Drs. Amr Zahran and Basma Mostafa present a case report detailing how careful use of implants in juvenile patients can yield positive results
Educational aims and objectives
This article aims to presents a divergent approach in which a modified split-crest technique was applied to treatment of a 13-year-old girl and both the positive and challenging aspects of treatment on younger patients.
Implant Practice US subscribers can answer the CE questions to earn 2 hours of CE from reading this article. Take the quiz by clicking here. Correctly answering the questions will demonstrate the reader can:
- Realize the various functional and psychological effects of missing teeth on young patients’ lives.
- Recognize some of the distinctive and significant differences between treating pediatric and adult patients.
- Recognize some procedures that may be necessary to provide adequate bone for implant placement.
- Realize some of the notably different aspects of the use of implants in youth from adults.
- Realize some of the advantages and disadvantages of placing dental implants on young patients.
This case report presents a divergent approach in which a modified split-crest technique was applied using a piezoelectric tip, one drill, and tapered implants. The split-crest surgery was performed with immediate placement of two tapered self-tapping dental implants in the anterior maxilla of a 13-year-old female patient. The patient had lost four of her maxillary anterior teeth as a result of an accident at 9 years old, with subsequent severe alveolar ridge resorption, leading to an average buccopalatal ridge width of less than 4 mm.
At 6 months postoperatively, the average increase of the alveolar ridge width was evaluated using cone beam computed tomography (CBCT) and found to be 1.92 ± 0.04 mm. The stability of the implants was also evaluated at 6 months, using the Periotest M (PTM) system. The two implants were found to have PTM values of -2.3 and -2.8, indicating good osseointegration. After 2 years, the PTM values were -2.4 and -2.8, with a 100% survival rate of the two osseointegrated implants. The implants were restored using a polyetheretherketone (PEEK) bridge, providing both satisfying function and esthetics to the patient.
Tooth loss as a result of trauma or congenital absence presents a major problem in young individuals. It causes functional impairment in addition to psychological disturbances (Wang, et al., 2015). Missing teeth in youth have been reported to have a negative impact on individuals’ emotional condition, social relations, and speech; smiling; and overall performance (Brahmin 2005). In such cases, oral rehabilitation is mandatory, even before reaching complete skeletal and dental maturation. The removable partial denture has been considered as the first treatment option in such conditions due to its ease of construction and relatively lower cost.
However, certain drawbacks are associated with this treatment modality such as a high incidence of caries, periodontal problems, and increased residual alveolar bone resorption. In addition, its removable nature is not favored by many patients.
Another recommendation for replacing the missing teeth is the resin-bonded bridge. It has been reported that this type of bridge has satisfying survival rates with debonding as a major concern.
These solutions have led many authors to discuss the use of implants in young patients (Mishra 2103).
The success and predictability of dental implant placement in adults requires optimum quality and quantity of alveolar bone. Proper treatment planning, as well as correctly performed surgery, is essential.
In addition, appropriate prosthetic restoration with good oral hygiene maintenance is also needed.
The same factors are also necessary for successful dental implants when placed in children, adolescents, or young adults in certain cases.
The distinctive and significant difference between treating pediatric and adult patients is that the outcome and success of treatment is highly influenced by the craniofacial growth and dentoalveolar development. Implants present for several years during facial growth can be embedded, relocated, or displaced during the growth of the jaws. The changes that occur as the adolescent grows should be compensated for by continuous design adjustment (Shah, et al., 2013; Percinoto, et al., 2001).
The most important target when using dental implants in growing patients is the preservation of bone. In cases of partially missing teeth, the insertion of dental implants can change the load mechanism to which bone is subjected and hence retard its resorption. Tooth loss as a result of trauma can affect the availability of sufficient bone volume for placing dental implants in many young healthy individuals due to the subsequent alveolar bone resorption following tooth extraction (Op Heij, et al., 2003; Sharma and Vergervik, 2006).
Various procedures may be necessary to provide adequate bone for implant placement. Bone augmentation with autogenous bone or any other grafting materials can be used. Guided bone regeneration (GBR) procedures using barriers and bone expansion or splitting techniques have been adopted for management of such volume deficiencies. Many of the drawbacks of using GBR — the invasiveness, potential need for a supplementary donor site, resorption of grafting materials, membrane collapse, exposure to infection, and delaying of implant installation for grafting maturation — have also been associated and recorded with using of autogenous grafts and membranes (Sharma and Vergervik, 2006; Schropp, et al., 2003; Aghaloo and Moy, 2007; McAllister and Haghighat, 2007; Machtei 2001).
Accordingly, there has been some discussion of applying noninvasive techniques of ridge splitting and expansion that do not subject the patient to much trauma. Several of these ridge-split techniques have been discussed in recent years, including the split-crest osteotomy, ridge expansion osteotomy, and frequent modifications of those techniques (Guirado, et al., 2005).
