Deformity of Craniofacial Skeleton by Traumatic Injuries

*Raja Kummoona*

## **Abstract**

Road traffic crashes on highways with high speed cars can end with termination of life. Immediately after the accident, the medical management includes early transportation by ambulance with highly equipped machines, skilled nurses and doctors to check blood pressure, blood loss, and breathing, administration of intravenous fluid plasma and collecting blood samples for blood grouping. Other treatment can be undertaken by ambulance staff such as temporary splinting (SPICA) of fractured legs and neck support. A helicopter may be used for urgent transport of injured patients with multiple injuries to highly equipped intensive care units in general hospitals. The cooperation of different specialties is required, such as neurosurgeons, craniomaxillofacial surgeons, chest surgeons, general surgeons, and orthopedic surgeons. The order of priority is head injuries, chest injuries, and abdominal injuries. Neglecting early treatment opportunities or delaying treatment results in severe deformities of the facial skeleton and damage to growth of the face in children, leading to severe deformity of the face. Isolated injuries to the eye orbit, nose, jaws, and temporo-mandibular joint (TMJ) may end in ankylosis of the joint in children. A series of clinical cases will be shown.

**Keywords:** trauma, injuries, craniofacial, deformity

## **1. Introduction**

Road traffic accidents (RTA) in highways occur due to a crash between cars or motorcycles and these crashes cause very common injuries worldwide. It's a disaster and can end in severe injuries to the drivers and passengers. There have been great advances in injury management and in the prevention of these severe cases; some of them with multiple injuries.

There are many steps in the process of early transportation to hospital by ambulance, with highly trained personnel with fully equipped ambulances. The process starts with checking blood pressure, pulse rate, measuring oxygen saturation, giving IV fluid, collecting plasma and blood samples for blood grouping, checking blood sugar. In cases with severe bleeding from the nose and mouth, they have to open the airways by performing a tracheotomy before reaching the emergency room in the hospital. Helicopter transportation might be used for critical cases with multiple injuries such as head injuries, severe facial skeleton injuries, chest injuries, abdominal injuries, and limb injuries [1].

There have been great advances in the radiological diagnostic tools including ultrasound and Doppler, three-dimension CT scan, MRI, and radiological X-ray equipment, including tomography with advances in biochemistry analysis. All these tools assist in the evaluation of the severity of injuries, in addition to proper clinical examination.

Many steps are taken to reduce the severities of car crashes with less damage to the head, chest, and abdominal organs by controlling the rate of speed, preventing alcohol consumption during driving, the wearing of helmet for motorcycle drivers, and compulsory shoulder seatbelts and seat restraints with a special chair for children in the back seat [1].

Vehicle safety measures are incorporated during the manufacturing of cars, from manufacturing air bags to protect the driver and all passengers in small cars, to having safety glass beads with collapsible steering to reduce the trauma to the head, face, and chest. Children should sit in the back in a special seat. All these measures have significantly reduced the incidence of road traffic crashes in both children and adults.

#### **1.1 Materials, results and discussion**

As we reported previously in 2011, clinical studies included 673 patients with craniofacial injuries and there were 530 males and 143 females, in the age range between 1 and 75 years (mean 38 years).

Distribution of injuries was as follows: fracture of the mandible 287 (42.64%), middle third injuries 39 (5.79%), and orbital injuries 236 (35.07%) including 12 cases of cranio-orbital ethmoidal injuries. In children, we reported 27 cases (4.0%) of the total cases, we reported also 52 cases that represent (7.73%) zygomatic complex, and zygoma and fracture nose were reported in 40 cases, which form (5.94%) the total cases. 1.

The many advances in the treatment of craniomaxillofacial injuries have been achieved by improvements in medication, tools of diagnosis, and anesthetic machines and medication. These are in addition to the skills and expertise of the anesthetists and care of injured patients by advancing trauma life support by application of the Kummoona 4 golden C rules and ATLAS [2] by,


Craniomaxillofacial injuries have been classified as follows:


**21**

*Deformity of Craniofacial Skeleton by Traumatic Injuries*

The most common anatomical area damaged in severe road traffic accidents in the cranial region was the frontal bone with anterior cranial fossa, roof of both

The facial skeleton consists of fifty small bones articulating like a pyramid, the top of the pyramid is the nasal tip. Seldom is only one bone of the facial skeleton fractured. The shape and function of the facial skeleton boney articulation acts as a shock absorber and cushion to absorb the impact of trauma and this is because these small bones of the facial skeleton also absorb the force of mastication transmitted along and through the buttress of bones to the base of the skull and this shock absorber of the facial skeleton also protects the vital structures from severe trauma to the underlying vital structures of vision, hearing, smell, taste, speech, and

In children, the growth of the face is not completed, except the orbit, in 7 years. Once trauma has occurred, the impact of severe trauma can displace the middle third of the face downward and backward by 45°, with the palate of the maxilla positioned on the dorsum of the tongue, obstructing oral airway with profuse bleeding from fractured nose due to injuries to ethmoidal arteries obstructing nasal airway. This combination of injuries is associated with head injuries, chest injuries,

If children survived from these injuries, they usually recover quickly. Mistreated cases end with severe deformities of the craniofacial region because they received great damage to the growth centers in the cranial sutures, base of skull (sphenoid-occipital synchondrosis), cartilage of the nose, and primary growth center in the condyle. Treatment of craniomaxillofacial trauma injuries requires expertise, skills and knowledge and these injuries should be treated in highly equipped cranial-maxillofacial centers. Mismanagement or delays in treatment end with severe deformities of the craniofacial region and end by destroying the life of the victim. Even an isolated fracture of the nose, orbit, zygoma, or jaw can end with obvious deformity

Our aim was directed to prevent complications, deformities, and to restore the

Severe cases of craniomaxillofacial injuries with head injuries and chest injuries need to be admitted immediately to an intensive care unit for a few days until the patient has recovered from the head and chest injuries before adequate treatment of

The treatment of a CSF leak usually follows the conservative principle of reduc-

2.Reduction of CSF leakage using carbonic anhydrase inhibitors (Acetazolamide {Diamox 3-kcl})250 mg twice daily, to correct hyperkalemia as a complication

3.The CSF leak usually stops within 4–5 days. If the CSF does not stop, a lumber

4.If the CSF leakage does not stop after all the previous procedures and measurement, perform a craniotomy indicated for Dura repair by piece of Gale apo-

The treatment of head injuries is the responsibility of the neurosurgeon, with

1.Reduction of intra cranial pressure (ICP) by elevation of the head by 45°

orbits, and nose with Dura tears and CSF leakage with head injury [1–3].

and abdominal injuries and is critical and a life threatening condition.

in a time where people are very concerned about their appearances.

tion and repair of craniofacial fractures through the following steps:

of Diamox and 4 triple antibiotics to prevent meningitis

puncture is required to reduce the ICP by aspiration of CSF

collaboration of the craniofacial surgeon [2].

neurosis or a piece of temporalis muscle and sutured watertight.

normal function and esthetic features of the craniofacial region.

the craniofacial injuries [1–4].

*DOI: http://dx.doi.org/10.5772/intechopen.91353*

swallowing.

#### *Deformity of Craniofacial Skeleton by Traumatic Injuries DOI: http://dx.doi.org/10.5772/intechopen.91353*

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

examination.

adults.

the total cases. 1.

times required).

vessels.

after blood grouping.

isolated nose fracture.

children in the back seat [1].

**1.1 Materials, results and discussion**

between 1 and 75 years (mean 38 years).

equipment, including tomography with advances in biochemistry analysis. All these tools assist in the evaluation of the severity of injuries, in addition to proper clinical

Many steps are taken to reduce the severities of car crashes with less damage to the head, chest, and abdominal organs by controlling the rate of speed, preventing alcohol consumption during driving, the wearing of helmet for motorcycle drivers, and compulsory shoulder seatbelts and seat restraints with a special chair for

Vehicle safety measures are incorporated during the manufacturing of cars, from manufacturing air bags to protect the driver and all passengers in small cars, to having safety glass beads with collapsible steering to reduce the trauma to the head, face, and chest. Children should sit in the back in a special seat. All these measures have significantly reduced the incidence of road traffic crashes in both children and

As we reported previously in 2011, clinical studies included 673 patients with craniofacial injuries and there were 530 males and 143 females, in the age range

Distribution of injuries was as follows: fracture of the mandible 287 (42.64%), middle third injuries 39 (5.79%), and orbital injuries 236 (35.07%) including 12 cases of cranio-orbital ethmoidal injuries. In children, we reported 27 cases (4.0%) of the total cases, we reported also 52 cases that represent (7.73%) zygomatic complex, and zygoma and fracture nose were reported in 40 cases, which form (5.94%)

The many advances in the treatment of craniomaxillofacial injuries have been

1.Control of breathing and maintenance of patient airway (tracheotomy some-

2.Control shock and circulation by intravenous fluid (IV), plasma, and blood

3.Control of bleeding by cauterization of small vessels and ligation of large

achieved by improvements in medication, tools of diagnosis, and anesthetic machines and medication. These are in addition to the skills and expertise of the anesthetists and care of injured patients by advancing trauma life support by

application of the Kummoona 4 golden C rules and ATLAS [2] by,

4.Control of bone fragments and soft tissue laceration.

