Dental Implants a myth or a possibility in Pediatric patients.

1. 1

2. IMPLANTS IN PEDODONTICS
BY
DEEPASHREE PAUL
2

3. WHAT IS AN IMPLANT?
A prosthetic device made of alloplastic material implanted
into the oral tissues beneath the mucosa and/or periosteal
layer, and on/within the bone to provide retention or support
to a prosthesis.
The final restoration looks, feels, & functions like a natural
tooth
3

4. HISTORY OF DENTAL
IMPLANTS
In 1952, Professor Per-Ingvar Branemark, a Swedish
surgeon, while conducting research into the healing patterns
of bone tissue, accidentally discovered that when pure
titanium comes into direct contact with the living bone
tissue, the two
literally grow together to form a permanent biological
adhesion. He named this phenomenon "osseointegration".
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5. FIRST IMPLANT DESIGN
BY BRANEMARK
All current implant
designs are
modifications of this
initial design
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6. Ledermann 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.
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7. TILL DATE IT WAS
BELIEVED THAT….
The replacement of teeth by implants is restricted to patients
with completed craniofacial growth.
Congenital partial anodontia and traumatic tooth loss are
frequently encountered in pediatric patients.
In such cases, oral rehabilitation is required even before
skeletal and dental maturation has occurred.
Removable partial denture is the treatment of choice, but it
has certain complications like increased caries rate,
periodontal complications, and increased residual alveolar
resorption.
Many authors have discussed the use of implants in children.
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8. SCANDINAVIAN CONSENSUS
CONFERENCE IN SONKOPING,
SWEDEN. 1996
At the consensus conference on oral implants in young
patients, it was agreed that implants should not be placed
until growth and skeletal development is completed or nearly
completed. ED and anodontia were made exceptions.
Also, back in 1988 according to National Institute of Health
consensus Development Conference on Dental Implants at
Bethesda, pediatric patients with ED could benefit from the
use of dental implants. Implants in the mandibular anterior
region can be placed to support an overdenture, from the age
of around 6 years, when the median sutures of the mandible
is closed.
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9. Dental implants for children are a new treatment modality.
There are two primary concerns:
(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.
9

10. 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.
In case of congenital partial anodontia, little alveolar bone is
present and placement of dental implant changes the load
mechanism on bone and retards its resorption.
So, these advantages must be weighed against the lack of long-
term in vivo evidence-based studies supporting the use of dental
implants in a child.
Oesterle LJ, Cronin RJ Jr, Ranly D. Maxillary implants and the growing patient. Int J Oral Maxillofac Implants 1993;8:377-87.
Cronin RJ Jr, Oesterle LJ. Implants use in growing patients. Dent Clin North Am 1998;42:1-35.
10

11. SUGGESTIONS FOR IMPLANT
PLACEMENT IN UNAFFECTED
PATIENTS
Extreme caution must be used in placing implants in children
because of growth changes in jaw and the dentition.
Whenever possible, implant placement must be delayed until
the age of 15 years for girls and 18 years for boys.
Growing patient treated with dental implant should have
adequate follow-up.
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.
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12. REASONS FOR THIS
EXCEPTION
In the totally anodontic patient, the vertical and
anteroposterior changes in alveolar development would be
minimal in whom considerable dental changes can be
expected with growth.
Psychological support
12

