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Splinting part2 /certified fixed orthodontic courses by Indian dental academy


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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

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Splinting part2 /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. INTRACORONAL TYPES:  Internal temporary splints include  wire ligation,  acrylic,  amalgam with an embedded wire, nylon fishing line, and  composite resin with or without embedded wire or  Internal temporary splints should be used only when permanent splinting is to follow.  They may also be used on a provisional basis when tooth prognosis is guarded.  Even when splinting cannot save teeth, it can provide a gradual and less distressing transition to full dentures.  Once an internal temporary device has been used, the patient may be committed to periodontal prosthesis.
  3. 3. Wire Ligation:  The intracoronal type of temporary stabilization serves well for posterior teeth, but has obvious disadvantages for the anterior segment.  Because forces against the maxillary teeth are often generated in a labial direction, there is often noted a movement of the teeth away from the splinting mechanism.  Realizing this problem, one could prepare a channel in these teeth on the labial, lingual, and proximal surfaces, utilize a circumferential wire ligation technique, and retain this with acrylic.  A major disadvantage to this means of stabilization is that the channels may prove to be undercut areas if the teeth are prepared for full crowns in the future.
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  7. 7. Wire and acrylic: ( A – splint)  Obin and Arvins have described a technique of stabilization whereby wire (usually twisted in the form of a braid) is fixed with acrylic into channels prepared in mobile teeth.  This approach can be utilized on the occlusal surfaces of posterior teeth and the lingual surfaces of anterior teeth.  The technique offers advantages over the other forms of stabilization because there is greater control over coronal forms, occlusion, embrasure areas, and aesthetics.  Unfortunately, because of the limited properties of self-curing acrylics, there is always the possibility of caries or breakage.  This can be a very serious sequela of the technique if it mismanaged or utilized as a permanent restoration.
  8. 8.  Acrylic internal temporary splints (A splints) require the preparation of a channel approximately 3 mm wide and 2 mm deep in several teeth.  The preparations should be slightly undercut for retention.  The pulpal surfaces should be coated with a protectant.  A piece of platinized knurled wire 22 to 16 gauge (0.64 to 1.3 mm in diameter) is placed in the channel.  Then self-cure acrylic is placed to fix the wire in the channel.  Adjust the occlusion and polish the splint.  This technique had been varied by Kessler by placing threaded pins incorporated in the teeth along with wire and acrylic.  This approach can be utilized more readily with anterior teeth.  As its major disadvantage is the possibility of recurrent caries, a restorative dentistry commitment is made prior to the utilization of this form of stabilization.
  9. 9.  The amalgam splint is similar to the A splint.  It has less strength than that of cast gold. Its use is limited to the posterior teeth.  Prepare the teeth in accordance with sound operative principles.  Because commercial steel matrix band cannot be used, make a matrix of self-cure acrylic. Condense the amalgam in one unit.  Two to five teeth may be splinted in this fashion.  A wire may be used for reinforcement.  Amalgam splints tend to fracture easily,
  10. 10.  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  Many ways exist to make acrylic splints.  One simple method employs duplicates of the patient's study models.  The temporary acrylic splint is then made on the models of the prepared teeth.  With time, acrylic wears, and breakage becomes a problem.  Consequently some clinicians prefer cast occlusals others are concerned with the cervical relation of the acrylic and prefer metal copings, which are less irritating to the gingiva and less likely to permit caries because of cement washout.
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  12. 12. Wire and Amalgam:  Because of the problems created by the use of acrylic, wire embedded in amalgam restorations seems to offer a more fa­vorable prognosis.  Lloyd and Baer have suggested the continuous amalgam splint as an easy, inex­pensive, and effective method of joining together and immobilizing posterior teeth.  A series of mesio-occlusodistal preparations are made in a quadrant of posterior teeth and then restored with amalgam that has wire embedded in it at the time of condensation.  Prior to the procedure a buccal, lingual and gingival matrix is fabricated in acrylic to control proximal gingival contours.
