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Australian Dental Journal

The official journal of the Australian Dental Association


Australian Dental Journal 2016; 61:(1 Suppl) 5973

doi: 10.1111/adj.12398

Splinting of teeth following trauma: a review and a new


splinting recommendation
B Kahler,* J-Y Hu, CS Marriot-Smith, GS Heithersay
*School of Dentistry, The University of Queensland, Queensland, Australia.
Private Practice, Melbourne, Victoria, Australia.
School of Dentistry, The University of Adelaide, South Australia, Australia.
Clinical Professor, School of Dentistry, The University of Adelaide, South Australia, Australia.

ABSTRACT
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 dam-
age 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.
Keywords: Flexible splinting, IADT guidelines, splinting duration, trauma, types of splints.
Abbreviations and acronyms: IADT = International Association of Dental Traumatology.

composite resin splinting when compared with suture


INTRODUCTION
splinting, suggesting the importance of physiological
Splinting has been advocated after repositioning of a movement on healing outcomes.8 Another study
tooth/teeth to stabilize the tooth/teeth and to optimize showed that teeth splinted for just 1 week were clini-
healing outcomes for the pulp and/or the periodontal cally firm,9 which indicated shorter splinting times
ligament.1 A splint has been defined as an apparatus could be considered. As a consequence of these and
used to support, protect or immobilize teeth that have other studies, the International Association of Dental
been loosened, replanted, fractured or subjected to Traumatology (IADT) guidelines recommend splinting
certain endodontic surgical procedures.2 Historically, types that are flexible rather than rigid and employed
splinting of teeth utilized the principles of jaw bone for shorter duration.10 The current recommendations
fracture with rigid, long-term immobilization for a of the IADT are summarized in Table 1.
few months.3 The validity of this approach was ques- The purpose of this review was to examine the
tioned when studies showed rigid immobilization IADT guidelines in relation to splints and the splinting
increased the incidence of pulp necrosis4 and external duration for the different types of trauma. In addition,
root resorption.46 The use of flexible splints arose a new protocol for splinting traumatized teeth is pro-
when animal experimentation reported a lower inci- posed that combines ease of application and removal
dence of ankylosis when teeth were subjected to mas- with no or minimal damage to enamel.
ticatory forces,7 which suggested that splints should
provide some functional movement of the traumatized
Types of splints
teeth. A flexible splint allows functional movement in
contrast to a rigid splint where the injured teeth are As detailed below, many types of splints have been
immobilized. A recent systematic review and meta- used and ideally should meet the following require-
analysis on autotransplanted teeth reported that the ments which have been modified from Andreasens
ankylosis rate was three times higher with wire and original recommendations in 1972.11 A splint should:
2016 Australian Dental Association 59
B Kahler et al.

(1) Allow periodontal ligament reattachment and In this case the left central incisor was not replanted
prevent the risk of further trauma or swallowing as the tooth was lost. An aesthetic splint was provided
of a loose tooth. (Fig. 2).
(2) Be easily applied and removed without additional
trauma or damage to the teeth and surrounding
Composite and shing line splints
soft tissues.
(3) Stabilize the injured tooth/teeth in its correct An alternative to wire is where fishing line replaces
position and maintain adequate stabilization wire and the line is secured with composite resin (see
throughout the splinting period. later in Fig. 12b).
(4) Allow physiologic tooth mobility to aid in peri- An interesting alternative at St Vincents Hospital,
odontal ligament healing. Sydney, utilizes whipper snipper nylon purchased
(5) Not irritate soft tissues. from a hardware store attached to the teeth with
(6) Allow pulp sensibility testing and endodontic coloured composite resin (Ultradent; flowable purple).
access. An example of this splint is shown in Fig. 3. The
(7) Allow adequate oral hygiene. coloured composite provides a guide for the removal
(8) Not interfere with occlusal movements. of the splint to minimize damage to enamel.
(9) Preferably fulfil aesthetic appearance.
(10) Provide patient comfort.
Orthodontic wire and bracket splints
This splint, which is extensively employed by pae-
Table 1. Current IADT recommendations for splinting dodontists in Australia, involves orthodontic brackets
time and type for various types of injuries bonded to the teeth with a resin-based orthodontic
Type of injury Splinting time Splinting type cement and connected with a light 0.014 NiTi flexible
wire. An example of this splint is shown in Fig. 4
Subluxation 2 weeks Flexible splint
Extrusive luxation 2 weeks Flexible splint
where the patient has sustained traumatic injuries to
Lateral luxation 4 weeks Flexible splint the maxillary right central and lateral incisors and the
Intrusive luxation 4 weeks Flexible splint maxillary right central incisor. Orthodontic bracket
Root fracture 4 weeks Flexible splint
Root fracture 4 months Flexible splint
splints allow teeth that have been intruded or not
(cervical 1/3)
Avulsion 2 weeks Flexible splint
Avulsion. Dry 4 weeks Flexible splint
time >60 minutes
Alveolar fracture 4 weeks No recommendation

Types of splints in current use

Composite and wire splints


Fig. 2 A composite resin pontic was bonded to the adjacent teeth to pro-
Composite and wire splints are perhaps the most com- vide an aesthetic splint.
monly used in clinical practice and are flexible splints
when the wire has a diameter of no greater than 0.3
0.4 mm.12 An example of a wire and composite resin
splint is shown in Fig. 1. Another example of a com-
posite and wire splint is shown in Fig. 2 following an
avulsion and subluxation injury to the central incisors.

