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An Immediate Plan by Dr. Ed Kusek

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Categories: Implant Dentistry;
An Immediate Plan 

Using novel adjunct techniques to help treat a patient’s nonrestorable fractured teeth

by Dr. Ed Kusek

This case involved a 41-year-old man who had a syncopal episode while watching a baseball game and fell forward on his face, causing trauma to the right cheek (zygoma, infraorbital and auricular) and anterior maxillary teeth. He was seen on site by a paramedic, and as a patient of record was seen the next day at the dental practice.

A full CBCT (Fig. 1) and photographs of the facial injuries (Fig. 2) were taken at the initial appointment. Evaluation of the CBCT showed horizontal fractures of Teeth #7 and #8 below the alveolar crest, with fractures into the pulp tissue making the teeth nonvital and nonrestorable by traditional methods. Because the patient was in pain, he was interested in a quick transition.
Dental Trauma Case
Fig. 1
Dental Trauma Case
Fig. 2


Treatment plan
1. Temporary root canal and place posts to lute the fractured incisal portions of the teeth (Fig. 3) to allow the patient to function without pain. Scan teeth to fabricate an Essix appliance (Dentsply Sirona) to replace #7 and #8 after extractions.
Dental Trauma Case
Fig. 3

2. Extract #7 and #8 and place immediate implants. Because of the time constraint, I would be unable to extrude #7 and #8 to gain better tissue and bone support, and because of the area of the fracture, I could not perform socket shielding. The patient would wear the Essix appliance for the healing time of three to four months.

3. Uncover implants with the use of a CO2 laser, place scan bodies (TruAbutment), and scan area (Trios, 3Shape) to create a gold-colored Atlantis abutment (Dentsply Sirona) and a fabricated lithium disilicate crown.

4. Seat the case in three weeks.

5. Maintenance.


Treatment considerations
  • A salivary diagnostic test (Oral DNA Labs) to determine if the patient is susceptible to periodontal disease.
  • Photobiomodulation treatment to decrease the treatment time.
  • Use of an erbium laser to create decortication and regional acceleratory phenomenon (RAP),1 which can increase bone-toimplant contact (Fig. 4).
  • Use of a CO2 laser to uncover implant and allow maximum connective tissue around the implant.
  • Use of an Nd:YAG laser (Deka Dental Lasers) for high-intensity laser treatment (HILT) to increase bone formation in site #8.2,3
  • Use of aqueous ozone4 (Biosure) to disinfect the osteotomy site before implant placement.

Dental Trauma Case
Fig. 4

CASE REPORT

Emergency root canal
Because of a scheduling issue in the practice, it wasn’t possible to place implants surgically right away, so the patient was treated for temporary root canals to allow him to function without pain. He was given 1 cc of local anesthetic with 20 mg of lidocaine and 10 mcg of epinephrine, then 4 cc of anesthetic with 40 mg of septocaine and 5 mcg of epinephrine.

I drilled to access the pulp chamber, verified the length with a Shofu apex locator and a periapical radiograph, then used ProLube root canal conditioner (Dentsply Sirona) and 10 cc of aqueous ozone (BioSure), and dried with a cannula (Ultradent), then paper points, to remove any liquid. The canals were then filled with Endo-Eze MTAFlow (Ultradent) and GuttaCore obturators (Dentsply). After a periapical radiograph to verify the position, I placed two Flexi-Posts (Essential Dental Systems) and used Mosaic composite (Ultradent) to bond the natural tooth to each post (Fig. 3). Occlusion was checked, adjusted and polished, and photobiomodulation was performed with an Evo laser (Ultradent) to decrease postoperative pain, swelling and the healing time for the patient.

