Considerations in Dental Implant Placement

in the Young Patient: A Surgeon’s 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 dento-
facial development, dental age, etiology of tooth loss, location of the miss-
ing 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 den-
tist, 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 pa-
C tients suffering from missing teeth. Etiolo-
gies 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 ec-
todermal dysplasia affects approximately 4.34%
of patients.1 Tooth agenesis presents with a spec-
trum of severity: hypodontia refers to the ab-
sence of 1-6 teeth, oligodontia refers to the ab-
sence 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 Ala-
bama, Birmingham, AL; Clinical Professor, Department of Oral and
Maxillofacial Surgery, University of Alabama at Birmingham, Bir-
mingham, 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 modification. They are fre-
quently seen by the lay person as an ideal sub-
stitution for a missing tooth, without under-
standing the implications of placing them in a
growing patient, and there is an acknowledged
pressure to use implants in younger patients.6
Often, the first question to a clinician when
young patients present with missing teeth sec-
ondary to trauma, or after tumor resections that
necessitated removal of permanent teeth, is
when the teeth will be replaced. Not infre-
quently, patients with congenital absence of per-
manent teeth are referred to the surgeon at or
near the conclusion of orthodontic therapy, re-
questing replacements. In addition, some clini-
cians 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 Advan-
tages of the implant approach include no prep-
aration of adjacent teeth and the aforemen-

