titanium trauma splint

Comfort and discomfort of dental traumasplints ^ a comparison of a new device (TTS)with three commonly used splintingtechniques

Traumatically loosened, displaced or avulsed perma-nent teeth are normally splinted. The splintingmethod used for stabilization should support period-ontal healing. Many di¡erent types of splinting tech-niques have been described in the literature (1^4).Today, an ideal splint should be passive and £exibleto allow physiologic tooth mobility. The duration of splinting should be as short as possible. Usually, theperiodontal ligament reaches most of its normalstrength 7^14 days following trauma. Both prolongedand rigid splinting may lead to adverse e¡ects, suchas ankylosis and replacement resorption (5^8). Inaddition, trauma splints should have optimal proper-ties for handling, application and removal.

Commonly used splinting techniques have beeninvestigated in vitro and in vivo (9^13). In a recent study,parameters such as tooth mobility (Periotest values),probing depths, plaque accumulation, bleeding onprobing and the chair time needed for splint applica-tion and removal were evaluated. The investigatedsplinting methods includedthe wire-composite splint(WCS), the button-bracket splint (BS), the resin splint(RS) and the new titanium trauma splint (TTS)(14). It couldbe shown that all four tested splints main-tained normal tooth mobility: TTS and WCS allow-ed a more physiologic and RS a critically reducedtooth mobility (horizontal Periotest values). Period-ontal parameters remained unchanged, re£ecting

 Dental Traumatology 2002; 18: 275–280 Cop yri ght  #  Bla ckwe ll Mun ksg aar d 200 2

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Filippi A, von ArxT, Lussi A. Comfort and discomfort of dentaltrauma splints ^ a comparison of a new device (TTS) with threecommonly used splinting techniques. DentTraumatol 2002;18:275^280.# Blackwell Munksgaard, 2002.

Abstract ^ The present experimental study compared four dentaltrauma splints in10 volunteers.The evaluated splints included awire-composite splint (WCS), a button-bracket splint (BS), a resinsplint (RS), and the newly developed titanium trauma splint(TTS). All splints were bonded to the labial surfaces of themaxillary lateral and central incisors and left in place for 1week.After splint removal, the next splint was placed after a 1-week restperiod. The sequence of splint applicationwas randomized for eachindividual. The following subjective parameters were assessedusing a visual analogue scale: sensitiveness of splinted teeth,irritation of the gingival margin, irritation of the lips, impairmentof speech, eating and oral hygiene.The results show that theapplication of BS leads to a signi¢cantly higher irritation of the lipsand greater impairment of speech compared to other splints(P < 0.05). The RS leads to an increased and signi¢cantly higherirritation of the gingiva (P < 0.05) owing to a signi¢cant increase incleaning di⁄culties (P < 0.05). In conclusion,WCS and TTSappear to be more accepted splints according to a subjectiveassessment by 10 volunteers.

Andreas Filippi1, Thomas von Arx

2,

Adrian Lussi3

1Department 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.:þ4161267 2609

Fax:þ41612672607

e-mail: [email protected]

Accepted 21 March, 2002

the excellent oral hygiene by the study subjects. Thechair time used for ¢xation and removal was signi¢-cantly lower forTTS.

From the patient’s perspective, it is important thatthese splints arecomfortable anddo not interfere withoral hygiene, speaking and eating. In addition, thesplints should not irritate adjacent tissues (gingiva,lips). The objective of this experimental study was tocompare and evaluate TTS, WCS, RS and BS withrespect to the subjective assessment by the patient.

Materials and methods

The study was conducted in 10 volunteers recruitedfrom the sta¡ of the Department of Oral Surgeryand Stomatology, University of Berne. All subjectswere female with a mean age of 21years and 6 months(range 17 years and 6 months to 34 years and9 months).The studydesignwasapprovedby theEthi-cal Commission of the Canton Berne (study-number:ZMK-OC1/2000) and the clinical study was carriedout according to the Helsinki declaration. The samestudydesign hasbeen usedin a previous paper analys-ing di¡erent clinical parameters, such as tooth mobi-lity, periodontal status, working time (9). All fourmaxillary incisors in all volunteers were free of cariesand periodontal diseases. All subjects were healthyand presented no medical contraindications for theplanned procedures.

Four di¡erent splinting methods were evaluated ineach individual, resulting in a total of 40 splints. Thesequence of splint application was determined at ran-dom. Each splint was left   in situ   for 7 days. Afterremoval, the next splint was placed after waiting forat least 1week.

