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INTRODUCTION
The periodontally compromised dentition offers many opportunities to debate the
efficacy of splinting. It frequently addresses the therapeutic goals of treatment, including
patient comfort with mastication and retention of teeth after orthodontic intervention.
A continued increase in mobility can be devastating in the presence of a reduced
periodontium. In such situations, normal or physiologic forces can no longer be tolerated
and a change in the attachment apparatus occurs.
Fauchard in 1723 ligated and banded teeth to stabilize them.
Hirschfield (1950) was one of the first modern periodontal author to advocate
ligation of periodontally diseased teeth using either stainless steel wire or silk.
His technique was extracoronal and involved only anterior teeth.
In 1951, Obinand Arbins advocated the use of self curing internal splint to
achieve temporary stabilization.
Cross in 1954 suggested the use of amalgam splint for fixation of mobile
posterior teeth.
Harrington (1957) modified the splint by incorporating a cemented stainless steel
wire.
Splinting is defined as joining of two or more teeth into a rigid unit by means of
fixed or removable devices
A splint, according to the glossary of periodontic terms (1986) is an an
appliance designed to stabilize mobile teeth in their functional position.
A splint is any appliance that joins two or more teeth to provide support.
A splint can be fabricated in the form of composite fillings, fixed budges, removal
partial prosthesis etc.
Splintee is the tooth that needs support.
Splinters are the adjacent teeth that provide support.
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In clinical practice, the treatment of mobile anterior teeth seems to be one of the most
common and most challenging situations practitioners face. Splinting stabilizes the teeth
as a unit by including healthy teeth, and redirects the forces from individual teeth to the
new unit as a whole including the healthier teeth results in a new increase in crown-root
ratio and a net decrease in force to the individual tooth, especially in a horizontal
direction. Horizontal forces are believed to be more traumatic than axial forces." The
most important aspect of splint design is to secure the teeth in all planes. Many times
this principle necessitates cross arch stabilization. This ensures tooth stability without
increasing mobility and allows the periodontal ligament of each to other to increase in
surface area," thus providing long-term retention."
EFFECTS OF SPLINTING
The stabilizing effects of a splint are transient.
Kegel W in 1979 concluded that there was no significant difference between splinted
and nonsplinted teeth of mobility of posterior teeth after scaling and root planing,
occlusal adjustment and oral hygiene instruction.
Galler et al in 1979 showed that splinting had little effect on tooth mobility after osseous
surgery.
Nyman et al in 1994 demonstrated long term stability and maintenance of splinted
dentitions that had greater than 50 % attachment loss of each abutment tooth. In the
absence of inflammation severely compromised dentitions could be maintained for
extended periods of time. Similar results were reported by Amsterdam in 1974.
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RATIONALE FOR SPLINTING
Objectives of splinting:
Rest is created for the supporting tissues giving them a favorable climate
for repair of trauma.
Redirection of forces - redirected in a more axial direction over all the teeth
included in the splint.
Redistribution of forces - ensures that forces do not exceed the adaptive
capacity.
Restoration of functional stability - functional occlusion stabilizes mobile
abutment teeth.
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. Psychological well being - gives the patient comfort from mobile teeth a
sense of well being.
Masticatory function is improved
Ideal requirements of the splint:
It should incorporate as many as firm teeth as necessary to reduce the extra loadon individual teeth to minimum.
It should hold the teeth rigid & not impose torsional stresses on any incorporated
teeth.
It should extend around the arch, so that anteroposterior forces & faciolingual
forces are counteracted.
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It should not interfere with occlusion. If possible. Gross disharmonies should be
eliminated before the application of splint.
It should not irritate the soft tissues, gingivae, cheeks, lips or tongue.
It should be designed so that it can be kekt clean. Interdental embrasures should
not be blocked by the splint.
Indications for splinting:
Indications and possible approaches for splint therapy include the following:
Stabilization of mobile teeth for masticatory comfort temporary, provisional, or
permanent splints.
Stabilization of mobile teeth during surgical, especially regenerative, therapy
temporary or provisional splint that may be removable or fixed.
Control of force of parafunction or bruxism- removable acrylic bite guard or
Hawley appliance with anterior bite plane.
Cross arch stabilization of an intact or virtually intact natural dentition or
preservation of arch integrity a permanent fixed splint is the most likely
approach.
Stabilization of a severely periodontally compromised tooth when more definitive
treatment is not possible a reinforced ribbon and resin or intracoronal wire and
resin splint is indicated.
Restoration of the vertical dimension of occlusion in a case of posterior bite
collapse- a. provisional splint or prosthesis to reestablish the correct vertical
dimension of occlusion followed by a permanent splint.
Prevention of the eruption of an unopposed tooth A- splint, bite guard, or
restoration of the missing opposing tooth. Restoration of the vertical dimension of occlusion in a case of posterior bite
collapse- a. provisional splint or prosthesis to reestablish the correct vertical
dimension of occlusion followed by a permanent splint.
Post orthodontic retention a fixed or removable retainer is indicated.
Redistribution of forces along the long axis of teeth.
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Stabilization of loose teeth to restore the patients psycological and physical well
being-a patient may be afraid of eating because of loose teeth, splinting restore a
sense of solid occlusion
Splinting is indicated when moderate to advance mobilities (2 degrees or more)
are present and cannot be treated by any other means.
Following loosening of teeth by accidental (or) surgical trauma. To immobilize
excessively mobile teeth so that the patient can chew more comfortably.
Contraindications for splinting:
Moderate tosevere mobility in presecnce of periodontal inflammation or primart
occlusal traumaInsufficient number of firm teeth to stabilize mobile teeth.
Prior occlusal adjustment has not been done on teeth with occlusal trauma or
occlusal interferences.