Fig. 3 A composite resin and whipper snipper nylon splint and purple
Fig. 1 A composite resin and wire splint. coloured composite (courtesy of Dr Peter Foltyn).
60 2016 Australian Dental Association
Splinting of teeth following trauma

Titanium trauma splints


The titanium trauma splint developed by von Arx18 is
a flexible splint made of titanium, 0.2 mm thick and
2.8 mm wide (Medartis AG, Basel, Switzerland). It
has a rhomboid mesh structure which is secured to
the tooth with flowable composite resin. A disadvan-
tage of this splint type is its relatively high cost. An
example of this splint type is shown in Fig. 6C. In this
application composite resin was used instead of flow-
able resin (e.g. Filtek Supreme Plus flowable restora-
tive; 3M ESPE, St Paul, MN, USA). The patient
initially presented with an arch bar splint (Fig. 6a)
which was replaced with a titanium trauma splint
Fig. 4 An orthodontic wire and bracket splint (courtesy of Associate because of gross irritation to the gingival tissues
Professor Sam Gue).
(Fig. 6b).
repositioned correctly to have the occlusal relation-
ships modified at a later date.13,14 However, care Arch bar splints
must be taken that orthodontic forces do not develop
stress that disturbs the healing phase of an injured Arch bar splints were initially adopted for maxillary
tooth.15 While this type of splint was found to be irri- and mandibular fractures in the 1870s and adapted
tating to the lips when compared to composite and for dentoalveolar trauma.19 A metal bar is bent into
wire splints and titanium trauma splints,16 this is gen- the shape of the arch and fixed with ligature wires.
erally not considered to be a clinical problem as any Disadvantages of this technique are that this type of
lip irritation can be avoided with the application of splint is rigid and arch bars may loosen and cause irri-
wax. tation. There may also be physical damage from the
ligature wires to the gingival tissues and the integrity
of the cemento-enamel junction.12 As stated earlier,
Fibre splints an example of an arch bar splint is seen in Fig. 6a.
Fibre splints use a polyethylene or Kevlar fibre mesh The degree of gingival irritation is seen in Fig. 6b.
and are attached either with an unfilled resin such as
OptibondTM FL (Kerr, USA) and/or with composite Wire ligature splints
resin. Materials such as Fiber-Splint (Polydentia SA
Mezzovico-Vira, Switzerland), RibbondTM (Ribbond Wire ligature splints are sometimes used by oral sur-
Inc., Seattle, USA) or EverStick (Stick Tech Ltd, geons in clinics where dental splinting materials may
Turku, Finland), which is a silinated E-type glass not be available and examples are shown in Figs. 7
fibre, are commercially available. An example of a and 8. These splint types are generally rigid and
Fiber-Splint is shown in Fig. 5 following an avulsion impinge on the gingival tissues with resulting inflam-
injury of the maxillary left central and lateral incisor mation, as seen in Fig. 8c taken immediately after
teeth. In a study of 400 root-fractured teeth by splint removal.
Andreasen et al., fibre splints were associated with the
highest frequency of favourable healing outcomes.17 Composite splints
Resin composite applied to the surfaces of teeth is a
rigid splint and accordingly is not recommended in
the IADT guidelines as shown in Table 1. However,
Fig. 9 is an example of a composite resin splint
applied to the labial surfaces of the maxillary right
central incisor and adjacent teeth. Composite splints
that are bonded interproximally to adjacent teeth are
also reported to be prone to fracture.19 Furthermore,
composite splints resulted in greater gingival irritation
when compared with wire and composite, an
orthodontic bracket splint or the titanium trauma
Fig. 5 Application of a bre splint bonded with the unlled resin splint.16 The potential for iatrogenic damage for all
OptiBond to splint an avulsed maxillary left central and lateral incisor splints that utilize composite resin as the adherent
(courtesy of Dr Dan Farmer).
2016 Australian Dental Association 61
B Kahler et al.

(a)

Fig. 7 Wire ligature splint.

approach could require further repositioning with sub-


sequent splinting in a dental office. An example of this
material and splinting application is shown in Fig. 10.
Other temporary splinting may be provided by the use
of the patients mouthguards, orthodontic retainers,
or aluminium foil adapted to the dental arch and cov-
ered with thermoplastic acrylic.20 The suturing of
avulsed and/or luxated teeth as part of emergency
treatment has been described as an alternative
approach.21

A exible splint
Berthold et al. reported in an in vitro study that com-
posite and wire splints where the wire was 0.41 rect-
angular orthodontic wire or 0.45 multistranded
(b) flexible orthodontic wire and the titanium trauma
splint were flexible splints.22 A wire composite splint
consisting of three stranded wires measuring 0.8 mm
x 1.8 mm was found to be rigid. Four resin composite
splints were also tested and found to be rigid. It was
also reported that composite splints may break during
the immobilization period and were difficult to
remove.22 In a further study Berthold et al. found that
the wire length influences rigidity and these authors
recommended splinting only one uninjured tooth
bilaterally.23
Fig. 6 (a) Radiograph of an arch bar secured by wire ligatures. (b) The In the study by Berthold et al.22 teeth were set in
arch bar and ligature splint has been replaced with a titanium trauma
splint. Gross gingival irritation caused by the arch bar splint is evident an acrylic resin model and periodontal mobility was
(courtesy of Dr Rob Hazlewood). mimicked with a soft silicon impression material
(Xantopren Comfort Light, Kulzer, Dormagen,
Germany). To avoid this limitation, Kwan et al.24
used a human cadaveric model. The results of this
cannot be understated and is discussed further in the study also found composite splints and composite and
section below on splint removal. wire splints where the wire diameter was greater than
0.4 mm were deemed to be rigid splints. These
authors considered a wire thickness of 0.4 mm as the
A splint for medical emergency departments
clinical threshold for flexible and rigid splints. The
An innovative approach in splinting developed by Dr use of nylon fishing line with a 20-pound test strength
Peter Foltyn at St Vincents Hospital, Sydney, is the also allowed for physiologic movement and provided
use of Stomahesive (ConvaTec Inc.), a skin barrier the advantage of a more aesthetic appearance than a
adhesive material used for superficial skin trauma. metal wire bonded across the anterior teeth.
This material can crudely hold teeth in the socket and Ebeleseder et al. in a study of 103 post-traumatic
cover coronal fractures to reduce sensitivity when splints made of composite resin and 0.017 x 0.025
patients are seen in emergency medical departments orthodontic steel wire where mobility was tested with
out of hours of routine dental practice. However, this Periotest mobility measurements reported immobiliza-
62 2016 Australian Dental Association
Splinting of teeth following trauma

