Continuing Education                                                                                                      ...
Continuing Education                                                                            allow occlusal clearance w...
Figure 5—Occlusal view of splint in place.   Figures 6 through 8—Postoperative anterior, right side and left side views. B...
Continuing Education                                                                                                      ...
Continuing Education                                                                              therefore more beneficia...
Continuing Education                               QUIZ May 2005InstructionsContemporary Esthetics offers 12 Continuing Ed...
Article clinical splinting
Article clinical splinting
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Article clinical splinting

  1. 1. Continuing Education E. Griffin Cole, DDS, PA Private PracticeTo Splint or Not To Splint: Austin, Texas Phone: 512.472.3565 Fax: 512.472.1210 Email: griffincole@yahoo.comTreating Periodontally Compromised Pocket depth readings within nor-Teeth by Improving Occlusion mal ranges were noted throughout the anterior region, with pockets as deep as 6 mm in the posterior quadrants. For clarity and con- hen faced with the sistency throughout this article, the W dilemma of how to maintain periodontally compromised teeth, res-torative dentists often splint mobile Abstract Although splinting periodontally compromised teeth is common practice, the limitations of its effectiveness are well documented. Oc- clusion must always be the prime consideration when deciding how to focus will be on the anterior teeth. Classification “Type 1+” mobil- ity was noted on teeth Nos. 23 and 26, with “Type 3” mobility notedteeth to stronger adjacent teeth in an treat a periodontally compromised dentition. Oftentimes, eliminating on teeth Nos. 24 and 25. Theeffort to prolong the life expectancy destructive bite interferences is all that is needed to create an environ- patient had an edge-to-edge incisalof the loose teeth. A 1961 study by ment where healing can occur. This article summarizes a 4-year history relationship with severe abfractionGlickman and colleagues clearly of a patient’s struggle to maintain a healthy periodontium in her wear on teeth Nos. 23 through 26.showed that although fixed splints mandibular anterior sextant. The patient’s bite patterns and excursions The abraded areas had worsenedprovide some beneficial distribution were carefully evaluated and improved when proper incisal guidance was during the past 5 years as describedof occlusal forces, the ideal way to created. The results were favorable and illustrated in the article. After by the patient and her records, as aalleviate excessive occlusal forces that this article is published, another year has passed and the patient’s anteri- result of the occlusal disharmony ofcause tooth or teeth mobility is to or teeth remain stable and further healing of the periodontium has her anterior bite.5 She exhibited aremove the destructive contacts.1 In occurred. cuspid-guided occlusion bilaterallyother words, dentists must change coupled with anterior excursivethe way the teeth contact by improv- Learning Objectives interferences (Figure 3). Splaying ofing overjet and/or distributing After reading this article, the reader should be able to: the lower incisors was also noted inocclusal and excursive contacts. ■ describe the clinical significance of splinting vs not splinting mobile excursive movements. The patient It is an accepted practice to teeth. experienced no discomfort whensplint mobile teeth, particularly ■ explain the limitations and potential negative consequences of chewing but did express concernlower incisors, to maintain the splinting teeth. about the obvious abrasions evidentpatient’s natural dentition as long as ■ explain the importance of occlusion in treating mobile teeth and use on the lower incisors. She noticedpossible.2,3 This is often the treat- this knowledge to identify and eliminate destructive contacts and that the incisors were loose but ex-ment of choice, if finances are pro- interferences. pressed no difficulty with mastica-hibitive. However, this treatment tion. In October 2000, her previousshould be planned as transitional dentist diagnosed approximatelyand short-term only. Occlusal The case presented in this arti- tory, though somewhat extensive, 70% bone loss around teeth Nos.forces applied to a single tooth in a cle shows how creating proper did not directly contribute to