Contemporary management of tooth replacement in the traumatized dentition.

0.95 MB·English

by  Alani, Aws

DentalTraumatology2012;doi:10.1111/j.1600-9657.2012.01122.x
Contemporary management of tooth
replacement in the traumatized dentition
REVIEW ARTICLE
AwsAlani1,RupertAustin2, Abstract – Dentaltraumacanresultintoothlossdespitebesteffortsatretaining
SerpilDjemal3 and maintaining compromised teeth (Dent Traumatol, 24, 2008, 379). Upper
1DepartmentofRestorativeDentistry,Newcastle anteriorteetharemorelikelytosufferfromtrauma,andtheirlosscanresultin
DentalHospital,Newcastle;2Departmentof significant aesthetic and functional problems that can be difficult to manage
Prosthodontics,Guy’sHospital,King’sCollege (EndodDentTraumatol,9,1993,61;IntDentJ59,2009,127).Indeed,teethof
LondonDentalInstitute,London;3Departmentof poor prognosis may not only present with compromised structure but trauma
RestorativeDentistryandTraumatology,Kings mayalsoresultindamagetothesupporttissues.Injurytotheperiodontiumand
CollegeHospital,London,UK alveoluscanhaverepercussionsonsubsequentrestorativeprocedures(Fig.19).
Where teeth are identified as having a hopeless prognosis either soon after the
Keywords: diagnosis;permanenttooth; incident or at delayed presentation; planning for eventual tooth loss and
prognosis;toothinjury;treatment replacement can begin at the early stages. With advances in both adhesive and
osseointegration technologies, there are now a variety of options for the
Correspondenceto:SerpilDjemal,
DepartmentofRestorativeDentistryand restorationofedentatespacessubsequenttodentaltrauma.Thisreviewaimsto
Traumatology,King’sCollegeHospital, identifykeychallengesintheprovisionoftoothreplacementinthetraumatized
CaldecotRoad,LondonSE59RT,UK dentition and outline contemporary methods in treatment delivery.
Tel.:[phone]
Fax:[phone]
e-mail:[email protected]
Re-useofthisarticleispermittedin
accordancewiththeTermsandConditions
setoutathttp://wileyonlinelibrary.com/
onlineopen#OnlineOpen_Terms
Accepted7January,2012
adulthood (12). The orthodontic-restorative interface
Treatmentconsiderationsandthecontinuumofcare
mayresultintreatmentoptionsthatdonotrequirefrank
Dental trauma can present with severe injuries on prosthetictoothreplacement.Techniquesinorthodontic
multiple teeth that were otherwise unrestored with no space closure and restorative augmentation with com-
history of intervention up to that point. Indeed, when posite may provide acceptable and serviceable results
teeth present with multiple concomitant injuries, the without the need for tooth tissue removal (Fig. 1) (13).
relative prognosis of individual units may be difficult to Where tooth positions and stages of root development
ascertain(4–6).Assuch,long-termplanningmaybebest are favourable autotransplantation of premolar, units
carried out after the acute healing phase is complete. In have shown excellent long-term results (Fig. 2) (14).
complex cases such as those of polytrauma, multidisci- Once post-trauma stabilization has been achieved, an
plinary team planning may be sought as treatment objective assessment of the dentition can commence.
options may depend onissues that the primary clinician Wherenon-vitalteethhavequestionablerestorabilitybut
may not be fully sensitive to. Phased treatment moving are amenable to endodontic treatment, the primary aim
from one discipline to another is a regular occurrence of preventing the development of an apical lesion and
where orthodontic treatment is required or where surgi- postponingextractioncanbeconsideredanastutewayof
cal intervention is envisaged (7, 8). These cases may be preserving the alveolar form (15, 16). Maintenance of
best planned and reviewed in joint team meetings with teeth in this way can aide implant provision especially
agreed strategies for future treatment (9, 10). In the where extraction and immediate placement is envisaged
developingdentition, theoptionofimplants maynot be once growth is complete.
available until growth is completed (11). In these cases, Contemporaryrestorationoftheedentatespaceinthe
an orthodontic opinion may be sought early in the traumatized dentition should ideally be independent of
process to assess future development and spacing. abutment teeth or minimally invasive without compro-
Indeed, as alveolar dimensions and gingival maturity misingmassandqualityoftoothstructure.Conventional
are likely to change through adolescence, treatment bridgework can result in loss of vitality of abutment
planning should focus on the definitive option once teeth, whereas removable partial dentures may result in
growthhasceased.Thissituationrequiressomeforesight significant plaque accumulation and also lack social
as longitudinal planning can optimize outcomes into acceptability (17–19). The utilization of minimally inva-
(cid:2)2012JohnWiley&SonsA/S 183
184 Alaniet al.
(a) (b)
Fig.1. (a) 21-year-old patient who pre-
viouslylost21becauseoftrauma.Ortho-
dontic space optimization was instigated
followed by composite augmentation of
the22tomimica21(b).
