Considerations in Dental Implant Placement in the Young Patient: A Surgeons Perspective

Jon D. Holmes, DMD, MD, FACS

Clinicians are often faced with young patients with missing teeth, and there is often associated pressure to replace these teeth with dental implants. When considering implant placement in younger patients, clinicians must be cognizant of the impact of further growth and dental arch development on the implant and adjacent teeth. Factors to consider include stage of dentofacial development, dental age, etiology of tooth loss, location of the missing teeth, and the potential need for site preservation or development strategies. Finally, clinicians should be aware of options for dealing with malposition that may develop as the patient ages. Careful planning at an early stage and communication between the orthodontist, restorative dentist, and surgeon is required for the best result. (Semin Orthod 2013;19: 24-36.) 2013 Elsevier Inc. All rights reserved.

linicians are often faced with young patients suffering from missing teeth. Etiologies vary and include congenital absence, trauma, decay, and more rarely, the surgical management of jaw tumors. Congenital absence of teeth linked to agenesis, oligodontia, and ectodermal dysplasia affects approximately 4.34% of patients.1 Tooth agenesis presents with a spectrum of severity: hypodontia refers to the absence of 1-6 teeth, oligodontia refers to the absence of 6 teeth, and anodontia refers to the loss of all teeth. In all cases, the third molar teeth are not considered.2 Congenital absence of maxillary lateral incisors occurs in 1%-2% of the population, and excluding third molars is second only to lower second premolars in this regard. Because they occupy such a crucial place in an esthetic smile, much has been written about the most effective replacement strategy for maxillary lateral incisors. Although

Private Practice, ClarkHolmes Oral and Facial Surgery of Alabama, Birmingham, AL; Clinical Professor, Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, AL. Address correspondence to Jon D. Holmes, DMD, MD, FACS, Clark Holmes Oral and Facial Surgery of Alabama, 1500 19th Street South, Birmingham, AL 35205. E-mail: j-holmes@mindspring.com 2013 Elsevier Inc. All rights reserved. 1073-8746/13/1901-0$30.00/0 http://dx.doi.org/10.1053/j.sodo.2012.10.001

canine substitution, restorative replacement with bridgework, and even autotransplantation offer options for replacement, implants remain a viable technique, and are often pursued by patients and families.2-5 Implants are often perceived as the most conservative approach because adjacent teeth do not require modication. They are frequently seen by the lay person as an ideal substitution for a missing tooth, without understanding the implications of placing them in a growing patient, and there is an acknowledged pressure to use implants in younger patients.6 Often, the rst question to a clinician when young patients present with missing teeth secondary to trauma, or after tumor resections that necessitated removal of permanent teeth, is when the teeth will be replaced. Not infrequently, patients with congenital absence of permanent teeth are referred to the surgeon at or near the conclusion of orthodontic therapy, requesting replacements. In addition, some clinicians believe early placement of dental implants will preserve bone, and have encouraged early referral for placement of dental implants after tooth loss. Several studies have validated the concept of osseointegration in a growing patient.7,8 Advantages of the implant approach include no preparation of adjacent teeth and the aforemen-

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tioned potential for preservation of bone. Questions remain, however, regarding appropriate timing, as further facial growth and development will result in changes of the remaining natural dentition and can lead to signicant malposition of the implant.9 With regard to anterior implants, an ideal esthetic result often remains a signicant challenge with implant replacement regardless of age at placement. Obtaining intact papillae and excellent stable gingival contours with implants is the challenge in implants placed in the esthetic zone, and is often dependent on the biotype (thick vs thin) of the patient, and maneuvers to prepare the implant site.10 Sharma and Vargervik7 offered a classication scheme when considering implants in the growing child. Group I consisted of patients with congenital missing teeth having adjacent permanent teeth; group II included children missing multiple teeth, with permanent teeth adjacent to the edentulous sites; and nally, group III included patients who were either completely edentulous in 1 arch or have only 1 or 2 teeth in poor position within the arch. Group III patients often represent patients suffering from ectodermal dysplasia. Given space limitations and the signicant differences in management strategies, this discussion will exclude group III, including cases of oligodontia and anodontia, and instead will focus on young patients presenting with 1 or 2 missing teeth, which often must consider adjacent permanent teeth. Placement of dental implants in the very young is a viable option in some severe cases of oligodontia and anodontia, and excellent reviews on treatment strategies for these patients are available.7,11 When implants are considered in the young patient population, clinicians must have a complete understanding of issues such as timing, site development, and managing complications that can occur with placement in the young patient. Dealing with these issues requires close interaction between the orthodontist, surgeon, and restorative dentist, and the purpose of this article is to address these issues from a surgeons perspective. This review will focus on implants placed for prosthetic reasons and not on implants placed for orthodontic anchorage. In addition, it will focus on patients in the permanent dentition stage and not on patients in primary or mixed dentition, with the exception of patients with retained primary teeth lacking a succedaneous successor.

