Treating trauma – restoring a patient’s smile after 12 years
Dr Paul Swanson shares an unusual implant case, treating a young patient in his 20s who experienced tooth avulsion as a result of trauma as a child.
Introduction
While unintentional tooth avulsion is fairly rare among the population, almost 1,800 cases were reported in London dental hospitals between 2012 and 2018. The most common reasons for traumatic injuries were falls, sports injuries, cycling accidents and traffic accidents, with the most at-risk teeth being the central maxillary incisors.[i] Dental trauma is also common in children and young adults, with around 25% of school-age children experiencing it in some form.[ii] Consequently, it’s important that dental professionals offer a myriad of treatment solutions to help restore young patients’ dentition.
Implant placement in young people is a rare and somewhat controversial issue. Typically, the minimum age for implantology has been considered as 18-21 for males and 16-18 for females,[iii] although effective treatment in younger patients has been documented.[iv] Factors such as the patient’s general health, the likelihood of further jaw growth, the number of teeth needing to be replaced and their anatomical features can all contribute to treatment success.[v]
In appropriate situations, the procedure can significantly improve a young adult’s quality of life, as well as their dental aesthetics and functionality. This is especially relevant when a patient presents who has been without an anterior tooth for many years. As such, dental implants should be considered on a case-by-case basis. The following presentation demonstrates the successful provision of implant treatment for a patient in his early twenties, following several years of a missing central incisor.
Patient presentation
A 22-year-old man requested dental rehabilitation some years after his father had successfully received implant treatment. The patient had lost his upper left central tooth in a sporting accident as a 9-year-old, which had had a negative impact as he grew up, especially during adolescence. He had undergone comprehensive orthodontics for several years – this was provided through a teaching hospital and had been disrupted due to Covid.
Assessment
A full clinical assessment was conducted, including clinical photographs and a CT scan. Evaluation of the bone level around the UL1 demonstrated sufficient volume for implant placement but indicated the need for supplementary simultaneous bone augmentation at the site, at the time of implant placement. Significant gingival recession was also identified on the upper left canine.
The patient was made aware of all treatment options, including the benefits and risks of each – no treatment, anterior bridge and implant placement. The latter remained the procedure of choice, offering a fixed and permanent solution.
Figure 1: Presentation
Figure 2: Radiograph taken during orthodontic treatment scaled
Figure 3: Pre-surgical treatment retracted anterior view scaled.
Figure 4: Pre-surgical treatment upper occlusal view
Treatment Plan
The diagnostic imaging was used to plan treatment digitally. A guided approach was selected in order to optimise accuracy of implant placement for ideal functionality and aesthetics. This would be combined with simultaneous guided bone regeneration (GBR), increasing stability for the implant and augmenting the buccal contour.
Soft tissue augmentation would also be required. This would enable the clinician to increase the soft tissue thickness in the proposed peri-implant tissues and to address the gingival recession in the anterior zone, reducing any further recession following implant surgery.
The images, scans and digital mock-up were sent to the laboratory for fabrication of the surgical guide and the temporary crown.
Surgical Treatment
On the day of surgery, local anaesthesia was administered around the UL1. A full thickness flap was raised to gain access to and better visualise the underlying bone. The guide was seated in the mouth and a Tapered Pro Conical implant (BioHorizons Camlog) 4.2mm diameter 10.5mm length was placed according to the exact position, angle and depth determined in the plan.
GBR was performed using MinerOss® X (BioHorizons Camlog), which delivers a combination of cancellous and cortical particles for efficient turnover into bone. This was packed densely around the implant and secured in place using a Mem-Lok® resorbable collagen membrane (BioHorizons Camlog).
Figure 5: A full thickness flap was raised
Figure 6: Tapered Pro Conical implant placed
Figure 7: GBR performed using MinerOss® X to stablise the implant and increase bone volume
Figure 8: Bone graft secured with Mem-Lok resorbable membrane
Figure 9: Soft tissue regeneration performed with NovoMatrix
Figure 10: Surgical site sutured closed tension-free
Soft tissue regeneration involved placing a NovoMatrix (BioHorizons Camlog) to rebuild the gingival thickness and achieve a good contour around the implant and neighbouring teeth. A 2mm height healing abutment was then fitted to support the grafting material and to enable easier access to the fixture at the time of exposure.
Tension-free passive closure was then ensured via periosteal release to cover the graft and allow a coronal repositioning of the gingival tissues at the UL3 site. The patient was provided with standard post-surgical oral hygiene instructions to aid healing. He returned to the practice for an initial surgical review, at which time radiographic evidence was collected to suggest successful bone remodelling and effective healing.
Restorative Treatment
The patient returned to the practice three months later for the second stage surgery, during which the implant was exposed. A lab-made provisional crown was placed, which had been designed to contour the soft tissues and enhance the aesthetic outcome.
He was then referred to the restorative dentist for the final screw-retained crown. This was provided alongside composite bonding and tooth whitening, enhancing the shape and colour of all the anterior teeth for optimal smile aesthetics. As a semi-professional football player, the patient was strongly advised to wear a custom-designed mouthguard to protect his implant and his natural teeth moving forward.
Figure 11: Radiograph immediately post-operative
Figure 12: Original aligner with denture tooth replaced while surgical site heals
Figure 13: Implant site one month post-operative
Figure 14: Final restoration three months post-operative
Figure 15: Radiographs shows good integration of implant
Outcomes & Reflections
It is unusual for patients as young as this to require and be suitable for implant treatment. In this particular situation, the patient had experienced a missing anterior tooth for many years, and so he was keen to find a solution.
Despite the atypical patient age, treatment depended on following the basic principles involved with any implant case. Working on the site of the central incisor, it was crucial to place the implant 3-4mm below the proposed gingival margin, ensuring the buccal bone was at least 2mm in width. The guided surgical approach was integral in maintaining the level of accuracy required to achieve this confidently. The Tapered Pro Conical implant with conical connection was selected to enable stability of the peri-implant hard and soft tissues in the long-term.
To discuss how you can implement the Tapered Pro Conical into your implant practice, contact our team.
For all your implant educational needs, visit our dedicated education website, where you can find a range of courses to suit you.
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Article Author
Following his qualification from the University of Liverpool in 2000 Paul continued his studies and obtained a Diploma in General Practice from the Royal College of Surgeons in 2003 and also completed the Diploma in Dental Implantology in 2008. This is the highest level of Implant training available in the U.K. and is a qualification held by only 50 dentists. Paul has additional qualifications allowing him to provide treatment with sedation which is invaluable when treating nervous patients. Paul accepts referrals from other practices across the city and also further afield for implant dentistry, showing the high regard in which he is held by his fellow dentists and also his patients. Paul is also employed by Liverpool University Dental Hospital where he helps train and mentor newly graduated dentists and more recently has also taken up a teaching post with the Royal College of Surgeons in London.
