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REVIEW ARTICLE |
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| Year : 2013 | Volume
: 31
| Issue : 1 | Page : 3-9 |
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Dental implants in growing children
SK Mishra1, N Chowdhary2, R Chowdhary3
1 Department of Maxillofacial Prosthodontics and Implantology, Veer Bahadur Singh Purvanchal University, Dental College, Azamgarh, Jaunpur, Uttar Pradesh, India
2 Department of Pedodontics, S. Nijalingappa Institute of Dental Sciences and Research, Gulbarga, Karnataka, India
3 Department of Maxillofacial Prosthodontics and Implanotlogy, S. Nijalingappa Institute of Dental Sciences and Research, Gulbarga, Karnataka, India
| Date of Web Publication | 27-May-2013 |
Correspondence Address:
S K Mishra
Department of Maxillofacial Prosthodontics and Implantology, Dental College, Azamgarh, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-4388.112392
 Abstract | | |
The replacement of teeth by implants is usually restricted to patients with completed craniofacial growth. The aim of this literature review is to discuss the use of dental implants in normal growing patients and in patients with ectodermal dysplasia and the influence of maxillary and mandibular skeletal and dental growth on the stability of those implants. It is recommended that while deciding the optimal individual time point of implant insertion, the status of skeletal growth, the degree of hypodontia, and extension of related psychological stress should be taken into account, in addition to the status of existing dentition and dental compliance of a pediatric patient.
Keywords: Children, dental implants, ectodermal dysplasia, growth, oligodontia
How to cite this article:
Mishra S K, Chowdhary N, Chowdhary R. Dental implants in growing children. J Indian Soc Pedod Prev Dent 2013;31:3-9 |
| Introduction | |  |
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. Many authors have discussed the use of implants in children. 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. Design changes must be incorporated into such prosthesis to compensate for growth changes. [1] 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. So, these advantages must be weighed against the lack of long-term in vivo evidence-based studies supporting the use of dental implants in a child. [2]
Review of literature
A systematic review of available articles published from 1963 to 2011, obtained from the PubMed database, was done using the terms "Growth," "Children," Dental Implants," Ectodermal dysplasia," and "Oligodontia," which are presented in [Table 1] and [Table 2]. Articles published in languages other than English were excluded. [Table 1] shows the synopsis of studies on growth and its influence on dental implants. [Table 2] shows the synopsis of studies of implant placement in ectodermal dysplasia (ED) and oligodontia patients. | Table 1: Synopsis of studies on growth and their influence on dental implants
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 | Table 2: Synopsis of studies on implant placement in ectodermal dysplasia and oligodontia patients
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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, although a good quality method is the use of serial cephalometric radiograph taken 6 months apart with superimposed orthodontic tracings. If no changes occur over a period of 1 year, one may assume that growth is complete. [3]
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). Children with ED do not have normal patterns of growth, and a risk and benefit analysis must be made to assess the value of implant placement, especially in anterior mandible where lateral growth is usually completed by 3 years of age. [4],[5],[6]
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.
- Whenever possible, implant placement must be delayed until the age of 15 years for girls and 18 years for boys. [3]
- Growing patient treated with dental implant should have adequate follow-up. [3]
- Further research is needed in the areas of implants in growing children. [3]
- 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. [7]
- It is still recommended to wait for the completion of dental and skeletal growth, except for severe cases of ED. [7]
Recommendation for implant placement by quadrant
Maxillary anterior quadrant is an important area for consideration due to traumatic tooth loss and frequent congenital tooth absence. [8] 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. [2] According to Krant, [9] 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.
Maxillary posterior quadrant is subject to same general growth factors described for the maxillary anteroposterior area. An additional growth factor is transverse maxillary growth at midpalatal suture, which produces rotational growth that anteriorizes the position of the maxillary molars. 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. [2]
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. [2]
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. [2]
| Discussion | | |
The benefits of implant use in growing patients are as important as the concerns for their premature use. Reports were published by Cronin et al. and Smith et al. [10] documenting the placement of endosseous implants in the anterior mandibular region as early as 5 years of age with positive treatment results. Prachar and Vaneek [11] present the results of a 5-year study on the use cylindrical or screw implants in adolescents of age 15-19 years. Regardless of the criterion used, the rate of success was always higher than 96% over the 5 years of study, whereas Shaw [12] reported that the dramatic growth changes occurring in infancy and early childhood were not conducive to the maintenance of implants. Prosthesis remodeling, as stated by Smith et al., [13] Brugnolo et al., [14] Guckes et al., [4] and Kearns et al., [15] is an undesirable condition due to the repetitive need to lengthen the transmucosal implant-to-prosthesis ratios and the potential load magnification. According to Dietschi and Schatz [16] and Mackie and Quayle, [17] implant placement in children younger than 16-18 years must be avoided.
According to Guckes et al., [18] 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. [19] stated that implants must be placed when growth is almost complete, except for rare cases of total aplasia as in ED. Elsewhere, it had been recommended that treatment with implants must be delayed until the age of 13 years, since an implant placed at the age of 7 or 8 may not be in a favorable position at the age of 16 years. 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. [20]
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. [20] It is rare. 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. [20],[21] 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. [22],[23]
According to the 1988 National Institute of Health consensus Development Conference on Dental Implants at Bethesda, pediatric patients with ED could benefit from the use of dental implants. [24]
Following the presented case and review of literature by Kramer et al. [25] in their article, they 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 [26],[27] 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.
From 1995, several case reports on children with ED have been published on the placing the implants in the canine region of the anodontic mandible to support an overdenture from the age of 3 to 6 years. [4],[13],[22] The youngest child reported was a French boy who had implants placed at the age of 1.5 years. [28] 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. [29] 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. [30]
The timing of implant placement in growing patients was discussed at a Scandinavian Consensus Conference in Sonkoping, Sweden, [31] where there was a general agreement that implant placement should be postponed until skeletal growth is completed or nearly completed in normal adolescents. In the individual with oligodontia or anodontia, however, earlier intervention could be indicated, especially in the mandible.
Anodontia and severe oligodontia were mentioned as exceptions to the rule.
| Conclusion | | |
Published reports on the use of dental implants in young patients are as yet very limited; long-term clinical studies are necessary for sound conclusions. If the goals of treatment planning favor implant use before skeletal maturation, parents of the child need to be informed about the benefits and possible complications of its use. More emphasis has to be given during prosthesis planning. Still, some children are treated with implants, and there are a few in whom the therapy may result in a better quality of life. However, the treatment can only be justified when the anticipated positive effects are greater than the drawbacks of the procedure. Furthermore, when utilizing techniques that are still not fully evaluated for the purpose intended, as clinicians and scientists, we have a greater responsibility of follow-up and monitoring the outcome. In order to determine the optimal individual time point of implant insertion, the status of skeletal growth, the degree of hypodontia, and extension of related psychological stress should be taken into account in addition to the status of existing dentition and dental compliance of the pediatric patient.[48]
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[Table 1], [Table 2]
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