Splinting

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

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

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

8. CAUSES

9. TRAUMA FROM OCCLUSION

10. ACUTE TFO

11. CHRONIC TFO It is more common and is of greater clinical significance. 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 It leads to increased tooth mobility.

12. PRIMARY TFO

13. 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. Ferenez in 1991 reported that there is little rationale for splinting teeth manifesting primary occlusal trauma.

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

15. ASSESSMENT OF TOOTH MOBILITY

16. CLINICAL MEASUREMENT

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

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

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

20. periodontometer Muhlemann in 1957

21. PERIOTEST

22. SPLINT

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

24. Simring in 1952 described the theory and practice of splinting in detail: 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 . 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.

25. 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.

26. RATIONALE Comfort and Psychologic well being of the patient 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 Redirection Of Forces : Splinting effects a redirection of force in a more axial direction over all the teeth included in a splint

27. 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 Preservation of arch Integrity Splinting restores proximal contacts that have been disrupted by missing and migrated teeth

28. INDICATION (AAP)

29. CONTRA-INDICATIONS

30. IDEAL SPLINT

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

32. 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

33. UNILATERAL AND BILATERAL SPLINTS

34. 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 : Fixed- Full crowns, pin ledge type of abutment retainers. Semirigid Removable - Telescopic crowns, clasp supported partial denture.  

35. 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)

36. 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

37. TEMPORARY SPLINTING INDICATIONS :

38. CHOICE OF SPLINTS

39. LIGATURE SPLINTS

40. FABRICATION

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

42. 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

43. 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)

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

45. WELDED BAND SPLINTS

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

47. 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.

48. NIGHT GUARD

49. Advantages Tends to stabilize mobile teeth Control bruxism and prevent excessive wear of teeth Prevent hypereruption of teeth without antagonists Eliminate trauma from occlusion Disadvantages Tend to rock and become flexible over use. 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.

50. EVALUATION

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

52. INTERNAL SPLINTS

53. ACRLYLIC SPLINTS

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

55. COMPOSITE SPLINT

56. 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

57. AMALGAM SPLINT

58. 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.

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

60. EVALUATION

61. 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.

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

63. INDICATIONS

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

65. CONTRAINDICATIONS

66. OBJECTIVES FOR SPLINTING WITH FPD

67. 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.

68. SWING LOCK DEVICES

69. OVER DENTURE

70. 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

71. 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.

72. 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 .

73. 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.

74. DRAWBACKS OF SPLINTING

75. 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.

76. 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.

77. REFERENCES Clinical periodontology : Carranza Clinical periodontology : Jan lindhe DCNA volume 43 Grant Stern and listgarten Ramfjord Decision making in Periodontics : Walter B Hall 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

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