A Multidisciplinary Anterior Trauma Case: It Takes a Team!

INTRODUCTION
Anterior trauma to the natural dentition in adults is a common occurrence that can often require a multidisciplinary approach with an organized and well-conceived treatment plan. When treatment planning these patients, thought must be given to issues dealing with restorative longevity and aesthetics. A plan must be created that makes treatment seamless for the patient’s day-to-day life, keeping in mind that our patients must continue to go about their routine during what can easily be a 6-month to one-year finality of treatment.

When dealing with substantial fractures in anterior teeth, thought must be dedicated to which of the teeth have the best long-term prognosis and what teeth, if any, may even need to be extracted. Important things to consider include deciding if implants or grafting procedures are needed, a rough timeline of treatment, and some idea of what the aesthetics and longevity can be expected out of each option.¹ With the recent advances in dental research and materials, placing anterior implants and being able to control the soft- and hard-tissue architecture as well as the aesthetic outcome to mimic natural dentition is much more predictable. The surgical procedures, prosthetic sequences, as well as laboratory material selection has made this possible. However, one key factor to take into consideration is the age of the patient. Age should always be considered when dealing with the thought process of keeping teeth versus removing them, as we should always be thinking of the most conservative approach while not sacrificing the prosthetic lifespan of each restoration.

CASE REPORT
Diagnosis and Treatment Planning
A 27-year-old male presented to our office after a surfing accident that resulted in a severe fracture of his maxillary incisors (Figures 1 to 3). Clinical and radiographic examination revealed pulpal exposure of the maxillary right lateral incisor (tooth No. 7), indicating the need for root canal therapy. The considerations included the longevity of endodontically treated anterior teeth in a young patient, and also determining if posts would be a necessary part of the restorative treatment.² With the large size of the fracture and little coronal tooth left, the pros and cons of preparing for a post pattern had to be considered. The maxillary right central incisor (tooth No. 8) was fractured coronally and presented with +2 mobility, indicating a fracture of the buccal plate. The maxillary left central incisor (tooth No. 9) showed a Class IV fracture on the mesial-incisal. There was a pulpal exposure with no mobility noted.

There are many questionable things that can happen in a trauma patient like this that can make creating a standard treatment plan difficult. Therefore, we refer to these to our patients as a fluid treatment plan. This means that the treatment plan may change throughout the course of treatment, depending on the circumstances.

Figure 1. Initial smile.	Figure 2. Initial retracted.

Figure 3. Initial full-face photo.

With the buccal plate of bone fractured, we had to consider removing the maxillary right central incisor (tooth No. 8) and to find a solution that would satisfy the function and aesthetics of the clinical challenges as presented. The options available for single-tooth replacement in the anterior region include a fixed partial denture (bridge), a resin-bonded restoration, or a single-tooth implant. As a part of the decision-making process, it is necessary to know all the available options of treatment, the pros and cons of each treatment option, and how to proceed with the actual treatment protocol.

The resin-bonded restoration option would be suitable if the adjacent teeth were virgin (untreated) teeth. This type of restoration would be used more as a temporary solution if, for example, we were going to place an implant and could not temporize immediately. Since both adjacent teeth were going to need root canal therapy, a resin-bonded restoration was not the treatment option of choice in this case.

A fixed partial denture (FPD) would be another option.³ Both adjacent teeth needed root canal therapy and crowns, and an FPD could be used as either a temporary restoration or a permanent one. An FPD is usually an easier and more predictable option to gain superior aesthetics in the pontic site. Advances in modern all-ceramic materials also allow for restorations that exhibit excellent strength and great aesthetic outcomes. However, using 2 endodontically treated teeth as abutments on a 3-unit bridge will always place the abutment teeth under more pressure than single-unit crowns. So whenever possible, the author prefers to go into a single-tooth situation.

Figure 4. Preparation/shade photo.	Figure 5. Initial provisionals.
Figure 6. Initial restorations.	Figure 7. “Temporary” restorations during implant therapy (retracted).
Figure 8. Temporary restorations during implant therapy (smile).	Figure 9. Three-month healing post-extraction and bone graft.
Figure 10. Three-month healing post-extraction and bone graft.	Figure 11. Implant placement.
Figure 12. Connective tissue (CT) graft.	Figure 13. Initial closure.
Figure 14. Need for pontic adjustment on the porcelain temporary fixed partial denture.	Figure 15. Tissue healing post-CT graft.

