|Year : 2022 | Volume
| Issue : 1 | Page : 1-6
Dental implants and its use in children: A narrative review
Dipti Chawla1, Aman Deep2, Sumit Chhatwalia1
1 Department of Orthodontics and Dentofacial Orthopedics, Bhojia Dental College and Hospital, Baddi, Himachal Pradesh, India
2 Department of Pediatric and Preventive Dentistry, H. P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India
|Date of Submission||25-Mar-2021|
|Date of Decision||10-Jun-2021|
|Date of Acceptance||24-Jun-2021|
|Date of Web Publication||24-Aug-2021|
Dr. Aman Deep
H. P. Government Dental College and Hospital, Shimla, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Among the various congenital dental abnormalities in children, loss of tooth due to trauma and hypodontia are few that are most prevalent. A wide range of treatment modalities are available for these abnormalities, however, removable prosthesis is the most common treatment option to be used, but a pitfall of this method is that it may increase the residual alveolar bone resorption and other problems related to periodontal support of the remaining teeth. Dental implants, another treatment modality, are generally advocated in adults or young patients that are beyond their craniofacial growth potential. This comprehensive review will discuss the use of dental implants in normal growing patients and some special scenarios including orthodontic consideration and mini-implant use in pediatric population. This review sorted the literature in main themes of influence of growth on the usage of dental implants in children; use of dental implants in children suffering from ectodermal dysplasia; use of dental implants in traumatic dental injuries sustained in children; and for orthodontics intervention during childhood. The literature was searched using databases such as PubMed, Scopus, MEDLINE, and Google. The titles and abstracts were screened, and full text was retrieved for publications that studied the use of dental implants in children in any form of intervention. The results indicated that scientific studies have documented high functional and esthetic results in cases of prosthetic treatments on implants, min-implants in children. However, the use of implants in children is high restricted to anterior mandibular region, with most clinicians opting for growth completion before implant placements. The establishment of the mastication, speech function, and normal appearance is highly crucial for growth of the jaws and facial bones. However, isolated use of mini-implants in growing children has definitely broaden the idea of the use of implant modification in children, yet to achieve maturation.
Keywords: Children, ectodermal dysplasia, growth, implants
|How to cite this article:|
Chawla D, Deep A, Chhatwalia S. Dental implants and its use in children: A narrative review. BLDE Univ J Health Sci 2022;7:1-6
Loss of a tooth or congenitally missing teeth can have a pulverizing impact on the child both socially and physically. Some glimpses of history take us back to 4000 years ago in ancient china, bamboo pegs were used to replace missing teeth and an Egyptian king had a copper peg hammered into his upper side of the jaw 3000 years ago. Although hammering pegs in to the skull seem rather deplorable thank God in 1952, Branemark, the orthopedic surgeon, discovered titanium implants with a peculiar property of osseointegration.
The use of implants in dentistry has become a commodity with high-grade reputation as it as nearest replacement to the natural tooth as possible. It's uses are primarily governed in situations such as traumatic Injuries leading to loss of permanent tooth, congenital loss of tooth, and developmental anomalies.
Loss of tooth due to trauma (13%) is the second most common reason in young teens according to a study done in Saudi Arabia. According to Ammanagi et al., 2010, the prevalence of ectodermal dysplasia (ED) is approximately 1 in every 100,000 live births. In a Study by Balaji, 2018, an estimation of 0.033% of all Indian population is suffering from orofacial clefts.
With such prevalence, it becomes imperative to discuss the role of dental implants in treating such conditions. However, treating young adults with such conditions using dental implants is altogether a different scenario.
Majority of literature supports the use of dental implants in young adults as a challengeable job, as developmental stage and implant location are two important factors that affect the placement of dental implant.
| Literature Review Methods|| |
Search strategy and keywords
An extensive search was conducted using Web of Knowledge and Electronic Database Resources including PubMed, Scopus; MEDLINE, and Google for relevant articles.
