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Review

Dental Implants in Growing Children – A review.

1
Dr. M.V. Raghunadha Bhatlu, 2Dr. Satyendra. T, 3Dr. Y. Ravishankar, 4Dr. Shameen Kumar. P
1
Postgraduate, Department of Prosthodontics, GITAM Dental College and Hospital, Visakhapatnam.
2,4
Senior Lecturer, Department of Prosthodontics, GITAM Dental College and Hospital, Visakhapatnam.
3
Vice Principal. Professor & Head, Department of Prosthodontics, GITAM Dental College and Hospital, Visakhapatnam.

CORRESPONDING AUTHOR:
Dr. Y. Ravishankar,
Vice Principal. Professor & Head,
Department of Prosthodontics, GITAM Dental College and Hospital,
Visakhapatnam – 530045, Andhra Pradesh, India.
Contact number: +919885307066
Email: raviys124@gmail.com

ABSTRACT
The aim of this literature review is to discuss the use of dental implants in normal growing children and in patients with ectodermal dysplasia
and the influence of maxillary and mandibular skeletal and dental growth on the stability of those implants.

Key words: Growing children, Implants, Ectodermal dysplasia

INTRODUCTION teeth. Abnormal alveolar ridge development also may be

Edentulism is usually associated with the aging present. Other physical signs can involve the sweat glands,
patient. Congenital partial anodontia and traumatic tooth scalp, hair, nails, skin pigmentation, and craniofacial
loss are rarely encountered in pediatric patients. In such structures (e.g. cleft lip and cleft palate). Children with ED
cases, oral rehabilitation is required even before skeletal and do not have normal patterns of growth, and a risk and
dental maturation has occurred. However, total or partial benefit analysis must be made to assess the value of implant
tooth loss also affects young individuals, mainly as a result placement, especially in anterior mandible where lateral
growth is usually completed by 3 years of age.
of trauma, decay, anodontia, or congenital and acquired jaw
Growth Changes As Seen In Maxilla14
defects involving the alveolar processes. Commonly
Sagittal growth and then vertical growth occurs
occurring congenital conditions are ectodermal
normally, but with displacement of implants there is
dysplasia(ED), Cherubism, Rieter Syndrome, Witkops
displacement of the entire bony complex without any risk,
Syndrome, Ellis Van Creveld Syndrome, Incontinentia
unless the prosthetic rehabilitation crosses the suture.
Pigmenti, and Focal Dermal Hypoplasia.
Maxillary implants also have the tendency to perforate the
For elderly patients, the use of oral implants has
floor of the nose due to remodeling changes. Transverse
become an accepted treatment modality for edentulism, and
growth in anterior maxilla is completed before growth spurt,
most of today's knowledge regarding implants is based
but the posterior width increase is in accordance with
on such practice. There has been hesitation to perform
increasing jaw length.
implant therapy for growing children; hence, few children
Increased maxillary width due to growth in the
to date have been provided with implant-supported
median suture is seen more posteriorly than anteriorly,
construction. Before skeletal and dental maturation takes
which results in transverse rotation of maxilla. This change
place removable prosthesis is the only treatment of
causes lateral segments to separate posteriorly than
choice. However, it may lead to increased caries rates,
anteriorly, and the result is increased distance between first
increased residual alveolar resorption, and other
molars than canines and decreased length of the dental arch
periodontal complications.
in the midsagittal plane.
Oral findings of ectodermal dysplasia
It includes multiple tooth abnormalities such as anodontia, Growth changes in mandible
hypodontia, and tapered, malformed, and widely spaced In the mandible, the amount of an anterior implant