A single-tooth implant would be the third option. Placement and restoration of anterior implants has become much more predictable, and site development has become easier.⁴ Predictable aesthetic results, especially in the anterior region, require proper preservation of the osseous and soft tissues surrounding the tooth being removed, as well as proper implant placement and prosthetic management. However, this is where the fluid treatment plan comes into play for the patient. To properly build the surrounding architecture and provisional to proper form and function may require multiple surgeries. There is also the key question of the type of provisional that is suitable for use within each patient’s lifestyle during the development process. A major advantage in a single-tooth implant is that one does not have to prepare the adjacent teeth. In this case, however, both adjacent teeth would ultimately become full-coverage crown preparations due to the trauma suffered. This was advantageous to us, knowing that we could make an FPD as a temporary during site development if we chose to place an implant. Using an FPD would allow us to alter the pontic site to create optimal gingival architecture if connective tissue (CT) grafts were needed. It also is predicable for 4 to 6 months for the patient’s lifestyle and should always be taken into consideration.

After completion of a thorough examination and all options explained to the patient, we opted to treat the anterior 4 maxillary incisiors (teeth Nos. 7 to 10) to restore his aesthetics and function.

Clinical Treatment
The patient was initially sent to an endodontist (Dr. Jason Deblinger) for root canal therapy on teeth Nos. 7 and 9. The patient returned immediately following the root canal therapy to begin temporization. The post patterns were prepared by the endodontist. Size one Flexi-Posts (Essential Dental Systems) were placed in teeth Nos. 7 and 9. After being properly fitted and treated, the canals were etched using 35% phosphoric acid (Ultra-Etch [Ultradent Products]) for 15 seconds, then rinsed and dried with paper points. OptiBond Solo Plus (Kerr) was coated inside the canals and around the coronal tooth structure air-dried and light-cured (Demi Plus curing light [Kerr]) for 10 seconds. A resin cement (RelyX Unicem [3M]) was injected into the post patterns and the posts were placed. Ti-Core Auto E (Essential Dental Systems) was then injected around the post and coronal tooth structure and light-cured, and allowed to set for 5 minutes.

Figure 16. Thickness of buccal tissue post-graft.

Teeth Nos. 7 and 9 were prepared for an FPD with a butt-joint margin design. Tooth No. 10 was minimally prepared for a porcelain laminate veneer. Tooth No. 8 had to be extracted and an implant eventually placed after site preparation, so the tooth was cut down to the gumline so the area could be temporized. A photo was taken with shade tabs next to the teeth to show the color of the prepared teeth (stump shade) to the laboratory team (Figure 4). A final impression was taken with heavy- and light-body polyether impression material (Impregum Soft [3M]), and a bite registration was taken using a vinyl polysiloxane (VPS) (Regisil [Dentsply Sirona]). A counter alginate impression (Jeltrate [Denstply Sirona]) was taken.

Provisional restorations were then fabricated using a direct mock-up technique using a the bis-acryl provisional material, Luxatemp Ultra (DMG America) and a flowable composite, LuxaFlow Ultra (DMG America), formulated specifically for use as an add-on resin for Luxatemp Ultra and other bis-acryl provisional materials.

The patient had stated that he wanted to maintain the character of his “old” teeth and did not want to look like he had 4 perfect teeth next to his natural dentition. Careful examination of the broken teeth he presented with, along with some photos that the patient brought into the office to share, allowed us to see the irregularities and recreate the form in the temporaries. The temporaries would be used as a blueprint to accurately communicate exactly what was desired in the restorations to our ceramist (Figure 5).

The patient was sent to a periodontist (Dr. Brian Chadroff) to extract tooth No. 8 and start to develop the site for the implant. The patient was also sent to the lab for a custom shade evaluation of his own natural dentition and instructed to return to our office in one week to put transitional restorations in.

Together with the patient and ceramist, we decided on an all-ceramic anterior bridge as a temporary restoration while the patient would go through the implant process to ensure the highest level of aesthetics as well as a high level of predictability. A single feldspathic porcelain laminate veneer was also placed on tooth No. 10. The restorations were checked on the model for accuracy before the patient was brought back to insert (Figure 6).

