Shameena K
JR3
Pediatric & Preventive Dentistry
INTRODUCTION
Managing posterior edentulous areas in pediatric patients poses
unique challenges owing to ongoing craniofacial growth and
development.
Loss of posterior teeth in children, whether from congenital issues,
trauma, or severe dental decay requiring extraction, can significantly
impair masticatory function and esthetics.
Additionally, it raises concerns about potential orthodontic and
skeletal complications if not addressed promptly.
Transitional implants have become a key solution in pediatric
dentistry and are crucial for maintaining occlusal stability and
preserving the alveolar bone structure.
Celar et al. (2002) believed that implant insertion is useful in growing
patients because it improves denture stability, esthetics, and
psychological well‑being, particularly in situations of ectodermal
dysplasia.
However, the literature also states that patients in their active
growth phase exhibit growth in the jaws to accommodate permanent
teeth.
Since implants possess fixed anchorage to the bone, they do not
exhibit any change in position with respect to the growing bone.
This results in occlusal discrepancies between the level of the
implant crown and the adjacent teeth. It also hinders bone formation
around implants resulting in ridge defects which would compromise
Hegdefurther prosthetic
R, Sargod S, Baliga S,rehabilitation.
Raveendran R. Transitional dental implant in adolescent patient – A
narrative review. J Indian Soc Pedod Prev Dent 2021;39:347-52.
Classically, it has been considered that there is a minimum age for placing
implants, 18-21 years in boys and a little earlier in girls, 16-18 years.
However, Taisse 2017 stated that it is possible to place implants before the
aforementioned ages as long as the benefits outweigh the risks.
Several authors have resorted to the possibility of placing
transitional or exceptionally small diameter implants in
adolescents, which can be replaced once the patient’s growth is
complete for psychological benefits, due to the limits of traditional
and fixed prostheses, including implants.
As compared to the definitive implant, transitional implants are
cost‑effective, offer simple and quick surgical and prosthetic
treatments, and restore esthetics and confidence of the patient for
social contact.
The implant–tissue interface is an extremely dynamic region of
interaction. This complex interaction involves not only biomaterial and
biocompatibility issues but also alteration of mechanical environment.
There are two forms of bone implant interaction; Linkow depicted it as
osseointegration and fibro-osseous integration.
Fibro-osseous integration, when there is a combination of thinly
defined fibrous
connection with 22% or less direct bone contact with the
implant;
Osseous integration, when there is 23% or more direct bone-to-
implant contact,
with no evidence of fibrous connective tissue anywhere.
CLINICAL APPLICATIONS OF TRANSITIONAL IMPLANTS
To provide a fixed provisional for protecting an osseous
grafted site.
To provide a vertical stop for a fixed prosthetic
reconstruction during the healing period.
To provide stability to the surgical stent during implant
placement.
To eliminate need for a temporary tissue borne
restoration.
Act as an orthodontic anchor for quick and effective
movement of other teeth.
Though not used for provisionalisation in these
situations, transitional implants are also used to
Stabilize
Kheur existent
M. Transitional dentures.
implants: an asset to implantology. J Interdiscip Dent
The critical measurements specific to implant placement
include the following:
1. At least 1 mm inferior to the floor of the maxillary and
nasal sinuses
2. Incisive canal (maxillary midline implant placement) to be
avoided
3. Five millimeters anterior to the mental foramen
4. Two millimeters superior to the mandibular canal
5. Three millimeters from adjacent implants
6. One- and one-half millimeters from the roots of the
Similar in several ways to natural teeth, the load-bearing
capacity of implants is qualified by several factors.
These factors include the number and size of the implants,
the arrangement and angulation of the implants, and the
volume and quality of the bone–implant interface.
Much of load-bearing capacity relates to the amount of the
implant surface area to which high-quality bone has
attached.
The same factors that maximize unloaded implant stability
in hard tissue continue to be important after the
Thick cortical and dense cancellous bone surrounding a
long, wide-diameter implant positioned in line with the
functional load offers the greatest load-bearing
capacity, providing the best prognosis for long-term
success.
