Predictability is a worthy goal for any practicing dentist. The study of evidence based models in dentistry has developed increasing predictability of the success of specific dental treatments and procedures in achieving optimum oral health.1 While dental treatments have continued to become more predictable, life, however, consistently presents unforseen situations. A traumatic dental injury is an unfortunate, common, and unpredictable occurrence that necessitates a predictable treatment solution.
The first contact between the dentist and the patient who has experienced a traumatic dental injury begins with an evaluation to determine the extent of the injury. Endodontic treatment or tooth loss may or may not be indicated at the time of injury or at a future date should any tooth involved become symptomatic. In the case that the injury is limited to fracture of a single tooth, predictable restorative treatment can be limited to a few options. The concept of Responsible Esthetics compels the practitioner to perform the most conservative treatment possible that will achieve functional and esthetic goals.2 If the tooth fragment is recovered, bonding the fragment back into place is often the most conservative and predictable repair. (Fig. 1) If the tooth fragment is lost, a class IV direct composite repair or indirect porcelain repair may be indicated depending upon the extent of the injury to the tooth. (Fig. 2) In the worst case scenario, the tooth can be determined to be nonrestorable, lost, and require either a fixed or removable prosthetic replacement.
In the case of traumatic injury resulting in the loss of a single anterior tooth with no damage to the adjacent teeth, the current standard of care generally indicates an endosseous dental implant as first choice of care for prosthetic replacement of the missing tooth. Esthetic and functional prosthetic restoration of this traumatic dental situation can be achieved predictably through proper planning and execution of treatment.
A 19 year old male in excellent health presented with a mobile maxillary lateral incisor exhibiting lingual coronal displacement and bleeding from the sulcus. (Fig. 3) The patient stated that he is involved in amateur bull riding and the traumatic injury occurred during his participation in the sport earlier that day. He noted that he was not wearing a protective mouthguard at the time that the injury occurred.
Clinical and radiographic evaluations were performed. It was determined that the tooth was fractured vertically in an apical direction from the facial to lingual aspects of the tooth. The fracture extended subcrestally with reference to the lingual bone and the coronal segment of the tooth was being held into the socket by periodontal ligament fibers. (Fig. 4) Due to the extent of the fracture, the tooth was determined to be nonrestorable.
Emergency evaluation and care were performed first. (Fig. 5) Before a focused treatment plan could be developed, the extent of the patient’s injury had to be identified and managed to eliminate pain, maintain reasonable function, and minimize risk for future associated complications such as bacterial infection.
Following stabilization of the affected area, an interdisciplinary case conference between the oral surgeon and the restorative dentist was scheduled. The patient was asked to return for a subsequent records and planning appointment, where the injured area would be reevaluated for any previously unaddressed issues.2 Functional esthetic restorative options for replacement of the nonrestorable tooth were discussed, and the patient elected to pursue restoration of tooth #7 with an endosseous implant, a custom zirconia abutment, and a porcelain crown. The patient emphasized that a natural, conservative, long-lasting result was his primary goal. Proper care for the selected future restoration was discussed including nightly wear of a hard protective occlusal guard, wear of a soft protective athletic mouthguard for sports, and the importance of optimal maintenance including regular cleanings and examinations was stressed.3
A comprehensive set of records was made of the patient’s presurgical condition including a detailed lab prescription to allow for proper communication between the dentist and the ceramist. Honigum Pro (DMG America; Ridgefield Park, NJ) polyvinyl siloxane impressions were made of both arches, and study models were fabricated in die stone.3,4,5,6 Occlusion was recorded with a Futar D (Kettenbach; Eschenburg, Germany) polyvinyl siloxane bite registration and a facebow transfer. Digital photographs documenting the preoperative shade, texture, and shape of surrounding teeth were made.3,4,6,7 All records were sent to the lab where the study models were mounted on a Stratos 2000 semi-adjustable articulator (Ivoclar Vivadent; Amherst, NY), and tooth #7 was waxed to full contour. Careful attention was given to the incisal and lingual contours to ensure that they conformed to the patient’s anterior and canine guidance. A Biocryl X (Great Lakes Dental Technologies; Tonawanda, NY) radiopaque acrylic surgical guide was also fabricated and delivered to the patient’s oral surgeon to assist in implant placement.
