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2. INDIAN DENTAL ACADEMY
Leader in continuing dental education
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3. Splinting
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4. 
The ultimate goal in successful management of mobile teeth is to restore
function and comfort by establishing a stable occlusion that promotes tooth
retention and the maintenance of periodontal health.

The clinical management of mobile teeth can be a perplexing problem,
especially if the underlying causes for that mobility have not been properly
diagnosed.

In some cases, mobile teeth are retained because patients decline
multidisciplinary treatment that might otherwise also include strategic
extractions.

Some mobile teeth can be treated through occlusal equilibration alone
(primary occlusal trauma) where as mobile teeth with a compromised
periodontium can be stabilized with the aid of provisional and/or definitive
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splinting (secondary occlusal trauma).

5. 
Tooth splinting have been accomplished since ancient civilizations to
decrease tooth mobility, to replace missing teeth & to improve form,
function, and esthetics.

Still splinting remains one of the poorly understood & controversial areas of
dental therapy.

This seminar discusses splinting…its, rationale, basic principles, indications,
contraindications, limitations and classifications.

Different types of tooth splinting are also reviewed.
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6. Definitions

A splint is a device used to immobilize the teeth, and it is one of the oldest
form of aids to periodontal therapy.

A Splint is an appliance for immobilization or stabilization of injured &
diseased parts. In dentistry, splinting is the joining together of two or more
teeth to increase resistance to applied force through stabilization.

A splint is an appliance that “joins two or more teeth in order to distribute
& redirect functional and parafunctional forces so as to bring them within
tolerance of the supporting tissues”.

Splinting is defined as “…the joining of two or more teeth into a rigid unit
by means of fixed or removable restorations or devices.”

A splint is any appliance that joins two or more teeth to provide support.
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7. 
According to Glossary of Periodontic Terms 1986 a splint is “an appliance
designed to stabilize mobile teeth”.

According to AAP (1996), a splint has been defined “as an apparatus,
appliance, or device employed to prevent motion or displacement of
fractured or removable parts.”

The Glossary of Prosthodontic Terms defines splint as “a rigid or flexible
device that maintains in position a displaced or movable part; also used to
keep in place & protect the injured part.”

Dawson defines splinting as “the joining of two or more teeth for the
purpose of stabilization”.
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8. TERMINOLOGY:
STABILIZATION:

Stabilization of a tooth is an increase in resistance to applied force by
providing reciprocal antagonisms and increasing the effective root area. The
force may remain the same, but the resistance is increased.
TEMPORARY SPLINT:

This is used on a short term basis, usually less than 6 months, and is often
advocated to stabilize teeth during periodontal treatment. It may or may
not 1ead to other types of splinting.
PROVISIONAL SPLINT:

This type of splint is used for a longer period of time from several months to
as long as several years. It is used for diagnostic purposes.
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9. 
It allows the clinician to see how teeth will respond to treatment.

It usually leads to more permanent forms of stabilization.
PERMANENT SPLINTS:

Permanent splinting of teeth that have been treated periodontally is also
referred to as Periodontal prosthesis.

Periodontal prosthesis may be defined as those restorative and prosthetic
endeavors that are indicated and essential in the total treatment of
advanced periodontal disease.
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10. EARLY HISTORY OF SPLINTING:

A Phoenician mandible from 500BC and another Phoenician prosthetic
appliance was found from 400 BC in modern day Lebanon that is comprised
of two carved ivory teeth attached to four natural teeth by gold wire.
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11. 
Archeological excavations of the Etruscan society (Eighth century BC to the
first century AD) have found evidence of their use of wire ligation and gold
bands to stabilize teeth.

In early 1700s Fauchard attempted tooth ligation.

In the 1900s several authors described splinting techniques that dated back
to the 1800s.

Hirschfeld (1950) was one of the first modern periodontal authors to
advocate ligation of periodontally diseased teeth using either stainless steel
wire or silk. His technique was extracoronal and involved only the anterior
teeth.

In the last 50 years, scientific principles evolved to treat patients with
compromised dentitions.
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12. WHEN TO SPLINT?

The splinting of mobile teeth is often, of value as a means of stabilization
before, during, and after periodontal therapy.

For most patients, splinting should be considered only after the preliminary
phase of periodontal therapy has been completed.

