A review of splinting of teeth following trauma

This summary  is based on the article published in the Australian Dental Journal: Splinting of teeth following trauma: a review and a new splinting recommendation (March 2016)

B Kahler; J-Y Hu; CS Marriot-Smith; GS Heithersay

Context 

• With advances in the understanding of healing processes of the periodontium, pulp and alveolar bone following various injuries, the role of splinting has become relatively well defined.
• This is generally reflected in the guidelines for trauma management published by the International Association of Dental Traumatology.
• While the widespread use of composite resin as an adhesive in various functional/flexible splinting systems has over many years allowed ease of application, removal of the material is not only time consuming but more seriously accompanied by minor or major iatrogenic damage to enamel.
• Dental materials science has continued to provide new materials and amongst them the development of resin activated glass-ionomer cement suitable for orthodontic bracket cementation has allowed the development of an alternative simplified splinting regimen for traumatized teeth which offers ease of application and removal with minimal or no iatrogenic damage to enamel.

Purpose of the Review

• Examine the International Association of Dental Traumatology guidelines in relation to splints and the splinting duration for the different types of trauma.
• Propose a new protocol for splinting traumatized teeth that combines ease of application and removal with no or minimal damage to enamel.

Key Messages

A splint should:

1. Allow periodontal ligament reattachment and prevent the risk of further trauma or swallowing of a loose tooth.
2. Be easily applied and removed without additional trauma or damage to the teeth and surrounding soft tissues.
3. Stabilize the injured tooth/teeth in its correct position and maintain adequate stabilization throughout the splinting period.
4. Allow physiologic tooth mobility to aid in periodontal ligament healing.
5. Not irritate soft tissues.
6. Allow pulp sensibility testing and endodontic access.
7. Allow adequate oral hygiene.
8. Not interfere with occlusal movements.
9. Preferably fulfil aesthetic appearance.
10. Provide patient comfort.

Splint Types

• Composite and wire splints: flexible splints when the wire has a diameter of no greater than 0.3– 0.4 mm.¹²
• Composite and fishing line splints: An alternative where fishing line replaces wire and the line is secured with composite resin.
• Orthodontic wire and bracket splints: involves orthodontic brackets bonded to the teeth with a resin-based orthodontic cement and connected with a light 0.014 NiTi flexible wire.
• Fibre splints: use a polyethylene or Kevlar fibre mesh and are attached either with an unfilled resin such as Optibond^TM FL (Kerr, USA) and/or with composite resin.
• The titanium trauma splint: is a flexible splint made of titanium, 0.2 mm thick and 2.8 mm wide.
• Arch bar splints: A metal bar is bent into the shape of the arch and fixed with ligature wires.
• Wire ligature splints: are sometimes used by oral surgeons in clinics where dental splinting materials may not be available.
• Composite splints: resin composite applied to the surfaces of teeth is a rigid splint and Composite splints that are bonded interproximally to adjacent teeth are also reported to be prone to fracture.¹⁹
• A splint for medical emergency departments: Stomahesive (ConvaTec Inc.), a skin barrier adhesive material used for superficial skin trauma. This material can crudely hold teeth in the socket and cover coronal fractures to reduce sensitivity when patients are seen in emergency medical departments out of hours of routine dental practice. This approach could require further repositioning with subsequent splinting in a dental office.

Splinting Duration

• A systematic analysis of splinting duration and periodontal outcomes for replanted avulsed teeth found that periodontal outcomes were unaffected by splinting duration when comparing short-term splinting (14 days or less) and long-term splinting (over 14 days).²⁶
• Studies concluded that there was no evidence to refute the current guidelines and suggested that periodontal outcomes were unaffected by splinting duration.²⁶
• An evidence-based appraisal of luxated, avulsed and root-fractured teeth also found that splinting duration was generally not a significant variable when related to healing outcomes.³⁰

Splint Removal

• It has been shown experimentally that debonding pliers generate shearing forces that result in irreversible damage to the enamel.
• The forces exerted may disturb the periodontal healing of the injured tooth.⁴⁷
• Both hand and ultrasonic scalers caused distinctive patterns of enamel detachment and therefore it was concluded that they should not be used for composite removal.

A New Simplified Splinting Regimen

• An alternative splinting adhesive systems which could be easily applied, have sufficient bond strength to withstand physical forces during the splinting
  period, yet be easily removed without damage to enamel.
• An experimental model was designed and developed to simulate the dentoalveolar complex which then allowed standardized, reproducible evaluations of splinting techniques using several test bonding adhesives.^48,49
• The GC Fuji Ortho fulfils the requirements of an ideal splinting adhesive material because of its ease of application without the need for enamel etching, ability to withstand physical forces during the splinting period, and most importantly ease of removal with minimal or no damage to the enamel surface.

Reference

List of References (PDF)