Timing Issues
The impact of facial development and growth on dental implant therapy has long been established. More recently, investigators have established that changes in the dental arch and facial skeleton continue into adulthood, and the impact on dental implant position relative to the natural teeth can be signicant.12,13 Although implants do not restrict growth per se, they can restrict the development of the alveolus and counter the natural mesial drift of the remaining dentition. The ankylosed tooth serves as an excellent model for what happens to implants placed before facial growth is complete. Malmgren and Malmgren14 demonstrated that reimplanted incisors that had ankylosed resulted in age-dependent degrees of infraocclusion: 3 1.5 mm in patients younger than 10 years, 2.5 mm in patients aged 10-12 years, and 1.5 mm in those aged 12-16 years.14 The amount of implant submergence and displacement depends on multiple factors, including the patients skeletal and dental age and growth pattern. A complete review of the mechanisms of facial growth is beyond the scope of this review, but concepts as they apply to timing of implant placement should be reviewed. Growth of the facial skeleton can be complete as early as at age 16-17 years in female individuals and as late as at age 21-22 years in male individuals.2,7 Contemporary research has demonstrated the continual changes to the maxilla and mandible throughout life, making it truly a moving target.12 Although one can speak in generalities regarding the impact of facial growth on implant timing and position, the impact of growth and development on the maxillary implants differs signicantly from those placed in the mandible and indeed within the various areas of each of the respective arches. Patterns of facial growth, ie, long face syndrome (LFS), short face syndrome (SFS), and normal growth pattern, can have different inuences on nal implant position even when the xtures are placed after facial growth is normally considered complete.15 Along with facial growth patterns, signicant differences exist between the maxilla and mandible with regard to dental implant timing and positioning.

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Maxilla
Changes in the maxilla often result in most signicant and esthetically disappointing alterations in the position of implants. Up to age 7 years, most maxillary growth occurs by displacement, whereas after age 7 years, most development is by enlargement of the maxilla.16 The maxilla moves down and forward as primary and permanent teeth develop and bone apposition occurs at sutures.7 The signicant vertical growth of the anterior maxilla and resulting infraocclusion of an implant placed early can lead to signicant challenges in obtaining an esthetically pleasing restoration. Thilander et al17 demonstrated a clear correlation between body length growth and implant infraocclusion. Odman and Thilander both demonstrated that implants placed before growth is complete do not change position, and do not move vertically with the remainder of the dentition, which leads to palatal displacement, as well as infraocclusion.18,19 Although transverse growth of the maxilla ceases early, implants placed up to age 9 years will result in formation of a diastema. Complications arising from transverse growth are typically worse in patients with short faces because transverse growth continues longer. Sagittal growth can result in loss of bone on the labial surface of the implant, which can lead to an unesthetic metallic thread showing through the labial tissue and an unhealthy periodontium, especially in thin biotypes.15 Facial growth patterns should be taken into account when planning maxillary implants. Vertical growth typically slows signicantly in female individuals around the age of 17 years and male individuals around the age of 20 years, but wide variations exist depending on the facial growth pattern. Signicant vertical growth of the maxilla can occur up to the age of 25 years in patients with a vertical growth pattern (LFS), and a vertical growth pattern is especially problematic because the patients usually have high smile lines, which will display the gingival margin. In a short face (SFS) or horizontal growth pattern, palatal displacement of implants will typically be more of an issue than infraocclusion because vertical changes of the maxilla tend to cease earlier around the age of 13 years. In a horizontal pattern, the natural teeth tip forward to compensate for forward growth of mandible up to

