Dental Splints and Tooth Protection in Transoral Surgery

Published Feb 28, 2026

Updated Mar 9, 2026

Transoral surgery represents one of the purest forms of minimally invasive surgery. By using the mouth as a single access port, we avoid external incisions, reduce visible scarring, and often accelerate recovery. But when the oral cavity becomes the surgical corridor, the structures that allow access (lips, teeth, gingiva, and tongue) must be carefully safeguarded.

Lip protection is the first step. Adequate lubrication before retractor placement is essential to prevent friction injuries. During lengthy procedures, lips are vulnerable to compression, thermal injury from energy devices, pinching between instruments, or even small unnoticed lacerations. These complications are avoidable, but only if we actively anticipate them. Regular intraoperative inspection and careful positioning are simple measures that significantly reduce risk.

Dental protection is even more critical. Surgery, of course, is technically easier in edentulous patients. Exposure is wider, retractor placement is more flexible, and there is no risk of dental fracture. Even in these cases, however, the gingiva must be protected from pressure and ischemic injury. However, in the vast majority of patients teeth are present, and they introduce a significant mechanical vulnerability.

Transoral retractors generate sustained and sometimes considerable forces. Without adequate load distribution, enamel erosion, tooth fracture, tooth mobility, or periodontal injury may occur. Dental injury is not a minor complication; it is painful, preventable, and frequently associated with medicolegal consequences.

Some retractor systems partially address this issue. The classical Crowe-Davis mouth gag incorporates a plastic interface over the dental arch support, reducing direct metal contact with enamel. Some of the more modern systems, such as LARS 2.0, go further by providing interchangeable upper dental supports with soft protective components designed to improve pressure distribution. These developments are welcome advances. Nevertheless, in many procedures, additional dental splints remain necessary.

Dental splints may be reusable, often metallic and part of institutional inventory, although today disposable plastic devices are far more common. Among these, it is important to distinguish between soft and semi-rigid splints, as their indications differ substantially.

Soft splints were originally designed to prevent enamel damage during orotracheal intubation. They are excellent at cushioning contact and preventing superficial abrasion. However, they are not engineered to tolerate sustained pressure from a mouth gag placed on the upper dental arch. Under these conditions, they may deform and fail to distribute load adequately. In our practice, soft splints are routinely used on the lower dental arch, not primarily to protect the teeth, but to protect the tongue: when the mouth gag blade depresses the tongue, its ventral surface may be compressed against the lower incisors. Depending on positioning and duration, this can lead to ischemic injury or laceration. A soft splint in the lower arch creates a protective interface that significantly reduces this risk.

For upper arch protection during transoral surgery, semi-rigid splints are more appropriate. These devices are designed to distribute pressure evenly across multiple teeth. Proper distribution of mechanical forces is the key to avoiding fractures, enamel damage, or periodontal trauma.

Interestingly, if we step outside the operating room and look at sports equipment, we find remarkably effective solutions. Thermoformable mouthguards, such as boxing protectors widely available from retailers, are inexpensive, adaptable, and easily customized by heat molding. Similarly, thermoformable DAMs offer individualized fitting with excellent load distribution. From a purely mechanical perspective, these devices are often ideal. They are comfortable, customizable, and dramatically cheaper than many medical-grade splints.

The problem, however, is regulatory. These sports mouthguards are not certified medical devices. Under current European medical device regulations, their use in the operating room is not permissible. This creates a paradox: technically effective, low-cost protective solutions exist, but they cannot be legally employed in surgical settings.

At the same time, new European regulations have significantly affected the distribution and cost of certified dental splints. Availability has become irregular in some regions, and prices have increased dramatically. In addition, many devices are not supplied sterile, creating further logistical challenges for operating room workflows.

Despite these obstacles, the principle remains unchanged: dental protection is an essential component of patient safety in transoral surgery. Minimally invasive surgery does not mean minimal responsibility. The mechanical forces generated during exposure are real, predictable, and preventable sources of injury.

Protecting lips, teeth, gingiva, and tongue is not an accessory step in transoral surgery—it is part of the technique itself. Patient safety must always come first.

J Granell

PD. The French option. Endohelp. Sterile. Dealer in Spain: Amevisa (see bellow). Cost (mar 2026): 4,35€.

Dealers