Tooth mobility

 defined as a visually perceptible movement of the tooth away from its normal position when a light
force is applied (Gher 1996)
 Type: physiologic and pathologic tooth movement
Etiology:
 Loss of tooth support
 Extension of inflammation from the gingival or from the periapex into the PDL
 Periodontal surgery
 Tooth mobility increases in pregnancy
 Pathologic process of the jaw
 Trauma from occlusion :injury resulting in tissue changes within the attachment apparatus as a
result of occlusal force
Indices: Miller 1950
Score 0 - no perceptible movement
Score 1- mobility greater than normal
Score 2- mobility of up to 1 mm in a buccolingual direction.
Score 3- movement of more than 1mm in a buccolingual direction combined with the ability to depress the
tooth.

Indices: Glickman 1972

0- Normal mobility
Grade I- Slightly more than normal
Grade II- Moderately more than normal
Grade III- Severe mobility faciolingually and / or mesiodistally combined with vertical displacement.

Indices: Lindhe 1997

Degree1: Movability of the crown 0.2- 1mm in horizontal direction.
Degree 2: Movability of the crown of the tooth exceeding 1 mm in horizontal direction.
Degree 3: Movability of the crown of the tooth in vertical direction as well.

Primary occlusal trauma:- injury resulting in tissue changes from excessive occclusal forces applied to a
tooth or teeth with normal support. (occurs when tissue reactions affect teeth with a normal periodontium)
It occurs in the presence of:
1- normal bone level
2- normal attachment level
3- excessive occlusal force (s).
Secondary occlusal trauma:- injury resulting in tissue changes from normal or excessive occlusal forces
applied to a tooth or teeth with reduced support (related to damage to an already compromised
periodontium with reduced height) .
it occurs in the presence of :
1- bone loss.
2- attachment loss.
3- normal / excessive occlusal force(s).
Clinical studies
 Mobility (progressive)
 Occlusal prematurities
 Thermal sensitivity
 Wear facets
 Muscle tenderness
 Fractured teeth
 Migration of teeth
Radiographic indicators
 Discontinuity and thickening of lamina dura
 Widened periodontal ligament space
  Evidence of root resorption and or bone loss
To diagnose trauma from occlusion
 History: teeth which are sensitive but not related to recession, caries or broken fillings, muscle pain,
problems with TMJ like clicking, limitation in opening or deviation
 Examination: attrition, decrease in vertical dimension, some teeth with edges chipped, broken
restoration, mobility of teeth, changes in position of teeth, sign and symptom of pulpal hyperemia
or pulpitis without any obvious cause
 Radiograph examination: widening in space of PDL
 Occlusal analysis: Impression-cast-bite registration-mounted on fully adjustable articulater (analyse
occlusion an determine area of premature contact
Treatment of Traumatic occlusal
 interfering hopeless tooth-extraction.
 new restoration of interfering teeth.
 diminshed occlusal table require placement [bridge,partial denture….]
 bite plane,night guard,now called [inter-occlusal appliance] a-prevent teeth from fully
interdigitating. b-help in preventing or minimizing isomeric contraction of muscles. c-abolish the
effect of mechanoreceptors.
 exercise for more harmonious occlusion.
 portable electromyography contain warning system[feed back] measures the electric potential on
the muscles.
(Occlusal adjustment in the treatment of primary traumatic injury, Stomatos, Vol 17, July/Dec 2011)
Repair occurs when occlusal forces are reduced or the tooth is moved away from them. If these forces
continue to act in a chronic fashion, tissues remodel to better absorb the impact. This fact results in changes
in the periodontal ligament, alveolar bone, cementum and dental pulp, periapical infl ammation, and root
resorption.
The periodontium may also become more resistant to withstand the conditions created. The consequences
of this phenomenon can be seen at the tooth level, leading to the formation of wear facets, severe attrition
of the occlusal surfaces, and even tooth fractures
Occlusal adjustment by selective grinding was indicated, because this technique can promote an equal
incidence of all forces on the teeth, which causes the physiological and geometric axes to match, thus
establishing a harmonious relationship among the elements of the stomatognathic system through the
elimination of occlusal interferences

