ABSTRACT
Background/Aim
Healing of the periodontal ligament (PDL) and pulp vitality is critical for successful management of traumatic dental injuries (TDI), which could be compromised due to adverse stress distributions caused by occlusal forces. As a common treatment to stabilize traumatized teeth, the impact of fiber splinting locations on the masticatory stress distribution in the PDL and dental pulp has not reached a consensus. The biomechanical effects of incisal and cervical fiber splinting on stress distribution in traumatized teeth were investigated in this study.
Material and Methods
A cone‐beam computed tomography (CBCT) scan of the patient's maxilla was processed using Mimics 22.0, Geomagic Wrap 2017, and SolidWorks 2018 to rebuild three‐dimensional finite element models. The fiber splints were modeled by bonding strips near the labial surfaces at the incisal and cervical regions of the anterior teeth. Three locations on the palatal surface: the incisal ridge, incisal third, and cervical third regions were loaded with force to simulate mastication. The ultimate stress distributions were analyzed by ANSYS 2021 R1.
Results
Comparative analysis of stress distribution caused by simulated occlusal forces revealed that incisal splinting consistently reduced stress concentration more effectively than cervical splinting on the PDL and apical foramen of traumatized teeth. The mean stress values in the PDL of traumatized teeth were 183,972 Pa (without splinting), 132,216 Pa (cervical splinting), and 75,294 Pa (incisal splinting). Compared to the CS group, the mean value of the four traumatized incisors' PDL in the IC group was decreased by 43%. The mean stress values around the apical foramen of traumatized teeth were 1,010,861 Pa (without splinting), 670,261 Pa (cervical splinting), and 415,661 Pa (incisal splinting). Compared to the CS group, the mean value around the apical foramen of the four traumatized teeth in the IC group was decreased by 37%.
Clinical Relevance
This study demonstrates that incisal splinting provides superior biomechanical advantages over cervical splinting by mitigating harmful stress concentrations on the PDL and dental pulp (apical foramen), potentially accelerating the PDL healing process and preserving pulp vitality in TDI.
Conclusion
Compared to cervical splinting, the biomechanical advantages of incisal splinting reduce stress concentration more effectively to improve prognosis in TDI.
Keywords: dental pulp, dental trauma, fiber splint, finite element analysis, periodontal ligament, stress distribution
1. Introduction
The incidence of traumatic dental injuries (TDI) is relatively high and has shown an upward trend with the improvement of societal civilization [1, 2, 3, 4]. Improper management of TDI induces serious psychological and physiological damage that could impose significant economic burdens on individuals and families due to severe complications [5, 6, 7, 8].
Maintaining the normal function of the periodontal ligament (PDL) and dental pulp preservation of traumatized teeth, which is still a challenge for unfavorable stress concentration caused by occlusal forces [9, 10]. Long‐term clinical observations have revealed that traumatized teeth with fiber splinting still exhibit a high rate of pulp necrosis [11, 12, 13], while excessive masticatory forces frequently lead to root resorption and may ultimately result in the treatment failure of TDI [14]. Notably, the impact of non‐functional occlusion on traumatized teeth is often overlooked [15]. Hidden risk factors, such as bruxism, can lead to more severe outcomes, accelerating the destruction of periodontal tissue and significantly increasing the probability of pulp necrosis [16]. Optimal management of TDI requires strategies that minimize the adverse stress to promote PDL and dental pulp healing.
Fiber splinting is a preferred method for stabilizing traumatized teeth. However, there remains no consensus regarding the optimal location of fiber splinting affecting the stress distribution on the PDL and dental pulp in TDI. The lack of research data often leads clinicians to rely on empirical approaches rather than evidence‐based guidelines. Previous finite element analysis (FEA) research has demonstrated a significant impact on stress distribution based on fiber splinting positions. Incisal splinting consistently showed a smaller area of stress concentration on the tooth root surface of traumatized teeth than cervical splinting [17]. To enhance the healing potential in TDI, the hypothesized similar impact on the PDL and dental pulp tissue was evaluated in this study.
2. Materials and Methods
The study uses real clinical CBCT data from a patient with four traumatized maxillary incisors (concussion), sourced from the Beijing Stomatology Hospital's database. Ethical approval (local research ethics committee number CMUSH‐IRB‐KJ‐PJ‐2019‐17) was obtained, ensuring compliance with research ethics.