24 Seminars in Orthodontics, Vol 19, No 1 (March), 2013: pp 24-36

 Considerations in Dental Implant Placement in the Young Patient
tioned potential for preservation of bone.
Questions remain, however, regarding appropri-
ate timing, as further facial growth and develop-
ment will result in changes of the remaining
natural dentition and can lead to significant mal-
position of the implant.9 With regard to anterior
implants, an ideal esthetic result often remains a
significant 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 classifica-
tion scheme when considering implants in the
growing child. Group I consisted of patients with
congenital missing teeth having adjacent perma-
nent teeth; group II included children missing
multiple teeth, with permanent teeth adjacent to
the edentulous sites; and finally, group III in-
cluded 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 ectoder-
mal dysplasia. Given space limitations and the
significant differences in management strate-
gies, this discussion will exclude group III, in-
cluding 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 com-
plete 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 surgeon’s perspective. This re-
view will focus on implants placed for prosthetic
reasons and not on implants placed for orthodon-
tic anchorage. In addition, it will focus on patients
in the permanent dentition stage and not on pa-
tients in primary or mixed dentition, with the ex-
ception of patients with retained primary teeth
lacking a succedaneous successor.
25
Timing Issues
The impact of facial development and growth
on dental implant therapy has long been estab-
lished. More recently, investigators have estab-
lished that changes in the dental arch and facial
skeleton continue into adulthood, and the im-
pact on dental implant position relative to the
natural teeth can be significant.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 com-
plete. Malmgren and Malmgren14 demon-
strated that reimplanted incisors that had an-
kylosed 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 submer-
gence and displacement depends on multiple
factors, including the patient’s 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 individu-
als and as late as at age 21-22 years in male
individuals.2,7 Contemporary research has dem-
onstrated the continual changes to the maxilla
and mandible throughout life, making it truly a
moving target.12 Although one can speak in gen-
eralities regarding the impact of facial growth on
implant timing and position, the impact of
growth and development on the maxillary im-
plants differs significantly from those placed in
the mandible and indeed within the various ar-
eas 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 influences on final
implant position even when the fixtures are
placed after facial growth is normally considered
complete.15 Along with facial growth patterns,
significant differences exist between the maxilla
and mandible with regard to dental implant tim-
ing and positioning.
26
Maxilla
Changes in the maxilla often result in most sig-
nificant and esthetically disappointing altera-
tions in the position of implants. Up to age 7
years, most maxillary growth occurs by displace-
ment, whereas after age 7 years, most develop-
ment 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 significant vertical
growth of the anterior maxilla and resulting in-
fraocclusion of an implant placed early can lead
to significant challenges in obtaining an esthet-
ically 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 infraocclu-
sion.18,19 Although transverse growth of the
maxilla ceases early, implants placed up to age 9
years will result in formation of a diastema. Com-
plications arising from transverse growth are typ-
ically 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. Ver-
tical growth typically slows significantly 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. Significant vertical growth of the max-
illa can occur up to the age of 25 years in pa-
tients 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 horizon-
tal pattern, the natural teeth tip forward to com-
pensate for forward growth of mandible up to
Holmes
age 25 years, which will not occur with an im-
plant.15
Mandible
Relative to the maxilla, growth and development
of the mandible typically has less impact on im-
plant position, and it is usually more forgiving
from an esthetic standpoint. Growth of the man-
dible is usually complete 2-3 years after men-
arche (age, 14-15 years) in female individuals
and can continue in male individuals up until
age 20 years, but typically most growth is com-
plete by age 18 years. Transverse growth in the
anterior is usually complete well before the ad-
olescent 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, es-
pecially in cases of severe oligodontia and an-
odontia.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 anodon-
tia.6,20 Similarly, Thielander et al19 demon-
strated that apposition of bone laterally com-
bined with resorption on the lingual that
accompanied mandibular growth in the poste-
rior 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 pat-
tern (ie, long face) often leads to more signifi-
cant issues of implant inclination and submer-
gences 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 significant alterations of anterior im-
plant position relative to the natural teeth. In
the mandible, the horizontal growth pattern ob-
served with SFS will often result in anterior man-
dible implants displacing lingual to the natural
teeth, whereas in the more vertical growth pat-
tern of LFS, implants will tend to become more
labial and infraoccluded. In SFS, implants will
typically develop infraocclusion in premolar
 Considerations in Dental Implant Placement in the Young Patient
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 man-
dible, and the resultant remodeling can result in
displacement of the implant in a lingual direc-
tion. There is not as much data available on
impact of growth on implants placed in poste-
rior mandible, and patients are typically less de-
manding of early placement, given this loca-
tion’s lower esthetic impact, which may allow
earlier placement if the surgeon takes into ac-
count 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 signif-
icant input on the facial growth pattern, and in
most cases, orthodontics should be completed
first. 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 edu-
cated 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 specific age when
definitive restoration can be undertaken. In gen-
27
eral, facial growth slightly lags long bone growth,
but in most cases, clinicians require a more ac-
curate assessment of the stage of facial develop-
ment. Dental casts do not seem to be an accurate
method of timing implant placement.6 Hand-
wrist films 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 super-
imposed cephalometric films 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 increas-
ingly 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 suitabil-
ity 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 typified by a greater vertical than hori-
zontal dimension and increased concavity of the
lower border. Because most clinicians have easy
access to cephalometric radiographs and are famil-
iar with their analysis, this method offers a distinct
advantage over hand-wrist films as a onetime as-
sessment of facial growth.24
Young Adults
An important issue that has come to the fore-
front 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 con-
tinuous 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 com-
plete. Vertical changes of 0.12-1.86 mm have
been demonstrated in adults up to age 40-55
28 Holmes
years.27 Thilander et al17 demonstrated that al-
though 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 demon-
strated that continuous eruption occurred after
growth was complete and led to a rate of infra-
occlusion 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 mar-
gin being more noticeable. His group found
fewer problems with infraocclusion in the ca-
nine region compared with the incisor region at
10-year follow-up, and fewer problems with im-
plants placed in the maxillary premolar area,
which was most likely secondary to compensa-
tory eruption of premolars in the opposing arch.
Certainly, esthetics were less a concern in the
premolar region in most patients. Multiple an-
terior implants placed in association with natu-
ral 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 summa-
rized 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 adja-
cent 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 de-
creased. These findings clarified 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 inter-
canine region is complete by age 11-12 years.7
Mandibular length and height, however, con-
tinue 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 recom-
mended that implant placement be delayed un-
til facial/skeletal growth was complete, espe-
cially in partial edentulous cases, but the
problem remains that age of growth cessation
varies widely.15,29 Although the most significant
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 uncer-
tainty and should be taken into account when
planning timing of placement.15 Informed con-
sent, 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 develop-
ment of bone and/or soft tissue to achieve an
esthetic implant restoration. Strategies for creat-
ing an ideal site for an implant are often depen-
dent on the etiology of the missing tooth. Issues
related to site preparation for implant and res-
toration in a case of a congenital missing incisor,
in which the lack of a developing tooth has left
a deficit of soft and hard tissue, will differ from
those in which a patient presents with a nonsal-
vageable traumatized incisor, in which case the
aim is site (or socket) preservation. The com-
mon goals of establishing a healthy bone foun-
dation and soft-tissue envelope, however, are the
same, and often require grafting of soft or hard
tissues. Retained primary teeth without a succes-
sor 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
buccal–lingual 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 preserva-
tion and development strategies for dental im-
plants based on differing etiologies for the miss-
ing tooth or teeth. Importantly, it should be
 Considerations in Dental Implant Placement in the Young Patient 29

