Tooth Stabilization

Continuing Education

Tooth Stabilization ImprovesPeriodontal Prognosis:

A Case ReportAuthored by Howard E. Strassler, DMD

Course Number: 117

Upon successful completion of this CE activity 2 CE credit hours may be awarded

A Peer-Reviewed CE Activity by

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention ofspecific product names does not infer endorsement by Dentistry Today. Information contained in CE articles andcourses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged tocontact their state dental boards for continuing education requirements.

Dentistry Today is an ADA CERPRecognized Provider.

Approved PACE Program ProviderFAGD/MAGD Credit Approvaldoes not imply acceptanceby a state or provincial board ofdentistry or AGD endorsement.June 1, 2009 to May 31, 2011AGD Pace approval number: 309062

ABOUT THE AUTHORS

Dr. Strassler is professor in the Depart-ment of Endodontics, Prosthodontics,and Operative Dentistry at the Universityof Maryland Dental School. He can bereached at [email protected].

Disclosure: Dr. Strassler has received research fundingfrom Ribbond.

INTRODUCTION

As patients are keeping their teeth throughout theirlifetimes due to advances in periodontal treatment, theprogression of periodontal disease does continue. For patientswith moderate to severe chronic periodontitis, the developmentof tooth mobility can be a significant factor compromisingtreatment prognosis.Mobility may be caused by inflammation ofthe periodontium, loss of periodontal attachment, or functionalor parafunctional forces on teeth.1 Splinting of teeth isconsidered to an important component of occlusal treatmentwhen tooth mobility is present.

This article discusses how stabilization of mobileperiodontally involved teeth can improve the long-termprognosis. A clinical case is presented to demonstrate thetreatment outcome that can be achieved with a stabilizationtechnique.

TOOTH STABILIZATION

A splint has been defined as an apparatus, appliance,or device employed to prevent movement or displacementof fractured or movable parts.2 In dentistry, splinting or toothstabilization usually refers to joining teeth together eitherunilaterally or bilaterally, to transmit increased stability tothe entire restoration. Typically, a splint is indicated due to asingle tooth or multiple teeth having mobility. Spear3presented 4 goals of occlusal treatment: (1) to control theamount of loading that occurs at the temporomandibularjoint; (2) to control the load that the tooth receives so thatthe periodontium is not overstressed; (3) to control the loadplaced on the occluding surfaces of the teeth; and (4) toproduce an occlusal relationship with no pathologicalsymptoms for the muscles of mastication.

When mobile teeth are present, tooth stabilization withsplinting can be a factor for successful occlusal treatment.

Tarnow and Fletcher4 described the indications andcontraindications for splinting periodontally involved teeth.They stated that the rationale to splint teeth should bebased upon the degree of periodontal compromise of thedentition, based upon the amount of radiographic bone lossand/or measured tooth mobility. The primary reasons tocontrol tooth mobility with periodontal splinting are: (1) primaryocclusal trauma; (2) secondary occlusal trauma; and (3)progressive mobility, migration, and pain on function.

Primary occlusal trauma is defined as injury resultingfrom excessive occlusal forces applied to a tooth or teethwith normal periodontal support. Secondary occlusaltrauma is injury resulting from normal occlusal forcesapplied to a tooth or teeth with inadequate periodontalsupport. Tooth mobility has been shown to contribute todecreased masticatory and occlusal function, as well aspatient discomfort when eating. Identification of progressivemobility requires repeated clinical observations over aperiod of weeks to months.

In the past, the use of splinting of periodontallycompromised teeth was contentious. The presumption wasthat the use of splinting to control tooth mobility wasrequired to control gingivitis, periodontitis, and pocketformation. It was assumed that mobility had a directrelationship to attachment loss and vertical osseous defect


1

Recommendations for Fluoride VarnishUse in CariesManagement

LEARNING OBJECTIVES:

After reading this article, the individual will learn:

The effects of tooth stabilization on the long-termprognosis of teeth with mobility due to periodontal disease.

A technique for stabilizing mobile teeth via splinting.

Tooth Stabilization ImprovesPeriodontal Prognosis:A Case Report

formation. Another assumption was that increasing toothmobility was a direct consequence of traumatic occlusion,bruxism, and clenching. Consensus also pointed to the factthat even normal physiologic function including masticationand swallowing contributed to tooth mobility.5

A number of periodontal clinical studies investigatedthese assumptions.When teeth were occlusally overloadedand other variables that contribute to periodontal diseasewere controlled, it was difficult to produce gingivitis,periodontitis, and pocket formation.6,7 Another studyreported no correlation between splinting and reducedtooth mobility during initial periodontal therapy.8 Control oftooth mobility with splinting after osseous surgery did notreduce mobility of the individual teeth.9 Tooth mobility,however, can be controlled and managed with splintingtherapy.10-12 The evidence demonstrates support for toothstabilization via splinting to improve the periodontalprognosis.1,11-17 Once teeth are splinted the splint must bemaintained, and the patient and clinician must becommitted to recalls on a regular basis for periodontalmaintenance. Splinting of teeth is a long-term commitmentby clinician and patient.

