Journal of Nepal Dental Association (2011), Vol. 12, No. 1, Jan.-Jun.

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Case Note

Extrusion splint technique in management of dental trauma: A case report

Dental Surgeon, 2Assistant Professor, 3Associate Professor, Department of Periodontics, College of Dental Surgery, B.P. Koirala Institute of Health Science, Dharan, Nepal.

Abstract Trauma to the teeth can be transmitted to the supporting structures, which get damaged. Intrusive luxation is an apical displacement of the tooth. Fracture of the alveolar bone usually accompanies this trauma. The intruded tooth is extruded surgically, repositioned and facilitated for endodontic treatment. This can cause mobility of the teeth. Such mobile teeth may require splinting for a specied period of time till the supporting tissues heals and the tooth becomes stable. This type of non-avulsive tooth displacement has worst prognosis if the biology of bone healing in the periapical area is not considered seriously. Key words: Dental trauma, Ellis and Daveys class VII, Extrusion splint, Anti and pro inammatory cytokines, Bone healing

Introduction Dentoalveolar traumas are observed and treated in dental clinics. Their severity depends on the energy of impact and direction of the causal agent, as well as on the resistance of the tissues surrounding the traumatized teeth, which are more susceptible at the anterior region1, along with immunological factors, particularly in cases of avulsion and replantation2. Facial and dental injuries may be more frequent than other irreversible damage like periodontal disease and caries in a near future, causing social, esthetic and psychological disturbances to the patients3, 4, 5. The term traumatic intrusion refers to displacement of a tooth deeper into the alveolar bone due to traumatic force and is usually associated with alveolar fracture. It comprises greater percentage of all injuries to the permanent teeth. It is usually associated with complications like pulp necrosis, inammatory root resorption, ankylosis and loss of marginal bone support. These complications may be overcome by early periodontal care adjunct with endodontic treatment6. Despite the widespread nature of dental trauma, there are very few published treatment aspect reports which aim to preserve the vitality of periodontium. Hence this case report aims to describe the technical management

of traumatically intruded tooth by extrusion splint technique keeping vital the periodontal ligament. Case report A male patient aged 28 years was referred to the Department of Periodontics, College of Dental Surgery BPKIHS, Dharan, Nepal, for periodontal evaluation of upper anterior teeth. The patient presented with a history of road trafc accident 5 days back. His medical history was uneventful. The patient had a fracture of left parasymphysis of mandible, for which an open reduction and internal xation using titanium plates under general anaesthesia had been performed by the Department of Oral and Maxillofacial Surgery. He was on antibiotic and anti-inammatory drugs for a week. On extraoral examination, there was a restricted mouth opening. Intraorally, 3-0 silk suture ligation was present with respect to 11 region/socket (FDI system), which was extracted on the day of the accident. Generalized inammation of the marginal and attached gingiva with loss of interdental papilla was observed with respect to the upper anteriors, Millers grade II mobility was noticed with respect to 21. Periapical radiograph of the upper anterior teeth revealed intrusion with respect to 12, 21 and 22 with alveolar bone fracture (Fig 1 and 2). Any

Correspondence Dr. Shankar Babu TP, Assistant professor, Department of Periodontics, College of Dental Surgery, B.P.Koirala Institute of Health Science, Dharan, Nepal, E-mail: [email protected] J. Nepal Dent. Assoc. (2011), Vol. 12, No. 1

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root fracture and periapical pathology was ruled out. Treatment plan was designed to extrude 12, 21 and 22 and stabilize them, maintaining the periodontal vitality, reduce the mobility of 21 and nally check the root resorption of traumatized teeth. The acid-etch composite and ligature wire splint was considered for this case. To reduce the extra load on individual teeth, a rm tooth was involved corresponding to Antes law. Ligature wire splint was fabricated to overcome plaque retentive area near the inamed gingiva and difculty in maintaining plaque free zone, the major disadvantage of acrylic tape (Riband). This splint holds the teeth rigid without producing torsional stresses on any incorporated teeth and extends around the arch so that the anteroposterior and faciolingual forces are counteracted. It also provides access for root canal treatment. A 0.7 mm stainless steel wire was used as it is exible enough to allow some physiological movement of the teeth but will still stabilize the traumatized tooth in its socket, and also because of its easy manipulation. The wire was twisted in two folds for braided appearance which will ease the composite stability and prevents the rotation in horizontal plane which is most common in thicker gauge stainless steel wire. Armamentarium used Light cure composite set Artery forceps Orthodontic wire cutters Normal saline Gauze pieces Tweezers 3-0 silk suture Extraction forceps(upper anterior) Cotton rolls Suction Air source to dry the teeth Tissue holding forceps Straight and curved Scissors

