Final Splint

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Presented by, Dr.B.Banupriya,

PG,dept of periodontology.

SPLINTING

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Types of mobility: 1. physiological mobility.

2. pathological mobility.

Physiological mobility;

All teeth have slight degree of mobility.

They vary in different times in a day.

They are greatest in the morning and progressively decreased due to the extrusion of teeth during limited occlusal contact during sleep.

TOOTH MOBILITY

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Mobility beyond the physiological range is termed abnormal or pathological mobility.

Increased mobility is caused by one or more of the following factors:

- loss of the tooth support due to bone loss.

- trauma from occlusion.

- extension of inflammation from the gingiva or from the periapex into the pdl.

- periodontal surgery temporarily increases the tooth mobility.

- tooth mobility is increased in pregnancy and some times in menstrual cycle or by the use of hormonal contraceptives.

- some pathological process of the jaws. Which includes osteomyelitis and tumors of the jaws.

TOOTH MOBILITY

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ASSESSMENT OF MOBILITY:

1. Its is elicited by exerting pressure on one side of the tooth under examination with an instrument or fingertip while placing a finger of the other hand on the other side of the tooth and its neighbour which is used as a fixed point so that relative movement can be discerned.

TOOTH MOBILITY

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2. other way is to place finger over the facial surface of the teeth while the patient grinds the teeth.

3. Periodontometer which is invented by muhelmann (1954) which is measured tooth displacement when a small force was applied to the tooth.

TOOTH MOBILITY

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4. Schulte et al (1992) have produced the periotest, which is a refinement of the muhlemann device.

- periotest is a horizontal rod which taps the tooth at a known velocity on impact the tooth is deflected and the contact time recorded. This ranges between 0.3-2.0 milliseconds, being shorter for stable than for mobile teeth.

TOOTH MOBILITY

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THE DEGREE OF MOBILITY:

1) grade 1: just discernible, 0.2- 1mm in a horizontal direction.

grade 2: Easily discernible, and over 1mm labiolingual displacement.

grade 3: well-marked labiolingual displacement, mobility of the tooth up and down in an axial direction.

2) grade 1: slightly more than normal.

grade 2: moderately more than mormal.

grade 3: severe mobility faciolingually and mesiodistally, combined with vertical displacement.

TOOTH MOBILITY

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Occlusal trauma:Occlusal trauma is described as trauma to theperiodontium from functional or parafunctionalforces causing damage to the attachmentapparatus of the periodontium by exceeding itsadaptive and reparative capacities.

CORRELATION BETWEEN TOOTH MOBILITY ANDOCCLUSION

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There are two forms of occlusal trauma are recognized:

1. Primary occlusal trauma is a condition in which the pathologic occlusal forces are considered the principal etiology for observed changes in the periodontium.

2. Secondary occlusal trauma occurs when the periodontium is already compromised by inflammation and bone loss. Consequently, occlusal forces which might otherwise be well tolerated in a healthy periodontium,now have deleterious effects because of preexisting periodontal disease. Teeth with a reduced adaptive capacity and compromised periodontium may then migrate when subjected to certain occlusal forces.

Occlusal trauma

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Other factors that contribute to tooth mobility include:• The number and distribution of the remaining

teeth in the arch.• The number of roots, root form, root proximity,

amount of interradicular bone, and a history of root amputation

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According to glossary of periodontic terms is “an appliance designed to stabilize mobile tooth” The Glossary of Prosthodontic Terms defines splinting as “…the joining of two or more teeth into a rigid unit by means of fixed or removablerestorations or devices.” The term Splint by definition is an appliance used for immobilization of injured or diseased parts.

SPLINTING - DEFINITION

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-The main objective of splinting is to decrease movement three-dimensionally -This objective often can be met with the proper placement of a cross-arch splint.

PRINCIPLES OF SPLINTING

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Unilateral splints that do not cross the midline tend to permit the affected teeth to rotate in a faciolingual direction about a mesio-distal linear axis.

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-If splinting is to achieve any measure of success, the center of rotation of the affected teeth must be located in the remaining supporting bone. In this way, the affected teeth are able to resist tooth movement. Otherwise, the prognosis for any splint will be unfavorable if the occlusal or masticatory forces exceed the resistance provided by the splinted teeth.(Malone W, Koth D).- Thus, the ideal splint should reorient and redirect all occlusal and functional forces along the long axis of teeth, prevent tooth migration and extrusion, and stabilize periodontally weakened teeth(Ferencz J. Splinting.)

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1. It should incorporate as many firm tooth as necessary to reduce the extra load on the individual teeth to a minimum.

2. It should hold the tooth rigid and not impose torsional stresses on the incorporated teeth.

3. It should extent around the arch, so that the antero posterior forces and faciolingual forces are counteracted.

4. It should not interfere with the occlusion. If possible, gross tooth disharmonies should be eliminated before the application of the splint.