Occlusion has been associated with periodontalhealth.18 Glickman19 postulated a model referring to the roleof controlling abnormal occlusal forces in obtainingimprovements in gingivitis and periodontitis that causegingival inflammation. His concept described that traumafrom occlusion had the potential to result in infrabonypockets and vertical osseous defects. Waerhaug, et al20and Manson21 reviewed a similar hypothosis and concludedthat there was little evidence to validate a relationshipbetween trauma from occlusion and severity of periodontaltissue breakdown. Occlusal trauma and mobility in theperiodontally compromised dentition can contribute to adeteriorating periodontal prognosis.1,13,14,18

In clinical studies with teeth occlusally overloaded,while other variables that contribute to plaque-inducedperiodontal disease were controlled, it was difficult toproduce gingivitis, periodontitis, or pocket formation.6,7Studies investigating posterior tooth mobility establishedthat during and after periodontal initial therapy there was nosignificant difference in the mobility of nonsplinted teeth and

splinted teeth (after removal of the splint).8-10,22 Increasedtooth mobility is detected clinically and described in termsof amplitude of displacement of the clinical crown. Again, itmust be reiterated that the cause of detected tooth mobilityshould be further clarifiedwhether by reduced height ofsupporting tissues as a result of plaque-inducedperiodontal disease, or by trauma from occlusion, or acombination thereof. Tooth mobility is reported duringperiodontal charting, often using the Miller Index.23 Degreezero mobility is considered physiologic, whereby the toothis mobile within the alveolus at approximately 0.1 to 0.2 mmin a horizontal direction. The Miller index defines a degree1 mobility as a tooth that moves approximately 0.5 to 1.0mm. A degree 2 mobility will exceed 1 mm in a horizontaldirection. A degree 3 classification refers to a tooth that notonly has a facial-lingual component but also is depressible.

There is no doubt that splinting does reduce toothmobility while the splint is in place.1,10,11,24-26 Currently, it isgenerally accepted that tooth mobility is an importantclinical parameter in predicting periodontal prognosis ofthose teeth.27 The main reasons to stabilize theperiodontally compromised dentition with splinting include:decreasing patient discomfort, increasing occlusal andmasticatory function, and improving the periodontalprognosis of mobile teeth.28 Further, regenerativeprocedures using membranes and bone graft have greaterpredictability if tooth movement is eliminated.29,30

Over the years there have been many differentrestorative techniques used for splinting teeth. Beforeadhesive restorative dentistry had been introduced theoptimal choice for splinting teeth was the use of fullcoverage cast restorations. Each tooth to be splinted had acrown placed and all the crowns were joined together.11,31The advantage of this technique was that the teeth could bestabilized with an acrylic resin provisional restoration duringperiodontal treatment. At the completion of active therapythe definitive cast restoration was fabricated andcompleted. Over the relatively short period of time oftreatment for some teeth the prognosis was difficult todefine and could lead to premature replacement of theporcelain-metal fixed-partial denture splint as teeth werelost. A more conservative approach had been reported


2

Tooth Stabilization Improves Periodontal Prognosis: A Case Report

using a cast gold restoration for the lingual surfaces of themobile teeth, with the used of pin retention placed in thetooth preparations and cast into the metal framework.32

The clinical success of adhesive bonded compositeresin to etched enamel led to case reports and techniquesusing a variety of materials. One modification of the castmetal lingual splint was use of a resin bonded adhesivetechnique to retain the splint.33,34 Direct placement, singlevisit splints have been described. Clinical techniques usingwires twisted around teeth and covered with resins,12 metaland nylon mesh embedded into resins,35 and for posteriorteeth the use of channels prepared into the occlusal andproximal surfaces of teeth or into existing amalgamrestorations with either cast bars or thick wires placed in thechannels and covered with resins have been reported.36,37Clinical failures of these materials were common becauseof loading stresses placed on the splint during normal andparafunction.12,38 Repairs of these splints usually led toovercontoured and overbulked restorations. Theseovercontoured restorations led to hygienic difficulties andfood and plaque retention.14,25

