to splint or not to splint? - border dental study group · 2019-11-14 · to splint or not to...
TRANSCRIPT
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)
SPLINT MATERIAL AND THICKNESS:
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)
SPLINT MATERIAL AND THICKNESS:
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
• Luxation (extrusion,
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
dentaltraumaguide.org
TYPES OF DENTAL INJURIES:(a) Periodontal injury • Concussion
• Subluxation
• Luxation (extrusion,
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
dentaltraumaguide.org
dentaltraumaguide.org
Reposition with digital pressure Apply acid etch on the labial surface
Light cure flowable composite resin
TYPES OF DENTAL INJURIES:(a) Periodontal injury • Concussion
• Subluxation
• Luxation (extrusion,
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
dentaltraumaguide.org
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
• Stabilise with a flexible splint for 2-weeks
dentaltraumaguide.org dentaltraumaguide.org
Reposition with digital pressure Apply acid etch on the labial surface
Light cure flowable composite resin
TYPES OF DENTAL INJURIES:(a) Periodontal injury • Concussion
• Subluxation
• Luxation (extrusion,
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
dentaltraumaguide.org
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
dentaltraumaguide.org
dentaltraumaguide.org
Prebend / contour wire
Reposition with digital pressureReposition with extraction forceps
dentaltraumaguide.org
Reposition with digital pressure Apply acid etch on the labial surface
Light cure flowable composite resin
dentaltraumaguide.org
Prebend / contour wire Light cure flowable composite resin
Apply orthodontic elastics
TYPES OF DENTAL INJURIES:(a) Periodontal injury • Concussion
• Subluxation
• Luxation (extrusion,
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
• Stabilise with a flexible splint for 4-weeks
dentaltraumaguide.org
TYPES OF DENTAL INJURIES:Lateral luxation
• Splinting: • Avoid the risk of aspiration - protect airway • Avoid the risk of losing tooth - change
suction tips
Clinical tips: • Support the alveolar bone • May require extrusion prior to repositioning • Confirm repositioning with a radiograph,
• Stabilise with a flexible splint for 4-weeks
dentaltraumaguide.org dentaltraumaguide.org
Reposition with digital pressureReposition with extraction forceps
dentaltraumaguide.org
Repositioned tooth Apply acid etch on the labial surface
Light cure flowable composite resin
TYPES OF DENTAL INJURIES:(a) Periodontal injury • Concussion
• Subluxation
• Luxation (extrusion,
intrusion, lateral)
• Avulsion Avulsion • Tooth is completely displaced out of its
socket.
• Stabilise with a flexible splint for 2-weeks
dentaltraumaguide.org
TYPES OF DENTAL INJURIES:Avulsion
• 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
• Stabilise with a flexible splint for 2-weeks
dentaltraumaguide.org dentaltraumaguide.org
Reposition with extraction forceps or digital pressure
Light cure flowable composite resin
Apply acid etch on the labial surface
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:
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
(b) Tooth injury • Uncomplicated crown fracture
• Complicated crown fracture
• Root fracture
dentaltraumaguide.org
TYPES OF DENTAL INJURIES:Root fracture
• Splinting: • Avoid the risk of aspiration - protect airway • Avoid the risk of losing tooth - change
suction tips
Clinical tips: • Support the alveolar bone • Apply apical pressure • Confirm repositioning with a radiograph,
incisor edge of adjacent teeth
• Stabilise with a flexible splint for 1-4 months depending on the location of the root fracture
dentaltraumaguide.org dentaltraumaguide.org
Reposition with digital pressure Apply acid etch on the labial surface
Light cure flowable composite resin
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
dentaltraumaguide.org
TYPES OF DENTAL INJURIES:Dentoalveolar fracture
Clinical tips: • Support the alveolar bone • Apply digital pressure • Confirm repositioning with a radiograph,
incisor edge of adjacent teeth
• Stabilise with a splint for 4 weeks • Extend splint only to adjacent teeth unless
otherwise indicated clinically
Berthold et al 2011, dentaltraumaguide.org
dentaltraumaguide.org
Reposition with digital pressure Apply acid etch on the labial surface
Light cure flowable composite resin
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
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
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
• Luxation (extrusion,
intrusion, lateral)
• Avulsion
(b) • Uncomplicated crown fracture
• Complicated 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: