splinting of teeth as a part of periodontal treatment, its benefits and disadvantages are lised in this presentation

1. SPLINTING
- DR. KAPIL ARORA

2. CONTENTS
O Introduction
O Tooth mobility
O Methods to access tooth mobility
O Conventional & latest
O Splints
O Splint’s definition
O Rationale
O Indications of tooth stabilization
O Contraindications

3. O Ideal splint
O Theoretical aims
O Biomechanics of splints
O Classification
O Types of splint
O Temporary
O Provisional
O Permanent
O Choice of splint
O Its evaluation
O Drawbacks of splinting
O Summary

4. INTRODUCTION

5. When such local
treatments fail to achieve
this and chewing is
uncomfortable, and where
periodontal support is so
reduced that increasing
mobility is inevitable,
further tooth support is
needed.
(Lindhe & Nyman 1977 )

6. TOOTH MOBILITY
DEFINITION:
Tooth mobility is defined as
a visually perceptible
movement of the tooth away
from its normal position
when a light force is applied.
( Gher 1996)

7. TYPES
O PHYSIOLOGIC TOOTH MOVEMENT
(MUHLEMANN
1951)
O PATHOLOGIC TOOTH MOVEMENT

8. CAUSES
Loss of tooth support
Extension of
inflammation from
the gingival or from
the periapex into the
PDL
Periodontal surgery
Tooth mobility
increases in
pregnancy
Pathologic process
of the jaw
Trauma from
occlusion

9. TRAUMA FROM OCCLUSION
• Acute
• Chronic
Depending
upon the
duration of
occurrence
• Primary
• Secondary
Depending
upon the
etiology

10. ACUTE TFO

11. CHRONIC TFO
O It is more common and is of greater
clinical significance.
O It is due to gradual changes in occlusion
produced by tooth wear, drifting
movement, extrusion of teeth combined
with parafunctional habits such as bruxism
and clenching, rather than as a sequelae
of acute TFO
O It leads to increased tooth mobility.

12. PRIMARY TFO

13. O In the case of primary occlusal trauma, the
periodontium is intact and not reduced,
thus the drifting of the teeth is due to an
excessive, continuous force resulting from
an occlusal disharmony.
O Ferenez in 1991 reported that there is little
rationale for splinting teeth manifesting
primary occlusal trauma.

14. SECONDARY TFO
O When the adaptive capacity of the tissue to
withstand occlusal force is impaired by bone
loss resulting from marginal inflammation.
O Reduces the periodontal attachment area and
alters the leverage on the remaining tissue.
O Periodontium becomes more vulnerable to
injury, and previously well tolerated occlusal
forces become traumatic.

15. ASSESSMENT OF TOOTH
MOBILITY
Conventional
methods
Clinical
measurements
Clinical indices
Newer
methods
Periodontometer
Periotest

16. CLINICAL MEASUREMENT

17. INDICES
O MILLER 1950
O Score 0 - no perceptible movement
O Score 1- mobility greater than normal
O Score 2- mobility of up to 1 mm in a
buccolingual direction.
O Score 3- movement of more than 1mm in a
buccolingual direction combined with the
ability to depress the tooth.

18. O GLICKMAN 1972
O 0- Normal mobility
O Grade I- Slightly more than normal
O Grade II- Moderately more than normal
O Grade III- Severe mobility faciolingually and /
or mesiodistally combined with vertical
displacement.

19. O LINDHE 1997
O Degree1: Movability of the crown 0.2-
1mm in horizontal direction.
O Degree 2: Movability of the crown of the
tooth exceeding 1 mm in horizontal
direction.
O Degree 3: Movability of the crown of the
tooth in vertical direction as well.

20. periodontometer
Muhlemann in 1957

21. PERIOTEST
A new method for determining tooth
mobility was invented by Schulte
and co-workers in 1987 and 1992.
when the Periotest (Siemens,
Germany) system was introduced.
The periotest device measures the
reaction of the periodontium to a
defined percussion force which is
applied to the tooth and delivered
by a tapping instrument.

