P E R I O D O N T I CPSE R I O D O N T I C S

Periodontal Splinting in General Dental Practice

SOPHIE J. WATKINS AND KENNETH W. HEMMINGS
(drifting) of periodontally involved teeth. A variety of factors can contribute to tooth mobility, including trauma; periapical or periodontal inflammation, decreased periodontal support and pathologically increased occlusal load. These clinical entities have been described as primary or secondary occlusal trauma (Table 1).3 Most commonly, mobility of teeth is caused by loss of support as a result of periodontal disease, although it is important to be aware that more than one factor may be involved (Figure 1). Diagnosis and clinical management should take this into account. When patients present with periodontal disease and mobile teeth, efforts should be directed at resolving the periodontal disease before considering occlusal management if the teeth are to be preserved. In the absence of periodontal disease the most likely cause of tooth mobility is primary occlusal trauma and therefore periodontal treatment would be inappropriate. Rare causes of tooth mobility such as abnormal root morphology, iatrogenically shortened roots following apical surgery, excessive loading during orthodontic movement, root resorption or intrabony pathology should not be forgotten. In the past it has been thought that mobility adversely affects periodontal destruction and healing. Fleszar, as recently as 1980,4 found that decreased mobility did in fact improve the response of affected teeth to periodontal therapy. The temptation has been in the past to treat periodontally involved teeth by early splinting. However, the
Dental Update July/August 2000

Abstract: Splinting periodontally involved teeth is a technique that has been in use for
centuries. This article gives a brief history and review of the literature concerning periodontal splinting and outlines the rationale and indications for the correct application of periodontal splinting in modern dental practice. The common types of splint and clinical techniques involved are described, addressing some of the clinical problems. Dent Update 2000; 27: 278-285

Clinical Relevance: Although periodontal splinting can be a useful tool in specific situations, it can be inappropriately applied and may create some technical difficulties in clinical management. It is therefore important that the clinician is well aware of the potential hazards involved in carrying out this type of treatment. The importance of careful periodontal monitoring and maintenance following splinting cannot be overstressed, because ongoing disease can be masked and access for hygiene compromised around periodontally involved teeth.

ental splinting involves joining the crowns of two or more teeth by more or less rigid means; so that their relative movement is restricted and the forces applied to one of the splinted teeth are transmitted to the root systems of all the linked teeth.1 This article will concentrate on the use of splints in periodontal disease. Splinting has been used as a form of dental treatment for centuries, and is one of the earliest known examples of dentistry: excavations of Egyptian remains at Gizeh in the early 1900s included a wire ligature around the cervical margins of lower left second and third molar teeth, the roots of the third molar having been resorbed. Calculus around both the teeth and wire

indicated that the appliance had been placed on a living patient and is thus one of the earliest known dental prostheses, dated at around 2500 BC. Tooth transplantation has been described as early as the ninth century AD, and ligatures of silk, gold and silver were used in the tenth and eleventh centuries by the Spanish physician Albucasis. Splinting loose teeth remained a popular treatment for mobility well into the twentieth century, and was used as an integral part of periodontal treatment planning by many clinicians.2 Splinting is still used in a wide variety of clinical situations: q q q q traumatic injuries to teeth; TMJ dysfunction; prevention of toothwear; permanent post-orthodontic retention; q pre-restorative treatment (identification of retruded contact position, RCP); q excessive movement or migration

Sophie J.Watkins, BDS, FDS (Rest Dent) RCPS, MSc, Senior Registrar in Restorative Dentistry, and Kenneth W. Hemmings, BDS, MSc, MRD RCS, FDS RCS, Consultant in Restorative Dentistry, Department of Conservative Dentistry, Eastman Dental Hospital, London.

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Definition Primary

The lesion that develops in the periodontium as a result of excessive occlusal forces during functional and parafunctional activities. The effect of abnormal occlusal forces on periodontal tissues in the absence of inflammation. A physiological adaptation of the periodontium results in mobility with no periodontal pocketing and radiographically a widened periodontal ligament. The effect of occlusal forces on teeth where the periodontium is already weakened by inflammation, giving rise to more complex breakdown of the periodontal structures.

Secondary

teeth to less mobile teeth by splinting lies in the fact that this results in a more favourable distribution of the forces acting on the teeth concerned, thus protecting those with reduced periodontal support. Indications for splinting are: q drifting; q improving comfort and function; q enhancing periodontal healing.