(a) (b)

(c) (d)

Fig. 8 (a) Interproximal wiring has been applied to splint a transversely fractured maxillary left central incisor. Not only has the fractured tooth been
poorly repositioned, but early gingival tissue irritation is apparent. (b) Radiograph of fractured maxillary left central incisor in Fig. 8a showing evidence
of poor apposition of the fractured segments. (c) Gingival laceration and inammation was evident on removal of the splint. (d) A radiolucency at the
fracture site, coupled with clinical symptoms led to a diagnosis of an infected root canal system in the coronal segment associated with inammation at
the fracture site. Endodontic treatment of the coronal segment to the level of the fracture site was instigated.

shown in Table 1. However, a systematic analysis of


splinting duration and periodontal outcomes for
replanted avulsed teeth found that periodontal out-
comes were unaffected by splinting duration when
comparing short-term splinting (14 days or less) and
long-term splinting (over 14 days).26 These authors
reported that the evidence for an association
between short-term splinting and an increased likeli-
hood of functional periodontal healing or decreased
incidence of replacement resorption was inconclu-
sive. It was concluded that there was no evidence to
refute the current guidelines and suggested that peri-
Fig. 9 A rigid composite splint has been applied to the labial surface of odontal outcomes were unaffected by splinting
the maxillary right central incisor and adjacent teeth.
duration.26
It seems surprising that the IADT guidelines for
tion did not exceed normal tooth firmness.25 These avulsed teeth with extended extraoral dry time
authors also found that there was no benefit from greater than 60 minutes recommend flexible splinting
extending the splint to more than one adjacent firm for 4 weeks despite the knowledge that the pre-
tooth. dictable outcome will be ankylosis with replacement
The IADT guidelines recommend a flexible splint resorption due to the death of the periodontal liga-
for all injury classifications except for alveolar frac- ment cells.9 Furthermore in animal experimentation
ture where no recommendation is given (Table 1). with monkeys, teeth that were splinted for 30 days
demonstrated increased areas of root resorption and
ankylosis when compared to teeth splinted for only
Splinting duration
7 days.5 This suggests that the duration of splinting
Splinting duration times as advocated in the IADT for all avulsion cases should be 2 weeks rather than
guidelines for the specific injury types are also 4 weeks for teeth replanted with greater than 60
2016 Australian Dental Association 63
B Kahler et al.

(a) tion in either of these avulsion categories and recom-


mend splinting for 2 weeks only, irrespective of the
extraoral time.29
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 Relevant findings will be dis-
cussed later under the specific injury types. However,
the guidelines are just recommendations and there
may be instances when patient comfort dictates that
functional splinting duration be extended, e.g. a trau-
matized immature maxillary central incisor which
continues to be mobile, especially if the lateral inci-
sors are yet to erupt.

(b) Levels of evidence


Kahler and Heithersay found that all studies regarding
decisions about splint type and duration included in
their systematic review were only Level 4 studies
as categorized by the Centre of Evidence-based
Medicine.30 Most of the studies were retrospective in
design. Randomized clinical trials are not applicable
in splinting decision choice studies as it would not be
ethical to deny patients the appropriate splinting
choice as advocated in the guidelines (Table 1). In
their review only studies that conducted a multivariate
analysis of variables that may affect outcomes were
included.
Fig. 10 (a) A Stomahesive splint placed at the Royal Brisbane
Hospital Emergency Department. (b) The Stomahesive splint
removed to reveal a crown-root fracture of the maxillary right central
Multivariate analyses
incisor and uncomplicated crown fractures of the left central and
lateral incisors.
Many factors have the potential to affect healing
outcomes for traumatized teeth. In addition to
splinting types and splinting duration, other vari-
ables identified included the age and gender of the
minutes of extended dry time. Andreasen et al. in a patient, stage of root development, severity of the
study of 400 avulsed and replanted teeth found that trauma and degree of dislocation. If the tooth was
there were no significant differences between teeth avulsed, other factors should also be considered
splinted from 0 to 20 days and 21 to 40 days, sug- such as the length of time before replantation, the
gesting that it is inconsequential whether avulsed storage medium utilized and whether further reposi-
teeth are splinted for either 2 or 4 weeks.27 How- tioning of the tooth is required.30 This evidence-
ever, animal28 and human9 studies which demon- based review identified studies where a multivariate
strated that strong gingival attachment to support a analysis was undertaken so that associations
tooth in the socket is attained after just 1 week sug- between the variables identified in univariate analy-
gest that the shorter duration of 2 weeks is indicated ses could be determined. The review identified 12
for both avulsion guidelines. Indeed, in the latter papers that utilized a multivariate analysis for the
study the frequency and extent of replacement following injuries: alveolar fractures,31 luxations,3234
resorption was significantly lower in the non-splinted luxation and avulsion,35 avulsion,27,36,37 and root-
teeth compared to the splinted teeth. As animal fractures.17,3840
experimentation has shown that normal masticatory Using a similar search study as employed in the
stimulation can partially prevent the development of 2008 review, only one further paper was identified
ankylosis in teeth following extraction and replanta- that employed a multivariate analysis and this was a
tion,7 a shorter splinting duration would appear prospective study on intrusion injuries.41 The signifi-
advantageous. Interestingly, the American Association cance of these papers will be discussed below in rela-
of Endodontists recommendations make no distinc- tion to each type of injury.
64 2016 Australian Dental Association
Splinting of teeth following trauma

