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Dr Alka Shukla
MDS student
 Introduction
 Definitions
 Historical perspective for splinting of teeth
 Rationale of splinting of teeth
 Indications
 Time duration
 Classification
 Ideal requirements
 Asthetic considerations
 Various techniques
 Acid etch technique
 Splinting with Fixed partial denture
 Splinting of avulsed tooth
 Splinting of periodontally compromised teeth.
 Splinting and postorthodontic retention
 Recent advances
 Desired properties of fibers that are reinforced
 Advantages of fiber reinforced material
 Implant and its role
 Steps in fiber reinforced splinting.
 Esthetic aspect of reinforced material
 Effects of splinting
 Drawbacks of splinting
 Maintenance of oral health in splintted teeth
 Conclusion
 References
 Medical and dental treatment often requires either pharmalogical or mechanical
intervention. Splinting is one of the mechanical approaches to provide improved
dental treatment.
 The dictionary meaning of splint is a thin piece of wood or other rigid material
used to immobilize a fractured or dislocated bone, or to maintain any part of the
body in a fixed position.
 And thus splinting means to secure, hold in position or support any injured part by
means of splint.
SPLINT:
 Splint is an appliance for the immobilization or stabilization of injured or diseased part.
- Caranza
 Splint is any apparatus, appliance, or device employed to prevent motion or displacement of
fractured or movable parts. - Francis G Serio
 Splint is a rigid or flexible device that maintains in position a displaced or movable part; also
used to keep in place and protect an injured part.
OR
 “It can also be defined as a rigid or flexible material used to protect, immobilize, or restrict
motion in a part.”
OR
“A device that maintains hard and/or soft tissue in a predetermined position”
– Glossary of Prosthodontic terms[GPT]
SPLINTING:
 In dentistry splinting is defined as “the joining of two or more teeth into a rigid
unit by means of fixed or removable restorations or devices.”
 According to Dawson splinting is “ joining together of two or more teeth for the
purpose of stabilization.”
 It refers to stabilization of traumatized teeth prevention of further damage to the
pulp and periodontal tissue during healing period, allowing the attachment
apparatus to regenerate. – Raymond’s text book of oral surgery
 It means tying teeth together, either unilaterally or bilaterally, to convey increased
stability to the entire unit.
 Early evidence of human desire to splint
weakened teeth can be seen in
archaeological finds from several ancient
civilizations.
 A Phoenician mandible from 500 BC
discovered near the ancient city of Sidon
demonstrates anterior teeth elaborately
bound together with gold wire.
 Remains from Egyptians [3000 to 2500 BC] have
shown the use of ligature wire[ gold wire]
 Use of silver wires to attach prosthesis to adjacent
natural teeth is also revealed.
 In olden days, extensive reconstructions replacing
missing teeth were placed on broken-down
diseased roots, and thus American dentistry was
labelled as “gold traps of sepsis”.
 Therefore tooth splinting have been accomplished since ancient civilization to
decrease tooth mobility ; to replace missing teeth, and to improve form & function,
esthetics.
 Treatment philosophy using splinting to stabilize the periodontal prosthesis patient
as espoused by faculty and graduates of the University of Pennsylvania first began
in 1959.
 It has been in the last 50 years that scientific principles have been used to treat
patients with compromised dentition.
 Control of forces of para-functional habits like bruxism.
 Stabilization of mobile teeth for masticatory comfort.
 Stabilization of mobile teeth during surgical , especially regenerative therapy.
 Cross arch stabilization of an intact or virtually intact natural dentition or
preservation of arch integrity .
 Stabilization of a severely periodontally compromised tooth when more definitive
treatment is not possible.
 Restoration of the vertical dimension of occlusion in a case of posterior bite
collapse.
 Prevention of the eruption of an unopposed tooth
 Retention of teeth in new position.
 Redistribution of forces along the long axis of teeth.
 Stabilization of loose teeth to restore patient’s psychological and physical well
being – a patient may be afraid to eat properly because of a severly loose tooth or
teeth . Splinting may restore occlusal stability , restore a sense of a solid occlusion
and improve esthetics
 According to Dawson, splinting is done to
 redirect stresses,
 redistribute forces,
 prevents supra-eruption,
 prevents migration,
 stabilize tipped teeth.
 Simring in 1952 described the theory and practice of splinting in detail: He emphasized
importance of direction of forces and the movement of teeth under occlusal loads.
 He rationalized the,need for splinting as the safety procedure to employ when a tooth
must withstand a force beyond its individual physiologic limits.
 Simring stressed that splinting is indicated where the traumatic effects of
occlusion are intense and the stimulating physiologic action of the occlusal forces needs
to be improved.
 According to Smukler and Lemmer ; splinting is indicated only when the mobility
of teeth is sufficient to hinder function or cause discomfort.
 According to Lemmerman;
 In traumatized tooth which could be -avulsed[ reimplantation]
- luxated
- root fracture
 In post acute trauma to prevent mobility.
 As part of occlusal therapy.
 As a replacement for missing teeth.
 Multiple mobile teeth as a result of bone loss [because of periodontitis.]
 As a treatment of secondary trauma from occlusion to provide functional stability.
 Stabilization of mobile teeth during healing after periodontal surgery.
 Stabilization of mobile teeth during surgical (regenerative) therapy.
 To gain stability, reduce or eliminate the mobility and to relieve the pain and
discomfort.
 Post –ortho treatment [ for retention]
 Time duration depends upon type and site of injury.
 According to Ingle textbook of endodontics:
 According to international association of dental traumatology[IADT] current
guideline: 2 weeks for extrusion luxation and 4 weeks for lateral luxation.
Type of injury duration recommended
Luxation 2-8 weeks
Root fracture 8-12 weeks
Avulsions 1 week
Alveolar fractures 3-4 weeks
 Splinting period
-according to Anderson
 Optimal splinting period for luxated teth is, to date, empirically-based.
