63668245 dental-update-periodontal-splinting-in-general-dental-practice


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63668245 dental-update-periodontal-splinting-in-general-dental-practice

  1. 1. P E R I O D O N T I CPSE R I O D O N T I C S Periodontal Splinting in General Dental Practice SOPHIE J. WATKINS AND KENNETH W. HEMMINGS (drifting) of periodontally involvedAbstract: Splinting periodontally involved teeth is a technique that has been in use for teeth.centuries. This article gives a brief history and review of the literature concerning periodontalsplinting and outlines the rationale and indications for the correct application of periodontalsplinting in modern dental practice. The common types of splint and clinical techniques A variety of factors can contribute toinvolved are described, addressing some of the clinical problems. tooth mobility, including trauma; periapical or periodontal inflammation, Dent Update 2000; 27: 278-285 decreased periodontal support and pathologically increased occlusal load.Clinical Relevance: Although periodontal splinting can be a useful tool in specific These clinical entities have beensituations, it can be inappropriately applied and may create some technical difficulties inclinical management. It is therefore important that the clinician is well aware of the potential described as primary or secondaryhazards involved in carrying out this type of treatment. The importance of careful periodontal occlusal trauma (Table 1).3 Mostmonitoring and maintenance following splinting cannot be overstressed, because ongoing commonly, mobility of teeth is causeddisease can be masked and access for hygiene compromised around periodontally involved by loss of support as a result ofteeth. periodontal disease, although it is important to be aware that more than one factor may be involved (Figure 1). Diagnosis and clinical managementD ental splinting involves joining the crowns of two or more teeth bymore or less rigid means; so that their indicated that the appliance had been placed on a living patient and is thus one of the earliest known dental should take this into account. When patients present with periodontal disease and mobile teeth,relative movement is restricted and the prostheses, dated at around 2500 BC. efforts should be directed at resolvingforces applied to one of the splinted Tooth transplantation has been the periodontal disease beforeteeth are transmitted to the root systems described as early as the ninth century considering occlusal management if theof all the linked teeth.1 This article will AD, and ligatures of silk, gold and silver teeth are to be preserved. In the absenceconcentrate on the use of splints in were used in the tenth and eleventh of periodontal disease the most likelyperiodontal disease. centuries by the Spanish physician cause of tooth mobility is primary Splinting has been used as a form of Albucasis. Splinting loose teeth occlusal trauma and thereforedental treatment for centuries, and is one remained a popular treatment for periodontal treatment would beof the earliest known examples of mobility well into the twentieth century, inappropriate. Rare causes of toothdentistry: excavations of Egyptian and was used as an integral part of mobility – such as abnormal rootremains at Gizeh in the early 1900s periodontal treatment planning by many morphology, iatrogenically shortenedincluded a wire ligature around the clinicians.2 roots following apical surgery, excessivecervical margins of lower left second Splinting is still used in a wide variety loading during orthodontic movement,and third molar teeth, the roots of the of clinical situations: root resorption or intrabony pathology –third molar having been resorbed. should not be forgotten.Calculus around both the teeth and wire q traumatic injuries to teeth; In the past it has been thought that q TMJ dysfunction; mobility adversely affects periodontal q prevention of toothwear; destruction and healing. Fleszar, as Sophie J.Watkins, BDS, FDS (Rest Dent) RCPS, q permanent post-orthodontic recently as 1980,4 found that decreased MSc, Senior Registrar in Restorative Dentistry, retention; mobility did in fact improve the and Kenneth W. Hemmings, BDS, MSc, MRD q pre-restorative treatment response of affected teeth to periodontal RCS, FDS RCS, Consultant in Restorative (identification of retruded contact therapy. The temptation has been in the Dentistry, Department of Conservative Dentistry, position, RCP); past to ‘treat’ periodontally involved Eastman Dental Hospital, London. q excessive movement or migration teeth by early splinting. However, the278 Dental Update – July/August 2000
