Management of dentoalveolar trauma in adult with nylon splinting and 15 days’ delay in treatment-Case report

Background and objective: Root fracture is relatively rare and represents only 0.5-7% of all dental trauma, its incidence is higher in children than in adults and depending on the way it occurs it can be vertical or horizontal , which depends on its location in the case of horizontal fracture, it can be generated at the level of the cervical, middle or apical third of the root, which depends on multiple factors such as the delay in treatment, the type of splint used, age, and fi xation time, the healing of the separated fragments may be impaired. Traditionally for the management of root fractures, rigid immobilizations were used for long periods of time, however, currently the management has changed towards the use of more fl exible splints such as nylon, orthodontic wires, sutures, among others. The objective of this study is to present the case of a 21-year-old male who suffers a motorcycle accident with multiple trauma injuries including subluxation, root fractures combined with complicated coronal fracture, root fracture with extrusive luxation and individual complicated coronal fracture; splinted with nylon and delayed in treatment for 15 days. Results: it was managed with nylon splinting (fi shing line) from tooth 14 to 24 for 25 days with root canal therapy in several teeth; After clinical and radiographic follow-up at 10 weeks, there is evidence of absence of symptoms, return of functionality, different types of segment consolidation despite the delay in treatment and high diastasis of the root fragments. Conclusion: Early diagnosis with the necessary procedures during trauma management, knowledge of the healing processes and adequate follow-up are key to a correct approach to root fractures. Case Report Management of dentoalveolar trauma in adult with nylon splinting and 15 days’ delay in treatment-Case report Sandra Milena Bornacelly Mendoza* General Dentist, Second Year Resident Postgraduate program in Endodontics, University Institution Colleges of Colombia-UNICOC, Colombia Received: 08 March, 2021 Accepted: 16 March, 2021 Published: 19 March, 2021 *Corresponding author: Sandra Milena Bornacelly Mendoza, General Dentist, Second Year Resident Postgraduate Program in Endodontics, University Institution Colleges of Colombia-UNICOC, Colombia, Tel: +573012805900; E-mail: ORCID: https://orcid.org/0000-0003-3564-7448


Introduction
Traumatic Dental Injuries (TDI) is recognized as a group of injuries affecting the tooth and its supporting structures due to a direct or indirect violent impact [1]. With a low incidence, TDI constitutes up to 5% of all injuries to the body [2] affecting individuals of all ages; although a higher prevalence is recognized in children than adults, due to the fact that children frequently adopt unpremeditated risk behaviors and their lack of coordination, as well as defects in their occlusion, can favor trauma unlike adults, in which TDI it can be the result of falls, sports activities or accidents; [3] for this reason, the greatest amount of evidence reported focuses on the management of dentoalveolar trauma in children and not in adults [2,3]. This type of injury can vary according to the type, location and direction of the impact, and it is believed that the coronal fracture is the most frequent, representing 65-75% of all dental trauma, followed by dislocation in 8-20% of the cases; [4] unlike the root fracture that occurs only in 0.5-7% of cases, [5] and the fracture can be located at the level of the cervical, middle or apical third of the root, it is characterized by compromising the cement root, dentin, pulp and periodontal ligament; where, generally the apical segment separation does not shift and the coronal segment may or may not shift in various ways [6,7].
In post-impact root fracture, the pulp and other damaged tissues begin the healing process which, it is considered, can be affected by factors such as the patient's age, tooth mobility, the degree of root formation, the location of the fracture, the diastasis of the fragments and time of handling in the attention; [7] although, for the latter, some studies support that it is not possible to signifi cantly demonstrate the negative effect of delaying treatment on fracture healing. [8] Since 1967 Andreasen and Hjorting-Hansen classifi ed the consolidation of fragments in this type of fracture as four possible scenarios: scarring with hard tissue, scarring with interposition of only connective tissue, apposition of bone and connective tissue and a fourth scenario with absence of scarring when granulation tissue appears; Any of the fi rst three scenarios is considered favorable, the interposition of granulation tissue being the least favorable because it represents an infl ammatory state [9].
Traditionally, root fractures were managed with repositioning of the coronal fragment and immobilization with rigid or semi-rigid splints given that, for years, dental splinting was based on the principles of maxillary fracture whose management is at the expense of rigid splints and for a long time; However, at present this approach has been rethought since the evidence has shown that the use of these can increase the incidence of pulp necrosis and the tendency to external root resorption, so today, to reduce such effects more fl exible immobilizations and shorter splinting times are recommended [8,10], with which satisfactory results and a success rate ranging from 54 to 77% have been reported in root fractures [5]. To be successful, knowledge of all aspects that may or may not be modifi able and affect the results is essential; likewise, the management of all the variables that may affect the prognosis of the treatment at the clinical level, such as the type and time of splinting [2,7].
Dental splints should ideally hold the tooth in position by allowing slightly physiological movements that promote healing, they should be affordable, easy to perform and aesthetically pleasing and stable throughout the fi xation period. [8,11] Some of the wires used in orthodontics are considered fl exible and have been classifi ed as suitable for splinting in dentoalveolar trauma injuries [1]. The use of nylon (fi shing line) has even been reported as a substitute for orthodontic wire in splinting, as this material provides a more aesthetic appearance, is functional, easily acquired, low cost and fl exible [8,10,11]. It is important to disclose some management guidelines for dentoalveolar trauma injuries that require splinting, because the treatment of these injuries involves a comprehensive approach and requires timely and accurate care [4] from the professional, who has the challenge of restoring dental aesthetics and functionality, positively impacting the health and comfort of those who suffer from it [2,4]. The objective of this study is to describe the management of a case of combined dentoalveolar trauma injuries in an adult patient with nylon splinting and treatment delay of 15 days.