Luxation injuries ties.42 In a study of 140 intruded teeth, the type of


splint (i.e. flexible, semi-rigid or rigid) and the
The type of splint and fixation period in multivari-
length of splinting time (shorter or longer than
ate analysis studies were generally not significant
6 weeks) were not significant in healing outcomes
variables on healing outcomes.3235,41 Andreasen
on teeth that were surgically repositioned.41
et al. did find that fixed splinting with orthodontic
bands and composite resin splints was a significant
variable for the development of intracanal calcifica- Concussion and subluxation
tion. The less traumatic application of a wire and
The IADT guidelines recommend a flexible splint for
composite resin splint showed similar outcomes as
2 weeks for subluxation injuries. However, splinting
teeth which were not splinted.34 Another study of
is generally not required for concussion or subluxa-
172 luxation injuries immobilized with rigid splints
tion injuries.19,43 Importantly, where multiple teeth
consisting of cap splints, ligature wires +/- acrylic
have had more severe injuries, adjacent teeth with
coverage reported that the fixation period was a sig-
either subluxation or concussion injuries can be
nificant variable for loss of alveolar bone.32 The
splinted without damage to the periodontal liga-
mean duration of immobilization in this study was
ment.43 In a study of 637 luxated teeth, teeth with
52 days. It is plausible in these instances that longer
concussion or subluxation injuries were splinted only
periods of immobilization resulted in bone loss from
if there were other injured teeth.33
periodontitis associated with oral hygiene difficul-

(a) (c)

(b) (d)

Fig. 11 (a) Photograph of the extruded maxillary right central incisor. (b) Photograph of the composite splint and gingival laceration. (c) A radiograph
showing open apices of the maxillary central incisors at the time of splint placement. (d) A 12-month review radiograph showing continued maturation of
the traumatized tooth (courtesy of Dr Jeremy Jansz).

2016 Australian Dental Association 65


B Kahler et al.

Extrusion
(a)
The IADT guidelines recommend a flexible splint for
2 weeks for extrusive luxation injuries. Figure 11 is
an example of an extrusion injury where there was a
dehiscence of the gingival tissues. The repositioned
tooth was splinted with composite resin, which is
likely to have allowed physiologic movement as it was
only bonded to the adjacent central incisor. However,
as the tooth had an open apex, continued root matu-
ration and intracanal calcification had occurred at a
12-month review.

Lateral luxation
The IADT guidelines recommend a flexible splint for
4 weeks for lateral luxation injuries.
(b)

Intrusion
The IADT guidelines recommend a flexible splint for
4 weeks for intrusive luxation injuries where the
intruded tooth/teeth have been repositioned as shown
in Fig. 12a and 12b.

Avulsion
The IADT guideline recommends a flexible splint for
2 weeks for avulsion injuries. For teeth that have been
avulsed and the extraoral dry time is greater than 60
minutes, the recommendation is a flexible splint for 4
weeks. The paradox of the recommendation for the
Fig. 12 (a) An intruded maxillary left central incisor where the tooth
latter injury was discussed earlier. has also been rotated to show the palatal surface. An extensive gingival
The type of splint and fixation periods were not laceration has occurred as a result of the trauma. (b) The intruded tooth
significant variables in a multivariate analysis for has been repositioned and splinted with composite resin and shing line.
The gingival laceration has been sutured (courtesy of Dr Derek Lewis).
pulp and periodontal healing outcomes in a study
of 400 replanted teeth.27,36 In another study of 128
replanted teeth, the fixation period was not a signif-
icant variable on healing outcomes. The type of fix- the recommendation is for a flexible splint for 4
ation was not disclosed.37 In an experimental study months.
on the effect of splinting upon periodontal healing The type of splint and fixation periods were gener-
after replantation of permanent incisors in monkeys, ally not significant variables in studies that used a
the authors reported that in teeth replanted after 18 multivariate analysis for assessment of pulp necrosis
minutes, the frequency and extent of replacement and type of healing/non-healing of the root-fractured
resorption was significantly lower in non-splinted fragments.17,3840 However, some significant relation-
teeth compared to the splinted teeth.6 A limitation ships were noted in a study of 95 root-fractured teeth.
of this study is that the teeth were splinted with an The type of splint was found to be significant for non-
orthodontic band-acrylic splint and the rigid nature healing between the fractured segments.38 In a study
of this splint may have also accounted for the of 400 root-fractured teeth, cap splints had the lowest
extent of the resorption. and Kevlar fibres the highest frequency of favourable
healing outcomes. No difference was noted in healing
outcomes for splinted and non-splinted teeth when
Root fracture teeth were not displaced.17 No effect on healing was
The IADT guideline recommends a flexible splint for noted when treatment was delayed for more than 3
4 weeks for root-fractured teeth. In cases where the days.14 However, it has been suggested that a splint is
root fracture occurred in the cervical third of the root, best placed within 24 hours.44