age 25 years, which will not occur with an implant.15

Mandible
Relative to the maxilla, growth and development of the mandible typically has less impact on implant position, and it is usually more forgiving from an esthetic standpoint. Growth of the mandible is usually complete 2-3 years after menarche (age, 14-15 years) in female individuals and can continue in male individuals up until age 20 years, but typically most growth is complete by age 18 years. Transverse growth in the anterior is usually complete well before the adolescent growth spurt. As a result, the anterior mandible between the mandibular foramen probably changes the least, making it the most favorable area for early implant placement, especially in cases of severe oligodontia and anodontia.20 The growth of the mandible is also far less dependent on the development of teeth compared with the maxilla, which often results in a Class III relationship in cases of anodontia.6,20 Similarly, Thielander et al19 demonstrated that apposition of bone laterally combined with resorption on the lingual that accompanied mandibular growth in the posterior body region would lead to implants being displaced to the lingual. This did not seem to occur as much in the anterior mandible. Sagittal growth becomes an issue only as it relates to rotation of the mandible in the sagittal plane, which can result in changes in implant inclination and is somewhat dependent on the facial growth type: normal, short face pattern, and long face pattern.21 A vertical growth pattern (ie, long face) often leads to more signicant issues of implant inclination and submergences of the implant as the mandible rotates and the remaining dentition erupts to maintain contact with the maxillary teeth.20 A short face or horizontal growth pattern can similarly result in more signicant alterations of anterior implant position relative to the natural teeth. In the mandible, the horizontal growth pattern observed with SFS will often result in anterior mandible implants displacing lingual to the natural teeth, whereas in the more vertical growth pattern of LFS, implants will tend to become more labial and infraoccluded. In SFS, implants will typically develop infraocclusion in premolar

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area. Also, in SFS, the natural teeth must tip forward to compensate for forward growth of mandible up to age 25 years, and implants placed in this area will not follow. LFS will have pronounced vertical growth up to age 25 years, which can lead to rotation of the mandible and compensatory changes of the natural teeth, which will also not be accompanied by implants. An excellent summary of the effect of facial development, tooth eruption, and mesial drift on dental implants was published by Heij and is highly recommended.15 In the posterior mandible, growth continues longer when compared with the anterior mandible, and the resultant remodeling can result in displacement of the implant in a lingual direction. There is not as much data available on impact of growth on implants placed in posterior mandible, and patients are typically less demanding of early placement, given this locations lower esthetic impact, which may allow earlier placement if the surgeon takes into account the future direction of displacement. Knowledge of the various patterns of facial growth and the changes that occur in different areas within the maxillary and mandibular arches can allow the surgeon some small amount of latitude in the timing of implant placement and allow them to make some small adjustments in implant positioning to compensate for future growth. Often, the orthodontist can offer significant input on the facial growth pattern, and in most cases, orthodontics should be completed rst. There are cases, however, in which careful planning can result in earlier implant placement and use of the implant as absolute anchorage. This is typically more easily accomplished in the posterior maxilla or mandible, where prosthetic adjustments for implant position are more easily accomplished. Timing of Implant Placement (Evaluating Growth) When determining the ideal time for implant placement, patients and families should be educated as to the precedence of dental and skeletal age over chronologic age. It is well accepted that chronologic age is a poor indicator of dental development or facial growth, but parents often have a false impression of the specic age when denitive restoration can be undertaken. In gen-

eral, facial growth slightly lags long bone growth, but in most cases, clinicians require a more accurate assessment of the stage of facial development. Dental casts do not seem to be an accurate method of timing implant placement.6 Handwrist lms can be compared with developmental standards in an atlas and allow a reasonable estimation of the stage of facial growth.22 The gold standard, however, remains 2 superimposed cephalometric lms taken 1 year apart showing no change.22,23 For practical purposes, growth can be considered stable if there is no change in distance from nasion to menton over 1 year.2 More recently, cervical maturation evaluated on a cephalometric radiograph has been increasingly used to determine the stage of craniofacial growth and development with regards to surgical intervention for dentofacial deformities. Although no studies on cervical maturation as it relates to the timing of implant placement have been done to date, it may serve a role in determining suitability for timing of implant placement as well. This analysis is based on 6 stages based on changes in the concavity of the lower border of the vertebral body, as well as its shape and height of the second through fourth cervical vertebrae. Completion of growth is typied by a greater vertical than horizontal dimension and increased concavity of the lower border. Because most clinicians have easy access to cephalometric radiographs and are familiar with their analysis, this method offers a distinct advantage over hand-wrist lms as a onetime assessment of facial growth.24 Young Adults An important issue that has come to the forefront is the impact of changes that occur after growth has been complete. Despite our success in judging when the peak of facial growth has passed, our increased understanding of the continuous changes of the facial skeleton and soft tissue can make planning static replacements more challenging. Along with changes in the soft tissues, including thinning and lengthening of the upper lip, the dynamic nature of the facial skeleton is becoming more appreciated.12,25,26 Continuous eruption of the natural teeth can lead to infraocclusion of implants placed beyond the time in which growth is considered complete. Vertical changes of 0.12-1.86 mm have been demonstrated in adults up to age 40-55

