Restoration of Trauma Patients: The Present Is as Important as the Future

The treatment of injuries to the permanent dentition resulting from facial trauma presents significant challenges to the dental office. Of course, most offices do not see traumatic injuries frequently. These trauma patients may be in pain and have aesthetic compromises and functional disruption. They are often upset and worried about the future of their teeth and smiles. The trauma often involves both hard and soft tissues, so all structures must be considered in decision making and will be factors in the healing process.

The swift resolution of the patients’ immediate needs must be balanced with their emotional abilities to make permanent treatment decisions quickly after their injuries. Once stabilized clinically, the patients can better choose their permanent treatments, and the clinicians can take into account their individual emotional and psychological needs as well as other considerations, such as cost, time, and the probabilities of success.

CASE REPORT
Diagnosis and Treatment Planning
A 52-year-old female patient presented to the dental office for treatment of dental injuries sustained in a fall (Figure 1). Her chief concern was facial pain and an inability to close her mouth due to the position of the traumatized teeth. Her upper lip lacerations had been sutured in the hospital ER during the evening of the fall. No teeth were completely avulsed, although the roots and surrounding cortical bone were clearly displaced outside of the maxillary alveolus (Figures 2 and 3). The soft tissue was completely intact around the teeth, and blood flow was not compromised. The specific findings were as follows:

Figure 1. One week after the inury occurred, swelling was still present and the stitches done in the ER remained in place.

• Tooth No. 4 in occlusion with Class II mobility;
• Tooth No. 5 completely displaced palatally;
• Tooth No. 6 intruded with Class III mobility;
• Tooth No. 7 intruded palatally with Class II mobility, enamel cracks evident;
• Tooth No. 8 palatally displaced, Class II mobility, fractures to clinical crown; and
• Tooth No. 9 had a chipped incisal edge.

The diagnostic findings and permanent treatment options were discussed with the patient, including the prognosis of each approach. While the overall prognosis of the teeth was poor, the removal of the displaced teeth and debridement of fractured bone would leave a catastrophic alveolar defect. Reconstruction was possible, but the process would be extensive and likely result in an overall aesthetic compromise. Therefore, as an immediate treatment, the patient elected to preserve the teeth and, thus, the bone and soft tissue. She was made aware that the endodontic therapy required to preserve the teeth might fail and necessitate removal of the teeth and reconstruction in the future.

Figure 8. Tooth position prior to preparation. Moderate reduction was necessary for teeth Nos. 6 and 7 (due to their more facial positon in the arch) and on the distal aspects of the central incisors (which were wider and more flared than ideal).	Figure 9. After minimal preparation, the shade was selected.

Oral Surgery
While under intravenous sedation, the patient’s displaced teeth were manually repositioned to allow for stable and repeatable occlusion. The teeth were stabilized in this position using orthodontic wire and composite resin. No incisions were made to avoid compromising blood flow to the structures around the avulsed teeth. The patient was then referred for endo­dontic treatment.

Endodontic Treatment
Two weeks after the accident, teeth Nos. 4 to 8 were nonresponsive to cold and very percussion sensitive. Palpation sensitivity was also noted over the roots of these teeth. Tooth No. 9 exhibited a mesial coronal fracture with various cracks, but all pulp tests were normal. Tooth No. 4 had a root fracture in the apical 3.0 mm, but prognosis was still deemed favorable. Endodontic therapy was completed on teeth Nos. 4 to 8, with a one-month recall set to reevaluate tooth No. 9 (Figures 4 and 5).

Figure 14. Our happy patient continues to feel fortunate that she could save her teeth and satisfy her aesthetic desires.