remembered that there is a role for site preser-

vation 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 discus-
sion held with regard to outcome. Especially in
cases of congenital missing lateral incisors, alter-
natives to implants may be the best choice.3-5
Once a decision has been made to pursue im-
plant replacement, however, strategies to maxi-
mize bone quantity and quality should be initi-
ated. 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 im-
plant, it may not be the most esthetic emergence
profile.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 pri-
mary teeth if erupting, but extraction if they Figure 1. (A) Ankylosed primary lateral incisors
maintained to preserve bone. (B) Extraction of pri-
were submering significantly or altering arch mary lateral, with immediate implant placement. (C)
form. Alternatively, decoronation can be an op- Placement of abutment for immediate temporization.
tion for the ankylosing and submerging molar (Color version of figure is available online.)
whether primary or permanent (refer to discus-
sion of decoronation later in the text). In cases
of extraction, the site can be grafted (refer to In cases of a congenital missing lateral, buc-
discussion later in the text), or alternatively, the cal–lingual development is greatly aided by orth-
distal permanent tooth can be allowed to erupt odontic site development: allowing the canine to
mesially for site development. erupt as near the central as possible followed by
30
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 difficult 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 with-
out compromising esthetics. Kokich et al31 have
suggested that bone developed with “orthodon-
tic site development” is more resistant to resorp-
tion and loss.32 When orthodontic site develop-
ment is not possible or the opportunity has been
lost, however, the site will often require develop-
ment through soft- and hard-tissue grafting tech-
niques.
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 sugges-
tion 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 in-
volves an anterior tooth. Similarly, young pa-
tients who present with a nonsalvageable de-
cayed tooth requiring extraction may wait some
years before replacement with a dental implant.
Options for dealing with the retained tooth in-
clude extraction with or without bone grafting
and decoronation.
Decoronation can help maintain buccal–lin-
gual dimensions and vertical bone height. Con-
tinued development of the alveolus with growth
over the root can continue in some cases. Often
the decoronated root undergoes gradual exter-
nal 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
Holmes
translation of the retained root fragment and
associated loss of buccal–lingual 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 place-
ment of the implant if a substantial amount of
root remains. Some authors have suggested re-
moval of some dentin to hasten internal root
resorbtion.37
Ankylosis of anterior teeth can lead to infra-
occlusion as well with restriction of the develop-
ment of the anterior alveolus.14 The tooth will
require decoronation, extraction, or surgical re-
positioning.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 anky-
losed, and it should probably be removed early
in the author’s opinion to maximize the poten-
tial 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 ex-
tracted 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 orth-
odontic extrusion with a temporary crown build-
up. 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 sig-
nificant losses of alveolar dimension. Up to 20%-
30% of the buccal–lingual 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 first
year on the facial aspect.40 Preservation of the
alveolar dimensions is important for future im-
plant placement, and use of different graft ma-
terials 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 op-
tion for nonsalvageable teeth is extraction and
to let the adjacent teeth erupt or drift into the
 Considerations in Dental Implant Placement in the Young Patient 31