Table 1. Occlusal trauma.3

lack of correlation between mobility or occlusal trauma and periodontal disease/ healing has been demonstrated by many authors.5-10 It is now widely accepted that the resolution of inflammation is the most important factor in the treatment of chronic periodontitis. Although trauma from occlusion may modify the progression of existing periodontitis,11 it does not initiate or aggravate gingivitis.12 Kantor, Polson and Zander13 showed that alveolar bone is regenerated after removal of both inflammation and traumatic factors.

stable jaw relationships with stable simultaneous multiple interocclusal contacts and smooth excursive movements unimpaired by occlusal interferences, and is described in detail by Wise.14 It may involve the adjustment of multiple tooth surfaces to achieve an ideal occlusion and is therefore a significant undertaking and is not recommended to the inexperienced practitioner. A trial adjustment on study casts may confirm that the procedure is not excessively destructive of tooth tissue and the aims of the adjustment are attainable (Figure 2).

Drifting
Drifting teeth are a common problem in patients with periodontally diseased teeth, and may result from normal forces acting on teeth with compromised periodontal support which can no longer withstand these forces.15 If the patient is concerned about appearance following drifting, after the disease has been controlled the teeth can be repositioned orthodontically. The result is, however, inherently unstable and splinting is generally advisable to prevent relapse. Indeed, the position of drifted teeth that are not treated orthodontically can be prevented from worsening by the provision of a splint. Similarly, adverse tooth movements such as over-eruption or tilting can be prevented by splinting.16 Splinting in this situation can be provided by a fixed or removable prosthesis and, although this may not be the primary function of the prosthesis, it should be taken into account whilst designing the appliance. It is important to stress that, if a fixed splint or a removable appliance is provided, this may have an adverse

CLINICAL MANAGEMENT
The options for the clinical management of mobile teeth include: q q q q no treatment; occlusal adjustment; extraction; splinting.

Extraction
It is important to be able to recognize whether a tooth is conservable or not and to consider whether retaining a certain tooth may be harmful to neighbouring teeth. If this is the case, extraction is the best course of action.

SPLINTING No Treatment
If the clinician considers the situation unlikely to deteriorate, this option may be acceptable to many patients. However, regular review is recommended. The scientific basis for joining mobile

Occlusal Adjustment
If an occlusal aetiological factor has been positively identified, occlusal adjustment may be indicated. Localized adjustment to a few teeth is relatively straightforward. Occlusal equilibration has been described as planned alteration of occlusal surfaces to provide
Dental Update July/August 2000

Figure 1. Radiographs demonstrating occlusal trauma. (a) Root treated upper first molar bridge abutment presented with distal and furcation pocketing of 67 mm. There was also distal caries. (b) Following root resection the pocketing was reduced to 4 mm, but mobility increased with widening of the periodontal ligament on the remaining (mesial) root.

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Figure 2. Trial occlusal adjustment on study casts. (a) The casts mounted in the retruded axis position demonstrate a large non-working side interference between /7 and /8 in right lateral excursion (arrowed). (b) Trial adjustment of the casts. The occlusal surfaces of the casts are painted before performing the trial adjustment. In this way it is possible to assess the necessary removal of tooth tissue, allowing the operator to assess how destructive this would be before carrying out the procedure clinically. In this case, extensive tooth reduction would be required to eliminate the interference, making it too destructive to carry out clinically without recourse to crowns or onlays.

but increase accumulation of plaque around the abutment teeth. Fixed splints may compromise the ability of patients to use interdental cleaning aids. Therefore, care must be taken in designing and making splints with good physiological contour to allow easy patient maintenance. Patients need regular instruction on oral hygiene and encouragement to maintain high levels of plaque control. Periodontal Monitoring Fixed splinting of teeth prevents clinical assessment and reduces patient awareness of increasing tooth mobility. Occasionally, if patients are lost from regular review, they may perceive a problem only when gross periodontal destruction has occurred and the whole splint is mobile. These potential complications should be stressed to patients. Effective recall systems should be in place and regular clinical and radiographic review carried out. Dental Caries If plaque control is inadequate in combination with dietary factors, fixed or removable splints may encourage dental caries in a susceptible patient. Cementation failure of fixed splints may go unnoticed until gross dental caries is observed. Prevention in the form of fluoride supplements, diet counselling and regular prophylaxis are therefore important, as well as regular review with careful inspection of margins allowing early maintenance if required. Maintenance of Splints Biological failure of splints is usually

effect on the patients ability to maintain good oral hygiene. Unless excellent plaque control is maintained, the periodontal condition may not be stable and could result in breakdown. Furthermore, a fixed splint may mask this deterioration: an added danger of which the operator must be aware. Meticulous monitoring and maintenance is therefore essential.

