Dental Traumatology 2015; 31: 493–503; doi: 10.1111/edt.12201
Replacement of severely traumatized teeth with immediate implants and immediate loading: literature review and case reports Lieping Sheng, Tory Silvestrin, Jing Zhan, Liqun Wu, Qirong Zhao, Zheng Cao, Zhifeng Lou, Qingfang Ma Dental Clinic, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
Key words: ankylosis; dental trauma; tooth injury; treatment; replacement resorption; permanent tooth Correspondence to: Tory Silvestrin, Loma Linda University – Endodontics, 11092 Prince Hall, Loma Linda, CA 92350, USA Tel.: +253 3077071 Fax: +909558 0122 e-mail: [email protected] Accepted 30 May, 2015
Abstract – One of the options for management of severely traumatized dentitions is to provide immediate implant placement with immediate loading. Three representative cases out of 15 patients with 23 traumatized teeth treated to date in our clinic are presented. None had labial bone fractures. The teeth were replaced with NobelReplace Groovy implants (Nobel Biocare, Gothenburg, Sweden) in the fresh sockets immediately after extraction. They were placed toward the palatal areas in the sockets and 3 mm below the gingival margins. If there were gaps between implants and sockets wider than 1 mm, particulate deproteinized bovine bone was grafted in the gaps. Immediately after placement, the implants were loaded with provisional prostheses. The final restorations were installed 3–4 months later. The patients were reevaluated clinically and radiographically 1–3 years after the final restorations had been placed. In all 15 patients, excellent functional and esthetic results were achieved. No implants showed radiolucency, peri-implant suppuration, or mobility. The patients were satisfied with the results. Immediate implant placement with immediate loading is an option that provides good treatment outcomes and allows good functional and esthetic results, as well as addressing the social/psychological aspects of dental trauma.
The anterior maxilla is the most traumatized region in the mouth. The injured teeth can usually be restored with conservative approaches (1–3). Severely damaged teeth that cannot be restored may be considered for replacement with dental implants. Implant-supported, single-tooth replacement is a treatment option that can replicate the missing dental anatomy and restore full function without altering or damaging the adjacent teeth (4, 5). One must, however, recognize that placement of dental implants in the maxillary anterior area still poses great challenges because of the high esthetic demands in this area. Tooth loss results in bone resorption and soft tissue collapse, with the end result of flat anatomical contours. The facial cortical plate over the roots of the anterior maxillary teeth is very thin and porous. After tooth loss, 40% to 60% of bone resorption occurs during the first year, mainly in the facial aspect of the alveolar ridge. This results in ridge migration to a more palatal position in relation to adjacent teeth and the opposite jaw (4). This may later necessitate an augmentation procedure prior to implant placement. Sufficient ridge dimension and facial cortical plate are essential for dental implantation and esthetic rehabilitation of the traumatized anterior maxillary area. Therefore, preservation of existing soft and hard tissue contours should be the goal of esthetic patient management of post-traumatic untreatable anterior maxillary teeth. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Immediate placement of a dental implant in an extraction socket was initially described more than 30 years ago by Schulte and Heimke in 1976 (5). Immediate implant placement and immediate loading has been reported in the dental literature (6, 7). This article presents clinical case reports illustrating the benefits of immediate implant placement with immediate loading and how this can be one of the approaches for management of such traumatized teeth. Literature review
Dental trauma resulting in lost or non-restorable teeth presents a complex situation for the dental practitioner and patient alike. The underlying alveolar bone and the adjacent soft tissues have also incurred the effects of trauma and are susceptible to remodeling. Patients prefer treatments that allow immediate replacement of the non-restorable tooth. Careful treatment planning taking into consideration all aspects of the specific patient situation is necessary for a favorable outcome. The clinician must consider both advantages and disadvantages associated with all possible dental procedures. Andreasen (8) classified luxation injuries as concussion, subluxation, extrusion, lateral luxation and intrusion, and the prognosis for such injuries is usually good with proper management. Replanted avulsed teeth have a low long-term prognosis if not replanted 493
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immediately (9–11); extraoral dry time of more than 8 min for an avulsed tooth has a detrimental effect on the periodontal ligament cells (9). Root resorption occurs in 95% of replanted teeth with a ‘dry time’ of 2 h or more (12, 13). Luxation and avulsion injuries combined with tooth fractures that render teeth nonrestorable may create situations where immediate placement of a dental implant could be considered. Dental trauma is often followed by root resorption (14). Repair-related (surface) resorption can occur if a localized injury to the periodontal ligament or cementum occurs, but these changes are often transient and mild (15). Infection-related (inflammatory) resorption can occur and leads to loss of cementum and dentin as well as loss of adjacent bone (15). Lastly, ankylosisrelated (replacement) resorption presents a challenge, particularly in growing children, preventing continued alveolar development. A procedure that has gained some acceptance in such cases is decoronation (16). Delayed negative outcomes of dental trauma such as root resorption occurring years after the injury have been reported (17). After experiencing dental trauma, patients should be advised to consult their dentists regularly. If delayed resorption occurs, timely management is important regardless of what treatment option is chosen. Certainly, if a dental implant is an option, prevention of bone loss is essential for successful treatment. External and internal resorption may occur several years after trauma despite the initial absence of this progressive pathosis (18). Pertl et al. (17) presented a case of a replanted avulsed maxillary central incisor in a 15-year-old patient in which the 9-year follow up showed complete root resorption that required grafting and subsequent dental implant placement. Early identification of any root resorption and subsequent management of this problem if possible will prevent critical loss of bony support for any future dental implant placement. Various crown fractures from trauma can for the most part be managed restoratively. In the case of root fractures, timely repositioning of displaced segments along with splinting can promote healing. If however the tooth fracture results in a non-restorable situation such as some crown–root fractures, removal of the remaining tooth structure and replacement with an implant may be in order. Dental trauma is most common in the maxillary anterior region (19). This area is one of the most technically demanding regions to restore with implants due to the esthetic demands associated with this region (20, 21). Further, loss of bone associated with traumatic tooth loss can result in reduced horizontal and vertical dimensions, and this leads to more difficult restorative efforts (20). Replacement of non-restorable teeth with dental implants in the anterior maxilla is an increasingly common treatment option that has become a treatment choice with usually predictable outcomes and high success rates (22, 23). This option can be favorably compared to the more traditional approaches of fixed and removable prosthetic replacements. Immediate implant placement in the so-called esthetic zone of the