22. A metal rod is
accelerated to a speed
of 0.2 m/s with the
device and maintained
at constant velocity
Upon impact the tooth
is deflected and the rod
decelerated
The contact time
between the tapping
head and tooth varies
between 0.3 and 2
milliseconds and is
shorter for stable than
mobile teeth

23. SPLINT
Any apparatus or device employed to
prevent motion or displacement of
fractured or movable parts.
(Hallmen WW )
An appliance for immobilization or
stabilization of injured or diseased parts.
(Glickman 1972)

24. In dentistry stabilization or splinting
commonly refers to tying teeth
together either unilaterally or bilaterally
to convey increased stability to the
entire unit. (AAP 1996)
A splint according to Glossary of
Periodontal Terms (1986) is an
appliance designed to stabilize mobile
teeth.

25. INDICATIONS
O LEMMERMAN 1976 :
O As part of occlusal therapy
O As a prevention of tooth drifting
O As a replacement for missing teeth
O As a treatment of secondary occlusal
trauma

26. O Simring in 1952 described the theory and
practice of splinting in detail:
O He emphasized the importance of direction
of forces and the movement of teeth under
occlusal loads, thus rationalized the need
for splinting as the safety procedure to
employ when a tooth must withstand a
forces beyond its individual physiologic
limits.
O Simring stressed that splinting is indicated
where the traumatic effects of occlusion are
intense and the stimulating physiologic
action of the occlusal forces needs to be
improved.

27. According to Caranza, two major
indications for periodontal splinting are a)to
immobilize excessively mobile teeth so that
the patient can chew more comfortably and
b)to stabilize teeth exhibiting increasing
mobility. He further defined three
procedures for provisional stabilization
which are a) the reinforced resin splint for
use in the posterior teeth, b) the acid etch
resin splint for use in anterior teeth, and c)
the resin bonded metal splint.

28. RATIONALE
O Comfort and Psychologic well being of the patient
O REST: Occlusal rest provided by splint therapy of
one form or another helps to eliminate or at least
to neutralize some of the adverse occlusal factors
that compound the effects of already existing
periodontitis
O Redirection Of Forces : Splinting effects a
redirection of force in a more axial direction over
all the teeth included in a splint

29. O Redistribution Of forces. The stabilization
of weakened teeth by splinting increases
resistance to applied force. The
redistribution of forces ensures that
excessive force on a single tooth does not
exceed the adaptive capacity of the
surrounding tissue and that jiggling
movements, which can contribute to further
bone loss in an existing periodontitis are
prevented
O Preservation of arch Integrity
O Splinting restores proximal contacts that
have been disrupted by missing and
migrated teeth

30. INDICATION (AAP)
Stabilize teeth when
tooth mobility
interferes with
normal masticatory
function and comfort
of the patient
Stabilize teeth in
secondary TFO
To prevent tipping or
drifting of the teeth
Prevent extrusion of
unopposed teeth
Stabilization of
mobile teeth during
surgical especially
regenerative
therapy. (Serio 1999)
Stabilize teeth
following orthodontic
movement
Ascertain whether
occlusal therapy will
be effective or not

31. CONTRA-INDICATIONS
When there is moderate to severe tooth mobility in the
presence of periodontal inflammation or primary trauma
Prior occlusal adjustment has not been done on teeth
with occlusal interferences and prior occlusal trauma.
There is an insufficient number of non mobile teeth to
adequately stabilize the mobile teeth.
Inadequate oral hygiene

32. IDEAL SPLINT
simple and
hygienic
economic
stable and
efficient
Non irritating
not interfere with
treatment
esthetically
acceptable
not provoke
iatrogenic
disease

33. THEORETICAL AIMS
O Rest is created for the supporting tissues, permitting
repair of trauma.
O Mobility is reduced immediately and, it is hoped,
permanently. In particular, jiggling movements are
reduced or eliminated.
O Forces received by any one tooth are distributed to a
number of teeth
O Proximal contacts are stabilized, and food impaction
(but not retention) is prevented.
O Migration and overerruption are prevented
O Masticatory function may be improved
O Appearance may be improved
O Discomfort and pain are eliminated

34. BIOMECHANICS
(RAMJFORD)
Limits amount of
force on a single
tooth
Aids in distribution of force
A mobile individual tooth
is capable of being
loaded and moved in
several directions:
mesio-distally,
buccolingually and
apical
When the mobile tooth is
splinted, the splint tends
to redirect lateral forces
into more vertical forces,
which the tooth is better
able to resist

35. UNILATERAL AND
BILATERAL SPLINTS

36. CLASSIFICATION
RAMFJORD’S CLASSIFICATION (1979)
TEMPORARY:
(2-6 months)
Fixed external type
e.g. Ligature wire, orthodontic bands.
Removable- RPD, Night guards, removable acrylic splints
PROVISIONAL :
8-12 months, diagnostic, used in borderline cases where the outcome of treatment cannot be
predicted. eg. Temporary external splints.
PERMANENT:
a) Fixed- Full crowns, pin ledge type of abutment retainers.
b) Semirigid
c) Removable- Telescopic crowns, clasp supported partial denture.

