SPLINTING

1. 57
Good morning

2. splinting
Presenter:
Shashwati Paul
Post Graduate Student
Dept. of Periodontology

3. CONTENTS
 Introduction
 Definitions
 Terminology
 History
 When to splint..
 Objectives of splinting
 Indications
 Contraindications
 Principles of splinting
 Ideal splint
 Mode of action

4.  Classification of splints
 Temporary stabilization
Extracoronal splints
Internal splints
 Provisional splinting
 Permanent splinting
 Literature review
 Drawbacks of splinting
 Conclusion
 References

5. INTRODUCTION
 The ultimate goal in successful management of mobile teeth is to restore function
and comfort by establishing a stable occlusion that promotes tooth retention and the
maintenance of periodontal health.
 The clinical management of mobile teeth can be a perplexing problem..
 In some cases, mobile teeth are retained because patients decline multidisciplinary
treatment that might otherwise also include strategic extractions.

6.  Some mobile teeth can be treated through occlusal equilibration alone (primary
occlusal trauma) where as mobile teeth with a compromised periodontium can be
stabilized with the aid of provisional and/or definitive splinting (secondary occlusal
trauma).
 Tooth splinting have been accomplished since ancient civilizations to decrease tooth
mobility and to improve form, function, and esthetics.
 Still splinting remains one of the poorly understood & controversial areas of dental
therapy.

7. Definitions
 An appliance for immobilization or stabilization of injured or diseased parts.
(Glickman 1972)
 A splint is any appliance that joins two or more teeth to provide support.(Grant
1988)
 According to Glossary of Periodontic Terms 1986 a splint is “an appliance designed
to stabilize mobile teeth”.

8.  According to AAP (1996), a splint has been defined “as an apparatus,
appliance, or device employed to prevent motion or displacement of fractured
or removable parts.”
 The Glossary of Prosthodontic Terms defines splint as “a rigid or flexible
device that maintains in position a displaced or movable part; also used to
keep in place & protect the injured part.”
 Dawson defines splinting as “the joining of two or more teeth for the purpose
of stabilization”.

9. TERMINOLOGY
STABILIZATION:
 Stabilization of a tooth is an increase in resistance to applied force by providing
reciprocal antagonisms and increasing the effective root area. The force may remain
the same, but the resistance is increased.
TEMPORARY SPLINT:
 This is used on a short term basis, usually less than 6 months, and is often advocated to
stabilize teeth during periodontal treatment. It may or may not 1ead to other types of
splinting.
PROVISIONAL SPLINT:
 This type of splint is used for a longer period of time from several months to as long as
several years.

10.  It allows the clinician to see how teeth will respond to treatment.
 It usually leads to more permanent forms of stabilization.
PERMANENT SPLINTS:
 Permanent splinting of teeth that have been treated periodontally is also referred to as
Periodontal prosthesis.
 Periodontal prosthesis may be defined as those restorative and prosthetic endeavors
that are indicated and essential in the total treatment of advanced periodontal disease.

11. HISTORY
 A Phoenician mandible from 500BC and another Phoenician prosthetic
appliance was found from 400 BC in modern day that was comprised of two
carved ivory teeth attached to four natural teeth by gold wire.

12.  Archeological excavations of the Etruscan society (Eighth century BC to the
first century AD) have found evidence of their use of wire ligation and gold
bands to stabilize teeth.
 In early 1700s Fauchard attempted tooth ligation.
 In the 1900s several authors described splinting techniques.

13.  Hirschfeld(1950) was one of the first modern periodontal authors to advocate
ligation of periodontally diseased teeth using either stainless steel wire or silk.
His technique was extracoronal and involved only the anterior teeth.
 In the last 50 years…..

14. WHEN TO SPLINT?
 The splinting of mobile teeth is often, of value as a means of stabilization
before, during, and after periodontal therapy.
 For most patients, splinting should be considered only after the preliminary
phase of periodontal therapy has been completed.

