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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 80-83

Rehabilitation of maxillofacialtrauma patient with dental implants: A case report


1 Department of Prosthodontics, Christian Dental College, Ludhiana, Punjab, India
2 Department of Oral and Maxillofacial Surgery, Christian Dental College, Ludhiana, Punjab, India

Date of Web Publication12-Jan-2018

Correspondence Address:
Nirmal Kurian
Department of Prosthodontics and Crown and Bridge, Christian Dental College, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_35_17

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  Abstract 


Motor vehicle accidents are among the main etiologic factors of maxillofacial injuries. Immediate and comprehensive treatment involving multiple disciplines is needed to successfully restore the damaged hard and soft tissues and reinstate the function and esthetics. This clinical report describes the oral rehabilitation of a young patient with mid-face and mandibular fractures and extensive loss of the dentoalveolar segments in the anterior mandible as a result of a road traffic accident. The patient underwent open reduction and rigid fixation of the fractures followed by implant placement and screw retained hybrid prosthesis fabrication for replacement of missing hard and soft tissues.

Keywords: Dental implants, hybrid prosthesis, screw retained prosthesis


How to cite this article:
Gandhi N, Gandhi S, Kurian N, Mehdiratta S. Rehabilitation of maxillofacialtrauma patient with dental implants: A case report. CHRISMED J Health Res 2018;5:80-3

How to cite this URL:
Gandhi N, Gandhi S, Kurian N, Mehdiratta S. Rehabilitation of maxillofacialtrauma patient with dental implants: A case report. CHRISMED J Health Res [serial online] 2018 [cited 2020 Jul 11];5:80-3. Available from: http://www.cjhr.org/text.asp?2018/5/1/80/223117




  Introduction Top


According to the WHO, motor vehicle accidents are the sixth leading cause of death in India with a greater share of hospitalization, deaths, disabilities, and socioeconomic losses in the young and middle-aged population.[1] Worldwide motor vehicle accidents are the leading cause of death among young people aged 15–29 years and cost countries 1%–3% of the gross domestic product.[2],[3] Nearly 1.3 million people die every year on the world's roads and 20–50 million people suffer nonfatal injuries, with many sustaining a disability as a result of their injury.[3] As maxillofacial area is the most traumatized and exposed, prompt, and appropriate management is necessary to significantly improve the prognosis for many of the dentoalveolar injuries, especially in the young patient.[4] Regrettably, much of this trauma related cases remains poorly managed, leading to a more complicated treatment at the time of tooth loss. Instantaneous and all-inclusive management involving multiple disciplines is needed to successfully reinstate the damaged hard and soft tissues, restore the function and esthetics and allow the patient to regain their self-esteem.[4],[5]

The placement of osseointegrated implants offers an opportunity to enhance the prosthetic support with different restorative designs. This clinical report describes the oral rehabilitation of a young patient with mid-face and mandibular fractures and extensive loss of the dentoalveolar segments in the anterior mandible as a result of a road traffic accident.


  Case Report Top


An 18-year-old young boy reported to the causality with an alleged history of trauma in March 2011. He had sustained multiple facial injuries and diagnosed to have bilateral Le Fort II and a right mandibular angle fracture with comminuted dentoalveolar fracture of 41–33 region. Open reduction and internal fixation with miniplates were done under general anesthesia to immobilize the fracture. Satisfactory occlusion was achieved following the surgery and patient was kept on regular follow up. 4 years later, patient reported to Department of Prosthodontics with a chief complaint of missing mandibular anterior and compromised esthetics with drooping lower lips. He had missing 41, 31, 32, and 33 teeth in the mandibular anterior region that required prosthetic restoration. The clinical and radiographic evaluation revealed severe bone loss in the edentulous area [Figure 1].
Figure 1: (a) Clinical photograph showing missing teeth. (b) Osteoprotegerin revealing severe bone loss and miniplates for fixation of fractures

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Diagnostic impressions were made during his first visit, and diagnostic casts were mounted on an articulator and studied for implant placement and rehabilitation. The patient was advised extraction of 42 due to poor periodontal condition followed by implant placement in 42, 32, and 33 region. Based on the diagnostic wax-up, a screw-retained prosthesis was advised for the patient.

Wax occlusion rims were fabricated, and the lip support and facial profile were evaluated. The occlusal vertical dimension was determined, and the casts were mounted in an articulator in a centric relation. Artificial teeth were selected and arranged on the occlusion rims used for registration, which was then evaluated in the oral cavity for pronunciation, appearance, and occlusion. The mandibular interim removable prosthesis was fabricated which was intended to be used during osseointegration of the implants. Based on the planned treatment, Noble active 4.3 mm × 15 mm, 4.3 mm × 11.5 mm, 4.3 mm × 13 mm implants were placed at 42, 32, and 33 region, respectively. After 3 months, the implants were uncovered, and healing abutments were seated. Subsequently, healing abutments were replaced with multiunit abutments, and an abutment level impression was recorded using open tray method and putty wash technique with polyvinyl siloxane impression material (AFFINIS, Coltene, Switzerland) [Figure 2]. The implant analogs were attached to the impression copings in the impression. The impression was poured with Type IV dental stone.
Figure 2: (a and b) Intraoral photograph at abutment level with transfer copings. (c) Open tray impression with impression copings