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years.27 Thilander et al17 demonstrated that although function was good, infraocclusion after cessation of body length growth and craniofacial growth was common. Almost 50% of implants placed and restored between the ages of 13 and 17 years had unacceptable esthetics. He demonstrated that continuous eruption occurred after growth was complete and led to a rate of infraocclusion of 0.1 mm per year, and cautioned that small changes became more of an esthetic issue in unilateral replacements of anterior teeth secondary to the asymmetry of the gingival margin being more noticeable. His group found fewer problems with infraocclusion in the canine region compared with the incisor region at 10-year follow-up, and fewer problems with implants placed in the maxillary premolar area, which was most likely secondary to compensatory eruption of premolars in the opposing arch. Certainly, esthetics were less a concern in the premolar region in most patients. Multiple anterior implants placed in association with natural posterior teeth have the potential to develop an anterior open bite over time.7 Changes in arch length continue beyond the completion of facial growth as well.12 Although development of good interincisor contacts with orthodontics can decrease the amount of infraocclusion that develops, incisor wear will lead to eruption of adjacent teeth.19 In 2009, Thilander13 summarized his previous work and concluded that changes continue into early adulthood (to age 31 years). These changes resulted in bone loss, with vertical defects developing between adjacent teeth and implants, and the loss of bone on the buccal aspect of the implant. Bone loss and vertical defects were worse when the distance between the implant and natural tooth was decreased. These ndings claried the importance of orthodontics to create an adequate space, to maintain the space, and to place the natural teeth in a stable position, with good retention.17 These changes into adulthood are not limited to the maxilla. Although remodeling occurs throughout life, mandibular growth in the intercanine region is complete by age 11-12 years.7 Mandibular length and height, however, continue to develop into early adulthood, and the mandibular alveolus remodels throughout life, with eruption.28 Although esthetics may be less a concern, growth in the posterior mandible and infraocclusion of the implant can lead to poor

crown-to-root ratio and loading problems for the implant and restoration. A consensus conference in 1995 recommended that implant placement be delayed until facial/skeletal growth was complete, especially in partial edentulous cases, but the problem remains that age of growth cessation varies widely.15,29 Although the most signicant period of growth is age probably 9-15 years for girls and 11-17 years for boys, variability with facial growth patterns can add further uncertainty and should be taken into account when planning timing of placement.15 Informed consent, growth pattern, and the possibility that revision of implant position and/or prosthesis may be necessary should be taken into account during placement of implants before the age of 15 years in girls and 17 years in boys. Site Development and Preservation Strategies Sites with missing teeth often require development of bone and/or soft tissue to achieve an esthetic implant restoration. Strategies for creating an ideal site for an implant are often dependent on the etiology of the missing tooth. Issues related to site preparation for implant and restoration in a case of a congenital missing incisor, in which the lack of a developing tooth has left a decit of soft and hard tissue, will differ from those in which a patient presents with a nonsalvageable traumatized incisor, in which case the aim is site (or socket) preservation. The common goals of establishing a healthy bone foundation and soft-tissue envelope, however, are the same, and often require grafting of soft or hard tissues. Retained primary teeth without a successor or ankylosed and submerging permanent teeth that are distorting the arch and require removal present other challenges. For esthetic and functional placement of an implant, there must be adequate height, as well as adequate buccallingual dimension both coronally and apically. The orthodontist is often tasked with developing and maintaining adequate coronal and apical space to allow for successful implant placement without damage to adjacent teeth. Here we will review some different site preservation and development strategies for dental implants based on differing etiologies for the missing tooth or teeth. Importantly, it should be