Patient not maintaining proper oral hygiene
Advantages of splinting
May establish final stability and comfort for patient with occlusal trauma.
Helpful to decrease tooth mobility and accelerate healing following acute trauma
to teeth.
Allows remodeling of periodontal ligament for splinted teeth.
Helpful in decreasing mobility favoring regenerative therapy.
Distributes occlusal forces over a wide area.
Disadvantages of splinting
o Hygienic: accumulation of plaque at the spinted margins to further periodontal
breakdown in a patient with already compromised periodontal support.
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o Mechanical: the splint being rigid may act as a lever with uneven distribution of
forces. If one tooth of the splint is in traumatic occlusion, it may injure the
periodontium of all teeth within the splint.
o Biological: development of caries is an unavoidable risk and thus requires
excellent maintainence by the patient.
PRINCIPLES OF SPLINTING
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.
Conversely, 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. 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.
Lines with arrows indicate direction of mobility in loosened teeth. Lines with circles
indicate points of stability of same arch. Splinting should include atleast two groups so
that they will reciprocally stabilize their mobilities by their points of firmness.
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MODE OF ACTION:
Loose teeth splinted to adjacent firm teeth may become stabilized.
When many teeth are loose, adjacent sextants should be included in the splint.
Teeth tend to loosen buccolingually yet may remain firm mesiodistally.
Cross-arch splinting reduces mobility, teeth are thus immobilized and occlusal
forces are better distributed.
Traumatism is minimized, repair is enhanced and teeth may become firm again.
Even when teeth do not tighten, the splint serves as an orthopedic brace that
permit useful function of loose teeth. .
Teeth are thus immobilized and occlusal forces are better distributed.
Teeth with reduced support often are hypermobile and may gradually increase ifthe teeth are not splinted.
CLASSIFICATION OF SPLINTS
According to type of splint:
1) A splint
2) Braided wire splint
3) Bonded composite resin
According to period of stabilization (Schluger et al):
1) Temporary splintis used on a short-term basis to stabilize teeth during
periodontal therapy or after a traumatic episode.
Worn for less than 6 months
o Removable occlusal splint with wireo Fixed intracorona;, extracoronal
2) Provisional splintis used for 6 months to 12 months for diagnostic information.
Provisional splints allow the clinician time to observe the healing response to
treatment and to make changes based on patient response; this enables the
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clinician to properly design a more permanent and biologically acceptable form of
stabilization.
3) Permanent splint is used indefinitely,
o Removable / Fixed
o intracorona;, extracoronal
o Full / partial veneer crowns soldered together
o Inlay/ onlay soldered together
Goldman, Cohen, Chacker has classified splints as;
A) Temporary Splints
1. Extra- coronal type
a. Wire Ligation
b. Orthodontic bands
c. Removable acrylic appliances
d. Removable cast appliances
2. Intracoronal type
a. Wire and acrylic
b. Wire and amalgam
B) Provisional Splints
1. All acrylic
2. Adapted metal band and acrylic
According to location of teeth:
1) exrracoronal
a) Night guard
b) Welded band
c) Tooth bonded plastic
2) intracoronal forms
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a) composite with wire
b) inlays
c) nylon wire
Permanent splint may be classified as:
1. Removable: External:
A; Continuous clasp devices
B. Swing lock devices
C; Over dentures
2. Fixed : Internal
A. Full coverage, coverage crown
B. Posts in root canal
C. Horizontal pin splints
3. Cast metal resin bonded fixed partial dentures ( Maryland splint)
4. Combined
A. Partial dentures and splinted abutment
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. Endodontic
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TEMPORARY EXTRACORONAL SPLINTS
S.
No.
Type of splint Features Advantages Disadvantages
1. Enamel
bonding
material
Tooth coloured bonding
material or clear plastic is
used.
Can be self polymerized or
UV light polymerized
cosmetic
durable
well tolerated
early repaired
strong enough to
eliminate the need
of wire ligation
Does not bind to
restorative
materials
2. Welded splints Stainless steel strip 0.003-
0.005 inch thick is welded to
form bands.
Can be fabricated directly in
patients mouth or on a
model.
Used in posterior teeth
Accidental
minor tooth
movement can
occur.
Can interfere
with oral
hygiene
3. Continuous
clasp
Made up of acrylic, gold,
stainless steel
Can be seated and removed
like a partial denture
Permits oral
hygiene
Can be removed
for social
arrangements
May be used only
at night
Not esthetic
Impedes speech
4. Composite
splint
Composite is cured on acid
etched tooth surface and
linked together
Simple
Usefull in
emergencies
Can break in
interdental
emergencies.
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Cannot be used
for long terms
TEMPORARY INTRACORONAL SPLINTS
S.
No.
Type of
splint
Features Advantages Disadvantages
1. Acrylic or
A- splint
Requires the preparation of
channel.
Can be used for
prolonged periods.
Breakage of
acrylic can
occur2. Amalgam
splint
Similar to A splint.
Series of mesio-occlusal-distal
preparations are made and then
restored with amalgam that has a
wire of diameter0.050 inches
embedded in it.
Less strength than cast gold
Limited to
posterior teeth.
Frequent
fracture of
amalgam
3. Acrylic full
crowns
can be fabricated on patients study
models or pressure molded splint
can be used
acrylic wears
and finally
breaks
4. Rochette
splint
A chrome cobalt splint fitting the
lingual surfaces of teeth is
constructed after taking impression
and then glued to teeth with
composite
No radical tooth
preparation.
Excellent stability
Can be regarded as
semipermanent
splint.
5. The
continuous
Stainless steel wire is fitted into a
groove & then fitted with self cure
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intracoronal
bar
acrylic.