  2. 2. P E R I O D O N T I C S Definition The lesion that develops in the periodontium as a result of excessive occlusal teeth to less mobile teeth by splinting forces during functional and parafunctional activities. lies in the fact that this results in a more favourable distribution of the forces Primary The effect of abnormal occlusal forces on periodontal tissues in the absence of inflammation. A physiological adaptation of the periodontium results in acting on the teeth concerned, thus mobility with no periodontal pocketing and radiographically a widened protecting those with reduced periodontal ligament. periodontal support. Secondary The effect of occlusal forces on teeth where the periodontium is already Indications for splinting are: weakened by inflammation, giving rise to more complex breakdown of the periodontal structures. q drifting;Table 1. Occlusal trauma.3 q improving comfort and function; q enhancing periodontal healing.lack of correlation between mobility or stable jaw relationships with stable Driftingocclusal trauma and periodontal disease/ simultaneous multiple interocclusal Drifting teeth are a common problem inhealing has been demonstrated by many contacts and smooth excursive patients with periodontally diseasedauthors.5-10 It is now widely accepted movements unimpaired by occlusal teeth, and may result from normal forcesthat the resolution of inflammation is the interferences’, and is described in detail acting on teeth with compromisedmost important factor in the treatment of by Wise.14 It may involve the adjustment periodontal support which can no longerchronic periodontitis. Although trauma of multiple tooth surfaces to achieve an withstand these forces.15 If the patient isfrom occlusion may modify the ‘ideal occlusion’ and is therefore a concerned about appearance followingprogression of existing periodontitis,11 it significant undertaking and is not drifting, after the disease has beendoes not initiate or aggravate recommended to the inexperienced controlled the teeth can be repositionedgingivitis.12 Kantor, Polson and Zander13 practitioner. A trial adjustment on study orthodontically. The result is, however,showed that alveolar bone is regenerated casts may confirm that the procedure is inherently unstable and splinting isafter removal of both inflammation and not excessively destructive of tooth generally advisable to prevent relapse.traumatic factors. tissue and the aims of the adjustment are Indeed, the position of drifted teeth that attainable (Figure 2). are not treated orthodontically can be prevented from worsening by theCLINICAL MANAGEMENT provision of a splint.The options for the clinical management Extraction Similarly, adverse tooth movementsof mobile teeth include: It is important to be able to recognize such as over-eruption or tilting can be whether a tooth is conservable or not prevented by splinting.16 Splinting inq no treatment; and to consider whether retaining a this situation can be provided by a fixedq occlusal adjustment; certain tooth may be harmful to or removable prosthesis and, althoughq extraction; neighbouring teeth. If this is the case, this may not be the primary function ofq splinting. extraction is the best course of action. the prosthesis, it should be taken into account whilst designing the appliance. It is important to stress that, if a fixed SPLINTING splint or a removable appliance isNo Treatment The scientific basis for joining mobile provided, this may have an adverseIf the clinician considers the situationunlikely to deteriorate, this option maybe acceptable to many patients. a bHowever, regular review isrecommended.Occlusal AdjustmentIf an occlusal aetiological factor hasbeen positively identified, occlusaladjustment may be indicated. Localizedadjustment to a few teeth is relatively Figure 1. Radiographs demonstrating occlusal trauma. (a) Root treated upper first molarstraightforward. Occlusal equilibration bridge abutment presented with distal and furcation pocketing of 6–7 mm. There was alsohas been described as ‘planned distal caries. (b) Following root resection the pocketing was reduced to 4 mm, but mobilityalteration of occlusal surfaces to provide increased with widening of the periodontal ligament on the remaining (mesial) root. Dental Update – July/August 2000 279