anterior maxilla requires conservative techniques to minimize loss of supporting bone. If remaining traumatized teeth need to be removed prior to implant treatment, they need to be removed most atraumatically to preserve alveolar bone. If unfavorable bony levels are present, a delayed implant placement can be considered after grafting the alveolar site (24). It should be noted that adults with no further growth expected are the primary target population for the replacement of traumatized dentition with immediate implants. Much of the included literature in this review was from populations of children and adolescents, as this is the most frequent demographic to incur trauma. The treatment options listed as alternatives to immediate implant placement are largely meant to illustrate options to provide the patient a means of preservation of the existing bony housing and soft tissue contours around a severely traumatized tooth until a more definitive option such as an immediate implant can be considered upon cessation of pubertal growth. Treatment outcomes of implant placement in patients with periodontitis-related tooth loss and in those with vertically root fractured teeth have been reported, but less attention has been paid to replacement of traumatized teeth (25, 26). Advantages of dental implants
Implant dentistry is a service that offers replacement of non-salvageable teeth providing patients with a mostly satisfactory outcome. The prognosis is usually good in addition to satisfactory patient acceptance, and implants have been shown to have a higher survival rate than fixed partial dentures (27). The management of patients with dental trauma benefits from a team effort that includes the general practitioner as well as dental specialists. Endodontists are frequently consulted regarding traumatized teeth, and now, many of them are also obtaining advanced education in implant dentistry. These practitioners can assess the traumatized tooth and—if indicated— proceed with the immediate replacement of the traumatized tooth with a dental implant (18). This treatment must be rendered in consultation with the referring dentist and with acceptance of the patient. One drawback to the conventional placement of dental implants is the amount of time required to complete a procedure. When hopeless teeth must be removed, a postextraction healing period of approximately 3–6 months has been recommended to allow for the formation and maturation of new bone within the socket area prior to implant placement. In such cases, 9–12 months must elapse before a definitive prosthesis can be delivered to the patient (23, 28–30). This significant delay in prosthetic rehabilitation is disconcerting and inconvenient for the patient who is already struggling with an inability to wear a conventional removable prosthesis. Immediate implant placement and placement of a provisional restoration provides the patient with immediate comfort and a stable esthetic restoration during the healing phase, reduces the number of surgical visits, eliminates the need for a second stage © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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clinical and radiographic examination showed that the implants had good bone integration and had maintained the bony and soft tissue levels very well with satisfactory esthetic outcomes (Fig. 4a,b). Case 2
A 66-year-old female with controlled hypertension presented several days after suffering a traumatic (a) (b)
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Fig. 7. Clinical photograph (a) and radiograph (b) of the implant which was restored with a Zirconium abutment and an all-ceramic crown after four months.
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Fig. 8. Clinical photograph (a) and CBCT scan (b) showing a complicated crown-root fracture of tooth 21 following accidental trauma. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Fig. 9. Clinical photograph (a) of the extracted crown and root of tooth 22. Note that the root was extracted atraumatically using an endodontic file screwed into the root canal. An implant was then placed into the fresh socket (b).
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Fig. 10. The clinical photograph (a) and radiograph (b) showing the implant restored with a provisional crown at same visit.
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patients in which immediate implant placement or bone grafting is not practical. So the age of the patient with a traumatized tooth must be evaluated carefully to assess future growth that will influence treatment decisions. Alternatives to dental implants
Preservation of traumatized teeth for as long as possible in young patients is a reasonable alternative to either immediate implant placement or attempted bone preservation. This may in some cases lead to tooth ankylosis. Complications secondary to ankylosis include esthetic compromise, orthodontic complications due to arch irregularity, lack of mesial drift, tilting of adjacent teeth, arch length loss, and the arrest of alveolar ridge growth locally (50). Treatment options for an ankylosed tooth are many and offer certain advantages and disadvantages with each. Early extraction of the ankylosed tooth and placement of an esthetic restoration risks losing horizontal and vertical bony dimensions such that future grafting would be difficult to reestablish a normal ridge contour (50).
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Early extraction of the ankylosed tooth with immediate grafting is another possible treatment option. But this option is not favorable in the anterior maxilla due to loss of ridge height and width over time and need for subsequent augmentation prior to implant placement (49). Failure to graft an extraction site leads to loss of up to 50% of the alveolar crestal bone width. Graft materials that resorb quickly may not be replaced with bone and potentially could lead to a failure of osseointegration and soft tissue encapsulation of the implant (18). Orthodontic space closure after extraction of an ankylosed tooth may be considered, but such treatment requires favorable orthodontic situations and extensive prosthodontic follow up (50). This technique has been described by Zachrisson (51), where an 11-year-old female had combined autotransplantation and orthodontic space closure of two avulsed and lost maxillary incisors managed via an interdisciplinary approach. Another successful report of the application of this technique is presented by Pithon (52), where a 17-yearold female with a recent history of avulsion of tooth 12 was treated orthodontically to close the space of the (a)
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Fig. 1. Clinical photograph (a) and radiograph (b) of teeth 11 and 21 with trauma-related cervical root fractures.
