ED of
the hypohydrotic type.
 Small children with no teeth at all in the mandible present
special treatment challenges in the effort to normalizing the
appearance and function during the years of growing up.
 Treatment with removable dentures around the age of 3
years is recommended by the largest support group of ED,
the National Foundation for ED, in the USA.

32.  Kramer et al. in their article, also recommended
the insertion of implants in those pediatric
patients who suffer from extended syndromal
hypodontia, such as seen in ED.
 The most suitable site for insertion seems to be
the anterior mandible; insertions in the maxilla
should be avoided or at least should not cross
the midline.
 Ryda established that all clinical judgment and
treatment for children should be performed
according to the United Nations Convention on
the Rights of the Child. Respect the child’s
development physically as well as
psychologically

33. studies on implant placement in ectodermal
dysplasia and oligodontia patients
 Bergendal et al,done Oral rehabilitation of a 3-year-old boy with severe ED
four primary teeth (53, 51, 61, 63) and four permanent teeth (16, 11, 21,
26) in upper jaw, no teeth in the lower jaw .During 3–6 years of age, upper
partial denture adapted to allow the mesial drift of the 16 and 26 teeth.
Two Branemark implants were inserted in the lower cuspid region at 6 years
of age and specially designed overdenture was constructed and result
showed that Over the next 4 years, the dentures were modified due to the
eruption of permanent teeth and growth. The implants are well
osseointegrated and stable and allowed the boy to use a lower denture.
 Alcon et al. done a study on 4-year-old ED patient with mandibular
endosseous implants and done follow-up of 6.3 years after loading and
found that vertical growth pattern changed to low angle due to lack of
alveolar growth in time, which was corrected by changing the vertical
heights of the abutment and prosthesis

34.  In a monocentric prospective study, the survival rate of implants
placed in the anterior mandible of pediatric patients with ED was
reported with 91% (Guckes et al. 2002).
 Interestingly, some reports have demonstrated that craniofacial
morphology did not differ significantly between implant-treated
and non-treated children with ED, suggesting that treatment
with intraosseous dental implants did not necessarily interrupt
normal craniofacial growth as assumed before (Johnson et al.
2002).
 In the long run, implants located at the anterior mandible
probably seem affected by the mandibular growth rotation,
which can result in a change in implant angulation (Becktor et al.
2001)

35. Other studies.....
 Guckes et al. done a prospective clinical trial on the effect of
endosseous dental implants on the mandible of children with ED.
Twenty-three adolescents (12–17 years) and 12 preadolescents
(7–11 years) were included in the study. 225 implants were
placed, and result shows that the Twenty-two implants failed
with a success rate of 91.3% (preadolescent group 88% and
adolescent group 90%). Osseointegrated implants in children
with ED seem to be a feasible treatment option .The mandible
continues to grow in a normal pattern and the implants
remained in the same position within the bone of the mandible
 Early implant placement and fixed prosthesis could be a good
treatment option for ED patient

36. RECOMMENDATION FOR IMPLANT PLACEMENT
BY QUADRANT
Maxillary anterior quadrant
 An important area for consideration due to traumatic tooth
loss and frequent congenital tooth absence.
 Vertical and anteroposterior growth changes in this area are
substantial.
 The vertical growth of the maxilla exceeds all other dimensions
of the growth in this quadrant; therefore premature implant
placement can result in the repetitive need to lengthen the
transmucosal implant connection which leads to poor implant-
to-prosthesis ratios and the potential to load magnification.

37.  According to Krant, the placement of implants in
the anterior maxillary quadrant before the age of
15 in female patients and 17 in male patients
should be attempted to achieve unique
treatment planning goals and with particular
emphasis on the only determination of skeletal
age, informed consent, and the possibility of
future implant replacement.