Figure 2. (A) Ankylosed and submerging first 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 di-
mensions. Unfortunately, the literature on sock-
et-grafting procedures consists primarily of case
studies or small case series examined in a retro-
spective manner. Although autogenous bone
grafts remain the gold standard for most bone
regeneration procedures, there is some evi-
dence 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 re-
quires a donor site with its associated morbidity.
Alternatives to autogenous bone include allo-
grafts, 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), tri-
calcium phosphates, or silicate-based bioactive
glasses. With the exception of bone morpho-
genic 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 mem-
brane). 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 non-
resorbable membrane resulted in the need for a
second surgery for removal.45 Despite the het-
32
erogenicity and anecdotal nature of most re-
ports, it would appear that most tooth move-
ment 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 resorp-
tion could lead to impaired tooth movement,
especially in cases of a slowly resorbing alloplas-
tic HA. For these reasons, slowly or nonresorb-
able HA ceramics should be avoided.46 Reichert
et al47 also demonstrated good results with tooth
movement through sites grafted with a resorb-
able HA bone allograft. This was a split-mouth
study in patients requiring bilateral bicuspid ex-
tractions. 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 nor-
mal 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 materi-
als. In cases of extraction of teeth at an early age
in which socket preservation is desired, the
slower resorption may be of benefit, but materi-
als must be able to undergo resorption to allow
tooth movement and bone remodeling. Normal
tooth eruption appears to occur with bone mor-
phogenic 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 re-
sults after grafting of posttraumatic and postex-
traction 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 re-
ceived 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-
Holmes
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 ar-
eas would have had adequate bone without graft-
ing. Certainly, many questions remain regarding
the ideal graft material, and often the best re-
sults are obtained when the surgeon uses a ma-
terial 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 flaps.10,28 It is often more
difficult to quantify soft-tissue deficits, and pa-
tient’s family often requires education as to their
importance. These procedures are more com-
monly 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 fixture, as well as the final
restoration. Determining the amount of space
needed is a critical first step. If the contralateral
tooth is present, determining the space between
the teeth requires only measurement of the con-
tralateral 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 sug-
gested 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 lev-
els between the implant and natural tooth and
result in blunted or lack of esthetic papillae.48
 Considerations in Dental Implant Placement in the Young Patient 33

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, espe-
cially 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. Inter-
radicular spacing is often overlooked. Root an-
gulation should be controlled to allow 5 mm
between the roots. Loss of this apical space
through inadequate retention after orthodon-
tics and before implant placement is one of the
more common problems encountered in the
author’s practice. Three-dimensional evaluation
of the site using cone-beam computed tomogra-
phy is the most reliable assessment of space be-
tween the roots. It may allow the surgeon to
angle an implant slightly to avoid proximity to
the roots. Figure 4. Good coronal and root space maintenance
An esthetic gingival contour with adequate provided by Maryland bridge.
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 ful planning must be done to ensure space main-
allow esthetic gingival margins and emergence. It tenance. This must include both the coronal
should be remembered that the crest of the alve- spacing and space between the roots. If implants
olar bone in adolescents is typically at the level of are planned within 6-12 months of orthodontic
the cementoenamel junction of the adjacent teeth, completion, a removable-type appliance, such as
whereas it typically lies 2 mm apical in the healthy an Essix or Hawley type with a pontic, is usually
adult periodontium.2 sufficient. However, if there will be a greater
Often, patients will finish orthodontic treat- delay, then consideration should be given to
ment years before implant placement, and care- space maintenance that is less dependent on
patient compliance (Fig 3). In the author’s prac-
tice, resin-bonded bridges seem to offer several
distinct advantages: there is little or no prepara-
tion of the adjacent teeth, they seem to control
the position of the crown and root of the adja-
cent teeth well, they are less dependent on pa-
tient compliance, and finally, 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 sug-
gested use of miniscrews with a temporary resto-
Figure 3. Radiograph demonstrating loss of coronal ration; there is a theoretic concern that the
space after noncompliance with removable retainer. screw could impair vertical development of the
34
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 debriefing
at the end of orthodontic treatment to outline to
the patient and family the goals of space main-
tenance and timing of the next step in the im-
plant 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 restora-
tion or an open bite. In some minor cases, re-
placement 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 con-
sidering 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 fur-
ther eruption of natural posterior teeth has re-
sulted in an anterior open bite of multiple ante-
rior implants, it is often more prudent and more
conservative to perform a segmental osteotomy
with repositioning than removal of the implants.
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 interdisci-
plinary 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. Clini-
cians 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
Holmes
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 develop-
ment, and early consultation is required. Orth-
odontic 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 con-
tinues to change throughout a patient’s lifetime,
and timing the placement of an implant will always
be a compromise, with the potential changes ne-
cessitating revision in some cases through altera-
tions 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 or-
thodontist, restorative dentist, and surgeon is the
key to success in planning implant placement in
the young patient.
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