Description of Treatment
The remaining root of tooth #7 was extracted by the oral surgeon. Due to a thin buccal plate and small fracture of the buccal bone, the surgeon decided to graft the surgical site and allow it to heal for three months prior to implant placement. During that time a bisacrylic provisional was bonded to the adjacent teeth to maintain esthetics. (Fig. 6)
After three months of healing time for the implant site the provisional was removed and a 3.25x11mm Biomet 3i Osseotite Certain Prevail endosseous implant (Zimmer Biomet; Palm Beach Gardens, FL) was placed in the #7 site using the acrylic surgical guide. A new provisional was fabricated with the apical segment contoured to cover but provide no contact with the healing cap of the newly placed implant. The provisional was bonded to the adjacent teeth, once again, for a three month period to allow for healing and osseointegration of the implant. (Fig. 7)
After three months and receiving restorative clearance from the oral surgeon (osseointegration confirmed by the oral surgeon), the patient was appointed to begin the restorative process. The bonded provisional was removed and a stock screw retained temporary implant post was modified with composite to develop proper emergence profile. Composite was bonded to the temporary post radially below the height of contour to pressure the tissue and emulate a tooth prepared for a crown restoration. (Fig. 8) When the desired initial tissue support was achieved, the composite on the provisional post was polished and the post was screwed into place. The access hole of the temporary post was filled with teflon tape prior to fabrication of a bisacrylic provisional crown. A polyvinyl siloxane stent made from the diagnostic waxup was filled with B1 Luxatemp Ultra (DMG America; Ridgefield Park, NJ) and placed over the prepared abutment and allowed to cure. After approximately 1 minute, the stent was gently removed with the bisacrylic provisional remaining inside. The provisional was removed from the stent, trimmed, and bonded with Optibond FL resin (Kerr Corp; Orange, CA) to the provisional abutment. (Fig. 9) The provisional crown was cured for 30 seconds with the Bluephase LED curing light (Ivoclar Vivadent; Amherst, NY). Excess material was removed with a #12 scalpel blade, and the provisional was smoothed and finished with abrasive discs (Cosmedent Inc.; Chicago, IL) and a rubber cup polisher (Cosmedent Inc.; Chicago, IL). The tissue was then allowed to heal and adapt to the temporary structure for a period of two weeks.
Development of the tissue at the implant site was monitored and modified at two week intervals. An access hole was drilled in the facial aspect of the provisional and it was removed as a screw retained provisional crown at each recall appointment. (Fig. 10) Modifications were made by adding composite to pressure the tissue and the crown was replaced each time. At the six week check appointment, the tissue development and shape of the provisional were approved by the patient and the restoring dentist.3,4 The provisional shape was recorded photographically and with a full arch polyvinyl siloxane impression. Additional digital photographs were made from multiple angles with at least two shade tabs per photograph to assist in shade matching and color mapping (hue, chroma, and value) prior to any dehydration of the teeth.3,4 (Fig. 11)
The provisional was then removed to visualize the restorative platform of the implant and to evaluate the surrounding tissue contours. (Fig. 12) On the bench, the provisional restoration was seated in an implant lab analog and Clear Bite transparent bite registration material (Den-Mat; Lompoc, CA) was expressed around it to form a matrix to record the subgingival contour of the provisional used to support the soft tissues. The provisional restoration was then removed and an open tray style impression coping was seated in the lab analog within the clear matrix material. Flowable composite was then injected around the impression coping and cured through the clear bite registration material to precisely replicate the emergence profile of the provisional restoration. The modified impression coping was then removed from the lab analog and clear matrix and utilized as a custom impression coping for the master restorative impression. (Figs. 13-16)
The modified open tray style impression coping was screwed into the implant. A check film radiograph was made to confirm accurate and positive seat of the impression coping. A master polyvinyl impression was made with Honigum Pro Light and Heavy impression material (DMG America; Englewood, NJ). Following set of the polyvinyl material, the impression coping was unscrewed and removed as part of the master impression. (Fig. 17) The screw retained provisional was replaced and tightened into position. Teflon tape was placed in the screw access and the facial access hole was filled with matching composite, cured, and polished. A Futar D (Kettenbach; Eschenburg, Germany) stick bite of the teeth in centric occlusion was made and photographed. All records were disinfected and sent to the ceramist accompanied by a completed laboratory prescription and all photographs taken to this point. The ceramist was instructed to use the impression of the approved provisional as a guide for the final shape, size, and contour of the porcelain restoration.
During the final provisional phase the patient was able to further reevaluate the provisional restoration. If he had requested any changes, they could have been communicated to the ceramist during this period. No changes were requested during this time.
On the ceramist’s receipt of the case, the records were reviewed and the material choice on the prescription was confirmed during a telephone conversation.2 Shape, shade, and characterization were discussed again and finalized in the planning stage. Producing the patient’s desired shade choice dictated an e.Max HTBL3 block (Ivoclar Vivadent; Amherst, NY) to be milled as a base shade for the implant crown. Cutback and layering of the milled implant crown was planned to develop restoration with the requested moderate incisal character and natural gingival staining with a lightly textured, polished gloss finish. Zirconia bonded to a titanium base was used to fabricate a custom implant abutment.
Master full arch working die models were fabricated of the implant (with a lab analog) and mounted on a Stratos 2000 semi-adjustable articulator (Ivoclar Vivadent; Amherst, NY) during the laboratory phase. The custom zirconia abutment was fabricated and tried on the model for appropriate emergence profile. Marginal accuracy of the full contour implant crown was then confirmed on the physical die model. Cutback of the full contour milled crown was performed as needed to allow for hand layering of IPS e.Max Ceram porcelain (Ivoclar Vivadent; Amherst, NY) to develop realistic translucency, depth, and character. Following layering and firing, it was hand finished and polished. The ceramist meticulously confirmed fit, esthetics, and function. The intaglio of the porcelain was lightly sandblasted and then acid etched for 1 minute with 9.5% HCl (Keystone Industries; Gibbstown, NJ). The crown and abutment were then steam cleaned and carefully packaged for return to the dentist ready for the seat appointment.
