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#### **Chapter 4**

## Perspective Chapter: Teeth Avulsion

*Manal Abdalla Eltahir, Randa Fath Elrahman Ibrahim and Hanan Alharbi*

#### **Abstract**

Tooth avulsion refers to total displacement of the tooth out of its alveolar socket. This chapter discusses the causes of avulsion for both primary and permanent dentition in addition to the prevalence of avulsion comparing it between before and during COVID-19 era. Successful outcomes depend on procedure conduction with immediate replantation of the avulsed tooth and good handling of the tooth keeping the tooth in suitable available storage media till a professional service is obtainable. Management of this type of dental trauma necessitates awareness and collaboration between the lay personal at the site of injury in addition to the important role of different dental professional. After replantation of the avulsed tooth, it should be kept immobile with preservation of the functional (physiological) mobility by application of suitable splint. There are adjunctive therapies including antibiotics, analgesics, mouth washes, and tetanus vaccines. Endodontic therapy should be initiated within 7–10 days from the time of avulsion, where the outcomes generally might be favorable or unfavorable. Newly emergent teledentistry played important role in the treatment of tooth avulsion, especially during COVID-19 period.

**Keywords:** avulsion, replantation, storage media, antibiotic, splinting, open apex, closed apex, trauma, dental emergency, teledentistry, tooth replantation

#### **1. Introduction**

Tooth avulsion is a very serious traumatic dental injury (TDI) as tooth loss may remarkably compromise the patient in both functional and psychological aspects [1, 2].

Among all dental traumas, avulsion of the permanent tooth accounts for up to 16% of all dental injuries and constitutes the most serious one. It is considered as one of the few emergency situations in dentistry [3]. By definition, tooth avulsion refers to the total displacement of the tooth out of its alveolar socket (**Figure 1**) [4]. Presence of the tooth outside the socket leads to deterioration of the pulp and periodontal ligaments (PDLs) due to the lack of blood and nerve supply to their cells in addition to the unfavorable external environment such as dryness and possible contamination [5]. This may end up with periodontal attachment damage, pulp necrosis, and eventually tooth loss [6]. The maxillary central incisors are the most frequently involved teeth; boys and the age group of 7–11 years old are more susceptible to this type of trauma [7].

**Figure 1.** *Tooth avulsion refers to the total displacement of the tooth out of its alveolar socket.*

#### **1.1 Epidemiology of avulsed teeth before and during COVID-19 pandemic**

The prevalence and incidence of reported traumatic dental injuries (TDIs) have significantly been affected during COVID-19 pandemic. In a retrospective analysis conducted at King's College Hospital Dental Institute in London, UK, there was around 46% reduction in presented cases with TDIs during the COVID-19 compared to the year before for the same period of time [8]. With respect to avulsion injuries, the study revealed a remarkable decline in cases by around 93%. It also showed an increase in the mean delay in presentation following TDIs from 2.4 days the year before to 5.3 days during COVID-19 [8]. The reasons behind these changes were mostly related to the lockdown and forcible closure of dental practices during the pandemic. Although the urgent dental cares services in hospitals were mostly available worldwide, patients were hesitant to reach out to such centers due to the perceived fear of acquiring viral infections. Other studies also showed the same steep reduction in reported TDIs and traumatic injuries generally during COVID-19 [8–10].

According to previous studies, demographic data of reported cases has not differed between COVID-19 and years before except having less admitted cases in group age older than 70-year-old [8].

#### **1.2 Causes**

The etiology of tooth avulsion varies according to the type of dentition. Avulsion in primary dentition is typically a result of hard objects hitting the teeth, whereas avulsion in permanent dentition is generally a result of falls, fights, sport injuries, automobile or bicycle accidents, and domestic abuse. In permanent and primary dentition, *Perspective Chapter: Teeth Avulsion DOI: http://dx.doi.org/10.5772/intechopen.105846*

avulsion generally occurs in the maxilla, and the most affected teeth are the maxillary central incisors (**Figure 2**). Increased overjet and incompetent lips were identified as potential etiological factors in such avulsion cases [11–13]. In rare cases, iatrogenic teeth avulsion during other procedures might happen and were reported in the literature [14–17].

#### **2. Management of the avulsed tooth**

Several factors should be considered [18], when treating a patient with an avulsed permenant tooth (**Figure 3**):

1.Patient's age

**Figure 2.** *Maxillary central incisors are the most frequently involved teeth in avulsions.*

**Figure 3.** *Factors should be considered in the treatment of tooth avulsion.*

7.Damage associated with the avulsed tooth

#### **2.1 Emergency treatment/management (at the site/and at the clinic)**

Multidisciplinary approach in avulsion injuries is essential and considered a cornerstone during the management process. Though the management of avulsions is highly dependent on the early actions taken following the trauma and the time spent till reaching out healthcare services, this is furthermore affected during COVID-19 pandemic due to international lockdowns and restricted accessibility to hospitals. Such times clearly signify the importance of public awareness of first-aid measures in TDIs, especially avulsion.

International guidelines have been proposed to address TDIs and avulsions injuries. According to the International Association of Dental Traumatology (IADT) guidelines [19–21] and the European Society of Endodontology position statement [22], certain systematic approach has to be adopted to treat teeth avulsions. Obviously, tooth avulsion leads to necrosis of disrupted pulp which requires endodontic treatment.

We will be talking about the management for teeth avulsion and treatment choices during COVID-19. Best approach to treat an avulsed permanent tooth is immediate replantation. Whether the case is admitted to emergency clinic or people at trauma site are instructed on phone, the following steps are to be considered:

History: Review patient history in case of any other injury (potentially more serious) is involved, simultaneously. If any vomiting, headache, unconsciousness, or drowsiness are reported, this should be further investigated at the hospital, and also, if there is a previous injury to the teeth or the alveolar bone or if the occlusion has further changed.

*Perspective Chapter: Teeth Avulsion DOI: http://dx.doi.org/10.5772/intechopen.105846*

How, when, and where the trauma/accident happened are all questions that should be answered. This will further help in evaluating the trauma for legal and insurance purposes. Any suspected abuse should be reported to local authority.

Anesthesia: administering local anesthesia is always recommended, preferably without vasoconstrictor [20].

Recent guidelines have detailed the plan on replanting tooth according to two main factors:

1.Extra-oral dry time: being less or more than 60 min.

2.Root maturation: closed or open apex.

For extra-oral dry time, it is used to assess periodontal ligament (PDL) cells' viability. The soonest the tooth is replanted, within 15 min, the most likely PDL cells are viable. When the extra-oral dry time exceeds 60 min, it is more likely that PDL cells are nonviable. In all situations, it is recommended to replant the tooth acknowledging that prognosis is best when replantation is within 15 min and poorest when it is after 60 min [20]. Ankylosis-related (replacement) root resorption is an expected outcome in cases of late tooth replantation [18, 20, 24].

#### **2.2 Factors might influence the success of replantation**

These factors are the patient's general health, the maturity of the root, the time the tooth is out of its socket, storage medium [11, 25–27], extra-alveolar permanence period, means of preservation, contamination, manipulation, and conditions of the avulsed tooth [28], and also relevant factors such as type of splint used and time of permanence (**Figures 4** and **5**).

#### **2.3 Storage media**

.

Successful healing after replantation may occur only if the damage to the PDL cells was minimal. Immediate replantation of the avulsed tooth into the socket at the site of the trauma has been suggested to prevent further damage to the PDL cells left on the root surface from desiccation. As this is not always attainable since the lay person at the trauma site may lack the skill and the willingness to try this procedure. In such situations, it is recommended to put the avulsed tooth temporarily in a storage medium capable of preserving PDL cells viability. Thus, the extra-alveolar dry time and the type of storage medium are the most critical factors. Prolonging the duration of dry storage causes necrosis of the PDL cells after 30–60 min and decreases greatly the chances of healing after replantation [29].

#### *2.3.1 Characteristics of the ideal storage medium [29]*

#### **Figure 4.**

*Factors might influence the success of tooth replantation.*

**Figure 5.** *Potential complications following tooth replantation.*

#### *2.3.2 Types of storage media*

In their quest for an ideal storage media, a wide variety of materials have been tested by a lot of researchers for their role as potential storage media. The recent guidelines of IADT recommend in descending order of preference, milk, HBSS (Hanks' Balanced Salt Solution), saliva, or saline as suitable and convenient storage mediums. Water is considered a poor medium but is better than dry storage. Other materials, some with promising results, include ViaSpan, propolis, and egg white [20, 30].

#### *<IP_ADDRESS> Milk*

Many authorities recognized milk as the most recommended storage medium for avulsed teeth. The ease of obtaining it at accident sites makes it a practical choice. The physiological properties of milk are significantly better than other solutions, and pH (6.5–7.2) and osmolality (270 mOsm/kg) are compatible with PDL cells. Milk contains a combination of nutritional substances such as amino acids, carbohydrates, and vitamins capable of maintaining PDL cell viability. In addition, the presence of epithelial growth factor stimulates the proliferation and regeneration of epithelial cell rests of Malassez and activates the alveolar bone resorption. Hence, the bone tissue may be isolated from the tooth and decreases the chances of ankylosis [30, 31]. However, it should be noted that few reports argued that replanted teeth stored in milk were subject to ankylosis [32–34].