66 2016 Australian Dental Association


Splinting of teeth following trauma

Figure 13 shows a root-fractured maxillary left cen- ures 15d and 15e were taken at a 4-year review. It
tral incisor that was not splinted as there was no dis- must be emphasized that in this case there have been
placement. At the 5-year review, the tooth has healed no adverse effects from rigid splinting, which is not
with connective tissue between the fractured frag- surprising as it is also commonly used to control
ments. relapse following orthodontic treatment.
Figure 14 shows a high cervical root fracture where Figure 16 shows a maxillary right central incisor
the maxillary left central incisor was rigidly splinted where the root-fractured coronal fragment was also
with a wire and composite resin. The tooth was sub- avulsed. The tooth had three different splints in a 24-
sequently extracted for orthodontic concerns and a hour period. In Fig. 16b the tooth was splinted with a
histological examination revealed hard tissue healing composite resin splint placed interproximally that
between the fractured fragments. A conclusion from debonded within hours of being placed. A composite
the examination of this tooth specimen was that hard resin and wire splint also debonded (Fig. 16c) and was
tissue healing occurred primarily from the dental pulp. replaced with a fibre Ribbond splint (Fig. 16d), which
This has led to an alternative view regarding the was the type of splint associated with the highest fre-
splinting of root fractures located near the cervical quency of associated favourable outcomes in a study of
region as logically it would seem that rigid splinting 400 root-fractured teeth.17 Pulp necrosis and infection
would provide a greater chance of uncomplicated pulp of the root canal system was evident at 6 weeks and
healing than the mobility associated with a flexible hence the coronal fragment had root canal treatment
splint. Andreasen et al. reported that with optimal and was filled with mineral trioxide aggregate.
repositioning of the coronal fragment, positive pulp
sensibility was a frequent finding in teeth with a dislo-
Alveolar fractures
cation of up to 0.5 mm and still occurred in 25% of
cases where the displacement was 0.5 to 1 mm.17 The IADT guideline recommends a splinting time of 4
Figure 15 shows a root-fractured maxillary central weeks though no recommendation is made in regard
incisor where the fracture is in the cervical third of to the rigidity of the splint. In a study with a
the root. In this instance the root was first splinted multivariate analysis of 71 teeth with alveolar frac-
with a flexible splint of composite resin and wire. At tures, the type of splint and fixation period was not a
6 weeks the tooth was responsive to pulp sensibility significant variable in the development of pulp necro-
testing so an orthodontic wire retainer (a rigid splint) sis or pulp canal obliteration.31
was constructed and placed, and then the flexible Furthermore, by definition, teeth with lateral luxa-
composite resin and wire splint removed. This was tion injuries have also sustained an alveolar fracture
done as a recent report has suggested this approach to injury. Therefore the splinting recommendation is
minimize adverse effects of further trauma.46 Fig- consistent for both injuries.

(a) (b) (c)

Fig. 13 (a) Radiograph of a root-fractured maxillary left central incisor where no displacement was noted at the time of fracture so no splint was placed.
(b) Radiograph taken at an 8-week review showing internal resorption remodelling in both the coronal and apical fragments. (c) Radiograph taken at a
7-year review showing extensive calcic reorganization at the fracture site and intracanal calcication in both the coronal and apical fragments.

2016 Australian Dental Association 67


B Kahler et al.

(a) (b) (c)

(d) (e)

Fig. 14 (a) Radiograph showing a cervically located root fracture in the maxillary left central incisor of a 9-year-old female. (b) Panoramic image taken 5
years later at age 14 showing the previously root fractured left central incisor and wire/composite splint in position. (c) Proximal view of the tooth follow-
ing extraction. (d) Radiographs taken from the proximal and labial surfaces. (e) Sagittal histological section in a labio-palatal plane showing pulp and hard
tissue deposition between the fractured segments, Van Giessen stain. Original magnication x 4. (Figs. 14ae reproduced from: Heithersay GS, Kahler B.
Healing responses following transverse root fracture: a historical review and case reports showing healing with (a) calcied tissue and (b) dense brous
connective tissue. Dent Traumatol 2013;29:253-26545).

Splint removal The same study found that tungsten carbide burs and
Soflex discs resulted in the least damage to the
Removal of rigid arch bar splints or interdental wiring
enamel. The use of magnification was also recom-
is often a difficult process involving unwiring and cut-
mended to best identify the enamel-resin interface.47
ting of wires close to the gingival margins with poten-
tial damage to soft tissues. Removing a splint in
which composite resin has been used is not only time The development of a new and simplied splinting
consuming, but iatrogenic injury to the enamel is an regimen
inevitable outcome.47 Techniques of composite
Clearly, a major limitation with the acid-etch com-
removal may involve debonding pliers, handscalers,
posite resin technique commonly used in splinting
ultrasonic scalers, tungsten carbide burs, diamond
traumatized teeth is the difficulty in removal of the
burs, Soflex disks (3M ESPE, St Paul, MN, USA), rub-
resin due to its strong bond strength to enamel. Iatro-
ber wheels and cups. It has been shown experimen-
genic damage to enamel is also an inevitable outcome.
tally that debonding pliers generate shearing forces
Hence research was initiated within the Discipline of
that result in irreversible damage to the enamel. Addi-
Endodontology at The University of Adelaide to eval-
tionally, the forces exerted may disturb the periodon-
uate alternative splinting adhesive systems which
tal healing of the injured tooth.47 Both hand and
could be easily applied, have sufficient bond strength
ultrasonic scalers caused distinctive patterns of enamel
to withstand physical forces during the splinting
detachment and therefore it was concluded that they
period, yet be easily removed without damage to
should not be used for composite removal. A similar
enamel.
recommendation applied to the use of diamond burs.
68 2016 Australian Dental Association
Splinting of teeth following trauma

(a) (b) (c)

(d) (e)

Fig. 15 (a) A high cervical root-fracture of the maxillary central incisor. (b) A functional composite resin and light wire splint placed on the day of injury
following a high cervical root fracture of the maxillary left central incisor. (c) At the 6-week follow-up, a hygienic rigid splint was placed on the palatal
surfaces of the incisor teeth. (d) Radiograph taken at a 4-year review. (e) Photograph of the hygienic splint taken at the 4-year review.

