PERIODONTAL SPLINTING

1. PERIODONTAL SPLINTING
DR.MD.SHADAB ANWAR
(PERIODONTICS)

2. One of the ways to learn is to know when
you're making failures - Robert Genn

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INTRODUCTION
Periodontal diseases are characterized by subgingival plaque formation,
gingival inflammation, loss of connective tissue attachment and loss of alveolar
bone.
As a result of the progressive loss of attachment tissue, the teeth involved in the
disease process eventually exhibit increased tooth mobility.
Thus, the reduction of mobility is an important objective of periodontal therapy.

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Root planning, curettage, oral hygiene and surgery may cause teeth to
tighten as inflammation is resolved. However, a transient increase in
mobility may occur immediately after surgery.
Occlusal adjustment, periodontal orthodontics and restorative dentistry may
alter occlusal relationships and redirect forces, thereby reducing
traumatism. This may result in the teeth becoming firmer.

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Increasing the support of loose teeth may also increase their firmness; the
device used for such treatment is the “SPLINT”.
Splint may be used to maintain periodontally migrated teeth that have
been repositioned.

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Any apparatus or device employed to prevent motion or
displacement of fractured or movable parts. (Hallmen et al
1996)
An appliance for immobilization or stabilization of injured or
diseased parts. (Glickman 1972)
DEFINITION
SPLINT

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According to Glossary of Periodontics Term 1986 a splint is
“an appliance designed to stabilize a mobile tooth”.
According to AAP (1996) a splint has been defined “as an
apparatus, appliance, or device employed to prevent motion or
displacement of fractured or mobile parts”.

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Rest is created for the supporting tissues giving them a favourable climate for
repair of trauma.
Reduction of mobility immediately and hopefully permanently. In particular,
jiggling movements are reduced or eliminated.
Redirection of forces - redirected in a more axial direction over all the teeth
included in the splint.
OBJECTIVES OF SPLINTING: -

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To preserve arch integrity - restores proximal contacts, reducing food
impaction & consequent break down.
To stabilize mobile teeth during surgical, especially during regenerative
periodontal therapy.
To prevent migration and over eruption.

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Redistribution of forces - ensures that forces do not exceed the adaptive
capacity. Forces/received by one tooth are distributed to a number of teeth.
Restoration of functional stability - functional occlusion stabilizes mobile
abutment teeth.
To preserve arch integrity - restores proximal contacts, reducing food
impaction & consequent break down.

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Psychologic wellbeing - gives the patient comfort from mobile teeth a sense of
wellbeing.
Masticatory function is improved.
Discomfort and pain are eliminated.

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Splints, like bridges may be fixed, removable, or a combination
of both.
They may be temporary, provisional, or permanent, according to
the type of material and duration of use.
TYPES OF SPLINTS

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They may be internal or external, depending on whether tooth
preparation is required or not.
Permanent splinting of teeth that have been treated periodontally
is also referred to as periodontal prosthesis.

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CLASSIFICATION
RAMFJORD’S CLASSIFICATION (1979)
1. Temporary:
a. Fixed-i Fixed external type (2-6 months) eg. Ligature wire, orthodontic
bands.
b. Removable-RPD, Night guards, removable acrylic splints

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Fixed external type
Ligature wire
Orthodontic bands.

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Removable
RPD
Night guards

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2. Provisional or Semi- permanent splints:
to be worn for several months & several years (8-12 months)
diagnostic used in borderline cases where the outcome of treatment
cannot be predicted.
eg. Temporary external splints (acrylic splints, metal bands)

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Temporary external splints
Etched Metal Splint
Removable acrylic splints

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3. Permanent:
used indefinitely
e.g
Fixed- Full crowns, pin ledge type of abutment retainers.
Semirigid
Removable- Telescopic crowns, clasp supported partial denture

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pin ledge type of abutment retainers.
Fixed
FULL CROWN

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Removable
Telescopic crowns
Clasp supported partial denture

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Grant, Stem and Listgarten(1988)
1. Temporary:
Extracoronal (External)- Ligature splint, Enamel bonding material, welded
bond splints, continous splints, night guards.
Intracoronal (Internal)- Acrylic splints, Composite splints, acrylic full
crowns.

