1) Implant placement in children and adolescents requires consideration of growth. While implants do not move with growth, they can affect alveolar development. 2) Patients are classified into three groups based on missing teeth: single tooth missing (Group I), multiple teeth missing with adjacent teeth (Group II), fully edentulous (Group III). 3) For Group I patients missing lateral incisors, implants can be placed after growth is complete. For cleft patients, grafting is often needed before implant placement. 4) Group II patients may receive early implants adjacent to permanent teeth, but restorations are provisional until growth ends. Fixed or removable options exist. 5) Group III patients

1. 13. Implants in Young Children and Adolescents
Arun Sharma DDS
Department of Preventive and Restorative Dentistry
UCSF School of Dentistry
John Beumer III DDS, MS
Division of Advanced Prosthodontics, Biomaterials and Hospital Dentistry
UCLA School of Dentistry
This program of instruction is protected by copyright ©. No portion of this program of instruction
may be reproduced, recorded or transferred by any means electronic, digital, photographic,
mechanical etc., or by any information storage or retrieval system, without prior permission.

2. Objectives
! Present some guidelines for implant therapy in children

3. Issues
! Should Implants should be
placed in children?
! If so, which patients?
! At what age should
implants be placed?

4. Implants in Young Children and Adolescents
Our Primary Concern with Implant Placement is Growth
! The newborn lacks pronounced alveolar ridges
! Maxillary vertical development comes with developing tooth buds and
the formation and eruption of teeth
! The maxilla comes down and forward secondary to sutural apposition
and with downward and forward growth of the alveolar process
associated with the eruption of primary and permanent teeth
! Growth of the mandible is not dependent on the presence of teeth

5. Implants in Young Children and Adolescents
Growth
! Inthe absence of maxillary teeth the alveolar ridges do not develop
and the maxilla will be underdeveloped sagitally and vertically
! Mandibular growth is not dependent on the presence of teeth
! Therefore, in the presence of anadontia or hypodontia the
relationship between the maxilla and mandible is disproportionate with
most patients developing Class III relationships

6. Implants in Young Children and Adolescents
Growth
! Implants do not change position with growth and do not move
vertically with alveolar development (Odman et al, 1991, Sharma
and Vargervik , 2006)
! Implants placed in the anterior portions of the maxilla and mandible
do not affect transverse growth of these structures (Thilander et
al, 1992)

7. Partial or Complete Anadontia
Patient Classification (Sharma and Vargervik, 2006)
! Group I – Children congenitally missing one tooth with adjacent
permanent teeth
! Group II – Children missing multiple teeth but with permanent teeth
adjacent to edentulous sites
! Group III – Children who are completely edentulous in one arch or
have one or two teeth in undesirable positions

8. Group I – Children congenitally missing one tooth with adjacent permanent teeth
Cleft lip and palate patients with single tooth defects secondary to partial anadontia
Cleft Partial Anadontia
Partial Anadontia

9. Group I – Children congenitally missing one tooth with adjacent permanent teeth
Dentition in Cleft Patients
! Missing Lateral
Incisors – 40%
! Supernumerary
Lateral Incisors– 7%
! Hypodontia – 50%

10. Group I – Children congenitally missing one tooth with adjacent permanent teeth
Management of the Missing Lateral Incisor in Clefts
Implants - Issues
! Growth - Skeletal Development
! Dental alveolar
! Mandible and maxilla
! It is advisable to wait until two consecutive
cephalometric films one year apart show no
evidence of growth
! Site development
! Horizontal and vertical deficiencies usually present Courtesy A Sharma

11. Group I – Children congenitally missing one tooth with adjacent permanent teeth
Note: Gingival
contours are not
quite normal
Why?
Scarring
Courtesy A Sharma
associated with
the closure and
grafting the cleft Consequences: None. Almost all cleft patients have a low smile line.

