Splinting procedure and steps in dentistry.

Dentistry Splinting Procedure

1. A Boon or Bane?A Boon or Bane?
Periodontal SplintingPeriodontal Splinting
Dr. T VedanDr. T Vedan
(Updated from Dr. G Abrahams)(Updated from Dr. G Abrahams)
Department Oral Medicine and Department Oral Medicine and
PeriodonticsPeriodontics
UWCUWC

3. IntroductionIntroduction
Technique of splinting has been used as a form of dental
treatment for centuries.
Early evidence of tooth splinting.
Ward and Weinberg (1961)

(Watkins et al, 2000).

4. Definition: SplintingDefinition: Splinting
“A rigid or flexible material used to protect, immobilize or resist
motion in a part” (Dictionary).
In dentistry “The joining of two or more teeth into a rigid unit by
means of fixed or removable restorations or devices”(Barzilay,
2000).

“An appliance designed to stabilize mobile teeth” (Glossary of
Periodontic terms, 1986).

5. Applications of splintingApplications of splinting
Splinting of teeth can be utilised in many clinical scenarios:
Traumatic injuries of teeth (avulsed, blunt trauma)
Mobile, migrating periodontally compromised teeth
Post-orthodontic retention
Management of TMJ dysfunction and parafunction with occlusal
splints
Prosthetic treatment where multiple abutments are necessary
 
Eley, 2004; Watkins, 2000; Barzilay, 2000.

6. Principles of splinting:Principles of splinting:
Should reduce movement 3 dimensionally
Centre of rotation of the affected teeth
must be located in the remaining
supporting bone.
No inflammation
Minimum one third of bone support
remaining.
Should allow for oral hygiene methods
Should not irritate soft tissues

7. Applications of splinting:Applications of splinting:

8. Etiology if mobility
Trauma
Pericapical infection
Periodontal disease
Occlusal trauma
Orthodontic treatment
Root resorption
Abnormal tooth morphology
Newman et al, 2008; Lindhe et al, 2008

9. TraumaTrauma
Traumatic injuries of teeth:
Fractures
Concussion
Avulsion
Luxation (displacement)
Intrusion
Post- trauma (flexible) splinting allows some physiological
loading of teeth which is beneficial to the periodontal
ligament.

10. TraumaTrauma
Tooth migration/ mobility may also be associated with
habits:
Pipe smokers
Pencil chewing
Tongue thrusting
Newman et al, 2008; Davies et al, 2001

11. Periodontal diseasePeriodontal disease
Characterized by accumulation of subgingival plaque, gingival
inflammation, loss of connective tissue attachment and bone
the affected teeth eventually leads to mobility.
Periodontally compromised teeth often begin to drift in
response to normal forces acting on teeth with compromised
periodontal support.
Destruction of the attachment apparatus also causes uneven
distribution of the occlusal load and subsequently additional
damage to the alveolar bone.
Splinting of compromised teeth allows the affected teeth to
gain support from neighbouring teeth.
Puri et al, 2012; Lindhe et al, 2008

12. Occlusal traumaOcclusal trauma
Definition:
“Trauma from occlusion is damage in the periodontium
caused by stress on the teeth produced directly or indirectly
by teeth of the opposing jaw” (WHO, 1978).
“An injury to the attachment apparatus of the tooth as a
result of excessive occlusal force” (AAP, 1986).
“Occlusal trauma can be defined as trauma to the
periodontium from functional or parafunctional forces
causing damage to the attachment apparatus of the
periodontium by exceeding its adaptive and reparative
capacities”
Davies et al, 2001

13. Occlusal traumaOcclusal trauma
Sources of excessive occlusal stress:
Abnormal or parafunctional activity
Dental treatment – creation of occlusal interferences
Occlusal disharmony
Periodontal disease

14. Occlusal traumaOcclusal trauma
Clinical features:
Increasing tooth mobility, migration or
drifting
Persistent discomfort on eating
Wear facets, attrition
Thermal sensitivity
Fremitus (vibration palpable when teeth
come into contact)

15. Occlusal traumaOcclusal trauma
Radiographic signs of occlusal trauma:
Discontinuity or thickening of the lamina
dura (compact bone that lies adjacent to
the PDL, allows attachment surface for
Sharpey’s fibres)
Widening of periodontal ligament space
(PDL)
Radiolucency and destruction of the
alveolar bone
Root resorbtion
Formation of angular bone defects