Cohen and Chacker have noted, "When large areas of attachment
apparatus have been destroyed, the artificial support offered by temporary
stabilization may allow a new, healthy tooth-bone relationship to be
established.

Therefore it would seem advisable that when the treatment plan is being
formulated the need for stabilization be determined on the basis of the,
nature and extent of the destructive process present.
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13. 
In addition, it is important that occlusal relationship be initially corrected
and again after definitive periodontal therapy.

Root planing, curettage, oral hygiene, and surgery may cause teeth to
tighten as inflammation is resolved.

Occlusal adjustment, periodontal orthodontics, and restorative dentistry
may alter occlusal relationships and redirect forces, thereby reducing
traumatism.

This may result in the teeth becoming firmer.

Increasing the support of loose teeth may also increase their firmness, the
device used for such treatment is the splint.
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14. INCREASED VERSUS INCREASING TOOTH MOBILITY:

Two clinical features should be analyzed to understand the full scope of the
relationship between occlusal trauma and tooth mobility.

The first is increased tooth mobility.

This process is the adaptation of the periodontium to occlusal forces that
may not necessarily be considered pathologic.

In the absence of inflammation, mobile teeth with a complete and healthy
connective tissue attachment can be maintained.

The radiographic appearance of a widened periodontal ligament (PDL)
space coupled with a clinical diagnosis of increased tooth mobility may
merely be manifestations of adaptive changes to increased functional
demand.
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15. 
Removal of the excess occlusal load through equilibration and perhaps,
conventional splint therapy can decrease and, often at times, eliminate
tooth mobility.

An occlusal equilibration that equalizes the occlusal stresses, produces
simultaneous tooth contacts, or harmonizes cuspal relations may be all that
is needed to reverse this mobility.

The second clinical feature is increasing tooth mobility.

This clinical condition is best managed by treating any localized
inflammation, performing an occlusal equilibration, and perhaps stabilizing
or splinting the affected mobile teeth.

Consequently, patients diagnosed with increased tooth mobility may need
only an occlusal equilibration and perhaps conventional splint therapy.
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16. 
Those individuals diagnosed with increasing tooth mobility must first
receive periodontal therapy.

Treatment should include an occlusal analysis and equilibration, if
needed, followed by a reevaluation for extraction or splinting of the
affected teeth.
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17. PRINCIPLES OF SPLINTING:

The main objective of splinting is to decrease movement threedimensionally.

This objective often can be met with the proper placement of a cross-arch
splint.

Conversely, unilateral splints that do not cross the midline tend to permit
the affected teeth to rotate in a faciolingual direction about a mesio-distal
linear axis.
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18. INDICATIONS FOR SPLINTING:

Splinting is indicated when moderate to advanced mobilities (2 degrees or
more) are present and cannot be treated by any other means.

There is no reason for splinting non mobile teeth or teeth with a slight, non
progressive mobility as a preventive measure.

Splinting should only be used with other necessary measures such as oral
hygiene instructions, root planing, pocket elimination, and occlusal
adjustment.

When pre-prosthetic surgery or orthodontic measures are called for they
should be completed before splinting whenever possible.
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19. 
One obvious indication for splinting is when a patient presents with multiple
teeth that have become mobile as a direct result of gradual alveolar bone
loss, a reduced periodontium.

A second indication for splinting is when the patient presents with increased
tooth mobility accompanied by pain or discomfort in the affected teeth.

Splinting may be a way to gain stability, reduce or eliminate the mobility,
and relieve the pain and discomfort.

Following loosening of teeth by accidental (or) surgical trauma.

To immobilize excessively mobile teeth so that the patient can chew more
comfortably.

To avoid dislodging teeth prior to and during re-constructive procedures
(Occlusal reconstruction).
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20. 
To stabilize teeth in their new positions after orthodontic repositioning.

As supportive measure to facilitate periodontal therapeutic procedures for
hypermobile teeth.
CONTRAINDICATIONS FOR SPLINTING:

Splinting teeth is not recommended if occlusal stability and optimal
periodontal conditions cannot be obtained.

Any tooth mobility present before treatment must be reduced by means of
occlusal equilibration combined with periodontal therapy.

Otherwise if the tooth involved does not respond, it must be extracted prior
to proceeding from provisional restorations to definitive treatment.