37. Grant, Stern and Listgarten(1988)
TEMPORARY:
 Extracoronal (External)-Ligature splint, Enamel bonding
material, welded bond splints, night guards
 Intracoronal (Internal)- Acrylic splints, Composite splints,
acrylic full crowns
II) PROVISIONAL SPILNTS
Serves to stabilize a permanently mobile dentition from the time
of initial tooth preparation until the time the dentition is
periodontally healthy enough for permanent restorations.
III) PERMANENT SPLINTS may be classified as follows:
Removable—external
 Continuous clasp devices
 Swing-lock devices
 Overdenture (full or partial)

38. Fixed—internal
 Full coverage, three-fourths coverage crowns
and inlays
 Posts in root canals
 Horizontal pin splints
3. Cast-metal resin-bonded fixed partial dentures
(Maryland splints)
4. Combined
 Partial dentures and splinted abutments
 Removable—fixed splints
 Full or partial dentures on splinted roots
 Fixed bridges incorporated in partial dentures,
seated on posts or copings

39. TEMPORARY SPLINTING
O INDICATIONS :
Following accidental
loosening of teeth by
trauma
As a supportive
measure to facilitate
periodontal therapeutic
procedures for
hypermobile teeth
To avoid dislodging of
teeth prior to and
during reconstruction
procedures
For anchorage and
temporary retention in
orthodontic therapy

40. CHOICE OF SPLINTS
the
severity of
mobility
the stage
of
treatment
involved
the
anticipated
outcome

41. LIGATURE SPLINTS

42. FABRICATION

43. O Ligatures are a
satisfactory means of
stabilizing anterior
teeth.
O Although ligation is a
form of temporary
splinting, ligatures
may be retained for
several months if they
are tightened and
replaced periodically.
O Poor esthetic
appearance
O May perform minor
tooth movements
O Can cause gingival
irritation due to plaque
or food accumulation.

44. A study measured the forces originated from stainless steel
wires when used for splinting. The results demonstrated that
square or round stainless- steel wires exerted lower forces
compared to rectangular or nickel-titanium wires. The study
also showed that the construction of a truly neutral arch was
difficult, and therefore the authors concluded that only dentists
experienced in the handling of orthodontic appliances should
use such materials for dental trauma splints.
Prevost J, Louis JP, et al, A study of forces
originating from stainless steel wires for splinting of
teeth. Endod Dent Traumatol 10:179-84, 1994

45. SPLINTS OF ENAMEL BONDING
MATERIAL
A simple method of external temporary
splinting employs tooth-bonding material
(self-polymerized, ultraviolet light
polymerized and white light polymerized
composite resins)

48. O ADVANTAGES:
O Such splints are cosmetic,
O fairly durable,
O and well tolerated by the patient
O DIS-ADVANTAGES:
O They are not able to resist heavy interocclusal
forces and fractures often occur.

49. WELDED BAND SPLINTS

51. O Bands may impinge on the gingiva.
O Poor esthetic appearance.
O May perform minor tooth movements
O Special attention should be given to plaque
control

52. CONTINUOUS CLASPS
Continuous clasps may
be made of acrylic, gold,
or cast stainless steel.
These simple splints may
be seated and removed
in the fashion of a partial
denture, or they can be
ligated to place.

53. NIGHT GUARD

54. OAdvantages
O Tends to stabilize
mobile teeth
O Control bruxism and
prevent excessive
wear of teeth
O Prevent hypereruption
of teeth without
antagonists
O Eliminate trauma from
occlusion
ODisadvantages
O Tend to rock and become
flexible over use.
O When single guards are used,
the patient may pit the
occlusal surface of the guard
against one or more
opposing teeth and cause
them to loosen.