Fig. 2. Pre-surgical CBCT scan in the sagittal plane (a) showing the fracture line and digital planning for implantation using Nobelprocera Software. The clinical photograph (b) shows the implants inserted in the fresh sockets immediately after extraction. The gaps between the sockets and the implants were filled with Bio-oss. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Replacing traumatized teeth with implants missing maxillary central incisor with acceptable outcomes as judged by both the patient and the clinician. Intentional extraction and immediate replantation is a possible alternative when ankylosis is diagnosed early and has affected only a small area of the root (15). Autotransplantation of a premolar tooth into the socket of the traumatized anterior maxillary tooth allows preservation of the supporting bony and gingival tissues and provides an esthetic replacement for the coronal tooth structure (51). Dharmani et al. (53) presented a case of a 17-year-old male 1-week post-trauma to tooth 12 where a horizontal root fracture was diagnosed and given a poor prognosis. The tooth was extracted and replaced with a mesiodens that was stabilized and received root canal treatment. Upon a 2-year recall, the tooth was judged esthetic and functional (53). Tsurumachi and Kuno (54) discussed autotransplantation of a maxillary premolar after extraction of an ankylosed incisor. This group noted the need to surgically resect the buccal root of the premolar, fill the resected root with composite, dress the palatal root with calcium hydroxide for 2 months, complete root canal treatment, and then initiate orthodontics (54). The predictability of autotransplantation has been further discussed regarding its acceptable esthetic and
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clinical surrogate measure outcomes by Czochrowska (55–57). A possible downside to this treatment is if it becomes necessary to remove bone during the site preparation (15), but in most cases, the preparation for the placement of the transplanted tooth can be made with little or no need to remove any of the remaining ankylosed root. Decoronation is a procedure in which the crown of the ankylosed tooth is resected and the resorbing root remains in the alveolar bone. This allows preservation of the alveolar bone and is more conservative and with less bone loss than that which occurs secondary to surgical extraction of an ankylosed tooth. The procedure has been reported quite extensively and shows excellent preservation of the height and width of the alveolar bone at the future implant site (16, 58, 59). Decoronation of a traumatized ankylosed tooth is often considered the treatment of choice in a growing patient not deemed a candidate for an immediate implant (50). Root extrusion is an option for some traumatized non-ankylosed teeth where crown lengthening would
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Fig. 3. Clinical photograph (a) and radiograph (b) taken after 6 months demonstrates good healing. The immediate loading with provisional crowns maintained the gingival margins and papillae satisfactorily. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Fig. 4. 12 month follow-up. The clinical photograph (a) shows the implants were restored with Zirconium abutments and all-ceramic crowns and provided esthetic restorations that maintained the soft tissue contours. The radiograph (b) shows the implants with good bone integration maintaining a satisfactory bone level.
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be contraindicated to avoid gingival recession and alveolar bone loss (especially in the esthetically demanding region of the anterior maxilla) (60). It needs to be noted, however, that root extrusion can only be used in situations where the traumatized tooth in question is not ankylosed and presents with an acceptable crown–root ratio. An unusual treatment for an avulsed tooth with poor prognosis is to replant the avulsed tooth to maintain the socket space for as long as possible and possibly until an implant may be placed (18). This is a technique that may be considered in situations of alveolar fracture or bony dehiscence that generally contraindicate the immediate placement of a dental implant. Often during avulsion injuries, fractures of the alveolar socket wall occur (61). Consideration of allowing the non-ankylosing root of a crown–root fractured tooth to remain in the alveolar bone offers alternative treatment options to implant placement in a patient where implant placement is relatively or absolutely contraindicated. Our case series presents outcomes of implants placed after trauma in cases where the walls of the bony socket were intact. It is uncertain what the impact of interrupted and fractured bony socket walls may have on the success of implant placement to replace previously traumatized teeth.
Case reports Case 1
A 31-year-old female with a non-contributory medical history was referred to the dental clinic for management of loose upper front teeth. The clinical examination revealed slight localized swelling of the marginal mucosa of teeth 11 and 21 with tenderness to palpation and percussion. The maxillary incisors had been splinted, and radiographs showed cervical root fractures of both central incisors (Fig. 1a,b). She reported a traumatic injury during endotracheal intubation for general anesthesia and the teeth had been splinted, but had not responded to 4 months of stabilization. They did respond to pulp testing, but prognosis for healing was poor. The patient requested replacement of the injured teeth. After presurgical cone-beam computed tomography (CBCT) scanning and digital software planning (Fig. 2a), the teeth were extracted and implants were inserted in fresh sockets (Fig. 2b) and restored with immediate loading provisional crowns (Fig. 3a,b). After 6 months, the implants were restored with zirconium abutments and all-ceramic crowns. The 12-month
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Fig. 5. Clinical photograph (a) and radiograph (b) tooth 22 with cervical root fracture caused by trauma.
Fig. 6. Clinical photograph (a) and radiograph (b) showing placement of the implant into the fresh extraction socket of tooth 22. The implant received an immediate provisional crown at same time. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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clinical and radiographic examination showed that the implants had good bone integration and had maintained the bony and soft tissue levels very well with satisfactory esthetic outcomes (Fig. 4a,b). Case 2
A 66-year-old female with controlled hypertension presented several days after suffering a traumatic (a) (b)
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Fig. 7. Clinical photograph (a) and radiograph (b) of the implant which was restored with a Zirconium abutment and an all-ceramic crown after four months.
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Fig. 8. Clinical photograph (a) and CBCT scan (b) showing a complicated crown-root fracture of tooth 21 following accidental trauma. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Fig. 9. Clinical photograph (a) of the extracted crown and root of tooth 22. Note that the root was extracted atraumatically using an endodontic file screwed into the root canal. An implant was then placed into the fresh socket (b).
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Fig. 10. The clinical photograph (a) and radiograph (b) showing the implant restored with a provisional crown at same visit.