 A splinting period of 2-3 weeks is normally sufficient in case of isolated injury
to the periodontal ligament i,e extrusion
 If injury is combined with a fracture of bone, 3-4 weeks is recommended.
 In case of comminution of bone, splinting of 6-8 weeks is suggested.
 Soft diet is recommened.
 There are various criteria to classify the splint.
 Mainly it is divided on the basis of purpose of use.
Based on purpose
Temporary Permanent/definitiveProvisional
Based on retention
Removable
Fixed
Based on arch
side involvement
Unilateral
Bilateral
Based on
rigidity
Rigid
Semi-rigid
Based on tooth
surface involved
Extra coronal
Intra-coronal
Based on
material used
Acrylic Resin
based
Traditional
resin
composite
Welded band
Ligature wire
Restorations
Fixed prosthetic
appliances
Arch bars
Fiber
reinforced
composite
Extracoronal Splinting :
 The simplest way to connect teeth to each other is the classic bonding method. The
enamel surface of the tooth is etched, [37% solution of phosphoric acid].
Composite resin can then be bonded to the etched surface.
 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.. Extra features such as grooves, pins and
parallel preparations increase the retentive capacity of these splints.
Mobile teeth have been prepared with
cingulum rests to
help support an extra-coronal composite-
resin-based splint.
 Intra-coronal Splinting
 Intra-coronal methods are also available. Composite-
resin restorations can be placed in adjoining teeth
and cured to eliminate any interproximal separation.
These restorations can be further reinforced with
metal wires, glass-reinforced fibres or pins.
 If restoration of the mouth includes crowns, the
crowns can be splinted to each other by solder joints
or precision attachments. The use of attachments
affords the practitioner the ease of preparing
nonparallel abutments yet achieves a splinted result.
Metal-based wire splint (Splint-
Lock System, Whaledent
Inc., New York, NY) is secured to
mobile teeth with individual metal-
based pins. The metal splint is then
covered and bonded to the mobile
teeth with composite resin.
 Andreasen has suggested few requirements for an acceptable splint:
◦ Direct application in the mouth without delay due to lab procedures
◦ Minimum trauma to the injured teeth
◦ Immobilization of injured teeth in normal arch position.
◦ Allowance for an adequate fixation period.
◦ No damage to adjacent teeth or soft tissues.
◦ No interference with occlusion , articulation or caries control.
 Allowance for endodontic access.[if needed]
 Provision for a reasonable esthetic appearance.
 Should be compatible to the oral structures.
 Should be able to bear occlusal forces.
 When teeth are joined together for purpose of splinting the technical elements of
marginal fit, correct contour and shape, cleansability and occlusion must be
accomplished.
 Connectors between the teeth can compromise the goal of achieving an esthetic
result by requiring modification of the shape and physical appearance of the
interproximal areas, incisal embrasures and gingival spaces.
 Splinting teeth together invariably creates an artifical esthetic barrier to the 3-
Dimensional appearance of teeth.
 For a splint to be successful , the connectors between teeth need to have a specific
thickness to provide strength in function and clinical durability.
Splinting
 Cold cure resins like Sevriton and Paladur offer great stability for prolonged
splinting periods.
 After repositioning and realigning the traumatized teeth, they and adjacent
supporting teeth must be cleaned. This needs to be done as atraumatically as
possible.
 Enamel should be polished with pumice, but it may not be possible all the time
hense rinsing the surface throughly should be done.
 The teeth must be dried and isolated with cotton rolls.
 Gingival bleeding must be controlled to prevent contaminating the tooth surfaces
intented for inclusion in splint.
 Exposed dentin in crown fracture area must be protected during splinting. This is
accomplished by direct application of Ca(OH)2 .
 Then etchant gel is applied on incisal third of labial surface for 30 secs followed by
20 secs of water spray, then air dried.
 Etched surface should appear “froast white” or “mat white”.
 Generally , inclusion in the splint of the two adajacent teeth is sufficient to support
the loosened tooth.
 In mixed dentition: splinting injured central to contralateral central is sufficient .
 Tooth surface chosen for the appliation of splint must not interfere with occlusion,
therefore for maxillary teeth its labial and for mandibular teeth its lingual.
 The resin is then placed and cured.
 Composite resins offer great stability and esthetics, but their complete removal is
cumbersome, especially as it can be difficult to distinguish enamel from the
composite material.
 Also traditional composites can not take much of occlusal load, and often get
fractured or deattached.
 Two main objective of this technique are:
 The patient is able to function comfortably and
 Splinted fixed prosthesis also serves to replace any missing teeth.
 It is usually accomplished after initial periodontal and initial occlusal therapy to halt
progressing mobility and thus to provide the patient comfort when chewing.
 Indications for splinting the teeth with advanced periodontal disease using fixed
cast restorations described by Lindhe are:
 When there is progressive mobility of teeth as a result of gradually increasing
width of periodontal ligament in teeth with loss of alveolar bone height.
 Increased mobility of a tooth or group of teeth that disturbs chewing ability or
comfort .
 It is not indicated if:
 Patient is comfortable during normal astication yet has increased mobility of a
tooth or teeth with loss of alveolar bone and a normal width of periodontal
ligament without increasing mobility or tooth migration.
 Occlusal stability cant be obtained with the provisional splinting.
 Consideration must be given to:
 Extraoral time. During this critical time,
the prognosis for successful replantation noticeably decreases as the out of
mouth time increases.
 Transport. Preferably the tooth will be
transported in the socket, but milk or water may be used to keep the tooth moist
The buccal vestibule may be recommened for adults but not for young children.
 Root surface:
The root surface must not be handled, scraped, brushed, or have any part removed; ca
n be rinsed with sterile water, saline, or tap water but not with caustic solutions, disin
fectants, or medicaments to clean the surface.