the 24 and 25 (Figure 4). In Aprilsplint are transmitted to the occlusal clearance and overjet of the chief complaint. However, her den- 2002, a periodontist recommendedremainder of the splinted teeth. In anterior teeth allowed the mobile tal history revealed a 10-year battle that she splint her mandibularessence, one “bad apple” is allowed teeth to heal and tighten in the with periodontal disease and a incisors together for stability, whichto spoil the bunch. There are periodontium. recently placed fixed composite led to the placement of a Ribbond-numerous studies showing that the splint joining the 4 mandibular in- supported (Ribbond, Inc) compos-injurious effect of excessive occlusal Case Presentation cisors. Also noted were numerous ite splint (Figure 5) <QA: Becauseforces on nonsplinted teeth is not A 76-year-old woman present- anterior restorations and 2 root canal of our Fair Play Policy, please men-transmitted to the adjacent teeth.4 ed with a chief complaint of severe- therapies on teeth Nos. 8 and 10. tion several other splints thatIf the destructive force is eliminat- ly abraded, loose, lower-front teeth The patient had regular, 6-month could have been used for this pro-ed, healing can occur. (Figures 1 and 2). Her medical his- hygiene visits in the past 5 years. cedure.>. Figure 4— Radiograph of lower incisors taken in October 2000 before placement of splint and restorative work. Notice the extent of bone lossFigure 1—Preoperative anterior view. Figure 2—Preoperative, right side, anterior Figure 3—Anterior view showing patient around central view. Notice the severe abfraction lesions just beginning to excurse into right incisor tooth and overjet relationship. working <QA: is this sentence finished?>. Nos. 24 and 25. Anterior interferences do not allow for a smooth working motion.2 May 2005 Contemporary Esthetics and Restorative Practice
  2. 2. Continuing Education allow occlusal clearance when overjet and eliminating anterior B y removing the deflective contacts and allowing the 2 “bad apples” to sit independently of the adjacent teeth, healing chewing. A detailed description of the splint, including its short-term solution as well as its potentially harmful action on the adjacent teeth, was presented to the patient.6 excursive interferences. By remov- ing the deflective contacts and allowing the 2 “bad apples” to sit independently of the adjacent teeth, healing could then occur.7 Placing could then occur. The recommended treatment permanent crowns offered a better was to restore the lower 4 incisors option to create the proper overjetTreatment Plan composite splint that would span with either composite fillings or and provide more predictable Discussion regarding treatment from cuspid to cuspid or restoring crowns and improve the anterior results. A discussion regarding place-options included creating a new the incisors with proper contours to bite stability by creating proper ment of permanent crowns on loose teeth ensued, including the strong possibility of short-term success and eventual loss of teeth. The patient understood all implications and accepted this recommended plan. After a thorough periodontal assess- ment and therapy, restorative treat- ment began. The patient’s main restorative goal was to “fix” the abraded teeth. Esthetics was not a priority for her. Preparation Before preparing teeth Nos. 23 through 26 for full coverage crowns, Vitrebond (3M ESPE) bases were placed in the abraded areas to add protection for the near- ly exposed pulps. Conservative preparations were made, tapering the incisal edges enough to create an overjet of approximately 1.5 mm. Although new porcelain crowns were also placed on teeth Nos. 8 and 9—No. 8 had root canal therapy and No. 9 had patch- work bonding—to help create the new overjet, this was not necessary to achieve our objective. Enough room was already available to allevi- ate the occlusal interferences. All margins were placed slightly supragingivally, so no retention cord was necessary. Impressions were made with Impregum (3M ESPE), and temporary crowns were made with Jet acrylic (Lang Dental Manufacturing Company, Inc) and splinted together to prevent any movement during the transition phase, which could affect the seat- ing of the permanent crowns. The temporary bridge was cemented with Durelon (3M ESPE), and all excess cement was carefully cleaned away. Excursive movements were checked to ensure no anterior inter- ferences of the cuspid-guided plane. Cementation The acrylic temporary was sec- tioned with a handpiece and re-4 May 2005 Contemporary Esthetics and Restorative Practice