38. MAXILLARY POSTERIOR QUADRANTS
 An additional growth factor is transverse maxillary growth at
mid-palatal suture, which produces rotational growth that
anteriorizes the position of the maxillary molars.
 Behaving similar to ankylosed teeth, implants cannot
participate in the maxillary growth processes of drift and
displacement,20 resulting in unpredictable implant dislocations
during growth
 Placement of osseointegrated dental
implants in the maxillary posterior quadrant
is best delayed until the age of 15 years in
females and 17 years in males.

39. Mandibular anterior quadrant
 Mandibular anterior quadrant is the best site for the
placement of an osseointegrated implant before skeletal
maturation.
 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
mandible should be of a retrievable design to allow for an
average increase of dental height of 5–6 mm as well as the
anteroposterior growth.

40. mandibular posterior quadrant
 The dynamic growth and development of the
posterior mandible in the transverse and
anteroposterior dimensions coupled with its
rotational growth presents multiple
treatment concerns.
 Placement of osseointegrated implants in
the posterior mandibular
quadrant is best delayed until
skeletal maturation.

41. Effect of Mesial drift of
teeth on implant
 Spontaneous mesial drift of teeth is well documented
 The lateral segment in the maxilla and mandible
(canine to first molar) moves on average of 5 mm
mesially between 10 to 21 years of age. the incisors
move only 2.5 mm bucally, causing a net loss in space
,which could lead to crowding.
 An implant does not take part in “spontaneous mesial
drift of teeth .”Thus an implant in the lateral region
could stop the mesial drift ,resulting in an asymmetric
arch while an implant in the anterior region cannot
follow the teeth and will become relatively more
lingually oriented with time.

42.  Reports were published by Cronin et al. and Smith et al.
documenting the placement of endosseous implants in the
anterior mandibular region as early as 5 years of age with
positive treatment results.
 Shaw reported that the dramatic growth changes occurring
in infancy and early childhood were not conducive to the
maintenance of implants.
The benefits of implant use in growing patients
are as important as the concerns for their
premature use

43.  According to Guckes et al., bone volume in children may not
be sufficient for the placement of implants in ideal positions
for prosthesis support. In the totally anodontic patient, the
vertical and anteroposterior changes in alveolar development
may not be as important as in the partially anodontic patient
in whom considerable dental changes can be expected with
growth.
 Bergendal et al.stated that implants must be placed when
growth is almost complete, except for rare cases of total
aplasia as in ED.

44. Choosing a proper implant
insertion age
 In cases of severe anodontia or oligodontia in the mandible, the
possibility or necessity exists to place implants even before the
pubertal growth spurt, since in this patient group few growth
changes occur in the anterior region after the age of 5-6 years,
especially because of the absence of teeth. For the maxilla, it is
suggested to wait until after the growth spurt.
Oesterle et al., observed that implants placed before the
cessation of growth especially in the maxilla are unpredictable in
their behavior and hence should be used with a great deal of
caution. He suggested that implants placed during the pubertal
period have a greater likelihood of success but still less than the
post-pubertal or post-growth implant.

45. Cronin et al., observed that if implants are placed during active
growth, they may be displaced or malpositioned by continued
growth and may require removal and replacement. Implants
placed after age 15 for girls and age 18 for boys have the most
predictable prognosis. Implants placed before these ages may
not be permanent and may have to be re-implanted.
Thilander et al concluded that osseointegrated implants in
pigs remained stable in place and either became buried in
alveolar bone, creating a deviation of the erupting adjacent
teeth, or were lost because of bone resorption. This study
recommended that implants not be placed posterior to the
canines during active growth. In addition, adjacent tooth
germs exhibited morphologic changes and disorders of
eruption

46. Recommendations for implant placement
according to the length of the edentulous
span
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.

47. Group I: Children who are congenitally
missing a single tooth and have adjacent
permanent teeth
 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 if the
restoration was remade to its appropriate length
to camouflage the submergence.

