Year : 2021 | Volume
: 7 | Issue : 2 | Page : 55--60
A review on dental implants in pediatric patients
Harikesavan Iyer, Uma B Dixit
Department of Pedodontics and Preventive Dentistry, DY Patil University – School of Dentistry, Navi Mumbai, Maharashtra, India
Department of Pedodontics and Preventive Dentistry, DY Patil University – School of Dentistry, Navi Mumbai, Maharashtra
Loss or absence of permanent teeth in a growing individual due to genetic or syndromic conditions, trauma, or due to extensive carious lesions requires prosthodontic rehabilitation. Conventional approaches such as removable partial dentures, complete dentures, and fixed dentures may not satisfy the needs of a growing patient due to its several disadvantages. In adults, the introduction of dental implants has offered a stable, durable, and hygienic alternative to missing teeth by restoring the function, preserving the alveolar bone and by giving excellent esthetics, restoring the individual's confidence and social acceptability. However, their use in a growing patient is still debatable. This study aims to present an in-depth review on the use of dental implants in pediatric dentistry. Implants in a growing child require special consideration because of osseointegration between implant and developing alveolar bone. The development of maxilla and mandible along with continued eruption of the remaining teeth plays an important role in ideal implant placement. Studies and case reports have advocated the use of implants in pediatric patients, but the results for ideal implant placement timing are still inconclusive. As these studies offer the evidence of the potential use of implants in growing individuals, further long-term, controlled studies should be planned to study the benefits.
|How to cite this article:|
Iyer H, Dixit UB. A review on dental implants in pediatric patients.Indian J Oral Health Res 2021;7:55-60
|How to cite this URL:|
Iyer H, Dixit UB. A review on dental implants in pediatric patients. Indian J Oral Health Res [serial online] 2021 [cited 2022 Jan 18 ];7:55-60
Available from: https://www.ijohr.org/text.asp?2021/7/2/55/333376
Loss or absence of a permanent tooth in an adolescent is not a rear occasion, reasons for which are multifold. Congenital hypodontia, trauma, or extensive carious lesions leading to extraction of the permanent teeth are some of the causes of tooth loss in children., Children with missing anterior teeth undergo humiliation and teasing at the hands of their peers. Missing posterior teeth affect mastication, cause drifting and tipping of adjacent teeth, and lead to malocclusion. Replacement of missing teeth at the earliest opportunity, therefore, is the necessity from both the child and the parents' perspective.
Plans to replace the missing teeth are based on each patient's systemic condition, developmental phase of cranium, maxilla and mandible, number of missing teeth, and anatomy of the hard and soft tissue. Although conservative prosthodontic rehabilitation such as removable partial dentures, fixed partial dentures, and complete dentures is the treatment alternatives in growing individuals, each of these has some drawbacks.,
Since the introduction of dental implants, they have offered a stable, durable, and hygienic alternative to missing teeth in adults. They can restore the function, preserve the alveolar bone, and can give excellent esthetics, restoring the individual's confidence and social acceptability. However, their use in a growing child is still debatable. This study aims to present an in-depth review of dental implants in pediatric dentistry.
Dental Implants in Pediatric Dentistry
In the past few decades, with the increased predictability of root form dental implants, there has been an increased interest in the potential use of dental implants in a growing child. Conservation of bone and stimulation of alveolar bone development are the reasons for dental implant placement. Other factors which may favor implant placement in children are excellent local blood supply, uncomplicated osseous healing, and positive immunobiologic resistance.
There are three categories of implant diameters that are available: mini-implant that ranges from 1.8 mm to 2.7 mm, standard sized implant having a diameter of 3.75 mm, and wide-body implant that ranges from 3.75 mm to 7 mm., Mini-implant designs have facilitated the use of implants in places difficult to place an implant-retained prosthesis, majorly in pediatric age group patients. Mini-implants, as compared to the conventional implants, are smaller in size thus making them ideal for replacing teeth in areas where space is limited. It is made of one part having a titanium screw with a ball-shaped head for stabilization, instead of the classic abutment.