On return from the ceramist, the porcelain restoration and abutment were inspected on the die for marginal fit and on the solid model for proper interproximal contacts. An Optragate lip retractor (Ivoclar Vivadent; Amherst, NY) was placed to assist in isolation. The provisional restoration was removed, and the implant interface was cleaned with chlorhexidine to remove any residual debris. The implant abutment was seated using a DuraLay acrylic (Reliance Dental Manufacturing LLC; Alsip, IL) seating jig. (Fig 18) Positive seat was confirmed with a radiograph prior to torquing the abutment to place. (Fig 19) The seated abutment was then torqued to 20Ncm per manufacturer’s instructions. The porcelain restoration was tried into the patient’s mouth and evaluated for fit and esthetics. The patient was then allowed to view and approve the esthetics of his smile in a hand mirror.8
The approved crown was removed from the patient’s mouth and carefully cleaned with Ivoclean cleaning paste (Ivoclar Vivadent; Amherst, NY) to remove any possible contamination. It was rinsed, dried, and Monobond silane coupling agent (Ivoclar Vivadent; Amherst, NY) was applied to the intaglio.9 Following one minute it was air dried, and a thin coating of All Bond Universal bonding agent (Bisco; Schaumberg, IL) was applied to the inside of the crown and air thinned. Vitique Clear Veneer Cement (DMG America; Ridgefield Park, NJ) was then applied to the restoration and it was immediately placed into a ResinKeeper light-safe box (Cosmedent Inc.; Chicago, IL) to prevent polymerization of the resin.3,4
The implant abutment was re-torqued to 20Ncm to compensate for any possible settling and teflon tape was placed in the implant screw access hole and covered with flowable composite. The abutment was cleaned with Ivoclean cleaning paste (Ivoclar Vivadent; Amherst, NY). A thin layer of Z-Prime Plus (Bisco; Schaumberg, IL) zirconia primer was applied to the #7 abutment and air dried. Two coats of All Bond Universal bonding agent (Bisco; Schaumberg, IL) was applied to the abutment and agitated for 20 seconds prior to air thinning to evaporate solvents. The abutment #7 was cured for 20 seconds with a Bluephase LED curing light (Ivoclar Vivadent; Amherst, NY). The crown was then removed from the light-safe box and seated on the abutment. Excess cement was removed with a Regular Microbrush (Microbrush International; Grafton, WI) and the crown was tacked into place for 5 seconds with the curing light.10 Additional excess was removed gently with a scaler, floss was passed through the contacts in the apical direction only, and the restoration was then cured fully for an additional 30 seconds from the facial and lingual.10 The margins were then inspected and any excess cured cement was removed with a #12 scalpel blade.10 Interproximal areas were cleaned with Epitex finishing strips (GC America; Alsip, IL). DeOx glycerin oxygen inhibiting gel (Ultradent Corp; West Jordan, UT) was expressed around all margins and the restoration was cured an additional 10 seconds to finalize polymerization.3,4,9 The lingual aspect was then polished with diamond paste and Flexibuff polishers (Cosmedent Inc.; Chicago, IL) in a slow speed handpiece and isolation was removed. (Fig. 20)
The patient’s occlusion was checked and smooth, proper contacts were verified with dental floss. Post-operative home care instructions were given and the patient was scheduled for a follow-up appointment for radiographic and photographic documentation as well as a follow-up check for function and esthetic evaluation.
The patient returned the following day. His functional occlusion was evaluated, and his teeth were inspected for any residual cement. Maxillary and mandibular alginate impressions were made along with a polyvinyl siloxane bite registration for fabrication of a maxillary full arch bite guard for nighttime wear and a custom soft sports mouthguard.3 Post-operative home care instructions were given and the patient was scheduled for a follow-up appointment for radiographic and photographic documentation, a final check for function and esthetic evaluation, and delivery of the patient’s maxillary appliances.3 (Fig 21)
Traumatic injuries can be the most stressful cases handled by any dentist. Development of a predictable protocol for managing trauma cases can greatly reduce stress for both the practitioner and the patient. Careful planning and precise execution can turn a disastrous situation into a restorative success that provides beautiful, functional, and long lasting results that exceed patient expectations.
Oral Health welcomes this original article.
Acknowledgements: The author would like to express sincere appreciation to Wayne B. Payne, MDT, AAACD and Tyler Payne for their technical expertise and collaboration on this case.
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About the Author
W. Johnston Rowe is an Accredited Member of the American Academy of Cosmetic Dentistry, past member and Chairman of the American Board of Cosmetic Dentistry, and has served as the AACD’s Chairman of Accreditation. He also serves as an Accreditation Examiner for the AAC. Dr. Rowe has been awarded Fellowships in the International College of Dentists and the Pierre Fauchard Academy. He is a graduate of the University of Tennessee College of Dentistry, and is a formally trained artist having graduated from Washington and Lee University with a Bachelor of Arts degree in Studio Art. Dr. Rowe maintains a full-time private practice in Jonesboro, Arkansas.