Eliminate the Unknown! by Drs. Jarron Tawzer and Joshua Nagao

Categories: Implant Dentistry;
Eliminate the Unknown! 

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.


Trauma Implant Case
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.

Trauma Implant Case
Fig.2
Trauma Implant Case
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.


Trauma Implant Case
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.

Trauma Implant Case
Fig.5
Trauma Implant Case
Fig.6
Trauma Implant Case
Fig.7

Trauma Implant Case
Fig.8
Trauma Implant Case
Fig.9
Trauma Implant Case
Fig.10


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).

Trauma Implant Case
Fig. 11
Trauma Implant Case
Fig. 12
Trauma Implant Case
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.
Trauma Implant Case
Fig. 14
Trauma Implant Case
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.


Trauma Implant Case
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.

Trauma Implant Case
Fig. 17

Trauma Implant Case
Fig. 18
Trauma Implant Case
Fig.19

Trauma Implant Case
Fig.20
Trauma Implant Case
Fig. 21

Trauma Implant Case
Fig.22
Trauma Implant Case
Fig. 23

Trauma Implant Case
Fig.24
Trauma Implant Case
Fig. 25

Trauma Implant Case
Fig.26
Trauma Implant Case
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.

Trauma Implant Case
Fig. 28

Trauma Implant Case
Fig.29
Trauma Implant Case
Fig.30

Trauma Implant Case
Fig. 31
Trauma Implant Case
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
1. Sigurdsson A. The treatment of traumatic dental injuries. Colleagues for Excellence. 2014:2–8.
2. Jose A, Nagori SA, Agarwal B, Bhutia O, Roychoudhury A. Management of maxillofacial trauma in emergency: An update of challenges and controversies. J Emerg Trauma Shock. 2016; 9(2):73–80.
3. Patel S, Puri T, Mannocci F, Navai A. Diagnosis and management of traumatic dental injuries using intraoral radiography and cone-beam computed tomography: An in vivo investigation. Journal of Endodontics. 2021; 47(6):914–923.
4. Palomo L, Palomo JM. Cone beam CT for diagnosis and treatment planning in trauma cases. Dent Clin North Am. 2009 Oct; 53(4):717–727.
5. Mangano FG, Admakin O, Bonacina M, et al. Trueness of 12 intraoral scanners in the full-arch implant impression: A comparative in vitro study. BMC Oral Health. 2020; 20:263.
6. Mangano F, Gandolfi A, Luongo G, Logozzo S. Intraoral scanners in dentistry: A review of the current literature. BMC Oral Health. 2017;17(1):149.
7. Czajkowska M, Walejewska E, Zadrozny L, Wieczorek M, Swieszkowski W, Wagner L, Mijiritsky E, Markowski J. Comparison of dental stone models and their 3D printed acrylic replicas for the accuracy and mechanical properties. Materials (Basel). 2020; 13(18):4066.
8. Roca-Millan E, Estrugo-Devesa A, Merlos A, Jané-Salas E, Vinuesa T, López-López J. Systemic antibiotic prophylaxis to reduce early implant failure: A systematic review and meta-analysis. Antibiotics 2021; 10(6):698.
9. https://kuleuvencongres.be/ENHD2018/guidelines-for-useof- l-prf.pdf
10. Borie E, Oliví DG, Orsi IA, et al. Platelet-rich fibrin application in dentistry: A literature review. Int J Clin Exp Med. 2015; 8(5):7922–7929.
11. Tekçe N, Fidan S, Tuncer S, Kara D, Demirci M. The effect of glazing and aging on the surface properties of CAD/CAM resin blocks. J Adv Prosthodont. 2018; 10(1):50–57.
12. Agrawal D, Gupta AS, Newaskar V, Gupta A, Garg S, Jain D. Narrow ridge management with ridge splitting with piezotome for implant placement: Report of 2 cases. J Indian Prosthodont Soc. 2014; 14(3):305–309.
13. Sohn D, Kim H. Simplified ridge and extraction socket augmentation using Sohn’s poncho technique. The Journal of Implant & Advanced Clinical Dentistry. 2018. 10(2):16–36.
14. Wilk BL. Intraoral digital impressioning for dental implant restorations versus traditional implant impression techniques. Compend Contin Educ Dent. 2015; 36(7):529–530, 532–533.


Author Bios
Dr. Jarron Tawzer 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 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.


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