Occlusal Adjustment

Indications for Occlusal Adjustment:

1. To eliminate isolated occlusal interferences, when a tooth becomes symptomatic after the
placement of a new, hyperoccluding restoration or following orthodontic treatment (In rare cases,
therapeutically-induced changes in occlusion can be associated with the onset of TMD-like
symptoms. In these uncommon instances, adjustment of the occlusion may be warranted, as it will
decrease the pain and mobility and it will improve function, but it should be undertaken with as
little invasiveness as possible.)
2. When it is determined that a periodontally involved tooth has increased mobility which is due to
traumatic occlusion rather than solely to attachment loss
3. In the management of symptomatic fractured teeth or of prosthetically restored teeth which fracture
repeatedly
4. Occasionally, prior to procedures which will result in major occlusal changes, such as prosthetic
reconstructions
5. Following orthodontic treatment to correct minor interferences that cannot be corrected solely by
tooth movement
6. As a form of limited supportive therapy, e.g. when a tooth in parafunction becomes hypermobile
and hypersensitive, keeping in mind that selective grinding does not replace treatment aimed at
decreasing parafunction (In these cases the occlusal contact should be reduced, but not eliminated
altogether.)
 7. Following occlusal splint therapy, selective grinding is indicated, once occlusal appliance therapy
has eliminated the TMD symptoms, and only if it is determined that the symptoms would disappear
permanently, if the occlusal contacts and jaw position provided by the appliance were permanently
reproduced in the patient’s occlusion.
8. Following the placement of implant-supported crowns, in order to decrease the incidence of
biomechanical complications, such as crown-screw loosening or denture tooth fracture.

Contraindications to Occlusal Adjustment

1. The absence of signs and symptoms of TMD

2. The presence of acute orofacial pain and /or dysfunction unrelated to occlusion
3. When the occlusal adjustment would require grinding beyond the enamel (e.g. slides greater than
2mm).

Occlusal Adjustment Guidelines

With respect to the removal of vertical interferences, the rule of thirds can be used to determine if selective
grinding should be attempted. Accordingly, if the occlusal interference represents a cusp tip occluding
against the opposing cusp incline close to the opposing fossa, selective grinding is likely to eliminate the
interference without exposing dentin. If, however, the cusp tip occludes against the opposing cusp incline
closest to the opposing cusp tip, selective grinding would likely expose dentin, and restorative procedures
would be, eventually, required.

With respect to the removal of horizontal, lateral or anterior-posterior interferences, it may be expected that
slides of less than 2mm can be eliminated by selective grinding.

Occlusal Adjustment Procedure for natural teeth or combinations of natural and fixed or removable
bridges

1. The patient is reclined.

2. The teeth are brought together the patient identifies the side of the first contact.
3. The first contact is identified with double-sided articulating paper (Accufilm) and confirmed with a
shim stock.
4. The contacting inclines are reshaped (using fine diamond or carbide burs) as either a cusp tip, if the
contact is near the cusp tip or as a flat surface, if the contact is near a fossa (as the inclines are
adjusted into cusp tips and flat surfaces, the VDO approaches the ICP, intercuspal position).
5. The teeth are adjusted so that the maximum number of teeth can occlude.
6. Once established, the posterior contacts should not be altered.
7. There should be only light contact between the anterior teeth.
8. Anterior guidance is developed by providing canine or canine and incisor contacts, when the
mandible moves anteriorly and laterally. The occluding surfaces in excursive movements are
marked with articulating paper of one colour and the maximum intercuspation contacts are marked
in a different colour. The posterior excursive contacts are then removed, creating the anterior
guidance.
9. If the canines are not in position to guide the mandible initially, the bicuspid or even molar buccal
cusps can be used. The posterior non-working contacts are removed.
10. The bicuspid and molar lingual cusps should not contact in lateral and anterior movements.
11. Once the occlusal adjustment in the reclined position is completed, the occlusion is evaluated with
the patient in the upright position. Here again, the contacts between the anterior teeth should be
lighter than that between the posterior teeth.