In contrast, a short, narrow-diameter implant placed in
an area of thin cortical bone, with less dense cancellous
bone and an off-axis angulation, will have compromised
load-bearing capacity and a poorer prognosis.
The angulation of the implants as it relates to the occlusal plane
and the direction of the occlusal forces is important in optimizing
the translation of the forces to the implants and the surrounding
bone.
Loads directed through the long axis of the implants are well-
tolerated.
Slightly off-axis loads are usually not clinically detrimental;
however, loads applied at angles greater than 20 off the long axis
result in load magnification and tend to initiate bone loss at the
implant–bone interface.
Again, if excessive loads persist, the bone loss will continue and
likely lead to implant failure.
Transitional implant
characteristics
Although the designs differ from system to system; the basic
design is of a self threading tapered screw with a diameter of
1.8-2.4 mm and intra-bony length of 7 -14 mm.
The length of these implants can be shortened by a simple
disc.
The head can also be bent to change its angulation up to 45
degrees to achieve parallelism between abutments.
The abutment head generally has a 5-degree taper, which
makes it optimal for retention of cement retained prostheses.
They are mainly composed of Cp titanium that are either
machined
Hegde R, Sargod S, or surface
Baliga treated
S, Raveendran to enhance
R. Transitional bone
dental implant to implant
in adolescent patient –
A narrative review. J Indian Soc Pedod Prev Dent 2021;39:347-52.
contact.
NANOPORE SURFACE
The Nanopore™ surface developed at the University of
Gothenburg in Sweden is a patented calcium oxidized,
nano-porous surface that features 3-dimensional
interconnecting porosities.
This unique surface consists of a thin layer of nano-
porous titanium oxide that is saturated with 11% calcium.
The characteristics of this unique and innovative surface
optimize tissue response, stimulate early bone deposition
and enhance osseointegration.
In a review focusing on topographic and chemical
properties of different implant surfaces, moderately rough
surfaces such as the Nanopore™ surface showed stronger
bone response than relatively smoother or rougher
surfaces.
Rough surfaces such as the aggressively etched and
blasted or the plasma sprayed surfaces have an increased
incidence of peri-implantitis due to the increased risk of
retaining bacteria when exposed to the oral environment.
Albrektsson T, Wennerberg A. Oral implant surfaces: Review focusing on
topographic and chemical properties of different surfaces and in vivo response
to them. Int J Prosthodont 2004;17:536-543.
A significant increase of bone
contact was found for smooth
Sa < 0.5 μm but more densely
peaked calcium incorporated
oxidized implants when
compared to somewhat rougher
Sa = 0.5-1.0 μm oxidized or
blasted implants.
• The moderately rough Nanopore™ surface with a Sa Value of
< 0.5 microns offers the benefits of a rough surface for early
bone apposition combined with an optimized soft tissue
friendly smoother surface, without the negative
characteristics of thicker and rougher anodic oxidation or
etched
Frojd V, and blasted
et al., Increased surfaces.
bone contact to a calcium-incorporated oxidized commercially
pure titanium implant: an in-vivo study in rabbits, Int J Oral Maxillofac Surg (2008)
INSTRUMENTATION
A transitional implant system kit contains all the
instrumentation required for preparing the osseous
receptor sites as well as inserting, removing, aligning, and
paralleling of implants.
The kit also includes an insertion wrench, a hand wrench,
a ratchet adaptor, paralleling pins, bending tool, and
retrieving tool.
The contrast of the drill depth markings against the black
Duracarb™ coating makes the depth markings more visible
during drilling procedures.
All five drills and insertion adapters are colour coded for
easy identification and visual communication
Implants are
All insertion directly lifted out of
All Myriad™
adapters when the packaging
implants can be
inserted into the using the insertion
lifted out of their
implant adapter, directly
titanium vials using
communicate a delivered to the
the insertion
tactile click to osteotomy site and
adapter connected
confirm a secure fit torqued into place
to the torque
of the insertion in one
ratchet or the
adapter into the uninterrupted
surgical handpiece.
implant. action
TORQUE RATCHET
• The recommended normal
torque for dental implants
generally falls within the range
of 30-45 Ncm, with some
manufacturers recommending a
specific range for their
implants. Insertion torque is
measured in Newton
centimeters (Ncm) and is
crucial for achieving primary
stability, which is essential for
successful osseointegration.
