Treatment of Traumatic Oral Injury: A Personal Account
One technician’s story about his own ongoing restorative journey.
For treatment of complex restorative cases, it is not uncommon for several members of the dental team to be involved—from the general dentist, oral surgeon, and endodontist, to the periodontist, orthodontist, and dental technician. Each lends specific expertise toward the goal of attaining the best possible outcome for the patient.
Dental technicians are sometimes among the first to become involved when the general dentist is trying to decide how to best restore the patient. Often technicians are asked to advise on what they think is achievable. Is there an all-ceramic option for this patient? Can a zirconia abutment be used? In a patient with a high lip line, should the choice be a porcelain-fused-to-metal or an all-ceramic solution. Technicians need to understand the benefits of all the different dental procedures. They assess the oral situation and decide how best to provide the patient with the most functionally esthetic restorations possible. They may advise that crown lengthening would really make the final results more esthetic or that orthodontics would be a better first answer to the patient’s problems and could make the restorative results less of a compromise.
Case consultation is becoming a larger part of the dental technician’s role. Material options change too quickly for most clinicians to keep current on all of them. Being an integral part of the restorative team is one of the most gratifying things about being a technician. It enables them to see the difference they can make in a person’s life.
It is important to remember that each case or prescription represents a person. It is easy to take that for granted and begin to lose sight of the case. The treatment plans and restorative work being done can all be broken down into dehumanizing technical components, but each added step or procedure represents time, money, and sometimes pain and aggravation to the patient. Dental professionals understand this in theory, but they may not fully grasp the effect it has on the patient when they have never personally experienced the procedures. Dental technicians sometimes grasp this to an even lesser extent because they do not perform the medical procedures and most are not in-practice technicians. So, much of their case knowledge is tangential or anecdotal; at least this was true for the author until recently.
The following is an account of how the author is no longer even slightly cavalier about treatment options and is reminded how every restorative patient has a story. This is a personal account of one suffering a traumatic oral injury and his restorative journey.
The author was running the 2011 LIVESTRONG™ marathon in Austin, Texas (Figure 1). After a grueling uphill stretch between miles 12 and 20, he was fairly worn out and was considering stopping after the 20-mile marker to regroup. As he hit the plateau after the hills, all of the sudden, and without warning, he collapsed.
Evaluating the Injury
The author regained consciousness and became aware of the people all around him. There were three big pools of blood in front of him, one of which contained a tooth. Numb with pain and covered in blood (Figure 2), the author’s mouth was filled with pieces of teeth and shards of bone. While waiting for emergency medical services to arrive and listening to the distracting cacophony of well-intended good Samaritans, all he could think about were the limitations of pink porcelain and how high his lip line was.
The author picked his lateral tooth up off the ground and placed it in his sweat-soaked pocket for the trip to the emergency room. Once he was admitted, the attending physician examined his condition and without preamble, decided to jam the avulsed lateral back in place. She then used over 50 stitches to close the wound on his chin and sent him off for the first of what became almost a week of tests. The whole time the author kept inquiring to see someone about the condition of his mouth.
Eventually the on-call maxillofacial specialist showed up. He examined the CT scans and the author’s mouth, and then looked at him quizzically when the author asked, “Will I be able to preserve my gingival architecture? Will these teeth have to be extracted and implants placed?” The specialist stopped staring at the author a little less oddly once he revealed his profession.
The battery of medical tests revealed that during the race, the author’s heart stopped beating, resulting in no blood flow to the brain and the sudden loss of consciousness. With the momentum from running, the author landed with all his weight on his chin and teeth, avulsing tooth No. 7 and impacting tooth No. 10 all the way to the gingival margin. Teeth Nos. 8 and 9 were fractured and contorted and the surrounding maxillary bone was shattered.
After undergoing all the tests in the hospital, the author was diagnosed as having a previously undiagnosed electro-physiology heart issue, with the medical recommendation being a surgically implanted pacemaker. However, before scheduling surgery, the specialists finally acknowledged and agreed something had to be done about his teeth, and the author was temporarily released from the hospital to see the oral surgeon.
Reconstruction Phase 1
After examining the author and hooking him up to a heart monitor, the surgeon injected shots of a non-epinephrine-based anesthetic in the affected area including at least two injections in the nerve bundle lingual to the central incisors.
The treatment plan called for pulling the impacted lateral incisor down but not out. It took a while for the surgeon to actually grip the tooth because so little was exposed, but he did bring it down successfully. Then he positioned the author’s teeth where he thought they should be by pushing them in place and molding the bone with his fingers. After he felt all were positioned correctly, he then luted an orthodontic wire from teeth Nos. 6 through 11—using the cuspids to anchor and stabilize the traumatized dentition (Figure 3 through Figure 6). The papilla between teeth Nos. 9 and 10 had been blunted from the trauma. Sutures were applied to try to keep it in place. Teeth Nos. 8 and 9 were then adjusted incisally with a diamond to keep them from touching in protrusive. The time spent in the oral surgeon’s office was the most difficult and stressful part of the entire experience up to this point.
