Tooth splinting: a review of the literature and consideration of the versatility of a wire-composite splint

Tooth Loss after Jaw Curettage Surgery: Associated Factors and Potential Benefit of Splint Application

Background

This retrospective study is aimed at (I) assessment of tooth loss and related parameters after jaw curettage of benign lesions and (II) assessment of the outcome of jaw curettage supported by splint insertion after at least six months of follow-up. Material and Methods. For (I), patients who had jaw curettage surgery in the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University (Guangzhou, China) from July 2015 to June 2019 were included. For part (II), consecutive patients who came to the department from July to December 2019 that were additionally treated with dental splinting were involved in this study. Based on the patient records, age, gender, initial tooth mobility, follow-up outcome, and potential tooth loss (intra- or postoperatively) were recorded. Based on available radiographs, alveolar crest bone loss and root surface area supported by bone (RSA) were determined.

Results

(I) 128 patients with 305 teeth were included, of which 40 teeth were lost (success rate 86.9%), without statistical difference in gender, age, or tooth type (P > 0.05). Tooth mobility, RSA, and the presence of alveolar crest bone defects were associated to tooth loss (P < 0.001). (II) 17 patients with a medium follow-up period of 11 months (range 9 to 13 months) were enrolled. All lesion-involving teeth supported by splint treatment at risks of loss were preserved, showing an effective tooth retention rate in 17/17 cases (74/74 teeth, success rate: 100%).

Conclusions

Tooth mobility and bone loss (lesion-related and/or periodontal) are potential risk predictors for tooth loss in the first year after jaw curettage surgery. Dental splints could be recommendable for teeth involved by jaw benign lesions with little bone support.

Mechanical evaluation of dental trauma splints fabricated using recentlydeveloped photo-polymerizable composites

This study aimed to determine functionality and mechanical properties of dental splints. Five splints were tested: a control splint Filtek Z350XT (ZF), two splints with G-Fix (GF) and Light Fix (LF), and two wire-composite splints with ZF (ZW) and Ortho Connect Flow (CW). Periotest values, elastic modulus, flexural, compressive, and diametral tensile strength were measured. ZW and CW showed no significant differences in flexibility in labial or occlusal pressure of upper central incisors. LF, GF, and ZF did not differ in labial or palatal pressure. ZW and CW had higher flexibility than LF, GF, and ZF. LF had the lowest flexural and compressive strength but the highest diametral tensile strength. This study showed that ZW and CW might be options for flexible splints, whereas LF and GF would be options for rigid splints. Additionally, CW and LF/GF might be simpler alternatives to ZW and ZF, respectively.

Guidelines for the Management of Traumatic Dental Injuries: 1. Fractures and Luxations of Permanent Teeth

Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young adults. Crown fractures and luxations are the most commonly occurring of all dental injuries. Proper diagnosis, treatment planning and followup are important for improving a favorable outcome. Guidelines should assist dentists and patients in decision making and for providing the best care effectively and efficiently. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the best current evidence based on literature search and professional opinion. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of TDIs. In this first article, the IADT Guidelines for management of fractures and luxations of permanent teeth will be presented.

A retrospective study of traumatic dental injuries in primary dentition: treatment outcomes of splinting

OBJECTIVE

Splinting in primary dentition is limited to several traumatic dental injuries. The prognosis associated with splint use has not been fully investigated. In this study, we investigated the outcomes of traumatic injuries in primary teeth treated with splinting.

MATERIALS AND METHODS

We retrospectively analysed 137 children with root fractures and lateral and extrusive luxation injuries to their primary teeth who were treated with semi-rigid splints between 2010 and 2016. Treatment outcomes were analysed in patients with follow-up periods of >6 months. The outcomes of splinting were based on clinical and radiographic evaluations performed during follow-up examinations.

RESULTS

In total, 182 primary teeth were examined, and of these, 90 teeth were treated using semi-rigid splints. In the splint group, pathological root resorption (31.1%) was the most common complication, whereas pathological tooth loss (25.0%) was found most common in the observation group. Splinting in root fractures showed a good prognosis, whereas in lateral and extrusive luxations, it did not (p < .05). There were no relationship between treatment delay and prognosis (p > .05).

CONCLUSIONS

Depending on the type of luxation, splint therapy results in acceptable outcomes and may be a feasible treatment option.