 Endodontic treatment. A tooth with an open apex should be
evaluated bimonthly for revitalization. A tooth with a fully formed apex should hav
e the pulp removed in 7 to 14 days after avulsion.
 Status of the alveolar process. Alveolar fractures may
require a modified splint design to provide additional strength for a longer splinting
duration.
 Obturation materials. Calcium hydroxide paste is used for a minimum of 6 to 24 m
onths before filling permanently with Gutta-percha.
 Selection of a splint. Each case is different and should be
treated as such. Special consideration must be given to splint design, which will dir
-ectly influence the desired result.
 The tooth is replanted into its socket after appropriate treatment. The socket should be
clear of debris and lightly aspirated of the blood clot, then the tooth is gently
replanted.
 Once the tooth is replanted , a semirigid splint must be placed so that the tooth is
sitting in the socket without any external forces placed on it and results in a decreased
chance for ankylosis of the tooth.
 Splint should remain in place for 7 to 10 days.
 The splint is attached using an acid-etch technique with composite resin.
 If alveolar fracture has occurred with the avulsion , the splint should be left in
place for 4-8 weeks.
 Radiographic evaluation
 When the splint is to be removed , it is important to remember that the replanted
tooth is still rather loose.
 Therefore to remove the splinting material carefully, with finger support on the
replanted tooth. Furthermore if endodontic treatment is indicated ; it should be
carried out prior to splint removal.
 Alveolar process fracture: treatment includes reduction and immobilization .
 After reduction with digital pressure, immobilization can be achived by splinting it
with arch bars or acid etch /resin technique. Intermaxillary splint is not required if the
splint used is stable 4 weeks duration . In children due to rapid healing 3 week.
 Periodontitis leads to bone loss which ultimately leads to mobility.
 Mobility is a condition demanding immediate attention in order to save the tooth,
causing discomfort to the patient, affecting speech, mastication, esthetics and oral
hygiene and leading to psychological trauma to the patient. Mobility is most
commonly noticed in the mandibular anterior region due to decreased thickness of
alveolar bone and comparatively less support in this region.
 According to Caranza, two major indications for periodontal splinting are
 a)to immobilize excessively,mobile teeth so that the patient can chew more co-
-mfortably and
 b)to stabilize teeth exhibiting increasing,mobility.
 He further defined three procedures for provisional stabilization which are
◦ a) the reinforced resin-splint for use in the posterior teeth,
◦ b) the acid etch resin splint for use in anterior teeth, and
◦ c) the resin-bonded metal splint.
 It was thought for many years that stabilizing teeth with periodontal disease was
necessary to control gingivitis, periodontitis and pocket formation.
 For many years, the optical choice for splinting teeth was the use of full coverage
cast restorations.
 Each tooth splinted had a crown placed and all the crown were joined together.
Drawback was amount of tooth structure that had to be removed when the teeth
were prepared to place the crowns.
 Then the use of resin bonded bridge was advocated.
 Later the technique where wire was twisted around teeth and covered with
resins[for anterior] and in posterior arch channels were prepared into the occlusal
surfaces of teeth and either cast bars or thick wires were placed in the channels and
covered with resins.
 In some cases removable partial dentures can act as splint.
 While using adhesive technique , wires, pins, nylon and stainless steel mesh are
incorporated. The inherent problem with these materials is their inability to be
chemically incorporated into dental resin.
 Retention after orthodontic treatment is still an important part of the treatment.
Splints are considered as an alternative for removable retainers.
 The first goal of orthodontists to suggest splinting in anterior teeth of patients after
treatment is to solve the problem of cooperation leading to frequent relapse of
crowding in the lower anterior segment.
 The elegance and efficiency of the lingual bonded retainers in the mandible, lack of
any need for patient cooperation, complete invisibility and finding a way to bypass
molars without undercut is their advantage over removable retainers. Initially,
Zachrisson proposed using a multi-strand wire for producing a canine-canine
retainer (Flexible Spiral Wire)
 Splinted cases (with round or rectangular wires) can benefit from stress
redistribution when biting small food particles and in lateral movement.
 Splinting was performed with stainless steel orthodontic wire, arch bars, old
restorations, welded bands and other materials which compromise the esthetics.
 Newer agents like selfcure acrylic, a widely marketed brand of quick-setting
cyanoacrylate ester adhesive (Super Bonder®) were introduced. The long-term
clinical and radiographic success of few case reports indicates that the splinting
technique using a quick-setting cyanoacrylate ester adhesive may be a feasible
option for making a rapid, simple and efficient contention of replanted teeth in
situations where the routinely used materials are not readily available.[Dental
Traumatology Volume 24, Issue 6, pages 695–697, December 2008]
 Newly developed laboratory-cured composite resins such as DiamondCrown
(Biodent Inc., Mont-Saint-Hilaire, QC) claim improved diametric tensile strength
and bonding capabilities. These materials may be considered for use in
extracoronal applications
 Recent innovations in materials allow metal frameworks to be air abraded and then
cemented in place with an adhesive resin cement, such as Metabond C&B. This
type of splint has greater inherent strength than a composite-resin splint created
intraorally .
metal splint created from
non-noble metal has been
bonded
with Metabond C&B cement
and is being used to secure
mobile teeth.
 Other newer material which is been introduced is Titanium Trauma Splint [TTS].It
is found quite effective and easy to use.
 Fiber reinforced splinting materials
 Strength
 Toughness
 Less water absorbtion
 Optical property
 Biocompatibilty
 Conformability
 A real breakthrough happened with the introduction of the etching method and the
development of fiber-reinforced materials.
 The new generation fiber reinforced splinting materials (Ribbond) have several
advantages over conventional splints such as –
 Strong with tensile strength 3 Gpa.
 Unsurpassed fracture toughness, modulus of elasticity 171 GPa.
 Water absorption is less than 1%
 Superior ease of use and manageability because its “memory free”
 Does not unravel, fall apart or rebound when cut or adapted
 Indefinite shelf life, cost effective.
