Dental trauma simulation training using four splinting models: A cross sectional study

Abstract Background/Aim Opportunities for dental students to obtain clinical experience in the management of traumatic dental injuries are scarce, and most dentists encounter difficulties with their first trauma patients after graduation. The aim of this study was to question students on the ease of handling of four types of flexible splints, with two common methods of bonding to the tooth. Material and methods A total of 161 fourth year dental students completed a simulated treatment of an avulsed tooth using orthodontic wire, Twistflex wire, nylon fishing line, and Powermesh as splints. The bonding materials were composite resin (Spectra ST LV) or glass ionomer cement (GC Fuji LC Ortho). The students then answered 16 questions on a 5‐point Likert scale, or with an open answer field. Results Most students agreed (48.8%) or strongly agreed (31.3%) that the simulated trauma exercise assisted their learning. There was strong agreement (68.8%) and agreement (28.7%) that the simulation added value to their dental training compared to didactic training only. Similarly, 52.3% of participants strongly agreed and 40% agreed that they felt engaged in the learning activity. Only 53.8% of the participants agreed and 7.5% strongly agreed that the simulation felt realistic. Most students (56.2%) found a Powermesh/composite splint was the easiest to place, and nylon fishing line/GC Fuji LC Ortho splints was the least difficult to remove (35%). Conclusion Wire‐free splints with composite bonding were judged as the easiest to place by students, while glass ionomer cement was the easiest to remove.

dental practitioners followed the correct splinting strategy or duration of splinting. 7,8 Another survey showed that a considerable number of dentists were unsure whether to replant primary teeth or to use a rigid splint after tooth avulsion, 9 and they apply treatment modalities that do not follow the contemporary standards of practice.
These findings highlight the need to improve the practical exposure of dental students to trauma situations in pre-clinical and clinical settings. 1 The University of Adelaide in Australia provides animal cadaver models for a realistic scenario and has incorporated the use of a sheep mandible for replantation and splinting training. 1 Other institutions teach through simulated exercises involving 3D printed teeth. 10,11 In oral and maxillofacial surgery and dental education, 3D printed models are successfully used to demonstrate the effects of impact and to create new fractures. 12 To avoid any damage to the enamel during removal after the splinting period, some authors recommend glass-ionomer cement (GIC), such as GC Fuji Ortho LC (GC Australasia Dental Pty Ltd.), as an alternative to composite resin. 1 Both GIC and composite resin are adherent materials that are easy to apply but composite resin is more time consuming and often complex to remove. GIC may be removed with hand instruments and its removal may cause less damage to the enamel of both the injured and supporting teeth. 13 Splints may consist of flexible metal stainless steel wire, nickel titanium orthodontic wire, fishing line, fiber, titanium mesh, or composite resin only that is bonded to the injured and adjacent teeth with composite resin. 13 Titanium Trauma Splints (Medartis AG), nylon splints, Ribbond (Ribbond Inc.), Kevlar, and fiberglass splints (EverStick, Stick Tech Ltd.) have been used with some resin materials proving too rigid after bonding. 14 Other authors have described using more flexible materials such as Twistflex wire (3 M Unitek) and Power chain (Yancheng TC Medical Equipment Co., Ltd.). 15 The Twistflex wire is constructed as an intertwined wire rope to form a single strand and is regularly used in orthodontics, for example, as a retainer and when maximum flexibility is desired. 16 Power chain consists of flexible rubber loops and is used in orthodontics to exert a pulling force. It is inexpensive and similar in elasticity to nylon fishing line, while offering the advantage of ease of application, with chain openings that contain the composite material well, similar to the Titanium Trauma Splint. 15 The most commonly recommended types of splints are orthodontic wire and fishing line, which are easier to place due to their ease of accessibility and low cost. 3,11 Procedural complexity influences the likelihood of a technique or material being used for the splinting method, and it is well known that the materials that are simple to use and methods that are simple to interpret are more likely to be adopted. 17 A recent study by Zafar et al. 11 used a 3D printed tooth model in a simulated avulsion scenario in a standard Typodont jaw model to evaluate the ease of application and removal of two types of splints (orthodontic wire with a composite resin splint and GIC with nylon fishing line). Two thirds of the participating students either did not favor or were neutral in their opinion toward splinting with a nylon fishing line/GC Fuji LC Ortho splint compared to a wire/composite resin splint. While nylon fishing line was judged as easier to use in other investigations, students in that study did not prefer it over orthodontic wire. However, more than half of the students noted that GIC was less cumbersome to remove than composite. In addition to easier handling, the nylon fishing line/GC Fuji LC Ortho splint was less damaging to the enamel during the removal process.
The aim of this study was to investigate the ease of procedural handling for student novices of four types of flexible splints, while using two common methods of bonding to the tooth. Participating fourth-year students were invited to complete an anonymous questionnaire on the usefulness and realism of their experiences during the exercise. The null hypotheses were that there is (1) no statistically significant difference in the type and bonding method of the examined splints, and (2) the simulated trauma exercise was a valuable learning experience in trauma education for undergraduate dental students.