The principal researcher of the study, Jun-Yi Hu, Prior to the application of the test adhesive, a stere-
developed an experimental model designed to simulate omicroscopic analysis of a defined area of the enamel
the dentoalveolar complex which then allowed stan- surface of each test specimen was made to form a
dardized, reproducible evaluations of splinting tech- baseline for post-removal analyses. The mounted teeth
niques using several test bonding adhesives.48,49 The were then subjected to a 24-hour thermocycling and a
model was then used to investigate the clinical appli- functional wear test which was followed immediately
cation of a splint using nylon fishing line (0.55 mm, by a shear-bond test using a Hounsfield Universal
Penn Professional fishing line equivalent to 40 lb Testing Machine. The defined enamel surfaces were
line) attached with 12 dental adhesive materials. Some then examined stereomicroscopically to assess surface
of the materials tested were in current usage and other roughness, enamel damage (Enamel Damage Index)
alternative materials had been developed primarily for and the presence of residual adhesive material (Adhe-
use in orthodontics. sive Remnant Index).
The specific aims of the study were to assess various The results of this study identified GC Fuji Ortho
splinting techniques in respect to the ease of applica- as fulfilling the requirements of an ideal splinting
tion and removal, and the effect on tooth structure adhesive material because of its ease of application
following splint removal. without the need for enamel etching, ability to with-

2016 Australian Dental Association 69


B Kahler et al.

(a) (b)

(c) (d)

(e) (f) (g)

Fig. 16 (a) A root-fractured maxillary right central incisor where the coronal fragment was also avulsed. (b) Radiograph of the replanted coronal fragment
where the coronal fragment was splinted with interproximal composite resin to the adjacent teeth. (c) The splint described in Fig. 16b debonded within
hours and was replaced with a composite and wire splint on the same day. Unfortunately, it also debonded from the lateral incisor later that day. (d) A
bre splint was the third splint placed in a 24-hour period. (e) At 6 weeks, a gingival swelling was evident as well as extrusion of the tooth and stretching
of the bre splint. (f) The coronal fragment was endodontically treated and the coronal fragment was root lled with mineral trioxide aggregate. (g) Radio-
graph taken at the 10-year review. A calcic barrier at the apex of the coronal fragment as a response to the placement of the mineral trioxide aggregate
as well as intracanal calcication of the apical fragment is evident. The adjacent incisor teeth were root lled in the interim period as a consequence of
the original injury.

stand physical forces during the splinting period, and are illustrated in Fig. 17. The injured tooth was the
most importantly ease of removal with minimal or no maxillary left central incisor.
damage to the enamel surface. The application of this The recommended procedures are as follows:
research has been developed both experimentally and (1) After repositioning the injured tooth, the labial
clinically and is now the favoured splinting regimen surfaces of the teeth to be splinted are cleaned
taught in the field of dental traumatology to under- and dried.
graduate students at the School of Dentistry, The (2) A suitable length of 40 Lb nylon fishing line is
University of Adelaide.50 The clinical procedures car- fitted to the labial surfaces of the injured tooth
ried out on a volunteer friend of one the investigators and the two adjacent teeth (Fig. 17a).

70 2016 Australian Dental Association


Splinting of teeth following trauma

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

Fig. 17 (ai) Showing the clinical procedures involved in the application and removal of a nylon shing line/GC Fuji Ortho LC splint as detailed in the
text.

(3) A capsule of Fuji Ortho LC is then gently (6) The GC Fuji Ortho LC is then partially light-
tapped or shaken to loosen the powder. The cured for 10 seconds.
end of the capsule plunger is then pressed (7) GC Fuji Ortho LC is then syringed onto the
against a flat surface so that it is flush with labial surface of the repositioned injured central
the body of the capsule, prior to activation for incisor while maintaining its correct position
1 second with an applicator gun and then with finger pressure (Fig. 17d). Again a cotton
mixed at high speed in an amalgamator/mixer pellet moistened in water can be used to manipu-
for 10 seconds. The working time after mixing late and smooth the splinting material (Fig. 17e).
is 3 minutes at 23 C. (8) Light-cure the entire splint for 40 seconds.
(4) GC Fuji Ortho LC capsule is then syringed onto (9) Trim the excess nylon fishing line and with scis-
the labial surfaces of the uninjured adjacent teeth sors (Fig. 17f) smooth the splint with a carborun-
and the fishing line is applied to the unpolymer- dum or Soflex disk to complete the splint
ized material (Fig. 17b). A cotton pellet moist- application (Fig. 17g).
ened in water can be used to facilitate the (10) Splint removal using stable finger rests,
manipulation of the GC Fuji Ortho LC over the removal of the splint is effected using either a
nylon fishing line. spoon excavator or flat plastic against the cre-
(5) A groove is then created on the incisal aspect of ated ledge on the incisal margin of the GC Fuji
the GC Fuji Ortho LC material and the enamel Ortho LC material (Figs. 17h, 17i). Any
surface using a flat plastic instrument (Fig. 17c). remaining material can be simply removed with
2016 Australian Dental Association 71
B Kahler et al.

