The seminar covers splinting in periodontics. it explains the overall topic in depth.

1. 1

2. • INTRODUCTION
• HISTORY
• DEFINITIONS AND TERMINOLOGIES
• CLINICAL RATIONAL FOR SPLINTING
• INDICATIONS & CONTRAINDICATIONS
• EFFECTS OF SPLINTING
• BASIC CONSIDERATIONS BEFORE SPLINTING
• TEMPORARY,PROVISIONAL & PERMANENT SPLINTS
• CONCLUSION
• REFERENCES 2

3. • The ultimate goal in successful management of mobile teeth is to restore
function and comfort by establishing a stable occlusion that promotes
tooth retention and the maintenance of periodontal health.
• Some mobile teeth can be treated through occlusal equilibration alone
(primary occlusal trauma) where as mobile teeth with a compromised
periodontium can be stabilized with the aid of provisional and /or
definitive splinting (secondary occlusal trauma)
3

4. Definitions :
• According to Glossary of Periodontic Terms 1986 : a splint is “an
appliance designed to stabilize mobile teeth”.
• According to AAP (1996), a splint has been defined “as an apparatus,
appliance, or device employed to prevent motion or displacement of
fractured or removable parts.”
• The Glossary of Prosthodontic Terms defines splint as “a rigid or flexible
device that maintains in position a displaced or movable part; also used
to keep in place & protect the injured part.”
• Dawson defines splinting as “the joining of two or more teeth for the
purpose of stabilization”.
4

5. TERMINOLOGY:
STABILIZATION:
• Stabilization of a tooth is an increase in resistance to applied force by
providing reciprocal antagonisms and increasing the effective root area.
The force may remain the same, but the resistance is increased.
TEMPORARY SPLINT:
• This is used on a short term basis, usually less than 6 months, and is often
advocated to stabilize teeth during periodontal treatment. It may or may
not 1ead to other types of splinting.
PROVISIONAL SPLINT:
• This type of splint is used for a longer period of time from several months
6

6. PERMANENT SPLINTS:
• Permanent splinting of teeth that have been treated periodontally is
also referred to as Periodontal prosthesis.
• Periodontal prosthesis may be defined as those restorative and
prosthetic endeavors that are indicated and essential in the total
treatment of advanced periodontal disease.
7

7. Phoenician mandible from 500BC and another Phoenician
prosthetic appliance was found from 400 BC in modern day
Lebanon that is comprised of two carved ivory teeth attached to
four natural teeth by gold wire.
8

8. • Archeological excavations of the Etruscan society (8th BC to the 1st
century AD) have found evidence of their use of wire ligation and gold
bands to stabilize teeth.
• In early 1700s : Fauchard attempted tooth ligation.
• In the 1900s : several authors described splinting techniques that dated
back to the 1800s.
• Hirschfeld (1950) was one of the first modern periodontal authors to
advocate ligation of periodontally diseased teeth using either stainless
steel wire or silk. His technique was extracoronal and involved only the
anterior teeth.
9

9. WHEN TO SPLINT
?
10

10. • Occlusal forces applied to a splints are shared by all teeth within the
splint even if the force is applied to only one section of the splint.
• Rigidity of the splint acts as lever, so that the forces applied to some
teeth in the splint may be much greater than before splinting.
• One tooth within the splint with occlusal disharmonies may cause
damage to periodontium of the other teeth in the splint.
11

11. INCREASED VERSUS INCREASING TOOTH MOBILITY
• Two clinical features should be analyzed to understand the full scope of the
relationship between occlusal trauma and tooth mobility.
The first is increased tooth mobility :
• Adaptation of the periodontium to occlusal forces that may not
necessarily be considered pathologic.
• Mobile teeth with a complete and healthy connective tissue
attachment and absence of inflammation can be maintained.
• Radiographic ( widened PDL space ) + clinically ( tooth mobility ) –
manifestation to increased functional demnads. 12

12. • Removal of the excess occlusal load through
equilibration and perhaps, conventional splint therapy
can decrease and, often at times, eliminate tooth
mobility
13

13. Increasing tooth mobility :
• Clinical condition is due to occlusal trauma compromised by presence
of inflammation and further destructive periodontal disease.
• Occlusal equilibration, periodontal therapy reevaluation for
extraction or splinting of the affected teeth.
14