Restorative Plan
After completion of the endodontic therapy, the patient returned for an evaluation and discussion of her long-term restorative options. The greatest long-term risk was loss of the injured teeth through resorption, endodontic failure, or bone loss. She stated that a fixed restorative option was important to her, as was an excellent aesthetic outcome. One option discussed was to extract teeth Nos. 4 to 8 due to their questionable long-term prognosis. This would require bone grafting and implant placement, with the possibility of a soft-tissue defect. She rejected the extraction option due to the unpredictable aesthetic outcome, and also due to her concerns about the healing phase and appearance of the temporary restorations. The other option was to keep teeth Nos. 4 to 8, and to place veneers to establish proper smile design and to restore the broken teeth. A minimal amount of tooth preparation would be required for veneers, so the teeth would not be compromised further by the restorative treatment. The risk to this approach was that the cost of the veneers would be lost if the teeth had to be removed in the future. However, the veneer option did not involve a removable appliance or long-term provisionals, incurred no surgical costs, and was a relatively straightforward aesthetic restoration. She opted for no extractions, and for restoration with veneers.¹

Clinical Records
Clinical records were obtained at the start of the restorative phase, which began 8 months after the injury occurred (Figures 6 to 8). A thorough functional exam revealed acceptable function.² There was no need to alter her vertical dimension, so the existing maximum intercuspation position could be used. A series of digital photos and a video (Canon 70D [Norman Camera]) were taken to analyze the aesthetic relationships between the face, teeth, and tissue. The use of video can capture maximum lip movement and tooth reveal during speech that static photography does not always record.³ Functional records were taken using the Kois Dento-Facial Analyzer (Panadent), a bite registration (Futar D [Kettenbach LP]) and a stick bite. These, along with a known metric (such as the length of No. 8), was used to verify the accuracy of casts and mounting for lab purposes. The patient reported that she loved the smile she had before the accident, so she brought photos taken before the injury to assist in recreating that smile. These records were sent to the lab to create a wax-up and silicone matrix to replicate the shape and contours of her old smile as closely as possible.

Restorative Phase: Clinical Protocol
A study model was used that indicated where tooth reduction would be needed to completely seat the silicone matrix (Virtual Putty [Ivoclar Vivadent]). Since the reductions were made entirely in enamel, no anesthetic was used. The silicone matrix was loaded with a bis-acryl provisional material (Luxatemp Ultra [DMG America]) and placed over unprepped teeth. The material was allowed to fully cure before removing the silicone matrix. Smile design was initiated by determining the final desired position of the teeth. The tooth shapes and position in the bis-acryl were evaluated for shape, contour, and alignment with normal lip movement. This technique ensured that tooth reduction was only done where necessitated by the final smile design.⁴

Once both the patient and dentist were satisfied with the final smile design, the patient was anesthetized. With the bis-acryl stent in place, depth cuts were made in the cervical, middle, and incisal thirds of the facial surface and preparations were finished and refined. A vinyl polysiloxane (Aquasil Ultra [Dentsply Sirona Restorative]) final impression, prep shades (Figure 9), and a bite registration were taken. The silicone matrix was again filled with the bis-acryl provisional material and placed over the teeth. After approximately one minute, the bis-acryl reached initial set. It was then removed and allowed to fully cure extraorally. The provisionals were then trimmed and polished. The teeth were spot etched (Ultra-Etch [Ultradent Products]) and an adhesive resin (OptiBond FL [Kerr]) was applied to the intaglio surfaces of the provisionals and seated. Before the final cure, a microbrush was used to clean off any excess resin, and a rubber tip stimulator was used to clear the interproximal areas. The posterior contact points were refined with articulating paper (TrollFoil [TrollDental USA]) and verified with shimstock. The chewing envelope of motion was then evaluated by having the patient sit up and chew a piece of gum with 200-µm articulating paper (Bausch) in place. All streaks on the linguals of the maxillary centrals and laterals were removed to ensure there was no friction during function.⁵

The patient returned one week later to evaluate the occlusion and to address any postoperative concerns. She reported no problems. Her speech and chewing felt normal and she had no negative impact to her lifestyle. She wore the provisionals a few more weeks to ensure that she remained satisfied with the aesthetics, particularly in the areas of bone/tissue loss where the clinical crown appeared longer. If that had been a concern, the use of pink porcelain to mask the length of the clinical crown could have been considered. After 4 weeks, she opted to forego the addition of pink porcelain in the final restorations as her normal lip dynamic did not reveal the excessive clinical crown length⁶ (Figures 10 and 11). Full occlusal, facial, photo, and video documentation were done again. This information was sent to the dental laboratory team (Matt Roberts, CDT of CMR Dental Lab [Idaho Falls, Idaho]) to capture any changes that had occurred during the 4 weeks of wearing the provisional restorations in the final restorations.