  3. 3. P E R I O D O N T I C S but increase accumulation of plaquea b around the abutment teeth. Fixed splints may compromise the ability of patients to use interdental cleaning aids. Therefore, care must be taken in designing and making splints with good physiological contour to allow easy patient maintenance. Patients need regular instruction on oral hygiene and Figure 2. Trial occlusal adjustment on study casts. (a) The casts mounted in the retruded axis encouragement to maintain high levels position demonstrate a large non-working side interference between /7 and /8 in right lateral of plaque control. excursion (arrowed). (b) Trial adjustment of the casts. The occlusal surfaces of the casts are painted before performing the trial adjustment. In this way it is possible to assess the necessary Periodontal Monitoring removal of tooth tissue, allowing the operator to assess how destructive this would be before carrying out the procedure clinically. In this case, extensive tooth reduction would be required to Fixed splinting of teeth prevents clinical eliminate the interference, making it too destructive to carry out clinically without recourse to assessment and reduces patient crowns or onlays. awareness of increasing tooth mobility. Occasionally, if patients are lost from regular review, they may perceive a problem only when gross periodontaleffect on the patient’s ability to maintain periodontal ligament (rigid splinting of destruction has occurred and the wholegood oral hygiene. Unless excellent root or alveolar fractures is still splint is mobile. These potentialplaque control is maintained, the recommended17). Rarely, mobile teeth complications should be stressed toperiodontal condition may not be stable undergoing periodontal surgery require patients. Effective recall systems shouldand could result in breakdown. temporary splinting until initial healing be in place and regular clinical andFurthermore, a fixed splint may mask is complete. However, questions should radiographic review carried out.this deterioration: an added danger of be raised concerning the prognosis ofwhich the operator must be aware. such teeth and the advisability of Dental CariesMeticulous monitoring and maintenance surgery. The advantages of splinting If plaque control is inadequate inis therefore essential. have been contested; Renggli et al.18–20 combination with dietary factors, fixed showed no difference in mobility before or removable splints may encourage and after wearing a splint. Indeed, many dental caries in a susceptible patient.Comfort and Function authors have found that increased Cementation failure of fixed splintsMobile teeth can be very distressing to mobility/occlusal trauma may not be may go unnoticed until gross dentalthe patient and may often be the detrimental to the health of the caries is observed. Prevention in the formpresenting complaint. Extreme mobility remaining supporting tissues.19,20 of fluoride supplements, diet counsellingcan interfere with speaking and eating. It and regular prophylaxis are thereforemust be stressed that active disease important, as well as regular review withshould be controlled as far as possible Disadvantages of Splinting careful inspection of margins allowingand the patient capable of maintaining a early maintenance if required.good standard of oral hygiene before Plaque Controlfurther treatment is considered. Removable splints allow the patient to Maintenance of SplintsAlthough a reduction in inflammation practise normal plaque control measures Biological failure of splints is usuallymay result in a decrease in mobility toacceptable levels, in the presence ofsevere periodontal involvement this maynot be complete and mobility may still a bconstitute a significant problem. In suchcases, splinting may be the only way ofresolving the situation.Periodontal HealingPost-trauma splinting of luxated orsubluxated teeth, allowing somephysiological loading of the teeth, is Figure 3. (a) Deep overbite causing trauma to the labial gingivae of the lower incisors. (b) A soft splint fitted over the maxillary teeth protects the gingivae.beneficial to the healing of the280 Dental Update – July/August 2000