2.1. Segmentation and Modeling
CBCT scans were exported into DICOM format and segmented using Mimics 22.0 to isolate enamel, dentin, pulp, and maxillary bone. Segmented parts were converted into STL files for surface modeling in Geomagic Wrap 2017. Periodontal Ligament Simulation: Tooth roots were offset by 0.38 mm to simulate the PDL (Figure 1H) [18], enhancing model accuracy as PDL is often too thin to be clearly visible in CBCT scans. Model Construction: A 3D maxillary model was built in SolidWorks 2018 (Figure 1D,G), including four traumatized incisors and two canines as abutments (Figure 1I). Points on the labial surfaces of each tooth were used to create curves for splint simulation, converted into thin strips (cross section 2.5 mm × 0.5 mm) representing incisal and cervical fiber splints (Figure 1E,F). Splints were integrated using Boolean operations to ensure proper fit without overlaps, enhancing model accuracy. Boundary condition: rigid fixation located at the lateral cross‐sections of maxilla to constrain the model.
FIGURE 1.
3D models for analysis of stress distribution. Red arrows represent the areas and directions of the force (10 N) loading at the upper anterior teeth. (A) Force loading at the cervical third on palatal surface, (B) Force loading at the incisal third on palatal surface, (C) Force loading at the incisal ridge, (D) Non splinting, (E) Incisal splinting, (F) Cervical splinting, (G, H, I) 3D models of the maxillary bone with teeth and PDL, PDL separated, teeth separated.
2.2. Finite Element Analysis (FEA)
The model was exported to Ansys software (2021, R1) for FEA using triangular parabolic elements. Three mesh densities (0.5, 1.0, 2.0 mm) were tested, and results showed < 6% variation in stress distribution, confirming convergence. The finite element models comprised the following mesh specifications: non‐splinting model: 623,791 nodes and 382,213 elements; incisal splinting model: 644,037 nodes and 393,949 elements; cervical splinting model: 643,555 nodes and 393,718 elements. Mesh Sensitivity Analysis was presented including aspect ratio and skewness of elements (Table 2). Material properties were assigned from literature (Table 1), all structures were assumed to be homogeneous, isotropic, and linearly elastic over simplification of the actual biomechanical behavior of the real tissue. Static force (10 N) with directions adjusted according to natural occlusion was loaded at the incisal edge, the incisal third, and the cervical third on the palatal surface of teeth to simulate the typical mastication scenarios (Figure 1A–C) [17, 19].
TABLE 2.
Mesh sensitivity analysis of the models.
| Group | Aspect ratio | Skewness |
|---|---|---|
| Non‐splinting model | 2.0267 | 0.28496 |
| Incisal splinting model | 1.9763 | 0.26938 |
| Cervical splinting model | 2.0053 | 0.27951 |
TABLE 1.
Material properties in the models.
| Structural | Young's modulus (MPa) | Poisson's ratio |
|---|---|---|
| Periodontal ligament | 0.68 | 0.45 |
| Enamel | 69,000.00 | 0.28 |
| Dentin | 18,600.00 | 0.31 |
| Dental pulp | 2.00 | 0.45 |
| Cortical bone | 13,700.00 | 0.30 |
| Medullary bone | 1300.00 | 0.30 |
| Fiber splint | 9000.00 | 0.30 |
3. Results
3.1. Stress Distribution on PDL
The equivalent (von Mises) stress distribution on the PDL was illustrated with a linear color scale, where blue represents low values and red represents high values (stress concentration). When force was loaded on the incisal ridge in the non‐splinting model, large‐scale red was observed at the tooth with PDL loss (Figure 2 Force Loading at Incisal Ridge: N right2), and relatively lower values at the teeth on both sides (Figure 2 Force Loading at Incisal Ridge: N right3, right1). The stress concentration on the left side is relatively mild (Figure 2 N Force Loading at Incisal Ridge: left 1, 2, 3). Compared with the non‐splinting group, the area of red on the PDL was significantly decreased on the right incisors and increased on the abutment teeth in the incisal‐splinting group. In contrast, the red area of PDL of the right lateral incisor was changed minimally, whereas the obviously increase on the right central incisors and decrease on the abutment teeth were observed in the cervical‐splinting group (Figure 2 Force Loading at Incisal Ridge: C).