15.  Cohen and Chacker have noted, "When large areas of attachment apparatus
have been destroyed, the artificial support offered by temporary stabilization
may allow a new, healthy tooth-bone relationship to be established.
 Therefore it would seem advisable that when the treatment plan is being
formulated the need for stabilization be determined on the basis of the nature
and extent of the destructive process present.

16.  Root planing, curettage, oral hygiene, and surgery may reduce the mobility as
inflammation is resolved.
 Occlusal adjustment, restorative dentistry may alter occlusal relationships and
redirect forces, thereby reducing traumatism  result in the teeth becoming firmer.
 Increasing the support of loose teeth may also increase their firmness, the device
used for such treatment is the splint.

17.  Two clinical features should be analyzed to understand the full scope of the
relationship between occlusal trauma and tooth mobility.
The first is increased tooth mobility.
 This process is the adaptation of the periodontium to occlusal forces.
 In the absence of inflammation, mobile teeth with a complete and healthy
connective tissue attachment can be maintained.
 The radiographic appearance of a widened periodontal ligament (PDL) space
coupled with a clinical diagnosis of increased tooth mobility may merely be
manifestations of adaptive changes to increased functional demand.

18.  Removal of the excess occlusal load through equilibration and perhaps,
conventional splint therapy can decrease and, often at times, eliminate tooth
mobility.
 An occlusal equilibration that equalizes the occlusal stresses, produces
simultaneous tooth contacts, or harmonizes cuspal relations may be all that is
needed to reverse this mobility.

19.  The second clinical feature is increasing tooth mobility.
 This clinical condition is best managed by treating any localized inflammation,
performing an occlusal equilibration, and perhaps stabilizing or splinting the affected
mobile teeth.
 Patients diagnosed with increased tooth mobility  may need only an occlusal
equilibration, perhaps conventional splint therapy.
 Individuals diagnosed with increasing tooth mobility  must first receive
periodontal therapy. Treatment should include an occlusal analysis and equilibration,
if needed, followed by a reevaluation for extraction or splinting of the affected teeth.

20. OBJECTIVES OF SPLINTING
 Rest is created for the supporting tissues giving them a favorable climate for repair of trauma.
 Reduction of mobility immediately and hopefully permanently. In particular jiggling
movements are reduced or eliminated.
 Redirection of forces - redirected in a more axial direction over all the teeth included in the
splint.
 Redistribution of forces - ensures that forces do not exceed the adaptive capacity.
Forces/received by one tooth are distributed to a number of teeth.
 Restoration of functional stability - functional occlusion stabilizes mobile abutment teeth.

21.  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.
 Psychologic well being - gives the patient comfort from mobile teeth a
sense of well being.
 Masticatory function is improved.
 Discomfort and pain are eliminated.

22. INDICATIONS
Stabilize teeth when tooth mobility
interferes with normal masticatory
function and comfort of the patient
Stabilize teeth in secondary TFO
To prevent tipping of the teeth
Prevent extrusion of unopposed
teeth
Stabilization of mobile teeth
during surgical especially
regenerative therapy.
Stabilize teeth following
orthodontic movement

23. CONTRAINDICATIONS FOR SPLINTING
 Splinting teeth is not recommended if occlusal stability and optimal
periodontal conditions cannot be obtained.
 Insufficient number of firm / sufficiently firm teeth to stabilize mobile teeth.

24. 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.

26. AN IDEAL SPLINT
simple and
hygienic
economic
stable and
efficient
Non
irritating
not
interfere
with
treatment
esthetically
acceptable
not
provoke
iatrogenic
disease

27. 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.
 Cross-arch splinting reduces mobility to the least common value.