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Fig. 12. Four year follow-up shows healthy appearing soft tissue around the crown. The radiograph (b) indicates satisfactory bone integration and maintenance. Fig. 11. Clinical photograph (a) and radiograph (b) showing the implant restored with Zirconium abutment and allceramic crown four months later.
cervical root fracture of tooth 22 (Fig. 5a). The radiograph (Fig. 5b) showed a short root that would present a problem supporting a prosthetic crown. The patient accepted the recommendation of replacing the tooth with an implant-supported crown. The root was extracted and a dental implant was inserted in the fresh socket and a provisional crown was placed immediately (Fig. 6a,b). The implant was permanently restored with zirconium abutment and all-ceramic crown after 4 months (Fig. 7a,b). Case 3
A few hours following a traumatic accident, a 26-yearold healthy female presented for consultation. Clinical and radiographic examination including CBCT showed that tooth 21 had a complicated crown–root fracture (Fig. 8a,b). Following acceptance of the treatment recommendation, the tooth was extracted and a dental implant was inserted in the fresh socket and a provisional crown was restored immediately (Figs 9a,b and 10a,b). After 3 months, the implant was restored with
zirconium abutment and all-ceramic crown (Fig. 11a, b). The clinical and radiographic follow-up evaluation 4 years later showed that the implant had provided a satisfactory esthetic outcome as well as good bone and soft tissue maintenance (Fig. 12a,b). Discussion
There are many options for managing patients with dental trauma. Often they include orthodontic treatment, removable partial dentures, fixed partial dentures, or autotransplantation. In recent years, implant dentistry has been included. Different placement and loading protocols have evolved to achieve quicker and easier surgical treatment times. Compared with delayed implants and delayed loading, immediate implant placement with immediate loading provides the patient with an esthetic appearance and provides the required dental support for soft and hard tissue structures at the extraction site. The biggest problem with immediate implant placement and immediate loading is that the stability of the soft tissue for long time periods is unpredictable. Often the labial bone is thin and the labial gingiva often follows the contour and position of the bone, © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Replacing traumatized teeth with implants so if recession of the bony architecture occurs, the gingiva may follow and this may cause an esthetic problem. The stability of the labial gingiva is affected by other parameters such as the periodontal biotype (62), the relationship of the alveolar bone to the long axis of the teeth, the position of the implant, and the shapes of the provisional and final prostheses. The case selection for this type of treatment is very important. Ideally, the patient has a thick and flat biotype and no bone has been lost on the labial aspects of the alveolar bone. Also important is that the thickness of the labial bone is more than 1 mm and the distance from the crest of bone to the gingival margin is less than 3 mm. The shape of the provisional restoration should be as close as possible to that of the natural tooth. It should have a good profile to support the soft tissue. Conclusion
Traumatic dental injuries must be managed in a timely manner to evaluate various treatment options and their prognosis. Dental implants have become recognized as reliable and practical replacements for lost, non-restorable, and ankylosed trauma-related teeth. Both shortand long-term outcomes need to be addressed in planning for each patient. Keeping existing teeth and preventing trauma are obviously the best ways to maintain a natural dentition, and that has a decided better longevity than that of dental implants (63). Choosing to extract a traumatized tooth needs to include a careful analysis of the value of keeping the natural tooth vs an implant; if a traumatized tooth is restorable, avoiding extraction is an important consideration, particularly in young patients. One can always choose to extract a tooth and place an implant, but once the decision is made to do so, then reversion back to a natural tooth is no longer possible (64). Dental implants in service for over 10 years present with a longevity that compared to compromised but retained natural teeth is inferior (65). Others have reported that severely compromised teeth have a marginally better survival than dental implants, but this advantage linearly decreases with increasing tooth compromise (66). The facial cortical plate overlying the roots of the maxillary anterior teeth is thin, and periapical infections as well as repeated surgical interventions can lead to labial plate resorption that can complicate future implant treatment (67). The decision to save or replace a traumatized tooth is a decision that must be carefully made and must include a thorough discussion with the patient (and/or guardians) about risks and benefits and also must include the desires of the patient (informed consent). Traumatized teeth often require multidisciplinary involvement by restorative dentists, pediatric dentists, endodontists, orthodontists, prosthodontists, periodontists, and oral and maxillofacial surgeons. Every specialty can provide input that may be of value in providing the patient with the best treatment. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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association with illicit drug use among adolescents. Dent Traumatol 2014;30:122–7. Shah RA, Mitra DK, Rodrigues SV, Pathare PN, Podar RS, Vijayakar HN. Implants in adolescents. J Indian Soc Periodontol 2013;17:546–8. Sharma AB, Vargervik K. Using implants for the growing child. J Calif Dent Assoc 2006;34:719–24. Op Heij DG, Opdebeeck H, van Steenberghe D, Quirynen M. Age as compromising factor for implant insertion. Periodontol 2000 2003;33:172–84. Thilander B, Odman J, Grondahl K, Friberg B. Osseointegrated implants in adolescents. An alternative in replacing missing teeth? Eur J Orthod 1994;16:84–95. Thilander B, Odman J, Grondahl K, Friberg B. Osseointegrated implants in adolescents. A three year study. Ned Tijdschr Tandheelkd 1995;102:383–5. Ledermann PD, Hassell TM, Hefti AF. Osseointegrated dental implants as alternative therapy to bridge construction or orthodontics in young patients: seven years of clinical experience. Pediatr Dent 1993;15:327–33. Sandor GK, Kainulainen VT, Queiroz JO, Carmichael RP, Oikarinen KS. Preservation of ridge dimensions following grafting with coral granules of 48 post-traumatic and postextraction dento-alveolar defects. Dent Traumatol 2003;19:221–7. Sapir S, Kalter A, Sapir MR. Decoronation of an ankylosed permanent incisor: alveolar ridge preservation and rehabilitation by an implant supported porcelain crown. Dent Traumatol 2009;25:346–9. Zachrisson BU. Planning esthetic treatment after avulsion of maxillary incisors. J Am Dent Assoc 2008;139:1484–90. Pithon MM. Treatment of class II malocclusion with open bite and absence of central maxillary incisor lost by trauma aided by use of orthodontic mini-implants. Dent Traumatol 2014;30:65–70. Dharmani U, Rajput A, Kamal C, Talwar S, Verma M. Successful autotransplantation of a mature mesiodens to replace a traumatized maxillary central incisor. Int Endod J 2014;115:15–21. Tsurumachi T, Kuno T. Autotransplantation of a maxillary first premolar to replace an ankylosed maxillary incisor: 7year follow-up. Int Endod J 2011;44:863–75. Czochrowska EM, Stenvik A, Album B, Zachrisson BU. Autotransplantation of premolars to replace maxillary incisors: a comparison with natural incisors. Am J Orthod Dentofacial Orthop 2000;118:592–600. Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU. Outcome of tooth transplantation: survival and success rates 17–41 years posttreatment. Am J Orthod Dentofacial Orthop 2002;121:110–9. Czochrowska EM, Stenvik A, Zachrisson BU. The esthetic outcome of autotransplanted premolars replacing maxillary incisors. Dent Traumatol 2002;18:237–45. Filippi A, Pohl Y, von Arx T. Decoronation of an ankylosed tooth for preservation of alveolar bone prior to implant placement. Dent Traumatol 2001;17:93–5. Sapir S, Shapira J. Decoronation for the management of an ankylosed young permanent tooth. Dent Traumatol 2008;24:131–5. Addy LD, Durning P, Thomas MB, McLaughlin WS. Orthodontic extrusion: an interdisciplinary approach to patient management. Dent Update 2009;36:212–4, 217–8. Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, Diangelis AJ et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88–96. Kan JY, Rungcharassaeng K, Lozada JL, Zimmerman G. Facial gingival tissue stability following immediate placement and provisionalization of maxillary anterior single implants: a
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Replacement of severely traumatized teeth with immediate implants and immediate loading: literature review and case reports Lieping Sheng, Tory Silvestrin, Jing Zhan, Liqun Wu, Qirong Zhao, Zheng Cao, Zhifeng Lou, Qingfang Ma Dental Clinic, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
Key words: ankylosis; dental trauma; tooth injury; treatment; replacement resorption; permanent tooth Correspondence to: Tory Silvestrin, Loma Linda University – Endodontics, 11092 Prince Hall, Loma Linda, CA 92350, USA Tel.: +253 3077071 Fax: +909558 0122 e-mail: [email protected] Accepted 30 May, 2015
Abstract – One of the options for management of severely traumatized dentitions is to provide immediate implant placement with immediate loading. Three representative cases out of 15 patients with 23 traumatized teeth treated to date in our clinic are presented. None had labial bone fractures. The teeth were replaced with NobelReplace Groovy implants (Nobel Biocare, Gothenburg, Sweden) in the fresh sockets immediately after extraction. They were placed toward the palatal areas in the sockets and 3 mm below the gingival margins. If there were gaps between implants and sockets wider than 1 mm, particulate deproteinized bovine bone was grafted in the gaps. Immediately after placement, the implants were loaded with provisional prostheses. The final restorations were installed 3–4 months later. The patients were reevaluated clinically and radiographically 1–3 years after the final restorations had been placed. In all 15 patients, excellent functional and esthetic results were achieved. No implants showed radiolucency, peri-implant suppuration, or mobility. The patients were satisfied with the results. Immediate implant placement with immediate loading is an option that provides good treatment outcomes and allows good functional and esthetic results, as well as addressing the social/psychological aspects of dental trauma.
The anterior maxilla is the most traumatized region in the mouth. The injured teeth can usually be restored with conservative approaches (1–3). Severely damaged teeth that cannot be restored may be considered for replacement with dental implants. Implant-supported, single-tooth replacement is a treatment option that can replicate the missing dental anatomy and restore full function without altering or damaging the adjacent teeth (4, 5). One must, however, recognize that placement of dental implants in the maxillary anterior area still poses great challenges because of the high esthetic demands in this area. Tooth loss results in bone resorption and soft tissue collapse, with the end result of flat anatomical contours. The facial cortical plate over the roots of the anterior maxillary teeth is very thin and porous. After tooth loss, 40% to 60% of bone resorption occurs during the first year, mainly in the facial aspect of the alveolar ridge. This results in ridge migration to a more palatal position in relation to adjacent teeth and the opposite jaw (4). This may later necessitate an augmentation procedure prior to implant placement. Sufficient ridge dimension and facial cortical plate are essential for dental implantation and esthetic rehabilitation of the traumatized anterior maxillary area. Therefore, preservation of existing soft and hard tissue contours should be the goal of esthetic patient management of post-traumatic untreatable anterior maxillary teeth. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Immediate placement of a dental implant in an extraction socket was initially described more than 30 years ago by Schulte and Heimke in 1976 (5). Immediate implant placement and immediate loading has been reported in the dental literature (6, 7). This article presents clinical case reports illustrating the benefits of immediate implant placement with immediate loading and how this can be one of the approaches for management of such traumatized teeth. Literature review
Dental trauma resulting in lost or non-restorable teeth presents a complex situation for the dental practitioner and patient alike. The underlying alveolar bone and the adjacent soft tissues have also incurred the effects of trauma and are susceptible to remodeling. Patients prefer treatments that allow immediate replacement of the non-restorable tooth. Careful treatment planning taking into consideration all aspects of the specific patient situation is necessary for a favorable outcome. The clinician must consider both advantages and disadvantages associated with all possible dental procedures. Andreasen (8) classified luxation injuries as concussion, subluxation, extrusion, lateral luxation and intrusion, and the prognosis for such injuries is usually good with proper management. Replanted avulsed teeth have a low long-term prognosis if not replanted 493
