14 year old missing laterals: When to place implants?

Best to leave to 18 and use e-max ( as lower will see the metal if pbm used ) maryland bridges until then to retain the spaces . The main issue ( I have done a number of these cases , and my twins are both missing these teeth ) is the development of the bone ridge will be incomplete as no teeth to develop the bucco-lingual width so ridge may be thin and need grafting . The way I hope to treat my kids is by leaving the ortho to later and by using ortho movement as a form of distaction the rebuild the ridge . Good luck Peter

I agree with you Peter. The ridge can be developed by orthodontic movement through the edentulous sites. I might consider waiting a but longer in males for implant placement. These can be a little tricky.

I agree wholeheartedly. These cases are tough I have several that I 'm waiting for growth to be complete. I am going to trace out two serial cephs. Boys can grow up to age 21. The bone can be augmented by ortho movement as a distraction as Peter stated and expansion and onlay grafting at implant placement Good Luck!

Who knows how an implant inserted at 21 y.o. will be at 30-40-50 y.o. ?

Hi Perioparis, Your point?

I have done a lot of ortho the last 42 years and I have yet to see one of these youngsters with more bone later than in the mid teens. What cortical bone was there disappears and the Lingual plate thins to paper thin. I am not an Orthodontist, but I have had discussions with a couple of very experienced Orthodontists about this problem. What often happens is that the Labial Plate disappears, the cortical bone disappears, a very thin Lingual plate is held for a few years, then that dissipates, leaving one with nothing. While it is true that, in general, there is a great benefit to delaying implant placement until bone growth has matured to the point of leaving a stationary ridge, the lower incisor anterior area can be considered differently. Other than development of the chin button from the basal bone, the ridge in that location can only resorb. There is no natural genetic pattern of building alvolar bone, Labial nor Lingual from #23 - 26 area. As such, in selected cases brought to me by Orthodontists, or my own orthodontic patients, in which we are facing the inevitable disappearance of the vertical alveolar ridge, I have placed implants with GBR to try to stabilize what little bone is there and to minimize further vertical and Labial loss. Usually a couple of 3.0mm x 8.0 mm x 2.0 mm Bicon implants are 1/3 to 1/2 embedded in basal bone with the balance resting in a "trough" channeled into the remaining Lingual plate, and a membrane or mesh holding the increased ridge width during healing. This "point of no return", where one ends up with no vertical structure without intervention, seems to be around 15-16 years of age. If these were adult cases with a thin Lingual plate, I suppose the Oral Surgeon could do a successful block graft, but once the ridge is totally gone and little to no attached gingiva is present, you are talking major intervention which it tough to do around the tiny existing incisors in the area. We all spent many years discussing this dilemma, and have only intervened where it was clear that the downside possibilities were less traumatic than had we left the case to resorb. So now you can all pile on!

You need 1.5 mm on each proximal aspect of the implant plus the diameter of the implant. Do you think you will be able to find 6 to 7 mm between the incisors ? and in this case, on each side ? One of the narrowest implant is from Anthogyr with a diameter of 2.8 mm. It will be my son or daughter, I will as my pros referee to do a maryland bridge with small preparations. 2 papers before decision : Kern M et Sasse M.- J. Adhes. Dent., 2011 Dierens et al. - Alteration in soft tissue levels and aesthetics over a 16-22 year period following single implant treatment in periodontally-healthy patients: a retrospective case series. J Clin Periodontol 2013;40:311-318

Maryland bridges may work. Orthodontics will not work as the bone is formed when the canines erupt into the position of the lateral and then are moved to their final position. Moving the canine into the position of the lateral and then moving it back sound very logical but is incredibly difficult and requires anchorage not present there. so ...no cigar there. Another option is tooth replacement moving canines into lateral position and remodeling, then moving bicuspids into canine position, etc, etc, leaving molars in a Class III relationship, but the replacement canines will be in Class I. a third option is using TADs with composite crowns, while the patient finishes growing, then replacing them for osseo-integrated implants. It is not vudu. This approach is taught by many doctors including Dr. Jason Cope, boarded orthodontist and PHD in bone physiology. I personally use it is I am not doing the tooth replacemtn option by tooth replacement mentioned above. All of this explanation is done to improve the life of adolescents, the hardest emotional stage of life. Hope it helps.

It's not so much the soft tissue recession down the road as it is further growth of the alveolus. In the area of the laterals it's not as critical as if there was just 1 missing central incisor. The alveolar ridge can keep growing well into the 3rd decade of life. the teeth move down with the growth but the implant stays put. Incisal edges can be off by 1mm or so. In the lateral area discussion revolves around placing the implants as early as possible to prevent atrophy of the ridges. Orthodontic distraction can be done later but that is certainly not a guarantee to work the way you expect.