Acrylic is then shaped and polished.
A gold bar may be cast to fit the
preparation & cemented in place.
MOD amalgam preparation can be
made in teeth to be stabilized and
linked by a bar cemented with
acrylic into a channel cut through
the amalgam.
REMOVABLE PERMANENT SPLINTS- EXTERNAL
S.No. Name of the
splint
Features Advantages Disadvantages
1. Removable
devices
incorporating
clasps &
fingers
Resemble partial
dentures
Support teeth from
lingual surface
May incorporate
additional support from
labial surface or use
intracoronal rests.
Palatal bars may be
added to provide a cross
arch splinting effect.
2. Swing lock
devices
Anterior teeth are fixed
by labial & lingual bars.
A distal extension partial
denture is attached to
the splint by a stress
Cosmetic
Useful in
advanced age
,poor physical
or mental
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breaker. status
In cases
where fixed
splinting is not
possible or
desirable.
3. Overdentures A full or partial denture is
constructed over
endodontically treated
abutments.
In cases
where few
teeth with
questionableprognosis
remain.
Favourable
crown root
ratio
Retention of
alveolar bone
around the
roots.
FIXED PERMANENT SPLINTS:
S.
No.
Name of the
splint
Features Advantages Disadvantages
1. Linked
inlays
In anterior teeth inlays fit into
dovetail preparation in the lingual
surface of the teeth.
In posterior teeth a series of
Splint can be
displaced
if excessive anterior
force is exerted on
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linked MOD inlays with occlusal
coverage is constructed.
the tooth.
2. Linked
crowns
Most reliable form of
immobilization.
Rigid
Strong
Most esthetic
Multiple abutment
fixed bridge may
be used to
replace missing
teeth
Allows to modify
the form of teeth
Requires tooth
preparation
May involve pulp
Requires great deal
of chairside time &
skill.
3. Telescopic
crowns
Telescopic crowns are soldered
together & fitted over gold
copings which are cemented on
to the teeth.
When fixed with
temporary cement it
may be removed
periodically for
cleaning &inspection.
4.
Multiple
pinlay splint
Modification of linked crown
splint in which three parallel
pinholes are made in six teeth.
Retention is not as
good as inlays or
crowns.
Can be used only
where functional
forces are not acting
to separate the
appliance from the
tooth.
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Paralleling eighteen
pinholes present
difficulty.
5. Palatal bar A palatal bar connecting two
fixed bridges in the upper molar
and premolar is made.
Bar is secured to the bridges on
both sides by means of
precission attachments
Screws, internal
attachments,sectional splinting,
telescope crown copings can be
used to overcome divergent
parallelism.
Provide cross arch
splinting.
6. Intraosseous
implant
splints
Implants of materials like steel or
vitreous carbon are used.
Still experimental
Vitreous carbon
permit a more
intimate contact
with host bone.
Pseudoligament
forming around
implant of blade type
is simply a capsule
formed around
foreign body & not a
true periodontal
ligament.
7. Combined
permanent
splints
Combination of fixed splints &
partial dentures
Governed by the distribution of
remaining teeth.
Modified with clasps, rests, bars
&stress breakers.
Useful in
periodontally
weakenedsituations where
fixed splints
cannot serve the
purpose.
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8 Endodontic
splints
Endodontic chrome cobalt
implants serve as splinting
device.
Extend beyond apex by 5 -10
mm into maxillary or mandibular
bone.
EXTRACORONAL SPLINTS
These are very simple and do not require any loss of tooth structure. These require less
chair time and are economical.
These may interfere with plaque removal and cosmetically poor due to bulky contour.
Wire Ligation:
Wire Ligation is the most commonly used means of stabilizing anterior teeth.
Usually teeth from canine to canine or Ist premolar to Ist premolar are included inthe splint.
About 12 inch (30.5 cm) length of 0.002 inch stainless steel wire is looped around
the teeth with lingual arch wire just incisal to cingulum.
The end of the wire are twisted together not very tightly distal to the last tooth
included. The inter dental wires are looped around both lingual & facial arch
wires & twisted tight so that the arch wire is pulled tight around the teeth just
apical to the contact point.
The interdental strands should not be so tight that they bring the arch wires into
contact or produce tooth movement.
Tighten the last interdental ligature after all the other interdental ligature.
Clip the ends of the wires short (2-3 mm) and bend them into the interdental
space to minimize catching food and to prevent injuring soft tissues.
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The gaps between the teeth are bridged by twisting the horizontal loop.
0.25 mm ligature wire must be contoured to avoid any interocclusal interference
on the lingual aspect of the splinted teeth.
Figure showing complete wire splinting
Care should be taken that the splint does not slip incisally or gingivally. The
horizontal wire can be secured against slipping on conical teeth by joining it to a
secondary loop at the neck of the tooth.
Self cure acrylic or composite acid etch resin may be placed over the wire carebeing taken to avoid blocking embrasure spaces. When set it is trimmed smooth
and polished so that it is comfortable to the soft tissues. This will improves
esthetic, reduce irritation and tend to prevent displacement.
Drawbacks:
Ligatures induce active forces on the ligated teeth, causing them to be moved
into new positions.
Steel wires break easily when knots are tightened. It can result in gingivitis partly due to mechanical irritation during splinting &
partly due to soft tissue injury.
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Welded Band Splints:
Welded Band splints are useful for temporary stabilization of posterior teeth.
Adapt a strip of stainless steel 0.003 0.005 inches thick to the tooth & weld it to
form band.
Weld the next strip to the mesial surface of the Ist band. Seat the two pieces
while adapting the 2nd strip to the tooth, and then weld the 2nd strip to form a
band. Several strips can be added. Contact points must permit the band material
to slip between the teeth.
