Comfort and discomfort of dental trauma splints ^ a comparison of a new device (TTS) with three commonly used splinting techniques

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1 Dental Traumatology 2002; 18: Copyright # Blackwell Munksgaard 2002 Printed in Denmark. All rights reserved DENTAL TRAUMATOLOGY ISSN Comfort and discomfort of dental trauma splints ^ a comparison of a new device (TTS) with three commonly used splinting techniques Filippi A, von ArxT, Lussi A. Comfort and discomfort of dental trauma splints ^ a comparison of a new device (TTS) with three commonly used splinting techniques. Dent Traumatol 2002;18: 275^280. # Blackwell Munksgaard, Abstract ^ The present experimental study compared four dental trauma splints in 10 volunteers. The evaluated splints included a wire-composite splint (WCS), a button-bracket splint (BS), a resin splint (RS), and the newly developed titanium trauma splint (TTS). All splints were bonded to the labial surfaces of the maxillary lateral and central incisors and left in place for 1week. After splint removal, the next splint was placed after a 1-week rest period.the sequence of splint application was randomized for each individual. The following subjective parameters were assessed using a visual analogue scale: sensitiveness of splinted teeth, irritation of the gingival margin, irritation of the lips, impairment of speech, eating and oral hygiene. The results show that the application of BS leads to a signi cantly higher irritation of the lips and greater impairment of speech compared to other splints (P < 0.05).The RS leads to an increased and signi cantly higher irritation of the gingiva (P < 0.05) owing to a signi cant increase in cleaning di culties (P < 0.05). In conclusion,wcs and TTS appear to be more accepted splints according to a subjective assessment by 10 volunteers. Andreas Filippi 1, Thomas von Arx 2, Adrian Lussi 3 1 Department of Oral Surgery, Oral Radiology and Oral Medicine, University of Basel, Basel, Switzerland, 2 Department of Oral Surgery and Stomatology, 3 Department of Operative Dentistry, University of Berne, Berne, Switzerland Key words: dental trauma splint; splinting method; discomfort; subjective assessment Dr Andreas Filippi, Department of Oral Surgery, Oral Radiology and Oral Medicine, University of Basle, Hebelstrasse 3, CH-4056 Basle, Switzerland Tel.: þ Fax: þ andreas.filippi@unibas.ch Accepted 21 March, 2002 Traumatically loosened, displaced or avulsed permanent teeth are normally splinted. The splinting method used for stabilization should support periodontal healing. Many di erent types of splinting techniques have been described in the literature (1^4). Today, an ideal splint should be passive and exible to allow physiologic tooth mobility. The duration of splinting should be as short as possible. Usually, the periodontal ligament reaches most of its normal strength 7^14days following trauma. Both prolonged and rigid splinting may lead to adverse e ects, such as ankylosis and replacement resorption (5^8). In addition, trauma splints should have optimal properties for handling, application and removal. Commonly used splinting techniques have been investigated in vitro and in vivo (9^13). In a recent study, parameters such as tooth mobility (Periotest values), probing depths, plaque accumulation, bleeding on probing and the chair time needed for splint application and removal were evaluated. The investigated splinting methods included the wire-composite splint (WCS), the button-bracket splint (BS), the resin splint (RS) and the new titanium trauma splint (TTS) (14). Itcouldbe shownthat all four tested splintsmaintained normal tooth mobility: TTS and WCS allowed a more physiologic and RS a critically reduced tooth mobility (horizontal Periotest values). Periodontal parameters remained unchanged, re ecting 275

In addition, the splints should not irritate adjacent tissues (gingiva, lips).