  13. 13.  The authors note two possible disadvantages, to this form of stabilization (l) The confinement of the procedure to only posterior teeth and (2) The possibility of fracture (usually at the narrow part of the isthmus).  A variation of this approach is to embed the wire in preexisting amalgam or gold restorations with acrylic.  The acrylic and wire embedded in amalgam or the amalgam-and wire technique as described by Lloyd and Baer ap­pears to have the advantage over the wireand-acrylic method.  Langeland and Langeland, utilized tagged acrylic monomer in experimentally prepared cavities of monkey teeth, and have shown the penetration of the monomer into the dentinal tu­bules next to the cavity.  Another advantage of the wire and acrylic embedded in amalgam is that a greater degree of mechanical retention can be achieved for the plastic in the amalgam.
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  15. 15. Wire, amalgam, and acrylic:  Trachtenberg has 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.  The author noted in an 18-month period of observation there had been no amalgam fractures or recurrent caries.
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  17. 17. Cast chrome-cobalt alloy bars:  Because of the disadvantages and weaknesses of threaded wire, a number of clinicians have utilized cast chrome-cobalt bars for reinforcement.  Baumhammers suggested condensing amalgam over a 14-gauge chromecobalt bar. He offered as an advantage, in­creased strength of the splint but also noted that inherent to this technique were the usual problems of amalgam deterioration.  Corn and Marks have expanded on this approach whereby a cast bar is fabricated on study casts prior to its insertion.  A channel is made in the teeth to be stabilized and chrome cobalt alloy bar cast. The bar is then inserted with acrylic into grooves prepared in the natural dentition.
  18. 18.  This technique can be utilized both in the anterior & posterior parts of the mouth.  The intracoronal type of temporary stabilization has served well for posterior teeth, but there are obvious disadvantages for the anterior segment.  Because forces against the maxillary teeth are often generated in a labial direction, there is often noted a movement of the teeth away from the splinting mechanism.  Realizing this problem, one could prepare a channel in these teeth on the labial, lingual, and proximal surfaces, utilize a circumferential wire ligation technique, and retain this with acrylic.  A major disadvantage to this means of stabilization is that the channels may prove to be undercut areas if the teeth are prepared for full crowns in the future.
  19. 19.  Again, the intra oral means of stabilization should be initiated only when the clinician appreciates the major disadvantages of these techniques.  Ideally, it would be beneficial to have a future restorative dentistry commitment.
  20. 20. Combination splinting technique:  Klassman and Zucker have described a combination wire-intracoronal splinting technique where 0.010 dead soft ligature is imbedded in prepared channels of the anterior teeth.
  21. 21. Techniques For Anterior Teeth:  There are several variations of the intracoronal splints for anterior teeth.  The indications for their use are the same as those for the posterior teeth.  Kessler describes a variation that provides excellent stabilization, has adequate retention, requires conservative removal of tooth structure, and yet in most patients preserves the original esthetics of the teeth because the cavity preparation is limited to the lingual aspect of t he tooth."
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  23. 23.  Internal temporary splints tend to be more serviceable than the external temporary splints, yet they have many of the same shortcomings.  Their value varies with their rigidity and accuracy of fit and the patient's susceptibility to caries.  The materials tend to wear and break and are dependent on the strength of the bonding medium.  The position of the splint, marginal adaptation, and interproximal joints tend to create plaque harbors, which lead to caries, calculus deposition, and inflammation.  Thus maintenance needs are increased, and oral hygiene procedures are made more difficult.  When only part of the occlusal surface is covered by the splint, occlusal contact may displace individual teeth from the splint.
  24. 24.  Extensive gingival recession, root indenta­tions, and furcations make tooth preparation more difficult, and pulp involvement may result.  Nevertheless, internal temporary splints have a definite place in periodontal treatment, provided they are used in situations for which they are suited.  When the need for temporizing ceases, there should be no hesitation about conversion to definitive splinting.  A delay may serve only to magnify the hazards involved in temporary splinting.  A major cause of failure in periodontal treatment is the lack of, or delay in executing, adjunctive prosthesis or permanent splinting in the patient who requires it.