Insufficient number of firm / sufficiently firm teeth to stabilize mobile teeth.
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21. The following qualifications identify an ideal splint : It should

be simple,

economic,

stable and efficient,

hygienic,

nonirritating,

not interfere with treatment,

esthetically acceptable, and

not provoke iatrogenic disease.
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22. OBJECTIVES OF SPLINTING:

Rest is created for the supporting tissues giving them a favorable climate for
repair of trauma.

Reduction of mobility immediately and hopefully permanently. In
particular jiggling movements are reduced or eliminated.

Redirection of forces - redirected in a more axial direction over all the teeth
included in the splint.

Redistribution of forces - ensures that forces do not exceed the adaptive
capacity. Forces/received by one tooth are distributed to a number of teeth.

Restoration of functional stability - functional occlusion stabilizes mobile
abutment teeth.
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23. 
To preserve arch integrity - restores proximal contacts, reducing food
impaction & consequent break down.

To stabilize mobile teeth during surgical, especially during regenerative
periodontal therapy.

To prevent migration and over eruption.

Psychologic well being - gives the patient comfort from mobile teeth a sense
of well being.

Masticatory function is improved.

Discomfort and pain are eliminated.
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24. MODE OF ACTION:

Loose teeth splinted to adjacent firm teeth may become stabilized.

Teeth tend to loosen buccolingually yet may remain firm mesiodistally.

When many teeth are loose, adjacent sextants should be included in the
splint.

Cross-arch splinting reduces mobility to the least common denominator.
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25. 
Teeth are thus immobilized and occlusal forces are better distributed.

Traumatism is minimized, repair is enhanced, and teeth may become
firm again.

Even when teeth do not tighten, the splint serves as an orthopedic brace
that permits useful function of mobile teeth.

Teeth with reduced support often are hypermobile and may gradually
increase if the teeth are not splinted.
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26. TYPES OF SPLINTS:

Splints, like bridges may be fixed, removable, or a combination of both.

They may be temporary, provisional, or permanent, according to the type of
material and duration of use.

They may be internal or external, depending on whether tooth preparation
is required or not.

Permanent splinting of teeth that have been treated periodontally is also
referred to as periodontal prosthesis.

However, splints are classified into the basic types for purposes of
discussion.
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27. A) According to the period of stabilization:
a) Temporary Stabilization: worn for less than 6 months.

Removable

Occlusal Splint with wire

Hawley appliance with arch wire

Fixed

Intracoronal

Amalgam

Amalgam & Wire

Amalgam , Wire & Resin

Composite Resin & Wire
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28. 
Extracoronal

Stainless steel wire with resins

Wire & Resin with acid etching

Enamel etching & composite resin

Orthodontic soldered bands, Brackets & Wire
b) Provisional splinting: to be used for months up to several years.
e.g. Acrylic splints, Metal band etc.
c) Permanent Splints: used indefinitely

Removable/Fixed

Extra/Intracoronal

Full/Partial veneer crowns soldered together.

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Inlay/Onlay soldered together.

29. B) According to the type of material:

Bonded composite resin splint

Braided wire splint

A – Splints.
C) According to the location on the tooth:
 Intracoronal

Composite resin with wire

Inlays

Onlays

Extracoronal

Night Guard

Tooth Bonded plastic and Welded bands
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30. Goldman, Cohen and Chacker Classification:
Temporary splints
A. Extra coronal type

Wire ligation

Orthodontic bands

Removable acrylic appliances

Removable cast appliances

Ultraviolet-light-polymerizing bonding materials
B. Intracoronal type

Wire and acrylic

Wire and amalgam

Wire, amalgam, and acrylic

Cast chrome-cobalt alloy bars with acrylic, or both.
Provisional splints

All acrylic

Adapted metal band and www.indiandentalacademy.com
acrylic

31. Ross, Weisgold and Wright Classification:
A. Temporary stabilization

Removable extra coronal splints

Fixed extra coronal splints

Intracoronal splints

Etched metal resin-bonded splints
B. Provisional stabilization

Acrylic splints

Metal-band-and-acrylic splints
C. Long-term stabilization

Removable splints

Fixed splints

Combination removable and fixed splints
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32. 
Before construction of any splint for periodontally involved dentitions,
certain basic considerations should be applied whenever possible:

For most patients, splinting should be considered only after the preliminary
phase of periodontal therapy has been completed, including the elimination
of all local factors contributing to inflammation and occlusal adjustment by
selective grinding.