2 Filippi et al. the excellent oral hygiene by the study subjects. The chair time used for xation and removal was signi cantly lower fortts. From the patient s perspective, it is important that these splints are comfortable and do not interfere with oral hygiene, speaking and eating. In addition, the splints should not irritate adjacent tissues (gingiva, lips). The objective of this experimental study was to compare and evaluate TTS, WCS, RS and BS with respect to the subjective assessment by the patient. Materials and methods The study was conducted in 10 volunteers recruited from the sta of the Department of Oral Surgery and Stomatology, University of Berne. All subjects were female with a mean age of 21years and 6 months (range 17 years and 6 months to 34years and 9 months).the studydesignwas approvedby theethical Commission of the Canton Berne (study-number: ZMK-OC1/2000) and the clinical study was carried out according to the Helsinki declaration. The same studydesign hasbeen used in aprevious paper analysing di erent clinical parameters, such as tooth mobility, periodontal status, working time (9). All four maxillary incisors in all volunteers were free of caries and periodontal diseases. All subjects were healthy and presented no medical contraindications for the planned procedures. Four di erent splinting methods were evaluated in each individual, resulting in a total of 40 splints. The sequence of splint application was determined at random. Each splint was left in situ for 7 days. After removal, the next splint was placed after waiting for at least 1week. All splints were bonded to the labial aspect of all maxillary incisors. By placing the splints coronally, they were kept away from the gingival margin and the papillae. After drying the teeth, etching of the enamel surface was performed with 35% phosphoric acid gel for 30 s. Subsequently, the gel was rinsed o with water and the etched surfaces were dried again. Athin layer of bonding agent was applied. After polymerization, the splints were placed with the techniques described below. Titanium trauma splint (TTS) After cutting to the desired length, thetts was bent to the labial aspects of the incisors. Per tooth, one rhombus of thetts was lled with light-curing composite (Tetric 1 Flow Chroma, Vivadent, Schaan, Liechtenstein) (Fig.1) with 30 s of polymerization. Wire-composite splint (WCS) An 0.16 in in. orthodontic wire was cut to the desired length, adaptedto the curvature of the incisors Fig. 1. TTS: titanium trauma splint (occlusal view). Fig. 2. WCS: wire-composite splint (occlusal view). using a plier and secured with identical composite (Fig.2). Button-bracket splint (BS) Button brackets for direct bonding (Dentaurum, Ispringen, Germany) were bonded with the same composite. Thereafter, a 0.3-mm soft wire (Remanium 1, Dentaurum, Ispringen, Germany) wasbraided from button to button to connect the four incisors. Finally, the wire was secured to each button with composite (Fig. 3). Resin splint (RS) The resin (Protemp 1 II, ESPE Dental, Seefeld, Germany) was mixed according to the manufacturer s instructions. Using a syringe, resin was continuously applied to the labial crown aspects connecting all incisors (Fig.4). The subjective study parameters were the following: sensitiveness of splinted teeth, irritation of gingival margin, irritation of the lips, impairment of speech, 276

Comfort and discomfort of dental trauma splints Fig. 3. BS: bracket splint (occlusal view). Fig. 4. RS: resin splint (occlusal view). eating and oral hygiene.

After completion of the study, the length of the markings onthe v.a.s. was measured in millimetres.

All data were analysed by descriptive methods using box plots. As they were not normally distributed, the Wilcoxon test for paired data was performed.

3 Comfort and discomfort of dental trauma splints Fig. 3. BS: bracket splint (occlusal view). Fig. 4. RS: resin splint (occlusal view). eating and oral hygiene. All study parameters were recordeddailybyeachvolunteer for each splintfollowing splint application.they were given a special form with a visual analogue scale (v.a.s.) (length 10 cm) for each parameter per day. After completion of the study, the length of the markings onthe v.a.s. was measured in millimetres. The statistical evaluation was performed at days1,4 and 7 to register not only the immediate e ects of the splints, but also a possible subsequent adaptation by the volunteers. All data were analysed by descriptive methods using box plots. As they were not normally distributed, the Wilcoxon test for paired data was performed. When employing multiple comparisons, the P-values were corrected using the Bonferroni adjustment procedure (Systat 5.2, Systat Inc., Evanston, IL, USA). The signi cant level chosen in all statistical tests was Results None of the subjects withdrew fromthe study; atotal of 40 splints could, therefore, be evaluated. The parameters impairment of eating and irritation of gingival margin showed no statistical di erences between the four splints. However, RS showed an increasing irritation of the gingiva over time compared to the other splints (day 1 vs. days 4and 7, P < 0.05) (Fig.5). Sensitiveness of teeth and lips was more severe for most splints on day 1, with a continuous recovery on the following days (Figs.6 and 7). Statistically signi cant di erences of sensitive teeth on day 1 were found for BS compared to WCS (P < 0.05) and of sensitive lips for BS compared to WCS and RS (P < 0.05). At days 4and 7, no statisti- Fig. 5. Irritation of the gingival margin (mean values and standard errors). Significant differences (P < 0.05) are marked. 277

Filippi et al. Fig. 6. Sensitiveness of teeth (mean values and standard errors). Significant differences (P < 0.05) are marked. Fig. 7. Irritation of the lips (mean values and standard errors).