| MATERIAL AND ME THODS
Ethical approval for this study was obtained by the Institutional Human Research Ethics Committee (Approval number: 2019002969).
The design was a cross-sectional study that followed the STROBE statement. The study involved completion of an anonymous questionnaire by 161 fourth-year dental students enrolled in a Bachelor of Dental Science (Honours) degree at The University of Queensland, Australia. All fourth-year students enrolled in DENT4070 (Advanced Dental Disciplines A) in Semester 1 (2021 and 2022) were invited to participate in the study and to answer questions on their experiences during simulated trauma splinting. The participant consent and information sheet, along with the questionnaire were distributed to students who agreed to participate. The students received a 60-minute lecture on splinting prior to the simulation activity, which was preceded by a lecture series on dental trauma in their previous (third) year of studies (9 h in total). The simulation training took place in a 2-h session, followed by a post-training questionnaire.
Materials used for the splinting simulation exercise included a natural human incisor to simulate an avulsion injury, which was fitted in the Typodont model as described previously. 11  and comparisons were made. Specific data analysis tests performed included descriptive statistics, such as frequencies and percentages.  (Figure 3). When asked what difficulties they encountered in conducting the trauma simulation exercise, the participants' responses included: "manipulating GIC and holding wire in place," "taking off composite," and "the application and setting time for Fuji Ortho was not ideal."

| DISCUSS ION
Simulated trauma splinting exercises are an important part of preclinical training for undergraduate dental students. Often dental students lack clinical hands-on exposure to trauma management in patients before graduation. 8 Later in their career, dentists perceive barriers to effectively treating dental trauma patients, and aside from time constraints and uncooperative patients, the lack of knowledge and skills are cited as obstacles. 9,18 The results of this study showed that the first null hypothesis that no statistically significant difference in type and bonding method of the examined splints must be rejected, as wire-free splints were easier to place than wire splints and composite resin was more difficult to remove than GIC. Part 2 of the null hypothesis was confirmed in that the simulated trauma exercise added a valuable learning experience in trauma education for undergraduate dental students.
Clinician competence is being scrutinized, with demands made of proof of continuing education, and such inspection affects both undergraduate dental student teaching as well as upskilling of dental professionals. 19 Effective pre-clinical training may help counteract the reality that the information in published trauma guidelines may not reach every dental clinician. 22 Literature on dental student trauma exercises supports both GIC and composite resin as satisfactory bonding materials for splints. 11 Nevertheless, it is unclear which type of splint is preferred by learners. The aim of this study was to examine the ease of handling of different splint types for student novices in simulated trauma exercise, while employing two accepted methods of bonding in an avulsed tooth scenario. An anonymous survey completed by the students brought answers on effectiveness and practicality of their experiences during the exercise.
In the learning task investigated in this study, an avulsed tooth scenario using a natural human maxillary incisor with blood (red paint) was employed. The dental students replanted the incisor tooth into a Typodont socket to simulate a recent avulsion injury.
This model has opened new avenues for training specific dental treatments that are difficult to replicate in a pre-clinical setting. 10 The materials used were orthodontic wire and Twistflex wire as flexible metal splints and Powerchain and nylon fishing line as nonmetal splints. The two types of wire are promoted as suitable in the trauma literature. Composite resin and wire splints may be the most commonly used flexible splints in clinical practice. 13 The wire diameter should be no greater than 0.016 inch or 0.4 mm, which was the case for both types of wire selected. 3 Powerchain and nylon fishing line are non-metal alternatives to wires and are comparable in flexibility. 15 Powerchain is a flexible, aesthetic, low-cost alternative to nylon fishing line that is used as in wire-free intermaxillary fixation in fractures of the jaws. 23 Powerchain was integrated into the study for its reported ease of adaptation, with negligible problems during application. 15 In this study, one wire and one wire-free splint each was fixed with GIC or composite resin. The glass ionomer selected is com-  24 Overall, a majority of 96.2% of students who completed the trauma splinting exercise agreed or strongly agreed that the simulation training should become mandatory in the dental curriculum. Considering that the F I G U R E 3 Participants rating of the ease of placement and removal of the various splints likelihood of dental students achieving hands on exposure to real life trauma remains rare, and immediate emergency management of a stressful dental injury by experienced clinicians is preferred, knowledge of new dentists in dental trauma treatment will continue to be limited. 25 In a questionnaire regarding dental trauma treatment strategies, two-thirds of the queried dentists felt unprepared in treating an avulsed tooth. 26 Apart from attending continuing education courses, simulated laboratory scenarios are a valuable adjunct in practicing components of the treatment, such as the repositioning of an avulsed tooth and bonding a correctly designed splint.
Treatment of traumatic dental injuries in permanent teeth expediently can strongly impact the tooth's prognosis. 2

| CON CLUS IONS
Adding simulated trauma exercises to the dental curriculum enhanced education for participating undergraduate students. It provided valuable learning benefits while stimulating interest to a degree that most students felt the training should become mandatory. Of the splints used, wire-free Powerchain and nylon fishing line were easier to apply compared to orthodontic wire or Twistflex wire, while glass ionomer cement was easier to remove than composite resin.

AUTH O R CO NTR I B UTI O N S
Sobia Zafar and Christine Peters: conceptualisation, Methodology, Writing, Editing, Review, Project Adminstration.

ACK N OWLED G M ENTS
The authors acknowledge the students who participated in the sur-

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.