#### *<IP_ADDRESS> HBSS (Hanks' Balanced Salt Solution)*

The HBSS is a sterile, isotonic, and physiologically balanced standard saline solution which is used in biomedical research to support the growth of many cell types. It is a nontoxic solution, biocompatible with PDL cells; its pH (7.2) and osmolality (320 mOsm/kg) are balanced and considered almost ideal. It is composed of glucose, sodium, calcium, potassium, and magnesium ions.

HBSS is highly recommended for its ability to provide long-term preservation of PDL cells viability and proliferation capacity. Its ingredients may further help to reconstitute the depleted cellular components of the PDL. HBSS is commercially available as "Save-A-Tooth." However, it is not found at most of the accident sites; this makes it an impractical storage medium [20, 29, 31, 32, 34].

#### *<IP_ADDRESS> Saliva*

The only advantage of saliva as a storage media is its ease of availability immediately on almost all accident sites. However, it presents a possible source of bacterial contamination for PDL cells. Its osmolality (60–70 mOsm/kg) is considerably lower than the physiological osmolality; thus, cells stored in saliva show swelling and membrane damage. Saliva is better than tap water or dry storage, but it can be used only for very short storage time [29–31].

#### *<IP_ADDRESS> Saline*

Normal saline, a 0.90% NaCl solution, has a physiological osmolality of 280 mOsm/kg which is compatible with the PDL cells. However, it is deficient in the essential nutrients, such as glucose, magnesium, and calcium which are needed to the normal metabolic functions of the cells of the PDL. Moreover, the hypotonic properties of saline induce rapid cellular lysis. Therefore, saline is not a good storage media unless for short periods only [29, 31].

#### *<IP_ADDRESS> Viaspan*

Viaspan is a cell culture media widely used for storing and transporting organs to be transplanted. It has 320 mOsm/kg osmolality and 7.4 pH which favors cell growth and viability of the PDL cells. It is nearly an ideal material for storage of avulsed teeth for long periods. However, its high cost, short vitality expiration, and the limited access to it especially at the accident sites make it difficult to find and use this storage medium [31, 35].

#### *<IP_ADDRESS> Egg white*

Egg white is considered a good storage media because of its high protein content, vitamins, and water. It is easily accessible and lacks microbial contamination with a pH of 8.6–9.3 and osmolality of 258 mOsmol/kg. Thus, it favors PDL cells viability and healing and presents a suitable choice for extended storage time [29, 31].

#### *<IP_ADDRESS> Tap water*

Tap water has an approximate osmolality of 30 mOsm/kg and a pH of 7.4–7.79. It is not considered a suitable storage medium for avulsed teeth. It has bacterial contamination; its hypotonicity and nonphysiologically pH and osmolality favor the PDL cell lysis. Cells stored in water did not maintain their viability. However, it is better than dry storage and should be used only when there are no other alternatives (**Table 1** and **Figure 6**) [29, 31].

#### **Table 1.**

*Characteristics of storage media.*

#### **2.4 Splinting**

After replantation, the treatment of choice is splinting [2]. By definition, splinting is an assembly to protect, stabilize, and immobilize loosened, fractured, replanted, and traumatized teeth [3]. Also splinting is defined by American Association of Endodontists as "a rigid or flexible device or compound used to support, protect, or immobilize teeth that have been loosened, replanted, fractured, or subjected to certain endodontic procedures" [36].

To allow immobilization of the teeth during the initial period, it is mandatory using the so-called splint which is essential for the repair of periodontal ligament [37]. The use of semirigid splint is more indicated than the rigid one, considering that the long period of splinting is not recommended due to its expected complications namely substitutive resorption or ankylosis [38, 39]. One of the adverse healing outcomes of splinting is that forceful placement of the splint may cause additional trauma to the already affected pulp of the avulsed tooth [40].

#### *2.4.1 Types of splints*

Many different splinting techniques have been described [41]:

Wire-composite splint, orthodontic splint, titanium trauma splint (TTS) splint, resin splint, Kevlar/fiberglass splint (fiberglass), self-etching and bonding material, and suture splint.

Kahler et al. also described splint types [42]:

#### **Semirigid/flexible (physiologic**) [43]:

In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left in place for about 4 weeks.

Cap splints and orthodontic bands were associated with a greater frequency of pulp necrosis and pulp canal obliteration when compared with acid etch resin splints and no splinting [44].

These splinting techniques were used prior to the development of a passively

Stabilize the tooth for 2 weeks using a passive flexible splint such as wire of a diameter up to 0.016″ or 0.4 mm bonded to the tooth and adjacent teeth. Keep the composite and bonding agents away from the gingival tissues and proximal areas. Second option is nylon fishing line (0.13–0.25 mm) which can be used to create a flexible splint, using composite to bond it to the teeth. Nylon (fishing line) splints are not recommended for children with mixed dentition, since the status of the other teeth may result in instability or loss of such splint.

#### *2.4.2 Management of the soft tissues and surrounding alveolar bone*

Tooth-supporting tissue injuries and lip injuries may be associated with avulsion [45]. Soft tissue tearing of the socket gingiva associated with avulsed tooth should be noted [46].

There are three benefits may be gained from the tight stitching of such tearing [47]:

1.Stop of the bleeding.

2.Avoid the penetration of microorganism into periodontium.

3.Allow the primary healing of the wound.

In addition to the soft tissue, the socket itself needs to be manipulated before replantation of the root, if the alveolar bone has collapsed, attempts should be made to reconstruct its wall [48].

#### **2.5 In clinic treatment**

#### *2.5.1 Root canal treatment in avulsed teeth*

#### *<IP_ADDRESS> Closed apex*

It is mandatory to initiate root canal treatment within 2 weeks of tooth replantation [20, 22]. Root canal treatment should start with intracanal medication; calcium hydroxide or antibiotic-corticosteroid paste dressing for 2 weeks up to 1 month or 6 weeks [49, 50] is followed by root canal filling.

#### *<IP_ADDRESS> Open apex*

No root canal treatment is performed at first, but a close follow-up is needed to detect any clinical or radiographic signs of pulp necrosis. The aim is to re-establish blood supply of open apices and maintain root development which could happen spontaneously after replantation.

Radiographic and clinical examination is indicted after 2 weeks, 4 weeks, 6– 8 weeks, 3 months, 6 months, 1 year, and yearly thereafter for at least 5 years. If there is any sign of external infection-related root resorption, endodontics intervention is advised whether it is apexification, root canal treatment, or regenerative endodontic procedures (REPs) [20, 22, 48].

#### *2.5.2 Regenerative/revitalization procedures and avulsions*

REPs have been proposed based on translational studies. In 2016, American Association of Endodontists and European Society of Endodontology have proposed clinical considerations and position statement; respectively, discussing REPs [51]. In avulsion injuries, REPs are only indicated in cases of immature root with open apex and signs of pulp necrosis. The clinical protocol is the same that have been proposed previously in the mentioned guidelines. A recent report implemented this approach to treat avulsed tooth and showed successful outcome with a 30-month follow-up [52]. The key is using biocompatible materials that would recruit stem cells to build hard tissue barriers and allow physiological growth of roots. Biocompatible materials could be MTA or tricalcium silicate cements, e.g. bioceramicsm that revealed successful outcomes in several reports [53].

#### **3. Adjunctive therapy**

#### **3.1 Antibiotic use**

Antibiotics given at the time of replantation to prevent the infection may occur due to tooth contamination or may be present in the storage media. Also, it can be prescribed prior to endodontic treatment. It is theoretically effective in preventing bacterial invasion of the necrotic pulp and; further, it may prevent the inflammatory resorption (**Figure 7**) [54].

In all cases, appropriate dosage for the patient's age and weight should be calculated.

Amoxicillin or penicillin remains the first choice due to their effectiveness on oral flora and low incidence of side effects. Alternative antibiotics should be considered for patients with an allergy to penicillin [55].

The effectiveness of tetracycline administered immediately after avulsion and replantation has been demonstrated in animal study [56, 57]. Specifically, doxycycline is an appropriate antibiotic to use because of its antimicrobial, anti-inflammatory, and anti-resorptive effects. But still doxycycline exerted no effect on the occurrence of complete pulp revascularization in replanted teeth [58]. Tetracycline or doxycycline is generally not recommended for patients under 12 years of age to avoid the risk of discoloration of permanent teeth [20, 56, 57].

#### *3.1.1 Indications of antibiotics in patients with avulsed tooth*

By searching the literature so far, there are some indications of antibiotic prescribed for the patient with avulsed tooth (**Figure 8**).