(a) (b) matology especially where immature pulp tissue may be
present. This concept is more relevant in the developing
dentition where changes in tooth position, alveolar
growth and tooth prognosis are still to be realized (21)
(Fig. 3). Where teeth have erupted to a level that
provides adequate surface area for bonding resin
bridges can be delivered. Indeed, their provision can
be considered a definitive option where there is inad-
equate bone volume and quality and where favourable
abutment teeth are present (21) (Fig. 4). This option
may be more carefully considered by the patient where
the need for numerous surgical episodes is required for
an osseointegrated restoration, in comparison, the
resin-bonded bridge can be delivered sooner with
minimal morbidity.
Preparationorconsolidation?
The median survival rate for resin bridges has been
shown to be just under 10 years with an 87.7% survival
rate of bridges and splints at 5 years (22, 23). Features
thathavebeenshowntoimprovesurvivalincludesurface
area covered by the retainer, operator experience and
Fig.2. (a)Longconeperiapicalof11followingtraumawhich
design (24). The extent to which the abutment can be
resulted in mid-root fracture of the 11. (b) The tooth was
extracted and an autotransplanted premolar was used to preparedvaries(20)andsuccesscanbeachievedwithout
replace. Composite augmentation and root canal treatment preparation; although this needs to be balanced against
was completed on a subsequent visit. Case courtesy of evidence that has suggested improved longevity when
the Department of Paediatric Dentistry, Newcastle Dental retentive featuressuchas restseats andguideplanesare
Hospital.
incorporated (24). Newer techniques in optimizing the
enamelsurfaceincludetheuseofintraoralsandblasting
sive techniques may be clinically successful without the prior to etching although this has not been evaluated
need for further intervention. fully (25). This technique may be particularly useful
where the tooth surface is extrinsically stained or where
residual resin remains from previous bonding attempts.
Traumaandtheresin-retainedtechnique
Indeed, the use of bioactive-glass air abrasion that can
The original work by Rochette some 40 years ago on selectively remove resin as opposed to enamel has also
a technique for bonding metal splints to periodon- been developed (26) (Fig. 5). Where gingival tissues
tally involved teeth has since undergone significant encroachonthepalatalaspectofthepotentialabutment,
developments and improvements in addition to new thiscanlimitthesurfaceareaforbondingandtheheight
concepts and indications (20). The ability to provide a of the connector (Fig. 6). These problems can be
prosthetic replacement without biologically harmful addressed utilizing electrosurgery to simultaneously
and irreversible preparations has applications in trau- augment the prospective pontic site to improve emer-
(a) (b)
Fig.3. (a)14-year-oldpatientpresentingwithdecoronationofthe21andsubluxationof11.Bothteethwererootcanaltreatedand
asymptomaticatreview.(b)Resin-bondedbridgeworkcantileveredfromthe22intothe21space.Theguardedprognosisofthe11
precludeditasanabutment.Oncegrowthiscompleted,thedefinitiverestorationofthe21areawithanimplantwillbeconsidered.
(cid:2)2012JohnWiley&SonsA/S
Management of toothreplacement in thetraumatized dentition 185
Fig.4. Resin-bonded bridge cantilevered from the 13 into the
12space.Initialinvestigationsrevealedtheneedforgraftingin
the 12 site for an implant. The patient was not keen on this
option,andadefinitiveresinbondedbridgewasfitted.
Fig.5. IntraoralsandblastingpriortoRBBcementationunder
gencewhilstalsoexposinggreaterenameltissuepalatally
rubberdamisolation.