28.  Teeth are thus immobilized occlusal forces are better distributed
traumatism minimized repair is enhanced  teeth may become firm
again.
 Even when teeth do not tighten, the splint serves as an orthopedic brace that
permits useful function of mobile teeth.
 Teeth with reduced support often are hypermobile and may gradually
increase if the teeth are not splinted.

29. Classification OF SPLINTS
 Splints, like bridges may be fixed, removable, or a combination of both.
 They may be temporary, provisional, or permanent, according to the type of
material and duration of use.
 They may be internal or external, depending on whether tooth preparation is
required or not.
 Permanent splinting of teeth that have been treated periodontally is also
referred to as periodontal prosthesis.

30. A) According to the period of Stabilization(Grant and Listgarten,1988)
a) Temporary Stabilization: worn for less than 6 months.
 Removable
Hawley appliance with arch wire
 Fixed
 Intracoronal
Amalgam
Amalgam & Wire
Amalgam , Wire & Resin
Composite Resin & Wire

31.  Extracoronal
Stainless steel wire with resins
Wire & Resin with acid etchin
Orthodontic soldered bands, Brackets & Wire
b) Provisional splinting: to be used for months up to several years.
e.g. Acrylic splints, Metal band etc.
c) Permanent Splints: used indefinitely
Removable/Fixed
Extra/Intracoronal
Full/Partial veneer crowns soldered together.
Inlay/Onlay soldered together.

32. B) According to the type of material:
Bonded composite resin splint
Braided wire splint
A – Splints.
C) According to the location on the tooth:
 Intracoronal
Composite resin with wire
Inlays
Onlays
 Extracoronal
Tooth Bonded plastic and Welded bands

33. Goldman, Cohen and Chacker Classification:
Temporary splints
A. Extra coronal type
 Wire ligation
 Orthodontic bands
 Removable acrylic appliances
 Removable cast appliances
 Ultraviolet-light-polymerizing bonding materials
B. Intracoronal type
 Wire and acrylic
 Wire and amalgam
 Wire, amalgam, and acrylic
 Cast chrome-cobalt alloy bars with acrylic, or both.
Provisional splints
 All acrylic
 Adapted metal band and acrylic

34. Ross, Weisgold and Wright Classification:
A. Temporary stabilization
 Removable extra coronal splints
 Fixed extra coronal splints
 Intracoronal splints
 Etched metal resin-bonded splints
B. Provisional stabilization
 Acrylic splints
 Metal-band-and-acrylic splints
C. Long-term stabilization
 Removable splints
 Fixed splints
 Combination removable and fixed splints

35. Before construction of any splint for periodontally involved dentitions, certain basic considerations
should be applied whenever possible:
 For most patients, splinting should be considered  only after the preliminary phase of
periodontal therapy has been completed.
 Exceptions …

36.  Coronal portions of the teeth….  the extracoronal method of splinting ..
 If the teeth obviously require extensive restorative therapy + periodontal therapy
 a form of intracoronal splinting…justified and preferable.
 The extent of splinting….the number of teeth involved…. degree of their
mobility.
 In all cases, a sufficient number of nonmobile teeth should be included in the
splint.

37.  Support of posterior teeth …. when anterior segments are mobile.
 If, in a case of occlusal trauma associated with severe bone loss…all the teeth
demonstrate hypermobility…cross arch splinting is beneficial.

38. TEMPORARY STABILIZATION
 Temporary stabilization is essentially a diagnostic procedure that, ideally, should
be reversible in nature.
 …a mechanical stabilization … decrease of hypermobility of the involved teeth
with time…expected..
Indications for Temporary Stabilization
 Temporary splints are used… until hypermobility is satisfactorily reduced or
eliminated and the teeth can function without the help of the splint….until the
dentition clearly requires long term stabilization.

39. The term temporary is applied
 To a splint that is used until stabilization is no longer necessary, for
example, in cases of mobility caused by orthodontic repositioning,
accidental or surgical trauma, or occlusal traumatism, all of a reversible
nature.
 As a phase in the therapy being undertaken to determine whether
mobility can be resolved by conservative methods or whether mobility
is caused by loss of support sufficient to create permanent mobility.

