The effect of interdental continuous loop wire splinting and intermaxillary fixation on the marginal gingiva

Judith L. Lello and Glenn E, Lello Department of Cariology, Periodontology and Preventive Dentistry, and Department of Maxillofacial Surgery, Dental Hospital, University of Z0rich, Switzerland

J. L. LelIo and G. E. Lello: The effect o f interdental continuous loop wire splinting and intermaxillary fixation on the marginal gingiva. Int. J. Oral Maxillofac. Surg. 1988; 17: 249-252.

Abstract. To study the influence of interdental loop-wire splinting and intermaxil- lary fixation on the marginal gingiva, 30 patients were evaluated clinically using different periodontal parameters, at 5 examination times. It was shown that despite a standardized oral hygiene regime including the use of a mouthrinse, gingival inflammation occurred for the duration of the splinting period. Factors other than the presence of limited plaque, such as gingival trauma due to splint application and subsequent mechanical irritation should be considered as possible aetiological factors. All investigated marginal gingival changes had totally reversed 2 weeks following loop-wire splint removal, apart from tooth mobility which did not re-attain pre-operative levels, the difference, however, being statistically insig- nificant.

Key words: intermaxillary fixation; gingivitis

Accepted for publication 8 March 1988

Many types of splints are used today in the treatment of jaw fractures and osteotomies. Little attention has been paid to the possible detrimental effect that the various splinting techniques may have on the periodontium. Of the few clinical investigations previously documented,~, 4, 6, 10 the general opinion was that the inflammatory gingival changes evident during the period of splinting were of a temporary nature, reverting in most cases to the pre-oper- ative state.

Statistical analysis of the results how- ever, was only carried out in the study of FROEHLICH & GAEBLER 4. Further, al- though oral hygiene was stressed to be an important factor, none of the above studies standardized the oral hygiene procedures undertaken by the patients, and were felt to be deficient in various other aspects.

In addition to their clinical study, BI- ENENGRAEBER et al? also investigated the periodonfium histologically in ani- mal experiments, however their results excluded serious permanent periodontal damage. A more recent clinical study by NGASSAPA et al. I5 performed on 6 beagles, confirmed the production of a

gingival inflammatory reaction which persisted throughout the splinting per- iod. In a further animal study by these same authors 16, investigating the histo- logical aspects, it was concluded that gingivitis developed as soon as 48 h after splinting, and this progressed into a de- finite periodontitis with resorption Of the alveolar bone after a splinting per- iod of 6 weeks. However it was empha- sized that no direct conclusions could be extrapolated to the human situation, and the importance of oral hygiene measures and the avoidance of trauma when splinting in humans was again stressed.

It was thus considered important in this investigation, to standardize the pa- tient's oral hygiene procedures in order to assess whether, in the presence of good oral hygiene and limited plaque, gingival inflammation and other changes recorded in the previous stud- ies, and the subsequent pathogenesis, would similarly occur.

The purpose of this study was there- fore to investigate the nature and degree of the marginal gingival changes occur- ring during interdental continuous loop-wire splinting and intermaxillary

fixation, and the duration and reversi- bility of these changes under the influ- ence of standardized oral hygiene pro- cedures. Interdental continuous loop- wire splinting was selected as the splin- ting method to be investigated as it was the method utilized in the MaxiUofacial Surgery Department of the University of Zurich.

Material and methods

32 patients requiring maxillofacial orthogna- thic surgery, with no history of any underly- ing gingival disease, were investigated. Two patients did not complete the study.

A minimum of 10 teeth (without orthodon- tic attachments), were required in a jaw for the inclusion of the patient in the study. Be- fore, but on the day of placement of the interdental continuous loop-wire splinting, patients were instructed in the oral hygiene procedures that were to be undertaken for the duration of the study, and assessed with respect to the following periodontal par- ameters: papillary bleeding index 13, perio- dontal pocket depth, plaque index ~7 and tooth mobility 2.

