Implant placement in the aesthetic zone after completion of growth

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Posted on By snjezana pohl In Implants

It happened that just a day after I`ve seen Richard Martin`s lecture about congenitally missing teeth this patient came for control.
18-year-old female patient was referred 2011 for implant placement #7 after completion of orthodontic treatment alio loco. A hand X-ray showed a completed growth. I explained to the patient that implant placement should be postponed for some years because:
skeletal growth is generally completed in girls at around age 17, and in boys around age 19. However, with completion of skeletal growth radiologically established, there will still be residual vertical growth of the dentoalveolar complex at 20% of population.
The patient was willing to postpone implant placement for one year, not more.
As first, soft tissue augmentation was done. After one year, an implant is placed in minimal invasive approach. Given the reduced volume of the alveolar ridge, the preparation was carried out using osteotomes and bone spreaders.
Four years after implant placement there is no vertical ledge between the implant supported crown and the adjacent teeth.
This case illustrates that minimal invasive approach (flapless, ridge expansion, tunnel technique for soft tissue augmentation) may be a very good alternative to more invasive implant site development techniques.
I would like to know how long do you wait with implant placement after completion of skeletal growth?




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15 Comments

Snjezana. I recommend bonded prosthetics for as long as the patient will tolerate. Knowing passive eruption to be more common than we wish to admit I suggest waiting into the 30's. However, if a patient is aware and accepts the likely changes over time and is willing deal with them, I would proceed as you have. BTW if you look at the incisal edges, it appears passive eruption may be occurring? Please continue to update us. Warmly. Chuck


Reply

Thank you Chuck for your comment. As you presume, patient was aware that there is a risk and bonded bridge was recommended. But is it really necessary to wait until 30`s? I am not advocate of implant placement before it is safe (it is my only one case that I`ve placed an implant in such young patient), I just want to exchange experiences and knowledge.
And regarding implant site development: since you prefer ridge expansion and CTG over more invasive procedures, I am sure that you would have done the same.
Warmly
Snjezana


Reply

Beautiful case Snjezana,

Difficult to time when it's the best moment to place the implant in a young patient, there are different opinions. Not sure if there is strong evidence on the field.

Did you use a surgical guide to place the implant flapless?

Warms regards


Reply

Andoni, it is nice to hear from you!
I used a surgical guide only for the initial bur, afterwards I slowly expanded a ridge, feeling with finger tips.
There are many papers to this topic (implants and age), one really discouraging tells that it is NEVER safe. At the higher age t is probably because of tooth wear and consequent dentoalveolar eruption.
Warm regards
Snjezana


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Chuck,

How would a bonded bridge permit passive eruption in the same way as the contra-lateral side ? Wouldn`t we, if passive eruption there is, find ourselves with a height discrepancy between central to cuspid on the left and right sides ?


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Dr. Oiknine,
Since Chuck is busy in his office and I am on vacation, let me mix in:)
I think Chuck wanted to say this:
If an implant is placed before vertical dentoalveolar growth is finished it is in infra-occlusion, has higher gingiva margin and vertical step to the adjacent crowns. And it is a disaster and our fault.
A bonded bridge has all of this but it is easy to replace and it is not such a big disaster and we don`t need to deal with implant removal and all consequences.
It can be done with only one wing.
Best regards
Snjezana


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Laurent. Whether it be passive eruption, dentoalveolar growth, mesial drift, intrusion ect. tooth response will remain DYNAMIC whether"splinted" or not. Perhaps the contra lateral teeth will respond differently depending upon forces, but in my observations it has not been detectable or measurable. On the contrary, when compared to Implant supported prosthetics which are STATIC by nature the differences are both noticeable and measurable over time. I hope this answers your question. Best regards. Chuck.