13. It is still recommended to wait for the completion of dental
and skeletal growth, except for severe cases of ED.
The ectodermal dysplasias represent a group of inherited disorders
characterized by defects in tissues that are derived from ectoderm. Freire-
Maia and Pinheiro describe more than 100 different taxonomic groupings of
ectodermal dysplasia across a wide spectrum of clinical presentation.
The classic form of ectodermal dysplasia (Christ-Siemens- Touraine
syndrome) is thought to be X-linked and involves hypodontia, hypohidrosis,
hypotrichosis, and a characteristic facies. Because these individuals don't
sweat, this condition is sometimes referred to as X-linked, hypohidrotic
ectodermal dysplasia (XLHED).
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14. In a monocentric prospective study, the survival rate of implants
placed in the anterior mandible of pediatric patients with ED was
reported with 91% (Guckes et al. 2002).
Interestingly, some reports have demonstrated that craniofacial
morphology did not differ significantly between implant-treated
and non-treated children with ED, suggesting that treatment with
intraosseous dental implants did not necessarily interrupt
normal craniofacial growth as assumed before (Johnson et al.
2002).
In the long run, implants located at the anterior mandible
probably seem affected by the mandibular growth rotation,
which can result in a change in implant angulation (Becktor et
al. 2001).
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15. GROWTH AND
IMPLANT PLACEMENT
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16. Transverse growth proceeds via mid palatal
suture. Increase is 3 times more posteriorly.
Although increase in width between posterior
teeth is smaller as a result of adaptive
changes within the dental arch. Length
increases by sutural growth and bone
apposition at the tuberosity; frontal part is
rather stable.
MAXILLA
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17. MANDIBLE
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18. The majority of transversal
growth of the mandible occurs
quite early in childhood; the
anteroposterior growth occurs
mainly at the posterior mandible
(Skieller et al. 1984).
In the last few years, several case reports of implant insertions in
the anterior mandible of children have been published (Bergendal
et al. 1991; Bergendal 2001; Kargul et al. 2001; Giray et al.
2003); most of the authors agree that the mandibular anterior
area seems to hold the greatest potential for very early use of an
implant-supported prosthesis
18

19. GROWTH
DETERMINATION
It is an important factor when planning implant placement in
children and adolescents.
No reliable indicator is available to determine when growth
has ceased.
Although, a good quality method is the use of serial
cephalometric radiograph taken 6 months apart with
superimposed orthodontic tracings. If no changes occur
over a period of 1 year, one may assume that growth is
complete.
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20. RECOMMENDATION FOR IMPLANT
PLACEMENT BY QUADRANT
Maxillary anterior quadrant
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.
20

21. Maxillary posterior quadrant
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.
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22. Mandibular anterior quadrant
It 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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23. 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.
23

24. The benefits of implant use in growing patients are as
important as the concerns for their premature use.
Reports were published by Cronin et al. and Smith et al.
documenting the placement of endosseous implants in the
anterior mandibular region as early as 5 years of age with
positive treatment results.
Prachar and Vaneek present the results of a 5-year study on
the use cylindrical or screw implants in adolescents of age
15-19 years. Regardless of the criterion used, the rate of
success was always higher than 96% over the 5 years of
study.
Whereas, Shaw reported that the dramatic growth changes
occurring in infancy and early childhood were not conducive
to the maintenance of implants.
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25. Planning dental
implants
25

26. IMPLANT
PROCEDURE/ STEPS
The dental implant process involves several steps that take
place over a time period that ranges from 0 to 6 months.
The typical process will include:
1. Pre-treatment consultation
2. Implant placement
3. Prosthetic attachment & loading
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27. PATIENT
CONSIDERATIONS
Medical history
– vascular disease
– immunodeficiency
– diabetes mellitus
– bisphosphonate use Biocompatibility of Material
Desired Mechanical Properties
• High yield strength
• Modulus close to that of bone
• Built-in margin of safety: Changes in
environment around implant
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28. Metallic Implant Surface
Problem:
Implant surface change with time due to oxidation,
precipitation…
Possible solutions:
• Oxide layers ( minimize ion release)
• Prosthetic component from noble alloys
• Phase stabilizers other than Al & V (eg. Ti-13Nb-
13Zr, Ti-15Mo-2.8Nb )
• Surface Modifications
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29. PRE-TREATMENT
CONSULTATION
Careful evaluation of dental and medical history to determine
if he/she is a good candidate
May include consultation with a specialist
May include specialized testing, i.e. CAT Scan, CBCT etc
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30. Limitations to Implant placement in the Maxilla
• Ridge width
• Ridge height
• Bone quality
Anatomic Limitations
Buccal Plate 0.5mm
Lingual Plate 1.0 mm
Maxillary Sinus 1.0 mm
Nasal Cavity 1.0mm
Incisive canal Avoid
Interimplant distance 1-1.5mm
Inferior alveolar canal 2.0mm
Mental nerve 5mm from foramen
Inferior border 1 mm
Adjacent to natural tooth 0.5mm
ANATOMIC CONSIDERATIONS
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31. RADIOGRAPHIC
EXAMINATION
Panoramic radiograph
• 20 to 30% distortion/magnification of the
anatomic structures
• Buccal to lingual width will not be appreciated
• Alveolar bone height, adjacent teeth and
anatomic structure.
CBCT or CT gives a more
detailed picture.
31