Approximately one week later, the patient was anesthetized, and the restorations were tried in for fit and accuracy with water. The lithium di­silicate (IPS e.max [Ivoclar Vivadent]) all-ceramic FPD was delivered using TempBond Clear (Kerr). After try-in, the e.max veneer was conditioned with silane (Ultradent Products), air-dried, coated with an unfilled resin (OptiBond FL [Kerr]), and then covered (protected from ambient light). The tooth was then cleaned of any debris and etched with 35% phosphoric acid (Ultra-Etch) for 15 seconds, rinsed with copious amounts of water, partially air-dried, and then blotted gently to avoid desiccation of the dentinal tubules. OptiBond Solo Plus was applied, air-thinned, and then light-cured for 10 seconds. LuxaFlow Ultra shade B1, used as the final cement, was applied to the tooth and the restoration was seated.⁵ Excess cement was cleaned away and then the e.max veneer was tack-cured apically with the curing light for 5 seconds. Cement was cleared interproximally, mesially, and distally then light-cured as well. Full light curing for 45 seconds, both from the facial and lingual directions, was then performed. The apical and lingual margins were adapted and then the occlusion was checked and adjusted as needed.

Figure 19. Healthy gingival architecture prior to final impression.	Figure 20. Custom impression coping.
Figure 21. Final impression technique.	Figure 22. Final restorations on model.
Figure 23. Custom abutment try-in.	Figure 24. Final restorations (IPS e.max [Ivoclar Vivadent]).

Figure 25. Final smile.

The patient returned to the clinic for periodic evaluation. At this point, if there were a need to adapt the pontic site after the initial healing had occurred, it could be done (Figures 7 and 8). The patient was instructed to return to the surgeon in 3 months for implant placement. At that time, we would know if an additional CT graft was needed to obtain proper apical facial height in our final restoration.

After 3 months, the patient returned to the periodontist (Dr. Chadroff). At this point in the treatment, an additional CT graft was indicated. Some facial thickness of tissue had been lost (Figures 9 and 10). Simultaneously, a 3i Nanotite Certain (4.0 x 13.0 mm internal hex) implant was placed along with a demineralized freeze-dried bone allograft and a vicryl membrane. The FPD was placed in the patient’s mouth and the next day was evaluated to ensure that the pontic site was adequate and that there was no pressure on the implant (Figures 11 to 14). All pressure was relieved from the pontic site and the FPD was re-cemented using TempBond Clear. The patient was instructed to return to Dr. Chadroff’s office to uncover the implant in 5 months.

At the time of uncovery, the tissue had healed nicely, and adequate thickness was present to move forward with creating a final restoration (Figures 15 and 16). Immediately following the uncovering of the implant, the patient was sent to my office to temporize the implant and start to sculpt the soft tissue around the implant. An alginate (Jeltrate) impression of the upper arch was taken and the FPD removed.

Temporizing Implants
At the time of uncovery, the tissue around the implant was full but not sculpted. We opted to spend 4 weeks in a screw-retained temporary to let the tissue form around a properly contoured abutment.⁶ A 3i PreFormance temporary abutment (Zimmer Biomet) was placed and trimmed on the implant. Provisionals were created using the bis-acryl provisional material (Luxatemp Ultra, shade A1). The crowns on teeth Nos. 7 and 9 were cemented using TempBond Clear. The stent was then filled with Luxatemp Ultra and allowed to set. Once removed, the screw was accessed and unscrewed with the temporary crown locked onto the temporary abutment. This was then put on an analog and the apical aspect of the crown sculpted using LuxaFlow Ultra, shaped and tried in and out to confirm sulcular support. Once the shape was ideal with the proper apical tissue support, the provisional was polished and screwed into place (Figures 17 and 18). This was then placed back into the patient’s mouth and allowed to heal 4 weeks prior to final impression.

Final Impression
The patient was called back in for the final impression of teeth Nos. 7 to 10. We anesthetized the area and re-prepped the veneer of tooth No. 10. Both temporary crowns were removed and margins were prepared to the correct position. Finally, the temporary crown and abutment was unscrewed from the implant (Figure 19) and a temporary impression coping was fabricated. The crown was screwed into an analog, and a VPS bite registration material (Regisil) was injected all around the crown (Figure 20). The temporary crown was then unscrewed from the analog and an impression coping was screwed into place, leaving the negative of the apical form of the crown. Flowable composite was then injected into the negative around the impression coping and cured for 30 seconds (Figure 20). The impression coping was then unscrewed, tried, and screwed into the implant in the patient’s mouth (Figure 21). A final impression was taken with heavy- and light-body Impregum Soft polyether impression material, and a bite registration was taken with Regisil VPS bite registration paste (Denstply Sirona). A counter impression was taken with Jeltrate counter alginate. Shade photos of the preparations were also taken and communicated with the laboratory. The temporaries were put back in place and the case was sent to the laboratory with a detailed lab script, photos of the temporaries, model of the temporaries and prep shade diagnostic photos.

