Tooth Splinting using Fiber Reinforced Composite & Metal-A comparison

Abstract

Mobility of the teeth is one of the most common compliant in patients with periodontitis. Splinting is the method of stabilization of these mobile teeth in mild to moderate condition. Tooth splinting has been accomplished since ancient civilization to decrease tooth mobility. Both fiber reinforced splinting and metal wire splinting has its own advantages and disadvantages. The various procedures in splinting technique indicate that this problem has received much attention.Keywords: Tooth stabilization, Fiber reinforced splinting, metal ligature wire splinting Introduction plinting is the most common technique practiced in dentistry. Patients with severe and chronic periodontitis development of tooth mobility will affect the prognosis of the patient. Mobility may be caused by inflammation of periodontium, loss of periodontal attachment or functional or parafunctional forces on teeth2. Splinting therapy may be applied with bonded external appliances, intra coronal appliances, or indirect cast restorations to connect multiple teeth, with a goal of improving tooth stability. According to Glossary of Periodontic terms 1986 defined as "An appliance designed to stabilize mobile teeth". "Any apparatus, appliance or device employed to prevent motion or displacement of fractured or movable parts in order to distribute occlusal forces evenly"-AAP(1996). Aims of Splinting 1. Rest is created on the supporting tissues, permitting repair of trauma. 2. Mobility is reduced immediately & it is hoped permanently Hirschfled L;1950. 3. Force received by any one tooth is distributed to number of teeth. 4. Proximal contacts are stabilized, & food impaction is prevented. 5. Migration of teeth is prevented. 6. Masticatory function is improved. 7. Discomfort & pain is eliminated Indications 1. Mobility of teeth that is increasing. 2. Mobility of teeth that impairs patient comfort. 3. Migration of teeth. 4. Prosthetics where multiple abutments are necessary. According to Tarnow & Fletcher described the indication and contraindications for splinting periodontally involved teeth.3 According to them the rationale of splinting teeth include the severity of periodontal disease as determined by the amount of radiographic bone loss and /or measured tooth mobility. Literature indicates that the reasons for tooth mobility with periodontal splinting are 1. Primary occlusal trauma, 2. Secondary occlusal trauma and 3. Progressive tooth mobility migration, pain on function.3 Earlier it was assumed that splinting was done to control tooth mobility, Gingival inflammation, periodontal pocket formation, because increase in the tooth mobility was a direct consequences of traumatic occlusion, bruxisim and clenching. It was suggested that even normal functions like mastication and swallowing would contribute tooth mobility.4 It was suggested that when teeth were subjected to occlusal overloading and other variables that contribute periodontal disease were well controlled, gingival inflammation, periodontal pocket formation did not occur.5 Wally Kegel et al performed a study in which patients with chronic destructive periodontitis patients were taken who had mobility in their teeth. Initial therapy, consisting of oral hygiene instruction, root curettage and occlusal adjustment, was performed over a 2-week period. At the time of initial therapy, teeth in contralateral segments were splinted with an intracoronal wire-and-acrylic splint. Tooth mobility and gingival inflammation were recorded in all four segments every 3 weeks for a 15-week monitoring period following initial therapy. The reduction in tooth mobility observed in both the splinted and unsplinted segments over the 17-week period can be attributed to the improved occlusal relationships and reduction in inflammation .6 Clinical Rationale for tooth stabilization and splinting * Occlusal therapy * Effects of splinting According to Grant (1988) A. Temporary - a. External (extracoronal) Ligature Splint Enamel bonding material Welded bonded splint Continuous splints Night Guards b.Internal (Intracoronal ) * Acrylic splints * Composite splints * Acrylic splints B.Provisional splints : Removable /fixed Removable splints The use of removable splints is simple reversible and inexpensive. The splinting of teeth may be less rigid in removable than in fixed type. The advantage of removable type of splinting can facilitate oral hygiene1. The removable splint is most widely used in case of emergency procedures. Hard acrylic occlusal splints: Occlusal splints is used in diagnosis of occlusal trauma in periodontitis patients and for retention of drifting of teeth. Two types of occlusal splints are given below based on the coverage full coverage/ Partial coverage. Fixed Permanent splint used indefinitely e.g removable/fixed, intracoronal/extracoronal Various commonly used splints 1. S Splints for anterior teeth a. Direct bonding system using acid etching technique and light cure resin. b. Intra coronal wire and acrylic wire resin splint - It uses preparations of a slot on the lingual aspect