Composite resins by their chemical nature are brittlematerials. In function when supporting pontics or stabilizingmobile teeth, cracks within the connector areas can lead tooutright fracture.39-42 The introduction of bondablereinforcement ribbons and fibers, when embedded intocomposite resins, created a laminated structure withimproved physical properties and a greater resistance tofracture. Research with fiber reinforced composite resinshas demonstrated that both glass, eg, Splint-It (PentronClinical) and ultra-high molecular weight polyethylene(UHMWPE) fiber reinforcement, eg, Ribbond THM(Ribbond) materials provide an increase in flexural strengthand flexural modulus of composite resins.39-41

Clinical evaluations of bonded fiber-reinforcedcomposite resin restorations for both splinting and for fixed-partial dentures have been clinically successful.43-45 Whenselecting reinforcement fibers for use in periodontalsplinting, since all such materials provide dental compositeresins with equivalent reinforcement properties, ease of useand an assortment of widths of the fibers are primarycriteria. In a multiuser evaluation, ease of use was a

primary criterion for acceptance of use of bondable fiberreinforcement.39

The following case report describes the use of a fiber-reinforced composite resin splint placed to stabilize aseverely periodontally compromised dentition in order toevaluate tooth prognosis. Over the next 6 years, thepatients compliance in oral hygiene and periodontalmaintenance improved the overall periodontal prognosis,leading to the treatment of the remaining maxillary teethwith a porcelain-metal fixed-partial denture. This casereport demonstrates that using the treatment techniquesdescribed when treatment planning similar clinicalsituations can lead to improved periodontal prognosis.

CASE REPORT

In 1991 a 40-year-old female presented to the dentalschool clinic for treatment. She had a past history of drugabuse, smoking, and psychiatric treatment for depression.Her first visit was due to acute pain that resulted in a toothextraction. She expressed a desire to seek regulartreatment. A treatment plan was formulated and she wasdiagnosed with adult moderate periodontitis. Over the next6 years she sought only intermittent care, with treatment fordental emergencies relating to acute pain. In early 1997 thepatient returned, and was examined and treatmentplanned. She had changes in her life circumstances thatwould lead to receiving more regular care and followingthrough on treatment.

This narrative will focus on the patients periodontalcare and restorative recommendations based upon herperiodontal conditions (Table) (Figure 1). One facultymember had suggested an immediate maxillary denturebased upon the patients periodontal status and financiallimitations. The patient rejected the idea of extracting themaxillary teeth. For the patients periodontal condition,scaling and root planing, occlusal adjustment to stabilizeher occlusion, and periodontal splinting with a bonded fiberreinforced ribbon composite splint was planned.

Periodontal and occlusal trauma contribute to toothmobility. Due to financial considerations, the treatment planfor an occlusal adjustment and the placement of a fiber


3


splint was based upon the patients desire to nothave a removable partial denture to provide forposterior support. In 1997, the placement andrestoration of implants was not as commonplaceas it is today, as furthermore, the cost of implanttreatment would have made restoration of theposterior area with implants unfeasible for thispatient. Although fiber splints would be aprovisional solution considering the patientsextensive bone loss (60%) and significant toothmobility without posterior occlusal support, thepatient was willing to have repairs of the splint aswould be needed when fractures occurred. TeethNos.4, 7, 8, 10, and 12 had degree 1mobility; teethNos. 5 and 11 had degree 2 mobility; and tooth No.9 was depressible with a degree 3 mobility.

Since the focus is whether or not splintingand tooth stabilization contribute to improvementin periodontal and tooth prognosis, treatment ofthe maxillary arch will be presented. As part ofinitial therapy all the teeth were scaled and rootplaned and polished (Figures 2a and 2b). Tocontrol occlusion and occlusal trauma, the teethwere occlusally adjusted. Also, since theprognosis was guarded for many of theremaining maxillary teeth, the decision was toplace a fiber reinforced composite resin splint toinclude all the maxillary teeth (Nos. 4 to 12)before pocket elimination surgery. The design ofthe fiber splint included endodontically treatedtooth No. 5 where a double fiber ribbon would beplaced into the pulp chamber, and this doublefiber would be included in the pontic area of No.6 to create a beam effect, strengthening theconnectors of this directly placed fixed-partialdenture.39 The advantages of a directly bondedfiber reinforced composite resin splint is that it is asingle-visit procedure and allows for an evaluationof tooth prognosis before treatment planning aporcelain-metal fixed-partial denture.1,31

Maxillary splints placed on the lingual surface withreinforcement materials have the disadvantage of wear

through the composite resin, perforating into thereinforcement material, and the forces of occlusion functionagainst the bond to the teeth can lead to fracture and


4


Figure 1. Radiographic view of maxillary dentition demonstrating 60%bone loss.

