Case 1
CC
A 42-year-old female presents to the dental office complaining of a fractured maxillary incisor. She states that she suffered the injury in an automobile accident 2 days earlier and that she is not in pain.
Fracture of an anterior tooth in an otherwise intact dentition is a traumatic event for any person. In addition to acute pain and the possibility of infection, there are always concerns about cosmetic replacement and problems in the future. Immediate replacement with a provisional restoration and the fabrication of a final restoration that has an excellent long-term prognosis should be the goals of the dentist.
HPI
The maxillary left central incisor was fractured during an automobile accident. The patient was a passenger in the vehicle. She was drinking from a travel mug when the impact with the inflated airbag occurred. The tooth had endodontic treatment 3 years before the accident and was restored with a ceramic crown. A fiber-reinforced resin endodontic post had been placed.
PMHX/PDHX/medications/allergies/SH/FH
The patient has an unremarkable medical history. She has no known allergies and takes no medications that would have an impact on her dental treatment. She has had regular dental care and has several restorations in the area of the injury, including full crowns and porcelain veneers.
It is imperative to obtain a complete medical history when evaluating alternative treatment options for the replacement of a tooth. Systemic medications, including bisphosphonates and antineoplastic agents, and medical conditions such as uncontrolled diabetes are known to have deleterious effects on wound healing and bone metabolism, and may be contraindications to implant placement.
Examination
The left maxillary central incisor was fractured slightly above the level of the alveolar crest of bone and was out of the mouth ( Fig. 39.1 ). The patient had no pain and had not taken any analgesic medications. She was upset about her injury and the prospects for replacement of the fractured tooth. There was no radiographic evidence of injury to adjacent teeth or bone. Intraoral and extraoral examination revealed no other injuries in either arch. There was no injury to the lips or other soft tissue. The anterior teeth were normal in appearance and showed neither discomfort on percussion nor abnormal mobility. Periodontal pocket depths were 3 mm or less, and there was no bleeding on probing. Oral health care was excellent. When making a full smile, the patient displayed the cervical lines of the maxillary incisors.
When a patient sustains trauma to an anterior tooth, there is often injury to adjacent tissues or in the opposite arch. A complete examination is necessary to determine whether there is damage to the teeth, bone, or soft tissue. Follow-up evaluations should be conducted to detect undisclosed damage to other teeth or bone. Fractures that are not displaced may not be evident on clinical or radiographic examination. The patient should be advised that additional problems might become evident in the future and that more treatment may be needed.
Imaging
Panoramic and periapical (intraoral) radiographs ( Fig. 39.2 ) were made and evaluated. There was no evidence of injury to the adjacent teeth or bone.
Consideration should be given to the use of cone-beam computed tomography (CBCT) to assess for damage to bony structures in the area of an injury. If there is evidence of soft tissue damage, the field of interest should be adequate to include all areas of concern. If this patient had sustained injury to the maxillary incisor as a result of impact to the mandible, it would have been appropriate to use additional imaging to evaluate the mandible, including the body, ramus, and condyle on both sides of the mouth.
Labs
No laboratory tests were indicated in the treatment of the current patient. If the patient had been on injectable or long-term oral bisphosphonate therapy, a serum C-terminal telopeptide test may have been appropriate. If the patient had diabetes, the appropriate test to measure blood glucose levels would be in order.
Treatment
Irreversible hydrocolloid (alginate) impressions were made of the upper and lower arches, and a shade was selected for a provisional prosthetic replacement. The patient was referred to an oral and maxillofacial surgeon for removal of the remainder of the fractured tooth and evaluation of the buccal plate of the alveolar bone, with a request that an endosseous dental implant be placed at the time of extraction. The surgical appointment was the next day. At that visit, the surgeon used minimally invasive techniques to remove the root fragment. It was determined that the alveolar bone was intact and that there was sufficient bone volume for immediate placement of the implant. A tapered titanium implant (4 mm in diameter, 13 mm long) was placed in the osteotomy site. Insertion torque was 50 N-cm, and no bone graft was necessary. A healing abutment was selected and placed. It had an emergence profile of 5 mm and was 2 mm high. The superior surface of the healing abutment was just below the level of the crest of the ridge. Before placement of the healing abutment, an index of the implant position was made with poly-vinyl siloxane material and an open-tray impression transfer assembly. A periapical radiograph was made to verify the seating of the healing abutment ( Fig. 39.3 ). The provisional restoration made for the patient was an Essix-type retainer. There was no load on the implant at the time of surgery. The surgical index was placed on a modified study model, and a screw-retained provisional restoration was made but was not placed on the implant at the time of surgery ( Fig. 39.4 ).
