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A splinting method for replantation of teeth in a noncontiguous arch
A splinting method for replantation of teeth in a noncontiguous arch Thomas H. Simpson, D.D.S.,” Gerald W. Hawington, D.D.S., M.S.D.,“” al&d Eugene Natkin, D.D.S., M.S.D.,“‘” fleattle, Wash. UNIVERSITY
OF WASHINGTON
A splinting technique is described which allows maximum stabilization and accurate repositioning of replanted teeth in a noncontiguous arch.
A
t various times during the mixed-dentition stage of tooth development a recently erupted tooth may normally be present without adjacent teeth: For example, one or both of the central incisors may have erupted but the lateral incisors may still be absent or only partially erupted (Fig. 1, A), or the central and lateral incisors may be present without adjacent canines (Fig. 1, B) . In these circumstances the teeth in question are particularly vulnerable to traumatic avulsion. Since one or perhaps both of the approximating teeth may be absent, it may be extremely difficult, after replantation, to obtain precise positioning and adequate stabilization of the avulsed tooth with the usual splinting procedures. The splinting technique to be described considerably facilitates accurate repositioning of the isolated or semi-isolated replanted tooth in its socket and effective stabilization in the desired position. SPLINTING
TECHNIQUE
For purposes of this description, it will be assumed that procedures preliminary to &plantation have been carried out and that the avulsed tooth has been replanted in its socket. A plastic fluoridation tray of sufficient size to overlay the entire arch is selected (Fig. 2). A film of petroleum jelly is applied to the inner surface of the tray. *Clinical Associate,Department of Endodontics, University of Washington. **Associate Professor and Director of Endodonbics Graduate Programs, Department of Endodontics, University of Washington. ***Professor and Chairman, Department of Endodontics, University of Washington. 104
Volume 38 Number 1
Splinting
method
for
replantation
of teeth
105
Big. 1. A, Right-year-old patient with noncontiguous maxillary arch. Permanent central incisors are fully erupted, but maxillary lateral incisors are not as yet present. B, Twelveyear-old patient. Maxillary incisors are present, but maxillary canines are not yet erupted.
Fig. 8. Plastic fluoridation tray used in fabrication of splint. Fig. 9. Initial seating of tray containing mix of acrylic.
A mix of quick-setting, tooth-colored, cold-cure acrylic is prepared and the tray is loaded. The mix should be sufficiently plastic to flow easily onto tooth surfaces, so that tooth detail will be accurately reproduced in the set acrylic. On the other hand, the mix should not be so “liquid” as to produce irritation of soft tissue by excess monomer. The tray is seated with gentle finger pressure (Fig. 3). The patient is instructed to close lightly against the outer occlusal surface of the tray. This will force the tray against the posterior teeth and will prevent excessive acrylic thickness in the molar region. Now pressure is applied to the facial aspect of the flanges to limit thickness of the facial surface of the acrylic. At the same time, occlusal pressure is applied in the canine area to minimize bulk over the biting surfaces in this area. When the acrylic is completely set, the tray is peeled off (Fig. 4). With a low-speed fissure bur, the labial acrylic around the replanted tooth is removed (Fig. 5). Acrylic is removed from the interproximal undercuts with a No. 12 scalpel blade, but the full depth of acrylic is left intact on the incisal and lingual surfaces (Fig. 6).
106
Simpson, Harrington,
Oral Surg. July, 1974
and Natkin
Fig. 4. Acrylic splint immediately after removal of tray.
---ll__l-_ -- _-_.-
--
Fig. 5. Labial acrylic removed around replanted tooth with low-speed fissure bur. Fig. 6. Acrylic removed from interproximal undercuts with scalpel.
After exposure the replanted tooth is held in position at the incisal surface with a plastic instrument and the splint is pried off (Fig. 7). At this stage of arch development there are not enough undercuts present to interfere with easy removal of the splint. The splint is trimmed vertically so that acrylic does not extend beyond the gingival margins. The marginal area of the splint is trimmed to a thickness of about 1 mm. Acrylic thickness, sufficient to withstand biting force, should be maintained in all other areas. Now the incisal and lingual acrylic is trimmed off in the area of the replanted tooth. The lingual acrylic is relieved sufficiently so that there is no acrylic contact with the replant when the splint is seated (Fig. 8). A mix of zinc oxyphosphate cement is placed in the areas of tooth impression in the splint. The teeth are dried, and the splint is seated firmly. When the cement has set, any excess is removed. The replanted tooth is put in its precise position and held in this position with the finger placed on the incisal edge. A mix of quick-setting cold-cure acrylic is flowed or painted onto the lingual surface of the replanted tooth with
Volume 38 Number 1
Fig.
