Temporary and Permanent Splinting
The term splint indicates the act of fastening or confining,
supporting, or bracing a displaced or movable part. In dentistry,
splinting designates tying together or uniting two or more
teeth in order to gain occlusal stability.There are numerous
of splint design constructed with different splint material
and aim at different purposes. In order to correctly and
maximally delivering the therapeutic benefit of an occlusal
splint, a clinician not only must understand the nature
of the mechanism of splint therapy but also must be accurated
in diagnosing the source of the problem. Several factors
must be taken into account upon construction of the splint
is to the determine whether the splint is temporary or permanent,
extent of tooth coverage, the present state of occlusal
harmonies in the patient and the oral habits of the patient.
Splint may serve as palliative treatment, or relieving symptom
appliance, or it serves as to permanently enhance the functional
aspect of patient dentition. Success in splint therapy lies
heavily on his or her ability to make an accurate diagnosis
concerning the etiology of the patient’s functional
Glossary of Periodontics term defines a splint as “any
apparatus, appliance, or device employed to prevent motion
or displacement of fractured or movable parts. A dental
splint is an appliance designed to immobilize and stabilize
loose teeth. Splint were classified as temporary, provisional,
or permanent on the basis of duration and purpose. Temporary
splints are those which are used less than 6 months during
periodontal treatment and may or may not lead to other types
of splinting. Provisional splints may be used from several
months to years for diagnostic purposes, and usually lead
to a more permanent types of stabilization. Permanent splint
is a type of splint which is worn indefinitely and could
be fixed or removable.
Morton Amsterdam and Lewis Fox in 1959 outlined the principles
and technics of splinting. They defined that the term provisional
splinting as the phase of restorative therapy utilizing
a biomechanical combination of tooth dressing coverages
and stabilization of teeth on an immediate and temporary
basis. The rationales given for the procedures are to protect
the investing structures of the teeth, to protect the pulp,
to control of forces and stress, to establish physiologic
occlusion, to be used as an evaluating procedure as revealed
by functional requirement of the case, to serve as purpose
of anchorage and stabilization of the cases requiring minor
tooth movement, to treat periodontal cases which required
both restorative and periodontal therapy to be executed
simultaneously or required immobilization or to maintain
periodontal result, and finally to establish the prognosis
of a questionable teeth as it affects the final treatment
plan. Requirement for the splints consists of color stability,
esthetics, protective to pulp and occlusal forces, ease
of fabrication and maintenance, safe, and capable of removal
Simring in 1952 described the theory and practice of splinting
in detail. He emphasized the importance of direction of
forces and the movement of teeth under occlusal loads, thus
rationalized the need for splinting as the safety procedure
to employ when a tooth must withstand a forces beyond its
individual physiologic limits. Since occlusal forces are
multidirectional, he noted that an ideal splint would have
to run not only mesiodistally but also buccolingually. In
this case, splinting was carried around the arch. He also
described the edentulous distance and the splinting effect.
When three or more missing posterior teeth are replaced,
the splinting effect must be increased by including at least
three abutments when opposed by the natural dentition or
a stationary bridge. Restoration replacing three or more
missing posterior teeth and employing only two abutments
may be considered when the opposing denture is a tissue
borned removable appliance due to the resulting low occlusal
force. 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.
Wherever splinting is indicated, thorough occlusal equilibration
and adjustment must be indicated first. Finally, the most
effective splinting is attainable only with cast crown soldered
Jens Waerhaug evaluate the justification for the splinting
in periodontal therapy as a protective mechanism in the
case of occlusal trauma. Clinical trials have shown the
splints can do no harm. However, they may indicate that
splinting may speed up destruction of bone rather than retard
it. Fixed splints caused interference with oral hygiene.
He outlined the adverse consequence for splinting as they
represents unnecessary expense for patients, both fixed
and removable splints may cause damage if not properly made,
they are substituted for real periodontal treatment which
is necessary to save teeth, and destruction of periodontium
continues undisturbed by the splints.
Lemmerman in 1976 reviewed the rationale for splinting.
He described the use of splinting as to device as to reduced
the mobility or stabilized an existing mobility. He described
the concept of reversible mobility, a type of mobility in
the normal periodontium and will be able to reverse to normal
following therapy. He compared this type to irreversible
mobility, which were the type observed in a reduced periodontium
and can only be reduced but never be completely eradicated.