I presume the reduced size of upper laterals is part of the same syndrome and they will be veneered . Is there any research on the effect on bone growth if the lower incisors are splinted by Maryland bridges? There is not much room for implants and might worth considering resin Maryland bridges until patient nearer 17 than 16 yrs and then if desired replacing with small diameter implants : 2.5 mm would probably work very . You would probably need to assess patients growth balanced against bone resorption in the region of the missing teeth to judge when and if to put the implants in .

1) Share the liability with the orthodontist ie let them tell you "when the patient is done growing" - - once the implant is placed, you'll have a B of a time moving it! So make sure it is in "the spot"! 2) Most likely you will need to develop BOTH the hard AND soft tissues ASSUMING you have space. Give yourself several of months lead time for healing etc before placing the implant 3) essex retainer/temporary, temporary zirconia Maryland bridge (super thin wings) etc etc for the waiting time between your permanent solution and now.

The arch shape and size can be maintained with a Linqual arch,Then the laterals and especially the canines can occupy the anterior space.( If aesthetics are a concern play games with composite).Hence maintaining a good bony ridge and be simply moved close to Implant placement.If the braces are still on now is the time to do this.Leave as is and no implant placement will be possible in 4 or 5 years

Hi Zaki , totally agree about 10 years ago I did that with a patient and she is still happy. Shame you could not make our ADI evening last night where this issue was raised ,and you could have shown your ortho distraction case . Perioparis , even after over 20 years most cases of mine show less of an issue than the adjacent teeth. very rarely do you see soft tiisue loss which is often seen over this time scale on the patients own dentition especially post ortho treatment . That is not taking into account the improvements in Implant design and materials used in regeneration . Another aspect I guess ( something I am doing for my kids by saving stem cells ) is the future of cell diferentiation and growng teeth ......but that always seems "10 years away" . Regards Peter

As every one knows that the bone need stimulation and function in order to exist. If bone will exist then even soft tissue will also exist over it. Is it not possible in such cases to give a implant, and keep changing the prosthesis as and when required for esthetics?

Woolfs law I think 1860 .

I have a really interesting case, a thirty year old Maryland bridge bilaterally in the mandibular first molar- first premolars bilaterally with missing first premolars. These bridges functioned very well for a long time. Just grafted the case and expanded the ridges for implants we'll see how it goes

sorry to budge in. Will a narrow diameter implant 2.8 or 3mm x 12mm one piece help to develop the bone,if not enough anterior/ posterior width use a 2mm diameter. Only thinking of possibliltis.

To answer both posts, I 've not had much luck getting an orthodontist to to this could be patient compliance, cost or buy in, or maybe the wrong orthodontist. Anyway if I have enough space for a 2.8 then placing a 3.0 which is only .2mm wider is usually a possibility using expanders and onlay grafting dehiscences. I find that trying to place any implant in extremely dense cortical bone although you get primary stability osteointegration is another story. I've yet to see studies on osteointegration in minis. An implant will not develop the bone but it can be a space-maintainer as the grafted bone develops. Now I have only grafted this case haven't placed the implants yet! My point was that this Marylyn bridge functioned a very long time the patient was tired of cleaning under it so opted for the implants vs a redo. What also helps is that the adjacent teeth preserved that bone but the problem is with a congenitally missing tooth the alveolus never fully develops without the eruption of the permanent tooth, ie an anklosed or submerged primary tooth is often seen. I had a thought perhaps grafting the sites at extraction of the deciduous tooth, but I 'm not sure how long the bone will last without a functioning implant to maintain it but the eruption of the missing permanent tooth with growth old still be an issue. Thanks for reading

Okay here goes I spoke with one of my orthodontic colleagues how about using TADS to prevent the centrals from moving back and closing the space? Would the canines look too strange as laterals? Or manipulating the space back again to build the ridges? Not having much ortho knowledge, could a young patient tolerate this? Would this affect the class I molar relationship or mess up the midlines? I just don"t get the orthodontists I have many as close friends but I don"t think you can trust em!

One really cannot move the canine root forward and properly torqued through that pre-maxillary suture. Even if it were possible, you'd have the canine eminence centered on the nares floor. The reality of these canine closure cases is that the pre maxilla is shrunken as the central incisors are drawn Distally and the lip support crashes. Most Canine to Lateral cases involve some tipping of the Canines. John

Hi John, I would agree with you but we're talking about the mandible here. Zaki

no growth for 6 months and pt is ready for implants.. check new encephalometric analysis with orthodontist and compare to one that's 6 months or older if no change pt stopped growing

The other option is that the canine and central incisors to be positioned in the mid line and place the implants in the canine area. You will not have to do any bone grafting and you will always have very good bone to work with. I have done this quite a few times and you get very good results.