  4. 4. P E R I O D O N T I C S Hard Acrylic Occlusal Splint: Occlusala b splints can be useful in the diagnosis of occlusal trauma in periodontal patients and for retention of drifting teeth (Figure 4). There are many descriptions of occlusal splints in the literature. The term covers full coverage, partial coverage and repositioning appliances, Figure 4. Hard maxillary occlusal splint. (a) Facial view. (b) Palatal view, showing the occlusal and are used in diagnostic and scheme adjusted to provide even contacts around the arch in the retruded axis position (black therapeutic procedures as outlined marks) and anterior guidance with immediate posterior disclusion in excursions (red marks). below: q TMJ dysfunction; q prevention of toothwear;the result of dental caries, progressive progressive drifting despite treatment. q to facilitate restorative proceduresperiodontal disease or endodontic In borderline cases, where the by establishing a stable retrudedcomplications. All restorations have a outcome of treatment cannot be contact position;finite lifespan and will eventually wear predicted, a provisional splint may be q assessment of patient tolerance toout unless more significant mechanical provided. an increase in occlusal verticalfailure occurs first. The very nature of Describing appliances as ‘permanent’ dimension;splinting means that splints are large is a relative term because it must be q stabilization of tooth position.and expensive prostheses. If prompt remembered that all restorations will failattention is not given to a mechanical in time. It is a term that can be Partial-coverage splints are notfailure there is a significant risk of misunderstood by patients and should be recommended for long-term use. Theremobile teeth drifting away from the used with caution. is a significant risk of over-eruption ofsplint. Repositioning or replacement of unopposed teeth, which leads tosuch teeth will complicate maintenance. Removable Splints disruption of the occlusal plane in one or A biological and financial cost/benefit The use of removable splints is simple, both arches and is difficult to rectify.analysis of splinting teeth should be reversible and inexpensive. The We therefore favour a full-coveragecarried out and compared with other splinting of teeth may be less rigid in maxillary hard acrylic occlusal splinttreatment options before confirming the removable splinting than using fixed providing even contacts in the retrudedmost appropriate treatment. alternatives, but they have the axis position, and anterior guidance in advantage of facilitating oral hygiene.19 protrusive and lateral excursions. In They are usually the most appropriate patients with Angles class III occlusalTypes of Splint splints for use in emergencies and relationship, it is often easier toSplints used in clinical practice can be diagnostic procedures. construct one for the mandibular arch.categorized as either removable or fixed. Vacuum-formed Splints: These This type of appliance is more time-The descriptive terms temporary or appliances are temporary or provisional consuming to construct than the vacuum-provisional refer to the durability of the in nature. They are most useful in formed acrylic splint as mounted studyappliance or the intended use. reducing the symptoms in traumatic casts are required for laboratory occlusions when incisal edges ofTemporary/Permanent/Provisional anterior teeth occlude directly on theTemporary splints can be defined as a gingivae or palate (Figure 3). Thesesplint intended for short or medium-term splints are also useful in the diagnosis ofuse, which may or may not be replaced TMJ dysfunction, when symptoms areby a permanent appliance. They may be usually alleviated by the use of a splint.used to stabilize the mobile teeth during In parafunctional patients the splintssurgery. Examples of temporary splints will show early deterioration and willinclude acrylic and wire splints21 and often perforate on the occlusal surface.vacuum-formed splints, which are The splint is usually best tolerated indescribed later. the upper arch. The alginate impression Permanent splints, such as linked is cast in the laboratory and a vacuum- Figure 5. Removable orthodontic retainer withrestorations, may be used for teeth that formed polythene splint of 2–3 mm in acrylic on the labial bow, adapted to the labialcannot maintain stability after treatment, thickness is made. Minimal adjustments surfaces of the teeth. This improves control overor teeth with increasing mobility or are made for patient comfort. the tooth position during the retention phase.282 Dental Update – July/August 2000