Establishment of experimental models to evaluate the effectiveness of dental trauma splints

The purpose was to describe a novel simple experimental model of injured teeth for developing dental trauma splints (DTS), and to test various splints by combining use of this model and the Periotest^® device. Rubber O-rings and spring washers were used to simulate and modify injured tooth mobility. Splinting effects were assessed among three kinds of DTS, including a composite splint and two wire-composite splints (1: rectangular orthodontic wire 0.533×0.635 mm, 2: cobalt-chromium alloy wire Φ0.9 mm). The Periotest values were measured three times for each tooth before and after splint insertion. The splinting effect was defined as the change in tooth mobility. Splinting effects significantly increased in the order wire-composite splint 1<wire-composite splint 2<composite splint (p<0.05). This model system could evaluate the effects of DTS including the differences among various splint methods, which showed reasonable reproducibility of dental trauma situations depending on severity in clinical usage.

Evaluation of the flexural properties of a new temporary splint material for use in dental trauma splints

The present study evaluated the flexural properties of a new temporary splint material, G-Fix, for use in dental trauma splints in comparison with other resin materials. Four types of resin materials were considered in the present study: MI Flow II, light-cured composite resin (MI); G-Fix, light-cured resin for splinting teeth (GF); Super-Bond C&B, adhesive resin cement (SB); and Unifast III, self-cured methyl-methacrylate resin (UF). The flexural properties of these four materials were tested according to ISO 4049. The flexural strength significantly increased in the order of UF (64.9 MPa) < SB (76.5 MPa) < GF (94.3 MPa) < MI (161.2 MPa). The elastic modulus significantly increased in the order of UF (2.11 GPa) ≒ SB (2.23 GPa) < GF (2.62 GPa) < MI (7.39 GPa). A splint made of GF may be more flexible than a composite splint, which is categorized as a rigid splint.

Dental Pulp Revascularization in a Replanted Avulsed Immature Maxillary Permanent Central Incisor

An 8-year-old girl sustained an accidental traumatic avulsion of her right maxillary permanent central incisor. She arrived with her mother at a hospital dental clinic with the right maxillary central incisor tooth wrappe in a wet paper towel over 1 hour after the injury. Replantation was accomplished without root surface alteration or root canal intervention. Clinical and radiographic follow-up examinations for over 1 year revealed continued root growth and apical development of the replanted avulsed immature maxillary central incisor with no signs or symptoms of pulpal or periapical pathosis. Excellent outcomes were achieved for periodontal ligament reattachment without removal of the periodontal membrane and pulp revascularization without endodontic intervention.

Routine Screening Radiography for Retained Wire Following Arch Bar Removal Is Not Indicated

PURPOSE

To estimate the screening test value of routine radiography after arch bar wire removal by assessing the incidence of retained wires and the importance of their sequelae.

MATERIALS AND METHODS

This was a retrospective medical record review. Records of arch bar removal procedures were examined and divided into those screened with radiography after removal (screen group) and those that were not screened (comparison group). The incidence of retained wire was calculated for each group. Study variables included wire-related radiographic or clinical findings.

RESULTS

Records of 546 mandible fractures were reviewed; 95 met the study criteria. Most exclusions were due to lack of arch bars, missing postoperative radiographs, or insufficient postoperative documentation. Of the 55 records in the screen group, 1 wire was detected (2%); of the 40 records in the comparison group, 1 wire was detected (3%). The total incidence of retained wire findings was not statistically different between the 2 groups and there were no adverse wire-related sequelae reported by any of the 95 patients.

CONCLUSION

Because of the low incidence of retained wires and wire-related sequelae, routine imaging after wire removal is probably not an effective screening test for retained wire and should be limited to situations in which there is clinical suspicion of retained wire.

A 22-year follow-up of an endodontic implant

Root fractures in the middle and apical thirds of the root are treated by repositioning and for approximately 6 weeks of immobilization while those in the cervical third are immobilized for 3 months. Even though the results are good, some root-fractured teeth are lost and replaced by dental implants or fixed partial dentures. One historic but effective treatment option for those root fractures with unfavorable crown to root ratios is an endodontic implant in middle and apical third root fractures. This method offers immediate stable fixation of a crown and its coronal root segment to the underlying alveolar bone. This report documents the long-term survival of a tooth treated with an endodontic implant. A 25-year-old male patient presented following a bicycle accident with a dislocated unfavorable root fracture in the middle third. The crown with the coronal root segment was secured to the bone using a commercially available endodontic implant. The apical part of the root was removed. Although the clinical and radiological follow-up results of the endodontic implant demonstrated a good clinical function and little bone loss, the implant ultimately had to be removed after 22 years of service due to pain and increasing mobility.

