DR SIMON STORGAARD JENSEN (Orcid ID : 0000-0002-3519-4103)

Accepted Article
Article type : Comprehensive Review

Timing of implant placement after traumatic dental injury

Simon Storgård Jensen, DDS, dr. odont.

Department of Oral & Maxillofacial Surgery

Centre of Head and Orthopedics

Copenhagen University Hospital

Address of correspondence:

Simon Storgård Jensen, DDS, dr. odont.

Department of Oral & Maxillofacial Surgery

Centre of Head and Orthopedics

Copenhagen University Hospital

Blegdamsvej 9

DK-2100 Copenhagen Ø

Denmark

e-mail: simon.storgaard@jensen.mail.dk

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/edt.12484
This article is protected by copyright. All rights reserved.
 Phone: +45 35 45 17 00
Accepted Article
Abstract

Dental implants are reliable to replace teeth lost due to traumatic dental injury (TDI). However,

dental implants behave like ankylosed teeth and should not be placed in growing individuals

due to the risk of infraposition. This risk may be reduced by ensuring arrested skeletal growth

and ideal incisal support.

Timing of implant placement may be immediate, early, conventional or late and is determined

by the extent of the trauma, remaining growth, conditions of the hard and soft tissues. Timing

should allow an observation period to properly evaluate the prognosis of concomitantly

traumatized neighboring teeth.

Orthodontic alignment is often necessary after TDI in young individuals to provide symmetric

dental conditions around the facial midline, to allow implant placement in the correct 3D

position for the later prosthetic reconstruction, and to ensure sufficient mesio-distal space that

leaves a minimum of 1.5mm of healthy alveolar bone between the future implant and

neighboring teeth.

Space and stable occlusion should be maintained by bonded retainers and a splint used during

the night. A partial prosthesis is usually recommended as a temporary replacement. If a fixed

provisional prosthesis is required, it is crucial that it does not interfere with remaining growth

and incisal support, and allows proper oral hygiene.

Keywords: Dental implant, Traumatic dental injury, Implant infraposition, Growth, Timing,

Provisional tooth replacement

This article is protected by copyright. All rights reserved.

 Introduction

Dental implant therapy constitutes a reliable treatment option in case of tooth loss due to
Accepted Article
traumatic dental injury (TDI) (1). However, TDI most often occurs in young patients (2), where

continuous growth of the facial skeleton contraindicates placement of dental implants due to

the risk of infraposition. In addition, concomitant damage to the gingiva and alveolar bone often

warrants a prolonged healing period (3). Finally, even though the situation may appear

dramatic and the prognosis hopeless immediately after the TDI, thorough replantation, fixation,

and suturing may provide favorable healing conditions for long-term tooth preservation and

should be considered as the first choice whenever feasible (www.dentaltraumaguide.org).

When previously traumatized teeth are deemed hopeless, and dental implants are considered

the treatment of choice for tooth replacement, the ideal timing of implant placement needs to be

determined (4). This article will discuss: timing of implant placement after TDI in adults, the

challenge of treating growing individuals, prerequisites for later implant therapy, methods to

monitor growth, plus provide a list of options for provisionalization and retention until dental

implants can be predictably placed.

Discussion

Timing of implant placement after TDI in adults depends on the extent of the TDI and on the

local anatomic conditions at the implant site. In case of tooth avulsion without any damage to

the supporting hard and soft tissues, the condition can be compared to a tooth extraction and

timing of implant placement can be planned accordingly. Timing of implant placement after

tooth extraction may be categorized as: immediate placement (type 1) within 24 hrs after

extraction, early (type 2) after 6-8 weeks, conventional (type 3) after 3 months, and late (type

4) after more than 6 months (5).

This article is protected by copyright. All rights reserved.