The retrieval of transitional implants is essential and
depends on the rate and type of osseointegration.
A lower torque values were seen during retrieval of
immediately loaded transitional implants, that is, 24 ±
7.3 Ncm for the mandible and 16.1 ± 4.8 Ncm in the
maxilla.
Simon H, Angelo A. Removal torque of immediately loaded transitional endosseous
implants in humans. Int J Oral Maxillofac Implants 2002;17(6):839–845.
PRF
Platelet-rich fibrin (PRF), a natural autologous scaffold, was
introduced almost 20 years ago. In a clinical setting, PRF is
prepared by the centrifugation of blood, with the coagulated
plasma being harvested and transferred to a defect site.
This fibrin matrix contains platelets and leukocytes as well as
a variety of growth factors and cytokines including
transforming growth factor-beta1 (TGF-β1), platelet-derived
growth factor (PDGF), vascular endothelial growth factor
(VEGF), interleukin (IL)-1β, IL-4, and IL-6.
Choukroun J, Miron RJ. Platelet Rich Fibrin in Regenerative Dentistry. Oxford Wiley-
Blackwell; 2017
Fibrin that forms during the final stages of the coagulation
cascade, combined with cytokines secreted by platelets,
makes PRF a highly biocompatible matrix especially in
damaged sites where the fibrin network acts also as a
reservoir of tissue growth factors.
These factors act directly on promoting the proliferation
and differentiation of osteoblasts, endothelial cells,
chondrocytes, and various sources of fibroblasts.
Choukroun J, Miron RJ. Platelet Rich Fibrin in Regenerative Dentistry. Oxford Wiley-
Blackwell; 2017
Implications of PRF in wound healing
Although leukocyte and platelet cytokines play an
important role in the PRF healing capacity, it has often
been suggested that it is the fibrin matrix supporting
these elements which is actually responsible for its
therapeutic potential.
The keys to tissue regeneration lie in their angiogenic
potential, their immune system control, their potential to
recruit circulating stem cells, and their ability to ensure
undisturbed wound closure/healing by epithelial tissues.
Neutrophils
This
trapped within
neutrophil
the fibrin clot
The fibrin activation
act to
degradation causes
eliminate
products secretion of This
incoming
directly proteases that contributes
bacteria and
stimulate facilitate their towards the
pathogens in
neutrophil penetration in prevention of
the wound site
migration and the basement bacterial
by
facilitate membrane of contamination
phagocytosis
transmigratio blood vessels, within the
and the
n into the in addition to surgical site.
production of
vascular their
toxic free
endothelium. contribution
radicals and
to degrade the
digestive
fibrin clot.
enzymes.
PRF also contains macrophages that are involved in the healing and repair
process by playing a key role in the transition between inflammation and
wound repair during osteogenesis.
PRF can modulate macrophage polarization in vitro by shifting the M1 toward
an M2-like phenotype.
a) Macrophages M1 type appear during tissue damage causing
inflammation,
b) M2 types dominate the scene to help tissue repair and remodeling with
the ensuing
resolution of inflammation.
As dental implants activate the immune system during the early stages of
osseointegration, it is plausible that an M2 polarization by PRF may reduce the
time lag for initiation of bone formation.
Nasirzade J, Kargarpour Z, Hasannia S, et al. Platelet-rich fibrin elicits an anti-
inflammatory response in macrophages in vitro. J Periodontol 2020;
Öncü & Alaaddinoglu, 2015 & Tabrizi et al., 2017 assessed the
impact of PRF prior to implant insertion. Higher ISQ values were
detected in the test group compared to noncoated implants. This
implies that PRF might enhance implant stability during the early
phase of osseointegration.
However Hehn et al., 2016 observed no effects on bone loss when a
PRF membrane was placed over the implant. There was even a
decrease in mucosa thickness after 3 months in the PRF group, and
the study was terminated after 10 cases.