of the tooth and stabilizing the teeth using stainless steel wire, placed in the slot 2. Splints for posterior teeth a. Intra coronal amalgam wire splints - It uses resin restoration with wire on proximal amalgam restored areas of tooth b. Bite guard c. Ridge occlusal splint d. Composite splint Currently it is generally accepted that tooth mobility is a important clinical parameter in predicting periodontal prognosis of those teeth.7 The main reason to stabilize periodontally compromised dentition with splinting include: decreasing patient discomfort, increasing occlusal and masticatory function and improving periodontal prognosis of mobile teeth.8 OCCLUSAL CONSIDERATIONS Occlusal considerations also should be taken into account before splinting the teeth. It is most important to evaluate the occlusion of the patients being treated for periodontal disease who have diminished bone support. In terms of occlusion alone, it is important to control, direction, magnitude, distribution and intensity of functional and parafunctional forces. Treatment should be planned so that the occlusal forces are transmitted to those teeth with greatest bone support. The success of adhesive bonded composite resin to the etched enamel led to case reports and techniques using a variety of materials. Clinical technique s using wires twisted around the teeth and covered with resins, metal and nylon mesh embedded in the resin and for posterior teeth use of channels prepared into occlusal and proximal surfaces of the teeth or into existing amalgam restorations with cast bars and thick wire placed channels and covered with resins have been reported.9,10 Failures of these materials because of loading stress placed on splint during normal functional and parafunction.11,12 Fiber Reinforced Splinting and Stainless Steel Metal Wire Splinting The reinforcing capacity of fibers is dependent on their adhesion to the resin, on the orientation of the fibers, and on impregnation with the resin.13 Other desirable physical properties of a fiber are good flexural strength and no requirement for mechanical retention on supporting teeth when compared to the conventional metallic-structured fixed prosthesis.14 This feature led to investigations concerning pre-impregnated and non pre-impregnated fibers used in conjunction with adhesive materials. Freilich et al. (2000) concluded that pre-impregnated systems are well indicated for direct applications, i.e., splinting or direct adhesive bridges. In these clinical applications, mechanical and physical properties of composite materials are strongly influenced by the structure and properties of the fiber-matrix interface, and differences between the elastic properties of the matrix and the fibers may modify the force transmission through the interface. The pre-impregnated reinforcement fibers create a substructure that has been shown to support 2-3 times more load and to have a flexural modulus that is 10 times higher than that of the hand-impregnated designs.15,16,17,18 Investigations done by K A Ebeleseder et al in 1996 done a study in 103 post traumatic splints, and tooth mobility was measured using periotest immediately before and after splint removal. The splints were made of composite resin and an 0.017 X 0.025" orthodontic steel wire. 481 teeth were measured. A statistic evaluation revealed that the immobilization effect did not exceed normal tooth firmness. Fixation to one neighboring tooth had less effect than fixation to two. Adjacent tooth gaps reduced the effect. The result was splint extensions had no influence. With the use of the Periotest device, more than 50% of all teeth with a true mobility of 20 Periotest-units or more were detectable as mobile in spite of the fixed splint.19 The following case reports describes the comparison of both fiber reinforced composite resin splinting and Stainless steel wire splinting placed to stabilize a severely periodontally compromised dentition. This case reports demonstrate that using the treatment techniques described when treatment planning similar clinical situations can lead to improved prognosis. Case report 1: Fiber reinforced composite splinting Female patient aged 23 years has reported to the Department of Periodontics, complaining of grade I mobility in 32, 33 42, 43, grade II gingival recession in relation to 43. On examination of medical history, no relevant history was noticed. On evaluation of dental history shows that she had a prior visit to dentist and got her 31, 41 extracted 2 months before due to mobility. Radiographic examination was taken reveals horizontal bone loss in middle third of the root in relation to lower anteriors (Fig 1). Consent of the patient was taken before scheduling the treatment plan. Complete history was taken, since the main focus was based on splinting the mobile teeth, initial therapy was based scaling and root planning and was done in relation to 42 and 43 due to presence of sub gingival calculus and gingival inflammation (Fig 2). Patient is asked to report after 4 weeks after scaling and root planning. PROCEDURE Based on prognosis of the teeth, a fiber reinforced