splinting

PERIODONTAL

SPLINTING

1. Definitions

2. Terminology

3. Early History

4. Objectives

5. Indications

6. Contraindications

7. Principles

8. Ideal Splint

9. Splintee / Splinters

10. Mode of Action

11. Classifications

12. Temporary Splints

13. Provisional Splints

14. Permanent Splints

15. Commonly Used Splints

16. Disadvantages

17. Case Reports

18. Conclusion

CONTENTS

SPLINTING – Definitions

“The joining of two or more teeth into a rigid unit

by means of fixed or removable restorations or

devices”

“The joining of two or more teeth for the purpose of

stabilization”

-Dawson

SPLINT – Definitions

“An appliance designed to stabilize mobile teeth”

-Glossary Of Periodontic Terms (1986)

“Any apparatus, appliance, or device employed to prevent

motion or displacement of fractured or movable parts in

order to distribute occlusal forces evenly”

-AAP (1996)

SPLINT – Definitions

“A rigid or flexible device that maintains in position a

displaced or movable part; also used to keep in place &

protect the injured part”

-Glossary Of Prosthodontic Terms

TERMINOLOGY

STABILIZATON

TEMPORARY SPLINT

PROVISIONAL SPLINT

PERMANENT SPLINT

EARLY HISTORY

A Phoenician mandible from 500BC found in modern day

Lebanon which has two carved ivory teeth attached to four

natural teeth by gold wire

Findings from digging of Egyptians (3000 -2500 B.C.) show

similar gold wiring

Romans used gold ribbons for splinting in the 1st century

B.C.

8th Century BC to 1st Century AD - excavations of Etruscan

society give evidence of use of wire ligation & gold bands to

stabilize teeth

Early 1700s - Fauchard attempted tooth ligation

1950 – Hirschfeld: ligation of periodontally diseased teeth

using SS Wire or Silk

Obin and Arvins (1951) – self curing internal splint

Cross (1954) – continuous amalgam splints

Harrington (1957) modified the splint by incorporating

cemented stainless steel wire

Wellensiek (1958), Shatzkin (1960) & Taatz (1964) – anterior

intra coronal splints.

Most complete literature review on tooth stabilization was by

Lemmerman in 1976.

OBJECTIVES

1. Providing rest to the supporting tissues

2. Redirection of forces

3. Redistribution of forces

4. Immediate reduction of mobility

5. Preserving arch integrity

OBJECTIVES

6. Restoration of functional stability

7. Psychological well being

8. Stabilizing mobile teeth during surgical, especially

regenerative therapy

9. Preventing migration and over eruption

10. Improving esthetics

INDICATIONS (Tarnow & Fletcher, 1986)

1. Stabilization of a severely periodontally compromised tooth

2. Stabilization of teeth after acute dental trauma

3. Stabilization of mobile teeth

for masticatory comfort

4. Redistribution of forces

along the long axis of teeth

5. Cross arch stabilization

6. Control of forces of parafunction or bruxing

7. Stabilize teeth in secondary occlusal trauma

8. Restoration of the vertical dimension of occlusion in case of

posterior bite collapse

9. Prevention of the eruption of an unopposed tooth

10. Post orthodontic retention

CONTRAINDICATIONS (Tarnow & Fletcher, 1986)