1.Replanted tooth with possibly contaminated root and/or storage media [20, 54] for medically compromised patient.

#### **Figure 7.**

*Adjunctive therapies in the treatment of avulsed tooth.*

#### **Figure 8.**

*Indication of antibiotics in patient with avulsed tooth.*

#### **3.2 Analgesic**

Prescription of analgesic is case-dependent; accordingly, it should be assessed individually. The use of stronger pain killer is unlikely [20, 48].

#### **3.3 Mouth wash**

Chlorhexidine (CHX) is a commonly used antiseptic mouthwash and is available over the counter (OTC); the use of adjunctive short-term of CHX can enhance oral hygiene by managing dental plaque [60].

The recent recommendation is to use a chlorhexidine (0.12%) mouth rinse twice a day for 2 weeks (during the entire period of splinting).

#### **3.4 Tetanus vaccine**

The possibility of environmental contamination of the injury can justify the administration of tetanus vaccine [19].

The patient should be sent to a physician for consultation regarding a tetanus booster within 48 h of the initial visit [20].

#### **4. Alternative treatment**

#### **4.1 Decoronation**

In cases of severe replacement resorption (RR) and ankylosis, decoronation can be considered as an alternative treatment with good clinical outcomes for children and adolescents to the age when an appropriate implant is possible. If carried out at the right time; it helps to preserve the bucco-palatal dimensions of the alveolar bone and at the same time allows for vertical bone growth. This enables for future implant insertion without the need for the costly and invasive procedure of alveolar ridge augmentation. However, this approach still needs solid studies to verify it [61, 62].

Timing of the decoronation is crucial and should be planned for each individual case with regard to the patient's age, growth intensity, and growth pattern. In young patients, it is advantageous to retain an ankylosed tooth, if possible, to act as a space maintainer. However, it is very necessary to intervene before the effect of infraposition causes significant arrested alveolar bone growth that makes a final prosthetic solution difficult. When ankylosis is diagnosed before the age of 10 years, there is a high risk of severe infraposition, and the tooth should be carefully monitored every 6 months. There is also a risk of severe infraposition during the pubertal growth spurt which varies in time from one person to another and thus needs also careful monitoring [63].

Clinically, the procedure is simple. Under local anesthesia and a full-thickness flap, the crown of the ankylosed tooth is sectioned earlier the cementoenamel junction. The root is cleaned with a K-file and washed with saline, and the canal is allowed to fill with blood and then the flap is repositioned. Subsequently, esthetics is maintained using an adhesive bridge [62].

#### **4.2 Autotransplantation**

Autotransplantation of an immature maxillary premolar to replace an ankylosed tooth is considered a highly successful alternative technique and is particularly indicated when crowding requires extraction of a premolar. To achieve pulpal revascularization and successful periodontal healing of the donor tooth, the ideal root should develop to three-fourths of the complete root length. In such cases, the whole root of the ankylosed tooth must be extracted, and a premolar will be transplanted in its place. The transplant tooth with its sound periodontal ligament will induce new bone formation, have continued root development, and even maintain its vitality. An esthetic restoration and orthodontic treatment will follow the transplant [64, 65].

#### **4.3 Partial prosthesis/dental implant**

#### *4.3.1 Prognosis and outcomes*

The long-term prognosis of replanted avulsed teeth shows great variability; the observed outcomes are greatly heterogeneous ranging from healing without symptoms to inflammation and rapid tooth loss. Many studies had shown a relatively low survival rate of replanted avulsed teeth, compared to other types of traumata, ranging from 50% to 83.3% [66]. Under favorable conditions, replanted teeth may be retained for 5 or 10 years and even few of them for a lifetime. However, some may fail very soon after replantation.

#### *4.3.2 Factors associated with unfavorable outcomes and low survival rate [65]:*

After replantation of the tooth, the prognosis commonly remains uncertain. Replacement resorption and inflammatory resorption are probable adverse outcomes in comparison with the more favorable functional healing (FH): [66]

#### • **Functional healing**

The damaged tissues including the cementum and dentin are being resorbed by multinuclear giant cells. In regions with minor damage, the ruptured periodontal fibers are being rebuilt (regeneration). In case of small resorption cavities, the denuded root surface is being recolonized by neighboring cementoblasts and these deposit the cementum in which the new periodontal fibers are anchored. This process represents healing with physiologic function (functional healing, FH) [66, 67].

#### • **Inflammatory (infection-related) root resorption**

Root surfaces affected by the trauma are quickly colonized by multinuclear giant cells. If these cells are continuously stimulated by microbial products from an infected root canal, not adequately treated, infection-related resorption (IRR, formerly named inflammatory resorption) will result. Provided the tooth is still restorable, adequate endodontic treatment might stop the progression of IRR.

#### • **Replacement resorption (ankylosis)** (**Figure 9**)

Replacement resorption is a special form of root resorption, and it follows serious luxation or avulsion injury. It is a common sequela of delayed replantation and/or dry storage. Due to excessive drying before replantation, the damaged periodontal ligament cells will start an inflammatory response over extended areas on the root surface. The resulting large resorption cavities may not be entirely covered by the cementoblasts in time. Regenerating alveolar bone will be attached directly onto the root surface. In time, through physiologic bone remodeling, the root cementum and dentin will be replaced by bone; a process termed replacement resorption (RR) or ankylosis-related root resorption [65–67].

If revascularization does not occur or appropriate endodontic therapy is not performed after tooth replantation, pulpal necrosis will occur. The combination of microbes in the root canal and the external surface of the root results in aggressive resorption and can lead to rapid tooth loss [20, 65].

In a growing patient and/or tooth with open apices, the ankylosed tooth shows severe and progressive infraocclusion. The alveolar bone will stop advancing in a coronal direction with the rest of the jaw leaving a big bone defect when the tooth is eventually lost causing major esthetic and functional challenges when it is time for the final replacement [48, 67].

**Figure 9.** *Replacement root resorption (ankylosis).*

#### **5. Follow-up**

Mature replanted teeth need clinical and radiographic monitoring at 2 weeks (with splint removal), 4 weeks, 3 months, 6 months, 1 year, and hence yearly for at least 5 years. For teeth with open apices where spontaneous pulp revascularization might occur, clinical and radiographic monitoring should be more frequent due to the high risk of infection-related (inflammatory) and/or ankylosis-related (replacement) root resorption. Therefore, replanted teeth with open apices should have clinical and radiographic monitoring at 2 weeks (with splint removal), 1 month, 2 months, 3 months, 6 months, 1 year, and hence yearly for at least 5 years [20].

Evaluation may include the following outcomes:

#### **5.1 Favorable outcomes**

The replanted tooth is

Pulp canal obliteration is expected and can be recognized radiographically sometime during the first year after the trauma.

#### **5.2 Unfavorable outcomes**

#### **6. Avulsion of primary teeth**

A relatively recent meta-analysis showed trauma of primary dentition to be as common as 22.7% [68] with variable prevalence of avulsion from 7 to 13% [69]. In general, avulsed primary teeth should not be replanted (according to the recommendations of the IADT) [19]. Nevertheless, there are case reports with varying degrees of success after replantation of primary teeth, whereas others reported negative results to the replanted primary tooth and its permanent successor. One systematic review concluded that here is a lack of high-quality studies to support this approach [69].

Such a severe injury to the primary tooth may have negative impact on the development and/or eruption of its permanent successor. Premature loss of avulsed primary teeth might sometimes lead to space loss, masticatory, speech, and esthetic problems; this may also cause negative impact on their behavior, pschological, and social well-being. Removable or fixed appliances present valid treatment options to minimize space loss and improve esthetics when necessary. Furthermore, movement of the tooth during avulsion and the proximity between the primary tooth and the germ of its developing successor may interfere with its further growth and maturation leading to the occurrence of enamel defects and tooth malformations. The risk of sequelae in the permanent successor after avulsion of primary teeth is higher when the injury occurs in young children (<2 years), when the trauma is of greater magnitude such as when more teeth are involved and lower jaw is affected [70, 71].

Sequelae to the permanent successor include (**Figure 10**) [70]:

#### 1.Malformations

#### 2.Enamel defects

• white/cream or yellow/brown demarcated opacities,

#### **Figure 10.**

*Sequelae of primary tooth avulsion.*

4.Combinations

#### **7. The role of teledentistry in the treatment of avulsed teeth**

Teledentistry can be used to monitor those traumatic injuries cases remotely. Teledentistry combines dentistry and telecommunications simultaneously with clinical information and images over remote distances for dental consultation and treatment planning [72].

In cases of traumatic injuries and avulsions specifically, initial emergency instructions could be delivered on phones till obtaining emergency healthcare services is possible. This helps in calming patients or patients' guardians and maintains the first actions of replanting teeth or storing it in proper storage medium according to the recommendations. Teledentistry is also used at times of follow-up to report symptoms or other complications. It is mainly essential when specialty dentist is not available, yet their consultation, supervision, and valuable support could be used by the dental team in managing such cases [73]. A report showed that around 60% of patients contacted the telemedical center during the so-called "out of office hours" for dental

trauma injuries. This percentage signifies the importance of having proper teledental channels addressing these incidents.

