Loss of tooth 2.2 due to sporting trauma: a case report

Introduction

Edentulism is a pathological condition characterized by the total or partial absence of natural teeth, which can also affect a single tooth.

Edentulism is mainly related to chronic inflammatory problems, such as untreated caries and periodontal disease, but also to trauma and oral cancer [1]. It is a worldwide phenomenon that occurs mainly in adulthood. Age is a predictive risk factor for tooth loss due to the progressive reduction in cell turnover [2–3]. Systemic factors are also related to the onset of edentulism. In particular, systemic diseases characterized by immunodeficiency, such as diabetes [4] and cardiovascular disorders [5], are considered potential risk factors for periodontitis and, consequently, tooth loss [6–7].

This condition remains widespread despite modern primary prevention measures aimed at reducing its prevalence. According to the 2022 WHO Global Oral Health Status Report, approximately 3.5 billion people worldwide were affected by oral diseases in 2019, with edentulism accounting for approximately 350 million cases. In Italy, the figure stands at 12.9%, corresponding to approximately 6.5 million adults aged 20 or older who have no teeth or are affected by partial edentulism [8].

Local factors, such as traumatic events, may also contribute to partial or single-tooth loss and therefore to the onset of edentulism. Studies indicate that the annual incidence of dental trauma is 4.5% [9] and that more than one billion people have experienced traumatic dental injuries [10].

Dental trauma is observed in primary dentition, with an incidence of 23%, and in permanent dentition, with an incidence of 15%. The maxillary central incisors are the teeth most frequently exposed to traumatic forces, accounting for approximately 70% of cases [11]. The anterior teeth are, in fact, the most exposed and among the least resistant to external traumatic forces. Males are more at risk, and sports are considered a major causal factor.

Traumatic force can act through a direct mechanism, by acting directly on the affected tooth, or through an indirect mechanism, by acting on the jawbones and then indirectly on the teeth. In this context, the Andreasen classification, which is widely adopted and recognized by the WHO, ranks avulsion as one of the most severe possible consequences of dental trauma [12–13].

Established guidelines exist for the management of traumatized teeth, including those lost at the time of injury or those shown to have a poor long-term prognosis [14]. When a tooth is considered hopeless, several treatment options can be used to restore function, including orthodontic treatment, a bridge on natural teeth, or implant-prosthetic rehabilitation, which requires a multidisciplinary approach. Especially in the anterior region, implant-supported fixed rehabilitation may represent an appropriate solution in terms of aesthetics and prognosis.

The treatment of aesthetic single-tooth loss requires a precise and accurate diagnostic study because it concerns a highly visible area that affects the patient’s quality of life. When aesthetic outcomes are planned [15], several factors must be considered, including tooth position and shape, tissue phenotype, and implant site and position. These elements require both surgical and prosthetic evaluation to achieve a harmonious restoration.

The outcome of the procedure can be facilitated by new digital technologies that use dedicated software. A completely digital workflow reduces time, costs, and patient discomfort [16]. Guided surgery is a reliable, reproducible, and safe method for performing implant surgery [17]. The workflow includes intraoral scanners, three-dimensional CBCT images, virtual planning software, and 3D printers, which allow treatment to be performed with greater safety [18]. Digital impressions are more comfortable for the patient and can limit errors in the design and fit of the future prosthesis [19].

The use of CAD/CAM technology has several advantages, including speed, ease of use, and quality of work [20]. The impression appears on the monitor as a three-dimensional image, and instructions are sent to a CAM system to manufacture the product before the procedure. This facilitates communication with the patient and the forwarding of the image to the laboratory through an image acquisition system connected to dedicated software [21]. The software receives the DICOM (Digital Imaging and Communications in Medicine) file containing the radiographic data and imports the virtual arch model in STL (Standard Tessellation Language) format [22]. Three-dimensional printed models can then be used for preoperative planning [23–24].

Computer-aided design and manufacturing therefore enable the surgical guide to be fabricated according to predefined parameters. Computer-guided surgery uses a surgical template supported by mucosa, teeth, or pins. The template reproduces the planned implant position from computerized data, converted into a guide for use during surgery, with or without flap elevation [25]. The guide reduces working time and provides a highly accurate implant position [26], although angular deviations can still occur. Accuracy may be influenced by bone density, mucosal thickness, surgical technique, template type, maxillary bone anatomy, and implant length [27–30].

Digital technology for implant-prosthetic rehabilitation is particularly beneficial for implant planning [31], especially when a precise implant angle is required in the aesthetic zone. It allows optimal use of residual bone and supports functional restoration while reducing recovery time.

Materials and methods

The case reported here presents one possible treatment plan for the aesthetic and functional rehabilitation of an edentulous site assisted by digital technologies. A 46-year-old male patient presented to the department with a negative general medical history and a history of sporting trauma that caused the loss of tooth 2.2. Intraoral clinical examination revealed a vestibular depression in area 2.2 due to post-traumatic atrophy, with slight loss of the alveolar process (Fig. 1). A level I orthopantomographic examination and a level II CBCT examination were performed, supporting the indication for implant-supported treatment of the edentulous site.

Because the treatment area was highly aesthetic, the procedure was planned, in agreement with the patient, using instruments designed to guide the clinical outcome. Guided surgery first involved taking a preliminary impression using an intraoral scanner, which recorded both arches and the correct occlusion (Fig. 2). The intraoral scan was sent to the laboratory as an STL file and used to create a virtual diagnostic wax-up previewing the final aesthetic result (Fig. 3). The STL files were then exported and matched, using dedicated software, with the CBCT DICOM file (Fig. 4).