 Safe , chemically inert and biocompatible.
 The unique combination of strength, esthetics and bondability
 Superior optical properties. It is translucent, practically colourless and
disappears within the composite.
 Physically, the open geometry of the tightly woven leno weave allows for
complete infusion and wet-out of the fibers by resin.
Splinting Procedure
 A groove (0.5 – 0.75 mm. deep and 3
mm. wide – which are the dimensions
of the splint material) is prepared on
the lingual surface between the incisal
and middle 1/3rd region.
 The area is isolated with cotton to
prevent contamination from saliva.

 Etchant and bonding agent is
applied.
 Flowable composite of appropriate
Shade is applied.
 Ribbond fiber material is cut
according to the required length
and placed lingually.
 The composite is light cured.
 Splint after initial placement.
 The cured splint is completely covered
with another layer of composite and
cured. Finishing and polishing is done
with rubber cups.
 The use of Ribbond Fiber reinforced periodontal splint represents a new generation
splint having properties which are far superior to all other types of periodontal
splints currently available which is enhancing its ever increasing popularity among
the clinicians.
 POST – SPLINTING INSTRUCTIONS
 Patients are instructed to the use of interdental brush( Ex Proxa – brush )
 Bass method of tooth-brushing is advised.
 The wide spread predictable use of root form implants has dramatically changed
the biomechanics of treatment planning for the partially edentulous patients when
splinting teeth , in particular , for the patient requiring a periodontal prosthesis. As
implants are incorporated in to treatment plans, the absolute need to retain severly
periodontally compromised teeth or root resected teeth as abutments for splinting
to carry multiple pontic loads has been reduced.
 Although the splinting must be planned to withstand the functional requirements of
occlusion and mastication, esthetic considerations must also be taken into account.
 The challenge in creating an esthetic result with fiber-reinforced composite splints
is that there is limited space in the connector region to create the three-dimensional
effect required to give teeth the appearance of individuality.
 Therefore careful planning in the diagnosis and treatment of the fiber splint is
essential to allow for adequate tooth preparation to give the illusion of non-
splinted teeth. When missing teeth are replaced with a fiber-reinforced, direct,
fixed partial denture, the pontic must be created to achieve an esthetically
pleasing result.-Strassler He, Serio CL [dental clinic north america, 2007
Apr;51(2):507-24]
 The stabilizing effects of a splint are transient.
 Studies have shown that after scaling and root planing,occlusal adjustment, and
oral hygiene education, therre was no significant difference in mobility between
splinted and non-splinted teeth.
 Galler et al showed that splintinghad little effect on tooth mobility after osseous
surgery.
 Nyman et al in their study done on patients with good oral hygiene standard and
dedication to the maintenance of their dentition, demonstrated long term stability
and maintenance of splinted dentitions that had greater than 50% attachment loss
of each abutment tooth.
◦ Severly periodontally compromised dentition could be maintained for extented
period of time, in some cases more than 20 years.
 Splinting alone can not provide stabilization. Other factors which contribute to its
success are:
◦ Level of inflammation control
◦ Cross arch stabilization: to minimize force vectors
 All splints have a tendency to interfere with patient self-care, and the self-cleansing
action of teeth and gingival tissues.
 Mechanical irritation: whenever splints contact the gingivae, it is almost
impossible to avoid irritation of a mechanical nature.
 Because of lack of proper cleansing action, bacterial colonization takes place;
which leads to inflammation on the adjacent soft tissue.
 Nabers has reported that night- guard appliances can open interproximal contacts
between teeth.
 Saturen has reported that wire ligatures are an undesirable form of temporary
splinting because they induce active forces on the ligated teeth , causing them to be
moved into new position.
 Extensive caries may develop under loose abutments and gross sepsis may follow
with minimal symptoms.
 Therefore it is imperative that all splints be inspected regularly.
 Effective personal plaque control, professional caries risk assessment, and periodontal
maintenance are crucial to the longevity of the splint and health of the splinted teeth.
 Both dental care provider and patient contribute to the success and longevity of the
dental splint and to the health of the supporting hard and soft tissues.
 During fabrication of splint clinician should be conscious of access and visibility
factors that facilitate effective patient oral hygiene procedures.
 Access :
◦ the splint must be placed with open gingival embrassures and be properly
contoured with no overhanging margins.
◦ Margins should be smooth.
 Visibility:
 This issue also influence effectiveness of patient self-care. Patient must be able
to discriminate between restorations, natural tooth surfaces while practising self-
care.
 After splint placement, the oral health care provider must deliver extensive home
care instructions to the patient.
 Selection and recommendation of mechanical plaque control devices depend on the
type of splint , and spacing surrounding splints.
Traditional floss
•Dental tape
•Tufted floss and Floss threader
Single tufted brush. Ex end-tuft, Sulcabrush
•Interdental brushes. Ex Proxabrush, Proxabrush Trav-ler
Traditional mechanical toothbrush
•Sonic and ultrasonic toothbrushes
•Powered interdental devices
Ex Hydro Floss, Interplak Waterjet, WaterPik Personal Dental system
Interdental
floss
Specialty brush
devices
Powered
toothbrushes
Oral irrigating
devices
 Splinting is a emperical approach in providing comfort to the patient. Initial days
though it had few drawbacks but by combining the chemical adhesive and esthetic
characteristic of composite resin with the strength enhancement of plasma treated,
high modulus, reinforcing ribbon, many shortcomings have been tamed.
Present day’s material can resist the load of masticatory forces without
undergoing fracture.
 Also the post stabilization maintenance requires combined efforts of clinician as well
as patient to give good results.
 Caranza –textbook of periodontology
 Raymond’s textbook of oral surgery- vol 1
 Torquil macphee- essentials of periodontology
 Andreasen’s textbook and colour atlas of Traumatic injuries of the teeth.
 Dental clinics of North America – tooth splinting and stabilization
 Ingle – textbook of endodontics.