7. Replanted
Splistisg
tooth
held in position
method
with
plastic
for
repkntatkm
instrument
while
of &Seth
splint
107
is removed.
Fig. 8. A, Labial view of splint after trimming. There is no contact of splint with replanted tooth, either proximally or in&ally, at this time. B, Incisal view of splint after trimming. All lingual contact has been eliminated. C, Full-arch occlusal view of trimmed splint.
a plastic instrument or brush to fill the space between the tooth and the splint (Fig. 9). Any acrylic that flows into proximal undercuts is removed. This is an important precaution since it will prevent the replanted tooth from being reextracted if the splint is dislodged. When the lingual acrylic has set, a second mix of acrylic is flowed over the incisal so that it overlaps about 2 mm. of the labial surface (Fig. 10). Again, any acrylic that flows into proximal undercuts is removed (Fig. 11). When the acrylic has set, the incisal and labial excess is removed (Fig. 12).
108
Simpson, Hawington,
and Natkin
Fig. 9. Replanted tooth is held in precise position while acrylic is added to lingual surface. F’inger position is maintained during entire period of acrylic set. Fig. 10. Additional acrylic flowed over in&al of replanted tooth to overlap labial surface by approximately 2 mm. Fig. 11. Removal of interproximal excess with scalpel. Fig. 2% Final appearance of splint after removal of labial and incisal excess.
The occlusion is adjusted until four-point contact has been established. A molar on either side and both canines should contact the splint. Home-care instructions are given to the patient and parent. The parent is instructed to call immediately if the splint loosens or comesoff. The patient should be seen at weekly intervals, and the splint should be removed after 3 or 4 weeks. BepriM requests to: Dr. Thomas H. Simpson School of Dentistry University of Washington Seattle, Wash. 98105
OF WASHINGTON
A splinting technique is described which allows maximum stabilization and accurate repositioning of replanted teeth in a noncontiguous arch.
A
t various times during the mixed-dentition stage of tooth development a recently erupted tooth may normally be present without adjacent teeth: For example, one or both of the central incisors may have erupted but the lateral incisors may still be absent or only partially erupted (Fig. 1, A), or the central and lateral incisors may be present without adjacent canines (Fig. 1, B) . In these circumstances the teeth in question are particularly vulnerable to traumatic avulsion. Since one or perhaps both of the approximating teeth may be absent, it may be extremely difficult, after replantation, to obtain precise positioning and adequate stabilization of the avulsed tooth with the usual splinting procedures. The splinting technique to be described considerably facilitates accurate repositioning of the isolated or semi-isolated replanted tooth in its socket and effective stabilization in the desired position. SPLINTING
TECHNIQUE
For purposes of this description, it will be assumed that procedures preliminary to &plantation have been carried out and that the avulsed tooth has been replanted in its socket. A plastic fluoridation tray of sufficient size to overlay the entire arch is selected (Fig. 2). A film of petroleum jelly is applied to the inner surface of the tray. *Clinical Associate,Department of Endodontics, University of Washington. **Associate Professor and Director of Endodonbics Graduate Programs, Department of Endodontics, University of Washington. ***Professor and Chairman, Department of Endodontics, University of Washington. 104
Volume 38 Number 1
Splinting
method
for
replantation
of teeth
105
Big. 1. A, Right-year-old patient with noncontiguous maxillary arch. Permanent central incisors are fully erupted, but maxillary lateral incisors are not as yet present. B, Twelveyear-old patient. Maxillary incisors are present, but maxillary canines are not yet erupted.
Fig. 8. Plastic fluoridation tray used in fabrication of splint. Fig. 9. Initial seating of tray containing mix of acrylic.