In general, implant placement may be indicated in pediatric patients and adolescents having anodontia, partial anodontia, congenitally missing teeth and teeth lost as a result of trauma, patients with ectodermal dysplasia (ED), cleft lip and palate and for the purpose of anchorage in orthodontics, patients requiring implant-assisted removable partial denture after permanent teeth extraction, extra support and retention under fixed partial denture, edentulous arches with minimal remaining bone in buccolingual dimension, and temporary anchorage for transplanted teeth. Dental implants are contraindicated in children with systemic disorders such as vascular conditions, uncontrolled diabetes, active chemotherapy or radiation therapy and psychiatric disorders, metabolic disorders associated with wound or bone healing, insufficient bone height or width for placement, uncontrolled parafunctional habits such as bruxism, lip or nail biting, and uncooperative patients and patients who cannot maintain and follow proper oral hygiene practices.
However, the major concern for its use is that if implants are present during several years of facial growth, there is a possibility of these implants becoming embedded, relocated, or displaced as the jaw grows. Hence, the clinician must have an understanding of the potential risks of placing the implants and the design changes in prosthesis required for growth changes.
Clinical Studies on Dental Implant Placement and its Relevance to Growth of Jaws
Implants in a growing child require special consideration because of osseointegration between implant and developing alveolar bone. Inserted implants, however, do not follow the spontaneous and continuous eruption of the natural dentition or the bone growth. Bjork implanted titanium pins of 1.5 mm height in the mandible of partially enodontic children with a mean age of 14.5 years for longitudinal cephalometric studies and reported that those in the path of erupting teeth were displaced and those placed in resorptive areas were lost. Pins placed in areas of appositional bone growth became embedded. Infraocclusion of implants placed in the mandible of enodontic patients aged 13–14.5 years was also reported by Brugnolo et al. Vertical growth of the jaws was suggested to be the culprit. However, anteroposterior and transverse growth seemed not to negatively influence the implant's position. This prompted redesigning of the prosthesis. The transverse growth of the mandible follows a distinct pattern. The width of the anterior portion of the arch is completed before the adolescent growth spurt, but the posterior portion of the mandible increases in the width in close association with the increase in the jaw length.
Another study by Kearns et al. investigated the feasibility of endosseous implants in growing children and assessed the position and stability of implants during growth. Six children with partial anodontia were included with a mean age of 11.2 years (range: 5–17 years). A total of 41 implants (19 maxillary and 22 mandibular) were placed in the patients. After a mean follow-up of 7.8 years, the prostheses needed remodeling to accommodate the facial growth. The implants were stable and did not move despite growth, thereby suggesting that transverse growth did not affect the implant position.
Guckes et al. recommended that treatment with implants must be delayed until the age of 13, since an implant placed at age 7 or 8 may not be in the same position at the age of 16. Cronin and Oesterle observed that in a totally enodontic patient, the vertical, transverse, and anteroposterior changes in alveolar development might not be as important as in a partially endodontic patient, in whom considerable dental change can be expected with growth. The authors recommended to wait for the completion of skeletal and dental growth before planning to place an implant in hypodontia patients.
The transverse and sagittal growth of maxilla follows a distinct chronology. The width of the anterior portion of the maxillary arch is completed before the adolescent growth spurt, but for the posterior portion, the increase in the width is closely associated with the increase in the jaw length. The width in the anterior portion increases mainly by growth at the mid-palatal suture. The mid-palatal suture is an important growth site that must be allowed to grow undisturbed, and any interference during its growth can result in dental crossbite. An implant-supported fixed prosthesis that crosses the mid-palatal suture may restrict transverse growth, and the restriction becomes greater as the implants are laced more and more posterior. A systematic review by Chrcanovic suggested that professionals should give a consideration to the observation of implants not participating in the maxillary and mandibular growth process of drift and displacement in patients with residual craniofacial growth. Hence, proper monitoring and necessary prosthetic changes need to be made as and when required during the growth process of the jawbones.
Clinical Studies on Dental Implants in Children with Ectodermal Dysplasia
Ectodermal dysplasia (ED) refers to a genetic syndrome which exhibits a congenital defect in two or more ectodermal structures of the body, namely, hair, nails, teeth, sweat glands, and epithelium of sense organs. Congenitally missing teeth, may range from a multiple to a few teeth. The degree of alveolar bone deficiency makes an implant-supported prosthesis an ideal treatment plan for these individuals. Children with ED do not have normal patterns of growth, therefore, risk and benefit analysis must be made to analyze the value of implant placement.
