Use of dental implants in children: A literature reviewCello Percinoto, DDS, MS, PhDVAna Elisa de Mello Vieira, DDSVCíntia Megid Barbieri, DDSVFabiola Lemos Melhado, DDSVKarina Silva Moreira, DDS'

The aim of this literature review is to discuss the use of dental implants in growing patients and theinfluence of maxillary and mandibular skeletal and dental growth on the stability of those implants.It is recommended to wait for the completion of derttal and skeletal growth, except for severe casesof ectodermal dysplasia. (Quintessence Int 2001:32:381-383)

Key words: cliildren. ectodermal dysplasia, growth, implant, rehabilitation, trauma.

Traumatic tooth loss or congenital partial anodon-tia, mainly in patients with ectodermal dysplasia, is

trequently encountered in children. In those cases,oral rehabilitation is required before skeletal and den-tal maturation, and removable prosthesis is often thetreatment of choice. However, it may lead to increasedcaries rates, increased residual alveolar résorption,and other periodontal complications.'

Recently, some authors have discussed the use ofimplants in children. From a physiologic standpoint,the conservation of bone may be the most importantreason for the use of dental implants in growingpatients,''̂ and it even may be beneficial in some casesto stimulate alveolar bone development.^

Other factors that favor implant placement in chil-dren are their excellent local blood supply, positiveimmunobiologic resistance, and uncomplicatedosseous healing."* On the other hand, an implant-retained prosthesis creates additional concerns notcreated by the adult patient, and the dental and skele-tal growth is a major confounding variable whenimplants are used in children.'

The aim of this study is to discuss the viability ofimplant use in growing patients.

REVIEW OFTHE LITERATURE

implanted pins in the jaws of children forlongitudinal cephalometric studies and reported that

'Department ot Pedialnc Dentistry, Paulista State University (UNESP],Araçatuba, Sao Paulo. Brazil.

Reprint requests: Dr Celio Perciroto, Rua José Bonifacio 1193, Araçatuba,Slo PaulD, Brazil, csp 16015-050. E-mail: peroinot@foa.uneäp.br

those in the path of erupting teeth were displacedand those placed in resorptive areas were lost. Pinsplaced in areas of appositional bone growth becameembedded.

Thilander et ai' concluded that osseointegratedimplants in pigs remained stable in space and eitherbecame buried in alveolar bone, creating a deviationof the erupting adjacent teeth, or were lost because ofbone résorption.

Ledermann et al'' in their 7-year follow-up with amean length of 35.5 months, reported a 90% successrate on 42 endosseous dental implants placed in 34patients aged 9 to 18 years. There was a positive softand osseous tissue reaction to the implants, and most ofthe failures occurred because of subsequent traumaticinjuries sustained during the healing phase after implantplacement. The major complication reported was thefailure of dental implants to respond to the verticalgrowth of adjacent teeth and alveolus due to ankylosis.

According to Smith et ai,̂ implant use in childrenwith ectodermal dysplasia is a treatment of choice,since its placement in the mandibular anterior regionof a 5-year-old patient did not affect adjacent toothbuds. Prosthesis remodeling was performed due toimplant suhmergence.

Brugnolo et al̂ noted the infraclusion of implantsplaced in patients aged 13 to 14.5 years, secondary tovertical growth, and prosthesis was redesigned.Anteroposterior and transverse growth seemed not tonegatively influence the implant's position.

Guckes et al'° described a case of a 3-year-oldpatient with ectodermal dysplasia in which dentalimplants located in the mandible and maxiila have notmoved despite growth. During the 5-year follow-up, theprosthesis was remodeled to accommodate eruption ofthe maxillary teeth and facial growth.

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Kearns et al" did not find evidence of restriction totransverse and sagittal growth due to implant use inchildren with ectodermal dysplasia. Prosthesis remod-eling was necessary in some patients secondary toimplant submergence.

DISCUSSION

The benefits of implant use in growing patients are asimportant as tbe concerns for their premature use.' Itis a controversial matter, and not many reports havebeen publisbed; therefore, an individual and carefuldiagnosis and treatment plan are required.

