PERIODONTAL SPLINTING

CONTENTS
1.

Definitions

10. Mode of Action

2.
3. 4. 5. 6. 7. 8.

Terminology
Early History

11. Classifications
12. Temporary Splints 13. Provisional Splints 14. Permanent Splints 15. Commonly Used Splints 16. Disadvantages 17. Case Reports

Objectives
Indications Contraindications Principles Ideal Splint

9.

Splintee / Splinters

18. Conclusion

SPLINTING Definitions

The joining of two or more teeth into a rigid unit by means of fixed or removable restorations or devices

The joining of two or more teeth for the purpose of stabilization -Dawson

SPLINT Definitions

An appliance designed to stabilize mobile teeth

-Glossary Of Periodontic Terms (1986)

Any apparatus, appliance, or device employed to prevent motion or displacement of fractured or movable parts in order to distribute occlusal forces evenly -AAP (1996)

SPLINT Definitions

A rigid or flexible device that maintains in position a

displaced or movable part; also used to keep in place &

protect the injured part

-Glossary Of Prosthodontic Terms

TERMINOLOGY

STABILIZATON

TEMPORARY SPLINT

PROVISIONAL SPLINT

PERMANENT SPLINT

EARLY HISTORY

A Phoenician mandible from 500BC found in modern day Lebanon which has two carved ivory teeth attached to four natural teeth by gold wire

Findings from digging of Egyptians (3000 -2500 B.C.) show

similar gold wiring

Romans used gold ribbons for splinting in the 1st century B.C.

8th Century BC to 1st Century AD - excavations of Etruscan

society give evidence of use of wire ligation & gold bands to stabilize teeth

Early 1700s - Fauchard attempted tooth ligation 1950 Hirschfeld: ligation of periodontally diseased teeth using SS Wire or Silk

Obin and Arvins (1951) self curing internal splint Cross (1954) continuous amalgam splints

Harrington (1957) modified the splint by incorporating cemented stainless steel wire

Wellensiek (1958), Shatzkin (1960) & Taatz (1964) anterior

intra coronal splints.

Most complete literature review on tooth stabilization was by

Lemmerman in 1976.

OBJECTIVES 1. Providing rest to the supporting tissues

2. Redirection of forces

3. Redistribution of forces

4. Immediate reduction of mobility

5. Preserving arch integrity

OBJECTIVES 6. Restoration of functional stability

7. Psychological well being

8. Stabilizing mobile teeth during surgical, especially regenerative therapy

9. Preventing migration and over eruption

10. Improving esthetics

INDICATIONS (Tarnow & Fletcher, 1986)

1. Stabilization of a severely periodontally compromised tooth

2. Stabilization of teeth after acute dental trauma

3. Stabilization of mobile teeth for masticatory comfort

4. Redistribution of forces along the long axis of teeth

5. Cross arch stabilization

6. Control of forces of parafunction or bruxing

7. Stabilize teeth in secondary occlusal trauma

8. Restoration of the vertical dimension of occlusion in case of

posterior bite collapse

9. Prevention of the eruption of an unopposed tooth

10. Post orthodontic retention

CONTRAINDICATIONS (Tarnow & Fletcher, 1986)

1.

Moderate to severe tooth mobility in the presence of

periodontal inflammation and/or primary occlusal trauma

2.

Insufficient number of firm or sufficiently firm teeth to stabilize mobile teeth

3.

Prior occlusal adjustment not done on teeth with occlusal

trauma or occlusal interferences

4.

Patient not maintaining oral hygiene

CLINICAL FEATURES Increased Mobility

RADIOGRAPHIC FEATURES Increased width of PDL Normal bone height Increased width of PDL Reduced bone height Normal width of PDL Reduced bone height

TREATMENT REQUIRED Occlusal equilibration

Increased Mobility

Occlusal equilibration

Increased Mobility Patient NOT functioning comfortably

Occlusal equilibration Splinting

PRINCIPLES

Should decrease movement 3 dimensionally

Centre of rotation of the affected teeth must be located in the remaining supported bone

No inflammation

Minimum of 1/3rd of bony support remaining

Occlusion must be adjusted prior to stabilization

Sufficient number of sound teeth should be involved

Non irritating to other soft tissues

Should allow for practice of oral hygiene methods

Should not impair or disturb the phonetic pattern

Esthetically pleasing

Crown root ratio should be considered

Favorable tooth position in the arch

No periapical pathology

IDEAL SPLINT (Simring & Thaller, 1956)

