Patients that have endured injury as a result of trauma present unique challenges in restorative treatment planning. The goals of the patient are combined with what is technically possible from a biomaterials standpoint and require a coordinated effort between the surgeon, restorative dentist and dental laboratory.

Communication during the initial phase of treatment is critical to achieving a successful dental treatment outcome.

A 21-year-old male patient was referred to me by his oral surgeon; he presented for an evaluation following a life-threatening motor vehicle accident (MVA) that resulted in severe trauma to his head and the loss of both legs.

The patient's goal was to recreate his smile as the integral "finish-line" to a long and arduous recovery and rehabilitation process. The posterior teeth were maintained and the patient was missing teeth 8-11 and 21-27. Due to the surgical reconstruction, the edentulous space was larger than what would accommodate teeth of natural proportion. As a result, the landmarks identifying the midline provided an important discrepancy (Bidra JPD 2009).

The examination revealed that he wanted an exact replica of his teeth prior to the traumatic injury. A diagnostic set-up was made to visually demonstrate the challenges related to the space available for prosthetic teeth relative to the retained natural teeth. The diagnostic set-up was duplicated with a thermoplastic material and a tooth-colored bis-acrylic was added to the matrix to allow for an intra-oral trial. The goal was to create a visual that showed that even though the spacing and tooth position looked esthetic on a model, it would not transfer well in the context of his facial features.

The diagnostic matrix was evaluated during the follow-up visit while discussing the restorative treatment options. Photos were taken with the diagnostic matrix and printed to facilitate a discussion regarding the midline position, incisal edge length and tooth contours. Clinical photos were shown to demonstrate restorative treatment possibilities, as well as challenges that had presented with similar scenarios.

As a result of the discussion, the patient provided clear goals as to the final restorative result. He wanted:

  1. White teeth (Shade 1M1)
  2. Teeth similar to photo taken prior to the traumatic injury, following orthodontic treatment.
  3. Fixed or cemented restorations supported by dental implants.
  4. Restorations that provided appropriate support for the upper and lower lips.
  5. Procedures related to placement of dental implants would be tolerable, but otherwise the patient was not interested in surgical treatment procedures to modify the hard and soft tissues of the residual alveolar ridges.

After our discussion, the patient left the office intending to seek additional opinions regarding restorative treatment options. He returned to our office 13 months later, and I will go over that portion of his treatment in my next article.

References:

Bidra AS, et. al. The relationship of facial anatomic landmarks with midlines of the face and mouth. Journal of Prosthetic Dentistry 2009; 102(2): 94-103. "The hierarchy of the anatomic landmarks closest to the midline of the face in smile was as follows: the midline of the oral commissures, natural dental midline, tip of the philtrum, nasion, and tip of the nose."

Douglas G. Benting, DDS, MS, FACP, Spear Visiting Faculty [ www.drbenting.com ]


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