Considerations in Dental Implant Placement in the Young Patient

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remembered that there is a role for site preservation and development in cases of nonimplant treatment plans as well. Congenital Absence of Teeth The majority of young patients presenting for consideration of dental implant rehabilitation are congenitally missing one or more teeth. Most commonly, this involves congenital missing lower premolars or maxillary lateral incisors. In cases of congenital missing teeth referred for implant consultation, consideration must be given to alternative strategies and frank discussion held with regard to outcome. Especially in cases of congenital missing lateral incisors, alternatives to implants may be the best choice.3-5 Once a decision has been made to pursue implant replacement, however, strategies to maximize bone quantity and quality should be initiated. These strategies are especially important in the anterior maxilla. Congenital absence of teeth in this area leads to a lack of bone height and width in most cases. In cases of congenitally missing teeth, there is often a retained primary tooth, which may be ankylosed. A decision must be made with regard to the disposition of the primary tooth in these cases. Extraction of retained primary molar teeth without a permanent successor leads to a loss of 25% of ridge width within 3 years and further 4% over next 3 years. Although this bone loss may not preclude placement of smaller implant, it may not be the most esthetic emergence prole.30 If possible, the primary tooth should be maintained (Fig 1). Ankylosed primary teeth that are submerging, however, are best removed early to avoid restriction of vertical growth of the alveolar process. These isolated defects are often compounded by tilting of the permanent teeth.11 In the posterior maxilla or mandible, Thilander et al17 recommended retaining primary teeth if erupting, but extraction if they were submering signicantly or altering arch form. Alternatively, decoronation can be an option for the ankylosing and submerging molar whether primary or permanent (refer to discussion of decoronation later in the text). In cases of extraction, the site can be grafted (refer to discussion later in the text), or alternatively, the distal permanent tooth can be allowed to erupt mesially for site development.

Figure 1. (A) Ankylosed primary lateral incisors maintained to preserve bone. (B) Extraction of primary lateral, with immediate implant placement. (C) Placement of abutment for immediate temporization. (Color version of gure is available online.)

In cases of a congenital missing lateral, buccallingual development is greatly aided by orthodontic site development: allowing the canine to erupt as near the central as possible followed by

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distalization.2 This may be aided by extraction of the primary lateral. It is important to take into account the space between the apices of the adjacent teeth and tailor mechanics to result in bodily movement of the cuspid while distalizing. Evaluation of root proximity in 3 dimensions can be difcult with periapical radiographs or panoramic radiographs, and a 3-dimensional cone-beam computed tomography can provide more information regarding the relationship of the adjacent roots (refer to discussion of spacing issues later in the text). In some cases, small adjustments to the angulation of the implant can allow the surgeon to avoid adjacent roots without compromising esthetics. Kokich et al31 have suggested that bone developed with orthodontic site development is more resistant to resorption and loss.32 When orthodontic site development is not possible or the opportunity has been lost, however, the site will often require development through soft- and hard-tissue grafting techniques. Loss of Teeth The incidence of trauma to the anterior incisors ranges from 5% to 11% in patients aged 8-12 years, with an increasing incidence seen with age and in male individuals. There is some suggestion that malocclusions with an overjet of 9 mm are more prone to maxillary incisor trauma.33 Peak incidence of traumatic injuries to anterior teeth occurs between the ages of 9 and 10 years.34 Therefore, most patients will wait 8-10 years before an implant is placed if it involves an anterior tooth. Similarly, young patients who present with a nonsalvageable decayed tooth requiring extraction may wait some years before replacement with a dental implant. Options for dealing with the retained tooth include extraction with or without bone grafting and decoronation. Decoronation can help maintain buccallingual dimensions and vertical bone height. Continued development of the alveolus with growth over the root can continue in some cases. Often the decoronated root undergoes gradual external replacement resorption and internal root resorption accompanied by vertical bone growth over the root fragment, instead of the vertical bone loss that accompanies infraocclusion35,36 (Fig 2). It should be noted, however, that apical