Figure 2. Clinical appearance of maxillary anterior teeth after scaling and rootplaning: (a) facial view and (b) lingual view.

Table. Clinical Findings Maxillary Arch April 7, 1997Missing: Nos. 1, 2, 3, 6, 13, 14, 15, 16

General bone destruction: 60% bone loss; generalized 3 to 4 mm bone loss

Widened PDL: generalized

Mobility: 1 degree: Nos. 4, 7, 8, 10, 12

2 degrees: Nos. 5, 11

3 degrees: No. 9

Furcation involvement: No. 12

Infrabony Defects: No. 4-D; No. 5-D; No. 9-M; No. 10-M

Prognosis maxilla: 3 to 5 years guarded 5 to 10 years guarded

Adult moderate periodontitis

Posterior bite collapse

Primary occlusal trauma

ba

failure.25,46 Perforation into the fiber reinforcement materialweakens the splint, and for the patient becomes a source ofirritation due to the roughness created on the lingualsurface due to the exposed fiber.41,45 With tooth preparationon the facial surface of anterior teeth to avoidovercontouring of the restoration (Figure 3) and occlusalpreparations for the posterior teeth, the splint was to befabricated. Placing the fiber reinforcement ribbon on thefacial surface is indicated for patients with occlusion on thelingual surface46,47 and in clinical circumstances when thepatient has a deep overbite.48 A structural benefit of placingthe fiber ribbon on the facial surface is that the fiberembedded into the adhesive composite resin is on thetensile side of the restoration, which places the forces ofocclusion on the splint in a favorable direction. The fiberribbon improves the flexural strength of the composite resinon the facial surface.40,41,45

For this case, a UHMWPE leno-weave, lock-stitch fiberribbon (Ribbond Reinforcement Ribbon, [Ribbond]) wasused. After etching, and adhesive and initial compositeresin placement, the fiber ribbon was placed (Figures 4aand 4b). The restoration was completed with facialveneering of the maxillary anterior teeth and a compositeresin pontic for the No. 6 site (Figures 5a to 5c). The patientwas shown how to maintain periodontal health of thesplinted teeth and remove plaque with a variety ofinterproximal cleaning aids.

Surgical treatment for pocket elimination included anapically positioned flap with osseous contouring (Figures6a and 6b). The tissue was apically positioned using amodified vertical mattress suture to stabilize the gingivaltissues apically on the teeth (Figures 7a and 7b). At 8weeks post surgery, the healing was excellent (Figure 8).The patient had an aesthetic complaint of dark triangles inthe gingival embrasures of the maxillary anterior teeth. Thedecision was to place porcelain veneers on Nos. 6 to 11.Since cost was a major factor in treatment decisions, theteeth were prepared for porcelain veneers, impressed, andtemporized.The veneers (Cerinate Porcelain Veneers, Den-Mat) were fabricated and paid for with a research account.The patient was placed on a 3- to 4-month periodontalmaintenance recall schedule. Over the next 3 years thepatient reduced her smoking habit, and because of her own


5


Figure 3.Facial preparation of themaxillary anterior teeth.

Figure 4.Placement of theRibbond fiberreinforcement ribbon:(a) facial view and(b) lingual view.

a

b

Figure 5.Completed restorationwith the fiberreinforced splint anddirect composite resinveneering:(a) facial view,(b) lingual view, and(c) radiographic view.

a

b

c

work and personal schedule, maintained a 4- to6-month recall schedule for periodontalmaintenance. Three years after treatment, thepatient had excellent periodontal health withminimal periodontal pocketing, and the splintand veneers were performing at a clinicallyacceptable level (Figure 9).

Over the next 3.5 years the splint wasrepaired 2 times at the mesial and distalconnector of the pontic on No. 6 withsubsequent fracture of the porcelain veneer ontooth No. 7. At the 6.5 year recall the periodontalhealth was being maintained (Figures 10a to10c). It was recommended to the patient thatinstead of repairing the splint and porcelainveneers, her periodontal prognosis was goodand it was time to restore the maxillary teethwith a porcelain-metal fixed-partial denture. Herwork situation and dental insurance allowed herto follow the restorative recommendations. Thesplint was removed and the maxillary teeth wereprepared for a porcelain-metal fixed-partialdenture (Figures 11a to 11c). The completedrestoration was cemented with a glass ionomercement (Figures 12a and 12b).