A mix of quick-setting, tooth-colored, cold-cure acrylic is prepared and the tray is loaded. The mix should be sufficiently plastic to flow easily onto tooth surfaces, so that tooth detail will be accurately reproduced in the set acrylic. On the other hand, the mix should not be so “liquid” as to produce irritation of soft tissue by excess monomer. The tray is seated with gentle finger pressure (Fig. 3). The patient is instructed to close lightly against the outer occlusal surface of the tray. This will force the tray against the posterior teeth and will prevent excessive acrylic thickness in the molar region. Now pressure is applied to the facial aspect of the flanges to limit thickness of the facial surface of the acrylic. At the same time, occlusal pressure is applied in the canine area to minimize bulk over the biting surfaces in this area. When the acrylic is completely set, the tray is peeled off (Fig. 4). With a low-speed fissure bur, the labial acrylic around the replanted tooth is removed (Fig. 5). Acrylic is removed from the interproximal undercuts with a No. 12 scalpel blade, but the full depth of acrylic is left intact on the incisal and lingual surfaces (Fig. 6).
106
Simpson, Harrington,
Oral Surg. July, 1974
and Natkin
Fig. 4. Acrylic splint immediately after removal of tray.
---ll__l-_ -- _-_.-
--
Fig. 5. Labial acrylic removed around replanted tooth with low-speed fissure bur. Fig. 6. Acrylic removed from interproximal undercuts with scalpel.
After exposure the replanted tooth is held in position at the incisal surface with a plastic instrument and the splint is pried off (Fig. 7). At this stage of arch development there are not enough undercuts present to interfere with easy removal of the splint. The splint is trimmed vertically so that acrylic does not extend beyond the gingival margins. The marginal area of the splint is trimmed to a thickness of about 1 mm. Acrylic thickness, sufficient to withstand biting force, should be maintained in all other areas. Now the incisal and lingual acrylic is trimmed off in the area of the replanted tooth. The lingual acrylic is relieved sufficiently so that there is no acrylic contact with the replant when the splint is seated (Fig. 8). A mix of zinc oxyphosphate cement is placed in the areas of tooth impression in the splint. The teeth are dried, and the splint is seated firmly. When the cement has set, any excess is removed. The replanted tooth is put in its precise position and held in this position with the finger placed on the incisal edge. A mix of quick-setting cold-cure acrylic is flowed or painted onto the lingual surface of the replanted tooth with
Volume 38 Number 1
Fig.
7. Replanted
Splistisg
tooth
held in position
method
with
plastic
for
repkntatkm
instrument
while
of &Seth
splint
107
is removed.
Fig. 8. A, Labial view of splint after trimming. There is no contact of splint with replanted tooth, either proximally or in&ally, at this time. B, Incisal view of splint after trimming. All lingual contact has been eliminated. C, Full-arch occlusal view of trimmed splint.
a plastic instrument or brush to fill the space between the tooth and the splint (Fig. 9). Any acrylic that flows into proximal undercuts is removed. This is an important precaution since it will prevent the replanted tooth from being reextracted if the splint is dislodged. When the lingual acrylic has set, a second mix of acrylic is flowed over the incisal so that it overlaps about 2 mm. of the labial surface (Fig. 10). Again, any acrylic that flows into proximal undercuts is removed (Fig. 11). When the acrylic has set, the incisal and labial excess is removed (Fig. 12).
108
Simpson, Hawington,
and Natkin
Fig. 9. Replanted tooth is held in precise position while acrylic is added to lingual surface. F’inger position is maintained during entire period of acrylic set. Fig. 10. Additional acrylic flowed over in&al of replanted tooth to overlap labial surface by approximately 2 mm. Fig. 11. Removal of interproximal excess with scalpel. Fig. 2% Final appearance of splint after removal of labial and incisal excess.
The occlusion is adjusted until four-point contact has been established. A molar on either side and both canines should contact the splint. Home-care instructions are given to the patient and parent. The parent is instructed to call immediately if the splint loosens or comesoff. The patient should be seen at weekly intervals, and the splint should be removed after 3 or 4 weeks. BepriM requests to: Dr. Thomas H. Simpson School of Dentistry University of Washington Seattle, Wash. 98105