1. Moderate to severe tooth mobility in the presence of

periodontal inflammation and/or primary occlusal trauma

2. Insufficient number of firm or sufficiently firm teeth to

stabilize mobile teeth

3. Prior occlusal adjustment not done on teeth with occlusal

trauma or occlusal interferences

4. Patient not maintaining oral hygiene

CLINICAL FEATURES

RADIOGRAPHIC FEATURES

TREATMENT REQUIRED

• Increased Mobility

• Increased width of PDL• Normal bone height

Occlusal equilibration

• Increased Mobility

• Increased width of PDL• Reduced bone height

Occlusal equilibration

• Increased Mobility• Patient NOT functioning comfortably

• Normal width of PDL• Reduced bone height

Occlusal equilibration ± Splinting

• Increased Mobility• Patient functioning comfortably

• Normal width of PDL• Reduced bone height

No occlusal adjustment required

PRINCIPLES

Should decrease movement 3 dimensionally

Centre of rotation of the affected teeth must be located in the

remaining supported bone

No inflammation

Minimum of 1/3rd of bony support remaining

Occlusion must be adjusted prior to stabilization

Sufficient number of sound teeth should be involved

Non irritating to other

soft tissues

Should allow for practice of

oral hygiene methods

Should not impair or disturb the phonetic pattern

Esthetically pleasing

Crown root ratio should be considered

Favorable tooth position in the arch

No periapical pathology

IDEAL SPLINT (Simring & Thaller, 1956)

SIMPLE

ECONOMIC

STABLE & EFFICIENT

HYGIENIC

NON-IRRITATING

IDEAL SPLINT

NO INTERFERENCE WITH TREATMENT

ESTHETICALLY ACCEPTABLE

NO IATROGENIC DISEASE

EASY CLEANSABLE

EXTEND AROUND ARCH

SPLINTEE

TOOTH THAT NEEDS SUPPORT

SPLINTERS

ADJACENT TEETH THAT PROVIDE SUPPORT

MODE OF ACTION

Loose teeth become stabilized

Occlusal forces are

better distributed

Trauma minimized, repair

enhanced

CLASSIFICATION OF SPLINTS

PERIOD OF STABILIZATION

TOOTH PREPARATION

TYPE OF MATERIAL

• Bonded composite resin

• Braided wire

• A-splints

• Temporary

• Provisional

• Permanent

• Intracoronal

• Extracoronal

GOLDMAN, COHEN, & CHACKER CLASSIFICATION

TEMPORARY PROVISIONAL

EXTRACORONAL INTRACORONAL

1. Wire ligation2. Orthodontic

bands3. Removable

acrylic appliances

4. Removable cast appliances

5. UV light polymerizing bonding materials

1. Wire and acrylic

2. Wire and amalgam

3. Wire, amalgam and acrylic

4. Cast chrome-cobalt alloy bars with acrylic

1. All acrylic

2. Adapted metal band and acrylic

ROSS, WEISGOLD, & WRIGHT CLASSIFICATION

TEMPORARY LONG TERMPROVISIONAL

1. Removable extracoronal

2. Fixed extracoronal

3. Intracoronal4. Etched metal-

resin bonded

1. Acrylic

2. Metal band & acrylic

1. Removable

2. Fixed

3. Combination of removable & fixed

FACTORS TO BE CONSIDERED

Mobility patterns of the teeth to be splinted

Crown to root ratio of involved teeth

Status of the remaining teeth in the arch

Nature and the extent of periodontal destruction

Method of therapy that will be employed

TEMPORARY SPLINTS

Essentially a diagnostic procedure; reversible

Mechanical stabilization – hypermobility reduction

Method chosen – simplest, least expensive, least time

consuming, esthetically acceptable, and should meet patient

needs

Aid in determining whether teeth with a borderline prognosis

will respond to therapy

EXTRACORONAL SPLINTS

1. Wire Ligation

Most common

Easy to construct; sturdy

Limitation – only where coronal form permits

Greatest use in – mandibular incisors

Hirschfield – loop tied at cervical line

2. Orthodontic Bands

Stabilize both anterior & posterior teeth

Attention to the contours of the bands

Contacts between teeth must be opened

Acrylic over the bands

Common path of insertion

3. Removable Acrylic Appliances

Dimensional instability of material may cause distortions

Imperative to check these frequently & make necessary

adjustments.