Andhra Pradesh State Dental Journal / April 2016 / Vol 9/ Issue 2 327
exposure or submergence of a posterior implant depends on
the direction and amount of rotation during growth.
Implants placed in the anterior portion are unable to change
angulation to compensate for the rotation of the mandibular
incisors erupt. The result could be implants positioned with
nonesthetic and non-functional inclinations relative to
adjacent or opposing teeth. They do not threaten symphyseal
growth, but the submergence of implants secondary to
alveolar bone appositional growth is a concern, besides the
concern of the implants possibly becoming exposed by
infradental résorption during the formation of the chin in
adolescents.
REVIEW OF LITERATURE
Children who suffer from extended hypodontia
or even anodontia and congenital syndromes such as
ectodermal dysplasia (characterized by an aplasia or
dysplasia of tissues of ectodermal origin—hair, nails, skin,
teeth). 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.
Bjork4 implanted pins in the jaws of children 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.
Cronin7 et al studied the growth of the mandible
as related to implants in children with a strong
rotational growth pattern. Posterior teeth continue to
erupt along with continued alveolar growth to maintain
the occlusal plane, possibly causing implants to become
deeply buried within the mandibular alveolar process as
related to implants in children with a strong rotational
growth pattern. And they suggested that successful
implants in the mandible are favored by the lack of
complicated suture.
Ledermann8 et al, in their 7-year follow-up with a
mean length of 35.5 months, reported a 90% success
rate on 42 endosseous dental implants placed in 34
patients aged 9 to 18 years. There was a positive soft and
osseous tissue reaction to the implants, and most of the
failures occurred because of subsequent traumatic injuries
sustained during the healing phase after implant
placement. The major complication reported was the
failure of dental implants to respond to the vertical growth
of adjacent teeth and alveolus due to ankylosis.
Brugnolo9 et al noted the infraocclussion of
implants placed in patients aged 13 to 14.5 years,
secondary to vertical growth, and prosthesis was
Andhra Pradesh State Dental Journal / April 2016 / Vol 9/ Issue 2
redesigned. Anteroposterior and transverse growth seemed
not to influence the implants position negatively
secondary to vertical growth, and prosthesis was
redesigned. Anteroposterior and transverse growth seemed
not to influence the implants position negatively.
According to Smith and Vargervik10, implant use
in children with ectodermal dysplasia is a treatment of
choice, since its placement in the mandibular anterior
region of a 5-year-old patient did not affect adjacent tooth
buds. Prosthesis remodeling was performed due to implant
submergence.
Guckes11 et al described a case of 3-year-old
patient with ectodermal dysplasia in which dental
implants located in the mandible and maxilla have not
moved despite growth. During the 5-year follow-up, the
prosthesis was remodeled to accommodate eruption of
the maxillary teeth and facial growth.
Kearns12 et al did not find evidence of restriction
to transverse and sagittal growth due to implant use in
children with ectodermal dysplasia. Prosthesis
remodeling was necessary in some patients secondary to
implant submergence.
Mikel Westwood15 and Duncan James in their
study showed that implants placed in the maxillary anterior
region have angulation changes, and hence less risk of
submersion. This is because there is less bone growth
vertically and implants are placed immediately after or
within few months of tooth removal to reduce loss of bone.
According to OpHeji1 et al, implants inserted
into pediatric patients do not follow the regular growth
process of the craniofacial skeleton and are known to
behave similar to ankylosed teeth, resulting in both
functional and esthetic disadvantages.
Rossi and Andreasen2 found that they could
interfere with the position and the eruption of adjacent
tooth germs, thus resulting in potential severe trauma to
the erupting teeth and the jaw bones.
Oesterle6 compared dental implants to ankylosed
primary teeth and documented that ankylosis arrests both
dental eruption and alveolar bone formation in the
affected area. An osseointegrated implant would behave
much like an ankylosed primary tooth, with the same
lack of alveolar growth and dental eruption, and thus it
would appear to submerge into the alveolus.
Effect of growth and implant placement in relation to
gender
Females complete majority of adolescent growth by 15
years of age and males continue growth even in their
twenties. There is a 20% increase in maxillary depth seen in
males between 15 and 25 years and 26% increase in
mandibular depth. Mandible is positioned 30% forward and
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maxillo-mandibular relation changes by 33%. Females show
small changes between 17 and 20 years and grow at early
20–30s which is the period known as post-fertilization
growth acceleration.
In males, posterior facial height increases more
than anterior facial height, whereas females show equal
increase in both anterior and posterior facial height. The
direction of growth is more horizontal in males similar to
that in adolescence. Females show a more vertical growth
pattern with a backward rotation of mandible leading to
increased skeletal vertical dimension. Males show a more
vertical growth in the posterior area of maxilla and
mandible, which results in a flatter angle between the
anterior cranial base and lower border of mandible leading
to a further increase in chin prominence.
In both the genders, maxillary incisors upright
themselves in adulthood with axis appearing near the crown.
The roots are positioned labially, but the mandibular
incisors show very little or no change. Due to the increase in
the inclination and protrusion of incisors of females, inter-
incisal angle stays the same but it becomes large in males.
The incisors upright by 2°–3°, with a significant change
occurring between 31 and 50 years. The maxillary molars
