|Year : 2021 | Volume
| Issue : 5 | Page : 642-645
Assessment of separation impact and perception of discomfort on various orthodontic separators: A comparative clinical study
Shaheen Vilayil Shamsuddin1, Sami Alshahrani2, George Sam3, Sumaya Yousuf Jeri4, Sriram Kirti Ranjan Bhuyan5, Deviprasad Mahanta6
1 Department of Pedodontics and Orthodontic Science, Division of Orthodontics, College of Dentistry, King Khalid University, Abha, Kingdom of Saudi Arabia
2 Department of Pedodontics and Orthodontic Science, College of Dentistry, King Khalid University, Abha, Kingdom of Saudi Arabia
3 Department of Preventive Dental Sciences, College of Dentistry, Prince Sattam Bin Abdul Aziz University, Alkharj, Kingdom of Saudi Arabia
4 Department of Orthodontics and Dentofacial Orthopedics, ITS-CDSR, Ghaziabad, Uttar Pradesh, India
5 Department of Orthodontics and Dentofacial Orthopedics, Hi Tech Dental College and Hospital, Bhubaneswar, Odisha, India
6 Department of Orthodontics and Dentofacial Orthopedics, Daswani Dental College, Kota, Rajasthan, India
|Date of Submission||24-Nov-2020|
|Date of Decision||14-Dec-2020|
|Date of Acceptance||15-Dec-2020|
|Date of Web Publication||05-Jun-2021|
Shaheen Vilayil Shamsuddin
Department of Pedodontics and Orthodontic Science, Division of Orthodontics, College of Dentistry, King Khalid University, Abha
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: This study aimed to evaluate the extent of separation and perception of pain and discomfort with the use of three different orthodontic separators. Materials and Methods: A total of sixty participants (26 males and 34 females) aged between 18 and 25 years were enrolled in this study. Participants were divided into three experimental groups: Group I: elastomeric separator, Group II: Dumbbell separators, and Group III: Kesling Separators. All the participants were asked to revisit 24 h after separator placement, and the effect of separation obtained by three different types of separators was measured. The space generated between premolars and molars was recorded separately on days 1, 3, and 7. The visual analog scales were used to assess pain. Results: The mean age in Dumbbell separators group was slightly more (23.32 ± 2.28) compared to Kesling Separators and Elastomeric separator group (22.46 ± 1.20 and 21.10 ± 1.19 years, respectively). The extent of separation on days 1, 3, and 7 was more in Group II study participants (0.20 ± 0.02, 0.32 ± 0.05, and 0.48 ± 0.07 mm, respectively) compared to other groups. A statistically significant (P = 0.022) difference was noted on day 7 in terms of no pain being recorded more in Group II participants, followed next by Groups III and I. Conclusion: This study concluded that the Dumbbell separators produce acceptable separation with negligible pain and discomfort when compared to elastomeric separators and Kesling separators.
Keywords: Discomfort, leaf gauge, orthodontic separators, visual analogue scale
|How to cite this article:|
Shamsuddin SV, Alshahrani S, Sam G, Jeri SY, Ranjan Bhuyan SK, Mahanta D. Assessment of separation impact and perception of discomfort on various orthodontic separators: A comparative clinical study. J Pharm Bioall Sci 2021;13, Suppl S1:642-5
|How to cite this URL:|
Shamsuddin SV, Alshahrani S, Sam G, Jeri SY, Ranjan Bhuyan SK, Mahanta D. Assessment of separation impact and perception of discomfort on various orthodontic separators: A comparative clinical study. J Pharm Bioall Sci [serial online] 2021 [cited 2022 Dec 1];13, Suppl S1:642-5. Available from: https://www.jpbsonline.org/text.asp?2021/13/5/642/317673
| Introduction|| |
The interspace between adjacent teeth is created with the use of orthodontic separators, which are metal appliances or rubber bands. Before the application of molar bands at the second orthodontic appointment, separators are placed in the region of molars. Generally, these are added 1 week before braces application, but then they can also be applied later. Spacers can either be rubber bands which are circular with a diameter of about 1 cm that are placed between mandibular and maxillary molars or may be small spring clips made of metal (spring separators) that separate the molars. In the year 1907, Angles first explained the importance of separating the teeth for band placement with the use of brass wires.