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immediately (9–11); extraoral dry time of more than 8 min for an avulsed tooth has a detrimental effect on the periodontal ligament cells (9). Root resorption occurs in 95% of replanted teeth with a ‘dry time’ of 2 h or more (12, 13). Luxation and avulsion injuries combined with tooth fractures that render teeth nonrestorable may create situations where immediate placement of a dental implant could be considered. Dental trauma is often followed by root resorption (14). Repair-related (surface) resorption can occur if a localized injury to the periodontal ligament or cementum occurs, but these changes are often transient and mild (15). Infection-related (inflammatory) resorption can occur and leads to loss of cementum and dentin as well as loss of adjacent bone (15). Lastly, ankylosisrelated (replacement) resorption presents a challenge, particularly in growing children, preventing continued alveolar development. A procedure that has gained some acceptance in such cases is decoronation (16). Delayed negative outcomes of dental trauma such as root resorption occurring years after the injury have been reported (17). After experiencing dental trauma, patients should be advised to consult their dentists regularly. If delayed resorption occurs, timely management is important regardless of what treatment option is chosen. Certainly, if a dental implant is an option, prevention of bone loss is essential for successful treatment. External and internal resorption may occur several years after trauma despite the initial absence of this progressive pathosis (18). Pertl et al. (17) presented a case of a replanted avulsed maxillary central incisor in a 15-year-old patient in which the 9-year follow up showed complete root resorption that required grafting and subsequent dental implant placement. Early identification of any root resorption and subsequent management of this problem if possible will prevent critical loss of bony support for any future dental implant placement. Various crown fractures from trauma can for the most part be managed restoratively. In the case of root fractures, timely repositioning of displaced segments along with splinting can promote healing. If however the tooth fracture results in a non-restorable situation such as some crown–root fractures, removal of the remaining tooth structure and replacement with an implant may be in order. Dental trauma is most common in the maxillary anterior region (19). This area is one of the most technically demanding regions to restore with implants due to the esthetic demands associated with this region (20, 21). Further, loss of bone associated with traumatic tooth loss can result in reduced horizontal and vertical dimensions, and this leads to more difficult restorative efforts (20). Replacement of non-restorable teeth with dental implants in the anterior maxilla is an increasingly common treatment option that has become a treatment choice with usually predictable outcomes and high success rates (22, 23). This option can be favorably compared to the more traditional approaches of fixed and removable prosthetic replacements. Immediate implant placement in the so-called esthetic zone of the
anterior maxilla requires conservative techniques to minimize loss of supporting bone. If remaining traumatized teeth need to be removed prior to implant treatment, they need to be removed most atraumatically to preserve alveolar bone. If unfavorable bony levels are present, a delayed implant placement can be considered after grafting the alveolar site (24). It should be noted that adults with no further growth expected are the primary target population for the replacement of traumatized dentition with immediate implants. Much of the included literature in this review was from populations of children and adolescents, as this is the most frequent demographic to incur trauma. The treatment options listed as alternatives to immediate implant placement are largely meant to illustrate options to provide the patient a means of preservation of the existing bony housing and soft tissue contours around a severely traumatized tooth until a more definitive option such as an immediate implant can be considered upon cessation of pubertal growth. Treatment outcomes of implant placement in patients with periodontitis-related tooth loss and in those with vertically root fractured teeth have been reported, but less attention has been paid to replacement of traumatized teeth (25, 26). Advantages of dental implants
Implant dentistry is a service that offers replacement of non-salvageable teeth providing patients with a mostly satisfactory outcome. The prognosis is usually good in addition to satisfactory patient acceptance, and implants have been shown to have a higher survival rate than fixed partial dentures (27). The management of patients with dental trauma benefits from a team effort that includes the general practitioner as well as dental specialists. Endodontists are frequently consulted regarding traumatized teeth, and now, many of them are also obtaining advanced education in implant dentistry. These practitioners can assess the traumatized tooth and—if indicated— proceed with the immediate replacement of the traumatized tooth with a dental implant (18). This treatment must be rendered in consultation with the referring dentist and with acceptance of the patient. One drawback to the conventional placement of dental implants is the amount of time required to complete a procedure. When hopeless teeth must be removed, a postextraction healing period of approximately 3–6 months has been recommended to allow for the formation and maturation of new bone within the socket area prior to implant placement. In such cases, 9–12 months must elapse before a definitive prosthesis can be delivered to the patient (23, 28–30). This significant delay in prosthetic rehabilitation is disconcerting and inconvenient for the patient who is already struggling with an inability to wear a conventional removable prosthesis. Immediate implant placement and placement of a provisional restoration provides the patient with immediate comfort and a stable esthetic restoration during the healing phase, reduces the number of surgical visits, eliminates the need for a second stage © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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clinical and radiographic examination showed that the implants had good bone integration and had maintained the bony and soft tissue levels very well with satisfactory esthetic outcomes (Fig. 4a,b). Case 2
A 66-year-old female with controlled hypertension presented several days after suffering a traumatic (a) (b)
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Fig. 7. Clinical photograph (a) and radiograph (b) of the implant which was restored with a Zirconium abutment and an all-ceramic crown after four months.
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Fig. 8. Clinical photograph (a) and CBCT scan (b) showing a complicated crown-root fracture of tooth 21 following accidental trauma. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Fig. 9. Clinical photograph (a) of the extracted crown and root of tooth 22. Note that the root was extracted atraumatically using an endodontic file screwed into the root canal. An implant was then placed into the fresh socket (b).
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Fig. 10. The clinical photograph (a) and radiograph (b) showing the implant restored with a provisional crown at same visit.