He suggest the possible rationales for splinting are a)to
prevent mobility or drifting, b)the use in post acute trauma
to enhance stabilization, c)prevention of drifting in normal
dentition during occlusal therapy, or to d)provide functional
comfort by preventing mobility in disease dentition. Thus
Lemmerman are referred to the importance of the clinician
to identify whether the drifting of teeth is a result of
primary occlusal trauma (injury resulting from excessive
occlusal forces applied to a tooth or teeth with normal
support), and secondary occlusal trauma (Injury resulting
from normal occlusal forces applied to a tooth or teeth
with inadequate support).
In the case of primary occlusal trauma, the periodontium
is intact and not reduced, thus the drifting of the teeth
is due to an excessive, continuous force resulting from
an occlusal disharmony. Elimination of this interference
will provide permanent relief from drifting and sometimes
completely reverse if diagnosed early. Splinting plays a
very minor role, if any, in the case of primary occlusal
trauma. Ferenez in 1991 reported that there is little rationale
for splinting teeth manifesting primary occlusal trauma.
In the case of secondary occlusal trauma, the periodontium
is reduced and the teeth lost a lot of support. The need
for splinting thus is more obvious as to achieve stabilization.
Splinting during or after periodontal treatment is often
aimed to achieve reduction of mobility to improved comfort
and function. Moreover, in the case which required periodontal
surgery, splinting is used to eliminate movements in the
healing area since micromovement of the surgical site may
inhibit repair to take place in the healing area. Ferenez
in 1991 also divided the splint into its duration of use:
short term splint, provisional splints, and long term splint.
Occlusal forces applied to a splints are shared by all teeth
within the splint even if the force is applied to only one
section of the splint. The rigidity of the splint acts as
lever, so that the forces applied to some teeth in the splint
may be much greater than before splinting. This phenomena
is utmost important in the case of unstable occlusion because
the inclusion of a mobile tooth in a splint does not completely
relieve the tooth of the burden of occlusal forces, nor
does it guarantee against injury from excessive occlusal
forces. One tooth within the splint with occlusal disharmonies
may cause damage to periodontium of the other teeth in the
splint, thus the occlusion needed to be stabilized prior
to splinting. According to Caranza, two major indications
for periodontal splinting are a)to immobilize excessively
mobile teeth so that the patient can chew more comfortably
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, the acid etch resin splint for use in anterior
teeth, and the resin bonded metal splint. As with any other
appliance in the mouth, oral hygiene must be emphasized
and must be taken into account in the design and construction
of the splint.
Ramjford classified splint as temporary, diagnostic or provisional,
or permanent. Temporary are used to reduce unfavorable occlusal
forces for a limited time. This type of splinting can be
seen in post acute trauma, in supportive measure in treatment
of advanced periodontal disease, and for anchorage in orthodontic
therapy. The diagnostic or provisional splint is used in
borderline cases in which the final result of the periodontal
treatment cannot be predicted with certainty at the time
of initial treatment planing. Permanent splints are constructed
to provide stability for teeth undergoing progressive tipping
or for teeth that have lost so much of their periodontal
support that they cannot carry out normal function if they
are left as single units. All splints should enhance the
stabilityy and function of the dentition. Temporary splints
could be fixed, external types such as in the use of annealed
stainless steel ligature wire (.010or .012 in.), single
or double, bonded to the teeth facially, lingually, or even
incisally. The splint of wire combined with acrylic is very
effective. Other temporary fixed external type included
orthodontic bands welded together (too cumbersome, poor
esthetics), cast splints of gold or chrome nickel alloy
cemented to the teeth and the facial and lingual parts tied
together with ligatuer wire. The most popular temporary
splint is the one made with acid etch, self polymerizing
resin, and composite material. The acrylic can be reinforced
with the orthodontic grid material or cast metal framework.
Denture teeth can be used to substitute for the tooth or
teeth missing and thus further increase the supporting periodontium.
Long term benefits from splints is illlusory, since the
teeth revert to its initial mobility when splint is removed.
Another type of temporary splint are the fixed internal
type of which the teeth must be prepared with the interproximal
box preparation with mark retention, then the teeth are
held together with metal wires with acrylic reinforced.
This type of appliance can be worn for up to 2 or 3 years.
