| Abstract|| |
Introduction: The wire composite splint as a general rule is placed on the middle third of labial surface of the tooth. This is due to ease of application, better isolation, and fewer chances of contamination. However, these assumptions are opinion-based, with no scientific evidence to support them. In addition, to best of our knowledge no research has been carried out to evaluate the effect of position of wire splints on the mobility of the affected tooth and anchor teeth. Aim: The aim of this study was to evaluate the effect of the cervico-incisal position of splinting wire on the mobility of a replanted tooth and anchor teeth in a cadaveric model. Methodology: Three cadavers (one female, 45 years old and two males, each 40 years old) were included in the study. periotest S was used to assess physiologic-tooth-mobility in three cadavers at baseline and after “extraction-replantation-wire-composite” splinting-protocol. Results: Greatest splint effect for horizontal-mobility was found to be 9.33 ± 0.57 for Cadaver-I (incisal-third), whereas it was highest (3.66 ± 2.51) for vertical-mobility in Cadaver-II (cervical third). Conclusion: Middle third position of wire composite splint have lowest splint effect on both horizontal and vertical mobility of replanted teeth, thus rendering the most favorable position for the establishment of physiologic mobility.
Keywords: Luxation, periodontium, Periotest S, splinting
|How to cite this article:|
Atif M, Tewari N, Mathur VP, Bansal K, Gangadharrao MR. Effect of inciso-cervical position of wire-composite splint on the mobility of an avulsed permanent tooth: A cadaveric model study. Indian J Dent Res 2020;31:758-62
|How to cite this URL:|
Atif M, Tewari N, Mathur VP, Bansal K, Gangadharrao MR. Effect of inciso-cervical position of wire-composite splint on the mobility of an avulsed permanent tooth: A cadaveric model study. Indian J Dent Res [serial online] 2020 [cited 2021 Jan 18];31:758-62. Available from: https://www.ijdr.in/text.asp?2020/31/5/758/306464
| Introduction|| |
Traumatic dental injuries (TDIs) can affect the tooth or its supporting structures with various degrees of severity. Luxation injuries and dentoalveolar fractures involve the periodontal ligament and alveolar bone, with or without mobility and the displacement of tooth/teeth., The prevalence of TDI ranges from 4 to 14%, and the most common teeth involved are maxillary central incisors. International Association of Dental Traumatology (IADT) guidelines have clearly defined diagnostic and treatment protocols for most of these injuries., The common treatment recommended is the immobilisation of teeth and supporting structures. The rationale behind splinting is the alleviation of pain and promotion of healing by allowing for the regeneration of traumatised tissues.,
The splinting of teeth dates back to 500BC in ancient Mesopotamia, where gold wires were used to stabilise mobile teeth. Its use in maxillofacial trauma is largely linked with the use of arch bars for rigid immobilisation. In periodontology, the use of wire-eyelet splinting is common. The use of rigid splints was first advocated for the splinting of traumatised teeth., However, it was found in animal studies that masticatory stimulation has a role in the prevention of development of ankylosis., The guidelines have emphasised the use of short-term, flexible splinting for 2-4 weeks in different categories of TDI.,
The advent of acid-etch technique and adhesive restorative materials, has lead to an increase in the application of composite splints or wire composite splints. Once metal and resin combinations were found to be successful, several variants of this were attempted. Studies have tried to evaluate the rigidity of various splinting techniques and factors governing stabilisation, msuch as type of splint, thickness of splinting wires and wire adhesion, on either typodonts or animal models.,,,,,,, Kwan et al.(2012) utilised the human cadavers for evaluating the ideal thickness of wire for physiological mobility of splinted teeth.
The general rule for placement in terms of position of wire composite splints is the middle third of the labial surface of the tooth. This is due to ease of application, better isolation and fewer chances of contamination. However, these assumptions are opinion-based, with no scientific evidence to support them. In addition, no research has been carried out to evaluate the effect of wire position on the mobility of the affected tooth and anchor teeth. Therefore, this study was planned to evaluate the effect of cervico-incisal position of splinting wire on the mobility of a replanted tooth and anchor teeth.