A modification of the welded band splint permits a single band thickness in the
contact area by the first band & so on.
Be careful that band does not impinge on the gingiva, polished to reduce plaqueretention also check the occlusion for interferences.
When multiple bands are welded together, it is necessary to have common path
of insertion so that composite fit of the multiple bands is the same as the fit of
individual band.
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Night Guards:
Indications:
In cases of bruxism .
In periodontal therapy when a full complement of teeth suffering from temporary
hypermobility is in need of support.
For treating temporomandibular joint dysfunction by correcting the condyle fossa
relationship.
As retention appliances after orthodontic treatment
Types:
Hard acrylic bite guard
Resilient acrylic bite guard
A variation of Hawley appliance
Procedure for impressions & working casts:
The teeth must be free from calculus, debris before taking the impression.
Alginate impression is made.
Casts are poured & then mounted on a semiadjustable articulator with the aid
of a face-bow.
Take the lateral registration & then set the articulator for greater functional
accuracy in the finished waxing.
Procedure for waxing:
2mm of clearance is made between the two members of articulator in the anterior
region by increasing the vertical dimension.
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Do not extend the wax gingivally beyond the height of contour to prevent
unnecessary adjustment during insertion.
For added strength, stainless steel wire may be luted over the occlusal surfaces
of the posterior teeth & lingual surfaces of anterior teeth.
The occlusal plane of the bite guards should approx imate the patients occlusal
plane.
With the help of a template, wax the mandibular bite guard.
Lubricate the occlusal portion of the waxed mandibular bite guard with petroleum
jelly and obtain the plane of maxillary bite guard by placing softened wax over the
teeth, and moving the upper member throughout all excursions while the wax is
still soft.
Trim off all excess wax.
Flask the casts, boil the wax out and process the bite guards in clear acrylic
resin.
Carefully remove the processed bite guards and trim and polish them.
Procedure for insertion and adjustment:
Check the bite guards for retention & stability.
Detect high spots with articulating ribbon and adjust the bite guards for maximum
contact in centric relation position and throughout all excursions of the mandible.
Highly polish the occlusal the bite guards, taking care to prevent warpage.
Instruct the patient in their removal, insertion and care and advise him to wear
both guards nightly.
Make periodic checks.
Drawbacks:
They can be worn only at night because they impede normal functions & are
unaesthetic.
They can open inter-proximal contacts between the teeth.
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Continuous clasps:
Continuous clasps may be made of acrylics, gold or cast stainless steel.
These simple splints may be seated & removed in the fashion of partial denture or they
can be ligated to place. They can be used as freely removable appliance with
advantages:
o Adequate oral hygiene is possible.
o Protracted temporary stabilization
o Can be removed for social engagement
o May be used at night only.
Disadvantages are not esthetic & impede speech. Care should be taken to avoid
irritating sharp edges and occlusal interference.
Rochette splint
Acid etch composite materials provide an opportunity for splinting without radical tooth
preparation. An impression of the teeth to be splinted is taken and a chrome cobalt
splint, fitting the lingual surface of these teeth is constructed. The lingual tooth surfaces
is dried and etched and splint is glued in position with the composite material. If
carefully prepared and in a good occlusal balance, this form of splinting provides
excellent stability and may be regarded as semi permanent splint.
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\
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Technique
Step 1. Evaluate occlusal contacts. This technique is contraindicated in patients with
deep overbite or minimal posterior occlusion.
Step 2. Evaluate proximal contacts. This will indicate the amount of material that can be
flowed onto lingual surface without creating unsupported material or an unsightly
situation.
Sup3 . Try in wire or mesh. Tight adaptation of material is very important for strength
and thickness of material. Floss may be used to hold the material in place while the wire
or mesh is secure. If canines are included in a continuous splint, it is usually necessary
replace a slight offset bend between the lateral incisor and canine to compensate for the
larger lingual dimension of the canine.
Step 4. Apply etchant,dentin bonding agent, and adhesives according to their
manufacturers' specifications. Layer material; if possible. flow a small amount of
material into the inter proximal areas to provide additional resistance to dislodgment.
Step 5. Check occlusal contacts.
Step 6. Refine and polish.
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Exrracoronal splints offer advantages over imracoronal splints: They require less time
because no tooth preparation is necessary, and are more reversible. The disadvantage
of extracoronal splints is initial compromise of phonetics and comfort. They may also
limit the patient's ability to perform oral hygiene.
Materials
The materials used in splint construction come in a variety of forms. The most
commonly used materials are resin composite, acrylic resin. and amalgam.
Resin composite is the most popular material used today in both exrracoronal and
intracoronal stabilization for several reasons: ease of application. Strength, esthetics
and relatively simple to repair. The biggest disadvantage to resin composite is the bond
strength. The newer materials are much stronger but must still be monitored for
breakage, which can allow tooth to migrate or caries to form.
Acrylic resin is used primarily in the provisional type of stabilization. The main
advantages of acrylic resin are: esthetics and strength (especially with crossarch
design).
The disadvantages of acrylic resin arc that it is difficult to repair and stains easily,
Amalgam is rarely used today because it fractures mo re easily and is very difficult to
repair.
INTRACORONAL SPLINTS
It includes acrylic, composite resin with or without embedded wire or amalgam with an
embedded wire.
Internal temporary splinting is used only when permanent splinting is to follow. Theymay also be used on provisional basis when tooth prognosis is guarded.
Acrylic splint- A-splint
It requires the preparation of channel approximately 3mm wide & 2 mm deep in several
teeth. Preparation is slightly undercut; internal surface is coated with protectant. Lay a
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piece of Platinized knurled wire (22-16 gauge) in the channel. Place self-cure acrylic
resin to fix the wire in the channel Adjust the occlusion and margins.
