FINAL Splinting

7/30/2019 FINAL Splinting

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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


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


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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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.

FINAL Splinting

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