Comfort and Function

Mobile teeth can be very distressing to the patient and may often be the presenting complaint. Extreme mobility can interfere with speaking and eating. It must be stressed that active disease should be controlled as far as possible and the patient capable of maintaining a good standard of oral hygiene before further treatment is considered. Although a reduction in inflammation may result in a decrease in mobility to acceptable levels, in the presence of severe periodontal involvement this may not be complete and mobility may still constitute a significant problem. In such cases, splinting may be the only way of resolving the situation.

periodontal ligament (rigid splinting of root or alveolar fractures is still recommended17). Rarely, mobile teeth undergoing periodontal surgery require temporary splinting until initial healing is complete. However, questions should be raised concerning the prognosis of such teeth and the advisability of surgery. The advantages of splinting have been contested; Renggli et al.1820 showed no difference in mobility before and after wearing a splint. Indeed, many authors have found that increased mobility/occlusal trauma may not be detrimental to the health of the remaining supporting tissues.19,20

Disadvantages of Splinting
Plaque Control Removable splints allow the patient to practise normal plaque control measures

Periodontal Healing
Post-trauma splinting of luxated or subluxated teeth, allowing some physiological loading of the teeth, is beneficial to the healing of the
280 Figure 3. (a) Deep overbite causing trauma to the labial gingivae of the lower incisors. (b) A soft splint fitted over the maxillary teeth protects the gingivae.

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Figure 4. Hard maxillary occlusal splint. (a) Facial view. (b) Palatal view, showing the occlusal scheme adjusted to provide even contacts around the arch in the retruded axis position (black marks) and anterior guidance with immediate posterior disclusion in excursions (red marks).

Hard Acrylic Occlusal Splint: Occlusal splints can be useful in the diagnosis of occlusal trauma in periodontal patients and for retention of drifting teeth (Figure 4). There are many descriptions of occlusal splints in the literature. The term covers full coverage, partial coverage and repositioning appliances, and are used in diagnostic and therapeutic procedures as outlined below: q TMJ dysfunction; q prevention of toothwear; q to facilitate restorative procedures by establishing a stable retruded contact position; q assessment of patient tolerance to an increase in occlusal vertical dimension; q stabilization of tooth position. Partial-coverage splints are not recommended for long-term use. There is a significant risk of over-eruption of unopposed teeth, which leads to disruption of the occlusal plane in one or both arches and is difficult to rectify. We therefore favour a full-coverage maxillary hard acrylic occlusal splint providing even contacts in the retruded axis position, and anterior guidance in protrusive and lateral excursions. In patients with Angles class III occlusal relationship, it is often easier to construct one for the mandibular arch. This type of appliance is more timeconsuming to construct than the vacuumformed acrylic splint as mounted study casts are required for laboratory

the result of dental caries, progressive periodontal disease or endodontic complications. All restorations have a finite lifespan and will eventually wear out unless more significant mechanical failure occurs first. The very nature of splinting means that splints are large and expensive prostheses. If prompt attention is not given to a mechanical failure there is a significant risk of mobile teeth drifting away from the splint. Repositioning or replacement of such teeth will complicate maintenance. A biological and financial cost/benefit analysis of splinting teeth should be carried out and compared with other treatment options before confirming the most appropriate treatment.

progressive drifting despite treatment. In borderline cases, where the outcome of treatment cannot be predicted, a provisional splint may be provided. Describing appliances as permanent is a relative term because it must be remembered that all restorations will fail in time. It is a term that can be misunderstood by patients and should be used with caution. Removable Splints The use of removable splints is simple, reversible and inexpensive. The splinting of teeth may be less rigid in removable splinting than using fixed alternatives, but they have the advantage of facilitating oral hygiene.19 They are usually the most appropriate splints for use in emergencies and diagnostic procedures. Vacuum-formed Splints: These appliances are temporary or provisional in nature. They are most useful in reducing the symptoms in traumatic occlusions when incisal edges of anterior teeth occlude directly on the gingivae or palate (Figure 3). These splints are also useful in the diagnosis of TMJ dysfunction, when symptoms are usually alleviated by the use of a splint. In parafunctional patients the splints will show early deterioration and will often perforate on the occlusal surface. The splint is usually best tolerated in the upper arch. The alginate impression is cast in the laboratory and a vacuumformed polythene splint of 23 mm in thickness is made. Minimal adjustments are made for patient comfort.