Another type of temporary splint are the removable splint
wich included the cast metal splint of Elbrecht, the acrylic
Hawley or other types of orthodontic appliance, the bite
guards or night guards. This type of splint is less stabilized
than the fixed type, but provided better oral hygiene and
convenience in construction.
In the case of diagnostic splint, a temporary external splints
for teeth that have a reasonable good periodontal prognosis
is recommended. The preferred technique is the acid etch
The permanent splints included the fixed, semirigid, or
removable splint with the use of anchorage internally or
externally to the teeth. Fixed permanent splints is most
recommended with utmost attention given to oral hygiene.
Principles in its construction included elimination of all
sources of gingival irritation, good access to oral hygiene,
excellent retention in all abutment preparation, and adequate
thickness or bulk of the splint and good solder joints.
The use of semi regid or precision attachment connection
can beused. Pin ledge type of abutment should be used for
fixed splint whenever possible. The removable permanent
splint included the use of telescoping crown and precision
attachment to constructed a cast metal splints, clasped
supported partial denture.
Glickman et al. (1961) evaluated the effects of splinting
teeth in hyperocclusion using five Rhesus monkeys. The forces
which applied to 1 tooth in a splint were transmitted to
all teeth within the splint. The direction of the initial
force was maintained and comparable areas of the splinted
periodontium were affected. The bifurcation and bifurcation
areas were most susceptible to excessive force. Forces applied
to non-splinted teeth were not transmitted to adjacent teeth
and force sufficient to cause necrosis did not cause pocketing.
Nyman et al. (1975) studied 20 patients who had originally
exhibited severe periodontal breakdown and extensive tooth
loss. Extensive fixed bridgework was placed following periodontal
therapy and the patients monitored for 2 to 6 years. No
further bone loss was observed between the insertion of
the fixed bridgework and the final examination. The authors
reported no increase in PDL width of the abutments or changes
In summary, regardless whichever type of splint to be use,
the rigidness, the oral hygiene, and stabilization of occlusion
are the critical factors in the splint design. Common dysfunctional
problem in splinting and oral rehabilitation are tipped
abutment teeth which required uprighting with orthodontic
appliance. It is also important that the splint be properly
articulated in lateral excursion, allowing lateral movements
with undue pressure on the splint. In the case of deep overbite,
sufficient overjet must be provided so that lateral excursion
are unrestricted. In patient with deep overbite and a markedly
curved arch in the anterior region, maxillary incisors must
be maintained for abutment, even if these teeth have extensive
loss of support and appear very loose.
Disadvantage of splinting included gingival irritation,
difficult oral hygiene access, interference of the splint
to normal interproximal wear and mesial drift, crown become
loose or fractured, interference with phonetics. With these
disadvantage in mind, splinting should only be done when
occlusal stability and adequate masticatory function desired.
It should never be used to substitute occlusal adjustment
therapy. Prognosis of the splinting teeth (tooth) relies
greatly on oral hygiene achieved in the area.
Ramjford further describes the biomechanics of the splint.
The reduction mobility is achieved by decreasing the occlusal
forces to the mobile tooth through occlusal equilibration
prior to splinting, and increasing the periodontal resistance
with the inclusion of other teeth into the splint. Splinting
allow better force distribution, directing the force to
be distributed over the entire splinting area thus better
periodontal support,and as a result of conditioned reflex
activity, masticatory function is directed toward the area
that most convenient and efficient for function. Lateral
force or tipping forces should be avoided as much as possible.
Functional contact should be in a straight line between
the abutment of the splint in order to avoid tipping forces
when biting forcefully. Mesial or distal force can be better
distributed when two single rooted teeth are splint together.
Intrusive forces are very well tolerated since their impact
is spread over a maximal number of principal periodontal
fibers. In order to achieve favorable a stabilization in
the faciolingual and mesiodistal direction, a splint has
to connect posterior and anterior segments or to engage
teeth in the opposite side of the arch for support. Such
a distribution of abutment produces the tripod effects:
a tipping force acts as a well toleated intrusive force
on one or more abutment. Fixed splint provided much greater
stability than the removable appliances, and thus is recommended
in splinting teeth with minimum residual support.
In summary, splint offered numerous therapeutic advantages
ranging from increase periodontal resistances to occlusal
relationship correction. Regardless of the type of splint
design, material, and method of fabrication, it must provide
good access to oral hygiene, rigid fixation, and also elimination
of occlusal trauma by providing force distribution and resistance
to occlusal overload.
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