Six weeks later, the patient was anesthetized and the provisionals were carefully removed. Small tags of resin will often remain on the teeth, particularly if not thoroughly removed where the tooth was spot etched, and will interfere with the final seat of the restorations. These areas of adhered resin were carefully removed using a sharp scaler. The teeth were microabraded using 27-µm aluminum oxide at 40 psi (PrepStart H20 [Zest Dental Solutions]), treated with 35% phosphoric acid for 15 seconds, and then rinsed and gently dried (not dessicated). Unfilled adhesive resin (One-Step [BISCO Dental Products]) was applied with a brush, air-thinned, and then light cured. The internal surfaces of the restorations were etched with 35% phosphoric acid, silane (RelyX Ceramic Primer [3M]) was applied, and then a layer of light-cured translucent RelyX Veneer Cement (3M) was applied. The IPS e.max (Ivoclar Vivadent) restorations were placed on the teeth and then spot cured.⁷ Excess cement was removed, and the final light curing was completed. Finally, the occlusion was refined as described earlier (Figures 12 and 13).

After completion of the restorative phase, an upper occlusal splint was fabricated and delivered to ensure the proper splinting of teeth and to also protect against any possible parafunctional habits.

CLOSING COMMENTS
Trauma that results in fractured and displaced teeth can have significant negative aesthetic, functional, and psychological impacts on patients. Facial traumatic dental injuries are emergencies that the dentist must be able to assess rapidly and manage appropriately. Once initial stabilization has taken place, the risk assessments and prognosis must be reviewed with the patient to determine the treatment plan that best suits his or her goals. Finances, aesthetics, function, and length of treatment are considerations, as well as reasonable predictability. The patient presented in this clinical case report has functioned comfortably with no adverse complications for more than 3 years now. She continues to be very thankful that she chose to save her teeth (Figure 14).

Acknowledgement
The author would like to acknowledge CMR Dental Lab (Idaho Falls, Idaho) and thank Matt Roberts, CDT, for the ceramic restorations fabricated in this case.

References

1. Bakeman EM, Kois JC. Maximizing esthetics/minimizing risk: the line of predictable success. Inside Dentistry. 2005;1:16-24.
2. Dawson PE. Centric relation. In: Dawson PE. Evaluation, Diagnosis, and Treatment of Occlusal Problems. 2nd ed. St. Louis, MO: Mosby; 1989:28-55.
3. Coachman C, Calamita MA, Sesma N. Dynamic documentation of the smile and the 2D/3D digital smile design process. Int J Periodontics Restorative Dent. 2017;37:183-193.
4. Terry DA, Leinfelder KF, Geller W, eds. Aesthetic and Restorative Dentistry: Material Selection and Technique. Stillwater, MN: Everest Publishing Media; 2009.
5. Kois JC. Functional Occlusion: Science Driven Management Manual. Seattle, WA: Kois Center; 2011:79.
6. Rufenacht CR. Principles of Esthetic Integration. Chicago, IL: Quintessence Publishing; 2000.
7. Magne P, Belser U. Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach. Chicago, IL: Quintessence Publishing; 2002.

Dr. Seay, a 2002 graduate of the New York University College of Dentistry, maintains a private practice in Mount Pleasant, SC, and is an accredited member of the Academy of Cosmetic Dentistry (AACD). She is a clinical instructor at the Kois Center in Seattle, Wash. Dr. Seay has published articles covering the art and techniques of aesthetic dentistry and serves on the advisory boards of several peer-reviewed journals. She was nominated in 2012 as one the “Top 25 Women in Dentistry” by Dental Products Report and has been listed in Dentistry Today’s Leaders in Continuing Education since 2017. She can be reached at (843) 375-0395 or via seayamanda@gmail.com.

Disclosure: Dr. Seay reports no disclosures.

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