  25. 25.  Sometimes proper interproximal contour and marginal adaptation can be ensured by the use of matrices.  The teeth to be splinted with composite resin are isolated with a rubber dam.  A narrow, beveled groove is placed circumferentially around each tooth.  This groove should be within the enamel and not exposing dentin. The teeth are pumice polished.  A 0.010 dead-soft single or double wire, polyester filament yarn or nylon monofilament line is placed in the grooves, ligating the teeth with continuous figure-eight loops.  The enamel is then etched with a 37% phosphoric acid solution for 60 seconds, rinsed thoroughly, and dried.  Self-polymerizing or light polymerizing composite resin is then placed,
  26. 26. PROVISIONAL SPLINTS:  As the name alone implies, the objective of a provisional splint is to absorb occlusal forces and stabilize the teeth for a limited amount of time.  Provisional splints can be useful adjuncts to many different types of treatment.  They provide insight into whether or not stabilization of the teeth provides any benefit before any irreversible definitive treatment is even initiated.  The provisional splint is a restoration usually fabricated in acrylic as part of a restorative dentistry program.  With this form of stabilization it is imperative that the patient go on to a permanent restorative program.  Because of the nature of these splints, they offer the optimum in stabilization.
  27. 27.  Provisional splints can either be placed externally or internally.  External splints typically are fabricated using  ligature wires,  nightguards,  interim fixed prostheses, and  composite resin restorative materials.  Internal splints, on the other hand, are fabricated using  composite resin restorative material with or without wire or fiber inserts.
  28. 28.  Most provisional splints are made using some form of external support in their design.  When anterior teeth require splinting, ligature wire is often used.  Dead-soft round stainless steel wires (0.25 to 0.30 mm) or brass wires have been recommended.  A 6-inch section of wire is cut and placed across the anterior teeth, apical to the proximal contacts and incisal to the cervical one-third on the facial surface and cingulum on the palatal surface.  Individual vertical wires are then placed between the teeth and tightened in a clockwise direction.  Occlusal devices are often recommended to patients with a history of bruxing and clenching to help stabilize teeth following selective occlusal adjustment.
  29. 29.  One of the more common devices used is a heat polymerized poly (methylmethacrylate) occlusal splint.  Typically, these devices overlap the incisal and occlusal one-third of the facial surfaces of the teeth, cover the entire occlusal surfaces of the teeth, and extend onto a portion of the hard palate.
  30. 30.  Provisional splinting can also be used when treating periodontally compromised patients with conventional fixed prosthodontics.  An interim restoration not only can improve esthetics, it can restore the occlusal scheme to be incorporated into any definitive prostheses.  After wearing a provisional splint, patients should be reevaluated to determine if treatment should proceed to a definitive restoration.  Only after the interim restoration has been worn by the patient can the design and occlusal form be evaluated.  This evaluation should be made before deciding to proceed with the definitive restoration.  Any design modifications can then be made in the definitive restoration.
  31. 31.  For the provisional splint, the enamel surfaces are etched for 10 seconds with 35% phosphoric acid, rinsed, and a light-activated, dentin-bonding agent is immediately applied and polymerized.  An appropriate shade of composite resin restorative material is selected, placed in the desired locations, and polymerized for 40 seconds.  The splint can also be reinforced several ways using one of the following materials: ligature wire, glass fiber, or a polyethylene fiber reinforced polymer. All acrylic:  The all acrylic type is probably the most common form provisional splint.  It is usually fabricated from a premade shell, or it is done directly at the chairside.  Its greatest limitation lies in its marginal adaptation.
  32. 32. 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 transfers, assemblages) will not cause the splints to warp or the margins to become distorted.
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  35. 35. PERMANENT STABILIZATION (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.  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 trauma and to and in the repair of the periodontal tissues.
  36. 36.  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.