14. • Main objective of splinting is to decrease movement three-
dimensionally.
• Proper placement of a cross-arch splint.
Unilateral splints that do not cross the midline tend to
permit the affected teeth to rotate in a faciolingual
direction about a mesio-distal linear axis.
15

15. • Moderate to advanced mobilities (2 degrees or more) are present and
cannot be treated by any other means.
• Pre-prosthetic surgery; after orthodontic repositioning; surgical trauma
• Multiple teeth that have become mobile as a direct result of gradual
alveolar bone loss, a reduced periodontium.
• Increased tooth mobility accompanied by pain or discomfort in the
affected teeth.
• To avoid dislodging teeth prior to and during re-constructive procedures
(Occlusal reconstruction).
16

16. • Moderate to severe tooth mobility in the presence of periodontal
inflammation and / or primary occlusal trauma.
• Insufficient number of firm / sufficiently firm teeth to stabilize
mobile teeth.
• Prior occlusal adjustment has not been done on teeth with occlusal
trauma or occlusal interferences.
17

17. • Simple,
• Economic,
• Stable and efficient,
• Hygienic,
• Nonirritating,
• Not interfere with treatment,
• Esthetically acceptable, and
• Not provoke iatrogenic disease.
18

18. • Rest
• Reduction of mobility
• Redirection of forces
• Redistribution of forces
• Restoration of functional stability
• To preserve arch integrity (proximal contacts)
• To stabilize mobile teeth during surgical, especially
during regenerative periodontal therapy.
• To prevent migration and over eruption.
• Psychologic well being
19

19. • Physiologic and pathologic tooth mobility :
Usually assesses as amplitude of crown displacement resulting from application of a
defined force (0.1N)
20

20. • In teeth with non-inflamed periodontal tissues, two basic factors determine the
degree of tooth mobility:
• Persistent mobility after correction of underlying periodontal condition –
PATHOLOGICAL MOBILITY
• If height of underlying periodontium reduced but no PDL widening, root mobility
exempted by such teeth will be same as teeth with normal periodontium :
PHYSIOLOGICAL MOBILITY
21
The height of the
supporting tissues
The width of the
periodontal ligament.

21.  TOOTH MOBILITY
If a combination of a widened periodontal ligament and a reduced
height of the periodontal support is the reason for the increased
mobility, occlusal adjustment may be sufficient to reduce the mobility
to an acceptable degree. However, if the patient’s subjective chewing
comfort is still disturbed, splinting may be considered.
OCCLUSAL ADJUSTMENT SPLINTING
WIDENING OF PDL
REDUCED HEIGHT OF
SUPPORTING TISSUES
22

22. IN ADVANCED PERIODONTAL CONDITIONS :
• Progressive breakdown of periodontium not able to tolerate
the normal masticatory forces.
• Periodontal therapy and occlusal adjustment of no value…
• SO WHAT CAN BE DONE ?????????
23

23. S. Kourkouta, K. W. Hemmings L. Laurell. Restoration of
periodontally compromised dentitions using cross-arch
bridges. Principles of perio-prosthetic patient
management BRITISH DENTAL JOURNAL VOLUME
203 NO. 4 AUG 25 2007
24

24. • The only way to preserve such dentitions is to use teeth as abutments of
cross arch design……and not unilateral fixed bridges.
• Cross arch design reduces lever effect of the occlusal forces and they
are evenly distributed…
• Unilateral bridge concentrates the masticatory forces of normal
magnitude onto the abutment teeth, worsening the underlying
periodontal condition.
25

25. A.On the basis of DURATION AND PURPOSE (LEMMERMAN in
1976)
Temporary splints – less than 6 months during periodontal
therapy
Provisional splint – several months to years for diagnostic
purpose
Permanent splint – worn indefinitely
REMOVABLE
FIXED
27

26. REMOVABLE
Occlusal Splint with wire
Hawley appliance with arch wire
FIXED
Intracoronal
Amalgam
Amalgam & Wire
Amalgam , Wire & Resin
Composite Resin & Wire
Extracoronal
Stainless steel wire with resins
Wire & Resin with acid etching
Enamel etching & composite
resin
Orthodontic soldered bands,
Brackets & Wire
Acrylic splints
Metal band etc.
Removable/Fixed
Extra/Intracoronal
Full/Partial veneer crowns
soldered together.
Inlay/Onlay soldered together.
28

