Digital technology facilitates treatment of trauma implant case
by Drs. Jarron Tawzer and Joshua Nagao
Dentistry can often feel like a
wash, rinse and repeat cycle.
Many day-to-day procedures
are predictable and formulaic,
and it’s not often that providers find
themselves unprepared when doing a
filling or crown.
Dental trauma is one of the few
situations that often requires creative
solutions and unorthodox management.
Something as simple as taking
diagnostic models can become
incredibly complicated in a trauma
case, especially with displaced or
avulsed teeth and injured soft tissues.
In the days immediately after a dental
trauma, the full extent of the injury
may not be apparent yet and additional
complications may arise down
the road; therefore, correct diagnosis
and timely treatment time are
both important factors that go into
successful treatment of dental and
facial trauma.1
These cases can become overwhelming
and it can be difficult
to know exactly where to begin.
Thankfully, the dental industry has
some emerging technologies that can
eliminate some of the unknowns and
facilitate a more successful outcome
from start to finish. With digital technology,
cases can be more efficiently
diagnosed, planned and treated.
The following case is an excellent
highlight of how one clinician applied
multiple digital technologies in
treating a patient who suffered a
workplace accident.
It is important to note that before
beginning any treatment for a trauma
case, the clinician should verify there
are no other major head or neck
injuries that would take precedence
over treatment of the oral cavity.
That includes injuries to airway,
cervical spine, cranium and other vital
structures that could be considered
life-threatening or out of the scope of
the provider’s practice.2
Patient presentation and history
The patient in this case, a 61-year-old
Hispanic man (Fig. 1), presented with
no underlying medical conditions,
medications or other contraindications
to surgical treatment. He had
been seen in the office a few years
before the incident and been referred
for periodontal evaluation and
treatment of the lower left quadrant,
but had not returned for any
follow-up treatment.
The patient’s wife, a regular patient
of the office, called after-hours and
reported that her husband had been
in a workplace incident involving a
chain that struck him in the lower jaw,
“knocking some teeth out of place.”
The patient was immediately examined
by an emergency room ear, nose
and throat specialist but there had been no oral surgeon on call. The dental
provider asked to have a picture of
the affected area sent by text to evaluate
the situation. Once it had been
received, the provider requested that
any treatment involving the dental
portion of the accident be addressed
in-office rather than through the
emergency department. The providers
at the hospital agreed with the request
and the patient was seen for evaluation
the next day at the dental office.
Fig. 1
Record collection
The patient arrived and filled out all
necessary consents for treatment.
A cone-beam computed tomography
(CBCT) image was taken on a Carestream
CS 8200 with a 12-by-10-cm
field of view. This volume was adequate
for treatment planning because
the possibility of mandibular jaw
fracture had been ruled out after the
patient underwent more detailed
imaging at the hospital during
their evaluation.
CBCT images and their interpretation
constitute the first important
step in gathering records to formulate
a treatment plan in a trauma case.
The data provides information about
the extent of the injury and allows
insight that would not be obtainable
through use of traditional intraoral
radiographs.3 The clinician can view
the extent of tooth fractures and the
position relative to the alveolar bone,
locate any alveolar fractures, visualize
the alveolar bone for potential
implant placement, and identify
potential anatomical features that
should be avoided.4
Once the CBCT data (Fig. 2) had
been collected and reviewed, the
clinician performed a dual-arch intraoral
scan (IOS) with a Carestream
CS 3600 scanner (although any IOS
device able to capture accurate
full-arch data could be used5). Being
able to digitally obtain full-arch
records such as the ones in Fig. 3
reduces patient discomfort, especially
in a trauma case where moving the
displaced teeth could cause significant
pain.6 Displaced teeth could also
impede a traditional impression tray
from fully seating and capturing necessary
information or cause further
displacement of the teeth.
Fig.2
Fig.3
The CBCT data showed that three
fractured lower incisors were nonrestorable
and would need to be
extracted.