Final Restorations
We decided on all-ceramic restorations and a metal custom abutment for tooth No. 8 with porcelain baked on to match the preparation shade of the adjacent teeth. The restorations were checked for accuracy first on the model (Figure 22). The patient was then anesthetized in the area. The custom abutment was tried in first (Figure 23), then the crowns and veneers with water for accuracy. The restorations were then conditioned (as described previously), and the abutment was torqued to 20 Ncm. The access hole was covered with a cotton pellet and filled with a flowable composite and then light cured. The dentition was isolated (OptraGate [Ivoclar Vivadent]) and the bonding protocol was completed. The all-ceramic e.max crowns and veneers were cemented using a dual-cured resin cement (in a clear shade) (NX3 Dual-Cure [Kerr]). The implant crown was cemented using Premier Implant Cement (Premier Dental Products). The excess cement was removed, the occlusion checked, and the patient was dismissed. The patient was brought back at 2 weeks for a post-delivery evaluation (Figures 24 and 25).

CLOSING COMMENTS
Complex multidisciplinary cases, like the one presented herein, are always the most challenging for many reasons. First, when they are trauma cases, the mindset of the patient is much different when coming in for treatment. These patients did not come in to beautify their smiles; they are typically looking to just get their previous smile back. Second, the trauma itself will always present more “what if?”s because you are probably not going to be working in a stable environment. The results typically take longer and cannot be rushed to achieve true aesthetics and function. This means that the treatment team needs to figure out a way to handle the patient for the duration of the treatment required.

There are different choices with various protocols available to handle cases like the one presented, but no matter which treatment option is chosen, it is critical that the clinician understand and accommodate the patient in a manner that takes the patient’s life outside of the dental office into consideration. As a result, effort and planning must be put toward managing the treatment of a trauma patient such as this one throughout an extended time frame, requiring the need for transitional restorations that feel permanent and do not chip, stain, or fall out. And finally, when the clinician and laboratory team are creating restorations that need to blend naturally into an existing dentition, one always must be much more critical of the work to truly deliver an aesthetic success.

Acknowledgment
The author acknowledges that success is a result of great dental and laboratory teams and an understanding and cooperative patient. He would like to thank his periodontist Dr. Brian Chadroff (private practice, New York, NY), endodontist Dr. Jason Deblinger (private practice, New York, NY), Dr. Andi-Jean Miro (Rosenthal Apa Group, New York, NY), and Calvin Munn (Jason J. Kim Dental Aesthetics, Long Island, NY) for his ceramic artistry.

References

1. Tikku AP, Chandra A, Bharti R. Are full cast crowns mandatory after endodontic treatment in posterior teeth? J Conserv Dent. 2010;13:246-248.
2. Schwartz RS, Robbins JW. Post placement and restoration of endodontically treated teeth: a literature review. J Endod. 2004;30:289-301.
3. Hebel K, Gajjar R, Hofstede T. Single-tooth replacement: bridge vs. implant-supported restoration. J Can Dent Assoc. 2000;66:435-438.
4. Bichacho N, van Dooren E, Fradeani M, et al. Tissue management and prosthetic considerations with immediate implantation in the anterior maxilla. In: Schwartz-Arad D. Ridge Preservation and Immediate Implantation. London, England: Quintessence Publishing; 2012:105-120.
5. Poss SD. Successful application of total-etch and self-etch techniques in adhesive dentistry. Inside Dentistry. 2011;7:80-81.
6. Caudry S. Temporizing immediate implants: creating the foundation for long-term success. Oral Health. 2014;104:50.

Dr. Apa is a graduate of New York University College of Dentistry and maintains private practices in New York City and Dubai, UAE. He is a member of the American Academy of Cosmetic Dentistry (AACD), ADA, and AGD. He is on the editorial advisory board for the Journal of Implant and Advanced Clinical Dentistry and has been named a Leader in Continuing Education by Dentistry Today for many years. He was a recipient of the AACD’s 2007 Cosmetic Dentistry Award as well as the recipient of the American Academy of Hospitality Services Five-Star Diamond Award. He can be reached by calling (212) 794-9600 or by visiting his practice website at rosenthalgrp.com.

Disclosure: Dr. Apa reports no disclosures.

Related Articles

Adherence to Guidelines After Dental Trauma Ensures Positive Outcomes

Traumatic Dental Injuries: Emergency Assessment and Treatment

Physiotherapy Prevents Permanent Damage in Pediatric Trauma Cases