Ideally, separators should provide acceptable and quick separation without causing pain or discomfort to the patient. Separators should also get cleaned easily and stay in place until the placement of bands. Separators are generally placed up to 1 week. However, separators can certainly lead to discomfort throughout the week because of the occlusal interferences.,
The elastic separator, which is dumbbell shaped is a type of separator which looks like a wide rubber band with rolled and thick edges. These separators help in achieving rapid teeth separation. It is suggested that they should be placed ½ h before fitting of band. The polyurethane elastomeric separators are beneficial for separation. To generate spaces between two teeth which are next to each other, rings of different thickness are positioned interproximal in the contact point for procedure of banding. A 0.016” round wire is used to make Kesling metallic ring separator. It consists of an occlusal arm, retentive arm, gingival arm, and coil/helix. It is held with pliers and then positioned so that separator's coil part lies buccally. This way banding is achieved in about 2 days. Thus, this study aimed to evaluate the efficiency of separation and analysis of discomfort caused by elastomeric separator, Kesling separators, and dumbbell orthodontic separators.
| Materials and Methods|| |
A total of sixty participants (26 males and 34 females) aged 18–25 years were enrolled in the study. All the included participants provided an informed consent. The enrolled participants had not received orthodontic treatment in the past, had no restorations or caries on the proximal surfaces of permanent first and second molars and second premolars, and had no sign of gingival or periodontal problems, no extractions in the past, and had good interproximal tooth contacts at the location of placement of separator.
The exclusion criteria consist of the presence of spacing in posterior part (open contacts), partially erupted second molars, patients unwilling for orthodontic treatment, patients with periodontal compromise, congenitally missing premolars, and molars.
Participants (20 in each group) were randomly divided into three experimental groups,
- Group I: Elastomeric separator
- Group II: Dumb-bell separators
- Group III: Kesling separators.
Before separator placement, oral prophylaxis was performed for all participants. A plier was used to place the commercially available Dumbbell separators and elastomeric separators. The same operator made the Kesling separators. Kesling separator consisted of gingival arm, occlusal arm, and a helix and was made of two separate springs and 0.016-in Australian wire, inserted into distal and mesial contacts of the first molar.
Measuring the separating effect
All the participants had to revisit after 1 day, and the effect of separation brought about by three different types of separators was measured. The space created between premolars and molars was noted distinctly (i.e., after 1st day, 3rd day, and 7th day). Simultaneously, the types and number of lost separators were also noted. A curved probe was used to remove the dumbbell and elastomeric separators, and light wire pliers were used to remove Kesling separators. The premolar and molar areas were dried by air spray. A leaf gauge with a sensitivity of 5/100 mm was used to measure the amount of separation between second premolar and molars intraorally and recorded on each day. After the separated space was measured, the same separators were positioned in the same site again. Abovementioned procedure was repeated on the scheduled days when participants returned to the department. The participants were trained not to have any food with hard consistency until separators were removed.
Assessment of pain using discomfort index card
There were six different visual analog scales (VAS) on a discomfort index card, 10 cm in length each, the ends of which are recorded to denote the restrictions of the pain experience; one end is thus defined with suitable verbal signifiers such as “no pain” and other end as “worst pain.” The VAS was counted by measuring in millimeters from the left side of the line to the vertical mark.
A SPSS software of version 20.0 (SPSS, Inc., Chicago, IL, USA) was used to analyze the collected data. Fisher's exact test was used to analyze quantitative data. The comparisons between efficacy of different orthodontic separators was measured using one-way analysis of variance. A P < 0.05 was considered statistically significant.
| Results|| |
The mean age comparison among the three study groups is as shown in [Table 1]. The participants enrolled in this study were 18–25 years. The mean age in Dumbbell separators group was slightly more (23.32 ± 2.28) compared to Kesling separators and elastomeric separator group (22.46 ± 1.20 and 21.10 ± 1.19 years, respectively). Nevertheless, the mean ages of all the three study groups did not show any statistically significant difference.
The amount of separation on 1st, 3rd, and 7th day was slightly more in Group II study participants (0.20 ± 0.02, 0.32 ± 0.05, and 0.48 ± 0.07 mm, respectively) followed next by Group III (0.17 ± 0.05, 0.24 ± 0.03, and 0.33 ± 0.01 mm, respectively) and Group I (0.11 ± 0.04, 0.19 ± 0.01, and 0.28 ± 0.04 mm, respectively). On day 3 and 7, a statistically significant difference was observed between the study groups and is as shown in [Table 2].
There was an increased reduction in the number of study participants who experienced worst pain in Group II as compared with Group I and Group III on day 3. The participants with no pain were more in Group II followed by Group III and Group I on day 7, and this was statistically significant (P = 0.022) [Table 3].
|Table 3: Assessment of pain (visual analog scale) among different study groups|
Click here to view
| Discussion|| |
Separation is a procedure in orthodontics whose objective is to slightly loosen the two adjacent teeth interproximally by wedging or forcing the teeth apart so as to make space for placement of orthodontic bands. The separators should preferably be placed easily in any contact, create minimal discomfort at first and through the separation period, and create sufficient space for banding, thus making the band fit to the tooth easily. Not just for banding, the teeth separation with separators is needed to part the deciduous teeth so that partially impacted permanent teeth could erupt easily, to part the teeth as a section of space gaining procedure and also to restore a tooth which is not positioned correctly in the arch. The separation of teeth brought about by orthodontic separators is based on wedge principle.,
Several studies have measured the response of pain in patients following placement of separators who undergo orthodontic treatment. Ngan et al. reported that discomfort and pain commenced after 4 h and amplified over the next 24 h after separator placement. As per Bondemark et al., pain associated with separators was worst on day 2, which waned practically completely by day 5. In our study, participants experienced worst pain on day 1, which steadily reduced by day 7.