Implant placement
One month later, when the schedule allowed an opening to place implants, the patient was treated to surgically place implants in place of #7 and #8. IV access was completed in the patient’s right antecubital fossa, in which blood was drawn to get enough samples to centrifuge to create platelet-rich fibrin (PRF), which would aid healing by using the patient’s own bone morphogenic proteins.5 Drugs administered: 20 mcg of dexmedetomidine, 5 mg of midazolam, 50 mcg of fentanyl, 8 mg of dexamethasone sodium phosphate, 40 mg of Solu-Medrol (IM) and 1 g of cephalosporin in total on completion of the sedation.

The teeth were extracted with the use of periotomes (Karl Schumacher) and forceps, followed by a flap procedure reflecting tissues from #6 mesial to #9 distal with use of a 10,600-nm CO2 laser, 0.5 mm spot size, for about one minute. This involved no releasing reflection, to help keep the facial plate attached to the periosteum that had been fractured in the accident. I then used Densah drills (Versah) in reverse mode and an Er,Cr:YSGG laser (Biolase) to decorticate the bone to improve bone-to-implant contact5 and disinfect the osteotomy site6 (Fig. 4). The area then was rinsed with 30 cc of aqueous ozone (Fig. 5).

I seated a 3.3-by-13-mm implant in site #7 and a 4.2-by-13-mm implant in site #8 (Ditron), then placed Bio-Oss collagen (Geistlich) soaked in PDF plasma (Fig. 6) into the gaps left from the sockets. This was followed by PRF membranes (Fig. 7) over this site and closure with 3.0 PTFE sutures (Salvin). Next, I treated the surgical site, the right and left submandibular lymph nodes, and the right and left subclavicular lymph nodes with photobiomodulation (PBM), and de-epithelized tissue with the erbium laser (Fig. 8) to speed the healing process. Then, the Essix appliance was seated, out of contact with soft tissues.
Dental Trauma Case
Fig. 5
Dental Trauma Case
Fig. 6
Dental Trauma Case
Fig. 7
Dental Trauma Case
Fig. 8

Follow-up visits and treatments
One week after implant placements (Fig. 9), the patient’s level of healing was evaluated, and I again performed PBM over the surgical site and lymph nodes. One week after that, the sutures were removed and PBM was performed again.
Dental Trauma Case
Fig. 9

Three months after implant placement (Fig. 10), a new CBCT was taken to determine the level of healing (Fig. 11). With topical and local anesthetic, a 10,600-nm CO2 laser was used to uncover the implant sites (Fig. 12), starting on the palatal side to allow adequate attached tissue on the facial aspect of the implants. I used scan bodies (Fig. 13) that fit a 3.3-mm internal hex, which are standard from many types of implants, but a radiograph was taken to confirm the scan bodies were seated correctly (Fig. 14) to the base of the implant. After the scan bodies were removed, I placed Consepsis antibacterial solution (Ultradent, Fig. 15) in the sites, followed by healing abutments (Fig. 16) to allow healing by secondary intention. A facebow (Fig. 17) was taken with the Panadent system.
Dental Trauma Case
Fig. 10
Dental Trauma Case
Fig. 11
Dental Trauma Case
Fig. 12
Dental Trauma Case
Fig. 13
Dental Trauma Case
Fig. 14
Dental Trauma Case
Fig. 15
Dental Trauma Case
Fig. 16
Dental Trauma Case
Fig. 17


Three weeks after the uncovering, a gold-colored Atlantis abutment was seated (Fig. 18) and tightened to 35 N of force twice, allowing two minutes to lapse to accommodate metal relaxation.7 Consepsis was placed (Fig. 19) into the implant site before seating the custom abutments. The area was isolated with an Umbrella (Ultradent) to seat FirstPlug material (35 N) to seal access, and a photograph was taken (Fig. 20) to record the access point if needed for future reference.
Dental Trauma Case
Fig. 18
Dental Trauma Case
Fig. 19
Dental Trauma Case
Fig. 20


