Contemporary management of tooth replacement in the traumatized dentition

Abstract

Dental trauma can result in tooth loss despite best efforts at retaining and maintaining compromised teeth (Dent Traumatol, 24, 2008, 379). Upper anterior teeth are more likely to suffer from trauma, and their loss can result in significant aesthetic and functional problems that can be difficult to manage (Endod Dent Traumatol, 9, 1993, 61; Int Dent J 59, 2009, 127). Indeed, teeth of poor prognosis may not only present with compromised structure but trauma may also result in damage to the support tissues. Injury to the periodontium and alveolus can have repercussions on subsequent restorative procedures (Fig. 19). Where teeth are identified as having a hopeless prognosis either soon after the incident or at delayed presentation; planning for eventual tooth loss and replacement can begin at the early stages. With advances in both adhesive and osseointegration technologies, there are now a variety of options for the restoration of edentate spaces subsequent to dental trauma. This review aims to identify key challenges in the provision of tooth replacement in the traumatized dentition and outline contemporary methods in treatment delivery.

Fig. 1

(a) 21-year-old patient who previously lost 21 because of trauma. Orthodontic space optimization was instigated followed by composite augmentation of the 22 to mimic a 21 (b).

Fig. 2

(a) Long cone periapical of 11 following trauma which resulted in mid-root fracture of the 11. (b) The tooth was extracted and an autotransplanted premolar was used to replace. Composite augmentation and root canal treatment was completed on a subsequent visit. Case courtesy of the Department of Paediatric Dentistry, Newcastle Dental Hospital.

Fig. 3

(a) 14-year-old patient presenting with decoronation of the 21 and subluxation of 11. Both teeth were root canal treated and asymptomatic at review. (b) Resin-bonded bridgework cantilevered from the 22 into the 21 space. The guarded prognosis of the 11 precluded it as an abutment. Once growth is completed, the definitive restoration of the 21 area with an implant will be considered.

Fig. 4

Resin-bonded bridge cantilevered from the 13 into the 12 space. Initial investigations revealed the need for grafting in the 12 site for an implant. The patient was not keen on this option, and a definitive resin bonded bridge was fitted.

Fig. 5

Intraoral sandblasting prior to RBB cementation under rubber dam isolation.

Fig. 6

(a) Previous trauma resulted in the loss of the 11. Note the excess tissue in the 11 site making potential pontic dimensions difficult to match with adjacent gingival margins. (b) Electrosurgery to create ideal pontic space for resin-bonded bridgework in addition to maximizing enamel surface area palatally on 21. (c) To maintain the soft tissue dimensions, the retainer was relined and fitted. (d) The definitive resin-bonded bridge cemented from the 21 cantilevered into the 11 space.

Fig. 7

(a) 15-year-old patient who suffered a combination of avulsions, alveolar and root fractures. These were managed surgically and primary closure was achieved. At an early stage, the lack of interocclusal space for subsequent restoration of the edentate space was apparent. (b) To create interocclusal space utilizing the Dahl approach, a resin-bonded bridge was cemented from the 13 to the 22 at an increased occlusal vertical dimension. (c) After 6 months of wear posterior contacts re-established and adequate interocclusal space was created for the placement of implants to definitively restore the space.

Fig. 8

Immediate resin-bonded bridgework for 21 space utilizing carbon fibre material.

Fig. 9

Rochette style bridge utilized in a multiphase treatment plan. This patient was fitted with the resin-bonded bridge immediately after extraction. The bridge was modified to accommodate a healing abutment and recemented after implant placement.

Fig. 10

(a) This patient suffered trauma to the 21 which was subsequently treated with orthograde endodontics followed by apical surgery. Because of persistent infection, the tooth was extracted. (b) CBCT examination revealed an obvious bony defect which was not amenable to implant placement. The feasibility of bone graft placement was also difficult to predict because of the lack of bone present to receive donor tissue.

Fig. 11

(a) Radiographic examination of the 11 and 12 showed external and internal inflammatory resorption and external replacement resorption. (b) The 11 and 12 were accessed and gutta percha removed and were subsequently decoronated with surgical closure.

Fig. 12

(a) Delayed presentation of a mid-root fracture and a periapical lesion. (b) The 21 was replaced with an implant.

Fig. 13

Piezo powered bone and periodontal ligament dissection.

Fig. 14

(a) Onlay graft in the 22 site where previous avulsion had resulted in deficient alveolar profile for implant placement. (b) Interim implant restoration 22. Note the lack of emergence. (c) Flowable composite modification of the interim restoration to create gradual emergence and form. (d) The definitive restoration with developed emergence form.

Fig. 15

Patient undergoing orthodontic extrusion for the purpose of implant site development in the 11 site. The 11 has been extruded utilizing a mini implant placed apically. Case courtesy of Bill Ip, Newcastle Dental Hospital.

Fig. 16

Traumatic loss of 11 and 12 resulted in a marked vertical and horizontal defect. The patient preferred the use of gingivally toned ceramic as opposed to bone and soft tissue grafting prior to implant placement. Case courtesy of Amre Maglad, Newcastle Dental Hospital.

Fig. 17

(a) Decoronation of 43 as a result of trauma. Because of the limited supragingival tissue available for restoration, the tooth was deemed as having a poor prognosis. (b) Definitive restoration after extraction and immediate implant placement.

Fig. 18

(a) This patient suffered numerous injuries subsequent to a road traffic accident approximately 25 years ago. She lost the majority of her mandibular teeth in addition to the need for grafting and fixation. Once stabilized, she was provided with an implant retained prosthesis. (b) Radiograph 20 years after initial provision. During this period, the patient presented with a variety of maintenance requirements that included clip fractures, abutment screw loosening, overdenture replacement and peri-implant mucositis.

Fig. 19

Poly-trauma presenting with decoronation of the 21, luxation of the 11, fracture of the implant crown 12, gingival lacerations and a sinus associated with the 11.