Each patient received the same brand of new toothbrush (Mentadent C ®) and the same monofluorophosphate-containing 7 brand of toothpaste (Mentadent C ®) as well

250 Lello and Lello

as a litre bottle of rinsing solution and a 10 ml measuring cup. A complete instruction sheet, detailing the oral hygiene regime to be followed was also given to each patient. Further verbal and visual instruction was given to underline the written instructions.

All patients were instructed in the "roll" toothbrushing technique 8, as it is easy to le- arn and is a relatively gentle technique 5, suit- able in the post-surgical phase. The patients were instructed to divide the two-minute brushing period ~4 into one minute for maxil- lary and one minute for mandibular teeth.

The 2 solutions used in the study were physiological saline and zinc fluoride/hexeti- dine, and the effects of the mouthrinses are to be reported later.

Patients were allocated alternatively to either group 1 or group 2. Grouping of the patients and allocation of the rinsing solution was unknown to the examiner.

Patients rinsed with 5 ml of the rinsing solution for 30 s, 4 times. Both toothbrushing and mouthrinsing were repeated three times daily18; during the period of, and until 4 weeks after removal of the interdental con- tinuous loop-wire splinting.

The oral hygiene procedures of each pa- tient were supervised once a day by the exam- iner, for the duration of their stay in hospital (average time 10 days), and further super- vised and encouraged at each subsequent weekly post-operative appointment to the Maxillofacial Clinic, as well as at each of the 5 examination times, when clinical evaluation of the changes in the marginal gingiva were made, using the parameters described pre- viously.

The 5 examination times were: on the day of, but before, placement of the interdental continuous loop-wire splinting; on the day of, but after, release of the intermaxillary fixation; on removal of the interdental splin- ting, and 2 and 4 weeks following removal of the splinting.

The examiner's ability in reproducing the above mentioned indices was determined in a pre-study trial to be a minimum of 90% accurate for each of the 4 parameters.

To evaluate the similarity of the 2 patient groups, Z 2 tests were performed for sex, and Mann-Whitney U-tests performed with re- spect to age, the time period of intermaxillary fixation and the duration of time that the interdental continuous loop-wire splinting was in place.

The data derived were subjected to two types of statistical analysis. Mean and stan- dard error of the mean were used as descrip- tive statistics.

Non-parametric statistical tests 3 were used to show firstly, what changes occured in the marginal gingiva of patients undergoing intermaxillary fixation and interdental con- tinuous loop-wire splinting, and secondly, to test the null hypothesis that these changes were the same in both groups, despite the use of two different mouthrinses. The tests used were the Wilcoxon matched pairs signed rank test for differences within groups and the

Mann-Whitney U-test for the 2 independent samples.

Two-sided testing was employed throughout.

Results

30 patients completed the study, 16 comprising group 1 (physiological sa- line mouthrinse) and 14 group 2 (zinc fluoride/hexetidine mouthrinse). There was no statistically significant difference between the 2 groups with respect to the following factors: age, sex, socio- economic distribution, average time period of intermaxillary fixation and length of time splinting was in place.

The average period of intermaxillary fixation was 5.87 weeks in group 1 pa- tients (range between 4 and 10 weeks) and 5.57 weeks in group 2 patients (range between 4 and 7 weeks). The av- erage period that the interdental con- t inuous loop-wire splinting was in place was 8.19 weeks in group 1 patients (range between 5 and 12 weeks) and 8.78 weeks in group 2 patients (range between 6 and 12 weeks).

Papillary bleeding index, p laque in- dex and tooth mobil i ty were studied in terms of total (buccal plus lingual values), pocket depth for interproximal values; and with the exception o f too th mobili ty all the parameters were also studied in terms of buccal and lingual values.

365 teeth from 27 jaws in 16 patients in group 1, were measured for each par- ameter, at each observation time, to give a total of 14,600 observations (8 values being recorded per tooth). 274 teeth f rom 21 jaws in 14 patients in group 2,

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Fig. 2. Mean interproximal periodontal pocket depth recorded for group 1 and group 2 patients at the 5 observation times.

were measured for each parameter, at each observation time, to give a total of 10,960 observations.