  3. 3. Figure 5—Occlusal view of splint in place. Figures 6 through 8—Postoperative anterior, right side and left side views. Besides improved esthetics, the overjet and overall shape of thePlaque and tartar accumulation was teeth was dramatically improved.evident.moved with hemostats. This in.-volved using a Midwest 245 carbidebur (Dentsply Professional) to care-fully cut the temporary into sepa-rate parts. Finishing burs, like thisone, cut smoothly without “jump-ing” during the process. The tem-porary was then sectionallyremoved with the hemostats with-out imparting too much stress onthe mobile teeth. The porcelain-to-gold crownschosen for this case were AuthenticPress-To-Metal Ceramics (Micro-star Corporation) with Authentic86 (The Argen Corporation) alloy(Ceramay). Authentic was chosenfor its biocompatibility and low-wear features. Its impressive esthet-ic and durable characteristics wereachieved by combining this press-able ceramic with a cast metal. TheAuthentic system provides an im-portant advantage for the techni-cian to transfer functional occlusalrecords from wax to ceramic withremarkable accuracy. Furthermore,the occlusal abrasion of Authenticis very similar to natural dentition. The crowns were fitted andcemented with Fuji I Cement (GCAmerica Inc) after conditioning theteeth with Fuji Plus Conditioner(GC America Inc). Because of thecompromised pulpal condition ofthis patient’s teeth, conditioningbefore cementation was an impor-tant step for avoiding postoperativesensitivity. Excursive movementswere again carefully checked andinterferences eliminated to allow forproper overjet/overbite clearance. Cuspid-guided occlusion withno anterior interferences was proper-ly established. Firm flossing contactswere created by design and, al-though esthetics was of little concernfor the patient, a rather nice finishwas realized (Figures 6 through 8).Posttreatment Assessment The patient returned to theContemporary Esthetics and Restorative Practice May 2005 5
  4. 4. Continuing Education before placement of the Ribbond Table—Results of the Mobility Analyses From All Phases of Treatment splint was less than that following splint therapy. The teeth showed Mobility the most movement immediately Tooth No. 23 Tooth No. 24 Tooth No. 25 Tooth No. 26 following splint removal. 2000 Without radiographs it is diffi- (Before splint 1 2 2 1 cult to gauge improvement when placement) teeth are splinted. Mobility cannot Year 2003 be accurately measured. A radi- (Immediately after 1+ 3 3 1+ ograph taken in October 2000 splint removal shows the anterior teeth (Figure 4). 2004 Notice the amount of bone loss (6-months after 1 2 1 1 around tooth No. 24; only the api- crown cementation) cal one third of the root is encased in bone. A radiographic image taken in April 2004 is shown in Figure 9. Notice the improvement in bony support around tooth No. 24. The Ribbond splint was placed in April 2002 and removed in October 2003—18 months—at which time the preparations were performed. The final radiographFigure 9—Radiograph of lower incisors Figure 10—Preoperative view of the severe Figure 11—Postoperative view demon- was taken in April 2004 (Figure 9),taken in April 2004. Notice the apparent gingival abrasions and “splayed” appear- strating the improved overjet and appear-improvement in bone topography around ance of the upper incisors. ance of the incisors. The patient’s cuspid- exactly 6 months following cemen-tooth No. 24. Mobility measurements con- guided excursions are now unimpeded by tation. The patient was pleasedfirm improvement in attachment. her incisors. with the results and particularly happy with the “shapely” new teethoffice 3 months later for a postop- from all phases of treatment. All “Type 1+” mobility to “Type 1.” and improved overjet (Figure 10).erative visit, which included reas- postoperative photographs were Tooth No. 24 improved from <AQ: There is no callout in textsessment of all pocket depths and a taken 6 months after cementation. “Type 3” mobility to a “Type 2” for Figure 11, yet you have a cap-detailed tissue evaluation. A second Although there was little level. Finally, tooth No. 25 tion for it. We usually don’t citefollow-up visit was completed 3 change in probing depths (eg, ini- improved significantly from a Figures in Conclusion, so I movedmonths after that—6 months since tial probing depths were satisfacto- “Type 3” mobility reading to a Figure 10 here. OK? Where do youseating permanent crowns—for ry), there was a significant reduc- “Type 1” reading. These results are want Figure 11 called out?