12. Group I – Children congenitally missing one tooth with adjacent permanent teeth
Management of the Missing Lateral Incisor in Clefts
Implants - Issues
! Consequences of early placement
! Implant will be submerged relative to the adjacent
teeth with the attendant esthetic consequences
! Less favorable implant biomechanics ie. crown
root ratios
Courtesy A Sharma

13. Note gingival contours. These are to be
expected given the scarring secondary to
the multiple surgical procedures necessary
to close and graft the cleft.
UCSF Data (Sharma and Vargervik, 2006) Courtesy A Sharma
! 24 patients (15 male, 9 female) ! 33 implants placed
! 9 bilateral clefts ! 31 implants restored
! 15 unilateral clefts ! 28 still in function

14. Grafting the Cleft and Placing the Implants
Average age in years
! Alveolar cleft bone graft - 14.3
! Range (12 – 26) Median 15
! Implant Placement - 18.1
! Range (14 – 28) Median 19

15. Group I – Children congenitally missing one tooth with adjacent permanent teeth
Most clefts present with either horizontal or
vertical bone deficiencies and require
grafting prior to implant placement
Implant Placement n = 33
! Adequate bone 15 (45.4%)
! Need for regraft 18 (54.6%)

16. Results
! Implants placed - 33 *2 implants failed at 2nd stage
! Implants restored - 31 *2 failed in a bilateral cleft after 4 years
! Implants in function - 28 *1 failed in a unilateral cleft after 11 years

17. Follow up Time (months)
! Time since placement - 133.6 mths
(Range 85 – 166. Median 130)
! Time since restored - 129 mths
(Range 74 – 158, Median 121)

18. Summary 2006 Data (Sharma and Vagervik, 2006)
! Dental Implants can be ! Dental implants placed in grafted
successfully placed in alveolar clefts can be successfully
grafted alveolar clefts – restored and loaded – 90.3%
93.9 % ! 2 implants lost in one patient after 4 yrs
! 1 implant lost after 11 years

19. UCSF Protocol (Sharma and Vargervik, 2006)
! Expand maxilla orthodontically (7 – 8 years)
! Close oro-nasal defect by grafting alveolar cleft (9 – 12 years)
! Guide cuspid into arch and maintain space for lateral
! If inadequate bone then regraft
! Place implant to replace lateral incisor (after growth is
completed 15 – 19 years)

20. Implants for those congenitally missing one tooth with adjacent
permanent teeth secondary to partial anadontia
Issues
Orthodontics
! Diastemas closed
! Occlusion
! Anterior guidance
! 7 mm between the root surfaces
of the adjacent teeth
Site enhancement
! Horizontal and vertical deficiencies

21. Implants for those congenitally missing one
tooth with adjacent permanent teeth secondary
to partial anadontia
• Consolidate the arch segments before implant placement
14 y/o
19 y/o

22. Timing for Implant Placement
Lateral cephalograms, taken one year apart
demonstrating no dento-alveolar change

23. Implants for the patient with missing lateral incisors
Distance
between roots
! 7 mm
Avoid small
diameter
implants

24. Implants for the patient with missing lateral incisors

25. Implants for the patient with missing lateral incisors
Issues
• Avoid small diameter
implants
• Implant position and
angulation
• Surgical templates
• Gingival contours
• Anterior guidance
• Screw retention

26. Implant position Surgical Placement
• Screw access channel should exit through the cingulum (arrow)
• Head of the implant should be 2-4 mm below the proposed CEJ
2-4 mm

27. This implant has been placed to Implant positioning
far beneath the gingiva.
Result: The depth
of the peri-implant is
excessive leading to
an increased risk of
Attachment peri-implantitis and
level progressive bone
loss around the
Gingival implant.
margin
30 months
later Avoid labial inclinations

28. Implant positioning
Custom abutments - Labially inclined implants

29. Implants for the patient with missing lateral incisors

30. Implants for the patient with missing lateral incisors
Brother – implant
placed at age 18
yrs 6 mths
Sister – implant
placed at age 16
yrs 2 mths

31. Implants in Patients with Ectodermal Dysplasia and Nonsyndromic Forms of Partial Anadontia
Group II – Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
Group III – Children who are completely edentulous in one arch or have one or two teeth in
undesirable positions

32. Heriditary Ectodermal Dysplasia
! Inherited: 1 in 100,000 live births
! Many variants
! Ectodermal tissues affected
! Hair
! Nails
! Teeth
! Sweat Glands