  5. 5. P E R I O D O N T I C S advantageous (Figure 6). A new a b technique, using flexible ceramic bonding fibre ribbon or cords such as GlasSpan or Ribbond (Sigma Dental Systems, Heideland 22, Germany) instead of wire to reinforce the composite resin gives a more aesthetic and useful alternative (Figure 6). Where a palatal appliance is provided, it is of obvious importance to ensure that the c Figure 6. (a) Twistflex® (Wildcat® Wire bulk of the splint does not interfere with GAC International Inc. Central Islip, NY inter-occlusal contacts or with guidance. 11722-1402, USA) orthodontic retainer, Resin-Bonded Splints: Laboratory- passively adapted to the palatal surfaces and fabricated splints may offer a more bonded to the teeth using composite resin. long-term solution to the chairside- (b) GlasSpan® (Exton, PA, USA) flexible ceramic fibre can be used as an alternative prepared splints described above. They to wire for reinforcing the composite resin are less bulky and can be placed in most splint (c) Finished result. situations, allowing greater occlusal control. Rochette originally described a perforated resin-bonded splint (Figure 7) in 1973.26 The technique was adaptedconstruction. The use of a facebow Orthodontic Retainer: Drifted and refined for tooth replacement. Therecording and a semi-adjustable periodontally involved teeth can be basic laboratory and chairsidearticulator considerably reduces repositioned orthodontically. Long-term procedures are now commonly used andchairside adjustment of the splint.3 If retention is necessary to prevent relapse. well known.27–29this is not possible, the RCP jaw Removable orthodontic retainers (Figure Today, a non-perforated frameworkregistration must be at the correct 5) can be used in long-term retention, (Figure 8) is recommended for use withocclusal vertical dimension (2–3 mm but are associated with periodontal modern Bis-GMA (e.g. Panavia 21) orincrease) and adjustment of the splint inflammation unless plaque control is 4-META cements (e.g. Superbondin excursions will be necessary. exemplary. They are unaesthetic, but C&B ). Retention should be optimized A well made splint can be retained by may be acceptable for night wear. by providing maximum coverage of thea friction fit. Additional retention can available enamel, but tooth preparationbe provided by ball-ended clasps or Fixed Splints should be kept to a minimum. ParallelAdams cribs as direct retainers, usually Composite/Acrylic and Wire: This guide planes also allow accurateon the first molars. Long-term occlusal temporary or semi-permanent splint is insertion and increase the bonding areastability of the splint requires several fabricated using a chairside, or direct, by removing undercut areas – and as aadjustments as mandibular technique. It is reversible, and relatively result can increase retention. Proximalrepositioning occurs. Good service strong, stable and aesthetic. The grooves and parallel walls do involvewould be considered to be 2–3 years of operative technique for making this type extensive tooth preparation (which isuse. In a bruxist patient, more frequent of splint has been widely described21–24 not usually necessary in most situationsreplacement will be required as a result and there are many variations. The in the authors’ opinion). In theof wear or fracture of the acrylic. technique involves adapting a wire, periodontal patient with anterior mesh or other former to the teeth to be splinted and covering it with composite resin etched to the enamel. The wire may be twisted around the teeth as a ligature or adapted to the palatal surfaces of the teeth, as long as it is passive in order to avoid orthodontic movement. Rosenberg described a variation using orthodontic grid material and acrylic.25 Using composite resin alone to link the teeth is likely to lead to early failure at contact points, as theFigure 7. Perforated resin-bonded splint, as material is brittle.23 A linking wire Figure 8. Resin-retained splint with a non-described by Rochette.26 provides flexibility and is therefore perforated framework. Dental Update – July/August 2000 283