New models created from the
stereolithography (STL) data gathered
during the scan would be used to
fabricate a temporary bridge, allowing
the patient to leave the office with a
fixed interim prosthesis. To create this
model, the STL data was imported
into Blue Sky Plan software, where
the partially avulsed teeth were
digitally “extracted” and teeth from
a model library were imported and
placed into ideal position.
The new STL was exported and
printed on a SprintRay Pro 95 resin
printer, and that model was used
to facilitate fabrication of the fixed
provisional (Fig. 4). This digital
process eliminates the need for stone
models that would have needed to
be poured, cured, ground and waxed
on. Digitally printed models have
also been shown to be more accurate
and mechanically sound than
stone counterparts.7
An extraoral examination showed
the incident had also caused enamel
fractures of the lower canines
(#22 and #27). These teeth would
be used as retainers for the fixed
temporary bridge.
Fig. 4
Preoperatory preparation
Before the procedure, an overview of
the treatment was discussed with the
patient and his wife, including what
materials would be used, risks, possible
complications and the timeline
for healing and ongoing treatment.
Consent for the procedure was given,
which included specific written
consent for the use of the biologics as
discussed. The patient did not report
any moral or religious aversion to
the proposed biologic materials, and
IV moderate sedation would be used
for the patient’s comfort.
During this conversation, the
3D models were being printed and put
through postprocessing steps using
the SprintRay Pro Wash/Dry and
ProCure devices.
Surgical procedure
While the 3D-printed models were
being finalized, the clinician began the
surgical process. The patient had been
given a 2 g loading dose of amoxicillin
upon arrival,8 and was now given supplemental
intravenous medications
including 30 mg Torodol and 8 mg
dexamethasone.
Four vials of blood were drawn
from the IV. The vials were spun at
2,700 rpm for three minutes, after
which platelet-rich fibrin liquid (PRF)
was drawn from the vials to mix with
bone particulate to form sticky bone.
The vials were placed back into the
centrifuge (IntraSpin) for another nine
minutes to prepare PRF membranes to
be used at the extraction site.9 Incorporating
PRF technology improves
handling, autogenous release of
growth factors, promotion of softtissue
healing and increased angiogenesis,
and reduces infection risk.10
The patient was also given local anesthetic
before start of the surgery.
The tissue around the avulsed teeth
was elevated from the underlying
structures; careful attention was paid
to maintaining the integrity of the
flap and avoiding tears (Fig. 5). Once
the tissue had been elevated from the
teeth, the coronal portions were easily
removed (Fig. 6). The remaining root
portions were removed with luxators
(Fig. 7) and the area was thoroughly
degranulated and irrigated. The site
was then grafted with Biohorizons
Genate blend, a 70/30 cortical/cancellous
allograft bone mix that had clotted
and formed sticky bone. Figs. 8–10
show sticky bone, handling properties and placement into the surgical site.
A pericardium membrane was
trimmed and placed over the particulate
graft (Fig. 11), followed by a PRF
membrane (Fig. 12). Full closure was
achieved with 4-0 Vicryl sutures. Once
closed, teeth #22 and #27 were prepped
for full-coverage crowns (Fig. 13).
Creation of temporary prosthetics
via digital technology
Once the surgical portion had been
completed, the clinician performed an
additional IOS of the area to create a
model with prepped teeth and a closed
surgical site (Fig. 14). A temporary
bridge was fabricated with bis-acryl
temporary material and cemented
temporarily, and the patient was
scheduled for follow-up examinations
two and four weeks later.
Meanwhile, the clinician imported
the scans into Blue Sky Plan and
designed a five-unit bridge. The STL
for the bridge was exported into
RayWare software and printed on a
Pro 55 resin printer in OnX ceramic
resin (SprintRay), which would provide
better strength and aesthetics than
the bis-acryl temporary fabricated at
the time of surgery. Finishing and polishing
was completed and the temporary
was coated with Optiglaze color
(GC America) for aesthetics.11
This 3D-printed temporary was
placed at the two-week postoperative
appointment, and images were
taken at the four-week postoperative
appointment (Fig. 15). The site was
then allowed to heal for four months.