40. When advanced periodontal disease dictates permanent fixation by extensive
restorative methods, but ….
(a) For economic reasons or
(b) Because prognosis for all remaining teeth is extremely doubtful or
(c) Because poor health seriously affects the longevity of the dentition
(d) Because the patient cannot emotionally accept the lengthy procedures of
permanent fixation.
 For temporary stabilization, the method … simplest, least expensive, and least
time consuming to construct, esthetically acceptable to the patient, and should
meet the needs of the individual.

41. The functions of a temporary splint may be listed as follows:
 To protect mobile teeth from further injury by stabilizing them in a favorable
occlusal relationship.
 To distribute occlusal forces so that teeth that have lost periodontal support
are not further traumatized.
 To aid in determining whether teeth will respond to therapy.

42. extracoronal
 Almost all the extracoronal forms of stabilization have certain inherent
disadvantages.
 It is often difficult to perform various surgical procedures in these areas
because of the nature of the appliance.
 Cosmetically…not very satisfying..

43. Wire ligation:
 Most commonly used type of stabilization.
 Easy to construct.
 Basic limitations is that it can be utilized only where coronal form permits.
 Because of this shortcoming it has its greatest use in stabilizing the
mandibular incisors.
 After an interproximal tie is made, connecting the buccal and lingual
segments of the mesh, tooth-colored, self-curing acrylic maybe placed over
the wire to obtain a more pleasing aesthetic result.

45. Orthodontic bands:
 Stabilizes both anterior and posterior teeth and so have the advantage over wire ligation in that they
are not limiting.
 It is important to give proper attention to the contours of the bands and to check their relationship to
the adjacent gingival tissue.
 Often the contacts between the teeth must be opened ….. a band or bands can be inserted.
 Again, acrylic may be placed over the bands for cosmetic purposes.
 When the multiple bands are welded together, it is necessary to have a common path of insertion so
that the fit of the multiple bands is the same as the fit of each individual band.

48. Removable acrylic appliances:
 If we utilize any form of acrylic appliance, the dimensional instability of the material may cause
distortions to occur.
 It is imperative to check these appliances frequently and to make any necessary adjustments.

49. Acrylic bite guards ( Night Guards):
 Night guards can be constructed in many ways, and they have a wide variety of
uses like treatment of bruxism and clenching.
 The most common type of appliance is one that covers the occlusal surfaces of the
teeth. For additional support the palate is often covered.
 Advantage : the teeth are freed of occlusal contact in all positions and excursions
of the mandible.

50.  An important consideration with all these appliances is that they must not
obliterate the interocclusal distance (free-way space).

51. Removable cast appliances:
 The removable cast appliance is usually a rigid casting either of gold or of chrome cobalt,
made to fit around the teeth.
 One end usually the anterior section, is not joined but is left open so that the casting can be
sprung over the undercuts and then ligated.
 The posterior end is continuous from the buccal to the lingual surface.
 Another modification ….. interlocking attachment on the distal end so that the appliance can
be locked after being sprung over the teeth.

53. Ultraviolet Light Polymerizing bonding materials:
 Restorative materials that are polymerized by ultraviolet light are very useful in
providing stabilization of excessively mobile teeth.
 These materials do not polymerize until they are exposed to ultraviolet light, they
provide prolonged working times for placement. shaping, and contouring, over extensive
areas of enamel.
 Basically the technique is a simple one and provides adequate stabilization if care is
taken during the actual operative procedures.

54.  The composite resin splint can be strengthened by adding wire, monofilament line to
reinforce the material.

56.  Extracoronal resin-bonded retainers, which can be fabricated in the dental laboratory, serve to
strengthen the overall bonded situation.
 The splints are usually cast from metals, usually non noble alloys that can be electrolytically
or chemically etched.
 This type of splint has greater inherent strength than a composite-resin splint created intraorally.
 Extra features such as grooves, pins and parallel preparations increase the retentive capacity of
these splints.