Priority was given to the reporting of empirical studies from peer-reviewed journals. Outcomes such as growth and timing of implant placement were included in the review. Studies that did not explicitly deal with the use of dental implants in children were excluded. In addition, nonempirical articles, non-English publications, and letters to editors and duplicates were also excluded from the review. This resulted in 773 papers. The initial screening of titles and abstracts resulted in 75 full-test papers; 698 were excluded for not being related to the topic. Of these 75 full-text reports, 23 articles were excluded because they did not meet the inclusion criteria. Thus, a total of 52 publications were included in the review.
Results of the literature search
The literature search was purposely wide ranging and multidisciplinary to include the data from different treatment modalities that employ the use of dental implants in children. These have been discussed under following headings.
| Growth and Dental Implant in Children|| |
Growth is one variable that interplays a pivotal role, while placement of implants in young adults. Growth is like a river you cannot stop it but can only divert its course. Growth in maxilla and mandible does not occur in one direction. It can be gauged in multidirections, mainly transverse, sagittal, and vertical. Teeth housed within the dental arches maintain their position by following pace with phases acceleration and remission of growth. This is mainly done through remodeling and drifting within the alveolar bone.
At early childhood, cranial base and growth at the median suture increase in width, thereby affecting the transverse growth of the maxilla. This is primarily seen at puberty and is the primal of the three dimensional to be completed in juvenility. Transverse rotation of maxillary arch can be seen resulting due to growth occurring at median suture and increasing maxillary width posteriorly as compared to anterior region.
Moorrees et al. suggested that a decrease of incisor-canine circumference noted from 13 to 18 years of age was associated with a decrease in arch length. In a long-term study carried out by Dager et al., it was observed that, in a 30-year period from approximately 17–47 years of age, overall the changes led to crowding in the dental arches. Bishara et al. observed that tooth size-arch length discrepancy increases significantly from early adolescence to mid-adulthood in both maxillary and mandibular arches.
It is well known that growth taking place in mandible is endochondral in origin, one of the primary growth sites in mandible being the condyle affects the sagittal dimension of growth. This fundamentally affects the facially profile of the child making it straighter from convex as present primitively.
The direction and amount of rotation occurring in a growing mandible are variables that depend on the amount of an anterior implant exposure or submergence of a posterior implant.
Montanari et al. reported a case of a child affected with ED, for which prosthetic rehabilitation was done at an age of 2 years and later at 11 years with implant-supported dentures, and he reported that no adverse effects were seen on implant position, while he gauged growth in sagittal and transverse direction.
Implants placed in the anteriorly in mandible are not able to change angulations to compensate for rotation of mandible. Furthermore, alveolar bone appositional growth lies a major concern, additionally implant might possibly be exposed due to infradental resorption, while chin is formed in adolescents.
The implant does not adapt with changes taking place in natural dentition. Unlike to the maxillary growth and development, most of the mandible will replace and develop seamlessly, but due to limitations in joint growth and early closure of symphysis, the extent of such development is trivial.
| Timing of Implant Placement in Growing Patients|| |
Cronin and Oesterle in his study had mentioned that placement of implants during active growth may result in displacement or malpositioning by continued growth and may require removal and replacement. Ages such as 15 in girls and 18 in boys generally provide some cushion for predicted prognosis.
Cessation of growth is a key indicator for implant placement in young adults. Chronologic age is not a true indicator of growth cessation as it varies widely. The average age in girls is 12 years, while the average age in boys is 14 years.
However, unpredictability glooms over when the confounding factors are growth, and hence skeletal marker generally has to be considered. In addition, individuals with short and long face types have shown changes up to the age of 25 years.
| Dental Implants in Ectodermal Dysplasia|| |
ED affects various ectodermal structures; these generally include skin, hair, nails, teeth, nerve cells, and sweat glands. There are two distinct types of ED hidrotic and hypohidrotic (anhidrotic) type.
Hypohidrotic ED (HED) is a genetic skin disease. Common symptoms include sparse scalp and body hair, reduced ability to sweat, and missing teeth. HED is caused by mutations in the EDA, EDAR, or EDARADD genes. Inherited as a X-Linked recessive pattern, however, other patterns are also seen.