32. INITIAL PLACEMENT
Place the dental implant
The healing period for dental implants varies depending on
the location and the health of the bone.
It can be as little as 6 weeks or as much as four months.
During this time, osseointegration takes place
The bone will heal & bond to the surface of the implant
32

33. First Surgical Phase (Implant Placement)
Under Local anesthetic the dentist places dental
implants into the jaw bone with a very precise
surgical procedure. The implant remains covered
by gum tissue while fusing to the jaw bone.
Second Surgical Phase (Implant Uncovery)
After approximately six months of healing. Under
local anesthetic, the implant root is exposed and a
healing post is placed over top of it so that the
gum tissue heals around the post.
Prosthetic Phase (Teeth)
Once the gums have healed, an implant crown is
fabricated and screwed down to the implant.
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34. SURGICAL PHASE-
TREATMENT PLANNING
• Evaluation of Implant Site
• Radiographic Evaluation
• Bone Height, Bone Width and Anatomic
considerations Basic Principles
• Soft/ hard tissue graft bed
• Existing occlusion/ dentition
• Simultaneous vs. delayed reconstruction
Anatomic Considerations
• Ridge relationship
• Attached tissue
• Interarch clearance
• Inferior alveolar nerve
• Maxillary sinus
• Floor of nose
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35. SURGICAL
PROCEDURE
STEP 1: INITIAL SURGERY
STEP 2: OSSEOINTEGRATION PERIOD
STEP 3: ABUTMENT CONNECTION
STEP 4: FINAL PROSTHETIC
RESTORATION
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36. FIBRO-OSSEOUS
INTEGRATION
• Fibroosseous integration
– “tissue to implant contact with dense collagenous
tissue between the implant and bone”
• Seen in earlier implant systems.
• Initially good success rates but extremely
poor long term success.
• Considered a “failure” by todays standards
Microscopic
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37. OSSEOINTEGRATION
Success Rates >90%
• Histologic definition
–“direct connection between living bone and loadbearing
endosseous implants at the light
microscopic level.”
Four factors that influence:
1. Biocompatible material
2. Implant adapted to prepared site
3. Atraumatic surgery
4. Undisturbed healing phase
37

38. Titanium implant (black) integrated into
bone (red): Histologic section
38

39. THEORIES OF
OSSEOINTEGRATION
Brånemark’s theory – implants integrate such that the bone
is laid very close to the implant without any intervening
connective tissue. The titanium oxide permanently fuses with
the bone, as Brånemark showed in 1950s.
Weiss' theory – fibro-osseous ligament formed between the
implant and the bone equivalent of the periodontal ligament
found in the gomphosis. He interpreted it as the peri-
implantal ligament with an osteogenic effect. He advocates
the early loading of the implant
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41. PROSTHETIC
PLACEMENT & LOADING
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43. 43

44. Screw Implants
(Left to Right: TPS screw,
Ledermann screw,
Branemark screw, ITI
Bonefit screw)
Cylinder Implants
(Left to Right: IMZ, Integral,
Frialit-1 step-cylinder,
Frialit-2 step-cylinder)
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45. OSSEOUO-INTEGRATED
IMPLANTS
A. Titanium screw.
B. Hydroxyapatite-coated screw.
C. Titanium plasma sprayed cylinder.
D. Hydroxyapatite coated cylinder
Rosenstiel et al, 2006
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46. ABUTMENT
MATERIALS
Titanium Zirconium Lithium disilicate on titanium base
46