I used hydrofluoric acid for one minute on the intaglio surface, then phosphoric acid for 20 seconds. Silane was placed and allowed to dry for one minute before Peak universal bond (Ultradent) was lightly coated on the intaglio surface and eCement (Bisco) was used to lute the crown. The case was seated (Fig. 21) before a periapical radiograph was taken (Fig. 22) to evaluate if there was any cement left around the crown. After it had been removed—confirmed with a new radiograph—occlusion was adjusted as needed and polished until it was satisfactory to the patient (Fig. 23).
Dental Trauma Case
Fig. 21
Dental Trauma Case
Fig. 22
Dental Trauma Case
Fig. 23


Two weeks later, during occlusal and tissue evaluation, it was determined to use an Nd:YAG laser to help increase bone formation at Site #8, because bone there had been fractured at the time of the accident and appeared to be immature at this time. The patient had no pain to function in all excursions.

Conclusion
The patient had an accident in which he passed out because of heat stroke. (After a full-head CT scan, it was determined there was no other reason for the patient to have lost consciousness during a baseball game.) Doing a quick root canal therapy allowed him to function without pain until he was able to get scheduled in the office.

The case shows a few different adjuncts to implant surgery that most offices do not incorporate:
  • Aqueous ozone disinfects bacteria and viruses in 15 seconds.
  • An erbium laser also has shown to be a good disinfectant in osteotomy sites where bacteria may still be present.
  • Photobiomodulation can speed healing time and decrease postoperative discomfort.
  • HILT utilized from Nd:YAG (Fig. 24) also allows bone to heal faster than traditional methods.
Dental Trauma Case
Fig. 24

I hope other clinicians will use some of these techniques to increase their success in implant dentistry.

References
1. Kim JW, Kim HY, Kim SY, Kim SJ. Impaired osseointegation of dental implants associated with orthognathic surgery: Possible regional acceleratory phenomenon. Clin Implant Dent Relat Res. 2019 Aug; 21(4):531–537.
2. Ezzati K, Laako EL, Salari A, Hasannejad A, Fekrazad ,. Aris A. The beneficial effects of high intensity laser therapy and co-interventions on musculoskeletal pain management: A systematic review. J Lasers Med Sci. 2020 Winter; 11(1):81–90.
3. Zati A, Desando G, Cavallo C, Buda R, Giannini S, Fortuna D, Facchini A, Grigolo B. Treatment of human cartilage defects by means of Nd:YAG laser therapy. Journ Biolog Reg & Hemostat Agen. 2012 Vol 26; (4)701–741.
4. Premjit Y, Sruthi NV, Pandiselvam R, Kothakota A. Aqueous Ozone: Chemistry, physiochemical properties, microbial inactivation, factors influencing antimicrobial effectiveness and application in food. Compr Rev Food Sci Food Saf. 2022 Mar; 21(2):1054–1085.
5. Aizawa H, Tsjino T, Watanabe T, Isobe K, Kitamura Y, Sato A, Yamaguchi S, Okudera H, Oduda K. Quantitive near-infrared imaging of platelet-rich fibrin (PRF) matrices: Comparative analysis of Bio-PRF, leukocyte-rich PRF, advanced PRF and concentrated growth factors. Int J Mol Sci; 2020. Jun 22; 21(12): 4426.
6. Kusek ER. Immediate implant placement into infected sites: Bacterial studies of the hydroacoustic effects of the YSGG laser. J. Oral Implantol. 2011 Mar; 37 No: 205–211.
7. Alfafi MA, Wadhwani C, Schwedhelm ER, Kattadiyil MT. Evaluating the effect of the protector cap and castable implant abutments reverse tightening values. J. Prosthet Dent. 2022 Nov 16: 3900–3913.

Author Bio
Ed Kusek Dr. Ed Kusek is a diplomate of the American Board of Oral Implantology, president of the American Academy of Implant Dentistry, a past president of the Academy of Laser Dentistry, and an adjunct professor at the University of Nebraska Medical Center College of Dentistry and the University of South Dakota dental hygiene school. He has earned mastership in the Academy of General Dentistry and Academy of Laser Dentistry, and is a member of Dentaltown’s editorial advisory board.


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