2. CONTENTS
INTRODUCTION
EVOLUTION OF SPLINTTING
DEFINITION
TOOTH MOBILITY
CLASSIFICATION OF SPLINTING
BIOMECHANICS OF SPLINTING
RATIONALE
CLINICAL RATIONALE OF SPLINTING
INDICATION
CONTRAINDICATION
FACTORS THAT GOVERN THE USE OF PERIODONTAL SPLINT
IDEAL PROPERTIES OF SPLINT
THEORATICAL AIMS OF SPLINT
PRINCIPLES OF SPLINTING
ADVANTAGES AND DISADVANTAGES OF SPLINTING
MATERIALS OF SPLINTING
EFFECT OF SPLINTING ON PERIODONTIUM
3. INTRODUCTION
Periodontal diseases are characterized by subgingival plaque formation,
gingival inflammation, loss of connective tissue attachment and loss of
alveolar bone.
As a result of the progressive loss of attachment tissue, the teeth involved
in the disease process eventually exhibit increased tooth mobility.
Thus, the reduction of mobility is an important objective of periodontal
therapy.
4. It is required to strengthen the supporting tissues reduces mobility and re-establish the
function.
Increasing the support of loose teeth may also increase their firmness;the device used for
such treatment is the “SPLINT”.
The need to stabilize periodontally involved mobile teeth has resulted in the development of
numerous types of splints, which allow for maximum repair of the periodontium during and
after periodontal therapy.
But any attempts to perform splinting techniques without adequate diagnostic techniques in
oral diagnosis, periodontal analysis or occlusal analysis can often lead to misapplication of
these procedures.
5. EVOLUTION OF SPLINTING
Early evidence of human desire to splint
weakened teeth can be seen in
archaeological findings
1. A phoenix mandible from 500 B.C.
demonstrated, loosened and periodontally
compromised anterior teeth bound together
by gold wire.
2. Findings from digging of Egyptians show
similar gold wiring.
3. The history of splinted dental prosthesis
progressed to using silver wire followed
later by appliances of gold wire or ribbon to
support loose teeth.
6. 4. Obin & Arvins (1951) advocated the use of self curing internal splint to achieve
temporary stabilization.
5. Harrington (1957) modified the splint by incorporating a cemented stainless steel
wire.
6. Wellensiek (1958), Shatzkin (1960) & Taatz (1964) presented approaches to the
anterior intra-coronal splints.
7. Cross (1954) suggested the use of a continuous amalgam splint for fixation of
mobile post teeth.
8. L’yod & Baer (1959) & later on Ward & Weinberg (1961) developed new
techniques using a plastic matrix or using wire reinforcement.
7. In 1993 Alvarez concluded that traumatized tooth to be splinted to avoid
constant movement that causes damage for the re-organization of periodontal
ligament.
He also stated that situation with
1. Fractured tooth or bone requires splinting for 6-8 weeks
2. With no fracture of tooth or bone may require splinting for 2-3 weeks.
In 2000, Trope et al. indicated avulsed tooth requires semirigid splint of 7-10
days
8. DEFINITION
Francis G. Serio - Splint is defined as an any apparatus, appliance device
employed to prevent motion or displacement of fractured or movable parts
Grant defined splint is an any appliance that joins two or more teeth to provide
support.
Macphee and Cowley –Splint is a rigid flexible appliance used to stabilize and
protect an injured part.
9. Glossary of Periodontics Term 1986 a splint is “an appliance designed to
stabilize a mobile tooth”.
According to AAP (1996) a splint has been defined “as an apparatus,
appliance, or device employed to prevent motion or displacement of
fractured or mobile parts”.
The Glossary of Prosthodontic Term defines a 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
10. TOOTH MOBILITY
Defined as a visually perceptible movement of the tooth away from its normal position
when a light force is applied. ( Gher1996)
PHYSIOLOGIC TOOTH MOBILITY:Teeth exhibit a certain degree of mobility
known as physiologic tooth mobility
PATHOLOGIC TOOTH MOBILITY: Tooth mobility secondary to infl ammation of
the periodontium and bone loss is considered as pathologic (Pollack, 1999)
11. Mobility is assessed as the amplitude of crown displacement resulting from the application of a
defined force (Muhlemann, 1954)
Two basic factors determining the degrees of tooth mobility are
The height of the supporting tissues
The width of the periodontal ligament
In the absence of periodontal disease, the most likely cause of tooth mobility is primary
occlusal trauma
12. Tooth mobility and occlusion
Occlusal trauma/trauma from occlusion is described 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 (Gher, 1996)
Generally, two forms of occlusal trauma are recognized:
1. Primary occlusal trauma: When the occlusal forces exceed the adaptive capacity of
the healthy teeth, trauma results (Carranza, 1996).