Craniomaxillofacial injuries have been classified as follows:

with midline split of the face with or without CSF leakage

**A.** Craniomaxillofacial injuries with cerebrospinal fluid (CSF) leakage

**B.** Fractures of middle thirds Le Fort I, Le Fort II, and Le Fort III and sometimes

**C.** Fracture of mandible and other isolated injuries such as simple zygoma fracture or more complicated zygomatic complex, orbital skeleton complex and

**20**

The most common anatomical area damaged in severe road traffic accidents in the cranial region was the frontal bone with anterior cranial fossa, roof of both orbits, and nose with Dura tears and CSF leakage with head injury [1–3].

The facial skeleton consists of fifty small bones articulating like a pyramid, the top of the pyramid is the nasal tip. Seldom is only one bone of the facial skeleton fractured. The shape and function of the facial skeleton boney articulation acts as a shock absorber and cushion to absorb the impact of trauma and this is because these small bones of the facial skeleton also absorb the force of mastication transmitted along and through the buttress of bones to the base of the skull and this shock absorber of the facial skeleton also protects the vital structures from severe trauma to the underlying vital structures of vision, hearing, smell, taste, speech, and swallowing.

In children, the growth of the face is not completed, except the orbit, in 7 years. Once trauma has occurred, the impact of severe trauma can displace the middle third of the face downward and backward by 45°, with the palate of the maxilla positioned on the dorsum of the tongue, obstructing oral airway with profuse bleeding from fractured nose due to injuries to ethmoidal arteries obstructing nasal airway. This combination of injuries is associated with head injuries, chest injuries, and abdominal injuries and is critical and a life threatening condition.

If children survived from these injuries, they usually recover quickly. Mistreated cases end with severe deformities of the craniofacial region because they received great damage to the growth centers in the cranial sutures, base of skull (sphenoid-occipital synchondrosis), cartilage of the nose, and primary growth center in the condyle.

Treatment of craniomaxillofacial trauma injuries requires expertise, skills and knowledge and these injuries should be treated in highly equipped cranial-maxillofacial centers. Mismanagement or delays in treatment end with severe deformities of the craniofacial region and end by destroying the life of the victim. Even an isolated fracture of the nose, orbit, zygoma, or jaw can end with obvious deformity in a time where people are very concerned about their appearances.

Our aim was directed to prevent complications, deformities, and to restore the normal function and esthetic features of the craniofacial region.

Severe cases of craniomaxillofacial injuries with head injuries and chest injuries need to be admitted immediately to an intensive care unit for a few days until the patient has recovered from the head and chest injuries before adequate treatment of the craniofacial injuries [1–4].

The treatment of a CSF leak usually follows the conservative principle of reduction and repair of craniofacial fractures through the following steps:


The treatment of head injuries is the responsibility of the neurosurgeon, with collaboration of the craniofacial surgeon [2].

We undertook research on CSF analysis by taking several samples from patients with head injuries and blood serum from the same patients to study the differences between the two samples. We used a high specific isoelectric focusing electrophoresis set on polyacrylamide gel for direct immunofixation of transferrin by a plex electrophoresis set and spectrophotometer for serum sample. Using this study, we can detect the CSF leakage due to traumatic injuries and differentiate it from serum exudate.

Through this research we were able to detect the concentration of the B2-Transferrin enzyme in CSF and this level was 90.26 ppm, which represents about 35 times more than that detected in serum exudate [1].

The facial skeleton and the face are the mirror of the body reflecting happiness, sadness, beauty, and ugliness. The face is a mirror of intelligence and dullness and it also shows the body's signs of disease such as paleness, dryness of skin, yellow skin, dark or bluish skin, blisters, or pigments. These are all features of illness.

## **2. Clinical features, deformities and treatments**

Trauma to the face and subsequent deformities is a disaster to the patient and our duty is to restore the normal architecture of the face by restoring esthetic and functional activity of the facial skeleton. The problem is that the face is not padded by clothing and traumatic impact has a direct effect on the soft and hard tissue of the face. Once an accident has happened, we have to direct our effort to repair the soft tissue properly as the first step and to put every piece of bone of the facial skeleton in its anatomical position and to fix it either by plating or by soft stainless steel wires of 0.25 and 0.5 mm as a basic principle. Soft tissue damage may be a laceration or loss of soft tissue and these are repaired using local rotational flaps or regional flaps such as the forehead flap or Kummoona lateral cervical flap [5].

Deformities of the frontal bone and anterior cranial fossa can occur with severe trauma to the area associated with severe nasal-ethmoidal-orbital bone injuries with CSF leakage and head injuries. Serious injuries require admission to intensive care units until the patient recovers from the head injuries. A craniotomy through a bi-coronal flap is used for exploration of the anterior cranial fossa after retraction of the brain. Dura are repaired by galea aponeurosis or a piece of temporalis muscle with watertight suturing with silk and reconstruction of the anterior cranial fossa and the roofs of both orbits by bone grafting from the iliac crest. The frontal bone is repaired by bone graft or by rubber silicone material (Sialastic). The nose can be reduced at the same time [3] (**Figures 1**–**3**).

#### **Figure 1.**

*(A) Severe traumatic injuries to the nasal-ethmoidal-orbital region with laceration of overlying skin in a 4-year-old boy. (B and C) Post-operative photo after reconstruction of the region after 2 years.*

**23**

**Figure 2.**

**Figure 3.**

*several operations.*

*Deformity of Craniofacial Skeleton by Traumatic Injuries*

Deformities of the face can occur either to the whole facial skeleton in a scattered manner or to a part of it, such as the orbital skeleton damage with the globe of the eyes, an isolated fracture roof with downward displacement of eye ball, a fracture of the medial wall with dislocation of medial canthi and damage to nasolacrimal duct with enophthalmos, fracture of the floor of the orbit featuring diplopia and enophthalmos, or fracture of the zygoma and lateral wall with displacement of

*(A) Severe injuries from a road traffic accident to the craniofacial region with CSF leakage, elongation of the face, and displacement of the facial skeleton downward and backward. (B) 3D CT scan of the face showing the severity of the injuries. (C) Three months post-operative photo showing restoration of the facial skeleton after* 

*(A) Severe road traffic accident with deformity of cranial-facial region with damage to frontal bone, anterior cranial fossa with Dura tear, CSF leakage, and nasal-ethmoidal-orbital skeleton and nasal bone. (B) Bi-coronal flap used for craniotomy and for exploration of the anterior cranial fossa, for reconstruction of Dura, anterior cranial fossa, roof of the orbits, frontal bone, and nasal-ethmoidal-orbital region by bone graft and Sialastic implant. (C) Post-operative photo after 3 months showing slight dislocation of medial canthal ligament.*

In more severe cases with compression of the superior orbital fissures, this can result in superior orbital fissure syndrome and will be manifested as exophthalmos, ptosis, ophthalmoplegia, and fixed pupil with loss of vision and loss of sensation in the surrounding area and edema of the eyelids. Immediate treatment may restore the function of the eye and vision by reduction of zygomatic bone and elevation of compression on the superior orbital fissure. If there has been a severe impact with a sharp object to the globe of the eye with severe laceration and with no response of the pupil to light, evisceration of the eye must be performed by an ophthalmologist [6–8] (**Figures 4**–**6**).

the zygomatic bone either downward or laterally or rotated or inward.

*DOI: http://dx.doi.org/10.5772/intechopen.91353*

**Figure 2.**

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

35 times more than that detected in serum exudate [1].

**2. Clinical features, deformities and treatments**

We undertook research on CSF analysis by taking several samples from patients with head injuries and blood serum from the same patients to study the differences between the two samples. We used a high specific isoelectric focusing electrophoresis set on polyacrylamide gel for direct immunofixation of transferrin by a plex electrophoresis set and spectrophotometer for serum sample. Using this study, we can detect the CSF leakage due to traumatic injuries and differentiate it from serum exudate. Through this research we were able to detect the concentration of the

B2-Transferrin enzyme in CSF and this level was 90.26 ppm, which represents about

The facial skeleton and the face are the mirror of the body reflecting happiness, sadness, beauty, and ugliness. The face is a mirror of intelligence and dullness and it also shows the body's signs of disease such as paleness, dryness of skin, yellow skin,

Trauma to the face and subsequent deformities is a disaster to the patient and our duty is to restore the normal architecture of the face by restoring esthetic and functional activity of the facial skeleton. The problem is that the face is not padded by clothing and traumatic impact has a direct effect on the soft and hard tissue of the face. Once an accident has happened, we have to direct our effort to repair the soft tissue properly as the first step and to put every piece of bone of the facial skeleton in its anatomical position and to fix it either by plating or by soft stainless steel wires of 0.25 and 0.5 mm as a basic principle. Soft tissue damage may be a laceration or loss of soft tissue and these are repaired using local rotational flaps or regional

Deformities of the frontal bone and anterior cranial fossa can occur with severe trauma to the area associated with severe nasal-ethmoidal-orbital bone injuries with CSF leakage and head injuries. Serious injuries require admission to intensive care units until the patient recovers from the head injuries. A craniotomy through a bi-coronal flap is used for exploration of the anterior cranial fossa after retraction of the brain. Dura are repaired by galea aponeurosis or a piece of temporalis muscle with watertight suturing with silk and reconstruction of the anterior cranial fossa and the roofs of both orbits by bone grafting from the iliac crest. The frontal bone is repaired by bone graft or by rubber silicone material (Sialastic). The nose can be reduced at the same time [3] (**Figures 1**–**3**).