a spoon excavator followed by simple enamel 8. Chung W-C, Tu Y-K, Lin Y-H, Lu H-K. Outcomes of
autotransplanted teeth with complete root formation: a system-
polishing with a rubber cup and prophylactic atic review and meta-analysis. J Clin Periodontol 2014;41:
paste. 412423.
While GC Fuji Ortho LC has been shown to fulfil the 9. Andreasen JO. Periodontal healing after replantation of trau-
requirements of an ideal splinting adhesive material, a matically avulsed human teeth. Assessment by mobility testing
practical alternative is GC Fuji 2 which has similar and radiography. Acta Odontol Scand 1975;35:325335.
physical characteristics and handling properties, and is 10. International Dental Association of Dental Traumatology.
Available at: URL: http://www.iadt-dentaltrauma.org/1-9%20%
more commonly used in dental practices. Fifth-year 20iadt%20guidelines%20combined%20-%20lr%20-%2011-5-
dental student evaluation of the handling of the two 2013.pdf. Accessed September 2015.
materials was strongly in favour of GC Fuji Ortho LC. 11. Andreasen JO. Traumatic injuries of the teeth. Copenhagen:
The technique is not confined to flexible splints and Munksgaard, 1972:154.
incorporation of wire of at least 0.8 mm diameter into 12. Oikarinen K. Comparison of the flexibility of various splinting
methods for tooth fixation. Int J Oral Maxillofac Surg
GC Fuji Ortho LC may be used where rigid splinting 1988;17:249252.
is indicated. Again this method of fixation has the 13. Dawoodbhoy I, Valiathan A, Lalani ZS, Cariappa KM. Splint-
advantage of simplicity of application and removal. ing of avulsed central incisors with orthodontic wires: a case
report. Endod Dent Traumatol 1994;10:149152.
14. Mackie IC, Wareen VN. Dental trauma: 3. Splinting, displace-
CONCLUSIONS ment injuries, and root fracture of immature permanent incisor
teeth. Dent Update 1998;15:332335.
While the type of splint and the splinting duration
15. Prevost J, Louis P, Vadot J, Granjon Y. A study of forces origi-
have not been generally shown to affect healing out- nating from orthodontic appliances for splinting of teeth.
comes, the IADT guidelines support the use of flexible Endod Dent Traumatol 1994;10:179184.
splints whenever possible. This has often been 16. Filippi A, von arx T, Lussi A. Comfort and discomfort of den-
achieved with the use of composite resin or orthodon- tal trauma splintsa comparison of a new device (TTS) with
three commonly used splinting techniques. Dent Traumatol
tic brackets and light wire. Both of these techniques 2002;18:275280.
have been shown to cause iatrogenic damage to the 17. Andreasen JO, Andreasen FM, Mejare I, Cveck M. Healing
enamel. A new protocol using a resin activated glass- of 400 intra-alveolar root fractures. 2. Effect of treatment
ionomer cement has been proposed that offers ease of factors such as treatment delay, repositioning, splinting type
and period and antibiotics. Dent Traumatol 2004;20:203
application and removal with minimal or no iatro- 211.
genic damage to enamel. 18. Von Arx T, Filippi A, Buser D. Splinting of traumatized teeth
with a new device: TTS (titanium trauma splint). Dent Trauma-
tol 2001;17:180184.
DISCLOSURE 19. Oikarinen K. Tooth splinting: a review of the literature and
consideration of the versatility of a wire-composite splint.
The authors have no conflicts of interest to declare. Endod Dent Traumatol 1990;6:237250.
20. DeAngelis AF, Barrowman RA, Harrod R, Nastri AL. Review
article: Maxillofacial emergencies: dentoalveolar and temporo-
REFERENCES mandibular joint trauma. Emerg Med Australas 2014;26:439
1. Oikarinen KS. Splinting of traumatized teeth. In: Andreasen JO, 445.
Andreasen FM, Andersson L, eds. Textbook and Color Atlas of 21. Lin S, Emodi O, El-Naaj IA. Splinting of an injured tooth as part
Traumatic Injuries to the Teeth. 4th edn. Copenhagen: Black- of emergency treatment. Dent Traumatol 2008;24:370372.
well Publishing, 2007:842851.
22. Berthold C, Thaler A, Petschelt A. Rigidity of commonly used
2. American Association of Endodontists. Glossary of Endodontic dental trauma splints. Dent Traumatol 2009;25:248255.
Terms. 8th edn. Available at: URL: http://www.nxtbook.com/
nxtbooks/aae/endodonticglossary/index.php. Accessed Septem- 23. Berthold C, Auer FJ, Potapov S, Petschelt A. Influence of wire
ber 2015. extension and type on splint rigidityevaluation by a dynamic
and a static measuring method. Dent Traumatol 2011;27:422
3. Kehoe JC. Splinting and replantation after traumatic avulsion. 431.
J Am Dent Assoc 1986;112:224230.
24. Kwan SC, Johnson JD, Cohenca N. The effect of splint material
4. Kristerson L, Andreasen JO. The effect of splinting upon peri- and thickness on tooth mobility after extraction and replanta-
odontal and pulpal healing after autotransplantation of mature tion using a human cadaveric model. Dent Traumatol
and immature permanent incisors in monkeys. Int J Oral Surg 2012;28:277281.
1983;12:239249.
25. Ebeleseder KA, Glockner K, Pertl C, Stadtler P. Splints made of
5. Nasjleti CE, Castelli WA, Caffesse RG. The effects of different wire and composite: an investigation of lateral tooth mobility
splinting times on replantation of teeth in monkeys. Oral Surg in vivo. Endod Dent Traumatol 1995;11:288293.
Oral Pathol Oral Med 1982;53:557566.
26. Hinckfuss SE, Messer LB. Splinting duration and periodontal
6. Andreasen JO. The effect of splinting upon periodontal healing outcomes for replanted avulsed teeth: a systematic review. Dent
after replantation of permanent incisors in monkeys. Acta Traumatol 2009;25:150157.
Odontol Scand 1975;33:313323.
27. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM.
7. Andersson L, Lindskog S, Bloml of L, Hedstr om K-G, Replantation of 400 avulsed permanent incisors. 4. Factors
Hammarstr om L. Effect of masticatory stimulation on den- related to periodontal ligament healing. Endod Dent Traumatol
toalveolar ankylosis after experimental tooth replantation. 1995;11:7689.
Endod Dent Traumatol 1985;1:1316.