The groups did not differ significant- ly at baseline for any of the parameters (total, buccal and lingual papillary bleeding index, interproximal, buccal and lingual per iodontal pocket depth, total, buccal and lingual plaque index and tooth mobility), when compared with respect to pre-operative obser- vations, employing the Mann-Whi tney U-test.

Figs. 1 to 4 are graphical represen- tations of the means recorded for group 1 and group 2 patients, for total papil- lary bleeding index, interproximal periodontal pocket depth, total plaque

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Fig. 1. Mean total papillary bleeding index recorded for group 1 and group 2 patients at the 5 observation times.

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Fig. 3. Mean total plaque index recorded for group 1 and group 2 patients at the 5 obser- vation times.

E f f e c t o f I M F on g ingiva 251

index and tooth mobility, at the five observation times.

The results show that the levels of gingival inflammation, periodontal pocket depth and tooth mobility in- creased to a maximum during the period that the loop-wire splinting was in place, and then decreased to approximately pre-operative levels, within 2 weeks af- ter removal of the loop-wire splint. Plaque index levels reached a maximum during the period of intermaxillary fix- ation and then decreased immediately after release of the fixation, despite the continued presence of the splinting.

Table 1 shows the results of the Man- n-Whitney U-test comparing group 1 and group 2 for each parameter at each observation period. The increase in total plaque index levels was significant- ly less in group 2 (zinc fluoride/hexeti- dine mouthrinse), than in group 1 (par- ameter PI, observation period 1-2). Group 2 also showed a significantly greater fall in plaque levels at the time of splint removal, and two and four weeks later (Table 1, parameter PI, obser- vation periods 1-3, 14 , and 1-5).

Discussion

The results of this study showed that all indices increased with time during the

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Observation Times Fig. 4. Mean tooth mobility recorded for group 1 and group 2 patients at the 5 obser- vation times.

Key to Figs. 1-4 Observation times." 1 = pre-operative. 2 = immediately follow- ing intermaxillary fixation release. 3 = immediately following wire splint removal 4 = 2 weeks following wire splint removal. 5 = 4 weeks following wire splint removal.

Table 1. Results of Mann-Whitney U-test comparing group l and group 2 for each parameter at each observation period.

Observation periods p-values

Parameter 1-2 1-3 l ~ 1-5 2-3 3-4 4-5

PBt Total 0.2890 0 .1142 0 .4927 0 . 3 6 0 4 0 .6179 ~ 0.9834 PPD Inter. 0.6775 0 .0558 0 .7082 0 .9006 0 .1239 ~ 0.5588 PITotal ~ ~ ~ ~ 0 .2797 0 .3603 0.9004 TM Total 0.2529 0 .8516 0 .8678 0 .3598 0 .1094 0 .8514 0.2354

Key to Table 1: Observation times: 1 = pre-operative. 2 = intermaxillary fixation release. 3 = wire splint removal. 4 = 2 weeks following wire splint removal. 5 = 4 weeks following wire splint removal.

Parameters: PBI = papillary bleeding index. PPD = periodontal pocket depth. PI = plaque index. TM = tooth mobility. Inter = interproximal. Boxed p-values are significant at the 5% level of significance.

period of splinting, except for plaque levels which reached a maximum at the time of intermaxillary fixation release. All monitored parameters had totally reversed within two weeks after wire splint removal; apart from tooth mo- bility, which did not quite re-attain the levels recorded pre-operatively, the dif- ference however being statistically insig- nificant.

These findings concur with those of BIENENGRAEBER et a l ) , and LENTRODT et a l : °, who also recorded post-operative tooth mobility to be in excess of that found pre-operatively.

H.KRLE & KREKELER 6 and FROEHL- ICH ~ GAEBLER 4 reported total reversi- bility of similar adverse marginal gin- gival changes, as well as tooth mobility, occurring as a result of intermaxillary fixation and interdental splinting.

It is interesting to note that despite significant falls in the plaque index levels after intermaxillary fixation re- lease, the gingival inflammation levels only significantly decreased after re- moval of the loop-wire splinting.