SIMPLE
ECONOMIC STABLE & EFFICIENT HYGIENIC NON-IRRITATING

IDEAL SPLINT NO INTERFERENCE WITH TREATMENT

ESTHETICALLY ACCEPTABLE
NO IATROGENIC DISEASE

EASY CLEANSABLE
EXTEND AROUND ARCH

SPLINTEE TOOTH THAT NEEDS SUPPORT

SPLINTERS ADJACENT TEETH THAT PROVIDE SUPPORT

MODE OF ACTION Loose teeth become stabilized

Occlusal forces are

better distributed

Trauma minimized, repair enhanced

CLASSIFICATION OF SPLINTS PERIOD OF STABILIZATION TOOTH PREPARATION

Temporary

Provisional
Permanent

TYPE OF MATERIAL

Intracoronal
Extracoronal

Bonded composite resin

Braided wire A-splints

GOLDMAN, COHEN, & CHACKER CLASSIFICATION TEMPORARY EXTRACORONAL 1. Wire ligation 2. Orthodontic bands 3. Removable acrylic appliances 4. Removable cast appliances 5. UV light polymerizing bonding materials INTRACORONAL PROVISIONAL

1. Wire and acrylic 2. Wire and amalgam 3. Wire, amalgam and acrylic 4. Cast chromecobalt alloy bars with acrylic

1. All acrylic 2. Adapted metal band and acrylic

ROSS, WEISGOLD, & WRIGHT CLASSIFICATION

TEMPORARY

PROVISIONAL

LONG TERM

1. Removable extracoronal 2. Fixed extracoronal 3. Intracoronal 4. Etched metalresin bonded

1. Removable 1. Acrylic 2. Fixed 2. Metal band & acrylic 3. Combination of removable & fixed

FACTORS TO BE CONSIDERED Mobility patterns of the teeth to be splinted

Crown to root ratio of involved teeth

Status of the remaining teeth in the arch

Nature and the extent of periodontal destruction

Method of therapy that will be employed

TEMPORARY SPLINTS

Essentially a diagnostic procedure; reversible

Mechanical stabilization hypermobility reduction

Method chosen simplest, least expensive, least time

consuming, esthetically acceptable, and should meet patient

needs

Aid in determining whether teeth with a borderline prognosis will respond to therapy

EXTRACORONAL SPLINTS 1. Wire Ligation Most common Easy to construct; sturdy Limitation only where coronal form permits Greatest use in mandibular incisors Hirschfield loop tied at cervical line

2. Orthodontic Bands

Stabilize both anterior & posterior teeth

Attention to the contours of the bands

Contacts between teeth must be opened

Acrylic over the bands Common path of insertion

3. Removable Acrylic Appliances

Dimensional instability of material may cause distortions Imperative to check these frequently & make necessary adjustments. Vital to check the path of insertion of appliance

4. Acrylic Bite Guards (Night Guards)

Treatment of bruxism and clenching Most common covers occlusal surface of teeth

For additional support palate is covered

Maxillary Hawley Bite Plane with a labial wire

Advantage posterior teeth freed of occlusal contact

Used in anterior overbite

Disarticulates posterior teeth

5. Removable Cast Appliances

Usually a rigid casting either of gold or of chrome cobalt Friedmans variation double continuous clasp casting

One end 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

Another modification is an interlocking attachment on the distal end

6. UV Light Polymerizing Bonding Materials Polson & Billen "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 popular kit NUVA SYSTEM (Caulk, Division of Dentsply lnternational Inc. Milford, Delaware)

The composite resin splint can be strengthened by adding wire, monofilament line, fiberglass or by using a fibre meshwork to reinforce the material

E.g.: RIBBOND, Ribbond Inc., Seattle, WA

Extracoronal resin-bonded retainers can strengthen the overall bonded situation

The splints are usually cast from metals, usually non noble alloys

Greater inherent strength

than composite-resin splint

Grooves, pins and parallel preparations increase retention

DIAMONDCROWN (Biodent Inc., Mont-Saint-Hilaire, QC) claims improved diametric tensile strength & bonding capabilities

INTRACORONAL SPLINTS 1. Wire Ligation Serves well for posterior teeth A channel is prepared on the labial, lingual and proximal

surfaces
Major disadvantage channels may become undercuts in

case crowns are needed later

2. Wire & Acrylic (A-Splint) Obin & Arvins wire fixed with acrylic in channels made in

mobile teeth
Utilized on occlusal surfaces of posteriors and lingual

surfaces of anteriors
Possibility of caries or breakage Utilized more readily with anterior teeth

3mm wide and 2mm deep channels Slight undercut

Pulp protection
Platinized knurled wire 22 to 16 gauge (0.64 1.3mm

diameter)
Major disadvantage recurrent caries

Kesslers variation of A-Splint

1 mm deep mesial and distal box is prepared parallel to long

axis
SnF2 or Ca(OH)2 varnish is applied and then threaded pin is placed Stainless steel wire is adapted around the pin while it passes through the slot

3. Amalgam Splint Limited to posterior teeth Teeth prepared with sound operative principles and amalgam is condensed 2 to 5 teeth may be splinted

Disadvantage Tend to fracture easily

4. Fixed Temporary Acrylic Bridges Used when permanent splints have to be given at a later

stage
With time acrylic wears and breaks Some clinicians prefer cast occlusals

Some prefer metal copings (less irritating and less likely to

cause caries due to cement washout)