#### **8. Discussion**

Tooth avulsion is the complete displacement of the tooth from its socket in the dental arch.

In this chapter, we tried to gather the scattered information about tooth avulsion. Despite the rich published literature, but still a lot of researches are needed to reach evidence-based conclusions.

Although the tooth avulsion is the topic of concern in general dentistry, we tried to write this perceived paper in the specialist's manner to reflect more light on many related details.

Causes of tooth avulsion are divided into those for deciduous dentition and other for permanent dentition which are differ from each in their pattern and severity of the trauma [11–17].

Epidemiology has shown a reduction of cases during COVID-19 era. This was explained by patients' perceived fear of acquiring viral infections and thus hesitancy to reach out to emergency centers [8–10].

Avulsion treatment outcomes are very dependent on the first-aid measure as well as the agility to seek dental treatment.

For the management, put it as two phases may let the whole picture organized and well determined by specific time (at the time of trauma) the first phase and the other which are at the clinic.

The storage media (milk, HBSS, saliva, or saline) are discussed in detail regarding the characteristic of each. Nevertheless, researches are still looking for an ideal medium; some materials such as propolis and egg white are very promising. However, the quality of evidence is considered low [74]; on the other hand, teeth splinting is discussed generally as well as specifically for the avulsed teeth (with and without alveolar bone fracture) [20].

The literature regarding the adjunctive therapies for the teeth avulsion showed the role of these therapies; in this chapter, we considered them concisely with stress upon the indications for each [19, 20, 48, 60].

Criteria of successful treatment is widely discussed which is depending on both clinical and radiographic features.

Alternative treatments for the avulsed tooth in cases of the failure of aforementioned treatment are decoronation, autotransplantation, partial prosthesis, and dental implant [61–65].

The key of optimum outcomes in avulsions cases rely on both radiographical and clinical follow-ups. This signifies the importance of teledentistry and its role in addressing such incidents [72].

The main adverse outcome of tooth replantation is replacement root resorption (ankylosis). It implies possible risks of infraocclusion, impairment of alveolar bone growth, and tooth loss. The risk increases dramatically with delayed replantation [20].

#### **9. Conclusion**

Tooth avulsion is one of few emergencies in dentistry; prevalence differs from area to area according to the cause and gender. Replantation, immediate or delayed is the

treatment of choice for the avulsed permanent tooth still immediate and proper replantation is important for long term good prognosis. Many factors may determine the outcome and use of antibiotic; although it is questionable, it is indicated in certain conditions. Although there is no strong evidence for their effect on healing, storage media is one of the factors for the preservation of the vitality of the tooth. It is used according to its availability at the trauma site. There are two stages in the treatment: emergency treatment and definitive treatment; even so, there is no grantee for the success of the treatment. Any avulsed tooth may be followed by complications, either immediately or lately. Despite the recommendation for the manager of the avulsed teeth, still not all recommendation can be applied for every avulsed tooth. Accordingly, any tooth has got special related factors which would determine the treatment plan after studying them carefully.

As a result, immediate and proper replantation is important for long-term good prognosis.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Acronyms and abbreviations**

*Perspective Chapter: Teeth Avulsion DOI: http://dx.doi.org/10.5772/intechopen.105846*

#### **Author details**

Manal Abdalla Eltahir<sup>1</sup> \*, Randa Fath Elrahman Ibrahim<sup>2</sup> and Hanan Alharbi<sup>3</sup>

1 Oral and Maxillofacial Surgery and Diagnostic Science, College of Dentistry, Qassim University, Qassim, Saudi Arabia

2 College of Dentistry, Qassim University, Qassim, Saudi Arabia

3 Department of Conservative Sciences, Division of Endodontics, College of Dentistry, Qassim University, Qassim, Saudi Arabia

\*Address all correspondence to<EMAIL_ADDRESS>
© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 5**

## Perspective Chapter: Splinting of Traumatized Teeth

*Eswari Ramassamy*

#### **Abstract**

Repositioning or replantation followed by stabilization with splint is the standard management of traumatized teeth. Numerous types of splints are being used and each type has its own advantages and disadvantages. Knowledge on the different types of splints and its effect on dental tissues so as to aid in the clinical decision on the type of splint to be used for managing a particular type of traumatic dental injury and its fixation period are important. Therefore, this chapter aims in explaining the different methods of splinting along with its advantages and disadvantages of each type along with the standard recommendation for duration of splinting.

**Keywords:** splinting, flexible splints, rigid splints, traumatized teeth, wire composite splints

#### **1. Introduction**

Splinting is recommended in the management of traumatic dental injuries which requires repositioning and stabilization of the luxated teeth. Earlier, the management of luxated teeth was similar to the management of fractures of Jaws, which are arch bars with wires and cap splints. But due to their negative effect on periodontal structures along with the advent of adhesive materials, a wide range of splints are being developed [1, 2]. A splint is "An apparatus used to support, protect or immobilize teeth that have been loosened, replanted, fractured or subjected to certain endodontic surgical procedures" [3]. The aim of this chapter is to enumerate the ideal requirements of splints, types and description of each types of splints and International Association of Dental Traumatology (IADT) recommendations of splinting duration and types.

#### **2. Ideal requirements of splints**

But, all the splinting techniques do not satisfy all the requirements mentioned above [1, 4, 5].

#### **3. Classification of splints**

Splints can be classified as Rigid splints Semi-rigid splints/Flexible splints

#### **3.1 Rigid splints**

Rigid splints are those splints which does not allow physiologic movement of the repositioned teeth [2].

Eg: Erich arch bars, Acrylic cap splint, Schuchardt splint, Interdental wiring methods like figure-eight wiring & loop wiring.

In case of arch bar splints (**Figure 1**) and the interdental wiring methods, the ligature wires used in these splints tend to become loose with time and come to rest on the marginal gingiva. This could cause gingival irritation and inflammation as it becomes the site for plaque deposition. The patient's inability to maintain good oral hygiene around the wires could worsen the condition [4, 6]. These splints also cause physical damage to gingiva and cementum surface when removed after the splinting period [7]. If these ligature wires, when positioned apical to the cervical prominence while splinting especially in a mobile tooth, they tend to elevate the tooth slowly making the cemento-enamel junction lose its integrity [4, 6].

Schuchardt splint was initially designed for splinting of luxation injuries. But its extreme rigidity and difficulty in adapting to the arch form accounts for its high thickness of 2 mm diameter bar made of aluminum-brass alloy. Acrylic cap splint is cemented on uninjured teeth when used for luxation injuries provides too much rigidity [6].

*Perspective Chapter: Splinting of Traumatized Teeth DOI: http://dx.doi.org/10.5772/intechopen.108908*

**Figure 1.** *Arch bar splint.*

In addition to these disadvantages, there is high incidence of pulp necrosis, external root resorption and ankylosis of the repositioned teeth when rigid splints are applied [2, 8].

For the above reasons, the usage of rigid splints is restricted only for stabilizing jaw fractures.

#### **3.2 Semi-rigid/flexible splints**

Flexible splints are those splints which allow functional movement of the stabilized teeth [4]. Studies conducted on animals had shown that normal masticatory stimulation can lower the incidence of ankylosis which led to the development of flexible splints so as to allow the functional movement of the traumatized and stabilized teeth [9].

Many varieties of flexible splints are being introduced. Most of these splints make use of the acid etch technique.

#### *3.2.1 Composite and wire splints*

Flexible wire composite splint (**Figure 2**) uses a wire of 0.3–0.4 mm in diameter bonded onto the labial surface of the teeth with composite [4]. Rigidity of the splint increases with increase in the thickness of wire or by adding composite in the interdental space [1]. Rigidity also increases with increase in the length of the wire splint [10].

The main advantage of this splint is that the materials used for the construction of this splint are routinely available in all dental clinics. Other advantages are it is well accepted by the patients, does not cause any injuries to the supporting structures and easy maintenance of oral hygiene. But a major disadvantage is that it can cause potential damage to enamel while removing [1].

#### *3.2.2 Other alternatives*

Many splints are being constructed using other materials as an alternative to wire.

a.Nylon/Fishing Line splint (**Figure 3**) – In this splint a thin nylon/Fishing line is used instead of wire. The advantages of this splint is that it is atraumatic to

**Figure 2.** *Wire composite splint.*

```
Figure 3.
Nylon line splint.
```
supporting structures, relatively esthetic, easy to maintain oral hygiene, inexpensive and comfortable for patient [11]. The main disadvantage is that it is slightly difficult to position the nylon line as it is thin. This problem can be overcome by fixing the nylon line and light curing the composite one tooth at a time and thus it is slightly time consuming [12].