Composite splints-A narrow, beveled groove is placed circumferentially around the
each tooth. Groove should be in the enamel, should not involve dentin. A 0.010 soft
single or double wire, polyester filament, nylon monofilament is placed in the groove
legating the teeth in figure of 8 configurations. Enamel is etched and light cure or self
cure composite is placed, polishing and finishing is done.
Amalgam splint- Used in posteriorteeth & is similar to A splint. Tooth is prepared and
amalgam is placed.2-5 teeth are splinted together. A wire may be used to reinforce
amalgam. Amalgam splints tend to fracture easily.
TEMPORARY SPLINTS
These are usually used over a period of from 1 6 months. The
most frequently used temporary splint is a brass or stainless steel wire
ligature splint, stabil ized with cold curing acrylic resin. This is an
excellent splint for anterior teeth and provides a h igh degree of stabil ity. It
is acceptable from the aesthetic view point and if properly constructed,
the embrasures are protected from food impaction. This type of splint has
largely replaced welded orthodontic bands and wire l igature splints
without acrylic, which were commonly used in the past. Direct bonding of
composite material after acid etching is now gradually replacing wire and
acrylic splints due to ease of fabrication, improved aesthetics and access
for cleaning.
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Practically all-removable temporary splints are modifications of
acrylic bite plates used as bite-freeing appliances. Splinting action is
gained by carrying the acrylic over onto either the labial surface of
anterior teeth or the buccal aspect of posterior teeth.
Indications for the use of temporary splints or bite-freeing appliances
Following loosening of teeth by trauma
To prevent cuspal contact and interlocking in bruxists or patients
with temporomandibular joint pain -dysfunction syndrome
To stabil ize teeth during surgical corrective phase therapy of
advanced periodontit is
For stabil ization of teeth during comprehensive occlusal
reconstruction
PERMANENT SPLINTS
Permanent splints are constructed to provide stabil ity for teeth that
have lost so much support that normal forces act as hyperfunctional
forces. Permanent splints are also used for retention of teeth following
orthodontic procedures.
All gingival irritation by the splint must be avoided.
Fixed splints must allow adequate access for oral hygiene.
Abutment teeth must be chosen carefully to provide adequate
support and retention for the fixed restoration.
For technical, aesthetic and economic reasons, the minimal numbers
of teeth are usually included to provide the support needed for the splint.
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This does not always lead to the most desirable type of splint and the
decision as to the number of teeth to be included is often based on poorly
defined clinical factors. Whenever feasible, pin-ledge preparations or
three-quarter crowns should be used for f ixed splints. The complete
coverage type of preparation with subgingival extension is the last choice
from the viewpoint of biological acceptabil ity. Full coverage crowns should
only be used when unavoidable. Precision attachment connections
between various parts of a splint come next to f ixed rigid splints in
providing stabil ity and controll ing the distribution of stress in a dentit ion.
Present day techniques frequently combine splinting with occlusal
reconstruction. Fixed retainers are preferable to removable appliances
with clasps. The use of the precision attachment brings the forces closer
to the axial center of the tooth when a removable partial denture is
necessary.
Even splinted teeth, which were not in occlusal contact, did not
escape injury, when only one member of the splint was traumatized. When
one of the teeth in a splint is subjected to excessive occlusal force, the
remaining teeth share the load.
Nabers has reported that night-guard appliances can open
interproximal contacts between teeth, and Saturen has reported that wire
ligatures are an undesirable form of temporary splinting because they
induce active forces on the l igated teeth, causing them to be moved into
new positions.
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Extensive caries may develop under loose abutments and gross
sepsis may follow with minimal symptoms. It is therefore imperative that
all splints be inspected regularly.
Since splints have many disadvantages accompanying their obvious
stabil izing advantages, splinting of teeth should be restricted to the
minimum needed to achieve occlusal stabil ity and adequate masticatory
function. Splints should never be used as a substitute for accuracy and
exactness in occlusal therapy of the individual teeth.
COMPOSITE SPLINTS WITH A CHANNEL:
Factors such as position of opposing teeth, crowding, spacing, rotations and size
of embrassures are important in planning this type of splint.
After proper shade selection, rubber dam is placed.
Grooves are prepared using a large round carbide bur at high speed with water
coolant, in the enamel layer at a level slightly apical to the contact points.Grooves are prepared in the enamel without reaching the dentin.
Figure showing grooves in anterior view & grooves in longitudinal view
Prepared surfaces are thoroughly polished with slurry of pumice and water, then
it is rinsed and dried with air. Thin layer of hard setting calcium hydroxide base is
coated over the exposed dentin surfaces to protect the pulp.
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A 0.001 dead, soft single or double wire is placed in the grooves, ligating the
teeth continuous with figure eight loops. Wood wedges are inserted to all the
embrassure spaces, so that embrasures are not packed with composite material.
37% phosphoric acid solution is applied to buccal, lingual and interproximal
spaces of the ligated teeth and resin is applied. Finishing of composite is done
thereafter.
NEW GENERATION BONDED REINFORCING MATERIALS FOR ANTERIOR
PERIODONTAL TOOTH STABILIZING AND SPLINTING
The challenge to place a thin but strong composite resin based splint was met with the
introduction of a high strength, bondable, bio compatible, esthetic, easy manipulated,
color neutral fiber that could be embedded into a raising structure. The fiber
reinforcement material provides an increase in flexural strength and flexural modulus of
composite resin. It has been demonatrated that a woven ribbon fiber reinforcement has
an advantage over loose or twisted fibre because it imparts a multidirectional
reinforcement to polymeric restorative resins. Currently five different woven and straight
fiber system for resin reinforcement are avaible
Product: Type of fiber
Ribbond reinforcement ribbon Lock stitch, woven, polyethylene ribbon
Connect Open weave polyethylene ribbon
Splint-It Open weaves glass fiber ribbon
DVA (Dental Ventures of America) Open tufts of polyethylene fibres.