Strauss FJ, Stähli A, Gruber R. The use of platelet-rich fibrin to enhance the outcomes of
implant therapy: a systematic review. Clin Oral Implants Res 2018;
CASE 1
A 13-year-old boy with oligodontia presented to the dental
outpatient department with concerns regarding the
absence of multiple teeth and pain in the lower left back
teeth region.
Upon clinical and radiographic evaluations, it was
determined that tooth 75 was to be extracted due to a
severe carious lesion beyond restorative repair.
Additionally, it was noted that the tooth bud for the lower
left premolar (tooth 35) was missing, complicating the
future management of the dental arch.
The extraction of tooth 75 was performed with the guardians’
consent, and the area was monitored for healing.
At the 3-month follow-up visit, cone-beam computed tomography
(CBCT) was used to assess the bone quality and dimensions at the
extraction site.
The CBCT scan revealed a bone height of 12.41 mm and a width of
4.8 mm in the region previously occupied by tooth 75.
Considering the patient’s age and the bone dimensions, the
decision was made to proceed with the placement of a transitional
implant to maintain space and to support future prosthetic
options.
PATIENT PREPARATION:
Before the procedure, the patient was instructed to use
chlorhexidine mouthwash (Hexidine®, ICPA Health Products,
Mumbai, India) for disinfection.
The surgical area was prepared using a meticulous antiseptic
protocol. The area was first scrubbed with a swab soaked in 10%
povidone-iodime for about 2 minutes.
The scrubbing motion started at the center of the surgical site
and extended outward to the periphery, with each swab being
discarded after use to prevent contamination.
Following the scrubbing, 10% povidone-iodine solution was
carefully painted onto the surgical area.
SURGICAL PHASE:
Local anesthesia (adrenaline 1:80,000; Lignox 2%A®, Indoco
Remedies Ltd., Thane, India) was administered, and a
midcrestal incision was made to raise a flap to expose the
surgical site.
A single 1 mm diameter drill was used to prepare the implant
site. PRF, prepared according to the protocol described by
Choukroun and Miron, was placed inside the drilled area to
enhance healing and promote tissue regeneration.
One-piece machined implants (2.5 × 11 mm Provi™ Myriad
implant system Straumann, Basel, Switzerland) were placed
equicrestally.
The final torquing of the implants achieved an insertion torque
of 30–40 N.
The surgical sites were closed using two interrupted silk
sutures to facilitate optimal healing.
Postoperative care involved prescribing 400 mg of ibuprofen
for pain management and a 0.12% chlorhexidine mouthwash to
help prevent infection.
The patient was also instructed to continue routine oral
hygiene practices.
PROSTHETIC PHASE:
After 3 months, a metal prosthesis was fabricated to
restore both the structural and functional elements of the
transitional implants.
Occlusal adjustments were made to ensure proper
alignment and function. The prosthesis was secured in
place using glass ionomer cement type I.
The patient was advised to avoid biting on the implant site
to prevent early dislodgement.
FOLLOW-UP VISITS
Follow-up visits were scheduled at 3, 6, 12, and 24 months to monitor
the clinical and radiographic condition of the transitional implants.
These visits were essential to check implant stability, soft tissue
health, and bone remodeling.
The implant remained stable even at the 2-year follow-up.
The future treatment plan included removal of the transitional
implants upon completion of craniofacial growth, which would be
verified by hand-wrist radiographs and lateral cephalometry,
followed by placement of definitive implants.
CASE 2
A 14-year-old female patient presented to the dental outpatient department
with complaints of pain and swelling due to a severe carious lesion in the
lower left back tooth region.
Upon clinical and radiographic examinations, the tooth was deemed
unsuitable for endodontic treatment, prompting its extraction with the
parent’s consent.
Following the extraction, the patient was scheduled for a follow-up
appointment after 3 months to assess the bone quality at the extraction site.
At the 3-month follow-up, cone-beam computed tomography revealed a bone
height of 13.2 mm and a width of 5.2 mm in the area.
Based on these findings, a decision to place a transitional implant was made.
DISCUSSION
Posterior transitional implants play a crucial role in
pediatric dentistry by addressing the challenges
associated with missing posterior teeth.