FIGURE 2.
The equivalent von Mises stress distribution in PDL of traumatic teeth and the abutment teeth. (N) No splinting. (C) Cervical splinting, (I) Incisal splinting, (Inner) Inside surface of PDL, (L) Labial side, (M) Mesial side (D) Distal side (P) Palatal side. Color scale: Red > 250,000 Pa, Yellow: 200,000–250,000 Pa, Light green: 150,000–200,000 Pa, Green: 100,000‐150,000 Pa, Cyan: 50,000‐100,000 Pa, Blue < 50,000 Pa. All figures share the same color scale for comparative purposes. Right 2/1, Left 2/1 are traumatized incisors; Right 3 and Left 3 are abutment canines.
Compared with the non‐splinting group (Figure 3 Force Loading at Incisal Ridge: blue curve), the incisal splinting group exhibited reduced periodontal ligament stress distribution in traumatized teeth. The curve of average stress value demonstrated higher values at the ends abutment teeth and lower values in the middle traumatized teeth (Figure 3 Force Loading at Incisal Ridge: green curve). This stress dispersion effect became more pronounced in teeth with significantly reduced periodontal support. In contrast, cervical splinting yielded inconsistent results: stress decreased in the right lateral incisor but increased in other traumatized teeth. The stress curve displayed lower value at the ends (abutment teeth) and higher values in the middle (traumatized teeth), indicating that the masticatory‐induced stress was concentrated in the traumatized teeth (Figure 3 Force Loading at Incisal Ridge: red curve).
FIGURE 3.
Average value in PDL of traumatic teeth and the abutment teeth. Blue curve: Non‐splinting (N), Red curve: Cervical splinting (C), Green curve: Incisal splinting (I). Pa: Pascal. Right 2/1, Left 2/1 are traumatized incisors, Right 3 and Left 3 are abutment canines. The mean of stress values in the PDL of traumatized teeth were 183,972 Pa (N), 132,216 Pa (C), and 75,294 Pa (I). Compared to the CS group, the mean value of the four traumatized incisors' PDL in the IC group decreased by 43% (One sample t‐test, p < 0.1). Detail data was displayed in Table 3.
When simulated force was applied to the cervical third of the palatal surface, there was no large‐scale red area exhibited in non‐splinting and incisal‐splinting models (Figure 2 Force loading at the cervical one third on the palatal surface: N, I). The red area of PDL of the right incisor was markedly increased in the cervical‐splinting group (Figure 2 Force loading at the cervical one third on the palatal surface: C).
Compared with the non‐splinting group (Figure 3 Force loading at the cervical one third on the palatal surface: blue curve), the incisal splinting group showed a slight reduction in periodontal ligament stress in traumatized teeth, with the curve maintaining a “high ends, low middle” pattern. However, no significant improvement in stress dispersion was observed for teeth with severe periodontal loss (Figure 3 Force loading at the cervical one third on the palatal surface: green curve). Conversely, cervical splinting increased stress in all traumatized teeth, with a “low ends, high middle” curve, suggesting stress concentration (Figure 3 Force loading at the cervical one third on the palatal surface: red curve).
When force was loaded on the incisal third on the palatal surface in the non‐splinting model, an extensive red area is observed on the PDL of the right incisors (Figure 2 Force loading at incisal one third on the palatal surface: N right2, right1). The red areas on the PDL of the remaining teeth are relatively less noticeable. Compared with the non‐splinting group, the area of red on the PDL was significantly decreased on the incisors and increased on the abutment teeth in the incisal‐splinting group (Figure 2 Force loading at incisal one third on the palatal surface: I). The alteration was much weaker in the cervical‐splinting group (Figure 2 Force loading at Incisal one third on the palatal surface: C).
Compared with the non‐splinting group, incisal splinting significantly reduced periodontal ligament stress in traumatized teeth, particularly in cases of compromised periodontal support. Cervical splinting demonstrated inferior stress dispersion efficacy compared to incisal splinting (Figure 3 Force loading at Incisal one third on the palatal surface).
Comparative analysis of the graphs revealed that the green curve (incisal splinting group) consistently lay below the red curve (cervical splinting group) in traumatized tooth regions.