translation of the retained root fragment and associated loss of buccallingual dimension may not preclude grafting before implant placement in all cases, but may mitigate loss of width.37 Also, there may be some concern with placement of the implant if a substantial amount of root remains. Some authors have suggested removal of some dentin to hasten internal root resorbtion.37 Ankylosis of anterior teeth can lead to infraocclusion as well with restriction of the development of the anterior alveolus.14 The tooth will require decoronation, extraction, or surgical repositioning.38 This may occur after replantation of a traumatically avulsed tooth, or in cases of a retained primary tooth without a permanent successor. If a vertical defect is apparent with the adjacent tooth, the primary tooth is likely ankylosed, and it should probably be removed early in the authors opinion to maximize the potential for the bone to follow the adjacent teeth and develop some height. This is especially true when the ankylosis occurs before age 10 years.14 After the growth spurt, it becomes less important to remove an ankylosed tooth.37 Similarly, if a tooth is fractured, the coronal part can be extracted while maintaining the root fragment, which, similar to decoronation discussed earlier in the text, may aid in preserving bone and gingival contours. Alternatively, a choice may be made to extract the coronal part, and use orthodontic extrusion with a temporary crown buildup. If this choice is made, the clinician must weigh this prolonged treatment in the young patient against the alternatives.37 Extraction of anterior teeth can lead to signicant losses of alveolar dimension. Up to 20%30% of the buccallingual dimension can be lost in the maxillary central area compared with the control unextracted side.39 Some authors have reported up to 40%-60% resorption in the rst year on the facial aspect.40 Preservation of the alveolar dimensions is important for future implant placement, and use of different graft materials in an attempt to preserve the site have been investigated.41 This is especially important in patients with a thin biotype, who seem to be more susceptible to buccal resorption. Similar to the congenital missing tooth, often the best option for nonsalvageable teeth is extraction and to let the adjacent teeth erupt or drift into the

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Figure 2. (A) Ankylosed and submerging rst molar causing deformation of arch form. (B) Decoronation with removal of tooth to a level 2-3 mm below crest of alveolus and grafting. (C) Radiograph obtained 5 months postoperatively, demonstrating bone development over retained root. (D) Further ridge development and displacement of root fragment, which is undergoing slow resorption.

site with later distalization termed orthodontic site development. If a tooth requires extraction and orthodontic site development is not a good option, a decision must be made regarding placement of a graft in an attempt to preserve or augment alveolar dimensions. Unfortunately, the literature on socket-grafting procedures consists primarily of case studies or small case series examined in a retrospective manner. Although autogenous bone grafts remain the gold standard for most bone regeneration procedures, there is some evidence that autogenous bone grafts placed in areas where teeth are subjected to orthodontic forces may lead to an increase in root resorption compared with alloplasts, such as -tricalcium phosphates.42,43 Autogenous grafting also requires a donor site with its associated morbidity. Alternatives to autogenous bone include allografts, which originate from the same species, and xenografts, which originate from a different

species, typically from bovine or swine sources. Currently, most alloplasts used in dentistry are synthetic materials of hydroxyapatite (HA), tricalcium phosphates, or silicate-based bioactive glasses. With the exception of bone morphogenic protein, most of the allografts, xenografts, and alloplasts in use are osteoconductive, and have little osteoinductive potential. The ideal alloplast or allograft for grafting sites in which orthodontic movement may be performed is still in question, as is the ideal technique with which to place the graft (eg, with or without a membrane). A recent review by Reichert et al44 found low level of evidence to support the superiority of one graft material or technique over the other. Tiefengraber demonstrated good results with using membranes alone, without grafting, for support of healing of extraction sites in a split-mouth study. However, their use of a nonresorbable membrane resulted in the need for a second surgery for removal.45 Despite the het-

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erogenicity and anecdotal nature of most reports, it would appear that most tooth movement through allografts is uneventful. In some studies, certain xenograft HA materials do not impair tooth movement or eruption, but the material seemed to be displaced into the oral cavity as the tooth erupted. Incomplete resorption could lead to impaired tooth movement, especially in cases of a slowly resorbing alloplastic HA. For these reasons, slowly or nonresorbable HA ceramics should be avoided.46 Reichert et al47 also demonstrated good results with tooth movement through sites grafted with a resorbable HA bone allograft. This was a split-mouth study in patients requiring bilateral bicuspid extractions. It is one of the few controlled studies. Although there have been some reports of slight root resorption with -tricalcium phosphate, overall, the material seems to have much better resorption properties and allows for more normal bone remodeling without interfering with tooth eruption or movement. Also, bioactive glasses seem to have little or no effect on tooth movement. In some cases, however, the material was encapsulated and sequestered out into the oral cavity similar to nonresorbable HA materials. In cases of extraction of teeth at an early age in which socket preservation is desired, the slower resorption may be of benet, but materials must be able to undergo resorption to allow tooth movement and bone remodeling. Normal tooth eruption appears to occur with bone morphogenic protein, the only material with true osteoinductive properties. Bone morphogenic protein has been shown not to impair normal tooth movement.44 Despite the fact that tooth movement and eruption can occur in the face of these allografts, questions remain regarding their utility and success in socket preservation. In one of the few prospective studies available, Sandor and colleagues demonstrated good results after grafting of posttraumatic and postextraction sites with resorbable coral granules in patients with a mean age of 13.6 years. These were patients with traumatic tooth loss or with ankylosed retained primary molars without a permanent successor (succedaneous) who received grafts with the intention of later implant placement. Although they did not show good site preservation in the anterior maxilla (82.4% of those who received grafts had inadequate bone for implant placement), they demon-