27. B.Short Term , Provisional And Long Term….. (FERENZ in
1991)
29

28. C. According to the type of material:
 Bonded composite resin splint; Braided wire splint; A –
Splints.
C. According to the location on the tooth:
30

29. • According to Caranza, two major indications
for periodontal splinting are
• a)to immobilize excessively mobile teeth so that the patient can chew
more comfortably
• b)to stabilize teeth exhibiting increasing mobility.
• He further defined three procedures for provisional stabilization which are
• the reinforced resin splint for use in the posterior teeth
• the acid etch resin splint for use in anterior teeth
• the resin bonded metal splint.
31

30. 33

31. 36

32. • Most popular temporary extracoronal wire ligature and acrylic
splint.
• Indicated for use around the mandibular anterior teeth and also
around maxillary anterior teeth.
Armamentarium
37

33. CLARK The Wire Ligature-Acrylic Splint J Periodotol 1969;40(6):371-379
38

34. 39

35. 40

36. • Stabilize both anterior and posterior teeth
• proper attention to the contours of the bands and to check their
relationship to the adjacent gingival tissue
• Teeth must be have open contcts so that a band or bands can be
inserted.
• Acrylic may be placed over the bands for cosmetic purposes
41

37. 42

38. 43
cast from metals, usually
non noble alloys that can
be electrolytically or
chemically etched
greater inherent strength than
a composite-resin splint
created intraorally.
Extra features such as grooves,
pins and parallel preparations
increase the retentive capacity
of these splints

39. DiamondCrown (Biodent Inc., Mont-Saint-Hilaire, QC) claim
improved diametric tensile strength and bonding capabilities.
• These materials may be considered for use in extracoronal applications.
• No long-term clinical data are available for these materials; however,
they seem promising at this time.
44

40. 45
most common type of appliance is one that
covers the occlusal surfaces of the teeth
usually covers the incisal & occlusal surfaces of
maxillary teeth with occlusal stops for all the
mandibular teeth on a flat surface area around
centric relation & with sufficient cuspid rise to
disocclude the posterior & anterior segments
during lateral & protrusive excursions
can be used only when there is an anterior
overbite so that the palatal bite plane can
disarticulate the posterior teeth.

41. • Another appliance is Hawley's bite plane.
• Used as a retainer for maxillary teeth with tendencies toward pathological
migration or relapse following orthodontic therapy.
• Often induces jiggling of such teeth.
• Biteplane - occlusal forces transmitted axially- eliminates jiggling forces
46

42. • Wire ligation,
• Wire and acrylic,
• Amalgam with an embedded wire &/acrylic and
• Composite resin with or without embedded wire.
INDICATIONS
• used only when permanent splinting is to follow.
• used on a provisional basis when tooth prognosis is guarded
47

43. 48
Klassman, Zucker Combination Wire—Composite Resin Intracoronal Splinting Rationale and
Technique J. Periodontol. August, 1976

44. 49

45. Indications :
• Terminal periodontal involvement when the prognosis for the remaining
abutments is not sufficient to warrant full or partial coverage cast
restorations.
• Economic consideration
• Lower anteriors, where root proximity contraindicates the use of full cast
coverage restorations.
• Aged or debilitated patients wrt time constraints
• Where prolonged temporary stabilization is needed with an eventual full
coverage commitment.
50

46. ADVANTAGES
• Comparative ease of fabrication
• Cost
• Longevity
• Esthetic
• No subgingival margins
• Contours
• Physical properties and manipulation.
DISADVANTAGES
• Potential pulpal initiation from acid
• occlusal wear
• Inability to control gingival third
contours.
• Lack of control of root and recurrent
caries.
• Inability to control root sensitivity
• Color
• primarily limited to anterior teeth.
51

47. • First popularized by Berliner
• Most commonly used in anterior teeth.
52
Becker, R.: Semi-Permanent Periodontal Splint: “A” splint. J. Michigan D.A., 46:306-309, 1964.
 Preparation of a channel approximately 3 mm wide and 2 mm deep in
several teeth.
 Pulpal surfaces should be coated with a protectant.
 Platinized knurled wire 22 to 16 gauge (0.64 to 1.3 mm in diameter) is
placed in the channel.
 Self-cure acrylic is placed to fix the wire in the channel.
 Occlusion is adjusted and the splint is polished .