All splints were bonded to the labial aspect of allmaxillary incisors. By placing the splints coronally,they were kept away from the gingival margin andthe papillae. After drying the teeth, etching of theenamel surface was performed with 35% phosphoricacid gel for 30 s. Subsequently, the gel was rinsed o¡ with water and the etched surfaces were dried again.Athin layerof bonding agent wasapplied. After poly-merization, the splints were placed with the techni-ques described below.

Titanium trauma splint (TTS)

After cutting to the desired length, theTTS was bentto the labial aspects of the incisors. Per tooth, onerhombus of theTTS was ¢lled with light-curing com-posite (Tetric1 Flow Chroma, Vivadent, Schaan,Liechtenstein) (Fig.1) with 30 s of polymerization.

Wire-composite splint (WCS)

An 0.16 in.0.22 in. orthodontic wire was cut to thedesiredlength, adaptedtothecurvature of theincisors

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 samecomposite. Thereafter, a 0.3-mm soft wire (Rema-nium1, Dentaurum, Ispringen, Germany) wasbraid-ed from button to button to connect the four incisors.Finally, the wire was secured to each button withcomposite (Fig. 3).

Resin splint (RS)

The resin (Protemp1 II, ESPE Dental, Seefeld,Germany) was mixed according to the manufac-turer’s instructions. Usinga syringe, resinwas continu-ously applied to the labial crown aspects connectingall incisors (Fig.4).

Thesubjectivestudyparameters werethe following:sensitiveness of splinted teeth, irritation of gingivalmargin, irritation of the lips, impairment of speech,

Fig. 1.  TTS: titaniumtrauma splint (occlusal view).

Fig. 2.  WCS: wire-composite splint (occlusal view).

Filippi et al.

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eating and oral hygiene. All study parameters wererecordeddailybyeachvolunteer foreach splint follow-ing splint application.They were given a specialformwith a visual analogue scale (v.a.s.) (length 10 cm)for each parameter per day. After completion of thestudy, thelengthof themarkings onthe v.a.s.was mea-sured in millimetres.

The statistical evaluationwas performedatdays1, 4and 7 to register not only the immediate e¡ects of the splints, but also a possible subsequent adaptationby the volunteers. All data were analysed by descrip-tive methods using box plots. As they were not nor-mally distributed, the Wilcoxon test for paired datawas performed. When employing multiple compari-sons, the P -values were corrected using the Bonferroniadjustment procedure (Systat 5.2, Systat Inc., Evan-ston, IL, USA). The signi¢cant level chosen in allstatistical tests was 0.05.

Results

None of thesubjectswithdrew from thestudy;atotalof 40 splints could, therefore, be evaluated.

The parameters ‘impairment of eating’and ‘irrita-tion of gingival margin’ showed no statistical di¡er-ences between the four splints. However, RS showedan increasing irritation of the gingiva over time com-pared to the other splints (day 1 vs. days 4 and 7,P < 0.05) (Fig.5). Sensitiveness of teeth and lips wasmore 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 teethon day 1 were found for BS compared to WCS(P < 0.05) and of sensitive lips for BS compared toWCS and RS (P <0.05). At days 4 and 7, no statisti-

Fig. 3.  BS: bracket splint (occlusal view).

Fig. 4.  RS: resin splint (occlusal view).

Fig. 5.  Irritation of the gingival margin

(mean values and standard errors). Sig-

nif icant dif ferences ( P <0.05) are

marked.

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Comfort and discomfort of dental trauma splints

cally signi¢cant di¡erences were found. Regardingimpairment of speech, signi¢cant di¡erences werefound on day 1 for BS compared to all other splints(P < 0.05) (Fig.8). The oral hygiene of the splintedmaxillary incisors was signi¢cantly impaired by RScomparedto the other splints throughoutthe splintingperiod (P < 0.05) (Fig.9).

Discussion

In addition to clinical parameters such as stability,physiologic mobility of splinted teeth as well as easeof use, splints in dental traumatologyshould not inter-fere with the patient’s comfort. However, most of thesplints currently used for treatment of traumatizedteeth result in some discomfort during the initial per-iod. Any mechanical or in£ammatory irritation of 

the healing soft tissues must be avoided. Maintenanceof oral hygiene is essential forhealing following dentaltrauma (15). Plaque accumulation is detrimental tothe periodontal healing of traumatized teeth (16,17).The presented results clearly show that BS as well asRS leads to more impairment. Compared tothe threeother splints, RS is di⁄cult to clean and thereforeleads to greater irritation of the gingival margin (seeFigs.5 and 9). BS is rather voluminous and irritatesmechanically, and therefore leads to clearly highersensitiveness of lips and impairment of speech com-pared tothe other splints, particularlyon day1 follow-ing splint placement (see Figs.7 and 8). However,TTS orWCS were much less irritating and were welltolerated by the volunteers.