Vital to check the path

of insertion of appliance

4. Acrylic Bite Guards (Night Guards)

Treatment of bruxism and clenching

Most common – covers occlusal surface of teeth

For additional support – palate is covered

Maxillary Hawley Bite Plane with a labial wire

Advantage – posterior teeth freed of occlusal contact

Used in – anterior overbite

Disarticulates posterior teeth

5. Removable Cast Appliances

Usually a rigid casting either of gold or of chrome cobalt

Friedman’s variation – double continuous clasp casting

One end is not joined but is left open so that the casting can

be sprung over the undercuts and then ligated

The posterior end is

continuous from the buccal

to the lingual surface

Another modification is an

interlocking attachment on

the distal end

6. UV Light Polymerizing Bonding Materials

Polson & Billen – "Because the materials do not polymerize

until they are exposed to ultraviolet light, they provide

prolonged working times for placement, shaping, and

contouring over extensive areas of enamel”

One popular kit – NUVA SYSTEM (Caulk, Division of

Dentsply lnternational Inc. Milford, Delaware)

The composite resin splint can be strengthened by adding wire,

monofilament line, fiberglass or by using a fibre meshwork to

reinforce the material

E.g.: RIBBOND, Ribbond Inc.,

Seattle, WA

Extracoronal resin-bonded retainers can strengthen the overall

bonded situation

The splints are usually cast from metals, usually non noble alloys

Greater inherent strength

than composite-resin splint

Grooves, pins and parallel

preparations increase retention

DIAMONDCROWN (Biodent Inc., Mont-Saint-Hilaire, QC)

claims improved diametric tensile strength & bonding

capabilities

INTRACORONAL SPLINTS

1. Wire Ligation

Serves well for posterior teeth

A channel is prepared on the labial, lingual and proximal

surfaces

Major disadvantage – channels may become undercuts in

case crowns are needed later

2. Wire & Acrylic (A-Splint)

Obin & Arvins – wire fixed with acrylic in channels made in

mobile teeth

Utilized on – occlusal surfaces of posteriors and lingual

surfaces of anteriors

Possibility of caries or breakage

Utilized more readily with anterior teeth

3mm wide and

2mm deep channels

Slight undercut

Pulp protection

Platinized knurled wire 22 to 16 gauge (0.64 – 1.3mm

diameter)

Major disadvantage – recurrent caries

Kessler’s variation of A-Splint

1 mm deep mesial and distal box is prepared parallel to long

axis

SnF2 or Ca(OH)2 varnish is applied and then threaded pin

is placed

Stainless steel wire is adapted around the pin while it passes

through the slot

3. Amalgam Splint

Limited to posterior teeth

Teeth prepared with sound operative principles and

amalgam is condensed

2 to 5 teeth may be splinted

Disadvantage – Tend to fracture easily

4. Fixed Temporary Acrylic Bridges

Used when permanent splints have to be given at a later

stage

With time acrylic wears and breaks

Some clinicians prefer cast occlusals

Some prefer metal copings (less irritating and less likely to

cause caries due to cement washout)

5. Wire & Amalgam

Lloyd & Baer – continuous amalgam splint

Series of mesial-occlusal-distal preparations

Restored with amalgam with wire embedded in it

Disadvantages - Limited to posterior teeth and possibility of

fracture

6. Wire, Resin, & Amalgam (Trachtenberg)

Embed the wire in

preexisting amalgam

with acrylic

Langeland et al –

tagged acrylic in

experimentally

prepared cavities

in monkeys

7. Cast Chrome-Cobalt Alloy Bars

Baumhammers – condensed amalgam over a 14 gauge

chrome-cobalt bar

Corn & Marks – cast bar fabricated on study casts prior to

insertion

A channel is made in the teeth to be stabilized; bar is

inserted with acrylic into grooves prepared

PROVISIONAL SPLINTS

May be used for months upto several years

Usually fabricated in acrylic

Stabilize a mobile dentition from initial tooth preparation to

the time for permanent restorations

Provide – Stability, Occlusal function, Good esthetic result

1. All Acrylic

Most common

Can be fabricated chairside

Limitation – marginal adaptation

2. Adapted Metal Bands & Acrylic

Amsterdam & Fox – copper / gold bands fitted and

incorporated into acrylic

Fulfills all objectives – exact marginal fit (caries control &

pulp protection)