*Perspective Chapter: Splinting of Traumatized Teeth DOI: http://dx.doi.org/10.5772/intechopen.108908*

**Figure 4.** *Power chain splint.*

#### *3.2.3 Suture splint*

It is the simplest form used as temporary splinting of traumatized deciduous teeth or partially erupted permanent teeth in a situation where the child is difficult to manage. It is a temporary splint because it is retained only for 3 to 4 days until the child becomes more receptive to a definitive treatment. A suture is placed over the incisal edge from palatal gingiva to the labial gingiva. (**Figure 5**) It prevents the tooth from extruding. But the biggest disadvantage of this splint is that sometimes the incisal edge has to be grooved to hold the suture material in position [1, 5].

#### *3.2.4 Orthodontic splint*

It requires the orthodontic materials like brackets and wires (**Figure 6**). The brackets are bonded to the teeth and are connected by 0.014 NiTi flexible wire [4].

It is indicated in a few clinical conditions like:

**Figure 5.** *Suture splint.*

**Figure 6.** *Orthodontic wire splint.*

i. severely malpositioned teeth which makes the placement of wire-composite splint difficult.

ii.In case of intrusive luxation, where repositioning of the tooth is to done [14].

The main advantage of this splint is that it is the least traumatic technique for repositioning tooth with intrusive luxation injury [14]. However, when used in other situations except intrusive luxation, care must be taken to reduce orthodontic forces that disturbs the healing of the luxated tooth [15].

It is known through studies that splints constructed with orthodontic materials always generate some amount of force over the teeth, but these forces could be reduced with certain conditions like the form of arch wire, type of cross section of the wire and the type of ligature used [16]. Hence, it is recommended that only trained clinician in handling orthodontic materials can utilize this splint properly. This becomes a major disadvantage of this splint [17]. Other disadvantages are the requirement of materials which are not commonly available in clinics and irritation to the lips and buccal mucosa and discomfort to the patient especially at the beginning of the treatment, which can be reduced by lubricating the lips [18].

#### *3.2.5 Fiber-reinforced composite splints*

These splints use fibers which are attached to the teeth either by unfilled resin or with composite [4].

The commercially available fibers are:

*Perspective Chapter: Splinting of Traumatized Teeth DOI: http://dx.doi.org/10.5772/intechopen.108908*

**Figure 7.** *Ribbond splint.*

Fiber splints are esthetically acceptable and it is easy to apply and remove. It does not cause any trauma to surrounding structures and maintenance of oral hygiene is easy. Fiber splints are associated with highest frequency of healing outcomes [19].

#### *3.2.6 Titanium trauma splint (TTS)*

This splint was developed by von Arx in collaboration with Medartis AG, Basel, Switzerland. The objective behind developing this splint was to optimize the splinting techniques, (i.e) ease of application and removal from the dental surgeon's aspect and increase in comfort and easy maintenance of oral hygiene from the patient's aspect.

It is a pre-fabricated splint made of titanium of 0.2 mm thickness and 2.8 mm width. Due to its least thickness, it is operator friendly, it does not require any special pliers or other instruments to manipulate; it can be easily adapted onto the arch by fingers. It is available in two different lengths 52 mm and 100 mm and it could be cut to the desired length.

Its unique design with a rhomboid mesh structure makes the splint more flexible without subjecting the splinted teeth to any orthodontic forces. Yet another advantage is that it could be easily secured to the teeth. The rhomboid openings are in the size of 1.8x2.8 mm and hence only a small area of bonding is needed with the tooth. It does not require a bulk composite around the splint; only a thin layer of flowable composite is required.

While removing the splint, the composite can be ground down to the level of TTS and the splint can be "peeled-off" easily from the tooth with a hemostat. Any remnant composite can be removed with easily with a curett and tooth surface can be polished [20]. The only disadvantage of this splint is its high cost [4].

#### *3.2.7 Resin splint*

This splint is applied with resin materials like Protemp and Luxatemp, which are used in temprorary prosthetic restorations and for lining prefabricated crowns. Luxatemp is dual cured; by both chemical and light cured, while Protemp is chemically cured material [1]. The resin materials are available in syringe forms and can be directly applied to the labial aspects of the crowns of the teeth to be splinted. Once the material is set/cured, any sharp edges can be removed to prevent irritation to the surrounding soft tissues [21].

The advantages are these materials do not exert any force on tooth during application and are acceptable esthetically and hygienically. They are not indicated when

the adjacent are not fully erupted and difficult in case of any edentulous area. The main disadvantage is that they tend to fracture easily and care must be taken during removal. [1].

### **4. Splinting type and duration**

#### **4.1 For permanent dentition**

Experiments and studies demonstrated that rigid immobilization for longer duration of time increased the risk of pulp necrosis, external root resorption and ankylosis. The International Association of Dental Traumatology (IADT) has formulated guidelines for the management of traumatic dental injuries. Based on current evidences, short-term, passive and flexible splints are recommended for splinting luxated, avulsed and root-fractured teeth. For alveolar bone fractures, splinting of teeth may be used for bone segment immobilization. Splinting duration depends on the type of dental injury. The duration of splinting for Permanent Dentition as given by IADT 2020 is given in **Table 1** [22].

#### **Table 1.**

*IADT guidelines for splinting duration of permanent dentition.*

#### **Table 2.**

*IADT guidelines for splinting duration of primary dentition.*

#### **4.2 For primary dentition**

According to IADT guidelines, splinting of primary dentition is recommended only in case of alveolar bone fractures. Root fractures and lateral luxations may occasionally require splinting. Only flexible splints are used including alveolar fracture where the splint is stabilized on adjacent uninjured teeth for 4 weeks. (IADT guidelines) The duration of splinting for Permanent Dentition as given by IADT 2020 is given in **Table 2** [22].

#### **5. Removal of splint**

One of the important requirement of a splint is that it should be applied and removed easily without causing any damage to the enamel surface. The resin-based materials cause iatrogenic enamel damage while removing them is a major concern. Various techniques are employed for removing the remnant composite material used for retaining the splints from the enamel surface. They are hand instruments like scalers and pliers, burs, abrasive discs, rubber wheels and cups. In an experimental study conducted to assess the surface roughness of enamel after employing various methods to remove the material, it was noted that Soflex discs and 16-blade tungsten carbide bur cause least damage to the enamel [17, 23].

#### **6. Emergency splinting**

Patients with multiple injuries as in road traffic accidents, often sustain dental injuries. Traumatic dental injuries not being life-threatening, emergency rooms not being equipped to manage traumatic dental injuries, inadequacy of knowledge and skill of medical personal handling the patients are the reasons for either delaying/ignoring the management of traumatic dental injuries [24, 25]. In such emergency situations, an easy to perform splinting technique is "criss-cross" pattern suture splints which can be rapidly placed by any medical personal. This splint can be placed with 2/0 silk suture material with a horizontal locking mattress design to keep the reimplanted tooth in position until the patient could be mobilized to Dental Department for more definitive management. The advantage of this technique is that it is a quick method which could be performed by any medical personal when the patient is treated under General Anesthesia for other injuries and does not delay the general treatment procedures.

The criss-cross pattern splint is given by the following steps:

Step 1 – the first bite (point 1 in **Figure 8**) is taken at the base of the distal interdental papilla on the labial side of the tooth to be repositioned and crossed over the incisal edge towards the mesial-palatal aspect.

Step 2 – suture then penetrates the base of the mesial interdental papilla (point 2 in **Figure 8**) on the palatal side and emerges out at the base of the distal interdental papilla on the palatal aspect (point 3 in **Figure 8**).

Step 3 – the suture then crosses over the incisal edge to pierce the base of the mesial interdental papilla on the labial aspect (point 4 in **Figure 8**).

Step 4 – from point 4, the suture retraces the path underneath the previous suture upto the criss-cross point (point 5 in **Figure 9**) on the labial aspect and winds around the point 5 to pierce at mid buccal region (point 6 in **Figure 9**) on the labial aspect.

Step 5 – knot is placed between point 1 and 6 (**Figure 9**) [24].

**Figure 8.** *Criss-cross splint.*

**Figure 9.** *Criss-cross splint.*

#### **7. Home-care instructions to parents**

Post-treatment maintenance of good oral hygiene is the key to uneventful healing of the injured tissues. Therefore, parents/caregivers must be sensitized about the importance of maintaining good oral hygiene and also taught the methods to maintain it. Most important instructions to be given are:

#### **8. Conclusion**

To summarize, splinting is important for stabilizing the luxated teeth; use of semirigid/flexible splints is mandatory as it allows functional movements of the tooth and short-term immobilization is recommended as longer period of splinting is associated with complications.

