The Clinical Problem ( Fig. 23.1 )
Synopsis
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The patient, a 20-year-old woman, suffered an injury to the anterior maxilla in a motor vehicle accident. There were no injuries to her lips or other perioral structures.
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Emergency care was provided immediately, and reconstruction commenced 3 months later.
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Treatment, over a period of 18 months, included two surgical procedures and dental rehabilitation, including gingival surgery.
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Treatment was provided by a team, which included a maxillofacial surgeon, restorative dentist, and dental technical laboratory.
The Aesthetic Problem ( Fig. 23.2 )
Following this injury, the patient was left with a significant dentofacial injury, which made her extremely self-conscious about her smile. She was also unable to speak clearly and could not eat satisfactorily. She believed that she could not continue with her education and that her chances for employment were diminished. These prospects made her emotionally depressed. She avoided social contacts and became withdrawn.
At the time of examination, after emergency care, the following conditions were noted:
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The maxillary central incisors, associated alveolar bone, and soft tissue had been avulsed.
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The maxillary left lateral incisor was fractured, devitalizing the dental pulp.
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Primary closure of the wound, without grafting, resulted in location of the labial frenulum at the crest of the alveolar ridge.
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There was significant deficiency in the volume of bone and soft tissue, including a lack of keratinized connective tissue.
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Lacking incisor teeth, the patient was unable to make all speech sounds clearly, would not smile without hiding her face behind her hand, and was in emotional distress.
A panoramic radiograph was made at the time of examination (see Fig. 23.2 ). Note the teeth missing at the maxillary midline and the impacted third molars.
The goal of treatment was to replace the missing teeth and tissue and restore the damaged teeth to appear and function in a manner consistent with long-term health. The plan of treatment that was selected included augmentation of bone and soft tissue, placement of two dental implants, and placement of dental restorations on the four maxillary incisor teeth. The procedures selected offered the best outcome, with the least compromise to remaining dental structures.
The alternative treatments were a removable partial denture or fixed partial denture. The location of the maxillary frenulum would have interfered with either type of restoration. Additionally, the patient rejected a removable prosthesis as an alternative. A fixed partial denture was not possible because of the damage to the adjacent teeth and the poor long-term prognosis in a young patient.
Surgical Preparation and Technique
Treatment
This reconstruction was accomplished in four stages—surgical restoration of bone and soft tissue with grafting, placement of dental implants, development of soft tissue contour for tooth replacement, and restoration of damaged and missing teeth. The time for healing and maturation of tissue in between stages was critical to the outcome of the procedures.
Bone augmentation was accomplished by reflection of the tissue and placement of a combination autogenous bone and allograft material, protected by a resorbable membrane. The autogenous bone was obtained during the surgical removal of the impacted maxillary and mandibular third molars. The flap was advanced, and the labial frenulum was repositioned to a location suitable for dental restorations. Healing after this procedure was 6 months.
After 6 months, the tissue was reflected minimally, and two dental implants were placed ( Fig. 23.3 ). The implants, which are made of chemically pure titanium and had chemically prepared surfaces, were placed into osteotomy sites prepared with low-speed rotary instrumentation under continuous irrigation. Under these circumstances, it is predictable that the implant will be colonized by bone and will achieve osseointegration. This interface can withstand the force of occlusal function and can support gingival tissues.
