In response to AAE members’ requests for more clinical content in their communications, the Resident and New Practitioner Committee introduced the Cases and Treatment Plans column. This recurring column will provide different perspectives and options for diagnosis and treatment, often from different disciplines of dentistry. If you have a case and treatment plan you would like to submit for publication, please contact Aly Hall at email@example.com.
By: Mark A. Odom, D.D.S.
On 8/27/13 my office received a frantic call from the mother of a young man who on had been beaten up while walking near the local university he was attending. The trauma occurred on the previous Saturday night, 8/25/13. She reported that he currently was still in the hospital and had numerous broken teeth and was in considerable pain. She also reported that air, cold or anything near the teeth caused him pain, making it hard for him to take his pain medications or to eat. She asked if I could see him if they could get him out of the hospital; I said yes. Several hours later the patient presented to my office with lip lacerations, bruises (facial), two black eyes and various facial contusions. The patient did not have a concussion and according to the medical report had no broken bones. It seems he had been beaten with a metal trash can lid.
The emergency exam revealed clinical crown fractures and visible pulp exposures on #7 and #10. The patient brought #8 with him, which had been avulsed in the attack. Upon clinical digital examination the clinical crown and a portion of the root of #9 fell into my hand. The tooth had fractured at least 6 mm sub-gingival and was not restorable. Because of the recent trauma, I did not pulp test any of the remaining teeth. I explained to the patient and the mother that once the patient was stable medically and had time to allow healing of the facial lacerations, we would test all of the remaining teeth. I noted chipped enamel on #25 and #24; however. no sensitivity to air was noted on the mandibular teeth.
Emergency treatment was completed on #7 and #10 utilizing 72 mg of 2% Lidocaine with epi. (100:000). Isolation of the teeth was difficult and as a result sterile saline was used to irrigate the canals of #7 &10. The canals were dressed with CaOH. Prior to starting the emergency procedures I called both a prosthodontist (my wife, who practiced in the adjacent office) and an oral surgeon and explained the situation to both doctors at which point the three of us began to coordinate a definitive treatment plan for this patient. It was decided that after I stabilized #7 and #10 the patient would immediately go next door, and the prosthodontist would then prep #s 7 and 10 and fabricate a 4-unit provisional FPD with temporary posts, so the patient had both his immediate esthetic concerns as well as a stabilization of the traumatized teeth taken care of. The patient would then see the oral surgeon for extraction of the retain root fragment of #9 and grafting of the #s 8 and 9 sites in anticipation of endosseous implant replacement.
Approximately two weeks later the patient returned to me again for a coordinated appointment with the prosthodontist, to complete the endodontics and provide post space, after which cast dowel core patterns were fabricated and delivered within two weeks. At this point the provisional was re-fabricated as a processed provisional to allow the patient a solid restoration to wear until implants were placed and integrated to allow definitive restoration. Implants were placed in the sites of #s 8 and 9. The decision to place adjacent implants was based on the concern for possible resorption in the future to #s 7 and 10 because of the trauma. Placement of implants in the site of both centrals allowed for the option of replacement of the laterals with a 2-unit implant retained FPD should a lateral fail in the future. The patient also had a low smile line and the gingival esthetics of the final restoration was not a concern. The final restorations consisted of 4 single-unit crowns.
In this scenario, I was the first responder, dentally. Having a good relationship with other specialists and being able to coordinate care allowed me to have a well staged treatment plan for this patient resulting in strong, long lasting restorations after a significant trauma. The patient did not require any additional endodontics and follow-up appointments were scheduled but the patient did not keep them because he moved out of the area to attend graduate school.