Fibre splint Open weave glass fiber ribbon
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RIBBOND SPLINTING:
History:
The origin of glass fibres for periodontal splints can be partly attributed to Paul
Belvedere who laid out the guidelines for such splints. Ribbond is a material based
on glass fiber & has a patented cross-link stitch leno weave structure.
Indications:
1. Retention period following orthodontic treatment.
2 Immediate tooth replacement in case of front tooth extraction.
3. Immobilization of a tooth after traumatic dislocation or incomplete dislocation.
4. Migration of anterior teeth with age and increased occlusal forces
5. Anterior alveolar fracture cases
Principles of splinting:
1. Upper anterior teeth should be splinted from the buccal side as the splint/tooth
interface on this surface would have to resist tensile forces which is acceptable
since the tensile bond strengths are higher for composite/tooth interfaces.
2. If a splint has to retain and resist movement from the palatal surface it would be
subjected to maximum shear forces and the shear resistance of composite/tooth
bonds are not exceptionally high.
3. Splint can be placed on the palatal surface of upper anterior teeth provided there
is sufficient occlusal clearance, the teeth are firm and stable and/or the splint is
being carried out for the sole purpose of acting as an orthodontic retainer.
4. Splint is placed on the lingual surface as the shear forces on the teeth would be
more on the buccal surface. Occasionally it may be necessary to create a wrap
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around design for certain teeth which have a very high degree of mobility and
additional support is required for the same.
Advantages:
1. It is a biocompatible, bondable, colourless & transparent material.
2. Unsurpassed manageability: Ribbonds cross link stitch leno weave provides
unsurpassed manageability without compromising its multidirectional integrity &
its ability to reinforce the composite. The lock stitch feature prevents slippage of
fibers with resin.
3. Lack of memory: Ribbond is virtually memory free which ensures close &
accurate adaptation. Such adaptation provides a laminate structure.
4. Indefinite shelf life: Ribbond has indefinite shelf life & does not need refrigeration,
maximizing cost effectiveness.
Ribbond products:
Available in
Original Ribbond
Ribbond-THM (Thinner Higher Modulus)
Ribbond-THM
Ribbond-THM is the most popular Ribbond product.
It is thinner (0.18 mm), easier to adapt, and has a higher modulus of elasticity
than the Original Ribbond. It is the preferred material for periodontal splints, orthodontic retainers, and
endodontic posts and cores, single pontic anterior bridges.
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Original Ribbond
Original Ribbond is a general purpose fiber reinforcement that can be used for
the same applications as Ribbond-THM.
It is thicker (0.35 mm) than Ribbond-THM.
Ribbond Triaxial
Ribbond Triaxial utilizes a triaxial braid to achieve the highest strength and
modulus of elasticity of any Ribbond product.
It is thicker (0.50 mm) and less adaptable than THM or Original Ribbond.
When used alone, it usually requires preparations. For cases with nopreparations, it can be used with other Ribbond products to reinforce the pontic
section of bridges and to restore endodontically treated teeth.
Starter Kits:
Three 22 cm long pieces of Ribbond in assorted sizes (2, 3, and 4 mm are the
standard widths)
Ribbond-THM Ortho (1 mm) for fixed retainers and 7 mm Ribbond-THM are also
available
The special Ribbond scissors
Easy to understand instructions
Dead soft tinfoil for pre-measuring in the mouth
Refill Kits:
Three 22 cm long pieces of Ribbond in assorted sizes, or one size one 68 cm
long piece
Easy to understand instructions (instructions are updated regularly)
Dead soft tinfoil for pre-measuring in the mouth
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Each kit comes with enough material to do about 18 to 20 canine-to-canine
periodontal splints or 12 to 13 posts and cores.
Resins
For most applications, three viscosities of composite resin will be needed.
1.Use an unfilled adhesive bonding resin or Ribbond Wetting Resin to wet the fibers
(do not use a resin that contains dentin primers or self-etching resins).
2.Use a soft filled composite or Ribbond Securing Composite for adhering the fibers
to the etched teeth.
3.Use a flowable composite for covering the over the cured Ribbond to act as a
smoothing/covering layer.
Steps of Ribbond splinting:
1. Extent of Splint
An attempt should be made as far as possible, to include terminal stable teeth in
the splint design to provide adequate support to the afflicted teeth with
compromised bone. A principle to be followed is regarding the long axis ofmovement of the teeth in question. Any given tooth will always display mobility
along a certain vertical long axis of movement along which the movement is
essentially in a bucco lingual direction. The idea of splinting teeth together is to
prevent movement of teeth by fusing multiple teeth with different long axis of
movements.
2. Isolation
Maxillary buccal splints isolation can be done with a cheek retractor and cotton
rolls. The tongue generally is isolated from the area of work by default due to the
anatomy. A high vacuum suction to remove the acid as well as maintain isolation.
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In mandibular anterior teeth, the rubber dam helps in controlling the tongue as
well as keeping away crevicular fluids and saliva. If a rubber dam is being placed
, extend the dam to one additional tooth on either side of the area being splinted.