48. Group II: Children who are missing more than a
few teeth, but have permanent teeth present
adjacent to edentulous sites
 In Group II patients removable prostheses are
used so as to orthodontically optimize teeth
positions and consolidate edentulous spaces.
 However, in some patients implants may be placed before
growth is completed, for 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 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

49. Group III: Children who are completely
edentulous in one arch or have one or two
teeth in poor positions in the arch.
 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.
 The downward and forward growth of the mandible and
subsequent jaw size discrepancy is a problem.
 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.

50.  Placement of dental implants cannot 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.
 The first published case of placing implants in a boy with
hypohydrotic ED and anodontia of the mandible was treated
at the Institute of Jonkoping and has been followed for more
than 20 years. 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.

51. studies on growth and their
influence on dental implants
 Bjork Implanted 0.5 × 1.5 mm tantalum pins in the jaw of
children and found that majority of implants were stable. Pins
in the path of erupting teeth and pins placed near a bone
surface undergoing resorption were displaced. Nearly all pins
placed in resorptive areas, such as the anterior mandibular
ramus or anterior maxilla, were lost and pins placed in the
areas of appositional bone growth gradually became
embedded.
 Johansson et al. has done a study on Single tooth implant
which was placed in a boy (12.3 years) and followed >4.5 years
and founded that the fixture did not move together with the
adjacent teeth as the maxillary growth went on.

52.  Prachar and Vaneek has done 5year study of the use
cylindrical or screw implants in adolescents (15–19 years).
n=135 patients .191 implants and the clinical success rate
was accessed by means of selected criteria, i.e., patient’s sex,
the type of implant, the cause of tooth defect, and the type
of prosthetic reconstruction supported by implant and found
that Regardless of the criterion used, the rate of success was
>96% over the 5 years of study.
 Brugnolo et al. done a study in which he placed the implants
in the patients aged 13–14.5 years, and found the
Infraocclusion of implants secondary to vertical growth.
Anteroposterior and transverse growth did not seem to
negatively influence the implant’s position.

53.  Thilander et al. done study on animal model to determine
whether implant placed in a growing child behaves as normally
erupting or ankylosed teeth.
 Six growing pigs (in five pigs four fixtures each, three into lower
jaw and one in the upper jaw. One as control). Amalgam markers
placed in the buccal cortical layer adjacent to the implant to
record growth. In control pigs, only amalgam markers were
placed but no implants. Monitored for 165 days with intraoral
and lateral cephalometric radiographs.
 Result showed that six of 21 implants failed. Mandibular
displaced lingually and maxillary palatally of the alveolar crest.
Implant retarded growth of the alveolar process and changed
the eruption path of tooth germs.

54. Conclusion
 In today's dental practice, the treatment plan
for edentulous spaces always includes the
option of implants. Not only do they assist in
providing a better life-style, but also
rehabilitate the patient to a more normal
masticatory function.The dental surgeon
shoulders the responsibility of responding to
the growing demands of an "aware patient."

55. REFERENCES
 Osseointegrated Dental Implants in Growing Children: A Literature Review
Nivedita Mankani, BDS, MDS1 * Ramesh Chowdhary, BDS, MDS2 Brijesh A.
Patil, MBBS, MS3 Nagaraj E., BDS, MDS1 Poornima Madalli, BDS, MDS1
 The Use of Metallic Implants in the Study of Facial Growth in Children :
Method and ApplicationARNE BJORKOrthodontic Department, Royal
Dental College, Copenhagen, Denmark
 Effect of implant placement in growing adults on craniofacial
development: A literature review D Anupama Prasad, D Krishna Prasad
Department of Prosthodontics IncludingCrown and Bridge and
Implantology,A. B. Shetty Memorial Institute of Dental Sciences, Nitte
University, Deralakatte, Mangalore, Karnataka, India
 Implants in adolescents Rohit A Shah, Dipika K Mitra, SilviaV
Rodrigues, Pragalbha N Pathare, Rajesh S Podar, Harshad NVijayakar
Department of Periodontology,T.P.C.T'sTerna Dental College, Nerul, Navi
Mumbai, Maharashtra, India