5. Wire & Amalgam Lloyd & Baer continuous amalgam splint Series of mesial-occlusal-distal preparations

Restored with amalgam with wire embedded in it

Disadvantages - Limited to posterior teeth and possibility of fracture

6. Wire, Resin, & Amalgam (Trachtenberg) Embed the wire in

preexisting amalgam
with acrylic

Langeland et al
tagged acrylic in experimentally prepared cavities in monkeys

7. Cast Chrome-Cobalt Alloy Bars Baumhammers condensed amalgam over a 14 gauge

chrome-cobalt bar

Corn & Marks cast bar fabricated on study casts prior to insertion

A channel is made in the teeth to be stabilized; bar is

inserted with acrylic into grooves prepared

PROVISIONAL SPLINTS

May be used for months upto several years

Usually fabricated in acrylic

Stabilize a mobile dentition from initial tooth preparation to

the time for permanent restorations

Provide Stability, Occlusal function, Good esthetic result

1. All Acrylic Most common Can be fabricated chairside

Limitation marginal adaptation

2. Adapted Metal Bands & Acrylic Amsterdam & Fox copper / gold bands fitted and

incorporated into acrylic

Fulfills all objectives exact marginal fit (caries control &

pulp protection)
Frequent removal is possible added strength of metal bands

PERMANENT SPLINTS

Continuous Clasp Devices

REMOVABL E

Swing Lock Devices Overdenture

FIXED CAST METAL RESIN BONDED FPDs COMBINE D ENDODONTIC POSTS

Full Coverage / th Crowns, Inlays Posts in Root Canals Horizontal Pin Splints Removable-Fixed Splints Fixed Bridges in Partial Dentures Partial Dentures & Splinted Abutments Full / Partial Dentures on Splinted Roots

Swing-Lock Devices

Used in situations where fixed splinting is not possible or

desirable

Advanced age, poor physical / mental status, questionable prognosis

Advantages Conceals metal, avoids torque

Overdentures

Used where few teeth with questionable prognosis remain

Advantages Favorable crown-root ratio, retention of alveolar bone around roots

Disadvantage Recurrent periodontal disease

FIXED SPLINTS

Full coverage - simple Inlays more conservative

Reciprocal stabilization in all directions

Palatal bar cross arch stabilization

Advantages comfortable, esthetic

Cast Metal Resin Bonded FPDs

Maryland splints Used with intact or very slightly altered enamel surfaces

Advantages functional, esthetic, reversible, economic

Not suitable for excessively mobile teeth under strong

occlusal load

I.

UNILATERAL SPLINTING

II.

BILATRAL / CROSS-ARCH SPLINTING

BILATRAL / CROSS-ARCH SPLINTING

A.

CONTINUOUS SPLINTS SEGMENT SPLINTS 1. 2. 3. 4. Non Rigid Connectors Soldered Joints Locking Rod And Tube Coping Connector

B.

 NON-RIGID CONNECTOR

SOLDERLESS JOINT

 LOCKING ROD & TUBE

COPING CONNECTOR

COMMONLY USED SPLINTS For Anterior Teeth 1. Wire Ligatures 2. Direct Bonding Systems 2. A-Splints 3. A-Splint 3. Bite Guards 4. Variation of A-Splint 4. Rigid Occlusal Splints 5. New Generation Bonded Reinforcing Materials with Composites 5. Composite Splints for Severe Bruxism For Posterior Teeth 1. Intracoronal Amalgam Wire Splints

J Can Dent Assoc 2000; 66: 440-443

J Can Dent Assoc 2000; 66: 440-443

Dental Traumatology 2006; 22: 345-349

J Prosthet Dent 2000; 84: 210-214

DISADVANTAGES OF SPLINTING

HYGIENIC

MECHANICAL

BIOLOGICAL

CONCLUSION
Composite resin splints with fiber reinforcement

BOON or BANE

REFERENCES 1. PERIODONTAL THERAPY Henry M. Goldman & D. Walter Cohen, 6th Ed

2. PERIODONTICS IN THE TRADITION OF GOTTLIEB AND ORBAN Grant, Stern & Listgarten, 6th Ed 3. PERIODONTAL DISEASES Schluger, Youdelis, Page, & Johnson, 2nd Ed 4. Periodontology 2000, Vol 4, 1994, 15-22

REFERENCES 5. Compendium Aug 2001, Vol 22, No. 8, 610-620 6. J Can Dent Assoc 2000; 66: 440-443 7. J Contemp Dent Pract Nov 2002; (3) 4: 10-22 8. DCNA, Vol 43, No. 1, 1999 9. BDJ, Vol 191, No.10, Dec 8, 2001

10. Dental Traumatology 2006; 22: 345-349

11. J Prosthet Dent 2000; 84: 210-214