57.  No long-term clinical data are available for these materials; however, they seem promising
at this time.

58. INTERNAL SPLINTS
 Internal temporary splints should be used only when permanent splinting is to
follow.
 They may also be used on a provisional basis when tooth prognosis is guarded.
 Even when splinting cannot save teeth, it can provide a gradual and less
distressing transition to full dentures.
 Once an internal temporary device has been used, the patient may be committed
to periodontal prosthesis.

59. Acrylic splints
A channel approximately 3 mm wide and 2 mm
deep in several teeth.
Undercut for retention
Pulpal surfaces should be coated with a
protectant
Platinized knurled wire in channel
Place self cure acrylic to fix wire in channel and
polish

60. Advantages
Minimal tooth preparation is required
Esthetic
Disadvantages
Tend to harbor plaque which can lead to caries, calculus
deposition and inflammation
The maintenance needs are increased.
If pulp protection is not given, pulp involvement may occur.

61. Composite Splint

66. Amalgam Splint

67. Acrylic Full Crowns
• Fixed temporary bridges may be made of acrylic crowns and pontics and
may also serve as temporary splints.
• They are used when permanent fixed splints will ultimately replace them.

68. DISADVANTAGES
 The material tend to wear and break.
 Tend to harbor plaque which can lead to caries, calculus deposition and
inflammation
 The maintenance needs are increased

69. PROVISIONAL SPLINTING
Provisional restorations serve to stabilize a permanently mobile dentition
from the time of initial tooth preparation until the time the dentition is
periodontally stable enough for permanent restorations

70. It provides
stability,
occlusal
function, and a
good esthetic
result
In addition, it
allows the
dentist to
determine the
optimum
esthetic and
functional
design to be
incorporated
into the future
permanent
splint.
The
provisional
splint can be
placed any
time after the
initial
periodontal
therapy is
complete
If the splint is
seated using
temporary
cement, it can
be removed
during
periodontal
treatment, thus
facilitating
access to the
root surfaces

71. PERMANENT SPLINTING: PERIODONTAL PROSTHESIS
 Permanent splinting is indicated whenever periodontal treatment does not
reduce mobility to the point at which the teeth can function without added
support.
 Such devices serve to stabilize loose teeth, to redistribute occlusal forces,
to reduce traumatism, and to aid in the repair of the periodontal tissues
 Permanent splints are fabricated after periodontal treatment has been
completed, when their use will extend the functional lifetime of the teeth.

72. Indications for splinting the patient with advanced periodontal disease
using fixed cast restorations (Lindhe et al in 1983)
 Progressive mobility of teeth as a result of gradually increasing
width of the periodontal ligament in teeth with loss of alveolar bone
height.
 Indicated when mobility disturbs chewing ability or comfort.

73. Contraindications
Splinting with fixed cast
restorations is not indicated if
occlusal stability cannot be
obtained with the provisional
acrylic bridge.
Splinting is not indicated for
the patient who is comfortable
during normal mastication yet
has increased mobility of a
tooth or teeth with loss of
alveolar bone and a normal
width of periodontal ligament
without increasing mobility

74. Objectives For Splinting With Fixed prosthesis
the patient is able to
function comfortably
tooth mobility is
normal or at least no
longer increasing
the splinted fixed
prosthesis also serves
to replace any missing
teeth

75. Removable Splints
 Incorporate continuous clasps that brace
loose teeth.
 They strongly resemble partial dentures,
and their features may be included in
partial dentures.
 They support the teeth from the lingual
surface and may incorporate additional
support from the labial surface.