| Materials and Methods|| |
The present study was planned in the Department of Pedodontics and Preventive Dentistry in collaboration with the Department of Forensic Medicine after ethical clearance was obtained from the Institute's Ethical Committee. Three cadavers (one female, 45 years old and two males, 40 years old each) were included in the study [Table 1]. They satisfied the inclusion criteria of presence of all maxillary anterior teeth with complete root maturation, clinical absence of apparent periodontal disease, no visible fracture of the crown or root, and no clinically visible root caries. The bodies were either unclaimed or had been donated to the Institute for educational and training purposes. The cadavers were preserved by means of a soft embalming procedure, which preserves the soft tissue in its 'lifelike' or supple state. The cadavers were freeze-preserved after the embalming procedure. All cadavers were less than one month old.
|Table 1: Characteristics of three cadavers and the position of splint wire used|
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The baseline physiologic tooth mobility of all the permanent maxillary incisors, that is, 11, 12, 21, 22 of each cadaver was recorded by means of Periotest S (Model no. 3218, Benheim, Germany) in both horizontal and vertical directions. Horizontal mobility was recorded with cadavers kept in a sitting position with the maxillary occlusal plane parallel to the floor whereas vertical mobility was recorded with the cadavers kept in a supine position. This was done to ensure to keep the Periotest device in horizontal plane. The handpiece of Periotest S was kept at the same level, and recording was done with the handpiece kept at the same position on the tooth surface. The permanent right maxillary central incisor of each cadaver model was extracted atraumatically by means of a periotome, elevator, and forceps, to simulate avulsion of the tooth without causing damage to adjacent teeth. Stainless steel wire of 0.4 mm diameter was used for splinting, along with hybrid composite (3M ESPE Z250, São Paulo, Brazil); Etchant (Scotch Bond multipurpose etchant, 37% phosphoric acid, (3M/ESPE, São Paulo, Brazil); Adper Single Bond 2 adhesive (3M/ESPE, São Paulo, Brazil) [Figure 1]. The wire was first adapted to fit passively to the labial surfaces of 11, 12, 21 and 22 by means of orthodontic pliers. In Cadaver I, the extracted 11 was repositioned and splinted with wire positioned at the incisal third of the tooth. The wire position was at the cervical third in Cadaver II and the middle third in Cadaver III. The size of the composite button was kept at 2 mm in all teeth. The mobility of splinted teeth was recorded by Periotest S in both horizontal and vertical directions. This reading was repeated 3 times for each tooth. All the readings of Periotest S were recorded by the same operator. The changes in mobility of tooth/teeth from baseline to splinting (”splint effect”) were also calculated. The three Periotest readings were used separately for statistical purpose. Kruskal-Wallis and Dunn's Pair wise comparison with Bonferroni correction were used to find the significant differences between and among the groups.
|Figure 1: Cadaveric model; (a) Extraction, (b) Replantation and (c) Splinting protocol|
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| Results|| |
The splint effect on the horizontal mobility of the replanted 11 in all three cadavers is shown in [Figure 2]. The greatest splint effect was found to be 9.33 ± 0.57 for Cadaver I (incisal third), followed by Cadaver II (3.33 ± 1.57, cervical third), with the least observed in Cadaver III (0.66 ± 0.57, middle third). A significant difference (P = 0.01) was found between the incisal and cervical third positions. However, the difference between the middle third and other positions was not statistically significant (P = 0.26).
|Figure 2: Effect of Splint on horizontal mobility in replanted teeth in three cadavers|
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The splint effect on the vertical mobility of the avulsed replanted tooth is shown in [Figure 3]. The greatest splint effect for vertical mobility was found in Cadaver II (3.66 ± 2.51, cervical third), and the least was seen in Cadaver III (2 ± 0, middle third). A statistically significant difference (p = 0.03) was found between incisal and cervical third positions. However, the difference between the middle third and incisal third positions (p = 0.10) as well as middle third and cervical third positions (p = 0.97) was not statistically significant.
|Figure 3: Effect of Splint vertical mobility in replanted teeth in three cadavers|
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The splint effect on horizontal and vertical mobility in anchor teeth (adjacent incisors) is shown in [Table 2]. Teeth 21 and 22 showed the least splint effect in both horizontal and vertical mobility in Cadaver III (middle third), whereas the least splint effect in 12 was observed in Cadaver II (cervical third).