strated good results in the posterior maxilla and mandible (93.5% of grafted sites were adequate for implant placement).41 A question arises, however, regarding the possibility that these areas would have had adequate bone without grafting. Certainly, many questions remain regarding the ideal graft material, and often the best results are obtained when the surgeon uses a material with which they are most familiar.42 It is likely that the younger the patient, the more likely the need for secondary grafting before implant placement despite any primary grafting at the time of tooth loss, and family should be informed accordingly. Although it often receives less attention than hard-tissue grafting, soft-tissue development is often required to provide adequate support for the bone grafts, provide healthy peri-implant tissue, and create esthetic soft-tissue contours. These maneuvers include connective tissue grafts and pedicled aps.10,28 It is often more difcult to quantify soft-tissue decits, and patients family often requires education as to their importance. These procedures are more commonly performed near the time of implant placement or restoration after the completion of growth. Some soft-tissue grafting, however, may be indicated after remodeling and thinning of the labial bone with aging to cover an unesthetic implant showing through soft tissue.

Spacing Issues
Implant placement requires adequate space for both the implant xture, as well as the nal restoration. Determining the amount of space needed is a critical rst step. If the contralateral tooth is present, determining the space between the teeth requires only measurement of the contralateral tooth. Unfortunately, in many cases of congenital missing laterals, both are missing. In these cases, alternative methods, such as Bolton analysis, the Golden proportion, or diagnostic wax-up by the restorative dentist can provide the orthodontist with valuable input on the proper dimensions.3-5 Although some authors have suggested 1 mm is adequate, ideally at least 1.5 mm is required at the coronal between adjacent teeth and an implant for periodontal health and esthetics.2 Less space will compromise bone levels between the implant and natural tooth and result in blunted or lack of esthetic papillae.48

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Papillae for single implants is determined by the bone height of the adjacent teeth. It is important to recall that movement of teeth in the adult may result in malposition of the papilla, especially in cases in which a large diastema is closed by moving centrals medially. This will not occur in children, so it is suggested that movement be accomplished early.49 Although smaller 1-piece implants are available that require less space, prosthodontic options are more limited. Interradicular spacing is often overlooked. Root angulation should be controlled to allow 5 mm between the roots. Loss of this apical space through inadequate retention after orthodontics and before implant placement is one of the more common problems encountered in the authors practice. Three-dimensional evaluation of the site using cone-beam computed tomography is the most reliable assessment of space between the roots. It may allow the surgeon to angle an implant slightly to avoid proximity to the roots. An esthetic gingival contour with adequate height in the area of the implant is often the most challenging to create. Most implant platforms are placed 3-4 mm apical to the gingival margin to allow esthetic gingival margins and emergence. It should be remembered that the crest of the alveolar bone in adolescents is typically at the level of the cementoenamel junction of the adjacent teeth, whereas it typically lies 2 mm apical in the healthy adult periodontium.2 Often, patients will nish orthodontic treatment years before implant placement, and care-

Figure 4. Good coronal and root space maintenance provided by Maryland bridge.

Figure 3. Radiograph demonstrating loss of coronal space after noncompliance with removable retainer.

ful planning must be done to ensure space maintenance. This must include both the coronal spacing and space between the roots. If implants are planned within 6-12 months of orthodontic completion, a removable-type appliance, such as an Essix or Hawley type with a pontic, is usually sufcient. However, if there will be a greater delay, then consideration should be given to space maintenance that is less dependent on patient compliance (Fig 3). In the authors practice, resin-bonded bridges seem to offer several distinct advantages: there is little or no preparation of the adjacent teeth, they seem to control the position of the crown and root of the adjacent teeth well, they are less dependent on patient compliance, and nally, the pontic does not impinge on the future implant site, which is especially important for primary and secondary grafted sites (Fig 4). They can also be removed and replaced to allow placement of an implant. The advantages of resin-bonded bridges have been outlined by others as well.2,50 Their use may be challenging in cases of deep bite and high interincisal angles. Some authors have suggested use of miniscrews with a temporary restoration; there is a theoretic concern that the screw could impair vertical development of the