This case report differs from the norm in performing a modified split-crest technique followed by immediate implant placement in a young patient to manage the atrophic maxillary ridge. The first author has previously described a modified approach of this technique within which expansion of the alveolar ridge and immediate implant placement are combined in a single process. Several instruments, including a piezoelectric tip and one tapered osteotomy drill, are essential to this technique.
In this case, the tapered implants were positioned into the determined osteotomy sites within the split channel. This placement was used to expand the bone during seating of the implants (Zahran, et al., 2016).
To the authors’ knowledge, this is the first case reporting the application of these approaches at such a young age.
This 13-year-old girl was referred to the first author’s private clinic. She was healthy with a normal medical history documented by the Cornell Medical Index Questionnaire (Brodman, et al., 1951).
She had been involved in a bicycle accident at 9 years old and subsequently lost four of her upper anterior teeth. She had been wearing a partial denture since the accident and was not satisfied with having a removable prosthesis.
The patient found her partial denture inconvenient and struggled with an inability to pronounce certain words. Her removable prosthesis required frequent removal for cleaning purposes following eating, and she was often teased for this. She was afraid to participate in various sporting activities for fear of dislodging the denture, which had a negative impact on her social life.
Clinical intraoral examinations revealed the absence of the maxillary anterior teeth with presence of severely atrophic ridge (Figure 1). Radiographic examination showed severe loss of the bone width at the edentulous area (Figure 2). Wrist carpal radiographs and multiple cephalometric radiographs were taken and performed with superimposed orthodontic tracings to assess the degree of skeletal maturity of the jaw bones. No changes occurred over a period of 6 months, leading to the assumption that bone growth was nearly complete. (It was also evident that the patient was very similar physically and in height to her mother.)
The study protocol was reviewed and approved by the ethical committee at the Faculty of Oral and Dental Medicine of Cairo University.
Clinically, the edentulous site demonstrated insufficient bucco-palatal ridge width (less than 4 mm) with more than 10 mm of residual bone height and sufficient vertical intermaxillary arch space upon centric occlusion. No local or systemic conditions that might contraindicate minor oral surgeries were detected. Oral habits that might endanger the osseointegration process, such as smoking or parafunctional habits, were not recorded. The patient and her mother were fully informed about the associated risks of the procedures. The mother, as the responsible guardian, signed an informed consent form to document her approval.
Figure 1: Preoperative intraoral photograph showing the four missing upper anterior teeth with the maxillary ridge deficiency
Figure 2: Preoperative CBCT showing the deficient maxillary alveolar ridge width measurements
Figure 3: Bone channel created by piezosurgery
Figure 4: Immediate postoperative photograph showing placed implants with expansion of bone
Figure 5: Six-month postoperative CBCT showing the increase in ridge width and the implant in place
Figure 6: Re-entry after 6 months showing bone growth
A preoperative evaluation was carried out that included a visual examination and palpation of the entire oral and paraoral tissues. Study casts were prepared to evaluate the intermaxillary space and type of occlusion. The buccopalatal alveolar ridge width at the implant site was measured using a bone caliper. Periapical and panoramic radiographs were taken for the recipient sites. CBCT was performed on the assigned sites for the study in order to determine the buccopalatal alveolar ridge width at the implant sites preoperatively.
The patient was anesthetized locally by infiltration anesthesia. A palatal subcrestal incision was created for the surgical site. Two oblique releasing incisions were then made on the buccal aspect. Dissection of the full thickness mucoperiosteal flap was performed to provide complete exposure of the alveolar bone. Using a piezoelectric surgery unit (VarioSurg, NSK — using the SG1 tip), a horizontal crestal cut was created along the crest of the bone (Figure 3). The cut extended through the cortical bone to reach the spongy bone. The depth of the horizontal cut was approximately the same length of the implant to be inserted.
Two vertical cuts were then created, and these were connected to the horizontal crestal cut. After ridge splitting, the osteotomy site was prepared using the new OsteoCare™ 3.25 mm Ultra drill, and two OsteoCare Maxi Z flat-end 3.75 mm x 10 mm dental implants were placed (Figure 4), and their positions were confirmed by immediate postoperative periapical radiographs.
Careful seating of these tapered implants into the bone was performed until all exposed threads were submerged and the platform remained flush with the crestal bone; then cover screws were inserted into the implants. This positioning of the implants created expansion through deformation between the split bony plates. Closure of the flap was performed using interrupted sutures with a 4-0 black silk suture material (Assut sutures).
Postoperative patient management
- Augmentin (Medical Union Pharmaceuticals) 1g tablets were prescribed twice daily for 5 days.
- Analgesics (Brufen, Khaira Pharmaceuticals and Chemical Industries) were prescribed 200mg 3 times per day for 5 days.