Splinting techniques

Wire secured to the teeth with composite (Figure 1) is the most favoured and widely-used splint, and can
be used in almost all types of tooth injury.
A clinical step-by-step technique is depicted in Figures 5-5d, and the Dental Trauma Guide also provides
detailed instructions.

 Always protect the airway.

 The stainless-steel wire should be pre-contoured to conform to the teeth and the diameter must not
exceed 0.4mm to remain flexible.
 The wire used should be passive in nature and not exert any unwanted orthodontic forces.
 Avoid excessive composite, which will limit the splint’s flexibility.
 Composite should not encroach on the embrasure spaces or the gingival margin.
 Contrasting shades of composite should be used in order to facilitate removal

Rationale

 Comfort and Psychologic well being of the patient

 REST: Occlusal rest provided by splint therapy of one form or another helps to eliminate or at least
to neutralize some of the adverse occlusal factors that compound the effects of already existing
periodontitis
 Redirection Of Forces: Splinting effects a redirection of force in a more axial direction over all the
teeth included in a splint
 Redistribution Of forces. The stabilization of weakened teeth by splinting increases resistance to
applied force. The redistribution of forces ensures that excessive force on a single tooth does not
exceed the adaptive capacity of the surrounding tissue and that jiggling movements, which can
contribute to further bone loss in an existing periodontitis are prevented
 Preservation of arch Integrity
 Splinting restores proximal contacts that have been disrupted by missing and migrated teeth

Theoretical aims

1- Rest is created for the supporting tissues, permitting repair of trauma.

2- Mobility is reduced immediately and, it is hoped, permanently. In particular, jiggling movements
are reduced or eliminated.
3- Forces received by any one tooth are distributed to a number of teeth
4- Proximal contacts are stabilized, and food impaction (but not retention) is prevented.
5- Migration and overerruption are prevented
6- Masticatory function may be improved
7- Appearance may be improved
8- Discomfort and pain are eliminated

Biomechanics (Ramjford)

Limits amount of force on a single tooth (A mobile individual tooth is capable of being loaded and moved
in several directions: mesio-distally, buccolingually and apical)

Aids in distribution of force (When the mobile tooth is splinted, the splint tends to redirect lateral forces
into more vertical forces, which the tooth is better able to resist)
Unilateral and Bilateral Splits

Classification according to Grant, Stern and Listgarten (1988)

Temporary splints

 Extracoronal (External)- Ligature splint, Enamel bonding material, welded bond splints, night
guards
 Intracoronal (Internal)- Acrylic splints, Composite splints, acrylic full crowns II)

Provisional spilnts

Serves to stabilize a permanently mobile dentition from the time of initial tooth preparation until the time
the dentition is periodontally healthy enough for permanent restorations.

Permanent splints may be classified as follows:

Removable—external

 Continuous clasp devices

 Swing-lock devices
 Overdenture (full or partial)

Fixed—internal

 Full coverage, three-fourths coverage crowns and inlays

 Posts in root canals
 Horizontal pin splints

3. Cast-metal resin-bonded fixed partial dentures (Maryland splints)

4. Combined

 Partial dentures and splinted abutments

 Removable—fixed splints
 Full or partial dentures on splinted roots
 Fixed bridges incorporated in partial dentures, seated on posts or copings

Temporary Splinting

Indications:
 Following accidental loosening of teeth by trauma
  As a supportive measure to facilitate periodontal therapeutic procedures for hypermobile teeth
 To avoid dislodging of teeth prior to and during reconstruction procedures
 For anchorage and temporary retention in orthodontic therapy

Ligatures are a satisfactory means of stabilizing anterior teeth. Although ligation is a form of temporary
splinting,

 ligatures may be retained for several months if they are tightened and replaced periodically.
 Poor esthetic appearance
 May perform minor tooth movements
 Can cause gingival irritation due to plaque or food accumulation.