*(A) Severe traumatic injuries to the nasal-ethmoidal-orbital region with laceration of overlying skin in a* 

*4-year-old boy. (B and C) Post-operative photo after reconstruction of the region after 2 years.*

dark or bluish skin, blisters, or pigments. These are all features of illness.

flaps such as the forehead flap or Kummoona lateral cervical flap [5].

**22**

**Figure 1.**

*(A) Severe road traffic accident with deformity of cranial-facial region with damage to frontal bone, anterior cranial fossa with Dura tear, CSF leakage, and nasal-ethmoidal-orbital skeleton and nasal bone. (B) Bi-coronal flap used for craniotomy and for exploration of the anterior cranial fossa, for reconstruction of Dura, anterior cranial fossa, roof of the orbits, frontal bone, and nasal-ethmoidal-orbital region by bone graft and Sialastic implant. (C) Post-operative photo after 3 months showing slight dislocation of medial canthal ligament.*

#### **Figure 3.**

*(A) Severe injuries from a road traffic accident to the craniofacial region with CSF leakage, elongation of the face, and displacement of the facial skeleton downward and backward. (B) 3D CT scan of the face showing the severity of the injuries. (C) Three months post-operative photo showing restoration of the facial skeleton after several operations.*

Deformities of the face can occur either to the whole facial skeleton in a scattered manner or to a part of it, such as the orbital skeleton damage with the globe of the eyes, an isolated fracture roof with downward displacement of eye ball, a fracture of the medial wall with dislocation of medial canthi and damage to nasolacrimal duct with enophthalmos, fracture of the floor of the orbit featuring diplopia and enophthalmos, or fracture of the zygoma and lateral wall with displacement of the zygomatic bone either downward or laterally or rotated or inward.

In more severe cases with compression of the superior orbital fissures, this can result in superior orbital fissure syndrome and will be manifested as exophthalmos, ptosis, ophthalmoplegia, and fixed pupil with loss of vision and loss of sensation in the surrounding area and edema of the eyelids. Immediate treatment may restore the function of the eye and vision by reduction of zygomatic bone and elevation of compression on the superior orbital fissure. If there has been a severe impact with a sharp object to the globe of the eye with severe laceration and with no response of the pupil to light, evisceration of the eye must be performed by an ophthalmologist [6–8] (**Figures 4**–**6**).

#### **Figure 4.**

*(A) Deformity of the orbit due to traumatic injuries with downward displaced eyeball due to fracture in the roof of the orbit of a 4-year-old boy. (B) Post-operative photo after reconstruction of the roof of the orbit by Sialastic implant.*

#### **Figure 5.**

*(A) Severe enophthalmos due to traumatic injury to the floor and medial wall of the orbit with dislocation of medial canthal ligament. (B) Reconstruction of the orbital floor by bone graft from iliac crest. (C) Post-operative photo after reconstruction of the floor and medial wall and fixation of median canthal ligament.*

#### **Figure 6.**

*(A) Severe injuries to orbital skeleton and content with loss of eyeball. (B) Reconstruction of all orbital skeleton with ptosis of upper lid required in a secondary surgery and artificial eyeball.*

**25**

**Figure 7.**

*multiple injuries. (D) Six months post-operative photo.*

*Deformity of Craniofacial Skeleton by Traumatic Injuries*

Bad injuries to the mandible with multiple fractures and delayed treatment can cause severe deformity with open bite and malocclusion. Usually the injuries affect the body and angle either as a favorite fracture or an unfavored fracture. The favorite fracture is not affected by muscles of mastication. The direction of the fracture line plays an important role in preventing displacement. The unfavorite type of fractures of the angle with displacement were affected by temporalis, medial pterygoid, and masseter muscles. These fractures required an open reduction through a submandibular incision, fixation of fragments done by plating or by soft stainless steel wire of 0.5 mm as a double eight crossing each other with inter maxillary fixation (IMF). A less severe form of this fracture angle might be treated by upper border wiring with IMF (**Figure 7A**–**D**).

*(A and B) Severe traumatic deformity of the mandible with open bite and injuries to cranial region with head injury and CSF leakage treated by craniotomy and Dural repair. (C) 3D CT scan of lower jaw showing* 

*DOI: http://dx.doi.org/10.5772/intechopen.91353*

*Deformity of Craniofacial Skeleton by Traumatic Injuries DOI: http://dx.doi.org/10.5772/intechopen.91353*

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

*(A) Deformity of the orbit due to traumatic injuries with downward displaced eyeball due to fracture in the roof of the orbit of a 4-year-old boy. (B) Post-operative photo after reconstruction of the roof of the orbit by* 

**24**

**Figure 6.**

**Figure 5.**

*canthal ligament.*

**Figure 4.**

*Sialastic implant.*

*(A) Severe injuries to orbital skeleton and content with loss of eyeball. (B) Reconstruction of all orbital* 

*(A) Severe enophthalmos due to traumatic injury to the floor and medial wall of the orbit with dislocation of medial canthal ligament. (B) Reconstruction of the orbital floor by bone graft from iliac crest. (C) Post-operative photo after reconstruction of the floor and medial wall and fixation of median* 

*skeleton with ptosis of upper lid required in a secondary surgery and artificial eyeball.*

Bad injuries to the mandible with multiple fractures and delayed treatment can cause severe deformity with open bite and malocclusion. Usually the injuries affect the body and angle either as a favorite fracture or an unfavored fracture. The favorite fracture is not affected by muscles of mastication. The direction of the fracture line plays an important role in preventing displacement. The unfavorite type of fractures of the angle with displacement were affected by temporalis, medial pterygoid, and masseter muscles. These fractures required an open reduction through a submandibular incision, fixation of fragments done by plating or by soft stainless steel wire of 0.5 mm as a double eight crossing each other with inter maxillary fixation (IMF). A less severe form of this fracture angle might be treated by upper border wiring with IMF (**Figure 7A**–**D**).

**Figure 7.**

*(A and B) Severe traumatic deformity of the mandible with open bite and injuries to cranial region with head injury and CSF leakage treated by craniotomy and Dural repair. (C) 3D CT scan of lower jaw showing multiple injuries. (D) Six months post-operative photo.*

#### **Figure 8.**

*(A) Severe deformity of the mandible due to intra-uterine injuries to the right temporo-mandibular joint and the child born with ankylosis of the TMJ. (B) One year post-operative after reconstruction of the right TMJ by Kummoona Chonro-Ossous graft at age of 5 years.*

The other types of fracture affect the ramus and the most common two types of fractures are the condylar (intra capsular) type and sub condylar type. The intracapsular type of fracture condyle is a very serious injury that requires special attention while the sub condylar type is treated by inter maxillary fixation (IMF) for 3–4 weeks.

Intracapsular fracture of the condyle in children is very serious. If mistreated, it can lead to ankylosis with severe deformity of the mandible and midface due to damage to the growth center in the condyle. Early treatment of an intracapsular fracture should be carried out by administration of a few drops of hydrocortisone to prevent adhesion and to reduce edema with IMF for 3–4 days to relief spasm of muscles and to remodel the shape of the condyle followed by early mobilization.

Once adhesion of the condyle had occurred and deformity of the jaw has appeared, we must excise the ankylosed joint with hyperplastic coronoid, reattach of the muscles of mastication and reconstruct the TMJ by using Kummoona Chondro-Osseous graft was harvested from iliac crest in children for restoration of growth, remodeling, and repair of the condyle (**Figure 8**). The graft can restore the growth of the mandible and midface and prevent residual deformity [2, 4, 6].

In craniofacial injuries, after reconstruction of the anterior cranial fossa and frontal bone, we have immediately to reduce and fix the middle third fracture of the facial skeleton including Le Fort I, II, III, and mid line split of the face. Reduction was achieved by using Rowe dis impaction forceps to move the displaced facial skeleton upward and forward in the reverse direction of the displacement of the middle third and to put the skeleton in its normal anatomical position with intermaxillary fixation (IMF).

Fixation of the facial skeleton was performed by using our techniques of fixation by suspension of middle third through the sandwich technique using soft stainless steel wire of 0.5 mm and making hole by using round bur in the frontal-zygomatic suture above the fracture line and the wire is passed below the zygoma down through the cheek to the lower arch bar fixed by wires and IMF and reinforced by a circum-mandibular wire with proper occlusion of the teeth.

**27**

Iraq

**Author details**

**3. Conclusion**

worldwide.

regions were also described.

Raja Kummoona

Council of Maxillofacial Surgery, Iraqi Board for Medical Specialization, Baghdad,

© 2020 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,

\*Address all correspondence to: raja\_kummoona@hotmail.com

provided the original work is properly cited.

*Deformity of Craniofacial Skeleton by Traumatic Injuries*

anatomical position and to get normal facial length and height.