Based on the bone quantity detected by tomographic examination, virtual planning was performed using software, resulting in the construction of a surgical guide. Because adjacent teeth were present, a tooth-supported fixed template was designed. This did not require intraoperative modification because it was generated specifically from preoperative imaging data, making it suitable for a case that requires high precision in the aesthetic area.

The surgical guide was manufactured using 3D printing techniques from the project’s digital STL files, enabling precision and product customization. The digital CAD/CAM workflow allowed visualization of the final result through the pre-surgical study of correct implant and prosthetic positioning. During the design phase, the position, angulation, and depth of the implant in site 2.2 were determined in advance, also guiding the correct prosthetic emergence (Fig. 5a–c).

Preoperative clinical and radiographic evaluations showed slight atrophy of the vestibular dimension; therefore, despite the use of guided surgery, a minimally invasive flap elevation was planned. The flapless technique is preferable only in optimal conditions, with sufficient bone and gingival tissue. In this case, the flap approach allowed soft- and hard-tissue management while preserving the amount of adherent gingiva.

Once consent had been obtained for the treatment plan, surgical rehabilitation of the area proceeded. After administration of local plexus anesthesia in the periapical area of the affected tooth and palatal reinforcement, the surgical template was inserted. The template was tooth-supported and had a bushing in area 2.2 (Fig. 6a). Implant placement was guided by the sleeve, which allowed insertion at the planned angle and depth. The final step involved repositioning the previously raised flap and suturing it with simple stitches around the implant (Fig. 6b). In accordance with postoperative management guidelines, the patient was discharged with routine post-surgical recommendations.

Results

In this case, guided surgery yielded favorable clinical results in implant precision and prosthetic rehabilitation. Digital pre-surgical planning allowed accurate implant placement and a high degree of correspondence between the planned and achieved positions, which is essential in areas of high aesthetic value. The use of the template also reduced the risk of complications, making the procedure less invasive and more predictable, resulting in reduced surgical trauma and healing time.

Discussion

Tooth loss, especially if prolonged, compromises function. Masticatory function and protrusive disocclusion are generally determined by the anterior teeth [32]. Partial edentulism also causes movement and physiological inclination of adjacent teeth and over-eruption of opposing teeth, resulting in occlusal imbalance.

Dimensional changes in the bone wall following tooth extraction, whether traumatic or otherwise, have a significant effect on treatment outcomes [33]. Bone atrophy associated with malocclusion resulting from tooth loss, especially when prolonged, compromises masticatory and phonetic functions as well as aesthetics, particularly in the anterior region. The clinician’s primary objective is to rehabilitate physiological functions in accordance with the principles of treatment predictability and biological risk.

Most dental traumas have a positive prognosis; however, intrusion and traumatic avulsion have been reported to have the highest risk of secondary resorption following reimplantation [11]. This case required level I and level II radiographic examinations. CBCT was justified for diagnosis and pre-surgical planning, as an aid to implant treatment, to optimize machine-dependent and patient-specific variables. The literature supports the use of CBCT for implant treatment planning, including linear measurements, three-dimensional assessment of the alveolar ridge, evaluation of the proximity of important anatomical structures, and fabrication of surgical guides [34–35].

In this case, three-dimensional imaging showed adequate bone quantity and density for implant placement, except for mild post-traumatic vestibular atrophy. The rehabilitation of partially or totally edentulous patients with implant-supported prostheses demonstrates favorable long-term outcomes. Correct implant positioning is essential for achieving good functional and aesthetic results and may require adequate alveolar bone and surrounding soft tissue [36].

Although the following studies concern full-arch rather than single-tooth rehabilitation, they provide additional background on implant-prosthetic rehabilitation outcomes in systemic patients and on digital protocols for immediate-load full-arch treatment [40], [41–42]. They should therefore be interpreted as contextual literature rather than as direct evidence for the present single-tooth traumatic case.

The preoperative study assesses the accuracy of implant placement by superimposing CBCT images and STL files from digital arch scans in specialized software, followed by fabrication of a surgical guide. The position and stabilization of the guide, the type of guidance, and the flap approach can influence the accuracy of guided implant surgery [37–38]. Similarly, three-dimensional radiographic images for bone-condition analysis are clinically important: bone quality, including density and height, is a significant predictor of implant placement accuracy in computer-guided surgery [39].

Conclusions

Partial or total edentulism causes functional and aesthetic deficits, affecting the patient’s chewing ability and quality of life.

There is no single treatment option; the choice is based on patient-specific assessment and on intraoral and extraoral clinical evaluation.

Implant-supported fixed restorations are a treatment alternative that can achieve favorable aesthetic and functional results closer to the physiological capabilities of natural teeth.

The development and use of new technologies allow reliable, predictable results to be obtained, even in complex cases, while reducing treatment invasiveness.

Virtual planning for implant-prosthetic rehabilitation using dedicated software allows optimal use of the remaining bone and pre-surgical selection of the implant. Previsualization of bone conditions and implant positioning on the software reduces the risk of operator error and operating time. This prosthetically guided approach supports favorable aesthetic and functional outcomes.

Computer-guided surgery minimizes procedural invasiveness and may reduce postoperative sequelae, thereby improving patient comfort after surgery. This case highlights the importance of rehabilitating edentulous areas. It is important to remember that no treatment is free from risks and complications; however, careful study and proper procedures increase the likelihood of achieving favorable results.