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Received: 2 December 2018    Revised: 17 July 2019    Accepted: 18 July 2019

DOI: 10.1111/edt.12504

CASE REPORT

Initial management and long‐term follow up after the

rehabilitation of a patient with severe dentoalveolar trauma: A
case report

Suet Yeo Soo1  | Julian D. Satterthwaite2 | Martin Ashley2

1
Faculty of Dentistry, The National
University of Malaysia (UKM), Kuala Lumpur, Abstract
Malaysia Dental trauma is common and for patients who suffer significant oral injuries, re‐
2
School of Dentistry, The University of
habilitation can be challenging to the clinical team. This case report describes the
Manchester, Manchester, UK
successful prosthetic replacement of multiple missing teeth lost due to severe den‐
Correspondence
toalveolar trauma, using iliac crest bone grafting, an implant‐retained removable
Suet Yeo Soo, Centre for Restorative
Dentistry, The National University of dental prosthesis and implant‐supported crowns. Good functionality and aesthetic
Malaysia (UKM), Jalan Raja Muda Abdul Aziz
outcome were achieved.
50300, Kuala Lumpur, Malaysia.
Email: suetyeosoo@hotmail.com
KEYWORDS
Funding information dento‐alveolar trauma, gunshot wound, implant‐supported prosthesis, oral rehabilitation
University of Manchester

1 | I NTRO D U C TI O N
Over the past decade, multi‐system injuries from violent crimes in‐
cluding gunfire have been on the rise in the United Kingdom.1 These
patients often require multi‐disciplinary input in their acute manage‐
ment and subsequent functional rehabilitation. 2 Dental interven‐
tions could be categorized as the management of any anatomical/
bony defect (bone augmentation, sinus lift or distraction) and pro‐
vision of dental prostheses.3‒5 Dental prostheses to replace missing
teeth and bone may be removable dental prostheses (RPD), fixed
dental prostheses (FDP) or implant‐supported prostheses.6,7
From a rehabilitation point of view, treatment plans need to be
constructed around the degree of tissue loss, patient compliance
with maintenance, existing dental conditions, aesthetic outcomes,
technical feasibility and patient preference.8‒10 The choice of treat‐
ment relies on a variety of factors, and patient acceptance of therapy
may depend on the implications of costs, desire for a fixed or remov‐
able solution, duration of treatment, complexity of therapy, previous
experience and surgical risks.8,9,11 Whilst an implant‐supported pros‐
thesis may in some circumstances have aesthetic and biomechanical
superiority, the cost and surgical risks often limit their use.7 A simple
removable prosthesis could be a preferred choice due to ease of oral
hygiene, cost‐effectiveness, shorter treatment duration, low com‐
8,9
plexity and lip support for ridge atrophy or defects. In cases where
the levels of retention and function are unsatisfactory with a remov‐
able dental prosthesis, a fixed dental prosthesis could be considered
as a treatment alternative.4
This case demonstrates the complexity of dental management in
a patient with complex dentoalveolar trauma as a result of a gunshot
wound. It also shows the significance of a delay in initiating various
stages of treatments due to patient factors. Iliac crest bone aug‐
mentation, implant‐supported crowns and an implant‐supported re‐
movable dental prosthesis with its associated flange and composite
stains were used in achieving a functionally and aesthetically pleas‐
ing outcome. No maintenance was needed from the time of initial
management for a period of 12 years, at which time the patient re‐
presented as he lost his removable prosthesis.
2 | C LI N I C A L R E P O RT
The patient, a male aged 36 years, had sustained a series of gun‐
shot injuries to his left jaw, left humerus, right femur and left chest
in June 1993. The initial maxillofacial assessment revealed that the
injuries involved a comminuted fracture of the left mandibular body,
loss of teeth from the left maxilla and mandible (Figure 1), skin and
tongue lacerations. His early stabilization management comprised
tracheostomy, wound closure and rigid inter‐maxillary fixation for