In the present study, intensity of pain/discomfort was measured with the help of VAS as it is one of the most frequently used tools for the assessment of pain and can be scored easily. The VAS is also a reliable and valid system of gauging isolated pain, being able to distinguish between minor changes in the intensity of pain. The VAS has also been found to be an important tool when patients have to distinguish between discomfort/pain in the anterior and posterior teeth.
In this study, Dumbbell separators group demonstrated more separation than elastomeric separators and Kesling separator group. These findings are in accordance with the results obtained by Shalini et al. and Malagan et al., who found that this parathion generated by Dumbbell separators to be more and fast.
Those Dumbbell separators which are similar to Maxian elastic separator were used in this study. The dumbbell separators produced constantly greater extent of separation on days 1, 3, and 7, and the separation effect was greater than all the separators used in Hoffmann study on days 1 and 3. A statistically significant difference was noted in the effect of separation brought about by Dumbbell separators than elastomeric separator and Kesling separator on days 3 and 7.
Sandhu et al. showed the highest extent of separation (0.412 mm of mean separation) in elastomeric separators group. This extent of separation is lesser than that obtained in our study. Several trials have measured the extent of separation over 7 days. In contrast to most of the other trials which place the separator 5–7 days prior band placement, Davidovitch et al. suggest that placement of separators could be done just 1 day before the placement of band.
The drawbacks of this study are that there exists an interpatient variation in morphology of contact point, tightness of contact, and threshold of pain. Therefore, the findings of the present study and the efficiency of any distinct separator pertaining to separation and ensuing pain may not be relevant to each patient. More trials which evaluate the effects of separation of various kinds of separators could be undertaken after considering factors such as diet and periodontal condition for an unbiased assessment.
| Conclusion|| |
This study concluded that the Dumbbell separators produce acceptable separation with negligible pain and discomfort when compared to elastomeric separators and Kesling separators.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shalini S, Verma G, Kedia NB. Separation efficacy of four different orthodontic separators. Int J Med Health Res 2020;6:7-9.
Sharma SK, Barthunia N, Pandit A, Singh A. Perception of discomfort and amount of separation from two types of orthodontic separators: A prospective study. Int J Oral Health Med Res 2017;4:35-38.
Bergius M, Berggren U, Kiliaridis S. Experience of pain during an orthodontic procedure. Eur J Oral Sci 2002;110:92-8.
Malagan MA, Biswas PP, Muddaiah S, Reddy R, Shetty BK, Preetham J, et al
. Comparison between efficacy of four different types of orthodontic separators. J Clin Diagn Res 2014;8:ZC41-4.
Tarvade S. Separators in orthodontics: A review. Orthod J Nepal 2016;6:37-40.
Cureton SL, Bice RW. Comparison of three types of separators in adult patients. J Clin Orthod 1997;31:172-7.
Proffit RW, Fields WH, Sarver MD. Contemporary Orthodontics. 4th
ed. St. Louis: Mosby Company; 2007. 412-13.
Kumari L, Nayan K. A comparative study of separation effect of four different types of seperators. Indian J Orthod Dentofacial Res 2019;5:130-2.
Ngan P, Kess B, Wilson S. Perception of discomfort by patients undergoing orthodontic treatment. Am J Orthod Dentofacial Orthop 1989;96:47-53.
Bondemark L, Fredriksson K, Ilros S. Separation effect and perception of pain and discomfort from two types of orthodontic separators. World J Orthod 2004;5:172-6.
Davidovitch M, Papanicolaou S, Vardimon AD, Brosh T. Duration of elastomeric separation and effect on interproximal contact point characteristics. Am J Orthod Dentofacial Orthop 2008;133:414-22.
Hoffmann WE. A study of four types of separators. Am J Orthod Dentofacial Orthop. 1972;62:67-73.
Sandhu GP, Kanase A, Naik CR, Pupneja P, Sudan S. Seperation effect and perception of pain & discomfort from 3 types of orthodontic sepertors. J Indian Orthod Soc 2013;47:6-9. [Full text]
[Table 1], [Table 2], [Table 3]