(TTS) with Three Commonly Used Splinting Techniques

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 Andreas Filippi1, Thomas von Arx2, trauma splints ^ a comparison of a new device (TTS) with three Adrian Lussi3 commonly used splinting techniques. DentTraumatol 2002;18: 1Department of Oral Surgery, Oral Radiology and Oral 275^280. # Blackwell Munksgaard, 2002. Medicine, University of Basel, Basel, Switzerland, 2Department of Oral Surgery and Stomatology, Abstract ^ The present experimental study compared four dental 3Department of Operative Dentistry, University of trauma splints in10 volunteers.The evaluated splints included a Berne, Berne, Switzerland 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 Key words: dental trauma splint; splinting method; application of BS leads to a signi¢cantly higher irritation of the lips discomfort; subjective assessment and greater impairment of speech compared to other splints Dr Andreas Filippi, Department of Oral Surgery, Oral (P < 0.05).The RS leads to an increased and signi¢cantly higher Radiology and Oral Medicine, University of Basle, Hebelstrasse 3, CH-4056 Basle, Switzerland irritation of the gingiva (P < 0.05) owing to a signi¢cant increase in Tel.: þ4161267 2609 cleaning di⁄culties (P < 0.05). In conclusion,WCS andTTS Fax: þ4161267 2607 appear to be more accepted splints according to a subjective e-mail: [email protected] assessment by 10 volunteers. Accepted 21 March, 2002

Traumatically loosened, displaced or avulsed perma- Commonly used splinting techniques have been nent teeth are normally splinted. The splinting investigated in vitro and in vivo (9^13).In a recent study, method used for stabilization should support period- parameters such as tooth mobility (Periotest values), ontal healing. Many di¡erent types of splinting tech- probing depths, plaque accumulation, bleeding on niques have been described in the literature (1^4). probing and the chair time needed for splint applica- Today, an ideal splint should be passive and £exible tion and removal were evaluated. The investigated to allow physiologic tooth mobility.The duration of splinting methods included the wire-composite splint splinting should be as short as possible. Usually, the (WCS),thebutton-bracket splint (BS),the resin splint periodontal ligament reaches most of its normal (RS) and the new titanium trauma splint (TTS) strength 7^14days following trauma. Both prolonged (14).Itcouldbe shownthat all fourtested splintsmain- and rigid splinting may lead to adverse e¡ects, such tained normal tooth mobility: TTS and WCS allow- as ankylosis and replacement resorption (5^8). In ed a more physiologic and RS a critically reduced addition, trauma splints should have optimal proper- tooth mobility (horizontal Periotest values). Period- ties for handling, application and removal. ontal parameters remained unchanged, re£ecting 275 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 anddo not interferewith 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 Fig. 1. TTS: titanium trauma splint (occlusal view). and Stomatology, University of Berne. All subjects were female with a mean age of 21years and 6 months (range 17years and 6 months to 34years and 9 months).ThestudydesignwasapprovedbytheEthi- cal 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 hasbeenused in aprevious paperanalys- ing 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 ran- dom. Each splint was left in situ for 7 days. After Fig. 2. WCS: wire-composite splint (occlusal view). removal, the next splint was placed after waiting for at least 1week. using a plier and secured with identical composite All splints were bonded to the labial aspect of all (Fig.2). maxillary incisors. By placing the splints coronally, they were kept away from the gingival margin and Button-bracket splint (BS) the papillae. After drying the teeth, etching of the enamel surface was performed with 35% phosphoric Button brackets for direct bonding (Dentaurum, acid gel for 30 s. Subsequently, the gel was rinsed o¡ Ispringen, Germany) were bonded with the same with water and the etched surfaces were dried again. composite. Thereafter, a 0.3-mm soft wire (Rema- 1 Athin layer of bonding agent was applied. After poly- nium , Dentaurum, Ispringen, Germany) wasbraid- merization, the splints were placed with the techni- ed from button to button to connect the four incisors. ques described below. Finally, the wire was secured to each button with composite (Fig.3). Titanium trauma splint (TTS) After cutting to the desired length, theTTS was bent Resin splint (RS) to the labial aspects of the incisors. Per tooth, one 1 The resin (Protemp II, ESPE Dental, Seefeld, rhombus of theTTS was ¢lled with light-curing com- 1 Germany) was mixed according to the manufac- posite (Tetric Flow Chroma, Vivadent, Schaan, turer’sinstructions. Usinga syringe, resinwascontinu- Liechtenstein) (Fig.1)with 30 s of polymerization. ously applied to the labial crown aspects connecting Wire-composite splint (WCS) all incisors (Fig.4). Thesubjectivestudyparameterswerethefollowing: An 0.16in. 0.22 in. orthodontic wire was cut to the sensitiveness of splinted teeth, irritation of gingival desiredlength, adaptedtothecurvature oftheincisors margin, irritation of the lips, impairment of speech, 276 Comfort and discomfort of dental trauma splints

eating and oral hygiene. All study parameters were recordeddailybyeachvolunteerforeachsplintfollow- ing splint application.They were given a special form with a visual analogue scale (v.a.s.) (length 10cm) for each parameter per day. After completion of the study,thelengthofthemarkingsonthev.a.s. wasmea- sured in millimetres. The statistical evaluationwas performedat 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 descrip- tive methods using box plots. As they were not normally distributed, the Wilcoxon test for paired data was performed. When employing multiple compari- sons, the P-values were correctedusing theBonferroni Fig. 3. BS: bracket splint (occlusal view). adjustment procedure (Systat 5.2, Systat Inc., Evan- ston, IL, USA). The signi¢cant level chosen in all statistical tests was 0.05.