Twelve years earlier, the patient wasdiagnosed with adult moderate periodontitis witha guarded prognosis for the maxillary teeth.After treatment of the maxillary arch with initialperiodontal therapy of scaling and root planing,placement of a periodontal splint fabricated witha leno-weave, UHMWPE fiber ribbon (Ribbond)reinforced adhesive light-cure composite resin,and then surgically treated with an apicallypositioned flap with osseous recontouring, thepatient was placed on a periodontalmaintenance program. Six and half years afterfiber-reinforced composite resin splinting, thepatients maxillary arch was restored with afixed-partial denture. At the 12 year recall, themaxillary teeth demonstrate recession andcervical notching adjacent to the fixed-partialdenture but with minimal gingival pocketing and


6


a b

Figure 6. Surgical treatment with an apically positioned flap with osseouscontouring: (a) facial view and (b) lingual view.

Figure 8. Eight weeks post surgery. Figure 9. Facial preparation of themaxillary anterior teeth.

a b

Figure 7. Gingival tissues sutured with a modified vertical mattress suture:(a) facial view and (b) lingual view.

a

b

c

Figure 10. A 6.5-year recall ofsplint: (a) facial view, (b) right facialview, and (c) left facial view.

a diagnosis of gingivitis (Figures 13a and 13b).During the last recall, the patient had

mandibular anterior teeth and the missingmandibular incisor replaced with a compositeresin pontic and fiber reinforced adhesivecomposite resin fixed-partial denture (RibbondTHM). Note the probing depth changes prior tothe initiation of periodontal treatment andsplinting in 1997 and continuing over the 12years of recall (Figure 14). The patient hasmaintained the remaining maxillary teeth.

CONCLUSION

In the past, the use of splinting ofperiodontally compromised teeth wascontentious. The presumption was that splintingto control tooth mobility was required to controlgingival inflammation, periodontitis, and pocketformation. The use of splinting therapy inconjunction with control of occlusal traumacan contribute to improved prognosis ofperiodontally compromised dentitions. Thisarticle presents a 12-year recall case for aperiodontally compromised maxillary dentitionin which the teeth were occlusally adjusted andsplinted as part of periodontal therapy. Thispatient was reasonably compliant in herattention to oral hygiene and following theperiodontal maintenance regimen. Splinting ofthe maxillary arch has contributed to anoutstanding result of changing the periodontalprognosis for the maxillary teeth from beingguarded to good. The patient is consideringthe placement of posterior implants to furtherstabilize the occlusal support and function.

Acknowledgement

The following clinicians provided clinicaltreatment and help with this patient: Drs. ClaudiaCarvalho-Storch, Bradley Phillips, JessicaIsenberg, Harlan Shiau, and Charlson Choi.


7


a

b

c

Figure 11. Preparations of themaxillary teeth for porcelain-metalfixed-partial denture: (a) facial view,(b) right facial view, and (c) leftfacial view.

a

b

a

b

Figure 12. Completed porcelain-metal fixed-partial denture(Nos. 4 to 12): (a) facial viewand (b) lingual view.

Figure 13. A 12-year recall ofporcelain-metal fixed-partial denturesplint (Nos. 4 to 12): (a) facial viewand (b) radiographic view.

Figure 14. Comparison periodontal charting of probing depths from start ofperiodontal initial therapy, at a 4.5-year recall, and at a 12-year recall.

REFERENCES

1. Serio FG. Clinical rationale for tooth stabilization andsplinting. Dent Clin North Am. 1999;43:1-6.

2. Hallmon WW, Carranza FA, Drisko CL, et al, eds.Periodontal Literature Reviews: A Summary of CurrentKnowledge. Chicago, Ill: American Academy ofPeriodontology; 1996.

3. Spear FM. Fundamental occlusal therapy considerations. In:McNeill C, ed. Science and Practice of Occlusion. Chicago,Ill: Quintessence Publishing Co; 1997:421-434.

4. Tarnow DP, Fletcher P. Splinting of periodontally involvedteeth: indications and contraindications. N Y State Dent J.1986;52:24-25.

5. Waerhaug J. Justification for splinting in periodontal therapy.J Prosthet Dent. 1969;22:201-208.

6. Bhaskar SW, Orban B. Experimental occlusal trauma.J Periodontol. 1955;26:270-284.

7. Ramfjord SP, Kohler CA. Periodontal reaction to functionalocclusal stress. J Periodontol. 1959;30:95-112.

8. Kegel W, Selipsky H, Phillips C. The effect of splinting ontooth mobility. I. During initial therapy. J Clin Periodontol.1979;6:45-58.

9. Galler C, Selipsky H, Phillips C, et al. The effect of splinting ontooth mobility. II. After osseous surgery. J Clin Periodontol.1979;6:317-333.