- Oral hygiene recommendations were provided, including the use of a soft toothbrush.
After a healing period of 6 months, postoperative periapical radiographs as well as CBCT scans were taken (Figure 5), and the clinical and radiographic increase of the alveolar ridge width were recorded. Surgical re-entry was then undertaken in order to assess the success of the modified split-crest technique and to position the healing collars on the newly-exposed implants (Figure 6). The Periotest M (Medizintechnik Gulden) was used to test implant stability at 6 months (Figure 7) before cementation of the bridge, and again at 2 years postoperatively.
Two weeks after fixation of the healing collars, indirect impressions were taken using OsteoCare impression transfers for the open-tray transfer technique. Impressions were given to the dental laboratory for construction of milled Peek bridge (Najeeb, et al., 2016). After fixation of the abutments, the final bridge was cemented using zinc polycarboxylate cement (Figure 8).
Figure 7: Six-month postoperative photograph showing the fixed healing collars to the implants with the use of the Periotest M to confirm osseointegration
Figure 8: Photograph showing the cemented PEEK bridge
Figure 9A: Six-month postoperative periapical radiograph showing implants in place
Figure 9B: Two-year postoperative periapical radiograph showing implants in place
The patient underwent immediate postoperative, 6-month, and 2-year postoperative examination and evaluation. The examination and evaluation criteria included review for the presence of peri-implant infection, any complaint of local pain at the site of implant insertion, and any complaint of neuropathies or paraesthesia. In addition, the patient was clinically evaluated for implant mobility.
Standardized periapical radiographs (Figures 9A and 9B) using the parallel technique, as well as panoramic radiographs and CBCT, were undertaken preoperatively, immediately postoperatively (within the first 24 hours), at 6 months, and after 2 years. CBCT scans were used to evaluate the total gain in alveolar ridge width in the buccopalatal dimension. They were also used to assess the stability of the marginal bone around the implant after the procedure and to record the postoperative ridge width.
The raw data obtained from the CBCT scan was imported into bespoke third-party software for secondary reconstruction and further clinical interpretation. The results recorded from each of the data sets were compared.
The preoperative image was fused to the postoperative image by manual registration through landmarks in the cranium. Accurate registration (superimposition) was automatically performed by the software.
Each image (primary and secondary) was color-coded for identification. First, key point measurements were recorded onto the primary image. The measurements on the primary image were held, and the primary image was removed to leave the secondary image. New measurements were then recorded on the secondary image in the identical plane, direction, and cut as that of the primary image to ensure standardization. The obtained data was then presented.
Two self-tapping titanium dental implants were placed in a 13-year-old female patient during the split-crest procedure. The diameter of the two inserted implants was 3.75 mm with a length of 10 mm.
Wound healing was normal around all the positioned implants without any signs of infection, suppuration, or mucositis at the peri-implant area. Initial pain and minor swelling was noted. These conditions were completely resolved by the 10th day postoperatively.
Osseointegration was clinically and radiographically checked and proven to be successful. The success criteria were a lack of mobility as checked by the Periotest M, and the absence of radiographic radiolucency at the bone-implant interface. The 2-year follow-up period showed the continued success of the treatment with no further bone loss as revealed radiographically.
Figure 10: Two-year postoperative photograph showing no discrepancy of occlusion
The preoperative bone width at the site of the first implant measured 3.72 mm. This changed after 6 months postoperatively to be 5.61 mm. The bone width gain was 1.89 mm. At the area where the second implant was inserted, the bone width was 3.70 mm, which changed after 6 months to 5.65 mm. The bone width gain was 1.95 mm.
The average bone width preoperatively was 3.71 ± 0.014 mm, which changed to 5.63 ± 0.028 mm after 6 months, showing a significant ridge width bone gain of 1.92 ± 0.042 mm with a p-value 0.0001.
The two implants were successfully osseointegrated when clinically assessed at 6 months postoperatively. The degrees of implant stability measured by Periotest M were -2.3 and -2.8 for the two implants after 6 months postoperatively. After 2 years, the Periotest M values were -2.4 and -2.8.
After the prosthesis was loaded, speech and pronunciation improved. Oral function was efficiently restored with high patient satisfaction within a limited time period. The 2-year follow-up reported no apparent vertical discrepancy between the implants and the adjacent natural teeth (Figure 10). The patient reported positive psychological consequence following the implant restoration and bridge fixation. At the end of the 2-year follow-up period, 100% success and survival rates were recorded.
The success and predictable long-term outcomes of dental implants in restoring partially edentulous cases in adults have been the base for many clinicians to broaden their application and use for younger patients who have lost their teeth as a result of agenesis and/or trauma (Shah, et al., 2013). Implant-supported prostheses can provide the essential requirements for proper function and esthetics (Tiedemann, et al., 2014).
