Article
The management of luxated teeth involves repositioning and splinting them for a period of 2–4 weeks depending on the type of displacement injury.1 The aim of splinting the teeth is to stabilize them to facilitate healing of the periodontal ligament.2 There are many designs and materials used to splint teeth, including the popular composite and wire splint, the titanium trauma splint and the fibre splint.2,3
Historically, teeth were splinted for extended periods with rigid immobilization, but several studies have shown that this approach leads to an increased risk of ankylosis.2,4 Andersson et al demonstrated that teeth subjected to masticatory stimulation resulted in less ankylosis, thus heralding the way forward with the flexible splint for shorter periods of time.5
The International Association of Dental Traumatology (IADT) recommends flexible splinting of traumatized teeth for 2 or 4 weeks as seen in Table 1. The only exception is for cervical 1/3 root fractures, which should be splinted for 4 months.1
| Type of injury | Splinting duration | Splint type |
|---|---|---|
| Subluxation | 2 weeks | Flexible |
| Extrusion | 2 weeks | Flexible |
| Lateral luxation | 4 weeks | Flexible |
| Intrusion | 4 weeks | Flexible |
| Root fracture (apical third and mid third) | 4 weeks | Flexible |
| Root fracture (cervical third) | 4 months | Flexible |
| Avulsion | 2 weeks | Flexible |
| Alveolar fracture | 4 weeks | Rigid |
There are a number of materials and types of splints used by clinicians involved in the management of dental trauma, with the most commonly used design being the composite and orthodontic wire splint. When splinting teeth in the mixed dentition, the titanium trauma splint is very useful because the malleability makes it easier to negotiate gaps and misaligned teeth.3
Arch bars and wire ligatures are sometimes used by maxillofacial teams, particularly when there is an associated mandibular fracture. These should be avoided, if at all possible, in the management of dental trauma alone, because they splint teeth rigidly, can damage the gingival tissues and may even act to extrude teeth.3
The composite and orthodontic wire splint can be regarded as the gold standard due to being predictable and cost-efficient with the bond strength between composite and enamel being approximately 29 MPa.6
However, it cannot be used when the teeth that are to be splinted have porcelain restorations on the labial surface (crowns or veneers).
This Technique Tip describes a simple alternative approach to splinting traumatized teeth that have previously been restored with porcelain restorations.
Case 1
A medically fit and healthy 45-year-old female was seen in a specialist trauma clinic 3 weeks after a bicycle accident when she collided with a car, resulting in displacement of three of her upper incisor teeth.
Clinical presentation (Figures 1 and 2)
At presentation, 3 weeks after the traumatic incident, the following were noted:
Radiographs
The peri-apical (Figure 3) and upper standard occlusal radiographs (Figure 4) revealed:
Acute trauma diagnoses
Due to the severity of the intrusion injuries, and the delay in presentation, the patient was warned that the long-term prognosis for her upper central incisors was guarded, and that it would be a good idea to proceed to root canal treatment of her UR1 and possibly UL2 as soon as possible after the acute management. She was also advised of the proposed trauma management and the challenge of splinting her teeth due to the porcelain-bonded-to-metal crowns present in the UR1 and UL1. After lengthy discussion, she was consented for photographs, digital repositioning of the teeth and splinting using a modified Essix retainer (MER).
Acute trauma management
Following anaesthesia with labial and palatal infiltrations, the UR1 and UL1,2 were digitally repositioned using a flat plastic instrument interproximally to disimpact the intruded teeth from the alveolar bone. This should be carried out carefully to avoid further trauma to the cementum.7
The UL2 was repositioned first and temporarily held to the UL3 by applying Triad (Dentsply Prosthetics, PA, USA) to the incisal edges of both teeth and light curing it. Triad is a light-cured resin material, which can be used for temporary immobilization of traumatized teeth. The UL1 and UR1 were then repositioned in a similar way in this order and secured with Triad on the incisal edges.
Once the teeth were in as close to the pre-trauma position as possible (determined by the occlusion, the patient's feedback and a pre-injury photo of the teeth from a ‘selfie’), Triad gel was applied to the cervical-third of the UR1, UL1,2 and light-cured as seen in Figure 5. Engaging the interproximal spaces aids retention of the Triad, and thereby temporarily holding the teeth in position allowing removal of the Triad on the incisal edges. An upper alginate impression was then taken and sent to the laboratory with a request for a modified Essix retainer (MER) to be fabricated.
The MER was designed to cover as little of the soft tissues as possible with enough material for retention and some flexibility. As seen in Figure 6, full occlusal coverage and partial labial and palatal coverage was requested.
The MER was fitted on the same day and the patient was advised to wear the retainer at all times, removing it twice a day to enable tooth brushing and to clean the MER. She was advised not to bite with her front teeth, but to cut all foods into small portions and to chew on her back teeth. The importance of resuming good oral hygiene was stressed and insertion and removal of the MER was demonstrated.
The usual splinting time for intrusive injuries is 4 weeks,1 but due to the risk of reduced compliance with the MER being a removable splint, a longer period of 6 weeks was recommended and agreed.
After 6 weeks, the patient was managing well, and her oral hygiene had improved with some reduction in the gingival inflammation noted previously (Figure 7). The UR1 and UL1,2 were found to be firm and were not tender to percussion or palpation. She was given further oral hygiene instruction, and root canal treatment was arranged for the UR1 along with restoration of the UL2 and UR3. She was advised that she no longer needed to wear the MER, which was disposed of.
At the 6-month review the patient was asymptomatic and was delighted that she had resumed normal function. She continued to work hard to improve her gingival health, and this was reflected in healthy-appearing gingivae as seen in Figure 8.
Case 2
A medically fit and healthy 29-year-old male patient was seen in a specialist trauma clinic 3 days after accidentally tripping and knocking his upper front teeth on the pavement, which resulted in the displacement of his UL1,2.
Clinical presentation (Figure 9)
At presentation, 3 days after the traumatic incident, the following were noted:
Radiographs (Figure 10)
The peri-apical radiograph (Figure 10) revealed:
Acute trauma diagnoses
The patient was advised of the proposed acute trauma management and the challenge of splinting his teeth due to the linked porcelain-bonded-to-metal crowns present in the UL1,2. He was also advised that the UL2 pulp was likely to become necrotic, and root canal treatment would need to be carried out. After lengthy discussion, he was consented for photographs, digital repositioning of the teeth and splinting using a MER.
Acute trauma management
Following anaesthesia with labial and palatal infiltrations, the UL1,2 linked crowns were digitally repositioned using pressure applied over the apices of the teeth, before moving the incisal edges labially, and back into the line of the arch. When the incisal edges were level, correct repositioning was assumed and Triad was applied incisally and cervically, engaging the interproximal areas for retention of the material and to immobilize the teeth in the same way as described in Case 1.
Following placement of the cervical Triad, the temporary splint on the incisal edges was removed and an upper alginate impression was taken for the fabrication of a MER (Figures 11 and 12).
The MER was fitted on the same day and the patient was advised to wear the retainer at all times, removing it twice a day to enable tooth brushing and to clean the MER. He was advised not to bite with his front teeth, but to cut all foods into small portions and to chew on his back teeth. The importance of resuming good oral hygiene was stressed and insertion and removal of the MER was demonstrated.9
He was reviewed 2 weeks later (Figure 13) and his oral hygiene had lapsed. Further oral hygiene instruction was given and he was reviewed again after 4 weeks. At this stage, his gingival health had improved significantly and he was advised to stop wearing the MER.
Case 3
A medically fit and healthy 35-year-old female was seen in a specialist trauma clinic 7 days after a road traffic accident, which resulted in displacement of an upper front tooth and a broken crown on an adjacent tooth. She gave a history of dental trauma 11 years previously involving all of her upper incisor teeth with subsequent restoration with porcelain-bonded-to-metal crowns of all four teeth.
Clinical presentation (Figure 14)
At presentation, 7 days after the traumatic incident, the following were noted:
Radiographs
The peri-apical (Figure 15) and the upper standard occlusal radiographs (Figure 16) revealed:
Acute trauma diagnoses
The patient was advised of the increased risk that the pulp of the UR2 may become necrotic due to the repeat trauma. After lengthy discussion, she was consented for photographs, digital repositioning of the teeth and splinting using a MER. She was also informed that the prognosis for the UR1 and UR2 was guarded due to the history of previous trauma and the lack of remaining coronal tooth tissue.
Acute trauma management
Following anaesthesia with labial and palatal infiltrations the UR1 was digitally repositioned applying apical pressure and a watch-winding action whilst holding the incisal edge. When complete repositioning was anticipated the patient was asked to bite together to check that she was able to bring her teeth back into maximum intercuspation. This quick check is useful, together with checking that the incisal edges are level to ensure that the displaced tooth is fully seated in its original position.7 The UR1 was then temporarily immobilized with Triad applied to the incisal edges and then cervically prior to taking an upper alginate impression as previously described.
The MER was designed to include composite to replace the missing tooth tissue in the UR2 as seen in Figure 17.
The MER was fitted on the same day and the patient was advised to wear the retainer at all times, removing it twice a day to enable tooth brushing and to clean the MER. She was advised not to bite with her front teeth but to cut all foods into small portions and to chew on her back teeth. The importance of resuming good oral hygiene was stressed and insertion and removal of the MER was demonstrated.
A splinting period of 4 weeks was selected, and at the review appointment, the UR1 was firm and the patient was advised that she could now seek replacement of the fractured UR2 crown.
At the 12-month review appointment, the patient had new crowns on all four upper incisors and was delighted with the appearance (Figure 18). All of these teeth were asymptomatic, and clinically, they were firm and there was no tenderness to palpation or percussion. The vitality of the UR2 pulp continues to be monitored.
Discussion
Acute trauma management and splinting of unrestored teeth can be challenging in itself without the added complication of how to manage teeth with porcelain restorations. This case series shows the use of a modified Essix retainer as a novel solution to this challenge.
The case series demonstrates the easy use of Triad to temporarily splint or stabilize teeth to aid taking an alginate impression for the fabrication of a MER. In the absence of Triad being available, composite, which is partially cured when in position, can be used in a similar way.7 Composite is a good alternative, and partially curing it enables it to be removed easily.
The CoJet (3M, ESPE, Seefeld, Germany) system, generally marketed as a chairside repair kit for indirect restorations, could be used to roughen the surface of porcelain restorations to retain a composite and wire splint. It is best used under rubber dam to try to contain the alumina particles and reduce the risk of inhalation. The resultant roughness might be unacceptable to the patient and is not easy to polish. There is also the risk of further roughening the porcelain surface when the composite and wire splint is removed.
The modified Essix retainer is a nifty solution to a challenging problem of trying to splint teeth with porcelain restorations present. The only disadvantage of using a removable MER is patient compliance, both in wearing it, as well as maintaining good oral hygiene. To this end, good communication and patient selection is essential.