10. Laudenbach KW, Stoller N, Laster L. The effects ofperiodontal surgery on horizontal tooth mobility. J Dent Res.1977;56:(Special Issue):288, abstract 596.

11. Amsterdam M. Periodontal prosthesis. Twenty-five years inretrospect. Alpha Omegan. 1974;67:9-23.

12. Pollack RP. Non-crown and bridge stabilization of severelymobile, periodontally involved teeth. A 25-year perspective.Dent Clin North Am. 1999;43:77-103.

13. Lindhe J, Nyman S. The role of occlusion in periodontaldisease and the biological rationale for splinting in treatmentof periodontitis. Oral Sci Rev. 1977;10:11-43.

14. Forabosco A, Grandi T, Cotti B. The importance of splintingof teeth in the therapy of periodontitis.Minerva Stomatol.2006;55:87-97.

15. Mosedale RF. Current indications and methods ofperiodontal splinting. Dent Update. 2007;34:168-178.

16. Baruch H, Ehrlich J, Yaffe A. Splintinga review of theliterature [in Hebrew]. Refuat Hapeh Vehashinayim.2001;18:29-40.

17. Giargia M, Lindhe J. Tooth mobility and periodontal disease.J Clin Periodontol. 1997;24:785-795.

18. Jin LJ, Cao CF. Clinical diagnosis of trauma from occlusion andits relation with severity of periodontitis. J Clin Periodontol.1992;19:92-97.

19. Glickman I. Occlusion and the periodontium. J Dent Res.1967;46:53-59.

20. Waerhaug J.The infrabony pocket and its relationship totrauma from occlusion and subgingival plaque. J Periodontol.1979;50:355-365.

21. Manson JD. Bone morphology and bone loss in periodontaldisease. J Clin Periodontol. 1976;3:14-22.

22. Renggli HH, Schweizer H. Splinting of teeth with removablebridgesbiological effects. J Clin Periodontol. 1974;1:43-46.

23. Miller SC. Textbook of Periodontia. 3rd ed. Philadelphia, Pa:The Blakiston Co; 1950:125.

24. Scharer P. die stegkonstruktion als vesteigungemittel imvestgebiss [thesis]. Zurich, Switzerland: University ofZurich; 1961.

25. Strassler HE, Haeri A, Gultz JP. New-generation bondedreinforcing materials for anterior periodontal tooth stabilizationand splinting.Dent Clin North Am. 1999;43:105-126.

26. Wheeler TT, McArthur WP, Magnusson I, et al. Modeling therelationship between clinical, microbiologic, andimmunologic parameters and alveolar bone levels in anelderly population. J Periodontol. 1994;65:68-78.

27. McGuire MK, Nunn ME. Prognosis versus actual outcome.II. The effectiveness of clinical parameters in developing anaccurate prognosis. J Periodontol. 1996;67:658-665.

28. Bernal G, Carvajal JC, Muoz-Viveros CA. A review of theclinical management of mobile teeth. J Contemp Dent Pract.2002;3:10-22.

29. Cortellini P, Tonetti MS, Lang NP, et al. The simplified papillapreservation flap in the regenerative treatment of deepintrabony defects: clinical outcomes and postoperativemorbidity. J Periodontol. 2001;72:1702-1712.

30. Fugazzotto PA. Special considerations, treatment selectioncriteria, and case reports. Postgrad Dent. 1999;6:31-39.

31. Siegel SC, Driscoll CF, Feldman S. Tooth stabilization andsplinting before and after periodontal therapy with fixedpartial dentures. Dent Clin North Am. 1999;43:45-76.

32. Tautin FS, Miller GE. Nonparallel pin splinting for mobileteeth. J Prosthet Dent. 1973;29:67-72.

33. Rochette AL. Attachment of a splint to enamel of loweranterior teeth. J Prosthet Dent. 1973;30:418-423.

34. Wood M, Thompson VP. Anterior etched cast resin-bondedretainers: an overview of design, fabrication, and clinicaluse. Compend Contin Educ Dent. 1983;4:247-258.

35. Strassler HE, Serio FG. Stabilization of the natural dentitionin periodontal cases using adhesive restorative materials.Periodontal Insights. 1997;4:4-10.

36. Liatukas EL. An amalgam and composite resin splint forposterior teeth. J Prosthet Dent. 1973;30:173-175.


8


37. Fusayama T. Permanent splint of highly mobile teeth.J Prosthet Dent. 1973;30:53-55.

38. Miller TE. A new material for periodontal splinting andorthodontic retention. Compendium. 1993;14:800-812.

39. Clinical Research Associates. Reinforcement fibers, forsplinting teeth. CRA Newsletter. 1997;21:1-2.

40. Strassler HE, Karbhari V, Rudo D. Effect of fiberreinforcement on flexural strength of composite. J Dent Res.2001;80:221. Abstract 854.