Types of Splint
Splints used in clinical practice can be categorized as either removable or fixed. The descriptive terms temporary or provisional refer to the durability of the appliance or the intended use. Temporary/Permanent/Provisional Temporary splints can be defined as a splint intended for short or medium-term use, which may or may not be replaced by a permanent appliance. They may be used to stabilize the mobile teeth during surgery. Examples of temporary splints include acrylic and wire splints21 and vacuum-formed splints, which are described later. Permanent splints, such as linked restorations, may be used for teeth that cannot maintain stability after treatment, or teeth with increasing mobility or
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Figure 5. Removable orthodontic retainer with acrylic on the labial bow, adapted to the labial surfaces of the teeth. This improves control over the tooth position during the retention phase. Dental Update July/August 2000

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Figure 6. (a) Twistflex (Wildcat Wire GAC International Inc. Central Islip, NY 11722-1402, USA) orthodontic retainer, passively adapted to the palatal surfaces and bonded to the teeth using composite resin. (b) GlasSpan (Exton, PA, USA) flexible ceramic fibre can be used as an alternative to wire for reinforcing the composite resin splint (c) Finished result.

construction. The use of a facebow recording and a semi-adjustable articulator considerably reduces chairside adjustment of the splint.3 If this is not possible, the RCP jaw registration must be at the correct occlusal vertical dimension (23 mm increase) and adjustment of the splint in excursions will be necessary. A well made splint can be retained by a friction fit. Additional retention can be provided by ball-ended clasps or Adams cribs as direct retainers, usually on the first molars. Long-term occlusal stability of the splint requires several adjustments as mandibular repositioning occurs. Good service would be considered to be 23 years of use. In a bruxist patient, more frequent replacement will be required as a result of wear or fracture of the acrylic.

Orthodontic Retainer: Drifted periodontally involved teeth can be repositioned orthodontically. Long-term retention is necessary to prevent relapse. Removable orthodontic retainers (Figure 5) can be used in long-term retention, but are associated with periodontal inflammation unless plaque control is exemplary. They are unaesthetic, but may be acceptable for night wear. Fixed Splints Composite/Acrylic and Wire: This temporary or semi-permanent splint is fabricated using a chairside, or direct, technique. It is reversible, and relatively strong, stable and aesthetic. The operative technique for making this type of splint has been widely described2124 and there are many variations. The technique involves adapting a wire, mesh or other former to the teeth to be splinted and covering it with composite resin etched to the enamel. The wire may be twisted around the teeth as a ligature or adapted to the palatal surfaces of the teeth, as long as it is passive in order to avoid orthodontic movement. Rosenberg described a variation using orthodontic grid material and acrylic.25 Using composite resin alone to link the teeth is likely to lead to early failure at contact points, as the material is brittle.23 A linking wire provides flexibility and is therefore

advantageous (Figure 6). A new technique, using flexible ceramic bonding fibre ribbon or cords such as GlasSpan or Ribbond (Sigma Dental Systems, Heideland 22, Germany) instead of wire to reinforce the composite resin gives a more aesthetic and useful alternative (Figure 6). Where a palatal appliance is provided, it is of obvious importance to ensure that the bulk of the splint does not interfere with inter-occlusal contacts or with guidance. Resin-Bonded Splints: Laboratoryfabricated splints may offer a more long-term solution to the chairsideprepared splints described above. They are less bulky and can be placed in most situations, allowing greater occlusal control. Rochette originally described a perforated resin-bonded splint (Figure 7) in 1973.26 The technique was adapted and refined for tooth replacement. The basic laboratory and chairside procedures are now commonly used and well known.2729 Today, a non-perforated framework (Figure 8) is recommended for use with modern Bis-GMA (e.g. Panavia 21) or 4-META cements (e.g. Superbond C&B ). Retention should be optimized by providing maximum coverage of the available enamel, but tooth preparation should be kept to a minimum. Parallel guide planes also allow accurate insertion and increase the bonding area by removing undercut areas and as a result can increase retention. Proximal grooves and parallel walls do involve extensive tooth preparation (which is not usually necessary in most situations in the authors opinion). In the periodontal patient with anterior

Figure 7. Perforated resin-bonded splint, as described by Rochette.26 Dental Update July/August 2000