Presentation of the case
We describe the case of a 21-year-old male patient who attended a consultation at the endodontics faculty clinic at the university institution colleges of Colombia in Bogotá for the management of a dentoalveolar trauma that occurred 15 days before the consultation date due to that the patient had multiple coronal fractures referred to the presence of spontaneous pain caused in the upper anterior teeth, as well as in the temporomandibular joint.
No relevant personal systemic history was reported, nor relevant family medical history, the patient only referred hospitalization for 2 days due to the accident with subsequent management at home of antiinfl ammatory analgesics and antibiotics for 6 days. The extraoral examination revealed the presence of multiple lacerations in the face and neck area, laceration and eversion of the upper lip, pain when opening and closing the right temporomandibular joint with a slight deviation in the shape of an "s" at the time of closure. The intraoral examination and dental history reveal the clinical fi ndings for teeth reported in Table 1.    which some combined injuries are evident ( Table 2). The patient is explained everything related to the treatment and fl exible splinting with nylon and resin is indicated in the fi rst visit, pertinent consents are signed, in addition the patient also gave his consent and approval for the study of his data and the publication of his case, and immobilization with nylon is carried out, carrying out the following steps: performed dental prophylaxis with a prophylactic brush and hydrogen peroxide,

Results and discussion
In

Subluxation 13
Horizontal root fracture in the middle third with complicated coronal fracture 12 Horizontal root fracture in the middle third with extrusive dislocation of the coronal fragment 11 Horizontal root fracture in the middle third 21 Horizontal root fracture in apical third with complicated coronal fracture 22 Complicated coronal fracture 23   tooth 13 that had a concussion and has only been under clinical and radiographic control. When pulp involvement is evident, endodontic therapy may be necessary and depending on the type of injury, surgical repositioning and / or stabilization with splints may be necessary [12]. There are several types of splints and the nylon splint (line fi shing) is a splint that combines the adhesive technique of composite resin with the use of taut nylon wire 0.6 to 0.7 millimeters in diameter, its has been tested and found to be as fl exible as thin stainless steel wire [8,11].
In root fracture, it is essential to relocate the fragments in case of displacement and to maintain a stable splinting, to facilitate its complex repair mechanism [9,12] since 1967 Andreasen and Hjorting-Hansen spoke about the different types of consolidation that can occur in the fractured segments, they state that type I scarring is more commonly found in root fractured teeth in which the coronal fragment is not dislocated or is only slightly dislocated as in tooth 22 of the present case, type II scarring According to these authors, it occurs when there is repair with interproximal connective tissue and on radiographs, the fragments may be separated by radiolucency and the fractured edges have a rounded appearance, as in our case occurred in teeth 11 and 12. It is considered that this type of repair is often after lateral dislocation or extrusion of the coronal fragment as occurred with the with tooth 11 in our case; type III, which is when there is consolidation with interproximal bone and connective tissue that can be radiographically evidenced as the separation of the fragments given by a bone bridge with radiolucency as occurred in tooth 21 and type IV, when there is formation of granulation tissue This occurs because the infected or necrotic pulp tissue causes an infl ammatory reaction in the fracture line, which has not been evidenced so far in our case [9,13].
The literature reports that horizontal fracture is more frequent in anterior teeth of young patients and is more frequent in the apical and middle third affected in 57% and 34% of the cases respectively; which is evident in our case since all the fractures occurred at the mid and apical level of the roots [6]. It has been considered that horizontal fracture of the middle third has a poor prognosis, due to the diffi culty of choosing which fragment should be preserved, in addition to the frequent formation of periodontal pockets [7]. In accordance with Wölner-Hanssen and von Arx T 2010.A horizontal fracture located in the apical third has a better prognosis and can be repaired many times while preserving pulp vitality; generally, it does not present mobility, the tooth is asymptomatic and does not require treatment [14]. In our case, tooth 22 presented a fracture in the apical third but due to the combined injury that additionally had a complicated crown fracture it was necessary to perform endodontic therapy. The literature reports that 10-year survival according to the location of the fracture is 89% for fractures in the apical third of the root, 78% when it is located in the middle third, and between 33-67% in the cervical [15]. The general fi nding is that apical and radicular fractures have a much higher probability of survival than the estimated survival of cervical fractures [5][6][7][8][9]15].