Guckes et al. described a case of a 3-year-old patient with ED with complete anodontia in primary dentition and few congenitally missing permanent tooth germs radiographically. Dental implant placement followed by prosthetic rehabilitation was the treatment of choice. Four mandibular dental implants of 3.3 mm in diameter and 13-mm length were inserted. Conventional maxillary denture and mandibular overdenture supported by 2 cast gold bars were secured to the implants. During the 5-year follow-up, the prosthesis was remodeled to accommodate eruption of maxillary teeth and facial growth. The implants were stable and did not move despite growth. The authors stated that transverse growth did not interfere with the implant's position in an enodontic patient and attributed this to the age of the patient and the nonexistence of a prosthesis crossing the mid-palatal suture.
A systematic review by Chrcanovic assessed the clinical outcome and survival rate of oral implants placed in individuals with ED based on previously published case reports and studies. Data from 90 publications were included in their final analysis that included 228 patients receiving 1472 implants. Age range was 2–56 years with the mean age of 20 years, where 321 implants were placed in children aged 2–17 years. Failure rate of 6.1% was noted with a mean follow-up of 61 months. The authors concluded that dental implants placed in ED patients presented with a high survival rate in children.
Sfeir et al. reported a case series of three children (11–12 years old) with ED, in whom mini-implants were used to support the prosthesis. For all three patients, mini-implants of varying diameters (1.8 mm–2.4 mm) and 13-mm length were placed in the mandibular/maxillary anterior region. All the patients received prosthetic rehabilitation over the implants. Authors reported that all the implants were well integrated without any abnormality seen in the growth and development of the jaws after the follow-up.
In 2015, Mello et al. documented a case report of oral rehabilitation of a 9-year-old female patient with ED. Two mini-implants of 1.6-mm diameter and 10 mm in length were used. After 2 weeks, the implants were covered with a prosthetic denture. After 6-month follow-up, the patient reported good adaptation of the prosthesis and satisfaction with the treatment.
A study by Bergendal et al. evaluated a total of 33 dental implants in 26 children up to 16 years of age with ED and anodontia in lower jaw. The authors reported loss of 20 implants due to improper osseointegration at a 2-year follow-up period, major risk factors being smaller jaw size and preoperative conditions. They concluded that dental implant placement could be avoided in children <16 years of age.
These above-mentioned studies and case reports have advocated the use of dental implants in ED patients with high survival rates owing to the difficulty in choosing other rehabilitative alternatives due to insufficient jaw structure. In these patients, a stable alternative which will improve child's quality of life should be the priority. As there is no standard protocol or a general consensus among researchers regarding the procedures and indications for placement of conventional or mini-implants in ED patients, all risks and benefits should be assessed and clinicians should select appropriate technique of placement based on knowledge and professional experience.
Clinical Studies on Dental Implants in Children with Alveolar Cleft Lip and Palate
Cleft lip or palate are the most common anomalies with a prevalence of 1:700 up to 1:500. Tooth deformities and agenesis are frequently seen in patients with an alveolar cleft and hence require prosthetic rehabilitation at a later stage of life. Dental treatment in these patients depends on the number of remaining teeth and their structure in the region of cleft.
A retrospective study conducted by Alberga et al. assessed the clinical and esthetic outcome following dental implant therapy in cleft patients. In 17 patients with a mean age of 11 years, 21 implants were placed followed by prosthetic rehabilitation after 3 months. Failure of only 1 implant was reported at 72-month follow-up. The authors concluded that patients had high implant survival, healthy peri-implant soft tissues, and high patient satisfaction.
Another study evaluated a long-term prognosis of 71 dental implants placed in cleft sites after bone grafting in 47 patients (age: 14.6 years to 54.6 years) with unilateral or bilateral clefts of the alveolar process. All patients underwent bone grafting after the complete eruption of permanent dentition to reconstruct the alveolar process. The diameter and length of the implants at each site were in the range from 3 mm to 4 mm and 8 mm to 15 mm, respectively. All patients received prosthetic rehabilitation after 6 months of implant placement. At the end of an 8-year clinical follow-up, all implants, except one, were in situ and stable with an overall survival rate to be 98.6%. With high survival rate for a longer period, the authors concluded that implant placement could be a reliable option in the cleft site for the patients. High success rate of 90.9% of implants placed in grafted alveoli of 16 patients (age range: 9.8–31.8 years, mean age of 14.1 years) with cleft lip, and palate was reported by Takahashi et al.