2. Secondary occlusal trauma: Reduced ability of the tissues (periodontitis) to resist the
occlusal forces (Carranza, 1996).
13. Degree of Movement
The degree of movement is indicated on an arbitrary scale of 0 to 3 given
by MILLER 1950
A reading of o indicates 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
14. Glickmans Index (1972)
• 0- Normal mobility
• Grade I- Slightly more than normal
• Grade II- Moderately more than normal
• Grade III- Severe mobility faciolingually and / or mesidistally
combined with vertical displacement.
15. 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.
16. The reduction of mobility is an important objective of periodontal therapy.
Root planing, curettage, oral hygiene, and surgery may cause teeth to tighten
as inflammation is resolved.
However, a transient increase in mobility may occur immediately after surgery.
Occlusal adjustment, periodontal orthodontics, and restorative dentistry may
alter occlusal relationships and redirect forces, thereby reducing traumatism.
One of the treatment of tooth mobility is SPLINTING
17. CLASSIFICATION OF SPLINTING
The choice of splint should be made after considering
factors such as
Tooth contour
Spacing of teeth
Location of the teeth in the arch
Length of the splinting period
Aesthetics
The degree of rigidity desired
18. A) According to the period of stabilization:
(a) Temporary stabilization
19. (b) Provisional stabilization: To be used for months up to
several years.- e.g. Acrylic splints, metal band
(c) Permanent splint:
20. B) According to the type of Material:
-Bonded composite resin button splint
- Braided wire splint
C) According to the location on the tooth
21. Goldman, Cohen & Checker Classification
Temporary splints
(1) Extra-coronal type
Wire ligation
Orthodontic bands
Removable acrylic appliances
Removable cast appliances
Ultraviolet-light-polymerizing bonding materials
(2) Intra coronal type
Wire & acrylic
Wire & amalgam
Wire, amalgam & acrylic
Cast chrome- cobalt alloy bars with acrylic, or both
Provisional splint
All acrylic
Adapted metal band and acrylic
22. Ross, Weisgold and Wright Classification
(1) Temporary stabilization
Removable extra coronal splints
Fixed extra coronal splints
Intra-coronal splints
Etched metal resin-bonded splints
(2) Provisional stabilization
Acrylic splints
Metal-band-and-acrylic splints
(3) Long term stabilization
Removable splints
Fixed splints
Combination removable and fixed splints
23. Grant, Stem and Listgarten Classification (1988)
(1) Removable (external)
Continuous clasp devices
Swing-lock devices
Over dentures (full or partial)
(2) Fixed (internal)
Full coverage, three-fourths coverage and inlays
Posts in root canals
Horizontal pin splints
(3) Cast metal resin bonded fixed partial denture (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
Others
Arch bar splint
Orthodontic wire and bracket splint
24.
25.
26.
27.
28. BIOMECHANICS OF SPLINTING
Theoretically, a splint limits the amount of force a single tooth can
receive during occlusal loading.
It does this by distributing occlusal forces over a large number of
teeth.
Splinting also alters the direction of applied forces.
A mobile individual tooth is capable of being loaded and moved in
several directions: mesio-distally, buccolingually and apically
29. 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.
In an individual tooth, the mesially directed force produces a center
of rotation in the apical third of its root.
The same force directed to the same individual tooth in a four unit,
fixed splint produces a center of rotation in the root of the first molar.
This produces a wider fulcrum about which the splint can rotate,
thereby redirecting the mesial force into a more vertical one.
30.
31. RATIONALE
To provide rest, reduce mobility, redirection of forces,
redistribution of forces and restoration of functional stability.
To promote healing of underlying periodontal tissues by
removing occlusal trauma.
To promote patient comfort & function.
32. Redirection of occlusal forces to all teeth included in the splint. This
ensures that forces are within the adaptive capacity of periodontium.
To preserve the arch integrity,splinting restores proximal contacts
reducing food impaction at proximal area.
To promote psychological well being.
To aid in effective surgical procedure
33. CLINICAL RATIONALE FOR SPLINTING
(Pollack, 1999; Serio, 1999; Siegel et al., 1999; Ramfjord and Ash, 1981; Lemmerman, 1976)
• To control parafunctional or bruxing forces.