55. EVALUATION

56. Rateitschak 1963 observed that orthodontics or
removable splints caused an initial increase in the
mobility which returned to baseline by 2 years.

57. INTERNAL SPLINTS
Internal temporary
splints should be used
only when permanent
splinting is to follow.
They may also be used
on a provisional basis
when tooth prognosis is
guarded
Even when splinting
cannot save teeth, it can
provide a gradual and
less distressing
transition to full
dentures.
Once an internal
temporary device has
been used, the patient
may be committed to
periodontal prosthesis.

58. ACRLYLIC SPLINTS
a channel approximately 3 mm wide and 2 mm deep in several
teeth.
undercut for retention
pulpal surfaces should be coated with a protectant
Platinized knurled wire in channel
Place self cure acrylic to fix wire in channel and polish

59. OAdvantages
O Minimal tooth preparation is
required
O Esthetic
ODisadvantages
O Tend to harbor plaque which can
lead to caries, calculus deposition
and inflammation
O The maintenance needs are
increased
O If pulp protection is not given, pulp
involvement may occur.

60. COMPOSITE SPLINT

62. USES:
 Treatment of post acute trauma to prevent mobility
 Preventing tooth drifting after loss of an adjacent tooth
 As a replacement for missing teeth using either a composite resin tooth
pontic or a natural tooth pontic
 As a treatment of secondary TFO
 As an endodontic post and
 for orthodontic retention
Fiber- Reinforced Composite Resin

68. AMALGAM SPLINT

69. ACRYLIC FULL CROWNS
Fixed temporary bridges may be made of acrylic
crowns and pontics and may also serve as
temporary splints.
They are used when permanent fixed splints will
ultimately replace them.

70. Disadvantage of using acrylic
crowns
O The material tend to wear and break.
O Tend to harbor plaque which can lead
to caries, calculus deposition and
inflammation
O The maintenance needs are increased
O If pulp protection is not given, irritation
may occur.

71. EVALUATION

72. PROVISIONAL SPLINTING
Provisional restorations serve to stabilize a
permanently mobile dentition from the time of
initial tooth preparation until the time the
dentition is periodontally stable enough for
permanent restorations
Morton Amsterdam and Lewis Fox in 1959
defined that the term provisional splinting as
the phase of restorative therapy utilizing a
biomechanical combination of tooth
dressing coverages and stabilization of
teeth on an immediate and temporary basis.

73. It provides
stability,
occlusal
function, and
a good
esthetic result
In addition, it
allows the
dentist to
determine the
optimum
esthetic and
functional
design to be
incorporated
into the future
permanent
splint.
The
provisional
splint can be
placed any
time after the
initial
periodontal
therapy is
complete
If the splint is
seated using
temporary
cement, it can
be removed
during
periodontal
treatment,
thus
facilitating
access to the
root surfaces

74. PERMANENT SPLINTING:
PERIODONTAL PROSTHESIS
o Permanent splinting is indicated whenever
periodontal treatment does not reduce mobility to
the point at which the teeth can function without
added support.
o Such devices serve to stabilize loose teeth, to
redistribute occlusal forces, to reduce
traumatism, and to aid in the repair of the
periodontal tissues
o Permanent splints are fabricated after periodontal
treatment has been completed, when their use
will extend the functional lifetime of the teeth.

75. INDICATIONS
Continuous
migration or
tipping of teeth
Radiographic evidence of
ongoing resorption of the
alveolar bone several
months after occlusal
adjustment
Progressive
TFO following
occlusal
adjustment,
expressed as
soreness of the
teeth to pressure
on percussion
during and after
function

76. Indications for splinting the patient with advanced
periodontal disease using fixed cast
restorations were described by Lindhe J et al in
1983.
1) progressive mobility of teeth as a result of
gradually increasing width of the periodontal
ligament in teeth with loss of alveolar bone
height.
2) indicated when mobility disturbs chewing
ability or comfort.
3) Another consideration requiring stabilization
is increased segmental bridge mobility
despite splinting in a sextant of teeth.