 Cohen’s pathways of pulp.
 Strassler He, Serio CL [dental clinic north america, 2007 Apr;51(2):507-24]
Splinting

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Splinting

  • 2.  Introduction  Definitions  Historical perspective for splinting of teeth  Rationale of splinting of teeth  Indications  Time duration  Classification  Ideal requirements  Asthetic considerations
  • 3.  Various techniques  Acid etch technique  Splinting with Fixed partial denture  Splinting of avulsed tooth  Splinting of periodontally compromised teeth.  Splinting and postorthodontic retention  Recent advances  Desired properties of fibers that are reinforced  Advantages of fiber reinforced material
  • 4.  Implant and its role  Steps in fiber reinforced splinting.  Esthetic aspect of reinforced material  Effects of splinting  Drawbacks of splinting  Maintenance of oral health in splintted teeth  Conclusion  References
  • 5.  Medical and dental treatment often requires either pharmalogical or mechanical intervention. Splinting is one of the mechanical approaches to provide improved dental treatment.  The dictionary meaning of splint is a thin piece of wood or other rigid material used to immobilize a fractured or dislocated bone, or to maintain any part of the body in a fixed position.  And thus splinting means to secure, hold in position or support any injured part by means of splint.
  • 6. SPLINT:  Splint is an appliance for the immobilization or stabilization of injured or diseased part. - Caranza  Splint is any apparatus, appliance, or device employed to prevent motion or displacement of fractured or movable parts. - Francis G Serio  Splint is a rigid or flexible device that maintains in position a displaced or movable part; also used to keep in place and protect an injured part. OR  “It can also be defined as a rigid or flexible material used to protect, immobilize, or restrict motion in a part.” OR “A device that maintains hard and/or soft tissue in a predetermined position” – Glossary of Prosthodontic terms[GPT]
  • 7. SPLINTING:  In dentistry splinting is defined as “the joining of two or more teeth into a rigid unit by means of fixed or removable restorations or devices.”  According to Dawson splinting is “ joining together of two or more teeth for the purpose of stabilization.”  It refers to stabilization of traumatized teeth prevention of further damage to the pulp and periodontal tissue during healing period, allowing the attachment apparatus to regenerate. – Raymond’s text book of oral surgery  It means tying teeth together, either unilaterally or bilaterally, to convey increased stability to the entire unit.
  • 8.  Early evidence of human desire to splint weakened teeth can be seen in archaeological finds from several ancient civilizations.  A Phoenician mandible from 500 BC discovered near the ancient city of Sidon demonstrates anterior teeth elaborately bound together with gold wire.
  • 9.  Remains from Egyptians [3000 to 2500 BC] have shown the use of ligature wire[ gold wire]  Use of silver wires to attach prosthesis to adjacent natural teeth is also revealed.  In olden days, extensive reconstructions replacing missing teeth were placed on broken-down diseased roots, and thus American dentistry was labelled as “gold traps of sepsis”.
  • 10.  Therefore tooth splinting have been accomplished since ancient civilization to decrease tooth mobility ; to replace missing teeth, and to improve form & function, esthetics.  Treatment philosophy using splinting to stabilize the periodontal prosthesis patient as espoused by faculty and graduates of the University of Pennsylvania first began in 1959.  It has been in the last 50 years that scientific principles have been used to treat patients with compromised dentition.
  • 11.  Control of forces of para-functional habits like bruxism.  Stabilization of mobile teeth for masticatory comfort.  Stabilization of mobile teeth during surgical , especially regenerative therapy.  Cross arch stabilization of an intact or virtually intact natural dentition or preservation of arch integrity .  Stabilization of a severely periodontally compromised tooth when more definitive treatment is not possible.  Restoration of the vertical dimension of occlusion in a case of posterior bite collapse.
  • 12.  Prevention of the eruption of an unopposed tooth  Retention of teeth in new position.  Redistribution of forces along the long axis of teeth.  Stabilization of loose teeth to restore patient’s psychological and physical well being – a patient may be afraid to eat properly because of a severly loose tooth or teeth . Splinting may restore occlusal stability , restore a sense of a solid occlusion and improve esthetics
  • 13.  According to Dawson, splinting is done to  redirect stresses,  redistribute forces,  prevents supra-eruption,  prevents migration,  stabilize tipped teeth.
  • 14.  Simring in 1952 described the theory and practice of splinting in detail: He emphasized importance of direction of forces and the movement of teeth under occlusal loads.  He rationalized the,need for splinting as the safety procedure to employ when a tooth must withstand a force beyond its individual physiologic limits.  Simring stressed that splinting is indicated where the traumatic effects of occlusion are intense and the stimulating physiologic action of the occlusal forces needs to be improved.
  • 15.  According to Smukler and Lemmer ; splinting is indicated only when the mobility of teeth is sufficient to hinder function or cause discomfort.  According to Lemmerman;  In traumatized tooth which could be -avulsed[ reimplantation] - luxated - root fracture  In post acute trauma to prevent mobility.  As part of occlusal therapy.  As a replacement for missing teeth.
  • 16.  Multiple mobile teeth as a result of bone loss [because of periodontitis.]  As a treatment of secondary trauma from occlusion to provide functional stability.  Stabilization of mobile teeth during healing after periodontal surgery.  Stabilization of mobile teeth during surgical (regenerative) therapy.  To gain stability, reduce or eliminate the mobility and to relieve the pain and discomfort.  Post –ortho treatment [ for retention]
  • 17.  Time duration depends upon type and site of injury.  According to Ingle textbook of endodontics:  According to international association of dental traumatology[IADT] current guideline: 2 weeks for extrusion luxation and 4 weeks for lateral luxation. Type of injury duration recommended Luxation 2-8 weeks Root fracture 8-12 weeks Avulsions 1 week Alveolar fractures 3-4 weeks
  • 18.  Splinting period -according to Anderson  Optimal splinting period for luxated teth is, to date, empirically-based.  A splinting period of 2-3 weeks is normally sufficient in case of isolated injury to the periodontal ligament i,e extrusion  If injury is combined with a fracture of bone, 3-4 weeks is recommended.  In case of comminution of bone, splinting of 6-8 weeks is suggested.  Soft diet is recommened.
