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.

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 load on 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 trauma Insufficient 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.

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.

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 if the 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 splint is 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 wire o Fixed intracorona;, extracoronal 2) Provisional splint is 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

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. 1.

Type of splint

Features Can be self polymerized or UV light polymerized

Advantages

Disadvantages

Enamel bonding material

Tooth coloured bonding material or clear plastic is used.

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 0.0030.005 inch thick is welded to form bands. Can be fabricated directly in patients model. Used in posterior teeth mouth or on a

Accidental minor tooth movement can occur. Can interfere with oral hygiene

3.

Continuous clasp

Made up of acrylic, gold, stainless steel

Permits oral hygiene Can be removed for social arrangements

Not esthetic

Impedes speech

Can be seated and removed like a partial denture

May be used only at night

4.

Composite splint

Composite is cured on acid etched tooth surface and linked together

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Simple Usefull in emergencies

Can break in interdental emergencies.

Cannot be used for long terms

TEMPORARY INTRACORONAL SPLINTS S. No. 1. Type of splint Acrylic or A- splint Requires the preparation of channel. 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 3. Acrylic full crowns can be fabricated on patients study models or pressure molded splint can be used acrylic wears and finally breaks Frequent fracture of amalgam Can be used for prolonged periods. Breakage of acrylic can occur 2. Amalgam splint Limited to posterior teeth. Features Advantages Disadvantages

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 acrylic. bar 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. Features Advantages Disadvantages

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
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Cosmetic Useful in advanced age ,poor physical or mental

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 questionable prognosis remain.

Favourable crown root ratio

Retention of alveolar bone around the roots.

FIXED PERMANENT SPLINTS: S. Name of the Features Advantages Disadvantages

No. splint 1. Linked inlays In anterior teeth inlays fit into dovetail preparation in the lingual surface of the teeth. if excessive anterior In posterior teeth a series of
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Splint can be displaced

force is exerted on

linked MOD inlays with occlusal coverage is constructed. 2. Linked crowns Most reliable form of immobilization. Strong Rigid

the tooth.

Requires tooth preparation May involve pulp

Most esthetic Requires great deal Multiple abutment fixed bridge may be used to replace missing teeth Allows to modify the form of teeth 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 Can be used only where functional forces are not acting to separate the appliance from the tooth. Modification of linked crown splint in which three parallel pinholes are made in six teeth. Retention is not as good as inlays or crowns. of chairside time & skill.

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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. 6. Intraosseous Implants of materials like steel or implant splints Still experimental vitreous carbon are used. 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 Governed by the distribution of remaining teeth. Modified with clasps, rests, bars &stress breakers.
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Provide cross arch splinting.

Combination of fixed splints & partial dentures

Useful in periodontally weakened situations where fixed splints cannot serve the purpose.

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 in the 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 care being 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 plaque retention 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 approximate 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. They may 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 posterior teeth & 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 t emporary splint is a brass or stainless steel wire ligature splint, stabilized with cold curing acrylic resin. This is an excellent splint for anterior teeth and provides a high degree of stability. It is acceptable from the aesthetic view point and if pro perly constructed, the embrasures are protected from food impaction. This type of splint has largely replaced welded orthodontic bands and wire ligature splints without acrylic, which were commonly used in the past. Direct bonding of composite material aft er 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 applian ces. 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 stabilize teeth during surgical corrective phase therapy of advanced periodontitis For stabilization of teeth during comp rehensive occlusal

reconstruction

PERMANENT SPLINTS
Permanent splints are constructed to provide stability for teeth that have lost so much support that normal forces act as hyperfunctional forces. Permanent splints are also used for retention of teeth f ollowing 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. W henever feasible, pin -ledge preparations or three-quarter crowns should be used for fixed splints. The complete coverage type of preparation with subgingival extension is the last choice from the viewpoint of biological acceptability. Full coverage crowns should only be used when unavoidable. Precision attachment connections

between various parts of a splint come next to fixed rigid splints in providing stability and controlling the distribution o f stress in a dentition. 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. W hen one of the teeth in a splint is subjected to excessive occ lusal 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 ligated 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 stabilizing advantages, splinting of teeth should be restricted to the minimum needed to achieve occlusal stability and adequate masticatory function. Splints should never be used as a substitu te 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: Ribbond reinforcement ribbon Connect Splint-It DVA (Dental Ventures of America) Fibre splint

Type of fiber Lock stitch, woven, polyethylene ribbon Open weave polyethylene ribbon Open weaves glass fiber ribbon Open tufts of polyethylene fibres. 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 no preparations, 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 of movement 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 may act 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 and fissure 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 prior controlled 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 cannot result 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 mechanically 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 concomitant 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.

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