4 Filippi et al. Fig. 6. Sensitiveness of teeth (mean values and standard errors). Significant differences (P < 0.05) are marked. Fig. 7. Irritation of the lips (mean values and standard errors). Significant differences (P < 0.05) are marked. cally signi cant di erences were found. Regarding impairment of speech, signi cant di erences were found on day 1 for BS compared to all other splints (P < 0.05) (Fig.8). The oral hygiene of the splinted maxillary incisors was signi cantly impaired by RS comparedto the other splintsthroughout the splinting period (P < 0.05) (Fig.9). Discussion In addition to clinical parameters such as stability, physiologic mobility of splinted teeth as well as ease of use, splints in dental traumatology should not interfere with the patient s comfort. However, most of the splints currently used for treatment of traumatized teeth result in some discomfort during the initial period. Any mechanical or in ammatory irritation of the healing soft tissues must be avoided. Maintenance of oral hygiene is essential for healing following dental trauma (15). Plaque accumulation is detrimental to the periodontal healing of traumatized teeth (16, 17). The presented results clearly show that BS as well as RS leads to more impairment. Compared to the three other splints, RS is di cult to clean and therefore leads to greater irritation of the gingival margin (see Figs.5 and 9). BS is rather voluminous and irritates mechanically, and therefore leads to clearly higher sensitiveness of lips and impairment of speech compared to the other splints, particularly on day1 following splint placement (see Figs.7 and 8). However, TTS orwcs were much less irritating and were well tolerated by the volunteers. The presented study only includes the subjective ndings of the volunteers. The clinical comparison 278

Comfort and discomfort of dental trauma splints Fig. 8. Impairment of speech (mean values and standard errors). Significant differences (P < 0.05) are marked. Fig. 9.

All tested splints ful l the current requirements of a dentaltrauma splint, such as direct intra-oral application, using everyday dental materials such as wires, brackets, composite and resin.

5 Comfort and discomfort of dental trauma splints Fig. 8. Impairment of speech (mean values and standard errors). Significant differences (P < 0.05) are marked. Fig. 9. Impairment of oral hygiene (mean values and standard errors). Significant differences (P < 0.05) are described in the text. of these four splints was reported previously (9). All tested splints ful l the current requirements of a dentaltrauma splint, such as direct intra-oral application, using everyday dental materials such as wires, brackets, composite and resin. All these splints stabilize traumatized teeth in the original position and bring about adequate xation and physiologic mobility for the entire immobilization period (4, 9). In conclusion, and with consideration of the presented subjective as well as the published clinical ndings (9),TTS andwcs can be particularly recommended for splinting of traumatized teeth: both splints only minimally irritate the soft tissues and are well tolerated by the patients. In addition, the TTS is characterized by shorter application and removal working times, what might be of importance with the younger patients in mind. References 1. Bedi R. The use of porcelain veneers as coronal splints for traumatised anterior teeth in children. Restor Dent 1989; 5:55^8. 2. CrollT. Bonded composite resin/ligature wire splint for stabilization of traumatically displaced teeth. Quintessence Int 1991;22:17^ Gupta S, Sharma A, Dang N. Suture splint: an alternative for luxation injuries of teeth in pediatric patients ^ a case report. J Clin Pediatr Dent 1997;22:19^ Oikarinen K. Tooth splinting: a review of the literature and consideration of the versatility of a wire-composite splint. Endod Dent Traumatol 1990;6:237^

6 Filippi et al. 5. Andreasen JO. The effect of splinting upon periodontal healing after replantation of permanent incisors in monkeys. Acta Odontol Scand 1975;33:313^ Berude JA, Hicks ML, Sauber JJ, Li SH. Resorption after physiological and rigid splinting of replanted permanent incisors in monkeys. J Endod 1988;14:592^ Kristerson L, Andreasen JO. The effect of splinting upon periodontal and pulpal healing after autotransplantation of mature and immature permanent incisors in monkeys. IntJ Oral Surg1983;12:239^ Nasjleti CE, Castelli WA, Caffesse RG. The effects of different splinting times on replantation of teeth in monkeys. Oral Surg1982;53:557^ von ArxT, Filippi A, Lussi A. Comparison of a new dental trauma splint device (TTS) with three commonly used splinting techniques. Dent Traumatol 2001;17:266^ Filippi A. Reimplantation nachtrauma. Einfluss der Schienung auf die Zahnbeweglichkeit. Z Zahna«rztl Implantol 2000;16:8^ Ebeleseder KA, Glockner K, Pertl C, Staedler P. Splints made of wire and composite: an investigation of lateral tooth mobility in vivo. Endod Dent Traumatol 1995;11: 288^ Oikarinen K. Comparison of the flexibility of various splinting methods for tooth fixation. Int J Oral Maxillofac Surg1988;17:125^ Oikarinen K, Andreasen JO, Andreasen FM. Rigidity of various fixation methods used as dental splints. Endod Dent Traumatol 1992;8:113^ von Arx T, Filippi A, Buser D. Splinting of traumatized teeth with a new device: TTS (titanium trauma splint). Dent Traumatol 2001;17:180^ Andreasen JO, Andreasen FM. Luxation injuries. In: Andreasen JO, Andreasen FM, editors. Textbook and color atlas of traumatic injuries to the teeth. Copenhagen: Munksgaard;1994. p. 315^ Ne RF, Witherspoon DE, Gutman JL. Tooth resorption. Quintessence Int 1999;30:9^ Trope M. Root resorption of dental and traumatic origin: classification based on etiology. Pract Periodont Aesthet Dent 1998;10:515^

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