A systematic review conducted by Wermker et al. investigated the optimal time for implant insertion in patients with cleft lip and palate after bone grafting and also assessed the long-term prognosis of inserted dental implants. Analysis included 460 patients with cleft lip and palate who received 670 implants with a mean age of 11.3 years. Dental implants with 5-year survival rates ranged from 80% to 96%. The authors concluded that patients showed high success rates and allowed sufficient oral rehabilitation after growth completion.
Regarding alveolar cleft patients, several studies have been published on dental implant therapy in children after completion of growth who require bone grafting. However, because of lack of sufficient prospective clinical studies on dental implants in growing cleft individuals, the available evidence is poor and insufficient.
Dental Implants in Children for Orthodontic Purpose
Osseointegrated implants are popularly used by orthodontists for the treatment of orthodontic abnormalities and anchorage purpose. Transverse growth of maxilla plays a vital role in the placement of implant for orthodontic anchorage purposes. The mid-palatal suture usually starts to close after puberty around the age of 11–13 years in girls and 14–16 years in boys, however, Persson and Thilander observed fusion of the mid-palatal suture in subjects ranging from 15 to 19 years. This should be kept in mind when planning for a placement of a mid-palatal implant as anchorage for orthodontic appliances. Mini-implant refers to temporary support devices which are placed with a simple surgical procedure in the alveolar bone and removed after completion of orthodontic treatment. Tseng et al. showed that mini-implants had a greater success rate when placed in the anterior regions of the upper and lower jaw. Motoyoshi et al. reported higher success rates when loading of the implants takes place at least 3 months after implant placement. Mini-implants increase bone support and enable orthodontic treatment with less traumatic surgical procedures. The treatment requires less time and cooperation from children than other conventional techniques. Successful management of skeletal Class III, bilateral posterior crossbite with maxillary atresia, tooth movements with the use of mini-implants in young children has been reported in the literature.
Clinical Studies on Dental Implants in Children for Single Tooth Replacement
Traumatic injuries result in avulsion of anterior teeth and can have a negative impact on the quality of life of the child. In such a circumstance, tooth replantation is usually recommended to restore the esthetic function. When tooth replantation is not possible due to delay in consultation and condition of the tooth, other alternatives need to be weighed. Various case reports presenting the use of implants for a single tooth replacement are found in the literature. Most have used mini-implants.
Jofré and Werner reported a case of a 10-year-old male patient with avulsed central incisor due to trauma 2 years before. A mini-implant of 1.8 mm in diameter and 11 mm in length was inserted in the maxillary anterior region followed by crown placement. During the 6-year follow-up, provisional crown was lost 6 times. Due to high frequency of provisional crown loss, caused by lack of retention and forward and downward displacement of maxilla during growth stage, the mini-implant was removed. This case report dealt with the potential risk involved in placing dental implant in a growing patient. However, a case report presenting the treatment of avulsed upper central incisors in a 10-year-old male reported satisfactorily stable, esthetic, and functional results at a 1-year follow-up of mini-implant supported crowns.
It is suggested that this treatment modality could be an ideal one for the loss of teeth in the mandibular region, thereby restoring the function, preserving the alveolar bone, giving excellent esthetics, and restoring child's confidence. However, long-term follow-up of patients receiving implants in the maxillary region is required to know about the potential risks involved and ways to deal with it.
Since few studies on the use of implants in growing patients have shown good success rate, its application in children is on the rise over the years. However, long-term clinical studies are necessary for sound conclusion, especially to understand at what age would it be appropriate to place the dental implants and the precautions needed during prosthetic rehabilitation throughout the follow-up period.
At this stage, the treatment can only be justified when the anticipated positive effects are greater than the drawbacks of the procedure. Much deliberation should go into planning the rehabilitative procedure for a young child, where the tooth/teeth loss demands an urgent, functional, and stable tooth/teeth replacement. To determine the optimal individual time 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. Parents must be informed about the benefits and possible complications of its use, and careful attention must be given to the design changes in prosthesis to compensate for growth changes.
A coordinated treatment by a dental team consisting of pediatric dentist, orthodontist, surgeon, and prosthodontist is mandatory to select appropriate implant placement technique and the type of implant to be placed in children. It is the responsibility of a pediatric dentist to properly monitor the follow-up and its outcome.
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