It is important to consider that in approximately 20-44% of cases of horizontal root fractures, the pulp becomes necrotic and endodontic therapy is necessary [16]. as happened in the present case in teeth 11 and 21, which at 15 days of evaluation responded negative to the cold test and slight color changes were observed in the crown. In our case, the fi lling of the canals was carried out to the level of the fracture without joining the apical segments, which coincides with Kocak et al (2008) who affi rm that, in most cases, the endodontic treatment of the coronal fragment is suffi cient as it is considered that the pulp in the apical fragment is still vital and it is believed that circulation at this level is generally not interrupted [17].
Since 1970, the relationship between the type of scarring and associated factors has been investigated, attributing infl uence to age, the stage of root development, the location of the fracture, mobility and dislocation of the coronal fragment, as well as the distance between the fragments with stretching or rupture of the pulp tissue at the level of the fracture [13,15]. and also the variables dependent on clinical management such as optimal repositioning and the type of splint are associated with a curative response [18]. In terms of time, studies have shown that teeth can be immobilized for only 1 week and be clinically fi rm so that long splinting times are no longer necessary; however, there may be cases in which the comfort of the patient requires extending the functional splinting for a longer time [15,18] and consequently the latest guidelines of the International Association of Dental Traumatology (IADT) recommend types of splints that are fl exible rather than rigid and that are used for less time [19].
Regarding the type of splint, few studies have evaluated the use of nylon as a splinting material, however, it is clear that the recommendation is to use fl exible materials; Ben Hassan 2016 in his study compares the Nylon splints with stainless steel, titanium, single and double fi berglass and it has been found that they are just as fl exible as those of stainless steel wire, and that it additionally has the advantage of its high aesthetics. It is considered disadvantages that it is diffi cult to place due to its small diameter and tendency to slip, which could easily break due to movement induced by the fi xed tooth but that this can be avoided with greater application of resin [11] and according to Andreassen 2004, age, root development, mobility and dislocation of the coronal fragment and sex are positively related to both pulp healing and repair of the hard tissue of the root fracture [13].
Although it is considered that only after 3 to 6 months, it is possible to make a reliable determination of the type of fracture union [20,21] in our case, favorable indications of fragment consolidation are evidenced at 10 weeks, favorable results are considered for IADT when the patient is asymptomatic, lack of mobility is achieved or that it is slightly increased and that signs of repair of the fragments as met in the present case, which has been managed in accordance with IADT guidelines, handling fl exible nylon splint for 23 days and it is expected to be able to carry out patient controls according to what is established, which indicates that for root fractures the Clinical and radiographic controls are necessary after 4 weeks, after 6-8 weeks, after 4 months, after 6 months, after 1 year and annually for at least 5 years [19].
It is essential to know their management of root fractures to be able to relocate the fragment in case of displacement and to make good management with stable splinting that favors complex biological repair mechanisms [19,22] Among the available fl exible splinting alternatives, nylon seems to be a promising immobilizer material, due to its aesthetics, fl exibility and economy that warrant further investigation [8,11].

Conclusion
Despite the delay in the management of the dentoalveolar trauma in the present case, the evaluation of the healing of the fragments at 10 weeks did not show evidence of granulation tissue formation, and on the contrary, indications of favorable consolidation between the segments were observed. Therefore, it is considered that until then, the results have been favorable and although some studies have supported the idea that the delay in treatment can infl uence the type of healing after a root fracture, more studies are required to investigate the effect of delay in the treatment of healing in root fractures since in essence the result of healing in these fractures seems to be more related to the stage of root formation, the affectation of the pulp state and the extension of the fracture that with the time of care.