• Stabilization of mobile teeth during surgical, especially regenerative therapy. Friedman
believed that unless splinted, mobile teeth may not respond as well to reattachment
procedures (Friedman, 1953; Ferencz, 1987).
• Stabilization of a periodontally compromised tooth when more definitive treatment is not
possible.
• Prevention of the supra-eruption of an unopposed tooth to eliminate the potential for the
development of periodontal problems (Hirschfield, 1937).
34. • Stabilization of loose teeth to restore the patient’s psychological and
physical well-being.
• Splinting during or following periodontal therapy is useful and
beneficial for controlling the effects of secondary trauma from
occlusion. Also, it improves the patient’s comfort and function
(Ferencz, 1987)
• The main objective and rationale of splinting and occlusal
adjustments are to control the progressive tooth mobility (Lindhe
and Nyman, 1977)
35. INDICATIONS
(Belikova and Petrushanko, 2013; Lemmerman, 1976):
Restore patients’ masticatory function and comfort
Stabilize teeth with increasing mobility that have not responded to occlusal
adjustment and periodontal treatment
Facilitate periodontal instrumentation and occlusal adjustment of extremely
mobile teeth
Prevent tipping or drifting of teeth and extrusion of unopposed teeth
Stabilize teeth, when indicated, following orthodontic movement
Create adequate occlusal stability when replacing missing teeth
Stabilize teeth following acute trauma
36. CONTRAINDICATIONS
Occlusal stability and optimal periodontal conditions cannot be obtained
(Nyman and Lang, 1994)
Poor oral hygiene
Insufficient number of non-mobile teeth to adequately stabilize mobile
teeth
Presence of occlusal interference
High caries activity
Overall poor prognosis
Crowding and malaligned teeth that may compromise the utility of splint
37. FACTORS THAT GOVERN THE USE OF
PERIODONTAL SPLINTS
1. All periodontal disease must be eliminated before they are
constructed. Inflammation of the periodontal structures can produce
mobility in the presence of normal occlusal forces and normal
periodontal support.
2. Include a sufficient number of firm teeth in the splint.
3. The splint should not impinge upon gingival, irritate the other parts
of oral mucous membrane or create a functional disharmony.
38. 4. The splint should not interfere with oral hygiene
5. The splint should be simple and esthetically acceptable.
6. Their construction should entail a minimum loss of tooth
structure.
7. Meticulous care by patient should be emphasized.
39. 8. Coronoplasty
Performed to relieve traumatic occlusion.
Excessive occlusal contacts from parafunction or deflective tooth
contacts are frequent causes of excessive mobility.
Whenever occlusion is the cause, occlusal therapy is always
performed first.
The mobility is then evaluated over time to determine if it resolves
before splinting is considered
40. IDEAL PROPERTIES OF SPLINT
(1) Simple
(2) Economic
(3) Stable And Efficient
(4) Hygienic
(5) Nonirritating
(6) Not Interfere With Treatment
(7) Esthetically Acceptable
(8) Not Provoke Iatrogenic Disease
41. THEORETICALAIMS
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.
42. Migration and overeruption are prevented.
Masticatory function may be improved.
Discomfort and pain are eliminated,
Appearance may be improved
43. PRINCIPLES OF SPLINTING
Should be simple in design without involving extensive tooth preparation
Should be stable and efficient, easily repaired
Should permit good plaque control
Should not hamper periodontal instrumentation
Should be non-irritating to the tissues
Should be esthetically acceptable
For every mobile tooth, at least two firm teeth should be present
44. ADVANTAGES
Alveolus remodeling of alveolar bone and periodontal ligament for
orthodontically moved tooth or teeth.
Provides healing of supporting structures.
Fine stability and comfort for patient will be provided.
Facilitates surgical procedures by keeping the tooth immobile.
Distributes occlusal forces on a wide area.
45. DISADVANTAGES
Accumulation of plaque can lead to further periodontal maintenance
Requires excellent OHI maintenance.
If one tooth in the splint is in traumatic occlusion, it can injure the
periodontium of all other teeth included in the splint.