[Transplantation of impacted canines]

Techniques for dental transplantation today are taking better advantage of the potential for healing of the periodontal ligament than in the past and have reduced the risk of ankylosis and root resorption to below 1.5%. The resulting improvement in prognosis has made it possible to more confidently plan procedures that include orthodontic treatment. Transplantations can offer a good end result in certain clinical situations that would otherwise be difficult to manage: ectopic teeth, transpositions, tooth trauma sequellae, advanced decay or advanced periodontitis, implanted hard to treat impacted teeth, and idiopathic ankylosis. This article describes the biological principles for transplantation using double periodontal ligament stimulation, explains the surgical techniques and provides several examples to expand on the treatment of impacted canines, whether or not they present with idiopathic ankylosis. Dental ankylosis is the fusion of the bone with the root. The idiopathic type occurs spontaneously before the eruption of the affected tooth. The etiology is unknown. Because the tooth becomes part of the process of osseous remodeling, it is progressively resorbed and then replaced by bony tissue. This process takes place rather quickly and weakens the tooth. Additionally, an early diagnosis makes it possible to plan a transplantation under favorable circumstances, as that is the only way to halt the ankylosis and to achieve an adequate implantation. In rare cases, the location of the ankylosis is surgically accessible and can be eliminated before resuming orthodontic traction.

Idiopathic ankylosis-resorption: diagnosis and treatment

Dental ankylosis involves the fusion of root to bone. The idiopathic form occurs spontaneously before the eruption of the tooth concerned. Etiology is unknown. As the tooth becomes part of the bone-remodeling process, it is gradually resorbed and is replaced by bony tissue. The process is quite rapid and weakens the tooth. Thus, early diagnosis makes it possible to perform a graft in optimal conditions, this being the only means of severing the ankylosis and achieving adequate eruption. In some rare cases, the ankylotic point of fusion can be reached surgically and can be eliminated before orthodontic traction is initiated.

International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth

Avulsion of permanent teeth is one of the most serious dental injuries, and a prompt and correct emergency management is very important for the prognosis. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the task group. The guidelines represent the current best evidence and practice based on literature research and professionals' opinion. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion or majority decision of the task group. Finally, the IADT board members were giving their opinion and approval. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of avulsed permanent teeth.

Management of maxillary alveolar bone fracture and severely intruded maxillary central incisor: report of a case

An 11-year-old male who injured his maxilla and right maxillary central incisor and lip during a fall was presented to our hospital. His lower lip and upper gingiva were lacerated with swelling and epistaxis, and he had a maxillary alveolar bone fracture and severe intrusion of the right maxillary central incisor, which had penetrated the floor of the nasal cavity with avulsion. Under local anesthesia, we repositioned the incisor and bone segment and fixed them with a titanium micromesh plate and self-tapping screws and splints. The incisor was also treated by root canal 3 days after the operation and was restored with a crown. We performed root canal filling 1 month later. Five months later, the plate and screws were removed. In prognosis of our case, no symptoms of inflammatory root resorption or ankylosis have observed for more than 1 year and 6 months of follow up based on both clinical and radiographic findings.

The Use of MMF Screws: Surgical Technique, Indications, Contraindications, and Common Problems in Review of the Literature

Mandibulo-maxillary fixation (MMF) screws are inserted into the bony base of both jaws in the process of fracture realignment and immobilisation. The screw heads act as anchor points to fasten wire loops or rubber bands connecting the mandible to the maxilla. Traditional interdental chain-linked wiring or arch bar techniques provide the anchorage by attached cleats, hooks, or eyelets. In comparison to these tooth-borne appliances MMF screws facilitate and shorten the way to achieve intermaxillary fixation considerably. In addition, MMF screws help to reduce the hazards of glove perforation and wire stick injuries. On the downside, MMF screws are attributed with the risk of tooth root damage and a lack of versatility beyond the pure maintenance of occlusion such as stabilizing loose teeth or splinting fragments of the alveolar process. The surgical technique of MMF screws as well as the pros and cons of the clinical application are reviewed. The adequate screw placement to prevent serious tooth root injuries is still an issue to rethink and modify conceptual guidelines.

Splinting--when and how?

The prognosis of a tooth following trauma is critical. This depends on various factors, including the type of splint used for immobilization and the immobilization period. This article discusses the above factors with an added note on splint removal.

CLINICAL RELEVANCE

This article is relevant for clinicians who treat traumatic injuries as it should help them to decide on the type of splint to be used and the period of immobilization.

Management of a complex dentoalveolar trauma: a case report

This paper describes the case of a 12-year-old male patient who presented a severe lateral luxation of the maxillary central incisors due to a bicycle fall. Treatment involved suture of the soft tissues lacerations, and repositioning and splinting of the injured teeth, followed by endodontic treatment and periodontal surgery. After a 2-year follow-up, clinical and radiographic evaluation revealed that the incisors presented satisfactory esthetic and functional demands.