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Hi Snjezana;
Your work is exceptional...
The orthodontic therapy....not so much.
The mandibular incisors are above the plane of occlusion and the maxillary incisors are too palatal.
It is very challenging to have every member of the team perform at the highest level.
I love seeing your work and your passion for excellence.
gerald


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Gerald, I am so glad that you give your comment. To tell the truth, I am relieved already if there is enough place mesial-distally to place an implant. Often there is no place apically.
I am also glad that orthodontic therapy was not done in our clinic. And in 2D it looks better than in 3D.
And I agree with you that all members of team should struggle to perform high level dentistry.
Best regards
Snjezana


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Hi Snjezana,

Nice long term result - Thank you for recognition- Did you place the implants at age 18 you said?

As Far as what is the right age-we can address all the literature on congen missing teeth and still end up at the crossroad- As well as continued bone resorption and movement of adjacent teeth even with fixed prosthesis- Factors such as leaving for college - Ins - play a role in my hands- As Chuck said I inform the patients of all the risks including passive eruption and we come to an understanding - In a worse case scenario with modern day prosthetics - digital files - can we not just change out if eruption is severe- I think post orthodontic movement is more of a dilemma than passive eruption after implant placement and do not see changes in the 30 yr olds also?

Professor so what is your age of placement now and do you have any say 2 yr follow up on 25 yr olds

excellent management-

Cheers,

Richard


Reply

Hi Richard,
you are welcome:)
She was 18 when the soft tissue augmentation was done, and 19 at implant placement. 19,5 receiving implant crown.24,5 now.
Post orthodontic movement is also a disturbing factor in many studies - not clear to distinguish changes caused by active eruption from changes post orthodontic therapy (most of the studies are naturally done on orthodontic patients).
She is my youngest patient with implant placement ever. Normally I succeed in pearsuasing the patient to postpone implant therapy. Mostly they are around 28 and till today I haven`t got problems.
I do have 2-3 patients 25yr old at time of implant placement with some years follow up, give me a day to find the images.
Cheers, until tomorrow
Snjezana



Reply

Snjezana
Take your time in finding the cases- it's the weekend !
In my hands getting a patient to wait until 25 is very difficult with all the life changes . You are very well-versed in the literature and have it on command at your fingertips I look at things from a very simple perspective and in all the studies that I've read and can remember on this subject are pretty much a wash- So my approach is from a regenerative capacity .when I look at the-healing capacity of third molars removal patients at age 16 versus age 20, the 16 yr old in most instances has a less eventful post operative course in relation to the bone, soft tissue ,blood supply and periosteal ability. So if we apply this to implant patient in regards to congenitally missing teeth , what are your thoughts?

Cheers

Richard


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Hi, Richard,

it will really take some time-I`ll try to get new images from my ex clinic if the patients came for recall. My ex clinic was also limited on OMS and majority of patients use to come only if there are problems.
Somehow I have only a few patients with congenitally missing teeth, most of implants at my young patients were consequence of child tooth trauma.
And to complications after third molars removal-don`t you think that formed roots at 25-years old play an important role? Sincerely, eventual greater regenerative capacity at younger subjects IMO don`t justify an earlier implant placement.
You are not the only one having difficulties to postpone implant therapy.
This is the reason why I posted this case and started discussion. It is safer to wait 10 years. But is it safe enough to wait 2 years after skeletal growth completion?
Cheers
Snjezana


Reply

Snjezana ,

Don't worry about finding that the cases we can have this conversation more as a point to point as far as root development I actually prefer a less root development because then we don't have to worry about proximity to the nerve. We also see more removal of thirds at a Younger age due to the trapping of the second molar and lack of ramus room -yes your point is good about regenerative capacity vs 25 - but I can I think that we can place sooner than 25 as well as the loss of bone and what temporary prosthesis ( I say temporary because if the goal is implant placement all forms of teeth to this point are provisional) can be done not all patients can afford multiple sets of provisional or interim restorations well - only recently with the onset of Emacs has the materials to use for bonded teeth has come of age as mentioned by Sailer et al in her 2014 paper In IJPRD .. To be continued

Cheers,

Richard


Reply

Thank you for literature.
Decementation is annoying and mostly happens on Saturday`s evening. I use to give my patients Essix as rescue.
Cheers, Snjezana


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