Another technique is the Halo Frame fixed by 4 pins to the skull and again two cheek wires attached to the Halo Frame and passed below the zygoma to the upper or lower arch bar. Another technique is the Box frame technique that requires insertion of 4 pins (2 in the frontal process of the frontal bone and 2 pins in the angle of the lower jaw) with 4 rods fixed after reduction of the displaced midface with IMF to achieve proper occlusion. The success of treatment is based on proper occlusion and proper fixation of the small bones of the facial skeleton to be sited in their

The aim of our research is to share our techniques and expertise in the treatment and management of traumatic craniofacial deformities with other colleagues

In this clinical research, we studied 673 patients with craniofacial injuries and deformities and the incidence of these injuries to affect various parts of craniofacial region, we did classify these injuries and how serious ,primary care described thoroughly and cases with cranial or LeFort III injuries might associated with CSF leakage ,methods of management were described by conservative technique if not by craniotomy. Different techniques for reduction and fixation of the craniofacial

This study shows the ability of the author to deal with very difficult cases of

craniofacial region. I hope this chapter satisfies the curiosity of the readers.

*DOI: http://dx.doi.org/10.5772/intechopen.91353*

Another technique is the Halo Frame fixed by 4 pins to the skull and again two cheek wires attached to the Halo Frame and passed below the zygoma to the upper or lower arch bar. Another technique is the Box frame technique that requires insertion of 4 pins (2 in the frontal process of the frontal bone and 2 pins in the angle of the lower jaw) with 4 rods fixed after reduction of the displaced midface with IMF to achieve proper occlusion. The success of treatment is based on proper occlusion and proper fixation of the small bones of the facial skeleton to be sited in their anatomical position and to get normal facial length and height.

## **3. Conclusion**

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

The other types of fracture affect the ramus and the most common two types of fractures are the condylar (intra capsular) type and sub condylar type. The intracapsular type of fracture condyle is a very serious injury that requires special attention while the sub condylar type is treated by inter maxillary fixation (IMF)

*(A) Severe deformity of the mandible due to intra-uterine injuries to the right temporo-mandibular joint and the child born with ankylosis of the TMJ. (B) One year post-operative after reconstruction of the right TMJ by* 

Intracapsular fracture of the condyle in children is very serious. If mistreated, it can lead to ankylosis with severe deformity of the mandible and midface due to damage to the growth center in the condyle. Early treatment of an intracapsular fracture should be carried out by administration of a few drops of hydrocortisone to prevent adhesion and to reduce edema with IMF for 3–4 days to relief spasm of muscles and to remodel the shape of the condyle followed by early

Fixation of the facial skeleton was performed by using our techniques of fixation by suspension of middle third through the sandwich technique using soft stainless steel wire of 0.5 mm and making hole by using round bur in the frontal-zygomatic suture above the fracture line and the wire is passed below the zygoma down through the cheek to the lower arch bar fixed by wires and IMF and reinforced by a

circum-mandibular wire with proper occlusion of the teeth.

Once adhesion of the condyle had occurred and deformity of the jaw has appeared, we must excise the ankylosed joint with hyperplastic coronoid, reattach of the muscles of mastication and reconstruct the TMJ by using Kummoona Chondro-Osseous graft was harvested from iliac crest in children for restoration of growth, remodeling, and repair of the condyle (**Figure 8**). The graft can restore the growth of the mandible and midface and prevent residual deformity [2, 4, 6]. In craniofacial injuries, after reconstruction of the anterior cranial fossa and frontal bone, we have immediately to reduce and fix the middle third fracture of the facial skeleton including Le Fort I, II, III, and mid line split of the face. Reduction was achieved by using Rowe dis impaction forceps to move the displaced facial skeleton upward and forward in the reverse direction of the displacement of the middle third and to put the skeleton in its normal anatomical position with

**26**

for 3–4 weeks.

*Kummoona Chonro-Ossous graft at age of 5 years.*

**Figure 8.**

mobilization.

intermaxillary fixation (IMF).

The aim of our research is to share our techniques and expertise in the treatment and management of traumatic craniofacial deformities with other colleagues worldwide.

In this clinical research, we studied 673 patients with craniofacial injuries and deformities and the incidence of these injuries to affect various parts of craniofacial region, we did classify these injuries and how serious ,primary care described thoroughly and cases with cranial or LeFort III injuries might associated with CSF leakage ,methods of management were described by conservative technique if not by craniotomy. Different techniques for reduction and fixation of the craniofacial regions were also described.

This study shows the ability of the author to deal with very difficult cases of craniofacial region. I hope this chapter satisfies the curiosity of the readers.

## **Author details**

## Raja Kummoona

Council of Maxillofacial Surgery, Iraqi Board for Medical Specialization, Baghdad, Iraq

\*Address all correspondence to: raja\_kummoona@hotmail.com

© 2020 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.

## **References**

[1] Kummoona R. Managements of maxillofacial injuries in Iraq. Journal of Craniofacial Surgery. 2011;**22**:1561-1567

[2] Kummoona R. Pediatrics maxillofacial injuries with special attention to fracture condyle. EC Pediatrics. 2017;**5**(6):170-171

[3] Kummoona R. Orbital trauma with special references to pediatrics and chilidren. EC Pediatrics. 2018;**7**(5)

[4] Kummoona R. Pediatrics and children facial deformity with special reference to Ankylosis of the TMJ. EC Pediatrics. 2018;**7**(3):112-115

[5] Kummoona R. Kummoona lateral cervical flap for reconstruction of oral defect after cancer surgery. Clinical Case Reports. 2018;**1**(1):1006

[6] Kummoona R. Temporomandibular joint ankylosis that affect children and reconstruction by Kummoona Chondro-Osseous Graft. EC Pediatrics. 2018;**7**(11)

[7] Kummoona R. Pediatrics and chilidren facial deformity with special reference to ankylosis of the temporomandibular joint. EC Pediatrics. 2018;**7**(3):112-115

[8] Kummoona R. Kummoona Chondro-Ossous graft good substitute to condylar growth center and fore correction of facial deformity in children. Archives of Otolaryngology and Rhinology. 2017;**3**(3):098-102

**29**

**Chapter 4**

**Abstract**

**1. Introduction**

cated as a means of immobilization [1–4].

replanted, or fractured [5–7].

replanted [4, 8, 9].

However, first of all, let us look at what a splint is.

*Naida Hadziabdic*

The Basics of Splinting in

Dentoalveolar Traumatology

Dentoalveolar trauma is considered an emergency condition and is challenging for every dentist. As primary and permanent teeth may suffer repercussions from an injury, a therapist must be mindful of which situations the use of splinting methods is required. In dentistry, a splint is a rigid or flexible device with the function of supporting, protecting, and immobilizing teeth that have been weakened (endodontically, periodontally), traumatically injured, replanted, or fractured. Generally, splinting is not recommended for primary teeth injuries such as luxation and avulsion. In permanent dentition, splint appliances are indicated for periodontal injuries, such as subluxation, luxation and avulsion, and hard tissue injuries such as class IV root fractures. Nowadays, there are many appliances that may be used for immobilization of traumatized teeth. Since this issue may sometimes be confusing for dental practitioners, this chapter deals with splint classification (rigid and flexible), the basic characteristics of splints, the indications, and methods of application.

**Keywords:** splinting, traumatized teeth, dentoalveolar trauma, immobilization

Since any dentoalveolar trauma is an emergency condition, it is a challenge for all dentists. Since both primary and permanent teeth may suffer injury, a dental therapist must first of all know the situations in which the use of a splint is indi-

A splint is a rigid or flexible device/aid used to support, protect, and immobilize

In order to even consider the use of a splint, it is necessary to know whether the traumatized tooth is primary or permanent and what kind of injury it has suffered. In general, the use of a splint is not recommended for injuries to milk teeth,

Repositioning is not recommended because there is a risk of infection which could endanger the tooth bud of the permanent tooth. An avulsed milk tooth is not

teeth that have been weakened (endodontically or periodontally), traumatized,

such as luxation or avulsion. Luxated milk teeth are most often extracted.

• Injuries to the periodontal tissue (subluxation, luxation, and avulsion)

In permanent dentition, the use of a splint is indicated for [10]:

• Injuries to the hard dental tissue (class IV root fractures)

## **Chapter 4**

## The Basics of Splinting in Dentoalveolar Traumatology

*Naida Hadziabdic*

## **Abstract**

Dentoalveolar trauma is considered an emergency condition and is challenging for every dentist. As primary and permanent teeth may suffer repercussions from an injury, a therapist must be mindful of which situations the use of splinting methods is required. In dentistry, a splint is a rigid or flexible device with the function of supporting, protecting, and immobilizing teeth that have been weakened (endodontically, periodontally), traumatically injured, replanted, or fractured. Generally, splinting is not recommended for primary teeth injuries such as luxation and avulsion. In permanent dentition, splint appliances are indicated for periodontal injuries, such as subluxation, luxation and avulsion, and hard tissue injuries such as class IV root fractures. Nowadays, there are many appliances that may be used for immobilization of traumatized teeth. Since this issue may sometimes be confusing for dental practitioners, this chapter deals with splint classification (rigid and flexible), the basic characteristics of splints, the indications, and methods of application.

**Keywords:** splinting, traumatized teeth, dentoalveolar trauma, immobilization

## **1. Introduction**

Since any dentoalveolar trauma is an emergency condition, it is a challenge for all dentists. Since both primary and permanent teeth may suffer injury, a dental therapist must first of all know the situations in which the use of a splint is indicated as a means of immobilization [1–4].

However, first of all, let us look at what a splint is.