16. Assessing tooth mobilityAssessing tooth mobility
Clinical assessment :
Application of force to the tooth crown with two blunt ended
instruments.
Grading of mobility: Millers Index (1950)
Degree 0: Normal physiological tooth movement of between 0,1-0,2
mm in a horizontal direction.
Degree 1: Increased mobility of the tooth to at most 1mm in a
horizontal direction.
Degree 2: Visually increased mobility of the tooth exceeding 1mm in
a horizontal direction.
Degree 3: Severe mobility of the tooth both in a horizontal and
vertical direction
Lindhe et al, 2008

17. Distinguish between Distinguish between
increasedincreased and and increasingincreasing
tooth mobilitytooth mobility
Increased
Adaptation of the
periodontium to occlusal forces
not considered pathologic.
Radiograph: widened PDL.
Absence of inflammation –
affected teeth can be
maintained by occlusal
equilibration and splinting (if
extensive mobility).
Increasing:
Presence of inflammation
(pocketing and bleeding in
affected sites) and tooth
mobility.
Periodontal treatment
must first be performed.
Thereafter – occlusal
interferences can be
corrected and teeth
splinted.
Puri et al, 2012.

18. Splinting as a treatment modalitySplinting as a treatment modality
Rationale: joining mobile teeth to less mobile teeth creating a
“Multi-rooted unit”,
This increases the total area of root resistance thus preventing a
local gross overload of force on the compromised tooth
Resulting in a force distribution among a number of teeth.
Involve individual or multiple teeth – depending on the clinical
situation.
Possible alternative in situations where extractions and implant
therapy is not a viable treatment option for the patient.
Splinting of mobile teeth should only be viewed as a short-term or
transitional treatment modality.
Watkins et al, 2000; Mosedale, 2007; Griffin, 2005

19. Indications splinting:Indications splinting:
Only be applied once periodontal treatment has been
performed, local factors eliminated and occlusal interferences
have been corrected.

Mobility is progressively increasing – the teeth are exposed to
extraction forces during function.
Multiple teeth that have become mobile and are drifting as a
result of gradual alveolar bone loss.
Restore proximal contacts that have been disrupted by the
migration of teeth.
Puri et al, 2012; Eley, 2004

20. Indications splinting:Indications splinting:
Stabilize moderate to advanced tooth mobility (teeth that
have not responded to occlusal adjustment and periodontal
therapy).
It permits and improves masticatory function and comfort.
To facilitate mechanical debridement and surgical
procedures of mobile teeth.
To protect, provide stability and rest for the tooth-supporting
tissues during the healing period after periodontal treatment.
Puri et al, 2012; Eley, 2004

21. Indications for splinting:Indications for splinting:
Redirection of forces - forces of occlusion can be
redirected in a more axial direction over the teeth in the
splint.
Redistribution of forces - there is stabilization in response to
the applied force. This ensures that forces do not exceed
the adaptive capacity of compromised teeth.
Psychological well-being - provides some psychological
comfort from the fear of the loss of loose teeth.
Puri et al, 2012; Eley, 2004

22. Contra-indications for splinting Contra-indications for splinting
In situations where occlusal stability and optimal
periodontal conditions cannot be obtained.
Occlusal or masticatory forces exceed the resistance
provided by the splinted teeth.
Puri et al, 2012; Eley, 2004

23. Classification of splintsClassification of splints
Eley, 2004, Mosedale, 2007

24. 1. Temporary splint1. Temporary splint
Indicated to stabilize teeth and absorb occlusal forces for
a limited period.
Usually not longer than 2 months.
Clinical scenarios : stabilize teeth during periodontal tx
/regenerative therapy/ after trauma.
NO tooth structure removed with placement.
Examples: composite resins (with or without wire)
Eley, 2004, Mosedale, 2007

25. 2. Provisional splint2. Provisional splint
Usually used for 4-6 months.
Used for diagnostic information.
Allows clinician to observe the healing response to treatment
and make adjustments based on patient response to
treatment.
At a later stage the clinician can design a more permanent
and biologically acceptable form of treatment.
Examples: acrylic splints, vacuum-formed splints.
Eley, 2004, Mosedale, 2007

26. 3. Permanent splint3. Permanent splint
Placed indefinitely.
Non-reversible device.
Requires tooth preparation.
Placed after completion of periodontal therapy and once
occlusal stability has been achieved.
Examples: fixed bridges, acrylic and chrome dentures
Eley, 2004, Mosedale, 2007