Trauma kits for the dental office

The old Boy Scout's motto, "Be Prepared," can be beneficially applied to the management of dental trauma. A large number of dental injuries occur every year, primarily in the 7- to 15-year age group. Preserving the natural dentition during that time period is critically important, because tooth loss at an early age presents significant lifelong dental problems. Being prepared to manage an emergency can make the difference between tooth loss and a successful outcome. Two factors contribute to achieving the better outcome: knowledge of the essentials of dental traumatology, and being prepared with the dental materials needed for appropriate treatment. It is the hope of the authors that these factors are clearly elucidated in this article.

Minor traumatic injuries to the permanent dentition

Treatment of traumatized teeth generally occurs in two phases: short-term emergency treatment and stabilization followed by endodontic management and review. These authors recently reviewed the endodontic considerations in the treatment of traumatized permanent anterior teeth, and in this article review the early management of traumatized permanent teeth. Preoperative assessment and emergency management are emphasized, as is the treatment of immature teeth for which continued development of the root system must be encouraged. Factors influencing long-term prognosis are discussed and the influence of various management strategies evaluated.

Analysis in vitro of direct bonding system with cyanoacrylate ester and orthodontic wires

The aim of this study was to evaluate the tensile strength of orthodontic wires bonded onto the enamel with cyanoacrylate ester. To obtain the specimens, 120 human premolars (extracted for orthodontic or periodontal reasons) were included in acrylic blocks of rapid polymerization with three teeth each. Four groups were formed with ten specimens each. In the specimens, a dental splint model was made with cyanoacrylate ester and round stainless steel wire. In groups I, II and III, cyanoacrylate ester was used with round steel wires, with variation in diameter: 0.014 inches; 0.016 inches and 0.018 inches, respectively. In group IV, round steel wire 0.018 inches was used with photo polymerizing resin composite with previous acid etching. The adhesive force of the materials was measured in two points under the action of the tensiometer (ETM-USA). The number of loose wires was counted along with those that remained fixed according to the different levels of force applied because of the direction of the tensile force (vertical or horizontal) and the diameter of the wire used. The data obtained were first submitted to a descriptive analysis and then submitted to a statistical analysis (Friedman's Test and Dunn's Test of Multiple Comparison - Epi-info 3.2). Within the limitations of the experimental conditions presented, the cyanoacrylate ester or 'Super Bonder' maintained bonded to enamel and steel wires (0.016 and 0.018 inches) during the tensile strength tests under different levels of applied forces.

Treatment of complex dentoalveolar injury--avulsion and loss of periodontal tissue: a case report

Dental avulsion is a common and complex injury which affects multiple oral tissues. In this case report, a 9-year-old girl patient with two traumatically avulsed maxillary central incisors with loss of periodontal tissue was presented. Treatment guidelines for avulsed permanent teeth with open apex were carried out. Bilateral laterally sliding flap procedure was performed, to repair loss of gingival soft tissue. Conventional immobilization was carried out for 6 weeks. Five months follow-up of the patient in whom replantation was performed resulted in positive sensitivity test, no symptoms of infection, pain or any discomfort and good periodontal wound healing. In conclusion, this report presents successful replantation and periodontal treatment of a patient with complex dentoalveolar injury.

Analysis of procedures used in tooth avulsion by 100 dental surgeons

Accurate diagnosis and adequate treatment plan may constitute very complex tasks, particularly in tooth avulsion, because several variables are involved. In addition to the technical knowledge and clinical experience directed toward the quality of treatment, patient education may favorably influence the survival of replanted teeth. The aim of this study was to analyze the procedures used in the management of tooth avulsion by 100 dental surgeons (DSs). Thus, by means of a descriptive questionnaire, information was obtained about the profile of the professionals interviewed, procedures used in cases of tooth avulsion, and patient orientation and education. One hundred properly filled questionnaires were obtained. Descriptive statistics was used for the data, and the chi-squared statistics was employed (epi-info 3.2 software). According to the results, this type of trauma is part of the routine of 15 DSs, although 71 have reported some experience with avulsed teeth. Great deficiencies were found regarding root surface treatment and occlusal adjustment. Positive findings were related to socket treatment, adjunctive therapy, and patient education and orientation (extra-alveolar period, storage medium, manipulation of the avulsed tooth, replantation by the own patient). It was possible to conclude that 47.5% of the procedures reported by 100 professionals interviewed are adequate, and patient education is favorable in 87.7% of cases, a fact that can positively interfere with the prognosis of tooth replantation.