41. Karbhari VM, Strassler H. Effect of fiber architecture onflexural characteristics and fracture of fiber-reinforced dentalcomposites. Dent Mater. 2007;23:960-968.

42. Ellakwa AE, Shortall AC, Marquis PM. Influence of fiber typeand wetting agent on the flexural properties of an indirect fiberreinforced composite. J Prosthet Dent. 2002;88:485-490.

43. Ayna E, Celenk S. Polyethylene fiber-reinforced compositeinlay fixed partial dentures: two-year preliminary results.J Adhes Dent. 2005;7:337-342.

44. Unlu N, Belli S. Three-year clinical evaluation of fiber-reinforced composite fixed partial dentures usingprefabricated pontics. J Adhes Dent. 2006;8:183-188.

45. Karbhari VM, Rudo DN, Strassler HE. The development andclinical use of leno-woven UHMWPE ribbon in dentistry.Proceedings of the Society for Biomaterials. 2003;29:15.Abstract 529

46. Iniguez I, Strassler HE. Polyethylene ribbon and fixedorthodontic retention and porcelain veneers: solving anesthetic dilemma. J Esthet Dent. 1998;10:52-59.

47. Strassler HE. Planning with diagnostic casts for successwith direct composite resin bonding. J Esthet Dent.1995;7:32-40.

48. Vitsentzos SI, Koidis PT. Facial approach to stabilization ofmobile maxillary anterior teeth with steep vertical overlapand occlusal trauma. J Prosthet Dent. 1997;77:550-552.


9


POST EXAMINATION INFORMATION

To receive continuing education credit for participation inthis educational activity you must complete the programpost examination and receive a score of 70% or better.

Traditional Completion Option:You may fax or mail your answers with payment to DentistryToday (see Traditional Completion Information on followingpage). All information requested must be provided in orderto process the program for credit. Be sure to complete yourPayment, Personal Certification Information, Answersand Evaluation forms, Your exam will be graded within 72hours of receipt. Upon successful completion of the post-exam (70% or higher), a letter of completion will be mailedto the address provided.

Online Completion Option:Use this page to review the questions and mark youranswers. Return to dentalCEtoday.com and signin. If youhave not previously purchased the program select it fromthe Online Courses listing and complete the onlinepurchase process. Once purchased the program will beadded to your User History page where a Take Exam linkwill be provided directly across from the program title.Select the Take Exam link, complete all the programquestions and Submit your answers. An immediate gradereport will be provided. Upon receiving a passing gradecomplete the online evaluation form. Upon submitting theform your Letter Of Completion will be providedimmediately for printing.

General Program Information:Online users may login to dentalCEtoday.com anytime inthe future to access previously purchased programs andview or print letters of completion and results.

POST EXAMINATION QUESTIONS

1. Mobility of teeth may be caused by:a. inflammation of the periodontium.b. loss of periodontal attachment.c. functional or parafunctional forces on teeth.d. all of the above.

2. A splint has been defined as an apparatus, appliance ordevice employed to prevent movement or displacementof fractured or movable parts. In dentistry splintingusually refers to joining teeth together to transmitstability to the entire restoration.a. Both statements are falseb. The first statement is true, the second statement is falsec. Both statements are trued. The first statement is false, the second statement is true

3. Tooth stability is important in occlusal treatment.According to Spear the goals of occlusal treatment are:a. to control loading that occurs at the temporomandibular joint.b. to control marginal leakage at the occlusal interface ofrestorative materials.

c. to control load placed on the occluding surfaces of teeth.d. both a and c.

4. The primary reason(s) for periodontal splinting ofmobile teeth is (are):a. primary occlusal trauma.b. secondary occlusal trauma.c. progressive mobility.d. all the above.

5. Primary occlusal trauma is defined as:a. wear on teeth during parafunction.b. injury that results from excessive occlusal forces appliedto a tooth or teeth with normal periodontal support.

c. injury that results from normal occlusal forces applied toa tooth or teeth with inadequate periodontal support.

d. mobility of teeth due to gingival inflammation andbone loss.

6. Tooth mobility can be controlled with splinting therapy.Once the teeth are splinted the splint only needs to bein place for 6 months to one year to allow the teeth tostabilize, then it can be removed.a. Both statements are trueb. The first statement is true, the second statement is falsec. Both statements are falsed. The first statement is false, the second statement is true


10


7. Occlusion is an important component of periodontalhealth. Occlusal trauma and mobility in the periodontallycompromised dentition can contribute to a deterioratingperiodontal prognosis.a. Both statements are trueb. The first statement is true, the second statement is falsec. Both statements are falsed. The first statement is false, the second statement is true

8. Tooth mobility can be detected clinically and is describedbased upon displacement of the tooth crown when movedwith 2 rigid dental instruments.The charting of toothmobility is based upon the:a. Loe-Silness index.b. Miller index.c. Mobility index.d. Periodontal index.