48. • The problem
• retention of the wire to the tooth
• the acrylic to the wire
• resultant acrylic and wire complex to the teeth. Berliner advocated the use of the
widest wire necessary to almost fill the preparations.
• This wire had a tendency to lock into the undercuts of the
preparations and acted to increase the retention of the acrylic.
53

49. • Variation of the A splint by Kessler by placing threaded pins incorporated in
the teeth along with wire and acrylic.
• Provides for primary stabilization when the wire is used alone and secondary
stabilization with greatly increased retention when the acrylic is inserted to cover
the wire.
54
The advantage of this variation of “A” splinting is that it greatly decreases the
possibility of breakage and the need for frequent repair.
Kessler Variation of the “A” Splint J Periodontal 1970

50. 55
Kessler Variation of the “A” Splint J Periodontal 1970

51. AMALGAM SPLINT
• Its use is limited to the posterior teeth.
• Less strength than that of cast gold.
• Teeth are prepared in accordance with sound operative principles.
• Condense the amalgam in one unit.
• Two to five teeth may be splinted in this fashion.
• Amalgam splints tend to fracture easily.
56

52. 57

53. • There are two possible disadvantages, to this form of
stabilization
• The confinement of the procedure to only posterior teeth
and
• The possibility of fracture (usually at the narrow part of
the isthmus).
59

54. • Wire, amalgam, and acrylic
• Trachtenberg (1976) combined the wire-and-amalgam and the
wire-and-acrylic techniques.
• This approach allows one to insert individual compound amalgam
restorations and finish their interproximal areas prior to insertion
of the wire and acrylic.
60

55. • After orthodontic treatment, teeth may require stabilization with either fixed or
removable appliances.
• Allows continued minor movements for the final positioning of teeth.
61

56. 62
patient with a removable orthodontic retainer. Optimal positioning of teeth has been achieved by orthodontic
movement; however, stabilization of teeth is required, and the unattractive spaces caused by undersized
maxillary teeth need to be closed. A carefully planned appointment is required to accomplish the following: (1)
remove any fixed orthodontic appliance, (2) add composite to close the diastemas, and (3) stabilize teeth with
a twisted stainless steel wire and composite.

57. • This unique splint allows some physiologic movement of teeth, yet
it holds them in the correct position.
• The splint should remain in place for at least 6 months to ensure
stabilization.
• Longer retention may be necessary, depending on the individual
situation and recommendations of the orthodontist.
63

58. • Fiber reinforced composite are structural materials with two different
constituents
• Reinforcing component: strength & stiffness
• Surrounding matirx: reinforcement & workability.
• Fiber-reinforcement materials can be made from
• polyethylene yarns woven to create a ribbon,
• glass fibers woven to create a ribbon
• short and long strands of glass fibers embedded in a resin matrix (preimpregnated
glass fibers).
• Unidirectional: long, parallel, continuous - Most Popular
• Braided & Woven. 64

59. 65

60. • Glass fibers are treated with a silane chemical coupling agent to
allow dental resins to chemically adhere to the glass fiber strands.
• To improve the bonding of resin to polyethylene fibers, these
synthetic polyethylene fibers are chemically treated with thorough
surface etching called plasma treatment, which allows the resin to
chemically bond to the polyethylene fibers. Without this
treatment, there would be no surface wetting of resin and
bonding between the 2 substrates.
66

61. 67

62. 68

63. 70

64. Facial and incisal embrasures are defined with finishing burs to enhance
esthetics. After finishing procedures, the rubber dam is removed, and the
occlusion is evaluated.
71

65. • Provide insight into whether or not stabilization of the teeth
provides any benefit before any irreversible definitive treatment
is even initiated.
• With this form of stabilization it is imperative that the patient
goes on to a permanent restorative program.
72

66. Provisional splints can either be placed externally or
internally.
 External splints typically are fabricated using
 Ligature wires,
 Nightguards,
 Interim fixed prostheses.
 Internal splints, on the other hand, are fabricated using
 Composite resin restorative material with or without wire or fiber
inserts. 73