The endodontic management of traumatized permanent anterior teeth: a review

Despite the many journal articles and reviews that have been published regarding the treatment of trauma to teeth, the endodontic management of these injuries is often still not fully understood. The purpose of this review is to establish clear and up-to-date guidelines for practitioners who are faced with treating dental injuries on a day-to-day basis, based on an assessment of current available scientific information relating to the endodontic management of these injuries. Treatment is discussed under the headings: infractions, uncomplicated crown fractures, complicated crown fractures, crown-root fractures, root fractures, luxation injuries, avulsion, root resorption, pulp canal obliteration and open-apex teeth. Emphasis is placed on the treatment of traumatized immature teeth where maintenance of pulp blood supply is important to encourage continued development of the root system. Only the treatment of traumatized permanent anterior teeth is reviewed. Information contained in this article is based on a review of the literature on dental trauma which involved a MEDLINE search using the key words "dental trauma" and the individual topics listed above. The guidelines produced by the International Association of Dental Traumatology, the American Academy of Pediatric Dentistry and the American Association of Endodontists were also reviewed and the recommendations contained in this paper are in concert with the major recommendations of these bodies.

An alternative method for splinting of traumatized teeth: case reports

Injuries to the dentoalveolar complex are fairly common and can be caused by a number of reasons. There are many techniques for repositioning and stabilizing traumatically luxated or avulsed teeth. Many of the splinting techniques previously advocated were time-consuming. Not only were the splints difficult to fabricate and difficult to remove, they also contributed to injury of the soft and hard supporting tissues. Ribbond (Ribbond Inc., Seattle, Wash) is basically a reinforced ribbon which is made from ultrahigh molecular weight polyethylene fiber having an ultrahigh modulus. It is used in dentistry for various purposes. The use of Ribbond appears to be an adequate and easy method for stabilization and fixation. It can be used in the treatment of dental injuries. In this article the use of Ribbond for the treatment of dentoalveolar injuries is described.

Effect of luxation type on pulpal blood flow measurements: a long-term follow-up of luxated permanent maxillary incisors

Laser Doppler flowmetry (LDF) is a non-invasive method to assess pulpal blood-flow (PBF). Dental injury has been associated with significant PBF reduction. The purpose of this study was to assess whether (i) the type of luxation trauma may affect PBF measurements and (ii) whether luxation type-related measurements may show short- and long-term changes of PBF values. In 41 trauma patients, 69 maxillary incisor treated by repositioning and splinting, and the respective contralateral homologous tooth were investigated by LDF to assess local PBF values. Perfusion units were recorded in four sessions, on the day of splint removal, and 12, 24 and 36 weeks after splint removal. Statistical analysis consisted of univariate analysis of variance for repeated measurements. For the LDF measurements, the main effect of the variable 'session' was not significant (P = 0.119). However, there was a significant 'session'/'luxation type' interaction (P = 0.000). Analysis of simple session-within-luxation type effects revealed intrusive luxations to be associated with a significant decrease in PBF values (P = 0.000), while subluxations (P = 0.568), lateral luxations (P = 0.980), extrusive luxations (P = 0.910), and avulsions (P = 0.996) showed no significant difference between session-related values. The PBF measurements did not change over time for the contralateral incisors (P = 0.996). The LDF may become useful in the detection of pulpal ischaemic episodes in luxated maxillary incisors after repositioning and splinting. Further studies are warranted to assess the validity of the diagnosis of post-traumatic 'ischaemic episodes' by comparing it with histological tooth pulp changes, and by determining how well it may predict course and response to treatments in clinical trials.

Use of laser Doppler flowmetry to predict vitality of luxated or avulsed permanent teeth

OBJECTIVE

Splinting of traumatically displaced or avulsed permanent teeth has been described as an effective modality in the treatment of patients with dental injuries. The purpose of this study was to investigate whether laser Doppler flowmetry (LDF) measurements of pulpal blood flow (PBF) and/or dental injury type may predict treatment outcome of splinting of permanent maxillary incisors.

STUDY DESIGN

The study comprised 64 patients undergoing dental trauma splinting, who were characterized by the presence of a single permanent maxillary incisor affected by a subluxation, luxation, or avulsion type injury. Perfusion units (PU) were taken in 2 sessions, on the day of splint removal (6 weeks after trauma; session I) and 12 weeks after splint removal (session II). At each session, when an injured permanent maxillary central incisor was recorded, the respective contralateral homologous tooth was used as a control. An adverse outcome occurring 36 weeks after splint removal was defined as the presence of "periapical radiolucency and/or grey discoloration." A multiple logistic regression analysis was used to compute the odds ratio for session-related PBF characteristics and dental injury type for adverse outcome (n=22) versus nonadverse outcome (n=42).

RESULTS

There was a significant increase in PBF values from session I to session II (P=.047) for teeth without an adverse outcome, whereas teeth affected by an adverse outcome showed a significant decrease in PBF values (P=.001). PBF measurements did not change over time for the control group of contralateral incisors (P=.185). For the outcome criterion of "presence of periapical radiolucency and/or grey discoloration," there was a significant association between the treatment outcome groups and the variables of dental injury type (P=.049), session-related PBF difference (P=.000), and session II-related PBF level (P=.000). Significant increase in risk of an adverse outcome occurred with a session-related PBF difference (PBF(Session I) - PBF(Session II)) of >/=0 PU (8.6 odds ratio) (P=.014), and a session II-related PBF level of </=2.8 PU (20.2 odds ratio) (P=.030).