Alternative splints include:

 fishing line nylon is used to replace the wire and offers an inexpensive and aesthetic alternative;
 orthodontic brackets and wire splints are useful if orthodontic alignment ofthe displaced tooth is
desired in addition to splinting;
 composite resin splints are quick to apply but can lead to gingival irritation as they can be very
difficult to clean7and prone to fracture – composite splints are rigid and therefore not
recommended;
 a Protemp splint (Figure 2) can be useful as a temporary emergency measure;
 fibre splints (Figure 3) consist of weaved polyethylene fibres (Ribbond) orglass fibres in a polymer-
resin gel matrix (EverStick) – they reportedly have high strength, are very easy to adapt and are
aesthetic;
 titanium trauma splints (Figure 4) are flexible titanium splints with a rhomboid mesh structure –
secured to teeth with flowable composite, they are easy to place and remove, but high cost is an
issue;
 suture splints may be required if there are multiple missing teeth, or in the mixed dentition where
conventional splinting is not possible; and,
 a removable Essix retainer splint can be of use where multiple teeth are involved

References

 Clinical periodontology :Shanatipriya Reddy 4th edition.

 Grant Stern and Listgarten
 Clinical periodontology :Carranza 10th edition
 Clinical periodontology: Jan Lindhe
 https://www.lenus.ie/bitstream/handle/10147/622673/art1.pdf?sequence=1&isAllowed=y

(Tips for splinting traumatised teeth, Journal of the Irish Dental Association | Oct/Nov 2017 : Vol 63 (5))

Splint removal

Correct splint removal is as important as placement. Aggressive removal can damage the teeth but
insufficient removal favours plaque retention and decalcification.There is no standard protocol for the
removal of composite resin materials but commonly-used techniques, including pliers, hand scalers,burs
and polishing disks (Sof-Lex, 3M ESPE), are shown in Figure 7. A study reported that composite removal
with abrasive discs (using progressively finer discs) and tungsten carbide burs (in a slow hand piece) result
in the smoothest enamel surface, but all techniques reportedly cause some iatrogenic damage.8Hand
scalers, ultrasonic scalers and diamond burs cause the most enamel surface roughness so are not
recommended. Final polishing is facilitated by the use of magnification3and articulating paper is useful to
mark the residual composite once the operator approaches the resin–enamel interface to prevent iatrogenic
damage to the enamel (Figure 8
References

 https://www.lenus.ie/bitstream/handle/10147/622673/art1.pdf?sequence=1&isAllowed=y

(Tips for splinting traumatised teeth, Journal of the Irish Dental Association | Oct/Nov 2017 : Vol 63 (5))
Types of splints
As detailed below, many types of splints have been used and ideally should meet the following
requirements which have been modified from Andreasen ’s original recommendations in 1972. A splint
should:
(1) Allow periodontal ligament reattachment and prevent the risk of further trauma or swallowing of a
loose tooth.
(2) Be easily applied and removed without additional trauma or damage to the teeth and surrounding soft
tissues.
(3) Stabilize the injured tooth/teeth in its correct position and maintain adequate stabilization
throughout the splinting period.
(4) Allow physiologic tooth mobility to aid in periodontal ligament healing.
(5) Not irritate soft tissues.
(6) Allow pulp sensibility testing and endodontic access.
(7) Allow adequate oral hygiene.
(8) Not interfere with occlusal movements.
(9) Preferably fulfil aesthetic appearance.
(10) Provide patient comfort.

Types of splints in current use

Composite and wire splints
Composite and wire splints are perhaps the most commonly used in clinical practice and are flexible splints
when the wire has a diameter of no greater than 0.3–0.4 mm.

