Teenagers & Dental Implants

A Consultation with Dr. Frank Celenza | Featured on Dear Doctor

Dear Doctor,
My daughter is 15 years old and is just finishing wearing braces. She is missing two of her upper front teeth which never developed. The orthodontist made space to have them replaced, but now we’re told she has to wait 2 to 3 more years before she can have implants. She desperately wants her teeth replaced. Why can’t implants be done now?

Dear Alicia,
This is an important question and the current wisdom is not to have implants placed until jaw and facial growth are complete. Although it varies from person to person, growth of the jaws in most cases is not complete until late teens. Of course, we are faced with the dilemma of waiting for the optimal time to place implants so that they will succeed on the one hand, and respecting the psychological needs of a teenager missing front teeth on the other.

Well, you may say, that still doesn’t answer the question. The rest of the answer has to do with the difference in the way in which teeth and implants attach to bone in which they are embedded.

Teeth are attached to the bone through a membrane called the periodontal ligament (peri-around, odont-tooth). The ligament is a living network which is composed of tiny fibrils made of a protein called collagen. The fibrils insert into the bone on one side and the tooth on the other. The most fascinating thing about this very special structure is that it is living and therefore capable of change. And it does, all the time. Specialized cells continually remove collagen and bone and make it anew; this does two things — it allows the teeth to react to stress, as when forces are applied such as in eating and allows movement of the teeth themselves through the magic of orthodontic treatment (braces). In addition, as the face changes throughout life and the teeth themselves wear, minute changes in the position of the teeth within the bone are compensated for by changes in the periodontal ligament. This “remodeling” process accommodates these changes.

An implant connection to the bone is quite different. Dental implants join biochemically to the bone by a process called osseo-integration (osseo – bone, integrate-to join or fuse with). This fusion, almost like pillars in concrete, allows no movement at all and stresses, even biting forces, are absorbed quite differently.

Consequently and most importantly, as the jaws continue to grow, the upper jaw may move in an outward and downward direction. The teeth will accommodate and move with jaw growth, but implants will not. As the upper jaw moves, the implants (and the crowns attached to them) remain stationary and so appear to intrude i.e. go back up into the jaw. This also affects the position of the gum tissues which also will not follow the growth of the jaws around the implants.

For these reasons, and since implants are a relatively permanent and best current solution to the problem of tooth replacement, it is better to wait until growth of the jaws and face is complete. Your orthodontist will be able to tell you when growth is complete by examination and specialized radiographs (x-rays) which will provide a good guideline. However, this is a very inexact science; it’s not really possible to determine exactly when a person has finished growing. Other factors can be indicative and helpful: Is your daughter still changing shoe and clothes sizes? Is she comparable in stature to her siblings and you, her parent(s)? These are good intuitive signs, but in the end, we add the science to our experience and make a judgment call.

There are many other good interim options for temporarily replacing the teeth for a few years, both aesthetically and comfortably until implants can be placed. For example, temporary “fixed-in” options like bonded bridges can be attached to the adjacent teeth with little if any irreversible change to them. You should consult your dentist about them.

Ultimately dentistry is an art form as well as science. This issue has been studied in the scientific literature and also proven in clinical practice. Sometimes, placing implants too early can be remedied by changing the crowns which attach to them. Other times it may mean removing and replacing the implants which may require bone regeneration — expensive and difficult options. Neither is as good an option as waiting for the correct time in the first place, even if it means waiting a little longer.

Hope this helps make sense of this issue.