Splinting of Traumatized Tooth - A Systematic Review

Introduction

Avulsion of tooth is the complete displacement (exarticulation) of the tooth from alveolus, severing the pulpal blood supply and exposing the cells of the periodontal ligament to the external environment.¹ Extra-oral period which influences the periodontal ligament vitality determines the prognosis and outcome. Thus the management should aim at preventing or minimizing inflammation from attachment damage and pulpal infection, thereby promoting periodontal healing.² Splinting helps in stabilizing the displaced tooth, allowing healing of the pulp and periodontium.¹ In case of an immature tooth with an incomplete root, splinting also retains the tooth in position. It was also reported that certain instances of self-replanted teeth without any treatment have shown retention in place for many years. Ideally, a splint should stabilize the tooth in the previously occupied area without further trauma or gingival injury, and allow adequate oral hygiene. Semi-rigid or flexible splinting allows physiologic tooth movement, facilitating functional stimuli that assists in healing. No clinical studies have evaluated the relationship between splinting and periodontal healing. Longer periods of splinting can lead to ankyloses of the tooth and replacement resorption which is not common with short period splinting. Ankylosis is one of the most common periodontal outcome after repositioning of the tooth.² It is now recommended the tooth to be kept in position by means of splinting for up to two weeks rather than six weeks as recommended previously; splinting for one week may be adequate for periodontal healing.³

The current guidelines for dentists in managing avulsed permanent teeth (excluding root fractures and alveolar fractures) recommend splinting periods as follows: The International Association of Dental Traumatology (IADT), up to two weeks; The American Academy of Pediatric Dentistry (AAPD), seven days; The American Academy of Endodontics (AAE), 7–14 days; The Royal College of Dental Surgeons England (RCDSE), 7–10 days. Acid-etch bonded composite resin splints (e.g., wire-composite), and titanium splints are recommended.^4,5

This paper reports a step wise systematic review of the literature analyzing and determining the effect of factors such as duration of splinting, splinting devices and the splinting technique on long term prognosis of traumatized teeth.

Materials and Methods

This systematic review was conducted adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines and the Joanna Briggs Institute critical appraisal checklist for systematic reviews.

Types of studies

Randomized controlled trials (RCTs) published over a period of 30 years were included in this review. Studies wherein splinting was done after repositioning following avulsion with different splint materials, with a follow up period were included.

PICO Question

Evidence-based studies use PICO question, which in this study was: P (problem): for a replanted avulsed permanent tooth; I (intervention): short-term splinting (14 days or less); C (comparator): compared with long term splinting (over 14 days); O (outcome): increased likelihood of successful periodontal healing. A cutoff point of 14 days was selected to accommodate collectively the current splinting guidelines of IADT, AAPD, AAE, and RCDSE.

Types of intervention

Splinting material used and the duration of splinting technique.

Types of outcome measures

1. Prognosis after splinting
2. Relationship between splint material and treatment outcome
3. Indication of root canal treatment in case of avulsion

Results

A total of five studies published from 1988 to 2018 were included.

Studies investigating effects of splinting duration

One retrospective and four prospective studies investigated splinting periods in relation to periodontal healing outcomes, using the criteria (Table 3).

The sample included 21 avulsed teeth, and replanted within 15 min of time over a period of five years. Andersson & Bodin found no relationship between rate of root resorption and splinting period.

Andreasen et al. in the prospective studies, reported that splinting periods of 40 days or more resulted in less frequent periodontal healing (not statistically significant) than shorter periods (Table 3). Chappuis et al, reported a survival rate of 95.6% (43/45) at one-year reexamination. Andreasen JO et al, observed no correlation between healing and splinting duration for a follow up period of up to eight years. At 96 week follow up after splinting, Emshoff et al, reported that 71% showed no clinical or radiographical findings of adverse outcome.

Direct comparison of short-term and long-term splinting

Only studies reporting splinting periods according to current guidelines of IADT, AAPD, AAE, and RCDSE were included. Two papers^1,4 provided data directly comparing short-term splinting (ST, 14 days or less) and long-term splinting (LT, over 14 days) in relation to periodontal healing outcomes (Table 4). Few teeth were excluded in the present study due to insufficient data on splinting periods or healing outcomes,^2,3,5 or due to misfit of splinting period (11–19 days), reducing sample size. A total of 83 teeth (ST splinting: 18; LT splinting: 65) were pooled (Table 4). After ST splinting, the periodontal outcomes varied after splinting technique (ST) significantly: 2/4 teeth,¹ 8/14 teeth⁴ ; total 10/18. After LT splinting, favorable periodontal outcomes also varied widely between the studies: 4/13 teeth,¹ 24/52 teeth⁴ ; 28/65.

Based on an evidence-based assessment of two papers reporting clinical studies on 83 replanted permanent teeth splinted according to current clinical guidelines (18 teeth for 14 days or less, 65 for more than 14 days), the present study suggests that the periodontal healing is not affected by duration of splinting. Andreasen et al, recommended splinting of teeth for up to 40 days, as splinting for 6 weeks or more resulted in lower frequency of healing. This large study was not included in the present study as the splinting periods (20 days, 21–40 days, 40 days) could not be adapted to fit within the selected classification by clinical guidelines of 14 days or less and more than 14 days. Thus, the present study is in accordance with the study done by Andreasen et al. Kinirons et al, in a study demonstarted a lesser prevalence of resorption in teeth splinted for 10 days or less, supporting current guidelines. Vitality of periodontal ligament cells (strongly affected by extraoral time and storage conditions) may have a greater effect on functional healing than splinting period.⁶