Frequent removal is possible – added strength of metal

bands

PERMANENT SPLINTS

REMOVABLE

FIXED

CAST METAL RESIN

BONDED FPDs

COMBINED

ENDODONTIC POSTS

Continuous Clasp DevicesSwing Lock

DevicesOverdenture

Full Coverage / ¾th Crowns, InlaysPosts in Root

CanalsHorizontal Pin Splints

Partial Dentures &

Splinted Abutments

Removable-Fixed Splints

Full / Partial Dentures on

Splinted Roots

Fixed Bridges in Partial Dentures

Swing-Lock Devices

Used in situations where fixed splinting is not possible or

desirable

Advanced age, poor physical / mental status, questionable

prognosis

Advantages – Conceals metal, avoids torque

Overdentures

Used where few teeth with questionable prognosis remain

Advantages – Favorable crown-root ratio, retention of

alveolar bone around roots

Disadvantage – Recurrent periodontal disease

FIXED SPLINTS

Full coverage - simple

Inlays – more conservative

Reciprocal stabilization in all directions

Palatal bar – cross arch stabilization

Advantages – comfortable, esthetic

Cast Metal Resin Bonded FPDs

Maryland splints

Used with intact or very slightly altered enamel surfaces

Advantages – functional, esthetic, reversible, economic

Not suitable for – excessively mobile teeth under strong

occlusal load

I. UNILATERAL SPLINTING

II. BILATRAL / CROSS-ARCH SPLINTING

BILATRAL / CROSS-ARCH SPLINTING

A. CONTINUOUS SPLINTS

B. SEGMENT SPLINTS

1. Non Rigid Connectors2. Soldered Joints3. Locking Rod And Tube4. Coping Connector

NON-RIGID CONNECTOR

SOLDERLESS JOINT

LOCKING ROD & TUBE

COPING CONNECTOR

COMMONLY USED SPLINTS

For Anterior Teeth For Posterior Teeth

1. Wire Ligatures

2. Direct Bonding Systems

3. A-Splint

4. Variation of A-Splint

5. New Generation Bonded Reinforcing Materials with Composites

1. Intracoronal Amalgam Wire Splints

2. A-Splints

3. Bite Guards

4. Rigid Occlusal Splints

5. Composite Splints – for Severe Bruxism

J Can Dent Assoc 2000; 66: 440-443

J Can Dent Assoc 2000; 66: 440-443

Dental Traumatology 2006; 22: 345-349

J Prosthet Dent 2000; 84: 210-214

DISADVANTAGES OF SPLINTING

HYGIENIC

MECHANICAL

BIOLOGICAL

CONCLUSION

Composite resin splints with fiber reinforcement

BOON or BANE

REFERENCES

1. PERIODONTAL THERAPY – Henry M. Goldman & D.

Walter Cohen, 6th Ed

2. PERIODONTICS IN THE TRADITION OF GOTTLIEB

AND ORBAN – Grant, Stern & Listgarten, 6th Ed

3. PERIODONTAL DISEASES – Schluger, Youdelis, Page, & Johnson, 2nd Ed

4. Periodontology 2000, Vol 4, 1994, 15-22

REFERENCES

5. Compendium Aug 2001, Vol 22, No. 8, 610-620

6. J Can Dent Assoc 2000; 66: 440-443

7. J Contemp Dent Pract Nov 2002; (3) 4: 10-22

8. DCNA, Vol 43, No. 1, 1999

9. BDJ, Vol 191, No.10, Dec 8, 2001

10. Dental Traumatology 2006; 22: 345-349

11. J Prosthet Dent 2000; 84: 210-214

THANK YOU