  • 19.  There are various criteria to classify the splint.  Mainly it is divided on the basis of purpose of use. Based on purpose Temporary Permanent/definitiveProvisional
  • 20. Based on retention Removable Fixed Based on arch side involvement Unilateral Bilateral Based on rigidity Rigid Semi-rigid Based on tooth surface involved Extra coronal Intra-coronal
  • 21. Based on material used Acrylic Resin based Traditional resin composite Welded band Ligature wire Restorations Fixed prosthetic appliances Arch bars Fiber reinforced composite
  • 22. Extracoronal Splinting :  The simplest way to connect teeth to each other is the classic bonding method. The enamel surface of the tooth is etched, [37% solution of phosphoric acid]. Composite resin can then be bonded to the etched surface.  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.. Extra features such as grooves, pins and parallel preparations increase the retentive capacity of these splints.
  • 23. Mobile teeth have been prepared with cingulum rests to help support an extra-coronal composite- resin-based splint.
  • 24.  Intra-coronal Splinting  Intra-coronal methods are also available. Composite- resin restorations can be placed in adjoining teeth and cured to eliminate any interproximal separation. These restorations can be further reinforced with metal wires, glass-reinforced fibres or pins.  If restoration of the mouth includes crowns, the crowns can be splinted to each other by solder joints or precision attachments. The use of attachments affords the practitioner the ease of preparing nonparallel abutments yet achieves a splinted result.
  • 25. Metal-based wire splint (Splint- Lock System, Whaledent Inc., New York, NY) is secured to mobile teeth with individual metal- based pins. The metal splint is then covered and bonded to the mobile teeth with composite resin.
  • 26.  Andreasen has suggested few requirements for an acceptable splint: ◦ Direct application in the mouth without delay due to lab procedures ◦ Minimum trauma to the injured teeth ◦ Immobilization of injured teeth in normal arch position. ◦ Allowance for an adequate fixation period. ◦ No damage to adjacent teeth or soft tissues. ◦ No interference with occlusion , articulation or caries control.
  • 27.  Allowance for endodontic access.[if needed]  Provision for a reasonable esthetic appearance.  Should be compatible to the oral structures.  Should be able to bear occlusal forces.
  • 28.  When teeth are joined together for purpose of splinting the technical elements of marginal fit, correct contour and shape, cleansability and occlusion must be accomplished.  Connectors between the teeth can compromise the goal of achieving an esthetic result by requiring modification of the shape and physical appearance of the interproximal areas, incisal embrasures and gingival spaces.  Splinting teeth together invariably creates an artifical esthetic barrier to the 3- Dimensional appearance of teeth.  For a splint to be successful , the connectors between teeth need to have a specific thickness to provide strength in function and clinical durability.
  • 30.  Cold cure resins like Sevriton and Paladur offer great stability for prolonged splinting periods.  After repositioning and realigning the traumatized teeth, they and adjacent supporting teeth must be cleaned. This needs to be done as atraumatically as possible.  Enamel should be polished with pumice, but it may not be possible all the time hense rinsing the surface throughly should be done.  The teeth must be dried and isolated with cotton rolls.  Gingival bleeding must be controlled to prevent contaminating the tooth surfaces intented for inclusion in splint.
  • 31.  Exposed dentin in crown fracture area must be protected during splinting. This is accomplished by direct application of Ca(OH)2 .  Then etchant gel is applied on incisal third of labial surface for 30 secs followed by 20 secs of water spray, then air dried.  Etched surface should appear “froast white” or “mat white”.  Generally , inclusion in the splint of the two adajacent teeth is sufficient to support the loosened tooth.  In mixed dentition: splinting injured central to contralateral central is sufficient .  Tooth surface chosen for the appliation of splint must not interfere with occlusion, therefore for maxillary teeth its labial and for mandibular teeth its lingual.  The resin is then placed and cured.
  • 32.  Composite resins offer great stability and esthetics, but their complete removal is cumbersome, especially as it can be difficult to distinguish enamel from the composite material.  Also traditional composites can not take much of occlusal load, and often get fractured or deattached.
  • 33.  Two main objective of this technique are:  The patient is able to function comfortably and  Splinted fixed prosthesis also serves to replace any missing teeth.  It is usually accomplished after initial periodontal and initial occlusal therapy to halt progressing mobility and thus to provide the patient comfort when chewing.
  • 34.  Indications for splinting the teeth with advanced periodontal disease using fixed cast restorations described by Lindhe are:  When there is progressive mobility of teeth as a result of gradually increasing width of periodontal ligament in teeth with loss of alveolar bone height.  Increased mobility of a tooth or group of teeth that disturbs chewing ability or comfort .  It is not indicated if:  Patient is comfortable during normal astication yet has increased mobility of a tooth or teeth with loss of alveolar bone and a normal width of periodontal ligament without increasing mobility or tooth migration.  Occlusal stability cant be obtained with the provisional splinting.
  • 35.  Consideration must be given to:  Extraoral time. During this critical time, the prognosis for successful replantation noticeably decreases as the out of mouth time increases.  Transport. Preferably the tooth will be transported in the socket, but milk or water may be used to keep the tooth moist The buccal vestibule may be recommened for adults but not for young children.  Root surface: The root surface must not be handled, scraped, brushed, or have any part removed; ca n be rinsed with sterile water, saline, or tap water but not with caustic solutions, disin fectants, or medicaments to clean the surface.