The presented study only includes the subjective¢ndings of the volunteers. The clinical comparison

Fig. 6.   Sensitiveness of teeth (mean values

and standard errors). Significant di ffer-

ences (P < 0.05) are marked.

Fig.7.  Irritation of the lips (mean values

and standard errors). Significant di ffer-

ences (P < 0.05) are marked.

278

Filippi et al.

of these four splints was reported previously (9). Alltested splints ful¢l the current requirements of a den-taltrauma splint, such as directintra-oralapplication,using everyday dental materials such as wires, brack-ets, composite and resin. All these splints stabilizetraumatized teeth in the original position and bringabout adequate ¢xation and physiologic mobility forthe entire immobilization period (4, 9).

In conclusion, and with consideration of thepresented subjective as well as the published clinical¢ndings(9),TTS andWCS canbe particularly recom-mended for splinting of traumatized teeth: bothsplints only minimally irritate the soft tissues andare well tolerated by the patients. In addition, theTTS is characterized by shorter application and

removal working times, what might be of importancewith the younger patients in mind.

References

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2. CrollT. Bonded composite resin/ligature wire splint for sta-bilization of traumatically displaced teeth. QuintessenceInt 1991;22:17^21.

3. Gupta S, Sharma A, Dang N. Suture splint: an alternativefor luxation injuries of teeth in pediatric patients ^ a casereport. J Clin Pediatr Dent 1997;22:19^21.

4. Oikarinen K.Tooth splinting: a review of the literature andconsideration of the versatility of a wire-composite splint.Endod Dent Traumatol 1990;6:237^50.

Fig. 8.  Impairment of speech (mean va-

lues and standard errors). Significant dif-

ferences (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.

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Comfort and discomfort of dental trauma splints

5. Andreasen JO. The effect of splinting upon periodontalhealing after replantation of permanent incisors in mon-keys. Acta Odontol Scand 1975;33:313^23.

6. Berude JA, Hicks ML, Sauber JJ, Li SH. Resorption afterphysiological and rigid splinting of replanted permanentincisors in monkeys. J Endod 1988;14:592^600.

7. Kristerson L, Andreasen JO. The effect of splinting uponperiodontal and pulpal healing after autotransplantationof mature and immature permanent incisors in monkeys.IntJ Oral Surg1983;12:239^49.

8. Nasjleti CE, Castelli WA, Caffesse RG. The effects of differ-ent splinting times on replantation of teeth in monkeys.Oral Surg1982;53:557^66.

9. von Arx T, Filippi A, Lussi A. Comparison of a new dentaltrauma splint device (TTS) with three commonly usedsplinting techniques. Dent Traumatol 2001;17:266^74.

10. Filippi A. Reimplantation nachTrauma. Einfluss der Schie-nung auf die Zahnbeweglichkeit. Z Zahna « rztl Implantol2000;16:8^10.

11. Ebeleseder KA, Glockner K, Pertl C, Staedler P. Splintsmade of wire and composite: an investigation of lateral

tooth mobility   in vivo. Endod Dent Traumatol 1995;11:288^93.

12. Oikarinen K. Comparison of the flexibility of varioussplinting methods for tooth fixation. Int J Oral MaxillofacSurg 1988;17:125^7.

13. Oikarinen K, Andreasen JO, Andreasen FM. Rigidity of various fixation methods used as dental splints. EndodDent Traumatol 1992;8:113^9.

14. von Arx T, Filippi A, Buser D. Splinting of traumatizedteeth with a new device: TTS (titanium trauma splint).Dent Traumatol 2001;17:180^4.

15. Andreasen JO, Andreasen FM. Luxation injuries. In:Andreasen JO, Andreasen FM, editors. Textbook and coloratlas of traumatic injuries to the teeth. Copenhagen:Munksgaard; 1994. p.315^82.

16. Ne RF, Witherspoon DE, Gutman JL. Tooth resorption.Quintessence Int 1999;30:9^25.

17. Trope M. Root resorption of dental and traumatic origin:classification based on etiology. Pract Periodont AesthetDent 1998;10:515^22.

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