Although most implant dentists prefer to placeimplants after growth is completed, upon sexual matu-rity, the appropriate age for installation of implantshas been discussed in the literature. Shaw'̂ reportedthat the dramatic growth changes occurring in infancyand early childhood were not conducive to the main-tenance of implants. According to Dietschl andSchatz'' and Mackie and Quayle,''* implant placementin children younger than 16 to 18 years must beavoided, or tbey will remain in infraclusion due toadjacent alveolar bone growth. Bergendal et al'^ statedthat implants must be placed wben growth is almostcomplete, except for rare cases of total aplasia, as inectodermal dysplasia. Elsewhere, it has been recom-mended tbat treatment witb implants must be delayeduntil tbe age of 13, since an implant placed at age 7 orS may not be in a favorable position at age 16.'̂

According to Guckes et al," bone volume in cbildrenmay not be sufficient for tbe placement of implants inideal positions for prostbesis support. In tbe totallyanodontic patient, the vertical and anteroposteriorchanges in alveolar deveiopment may not he as impor-tant as in the partially anodontic patient, in whom con-siderable dental cbange can be expected with growth.'

It is recommended to wait for tbe completion ofskeletal and dental growtb before planning to place animplant; however, many physiologic and psychologicalfactors create pressure to commence earliertreatment.^''5 The use of conventional prosthesesbefore placing implants is encouraged, since it helps tocondition the growing patient and provides estheticand functional information for the subsequent implanttreatment plan.'^ The use of a conventional prosthesisis also important until the patient achieves a moreappropriate level of maturity.

Osseointegrated implants befiave like ankylosedte et h,'''''̂ '•'•'* arresting both eruption and alveolar bonegrowtb and not adapting to changes secondary toalveolar bone growth. Therefore, an implant placed inthe maxillary posterior quadrant of a growing patientcan become very embedded in bone, and its apical

portion can become exposed witb the remodeling ofthe nasal floor,'

Because implants are unahle to move mesiaily withthe changes in growth, disturbances in alignment andocclusion occur.' If they are placed hefore the cessa-tion of growth, their hefiavior is not very predictablesince growth patterns are individual.

Prosthesis remodeling, as stated by Smith et al,*Brugnolo et al,* Guckes et al,'" and Kearns et al," isan undesirable condition, since tbe repetitive need tolengthen the transmucosal implant connection resultsin poor implant-to-prosthesis ratios and the potentialof load magnification.

The midpalatal suture is an important growth sitethat must be allowed to grow undisturbed, and anyinterference during its growth can result in dentalcrossbite. A fixed prosthesis that crosses the mid-palatal suture and is attached to implants may restricttransverse growth, and the restriction becomes greateras tbe implants are placed more and more posterior.'Brugnolo et aF stated tbat transverse growth did notinterfere with the implant's position, and that thatmay be due to tbe age of the patients and to thenonexistence of a prosthesis crossing tbe midpalatalsuture. When the maxilla widens at its midline suture,the central incisor teeth change their position in thebone to compensate and are prevented from separat-ing by the periodontal fibers. Implants are not subjectto this compensatory system, and if located in theanterior on opposite sides of the midpalatal suture ofa child, they will be carried apart for a significant dis-tance by transverse growtb, creating estbetic andfunctional problems.'

In tbe mandible, tbe amount of an anterior implantexposure or submergence of a posterior implantdepends on tbe direction and amount of rotation dur-ing growth. Implants placed in the anterior portion areunable to change anguiation to compensate for therotation of the mandihlc as incisors erupt The resultcould be implants positioned with nonesthetic andnonfunctional inclinations relative to adjacent oropposing teeth. They do not threaten symphysealgrowth, hut the submergence of implants secondary toalveolar bone appositional growth is a concern,hesides the concern of the implants possihly hecomingexposed by infradental résorption during the forma-tion of the chin in adolescents.'

Tooth eruption and alveolar growth must be seen asnegative factors for implant use in children. Therefore,implant placement must he postponed to allow com-plete growth. This is true mainly for males because oftheir longer growth period. If implant-supported pros-theses were shown to have positive effects on cranio-facial growth, social development, and food choice,their use would he routinely recommended in young

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patients. If positive effects are expected, implantsshould be placed in the mandibular anteriorquadrant." According to the 1988 National Instituteof Health Consensus Development Conference onDental Implants at Bethesda, pédiatrie patients withectodermal dysplasia could benefit from the use ofdental implants.^

The published reports about implant use in youngpatients are as yet very limited, and long-term clinicalstudies are necessary for sound conclusions. If thegoals of treatment planning favors implant use beforeskeletal maturation, parents must be told about thebenefits and possible complications of its use. andcareful attention must be given to prosthesis design.

CONCLUSION

1. Implant location, the sex of the patient, and theskeletal maturation level are the most importantfactors in the final decision of when to placeimplants.

2. It is still recommended to wait for the completionof dental and skeletal growth, except for severecases of ectodermal dysplasia.

REFERENCES

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