  • 36.  Endodontic treatment. A tooth with an open apex should be evaluated bimonthly for revitalization. A tooth with a fully formed apex should hav e the pulp removed in 7 to 14 days after avulsion.  Status of the alveolar process. Alveolar fractures may require a modified splint design to provide additional strength for a longer splinting duration.  Obturation materials. Calcium hydroxide paste is used for a minimum of 6 to 24 m onths before filling permanently with Gutta-percha.  Selection of a splint. Each case is different and should be treated as such. Special consideration must be given to splint design, which will dir -ectly influence the desired result.
  • 37.  The tooth is replanted into its socket after appropriate treatment. The socket should be clear of debris and lightly aspirated of the blood clot, then the tooth is gently replanted.  Once the tooth is replanted , a semirigid splint must be placed so that the tooth is sitting in the socket without any external forces placed on it and results in a decreased chance for ankylosis of the tooth.  Splint should remain in place for 7 to 10 days.  The splint is attached using an acid-etch technique with composite resin.
  • 38.  If alveolar fracture has occurred with the avulsion , the splint should be left in place for 4-8 weeks.  Radiographic evaluation  When the splint is to be removed , it is important to remember that the replanted tooth is still rather loose.  Therefore to remove the splinting material carefully, with finger support on the replanted tooth. Furthermore if endodontic treatment is indicated ; it should be carried out prior to splint removal.
  • 39.  Alveolar process fracture: treatment includes reduction and immobilization .  After reduction with digital pressure, immobilization can be achived by splinting it with arch bars or acid etch /resin technique. Intermaxillary splint is not required if the splint used is stable 4 weeks duration . In children due to rapid healing 3 week.
  • 40.  Periodontitis leads to bone loss which ultimately leads to mobility.  Mobility is a condition demanding immediate attention in order to save the tooth, causing discomfort to the patient, affecting speech, mastication, esthetics and oral hygiene and leading to psychological trauma to the patient. Mobility is most commonly noticed in the mandibular anterior region due to decreased thickness of alveolar bone and comparatively less support in this region.  According to Caranza, two major indications for periodontal splinting are  a)to immobilize excessively,mobile teeth so that the patient can chew more co- -mfortably and  b)to stabilize teeth exhibiting increasing,mobility.
  • 41.  He further defined three procedures for provisional stabilization which are ◦ a) the reinforced resin-splint for use in the posterior teeth, ◦ b) the acid etch resin splint for use in anterior teeth, and ◦ c) the resin-bonded metal splint.  It was thought for many years that stabilizing teeth with periodontal disease was necessary to control gingivitis, periodontitis and pocket formation.  For many years, the optical choice for splinting teeth was the use of full coverage cast restorations.  Each tooth splinted had a crown placed and all the crown were joined together. Drawback was amount of tooth structure that had to be removed when the teeth were prepared to place the crowns.
  • 42.  Then the use of resin bonded bridge was advocated.  Later the technique where wire was twisted around teeth and covered with resins[for anterior] and in posterior arch channels were prepared into the occlusal surfaces of teeth and either cast bars or thick wires were placed in the channels and covered with resins.  In some cases removable partial dentures can act as splint.  While using adhesive technique , wires, pins, nylon and stainless steel mesh are incorporated. The inherent problem with these materials is their inability to be chemically incorporated into dental resin.
  • 43.  Retention after orthodontic treatment is still an important part of the treatment. Splints are considered as an alternative for removable retainers.  The first goal of orthodontists to suggest splinting in anterior teeth of patients after treatment is to solve the problem of cooperation leading to frequent relapse of crowding in the lower anterior segment.
  • 44.  The elegance and efficiency of the lingual bonded retainers in the mandible, lack of any need for patient cooperation, complete invisibility and finding a way to bypass molars without undercut is their advantage over removable retainers. Initially, Zachrisson proposed using a multi-strand wire for producing a canine-canine retainer (Flexible Spiral Wire)  Splinted cases (with round or rectangular wires) can benefit from stress redistribution when biting small food particles and in lateral movement.
  • 45.  Splinting was performed with stainless steel orthodontic wire, arch bars, old restorations, welded bands and other materials which compromise the esthetics.  Newer agents like selfcure acrylic, a widely marketed brand of quick-setting cyanoacrylate ester adhesive (Super Bonder®) were introduced. The long-term clinical and radiographic success of few case reports indicates that the splinting technique using a quick-setting cyanoacrylate ester adhesive may be a feasible option for making a rapid, simple and efficient contention of replanted teeth in situations where the routinely used materials are not readily available.[Dental Traumatology Volume 24, Issue 6, pages 695–697, December 2008]
  • 46.  Newly developed laboratory-cured composite resins such as DiamondCrown (Biodent Inc., Mont-Saint-Hilaire, QC) claim improved diametric tensile strength and bonding capabilities. These materials may be considered for use in extracoronal applications  Recent innovations in materials allow metal frameworks to be air abraded and then cemented in place with an adhesive resin cement, such as Metabond C&B. This type of splint has greater inherent strength than a composite-resin splint created intraorally . metal splint created from non-noble metal has been bonded with Metabond C&B cement and is being used to secure mobile teeth.
  • 47.  Other newer material which is been introduced is Titanium Trauma Splint [TTS].It is found quite effective and easy to use.  Fiber reinforced splinting materials
  • 48.  Strength  Toughness  Less water absorbtion  Optical property  Biocompatibilty  Conformability
  • 49.  A real breakthrough happened with the introduction of the etching method and the development of fiber-reinforced materials.  The new generation fiber reinforced splinting materials (Ribbond) have several advantages over conventional splints such as –  Strong with tensile strength 3 Gpa.  Unsurpassed fracture toughness, modulus of elasticity 171 GPa.  Water absorption is less than 1%  Superior ease of use and manageability because its “memory free”
  • 50.  Does not unravel, fall apart or rebound when cut or adapted  Indefinite shelf life, cost effective.  Safe , chemically inert and biocompatible.  The unique combination of strength, esthetics and bondability  Superior optical properties. It is translucent, practically colourless and disappears within the composite.  Physically, the open geometry of the tightly woven leno weave allows for complete infusion and wet-out of the fibers by resin.