Figure 8. Resin-retained splint with a nonperforated framework. 283

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Figure 9. (a) Periodontally involved teeth may cause problems during impression taking due to their mobility and the large embrasure spaces, which may cause difficulty in removing the impression. (b) A temporary splint made of pink acrylic resin Triad visible light cure reline material (Dentsply International Inc., York, PA, USA) is adapted to the labial surfaces of the teeth to stabilize them, and soft wax is placed in the embrasure spaces and undercuts to prevent the impression material engaging deep undercuts.

localized or generalized recession, it can be difficult to mask interproximal metal connectors. For splint rigidity, it is rarely wise to reduce connector height below 3 mm. Composite resin additions can be used to cover unsightly metal. Practical points: q Impression taking and cementation of restorations can be problematic when teeth are mobile. Temporary splinting of teeth and the use of a low-viscosity impression material can be useful in overcoming some of these problems. Composite resin, acrylic (Figure 9a) or impression compound can be useful temporary splinting materials. q Interdental spacing often needs blocking out with soft wax to prevent impression material engaging deep undercuts. This facilitates removal of the impression, and not the teeth (Figure 9b)! q All luting cements perform best in thin section, thereby increasing the longevity of the restoration. Great care must be exercised to ensure teeth are held intimately in contact with the splint during cementation. Splinted Conventional Crown and Bridgework Splinted crowns still have a place where the teeth are heavily restored. However, these splints are time284

consuming to prepare and therefore costly in chairside and laboratory time. Parallel and non-undercut preparations of multiple teeth are demanding and are destructive of tooth tissue, and movement of the abutments during cementation can lead to poorly fitting margins and failure (Figure 10a). Telescopic crowns, or the use of copings and a superstructure, can provide a useful alternative (Figure 10b,c). Maintenance and tooth loss can more easily be accommodated than with conventional splinting, but aesthetics and periodontal health can be compromised due to increased bulk of the superstructure. The practical points mentioned above

for resin-bonded splinting also apply to conventional crown and bridgework. In addition, it is often difficult to obtain perfect impressions of multiple tooth preparations within a single impression. The use of a pick-up procedure allows the dies of multiple abutment teeth to be located on a single working cast, and allows the opportunity to overcome the problems of excessive tooth mobility if transfer copings (e.g. acrylic bonnets) are linked passively before taking a locating impression (Figure 11). It is wise to verify the accuracy of the working casts before committing your technician to extensive laboratory work. This can be simply achieved by using a bite fork lined with compound and refined with temporary cement. The indentations created by the teeth should correspond to those on the working cast (Figure 12). In common with any extensive restorative dentistry, maintenance is of paramount importance. It must be remembered that splinting teeth can often delay the presentation of mechanical and biological failures. Late diagnosis of dental caries, cementation failure and further periodontal breakdown may result in difficult maintenance, if not catastrophic failure. Patients require effective recall, careful review and

c
Figure 10. Linked crowns (a) can be difficult to cement due to independent movement of the abutment teeth leading to poor marginal fit and failure. Gold copings (b) with telescopic crowns (c) facilitate access for maintenance of abutment teeth when splinted crowns are used.

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4.

5.

6.

Figure 11. Acrylic resin Duralay (Reliance Dental Mfg. Co., Worth, Illinois, USA) bonnets are placed over the teeth and passively linked with wire to prevent them from moving relative to one another during impression taking. (Slide courtesy of Mr Alex Gow, Specialist Registrar in Restorative Dentistry, Eastman Dental Hospital.)

7.

8.

9.

prompt intervention to preserve what remains.

10.

CONCLUSIONS
The value of splints in periodontal therapy has been called into question in the last decade, but may be indicated in some circumstances. It is important to remember that splinting rarely improves periodontal health and may serve only to mask a problem. Therefore, the decision to splint teeth should not be taken lightly and should be considered only following appropriate periodontal management, with thorough maintenance following splinting. In this context, it is important to ensure that the patient is aware of the potential pitfalls in order to safeguard compliance with continued monitoring and maintenance. The indications for splinting are usually limited to improving patient comfort and controlling tooth movement in teeth with periodontal health but reduced support. Clinical techniques have been developed to help the practitioner provide such treatment or consider referral to a specialist.

11.

12.

13.

14.