Development of caries is an amenable risk
46. MATERIAL USED FOR SPLINTING
1. Ligature wire -Stainless steel wire, brass wire
2. Night guards-Heat polymerized poly-methyl methacrylate
3. Welded stainless steel band splints
4. Castable splints-stainless steel or gold or acrylic
5. Amalgam splint
6. Pin & screw continuous clasp splint
47. 7. Monofilament nylon composite splint
8. Wire composite splint
9. composite or fiber reinforced composite as internal splint
a) Reinforced with metal wires
b) Glass reinforced fibers or pin. (Brazilay,2000)
48. In common clinical practice, splinting is usually done for
anterior/posterior segments
A)Splinting for anterior teeth:
1. Direct bonding system:
It uses an acid technique and a
light cured resin in
interproximal areas to splint the
teeth. Unfilled resins may also
be used as it shows high
resistance to fracture. Adequate
compressive strength and
minimal marginal leakage.
49. 2. Intracoronal wire &acrylic wire resin splint:
It uses preparation of a slot on the lingual
aspect of the tooth and stabilizing teeth
using a stainless steel wire placed in the
slot. Slot prepared midway between
cingulum & incisal edge about 1.5mm
deep. It is then half filled with resin and
stainless steel wire is adapted into the slot.
The resin is then placed over the wire to
seal the slot.
50. B) Splinting for posterior teeth
1. Intracoronal amalgam wire splint:
It uses resin restoration in proximal amalgam
restored areas of tooth re-inforced with wire to
stabilize posterior teeth.A splint is utilized
with slot preparation 1.5mm deep and 2-3mm
wide. A braided stainless steel wire is used &
covered with resin, before finishing &
polishing
2. Bite /night guard: Ideal occlusal may
require occlusal adjustment, orthodontics
&restotative dentistry to eliminate occlusal
habits. The occlusal splint may be rigid or
soft, made of acrylic or composite. It is often
diagnostic as well as therapeutic.
51. Extra-coronal splinting
• The simplest way to connect
teeth to each other is the classic
bonding method.
• The enamel surface of the tooth
is etched, most commonly with
37% phosphoric acid.
• Composite resin can then be
bonded to the etched surface
and used to rigidly connect the
teeth to each other.
• The composite resin splint can
be strengthened by adding
fibers to the splint or by using a
fiber meshwork
• e.g., Ribbond (Ribbond Inc.,
Seattle, WA, USA) to reinforce
the material
52. Removable and fixed prostheses
• When one or two teeth are missing or have to be removed because they have a
poor prognosis, a decision has to be made about the question of replacement of
the missing teeth as well as stabilizing the remaining teeth.
• There have been controversies about the use of periodontally compromised
teeth as abutment teeth.
• Several studies accepted such teeth as abutments if favorable crown:root ratios
were available or generated by addition of another abutment tooth.
53. • If the crown:root ratio of a periodontally
compromised tooth is not favorable, a
decision can be made to extract that tooth.
• The extracted tooth can then be used as a
natural tooth pontic after extra-oral root canal
and splinting with the adjacent teeth
54. EFFECT OF SPLINTING ON PERIODONTIUM
Splinting of the teeth will not prevent or retard apical downgrowth of plaque and
associated attachment loss.
In a study done by Gallers et al., it was found that attachment levels and bone
levels were similar in splinted and non-splinted teeth following osseous surgery.
Splinting of the tooth helps in redistributing the occlusal forces over a larger
area.
In a study done by Mandel and Viidik, it was found that rigid splinting of
luxated teeth did not improve the mechanical properties of the periodontal
ligament during healing.
55. In a study conducted by Mangla and Kaur, it was stated that splinting
mobile teeth act as an adjunct to periodontal treatment and maintenance
and hence is recommended.
Selecting the right splint for the right procedure is done based on the
discretion of the advantages and disadvantages of each.
A splint should be designed in such a way that it attracts the
Least plaque and calculus,
Able to be retained for the specified time,
Is able to carry out its designated function,
Does not interfere with healing and esthetics
56. Tooth mobility is a common sequel to periodontitis and trauma from occlusion.
Mobility, bone loss and attachment loss associated with trauma from occlusion
can be reduced by eliminating trauma.
Periodontally compromised teeth with poor prognosis can also be retained for a
longer time by using splints, until a more definative treatment is planned for the
patient.
Splints are becoming an integral part of periodontal therapy and maintenance.
However, it should be noted that splinting itself will not eliminate the cause of
tooth mobility.
They are only an aid in stabilizing the mobile tooth, and mobility may revert
once the splints have been removed.
Hence, splinting is an essential adjunct in addition to cause-related therapy in
the treatment of mobile teeth
CONCLUSION
57. REFERENCE
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Saleem Bhat To Splint or Not to Splint: The Current Status of Periodontal Splinting Journal of the
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Volume 07, Issue 03, 2020
