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 ofsplinting should be as short as possible. Usually, theperiodontal ligament reaches most of its normalstrength 7^14 days following trauma. Bothprolongedand 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 vitroand in vivo (9^13). Ina 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 included thewire-composite splint(WCS), thebutton-bracket splint (BS), the resin splint(RS) and the new titanium trauma splint (TTS)(14). Itcouldbe shownthat all four tested splintsmain-tained normal tooth mobility: TTS andWCS 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 Copyright # Blackwell Munksgaard 2002Printed in Denmark. All rights reserved DENTAL TRAUMATOLOGY

ISSN 1600–4469

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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 for1week.After splint removal, the next splint was placed after a1-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 andTTSappear to be more accepted splints according to a subjectiveassessment by10 volunteers.

Andreas Filippi1, Thomas von Arx2,Adrian Lussi31Department of Oral Surgery, Oral Radiology and OralMedicine, University of Basel, Basel, Switzerland,2Department of Oral Surgery and Stomatology,3Department of Operative Dentistry, University ofBerne, Berne, Switzerland

Key words: dental trauma splint; splinting method;discomfort; subjective assessment

Dr Andreas Filippi, Department of Oral Surgery, OralRadiology and Oral Medicine, University of Basle,Hebelstrasse 3, CH-4056 Basle, SwitzerlandTel.:þ4161267 2609Fax:þ4161267 2607e-mail: andreas.filippi@unibas.ch

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 that

these splints are comfortable anddonot interferewithoral 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 femalewith ameanage of 21years and 6months(range 17 years and 6months to 34 years and9months).The studydesignwasapprovedbytheEthi-cal Commission of the Canton Berne (study-number:ZMK-OC1/2000) and the clinical study was carriedout according to the Helsinki declaration.The samestudydesign hasbeenused inapreviouspaperanalys-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 in

each individual, resulting in a total of 40 splints.Thesequence of splint applicationwas 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 all

maxillary 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 performedwith 35%phosphoricacid gel for 30 s. Subsequently, the gel was rinsed o¡with water and the etched surfaces were dried again.Athin layerof bondingagentwas applied. Afterpoly-merization, the splints were placed with the techni-ques described below.

Titanium trauma splint (TTS)

After cutting to the desired length, theTTSwas bentto the labial aspects of the incisors. Per tooth, onerhombus of theTTSwas ¢lledwith 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 thedesired length, adaptedtothecurvatureof 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 frombutton 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, resinwascontinu-ously applied to the labial crown aspects connectingall incisors (Fig.4).The subjective studyparameterswerethe following:

sensitiveness of splinted teeth, irritation of gingivalmargin, irritation of the lips, impairment of speech,

Fig. 1. TTS: titanium trauma splint (occlusal view).

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

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eating and oral hygiene. All study parameters wererecordeddailybyeachvolunteer foreach splintfollow-ing splint application.They were given a special formwith a visual analogue scale (v.a.s.) (length 10 cm)for each parameter per day. After completion of thestudy, the lengthof themarkingsonthev.a.s.wasmea-sured in millimetres.The statistical evaluationwas performedatdays1,4

and 7 to register not only the immediate e¡ects ofthe splints, but also a possible subsequent adaptationby the volunteers. All datawere analysed by descrip-tive methods using box plots. As they were not nor-mally distributed, theWilcoxon test for paired datawas performed.When employing multiple compari-sons, theP-valueswere correctedusing theBonferroniadjustment procedure (Systat 5.2, Systat Inc., Evan-ston, IL, USA). The signi¢cant level chosen in allstatistical tests was 0.05.

Results

Noneofthe subjectswithdrew fromthe study;atotalof40 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 day1, 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-nificant differences (P < 0.05) aremarked.

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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 RScomparedtotheother splintsthroughoutthe 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 indental traumatology should 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 tissuesmustbe avoided.Maintenanceoforal hygiene is essential forhealing followingdentaltrauma (15). Plaque accumulation is detrimental tothe periodontal healing of traumatized teeth (16,17).The presented results clearly show that BS as well asRS leads tomore impairment. Compared to the 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-paredtothe other splints, particularlyonday1follow-ing splint placement (see Figs.7 and 8). However,TTS orWCSwere much less irritating andwere welltolerated by the volunteers.The presented study only includes the subjective

¢ndings of the volunteers. The clinical comparison

Fig. 6. Sensitiveness of teeth (meanvaluesand standard errors). Significant differ-ences (P< 0.05) are marked.

Fig. 7. Irritation of the lips (mean valuesand standard errors). Significant differ-ences (P< 0.05) are marked.

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of these four splints was reported previously (9). Alltested splints ful¢l the current requirements of a den-taltrauma splint, suchasdirect intra-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 the

presented subjective as well as the published clinical¢ndings (9),TTSandWCScanbeparticularly 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

removalworking times, whatmight be of importancewith the younger patients in mind.

References

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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 (meanvalues and standard errors). Significantdifferences (P< 0.05) are described inthe text.

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

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

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