|Table 2: Effect of composite wire splint on horizontal and vertical mobility at incisal, cervical and middle third in anchor teeth|
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| Discussion|| |
The current recommendations on the duration and use of flexible splints were derived from the findings of studies conducted on either animal models or artificial teeth. The periodontal tissues and dimensions of teeth and tooth roots of animals differ from those of humans in various respects, making them less suitable for studying the effect of splinting on the mobility of traumatised teeth. Artificial models for in vitro studies (e.g. Berthold et al., Franz et al., Zhu et al.,) were selected in an attempt to mimic the mobility of avulsed/splinted natural teeth. These acrylic models lack clinical relevance and true representation of human periodontal ligament cells. Randomised controlled trials would, hypothetically, have been the best study design for exploring the scientific evidence for splinting. However, a prospective study is difficult, as it requires a large sample size with similar types of injuries in patients of matched characteristics.,
Cadaveric models can be an excellent replication of the human periodontium, and the results obtained can be extrapolated to the clinic. The conventional embalming techniques results in hardening of the soft tissues, which makes them less ideal for training and research purposes. The use of soft embalming procedure, using a novel method of whole body preservation developed by the institute, preserves the cadaver and it remains relatively soft for a longer period of time. The tissue also retains a lifelike feel like a normal living patient. Hence, the present study was planned for cadaveric models.
Kwan et al. (2002) used a single cadaver to study different splinting materials. The limitation of this study was a variable increase in pre-splint mobility with each step of splinting and splint removal. In the present study, three cadavers were used to study the effect of splinting, so that the processes of removal and replantation of the tooth were not required and a single splint position was tested, thus eliminating the limitation of increased pre-splint mobility.
Previous researchers have recommended wire and composite splints as the most physiologically appropriate type of splint. This is also the most commonly used splinting technique in the clinic at present.,, Kwan et al. showed that stainless steel or nickel titanium wire with a diameter of 0.016' (0.4 mm) was best for the splinting of traumatised teeth. Franz et al. studied the point dimensions of adhesives and observed no significant effect on the physiologic mobility of splinted teeth. None of the researchers evaluated the effect of the inciso-cervical position of wire and its effect on the mobility of affected and adjacent anchor teeth. The recommendation for placement in the middle third is based on opinions or clinical experience and lacks any scientific basis. Hence, this study was planned to evaluate the effects of wire position and the size of composite adhesion using the 0.016' SS wire and 2-mm resin composite buttons. The splinting of teeth was done between the lateral incisors, that is, 12, 11, 21, 22 based on the recent evidence that splinting one or two uninjured teeth on either side has no significant influence on the mobility of the injured tooth. Periotest is a device widely used for the measurement of teeth and implants in clinical and experimental settings and has been shown to have high degrees of both sensitivity and specificity.
The position of a wire composite splint that brings the mobility of a replanted tooth closest to that of a physiologic tooth without affecting the mobility of adjacent anchor teeth can be most appropriate for the healing and regeneration of periodontal tissue.,,,, The splint effect as a determinant of change in mobility has been evaluated by Kwan et al. (2002) for testing the thickness of wire. This study also evaluated this parameter for the replanted tooth and adjacent teeth. The splint effect in a replanted tooth, for both horizontal and vertical mobility, was lowest when the splint was placed in the middle third of the tooth, and highest for horizontal mobility in the incisal third position and for vertical mobility in the cervical third position. Recently, the concept of active stabilisation has also been revisited, suggesting controlled force application in wire composite splints for the prevention of ankylosis.
The results also revealed a change in the mobility of adjacent anchor teeth after splinting. The maximum change in combined horizontal and vertical mobility was seen in the maxillary left central incisor. The maximum splint effect for horizontal tooth mobility was seen in tooth 21 for splinting in the cervical position, whereas it was greatest for the incisal third position for vertical tooth mobility. The use of different cadavers for three different positions of splinting might have led to confounding factors, thereby affecting the results of the study. Also, there was a difference in the pre-splint mobility of the teeth. This lack of standardisation was a limitation of the study design, but its effect on the results was eliminated as the splint effect was taken as the primary outcome measure.
| Conclusions|| |
Based on the results of the present study following conclusions can be drawn
- Middle third position for wire placement in a wire composite splint was found to have the lowest splint effect on both horizontal and vertical mobility of replanted teeth, thus rendering the most favorable position for the establishment of physiologic mobility.
- Splint effect was found to be greatest for horizontal mobility in the incisal third position and for vertical mobility in the cervical third position.
- Splinting affects the adjacent anchor teeth in terms of changes in mobility from baseline.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Nitesh Tewari
Division of Pedodontics and Preventive Dentistry, 6th Floor, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi - 110029
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]