A splint is a rigid or flexible device/aid used to support, protect, and immobilize teeth that have been weakened (endodontically or periodontally), traumatized, replanted, or fractured [5–7].

In order to even consider the use of a splint, it is necessary to know whether the traumatized tooth is primary or permanent and what kind of injury it has suffered.

In general, the use of a splint is not recommended for injuries to milk teeth, such as luxation or avulsion. Luxated milk teeth are most often extracted. Repositioning is not recommended because there is a risk of infection which could endanger the tooth bud of the permanent tooth. An avulsed milk tooth is not replanted [4, 8, 9].

In permanent dentition, the use of a splint is indicated for [10]:


**28**

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

[1] Kummoona R. Managements of maxillofacial injuries in Iraq. Journal of Craniofacial Surgery. 2011;**22**:1561-1567

[3] Kummoona R. Orbital trauma with special references to pediatrics and chilidren. EC Pediatrics. 2018;**7**(5)

[4] Kummoona R. Pediatrics and children facial deformity with special reference to Ankylosis of the TMJ. EC

[5] Kummoona R. Kummoona lateral cervical flap for reconstruction of oral defect after cancer surgery. Clinical Case Reports. 2018;**1**(1):1006

[6] Kummoona R. Temporomandibular joint ankylosis that affect children and reconstruction by Kummoona Chondro-Osseous Graft. EC Pediatrics. 2018;**7**(11)

[8] Kummoona R. Kummoona Chondro-Ossous graft good substitute to condylar growth center and fore correction of facial deformity in children. Archives of Otolaryngology and Rhinology.

[7] Kummoona R. Pediatrics and chilidren facial deformity with special reference to ankylosis of the temporomandibular joint. EC Pediatrics. 2018;**7**(3):112-115

2017;**3**(3):098-102

Pediatrics. 2018;**7**(3):112-115

[2] Kummoona R. Pediatrics maxillofacial injuries with special attention to fracture condyle. EC Pediatrics. 2017;**5**(6):170-171

**References**

## **2. Types of splint**

Splints are categorized as:


This categorization of splints is based on the possibility of the physiological mobility of the tooth [11]. Thus, a rigid splint does not permit any physiological mobility of the tooth and thereby creates the conditions for complications in the sense of ankylosis or external resorption [5].

In the case of a nonrigid or semirigid splint, the physiological functional mobility of the traumatized tooth is possible, which is more favorable for the healing of the periodontal ligament (PDL), and thereby the risk of ankylosis or external resorption of the tooth root is reduced [12].

## **2.1 Types of rigid and semirigid splints**

Rigid splints:


Semirigid splints:


## *2.1.1 Rigid splints*

## *2.1.1.1 Suture splints*

Soft wire and surgical thread can be used as materials for this type of splint [13–15]. The use of soft wire is indicated for mixed dentition. The wire is woven around the traumatized and neighboring teeth (**Figure 1**). Immobilization of this kind should be brief—only a few days. The weaknesses of this type of immobilization are that the metal thins and breaks with chewing, and it also prevents good oral hygiene, which leads to gingivitis [16].

When there are no neighboring teeth to which the splint may be fixed, the use of a surgical suture is indicated for the sake of immobilization (**Figure 2**).

**31**

*2.1.1.2 Arch bar splints*

*A surgical suture used as a suture splint.*

**Figure 2.**

**Figure 1.**

*Wire acting as a suture splint.*

everyday use [18].

*2.1.1.3 Acrylic splints*

• The direct method

• The indirect method

splint of this type is the Pfeiffer splint. This splint may be made in two ways:

These are ready-made metal bars with hooks onto which the wire is woven which fixes the metal brackets to the teeth [17] (**Figure 3**). The bars are placed right up against the gums which cause irritation, and they are therefore impractical for

As their name suggests, these splints are made from acrylic material [19, 20]. They are not used for isolated dental traumas. They are indicated in cases of luxation of a tooth in combination with a fracture of the alveolar bone. The best-known

*The Basics of Splinting in Dentoalveolar Traumatology DOI: http://dx.doi.org/10.5772/intechopen.88061*

*The Basics of Splinting in Dentoalveolar Traumatology DOI: http://dx.doi.org/10.5772/intechopen.88061*

**Figure 1.** *Wire acting as a suture splint.*

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

This categorization of splints is based on the possibility of the physiological mobility of the tooth [11]. Thus, a rigid splint does not permit any physiological mobility of the tooth and thereby creates the conditions for complications in the

In the case of a nonrigid or semirigid splint, the physiological functional mobility of the traumatized tooth is possible, which is more favorable for the healing of the periodontal ligament (PDL), and thereby the risk of ankylosis or

Soft wire and surgical thread can be used as materials for this type of splint [13–15]. The use of soft wire is indicated for mixed dentition. The wire is woven around the traumatized and neighboring teeth (**Figure 1**). Immobilization of this kind should be brief—only a few days. The weaknesses of this type of immobilization are that the metal thins and breaks with chewing, and it also prevents good oral

When there are no neighboring teeth to which the splint may be fixed, the use of

a surgical suture is indicated for the sake of immobilization (**Figure 2**).

**2. Types of splint**

• Rigid splints

Rigid splints:

• Suture splints

• Arch bar splints

• Acrylic splints

• Composite splints

Semirigid splints:

• Fiber splints

*2.1.1 Rigid splints*

*2.1.1.1 Suture splints*

Splints are categorized as:

• Nonrigid/semirigid/flexible splints

sense of ankylosis or external resorption [5].

**2.1 Types of rigid and semirigid splints**

• Orthodontic brackets and arches

• Wire and composite splints

• Titanium trauma splints (TTS)

hygiene, which leads to gingivitis [16].

external resorption of the tooth root is reduced [12].

**30**

#### **Figure 2.** *A surgical suture used as a suture splint.*

## *2.1.1.2 Arch bar splints*

These are ready-made metal bars with hooks onto which the wire is woven which fixes the metal brackets to the teeth [17] (**Figure 3**). The bars are placed right up against the gums which cause irritation, and they are therefore impractical for everyday use [18].

## *2.1.1.3 Acrylic splints*

As their name suggests, these splints are made from acrylic material [19, 20]. They are not used for isolated dental traumas. They are indicated in cases of luxation of a tooth in combination with a fracture of the alveolar bone. The best-known splint of this type is the Pfeiffer splint.

This splint may be made in two ways:


**Figure 3.**

*(A) Ready-made metal arch, (B) metal arch fixed with wire to the upper teeth, (C) intermaxillary fixation, and (D) the appearance of gums after being irritated from the use of a ready-made splint.*

## *2.1.1.3.1 The direct method*

This method is performed directly in the patient's mouth, and for that reason, it is very uncomfortable because the acrylic sets in the mouth, creating an unpleasant warm reaction.

**33**

**Figure 4.**

*Equipment for creating an acrylic Pfeiffer splint.*

*The Basics of Splinting in Dentoalveolar Traumatology DOI: http://dx.doi.org/10.5772/intechopen.88061*

• Pour the blended acrylic onto the piece of sterile gauze.

patient to bite down, and check the occlusion.

• Once it has set, remove the splint from the mouth.

indicated.

in place.

occlusion.

• Blend the acrylic.

• Protect the gums with Vaseline.

• First of all, establish the type of injury and decide if using a Pfeiffer splint is

• Check the position of the teeth in central occlusion and remember those positions.

• Use the scissors to cut the edge of the gauze to create a rectangular shape, so the future splint will cover two neighboring teeth on each side of the injured tooth.

• Shape the splint over the vestibular and palatal surfaces of the tooth, tell the

• Use the grinder on the internal side of the splint to make room for the phosphate cement. In addition, it is necessary to use the grinder to work on the vestibular part of the splint so the cervical third of the crown is exposed, which will make it possible to test the vitality of the tooth while the splint is

• The blended phosphate cement is poured into the prepared splint after which the splint is cemented in the patient's mouth, with verification of the central

The following materials are needed for this method (**Figure 4**):


The procedure (**Figure 5**):


*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

This method is performed directly in the patient's mouth, and for that reason, it is very uncomfortable because the acrylic sets in the mouth, creating an unpleasant

*(A) Ready-made metal arch, (B) metal arch fixed with wire to the upper teeth, (C) intermaxillary fixation,* 

The following materials are needed for this method (**Figure 4**):

*and (D) the appearance of gums after being irritated from the use of a ready-made splint.*

• Self-adhesive acrylic (powder and liquid)

• A container for mixing the acrylic

• A piece of sterile gauze

• Glass for mixing

• Scissors

• Pliers

• Grinder

• A spatula for mixing

The procedure (**Figure 5**):

**32**

*2.1.1.3.1 The direct method*

warm reaction.