33. Ectodermal Dysplasia
Dental Problems
! Unpredictable tooth eruption and loss
! Poorly shaped crowns and roots
! Defective enamel formation
! Lack of alveolar development with
closed vertical dimension of
occlusion
! Class III jaw relation
! Prosthodontic challenges
! Group II vs Group III

34. Group II - Children missing multiple teeth but with permanent teeth adjacent
to edentulous sites
–

35. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
Implants - Advantages
! Improved stability, retention
and support
! Improved mastication
efficiency
! Preservation of residual
tissues
! Remaining teeth
! Bone

36. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
Issues
– Orthodontic care
• Consolidate
permanent dentition
and the edentulous
spaces

37. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
Issues
! Growth and timing of
implant placement
! Prefer to wait until
growth is completed
! Implants
can be considered
prior to completion of growth
but the patient and family
must recognize that the
restoration is provisional

38. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
Issues
– Retention of residual
permanent dentition
• Permanent and deciduous
dentition are often used to
support provisional
restorations
• Permanent dentition may be
sacrificed at a later date in
order to idealize the position
and arrangement of implants

39. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
Issues
– Interocclusal space
• Even when patients retain
some permanent dentition
there may be excessive
interocclusal space
• The vertical dimension of
occlusion must be restored if
facial height and an a
favorable esthetic result
obtained

40. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
Issues
! Orthognathic surgery
! Occlusal plane
! Fixed vs removable
! Lack of maxillary
development favors
removable in the
maxilla
! In the mandible fixed is
generally favored

41. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
! Early implant
placement in the
presence of
permanent molars
! Continued alveolar
development and the
resultant open bite From Sharma A and Vargervik K, 2006

42. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
Timing for Implant Placement
Lateral cephalograms, taken one year
apart demonstrating no dento-alveolar
change

43. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
Surgical Issues
! Volume of bone at desired
implant sites
! Lack of keratinized attached
tissues

44. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
Prosthodontic Issues
! Status of existing permanent dentition – which teeth to retain, which to remove
! Implant positions and arrangement
! Vertical dimension of occlusion – How much interoccclusal space
! Occlusal plane
! Fixed vs removable

45. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
The maxillary overlay removable partial denture. This prosthesis restores the vertical dimension of
occlusion, helps idealize the occlusal plane and replaces the missing dentition.

46. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
Fixed was chosen in this patient. Why? Key design features
! Central incisors presented with normal size and shape ! No ridge laps
! Development of the maxilla was relatively normal
! Proxy bush access
! Normal amount of interocclusal space Courtesy T.L. Chang

47. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
! The bar in the anterior region was milled to a 3 degree taper
! This custom substructure was designed to resolve implant angulation problems
Courtesy T.L. Chang

48. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
! At UCLA we prefer retrievable restorations as opposed to cemented ones. Therefore
the suprastructure was retained with lingual set screws
Courtesy T.L. Chang

49. Group II - Children missing multiple teeth but with permanent teeth adjacent to edentulous sites
! Finished
prosthesis
! Note the
pink
porcelain
Courtesy T.L. Chang

50. Group III – Children who are completely edentulous in one arch or have one or two teeth
in undesirable positions

51. Group III – Children who are completely edentulous in one arch or have one or two teeth
in undesirable positions
Conventional prosthodontic
options are undesirable
Why?
! Resorption
! Loss of keratinized
attached tissues
! Wear and tear on existing
dentition

52. Group III – Children who are completely edentulous in one arch or have one or two teeth
in undesirable positions
Issues
! Timing of implant placement
! Effect of growth on implants
! Effect of implants on growth
! Long term success rate ?
! Compliance
! Risk vs reward

53. Group III – Children who are completely edentulous in one arch or have one or two teeth
in undesirable positions
• Growth
– No dentoalveolar growth
– Downward and forward growth of the
mandible
From Sharma A and Vargervik K, 2006

54. Group III – Children who are completely edentulous in one arch or have one or two teeth
in undesirable positions
• Implants placed anterior portion of the maxilla and mandible
• Fixed vs Removable