The use of implants in youth differs notably from adults. Special attention must be given to the growth pattern of the young because a diversity of changes occurs in the dentition and jaws of these individuals (Mishra, et al., 2013). In adult patients, the use of osseointegrated dental implants is frequently the treatment of choice as their performance is independent from adjacent teeth.
Meanwhile, implant placement in young individuals involves the risk of position relationship problems due to the “ankylosed” nature of the implant. The implants placed in young individuals might not follow the dentoalveolar development. This nature could lead to infra-occlusion of the ankylosed implant with possible periodontal, occlusal, and esthetic consequences in the future.
On the other hand, reviewing the concept that has been established by various studies that alveolar remodelling and growth does not end at puberty and that vertical discrepancy between a single dental implant and its neighboring natural teeth may possibly still occur in adulthood encouraged us to insert the dental implant in our young 13-year-old patient (Mishra, et al., 2013; Bernard, et al., 2004; Jemt, et al., 2006). It was documented that the delay of dental implant insertion in youth does not essentially exclude future complications.
The placement of dental implants in young patients can provide both functional and psychological benefits.
The ankylosed implant is fixed into the alveolar bone and, therefore, might provide the patient with more natural sensation. On top of this, the security that a fixed prosthesis provides has a tremendous psychological benefit for the patient (Spriggs, et al., 2007), as occurred in this case with our female patient, who was happy and satisfied with her fixed restoration.
Papers have been published reporting the use of dental implants in the anterior mandibular area at 5 years of age with affirm-ative successful treatment results (Wang, et al., 2015). Prachar and Vaneek (2003) also presented the results of using both cylindrical or screw implants in youths aged 15-19 years. With the various measures performed, the success rate was constantly higher than 96% over the 5-year study period. These studies are in line with this case report, which shows 100% success and survival rates of the two inserted implants over the 2-year follow-up period.
On the other hand, Shaw (1977) has previously mentioned that the dramatic growth changes that occur in infancy and early childhood are not conducive to the maintenance of dental implants. Other researchers have suggested that treatment with implants must be postponed until the age of 13 years (which is in line with this case), since an implant placed at the age of 7 or 8 may not be in a favorable location when the patient is 16. These researchers concluded that the benefits of implant use in growing patients are as important as the concerns for their premature use (Kramer, et al., 2007).
The presence of a maxilla with deficient bone is a challenging issue in the use of dental implants for replacing missing teeth. Following tooth extraction as a result of trauma, a continuing alveolar bone resorption process is present, which leads to alveolar bone deficiency.
Where maxillary teeth are nonexistent, alveolar ridge development will be defective, and the maxilla will remain underdeveloped — both in the sagittal and vertical planes — causing inappropriate upper to lower jaw relationships (Ribeiro-Junior, et al., 2009). This was the condition in this case, which presented an average deficient ridge width of 3.71 ± 0.014 mm.
Many treatment modalities have been implemented for augmenting and correcting this defective alveolar bone (Aghaloo and Moy, 2007; McAllister and Haghighat, 2007). The modification of the split-crest technique previously discussed by Zahran, et al., 2016, was applied in this case and combined with immediate placement of tapered implants to expand the bone, as an alternative to the use of ridge expanders or osteotomes.
The tapered implants used in this case are more controllable during the expansion procedure, easing the bone plates apart gradually and minimizing the risk of fracturing the buccal plates. The two implants were successfully osseointegrated as revealed by the Periotest M values, and the supporting alveolar bone was also preserved.
This case is unusual in that, to the authors’ knowledge, it is the first attempt in performing the split-crest technique at such a young age. The obtained results of the current report revealed an average bone gain of 1.92 ± 0.042 mm after 6 months postoperatively, without the use of any bone grafting materials or barrier membranes to block the defective space.
These results were similar to many studies performed on adults that have reported satisfactory ridge bone gain without the use of grafting materials with a high success and survival rates. Chiapasco, et al., 2006, reported a final mean bone gain of 4 mm and Holtzclaw, et al., 2010, showed a mean bone gain of 4.03 mm. Meanwhile, Sohn, et al., 2010, reached a bone gain of 2.7 mm. Zahran, et al., 2016, revealed a total mean bone gain of 2.93 mm, also after 6 months, which is in line with the present work done.
Implant placement in our 13-year old patient allowed us to track her growth, the prognosis, and the positions of the inserted implants in the 2-year follow-up period, which revealed no apparent vertical discrepancy between the implants and the natural teeth.
This case study illustrates a novel treatment option with 2-year follow-up in which a modified split-crest technique was applied with immediate implant placement, which successfully osseointegrated.
Adequate alveolar bone width gain was achieved, with a proper restoration of function and esthetics. This applied treatment modality provides an encouraging therapeutic option in management of deficient maxillary ridges in young individuals.
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