DR SUET YEO SOO (Orcid ID : 0000-0003-1363-622X)

Accepted Article
Article type : Case Report

TITLE:

Initial management and long-term follow-up after the rehabilitation of a patient with
severe dentoalveolar trauma: a case report

Suet Yeo Soo, DDS, MSc, MFDS RCS,a Julian D Satterthwaite, BDS, MSc, PhD, FDS, MFDS RCS,

FDS(Rest Dent), FHEA,b Martin Ashley, BDS, FDS (Eng), FDS(Rest Dent), MPhilc

a
Lecturer and Clinical Consultant in Restorative Dentistry, The National University of Malaysia

(UKM), School of Dentistry, Kuala Lumpur, Malaysia.

b
Senior Lecturer and Honorary Consultant in Restorative Dentistry, The University of Manchester,

School of Dentistry, Manchester, United Kingdom.

c
Consultant and Honorary Senior Lecturer in Restorative Dentistry, The University of Manchester,

School of Dentistry, Manchester, United Kingdom.

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/edt.12504
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 Corresponding author:

Dr Suet Yeo Soo

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Department of Restorative Dentistry, The National University of Malaysia (UKM)

Jalan Raja Muda Abdul Aziz 50300 Kuala Lumpur, Malaysia.

Email: suetyeosoo@hotmail.com

Conflict of interest declaration:

We have no conflict of interest to declare.

ACKNOWLEDGEMENTS

The authors thank the technicians at the School of Dentistry, The University of Manchester for their

laboratory support.

ABSTRACT:

Dental trauma is common and for patients who suffer significant oral injuries, rehabilitation

can be challenging to the clinical team. This case report describes the successful prosthetic

replacement of multiple missing teeth lost due to severe dentoalveolar trauma, using iliac

crest bone grafting, an implant-retained removable dental prosthesis and implant-supported

crowns. Good functionality and aesthetic outcome were achieved.

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 INTRODUCTION:
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Over the past decade, multi-system injuries from violent crimes including gunfire

have been on the rise in the United Kingdom.1 These patients often require multi-disciplinary

input in their acute management and subsequent functional rehabilitation.2 Dental

interventions could be categorised as the management of any anatomical/bony defect (bone

augmentation, sinus lift or distraction) and provision of dental prostheses.3-5 Dental

prostheses to replace missing teeth and bone may be removable dental prostheses (RPD),

fixed dental prostheses (FDP), or implant-supported prostheses.6,7

From a rehabilitation point of view, treatment plans need to be constructed around the

degree of tissue loss, patient compliance with maintenance, existing dental conditions,

aesthetic outcomes, technical feasibility and patient preference.8-10 The choice of treatment

relies on a variety of factors and patient acceptance of therapy may depend on the

implications of costs, desire for a fixed or removable solution, duration of treatment,

complexity of therapy, previous experience and surgical risks.8,9,11 Whilst an implant-

supported prosthesis may in some circumstances have aesthetic and biomechanical

superiority, the cost and surgical risks often limit their use.7 A simple removable prosthesis

could be a preferred choice due to ease of oral hygiene, cost-effectiveness, shorter treatment

duration, low complexity and lip support for ridge atrophy or defects.8,9 In cases where the

levels of retention and function are unsatisfactory with a removable dental prosthesis, a fixed

dental prosthesis could be considered as a treatment alternative.4

This case demonstrates the complexity of dental management in a patient with

complex dentoalveolar trauma as a result of a gunshot wound. It also shows the significance

of a delay in initiating various stages of treatments due to patient factors. Iliac crest bone

augmentation, implant-supported crowns, and an implant-supported removable dental

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 prosthesis with its associated flange and composite stains were used in achieving a

functionally and aesthetically pleasing outcome. No maintenance was needed from the time
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of initial management for a period of 12 years, at which time the patient re-presented as he

lost his removable prosthesis.

CLINICAL REPORT:

The patient, a male aged 36 years, had sustained a series of gunshot injuries to his left

jaw, left humerus, right femur and left chest in June 1993. The initial maxillofacial

assessment revealed that the injuries involved a comminuted fracture of the left mandibular

body, loss of teeth from the left maxilla and mandible (Figure 1), skin and tongue lacerations.