76. Swing Lock Devices

77. Over Denture

78. Literature review on splinting

79.  Rengglie et al 1984 studied the use of bridges placed 3 to 4 months following
the surgical therapy. This bridge is then removed daily for oral hygiene. The
mobility of the abutment teeth did not have an increase in mobility.
 The interesting thing about the study was that the mobility of the non-
splinted teeth was also reduced. Therefore, the author concluded that
harmonious occlusion is the reason why all the teeth lost their mobility, not the
splinting.

80.  Kegel et al 1979 studied mobility of the teeth after scaling and root
planning, occlusal adjustment, and oral hygiene using 7 patients, split
mouth design. They found there were no change in tooth mobility
between splinted and non-splinted groups of the teeth.
 There were also no difference in bleeding on probing, gingival
bleeding, attachment level, or radiographic bone scores. Splinted teeth
did not have any clinical advantage over the non-splinted teeth.

81.  Glickman et al. (1961) evaluated the effects of splinting teeth in
hyperocclusion using five Rhesus monkeys. The forces which
applied to 1 tooth in a splint were transmitted to all teeth within the
splint. The direction of the initial force was maintained and
comparable areas of the splinted periodontium were affected.
 The bifurcation areas were most susceptible to excessive force.
Forces applied to non-splinted teeth were not transmitted to adjacent
teeth.

82.  Galler et al. 1979 also used split mouth design during and following the
osseous surgery. During the follow-up period of 24 weeks, it was observed
that splinting had no effect on mobility at any time during the examination.
 There were no differences between the two groups in terms of mobility and
the amount of the bone removed, regardless of whether the teeth were
splinted or not-splinted. The post-operative mobility was only dependent
on the pre-operative mobility.

83.  Nyman et al. (1975) studied 20 patients who had originally
exhibited severe periodontal breakdown and extensive tooth loss.
Extensive fixed bridgework was placed following periodontal
therapy and the patients monitored for 2 to 6 years.
 No further bone loss was observed between the insertion of the fixed
bridgework and the final examination. The authors reported no
increase in PDL width of the abutments or changes in mobility.

84.  Schulz A in 2000 conducted a study to evaluate the effect of splinting teeth on the
results of periodontal reconstructive surgery using a specific carbonate bone
replacement graft (BRG) material. Forty-five patients were randomly treated with
a periodontal surgery approach. In the presplint group, teeth were splinted to at
least two rigid teeth before surgery, in the postsplint group, teeth were splinted at
suture removal, and in the nonsplint group, the treated teeth were not splinted at
all.
 A decrease in PPD and tooth mobility and a gain of CAL were seen following
the use of BRG in presplint teeth. In the same group, PPD and tooth mobility
were significantly reduced compared to nonsplint teeth. The less favourable
improvement in periodontal function of postsplint or nonsplint teeth seemed to be
due to the loss of BRG material caused by tooth mobility. These results indicate
that an undisturbed wound healing process using BRG together with tooth
stability is beneficial to overall clinical success.

85. DRAWBACKS OF SPLINTING
Gingival
irritation
Difficult oral
hygiene access
Crown becomes
loose or fractured
interference of
the splint to
normal
interproximal
wear and mesial
drift
Interference with
phonetics

86. conclusion
 Splinting mobile teeth acts as an adjunct to periodontal treatment and
maintenance and hence is recommended.
 However , selecting the right splint for the right case is important.
 Splint should be designed such that …
 Thus splinting can be considered as an essential part of periodontal
treatment to increase the longevity of periodontally compromised teeth
with mobility.

87. REFERENCES
 Carranza’s clinical periodontology 10th edition
 Lindhe 4th edition
 Grant 6th edition
 Kathariya R, Devanoorkar A, Golani R. To splint or not to splint: The
current status of periodontal splinting. Journal of the international academy
of periodontology 2016;18(2):45-56.
 Sturer,nyman, Niklaups, Lang. Tooth mobility and the biological - rationale
for splinting teeth. Periodontology 2000.1994;4:15-22.