Thus apart from the splint encourag- ing plaque accumulation, which in turn provokes gingival inflammation 9, H, 12, 15. ~6, 19, the splint also has a direct trau- matic effect. This is in accordance with the animal model work of NGASSAPA et a l ) 5 who also found that the degree of inflammation did not depend only on the amount of plaque. They suggested that application of the wire ligatures may cause trauma to the gingiva and secondly that the constant presence of the splints prevents healing and acts as a constant irritating factor, causing in- flammation. The actual physical and it-

ritant effect of the wire itself may there- fore be of importance, as well as the mechanical effect in the form of hori- zontal and vertical forces exerted on the teeth during interdental loop-wire splin- ting and intermaxillary fixation.

It is interesting to note that the pre- operative tooth mobility levels recorded were not completely re-attained for either group, by four weeks after wire splint removal, although the slight in- crease at this time over the pre-operative levels was not significant. This could possib!y reflect a widening or loosening of the periodontal ligament by forces produced as a result of the wire being tightly twisted about and between the teeth and between the jaws, causing areas of tension and compression within the periodontium, similar to forces gen- erated during orthodontic treatment.

Another possible cause of the slow recovery of the tooth mobility values to their original pre-operative levels, may be that the surgically altered occlusion resulted in occlusal trauma and hence increased tooth mobility.

Alternatively, the increased levels of gingival inflammation recorded during the period of loop-wire splint retention, may have led to loss of the connective tissue attachment resulting in a slight increase in tooth mobility, post-operati- vely. The question as to whether or not the presence of splinting initiates bone loss is hard to elucidate. Radiological findings in the animal model have sug- gested that alveolar bone resorption does take place under these conditions 15. In the clinical part of the study of NGAS- SAI'A et al. 25, gingivitis occurred after 48 h, 3 and 6 weeks. This is not in

252 Lello and Lello

contradiction to the clinical findings of this investigation, and those of BIENEN- GRAEBER et al. 2, LENTRODT el aD °, FROEHLICH & GAEBLER 4, and H~RLE & KREKEER 6. However histological evalu- ation of the periodontium, in a further animal study by the same authors ~6, revealed that what was clinically scored as gingivitis after a splinting period of 6 weeks, had developed into periodontitis with resorption of the alveolar bone. As the authors stress, however, direct conclusions cannot be drawn from these animal studies and extrapolated in full to humans, as splinting is less t raumatic than in dogs and normally oral hygiene measures, including the use of a mouth- rinse especially during the period of intermaxillary fixation, is carried out by splinted patients.

Conclusions

From this study, it can be concluded that the changes occurring in the mar- ginal gingiva in patients with interdental continuous loop-wire splinting and intermaxillary fixation, under the stan- dardized oral hygiene condit ions perti- nent to this investigation, were those of an inf lammatory gingival hyperplasia, namely; increased bleeding upon prob- ing, increased periodontal pocket depth, increased plaque levels and increased tooth mobility.

Thus, despite good oral hygiene and limited plaque accumulation, adverse gingival changes did occur during the period of splinting. The degree of in- f lammation did no t therefore seem to be dependent only on the amoun t of plaque accumulation.

All changes occurring in the marginal gingiva had totally reversed two weeks following wire splint removal, apart from tooth mobility, which did not quite

re-attain the levels recorded preoperati- vely (difference insignificant) by 4 weeks following loop-wire splint removal, the end of the study period.

Acknowledgements - Grateful appreciation is extended to Professor H. R. Muehlemann (formerly Head Department of Cariology, Periodontology and Preventive Dentistry) and Professor H. L. Obwegeser (formerly Head Department of Maxillofacial Surgery) of Dental Hospital, University of Zfirich for the opportunity and permission to undertake this study. The authors would also like to thank Dr. Piet Becker of the Medical Re- search Council, South Africa for his assist- ance with the statistical evaluation of the data.

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Address: Glenn E. Lello Department of Maxillofacial Surgery Medical University of South Africa PO.Box D22 Medunsa 0204 RSA