His early stabilisation management comprised tracheostomy, wound closure and rigid inter-

maxillary fixation for his fractured mandible. After he was stabilised medically, he was

referred to the dental hospital for restorative dentistry management.

The patient did not attend for treatment for prosthodontic rehabilitation until he was

again referred by his General Dental Practitioner 6 years after the trauma in 1999. Intraoral

examination revealed a significant maxillary defect with five missing teeth (maxillary left

central incisor to maxillary left second premolar) and two missing mandibular teeth

(mandibular left second premolar and mandibular left first molar) [Figure 2]. A radiographic

stent was used to assist interpretation of a computerised tomography scan of the affected

areas. The mandibular alveolar ridge was adequate for dental implant placement but the

maxillary ridge required augmentation with a bone graft to allow implant placement. The

reconstruction of the maxilla was a challenge due to the extensive dento-alveolar bone loss in

that region. Grafting would allow for implant placement but would still result in a significant

alveolar defect. Hence, the plan was to support a removable dental prosthesis with an

extended superstructure joining three dental implants.

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 In 2000, the patient underwent surgical augmentation of the maxilla, using cortico-
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cancellous bone blocks harvested from the right anterior iliac crest (Figure 3). The

radiographic stent was adapted for use as a surgical stent. Exploration revealed that despite

some resorption, there remained adequate bone for implant placement. Three dental implants

(Astra Tech Osseo Speed; Dentsply Sirona) were placed on the left side of the maxilla and

two dental implants (Astra Tech Osseo Speed; Dentsply Sirona) were placed in the

mandibular left posterior area in September 2002. Six months after the implants were

inserted, they were surgically exposed and healing abutments were placed.

The patient attended the Restorative Dentistry Department eight weeks after the

implants were uncovered. Two cement-retained implant crowns with customised titanium

abutments were placed for the mandibular left second premolar and mandibular left first

molar (Figure 4).

For the three maxillary implants, uni-abutments were placed and an abutment level

impression using an open tray technique was used with polyether impression material

(Impregum, 3M ESPE) to pick up the impression copings. Subsequent to recording of the

occlusal relationships, and a trial to confirm tooth position, a milled beam was constructed

using precious (high palladium) bonding alloy (Figure 5). The fitting of the milled beam was

checked in the patient’s mouth to ensure passive fit by using the Sheffield test. An

orthopantomogram was taken after insertion of the milled beam (Figure 6). A try-in of the

maxillary removable dental prosthesis with acrylic teeth was also performed for approval of

aesthetics before the definitive prosthesis was processed. A mutually protected occlusion was

planned for the occlusal scheme as this design has been reported to be the most efficient in

terms of mastication 12. The definitive prosthesis was designed with acrylic layered over a

gold sleeve that fitted intimately over the milled beam (Figure 7).

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 As this patient's gingival tissue exhibited pigmentation, recreating this in the

prosthesis was important. Clinical photographs were taken of the areas to be characterised, in
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order to duplicate the patient’s gingival pigmentation on the prosthesis flange. Composite

stains (Visio.paint; Visio.lign) were painted to mimic the pigmentation of the patient’s tissues

and the maxillary implant-supported removable dental prosthesis was adequately designed to

integrate with the patient’s smile (Figure 8). This phase of treatment was completed in May

2004.

The patient attended in 2016, 12 years after the completion of his initial restoration.

He had lost his removable prosthesis in a diving accident. Apart from that, he remained

satisfied with his prosthesis in terms of functionality and appearance. He was maintaining an

adequate standard of dental hygiene and was otherwise healthy. All five implants (maxillary

and mandibular) and the milled beam were intact. A periapical radiograph of the maxillary

left implants revealed long term stability of the osseointegrated implants in the augmented

bone (Figure 9).

The milled beam was serviceable, but the design was not suitable for pick-up. Hence,

treatment involved a new abutment level impression with polyether (Impregum, 3M ESPE).

