Dental implant is a replacement treatment modality. This article explains the classification, indications, contraindications and recommendations for dental implant placement.

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Dental Implants

1. There is a large number of youngsters affected by absence or loss of teeth because of congenital hypodontia or trauma.
2. Total anodontia is congenital absence of all the teeth in the primary dentition and/or the permanent dentition and is a rare condition.
3. Hypodontia or oligodontia is the absence of one or a few teeth that may manifest in several genetic and syndromic conditions, and congenitally missing teeth are commonly found in healthy individuals and will occur without association of any developmental disorders.
4. Apart from this trauma is a frequent cause of tooth loss in children.
5. Loss of teeth ends up in loss of function, and lack of normal alveolar growth, in conjunction with unpleasant esthetics that hampers the psychosocial development of young child.
6. Traditionally, management of single tooth loss in the young child has been done by conservative means such as Maryland Bridge, resin-bonded restorations, or removable prosthesis in cases of multiple missing teeth.
7. But these treatments are not satisfactory and have their drawbacks.
8. The primary concerns of implants in young patient is danger of them becoming embedded, relocated, or displaced as the jaw grows. From a physiologic standpoint, conservation of bone could also be the foremost important reason to be used of implant during a growing patient.

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Classification of Implants

1.  Depending on the placement with the tissue

• Epiosteal implants
• Transosteal implants
• Endosteal implants

2. Depending on material used

• Metallic Implants (titanium, titanium alloy, cobalt chromium molybdenum alloy)
• Non-Metallic Implants (Ceramics, Carbon)

3. Depending on their reaction with bone

• Bio active (hydroxyapatite)
• Bio inert implants

4. Depending on treatment options

Mish in 1988 reported five prosthetic options of implants.

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Indications 

Indications for use of implants in adolescents:

• Paediatric patients with dysplasia
• In patients with a cleft of the alveolus and palate and
• Adolescents having anodontia, partial anodontia, congenitally missing teeth, or teeth lost as a result of trauma

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Contraindications

Contraindications for use of dental implants:

• Prepubertal age group
• Individuals with the pubertal growth spurt
• Inadequate M-D space

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Growth of Maxilla

1. Growth of maxilla occurs in two ways: by apposition and by superficial remodeling. Although the maxilla grows forward and downward, its frontal surface is remodeled and bone removed from most of the anterior surface.
2. It is notable because the largest portion of the anterior surface of the maxilla is in the resorption area, not in the apposition area. The total change in growth is the result of the translation of the maxilla forwards and downwards and simultaneous surface remodeling.
3. According to Andreasen (1993), the implants placed within the jaws in growth do not erupt like natural teeth. They behave like ankylosing teeth, resulting in infra-occlusion.

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Growth of Mandible

In contrast to the maxilla, both endochondral and periosteum activities are important within the growth of the mandible.

The absence of a complicated suture as it takes place in maxilla, is the success of implant placement in mandible. As transverse growth in the region of lower incisors and canines ceases early, mandibular anterior implants have better prognosis in young patients than those placed in other areas of the mandible.

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Multidisciplinary Approach

1. Successful implant treatment in children has been achieved by several clinicians once they incorporated a multidisciplinary approach in their treatment plan.
2. The dentition present in the patient, residual space between the teeth present in the arch, amount of alveolar bone, and the timing of implant placement are the important factors to be considered when treating a child with a missing tooth, apart from growth.
3. Preservation of primary teeth till their root resorption, prevention of caries, or endodontic treatment to prevent any periapical pathology and subsequent bone loss is important for later implant placement. It prevents the loss of arch length and maintains the alveolar bone height.
4. The pediatric dentist should be capable of managing the primary dentition to create a healthy oral cavity for a future implant. Montanari et al(2013), advocated a dental multidisciplinary team that includes a pediatric dentist, an orthodontist, a prosthodontist, and an oral and maxillofacial surgeon for a successful outcome in implant placement in children.

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Growth Assessment

1. Chronologic age isn't a real indicator of growth cessation. There is a wide range of pubertal growth spurt in boys (11–17 years) and girls (9–15 years). There is no accurate indicator as to when growth has ceased. Assessment of growth is predicated on cephalometric radiographic examination.
2. Serial cephalometric radiographs are taken 6 months apart, and their tracings are superimposed to make sure that no growth has taken place. Although it is the most reliable method, it takes a lot of time and delays implant insertion.
3. Another accurate way of determining skeletal age is to require a hand-wrist radiograph and compare it to a consistent atlas.
4. Three quick indicators of growth completion are the appearance of adductor sesamoid of the thumb, capping of the epiphysis of the middle phalanx of the third finger, and fusion of the epiphysis and diaphysis of the radius.
5. As the skeletal growth of the long bones is complete, facial growth stops, or it is safe to assume that it is near completion and implants can be safely placed.

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Recommendation for Implant Placement

Maxillary Anterior Quadrant

Implant placement by quadrant, 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 expansion in the quadrant; therefore premature implant placement may end up in the repetitive need to lengthen the transmucosal implant connection which leads to poor implant-to-prosthesis ratios.

Maxillary Posterior Quadrant

The maxillary posterior quadrant is subject to the 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 anteriorises the position of the maxillary molars.

Placement of osseointegrated dental implants within the maxillary posterior quadrant is best delayed until the age of 15 years in females and 17 years in males.16 Mandibular anterior quadrant is the best location for the osseointegrated implant before skeletal maturation.

Mandibular Anterior Quadrant

The 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 within the anterior mandible should be of a retrievable design to permit for a mean increase of dental height of 5–6 mm, also as the anteroposterior growth.

Mandibular Posterior Quadrant

Mandibular posterior quadrant the dynamic growth and development of the posterior mandible within the transverse and anteroposterior dimensions including its rotational growth present multiple treatment concerns.

Placement of osseointegrated implants in the posterior mandibular quadrant is best delayed until skeletal maturation occurs.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Neha Kalantri is a practising dentist from Nashik.