67. Adapted metal bands and acrylic
• Amsterdam and Fox have described the use of copper or gold bands
fitted exactly to the subgingival termination of prepared teeth and then
incorporated into self-curing acrylic.
• This technique fulfills all the objectives of a provisional restoration in
that an exact marginal fit is achieved for caries-control and pulpal
protection.
• Also, protective sub-gingival and supragingival coronal forms are more
easily obtained, thus helping to achieve and maintain the health of the
gingival tissue.
• Because of the added strength of the metal bands, frequent removal of
the splints for various operative procedures (that is, impressions, coping
74

68. Intracoronal methods are also available.
• Composite-resin restorations can be placed in adjoining teeth and cured to
eliminate any interproximal separation.
• These restorations can be further reinforced with metal wires, glass-reinforced
fibers or pins.
• If restoration of the mouth includes crowns, they can be splinted to each
other by solder joints or precision attachments.
75

69. 76

70. Indications
• Periodontally involved teeth warranting extraction
• Teeth having fractured roots
• Teeth unsuccessfully reimplanted after avulsion
• Root canal treatment been unsuccessful.
• As interim restorations until an extraction site heals if
conditions require a conventional bridge or an implant.
77

71. Precautions
(1)The extracted tooth and abutments must be in reasonably good condition,
especially the pontic, because it may become brittle and more susceptible to
fracture
(2)The abutment teeth should be fairly stable
(3)The tooth to be replaced because a pontic must not participate in heavy centric
or functional occlusion.
(4)If the adjacent teeth are mobile, it is frequently necessary to secure them by
splinting with composite.
78

72. Pre operative
Hope less prognosis w.r.to 31 31 was extracted under Local Anaesthesia Socket was curetted
Remnants of PDL and
necrotic cementum
were removed
Apical reduction done with air rotor
Pontic design
79

73. Pulp extirpation
done Apex etched, bonded
42, 41, 32 etched, bondedApex sealed with
Flow Plus Composite
31 placed and splinted with INFIBRA
80

74. Immediate post
operative
3 months post operative
81

75. Advantages:
It is of the right size, shape and colour.
Good aesthetic results
Preservation of natural crown structure
Reduced psychological impact on the patient
Micro-resiliency of pontic allows stimulation of underlying tissue and
avoids excessive post-extraction ridge resorption
82

76. • Permanent splinting of teeth that have been treated periodontally is also
referred to as Periodontal prosthesis.
• Periodontal prosthesis may be defined as those restorative and prosthetic
endeavors that are indicated and essential in the total treatment of advanced
periodontal disease.
• Permanent splinting is indicated whenever periodontal treatment does not
reduce mobility to the point at which the teeth can function without added
support.
83

77. • Such devices serve to stabilize loose teeth, to redistribute occlusal
forces, to reduce trauma 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.
• Also used for retention of teeth following orthodontic procedures and to
prevent eruption of teeth without antagonists.
84

78. 85

79. 4. COMBINED
A. Partial dentures and splinted abutments
B. Removable / fixed splints
C. Full or partial dentures on splinted roots
D. Fixed bridges incorporated in partial dentures, seated on posts or
copings
5. ENDODONTIC POSTS.
86

80.  May be useful in situations in which fixed splinting is not possible or
desirable.
 For eg. In advanced age, in poor physical or mental status, or when the
prognosis is questionable, the dentist chooses to avoid full coverage.
 The cosmetic disadvantages of labial continuous clasping can be overcome
by use of the swing –lock appliance, which tends to conceal the metal of the
splint and avoid torque.
87

81. 88

82. 89

83. 90

84. 91

85. Maryland bridge
92

86. Periodontal Prosthesis
Miller T. Immediate and indirect woven polyethylene ribbon-reinforced periodontal-
prosthetic splint: A case report Quintessence Int ¡995:26:267-271
93

87. 94

88.  Overloading the surrounding bone is assumed to cause microfractures that
may lead to implant loss, mechanical failure of the implants, or fatigue
fractures of the prosthetic components.
 Hence, the objectives of splinting implant crowns together are to
 favorably distribute the applied forces between the implants
 to minimize the transfer of horizontal load to the bone-implant interface
 to increase the bone surface area
95