3. Tooth Preparation:
Figure showing groove preparation
Groove Preparation: The groove has to begin from the buccal surface about
0.5 to 0.75 mm median to the distoproximal line angle & ends on the other
terminal tooth in the same position. The groove runs right through the entire
buccal surfaces of all the intermediary teeth & dip into both the proximal
surfaces of all the intermediary teeth as well as the mesio-proximal surfaces
of the terminal teeth. The groove should be prepared with an air rotor & a
thick blunt ended tapering fissure bur in one smooth stroke without any
irregularities on the lateral line angles of the groove. The groove should be
ideally between 0.5 to 0.75 mm deep. The bur is held at 90 degrees to the
buccal surface. The groove should be as parallel as possible to the incisal
line angle.
The groove should be placed in the incisal third of the tooth surface when
preparing for a maxillary splint.
The position of the groove is slightly more apical in the mandibular teeth. A
minor advantage of a slightly apical position of the mandibular groove is that
it allows the operator to utilize the starting bulge of the cingulum which mayact as a seat for placement of the fiber.
Beveling the Groove: This step is necessary to obtain precise aesthetics
since the bevel will help in blending the composite material with the tooth
surface to create a natural appearance. The bevel can be done with a
medium to thick round headed tapered fissure diamond bur or its equivalent.
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The bevel should be a 30 to 40 degree bevel on all the surface margins of
the groove. All the margins should be beveled.
The bur should be held at an angle of about 45 degrees to buccal surface
and lightly brushed along the margins. The bevel should extend about 1 to
1.5 mm from the groove along the buccal margins.
If choosing not to make a channel preparation, prevent the terminal ends of
the splint from being exposed over time by cutting a depression in the
enamel towards the distal of the fossa of the terminal teeth. When adapting
the Ribbond to the teeth, tuck the terminal ends into these depressions.
4. Sizing and Trimming
Measure the teeth and cut the Ribbond. Make a pattern by closely adapting a
piece of tinfoil or dental floss to the teeth. Tuck the pattern into the
interproximal contacts in the same manner as the Ribbond will be adapted
Use cotton pliers to remove the Ribbond from the package and cut to the
measured length. Place the cut piece on a clean surface until ready to use as
fiber.
5. Preparation of tooth surface:
Prepare lingual surfaces and labial interproximals for bonding. Clean the teeth
with a sandblaster or prophy jet or use a diamond bur to roughen the enamel
prior to cleaning. Finishing strips should be used to clean the interproximals.
Prepare the teeth for bonding (pumice, acid-etch, and apply a thin layer of
bonding adhesive.
Enamel may be etched for upto 20 seconds but the dentin should only be etched
for about 5 to 10 seconds. The acid should be first applied along the peripheries
of the groove and the beveled area of all the teeth and then lastly placed within
the groove.
The next step is to start washing the teeth with a gentle steam of water.
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Apply the bond on a relatively wet tooth surface. The bond is then lightly dried
with a light blast of air after waiting for about 15 seconds. This is to allow the
solvent as well as the priming agent which is generally included in the fifth
generation bonding agents to evaporate. Once the bonding agent has been dried
with a gentle stream of air it should be polymerized with a light cure gun. All
areas of the teeth where the bond has been applied has to be poylmerized for 20
seconds. After the polymerization the bonded area should have a shiny glassy
appearance.
Optional block-out and stabilization technique: After acid etching, apply a vinyl
polysiloxane block-out gingival to the area to be splinted. This stabilizes the teeth
during splint construction and makes clean up easier.
6. Fiber Placement
Apply composite in labial interproximals. To reduce the possibility of the teeth
rotating and debonding, apply a small amount of tooth shade filled composite to
the labial interproximals. Do not force the composite through to the lingual
surface. Cure.
Figure showing placement of composite in interproximals
Wet the Ribbond with unfilled bonding adhesive, composite sealant or pit andfissure sealant and blot off the excess with a lint free gauze or patient bib. The
wetted Ribbond may now be touched with powder free gloves or clean fingers.
Do not cure yet.
Apply filled composite to the teeth. Apply a thin layer of paste-like, medium
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viscosity, translucent composite resin at the level of the contact area. A Centrix
syringe makes application easier. Do not cure yet.
Figure showing placement of composite
Adapt the Ribbond. Holding the wetted Ribbond with cotton pliers, position one
end of the Ribbond against the composite on the tooth. Press the Ribbond
through the composite with your finger or an instrument.
Figure showing adaptation of Ribbond on the tooth surface
Adapt the Ribbond in the interproximal contact. To avoid pulling out the Ribbond
that has already been adapted, hold the adapted part in position with a finger or
an instrument. Place the Ribbond deep into the adjacent interproximal contact
with an instrument. Continue until the entire length is adapted. Do not cure yet.
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Figure showing adaptation of ribbond in inteproximal areas
Remove excess composite with a composite instrument prior to curing.
Using a syringe or an applicator brush, cover the splint with a flowable
composite. Make the covering layer as smooth as possible prior to curing.If a
flowable composite is not available, apply a thin layer of filled composite resin
over the splint and smooth it with a washed, gloved finger that has been wetted
with unfilled bonding adhesive. If a channel preparation is used, cover the
Ribbond with a filled composite resin. Light-cure the covering layer of composite.
Figure showing covering of the splint with composite material
Check occlusion, finish and polish. Remove excess composite and polish with a
composite-resin polishing paste. Ribbond does not polish well.
Do not cut into Ribbond fibers.
The finished splint is thin, comfortable and esthetic.
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PRE-IMPPREGNATED GLASS FIBER FOR REINFORCING
COMPOSITES
An improved approach is to use a reinforcing fibre bundle that first as been effectively
impregnated with a resin either during a careful chairside procedure or in a priorcontrolled manufacturing process.
In the former case clinician buys non-impregnated fiber reinforcement and impregnation
may be done as the splint is being constructed. Alternatively, the clinician may use
strips of reinforcing fiber bundles that already have been impregnated with resin.( splint
IT).