(27). The maintenance of soft tissue postsurgery can be
achieved by way of relining a removable prosthesis
(Fig. 6c). the cement lute to the retainer wing being stronger than
Where there is a lack of interocclusal space between that to metal because of greater linearity between the
potential resin-retained abutments and opposing tooth materials. The dentist has the choice of fabricating the
units, the cementation of restorations at an increased prosthesis directly (if for example an avulsed tooth is
occlusal vertical dimension to create space has been available to be modified) or indirectly (Fig. 8). One
described (28). This technique can prevent the need for consideration is the need for greater occlusal clearance
tooth preparation and where there is limited prosthetic requiredfortheretainers,andcantileverdesignsmaynot
envelopeforfuturerestorations,spacecanbecreatedfor be achievable because of the lack of rigidity.
definitiveplanning(Fig. 7).Axialtoothmovementsvary Apracticaladvantageofresin-bondedbridgesistheir
between individuals; younger patients have a greater retrievability, especially where a multiphase treatment
scope for a combination of intrusion and eruption, plan is envisaged (Fig. 9). Initial cementation post-
whereas in older patients, the movements are predom- trauma may provide an interim measure until growth is
inantly intrusion (29). completedorthedentitionfullystabilized.Resin-bonded
bridges lend themselves to this ethos as removal is
relatively straightforward by ‘tapping off’ the bridge
Newmodalities
when needed. The use of glass ionomer cement as
Technologicaldevelopmentsinadhesivetechnologyhave opposed to resin composite has also been recommended
resulted in the ability to utilize the crowns of avulsed where removal is envisaged at a later date.
teeth as pontics in an immediate manner (Fig. 8) (30).
Further to this, the development of fibre-reinforced
Utilizationinmulti-phasedtreatment
resin-bonded bridges has presented clinicians with
greater choice when considering minimally invasive Banerji and colleagues examined the use of RBBs as an
optionsfortoothreplacement(31).Thesematerialshave interim restoration during implant treatment (33). The
been described as resin-based restorations containing study examined two phases in the use of the Rochette
fibres aimed at enhancing their physical properties (32). bridge, the first after immediate cementation following
As the framework is tooth coloured, aesthetic problems extractionandthesecondatthetimeofimplantsurgery
relatingtoshowthroughofabutmentscanbeminimized and recementation. In the first phase, 16% of bridges
(32). There is potential for development of the bond of requiredrecementationincomparisonwith27.5%andin
(a) (b)
Fig.6. (a) Previous trauma resulted in
the lossof the11. Notethe excess tissue
in the 11 site making potential pontic
dimensions difficult to match with adja-
centgingivalmargins.(b)Electrosurgery
to create ideal pontic space for resin- (c) (d)
bonded bridgework in addition to max-
imizing enamel surface area palatally on
21.(c)Tomaintainthesofttissuedimen-
sions,theretainerwasrelinedandfitted.
(d) The definitive resin-bonded bridge
cemented from the 21 cantilevered into
the11space.
(cid:2)2012JohnWiley&SonsA/S
186 Alaniet al.
(a) (b) (c)
Fig.7. (a)15-year-oldpatientwhosufferedacombinationofavulsions,alveolarandrootfractures.Theseweremanagedsurgically
andprimaryclosurewasachieved.Atanearlystage,thelackofinterocclusalspaceforsubsequentrestorationoftheedentatespace
wasapparent.(b)TocreateinterocclusalspaceutilizingtheDahlapproach,aresin-bondedbridgewascementedfromthe13tothe
22atanincreasedocclusalverticaldimension.(c)After6monthsofwearposteriorcontactsre-establishedandadequateinterocclusal
spacewascreatedfortheplacementofimplantstodefinitivelyrestorethespace.
Fig.8. Immediate resin-bonded bridgework for 21 space uti-
lizingcarbonfibrematerial. Fig.9. Rochettestylebridgeutilizedinamultiphasetreatment
plan. This patient was fitted with the resin-bonded bridge
immediately after extraction. The bridge was modified to
the second phase, 7.2% of bridges required recementa- accommodateahealingabutmentandrecementedafterimplant
placement.
tion in both phases (33). Interestingly, there was
marginal difference in probability of survival between
thetwophasesover200 dayswithphaseonebeing80% resin-retained bridgework is limited. Indeed, if occlusal
andphasetwo78%.Thisstudyprovidessomescopefor factors and abutment teeth are unfavourable, the clini-
RBBuseinthelongitudinaltreatmentofthetraumatized cianmustconsiderdentalimplantsasanalternativefixed
dentition (33). treatment option.