Table 3 presents the average stress values on the periodontal ligament (PDL) for traumatized teeth. The mean stress values were 183,972 Pa (no splinting), 132,216 Pa (cervical splinting), and 75,294 Pa (incisal splinting). Compared to the cervical splinting (CS) group, the mean stress value in the incisal splinting (IC) group was reduced by 43% (One sample t‐test, p < 0.1).
TABLE 3.
Average value of stress on PDL (periodontal ligament) units: Pa.
| Right 3 | Right 2 | Right 1 | Left 1 | Left 2 | Left 3 | |
|---|---|---|---|---|---|---|
| Force loading at the incisal ridge | ||||||
| Non splinting | 178,900 | 237,330 | 106,710 | 92,338 | 81,700 | 97,055 |
| Cervical splinting | 93,894 | 190,190 | 203,750 | 100,680 | 83,470 | 78,935 |
| Incisal splinting | 134,560 | 117,990 | 105,310 | 74,041 | 75,112 | 99,752 |
| Force loading at the cervical third on palatal surface | ||||||
| Non splinting | 90,885 | 89,918 | 50,063 | 49,859 | 55,828 | 70,586 |
| Cervical splinting | 72,288 | 133,270 | 138,320 | 77,848 | 57,459 | 52,313 |
| Incisal splinting | 90,314 | 79,362 | 47,913 | 40,416 | 45,584 | 60,442 |
| Force loading at the incisal third on palatal surface | ||||||
| Non splinting | 75,998 | 1,022,400 | 221,260 | 100,940 | 99,322 | 67,512 |
| Cervical splinting | 111,070 | 185,090 | 216,730 | 113,870 | 85,917 | 73,276 |
| Incisal splinting | 124,780 | 104,100 | 76,569 | 68,871 | 68,260 | 82,284 |
3.2. Stress Distribution at the Apical Foramina
When simulated force was applied to the incisal ridge: Incisal splinting and non‐splinting models displayed a dominant area by green and yellow (Figure 4: Force Loading at Incisal Ridge: N, I); drastically increased red area in the cervical‐splinting model was observed on the PDL of right incisors (Figure 4: Force Loading at Incisal Ridge: C: right2, right1). Compared with the non‐splinting and incisal‐splinting group (Figure 5: Force Loading at Incisal Ridge: blue and green curve), the cervical splinting model exhibited the property of transmitting stress to traumatized teeth. The curve demonstrated that the stress at the apical foramina more fluctuated (Figure 3: Force Loading at Incisal Ridge: red curve).
FIGURE 4.
The equivalent von Mises stress distribution in regions around apical foramina of traumatic teeth and the abutment teeth. (N) No splinting, (C) Cervical splinting, (I) Incisal splinting. Color scale: Red > 900,000 Pa, Yellow: 700 000–900,000 Pa, Light green: 500 000–700,000 Pa, Green: 300 000–500,000 Pa, Cyan: 100 000–300,000 Pa, Blue < 100,000 Pa. All figures share the same color scale for comparative purposes. Right 2/1, Left 2/1 are traumatized incisors; Right 3 and Left 3 are abutment canines.
FIGURE 5.
Average value of stress in regions around apical foramina of traumatic teeth and the abutment teeth. Blue curve: Non‐splinting (N), Red curve: Cervical splinting (C), Green curve: Incisal splinting (I). Pa: Pascal. Right 2/1, Left 2/1 are traumatized incisors, Right 3 and Left 3 are abutment canines. The mean of stress values around the apical foramen of traumatized teeth were 1,010,861 Pa (N), 670,261 Pa (C), and 415,661 Pa (I). Compared to the CS group, the mean value around the apical foramen of the four traumatized teeth in the IC group decreased by 37% (One sample t‐test, p < 0.1). Detail data was displayed in Table 4.
When force was loaded on the cervical third of the palatal surface, compared with the non‐splinting group (Figure 4: Force Loading at cervical third of the palatal surface: N), high‐value area of the cervical splinting model exhibited increased on right central incisor and decreased on the abutment (Figure 4: Force Loading at cervical third of the palatal surface: C), this disadvantageous stress distribution was reversed obviously in incisal‐splinting model (Figure 4: Force Loading at cervical third of the palatal surface: I). Curve of the incisal‐splinting model displayed a “high ends, low middle” pattern (Figure 5: Force Loading at cervical third of the palatal surface: green curve), whereas the cervical splinting increased periapical stress in traumatized teeth, with a “low ends, high middle” pattern (Figure 5: Force Loading at cervical third of the palatal surface: red curve).