5. It should not irritate the pulp.

6. It should not irritate the soft tissues.

7. It should be designed so that it can be kept clean. Interdental embrasure spaces should not be blocked by a splint.

REQUIREMENTS

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Indications and Contraindications forSplinting

Indication:- when a patient presents with multiple teeth that have become mobile as a direct result of gradual alveolar bone loss.- when the patient presents with increased tooth mobility-accompanied by pain or discomfort in the affected teeth.-Splinting may be a way to gain stability, reduce or eliminate the mobility, and relieve the pain and discomfort.

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Contraindications:-Splinting teeth is not recommended if occlusal stability and optimal periodontal conditions cannot be obtained. -Any tooth mobility present before treatment must be reduced by means of occlusal equilibration combined with periodontal therapy; otherwise if the tooth involved does not respond, it must be extracted prior to proceeding from provisional restorations to definitive treatment.

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CLASSIFICATION

Provisional splinting temporary permanent

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The temporary splints are

- Simple wire ligature.

- composite resin splint

- vaccum-formed removable acrylic splint.

Indications:

1)Trauma caused by occlusal and oral parafunctions

2) It can be used as an emergency procedure with extremely mobile tooth

3) It serves to reduce trauma – mechanical, instrumental- during periodontitis therapy

TEMPORARY SPLINTING

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-The serve as a fixed splint for a few days to several weeks.-They are seldom used today because of the esthetic considerations

WIRE SPLINT

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PROCEDURES: - Soft steel wire of 0.25mm diameter is wrapped around the facial and the oral surface of the teeth to be splinted. -The ligature/splint is tightened by twisting the ends. -The stabilization of the individual teeth is accomplished by the application of interdental ligatures. - Acid-etch resin stops/ thin mix of quick set acrylic may be applied to the labial surface to prevent the wire from sliding apically - The wire ligature/splint is used intra and post-operatively, in most cases in combination with a wound dressing.

WIRE SPLINT

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WIRE SPLINTS

Circumferential wiring

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- They are most commonly used fixed splint.- They can be used with or without tooth preparation.- without a cavity preparation or grooves they are strong enough- Fracture of such a splint is common if more than 3-4 teeth are included.- Newer fiber splint tooth stabilization are used.

COMPOSITE RESIN SPLINT

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With no tooth preparation:- following thorough cleaning of teeth and under the rubberdam,- the proximal surfaces are acid etched and resin is applied.- The apical region must be left open for oral hygeine.

COMPOSITE RESIN SPLINT

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-This is a removable temporary splint -They can be made of acrylic resin pulled under vaccum. - They are used only for short period of retention for individual teeth.-Some splints were formely used as bitegaurd in the treatment oral parafunctions.-Any way this is not proved to be effective and today michigan splint is used.

VACCUM FORMED REMOVABLE ACRYLIC SPLINT

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SEMIPERMANANT/ PERMANENT: 1)It enhance masticatory comfort when teeth are highly mobile 2) To stabilize the teeth during periodontal healing space esp following regenerative therapy 3)awaiting long term prognosis 4) Retention following orthodontic treatment

INDICATIONS FOR VARIOUS TYPES OF SPLINTING

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In case of class III caries with mobile tooth this type of splints are used.

COMPOSITE RESIN SPLINT WITH TOOTH PREPARATION

Caries is removed and a class III cavity preparation done.

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Rubber dam placed and cavity is restored with composite resin.

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Resin is cured. Finished and polished Note: the apical area of tooth is not include in the restoration. This is to facilitate ID cleaning.

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-They are fabricated as a cast chrome- cobalt alloy frameworks incorporating typical partial denture clasps.-They are indicated for wearing in nights.- often in the retentive appliance following orthodontics or surgical therapy.

REMOVABLE SEMI PERMANENT

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PERMANENT SPLINTING:

1. used for complex rehabilitation where the abutments are highly mobile or only few abutments must support the reconstruction,particularly when such abutment teeth have minimal periodontal support.

2. distribution of occlusal forces when parafunctions cannot be eliminated. In such cases there is a increasing tooth mobility and tooth migration

INDICATIONS FOR VARIOUS TYPES OF SPLINTING

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-Soon after the introduction of the acid etch technique for anterior restorations, the so called adhesive bridges and adhesive splints were propagated by Rochette in 1973.-Recently this technique had been refined particularly, various methods for enamel preparation have been developed, that ensures adequate retention of such reconstructions following only very conservative preparation (marinello et al 1988).

PERMANENT SPLINTING

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Procedure :

- A Rubber dam must be placed in the area of operation before acid-etching and subsequent seating of the splint.

-An elegant preparation only in enamel which is scarcely visible because enamel must be maintained, otherwise adhesion following acid etch is not guaranteed because only bonding to enamel is secure.

-proximal surfaces of the teeth are rendered parallel

- fine grooves are prepared.

- for occlusal support, shallow, peg-shaped depressions at the margin and above the lingual tubercle are created.

- the incisal edges are not included for aesthetic reasons.

EXTRACORONAL SPLINTING

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-The extra coronal splints are seated with the composite resin. -The splints should be placed in such a way that it should facilitate scaling and possible surgical interventions can be continued without compromise.

