Clinical
Fig 2
Photograph showing extent of displacement of coronal fragment following horizontal root fracture
Continued »
adhered to when fabricating a chairside splint. Wire-composite splinting is most commonly used and adheres to these principles if placed correctly. Guidelines previously recommended utilisation of rigid and non-rigid splint for different injuries but this has now been replaced by a protocol of non-rigid splinting for all injuries, of varying duration. This usually takes the form of an 0.ı6 Ni-Ti orthodontic archwire, although newer products on the market may supersede this (Fig 4). Care should be taken initially to
pre-bend the wire where possible to adapt it well to the labial surfaces of the injured and supporting teeth. This avoids application of an orthodontic force to the region. Teeth should be spot etched at the mid-labial aspect and a small amount of bonding agent added with the tip of a probe. Over-zealous application of bonding agent results in difficulties in the removal of excess composite at the splint debond appointment. This may have obvious implications for direct physical trauma and potential heat transfer to an already injured pulp. Composite should be placed at the mid-labial aspect of the teeth, well clear of the gingival margin and should be polished to avoid any overhangs, which may act as a plaque trap and a source of irritation to the patient. Splinting of teeth by direct composite union should be avoided due to its rigid nature, difficulties in maintaining oral hygiene and in removal.
Review protocol A robust review protocol is essential in the management of these cases. Various timings have been suggested and a common-sense approach should prevail. The necessity for regular review is dependent on the severity of the initial injury and the likelihood of healing complications later. In general, review
Fig 3
Same patient from Fig 2 following re-positioning and splinting
should be arranged one week, two weeks, four weeks, three months and six months following the date of the injury although slight variations have been proposed to this. The key to review of traumatic injuries
lies in establishment of baseline readings at the initial appointment and subsequent repetition of the examination and recording of results. This can be aided by the development of a custom trauma screen for in-office dental software or a simple stamp for written records. This ensures that nothing is missed at review. Care must be taken in the interpretation
of the results of sensibility tests in the aftermath of these injuries. Literature has suggested that teeth presenting giving positive responses at the initial appointment have a better pulpal prognosis but a period of monitoring is essential before committing any tooth to root canal treatment. The only exception to this appears to be avulsed permanent teeth, in which treatment can be initiated immediately. A common-sense approach should
be adopted towards repeat radiographic examination. Over-exposure of the patient by taking excessive numbers of radiographs is ill-advised both in terms of the ALARA principle and also in terms of diagnostic yield. Splint removal based on the timings
outlined above is best carried out by removing the composite from the injured tooth/teeth first. This allows for their assessment in terms of mobility prior to deciding on whether to debond the whole splint or not. This saves time and avoids subsequent manipulation of injured teeth (Fig 5).
Definitive endodontic treatment A decision on the necessity and timing of endodontic treatment on traumatised teeth must be taken following comparison
Continued » Ireland’s Dental magazine 27
Fig 4a
Titanium trauma splinting wire (Note spaces in wire which may facilitate placment of composite)
Fig 4b
Fig 5
Patient from Fig 1 at one week review appointment. Note vast improvement in condition of soft tissues
Table 2 INJURY Subluxation Lateral luxation Intrusion Extrusion Avulsion Root Dento-alveolar (weeks) TYPE TIME 2 4 4 2 2
4 weeks - 4
months 4
Flexible Flexible Flexible Flexible Flexible Flexible Flexible
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