Results Noneofthesubjectswithdrew fromthestudy;atotalof 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 continu- ous 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 Fig. 4. RS: resin splint (occlusal view). WCS and RS (P < 0.05). At days 4and 7, no statisti-

Fig. 5. Irritation of the gingival margin (mean values and standard errors). Sig- nificant 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). Significant differences (P < 0.05) are marked. cally signi¢cant di¡erences were found. Regarding the healing soft tissues must be avoided.Maintenance impairment of speech, signi¢cant di¡erences were of oral hygiene is essential forhealing following dental found on day 1 for BS compared to all other splints trauma (15). Plaque accumulation is detrimental to (P < 0.05) (Fig.8). The oral hygiene of the splinted the periodontal healing of traumatized teeth (16,17). maxillary incisors was signi¢cantly impaired by RS The presented results clearly show that BS as well as comparedtotheothersplintsthroughoutthe splinting RS leads to more impairment. Compared to the three period (P < 0.05) (Fig. 9). other splints, RS is di⁄cult to clean and therefore leads to greater irritation of the gingival margin (see Discussion Figs.5 and 9). BS is rather voluminous and irritates mechanically, and therefore leads to clearly higher In addition to clinical parameters such as stability, sensitiveness of lips and impairment of speech com- physiologic mobility of splinted teeth as well as ease paredtothe other splints, particularlyon day1follow- of use, splints in dentaltraumatology should notinter- ing splint placement (see Figs.7 and 8). However, fere with the patient’s comfort. However, most of the TTS orWCS were much less irritating and were well splints currently used for treatment of traumatized tolerated by the volunteers. teeth result in some discomfort during the initial per- The presented study only includes the subjective iod. Any mechanical or in£ammatory irritation of ¢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. 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 removal working times, what might be of importance tested splints ful¢l the current requirements of a den- with the younger patients in mind. taltrauma splint, suchas direct intra-oralapplication, using everyday dental materials such as wires, brackets, composite and resin. All these splints stabilize References traumatized teeth in the original position and bring 1. Bedi R. The use of porcelain veneers as coronal splints for about adequate ¢xation and physiologic mobility for traumatised anterior teeth in children. Restor Dent 1989; the entire immobilization period (4,9). 5:55^8. 2. CrollT. Bonded composite resin/ligature wire splint for sta- In conclusion, and with consideration of the bilization of traumatically displaced teeth. Quintessence presented subjective as well as the published clinical Int 1991;22:17^21. ¢ndings (9),TTSandWCScanbe particularlyrecom- 3. Gupta S, Sharma A, Dang N. Suture splint: an alternative mended for splinting of traumatized teeth: both for luxation injuries of teeth in pediatric patients ^ a case report. J Clin Pediatr Dent 1997;22:19^21. splints only minimally irritate the soft tissues and 4. Oikarinen K.Tooth splinting: a review of the literature and are well tolerated by the patients. In addition, the consideration of the versatility of a wire-composite splint. TTS is characterized by shorter application and Endod DentTraumatol 1990;6:237^50. 279 Filippi et al.

5. Andreasen JO. The effect of splinting upon periodontal tooth mobility in vivo. Endod Dent Traumatol 1995;11: healing after replantation of permanent incisors in mon- 288^93. keys. Acta Odontol Scand 1975;33:313^23. 12. Oikarinen K. Comparison of the flexibility of various 6. Berude JA, Hicks ML, Sauber JJ, Li SH. Resorption after splinting methods for tooth fixation. Int J Oral Maxillofac physiological and rigid splinting of replanted permanent Surg1988;17:125^7. incisors in monkeys. J Endod 1988;14:592^600. 13. Oikarinen K, Andreasen JO, Andreasen FM. Rigidity of 7. Kristerson L, Andreasen JO. The effect of splinting upon various fixation methods used as dental splints. Endod periodontal and pulpal healing after autotransplantation DentTraumatol1992;8:113^9. of mature and immature permanent incisors in monkeys. 14. von Arx T, Filippi A, Buser D. Splinting of traumatized IntJ Oral Surg1983;12:239^49. teeth with a new device: TTS (titanium trauma splint). 8. Nasjleti CE, CastelliWA, Caffesse RG.The effects of differ- DentTraumatol 2001;17:180^4. ent splinting times on replantation of teeth in monkeys. 15. Andreasen JO, Andreasen FM. Luxation injuries. In: Oral Surg1982;53:557^66. AndreasenJO, Andreasen FM, editors.Textbook and color 9. von ArxT, Filippi A, Lussi A. Comparison of a new dental atlas of traumatic injuries to the teeth. Copenhagen: trauma splint device (TTS) with three commonly used Munksgaard;1994. p. 315^82. splinting techniques. DentTraumatol 2001;17:266^74. 16. Ne RF, Witherspoon DE, Gutman JL. Tooth resorption. 10. Filippi A. Reimplantation nachTrauma. Einfluss der Schie- Quintessence Int 1999;30:9^25. nung auf die Zahnbeweglichkeit. Z Zahna«rztl Implantol 17. Trope M. Root resorption of dental and traumatic origin: 2000;16:8^10. classification based on etiology. Pract Periodont Aesthet 11. Ebeleseder KA, Glockner K, Pertl C, Staedler P. Splints Dent 1998;10:515^22. made of wire and composite: an investigation of lateral

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