>reevaluation. The table above shows tion in mobility readings. Teeth particularly noteworthy because thethe results of the mobility analyses Nos. 23 and 26 tightened from mobility of the patient’s teeth T he patient was pleased with the results and particularly happy with the “shapely” new teeth and improved overjet. Conclusion Splinting teeth to keep the weak ones around longer is only a good plan if no other permanent options are possible. Besides creat- ing a plaque problem, splinting can at times be detrimental to the health of the strong teeth. Re- moving interferences and deflective contacts is the key to creating an environment where loose teeth can “heal” and tighten in their sockets. Of course, excellent home care and6 May 2005 Contemporary Esthetics and Restorative Practice
  5. 5. Continuing Education therefore more beneficial. ■ the ceramists at Summit Dental R emoving the patient’s splint and Laboratory of Waco, Texas for the Disclosure beautifully crafted restorations pre- individualizing her incisors created the The author received no com- sented in this article. pensation or royalties from any of best opportunity for healing. the manufacturers discussed in this References 1. Glickman I, Stein RS, Smulow JB. The effect of article. increased functional forces upon the periodon-proper maintenance is absolutely individualizing her incisors created tium of splinted and non-splinted teeth. Jessential for success. In this case, the best opportunity for healing. Acknowledgment Periodontol. 1961;32:290-300. <QA: Please verify reference No. 1, could not find>removing the patient’s splint and Her home care became easier and The author would like to thank 2. Quirynen M, Mongardini C, Lambrechts P, et al. A long-term evaluation of composite-bond- ed natural/resin teeth as replacement of lower incisors with terminal periodontitis. J Periodontol. 1999;70(2):205-212. 3. Pollack RP. Non-crown and bridge stabilization of severely mobile, periodontally involved teeth. A 25-year perspective. Dent Clin North Am. 1999;43(1):77-103. 4. Serio FG, Hawley CE. Periodontal trauma and mobility. Diagnosis and treatment planning. Dent Clin North Am. 1999;43(1):37-44. 5. Rees JS, Jagger DC. Abfraction lesions: myth or reality? J Esthet Restor Dent. 2003;15(5):263-271. 6. Watkins SJ, Hemmings KW. Periodontal splinting in general dental practice. Dent Update. 2000;27(6):278-285. 7. Bernal G, Carvajal JC, Munoz-Viveros CA. A review of the clinical management of mobile teeth. J Contemp Dent Pract. 2002;3(4):10-22. Product References Product: Ribbond Manufacturer: Ribbond, Inc Address: 1402 3rd Ave. Suite 1030 Seattle, WA 98101 Phone: 800.624.4554 Fax: 206.382.9354 Products: Vitrebond, Impregum, Durelon Manufacturer: 3M ESPE Address: Bldg. 275-25E-03 St. Paul, MN 55144 Phone: 800.634.2249 Fax: 612.733.2481 Product: Jet Acrylic Manufacturer: Lang Dental Manufacturing Company, Inc Address: 175 Messner Dr. Wheeling, IL 60090 Phone: 800.222.5264 Fax: 708.215.6678 Product: Midwest 245 Carbide Bur Manufacturer: Dentsply Professional Address: 901 W. Oakton St. Des Plains, IL 60018 Phone: 800.800.2888 Fax: 800.640.6165 Product: Authentic Press-To-Metal Manufacturer: Microstar Corporation Address: 1635 Lake Parkway Suite J Lawrenceville, GA 30043 Phone: 800.313.6427 Fax: 770.339.3188 Product: Authentic 86 Manufacturer: The Argen Corporation Address: 5855 Oberlin Dr. San Diego, CA 92121 Phone: 800.255.5524 Fax: 858.626.8686 Products: Fuji I Cement, Fuji Plus Conditioner Manufacturer: GC America Inc Address: 3737 W. 127th St. Alsip, IL 60803 Phone: 800.323.7063 Fax: 800.423.29638 May 2005 Contemporary Esthetics and Restorative Practice
  6. 6. Continuing Education QUIZ May 2005InstructionsContemporary Esthetics offers 12 Continuing Education (CE) credit hours per year. Each clinical CE article is followed by a 10-question, multiple-choice test, providing 1 hour ofcredit. To receive credit, record your answers on the enclosed answer sheet or submit them on a separate piece of paper. You may also phone your answers in to (888) 596-4605,or fax them to (703) 404-1801. Be sure to include your name, address, phone number, Social Security number, and method of payment. The deadline for submission of quizzesis 12 months after the date of publication. Participants must attain a score of 70% on each quiz to receive credit. To register, call (888) 596-4605. Participants are urged to contacttheir state registry boards for special CE requirements. 