### **Author details**

Eswari Ramassamy

Department of Pediatric and Preventive Dentistry, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India

\*Address all correspondence to<EMAIL_ADDRESS>
© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 6**

## Perspective Chapter: Orbital Reconstruction and Orbital Volume

*Yousry Eldek, Heba Sleem, Mohamad Katamesh and Fahmy Hasanin*

#### **Abstract**

Orbital fractures are common presentation in the head and neck trauma centers. They can result in functional and esthetic problems. The primary goal in the repair of the orbital fractures is to restore the orbital shape and volume, free the incarcerated or prolapsed orbital tissue from the fracture defect, and span the bony defect with reconstructive implant material. Titanium mesh was very appropriate reconstructive material for anatomic reconstruction. The orbit has a special complex geometry which makes perfect anatomic reconstruction very difficult. The manual process of fitting and adapting the implant within the orbit is time consuming and operator dependent. The advanced techniques in maxillofacial imaging and computer assisted techniques resulted in improvement in the implant design for management of orbital fractures. The current study was made to review the accuracy of adapting the titanium mesh using STL model versus conventional technique for restoring the orbital volume in management of orbital floor fracture.

**Keywords:** orbital reconstruction, orbital volume, titanium mesh, STL model, computer assisted surgery

#### **1. Introduction**

Orbital fractures are one of the most common fractures of the midface and result in significant complications such as enopthalmos, diplopia, restriction of gaze, and dystopia [1]. Orbital reconstruction aims to restore the normal orbital volume and architecture and reduce the herniated orbital tissues to prevent the compications [2]. The choice of the implant material depends on many factors such as: size of the defect, involvement of many walls, adaptation to internal contours, restoration of accurate volume, presence of adjacent sinus cavity, prevention of displacement, restriction of ocular motility, risk of further trauma, and early versus late repair [3].

**Avashia et al.** reviewed the materials used for orbital reconstruction and classified it into biological materials and manufactured materials. Biologic materials include autografts, allogarfts, xenografts. Manufactured materials include resorbable materials as polymers and nonresorbable materials as porous polyethylene, bioactive glass, silastic rubber, titanium, teflon, nylon, and other materials. Avashia et al. reported no consensus for any material as the optimal choice for orbital floor reconstruction [4].

Many surgical techniques have been adopted and evaluated for correction of orbital volume. Topography of the orbital floor (S shape in sagittal plane) is one of the difficult factors during insertion and manipulation of reconstructive material. However there is a continuous search and study for the best method to achieve accuracy, feasibility, and reliability for restoration of the orbit [5].

#### **2. Titanium implant**

Literature review revealed the use of many surgical approaches and many implant materials for orbital reconstruction. Titanium mesh was very appropriate reconstructive material for anatomic reconstruction [6]. Titanium implants are considered as an established implant material to reconstruct the orbital and craniofacial skeleton. There are many forms and shapes of titanium mesh and different thickness and sizes [7].

Titanium mesh is the most commonly used reconstructive material for orbital reconstruction [8]. Intra-operative manual bending and adaptation to the titanium mesh after exposure and reduction of fractured segments is a traditional or conventional technique. However, this leads to more dissection, multiple trials, and longer operative time especially in comminuted fractures. This technique makes the reconstruction process a subject of interpersonal variation because the manipulation and bending of the implant material depends on the operator experience [9].

Titanium meshes have high biocompatible properties. They are easily molded to fit simple and complex orbital defects. They can provide a strong support without change in the shapes or locations over time. They can be fixed to adjacent bone. They have many good characters such as: availability, easy sterilization, and a wellrecognized osseointegration. Titanium has a high corrosion resistance because of the spontaneously forming thin oxide layers on the surface. This guarantees its passive behavior to avoid toxic or allergic reactions [4].

In 2009**, Lee and Nunery** revealed that the use of titanium mesh in the orbital floor can lead to fibrous adhesion around the implant resulting in diplopia or restricted eye movement after orbital floor repair by 2 months. It is a rare complication which requires replacing the titanium mesh with another implant. They considered the titanium itself caused fibrous adhesion and named it "orbital adherence syndrome" [10]. However, in 2013, **Kersey et al.** revealed in their study that the fracture can result in rupture or splitting through the periorbita, causing fibrous adhesion due to inadequate separation between the orbital contents and the bone or the implant and this complication can ocuur occur with or without the titanium implant [11].

#### **3. Computer assisted surgery**

The orbit has a special complex geometry, so the perfect anatomic reconstruction is very difficult. The process of fitting and adapting the implant in the orbit is time consuming and operator dependent. The narrow field in addition to the complex anatomy of the orbit make the orbital reconstruction difficult and almost impossible to achieve "true-to-original" 3D shape [12].

The management of the orbital fractures has changed over the years. The advanced techniques for maxillofacial imaging and computer assisted techniques lead to an improvement in the implant design for orbital reconstruction [13].

#### *Perspective Chapter: Orbital Reconstruction and Orbital Volume DOI: http://dx.doi.org/10.5772/intechopen.106369*

Over the last 2 decades, there was great and rapid improvement in the computed tomography which has added a third dimension to the imaging of complex craniomaxillofacial deformity. This development has significantly decreased the degree of inaccuracy that is inherent in any clinical assessment. Three dimensional (3D) reconstruction from volume data collected from helical CT is now an established technique in craniomaxillofacial surgery to provide animated screen images and accurate reproduction of the hard and/or soft tissues with models [14].

The development of computer assisted surgeries represents a new technology and a turn point in the field of craniofacial reconstruction. Some of the computer assisted techniques are used for virtual reconstruction of the fractured orbit and rapid prototyping. STL model was used for adapting and contouring the orbital mesh to allow accurate orbital volume, decrease operative time, decrease hospital costs, strengthen the surgical skills, and improve patient outcomes [15–17].

**Lim et al.** found that the direct intraoperative trimming and adaptation may take long operative time depending on the extension of the defect and experience of the surgeon when compared with STL models [18]. On the other hand, preoperative rapid prototyping reduces the intraoperative time, risk of orbital mesh malposition, poor anatomical contour, and trauma to soft tissue because of multiple insertions during trimming and adaptation of the titanium mesh [19].

Rapid prototyping is a new technique characterized by rapidly and accurately preparing solid bodies with complex shapes, so it has a promising and extensive application in the medical fields [20]. Since its introduction into craniomaxillofacial surgery in the 1990s, it has been used for the treatment of various medical problems, such as orbital hypertelorism, craniosynostosis, facial asymmetry, craniomaxillofacial defects, maxillofacial implants, orthognathic surgery, tumor surgery [21].

Rapid prototyping is a three dimensional (3D) printing process which involves an additive manufacturing technology which offers an expedient and accurate reproduction of an osseous anatomy. The intact orbit was mirrored onto the fractured one to create virtual model. The virtual model data were converted to STL (Standard Triangulation Language or Standard Tessellation Language) format to form a solid physical orbital model using a 3D printer and computer-aided manufacturing machines. STL model was used to adapt and contour the orbital mesh to allow accurate orbital volume, decrease risks and time consuming, and help improve postoperative results [18, 21].

In 1986, **Hull** introduced the stereolithography apparatus (SLA) technique to create an accurate, hardened, three dimensiona; acrylic models from CT data [22, 23]. In 1990, the first stereolithographic patient model was built. It represented an actual three- dimensional model to reproduce the anatomy of a patient based on CT images taken during that patient's examination [24].

In 1998, **Perry et al.** reported that 3D models of the facial skeleton differ in their accuracy, reproducibility and cost. The early attempts to build and form models from CT scans were stacked polystyrene slices where each of which represented a corresponding slice from an axial scan. Since then model building has developed into 2 distinct processes: computer aided manufacture (CAM) and stereolithography. In the computer aided manufacture (CAM) technique, the models are milled by computer guidance from different materials as soft expanded polyurethane and titanium alloy. It is considered as a removal process by an expensive milling machine. Stereolithography is a computer controlled construction process including 0.25 mm layer by layer polymerization of LASER curable liquid resin which are built on top of each other. It is accurate, slow and expensive technique [14]**.**

In 1999, **Holck et al.** described the benefits of the sterolithography (SLA) modeling system for planning the surgery for bony orbital pathology. They reported that the SLA models were beneficial preoperatively for evaluating the dimensions of the bony defects and surgical planning. Intraoperatively, SLA models facilitated the surgical rehabilitation of the orbit leading to postoperative satisfactory results [24]**.**

In 2006, **Metzger et al**. measured the accuracy of a technique for making individual preformed titanium meshes for orbital fractures. The study included 5 patients with unilateral orbital fractures and the patients underwent preoperative CT scans of 1 mm thickness followed by surgical planning using surgical planning software, then stereolithographic models were built after using the mirroring tool from unaffected side on affected side. Titanium meshes were then adapted manually on the STL models and sterilized. Intra-operatively, the meshes were positioned with the aid of navigation tools to ensure correct placement of the mesh as on the template by using reference points. Postoperative CT scans were obtained to compare the actual position of the titanium mesh implant to the planned position of the orbital floor. They reported accurate reproduction of the planned surgery [25].