When force was loaded on the incisal third on the palatal surface in non‐splinting model, a dominant red area was observed on periapical of the traumatized teeth (Figure 4: Force loading at incisal one third on the palatal surface: N: right2, right1, left2). High value area was significantly decreased on the incisors and increased on the abutment teeth in the incisal‐splinting group (Figure 4: Force loading at incisal one third on the palatal surface: I). The stress‐optimizing buffering seemed ineffective in the cervical‐splinting group (Figure 4: Force loading at incisal one third on the palatal surface: C).
Compared with the non‐splinting and cervical‐splinting models (Figure 5: Force loading at Incisal one third on the palatal surface: N), periapical stress in traumatized teeth was reduced in splinting models. It was noticeable that the green curve (Figure 5: Force loading at Incisal one third on the palatal surface: I) remained consistently below the red curve (Figure 5: Force loading at Incisal one third on the palatal surface: C), confirming the superior efficacy of the incisal splinting.
Table 4 displays the average stress values in the periapical region of the teeth. The mean stress values around the apical foramen for traumatized teeth were 1,010,861 Pa (non‐splinting), 670,261 Pa (cervical splinting), and 415,661 Pa (incisal splinting). Compared to the cervical splinting (CS) group, the mean stress value around the apical foramen in the incisal splinting (IC) group was reduced by 37% for the four traumatized teeth (One sample t‐test, p < 0.1).
TABLE 4.
Average value of stress in region around apical foramen units: Pa.
| Right 3 | Right 2 | Right 1 | Left 1 | Left 2 | Left 3 | |
|---|---|---|---|---|---|---|
| Force loading at the incisal ridge | ||||||
| Non splinting | 599,290 | 793,530 | 622,440 | 499,700 | 526,610 | 442,490 |
| Cervical splinting | 441,150 | 794,930 | 1,203,600 | 460,750 | 604,400 | 401,910 |
| Incisal splinting | 561,200 | 525,290 | 531,290 | 425,280 | 429,130 | 393,880 |
| Force loading at the cervical third on palatal surface | ||||||
| Non splinting | 582,710 | 428,930 | 443,540 | 438,950 | 326,690 | 419,790 |
| Cervical splinting | 351,620 | 356,730 | 750,540 | 301,010 | 270,490 | 127,310 |
| Incisal splinting | 717,140 | 302,200 | 310,850 | 235,670 | 182,820 | 341,120 |
| Force loading at the incisal third on palatal surface | ||||||
| Non splinting | 397,710 | 5,427,500 | 1,390,600 | 471,740 | 760,100 | 281,240 |
| Cervical splinting | 606,390 | 835,330 | 1,245,600 | 527,980 | 691,770 | 325,600 |
| Incisal splinting | 686,340 | 476,120 | 623,970 | 396,030 | 549,280 | 445,840 |
4. Discussion
The stress distribution in the PDL during mastication can be effectively buffered by the supportive capacity of a normal PDL, which is essential for maintaining tooth stability and functionality [20]. When the applied loading force exceeds the PDL's supportive capacity, it induces tooth mobility and displacement [21, 22]. In TDI, fiber rupture triggers secondary hemorrhage, exudation, and inflammation, dramatically reducing PDL buffering capacity [23, 24]. When disadvantageous masticatory stress concentration accompanying the minimized buffering capacity occurs in the PDL, further damage may lead to severe outcomes such as root resorption [25]. Therefore, reducing masticatory stress on the periodontal ligament and creating favorable conditions for its healing are critical steps in the management of TDI.
The unique anatomical structure of the apical foramen, serving as a narrow passage to maintain the vitality of the dental pulp, makes it prone to stress concentration [26]. Stress concentration around the apical foramen may cause localized microcirculation impairment, disrupting nutrient supply to the pulp and resulting in necrosis [27]. Drastic reduction of periodontal supportive capacity accompanied by improper treatment induced overwhelming stress around the apical foramen might occur frequently in TDI. Such disadvantageous stress concentration may result in further damage to the pulp and compromise treatment outcomes of TDI [28, 29].