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An FP-3 screw-retained prosthesis design was selected as the patient exhibited severe bone resorption in the edentulous area; thus necessitating the replacement of both hard and soft tissue by the prosthesis. A Computer-aided design and computer-aided manufacture fabricated titanium framework trial was done to check for the passivity of the prosthesis following which a screw-retained hybrid prosthesis was fabricated according to the previously done diagnostic wax-up [Figure 3] and [Figure 4].
Figure 3: (a) Intraoral computer-aided design and computer-aided manufacture titanium framework trial. (b) Radiographic verification of computer-aided design and computer-aided manufacture titanium framework passivity

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Figure 4: (a) Screw retained prosthesis with screw access channels. (b) Intra-oral photograph of final prosthesis. (c) Clinical photograph of patient with screw retained hybrid prosthesis with excellent esthetics

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Patient was scheduled for regular follow-up every 2 months for the first 6 months and thereafter once in every 6 months and oral prophylaxis using special plastic tips was carried out during each appointment.


  Discussion Top


In patients with severe oral and maxillofacial trauma, the loss of the alveolus and teeth results in both esthetic and functional deformities.[5] The alveolar changes that occur following dentoalveolar trauma are determined by the extent of the osseous injury and whether or not appropriate therapy was performed. If an avulsed tooth cannot be returned to its socket immediately, placing an implant into the extraction socket is the preferred option; however, in this situation, the implants could not be placed due to the nature of the trauma the patient had suffered and hence, the placement of implants was done after complete recovery of the patient.[6]

The FP-3 restoration appears to replace the natural teeth crowns and a portion of the soft tissue. Basically, two approaches for a FP-3 prosthesis exist: a hybrid restoration of denture teeth, acrylic, and metal substructure or a porcelain-metal restoration.[7] An alternative to the traditional porcelain-metal-fixed prosthesis is a hybrid restoration. This restoration design uses a smaller metal framework, with denture teeth and acrylic to join these elements together. This restoration is less expensive to fabricate and is highly esthetic (premade denture teeth and pink soft tissue replacement). The hybrid prosthesis is easier to repair because the denture tooth can be replaced with less risk than adding porcelain to a traditional restoration. The crown height space determination for a hybrid versus the traditional porcelain-metal restoration is 15 mm from the bone to the occlusal plane. When less space is available, the porcelain--metal restoration is suggested. When more intraarch space is present, a hybrid restoration is fabricated.[8],[9],[10] The decision to fabricate a hybrid prosthesis was made taking into account the presence of crown height space of >15 mm. Moreover, the patient had great esthetic demand as teeth were in smile and speech zones. FP3 fixed prosthesis is the suitable option which replaces the natural teeth and pink colored restorative material to replace the soft tissue portion. The primary factor that determined the restoration type was the amount of inter-arch space, other additional factors were drooping lower lip as well as mandibular lip line during the speech. It had an advantage being less expensive and highly esthetic restoration. Moreover, the use of multiunit abutments in tilted implants inanterior resorbed mandible aided in achieving proper orientation of individual implant in relation to each other which becomes vital for long-term success of the prosthesis. Therefore, for large implant reconstructions involving severe bone defects where complications are anticipated, screw-retained hybrid restorations become the treatment of choice since these restorations replace natural teeth and a portion of soft tissue. The main advantage of screw-retained restorations is the predictable retrievability that can be achieved without damaging the restoration or fixture. The gingival response is found to be better when using screw-retained crowns since no cement is used.[11]

Implant maintenance regimen is as important as the very decision to restore the defects with dental implants. Implant maintenance principles should include regular evaluation of implants and their surrounding tissues and prostheses; occlusal examination; review and reinforcement of oral hygiene; removal of plaque and calculus; treatment of disease or repair of prostheses, as required; and the institution of customized preventive measures.[12] Following the restoration of an implant, the patient should be re-evaluated regularly (i.e., every 3–4 months) during the 1st year. After the 1st year, the response of the peri-implant tissues should be assessed, at which time the appropriate frequency of periodontal maintenance should be determined.[13] Whenever any abnormality is identified, appropriate treatment should be pursued according to the diagnosis reached during the examination. Such treatment may include, but should not be limited to, instructions on oral hygiene, removal of supra-and sub-gingival plaque and calculus, occlusal adjustment, relining of a removable prosthesis or surgery.