**Figure 3.**

• Vaseline


**Figure 4.** *Equipment for creating an acrylic Pfeiffer splint.*

#### **Figure 5.**

*Creating a Pfeiffer splint using the direct technique: (A) blending the acrylic, (B) pouring the blended acrylic onto the sterile gauze, (C) cutting the edges of the gauze onto which the acrylic was poured, (D) the rectangular-shaped gauze, (E) adjusting the splint over the vestibular and palatal surface of the tooth, (F) the inside of the splint, (G) verification of the splint in central occlusion, (H) removing the splint for processing, (I) creating space for the cement, (J) processing-cutting the edges of the splint, (K) phosphate cement, (L) the final appearance of the splint with the cement inside, (M) cementing the splint, (N) inserting the splint with verification of the central occlusion (side view), (O) the centered splint in the mouth (front view), and (P) testing the vitality of the tooth.*

## *2.1.1.3.2 The indirect method*

This method differs from the previous one in how it is executed (**Figure 6**):


#### **Figure 6.**

*The indirect method of creating a Pfeiffer splint: (A) the wax model and (B) the acrylic splint on the model.*

**35**

**Figure 7.**

*A splint made exclusively from composite material.*

*The Basics of Splinting in Dentoalveolar Traumatology DOI: http://dx.doi.org/10.5772/intechopen.88061*

the crown of the tooth remains uncovered.

• The wax model is exchanged for acrylic.

*2.1.1.4 Composite splints*

the classical way:

very close to them.

*2.1.2 Semirigid splints*

applying wax.

*2.1.2.1 Orthodontic splints*

• On the basis of the models, a splint is created in wax so that the cervical part of

Only composite materials are used to make this kind of splint (**Figure 7**). The technique is very simple because it consists of working with composite material in

• The splint is cemented in the same way as in the previous method.

• Conditioning of the enamel of the injured and neighboring teeth

caused by avulsion and when the neighboring teeth are intact.

and that the action of orthodontic forces is possible.

• Application of the adhesive and composite material with polymerization

The weakness of a composite splint is its tendency to split due to the action of interdental occlusal forces. It also may irritate the surrounding gums if it is placed

A so-called interapproximal composite splint is a sub-type of this splint. The specific feature of this splint is that composite material is also placed on the approximal surface of the traumatized and neighboring teeth. This kind of splint is quite insecure and may only be used in cases when there has not been any major damage

For this type of splint, orthodontic brackets and orthodontic wire are needed [21] (**Figure 8**). The brackets are placed in the middle third of the labial surface of the tooth. They are connected by orthodontic wire, 0.016 mm in diameter, which is passively adapted. There are some who claim that orthodontic wire is not "passive"

The advantage of immobilization using an orthodontic splint is the possibility of synchronizing the movement of the teeth, which is particularly important in cases of intrusion. The weakness is the irritation of the lips, which can be avoided by


## *2.1.1.4 Composite splints*

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

**34**

**Figure 6.**

*2.1.1.3.2 The indirect method*

*testing the vitality of the tooth.*

**Figure 5.**

This method differs from the previous one in how it is executed (**Figure 6**):

*Creating a Pfeiffer splint using the direct technique: (A) blending the acrylic, (B) pouring the blended acrylic onto the sterile gauze, (C) cutting the edges of the gauze onto which the acrylic was poured, (D) the rectangular-shaped gauze, (E) adjusting the splint over the vestibular and palatal surface of the tooth, (F) the inside of the splint, (G) verification of the splint in central occlusion, (H) removing the splint for processing, (I) creating space for the cement, (J) processing-cutting the edges of the splint, (K) phosphate cement, (L) the final appearance of the splint with the cement inside, (M) cementing the splint, (N) inserting the splint with verification of the central occlusion (side view), (O) the centered splint in the mouth (front view), and (P)* 

*The indirect method of creating a Pfeiffer splint: (A) the wax model and (B) the acrylic splint on the model.*

• First an impression is taken of the jaw in alginate.

• Various models are created in the laboratory.

Only composite materials are used to make this kind of splint (**Figure 7**). The technique is very simple because it consists of working with composite material in the classical way:


The weakness of a composite splint is its tendency to split due to the action of interdental occlusal forces. It also may irritate the surrounding gums if it is placed very close to them.

A so-called interapproximal composite splint is a sub-type of this splint. The specific feature of this splint is that composite material is also placed on the approximal surface of the traumatized and neighboring teeth. This kind of splint is quite insecure and may only be used in cases when there has not been any major damage caused by avulsion and when the neighboring teeth are intact.

## *2.1.2 Semirigid splints*

## *2.1.2.1 Orthodontic splints*

For this type of splint, orthodontic brackets and orthodontic wire are needed [21] (**Figure 8**). The brackets are placed in the middle third of the labial surface of the tooth. They are connected by orthodontic wire, 0.016 mm in diameter, which is passively adapted. There are some who claim that orthodontic wire is not "passive" and that the action of orthodontic forces is possible.

The advantage of immobilization using an orthodontic splint is the possibility of synchronizing the movement of the teeth, which is particularly important in cases of intrusion. The weakness is the irritation of the lips, which can be avoided by applying wax.

**Figure 7.** *A splint made exclusively from composite material.*

**Figure 8.** *An orthodontic splint.*

## *2.1.2.2 Wire-composite splints*

The splint that is used most often in everyday practice is a wire-composite splint [6, 22]. To make it, any composite material and orthodontic wire, 0.3–0.4 mm in diameter, are needed. It is indicated in all cases of traumatic injuries (**Figure 9**). Contraindications for the use of a wire and composite splint are when the teeth have artificial crowns and large fillings or in the teeth with exceptionally small crowns.

The technique for making one is quite simple:


**37**

**Figure 10.**

*(A) Fishing line used as a splint and (B) fishing line.*

*The Basics of Splinting in Dentoalveolar Traumatology DOI: http://dx.doi.org/10.5772/intechopen.88061*

These types of splint include [6, 23, 24]:

• Fishing line [25] (**Figure 10**)

• Glass-ionomer fiber

• Ribbond splint

• Kevlar fiber

composite splint.

*2.1.2.3.1 Ribbond splint*

cured for about 10 s.

wire are positioned.

*2.1.2.3 Fiber splints*

• After rinsing and drying, they are coated with the bonding substance and light

• The composite material is placed over the tooth and over that an arch, braces, or

• Light curing should first be performed on the healthy teeth on one side; then the tooth should be repositioned, followed by light curing (polymerization); and then the wire should be light cured on the healthy teeth on the other side.

• In order to avoid shifting a replanted tooth while polymerizing the wires, the splint may also be fixed as follows: after repositioning, the patient bites down on softened wax (as when taking an impression for prosthetics-bite registration). The tooth remains in the desired position during the fixation of the splint to the tooth.

Fishing line and glass-ionomer fiber are used in the same way as in a wire-

This type of splint relies on the use of special polyethylene fibers, Ribbond fibers, and composite materials [6, 26] (**Figure 11**). In dental traumatology, Ribbond fiber splints are fixed and extra-coronary. They are used intracoronarily in cases of periodontitis, where it is necessary to create cavities in the teeth to place the fiber.

**Figure 9.** *Making a wire-composite splint.*


## *2.1.2.3 Fiber splints*

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

The splint that is used most often in everyday practice is a wire-composite splint [6, 22]. To make it, any composite material and orthodontic wire, 0.3–0.4 mm in diameter, are needed. It is indicated in all cases of traumatic injuries (**Figure 9**). Contraindications for the use of a wire and composite splint are when the teeth have artificial crowns and large fillings or in the teeth with exceptionally small crowns.

• Orthodontic wire of the selected length is shaped directly in the patient's mouth

*2.1.2.2 Wire-composite splints*

**Figure 8.**

*An orthodontic splint.*

The technique for making one is quite simple:

to cover 2–3 teeth on each side of the injured tooth.

• The labial surface is conditioned using orthophosphoric acid.

**36**

**Figure 9.**

*Making a wire-composite splint.*

These types of splint include [6, 23, 24]:


Fishing line and glass-ionomer fiber are used in the same way as in a wirecomposite splint.

## *2.1.2.3.1 Ribbond splint*

This type of splint relies on the use of special polyethylene fibers, Ribbond fibers, and composite materials [6, 26] (**Figure 11**). In dental traumatology, Ribbond fiber splints are fixed and extra-coronary. They are used intracoronarily in cases of periodontitis, where it is necessary to create cavities in the teeth to place the fiber.

**Figure 10.** *(A) Fishing line used as a splint and (B) fishing line.*

Ribbond fibers are popular as a form of immobilization due to their properties:


The technique for placing a Ribbond splint:


**39**

*The Basics of Splinting in Dentoalveolar Traumatology DOI: http://dx.doi.org/10.5772/intechopen.88061*

the composite.

*Titanium trauma splint (TTS).*

and manner of application as Ribbond splints.

**3. The features of an acceptable splint**

• It is simple to create and put in place.

• It prevents further traumatization of the injured tooth.

*2.1.2.4 Titanium trauma splint (TTS)*

*2.1.2.3.2 Kevlar fiber*

**Figure 12.**

wire-composite splint.

• Apply the adhesive on the conditioned surface of the teeth.

ite material is removed. Each tooth is then light cured for 30–40 s.