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Composite splints Ligature wire

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Serves to stabilize a permanently mobile dentition from the time of initial tooth
preparation until the time the time the dentition is periodontally healthy enough
for permanent restorations.
2. Provisional Spilnts

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It may be classified as follows:
A. Removable—external
a) Continuous clasp devices
b) Swing-lock devices
c) Overdenture (full or partial)
3. Permanent Splints

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B. Fixed—internal
e.g.
a) Full coverage, three-fourths coverage crowns and
inlays
b) Posts in root canals
c) Horizontal pin splints

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C. Cast-metal resin-bonded fixed partial dentures (Maryland splints)
D. 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
E. Others
a) Arch bar splint
b) Orthodontic wire and bracket splint

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Ross, Weisgold and Wright Classification
(MODIFIED CLASSIFICATION)
Removable extra coronal splints
Fixed extra coronal splints
Intra-coronal splints
Etched metal resin-bonded splints
1. Temporary stabilization

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Acrylic splints
Metal-band-and-acrylic splints
2. Provisional stabilization
3. Long term stabilization
Removable splints
Fixed splints
Combination removable and fixed splints

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Goldman, Cohen & Checker Classification
A. Temporary splints
1) Extra-coronal type 2) Intra coronal type
Wire ligation
Orthodontic bands
Removable acrylic appliances
Removable cast appliances
Ultraviolet-light-polymerizing
bonding materials
Wire & acrylic
Wire & amalgam
Wire, amalgam & acrylic
Cast chrome- cobalt alloy bars
with acrylic, or both

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Extra-coronal type

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Intra coronal type

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B. Provisional splint
All acrylic
Adapted metal band and acrylic

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THE IDEAL QUALITIES OF A SPLINT
It should be simple, economic, stable and efficient
Non-irritating, not interfere with treatment,
Esthetically acceptable, Biologically compatible
Should not provoke iatrogenic disease
(Simring & Thaller, 1956)

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Should not cause entrapment of food
Should not impair phonetics(speech)
Protect the gingiva from food impaction
Rigid and durable
Easily cleansabl

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Principles of splinting
Inclusion of sufficient area of healthy teeth. Healthy teeth included in the
splint should have double the area of root surface than the mobile teeth to
be splinted.
If one tooth included in the splint is in a traumatic occlusion, the
periodontal tissue of the remaining teeth may also be injured. So
coronoplasty to be performed in most of the cases.

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Should not interfere with occlusion.
Esthetically acceptable.
To avoid forces from lip, cheek and tongue.
It should be fabricated in such a way as to facilitate proper plaque
control

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Indications (AAP)
Stabilize moderate to advance tooth mobility that cannot be treated by
other means.
Stabilize teeth when increased tooth mobility interferes with normal
masticatory function and comfort of the patient.
Stabilize teeth in secondary occlusal trauma.
Prevent tipping or drifting of the teeth.
Prevent extrusion of unopposed teeth.

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Facilitate splinting.
Stabilization of mobile teeth during surgical especially regenerative
therapy. (Serio 1999).
Stabilize teeth following acute trauma.
Stabilize teeth following orthodontic movement.
Ascertain whether occlusal therapy will be effective or not.

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Contraindications
Severe tooth mobility.
Insufficient number of firm teeth.
Patient with very poor oral hygiene.
A tooth on which occlusal trauma has been reduced. Teeth with severe
inflammation and pathology.

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Advantages
Alveolus remodeling of alveolar bone and periodontal ligament for
orthodontically moved tooth or teeth.
Provides healing of supporting structures.
Fine stability and comfort for patient will be provided.
Facilitates surgical procedures by keeping the tooth immobile.
Distributes occlusal forces on a wide area.

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Disadvantages
Accumulation of plaque can lead to further periodontal maintenance.
Requires excellent OHI maintenance.
If one tooth in the splint is in traumatic occlusion, it can injure the
periodontium of all other teeth included in the splint.
Development of caries is an amenable risk.

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Material used for splinting
Ligature wire -Stainless steel wire, brass wire
Night guards-Heat polymerized poly-methyl methacrylate
Welded stainless steel band splints
Castable splints-stainless steel or gold or acrylic
Amalgam splint

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Pin & screw continuous clasp splint
Monofilament nylon composite splint
Wire composite splint
composite or fiber reinforced composite as internal splint
a) Reinforced with metal wires
b) b) Glass reinforced fibers or pin. (Brazilay,2000) (not recommended)

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TRADITIONAL TECHNIQUES
TITANIUM TRAUMA SPLINT(TTS) CAST METAL SPLINT COMPOSITE WIRE SPLINT
COMPOSITE INTERLOCKING SPLINT BAND-ARCH WIRE SPLINT