  37. 37.  Permanent splints may be classified as follows:  1. REMOVABLE - EXTERNAL  A. Continuous clasp devices  B. Swing - lock devices  C. Overdenture (full or partial)  2. FIXED - INTERNAL  A. Full coverage, three-fourths coverage crowns and inlays  B. Posts in root canals  C. Horizontal pin splints  3. CAST-METAL RESIN-BONDED FIXED PARTIAL DENTURES (MARYLAND SPLINTS)
  38. 38.  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.
  39. 39. Removable – External : Swing – lock devices :  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.
  40. 40. Overdenture :  When few teeth with questionable prognosis remain, an overdenture may be used. Advantage :  More favorable crown-root ratio and retention of alveolar bone around roots. Disadvantage :  Long-term use has high incidence of recurrent periodontal disease.  Patient must carry out adequate plaque control measures.
  41. 41. Fixed-internal :  Fixed permanent devices may incorporate a series of soldered castings, such as crowns, three – quarter crowns, telescope crowns, inlays, horizontal pin splints spin ledges.  Splint is cemented to place.  Full coverage is simple to perform (if recession is not extensive and teeth are parallel) otherwise inlays or pin ledges may be more conserving of tooth structure and simpler to use.  It is important that these splints be rigid  Ideally the teeth and splint should be reciprocally stabilized in all directions (i. e., mesial, distal, vestibules and apical).
  42. 42. Palatal bar :  A palatal bar connecting two fixed bridges in the upper molar and premolar areas is useful.  This palatal bar is secured to the bridges on both sides by means of precision attachments and provides cross – arch splinting.  When all segments cannot be paralleled, Jeweler’s screws or internal attachments may be used to combine segments of the splint.  Sectional splinting or splinted telescope crown copings also can overcome divergent parallelism.  The teeth must be capable of supporting a splint.  The fixed splint, properly made, is one of the most effective dental restoration for stabilization of teeth.  It is comfortable and esthetic.
  43. 43. Cast-metal resin bonded fixed partial denture (Maryland splints) :  These are used with intact or very slightly altered enamel surfaces.  This type of fixed prosthesis is functional, esthetic, reversible and economic.  It consists of a metal frame bonded with resin to tooth enamel.  Retention is enhanced by perforations or by slots.  The success rate is good. Although the original use was for anterior teeth, but can be designed for posterior teeth  The enamel bond is fairly strong, however excessively mobile teeth under a strong occlusal load can break loose from the metal framework.
  44. 44. Combined Permanent Splints :  Despite the advantages inherent in fixed splinting, instances occur of periodontally weakened dentitions, in which a combination of fixed splinting and partial dentures will best answer the needs of the patient.  These instances are governed by the distribution of remaining teeth.  When partial dentures are used, the abutment teeth are best splinted where feasible, with clasps and rests so placed that stabilization is afforded in all directions.  When the teeth are mobile, they may be jeopardized if the partial denture is completely dependent on the abutments. In these cases stress breakers may be used.  When a few teeth remain, a partial denture partly supported by means of telescope crowns can be used. The partial denture then serves as the splint.
  45. 45.  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, glassreinforced fibres or pins.  If restoration of the mouth includes crowns, the crowns can be splinted to each other by solder joints or precision attachments.  The use of attachments affords the practitioner the ease of preparing nonparallel abutments yet achieves a splinted result.
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  49. 49. Category Product Characteristics Interdental floss devices Traditional floss Waxed, unwaxed, flavored, unflavoured, fluoride coated, baking soda coated Dental tape Tufted floss Super Floss (Oral - B) NUFloss (NUFloss) Knitting yarn Floss threaders Specialty brush devices Single-tufted brush End-Tuft (Butler) Sulcabrush (Sulcabrush Inc.) Flavored, unflavored, Polytetrafluoroethylene Single, precut 2-foot lengths, 5-inch tufted segmented adjacent to a 3-inch stiffened end used for insertion under occluded contact. Available in a roll that can be cut to preferred lengths. Alternate 1.5 inch plain floss with the 1 -inch tufted portions. Use in conjunction with floss threader Synthetic, not wool Flat end and tapered end bristle heads Double-ended; firm tapered bristles; angled brush head; packaged with 2 extra replacement brushes. Interdental brushes Proxabrush (Butler) Various sizes of cylindrical and tapered refill brushes Proxabrush Trav-Ler (Butler) Compact, pocket size Interdental Brush Plastic-coated center (Oral - B) Wire, extrafine tapered and cylindrical refill brushes
  50. 50. DISADVANTAGES RELATED TO SPLINTING: Difficulty of performing the extensive restorative procedure  The knowledge required to prepare the dentition adequately to accept the splint is probably more important than all other factors combined.  Many patients that require reconstruction also may require many months of initial periodontal, orthodontic, and endodontic care.  By neglecting to carry such care, the clinician can expect failure, irrespective of excellence in the restorative and technical phases.