47. STAINLESS STEEL
 Guide drill
 2mm twist drill
 Pilot drill
 3mm twist drill
 Countersink
TITANIUM
• Tap
• Implant
• Coverscrew
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48. OTHER TYPES
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49. SUBPERIOSTEAL
IMPLANTS
49

50. TISSUE RESPONSE TO
IMPLANTATION
Stages include
1. hematoma formation and mesenchymal tissue development
2. woven bone formation through the intramembranous
pathway
3. lamellar bone formation on the spicules of woven bone
Blood cells entrapped at the implant interface are activated and
release cytokines and other soluble, growth and differentiation
factors
The formed fibrin matrix acts as a scaffold (osteoconduction) for
the migration of osteogenic cells and eventual differentiation
(osteoinduction) of these cells in the healing compartment
Osteogenic cells form osteoid tissue and new trabecular bone
that eventually remodels into lamellar bone in direct contact
with most of the implant surface (osseointegration)
50

51. PERI-IMPLANT
OSTEOGENESIS
Peri-implant osteogenesis can be in distance and in contact
from the host bone.
Distance osteogenesis refers to the newly formed peri-
implant bone trabeculae that develop from the host bone
cavity towards the implant surface.
Contact osteogenesis refers to the newly formed peri-implant
bone that develops from the implant to the healing bone
A thin layer of calcified and osteoid tissue is deposited by
osteoblasts directly on the implant surface. Blood vessels
and mesenchymal cells fill the spaces where no calcified
tissue is present
51

52. The early peri-implant trabecular bone formation ensures
tissue anchorage that corresponds to biological fixation of
the implant. This begins at 10 to 14 days.
At three months post-implantation, a mixed bone texture of
woven and lamellar matrix can be found around different
types of titanium implants
Implant anchorage
Dr. C. de Putter (1985) proposed two ways
of implant anchorage or retention –
mechanical and bioactive
52

53. HEALING
Soft-tissue to implant interface
• Successful implants have an– Unbroken, perimucosal seal between
the soft tissue and the implant abutment surface.
• Connect similarly to natural teeth-some differences.
– Epithelium attaches to surface of titanium much like a natural tooth
through a basal lamina and the formation of hemidesmosomes.
Connection differs at the connective tissue
level.
• Natural tooth Sharpies fibers extent from the bundle bone of the
lamina dura and insert into the cementum of the tooth root surface
• Implant: No Cementum or Fiber insertion.
Hence the Epithelial surface attachment is IMPORTANT
53

54. FACTORS INHIBITING
OSSEOINTEGRATION
Excessive implant mobility and micromotion
Inappropriate porosity of the porous coating of the implant
Radiation therapy
Pharmacological agents such as cyclosporin A, methotrexate
and cisplatinum, warfarin and LMWH, NSAIDs especially
selective COX-2 inhibitors
Patient factors such as nutritional deficiency, renal
insufficiency etc
54

55. POINTS TO REMEMBER
• Metallic, ceramic or polymeric materials used (eg.
titanium, tantalum, aluminum, niobium, nickel, zirconium,
hafnium)
• Bone – implant connection need not be 100%
• Stability of fixation is more important than degree of
contact
• Clinically asymptomatic rigid fixation of alloplastic
materials is achieved, and maintained, in bone during
functional loading.
• When osseointegration occurs, the implant is tightly held
in place by the bone.
• The process typically takes several weeks or months to
occur
55

56. • First evidence of integration occurs after a few weeks,
while more robust connection is progressively effected
over the next months or years.
• Though the osseointegrated interface becomes resistant
to external shocks over time, it may be damaged by
prolonged adverse stimuli and overload, which may result
in implant failure.
• The absence of micromotion at the bone-implant interface
is necessary to enable proper osseointegration
56

57. • There is a critical threshold of micromotion above which a
fibrous encapsulation process occurs, rather than
osseointegration
• The absence of cementum on the implant surface
prevents the attachment of collagen fibers. However, when
such cells are present, cement may form on or around the
implant surface, and a functional collagen attachment may
attach to it
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