In 2006, **Schon et al.** used individually preformed implants to reconstruct an extensive orbital floor fractures in 19 patients. The orbital floor and walls were studied by preoperative diagnostic CT scan data. The form of the virtual reconstructed orbit was printed into a model for the orbital cavity by a template machine. They reported that the orbital reconstruction using a preformed implants is less time consuming, more accurate, and less invasive in comparison to free hand efforts for the restoration of the orbital fractures using titanium mesh and calvarial grafts [26]**.**

In 2010, **Zhang et al.** studied 21 patients with delayed treatment of unilateral impure fracture of the orbit and post-traumatic enophthalmos. They used anatomically adaptive titanium mesh depending on computer-aided design and computeraided manufacturing techniques (CAD/CAM). After exposure to orbital floor defect and reduction to the herniated soft tissue, the titanium mesh was placed to restore the internal orbit. Measurements were taken to evaluate the change in the degree of enophthalmos and orbital volume before and after surgery. They found that this method was useful to some degree to decrease the expanded orbital volume and correct post-traumatic enophthalmos [27].

In 2012, **He et al.** made a retrospective review of a consecutive clinical case series. 64 patients from 2008 to 2010 were diagnosed with delayed orbitozygomatic fractures with enophthalmos. Traditional surgery and computer-assisted treatment (navigation and 3D models) were used for zygoma reduction. They found that computer-assisted surgery can improve the treatment results [28].

In 2016, **Oh et al.** made a study to use individualized prebent titanium-Medpor mesh implants and stereolithographic modeling in a series of patients who underwent orbital wall reconstruction. They obtained good results and concluded that orbital reconstruction can be optimized by using individually manufactured rapid prototype skull model and premolded synthetic scaffold by computer-aid of mirroring-reconstruction of 3-dimensional images and 3-dimensional printing techniques [29].

**In 2020, Sigron et al.** made a study to compare the efficacy of the intraoperative bending of titanium mesh with the efficacy of pre-contoured "hybrid" patientspecific titanium mesh using 3D-printed anatomical models as bending guides for the surgical repair of isolated orbital floor fractures. They concluded that t the use of 3D-printed orbital models leads to a more accurate reconstruction and a time reduction during surgery [30].

#### **4. Orbital volume measurement**

Orbital volume measurement after maxillofacial trauma reveals a significant data for evaluating the severity of the injury and prevention of possible complications caused by enophthalmos [31]. The Volume of the orbit is the space formed by the size and position of the orbital walls [32].

In 1873 in France, **Gayat** may have been the first to publish orbital volume data [33]. He used lead pellets to fill the orbital cavity of 11 skulls and poured them into a graduated cylinder to determine the orbital volume. He found the average of the orbital volume approximately equal to 29 cm3 . After **Gayat**, some authors used alternative methods for measurement on corpses using silicone, water, glass beads or sand were used [34].

During the 20th century, OVM for living patients became possible with the development of medical imaging techniques. The first OVM for a living patient was performed in the 1960's with manual evaluation of roentgenographic images [33].

With the advent of tomodensitometry, volume measurement of irregular objects became possible. In 1985, **Forbes et al.** transferred the data from CT scan images to special program to calculate the volume of the orbital structures. The software counted the number of pixels to calculate the volume according to the number of slices and special formulas [35].

Manual segmentation for OVM (planimetry methods) is considered to be the most common method for this purpose. It depends on the summation of the manually delineated areas obtained from a CT images [36]. The operator manually delineates the boundaries of the orbital bone cavity on a series of CT slices. The boundaries are defined by the operator and not by standard charts. This can represent a source of errors with low reproducibility. Planimetry method is extremely time-consuming to be accurate but its advantage lies in its availability on all standard medical imaging softwares [37].

Automatic methods for OVM contains automatic segmentation of the orbital cavity which can be undertaken using a function integrated within software. This method relies on atlas segmentation [38]. Semi-automatic method for OVM is defined as a method using volumetric built-in functionality in software, combined with manual adjustments. Various semi-automatic methods are available, depending on the software used. The are some softwares which are considered as different methods described in the literature for OVM [37]**.**

Several studies have shown a correlation between an increased OV and enophthalmos. Using planimetry, **Whitehouse et al**. showed that enophthalmos increased by 0.8 mm per 1 cm3 of OV expansion [39]. In 1993, **Charteris et al**. proposed that the amount of increase in the orbital volume may determine the need for surgical intervention [40].

Some authors consider the OV as a predictive of long-term symptoms, while other authors did not find a significant correlation between an increased OV and enophthalmos [41]. Choi et al. showed that the OV cannot be considered as a reliable measure to estimate the size of enophthalmos because of inter-individual variations in the OV [42].

The use of intraoperative navigation during the orbital surgery according to data from CT scans or MRI assisted in implementation of preoperative plan, volume measurement, and protecting the vital structures [38]. In the recently published studies, administration of CT images was recommended as the standard method to determine the volume of the orbital cavity in living patients [34]. However, there is no consensus concerning the gold standard for orbital volume measurement [43].

The difference in the volume of bony orbit can reach 0–8% between the right and left orbit when measured in the same person [35, 44], and up to 22% between subjects [32]. This normal difference can be considered as a protective factor for the surgeon, allowing him some malleability in the work for not insisting to achieve the ideal OV and reflecting the great tolerance in orbital volumetric restoration. A perfect symmetry between the 2 orbits is not necessary, and a variation of around 10–20% of the volume between the 2 orbits may involve no or only minor imperceptible facial irregularity. This minor difference may lead to a satisfactory result for the patient and the surgeon [44].

Stereolithography (SLA) technology developed into many types such as powder bed fusion, fused deposition modeling (FDM), selective laser sintering (SLS) for 3D printing which is known as additive manufacturing or desktop fabrication. Some metals as titanium, silver, gold, steel, and stainless steel can be used as raw materials for 3D printing. However, the plastics are most commonly used such as: acrylonitrile butadiene styrene (ABS) or "Lego" plastic material, polylactic acid (PLA) which is readily available in soft and hard grades, polyvinyl alcohol (PVA), and polycarbonate (PC). ABS materials are sturdy, strong, and providing more structural integrity than PLA which is less expensive, more biocompatible, and providing more precise prints [45–48].

#### **5. Conclusion**

Both techniques conventional technique and STL model for titanium mesh adaptation lead to significant correction of the orbital volume. Conventional technique is still a valid and cheap method among the attractive new techniques. STL technique is helpful in the cases presented with massive orbital disruption and/or malunion. It offers less operative time and less tissue manipulation.

*Perspective Chapter: Orbital Reconstruction and Orbital Volume DOI: http://dx.doi.org/10.5772/intechopen.106369*

#### **Author details**

Yousry Eldek1 \*, Heba Sleem<sup>2</sup> , Mohamad Katamesh2 and Fahmy Hasanin3

1 Oral and Maxillofacial Specialist, Nasser Institute Hospital, Cairo, Egypt

2 Faculty of Dentistry, Professor of Oral and Maxillofacial Surgery, Ain Shams University, Cairo, Egypt

3 Faculty of Dentisry, Professor of Oral and Maxillofacial Surgery, Cairo University, Cairo, Egypt

\*Address all correspondence to<EMAIL_ADDRESS>
© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 7**

## Perspective Chapter: Trauma from Occlusion – Practical Management Guidelines

*Prashanth Shetty, Shweta Hegde, Shubham Chelkar, Rahul Chaturvedi, Shruti Pochhi, Aakanksha Shrivastava, Dudala Lakshmi, Shreya Mukherjee, Pankaj Bajaj and Shahzada Asif Raza*

#### **Abstract**

Occlusal trauma is trauma to the periodontium from functional or parafunctional force's causing damage to the teeth and its attachment apparatus by exceeding its adaptive and reparative capacities. Occlusal instability is a common cause for trauma from occlusion, resulting in numerous complications. It often leads to interference which reflexively shifts or slides the jaw forward on one or both the side to find a spot where most teeth come together. This action protects the teeth from injury caused by chewing on just one tooth. Overtime, this shift can cause a whole host of problems from TMJ pain, post restorative complications, headache, tooth sensitivity, recession, broken and loss of teeth and orofacial pain. These occlusal interferences and bite discrepancies are treatable with minimally invasive dentistry. Occlusal equilibration is a therapy that is used when the cause of trauma is due to occlusal instability. This involves the reshaping of the teeth where the improper biting surfaces are located. The key lies in decoding the cause, but often treatment is only directed towards the effects. Only a thorough evaluation and occlusal analysis will lead to a definitive diagnosis that will help in better anticipation of the damages.

**Keywords:** occlusal trauma, occlusal instability, occlusal interferences, occlusal analysis, biometric analysis, occlusal equilibration

#### **1. Introduction**

Ideal occlusion is characterized by simultaneous contacting of all teeth at maximum intercuspation, with an equal intensity force on right and left side of the arch. This helps to preserve all the physiological components of the stomatognathic system namely the occlusion, the attachment apparatus, TMJ and the neuromusculature in harmony as they are closely interrelated. When the functional or parafunctional occlusal forces exceeds the capacity for adaptation and repair of one tooth or group of teeth and its attachment, limited or progressive injury occurs. This is called occlusal trauma. In the presence of interference, the jaw will reflexively shift and slide forward on one or both the side to find a spot where most teeth come together. An unstable occlusion is a common cause for numerous post restoration complications. Overtime, this may cause a whole host of problems from TMJ pain, headache to sensitivity, recession, broken and lost teeth and Orofacial Pain.