 Immediate implant placement is rarely a realistic scenario since TDI is never planned. However,

an immediate approach can be considered if the patient reports to the clinic with an avulsed
Accepted Article
tooth that could not be localized or with a non-restorable tooth remnant and if the following

conditions apply: Intact socket walls and a facial bone wall thickness of at least 1 mm, thick soft

tissue phenotype; no acute infection at the implant site, and bone apical and palatal to the

socket to provide ideal primary implant stability. If these conditions do not apply, immediate

implant placement will be prone to an esthetically displeasing retraction of the facial mucosal

margin and implant failure (6).

Early implant placement is indicated in most cases provided that the pre-existing bone can

ensure ideal implant stability. Six to eight weeks of healing will lead to complete soft tissue

closure. However, simultaneous contour augmentation of the facial bone wall is most often

necessary to provide long-term support of the facial soft tissues (7).

Twelve to 16 weeks of healing will allow significant bone healing in the socket and may thus be

indicated in cases where the bone conditions do not provide sufficient primary implant stability

for the implant in the restoratively correct 3D position using an early placement protocol (6).

Severe trauma to the supporting hard and soft tissues may warrant prolonged healing and in

these cases a late implant placement protocol may be applied (3). Postponed implant placement

may also be indicated in cases where final evaluation of the prognosis of neighboring

traumatized teeth dictates a longer period of observation.

Risk of implant infraposition is the main reason why dental implants should not be placed in

growing individuals (Fig 1). Implants behave like ankylosed teeth and will not erupt in

synchrony with the neighboring teeth or follow the growth of the alveolar process (8). The risk

of implant infraposition is most pronounced in the anterior maxilla (9), which, unfortunately, is

also the area most prone to TDI and the most esthetically exposed area (10).

This article is protected by copyright. All rights reserved.

 To prevent infraposition, dental implants should not be placed in growing individuals. The

average degree of implant infraposition has been shown to decrease with increasing age (11).
Accepted Article
However, even mature adults (>40 years of age) may experience implant infrapostion of

>1.5mm when evaluated 5 to 18 years after implant placement (12, 13). Thus, an age threshold

cannot be identified where implants can be placed without risk of infraposition. The degree of

infraposition of dental implants has been directly correlated to remaining increase in body

height (14). On the other hand, even patients without signs of ongoing skeletal growth may

develop an infraposition of up to 2.2 mm (8, 13). Therefore, arrest in skeletal growth cannot be

used as the single measure to predictably prevent implant infraposition. Hand-and-wrist

radiographs are used to estimate the patient's skeletal age and especially to predict the

adolescent growth spurt (15, 16). However, they are not ideal to determine cessation of cranio-

facial growth. An explanation for late infraposition of implants placed in adult patients is most

likely the phenomenon of slight continuous eruption of neighboring teeth. This takes place even

in adults. Continuous eruption has been analyzed in long-term studies of normal patients, which

revealed an annual vertical eruption of 0.07–0.1 mm of incisors in adults aged 20–40 years (17-

20). Such continuous eruption and growth of the alveolar process may predictably be evaluated

by superimposed lateral cephalometric radiographs taken with intervals of a minimum of 1 year

(21).

To reduce the risk of continuous eruption of neighboring teeth it is highly recommended that

any orthodontic treatment prior to implant therapy in young individuals should aim at

establishing ideal contacts between upper and lower incisors.

In the author's clinic, a practical approach to minimize the risk of implant infraposition is to

ensure arrested skeletal growth documented by two body height measurements at least one

year apart in combination with ideal inter-incisal contact. Using this approach, only a few

clinically significant problems with infra-positioned implants have been noted.

This article is protected by copyright. All rights reserved.

 In addition to inter-incisal support and arrested growth, sufficient mesio-distal distance

between neighboring teeth, sufficient vertical space to antagonists, and symmetric conditions in
Accepted Article
the dentition should be verified before implant therapy can be considered.

Mesio-distal space should be measured slightly lingually in the exact position where the future

implant is planned using a caliper allowing internal measurements (Fig. 2). The space should be

identical to the mesio-distal dimensions of the contralateral tooth respecting symmetry around

the facial and dental midlines (Fig. 3). Moreover, it should allow placement of an implant of

ideal dimensions for the expected future loading conditions respecting preservation of 1.5 mm

of intact alveolar bone towards the neighboring teeth. It is important to be aware that retained

space from a traumatized tooth does not necessarily provide sufficient space for later implant

placement. This especially applies to the regions of the upper lateral and lower incisors.