Limitationsofthetechnique Osseointegrationinthetraumatizeddentition
Resin-retained bridges have disadvantages that may
Managingtheaftermathoftrauma
result in the consideration of alternative options. The
reported survival rates may be less than alternative, Planning for implants in the trauma patient can be
albeit more invasive options, such as conventional challenging as well as clinically difficult particularly
bridges or implants (23). Indeed, the degree of patient when the extent of trauma is directly related to the
satisfactionwithresin-bondedbridgesappearstobehigh feasibility oftreatment(Fig. 10).Postextractionchanges
anddoesnotseemtobeinfluencedbytheoccurrenceof can result in buccal bone loss making implant provision
failureorthepossibilityofrecementation(34).Provision more difficult (36). Attempts at maintaining hard and
of RBBs retained by thin anterior teeth may result in soft tissue topography have included atraumatic extrac-
metal show through which may not be acceptable to tion techniques in combination with adjunctive tissue
some patients. This can be minimized by use of an regeneration (37). In comparison, the pathophysiology
opaque cement (20).Try-in of the restoration is difficult of dental trauma with the possibility of a superimposed
due to absence of retention without cementation. This endodontic infection fuelling the resorptive process
can be remedied using calcium hydroxide-based lining results in a more aggressive and rapid loss of bone and
materialstotemporarilyfixatethebridgeinsitutoassess soft tissue contour. Ankylosis and progressive bone or
aesthetics (35). Occlusal control may be difficult to root resorption can further complicate treatment. As a
achieve because of the encroachment on previous ante- result, techniques of elective decoronation have been
rior guidance pathways, in cases of poly-trauma, described with the aim of preventing infraocclusion and
potential abutment teeth may be compromised preclud- allowing alveolar development to continue (38–40)
ing them as suitable abutments. In cases where multiple (Fig. 11).Wherehorizontalfracturespresent,theextrac-
adjacent teeth are lost, the scope for the provision of tion of both fragments or simply the most coronal
(cid:2)2012JohnWiley&SonsA/S
Management of toothreplacement in thetraumatized dentition 187
portion needs to be considered (Fig. 12). Attempts at
(a)
retrieval of an apical fragment may result in the loss of
further bone because of restricted access. In contrast,
retentionofthefragmentanditsremovalattheimplant
placement stage although desirable may be difficult to
achieve. This remains an area where the clinician’s best
judgment in retaining as much bone as possible for
implantplacementneedstobebalancedagainsttheneed
for fragment removal.Recent innovationsinatraumatic
exodontiahaveincludedtheuseofimplantdrillstothin
root walls prior to implant placement and the use of
special elevators and modified piezo tips for dissecting
theperiodontalligament(41–43)(Fig. 13).Thedifficulty
in dealing with such cases may require input from
surgical colleagues in the execution of adjunctive proce-
dures for subsequent implant placement.
Optimizationoftheedentatesite
Where multiple teeth are lost or alveolar bone has
resorbedfollowingtrauma,theneedforadjunctivebone
grafting prior to provision of implants may need to be
considered. Indeed, the clinical appearance may not
reveal the true extent of the bone deficit because of
hypertrophy of the mucosa (Fig. 10). The assessment
of the edentate site can be evaluated using a variety of
techniquessuchasclinicalridgemappingorconebeam–
computerizedtomography(44).Wherethereisalackof
bone width in the presence of adequate vertical height,
onlaygraftingcanbeutilized(Fig. 14).Thiscanestablish
bucco-palatalbonewidthbutalsoimprovesthescopeto
placetheimplantintheappropriateaxialandmesio-distal
(b)
position.Theoptionsfordonorsitesincludetheascend-
ing ramus, the anterior mandible or an extra-oral site.
Adjunctive procedures are not without complications;
partialortotalblockgraftfailurehasbeendocumentedat
7% and 8%, respectively (45). In contrast, soft tissue
complications were more common ranging from mem-
brane exposure (30%), incision line opening (30%),
perforation of the mucosa over the graft site (14%) and
infectionofthegraftsite(13%)(45).
Forcible orthodontic eruption of an otherwise unre-
storablelateralincisorforthepurposesofalveolarbone
development has been described (46) (Fig. 15). In cases Fig.10. (a) This patient suffered trauma to the 21 which was
where vertical augmentation is required, distraction subsequentlytreatedwithorthogradeendodonticsfollowedby
osteogenesis can be considered either for a single or apical surgery. Because of persistent infection, the tooth was
multiple unit sites. The movement of arch segments by extracted. (b) CBCT examination revealed an obvious bony
way of distraction osteogenesis has been described for defect which was not amenable to implant placement. The
feasibilityofbonegraftplacementwasalsodifficulttopredict
implantsiteoptimization(47).Distractiondevicesplaced
becauseofthelackofbonepresenttoreceivedonortissue.
after osteotomy preparation can be transalveolar or
extra-alveolar and can require surgical fixation.