The author returned to the hospital the next day for surgical placement of the pacemaker and then returned to his home in Dallas-Fort Worth. After a few days of recuperation, he went back to work at the laboratory.
The author made an appointment to see his general dentist not long after returning to work. The general practitioner was going to examine the author’s current situation after oral surgery, take comprehensive records, build up the broken teeth with composite, and “quarterback” the case with any additionally needed specialists.
Two things happened that the author was not expecting at that appointment. The first one involved the composite build-ups. The author’s smile had never been a perfect smile. He had a diastema, asymmetric centrals, and crowded lower incisors (Figure 7 and Figure 8). But these issues had never impacted his broad smile. However, after the accident, that changed. He had started putting his hand in front of his mouth when laughing, and noticed people looking at his teeth when he was speaking. His tooth display in repose did not have the normal 2 mm of incisal edge normally seen in male patients of the author’s age (Figure 9).
With the orthodontic wire placed by the oral surgeon still in place, the general dentist masterfully restored the author’s tooth form. He added composite to teeth Nos. 7 through 9 and carefully worked out the occlusion. He smoothed, cleaned, and reshaped the teeth, returning them to their natural form and even leaving the pre-existing diastema (Figure 10 through Figure 13).
The composite restorations made the author feel human again. He had been completely unaware of how self-conscious he had become about his broken teeth until they were restored. It renewed a sense of self-confidence that he had not realized was missing and gave him an enormous feeling of gratitude toward his dentist and staff.
Reconstruction Phase II
From the first moment he realized his teeth were fractured, the author began thinking about how he would fabricate restorations to restore them. His first thought was to restore them with veneers. He believed in a little asymmetry in dental restorations, so he thought he would fabricate the centrals unevenly and dominant, using opalescent blue, mamelon porcelains, a halo effect, and dominant chroma at the cervical. All four teeth might possibly need root canals, so he considered that he may have to use some masking porcelains on any discolored areas. He had just completed an IPS e.max® course with Oliver Brix the month before and could not decide if he would use IPS e.max or the VITA porcelains he was more familiar with. He was certain though that the next step would be veneers.
He was wrong. The next step was a trip to the endodontist for four root canals. Endodontic treatment of teeth is fairly commonplace in restorative dentistry. However, it is not so common for the individual having them done. It took two appointments at the endodontist’s office and one with the general dentist to complete the procedures.
After the last visit with the general dentist regarding the root canals, the author asked when he thought the teeth could be prepared for veneers. The dentist disagreed with the author’s restorative solution, telling him that full-coverage restorations were next in this situation and that orthodontic treatment needed to be considered.
The dentist explained that ankylosis was a concern in this case. There was no way to know if the traumatized teeth would reattach, if all or some would be lost, or if some level of ankylosis would set in. This was especially a concern for the tooth that had been re-implanted. The treatment plan called for the teeth to be moved into their proper positions. Even though the oral surgeon had done his best, the teeth were still out of position. The maxillary bone was in the process of healing, and applying orthodontic treatment would help “tighten up” the surrounding bone and better stabilize the teeth.
Faced with this logic, the author was then presented with the treatment concept of pursuing complete orthodontics to straighten the remaining teeth. Why not go for the best restorative scenario? It was a treatment plan that would result in the best long-term outcome and a more positive restorative result. But the author would be faced with 12 to 18 months of braces. He had to decide if he really wanted to deal with all the additional hassle and the expense.
Reconstruction Phase III
The author thought about all the case consultations and treatment plans he had been involved in over the years. So many were study models on a patient with severe crowding who was demanding veneers. As the consulting dental technician on such cases, the author often asked if the patients would consider orthodontics, given that the final outcome would be so much better if orthodontic treatment were part of the treatment plan.
Knowing this, the author realized that complete orthodontic treatment would allow the best possible, conservative, long-term result. Currently the author is still in braces (Figure 14). The root canals still look good. The bone is healing and regenerating, and ankylosis has not come knocking yet. He is still a long way from final restorations. His heart is doing well, and much to his wife’s chagrin, the cardiologist has cleared him for another marathon.
Each patient has a story. Sometimes the restoration is just the cherry on top of a large sundae. It may require many specialists and an abundance of time and resources for the patient to have a successful restorative outcome. Dental technicians can and should be an integral part of that success. Most cases benefit from an interdisciplinary approach. As part of case consultations, dental team member often ask themselves, “What would you do if it were your mouth?” The author now has a much greater respect for that question and the considerations the dental team must keep in mind when finding the best clinical solution for each individual patient.
About the Author
Kyle Swan, CDT
Functional Esthetics, Inc.