On the rst visit, the patient was informed about the prospects of repositioning and splinting the teeth. Written

informed consent was taken. The placement of an acidetch composite and wire splint was relatively easy. The important part of this technique was to have good moisture isolation for the acid-etch composite to bond to the enamel surface. The procedure started with a preprocedural rinse to remove any debris from the mouth following which both the right and left infraorbital nerve blocks were administered along with the nasopalatine nerve block, to reduce discomfort to the patient .The braided ligature wire was manipulated to include the traumatized tooth and one sound tooth on either side based on pericemental area. Ideally, the wire should be positioned in the junction of incisal and middle third of the labial surface of the crown, away from the gingival margin to aid proper cleaning of the interdental areas by proxabrush. Repositioning of the intruded tooth was done using an extraction forceps (Fig 3). A gauze piece was used to remove blood, plaque, debris and saliva from the teeth. The teeth were then isolated with cotton rolls and suctioning in between so that the working area was free from saliva. The buccal surface of the teeth was etched in the position where the wire was to be placed, for 20 seconds then washed until all etchant had been removed. The area was dried, bonding agent was applied over the etched area and cured for 40 seconds, followed by placement of an increment of composite on each etched area using a at plastic lling instrument. Then the wire was pressed into the composite and a second increment of composite was placed onto the rst, embedding the wire in composite. The intruded teeth were held in their extruded position using a tweezer. To produce a smooth surface a layer of bonding agent was applied over it and cured for 40 seconds on each tooth (Fig 4). 3-0 silk suture was placed in the interdental areas in order to facilitate reattachment of the interdental papillae. Emergency access opening was done and pulp was extirpated, close dressing was given. Root canal treatment was postponed till the stabilization achieved (Fig 5). The patient was advised not to bite from the anterior teeth, maintain oral hygiene and to continue with the medications, and was recalled after one week for evaluation. Patient was prescribed Chlorhexidine 0.2% and multivitamin tablets. In the second visit, patient was examined for splint stability. It was proper but the oral hygiene was not maintained. The interdental papillae had not gained its attachment properly so the suture removal was postponed for one more week (Fig 6). Patient was advised to continue Chlorhexidine mouthwash to aid in oral hygiene maintenance and multivitamin tablets till further assessment. In the third visit, the interdental papillae had reattached and gingival inammation had subsided. The sutures were removed followed by a thorough irrigation with

Armamentarium

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Fig 1: Pre operative IOPA

Fig 2: Pre operative clinical view

Fig 3: Extrusion using extraction forcep

Fig 4: Stabilizing in new position and splinting

Fig 5: Intruded teeth is in new extruded position

Fig 6: Post operative. Teeth acquired new position

povidone iodine and normal saline to clear the debris. An ultrasonic supragingival scaling was performed and the patient was reinforced with the oral hygiene instructions. He was recalled after 15 days for further evaluation. In this visit, mobility of all the splinted teeth were reduced. Oral hygiene maintenance was good. No signs of soft tissue inammation were found. Taking the patient compliance and oral hygiene performance recall visit was extended to 2 months. Chlorhexidine mouth rinse was terminated and warm salt water gargle was recommended till his next visit. Multivitamin tablets were continued for other 2 months. This fth appointment was 3 months later from splinting date. Mobility was in physiologic range. No soft tissue inammation was appreciated. Splint was removed and patient referred to completion of root canal treatment and prosthodontic care. Discussion Dental traumas are often a result of falls, play, sports, and motor vehicle accidents. There are few published reports highlighting its relationship with socio-economic status and they present conicting results7,8,9. The classication of trauma to anterior teeth is as follows:

Ellis and Davey Classication: (1970)10 Class 1 Class 2 Class 3 Simple fracture of the crown, involving little or no dentin Extensive fracture of the crown involving considerable dentin, but not the pulp. Extensive fracture of the crown involving considerable dentin and exposing dental pulp. The traumatized tooth which become non-vital with or without loss of crown structure. Loss of tooth Root fracture with or without loss of crown structure Displacement of a tooth without fracture of crown or root. Fracture of crown enmass. Traumatic injuries of deciduous teeth.