55. Group III – Children who are completely edentulous in one arch or have one or two teeth
in undesirable positions
Delivery – Age 13 From Sharma A and Vargervik, 2006)

56. Group III – Children who are completely edentulous in one arch or have one or two teeth
in undesirable positions
Age 13 Age 17

57. Group III – Children who are completely edentulous in one arch or have one or two teeth
in undesirable positions
Age 20 with remake of the prosthesis following orthognathic surgery

58. Group III – Children who are completely edentulous in one arch or have one or two teeth
in undesirable positions
Issues
Provisionalization
Courtesy Dr. R. Faulkner
Fate of permanent dentition

59. Group III – Children who are completely edentulous in one arch or have
one or two teeth in undesirable positions
Issues
! Provisionalization
! Fate of permanent dentition Courtesy Dr. R. Faulkner

60. Group III – Children who are completely edentulous in one arch or have one or two teeth
in undesirable positions
Completed restorations
Courtesy Dr. R. Faulkner

61. Group III – Children who are completely edentulous in one arch or have one or two teeth
in undesirable positions
• Implants can be placed at an early age dependent upon
compliance
• Surgery may be necessary when growth is complete to correct
the anticipated jaw discrepancy

62. UCSF Study (Sharma A and Vargervik K, 2006)
Study Population
Average Age
Implant Placement 10.8 (5 to 14) yrs
Implant Restoration 12.3 (6 to 15) yrs.

63. UCSF Study (Sharma A and Vargervik K, 2006)
Followup – October 2005
Time since placed 139 (125 - 170) months
Time since restored 130 (117 – 162) months

64. UCSF Study (Sharma A and Vargervik K, 2006)
Mandible Maxilla
! 24 implants placed ! 22 implants placed
! 24 implants restored ! 21 implants restored (1 failed at 2nd stage)
! 100% integration ! 20 implants in function (Oct 2005) 1lost in
1998
! 6 removable and 1 fixed
! 6 removable prosthesis
prosthesis

65. Maxillary Implants Mandibular Implants
(6 patients) (7 patients)
! Sinus lift 2 pts Alveoplasty 7 pts
! Bone graft (iliac) 3 pts Bone grafts (iliac) 3 pts
! Implants placed 22 Implants placed 24

66. Complications
! Poor oral hygiene 4
! Soft tissue hypertrophy 3
! Difficulty adapting 2

67. Prosthetic Revision – 5 patients
! 1 maxillary overdenture
! 2 maxillary RPD’s
! 3 mandibular overdentures
! 1 mandibular fixed

68. UCSF Study (Sharma A and Vargervik K, 2006)
Summary
! Implants can be placed in patients with ED
! Implants can be successfully restored and loaded in patients with ED
! Growth does not alter implant position (ankylosed)
! Implants do not interfere with the growth

69. Implants for the Growing Child
! Edentulous growing
patient – Consider
placing early
! Partially
dentate
growing patient-
approach with
caution

70. Selected References
• Hickey A, Vego T: Prosthetic treatments for patients with ectodermal dysplasia. J Prosthet Dent
86:364-8, 2001
• Guckes A, Scurria M, King T, et al: Prospective clinical trial of dental implants in persons with
ectodermal dysplasia J Prosthet Dent 88:21-25, 2002
• Sharma A and Vargervik K: Using implants for the growing child. J Calif Dent Assoc 34:71
9-724, 2006
• Odman J, Grodhal K et al: The effect of osseointegrated implants on dentoalveolar development: A
clinical and radiographic study in growing pigs Eur J Orthod 13:279-286, 1991

71. Selected References
• Thilander B, Odman J, et al: Aspects of osseointegrated implants inserted in growing jaws: A
biometric and radiographic study in the young pig. Eur J Orthod 14:99-109, 1992
• Kearns G, Perrott D, Sharma A: Placement of endosseous implants in grafted alveolar clefts.
Cleft Palate Craniofac J 34:520-5, 1997
• Kearns G, Sharma A, et al: Placement of implants in children and adolescents with heredity
ectodermal dysplasia. Oral Surg Oral Med Oral Path Oral Radiol Endod 88:5-10, 1999