For retention of the edentulous space after TDI, and equally important, of the symmetric stable

occlusion and inter-incisal support after orthodontic treatment, lingually bonded retainers

combined with a splint used during the night is recommended (22).

The temporary restoration is a more delicate matter. The patient would normally prefer a fixed

solution such as a resin-bonded bridge and does not want to be concerned more about the

missing tooth/teeth until the time of implant placement. Today, resin-bonded bridges are most

predictably retained on one abutment tooth only (23). However, this solution will not prevent

relapse after orthodontic treatment in terms of recurrence of rotations and malalignments. On

the other hand, a resin-bonded bridge retained on two abutment teeth may interfere with

ongoing growth, which may lead to impaction of the central incisor (Fig. 4) and an unstable

situation when the bridge is removed. Moreover, occlusal contact on the metal frame may cause

facial displacement of the abutment teeth (Fig. 4). Furthermore, there is a risk of loss of

retention on one of the abutment teeth. If this remains undiagnosed, there is a high risk of caries

and of recurrence of the previous malposition of one or more teeth. Finally, de- and re-mounting

This article is protected by copyright. All rights reserved.

 of the bridge during later bone augmentation and implant procedure is complicated and not

without risk of damaging neighboring teeth.

Accepted Article
If a fixed solution is demanded, a temporary anchorage device (TAD) may retain a fixed

provisional solution without interfering with remaining growth or inter-incisal support (Fig. 5).

This temporary solution will not provide retention of any orthodontic treatment and should

therefore be combined with bonded retainers and a splint.

Usually, a removable partial denture is recommended which permits access for proper oral

hygiene, and can easily be modified during the different steps involved in the surgical phases of

the implant treatment.

Acknowledgements The author denies any conflict of interest related to this study

References

1. Chesterman J, Chauhan R, Patel M, Chan MF. The management of traumatic tooth loss with

dental implants: Part 1. Br Dent J 2014;217:627-33.

2. Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent

teeth in a Danish population sample. Int J Oral Surg 1972;1:235-9.

3. Seymour DW, Patel M, Carter L, Chan M. The management of traumatic tooth loss with dental

implants: part 2. Severe trauma. Br Dent J 2014;217:667-71.

4. Chen ST, Buser D. Clinical and esthetic outcomes of implants placed in postextraction sites. Int

J Oral Maxillofac Implants 2009;24 Suppl:186-217.

This article is protected by copyright. All rights reserved.

 5. Hammerle CH, Chen ST, Wilson TG, Jr. Consensus statements and recommended clinical

procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac
Accepted Article
Implants 2004;19 Suppl:26-8.

6. Morton D, Chen ST, Martin WC, Levine RA, Buser D. Consensus statements and recommended

clinical procedures regarding optimizing esthetic outcomes in implant dentistry. Int J Oral

Maxillofac Implants 2014;29 Suppl:216-20.

7. Buser D, Chappuis V, Bornstein MM, Wittneben JG, Frei M, Belser UC. Long-term stability of

contour augmentation with early implant placement following single tooth extraction in the

esthetic zone: a prospective, cross-sectional study in 41 patients with a 5- to 9-year follow-up. J

Periodontol 2013;84:1517-27.

8. Thilander B, Odman J, Lekholm U. Orthodontic aspects of the use of oral implants in

adolescents: a 10-year follow-up study. Eur J Orthod 2001;23:715-31.

9. Chang M, Wennstrom JL. Longitudinal changes in tooth/single-implant relationship and bone

topography: an 8-year retrospective analysis. Clin Implant Dent Relat Res 2012;14:388-94.

10. Skaare AB, Jacobsen I. Dental injuries in Norwegians aged 7-18 years. Dent Traumatol

2003;19:67-71.