EXTRA CORONAL SPLINTS

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Case report : there is grade two mobility in 31,41

Radiograhic findings shows prounced attachment loss in 31,32 and also between 41,42

In order to decrease the trauma during impeding periodontal therapy and increase the patient comfort – an extracoronal splint was planed.

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Tooth preparation which is confined only to the enamel

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when a cobalt chrome splint is used then it is called a rochette without tooth preparation.

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-Composite resin restoration can be placed in adjoining teeth and cured to eliminate any interproximal separation.-These restoration can be further re-inforced with

- metal wires.

- glass reinforced fibers or pins

INTRA CORONAL SPLINTING

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-Telescoping crowns soldered together can also be used.

- crowns can splinted to each other by solder joints or precision attachments.

Precision joints are cemented in the adjacent tooth with appropriate tooth preparation.

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They are modification of the modification of linked crown splint is the multiple pin hole splints.

The reduce the tooth tissue loss.

Three parallel pin holes are made in the tooth to be splinted.

Usually six teeth are included in the splint

Pin retention is not as good as inlays or the crowns, therefore this appliance can only be used successfully where functional forces are not acting.

PINLAY SPLINT

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• In the posterior region a series of linked MOD inlays are made with full occlusal coverage can make a satisfactory splint.

• Inlays that fit into the dovetail preparations in the lingual surface of the anterior teeth may be displaced if an excessive anterior forces are exerted on any individual tooth.

USING LINKED INLAYS

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A transverse groove, about 2-3 mm wide, is cut in the lingual surface of anterior teeth coronal to the cingulum, or in the occlusal surface of the posterior teeth.

The groove is made about 1.5 mm deep with slight undercut.

The groove is filled with acrylic and a stainless steel wire is bend to embed in the acrylic.

After the acrylic is trimmed is trimmed and polished.

From this an alternative is processed with gold bar may be casted to fit the preparation and cemented.

To improve retention pin hole prep done in the groove.

THE CONTINUOUS INTRACORONAL BARS

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They are the variation of the continuous intracoronal splint

It is strong and well retained.

But it can be used in pulp ressesion cases.

A form of continuous intracoronal bar used to stabilize the posterior segments.

They consists of MOD amalgam fillings placed in the teeth to be stabilize.

HORIZONTAL PIN SPLINT

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They are used in orthodontics

They lingually bonded to the tooth.

It is flexible and it allows tooth within the splint to exert physiological mobility.

The wire used is flexible, rectangular, braided, stainless steel and 0.0125 inches.

They are placed in the lingual portion of the teeth after etching and bonding agent is applied and cured after flowable composite is applied

Disadvantages:

They are subjected to mechanical stress.

when it is too thin and it is not passively placed on the enamel then there is undesirable tooth movement .

FLEXIBLE SPIRAL WIRE SPLINT

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PROSTHETIC STABILIZATION – LONG TERM TEMPORARY.

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-In case of advanced, aggressive periodontitis, the stability of the periodontal treatment results must be over an extended period of time before seating a definitive, fixed replacement.

- In order to avoid any trauma to the highly mobile teeth during this consolidation periods, the use of fixed long term temporary is warranted.

PROSTHETIC STABILIZATION – LONG TERM TEMPORARY.

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Method:-due to aggressive periodontitis if there is any discrepancies in the arch alignment.

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If the planned fixed bridgework reconstruction requires a harmonic dental arch then a minor orthodontic procedure can be done despite of advanced attachment loss.

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- During open periodontal therapy wire ligature splints were applied to reduce trauma during the surgical procedure.

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-Tooth preparation is done and the temporary crowns are placed.-Later a long term temporary bridges are placed.-They have an unsure prognosis!Advantages: - greater stability of the contruction. - better distribution of chewing forces. - psychological well being.

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Final finished restoration

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Fiber- splint tooth stabilization

RECENT ADVANCES IN SPLINTING

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TOOTH STABILIZATION FOLLOWING TRAUMA WITH THE FIBER

REINFORCED

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LINGUALLY PLACED FIBER- TOOTH STABILIZATION

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Thank you

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1.The journal of contemporary dental practice. A review of clinical management of mobile tooth.vol:3 no.4 nov15,2002.

2.Color atlas of dental medicine- periodontology by Herbert F. Wolf, Edith M.& Klaus H. Rateitschak , Thomas M. Hassell. 3rd and expanded edition.

3. Laboratory prospective from the inside out, journal inside dentistry jan 2008Splints Are Not Just for TMJ Therapy Part II: Fabrication Technique

Greg Vigoren, DDS; and Edward A. McLaren, DDS.

4. Periodontology the essentials- google books from the www.google.com.

5. www.ribbond .com

6. Splinting teeth – a review of the methodology and clinical case report by izchak barzilay,DDS.cert. prostho., M.S

7. Periodontics by BM ELEY and JD MANSON. Fifth edition

REFERENCES