CONCLUSION

The data suggest the LDF test to be a valuable diagnostic adjunct for luxated teeth showing signs of adverse outcomes. Predictive modeling may provide clinicians with the opportunity to identify "at-risk" teeth early and initiate specific treatments.

Diagnostic characteristics of pulpal blood flow levels associated with adverse outcomes of luxated permanent maxillary incisors

Laser Doppler flowmetry (LDF) is a non-invasive method to assess pulpal blood flow (PBF). Dental injury has been associated with significant PBF reduction. The purpose of this study was (i) to describe PBF characteristics of teeth with specific clinical outcomes, and (ii) to demonstrate diagnostic characteristics for different threshold PBF values for detection of specific multiple adverse outcomes. In 80 trauma patients, a single maxillary incisor treated by repositioning and splinting, and the respective contralateral homologous control tooth were investigated by LDF to assess local PBF values. Perfusion units (PU) were taken in two sessions, on the day of splint removal (session I), and 12 weeks after splint removal (session II). The ability of session II-related PBF measurements at 2.9, 6.4 and 9.9 PU levels to identify adverse outcomes occurring 36 weeks after splint removal was investigated. Adverse outcomes were classified as type I (loss of sensitivity), type II (periapical radiolucency), type III (grey discolouration), type IV (loss of sensitivity and periapical radiolucency), and type V (loss of sensitivity, periapical radiolucency and grey discolouration of crown). Receiver-operator characteristic (ROC) curves were used to evaluate the sensitivity and specificity of PBF assessments. There was a significant increase in PBF values from session I to session II (P=0.0001) for teeth without an adverse outcome, while teeth affected by a type II-V outcome showed a significant decrease in PBF values (P <0.05). PBF measurements did not change over time for the contralateral incisors (P >0.05). A type IV and V outcome occurred in 21 and 24% of the instances, respectively. The PBF of 2.9 PU demonstrated a sensitivity of 70% and a specificity of 93% for type V outcomes. The best likelihood ratio was found for the PBF 2.9 PU level and incisors associated with a type V outcome. The data suggest that the LDF test to be a valuable diagnostic adjunct for luxated teeth showing signs of adverse outcomes including grey discolouration or a combination of other signs. However, it may also become necessary to apply clinical decision-making methods in order to correctly evaluate the value of information gathered. The clinical implication is that LDF may become useful in the prediction of adverse outcomes at a much earlier time period than may be accomplished by standard sensitivity tests.

Intentional replantation of an immature permanent lower incisor because of a refractory peri-apical lesion: case report and 5-year follow-up

We performed an intentional replantation of an immature lower incisor that had a refractory peri-apical lesion. The incisor was extracted and the peri-apical lesion was removed by curettage. The root canal of the tooth was then rapidly irrigated, and filled with a calcium hydroxide and iodoform paste (Vitapex(R)), after which the tooth was fixed with an arch wire splint. Five years later, no clinical or radiographic abnormalities were found, and the root apex was obturated by an apical bridge formation. A team of two dentists is essential to prevent a prolonged operation time, thus eliminating any of the causes of ankylosis. Furthermore, calcium hydroxide and iodoform paste, along with an arch wire splint retained with composite resin, led to good healing of the periodontal tissue after the intentional replantation. Our results indicate that intentional replantation is a useful method for an immature tooth with refractory peri-apical problems.

Assessing revascularization of avulsed permanent maxillary incisors by laser Doppler flowmetry

BACKGROUND

Laser Doppler flowmetry, or LDF, is a noninvasive method used to assess pulpal blood flow, or PBF. Dental avulsion is associated with loss of pulpal sensitivity. The authors conducted this study to assess whether LDF could be used to detect revascularization of replanted teeth.

METHODS

The authors used LDF to assess the PBF values of avulsed permanent maxillary incisors treated using replantation and splinting in 17 subjects. They took measurements at four sessions: on the day of splint removal and at 12 weeks, 24 weeks and 36 weeks after splint removal. Five vital control teeth and five nonvital control teeth were used to assess the background signal. At 36 weeks, the authors determined clinically and radiographically whether revascularization had occurred.

RESULTS

LDF readings correctly predicted the pulp status in 88.2 percent of the readings. Of the readings for vital teeth, 100 percent were correct, and of the readings for nonvital teeth, 80 percent were correct. Univariate analysis of variance demonstrated that in revascularized teeth, the PBF value increased significantly from splint removal to week 12 after splint removal and from week 24 to week 36 after splint removal. In the teeth that failed to revascularize, the PBF value dropped significantly from week 24 to week 36 after splint removal.