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patients in which immediate implant placement or bone grafting is not practical. So the age of the patient with a traumatized tooth must be evaluated carefully to assess future growth that will influence treatment decisions. Alternatives to dental implants
Preservation of traumatized teeth for as long as possible in young patients is a reasonable alternative to either immediate implant placement or attempted bone preservation. This may in some cases lead to tooth ankylosis. Complications secondary to ankylosis include esthetic compromise, orthodontic complications due to arch irregularity, lack of mesial drift, tilting of adjacent teeth, arch length loss, and the arrest of alveolar ridge growth locally (50). Treatment options for an ankylosed tooth are many and offer certain advantages and disadvantages with each. Early extraction of the ankylosed tooth and placement of an esthetic restoration risks losing horizontal and vertical bony dimensions such that future grafting would be difficult to reestablish a normal ridge contour (50).
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Early extraction of the ankylosed tooth with immediate grafting is another possible treatment option. But this option is not favorable in the anterior maxilla due to loss of ridge height and width over time and need for subsequent augmentation prior to implant placement (49). Failure to graft an extraction site leads to loss of up to 50% of the alveolar crestal bone width. Graft materials that resorb quickly may not be replaced with bone and potentially could lead to a failure of osseointegration and soft tissue encapsulation of the implant (18). Orthodontic space closure after extraction of an ankylosed tooth may be considered, but such treatment requires favorable orthodontic situations and extensive prosthodontic follow up (50). This technique has been described by Zachrisson (51), where an 11-year-old female had combined autotransplantation and orthodontic space closure of two avulsed and lost maxillary incisors managed via an interdisciplinary approach. Another successful report of the application of this technique is presented by Pithon (52), where a 17-yearold female with a recent history of avulsion of tooth 12 was treated orthodontically to close the space of the (a)
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Fig. 1. Clinical photograph (a) and radiograph (b) of teeth 11 and 21 with trauma-related cervical root fractures.
Fig. 2. Pre-surgical CBCT scan in the sagittal plane (a) showing the fracture line and digital planning for implantation using Nobelprocera Software. The clinical photograph (b) shows the implants inserted in the fresh sockets immediately after extraction. The gaps between the sockets and the implants were filled with Bio-oss. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Replacing traumatized teeth with implants missing maxillary central incisor with acceptable outcomes as judged by both the patient and the clinician. Intentional extraction and immediate replantation is a possible alternative when ankylosis is diagnosed early and has affected only a small area of the root (15). Autotransplantation of a premolar tooth into the socket of the traumatized anterior maxillary tooth allows preservation of the supporting bony and gingival tissues and provides an esthetic replacement for the coronal tooth structure (51). Dharmani et al. (53) presented a case of a 17-year-old male 1-week post-trauma to tooth 12 where a horizontal root fracture was diagnosed and given a poor prognosis. The tooth was extracted and replaced with a mesiodens that was stabilized and received root canal treatment. Upon a 2-year recall, the tooth was judged esthetic and functional (53). Tsurumachi and Kuno (54) discussed autotransplantation of a maxillary premolar after extraction of an ankylosed incisor. This group noted the need to surgically resect the buccal root of the premolar, fill the resected root with composite, dress the palatal root with calcium hydroxide for 2 months, complete root canal treatment, and then initiate orthodontics (54). The predictability of autotransplantation has been further discussed regarding its acceptable esthetic and
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clinical surrogate measure outcomes by Czochrowska (55–57). A possible downside to this treatment is if it becomes necessary to remove bone during the site preparation (15), but in most cases, the preparation for the placement of the transplanted tooth can be made with little or no need to remove any of the remaining ankylosed root. Decoronation is a procedure in which the crown of the ankylosed tooth is resected and the resorbing root remains in the alveolar bone. This allows preservation of the alveolar bone and is more conservative and with less bone loss than that which occurs secondary to surgical extraction of an ankylosed tooth. The procedure has been reported quite extensively and shows excellent preservation of the height and width of the alveolar bone at the future implant site (16, 58, 59). Decoronation of a traumatized ankylosed tooth is often considered the treatment of choice in a growing patient not deemed a candidate for an immediate implant (50). Root extrusion is an option for some traumatized non-ankylosed teeth where crown lengthening would
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Fig. 3. Clinical photograph (a) and radiograph (b) taken after 6 months demonstrates good healing. The immediate loading with provisional crowns maintained the gingival margins and papillae satisfactorily. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Fig. 4. 12 month follow-up. The clinical photograph (a) shows the implants were restored with Zirconium abutments and all-ceramic crowns and provided esthetic restorations that maintained the soft tissue contours. The radiograph (b) shows the implants with good bone integration maintaining a satisfactory bone level.
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be contraindicated to avoid gingival recession and alveolar bone loss (especially in the esthetically demanding region of the anterior maxilla) (60). It needs to be noted, however, that root extrusion can only be used in situations where the traumatized tooth in question is not ankylosed and presents with an acceptable crown–root ratio. An unusual treatment for an avulsed tooth with poor prognosis is to replant the avulsed tooth to maintain the socket space for as long as possible and possibly until an implant may be placed (18). This is a technique that may be considered in situations of alveolar fracture or bony dehiscence that generally contraindicate the immediate placement of a dental implant. Often during avulsion injuries, fractures of the alveolar socket wall occur (61). Consideration of allowing the non-ankylosing root of a crown–root fractured tooth to remain in the alveolar bone offers alternative treatment options to implant placement in a patient where implant placement is relatively or absolutely contraindicated. Our case series presents outcomes of implants placed after trauma in cases where the walls of the bony socket were intact. It is uncertain what the impact of interrupted and fractured bony socket walls may have on the success of implant placement to replace previously traumatized teeth.
Case reports Case 1
A 31-year-old female with a non-contributory medical history was referred to the dental clinic for management of loose upper front teeth. The clinical examination revealed slight localized swelling of the marginal mucosa of teeth 11 and 21 with tenderness to palpation and percussion. The maxillary incisors had been splinted, and radiographs showed cervical root fractures of both central incisors (Fig. 1a,b). She reported a traumatic injury during endotracheal intubation for general anesthesia and the teeth had been splinted, but had not responded to 4 months of stabilization. They did respond to pulp testing, but prognosis for healing was poor. The patient requested replacement of the injured teeth. After presurgical cone-beam computed tomography (CBCT) scanning and digital software planning (Fig. 2a), the teeth were extracted and implants were inserted in fresh sockets (Fig. 2b) and restored with immediate loading provisional crowns (Fig. 3a,b). After 6 months, the implants were restored with zirconium abutments and all-ceramic crowns. The 12-month
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Fig. 5. Clinical photograph (a) and radiograph (b) tooth 22 with cervical root fracture caused by trauma.