Exceptions are dentitions with so much mobility that adequate occlusal
adjustment is impossible.

In these circumstances the teeth should be stabilized as early as possible,
and then the occlusion can be definitively adjusted.

The method of splinting is dictated by the cause and degree of mobility, the
coronal condition of the teeth to be incorporated in the splint and evaluation
of the state of hypermobility, whether temporary or permanent.
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33. 
If the coronal portions of the teeth are in relatively good condition, the
extracoronal method of splinting should be used.

If, however, the teeth obviously require extensive restorative therapy, as
well as periodontal therapy, a form of intracoronal splinting is justified and
preferable.

The extent of splinting is dictated primarily by the number of teeth
involved and the degree of their mobility.

In all cases, a sufficient number of nonmobile teeth should be included in the
splint.

If all the teeth in a quadrant demonstrate hypermobility, splinting should
be extensive enough to include the support of anterior teeth and, on
occasion, teeth on the opposite side of the arch.
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34. 
For the same reason, the support of posterior teeth is often necessary when
anterior segments are mobile.

If, in a case of occlusal traumatism associated with severe bone loss, all the
teeth demonstrate hypermobility, cross arch splinting is beneficial.

With splinting, a group of single rooted teeth in effect becomes a
multirooted unit.

The patient must be informed that future restorative measures are usually
necessary when any form of intra or circumcoronal splinting is used.

All methods of splinting have advantages and disadvantages.

Ironically, some methods of stabilization by splinting are so time consuming
and demanding in construction that they are most impractical and
expensive.
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35. TEMPORARY STABILIZATION

Temporary stabilization is essentially a diagnostic procedure that, ideally,
should be reversible in nature.

By splinting, we expect a mechanical stabilization and hope that a decrease
of hypermobility of the involved teeth will result with time.
Indications for Temporary Stabilization

Temporary splints are used both until hypermobility is satisfactorily
reduced or eliminated and the teeth can function without the help of the
splint or until the dentition clearly requires long term stabilization.
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36. The term temporary is applied

To a splint that is used until stabilization is no longer necessary, for
example, in cases of mobility caused by orthodontic repositioning,
accidental or surgical trauma, or occlusal traumatism, all of a reversible
nature.

As a phase in the therapy being undertaken to determine whether mobility
can be resolved by conservative methods or whether mobility is caused by
loss of support sufficient to create permanent mobility (as in occlusal
traumatism associated with periodontitis), by root resorption, or any
extrinsic or intrinsic precipitating factors.

When advanced periodontal disease dictates permanent fixation by
extensive restorative methods, but this cannot be done either
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37. 
(a) For economic reasons or

(b) Because prognosis for all remaining teeth is extremely doubtful or

(c) Because poor health seriously affects the longevity of the dentition, or
even the life of the patient or

(d) Because the patient cannot emotionally accept the lengthy procedures of
permanent fixation.

For temporary stabilization, the method chosen should be the simplest, least
expensive, and least time consuming to construct, should be esthetically
acceptable to the patient, and should meet the needs of the individual.
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38. The functions of a temporary splint may be listed as follows:

To protect mobile teeth from further injury by stabilizing them in a
favorable occlusal relationship.

To distribute occlusal forces so that teeth that have lost periodontal support
are not further traumatized.

To aid in determining whether teeth with a borderline prognosis will respond
to therapy.
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39. EXTRACORONAL TYPES

Unfortunately almost all the extracoronal forms of stabilization have
certain inherent disadvantages.

They usually are a detriment to good oral physiotherapy because of their
bulk, thus interrupting proper coronal forms.

It is often difficult to perform various surgical procedures in these areas
because of the nature of the appliance.

The appliances frequently leave a great deal to be desired cosmetically.
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40. Wire ligation:

Wire ligation is probably the most commonly used type of stabilization.

It is easy to construct and rather sturdy.

However, one of its basic limitations is that it can be utilized only where
coronal form permits.

Because of this shortcoming it has its greatest use in stabilizing the
mandibular incisors.