Home care devices and aids that have been shown to be safe for use around implant surfaces include interdental brushes with nylon coated core wire, soft toothbrushes (both manual and power), end-tuft brushes, gauze, many types of floss (e.g., plastic, braided nylon, coated, floss with a stiffened end to clean under bridges (Superfloss, Proctor and Gamble, Cincinnati, OH), dental tape, Postcare implant flossing aid), stannous fluoride gel and chlorhexidine. Home care instructions should be customized according to implant design and accessibility.[14],[15]

Scaling and root planing procedures entail the use of plastic curettes and fine polishing pastes. Professional maintenance should include removing both hard and soft deposits with plastic scalers. Conventional stainless steel, titanium, and gold-tipped instruments may scratch the implant surface, which facilitates biofilm growth. Conventional ultrasonic tips also seem to significantly damage the implant surface. Recent studies have shown that newly developed plastic-covered and novel metallic copper alloy ultrasonic scaler tips have minimal effects on the titanium surface of implants.[16],[17] Mechanical debridement, supplemented with the application of chlorhexidine, may be beneficial for patients with peri-implant mucositis, reducing plaque, inflammation, and probing depth and allowing a gain in clinical attachment level.[15],[18]


  Conclusion Top


Immediate and comprehensive treatment involving multiple disciplines is needed to successfully restore the function and esthetics, in maxillofacial injuries resulting from motor vehicle accidents. This treatment paradigm illustrates the contribution of dental implants with proper oral hygiene follow-up as an effective treatment modality in restoring a patient to near normal function and esthetics. The paper has also outlined a standardized, evidence-based assessment, and intervention protocol to assist practitioners in the maintenance care of dental implants.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ministry of Health and Family Welfare. Integrated Disease Surveillance Project- Project Implementation Plan 2004-2009. New Delhi: Government of India; 2004. p. 1-18.  Back to cited text no. 1
    
2.
World Health Organisation. Road Traffic Injuries Fact Sheet, 2013. Available from http://www.who.int/mediacentre/factsheets/fs358/en/.[Last updated on 2017 May 01].  Back to cited text no. 2
    
3.
United Nations Decade of Action for Road Safety 2011-2020. Available from: http://www.decadeofaction.org. [Last accessed on 2013 Jul 15].  Back to cited text no. 3
    
4.
Yamano S, Nissenbaum M, Dodson TB, Gallucci GO, Sukotjo C. Multidisciplinary treatment for a young patient with severe maxillofacial trauma from a snowmobile accident: A case report. J Oral Implantol 2010;36:141-4.  Back to cited text no. 4
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5.
Schwartz-Arad D, Levin L. Post-traumatic use of dental implants to rehabilitate anterior maxillary teeth. Dent Traumatol 2004;20:344-7.  Back to cited text no. 5
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6.
Singh M, Kumar L, Anwar M, Chand P. Immediate dental implant placement with immediate loading following extraction of natural teeth. Natl J Maxillofac Surg 2015;6:252-5.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Branemark PI, Zarb GA, Albrektsson T. Tissue Integrated Prosthesis. Chicago: Quintessence; 1985.  Back to cited text no. 7
    
8.
Misch CE, MischDIetsh F. Preimplant prosthodontics. In: Misch CE, editor. Dental Implant Prosthetics. St. Louis: Mosby; 2005.  Back to cited text no. 8
    
9.
Misch CE, Goodacre CJ, Finley JM, Misch CM, Marinbach M, Dabrowsky T, et al. Consensus conference panel report: Crown-height space guidelines for implant dentistry-part 1. Implant Dent 2005;14:312-8.  Back to cited text no. 9
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10.
Misch CE. Dental Implant Prosthetics. 2nd ed. Philadelphia, PA, United States: Elsevier Health Sciences; 2014.  Back to cited text no. 10
    
11.
Shadid R, Sadaqa N. A comparison between screw- and cement-retained implant prostheses. A literature review. J Oral Implantol 2012;38:298-307.  Back to cited text no. 11
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12.
Cohen RE, Research, Science and Therapy Committee, American Academy of Periodontology. Position paper: Periodontal maintenance. J Periodontol 2003;74:1395-401.  Back to cited text no. 12
    
13.
Shumaker ND, Metcalf BT, Toscano NT, Holtzclaw DJ. Periodontal and periimplant maintenance: A critical factor in long-term treatment success. Compend Contin Educ Dent 2009;30:388-90, 392, 394.  Back to cited text no. 13
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14.
Humphrey S. Implant maintenance. Dent Clin North Am 2006;50:463-78.  Back to cited text no. 14
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15.
Todescan S, Lavigne S, Kelekis-Cholakis A. Guidance for the maintenance care of dental implants: Clinical review. J Can Dent Assoc 2012;78:c107.  Back to cited text no. 15
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16.
Mann M, Parmar D, Walmsley AD, Lea SC. Effect of plastic-covered ultrasonic scalers on titanium implant surfaces. Clin Oral Implants Res 2012;23:76-82.  Back to cited text no. 16
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17.
Chen S, Darby I. Dental implants: Maintenance, care and treatment of peri-implant infection. Aust Dent J 2003;48:212-20.  Back to cited text no. 17
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18.
Goyal CR, Lyle DM, Qaqish JG, Schuller R. Evaluation of the plaque removal efficacy of a water flosser compared to string floss in adults after a single use. J Clin Dent 2013;24:37-42.  Back to cited text no. 18
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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