72 2016 Australian Dental Association


Splinting of teeth following trauma

28. Andreasen JO. A time-related study of periodontal healing 41. Andreasen JO, Bakland LK, Andreasen FM. Traumatic intru-
and root resorption activity after replantation of mature sion of permanent teeth. Part 3. A clinical study of the effect of
permanent incisors in monkeys. Swed Dent J 1980;4:101 treatment variables such as treatment delay, method of reposi-
110. tioning, type of splint, length of splinting and antibiotics of 140
29. American Association of Endodontists. The treatment of trau- teeth. Dent Traumatol 2006;22:99111.
matic dental injuries. Available at: URL: http://www.aae.org/ 42. Ngassapa DN, Friehofer HP, Maltha JC. The reaction of the
uploadedfiles/publications_and_research/newsletters/endodontics_ periodontium to different type of splints. 1. Clinical aspects.
colleagues_for_excellence_newsletter/ecfe_summer2014%20final. J Oral Maxillofac Surg 1986;51:240249.
pdf. Accessed September 2015. 43. Andreasen FM, Andreasen JO. Concussion and subluxation. In:
30. Kahler B, Heithersay GS. An evidence-based appraisal of splint- Andreasen JO, Andreasen FM, Andersson L, eds. Textbook and
ing luxated, avulsed and root fractured teeth. Dent Traumatol Color Atlas of Traumatic Injuries to the Teeth. 4th edn. Copen-
2008;24:210. hagen: Blackwell Publishing, 2007:404410.
31. Andreasen JO. Fractures of the alveolar process of the jaw. 44. Andreasen JO, Andreasen FM, Skeie A, Hjrting-Hansen E. Effect
Scand J Dent Res 1970;78:263272. of treatment delay upon pulp and periodontal healing of traumatic
32. Andreasen JO. Luxation of permanent teeth due to trauma. A dental injuriesa review article. Dent Traumatol 2002;18:116128.
clinical and radiographic follow-up study of 189 injured teeth. 45. Heithersay GS, Kahler B. Healing responses following trans-
Scand J Dent Res 1970;78:273286. verse root fracture: a historical review and case reports showing
33. Andreasen FM, Vestergaard-Pedersen B. Prognosis of luxated healing with (a) calcified tissue and (b) dense fibrous connective
permanent teeththe development of pulp necrosis. Endod Dent tissue. Dent Traumatol 2013;29:253265.
Traumatol 1985;1:207220. 46. Andreasen JO, Ahrensburg SS, Tsilingaridis G. Tooth mobility
34. Andreasen FM, Yu Z, Thomsen BL, Andersen PK. Occurrence changes subsequent to root fractures: a longitudinal clinical study
of pulp canal obliteration after luxation injuries in the perma- of 44 permanent teeth. Dent Traumatol 2012;28:410414.
nent dentition. Endod Dent Traumatol 1987;3:103115. 47. Cehreli ZC, Lakshmipathy M, Yazici R. Effect of different
35. Oikarinen K, Gundlach KKH, Pfeifer G. Late complications of splint removal techniques on the surface roughness of human
luxation injuries to teeth. Endod Dent Traumatol 1987;3:296 enamel: a three-dimensional optical profilometry analysis. Dent
302. Traumatol 2008;24:177182.

36. Andreasen JO, Borum MK, Jacobsen MK, Andreasen FM. 48. Hu J-Y, Heithersay GS. An evaluation of alternate splinting
Replantation of 400 avulsed permanent incisors. 2. Factors adhesives in the management of dental trauma. Aust Dent J
related to pulpal healing. Endod Dent Traumatol 1995;11:59 2011;56:S16.
68. 49. Hu J-Y. An evaluation of alternative splinting adhesives. Ade-
37. Kinirons MJ, Gregg TA, Welbury RR, Cole BOI. Variations in laide: The University of Adelaide, 2000. Honours degree thesis.
the presenting and treatment features in replanted permanent 50. Marriot-Smith C, Marino V, Heithersay GS. A preclinical den-
incisors in children and their effect on the prevalence of root tal trauma teaching module. Dent Traumatol 2015 Dec 15. doi:
resorption. Br Dent J 2000;189:263266. 10.1111/edt.12251 [Epub ahead of print].
38. Andreasen FM, Andreasen JO, Bayer T. Prognosis of root frac-
tured incisors: prediction of healing modalities. Endod Dent
Traumatol 1989;5:1121. Address for correspondence:
39. Cvek M, Andreasen JO, Borum MK. Healing of 208 intra-
Dr Bill Kahler
alveolar root fractures in patients aged 717 years. Dent Trau- 9th Floor, 141 Queen Street
matol 2002;17:5362. Brisbane QLD 4000
40. Welbury RR, Kinirons MJ, Day P, Humphreys K, Gregg TA. Australia
Outcomes for root-fractured permanent incisors: a retrospective
study. Pediatr Dent 2002;24:98102.
Email: w.kahler@uq.edu.au

2016 Australian Dental Association 73

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