Hidrotic ED, an inherited disorder with lethal homozygous state, presents with clinical features that include nail dystrophy with associated hair defects and palmoplantar dyskeratosis. No abnormality of sweat glands and teeth is seen. In addition, oral findings of ED include multiple tooth abnormalities and abnormal alveolar ridge development.,
Children with ED have affected growth patterns and henceforth require a risk and benefit analysis for implant placement, especially in anterior mandible where lateral growth is usually completed by 3 years of age.
Guckes et al. conducted a study in 3-year-old children and placed implants in maxillary and mandibular arches with a follow-up of 5 years where he concluded that implants did not move despite growth, while prosthesis was remodeled to accommodate the eruption of maxillary teeth and facial growth.
Smith et al. in his study in which implants were placed in the mandible of 5-year-old patients concluded that placing implants at such an age in mandibular arch is the treatment of choice, also it did not affect the developing tooth buds; however, the prosthesis was remodeled due to implant submergence.
Kearns et al. in his prospective case series where six patients with ED were treated with 41 implants placed in 5–17 years of children. The cases were reviewed where he concluded that survival rate is 97.6% up to 10 years after prosthesis insertion. In addition, endoosseous implants can be successfully placed in patients with ED to counter submergence of the implant relative to the adjacent natural dentition due to growth modifications.
Bergendal et al.,, surveyed dental implants in children up to 16 years in age in Sweden in 1985–2005 where he concluded that dental implants were rarely used treatment modality in children <16 years of age. Furthermore, the failure rate in children with tooth agenesis was slightly higher than that reported for adult individuals. The small jaw size and preoperative conditions, rather than ED, were thought to be the main risk factors.
Finnema et al. in his retrospective case study in 13 oligodontia patients with a follow-up of 8 years reported a survival rate of 90% postprosthesis insertion. Furthermore, they reported implant failure rate of 14% in maxilla and 4% in mandible. Similar results were also reported in the study done by Durstberger et al.
| Dental Implants in Children Suffering from Traumatic Dental Injuries|| |
Since the prevalence of traumatic injuries is higher in children, reimplantation is the preferred treatment of choice however, failure in initial approach, or inappropriate intervention invariably leads to greater loss of the tooth., Other than reimplantation, various different strategies for anterior prosthetic rehabilitation in children victim of dental avulsion can be found in the literature some of which are attachment of artificial teeth in braces, tooth replantation, removable partial dentures, space closure with fixed orthodontic appliances, followed by anatomization of lateral incisors and canines, and adhesive prosthesis. Mini implants have been another modality that has been used to address such conditions. However, these implants tend to get ankylosed, and when placed in growing individuals, these interfere with bone growth so placed of such implants become extremely strategic and requires comprehensive planning. While on the other hand, these implants rarely cause tissue damage when removed, also the technique is low cost and minimally invasive; it also gives us additional advantage to enable prosthetic rehabilitation intervention in only one appointment.
Wang et al. in his study treated a patient 17 years of age with maxillofacial defects and described various techniques for the restoration of facial morphology and function. Osteomyocutaneous and muscular flap procedures in combination with dental implants were used to restore facial morphology, articulation, and mastication. In general, to gain adequate space after orthodontic treatment, implant placement is carried out. However, depending on the needs and anatomy of individuals such as Kuo et al. reported placement of orthodontic implant subsequent to traumatic loss of upper incisor.
Yamano et al. in a report presented a case in which a 15-year-old child met with a snowmobile accident and got maxillofacial and mandibular defects. The patient was treated with multidisciplinary rehabilitation to restore unction and esthetics. Some other treatment options were autologous corticocancellous grafts, fixture placement, and implant-supported prosthesis.