Class 4 Class 5 Class 6 Class 7 Class 8 Class 9

Immediate care is required in cases of dentoalveolar trauma. This type of emergency situation often requires several sessions for treatment, continuity for investigation and even treatment of possible sequelae11. Traumatic intrusion of the teeth indicates that the alveolar

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socket has sustained a compression fracture to permit the new tooth position. There will be microfracture in the cribriform plate of the socket and tooth is relatively unaffected because the mineral density of dentine and cementum is much higher than the surrounding bone, this is in accordance with theory of weakness. Traumatic tooth intrusion is less frequent, approximately 4.5% of the entire trauma to the maxillary incisor, than lateral displacements (9.4%)12. This type of nonavulsive tooth displacement has worst prognosis if the biology of bone healing in the periapical area is not considered seriously. The bone healing occurs basically by three phases, inammatory phase, broblastic phase and matrix formation and remodeling phase13. Microfracture fragments of the periradicular bone forms a niche for initiation of inammatory reaction. Anti and pro inammatory cytokines inhabit the area along with blood clot in matter of few hours. These cytokines activate the granulation tissue formation and broblastic proliferation. This is the phase where the various growth factors (GF) like platelet derived GF, transforming GF, insulin GF etc. will induce bone formation with the residual bony fragments. Osteoclasts get activated and thereby stimulate osteoblasts to start bone matrix formation. Scaffold for the bone formation will be furnished by the broblastic proliferation of granulation tissue. Hence the microfrature fragment of the alveolar socket aids as autogenous graft and is very essential for the speedy bone growth in periapex of the tooth. The debatable part in this biological bone healing is initiation of vital root resorption. Vital root resorption is a common and expected complication while autogenous graft in use. This can be best explained by vigorous inammatory reaction and lower pH activates the osteoclasts osteoprotegrine cycle. To prevent this expected root resorption, tooth is non-vitalized by emergency access opening and subsequently root canal treatment. There are different views about the treatment and outcome of intruded teeth. Some consider surgical repositioning and splinting the teeth whereas some feel if left alone the intruded teeth will re-erupt or extruded by the use of orthodontic forces14. Once the tooth is in position within the dental arch, it is splinted for 2 to 3 months taking mobility as deciding factor. Recent evidence suggests that immediate application of extrusive orthodontic force is necessary to prevent ankylosis in the intruded position15. During the treatment, main concern was about the restoration of the periodontal attachment which would ensure the re-establishment of integrity between the tooth and its supporting tissues. Minimum extrusive force (approximately 60 90N) was used using extraction forcep to prevent tearing of periodontal bers. Torn periodontal bers heals by reattachment, this will not hamper the eventful healing.

In some situations, excessive extrusion force will cause cemental tear, this will lead to partial ankylosis in that area which is regarded uneventful in the recent treatment consequence. Ankylosis of tooth results in signicant root resorption in 3-5 years time. Apart from the ease in plaque control and reduced surface area for plaque retention, stainless soft wire can be manipulated directly in the oral cavity in emergency management of dental trauma whereas thicker gauge wire needs model for its manipulation and then transferred to oral cavity. Intraoral manipulation can also be done effectively with acrylic ber splint. Stabilizing of the traumatized tooth in this procedure is in contradiction with Andreasen et al., oral hard tissue is in constant friction with both various soft tissue and hard structure itself, and this constant friction will handicap the healing process. The major concerns in this extrusion splint technique are thorough oral hygiene maintenance as in any other periodontal reparative procedures, relief from occlusion during healing march, regular short recall visits for oral hygiene and periodontal health evaluation and last but not the least, fair appraisal of quality of life of the patient. In conclusion, this newer technique competes successfully with the standard stabilization methods of traumatized tooth overcoming majority of their side effects. This can be used as regular treatment modality both in primary and secondary dentition. Vital periodontium achieved from this method protects the tooth further from minor trauma and major inammatory disease of tooth supporting structure by their physical and immunological properties respectively. Further longitudinal, prospective and clinical comparative study with large sample size is required to evaluate its effect against acrylic ber splint and other standard extra and intra coronal splint. This technique requires comparison with removable splints and then can be used as gold standard in case of esthetic areas. References
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