CONCLUSIONS

The results of this study suggest that LDF accurately diagnoses revascularization of avulsed maxillary incisors after replantation and splinting.

CLINICAL IMPLICATIONS

LDF may become useful in detecting revascularization much earlier than standard sensitivity tests.

Clinical outcomes for permanent incisor luxations in a pediatric population. II. Extrusions

A longitudinal outcome study was undertaken to identify variables that significantly influenced outcomes for extruded permanent maxillary incisors of children and adolescents. Clinical and radiographic data was available for 35 patients (18 males, 17 females) representing 55 incisors. Mean age at the time of injury was 10.6 years (range: 7.1-17.8 years). Mean time elapsed to follow up was 1320 days (range: 423-2887 days). Survival analysis was used to identify variables significantly related to the prognosis of these teeth. The loss of an incisor following extrusion was uncommon as only one tooth (1/55) required extraction. There was no statistically significant difference in survival between severely extruded teeth and avulsions that had been stored in physiological media (P > 0.10). Pulp necrosis (PN) was the most common complication following injury (43%) and it most often occurred during the first year. Although not statistically significant, a trend towards increased PN was found with more severely extruded teeth (P = 0.20, relative risk = 2.08). Pulp canal obliteration (PCO) was the second most common outcome (35%). The degree of extrusion was proven to be significantly associated with the development of PCO (P = 0.03, relative risk = 0.33). Root resorption was an uncommon outcome (3/55). This study represents the first outcome data on extrusions to permanent maxillary incisors in an exclusively pediatric population.

Evaluation of pulpal blood flow after tooth splinting of luxated permanent maxillary incisors

Laser Doppler flowmetry (LDF) is a non-invasive method to assess pulpal blood flow (PBF). Dental injury has been associated with losses of pulpal sensibility. The purpose of this study was to assess whether LDF could be used to detect short- and long-term changes of PBF values of luxated permanent maxillary central incisors after repositioning and splinting. In 18 trauma patients, a single maxillary incisor treated by repositioning and splinting, and the respective contralateral homologous tooth were investigated by LDF to assess local PBF values. Perfusion units (PU) were taken in four sessions: on the day of splint removal, and 12, 24, and 36 weeks after splint removal. Analysis of the luxation type-related PBF measurements revealed intrusion type-related PBF values to be associated with a significant decrease in PBF values (P < 0.05), while lateral luxation and extrusion type-related PBF values showed no significant difference between the session-related values (P > 0.05). PBF measurements did not change over time for the contralateral incisors (P > 0.05). Teeth affected by an intrusion-type luxation injury remained unresponsive to sensitivity testing at follow up, while 3 (60%) developed grey discoloration of the crown. LDF may become useful in the detection of ischemic episodes of luxated maxillary central incisors after repositioning and splinting. Further studies are warranted to assess the validity of post-traumatic 'ischemic episodes' by comparing it to histological tooth pulp changes.

Clinical outcomes for permanent incisor luxations in a pediatric population. III. Lateral luxations

A longitudinal outcome study was designed to identify variables that influenced tooth survival as well as pulpal and periodontal outcomes of laterally luxated permanent maxillary incisors of children and adolescents. All cases were treated between June 1988 and June 1998 in a teaching hospital clinic. Clinical and radiographic data were collected for 42 patients (26 males, 16 females) that represented 58 permanent maxillary incisors. Mean age at the time of injury was 11.4 years (range: 6.3-17.8 years). Mean follow-up time was 1460 days (range: 183-3905 days). In the entire sample (n = 58), no incisors required extraction. Survival analysis and logistic regression were used to identify variables significantly related to the survival and healing outcomes of these incisors. Pulp necrosis (PN) (40%) and pulp canal obliteration (PCO) (40%) were common healing complications. Proportional hazards (Cox) regression showed that PN develops within the first year. Logistic regression demonstrated that root development (P = 0.3, PN; P = 0.8, PCO) and extent of lateral luxation (P = 0.5, PN; P = 0.9, PCO) were not significantly related to PN and PCO. This study provides the first report of incisor survival in children and adolescents following lateral luxation injuries.