84  |  wileyonlinelibrary.com/journal/edt
© 2019 John Wiley & Sons A/S. Dental Traumatology. 2020;36:84–88.
Published by John Wiley & Sons Ltd
SOO et al.
F I G U R E 1   Orthopantomogram taken in June 1993
demonstrating the loss of left maxillary teeth, fractured body of left
mandible and gunshot artefacts
his fractured mandible. After he was stabilized medically, he was re‐
ferred to the dental hospital for restorative dentistry management.
The patient did not attend for treatment for prosthodontic
rehabilitation until he was again referred by his General Dental
Practitioner 6 years after the trauma in 1999. Intraoral examina‐
tion revealed a significant maxillary defect with five missing teeth
(maxillary left central incisor to maxillary left second premolar) and
two missing mandibular teeth (mandibular left second premolar and
mandibular left first molar; Figure 2). A radiographic stent was used
to assist interpretation of a computerized tomography scan of the
affected areas. The mandibular alveolar ridge was adequate for den‐
tal implant placement but the maxillary ridge required augmentation
with a bone graft to allow implant placement. The reconstruction of
the maxilla was a challenge due to the extensive dentoalveolar bone
loss in that region. Grafting would allow for implant placement but
would still result in a significant alveolar defect. Hence, the plan was
to support a removable dental prosthesis with an extended super‐
structure joining three dental implants.
In 2000, the patient underwent surgical augmentation of the
maxilla, using corticocancellous bone blocks harvested from the right
anterior iliac crest (Figure 3). The radiographic stent was adapted
for use as a surgical stent. Exploration revealed that despite some
resorption, there remained adequate bone for implant placement.
F I G U R E 2   Extensive maxillary dentoalveolar defect with
missing maxillary and mandibular teeth (August 1999)
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Three dental implants (Astra Tech Osseo Speed; Dentsply Sirona)
were placed on the left side of the maxilla and two dental implants
(Astra Tech Osseo Speed; Dentsply Sirona) were placed in the man‐
dibular left posterior area in September 2002. Six months after the
implants were inserted, they were surgically exposed and healing
abutments were placed.
The patient attended the Restorative Dentistry Department
eight weeks after the implants were uncovered. Two cement‐re‐
tained implant crowns with customized titanium abutments were
placed for the mandibular left second premolar and mandibular left
first molar (Figure 4).
For the three maxillary implants, uni‐abutments were placed and
an abutment level impression using an open tray technique was used
with polyether impression material (Impregum, 3M ESPE) to pick up
the impression copings. Subsequent to recording of the occlusal re‐
lationships, and a trial to confirm tooth position, a milled beam was
constructed using precious (high palladium) bonding alloy (Figure 5).
The fitting of the milled beam was checked in the patient's mouth to
ensure passive fit by using the Sheffield test. An orthopantomogram
was taken after insertion of the milled beam (Figure 6). A try‐in of
the maxillary removable dental prosthesis with acrylic teeth was also
performed for approval of aesthetics before the definitive prosthe‐
sis was processed. A mutually protected occlusion was planned for
the occlusal scheme as this design has been reported to be the most
efficient in terms of mastication12. The definitive prosthesis was de‐
signed with acrylic layered over a gold sleeve that fitted intimately
over the milled beam (Figure 7).
As this patient's gingival tissue exhibited pigmentation, recreat‐
ing this in the prosthesis was important. Clinical photographs were
taken of the areas to be characterized, in order to duplicate the pa‐
tient's gingival pigmentation on the prosthesis flange. Composite
stains (Visio.paint; Visio.lign) were painted to mimic the pigmenta‐
tion of the patient's tissues, and the maxillary implant‐supported
removable dental prosthesis was adequately designed to integrate
with the patient's smile (Figure 8). This phase of treatment was com‐
pleted in May 2004.
The patient attended in 2016, 12 years after the completion of
his initial restoration. He had lost his removable prosthesis in a div‐
ing accident. Apart from that, he remained satisfied with his prosthe‐
sis in terms of functionality and appearance. He was maintaining an
adequate standard of dental hygiene and was otherwise healthy. All
five implants (maxillary and mandibular) and the milled beam were
intact. A periapical radiograph of the maxillary left implants revealed
long‐term stability of the osseointegrated implants in the augmented
bone (Figure 9).
The milled beam was serviceable, but the design was not suit‐
able for pickup. Hence, treatment involved a new abutment level
impression with polyether (Impregum, 3M ESPE). Impression cop‐
ings were placed on the maxillary implants and connected with resin
pattern (Duralay, Reliance Dental Mfg. Co; Figure 10) to reduce the
likelihood of distortion. The original beam was placed on the master
model to assess for passive fit and verify the impression/model. A
new removable dental prosthesis with a new corresponding sleeve
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86       SOO et al.