composite splinting was planned for the patient. The area to be splinted is etched for 60 seconds (Fig 3). Then remove the acid by spraying it for 30 seconds and carefully blow the operated site dry. Then the bonding agent is applied over the teeth and cured. The length of the fiber splint material is assessed and the fiber splint is cut to the required size (Fig 4). The fiber splint is positioned in the tooth surface. Place the strip on the tooth surface and composite placed over it and curing is done in separately in individual tooth. The strip is placed on the next adjacent teeth and the procedure is repeated until the teeth to be splinted is completed (Fig 5). Patient is given oral hygiene instruction and asked to report after every 4 weeks and splint was removed after 4 months. The mobility was reduced and the occlusion was functional. Case report 2: Stainless steel metal wire splinting Male patient aged 25 years male had reported to the Department of Periodontics complaining of mobility in the lower anterior teeth region (Fig 6). On examination of medical history reveals no relevant history was noticed .On examination of dental history reveals that this is the first visit to dentist. Radiographic evidence showed that there was a uniform horizontal bone loss (Fig 10). Complete history was taken. Grade III gingival recession was observed in 31 and Grade II gingival recession was observed in 32. Grade I mobility was noticed in 31 and 41 region. Through scaling and root planning was done (Fig 7). Patient was asked to report after 4 weeks for review. Stainless steel wire splinting was planned for the patient to control mobility. PROCEDURE Splinting was planned in relation to 31-33 & 41-43. The acid etching is done using phosphoric acid (etchant) on the tooth surface. Ligature wire is used to splint the anterior teeth. Bonding agent is applied on the teeth to be splinted, composite resins are placed on the adjoining teeth and they are reinforced with the metal wire (Fig 8,9). DISCUSSION Splinting if well placed and maintained under patients compliance, and on removal helps to reduce mobility and gives stability. The advantage of stainless steel metal wire bonded with composite splinting is it quick and easy to adapt and removal of the splint is easy, good vertical flexibility & controls tooth mobility. The advantage of fiber reinforced composite splinting is that aesthetically pleasing, low level of fracture frequency. More superior than any other type of splinting CASE REPORT 1 : FIBER REINFORCED COMPOSITE SPLINTING References * RenggliHH, SchweizerH Splinting of teeth with removable bridges. Biological effects.JClin Periodonto l1974;1:43-46 * Serio FG. Clinical rationale for tooth stabilization and splinting. Dent Clin North Am.1999;43:1-6. * Tarnow DP, Fletcher P. Splinting of periodontally involved teeth: indications and contraindications. NY State Dent J. 1986;52:24-25. * Waerhaug J. Justification for splinting in periodontal therapy. J Prosthet Dent. 1969;22:201-208. * Bhaskar SN, Orban B. Experimental occlusal trauma. J Periodontol. 1955;26:270-284 * Kegel W, Selipsky H, Phillips C. The effect of splinting on tooth mobility. I. During initial therapy. J Clin Periodontol. 1979;6:45-58. * McGuire MK, Nunn ME. Prognosis versus actual outcome.II.The Effectiveness of clinical parameters in developing accurate prognosis. J Periodontol.1996;67:658-665 . * Bernal G,Carvajal JC, Munoz-Viveros CA.A review in clinical management of mobile teeth. J Contemp Dent Pract 2002;3:10-12. * Liatukas EL. An amalgam and composite resin splint for posterior teeth. J Prosthet Dent. 1973;30:173-175. * Fusayama T. Permanent Splint of highly mobile teeth. J Prosthet Dent.1973;30:53-55. * Pollack LP.Non crown and bridge stabilization of severely mobile,periodontally involved teeth. A 25 -Year Perspective Dent Clin North Am.1999;43:77-103. * Miller TE.A new material for Periodontal splinting and orthodontic retension. Compendium.1993;14:800-812. * Vallittu PK, Narva K. Impact strength of a modified continuous glass fiber polymethyl methacrylate. Int J Prosthodont. 1997;10(2):142-8 * Feinman RA, Smidt A. A combination porcelain/fiber-reinforced composite bridge: a case report. Pract Periodontics Aesthet Dent. 1997;9(8):925-9. * Freilich MA, Karmaker AC, Burstone CJ, Goldberg AJ. Development and clinical applications of a light-polymerized fiber-reinforced composite. J Prosthet Dent. 1998 Sep;80(3):311-8 * Goldberg AJ, Burstone CJ. Flexural properties and fiber architecture of commercial fiber reinforced composites. J Dent Res. 1998;77:226. * Freilich MA, Ducan JP, Meirs JC, Goldberg AJ. Preimpregnated, fiber-reinforced prosthesis. Part I. Basic rationale and complete-coverage and intracoronal fixed partial denture designs. Quintessence Int. 1998;29(11):689-96. * Meiers JC, Freilich MA. Conservative anterior tooth replacement using fiber-reinforced composite. Oper Dent. 2000;25(3):239-43. * K A Ebeleseder, K Glockner, C Pertl, P Städtler: Splints made of wire and composite: an investigation of lateral tooth mobility in vivo. Endodontics & dental traumatology 01/1996; 11(6):288-93. Go Back