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alveolus and result in a vertical defect, which will require further site development.50 It is likely that one of the most important components of orthodontic preparation is a careful debrieng at the end of orthodontic treatment to outline to the patient and family the goals of space maintenance and timing of the next step in the implant process. Dealing with Implant Malposition Despite our efforts to plan and execute the best implant restoration, further development can result in infraocclusion of the implant restoration or an open bite. In some minor cases, replacement of the restoration may be all that is required. In more extreme cases, surgeons often must be creative in their approach. One should avoid the impulse to remove the implant and graft for later implant placement, without considering alternative treatments for the malposed implant. Often, implants can be repositioned using osteotomies, with immediate repositioning or distraction osteogenesis if distance is too great to move without compromising the blood supply. Similar techniques have been used in cases of ankylosed teeth, and are applicable to the implant as well.38,51,52 In cases in which further eruption of natural posterior teeth has resulted in an anterior open bite of multiple anterior implants, it is often more prudent and more conservative to perform a segmental osteotomy with repositioning than removal of the implants.

until growth is complete in most cases. Although implants may not be placed before growth is complete, planning for their future placement early can allow for orthodontic site development, and early consultation is required. Orthodontic site preparation or early grafting may be indicated, making early consultation and input from the orthodontist, restorative dentist, and surgeon necessary to ensure the best outcome. It is also important to recall that the face continues to change throughout a patients lifetime, and timing the placement of an implant will always be a compromise, with the potential changes necessitating revision in some cases through alterations of the restoration or implant position itself. By far, the riskiest area for early placement is the anterior maxilla, followed by the posterior maxilla. Multidisciplinary planning with input from the orthodontist, restorative dentist, and surgeon is the key to success in planning implant placement in the young patient.

References
1. Silverman NE, Oligodontia AJL: A study of its prevalence and variation in 4032 children. J Dent Child 46:470-477, 1979 2. Krasnig M, Fickl S: Congenitally missing lateral incisors-a comparison between restorative, implant and orthodontic approaches. Dent Clin North Am 5:283-299, 2011 3. Kokich VO, Kinzer GA: Managing congenitally missing lateral incisors. Part I: Canine substitution. J Esthet Restorative Dent 17:5-10, 2005 4. Kokich VO, Kinzer GA: Managing congenitally missing lateral incisors. Part II: Tooth-supported restorations. J Esthet Restorative Dent 17:76-84, 2005 5. Kokich VO, Kinzer GA: Managing congenitally missing lateral incisors. Part III: Single-tooth implants. J Esthet Restorative Dent 17:202-210, 2005 6. Cronin RJ, Oesterle LJ: Implant use in growing patients. Treatment planning concerns. Dent Clin North Am 42: 1-34, 1998 7. Sharma AB, Vargervik K: Using implants for the growing child. J Calif Dent Assoc 34:719-724, 2006 8. Westwood RM, Duncan JM: Implants in adolescents: A literature review and case reports. Int J Oral Maxillofac Implants 11:750-755, 1996 9. Hwang D, Wang HL: Medical contraindications to implant therapy: Part II: Relative contraindications. Implant Dent 16:13-23, 2007 10. Matouk M, Sclar AG: Oral connective tissue grafting: Evidence-based principles for predictable success. Oral Maxillofac Surg Clin North Am 14:241-257, 2002 11. Sclar AG, Kannikal J, Ferreira CF, et al: Treatment planning and surgical considerations in implant therapy for patients with agenesis, oligosontia and ectodermal dysplasia: Review and case presentation. J Oral Maxillofac Surg 67(suppl 3):2-12, 2009

Conclusions
Implants have become a well-known option to most patients and families, and are often seen by family and clinicians as an ideal replacement. Less well known to family members and patients is the need for waiting, and careful interdisciplinary planning. Family or patients often put pressure on the clinician to proceed with tooth replacement. Clinicians should resist and take the time to develop a multidisciplinary plan that has the highest chance of long-term success from a functional and esthetic standpoint. Clinicians must educate patients and their family with regard to the alternatives available to implant therapy. If implants are chosen, they must then be counseled on the necessary steps to prepare for implant placement and the need for waiting

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