F I G U R E 6   OPG showed post‐insertion of milled beam and

F I G U R E 3   Intraoral view following bone graft (March 2000) dental implants (October 2008)

F I G U R E 7   Corresponding sleeve in the fitting surface of

F I G U R E 4   Dental implants on mandibular left region (May prosthesis (February 2004)
2003)

F I G U R E 5   Precious (high palladium) bonding alloy milled beam F I G U R E 8   Labial view of original definitive restoration (April
(February 2004) 2004)

(to engage the original milled beam) was constructed. Upon provi‐ 3 | D I S CU S S I O N
sion of a new implant‐supported removable dental prosthesis and
completion of treatment, he was discharged to care and monitoring Dentoalveolar trauma leads to loss of hard (teeth and bone) and soft
by his primary care practitioner (Figure 11). (gingivae and mucosa) tissues. Rehabilitation to create a prosthesis
SOO et al.
F I G U R E 9   Intact maxillary implants and milled beam 12 y later
(January 2016)
F I G U R E 1 0   Impression copings were connected with a resin
pattern (March 2016)
that is retentive, stable and attractive can be challenging for the den‐
4,6,13
tal team.
The union of the comminuted mandibular fracture provided a
stable mandibular ridge and adequate bone for implant placement.
Implants were the most functionally appropriate management for
this gentleman, taking into account the support and retention prob‐
lems associated with a removable dental prosthesis to restore a dis‐
tal extension denture base.14
Restoration of the maxilla was more complicated, due to the
extensive bone loss, a high lip line and the pigmented mucosa. In
view of the large bone defect, and due to the sizable quantity of
required bone, iliac crest autologous grafts were preferred for
bone formation, rather than intraoral harvest sites, which would
provide smaller bone volumes.15‒17
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F I G U R E 1 1   New implant‐supported maxillary RPD (June 2016)
Despite the significant delay between bone grafting and dental
implant placement, sufficient bone remained after grafting.18 A pos‐
sible explanation for this finding is that the patient did not wear a
prosthesis during this period, so no functional pressures were ap‐
plied to the grafted surgical area.
Due to the large bone defect, construction of a conventional fixed
dental prosthesis would not have allowed adequate maintenance of
oral hygiene and adequate aesthetic results. Hence, a milled bar im‐
plant‐supported maxillary removable dental prosthesis was fabricated.
The bar was fabricated with a wax‐up, milled and then cast in precious
metal bonding alloy. The corresponding sleeve was constructed to fit
over the milled bar precisely using the lost wax technique.
During remedial treatment, direct pickup of the existing milled
beam procedure would usually be carried out for construction of a
new prosthesis. However, in this case, although the old milled beam
was still intact, pickup of the milled beam was not feasible. This was
due to the lack of additional retentive component in the original
milled beam and also the presence of undercuts. Hence, the treat‐
ment involved a new abutment level impression to construct a new
maxillary removable prosthesis.
During the re‐presentation visit, the survival and overall patient
satisfactions with the milled bar implant‐supported prosthesis were
high, consistent with previous publications19 The titanium abut‐
ments and cement‐retained crowns on the left mandibular region
remained serviceable after more than 10 years. 20,21
AC K N OW L E D G E M E N T S
The authors thank the technicians at the School of Dentistry, The
University of Manchester for their laboratory support.
C O N FL I C T O F I N T E R E S T
We have no conflict of interest to declare.
ORCID
Suet Yeo Soo  https://orcid.org/0000-0003-1363-622X
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88       SOO et al.
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How to cite this article: Soo SY, Satterthwaite JD, Ashley M.
Initial management and long‐term follow up after the
rehabilitation of a patient with severe dentoalveolar trauma: A
case report. Dent Traumatol. 2020;36:84–88. https​://doi.
org/10.1111/edt.12504​
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