27. Qualities of ideal splint:Qualities of ideal splint:
Simple, efficient, economical.
Non-irritating - not impinge or irritate the soft tissues,
gingiva, cheeks or lips.
Aesthetically acceptable and biologically compatible.
Rigid and durable - not allowing torsional stresses on the
teeth.
Not impair speech.
Not promote food impaction.
Eley, 2004, Mosedale, 2007

28. Qualities of ideal splint:Qualities of ideal splint:
It should incorporate as many healthy, firm teeth to
assist in minimising the load on the individual affected
teeth.
Should extend across the arch, so that the anterior-
posterior forces and bucco-lingual forces are
counteracted.
Does not interfere with the occlusion – gross occlusal
interferences should be eliminated prior to placing the
splint.
Design should not block the embrasure spaces and
allow proper oral hygiene maintenance by the patient.
Eley, 2004, Mosedale, 2007

29. Placement of a composite splint (with or Placement of a composite splint (with or
without wire):without wire):
Wire (dead-soft round stainless steel wires – usually 0,25 to
0,30mm thickness) is adapted to the tooth arch for
placement on the teeth.
Wire is placed apical to proximal contacts and incisal to
the cervical contacts.
Eley, 2004

30. Materials needed:Materials needed:
1
2
3

31. Placement of a composite splint (with or Placement of a composite splint (with or
without wire):without wire):
Moisture control is essential during splinting and
the use of a rubberdam is advocated.
Enamel surfaces must be properly cleaned to
achieve an adequate etching of the area.
The enamel is etched for 15-20 seconds with
35% phosphoric acid, rinsed, dried and a light
curable dentin-bonding agent is applied.
Composite filling material (with or without a
wire) is placed and cured.

38. Disadvantages of splintingDisadvantages of splinting
Plaque control
Removable splints allow the patient to practise normal plaque
control measures.
Fixed splinting modalities may compromise the ability of
patients to maintain adequate plaque control.
Periodontal monitoring
Fixed splints prevent proper clinical assessment of teeth and
also reduces the patients awareness of increasing tooth
mobility.
Effective recall systems need to be established with regular
clinical and radiographic review.  Watkins, 2000

39. Disadvantages of splintingDisadvantages of splinting
Dental caries
In the presence of poor plaque control associated with poor
splint design, there is a risk for caries development.
Thus regular review, plaque control and proper splint design is
essential to prevent detrimental effects.
Maintenance of splints
Biological failure of splints can be the result of dental caries,
progressing periodontal disease, endodontic failures and
mechanical splint failure.
Occlusion needs to be meticulously monitored and finely
adjusted after splint placement . Watkins, 2000

40. ConclusionConclusion
Periodontal splinting can be a useful tool in specific
situations.
However if applied incorrectly, it can have a further
detrimental effect.
After placement of a splint, vigilant periodontal
maintenance and monitoring is essential.
Splinting is never a substitute for thorough diagnosis and
effective periodontal treatment.
Decision to splint should not be taken lightly and should
only be considered following appropriate periodontal
and occlusal management.
Watkins, 2000; Mosedale, 2007

41. References
Barzilay, I. (2000). Splinting teeth – A review of the methodology and clinical case reports. J
Can Dent Asso; 66:440-443.
Bernal,G. Carvajal,JC. & Munoz, CA.(2002). A review of the clinical management of mobile teeth. The Journal of
Contemporary Dental Practice; Volume 3, No4.
Davies, SJ. Gray, RJM. Linden, GJ. & James, JA. (2001). Occlusal considerations in periodontics. British Dental Journal;
191(11): 597-604.
Eley, BM. (2004). Periodontics. Fifth edition. Wright; pg: 361-368.
Griffin, EC. (2005). To splint or not to splint: Treating periodontally compromised teeth by improving occlusion.
Contemporary Aesthetics and Restorative Practice. Continuing Education.
Lindhe, J. Lang, NP. & Karring, T. (2008). Clinical periodontology and Implant Dentistry. Blackwell Munksgaard.Volume
2: 183-249.
Mosedale, RF. (2007). Current indications and methods of periodontal splinting. Dental Update; 34: 168-180.
Newman,M. Takei, HH. Klokkevold, PR. Carranza, FA. (2006). Caranza’s Clinical Periodontology –Tenth Edition.
Saunders.
Puri, MS. Grover, HS. Gupta, A. Puri,N. & Luthra, S. (2012). Splinting – A healing touch for an ailing periodontium.
Journal of Oral health and Community Dentistry; 8: 145-148.
Watkins, SJ. & Hemmings, KW. (2000). Periodontal splinting in general dental practice. Dental Update; 27: 278-285.