A latest retrospective case audit of 100 replanted avulsed teeth showed 41% of root resorption (ankylosis).The present study showed, improvement of replacement resorption in 44% of the pooled sample receiving brieftime period splinting and in 48% of the pooled pattern receiving long-term splinting.Transient replacement resorption might also reflect gradual substitute resorption, which may be affected by metabolic conditions, physiologic bone turnover and affected person age. In the teeth with extended extra oral time where the chances of resorption is higher, the splinting time period must be considered along with the extra oral time.²

Various methods of splinting may effect the clinical or tooth development which needs early/late splint removal, altering the treatment outcomes. For example, teeth with immature short roots, horizontal root fractures or alveolar bone fractures may require splinting beyond 14 days to ensure stability. Dentists must be reassured about the splinting to maintain the periodontal restoration up to 14 days. However, plaque buildup, difficult oral hygiene, esthetics, and patient comfort must be considered in long-term splinting.²

When splinting was used to stabilize surgically repositioned teeth, three different types of splints were tested. The statistical analysis confirmed no difference in the remedy final results (PN, RR and MA) among the ones. In a unique evaluation, it became examined whether bendy and semi-rigid in comparison to rigid splinting showed any difference in recuperation, and this will not be proven.⁷

In this prospective clinical study, 19 patients (7 females, 12 males, minimum age: 45, maximum: 72 years old) received FRC splints at the Ege University, Dental School, Department of Prosthodontics, Izmir, Turkey, Overall survival rate was 94.8% (Kaplan–Meier). The survival rate became no longer significantly tormented by the composite kind 1(Filtek-drift/Filtek ideal: 100%, Tetric waft/Tetric Ceram: 96% (p = zero.ninety two) [Kaplan–Meier, Log Rank (Mantel–Cox) (CI = 95%)]. chance ratio for Tetric glide/Tetric Ceram organization was 0.05 (95% CI) and for Filtek float/Filtek splendid institution zero.00 (95% CI). They concluded that Direct teeth splinting with E-glass FRC cloth completed correctly up to four years. Periodontal popularity of the splinted enamel showed reduced Periodontal Pocket depth and medical attachment level.⁸

Oskar et al, after his study which assessed the relation between suture splinting for 1 week or rigid fixation for four weeks on final root period, root duration increment, and the third molars which were relocated from position depicted transplants in the rigid organization found out a substantially decrease final root period (P.002) and root period increment (P.001) than the ones in the suture organization. The differences were observed to be greater stated in transplants at in advance developmental stages. The transplantation mobility were not having any differences in their values. The outcomes of his look at suggest that extended time rigid fixation of autotransplanted immature third molars showed a significantly terrible affect on final root period and root length increment, mainly in transplants at in advance developmental levels.⁹

Filippi et al, did an experimental study to as compared 4 types of splints in subjects with trauma which covered a twine-composite splint (WCS), a button-bracket splint (BS), a resin splint (RS), and the newly advanced titanium trauma splint (TTS). The devices were attached to the maxillary lateral incisors on the labial aspect and primary incisors and left in place for 1week. Splint became loosened after a 1-week relaxation period following the splinted device removal. The sequence in which the splint to be applied become randomized for every person. the subsequent subjective parameters have been assessed the usage of a visual analogue scale: sensitivity in the splinted enamel, infection of the marginal gingiva, lip mucosal irritation, difficulty in speech, ingesting and oral hygiene. The effects illustrated the use of BS leads to a drastically higher irritation of the lips and extra impairment of speech in comparison to other splints (P<0.05). The RS ends in an increased and drastically better inflammation of the gingiva (P<0.05) due to a large boom in cleansing difficulties (P<0.05). In end, WCS and TTS appear to be more common splints in keeping with a subjective evaluation.¹⁰

Christine Berthold et al, evaluated the stress of numerous normally used splints in vitro and concluded that bendy or semirigid splints inclusive of the titanium trauma splint and wire-composite splints and a couple of non-rigid devices are useful in splinting enamel which had to dislocate trauma and fracture of the root, in contrast, rigid splints which include both the use of composite and wire and the titanium ring splint can be used to deal with alveolar method fractures.¹¹

Studies by Loe H et al, and Gregg TA et al, have documented that after a storage time of 15 minutes or less, healing with functional PDM is possible.^12,13 After longer extraoral periods, severe cell damage and root resorption have been documented by Hammerstro et al, and Dorney B et al, ^14,15 Studies by Anderson el al, confirms earlier experimental studies and clinical observations that replanted tooth after a short extraoral time (less than 15 min) will heal with no or limited root resorption. If root resorption occurs the resorption will be limited to a small area and only in a few instances be progressive.⁷

Most of the teeth without resorption were either immediately replanted or replanted within 10 min. In contrast, all teeth that had been subjected to 15 min extraoral storage showed signs of root resorption. Consequently, the extraoral time seemed to be a more important factor than the trauma of avulsion for the subsequent appearance of root resorption.⁷

Conclusion

This qualitative systematic review on splinting duration and healing of periodontium, primarily based on five papers, each reporting both short-term splinting (14 days or much less) and long term splinting (over 14 days), indicate that the success rate of periodontal recuperation after replantation is not affected by splinting period. The evidence for an affiliation between short-term splinting and an increased probability of purposeful periodontal recuperation, a suitable recovery outcome, or decreased development of alternative resorption seems inconclusive. Within the limitations of the present study and advocating further research, it can be concluded that dentists continue to use the currently recommended splinting periods in managing replanted permanent teeth.

Conflicts of Interest

None