These implants are vital for temporarily maintaining
masticatory function and preserving the vertical
dimension of occlusion, which is essential for overall
dental health.
They help prevent mesial migration and tilting of adjacent
teeth, preserve the alveolar bone, and ensure space for
the eruption of permanent teeth, thus reducing the risk of
Typically, transitional implants range from 1.8 to 2.8 mm in
diameter and 7 to 14 mm in length.
Constructed from commercially pure (cp titanium), they
benefit from the material’s biocompatibility and effective
bone integration.
Surface modifications such as plasma spraying or etching
are used to enhance fibro osseointegration and ensure
stable bone-to-implant contact.
Despite these advancements, transitional implants face
challenges with retention and long-term success owing to
the dynamic oral environment of growing children.
Transitional implants have demonstrated fibro-osseous
integration, allowing easy removal.
As a result, they can be replaced with minimal adverse
effects due to their modified bone-implant contact.
Research highlights the importance of transitional
implants in maintaining alveolar bone height and integrity,
which is crucial for definitive implant placement.
Variations in success rates emphasize the need for
adjunctive therapies to improve implant stability and
retention.
PRF has emerged as a promising adjunctive treatment that
potentially enhances the outcomes of transitional implant
therapies.
PRF is an autologous biomaterial derived from the blood of
patients and is rich in platelets, leukocytes, and growth
factors within a fibrin matrix.
This biological substance is instrumental in wound healing,
tissue regeneration, and the modulation of inflammatory
responses.
Advanced forms of PRF, such as leukocyte- and platelet-
rich fibrin (L-PRF) and advanced platelet rich fibrin (A-
PRF), have expanded their use in dentistry, including the
management of gingival recession, guided bone
Shuai Guan et al in 2023 conducted a systematic review
and meta analysis on clinical application of platelet-rich
fibrin to enhance dental implant stability and concluded
that PRF can increase implant stability after implant
surgery. PRF may also have a role in accelerating bone
healing and tends to promote new bone formation at the
implant site.
In implant dentistry, PRF has demonstrated significant
potential for improving implant stability and promoting
osseointegration, particularly during the critical early
healing phase.
Applied around traditional implants, PRF accelerates soft
tissue healing, reduces marginal bone loss, and supports
peri-implant tissues, contributing to enhanced long-term
implant success.
Its biological scaffold properties facilitate tissue repair
mechanisms and mitigate the risks associated with
PRF also enhances bone regeneration and supports fibro
osseointegration by stimulating osteoblast activity and facilitating
new bone formation at the implant site.
This promotes better integration and reduces the risk of implant
failure.
This biological enhancement not only improves the immediate
stability of transitional implants but also prepares the alveolar
ridge for future definitive implant placements, ensuring a smoother
transition from temporary to permanent dental solutions.
CONCLUSION
In summary, incorporating PRF into posterior
transitional implant therapies represents a significant
advancement in pediatric dentistry.
By harnessing PRF’s regenerative properties, clinicians
can optimize treatment outcomes, minimize
complications, and enhance the overall quality of care
for young patients.
CROSS REFERENCE
A 12-year-old girl in her initial clinical examination revealed a
diastema and congenitally absent maxillary lateral incisors, with
the canines positioned apart from the lateral incisor spaces.
Angle’s class I was on the right side and ended on the left side,
with proclined upper anteriors. Treatment objectives were to
correct proclined maxillary incisors, maintain a class I
relationship to correct midline spacing, and replace the missing
lateral incisor space with a transitional implant.
A 12-year-old girl with poor esthetics visited the Pediatric Dental
Outpatient Department having noncontributory medical and
dental history. The intraoral examination revealed mixed
dentition and molars to be in Angle’s class I molar relationship.
She also presented with the maxillary posterior right segment in
buccal crossbite (tooth no. 12, 13, and 15) and the absence of
22. The permanent maxillary right lateral incisor (tooth no. 12)
was peg-shape. The cephalometric analysis highlighted a
skeletal class I relationship. These clinical aspects created
pronounced malocclusion with esthetics deficiencies.