  6. 6. P E R I O D O N T I C S for resin-bonded splinting also apply toa b conventional crown and bridgework. In addition, it is often difficult to obtain perfect impressions of multiple tooth preparations within a single impression. The use of a pick-up procedure allows the dies of multiple abutment teeth to be located on a single working cast, and allows the opportunity to overcome Figure 9. (a) Periodontally involved teeth may cause problems during impression taking due to the problems of excessive tooth their mobility and the large embrasure spaces, which may cause difficulty in removing the mobility if transfer copings (e.g. acrylic impression. (b) A temporary splint made of pink acrylic resin Triad visible light cure reline bonnets) are linked passively before material (Dentsply International Inc., York, PA, USA) is adapted to the labial surfaces of the taking a locating impression (Figure teeth to stabilize them, and soft wax is placed in the embrasure spaces and undercuts to prevent the impression material engaging deep undercuts. 11). It is wise to verify the accuracy of the working casts before committing your technician to extensive laboratorylocalized or generalized recession, it consuming to prepare and therefore work. This can be simply achieved bycan be difficult to mask interproximal costly in chairside and laboratory time. using a bite fork lined with compoundmetal connectors. For splint rigidity, it Parallel and non-undercut preparations and refined with temporary cement.is rarely wise to reduce connector of multiple teeth are demanding and are The indentations created by the teethheight below 3 mm. Composite resin destructive of tooth tissue, and should correspond to those on theadditions can be used to cover movement of the abutments during working cast (Figure 12).unsightly metal. cementation can lead to poorly fitting In common with any extensivePractical points: margins and failure (Figure 10a). restorative dentistry, maintenance is of Telescopic crowns, or the use of paramount importance. It must beq Impression taking and cementation copings and a superstructure, can remembered that splinting teeth can of restorations can be problematic provide a useful alternative (Figure often delay the presentation of when teeth are mobile. Temporary 10b,c). Maintenance and tooth loss can mechanical and biological failures. splinting of teeth and the use of a more easily be accommodated than Late diagnosis of dental caries, low-viscosity impression material with conventional splinting, but cementation failure and further can be useful in overcoming some aesthetics and periodontal health can periodontal breakdown may result in of these problems. Composite be compromised due to increased bulk difficult maintenance, if not resin, acrylic (Figure 9a) or of the superstructure. catastrophic failure. Patients require impression compound can be The practical points mentioned above effective recall, careful review and useful temporary splinting materials.q Interdental spacing often needs blocking out with soft wax to a b prevent impression material engaging deep undercuts. This facilitates removal of the impression, and not the teeth (Figure 9b)!q All luting cements perform best in thin section, thereby increasing the longevity of the restoration. Great care must be exercised to ensure c teeth are held intimately in contact Figure 10. Linked crowns (a) can be with the splint during cementation. difficult to cement due to independent movement of the abutment teeth leading toSplinted Conventional Crown and poor marginal fit and failure. Gold copings (b) with telescopic crowns (c) facilitateBridgework access for maintenance of abutment teethSplinted crowns still have a place when splinted crowns are used.where the teeth are heavily restored.However, these splints are time-284 Dental Update – July/August 2000
  7. 7. P E R I O D O N T I C S crown and bridge procedures. Holland: Dental equilibrium between forces acting on a tooth Center for Postgraduate Courses, 1985; p.25. and the resistance of the supporting tissues). 4. Fleszar TJ, Knowles JW, Morrison EC, Burgett Angle Orthod 1978; 48: 175–186. FG, Nissle RR, Ramfjord SP. Tooth mobility and 16. Love WD, Adams RL. Tooth movement into periodontal therapy. J Clin Periodontol 1980; 7: edentulous areas. J Prosthet Dent 1971; 25: 271– 495–505. 278. 