To splint or not to splint? - Border Dental Study Group · 2019-11-14 · To splint or not to splint - a review of current splinting protocols splint (splĭnt) noun: 1.A rigid device

To splint or not to splint? A review and application of current splinting protocols

Dr Kim Mai Dang, Specialist Endodontist BMedSci(Hons), BDent(Hons) Syd, DCD(Endo) Melb

DENTAL TRAUMA dentaltraumaguide.org

OUTLINE

• Biological consequences of dental trauma

• Aims of splinting

• Properties of splinting material

• Decision-making for splinting

• Indications

• Duration

• Type of dental trauma

• How to reposition and splint

Gingival tissues: development of new junctional epithelium and connective tissue fibre union occurs as early as 7 days

Periodontal Ligament: • Necrotic PDL and cementum removed by phagoctyes • PDL union begins 4-7 days post trauma • PDL heals and regains 50-60% mechanical strength by

14 days • Complete healing occurs 8 weeks post trauma

(Andreasen 1980, Nasjleti et al 1975, Hurst 1972)

(Andreasen & Lovschall 2007, Mandel & Viidik 1989, Andreasen 1980)

GINGIVAL AND PERIODONTAL HEALING:

Alveolar bone • Loss of blood supply • Loss of innermost layer of periodontium

Stages of healing: 1. Coagulation 2. Granulation tissues formation and osteoblast

differentiation by day 7 3. Connective tissues formation by day 20 4. Bone development and marrow formation by day 38 5. Bone remodelling and maturation by 2-4 months

(Evian et al 1982, Simpson 1969)

ALVEOLAR BONE HEALING FOLLOWING TRAUMA:Maintain the repositioned tooth in correct position, provide

patient comfort and improved function.

(Honório et al 2015)

AIMS OF SPLINTING:

splint (splĭnt)

noun: 1. A rigid device used to prevent motion of a joint or the

ends of a fractured bone.

2. A dental appliance put on the teeth to protect them from riding or from moving out of place

The American Heritage® Stedman's Medical Dictionary. Houghton Mifflin Company. http://dictionary.reference.com/browse/splint (accessed: August 08, 2015).

To splint or not to splint - a review of current splinting protocols splint (splĭnt)

noun: 1. A rigid device used to prevent motion of a joint or the

ends of a fractured bone.

2. A dental appliance put on the teeth to protect them from riding or from moving out of place

The American Heritage® Stedman's Medical Dictionary. Houghton Mifflin Company. http://dictionary.reference.com/browse/splint (accessed: August 08, 2015).

To splint or not to splint - a review of current splinting protocolsDental splint

AMERICAN ASSOCIATION OF ENDODONTICS:

A rigid or flexible device or compound used to support, protect or immobilise teeth that have been loosened, replanted, fractured or subjected to certain endodontic surgical procedures

(Oikarinen K 1990)

Desirable properties of a splint - biological consideration

• Physiological healing • Stabilises the repositioned tooth • Adequate fixation • Non irritating to the soft tissues, periodontal tissues and

non -cariogenic • Cause no damage upon placement and removal • Not exert orthodontic forces on splinted teeth

SPLINT MATERIALDesirable properties of a splint - chairside management • Easy application • Readily available • Cause minimal damage to tooth structure upon removal • Allows for pulp testing • Allows for endodontic treatment • Relatively inexpensive

SPLINT MATERIAL

Von Arx 2001

Desirable properties of a splint - patient consideration • Patient comfort • No occlusal inference • Aesthetic appearance • Easy to access and maintain oral hygiene

SPLINT MATERIAL

dentaltraumaguide.org

Rigid • Cervical root fractures, alveolar bone fractures • Eg. stainless steel >0.5mm

Flexible device • Allows for optimal pulp and periodontal ligament healing • Eg. nylon, stainless steel, Nickel Titanium up to 0.016

(0.4mm)> direct composite splint

Compound • Eg. Orthodontic bracket and wire

(Kwan et al 2012, Berthold et al 2009)

TYPES AND EFFECT OF SPLINT MATERIAL AND THICKNESS:

Rigid Eg. Stainless steel wire > 0.016 (0.5mm), direct composite resin alone (eg ProTemp), Titanium Ring Splint

(Berthold et al 2009, Kwan et al 2011, Kwan et al 2012)

SPLINT MATERIAL AND THICKNESS:

Stainless steel wire > 0.016 or

Composite resin alone (eg ProTemp)

Titanium Ring Splint

Rigid Eg. Stainless steel wire > 0.016 (0.5mm), direct composite resin alone (eg ProTemp), Titanium Ring Splint

• Direct composite resin reinforced with fibreglass ribbon

(Berthold et al 2009, Kwan et al 2011, Kwan et al 2012)


Composite resin alone (eg ProTemp)

Flexible Eg. nylon, stainless steel, Nickel Titanium up to 0.016 (0.4mm)

(Kwan et al 2012, Kwan et al 2011, Berthold et al 2009, Hy JY 2011 - Hons Thesis)


Stainless steel wire < 0.016 with composite resin

or GIC based cement

Titanium Trauma Splint (TTS)

Orthodontic bracket and wire

TYPES OF DENTAL INJURIES:

Dental hard tissue injuries

(a) Periodontal injury • Concussion

• Subluxation

• Luxation (extrusion,

intrusion, lateral)

• Avulsion

(b) Tooth injury • Uncomplicated crown fracture

• Complicated crown fracture

• Root fracture

(c) Dentoalveolar fracture

TYPES OF DENTAL INJURIES:(a) Periodontal injury • Concussion

• Subluxation


intrusion, lateral)

• Avulsion Concussion

• An injury to the tooth-supporting structures without increased mobility or displacement of the tooth, but with pain to percussion.