A latency period of 1 week prior to commencing the loss of two adjacent teeth is present. Where bone
distraction at the rate of 0.5–1 mm a day has been volume is adequate but soft tissues are deficient, the
recommended although this will depend on the individ- clinician may consider the use of graft procedures to
ual case and the magnitude of distraction required (48). optimize soft tissue coverage. Alternatively, the patient
maybekeenonanimplant-basedrestorationwithoutthe
need for adjunctive grafting. The option of gingivally
Theimportanceofsupporttissueprofile
tonedceramicasanalternativetoverticalaugmentation
Where adequate alveolar mass and gingival biotype is andsofttissuegraftinghasbeenrecentlyhighlighted(49)
present, the provision of implant restorations anteriorly (Fig. 16).
can be predictable providing adequate aesthetics and Thegingivalcomponent ofa restoration isimportant
function.Suchprovisionmaybemorecomplicatedwhen especially where osseointegration is planned. The aes-
(cid:2)2012JohnWiley&SonsA/S
188 Alaniet al.
thetics of the gingiva associated with a restoration has
(a) (b)
been shown to be a factor in the success of the
restoration (50). Patients with a thicker biotype have
shownmorefavourablelong-termresultsthanthosewith
thinnersofttissues(51).Inarecentstudyof513patients
presenting with orofacial trauma, 29.2% had signs of
eithergingivalororalmucosainjuries(52).Bothbiotype
and previous trauma injuries may affect the degree to
which these tissues can be manipulated. Techniques in
the creation of a gradual natural emergence profile of
implant restorations have been described (53, 54)
(Fig. 14). These techniques aim to manipulate the peri-
implant tissues to create a more natural emergence.
Foresight in the management of soft tissues in acute
traumabyoptimizinghealingmayimprovethescopefor
tissue manipulation for future restorations.
Fig.11. (a)Radiographicexaminationofthe11and12showed
external and internal inflammatory resorption and external
Timingofimplantplacement
replacement resorption. (b) The 11 and 12 were accessed and
guttapercharemovedandweresubsequentlydecoronatedwith Thevarioustimingsofimplantplacementpostextraction
surgicalclosure.
haverecentlybeeninvestigated(55).Asystematicreview
comparing the outcomes of immediate, immediate
delayedandordelayedimplantssuggestedthatimmedi-
(a) (b) ateandimmediatedelayedplacementcamewithahigher
chance of postoperative complications although imme-
diate placement may present with better aesthetic out-
comes (55) (Fig. 17). Despite these conclusions, the
authorsfeltthereisaneedforbetterqualityofevidence
as the current literature is sparse, underpowered and
carriedahighriskofbias(55).Morespecificstudieshave
examined the outcomes of implants placed in extraction
sites of teeth with periapical lesions (56–58). One
systematic review concluded that the immediate
approach may require thorough debridement of the
extraction socket, prophylactic antibiotics, tissue regen-
eration and in some cases result in impaired bone to
implant contact (58). Other controlled studies have
shown favourable results with limited complications
andsurvivalupto3 years(56,57).Aslong-termoutcome
studies are lacking, the predictability and longevity of
placingimplantsimmediatelyintoextractedsitesisstillto
Fig.12. (a)Delayedpresentationofamid-rootfractureanda be realized. Where teeth are avulsed in an acute trauma
periapicallesion.(b)The21wasreplacedwithanimplant. situation, the clinician may be faced with the option of
placingan implantinto arecentlytraumatized site. This
decisioncanbedifficultastheuncertaintiesofprognosis
of adjacent teeth and the status of bone in the avulsion
site itself can be hard to judge. Immediate implant
placement reduces the number of surgical episodes and
treatment time. The procedure may be technique sensi-
tive,theremaybealackofkeratinizedtissueavailablefor
flapadaptation,andthesitemorphologymaycomplicate
optimal placement. In contrast, the delayed immediate
approach at 4–8 weeks which will have increased kera-
tinized soft tissue available in addition to assessment of
any developing pathologies. Unfortunately, the healing
sitemayhavealreadyundergonesignificantresorptionby
thetimetheimplantisplaced.
Theimplantprovisionpathwayintraumapatientshas
been examined in a retrospective study (59) where
implants were placed in 42 sites between 6 months to
11 years post-trauma. In 17% of cases, there was a
Fig.13. Piezo powered bone and periodontal ligament dissec-
deficiency of bone that required adjunctive procedures.
tion.