• Apply the flowable composite material to the tooth and then the Ribbond tape, which is pressed into the composite applied and smoothed, and excess compos-

• Using a drill, we remove the excess composite material and polish the surface of

Kevlar fiber, poly-paraphenylene terephthalamide, is a synthetic, organic fiber of exceptional strength (five times stronger than metal). As well as being used to make bulletproof vests and in the aero-industry, it is used in dental traumatology as a means of immobilizing teeth [6]. It has the identical features, therapeutic effect,

A TTS is a more recent splint, made from pure titanium, only 0.2 mm in thickness, which makes it significantly easier to apply to the tooth [6, 23, 27–29]. It is available in 52 and 100 mm lengths. It is designed in the form of a rhomboid mesh, which makes it easier to be fixed and makes it flexible in all dimensions (**Figure 12**). The size of the rhomboid opening, 1.8 × 2.8 mm, reduces the quantity of composite material used to fix it to the surface of the tooth, making it easier to remove the splint. It is fixed to the tooth in the same way as a wire-composite splint. The weakness of this splint system is that it is very expensive in comparison with a

In view of the diversity of splints which may be used for traumatized teeth, the following features of a good splint should be used as guidelines in selection [4]:

• Wash the acid off with water, and dry.

*The Basics of Splinting in Dentoalveolar Traumatology DOI: http://dx.doi.org/10.5772/intechopen.88061*

**Figure 12.** *Titanium trauma splint (TTS).*

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

Ribbond fibers are popular as a form of immobilization due to their properties:

• The surface of the fiber is treated using an electrochemical plasma procedure, so the mechanical properties of the fibers are improved, as well as bonding to

• Their permeability to light makes work possible with any form of composite

• Determine the length of the Ribbond tape (measure the length with dental floss).

• Cut the Ribbond tape using special scissors. In this process the tape must not be touched by hand to avoid contamination. The tape should be held with tweezers

• Parts of the vestibular surfaces of the injured and neighboring teeth are condi-

• The tape is impregnated with bonding agent or fissure sealant material.

• They are exceptionally strong, thanks to the special way they are woven.

• They have excellent properties relating to manipulation.

The technique for placing a Ribbond splint:

• Clean the vestibular surface of the tooth.

or cotton gloves until it is impregnated.

tioned with orthophosphoric acid for 30 s.

• Wash the acid off with water, and dry.

• Store the tape in a dark place.

the composite resin.

material.

**Figure 11.** *A Ribbond splint.*

**38**


## *2.1.2.3.2 Kevlar fiber*

Kevlar fiber, poly-paraphenylene terephthalamide, is a synthetic, organic fiber of exceptional strength (five times stronger than metal). As well as being used to make bulletproof vests and in the aero-industry, it is used in dental traumatology as a means of immobilizing teeth [6]. It has the identical features, therapeutic effect, and manner of application as Ribbond splints.

## *2.1.2.4 Titanium trauma splint (TTS)*

A TTS is a more recent splint, made from pure titanium, only 0.2 mm in thickness, which makes it significantly easier to apply to the tooth [6, 23, 27–29]. It is available in 52 and 100 mm lengths. It is designed in the form of a rhomboid mesh, which makes it easier to be fixed and makes it flexible in all dimensions (**Figure 12**). The size of the rhomboid opening, 1.8 × 2.8 mm, reduces the quantity of composite material used to fix it to the surface of the tooth, making it easier to remove the splint. It is fixed to the tooth in the same way as a wire-composite splint. The weakness of this splint system is that it is very expensive in comparison with a wire-composite splint.

## **3. The features of an acceptable splint**

In view of the diversity of splints which may be used for traumatized teeth, the following features of a good splint should be used as guidelines in selection [4]:


## **4. Recommendations for the type and duration of immobilization depending on the type of trauma**

In dentoalveolar traumatology, answers have not been found for all the questions that arise, especially regarding the duration of the use of splints. The effect of the duration of immobilization, that is, keeping a splint in place during the healing of the periodontal ligament, has still not been explained in clinical studies. The longterm use of a splint leads to ankylosis and replacement resorption. On the other hand, it has not been confirmed that there is a better outcome of healing in the case of the short-term use of a splint [30].

The current trends in dentoalveolar traumatology recommend the use of a splint in cases of luxation and avulsion of a tooth and in fractures of the root and alveolar ridge [31]. **Table 1** shows basic guidelines for the use of splints, in relation to the type of trauma, the duration of mobilization, and the type of splint.


#### **Table 1.**

*Recommendations for the type and duration of immobilization depending on the type of trauma.*

## **5. Conclusions**

There is a large selection of splints which are indicated for tooth trauma (**Table 2**).

Modern trends in dentoalveolar traumatology support the use of functional and flexible splints for luxation and avulsion.

**41**

**Table 2.**

than the type of splint selected.

The prognosis for traumatized teeth is more determined by the type of trauma

The type of splint and the duration of immobilization, therefore, may not be

considered significant variables in terms of the outcome of healing.

*Classification of splints with indications, contraindications, advantages, and disadvantages.*

*The Basics of Splinting in Dentoalveolar Traumatology DOI: http://dx.doi.org/10.5772/intechopen.88061*

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

• It enables physiological movement and therefore healing.

• It does not obstruct endodontic treatment when necessary.

**4. Recommendations for the type and duration of immobilization** 

type of trauma, the duration of mobilization, and the type of splint.

There is a large selection of splints which are indicated for tooth trauma

*Recommendations for the type and duration of immobilization depending on the type of trauma.*

Modern trends in dentoalveolar traumatology support the use of functional and

In dentoalveolar traumatology, answers have not been found for all the questions that arise, especially regarding the duration of the use of splints. The effect of the duration of immobilization, that is, keeping a splint in place during the healing of the periodontal ligament, has still not been explained in clinical studies. The longterm use of a splint leads to ankylosis and replacement resorption. On the other hand, it has not been confirmed that there is a better outcome of healing in the case

The current trends in dentoalveolar traumatology recommend the use of a splint in cases of luxation and avulsion of a tooth and in fractures of the root and alveolar ridge [31]. **Table 1** shows basic guidelines for the use of splints, in relation to the

**Type of trauma Duration of immobilization Type of splint** Subluxation 2 weeks Flexible Extrusive luxation 2 weeks Flexible Avulsion 2 weeks Flexible Lateral luxation 4 weeks Flexible Fracture of the central third of the root 4 weeks Rigid Fracture of the cervical third of the root 4 weeks Rigid Fracture of the alveolar process 4 months Rigid

• It makes maintenance of oral hygiene possible.

• It makes it possible to monitor vitality.

**depending on the type of trauma**

of the short-term use of a splint [30].

• It does not obstruct occlusion.

• It is aesthetic.

• It is easily removed.

**40**

**5. Conclusions**

flexible splints for luxation and avulsion.

(**Table 2**).

**Table 1.**


#### **Table 2.**

*Classification of splints with indications, contraindications, advantages, and disadvantages.*

The prognosis for traumatized teeth is more determined by the type of trauma than the type of splint selected.

The type of splint and the duration of immobilization, therefore, may not be considered significant variables in terms of the outcome of healing.

## **Acknowledgements**

The author would like to thank Armin Klančević, DMD, for his contribution of drawing all the figures for this chapter.

## **Conflict of interest**

The authors declare there is no conflict of interest.

## **Author details**

Naida Hadziabdic Department of Oral Surgery, Faculty of Dental Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina

\*Address all correspondence to: nsulejma@yahoo.com

© 2020 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.

**43**

*The Basics of Splinting in Dentoalveolar Traumatology DOI: http://dx.doi.org/10.5772/intechopen.88061*

> of splinting. Acta Odontologica Scandinavica. 2018;**76**:253-256. DOI: 10.1080/00016357.2017.1414956

[9] Malmgren B, Andreasen JO, Flores MT, Robertson A, Diangelis AJ, Andersson L, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dental Traumatology. 2012;**28**:174-182. DOI: 10.1111/j.1600-9657.2012.01146.x

[10] Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dental Traumatology. 2012;**28**:88-96. DOI: 10.1111/j.1600-9657.2012.01125.x

[11] Mazzoleni S, Meschia G, Cortesi R, Bressan E, Tomasi C, Ferro R, et al. In vitro comparison of the flexibility of different splint systems used in dental traumatology. Dental Traumatology. 2010;**26**:30-36. DOI: 10.1111/j.1600-9657.2009.00843.x

[12] Burcak Cengiz S, Stephan Atac A, Cehreli ZC. Biomechanical effects of splint types on traumatized tooth: A photoelastic stress analysis. Dental Traumatology. 2006;**22**:133-138. DOI: 10.1111/j.1600-9657.2006.00339.x

[13] Gupta S, Sharma A, Dang N. Suture splint: An alternative for luxation injuries of teeth in pediatric patients—A case report. The Journal of Clinical Pediatric Dentistry. 1997;**22**:19-21

[14] Neaverth EJ, Georig AC. Technique and rationale for splinting. Journal of the American Dental Association. 1980;**100**:56-63. DOI: 10.14219/jada.

