Dental splinting

Splinting is one of the oldest forms of aids to periodontal therapy. By redistribution of forces on the affected teeth the splint minimizes the effects caused by loss of support. Splinting teeth to each other allows weakened teeth to be supported by neighbouring teeth. This presentation reviews the rationale, techniques, advantages and ill effects of stabilization of teeth by splinting as an aid to periodontal therapy. With the acceptance and clinical predictability of adhesive procedures, the use of conservative bonding techniques to splint teeth offers a useful alternative to more invasive restorative procedures. Loss of tooth-supporting structures results in tooth mobility. Increased tooth mobility adversely affects function, aesthetics, and the patient’s comfort. Splints are used to overcome all these problems. When faced with the dilemma of how to manage periodontally compromised teeth, splinting of mobile teeth to stronger adjacent teeth is a viable option. This prolongs the life expectancy of loose teeth, gives stability for the periodontium to reattach, and improves comfort, function and aesthetics.

1. DR. SHRADDHA KODE SPLINTING – A HEALING THERAPY FOR THE PERIODONTIUM

2. PATIENT: “Some of my teeth are mobile”

3. Dental splinting (Glossary of Prosthodontic Terms 1999): The joining of two or more teeth in to a rigid unit by means of fixed or removable restorations/ devices. Periodontal Splint (Glossary of Prosthodontic Terms): Rigid or flexible device that maintains in position a displaced or movable part, also used to keep in place and protect an injured part. WHAT IS SPLINTING?

4. HISTORY Phoenician mandible from 500BC found in modern day Lebanon which has two carved ivory teeth attached to four natural teeth by gold wire. Obin and Arvin’s (1951) – Self curing internal splint Egyptians(3000 -2500 B.C.) show similar gold wiring Early 1700s-Fauchard attempted tooth ligation

5. Wellensiek(1958), Shatzkin(1960) & Taatz(1964) – intra coronal splints Harrington (1957) – Modification of splint by incorporating cemented stainless steel wire Most complete literature review on tooth stabilization was by Lemmerman in 1976 Cross(1954) – Continuous amalgam splints PRESENT Bondable Fibre Splinting

6. OBJECTIVES To provide rest to the supporting tissues Redistribution of forces Redirection of forces Preservation of arch integrity Restoration of functional stability Psychological well being Promote healing Increase patient’s esthetics, comfort and function

7. IDEAL SPLINT (Simring & Thaller, 1956)

8. Stabilise moderate to advanced tooth mobility that cannot be treated by other means Stabilise teeth with increased tooth mobility interfering with normal masticatory function Secondary occlusal trauma Prevent tipping or drifting of teeth Prevent extrusion of unopposed teeth Stabilization of mobile teeth during surgical especially regenerative therapy ( Serio 1999) Stabilise teeth following acute trauma Stabilise teeth following orthodontic movement INDICATIONS

9. When there is moderate to severe tooth mobility in the presence of periodontal inflammation or primary trauma (Nyman and Lang, 1994) Insufficient number of non-mobile teeth to adequately stabilise mobile teeth Poor oral hygiene High caries activity Crowding and malaligned teeth that may compromise the utility of splint CONTRAINDICATIONS

10. ADVANTAGES DISADVANTAGES Establish stability and comfort for patients with occlusal trauma Difficulty in maintaining oral hygiene Helps to accelerate healing following acute trauma and regenerative therapy Leads to caries development Allows remodelling of alveolar bone and PDL for splinted teeth Can destroy other teeth if the forces are not distributed properly Distribute occlusal forces over a wider area Technical difficulty

11. PRINCIPLES OF SPLINTING Inclusion of sufficient number of healthy teeth Splinting around the arch Coronoplasty may be performed to relieve traumatic occlusion

12. Splints should facilitate proper plaque control Splints should be esthetically acceptable Splints should not interfere with occlusion

13. By Weisgold CLASSIFICATION OF SPLINTS Temporary splints <6 months To stabilise teeth during periodontal treatment May or may not lead to other types of splinting Provisional or Semi- permanent splints Few months to as long as several years For diagnostic purpose To see how teeth will respond to treatment To see how missing teeth may be replaced Permanent splints used indefinitely Can be fixed or removable