89. • Rateitschak (1963)… stated that orthodontics or removable splints caused an initial
increase in the mobility which returned to baseline by 2 years.
• Nyman et al. (1975)… reported no increase in PDL width of the abutments or
changes in mobility.
• Renggli et al. (1984)… reductions in mobility may have been due to the
establishment of a harmonious occlusion and not necessarily due to splinting.
• Kegel et al. (1979)… initially more mobile but received no significant benefit from
splinting.
• Mandel and Viidik (1989)… rigid splinting of the luxated teeth did not improve the
mechanical properties of the PDL during healing.
96

90.  Schmid (1979) …reported 50% reduction in mobility of periodontally involved teeth
after splinting
 Forabasco (2006) …improves prognosis of periodontally affected teeth after splinting
 Hochman N, Yaffe A, Ehrlich J (1992) ... in retrospective 17-year,
longitudinal study monitoring 66 patients with fixed partial denture and removable
partial denture restorations revealed that perceptive splinting was beneficial and
enhanced the longevity of the restoration
3. Hochman N, Yaffe A, Ehrlich J Splinting: a retrospective 17-year follow-up study. J Prosthet
Dent.1992 May;67(5):600-2. 97

91.  Schulz A 2000 3 evaluate the effect of splinting teeth on the results of periodontal
reconstructive surgery using a specific carbonate bone replacement graft (BRG)
material. Results indicated that an undisturbed wound healing process using BRG
together with tooth stability is beneficial to overall clinical success.
 Sekhar LC et al (2011) 4 determined the effects of splinting over unsplinted mobile
teeth following periodontal surgery and compared the efficacy of
two splinting materials, i.e. Ribbond ribbon + Composite with Stainless steel wire +
Composite. Splint had a promising and beneficial effects on anterior teeth exhibiting
Grade I to Grade II degrees of mobility. Splinting is recommended as an adjunct
to periodontal surgery in the treatment of hypermobile teeth, especially in cases
where patient discomfort is a prominent factor.
3. Schulz A, Hilgers RD, Niedermeier W. The effect of splinting of teeth in combination with reconstructive
periodontal surgery in humans. Clin Oral Investig. 2000 Jun;4(2):98-105.
4. Sekhar LC1, Koganti VP, Shankar BR, Gopinath A A comparative study of temporary splints: bonded
polyethylene fiber reinforcement ribbon and stainless steel wire + composite resin splint in the treatment of
chronic periodontitis. J Contemp Dent Pract. 2011 Sep 1;12(5):343-9.
98

92. • Splints offer numerous therapeutic advantages ranging from increase
periodontal resistances to occlusal relationship correction.
• Regardless of the type of splint design, material and method of fabrication, it
must provide good access to oral hygiene, rigid fixation, and also elimination
of occlusal trauma by providing force distribution and resistance to occlusal
overload.
• Splinting may thus serve as a boon, improving the health of the periodontium,
thereby decreasing tooth mobility, but may become a bane if used incorrectly
or not managed properly. 100

93. • SPLINTING Periodontal literature reviews. J Periodontol
• Splinting Teeth — A Review of Methodology and Clinical Case Reports
• Tooth mobility and the biological - rationale for splinting teeth. Periodontology 2000, Vol. 4,
1994, 15-22.
• Clark The Wire Ligature-Acrylic Splint. J Periodontol
• Lemmerman Rationale for Stabilization J. Periodontol. July, 1976
• Miller T Immediate and indirect woven polyethylene ribbon-reinforced periodontal-
prosthetic splint: A case report Quintessence Int 1995:26:267-271
• Hochman N, Yaffe A, Ehrlich J Splinting: a retrospective 17-year follow-up study. J Prosthet
Dent.1992 May;67(5):600-2.
• Schulz A, Hilgers RD, Niedermeier W. The effect of splinting of teeth in combination with
reconstructive periodontal surgery in humans. Clin Oral Investig. 2000 Jun;4(2):98-105.
• Sekhar LC1, Koganti VP, Shankar BR, Gopinath A A comparative study of temporary
splints: bonded polyethylene fiber reinforcement ribbon and stainless steel wire +
composite resin splint in the treatment of chronic periodontitis. J Contemp Dent Pract. 2011
Sep 1;12(5):343-9.
101

94. 102