In another study done by Andersson et al. where 42 single implants were placed in 34 trauma-related edentulous patients. In addition, upper central incisor generally is lost with an incidence of 75%, while lateral incisors have 21% frequency of getting traumatically lost. Here, the general consensus was to wait for implant placement until complete growth had occurred. When roots of the traumatized tooth are preserved, it generally leads to favor preservation of the bone volume enabling better prognosis for implant placement. Finally, this study concluded that replacing single tooth implant after trauma in the anterior region of the maxilla is the generally recommended for functional and esthetic outcome.
| Mini Implants and Orthodontic Considerations in Children|| |
In orthodontic treatment, one thing that is primarily to be achieved is the required movement of the tooth with least number of undesirable effects. From a long time ago, basal bone anchorage was suggested as an alternative to increase in the number of teeth so that conventional anchorage can be achieved. The most commonly used mini implant system is the screw type system. Miniplates are another modality that can be useful for intrusion, however, cooperation of an oral surgeon and separate procedures for insertion and removal are some pitfalls of this treatment modality.
| Mechanism of Placement of an Orthodontic Implant|| |
Prosthodontic implants, surgical bone screws, and orthodontic mini-implants constitute some among the wide array of osseointegrated dental implants. The type of implant majorly affects their success requirements. For example, in case of osseointegrated prosthodontic implants, stability for long period under strong masticatory loads is required; however, on the contrary, stability for 4–6 weeks or until callus formation is required for surgical bone screws. However, all implants have same biologic principles and differ only in their implant interface criteria for success and failure.
Adequate support from tissues surrounding the implant is a preliminary requirement for any type of implant to function. Orthodontic implant differs from a prosthodontic implant as light forces are conferred for a short period of time in an orthodontic implant. However, support derived from fibrous connective tissue helps in removal of implants and is advantageous for the clinician. However, instability because of increased mobility is one of few drawback besides fibrous connective tissue is not able to support load when placed postoperatively.,
Fibrous tissue formation interfacing bone and implant results in implant loosening; hence to keep the implant stable, the implant must be supported sufficiently by the supporting bone tissue rather than any different tissue. Microscopically, lamellar bone with regard to woven bone is more appropriate when physical strength and other characteristics are considered. Support from cortical bone at macroscopic level as compared to cancellous bone is more important.
| Considerations for Growing Individual|| |
While placing an implant in a young child, some special considerations need to be given particularly the presence of permanent tooth bud they are growing within the alveolar bone. In addition to that, the quality and quantity of bone are relatively poor in patients of younger age group, compromising its primary stability. Moreover, growth at the mid palatal suture is still occurring in young patients. Henceforth, it is wisely to avoid such area where permanent tooth buds have not yet erupted. In addition, success rate in individuals of less age group generally shows poor prognosis in particularly the area of maxillary buccal section. Superior bone quality can be achieved in area particularly the first and second premolar region also it provides more favorable accessibility. Deeper placement of implants provides better healing and treatment periods with added advantage of minimizing stress.
Kuroda et al. in 2007 did a study, in which he concluded that peak of pain after mini implant placement was seen from 1 to 20 h and thereafter declined. According to him, restraint of supporting soft tissues could have resulted in drop in pain level.
Bustamante et al. in his study concluded that 20% of his patient complained about numbness from the anesthetic, while 40% showed pressure from mini-implant, only 10% of the patients said that the procedure was too lengthy. Furthermore, he concluded that 40% of the patients had oral hygiene difficulties, while 10% had mastication difficulties, only 10% had psychological pain. However, in his study, he agreed to the fact that mini-implants had some major complexities in particular related to the discomfort level to the patients and the surgical procedure.
| Conclusion|| |
Placing implants in growing children is challenging phenomenon as it has its advantages and concerns about the early placement. Lack of literature and fewer research materials has resulted in decreased standardization. The precise diagnosis and treatment by dentists for each individual case is the matter of the utmost importance. In a general consensus, it is considered not to place implants in growing age and that placement of implants is best suited after child attains sexual maturity. However, looking over the horizon mini-implants has emerged as a valid treatment option to be considered in growing individuals for preprosthetic and orthodontic anchorage treatment options. They can not only be used in multidisciplinary restorative treatment but also improvement of local discrepancies. Some of its adjunctive uses are molar intrusion, molar protraction, and uprighting.
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Conflicts of interest
There are no conflicts of interest.
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