15.

crown and bridge procedures. Holland: Dental Center for Postgraduate Courses, 1985; p.25. Fleszar TJ, Knowles JW, Morrison EC, Burgett FG, Nissle RR, Ramfjord SP. Tooth mobility and periodontal therapy. J Clin Periodontol 1980; 7: 495505. Ericsson I, Lindhe J. Lack of significance of increased tooth mobility in experimental periodontitis. J Periodontol 1984; 55: 447452. Bhaskar SN, Orban B. Experimental occlusal trauma. J Periodontol 1955; 26: 270284 Glickman I. Inflammation and trauma from occlusion, co-destructive factors in chronic periodontal disease. J Periodontol 1963; 34: 5 10. Glickman I, Smulow JB, Vogel G, Passamoti G. The effect of occlusal forces on healing following mucogingival surgery. J Periodontol 1966; 37: 319325. Lindhe J, Ericsson I. The influence of trauma from occlusion on reduced but healthy periodontal tissues in dogs. J Clin Periodontol 1976; 3: 110122. Nyman S, Lindhe J. Persistent tooth hypermobility following completion of periodontal treatment. J Clin Periodontol 1976; 3(2): 8193. Nyman S, Lindhe J, Ericsson I. The effect of progressive tooth mobility on destructive periodontitis in the dog. J Clin Periodontol 1978; 5: 213225. Svanberg G. Influence of trauma from the occlusion on the periodontium of dogs with normal or inflamed gingiva. Odont Revy 1974; 25: 165178. Kantor M, Polson AM, Zander HA. Alveolar bone regeneration after removal of inflammation and traumatic factors. J Periodontol 1976; 47: 687695. Wise MD. Occlusal adjustment and equilibration. In: Failure in the Restorative Dentition; Management and Treatment. London: Quintessence, 1995; pp.225235. Proffitt W. Equilibrium theory revisited. Factors influencing the position of teeth (i.e.

16.

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29.

equilibrium between forces acting on a tooth and the resistance of the supporting tissues). Angle Orthod 1978; 48: 175186. Love WD, Adams RL. Tooth movement into edentulous areas. J Prosthet Dent 1971; 25: 271 278. Andreasen JO, Andreasen FM. Textbook and Colour Atlas of Traumatic Injuries to the Teeth, 3rd ed. Copenhagen: Munksgaard, 1994; pp.297, 347 348, 439. Renggli HH. Splinting of teeth An objective assessment. Helv Odont Acta 1971; 15: 129. Renggli HH, Schweizer H. Splinting of teeth with removable bridges. Biological effects. J Clin Periodontol 1974; 1: 4346. Renggli HH, Allet B, Spanauf AJ. Splinting of teeth with fixed bridges: biological effect. J Oral Rehabil 1984; 11: 535537. Clark JW, Weatherford TW, Mand WV. Wire ligature Acrylic splint. J Periodontol 1969; 40: 371375. Klassman B, Zucker HW. Combination wirecomposite resin intracoronal splinting: Rationale and technique. J Periodontol 1976; 47(8): 481486. Polson AM, Billen J. Temporary splinting using ultraviolet-light-polymerised bonding materials. J Am Dent Assoc 1974; 89: 11371141. Saravanamuttu R. Post-orthodontic splinting of periodontally involved teeth. Br J Orthodont 1990; 17: 2932. Rosenberg S. A new method for stabilization of periodontally involved teeth. J Periodontol 1980; 51: 469473. Rochette AL. Attachment of a splint to enamel of lower anterior teeth. J Prosthet Dent 1973; 30: 418423. Simonsen R, Thompson V, Barrack G. Etched Cast Restorations. Clinical and Laboratory Techniques. Chicago: Quintessence, 1983. Tay WM. Classification and assessment of composite retained bridges. Restor Dent 1986; 2: 1518. Tay WM. Resin bonded bridges. 1. Materials and methods. Dent Update 1988; 15: 1014.

c
Figure 12. A facebow bitefork, refined with Temp Bond cement (Kerr UK Ltd., Peterborough, PE3 8YP) (a) is adapted to fit the preparations (b) and used to verify the accuracy of the master cast (c).

REFERENCES
1. Smith BJ, Setchell D. In: Rowe, AHR, ed. Companion to Dental Studies Vol.3: Clinical Dentistry. Oxford: Blackwell Scientific Publications, 1986; pp.519529. Weinberger BW. An Introduction to the History of Dentistry, Vol.1. St. Louis: C.V. Mosby, 1948; p.75. Pameijer HN. Periodontal and occlusal factors in

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