Impression copings were placed on the maxillary implants and connected with resin pattern

(Duralay, Reliance Dental Mfg. Co)[Figure 10] to reduce the likelihood of distortion. The

original beam was placed on the master model to assess for passive fit and verify the

impression/model. A new removable dental prosthesis with a new corresponding sleeve (to

engage the original milled beam) was constructed. Upon provision of a new implant-

supported removable dental prosthesis and completion of treatment, he was discharged to

care and monitoring by his primary care practitioner (Figure 11).

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 DISCUSSION:

Dento-alveolar trauma leads to loss of hard (teeth and bone) and soft (gingivae and
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mucosa) tissues. Rehabilitation to create a prosthesis that is retentive, stable and attractive

can be challenging for the dental team.4.6.13

The union of the comminuted mandibular fracture provided a stable mandibular ridge

and adequate bone for implant placement. Implants were the most functionally appropriate

management for this gentleman, taking into account the support and retention problems

associated with a removable dental prosthesis to restore a distal extension denture base.14

Restoration of the maxilla was more complicated, due to the extensive bone loss, a

high lip line and the pigmented mucosa. In view of the large bone defect, and due to the

sizable quantity of required bone, iliac crest autologous grafts were preferred for bone

formation, rather than intra-oral harvest sites, which would provide smaller bone volumes.15-
17

Despite the significant delay between bone grafting and dental implant placement

sufficient bone remained after grafting.18 A possible explanation for this finding is that the

patient did not wear a prosthesis during this period, so no functional pressures were applied

to the grafted surgical area.

Due to the large bone defect, construction of a conventional fixed dental prosthesis

would not have allowed adequate maintenance of oral hygiene and adequate aesthetic results.

Hence, a milled bar implant-supported maxillary removable dental prosthesis was fabricated.

The bar was fabricated with a wax-up, milled and then cast in precious metal bonding alloy.

The corresponding sleeve was constructed to fit over the milled bar precisely using the lost

wax technique.

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 During remedial treatment, direct pick up of the existing milled beam procedure

would usually be carried out for construction of a new prosthesis. However, in this case,
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although the old milled beam was still intact, pick up of the milled beam was not feasible.

This was due to the lack of additional retentive component in the original milled beam and

also the presence of undercuts. Hence, the treatment involved a new abutment level

impression to construct a new maxillary removable prosthesis.

During the re-presentation visit, the survival and overall patient satisfactions with the milled

bar implant-supported prosthesis were high, consistent with previous publications.19 The

titanium abutments and cement–retained crowns on the left mandibular region remained

serviceable after more than 10 years.20,21

SUMMARY:

This case-report describes the complex clinical stages involved in the initial and subsequent

rehabilitation of a patient following a gunshot wound that caused severe maxillary and

mandible dento-alveolar trauma. At both stages, the clinical management yielded high

functionality and aesthetic outcomes.

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 3. Özkurt Z, Kazazoğlu E. Treatment modalities for single missing teeth in a Turkish

subpopulation: an implant, fixed partial denture, or no restoration. J Dent Sci. 2010; 5:183-8.
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 15. Misch CE, Dietsh F. Bone-grafting materials in implant dentistry. Implant Dent. 1993;

2:158-67.
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16. Myeroff C, Archdeacon M. Autogenous bone graft: donor sites and techniques. J Bone

Joint Surg. 2011; 93:2227-36.

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 List of Figure Legends

Figure1: Orthopantomogram taken in June 1993 demonstrating the loss of left maxillary
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teeth, fractured body of left mandible and gun shot artefacts.

Figure 2: Extensive maxillary dento-alveolar defect with missing maxillary and mandibular

teeth (August 1999).

Figure 3: Intraoral view following bone graft ( March 2000).

Figure 4: Dental implants on mandibular left region (May 2003).

Figure 5: Precious (high palladium) bonding alloy milled beam (February 2004).

Figure 6: OPG showed post-insertion of milled beam and dental implants (October 2008).

Figure 7: Corresponding sleeve in the fitting surface of prosthesis (February 2004).

Figure 8: Labial view of original definitive restoration (April 2004).

Figure 9: Intact maxillary implants and milled beam 12 years later (January 2016).

Figure 10: Impression copings were connected with a resin pattern (March 2016).

Figure 11: New implant-supported maxillary RPD (June 2016).

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