upright in males and tip slightly in females. Even though
both the genders demonstrate similar growth tendencies,
arch width differences are noted. Males have an arch width
greater than females, the difference varying from 0.5 mm in
the lateral incisor area to 3 mm in the molar area. Greater
size of maxillary arch in males is due to faster rate of
pubertal growth and longer period of growth available for
males compared to females. The female growth is seen to be
completed by the age of 15 years and males continue growth
through 17–25 years; therefore, most of the male patients
are risky candidates for placement of implants before the
completion of 25 years.
Cronin et al observed that implants placed
during the active growth period they may be displaced or
malpositioned by continued growth and may require
removal and replacement. Implants placed after age of 15
for girls and age 18 for boys shows good prognosis16.
Suggestions for implant placement in unaffected
patients13
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. 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.
Andhra Pradesh State Dental Journal / April 2016 / Vol 9/ Issue 2
4. It is still recommended to wait for the completion of
dental and skeletal growth, except for severe cases of
Ectodermal Dysplasia.
5. Further research is needed in the areas of implants in
growing children.
There are two primary concerns while placement of
implants in growing individuals.
(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.
From a physiologic stand point, the conservation of
bone may be the most important reason for use of dental
implant in a growing patient
Recommendation for implant placement by
quadrant13
Maxillary anterior quadrant is 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.
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 attempted to achieve
unique treatment planning goals and with particular
emphasis on the only determination of skeletal age, 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.
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.
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 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.
Philippe D ledermann et al suggested a
waiting period of minimum of 6 months for maxilla and
minimum of 5 months for mandible based on well-known
differences in osseous trabecular structure between the
maxilla and the mandible as well as the clinical observations
of Ti implants placed in adults.17
Implant Placement as Related To Mandibular
Growth14
Danny Heij in found that patients with normal
facial type show mandibular rotation in sagittal plane.
Mandibular growth in males continues up to the age of 20-
30 years. In the long face type, frontally placed implants in
the mandible tend to become more vestibularly placed due
to growth changes. In the 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. Thilander and Odman in a 10-year follow-up
study have demonstrated infra-occlusion of 0.1–2.2 mm.
Danny Heij found that teeth show spontaneous mesial drift
such that a medial movement of 5 mm is seen in the area
between canine and first molar between the age of 10 and 21
years.
Placement of implants in the maxilla in the region
of central incisors leads to a diastema between implant and
natural teeth, and there is subsequent shift of the midline to
the side of implant placement.
Recommendations for the Placement of Implants in
the Maxilla13
Considering the evidence presented, osseointegrated
implants in the maxilla of growing patients must be
undertaken with a great deal of caution. Implants placed
before the cessation of growth are unpredictable in their
behavior. Hence, implants placed in the early mixed
dentition have a poor prognosis of continued usefulness
through puberty. Rigid transpalatal prostheses in the pre
pubertal or early pubertal patient should be avoided to allow
unrestricted transverse maxillary growth. Implants placed
during the pubertal period have a greater likelihood of
success, but still less than the post pubertal or post growth
implant.
Andhra Pradesh State Dental Journal / April 2016 / Vol 9/ Issue 2
DISCUSSION
Anodontia is a condition in which missing single
anterior tooth or multiple missing teeth, is definitely a dental
handicap and subjects would definitely wish to have teeth
restored at the earliest. Independent of the number of
permanent teeth missing and the cause of dysfunction,
prosthodontic treatment should be initiated during
adolescence. Interim treatment should be undertaken before
enrollment to school since it would influence
communication behavior, self-esteem, and academic
performance of children as no treatment would interfere
with the growth potential which is already impaired by
missing teeth.
Retention and stability of prosthesis are difficult to
attain in patients with ectodermal dysplasia because of
dryness of mucosa and underdeveloped maxillary
tuberosities as well as alveolar ridges. The available quality
of bone in subjects with ectodermal dysplasia is very poor
and immature with a lot of limiting factors such as position
of mandibular nerve, developing permanent teeth, extent of
nasal cavities and maxillary sinuses. All these potential risk
factors should be of concern while an attempt is made of
placing implants in young patients, especially children, as
implant placement in growing adults is restricted to those
with completed development of craniofacial skeleton.
Periodic recall is a necessary step in young ectodermal
dysplasia patients as it calls for modification and
replacement of the given prosthesis due to growth and
development in the coming years.
CONCLUSION:
No definite conclusions can be drawn from such
short-term studies. To prevent interruption of maxillary
growth, rigid prosthesis crossing midpalatine suture should
be avoided as far as possible. By using mini implants and
provisional implants which provide scope for repair and
replacement once the child has completed the growth and
also would guard the patient’s self-esteem and socialization
in the interim growing phase by providing fixed prosthesis
which could be used with least complications but maximum
comfort.
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