11. Schwartz-Arad D, Bichacho N. Effect of age on single implant submersion rate in the central

maxillary incisor region: a long-term retrospective study. Clin Implant Dent Relat Res

2015;17:509-14.

12. Andersson B, Bergenblock S, Furst B, Jemt T. Long-term function of single-implant

restorations: a 17- to 19-year follow-up study on implant infraposition related to the shape of

the face and patients' satisfaction. Clin Implant Dent Relat Res 2013;15:471-80.

This article is protected by copyright. All rights reserved.

 13. Bernard JP, Schatz JP, Christou P, Belser U, Kiliaridis S. Long-term vertical changes of the

anterior maxillary teeth adjacent to single implants in young and mature adults. A retrospective
Accepted Article
study. Journal of clinical periodontology 2004;31:1024-8.

14. Thilander B, Odman J, Grondahl K, Friberg B. Osseointegrated implants in adolescents. An

alternative in replacing missing teeth? Eur J Orthod 1994;16:84-95.

15. Grave KC, Brown T. Skeletal ossification and the adolescent growth spurt. Am J Orthod

1976;69:611-9.

16. Hagg U, Taranger J. Skeletal stages of the hand and wrist as indicators of the pubertal growth

spurt. Acta Odontol Scand 1980;38:187-200.

17. Forsberg CM, Eliasson S, Westergren H. Face height and tooth eruption in adults--a 20-year

follow-up investigation. Eur J Orthod 1991;13:249-54.

18. Iseri H, Solow B. Continued eruption of maxillary incisors and first molars in girls from 9 to

25 years, studied by the implant method. Eur J Orthod 1996;18:245-56.

19. Kawanami M, Andreasen JO, Borum MK, Schou S, Hjorting-Hansen E, Kato H. Infraposition of

ankylosed permanent maxillary incisors after replantation related to age and sex. Endod Dent

Traumatol 1999;15:50-6.

20. Tallgren A, Solow B. Age differences in adult dentoalveolar heights. Eur J Orthod

1991;13:149-56.

21. Mishra SK, Chowdhary N, Chowdhary R. Dental implants in growing children. J Indian Soc

Pedod Prev Dent 2013;31:3-9.

22. Olsen TM, Kokich VG, Sr. Postorthodontic root approximation after opening space for

maxillary lateral incisor implants. Am J Orthod Dentofacial Orthop 2010;137:158 e151-; 158-

159.

This article is protected by copyright. All rights reserved.

 23. Thoma DS, Sailer I, Ioannidis A, Zwahlen M, Makarov N, Pjetursson BE. A systematic review

of the survival and complication rates of resin-bonded fixed dental prostheses after a mean
Accepted Article
observation period of at least 5 years. Clin Oral Implants Res 2017;28:1421-32.

Figure legends:

Fig. 1 29-year old female with bilateral congenitally missing upper lateral incisors.

Dental implants were placed at the age of 17. The patient complaints of gradually shortening of

the implant-supported single crowns over the years.

Fig. 2 Measurement of available mesio-distal space using a caliper. The caliper should be

able to perform internal measurements for the clinician to be able to measure at the exact

location where the future implant should be placed.

Fig. 3 18-year old female with a previous lateral luxation of the upper right central

incisor. Orthodontic treatment is indicated to correct the anterior crowding to be able to

provide an implant-supported crown with a symmetric appearance around the facial midline

and compared to the intact left central incisor

Fig. 4 A. Facial and B. occlusal view of acid-etched bridge temporarily replacing an

upper left congenital missing lateral incisor. Note the impaction and facial displacement of the

left central incisor compared to the right side.

This article is protected by copyright. All rights reserved.

 Fig. 5 18-year old female with a previously avulsed upper right central incisor. A. Facial

and B. occlusal view of the provisional replacement, which is retained by two temporary
Accepted Article
anchorage devices (TADs). Neighboring teeth are retained after orthodontic treatment with

lingually bonded retainers and the patients uses a splint during night.

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.