[15] Lin S, Emodi O, Abu El-Naaj I. Splinting of an injured tooth as part

archive.1980.0026

[1] Rao A, Rao A, Shenoy R. Splinting— When and how? Dental Update. 2011;**38**:341-342, 344-6. DOI: 10.12968/

[2] Andreasen JO, Ahrensburg SS, Tendal B. Inappropriate use of meta-analysis in an evidence-based assessment of the clinical guidelines for replanted avulsed teeth. Timing of pulp extirpation, splinting periods and prescription of systemic antibiotics. Dental Traumatology. 2010;**26**:451-452. DOI: 10.1111/j.1600-9657.2010.00911.x

[3] Andreasen JO, Lauridsen E, Andreasen FM. Contradictions in the treatment of traumatic dental injuries and ways to proceed in dental trauma research. Dental Traumatology. 2010;**26**:16-22. DOI: 10.1111/j.1600-9657.2009.00818.x

[4] Brown CL, Macie IC. Splinting of traumatized teeth in children. Dental Update. 2003;**30**:78-82. DOI: 10.12968/

[5] Ben Hassan MW, Andersson L, Lucas PW. Stiffness characteristics of splints for fixation of traumatized teeth. Dental Traumatology. 2016;**32**:140-145. DOI:

[6] Kahler B, Hu JY, Marriot-Smith CS, Heithersay GS. Splinting of teeth following trauma: A review and a new splinting recommendation. Australian Dental Journal. 2016;**61**:59-73. DOI:

[7] Kahler B, Heithersay GS. An evidence-based appraisal of splinting luxated, avulsed and root-fractured teeth. Dental Traumatology. 2008;**24**:2-10. DOI: 10.1111/j.1600-9657.2006.00480.x

[8] Cho WC, Nam OH, Kim MS, Lee HS, Choi SC. A retrospective study of traumatic dental injuries in primary dentition: Treatment outcomes

denu.2003.30.2.78

10.1111/edt.12234

10.1111/adj.12398

**References**

denu.2011.38.5.341

*The Basics of Splinting in Dentoalveolar Traumatology DOI: http://dx.doi.org/10.5772/intechopen.88061*

## **References**

*Maxillofacial Surgery and Craniofacial Deformity - Practices and Updates*

The authors declare there is no conflict of interest.

The author would like to thank Armin Klančević, DMD, for his contribution of

Department of Oral Surgery, Faculty of Dental Medicine, University of Sarajevo,

© 2020 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,

**Acknowledgements**

**Conflict of interest**

drawing all the figures for this chapter.

**42**

**Author details**

Naida Hadziabdic

Sarajevo, Bosnia and Herzegovina

provided the original work is properly cited.

\*Address all correspondence to: nsulejma@yahoo.com

[1] Rao A, Rao A, Shenoy R. Splinting— When and how? Dental Update. 2011;**38**:341-342, 344-6. DOI: 10.12968/ denu.2011.38.5.341

[2] Andreasen JO, Ahrensburg SS, Tendal B. Inappropriate use of meta-analysis in an evidence-based assessment of the clinical guidelines for replanted avulsed teeth. Timing of pulp extirpation, splinting periods and prescription of systemic antibiotics. Dental Traumatology. 2010;**26**:451-452. DOI: 10.1111/j.1600-9657.2010.00911.x

[3] Andreasen JO, Lauridsen E, Andreasen FM. Contradictions in the treatment of traumatic dental injuries and ways to proceed in dental trauma research. Dental Traumatology. 2010;**26**:16-22. DOI: 10.1111/j.1600-9657.2009.00818.x

[4] Brown CL, Macie IC. Splinting of traumatized teeth in children. Dental Update. 2003;**30**:78-82. DOI: 10.12968/ denu.2003.30.2.78

[5] Ben Hassan MW, Andersson L, Lucas PW. Stiffness characteristics of splints for fixation of traumatized teeth. Dental Traumatology. 2016;**32**:140-145. DOI: 10.1111/edt.12234

[6] Kahler B, Hu JY, Marriot-Smith CS, Heithersay GS. Splinting of teeth following trauma: A review and a new splinting recommendation. Australian Dental Journal. 2016;**61**:59-73. DOI: 10.1111/adj.12398

[7] Kahler B, Heithersay GS. An evidence-based appraisal of splinting luxated, avulsed and root-fractured teeth. Dental Traumatology. 2008;**24**:2-10. DOI: 10.1111/j.1600-9657.2006.00480.x

[8] Cho WC, Nam OH, Kim MS, Lee HS, Choi SC. A retrospective study of traumatic dental injuries in primary dentition: Treatment outcomes

of splinting. Acta Odontologica Scandinavica. 2018;**76**:253-256. DOI: 10.1080/00016357.2017.1414956

[9] Malmgren B, Andreasen JO, Flores MT, Robertson A, Diangelis AJ, Andersson L, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dental Traumatology. 2012;**28**:174-182. DOI: 10.1111/j.1600-9657.2012.01146.x

[10] Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dental Traumatology. 2012;**28**:88-96. DOI: 10.1111/j.1600-9657.2012.01125.x

[11] Mazzoleni S, Meschia G, Cortesi R, Bressan E, Tomasi C, Ferro R, et al. In vitro comparison of the flexibility of different splint systems used in dental traumatology. Dental Traumatology. 2010;**26**:30-36. DOI: 10.1111/j.1600-9657.2009.00843.x

[12] Burcak Cengiz S, Stephan Atac A, Cehreli ZC. Biomechanical effects of splint types on traumatized tooth: A photoelastic stress analysis. Dental Traumatology. 2006;**22**:133-138. DOI: 10.1111/j.1600-9657.2006.00339.x

[13] Gupta S, Sharma A, Dang N. Suture splint: An alternative for luxation injuries of teeth in pediatric patients—A case report. The Journal of Clinical Pediatric Dentistry. 1997;**22**:19-21

[14] Neaverth EJ, Georig AC. Technique and rationale for splinting. Journal of the American Dental Association. 1980;**100**:56-63. DOI: 10.14219/jada. archive.1980.0026

[15] Lin S, Emodi O, Abu El-Naaj I. Splinting of an injured tooth as part of emergency treatment. Dental Traumatology. 2008;**24**:370-372. DOI: 10.1111/j.1600-9657.2007.00530.x

[16] Lello JL, Lello GE. The effect of interdental continuous loop wire splinting and intermaxillary fixation on the marginal gingiva. International Journal of Oral and Maxillofacial Surgery. 1988;**17**:249-252. DOI: 10.1016/ s0901-5027(88)80050-x

[17] Berthold C, Thaler A, Petschelt A. Rigidity of commonly used dental trauma splints. Dental Traumatology. 2009;**25**:248-255. DOI: 10.1111/j.1600-9657.2008.00683.x

[18] Oikarinen K. Comparison of the flexibility of various splinting methods for tooth fixation. International Journal of Oral and Maxillofacial Surgery. 1988;**17**:125-127. DOI: 10.1016/ s0901-5027(88)80166-8

[19] Oikarinen K. Tooth splinting: A review of the literature and consideration of the versatility of a wirecomposite splint. Endodontics & Dental Traumatology. 1990;**6**:237-250. DOI: 10.1111/j.1600-9657.1990.tb00426.x

[20] Alexander PC. Replantation of teeth. Oral Surgery, Oral Medicine, and Oral Pathology. 1956;**9**:110-114. DOI: 10.1016/0030-4220(56)90181-5

[21] Dawoodbhoy I, Valiathan A, Lalani ZS, Cariappa KM. Splinting of avulsed central incisors with orthodontic wires: A case report. Endodontics & Dental Traumatology. 1994;**10**:149-152. DOI: 10.1111/j.1600-9657.1994.tb00541.x

[22] Croll TP, Helpin ML. Use of selfetching adhesive system and compomer for splinting traumatized incisors. Pediatric Dentistry. n.d.;**24**:53-56

[23] von Arx T. Splinting of traumatized teeth with focus on adhesive techniques. Journal of the California Dental Association. 2005;**33**:409-414

[24] Kargul B, Caglar E, Kabalay U. Glass fiber-reinforced composite resin as fixed space maintainers in children: 12-Month clinical follow-up. Journal of Dentistry for Children (Chicago, Ill.). 2005;**72**:109-112

[25] Marriot-Smith C, Marino V, Heithersay GS. A preclinical dental trauma teaching module. Dental Traumatology. 2016;**32**:247-250. DOI: 10.1111/edt.12251

[26] Yildirim Öz G, Ataoǧlu H, Kir N, Karaman AI. An alternative method for splinting of traumatized teeth: Case reports. Dental Traumatology. 2006;**22**:345-349. DOI: 10.1111/j.1600-9657.2005.00364.x

[27] Filippi A, Von Arx T, Lussi A. Comfort and discomfort of dental trauma splints—A comparison of a new device (TTS) with three commonly used splinting techniques. Dental Traumatology. 2002;**18**:275-280. DOI: 10.1034/j.1600-9657.2002.00121.x

[28] Stellini E, Avesani S, Mazzoleni S, Favero L. Laboratory comparison of a titanium trauma splint with three conventional ones for the treatment of dental trauma. European Journal of Paediatric Dentistry. 2005;**6**:191-196

[29] Von Arx T, Filippi A, Lussi A. Comparison of a new dental trauma splint device (TTS) with three commonly used splinting techniques. Dental Traumatology. 2001;**17**:266-274. DOI: 10.1034/j.1600-9657.2001.170605.x

[30] Hinckfuss SE, Messer LB. Splinting duration and periodontal outcomes for replanted avulsed teeth: A systematic review. Dental Traumatology. 2009;**25**:150-157. DOI: 10.1111/j.1600-9657.2008.00761.x

[31] Qin M, Ge L, Bai R. Use of a removable splint in the treatment of subluxated, luxated and root fractured anterior permanent teeth in children. Dental Traumatology. 2002;**18**:81-85. DOI: 10.1034/j.1600-9657.2002.180207.x

**45**

Section 2

TMJ and

Maxillomandibular

Lesions

Section 2