Fig. 6. Clinical photograph (a) and radiograph (b) showing placement of the implant into the fresh extraction socket of tooth 22. The implant received an immediate provisional crown at same time. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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clinical and radiographic examination showed that the implants had good bone integration and had maintained the bony and soft tissue levels very well with satisfactory esthetic outcomes (Fig. 4a,b). Case 2
A 66-year-old female with controlled hypertension presented several days after suffering a traumatic (a) (b)
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Fig. 7. Clinical photograph (a) and radiograph (b) of the implant which was restored with a Zirconium abutment and an all-ceramic crown after four months.
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Fig. 8. Clinical photograph (a) and CBCT scan (b) showing a complicated crown-root fracture of tooth 21 following accidental trauma. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Fig. 9. Clinical photograph (a) of the extracted crown and root of tooth 22. Note that the root was extracted atraumatically using an endodontic file screwed into the root canal. An implant was then placed into the fresh socket (b).
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Fig. 10. The clinical photograph (a) and radiograph (b) showing the implant restored with a provisional crown at same visit.
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Fig. 12. Four year follow-up shows healthy appearing soft tissue around the crown. The radiograph (b) indicates satisfactory bone integration and maintenance. Fig. 11. Clinical photograph (a) and radiograph (b) showing the implant restored with Zirconium abutment and allceramic crown four months later.
cervical root fracture of tooth 22 (Fig. 5a). The radiograph (Fig. 5b) showed a short root that would present a problem supporting a prosthetic crown. The patient accepted the recommendation of replacing the tooth with an implant-supported crown. The root was extracted and a dental implant was inserted in the fresh socket and a provisional crown was placed immediately (Fig. 6a,b). The implant was permanently restored with zirconium abutment and all-ceramic crown after 4 months (Fig. 7a,b). Case 3
A few hours following a traumatic accident, a 26-yearold healthy female presented for consultation. Clinical and radiographic examination including CBCT showed that tooth 21 had a complicated crown–root fracture (Fig. 8a,b). Following acceptance of the treatment recommendation, the tooth was extracted and a dental implant was inserted in the fresh socket and a provisional crown was restored immediately (Figs 9a,b and 10a,b). After 3 months, the implant was restored with
zirconium abutment and all-ceramic crown (Fig. 11a, b). The clinical and radiographic follow-up evaluation 4 years later showed that the implant had provided a satisfactory esthetic outcome as well as good bone and soft tissue maintenance (Fig. 12a,b). Discussion
There are many options for managing patients with dental trauma. Often they include orthodontic treatment, removable partial dentures, fixed partial dentures, or autotransplantation. In recent years, implant dentistry has been included. Different placement and loading protocols have evolved to achieve quicker and easier surgical treatment times. Compared with delayed implants and delayed loading, immediate implant placement with immediate loading provides the patient with an esthetic appearance and provides the required dental support for soft and hard tissue structures at the extraction site. The biggest problem with immediate implant placement and immediate loading is that the stability of the soft tissue for long time periods is unpredictable. Often the labial bone is thin and the labial gingiva often follows the contour and position of the bone, © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Replacing traumatized teeth with implants so if recession of the bony architecture occurs, the gingiva may follow and this may cause an esthetic problem. The stability of the labial gingiva is affected by other parameters such as the periodontal biotype (62), the relationship of the alveolar bone to the long axis of the teeth, the position of the implant, and the shapes of the provisional and final prostheses. The case selection for this type of treatment is very important. Ideally, the patient has a thick and flat biotype and no bone has been lost on the labial aspects of the alveolar bone. Also important is that the thickness of the labial bone is more than 1 mm and the distance from the crest of bone to the gingival margin is less than 3 mm. The shape of the provisional restoration should be as close as possible to that of the natural tooth. It should have a good profile to support the soft tissue. Conclusion
Traumatic dental injuries must be managed in a timely manner to evaluate various treatment options and their prognosis. Dental implants have become recognized as reliable and practical replacements for lost, non-restorable, and ankylosed trauma-related teeth. Both shortand long-term outcomes need to be addressed in planning for each patient. Keeping existing teeth and preventing trauma are obviously the best ways to maintain a natural dentition, and that has a decided better longevity than that of dental implants (63). Choosing to extract a traumatized tooth needs to include a careful analysis of the value of keeping the natural tooth vs an implant; if a traumatized tooth is restorable, avoiding extraction is an important consideration, particularly in young patients. One can always choose to extract a tooth and place an implant, but once the decision is made to do so, then reversion back to a natural tooth is no longer possible (64). Dental implants in service for over 10 years present with a longevity that compared to compromised but retained natural teeth is inferior (65). Others have reported that severely compromised teeth have a marginally better survival than dental implants, but this advantage linearly decreases with increasing tooth compromise (66). The facial cortical plate overlying the roots of the maxillary anterior teeth is thin, and periapical infections as well as repeated surgical interventions can lead to labial plate resorption that can complicate future implant treatment (67). The decision to save or replace a traumatized tooth is a decision that must be carefully made and must include a thorough discussion with the patient (and/or guardians) about risks and benefits and also must include the desires of the patient (informed consent). Traumatized teeth often require multidisciplinary involvement by restorative dentists, pediatric dentists, endodontists, orthodontists, prosthodontists, periodontists, and oral and maxillofacial surgeons. Every specialty can provide input that may be of value in providing the patient with the best treatment. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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