77. CONTRAINDICATIONS
Splinting with fixed cast restorations
is not indicated if occlusal stability
cannot be obtained with the
provisional acrylic bridge. The
alternative treatments are the
complete denture or the full implant-
supported prosthesis
Splinting is not indicated for the
patient who is comfortable during
normal mastication yet has increased
mobility of a tooth or teeth with loss
of alveolar bone and a normal width
of periodontal ligament without
increasing mobility or tooth migration

78. OBJECTIVES FOR SPLINTING
WITH FPD
the patient is able
to function
comfortably
tooth mobility is
normal or at least
no longer
increasing
the splinted fixed
prosthesis also
serves to replace
any missing teeth

79. REMOVABLE SPLINTS
 Incorporate continuous
clasps and fingers that brace
loose teeth.
 They strongly resemble
partial dentures, and their
features may be included in
partial dentures.
 They support the teeth from
the lingual surface and may
incorporate additional
support from the labial
surface or use intracoronal
rests.

80. SWING LOCK DEVICES

81. OVER DENTURE

82. Rengglie et al 1984 studied the use of telescoping bridges placed
3 to 4 months following the surgical therapy. This bridge is then
removed daily for oral hygiene. The mobility of the abutment teeth
did not have an increase in mobility.
The interesting thing about the study was that the mobility of the
non-splinted teeth was also reduced. Therefore, the author
concluded that harmonious occlusion is the reason why all the
teeth lost their mobility, not the splinting

83. A study by Glickman et al in 1961
showed that although fixed splints
provide some beneficial distribution
of occlusal forces, the ideal way to
alleviate excessive occlusal forces
that cause tooth or teeth mobility is
to remove the destructive contacts.

84. Kegel et al 1979 studied mobility of the teeth
after scaling and root planning, occlusal
adjustment, and oral hygiene using 7 patients,
split mouth design. They found there were no
change in tooth mobility between splinted
and non-splinted groups of the teeth. There
were also no difference in bleeding on probing,
gingival bleeding, attachment level, or
radiographic bone scores. Splinted teeth did not
have any clinical advantage over the non-
splinted teeth.

85. Galler et al. 1979 also used split mouth design
during and following the
osseous surgery. During the follow-up period of
24 weeks, it was observed that splinting had no
effect on mobility at any time during the
examination. An overall 0.6 mm of supporting
bone was removed during the osseous surgery
and there were no differences between the two
groups in terms of mobility and the amount of
the bone removed, regardless of whether the
teeth were splinted or not-splinted. The post-
operative mobility was only dependent on the
pre-operative mobility.

86. DRAWBACKS OF SPLINTING
Gingival irritation
Difficult oral
hygiene access
Crown becomes
loose or fractured
interference of the
splint to normal
interproximal wear
and mesial drift
Interference with
phonetics

87. Glickman et al. (1961) evaluated the effects of
splinting teeth in hyperocclusion using five
Rhesus monkeys. The forces which applied to
1 tooth in a splint were transmitted to all teeth
within the splint. The direction of the initial
force was maintained and comparable areas
of the splinted periodontium were affected.
The bifurcation and bifurcation areas were
most susceptible to excessive force. Forces
applied to non-splinted teeth were not
transmitted to adjacent teeth and force
sufficient to cause necrosis did not cause
pocketing.

88. Nyman et al. (1975) studied 20 patients who had
originally exhibited severe periodontal
breakdown and extensive tooth loss. Extensive
fixed bridgework was placed following
periodontal therapy and the patients monitored
for 2 to 6 years. No further bone loss was
observed between the insertion of the fixed
bridgework and the final examination. The
authors reported no increase in PDL width of the
abutments or changes in mobility.

90. REFERENCES
O Clinical periodontology : Carranza
O Clinical periodontology : Jan lindhe
O DCNA volume 43
O Grant Stern and listgarten
O Ramfjord
O Decision making in Periodontics : Walter B
Hall
O Glickman I, Stein RS, Smulow JB. The effect
of increased functional forces upon the
periodontium of splinted and non-splinted
teeth. JPeriodontol. 1961;32:290-300

91. O E. Griffin Cole,To Splint or Not To Splint:
Treating Periodontally Compromised
Teeth by Improving Occlusion May 2005
Contemporary Esthetics and Restorative
Practice
O Trauma from occlusion: a review
Commander R. “Dave” Rupprecht, DC,
USN 2004
O Dr P. Jayachandran ,Tooth Mobility, JSIPK
,Nov 2009