Preimpregnated systems are preferable as they eliminate steps for clinician and also
have high flexural strength (1 mm thick sample can approach 1000MPa.)
Current commercially FRCs are light cured bis-GMA systems. They are easy to handle
and exhibit high mechanical properties, having upto 7 times the strength and much
greater rigidity than particulate composites. These are not opaque and have no
undesirable optical properties. In splinting application, this allows a relatively thin
(approx 0.5mm) layer of particulate composite to be placed over FRC substructure while
maintaining a good esthetic appearance.
TREATMENT OF INCREASED TOOTH MOBILITY
A number of situations will be described below which may call for treatment aimed at
reducing an increased tooth mobility.
Situation I
Increased mobility of a tooth with increased width of the periodontal ligament but
normal height of the alveolar bone
If a tooth (for instance a maxillary premolar) is fitted with an improper filling or crown
restoration, occlusal interferences develop and the surrounding periodontal tissues
become the seat of inflammatory reactions, i.e. trauma from occlusion.
If the restoration is so designed that the crown of the tooth in occlusion is subjected to
undue forces directed in a buccal direction, bone resorption phenomena develop in the
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buccal-marginal and lingual-apical pressure zones with a resulting increase of the width
of the periodontal ligament in these zones.
The tooth becomes hypermobile or moves away from the traumatizing position. Since
such traumatizing forces in teeth with normal periodontium or overt gingivitis cannotresult in pocket formation or loss of connective tissue attachment, the resulting
increased mobility of the tooth should be regarded as a physiologic adaptation of the
periodontal tissues to the altered functional demands.
A proper correction of the anatomy of the occlusal surface of such a tooth, i.e. occlusal
adjustment, will normalize the relationship between the antagonizing teeth in occlusion,
thereby eliminating the excessive forces.
As a result, apposition of bone will occur in the zones previously exposed to resorption,
the width of the periodontal ligament will become normalized and the tooth stabilized,
i.e. it reassumes its normal mobility(Waerhaug & Randers-Hansen 1966
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Situation II
Increased mobility of a tooth with increased width of the periodontal ligament and
reduced height of the alveolar bone
If a tooth with a reduced periodontal tissue support is exposed to excessive horizontal
forces (trauma from occlusion), inflammatory reactions develop in the pressure zones of
the periodontal ligament with accompanying bone resorption. These alterations are
similar to those which occur around a tooth with normal height of the supporting
structures; the alveolar bone is resorbed, the width of the periodontal ligament is
increased in the pressure/tension zones and the tooth becomes hypermobile. If the
excessive forces are reduced or eliminated by occlusal adjustment, bone apposition to
the pretrauma level will occur, the periodontal ligament will regain its normal width and
the tooth will become stabilized.
Conclusion: Situations I and II
Occlusal adjustment is an effective therapy against increased tooth mobility when such
mobility is caused by an increased width of the periodontal ligament.
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Situation III
Increased mobility of a tooth with reduced height of the alveolar bone and normal
width of the periodontal ligament
The increased tooth mobility which is the result of a reduction in height of the alveolar
bone without a concomitant increase in width of the periodontal membrane cannot be
reduced or eliminated by occlusal adjustment. In teeth with normal width of the -
ligament, no further bone apposition on the walls of the alveoli can occur. If such an
increased tooth mobility does not interfere with the patients chewing function or
comfort, no treatment is required.
Consequently, splinting is indicated when the mobility of a tooth or a group of teeth is so
increased that chewing ability and/or comfort are disturbed.
Situation IV
Progressive (increasing) mobility of a tooth (teeth) as a result of gradually
increasing width of the reduced periodontal ligament
Teeth in such a dentition are still available for periodontal treatment may, after therapy,
exhibit such a high degree of mobility or even signs of progressively increasing
mobility that there is an obvious risk that the forces elicited during function may me-
chanically disrupt the remaining periodontal ligament components and cause extraction
of the teeth.
Only by means of a splint will it be possible to maintain such teeth. In such cases a fixed
splint has two objectives:
(1) To stabilize hypermobile teeth and
(2) To replace missing teeth.
Conclusion: Situation IV
Splinting is indicated when the periodontal support is so reduced that the mobility of the
teeth is progressively increasing, i.e. when a tooth or a group of teeth during function
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are exposed to extraction forces.
Situation V
Increased bridge mobility despite splinting
Proper treatment of the plaque-associated lesions often includes multiple extractions.
The remaining teeth may display an extreme reduction of the supporting tissues con-
comitant with increased or progressive tooth mobility They may also be distributed in
the jaw in such a way as to make it difficult, or impossible, to obtain a proper splinting
effect even by means of a cross-arch bridge.
An increased mobility of a cross bridge/ splint can be accepted provided the mobility
does not disturb chewing ability or comfort and mobility of the splint is not progressively
increasing.
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CONCLUSION
The value of splinting has been debated for decades. Most of the data about splinting
come from clinical observations rather than from scientific studies, but that does not
mean that these findings shou ld be discounted altogether.
Splinting in any form, temporary, provisional, or permanent, provides the clin ician with
invaluable information during the course of treatment. At the same time, splinting
increases the patient's comfort and function. Splinting should be considered, therefore,
as part of an overall treatment plan in patients with moderate-to -severe tooth mobility.
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REFRENCES
1. Clinical periodontology; Newman, Takei, Klokkevold, Carranza; 10th edition
2. Clinical periodontology and implant dentistry, Jan Lindhr, 5th edition
3. Periodontics by B M Eley & J D Manson
4. A Review of the Clinical Management of Mobile Teeth, Guillermo Bernal, The journal
of contemporary dental practice, 2002, 1-11.
5. DCNA, 1999.