Establishing a stable and harmonious occlusion goes a long way in preventing the deterioration of the dentition and its associated structures [1]. Trauma from occlusion is a clinical finding often ignored by the dentist as it is not a part of the chief complaint. The key lies in decoding the cause, but most often treatment is only directed towards the effects. Only a thorough evaluation and occlusal analysis will lead to a definite diagnosis. A good diagnosis helps in better anticipation of the direction the damages will take.

Digital occlusal analysis is a powerful tool which provides the dentists with an objective reproducible data. These occlusal technologies along with a biometric approach will allow for an accurate diagnosis treatment and reevaluation of the inter relationship between teeth, muscles & joints [2].

#### **2. Terminologies used with trauma from occlusion**

#### **2.1 Trauma from occlusion**

Occlusal trauma was defined as "An injury to the attachment apparatus as a result of excessive occlusal force" "Glossary of Periodontics terms" (American Academy of Periodontology 1986), [3].

#### **2.2 Occlusal interferences**

Any contact that inhibits the remaining occluding surfaces from achieving stable and harmonious contacts.

#### **2.3 Occlusal adjustment**

Reshaping of the occlusal surfaces of teeth by grinding to create harmonious contact relationships between the upper and lower teeth, or orthodontic movement of the teeth to create more harmonious contact relationship.

#### **2.4 Fremitus**

A palpable or visible movement of a tooth when subjected to occlusal forces (also known as functional mobility).

#### **2.5 Premature occlusal contact**

A condition of tooth contact that diverts the mandible from a normal path of closure.

*Perspective Chapter: Trauma from Occlusion – Practical Management Guidelines DOI: http://dx.doi.org/10.5772/intechopen.105960*

#### **3. Classification**

#### **3.1 Glickman's classification (1953)**

#### *3.1.1 According to duration of cause*

#### I.Acute trauma from occlusion:

This type of trauma is caused because of abrupt occlusal impact, like due to biting on a tough object or high restorations or prosthetic appliances. The clinical signs and symptoms of the condition include tooth pain and sensitivity to percussion, fremitus, tooth mobility and once the cause is removed, symptoms subside and complete healing takes place [4–7].

#### II.Chronic trauma from occlusion:

When abnormal occlusal forces are exerted on the tooth-supporting structures for a longer duration of time, chronic trauma from occlusion occur. It is more significant than the acute condition because it results in progressive changes in occlusion clinically seen as tooth migration, tooth wear and extrusion of teeth [4–7].

#### *3.1.2 According to nature of cause*

I.Primary trauma from occlusion:

It refers to the injury resulting from excessive occlusal forces applied to a tooth or teeth with adequate support

#### II.Secondary trauma from occlusion:

It refers to the injury resulting from normal occlusal forces applied to a tooth or teeth with inadequate support.

#### **3.2 Box's classification**

#### *3.2.1 Physiologic occlusion*

Box defined it as a condition, in which the systems of forces acting upon the tooth during the occlusion are in a state of equilibrium, and they do not and cannot change the normal relationship existing between the tooth and its supporting structures [8].

#### *3.2.2 Traumatic occlusion*

The damage produced in the periodontium is due to the overstress produced by the occlusion (**Table 1**).

#### *Dental Trauma and Adverse Oral Conditions - Practice and Management Techniques*

**Table 1.** *Etiology of trauma from occlusion.*

#### **4. Pathophysiology of trauma from occlusion**

Excessive occlusal force

↓ **Soft tissue change**

Traumatic v shaped gingival crescent Stillman's cleft (indentations in the gingival margin generally on one side of tooth) McCall's festoons (Buccal Bone dehiscence)

Absence of stippling – Edema secondary to trauma

↓ Alteration in occlusal forces

↓

#### **Hard tissue change**

Occlusal wearing pattern of tooth not attributed to any abnormality in patient diet

↓

Tooth mobility, migration, shifting & tilting of tooth

↓ Discomfort on eating ↓ Sensitivity of teeth

↓ Hypertonicity of muscle

↓

Mandibular deviation

#### **5. Stages of tissue response to excessive occlusal forces**

Excessive force of occlusion causes the tissue to respond in three stages Injury, repair and adaptive remodeling of periodontium.

#### **5.1 Stage 1: injury**

Soft tissue injury is the immediate result of excessive occlusal forces. The magnitude of forces varies from slightly excessive, greater then excessive or severely high.

#### *Perspective Chapter: Trauma from Occlusion – Practical Management Guidelines DOI: http://dx.doi.org/10.5772/intechopen.105960*

The centre of rotation of a single rooted tooth lies at the junction of middle and apical third of the tooth and is located near the furcation area of the multirooted teeth.

When excessive occlusal forces are subjected to teeth they rotate around the fulcrum of rotation. This rotation in the tooth socket creates areas of presser and tension on the opposite side of the fulcrum. When the force is unidirectional, these are created on the opposite surface, whereas in the case of jiggling forces these areas may co – exist on the same surface.

Effect of excessive occlusal forces on the periodontium.

**Slightly excessive forces**- simulates bone resorption in area of presser, causing the widening of periodontal ligament space. Elongation of PDL fibers takes place in the areas of tension.

**Greater than slightly excessive forces**- caused marked changes in the tooth supporting structures producing areas of hyalinization and necrose when excessive compressive forces are produced from trauma from occlusion.

**Severely high occlusal force**- results in thrombosis, hemorrhage, tearing & widening of pdl space and undermined bone resorption. If the forces are removed, or tooth moves away the periodontium is completely repaired.

#### **5.2 Stage 2: repair**

Takes place when the damage tissue is replaced by new connective tissue and cells. This is a well-regulated mechanism and the healing process is directly or indirectly facilitated by the extracellular matrix and certain inflammatory mediators. The activity is increased during TFO & the body tries to reinforce the trabeculae within the new bone by a process known as buttressing bone formation. When it occurs in the buccal and lingual surface of the alveolar bone it is known as peripheral buttressing and central buttressing when this process occurs within the bone this helps to bear increased occlusal load. There is a shelf-life thickening of the bone on the labial or lingual surface of the alveolar bone is referred to as lipping.

#### **5.3 Stage 3: adaptive remodeling of the periodontium**

Establishes a structural relationship in such a way that the forces of occlusion are no longer harmful to the periodontium, and the repair process can keep pace with the destructive occlusal forces.

Tooth mobility is an important clinical sign when TFO is increase it occurs in two phases the initial phase there is an increase in the width of the PDL and reduction of the number of the periodontal fibers leading to alveolar bone resorption.

The second phase results in the permanent widening of the PDL space which occurs after the repair of the traumatic lesion as an adaptation to the increased forces.

#### **6. Is traumatic occlusion reversible?**

If excessive occlusal forces are neutralized, healing takes place. The presence of plaque may however impair healing so resolution of inflammation should be first initiated. Injury caused by TFO is reversible but there may or may not be complete restoration of the supporting structures of the tooth.

#### **7. Examination, evaluation, diagnosis and prognosis of trauma from occlusion**

Clinical history of the patient and clinical examination are the cornerstones of correct diagnosis of TFO.

#### **7.1 Clinical features of occlusal trauma**

#### **7.2 Tooth mobility**

Miller's Index (1938) is most often used to classify tooth mobility. Normal physiological movement vary between 10 μm and 150 μm and is not detectable on examination.

Class 0 – Within physiologic range when force is applied.

Class I – Mobility more the physiologic range.

Class II – Tooth moves upto 1 mm or more laterally (mesiodistal/buccolingual). Inability to vertically depress the tooth (apicocoronally).

Class III – Tooth can be moved 1 mm or more laterally (labiolingually or mesiodistally). Tooth can be depressed in a vertical direction.

#### **7.3 Fremitus test**

TFO can clinically detected using this test. The movement or vibratory pattern is measured when the teeth are placed in contacting positions and during lateral and protrusive movements.

In this test the vibratory movement of the tooth/teeth is identified and graded by placing dampened index finger along the labial surfaces of maxillary teeth.

The patient is asked to tap the teeth together in MIP and then grind systematically in lateral and protrusive movements.

Classification system used:

Class I fremitus: Mild movements/vibration detected.

Class II fremitus: No visible movements/easily palpable vibration.

Class III fremitus: Movements are visible to the naked eye.

#### **7.4 Radiographic signs**

#### **Radiographical Features**

1.Hypercementosis.

2. Secondary dentin laid down in the pulp chamber.

#### **8. Occlusal trauma and implants**

Osseointegration of implants is a direct structural and functional connection between ordered living bone and the surface of a load carrying implant.