Fig. 14
Fig.15
Comprehensive examination
Because the initial examination and
treatment had been done on an emergency
basis, a comprehensive exam
still needed to be completed to fully
evaluate the extent of the damage
caused by the accident.
During the comprehensive exam, it
was found that tooth #21 also had suffered
a nonrestorable fracture, as seen
in Fig. 16. This site was planned for an
extraction with immediate placement
to be completed at a future appointment,
alongside placement of implants
in the incisor area. A treatment plan
involved full-coverage crowns on #22
and #27, two implants in the incisor
area to replace the three missing
incisors, and implant placement in the
site of #21.
Fig. 16
Implant placement
New CBCT data was acquired after
four months of postextraction healing.
Although the area had healed well
with sufficient bone height, the ridge
was slightly thin (Fig. 17), so the clinician
chose to expand it via ridge split
and place two implants concurrently,
thus shortening overall healing time.12
This surgery would also involve the extraction of Tooth #21 and immediate
implant placement in the same
site. The “poncho” technique was used
by placing a PRF membrane through
the healing abutment to promote softtissue
stabilization and speed regeneration.13 Figs. 18–27 show the implant
placement procedure. All implants
in this case are MegaGen Anyridge,
which we believe are the best implants
on the market today. The temporary
was removed for the surgical procedure
and replaced after surgery.
Fig. 17
Fig. 18
Fig.19
Fig.20
Fig. 21
Fig.22
Fig. 23
Fig.24
Fig. 25
Fig.26
Fig. 27
Final restoration using
digital technology
After allowing four months of healing
time, the sites were uncovered and
evaluated via resonance frequency
analysis, which indicated the implants
were sufficiently integrated for
restoration. The scanner was used to
take digital records, including full-arch opposing scan, bite registration,
tissue contour scan, full-arch implant
position scan using scan bodies
(Fig. 28) and shade for color-matching
purposes. The restorations were
fabricated as a single, screw-retained
implant crown for the #21 site, a
three-unit prosthesis on two custom
abutments in the incisor area, and two
full-coverage crowns for teeth #22 and
#27. Figs. 28–32 show the custom abutments
and final ceramic restorations.
Fig. 28
Fig.29
Fig.30
Fig. 31
Fig. 32
Conclusion
Digital dentistry is a powerful tool
that can make the planning and execution
of trauma cases more efficient
and with a more predictable outcome.
Implementation of this technology can
provide better patient experiences and
should be employed when appropriate Digital techniques are less costly
than traditional techniques, increase
efficiency and allow the clinician to
eliminate wasteful chair time and
planning hours.14
References
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l-prf.pdf
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Dr. Jarron Tawzer earned his undergraduate degree from
Utah State University and graduated from Oregon Health
and Science University School of Dentistry. He lives and
practices in Logan, Utah, focusing on implants and cosmetic
dentistry. Tawzer mentors at the Implant Pathway dental
implant center in Phoenix, training dentists in complicated
atraumatic extractions, bone grafting and dental implants.
He has dedicated much of his career to advancements in
dentistry, particularly dental implants and cosmetic dentistry.
Dr. Joshua Nagao earned his DDS from The Ohio State
University College of Dentistry, graduating first in his class
clinically. Nagao is particularly passionate about dental
surgery, including implant placements, sedation dentistry
and complex reconstructions. He is a faculty member
and mentor at Implant Pathway, an associate fellow in the
American Academy of Implant Dentistry and a diplomate in
the American Board of Oral Implantology. Nagao is also the
creator of @implantsanta, a social media page dedicated to
digital dental surgery and high-quality photography.