  51. 51. Cost:  Socio economic factors could deflect treatment away from the ideal.  Quality cannot be compromised on any part of the splint.  Each unit of the splint is like the link of a chain, and the splint is no better than its weakest unit. Technical Difficulty:  Unfortunately, few technicians are trained adequately to create a periodontal prosthetic reconstruction that is truly biologically compatible with the stomatognathic system.  The achievement of excellent marginal adaptation, good contour, functional occlusion, and esthetic acceptance by the patient usually is expected but is difficult and rarely attained in full arch splints.
  52. 52. Repair and maintenance:  The repair of a single restoration is accomplished easily, because at worst, it can be redone.  The repair of one unit of an extensive splint, however, can be difficult and expensive, at best the result is often a compromise.  Mechanical failures, such as porcelain fracture and solder joint separation, are more frequent in multi unit splints than in smaller segments.  Cement wash outs can occur without showing any signs until the pulp has become involved and endodontic problems are difficult to resolve. Additional Tooth Reduction:  All the teeth in a rigidly splinted segment require composite draw, which requires additional tooth reduction and pulpal damage is not uncommon.
  53. 53. Plaque Removal:  Well designed periodontal prosthetic splints, however, need not compromise plaque removal.  They may complicate the conventional use of floss, but the use of floss usually is not indicated in plaque control for patients with splints.  Interdental brushes and wooden tooth picks are better suited to these patients because they are the only adjunctive plaque-control aids that can effectively remove plaque from the proximal surface of roots, where many concavities exist.
  54. 54. DISADVANTAGES OF SPLINT :  They may be grouped under :  Hygienic  Mechanical  Biological. Hygienic :  All splint hamper the patient self care. Accumulation of plaque at the splinted margins can lead to further periodontal breakdown in a patient with already compromised periodontal support.  It is also difficult to achieve proper contour of a splint at the gingival margin, especially in the interproximal areas.  (If the roots of the teeth to be splinted are very close together, it may be impossible to achieve periodontal health in the interproximal areas after the splinting).
  55. 55. Biological :  Development of caries is an unavoidable risk.  It requires excellent maintenance by the patient.  Splints, especially full coverage splints, may allow the development of extensive caries under loose abutments, without symptoms. I  t is very important that splints be inspected regularly and that the patient be examined for the development of caries.  Splints should never be used as a “shotgun” substitute for accuracy and precision in occlusal therapy of the individual teeth
  56. 56. Conclusion:  The single observation of tooth mobility is not unto itself sufficient justification to splint teeth.  Tooth mobility alone does not necessarily indicate the existence of an underlying pathologic condition.  Splinting teeth to each other allows weakened teeth to gain support from neighbouring ones.  Splinting is best viewed as a preventive treatment measure for teeth that have minimal or no bone loss, yet are clinically mobile.  However, splinting makes oral hygiene procedures difficult.  Therefore, to ensure the longevity of the connected teeth, special attention must be given to instructing the patient about enhanced measures for oral hygiene after placement of the prosthesis.
  57. 57.  Splinting affords no guarantee that occlusal stress can be completely eliminated.  Before treatment is started, it is recommended that the cause of any mobility be identified  to determine if it is related to an occlusal discrepancy.  It may be that an occlusal equilibration and splinting (provisional or definitive) may actually prevent tooth loss and restore both patient comfort and function.  Thus splinting may 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.
  58. 58. Thank you all………