Hirschfeld suggests a loop tied at the cervical line on poorly contoured teeth
to prevent slippage of the main wire.

After an interproximal tie is made, connecting the buccal and lingual
segments of the mesh, tooth-colored, self-curing acrylic is painted over the
wire to obtain a more pleasing aesthetic result.
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41. 
This method may offer the advantage of greater stability while producing a
splint that is thin in a buccolingual direction and quite acceptable to the
patient.
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43. Orthodontic bands:

Orthodontic bands tend to stabilize both anterior and posterior teeth and
therefore have the advantage over wire ligation in that they are not
limiting.

It is important to give proper attention to the contours of the bands and to
check their relationship to the adjacent gingival tissue.

Often the contacts between the teeth must be opened so that a band or
bands can be inserted.

Again, acrylic may be placed over the bands for cosmetic purposes. The
bands may be welded directly or indirectly.

When the multiple bands are welded together, it is necessary to have a
common path of insertion so that the composite fit of the multiple bands is
the same as the fit of eachwww.indiandentalacademy.com
individual band.

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46. Removable acrylic appliances:

The clinician must be aware of the fact that when he utilizes any form of
acrylic appliance, the dimensional instability of the material may cause
distortions to occur.

It is imperative to check these appliances frequently and to make any
necessary adjustments.

It is also vital to check the path of insertion of the appliance, since the
appliance must not be traumatic as it goes to its final seat.
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47. Acrylic bite guards ( Night Guards):

Night guards can be constructed in many ways, and they have a wide
variety of uses like treatment of bruxism and clenching.

The most common type of appliance is one that covers the occlusal surfaces
of the teeth. For additional support the palate is often covered.

Another appliance frequently used is the maxillary Hawley bite plane with
a labial wire.

This appliance has an advantage in that the posterior teeth are freed of
occlusal contact in all positions and excursions of the mandible.

It can be used only when there is an anterior overbite so that the palatal
bite plane can disarticulate the posterior teeth.
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48. 
When there is no overbite a labial lip of acrylic over the maxillary anterior
teeth will often suffice.

An important consideration with all these appliances is that they must not
obliterate the interocclusal distance (free-way space).
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49. Removable cast appliances:

The removable cast appliance is usually a rigid casting either of gold or of
chrome cobalt, made to fit around the teeth.

Friedman has suggested a useful variation utilizing a double
continuous clasp casting.

One end usually the anterior section, is not joined but is left open so that
the casting can be sprung over the undercuts and then ligated.

The posterior end is continuous from the buccal to the lingual surface and is
distal to the most posterior tooth.

Another modification is an interlocking attachment on the distal end so
that the appliance can be locked after being sprung over the teeth.

Obviously, with any form of removable splint, it is only effective if the
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patient wears the appliance.

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51. Ultraviolet Light Polymerizing bonding materials:

Restorative materials that are polymerized by ultraviolet light are very
useful in providing stabilization of excessively mobile teeth.

As Polson and Billen have stated, "Because the materials do not polymerize
until they are exposed to ultraviolet light, they provide prolonged working
times for placement. shaping, and contouring, over extensive areas of
enamel."

One of the more popular polymerizing kits is the Nuva System (Caulk,
Division of Dentsply lnternational Inc. Milford, Delaware).

Basically the technique is a simple one and provides adequate stabilization
if care is taken during the actual operative procedures.
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55. 
The composite resin splint can be strengthened by adding wire,
monofilament line, fiberglass or by using a fibre meshwork (e.g., Ribbond,
Ribbond Inc., Seattle, WA) to reinforce the material.
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57. 
Extracoronal resin-bonded retainers, which can be fabricated in the dental
laboratory, serve to strengthen the overall bonded situation.

The splints are usually cast from metals, usually non noble alloys that can
be electrolytically or chemically etched.

This type of splint has greater inherent strength than a composite-resin
splint created intraorally.

Extra features such as grooves, pins and parallel preparations increase the
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retentive capacity of these splints.

58. 
Newly developed laboratory-cured composite resins such as DiamondCrown
(Biodent Inc., Mont-Saint-Hilaire, QC) claim improved diametric tensile
strength and bonding capabilities.

These materials may be considered for use in extracoronal applications.

No long-term clinical data are available for these materials; however, they
seem promising at this time.
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60. Thank you all….
To be
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