5. Ericsson I, Lindhe J. Lack of significance of 17. Andreasen JO, Andreasen FM. Textbook and increased tooth mobility in experimental Colour Atlas of Traumatic Injuries to the Teeth, 3rd periodontitis. J Periodontol 1984; 55: 447–452. ed. Copenhagen: Munksgaard, 1994; pp.297, 347– 6. Bhaskar SN, Orban B. Experimental occlusal 348, 439. trauma. J Periodontol 1955; 26: 270–284 18. Renggli HH. Splinting of teeth – An objective 7. Glickman I. Inflammation and trauma from assessment. Helv Odont Acta 1971; 15: 129.Figure 11. Acrylic resin Duralay® (Reliance occlusion, co-destructive factors in chronic 19. Renggli HH, Schweizer H. Splinting of teeth withDental Mfg. Co., Worth, Illinois, USA) bonnets periodontal disease. J Periodontol 1963; 34: 5– removable bridges. Biological effects. J Clinare placed over the teeth and passively linked 10. Periodontol 1974; 1: 43–46.with wire to prevent them from moving relative 8. Glickman I, Smulow JB, Vogel G, Passamoti G. 20. Renggli HH, Allet B, Spanauf AJ. Splinting of teethto one another during impression taking. (Slide The effect of occlusal forces on healing with fixed bridges: biological effect. J Oral Rehabilcourtesy of Mr Alex Gow, Specialist Registrar in following mucogingival surgery. J Periodontol 1984; 11: 535–537.Restorative Dentistry, Eastman Dental Hospital.) 1966; 37: 319–325. 21. Clark JW, Weatherford TW, Mand WV. Wire 9. Lindhe J, Ericsson I. The influence of trauma ligature – Acrylic splint. J Periodontol 1969; 40: from occlusion on reduced but healthy 371–375. periodontal tissues in dogs. J Clin Periodontol 22. Klassman B, Zucker HW. Combination wire-prompt intervention to preserve what 1976; 3: 110–122. composite resin intracoronal splinting: Rationaleremains. 10. Nyman S, Lindhe J. Persistent tooth and technique. J Periodontol 1976; 47(8): 481–486. hypermobility following completion of 23. Polson AM, Billen J. Temporary splinting using periodontal treatment. J Clin Periodontol 1976; ultraviolet-light-polymerised bonding materials. JCONCLUSIONS 3(2): 81–93. Am Dent Assoc 1974; 89: 1137–1141. 11. Nyman S, Lindhe J, Ericsson I. The effect of 24. Saravanamuttu R. Post-orthodontic splinting ofThe value of splints in periodontal progressive tooth mobility on destructive periodontally involved teeth. Br J Orthodont 1990;therapy has been called into question in periodontitis in the dog. J Clin Periodontol 1978; 17: 29–32. 5: 213–225. 25. Rosenberg S. A new method for stabilization ofthe last decade, but may be indicated in 12. Svanberg G. Influence of trauma from the periodontally involved teeth. J Periodontol 1980;some circumstances. It is important to occlusion on the periodontium of dogs with 51: 469–473.remember that splinting rarely normal or inflamed gingiva. Odont Revy 1974; 25: 26. Rochette AL. Attachment of a splint to enamelimproves periodontal health and may 165–178. of lower anterior teeth. J Prosthet Dent 1973; 30: 13. Kantor M, Polson AM, Zander HA. Alveolar bone 418–423.serve only to mask a problem. regeneration after removal of inflammation and 27. Simonsen R, Thompson V, Barrack G. Etched CastTherefore, the decision to splint teeth traumatic factors. J Periodontol 1976; 47: 687–695. Restorations. Clinical and Laboratory Techniques.should not be taken lightly and should 14. Wise MD. Occlusal adjustment and equilibration. Chicago: Quintessence, 1983.be considered only following In: Failure in the Restorative Dentition; Management 28. Tay WM. Classification and assessment of and Treatment. London: Quintessence, 1995; composite retained bridges. Restor Dent 1986; 2:appropriate periodontal management, pp.225–235. 15–18.with thorough maintenance following 15. Proffitt W. Equilibrium theory revisited. Factors 29. Tay WM. Resin bonded bridges. 1. Materials andsplinting. In this context, it is important influencing the position of teeth (i.e. methods. Dent Update 1988; 15: 10–14.to ensure that the patient is aware ofthe potential pitfalls in order tosafeguard compliance with continuedmonitoring and maintenance. a b The indications for splinting areusually limited to improving patientcomfort and controlling toothmovement in teeth with periodontalhealth but reduced support. Clinicaltechniques have been developed to helpthe practitioner provide such treatmentor consider referral to a specialist. c Figure 12. A facebow bitefork, refined withREFERENCES Temp Bond® cement (Kerr UK Ltd.,1. Smith BJ, Setchell D. In: Rowe, AHR, ed. Peterborough, PE3 8YP) (a) is adapted to fit Companion to Dental Studies Vol.3: Clinical Dentistry. the preparations (b) and used to verify the Oxford: Blackwell Scientific Publications, 1986; accuracy of the master cast (c). pp.519–529.2. Weinberger BW. An Introduction to the History of Dentistry, Vol.1. St. Louis: C.V. Mosby, 1948; p.75.3. Pameijer HN. Periodontal and occlusal factors in Dental Update – July/August 2000 285