Composite and fishing line splints

An alternative to wire is where fishing line replaces wire and the line is secured with composite resin. The
coloured composite provides a guide for the removal of the splint to minimize damage to enamel.
Orthodontic wire and bracket splints
This splint, which is extensively employed by paedodontists in Australia, involves orthodontic brackets
bonded to the teeth with a resin-based orthodontic cement and connected with a light 0.014 NiTi flexible
wire. Orthodontic bracket splints allow teeth that have been intruded or not repositioned correctly to have
the occlusal relation-ships modified at a later date. However, care must be taken that orthodontic forces do
not develop stress that disturbs the healing phase of an injured tooth. While this type of splint was found to
be irritating to the lips when compared to composite and wire splints and titanium trauma splints, this is
generally not considered to be a clinical problem as any lip irritation can be avoided with the application of
wax

Fibre splints
Fibre splints use a polyethylene or Kevlar fibre mesh and are attached either with an unfilled resin such as
Optibond FL (Kerr, USA) and/or with composite resin. Materials such as Fiber-Splint (Polydentia
SAMezzovico-Vira, Switzerland), RibbondTM (RibbondInc., Seattle, USA) or EverStick (Stick Tech
Ltd,Turku, Finland), which is a silinated E-type glassfibre, are commercially available. An example of a
Fiber-Splint is shown in Fig. 5 following an avulsion injury of the maxillary left central and lateral incisor
teeth. In a study of 400 root-fractured teeth by Andreasenet al., fibre splints were associated with the
highest frequency of favourable healing outcomes.

Titanium trauma splints

The titanium trauma splint developed by von Arx18isa flexible splint made of titanium, 0.2 mm thick
and2.8 mm wide (Medartis AG, Basel, Switzerland). It has a rhomboid mesh structure which is secured to
the tooth with flowable composite resin. A disadvantage of this splint type is its relatively high cost. An
example of this splint type is shown in Fig. 6C. In this application composite resin was used instead of
flow-able resin (e.g. Filtek Supreme Plus flowable restorative; 3M ESPE, St Paul, MN, USA). The patient
initially presented with an arch bar splint (Fig. 6a) which was replaced with a titanium trauma splint
because of gross irritation to the gingival tissues(Fig. 6b).

Arch bar splints

Arch bar splints were initially adopted for maxillary and mandibular fractures in the 1870s and adapted for
dentoalveolar trauma.19A metal bar is bent into the shape of the arch and fixed with ligature wires.
Disadvantages of this technique are that this type of splint is rigid and arch bars may loosen and cause
irritation. There may also be physical damage from the ligature wires to the gingival tissues and the
integrity of the cementoenamel junction. As stated earlier, an example of an arch bar splint is seen in Fig.
6a.The degree of gingival irritation is seen in Fig. 6b.

Wire ligature splints

Wire ligature splints are sometimes used by oral surgeons in clinics where dental splinting materials may
not be available and examples are shown in Figs. 7and 8. These splint types are generally rigid and impinge
on the gingival tissues with resulting inflammation, as seen in Fig. 8c taken immediately after splint
removal.

Composite splints
Resin composite applied to the surfaces of teeth is a rigid splint and accordingly is not recommended in the
IADT guidelines as shown in Table 1. Composite splints that are bonded interproximally to adjacent teeth
are also reported to be prone to fracture.19Furthermore,composite splints resulted in greater gingival
irritation when compared with wire and composite, an orthodontic bracket splint or the titanium
traumasplint.16The potential for iatrogenic damage for all splints that utilize composite resin as the
adherent cannot be understated and is discussed further in thesection below on ‘splint removal’

References
 https://onlinelibrary.wiley.com/doi/full/10.1111/adj.12398
(Splinting of teeth following trauma: a review and a new splinting recommendation, Australian Dental

Journal, 29 February 2016, Volume 61, Issue S1)