  • 51. Splinting Procedure  A groove (0.5 – 0.75 mm. deep and 3 mm. wide – which are the dimensions of the splint material) is prepared on the lingual surface between the incisal and middle 1/3rd region.  The area is isolated with cotton to prevent contamination from saliva. 
  • 52.  Etchant and bonding agent is applied.  Flowable composite of appropriate Shade is applied.
  • 53.  Ribbond fiber material is cut according to the required length and placed lingually.  The composite is light cured.
  • 54.  Splint after initial placement.  The cured splint is completely covered with another layer of composite and cured. Finishing and polishing is done with rubber cups.
  • 55.  The use of Ribbond Fiber reinforced periodontal splint represents a new generation splint having properties which are far superior to all other types of periodontal splints currently available which is enhancing its ever increasing popularity among the clinicians.  POST – SPLINTING INSTRUCTIONS  Patients are instructed to the use of interdental brush( Ex Proxa – brush )  Bass method of tooth-brushing is advised.
  • 56.  The wide spread predictable use of root form implants has dramatically changed the biomechanics of treatment planning for the partially edentulous patients when splinting teeth , in particular , for the patient requiring a periodontal prosthesis. As implants are incorporated in to treatment plans, the absolute need to retain severly periodontally compromised teeth or root resected teeth as abutments for splinting to carry multiple pontic loads has been reduced.
  • 57.  Although the splinting must be planned to withstand the functional requirements of occlusion and mastication, esthetic considerations must also be taken into account.  The challenge in creating an esthetic result with fiber-reinforced composite splints is that there is limited space in the connector region to create the three-dimensional effect required to give teeth the appearance of individuality.  Therefore careful planning in the diagnosis and treatment of the fiber splint is essential to allow for adequate tooth preparation to give the illusion of non- splinted teeth. When missing teeth are replaced with a fiber-reinforced, direct, fixed partial denture, the pontic must be created to achieve an esthetically pleasing result.-Strassler He, Serio CL [dental clinic north america, 2007 Apr;51(2):507-24]
  • 58.  The stabilizing effects of a splint are transient.  Studies have shown that after scaling and root planing,occlusal adjustment, and oral hygiene education, therre was no significant difference in mobility between splinted and non-splinted teeth.  Galler et al showed that splintinghad little effect on tooth mobility after osseous surgery.
  • 59.  Nyman et al in their study done on patients with good oral hygiene standard and dedication to the maintenance of their dentition, demonstrated long term stability and maintenance of splinted dentitions that had greater than 50% attachment loss of each abutment tooth. ◦ Severly periodontally compromised dentition could be maintained for extented period of time, in some cases more than 20 years.  Splinting alone can not provide stabilization. Other factors which contribute to its success are: ◦ Level of inflammation control ◦ Cross arch stabilization: to minimize force vectors
  • 60.  All splints have a tendency to interfere with patient self-care, and the self-cleansing action of teeth and gingival tissues.  Mechanical irritation: whenever splints contact the gingivae, it is almost impossible to avoid irritation of a mechanical nature.  Because of lack of proper cleansing action, bacterial colonization takes place; which leads to inflammation on the adjacent soft tissue.  Nabers has reported that night- guard appliances can open interproximal contacts between teeth.
  • 61.  Saturen has reported that wire ligatures are an undesirable form of temporary splinting because they induce active forces on the ligated teeth , causing them to be moved into new position.  Extensive caries may develop under loose abutments and gross sepsis may follow with minimal symptoms.  Therefore it is imperative that all splints be inspected regularly.
  • 62.  Effective personal plaque control, professional caries risk assessment, and periodontal maintenance are crucial to the longevity of the splint and health of the splinted teeth.  Both dental care provider and patient contribute to the success and longevity of the dental splint and to the health of the supporting hard and soft tissues.  During fabrication of splint clinician should be conscious of access and visibility factors that facilitate effective patient oral hygiene procedures.  Access : ◦ the splint must be placed with open gingival embrassures and be properly contoured with no overhanging margins. ◦ Margins should be smooth.
  • 63.  Visibility:  This issue also influence effectiveness of patient self-care. Patient must be able to discriminate between restorations, natural tooth surfaces while practising self- care.  After splint placement, the oral health care provider must deliver extensive home care instructions to the patient.  Selection and recommendation of mechanical plaque control devices depend on the type of splint , and spacing surrounding splints.
  • 64. Traditional floss •Dental tape •Tufted floss and Floss threader Single tufted brush. Ex end-tuft, Sulcabrush •Interdental brushes. Ex Proxabrush, Proxabrush Trav-ler Traditional mechanical toothbrush •Sonic and ultrasonic toothbrushes •Powered interdental devices Ex Hydro Floss, Interplak Waterjet, WaterPik Personal Dental system Interdental floss Specialty brush devices Powered toothbrushes Oral irrigating devices
  • 65.  Splinting is a emperical approach in providing comfort to the patient. Initial days though it had few drawbacks but by combining the chemical adhesive and esthetic characteristic of composite resin with the strength enhancement of plasma treated, high modulus, reinforcing ribbon, many shortcomings have been tamed. Present day’s material can resist the load of masticatory forces without undergoing fracture.  Also the post stabilization maintenance requires combined efforts of clinician as well as patient to give good results.
  • 66.  Caranza –textbook of periodontology  Raymond’s textbook of oral surgery- vol 1  Torquil macphee- essentials of periodontology  Andreasen’s textbook and colour atlas of Traumatic injuries of the teeth.  Dental clinics of North America – tooth splinting and stabilization  Ingle – textbook of endodontics.  Cohen’s pathways of pulp.  Strassler He, Serio CL [dental clinic north america, 2007 Apr;51(2):507-24]