(cid:2)2012JohnWiley&SonsA/S
Management of toothreplacement in thetraumatized dentition 189
(a) (c)
(c1)
(b) (d)
Fig.14. (a) Onlay graft in the 22 site where previous avulsion had resulted in deficient alveolar profile for implant placement.
(b)Interim implantrestoration 22.Notethelackofemergence. (c)Flowablecompositemodificationoftheinterimrestoration to
creategradualemergenceandform.(d)Thedefinitiverestorationwithdevelopedemergenceform.
Fig.16. Traumatic loss of 11 and 12 resulted in a marked
Fig.15. Patient undergoing orthodontic extrusion for the
verticalandhorizontaldefect.Thepatientpreferredtheuseof
purpose of implant site development in the 11 site. The 11
gingivally toned ceramic as opposed to bone and soft tissue
hasbeenextrudedutilizingaminiimplantplacedapically.Case
grafting prior to implant placement. Case courtesy of Amre
courtesyofBillIp,NewcastleDentalHospital.
Maglad,NewcastleDentalHospital.
Four of the 42 implants exhibited postsurgical compli- speculate as to whether immediate implantation follow-
cations, whereas five exhibited complications after ingtoothlossmayhavepreventedtheneedforgrafting.
cementation of the crown. One significant finding was This view may be strengthened by a more recent
that patients who had long-standing tooth loss required retrospective study of 53 trauma patients provided with
grafting.Inadditiontothis,allpatientswhohadlosttwo implants. Eighty-one per cent required bone augmenta-
or more adjacent teeth also required grafting. One may tionthatincludedonlaygraftsorguidedboneregenera-
(cid:2)2012JohnWiley&SonsA/S
190 Alaniet al.
(a) (b)
Fig.17. (a)Decoronationof43asaresultoftrauma.Becauseofthelimitedsupragingivaltissueavailableforrestoration,thetooth
wasdeemedashavingapoorprognosis.(b)Definitiverestorationafterextractionandimmediateimplantplacement.
(a) (b)
Fig.18. (a)Thispatientsufferednumerousinjuriessubsequenttoaroadtrafficaccidentapproximately25yearsago.Shelostthe
majorityofhermandibularteethinadditiontotheneedforgraftingandfixation.Oncestabilized,shewasprovidedwithanimplant
retained prosthesis. (b) Radiograph 20years after initial provision. During this period, the patient presented with a variety of
maintenance requirements that included clip fractures, abutment screw loosening, overdenture replacement and peri-implant
mucositis.
ing care is likely to be of great significance in future as
our patients are living for longer (61).
Biologicalcomplicationssuchasperi-implantitishave
been reported to be as high as 56% (62). Mechanical
complications such as abutment screw fracture or
loosening also need consideration. Mechanical compli-
cationsmaybemorelikelyinapatientwhoissusceptible
to trauma. Stuebinger and colleagues reported the
bending of abutment screws in a patient who sustained
traumatohisimplant restorations(63).Allen andAllen
Fig.19. Poly-trauma presenting with decoronation of the 21,
(64) reported the fracturing of inter-implant bone
luxation of the 11, fracture of the implant crown 12, gingival
subsequent to a blow to the face which also resulted in
lacerationsandasinusassociatedwiththe11.
abutment screw bending. Flanagan (65) reported the
fracturing of implant crowns when soft tissue injuries
were sustained. It would seem sensible to consider the
tion and 47% underwent immediate placement and in
likelihood of repeat trauma and its repercussions on
some cases with immediate loading (60). The authors
tooth replacement and subsequent maintenance when
found a 45% complication rate, although complications
managing this group of patients.
were significantly less in those cases with no previous
historyofperiapicalpathology.Theresultsofthisstudy
maystrengthenthecaseforremedialrootcanaltreatment Conclusion
todecreasethepresenceofinflammationandpotentially
The provision of tooth replacement in the traumatized
increaseboneforapicalengagementoftheimplant.
dentitionhasspecificchallengesthatmaynotbepresentin
patientswhohavesufferedplaque-relatedtoothloss.This
Long-termmaintenanceofimplantsinthetraumapatient can make the treatment planning process more difficult
Asthemajorityoftraumaticinjuriesoccurintheyoung requiringadjunctiveprocedurestoaidthedefinitiveresult.
or adolescent patient, the restorative dentist needs to
consider the longevity and serviceability of the restora-
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