• Splinting is not indicated



• Subluxation


intrusion, lateral)

• Avulsion Subluxation

• An injury to the tooth supporting structures resulting in increased mobility, but without displacement of the tooth. Bleeding from the gingival sulcus confirms the diagnosis

• Flexible splint (2-weeks) if necessary for comfort



Reposition with digital pressure Apply acid etch on the labial surface

Light cure flowable composite resin


• Subluxation


intrusion, lateral)

• Avulsion Extrusive luxation

• Partial displacement of the tooth out of its socket; alveolar socket bone is intact.

• Stabilise with a flexible splint for 2-weeks


TYPES OF DENTAL INJURIES:Extrusive luxation

• Splinting: • Avoid the risk of aspiration - protect airway • Avoid the risk of losing tooth - change

suction tips

Clinical tips: • Support the alveolar bone • Avoid applying excessive apical force • Confirm repositioning with a radiograph,

incisor edge of adjacent teeth


dentaltraumaguide.org dentaltraumaguide.org




• Subluxation


intrusion, lateral)

• Avulsion Intrusive luxation

• Displacement of the tooth into the alveolar bone.

• Accompanied by comminution or fracture of the alveolar socket

• Stabilise with a flexible splint for 4-6 weeks


TYPES OF DENTAL INJURIES:Intrusive luxation

Clinical tips: • Support the alveolar bone • Aim to reposition to the same position as the

contralateral tooth • Confirm repositioning with a radiograph

incisor edge of adjacent teeth • Stabilise with a flexible splint for 4-6 weeks



Prebend / contour wire

Reposition with digital pressureReposition with extraction forceps





Prebend / contour wire Light cure flowable composite resin

Apply orthodontic elastics


• Subluxation


intrusion, lateral)

• Avulsion Lateral luxation

• Displacement of the tooth other than axially • Accompanied by comminution or fracture of

either the labial or the palatal/lingual alveolar bone



TYPES OF DENTAL INJURIES:Lateral luxation


suction tips

Clinical tips: • Support the alveolar bone • May require extrusion prior to repositioning • Confirm repositioning with a radiograph,



Reposition with digital pressureReposition with extraction forceps


Repositioned tooth Apply acid etch on the labial surface



• Subluxation


intrusion, lateral)

• Avulsion Avulsion • Tooth is completely displaced out of its

socket.



TYPES OF DENTAL INJURIES:Avulsion


suction tips

Clinical tips: • Support the alveolar bone • Avoid applying excessive apical force • Confirm repositioning with a radiograph,




Reposition with extraction forceps or digital pressure


Apply acid etch on the labial surface




• Subluxation


intrusion, lateral)

• Avulsion



• Root fracture



Root fracture • Fracture confined to the root • Splinting not always indicated • If splinting, then duration is dependent on

level of fracture and degree of mobility



• Root fracture


TYPES OF DENTAL INJURIES:Root fracture


suction tips

Clinical tips: • Support the alveolar bone • Apply apical pressure • Confirm repositioning with a radiograph,


• Stabilise with a flexible splint for 1-4 months depending on the location of the root fracture




TYPES OF DENTAL INJURIES:(c) Dentoalveolar fracture

Dentoalveolar fracture • A fracture of the alveolar process; may or

may not involve the alveolar socket

• Splinting for 4 weeks


TYPES OF DENTAL INJURIES:Dentoalveolar fracture

Clinical tips: • Support the alveolar bone • Apply digital pressure • Confirm repositioning with a radiograph,


• Stabilise with a splint for 4 weeks • Extend splint only to adjacent teeth unless

otherwise indicated clinically

Berthold et al 2011, dentaltraumaguide.org




Gingival tissues: • reversible damage if periodontium was healthy prior to

trauma • Irritation or damage from splint can lead to soft tissue

injury

Periodontal Ligament: • Slight mobility during initial healing phase allows for

physiological resorption of ankylotic sites in replanted teeth

(Andreasen & Lovschall 2007, Mandel & Viidik 1989, Andreasen 1980)

EFFECTS OF SPLINTING ON DENTAL TISSUES

Current evidence supports short-term, non-rigid splints: - Luxated, - Avulsed and - Root fractured teeth

Healing prognosis related to type of injury rather than type or duration of splint

Trend towards improved periodontal healing following splinting for shorter periods

Hinckfuss & Messer (2009), Kahler & Heithersay (2008) Andreasen et al (2006) Oikarinen (1990)

CONSIDERATIONS OF SPLINTING ON HEALING



• Subluxation


intrusion, lateral)

• Avulsion



• Root fracture


SUMMARY:

• Determine the type of dental trauma • Periodontal injury: flexible splint for up to 2 weeks • Tooth injury: splint where applicable • Dentoalveolar injury: splint for 4 weeks

Type and duration of splint does not affect healing outcome following dental trauma

SUMMARY:Dental hard tissue injuries

(a) Periodontal injury• Concussion

• Subluxation


intrusion, lateral)

• Avulsion

(b) • Uncomplicated crown fracture


• Root fracture

(c)

Clinical tips: • Protect the airway • Change suction tips • If splinting, prebend wire and splint the injured tooth

last • Analgesics, oral hygiene and dietary advice • Reappoint for appropriate review

SUMMARY:

Documents

To splint or not to splint? - Border Dental Study Group · 2019-11-14 · To splint or not to splint - a review of current splinting protocols splint (splĭnt) noun: 1.A rigid device