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NEW ADVANCES
FIBRE-REINFORCED
COMPOSITE
SPLINT(FRCS)

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COMMERCIALLY AVAILABLE FIBRES
i. OPEN WEAVE GLASS FIBRES – INTERLIG
ii. LENO WEAVE POLYETHYLENE FIBRES – RIBBOND
iii. UNI-DIRECTIONAL PRE-IMPREGNATED GLASS FIBRES SPLINT-IT
(everStickPERIO is a bundle of pre-impregnated unidirectional
glass fibres.)
Dentapreg

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INTERLIG SPLINT
(OPEN WEAVE GLASS FIBRES)

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RIBBOND SPLINT
(LENO WEAVE POLYETHYLENE FIBRES )

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EverStick-PERIO
EverStickPERIO is a bundle of pre-impregnated unidirectional glass fibres

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Freshly drawn glass fibres degrade on
exposure to moisture and humidity Hence,
they are coated with resins for high
strengths and called pre-impregnated .
They dissipate stresses
and prevent crack
propagation when
exposed to multi-
directional forces.
GLASS FIBRES
Glass fibers are difficult to adapt.
Have lots of memory & are difficult to adapt to the contours of the teeth.
Glass fibers are stiff.
DISADVANTAGE:-

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DISADVANTAGE:-

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ADVANTAGES:-
Leno weave cross-linked and lock-stitched polyethylene fibres
Resistant to sliding and shifting forces
Ultrahigh tensile strength
Adapts well to the teeth
Final finish is esthetic and smoother
Does not splay when cut
Have very little memory and do not unravel when cut
POLY-ETHYLENE FIBRES

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ADVANTAGES:-

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PROCEDURE
Clean surfaces to be bonded Measure required length of fibre

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Etch all surfaces Apply bond according to instructions

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Place an uncured layer of
flowable COMPOSITE
Take pre- cut fibre length
Composite

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Tack cure the fibres for 5 seconds per tooth into the uncured resin

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Place a thin layer of composite and cure 40 seconds per tooth
Finish and then evaluate the occlusion

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TIPS
Un-polymerised fibre areas should be well protected from light
source
Good isolation should be achieved
In mandibular teeth, groove should be placed more apical. Cingulum
should act as a seat for placement of fibre

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In posterior teeth, groove is placed on occlusal surface with one
abutment tooth on each side
Proper polishing should be done for a smooth finish

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The mobility of teeth is a common complaint of patients with fairly advanced
periodontal disease. It is caused by a loss of supporting bone caused due to
periodontal disease. Dental Splint is an appliance designed to immobilize and
stabilize mobile loose teeth. Various methods of splinting should be applied
depending upon prognosis of mobile teeth and periodontal conditions of surrounding
teeth.
Conclusion

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Kamath S, Bhavasar NV. Periodontal splints A Boon or a Bane? JISP, 21-25.
Current concepts in Periodontics. B.R.R. Varma & R.P. Nayak, 309-311.
The Practice of Periodontia. Sidney Sorrin. 340-358.
Clinical Periodontology. 1st edition Glickman, 922-926.
Carranza Clinical Periodontology. Newmann MG, Takei HH Klokkevold PR, Carranza FA.
11th edition. 1065.
Clinical Decisions in Periodontology. Walter B. Hall, 131-132. 7. Barzilay I. Splinting teeth-
a review of methodology and clinical case reports Journal of the Canadian Dental
Association. 2000; 66:440-443.
References

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Bremner, M. D. K. The Story of Dentistry, 3rd Ed., Brooklyn, N. Y., Dental Items of Interest.
Turnelis H.Pameijer, Richard E.Stallard: A method for quantitative measurement of tooth
mobility. J Periodontol vol 44,no.6;339-346.
Timothy,J.O’ Leary: Indices for measurement of tooth mobility in clinical studies .J. Periodontal
Res 9,1974;suppl.14;94-105.
Bernard H.Wasserman, Arnold M. Geiger, Livia. R. Turgeon: Relationship of occlusion and
Periodontal disease: Part VII – Mobility. J. Periodontol, September 1973, Vol 44,No. 9,572-578.
Siguard P. Ramfjord and Major M. Ash: Significance of occlusion in the etiology and treatment
of early, moderate and advanced periodontitis. J Periodontol.1981 September ,511-515.

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