1. The Glickman and Stein study clearly showed the 4. During preparation, tapering the incisal edges b. Open margins ideal way to alleviate excessive occlusal forces enough created an overjet of approximately how c. Plaque biofilm causing mobility of a tooth or teeth is to: long? d. Postoperative sensitivity a. splint the teeth. a. 0.5 mm b. brace the teeth with a swing lock RPD. b. 1.5 mm 8. When were all postoperative photographs taken? c. remove the destructive contacts. c. 2.5 mm a. Immediately after cementation d. brace the teeth with an orthodontic retainer. d. 3.5 mm b. 1 day after cementation c. 1 week after cementation 2. What offered a better option to create the proper 5. Where were all the margins placed? d. 6 months after cementation overjet and provide more predicable results? a. Slightly supragingivally a. Gold onlays b. At the crest of the sulcus 9. It is difficult to gauge improvement when teeth are b. Placing permanent crowns c. 0.5 mm subgingivally splinted without what? c. Acrylic veneers d. 1 mm subgingivally a. Impressions d. Porcelain veneers b. Radiographs 6. The acrylic temporary was removed using c. Perioprobe sounding 3. What was the patient’s main restorative goal? hemostats: d. Pre- and postsplinting photographs a. Esthetics a. after sectioning it. b. Phonetics b. before sectioning it. 10. Splinting teeth to keep the weak ones around c. Form c. during sectioning longer is a good plan only if: d. “Fix” the abraded teeth. d. in one piece. a. no other permanent options are possible. b. there is limited room for a RPD. 7. Conditioning the teeth before cementation is c. the teeth are less that +1 mobile. an important step to avoid what? d. the patient’s diet is limited to soft food. a. Poor fitting crownsAnswer Form May 2005 CERP STATUS Payment by Credit Card (Please use a Visa, MasterCard, or American Express Card) ■ Presently Enrolled in CE Program Please enroll me in the Contemporary Esthetics and Restorative Practice Continuing Education Program marked below: Not Enrolled ■ 1 exam completed = $14.00 ■ Please enroll me in the 12-month CE Program for $134 (a 20% saving versus paying for each exam individually). Program includes all 12 exams in Contemporary Esthetics and Restorative Practice for 1 year (excluding supplements). (PLEASE PRINT CLEARLY) SSN ■ CHECK (payable to Ascend Media’s Dental Learning Systems) ■ CREDIT CARD – Please complete information and sign below: Expiration Date: Mo/Y ADA/AGD#: ____________________________ Card Number Name __________________________________________ ■ Visa ■ MasterCard ■ American Express Address_________________________________________ City ____________________________________________ ______________________________________ ______________ SIGNATURE DATE State ______ Zip __________ Daytime Fax ____________ Daytime Phone ___________________________________ PROGRAM EVALUATION Please evaluate this issue’s programs by responding • Did the lessons achieve their Please make checks payable to ASCEND MEDIA’S DENTAL LEARNING SYSTEMS to the following statements, using the scale of: educational objectives? . . . . . . ■ Yes ■ No and mail with this form to: Dental Learning Systems CE Department, 3 = Excellent to 1 = Poor. • Did the articles present new 405 Glenn Drive, Suite 4, Sterling, VA 20164-4432 • Clarity of objectives . . . . . . . . . . . . . . 3 2 1 information? . . . . . . . . . . . . . . ■ Yes ■ No CIRCLE ANSWERS • Usefulness of the content . . . . . . . . . 3 2 1 • How much time did it take you to complete the CE? . . . . . . . . ______ min • Benefit to your clinical practice . . . . . . 3 2 1 1. a b c d SCORING SERVICES • Usefulness of the references . . . . . . . 3 2 1 2. a b c d • By Mail 3. a b c d • Quality of the written presentation . . . 3 2 1 PRACTICE INFORMATION • Fax: 703-404-1801 ■ DDS/DMD ■ Full-time registered Hygienist 4. a b c d • Quality of the illustrations . . . . . . . . . . 3 2 1 ■ Dental Asst. ■ Part-time registered Hygienist 5. a b c d • Phone-in: • Clarity of review questions . . . . . . . . 3 2 1 6. a b c d 888-596-4605 ■ General Prac. ■ Periodontist (9am-5pm ET, Mon.-Fri.) • Relevance of review questions . . . . . 3 2 1 7. a b c d ■ Oral Surgeon ■ Prosthodontist Please list future CE topic preferences: ___________ • Customer Service ■ Endodontist ■ Other (includes dentists with 8. a b c d Questions? Please Call: ____________________________________________ ■ Pedodontist (nonspecified ADA specialty) 9. a b c d 888-596-4605 10. a b c d DEADLINE FOR SUBMISSION OF ANSWERS IS 12 MONTHS AFTER THE DATE OF PUBLICATION.Contemporary Esthetics and Restorative Practice May 2005 9

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