In the treatment of TDI, fiber splinting aims to stabilize traumatized teeth and promote healing. In this study, the positioning of fiber splints, depending on FEA, was indicated to significantly affect stress distribution induced by simulated masticatory forces within the PDL and apical regions. Incisal splinting has been shown to be more effective in reducing stress than cervical splinting. For teeth with severe alveolar bone loss, this positioning is particularly beneficial, as it could more effectively buffer the stress caused by simulated masticatory forces loaded on the significantly reduced PDL supportive capacity. The reduced stresses observed in the incisal splinting configuration may clinically correspond to a lower risk of pulp necrosis or root resorption, potentially enhancing long‐term tooth survival.
After connecting with abutment teeth, occlusal adjustment of the traumatized teeth should be performed to minimize the masticatory stress [30], which is not commonly carried out on the abutment teeth. This study indicated that post‐splinting masticatory stress was possible to concentrate on the traumatized tooth, particularly in cases where severe periodontal loss occurs with cervical splinting. Such conditions necessitate careful consideration of occlusal adjustment on the abutment teeth to alleviate the trauma to the PDL and pulp caused by concentrated stress during mastication.
The consistency between numerical simulations and current clinical recommendations has been elevated to a fairly credible degree [31, 32]. To enhance the reliability of the FEA, a slice thickness of 76 μm was adopted for the CBCT data in this study. Teeth were segmented into enamel, dentin, and pulp, while alveolar bone was divided into cortical and medullary bone, with material parameters assigned based on established literature. Convergence validation and mesh sensitivity analysis were conducted within a confidence interval. Nevertheless, inherent flaws in FEA systems and methods, such as isotropic assumptions, inevitably introduce biases and compromise the reliability of the results.
As a specialized fibrous connective tissue, the periodontal ligament (PDL) exhibits an elastic modulus directly correlated with the orientation and density of its collagen fibers. Research demonstrates that region‐specific collagen fiber architecture and composition are critically linked to mechanical properties [33]. Dental trauma disrupts the collagen fiber network, causing disorientation or fragmentation of fibers and thereby diminishing PDL mechanical support capacity [33]. Furthermore, trauma compromises the integrity of the extracellular matrix (ECM), potentially impairing viscoelastic properties and further degrading biomechanical function [34]. Secondary inflammatory responses in PDL following acute trauma lead to ECM degradation and dysregulation of cell‐matrix interactions, which also participate in the alteration of PDL elastic modulus [35]. The unvalidated assumption of elastic modulus for traumatized PDL represents a fundamental flaw that rendered the simulated analytical results quantitatively unreliable.
Three typical static forces with fixed values were employed to load on the model to simulate mastication in this study. The limitations of this approach were obvious in addressing complex, continuously changing masticatory scenarios. To simulate the real mastication, the factors such as the different directions and magnitudes of the force, the individual shape of the occlusal surface, and other uncontrollable variables should also be taken into account.
Iterative upgrade of software algorithms and optimized assumption of material properties can reduce the likelihood of biases, thereby enhancing the reliability and objectivity of FEA solutions in sectors such as healthcare and engineering [36]. Clinical validation in the future via larger multicenter RCTs with extended follow‐up (monitoring pulp vitality and PDL integrity) and usage of multi‐patient data are essential to address these limitations before translation of research findings into practice.
This study found that the positioning of fiber splints significantly influenced stress distribution in PDL and apical regions of TDI under simulated masticatory forces. Incisal splinting demonstrated a greater reduction in stress compared to cervical splinting. This configuration may clinically correlate with a lower risk of pulp necrosis or root resorption, potentially improving long‐term tooth survival.
Author Contributions
All authors contributed substantially to the conception and design of the study. Data collection was carried out by Qian‐wen Ding and Tianjiao Wang. Qian‐wen Ding was also responsible for data analysis and drafting the manuscript. Tianjiao Wang and Xin Tong contributed to revising the manuscript and providing key research ideas. All authors reviewed and approved the final version for publication.
Funding
This work was supported by National Natural Science Foundation of China, 81100765, 81570990.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
This study was supported by grants from the National Natural Science Foundation of China (Nos. 81100765, 81570990).
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.