CASE STUDY Table 2: Splinting recommendations, per injury Concussion and subluxation: only recommended for comfort Alveolar bone fracture: semi-rigid for 4-6 weeks Lateral Luxation: semi-rigid splint for 4 weeks; if x-ray shows further breakdown, additional splinting may be necessary Extrusion: splint recommended for 2 weeks Intrusion: splint must be long enough to support tooth during remodeling of socket; semi-rigid splint for 6-8 weeks Avulsion: if socket intact, 7-10 days Root fracture: mid-root fractures – semi-rigid for 4 weeks; cervical root fractures possibly longer intruded less than 3mm; if no movement after 2-4 weeks, reposition surgically or orthodontically before ankylosis can develop; if the tooth is intruded beyond 7mm, reposition surgically.” 10 The prognosis of intrusive injuries may be poor. According to Andreasen, looking at nine studies, pulp necrosis was found in a range of 45-96% of intruded teeth and root resorption was found in a range of 31-80%. 7 Avulsed teeth should be splinted after re-implanta-tion for 2 weeks (if the tooth was re-implanted prior to arrival at the clinic or if extra-oral dry time was less than 60 minutes) or for 4 weeks (if the extra-oral dry time was greater than 60 minutes). 10 Per Andreasen, the following table describes splint-ing recommendations, per injury in Table 2. The neces-sity and methodology of splinting of traumatized teeth is also variable and consistently debated. According to Andreasen: “The most important discovery in recent decades has been that splinting in general can have an adverse effect on the healing processes in the periodon-tium and pulp after trauma. Thus, non-physiologic fixa-tion of displaced teeth can induce periodontal and pulpal healing problems’ and long-term splinting may not only prolong the wound healing process in the periodontal ligament, but may also lead to preservation of an otherwise transient ankylosis.” 7 In general, to promote periodontal and pulpal heal-ing, slight mobility (no splint) is better than rigid splinting. Requirements for a splint include: b internal adaptation: placed intraorally, in a timely manner; b placement and removal: simple technique for placement, ideally in a compromised working field; b tooth stabilization: adequate stabilization for duration of time worn; b tooth physiology: allow passive physiologic movement – vertically and horizontally; b occlusion: should not impeded jaw movement/occlusion; b endodontic acess: allow for endodontic testing and treatment if warranted; b oral hygiene: proper hygiene possible, ideally placed away from gingival tissue, does not increase periodontal injuries or promote caries; b esthetic: especially consider placement is usually on labial surface of anterior teeth; b cost effective. 11 Possible flexible splints may be constructed of suture materials, power chains, fishing line or light “titanium” orthodontic wires. Semi-rigid splints may be constructed of fiber splints or heavier orthodontic wires while rigid splints may consist of triad, arch bars or heavy orthodontic wires. Extra-coronal splinting of a traumatized tooth, however, may not lead to improved outcomes. For instance, Hinckfuss’ meta-analysis of splinting showed that some animal models of replanted avulsed teeth showed favorable and unfavorable results. She summa-rized by stating, “The evidence for an association between short term splinting and an increased likelihood of functional periodontal healing, an acceptable healing outcome, or decreased development of replacement resorption appears inconclusive.” 13 Interestingly, Kinde-lan disagrees in theory and felt that occlusal stimuli promotes the regeneration of the periodontal ligament and prevents dentoalveolar ankylosis; they postulated “that an orthodontic archwire may be used to distribute or deliver the appropriate force to a transplanted (and thus it may be inferred, a replanted) tooth to avoid root resorption and ankylosis whilst stimulating periodontal ligament repair and improving the prognosis.” 14 The inappropriate use of rigid splinting may also be associated with an increased rate of pulp necrosis and ankylosis. This may be associated with additional trauma during splint application (especially during two-step, lab-fabricated splints) and the risk of bacterial invasion in the PDL due to the close proximity of the splint to the gingival wound and impaired oral hygiene. 15 According to Andreasen, the use of systemic antibi-otics is presently unsettled. He stated that if antibiotics are indicated, they should be started as early as possible – within 3-4 hours of trauma – and used for only a “few” days. For avulsions, the value is questionable, but they may lessen resorption of root surfaces. He continues, “with regards to luxation and root fractures, …none showed any preference in healing (pulp or periodontal) in the treated groups. In fact, in three studies a significantly higher rate of infection was found in the antibiotic treatment groups. Presently it only seems relevant to use antibiotics in cases of replantation of avulsed teeth.” 7 14 Spring 2019 JAOS
Journal of the American Orthodontic Society Spring 2019: Page 14