Comfort and discomfort of dental trauma splints - a comparison of a new device (TTS) with three commonly used splinting techniques

The present experimental study compared four dental trauma splints in 10 volunteers. The evaluated splints included a wire-composite splint (WCS), a button-bracket splint (BS), a resin splint (RS), and the newly developed titanium trauma splint (TTS). All splints were bonded to the labial surfaces of the maxillary lateral and central incisors and left in place for 1 week. After splint removal, the next splint was placed after a 1-week rest period. The sequence of splint application was randomized for each individual. The following subjective parameters were assessed using a visual analogue scale: sensitiveness of splinted teeth, irritation of the gingival margin, irritation of the lips, impairment of speech, eating and oral hygiene. The results show that the application of BS leads to a significantly higher irritation of the lips and greater impairment of speech compared to other splints (P < 0.05). The RS leads to an increased and significantly higher irritation of the gingiva (P < 0.05) owing to a significant increase in cleaning difficulties (P < 0.05). In conclusion, WCS and TTS appear to be more accepted splints according to a subjective assessment by 10 volunteers.

Tooth auto-transplantation with double periodontal ligament stimulation to replace periodontally compromised teeth

BACKGROUND

The healing process of autotransplantation puts 2 different tissues in competition: the ligament on the root surface and the bone tissue of the alveolus. This study shows the effects of a protocol with 2 surgical stages, which promote ligament repair, inhibit adhesion between bone and dental root, and reduce the occurrence of the ankylosis-root resorption phenomenon.

METHODS

Forty-three patients, 33 to 73 years old, received 47 transplantations of mature teeth (including retained teeth) during a 5-year period. During the first surgical step, the transplanted tooth is extracted, measured, immediately replaced in its origin site, and maintained with an original suture technique. The alveolus to which the tooth will be transplanted is adapted after extraction of the periodontally compromised tooth. The second surgery occurs at day 14, when regeneration of periodontal ligament (PDL) is at a maximum (first stimulation). The tooth is transplanted in its new alveolus and retained using the same suture technique to avoid a rigid splint and to create mechanical stimulation of the PDL (second stimulation).

RESULTS

The results were 95.75% positive with normal PDL, with a 4.25% failure rate (transplant loss) and no ankylosis. Mean probing reduction was 8.37 +/- 3.0 mm. Mean radiographic bone gain was 7.73 +/- 4.32 mm.

CONCLUSIONS

This study suggests that auto-transplantation with double PDL stimulation can be a viable treatment in clinical practice, especially to replace teeth with large periodontal lesions, deep furcation defects, and/or root fractures. This study shows the high potential of stimulated PDL to regenerate alveolar bone and periodontal structures in severe destruction sites.

Comparison of a new dental trauma splint device (TTS) with three commonly used splinting techniques

Splinting is the standard of care for stabilization of replanted or repositioned permanent teeth following trauma. The present experimental study compared four dental trauma splints in 10 volunteers. The evaluated splints included a wire-composite splint (WCS), a button-bracket splint (BS), a resin splint (RS), and a new device (TTS=Titanium Trauma Splint) specifically developed for splinting traumatized teeth. All splints were bonded to the labial surfaces of the maxillary lateral and central incisors. Splints were left in place for 1 week. After splint removal, the next splint was placed after a 1-week rest period. The sequence of splint application was randomized for each individual. The following parameters were assessed: tooth mobility with horizontal and vertical Periotest values (PTV) before and after splint application and splint removal, respectively; probing depths, plaque and bleeding on probing indices before splint application and removal, and chair time needed for splint application and removal. After splint application, horizontal PTV were significantly lower in central incisors for BS compared to TTS (P=0.04), and for RS compared to TTS (P=0.005) and to WCS (P=0.006). Reduction of lateral tooth mobility (=splint effect) expressed by the difference between horizontal pre- and postoperative PTV was significantly greater in RS compared to TTS and WCS (P<0.05) for central as well as for lateral incisors. However, changes of vertical tooth mobility were not significant across the splinting techniques. Periodontal parameters remained unchanged, reflecting the excellent oral hygiene by the study subjects. The chair time needed for splint application was significantly shorter for TTS (P<0.01). In conclusion, all tested splints appeared to maintain physiologic vertical and horizontal tooth mobility. However, the latter was critically reduced in RS splints.

Splinting of traumatized teeth with a new device: TTS (Titanium Trauma Splint)

Displacement injuries of permanent teeth are an increasing emergency in the dental office. Children and adolescents are particularly prone to dental trauma due to participation in risky activities. Repositioning or replantation with subsequent stabilization by a dental splint is the standard of care for most displaced or avulsed permanent teeth. Non-rigid fixation allowing physiologic tooth mobility has been shown to be desirable for periodontal healing. A flexible splint of short duration appears to reduce the risk of dentoalveolar ankylosis or external replacement resorption. Different splinting techniques are currently recommended for stabilization of repositioned or replanted teeth, including a wire-composite splint, an orthodontic bracket splint or a resin splint. Each splinting option has its specific advantages and shortcomings. This paper describes a new splinting technique which offers improved comfort and handling to the patient and dentist alike.