14. Modified classification by Ross, Weisgold and Wright Temporary splints Provisional splints Acrylic splints Gold band and acrylic splints Permanent splints Removable Fixed Combination Extra-coronal Intra-coronal Wire & acrylic Wire & amalgam Wire,acrylic & amalgam Removable Acrylic bite guards Cast removable clasp appliance Fixed Wire & acrylic splints Wire mesh & acrylic splints Orthodontic bands soldered in series

15. TRADITIONAL TECHNIQUES TITANIUM TRAUMA SPLINT CAST METAL SPLINT COMPOSITE WIRE SPLINT COMPOSITE INTERLOCKING SPLINT BAND-ARCH WIRE SPLINT

16. ADVANTAGES Easy to use Esthetically pleasing Less incidences of fracture at metal-resin interface Acts as a stress bearing component Increases toughness of material by crack-deflecting mechanism NEW ADVANCES FIBRE-REINFORCED MATERIALS

17. COMMERCIALLY AVAILABLE FIBRES LENO WEAVE POLYETHYLENE FIBRES – RIBBOND UNI-DIRECTIONAL PRE-IMPREGNATED GLASS FIBRES SPLINT-IT OPEN WEAVE GLASS FIBRES – INTERLIG

18. Freshly drawn glass fibres degrade on exposure to moisture and humidity Hence, they are coated with resins for high strengths and called pre-impregnated They dissipate stresses and prevent crack propagation when exposed to multi-directional forces COLD PLASMA TREATMENT Hydrophobic hydrophilic state CREATION OF A CHEMICAL BOND WITH RESIN AND FIBRE

19. Leno weave cross-linked and lock-stitched polyethylene fibres Resistant to sliding and shifting forces Ultrahigh tensile strength THM RIBBOND – 0.18mm thick Thinner than RIBBOND but not better breaking resistance Adapts closely to the teeth Final finish is esthetic and smoother

20. PROCEDURE Place wedges in the interdental spaces as necessary, so that the spaces to be cleaned are not filled with composite. If you are working without wedges, be careful not to block these spaces with composite. Clean the teeth - All surfaces of the teeth to be splinted are thoroughly polished with a slurry of pumice and water using a rotating brush, rinsed and dried with air. Measure the fibre using periodontal probe or dental floss and cut the fibre and saturate it with bonding agent

21. Acid etching – 37% phosphoric acid is applied to the interproximal and lingual surfaces to be bonded with an applicator tip for 30seconds. Rinse with water and dry. Lightly frosted appearance can be seen. A hand instrument is used to place a small amount of composite onto the lingual surfaces (but not cured) Bonding agent is applied, lightly blown with air, and cured to all etched surfaces

22. The bonded strip is then covered incrementally with flowable composite, resulting in a smooth surface By using a gloved finger, the strip is pressed into uncured composite and cured initially into place Finish and then evaluate the occlusion

23. TIPS In posterior teeth, groove is placed on occlusal surface with one abutment tooth on each side In mandibular teeth, groove should be placed more apical. Cingulum should act as a seat for placement of fibre In maxillary teeth, groove should be placed at the incisal third of the tooth surface Good isolation should be achieved Un-polymerised fibre areas should be well protected from light source Proper polishing should be done for a smooth finish

24. CONCLUSION Effective plaque control and professional caries risk assessment is crucial for longevity of the splint By combining the chemical adhesive and esthetic characteristics of composite resin with strength enhancement of fibre reinforcing material, dentists can provide patients with restorations and splints that resist the load bearing forces of occlusion and mastication

25. Prichard 2 nd edition Lindhe 5 th edition Shailly et al; Splinting – A Healing Touch for an Ailing Periodontium; Journal of Oral Health Community Dentistry; September 2012 Edwin et al; Aspects in Effectiveness of Glass- and Polyethylene-Fibre Reinforced Composite Resin in Periodontal Splinting;2016 Davies et al; Occlusal considerations in Periodontics; British Dental Journal, Volume 191, NO. 11, DECEMBER 8 2001 597 Guillermo et al; A Review of the Clinical Management of Mobile Teeth; The Journal of Contemporary Dental Practice, Volume 3, No. 4, November 15, 2002 Rahul et al; To Splint or Not to Splint: The Current Status of Periodontal Splinting; Journal of the International Academy of Periodontology · April 2016 REFERENCES