9. The main reasons for stabilizing the periodontallycompromised dentition with splinting include:a. reduces calculus deposition.b. reduces cervical caries.c. improves periodontal prognosis of mobile teeth.d. all of the above.

10. Periodontal splinting has been accomplished with allthe following techniques EXCEPT.a. Fixed-partial dentures (crown and bridge)b. Polyvinyl siloxane bondingc. Nonparallel pin splintd. Direct adhesive composite with fiber reinforcement

11. In the past, composite resins embedded with wires, metalmesh, and nylon mesh had clinical failures because:a. they were too narrow for teeth.b. they were too wide for teeth.c. they were too long for teeth.d. loading stresses placed on the splint during normal andparafunction caused fracture.

12. Composite resins are brittle materials. Bondablereinforcement ribbons and fibers of ultra-high molecularweight polyethylene (eg, Ribbond) and glass, eg, (Splint-It),when embedded in composite resin with splinting, create alaminated structure with improved physical properties ofthe composite and a greater resistance to fracture.a. Both statements are trueb. The first statement is true, the second statement is falsec. Both statements are falsed. The first statement is false, the second statement is true

13. In the case report a maxillary splint with a leno-weave,lock-stitch ultra-high molecular weight polyethyleneribbon (Ribbond) was placed on the facial surface. Thereason(s) for placing the splint on the facial surfacewas (were):a. places the forces of occlusion on the tensile sideof the restoration, resisting the forces of occlusion.

b. avoids wearing through the composite, which would cause aperforation to the fiber reinforcement and weaken the splint.

c. performation of the composite into the fiber splint can causeroughness on the lingual surface due to exposed fiber.

d. all of the above.

14. When using a fiber reinforced ribbon for splinting, aftertooth cleaning and/or preparation, the tooth is etched, andadhesive and composite resin are placed.The fiber is thenembedded into the composite resin before light curing.a. Both statements are trueb. The first statement is true, the second statement is falsec. Both statements are falsed. The first statement is false, the second statement is true

15. In the case report the fiber reinforced composite resinadhesive splint was placed to stabilize the patientsmobile teeth because of the guarded periodontalprognosis. As part of treatment the teeth were scaledand root planed, and after splinting, this patient hadpocket elimination surgery because of the severity ofher periodontal condition.a. Both statements are trueb. The first statement is true, the second statement is falsec. Both statements are falsed. The first statement is false, the second statement is true

16. The use of splinting therapy in conjunction with controlof occlusal trauma can contribute to improvedprognosis of periodontally compromised dentitions.The only type of splinting therapy that will work tostabilize teeth is fiber reinforcement of composite resin.a. Both statements are trueb. The first statement is true, the second statement is falsec. Both statements are falsed. The first statement is false, the second statement is true


11


PROGRAM COMPLETION INFORMATION

If you wish to purchase and complete this activitytraditionally (mail or fax) rather than Online, you mustprovide the information requested below. Please be sure toselect your answers carefully and complete the evaluationinformation. To receive credit you must answer at least sixof the eight questions correctly.

Complete online at: www.dentalcetoday.com

TRADITIONAL COMPLETION INFORMATION:Mail or Fax this completed form with payment to:

Dentistry TodayDepartment of Continuing Education100 Passaic AvenueFairfield, NJ 07004Fax: 973-882-3662

PAYMENT & CREDIT INFORMATION:Examination Fee: $40.00 Credit Hours: 2.0Note: There is a $10 surcharge to process a check drawn onany bank other than a US bank. Should you have additionalquestions, please contact us at (973) 882-4700. I have enclosed a check or money order. I am using a credit card.

My Credit Card information is provided below. American Express Visa MC Discover

Please provide the following (please print clearly):

Exact Name on Credit Card

Credit Card # Expiration Date

Signature

PROGRAM EVAUATION FORMPlease complete the following activity evaluation questions.Rating Scale: Excellent = 5 and Poor = 0Course objectives were achieved.Content was useful and benefited yourclinical practice.Review questions were clear and relevantto the editorial.Illustrations and photographs wereclear and relevant.Written presentation was informativeand concise.How much time did you spend readingthe activity & completing the test?



ANSWER FORM: COURSE #: 117Please check the correct box for each question below.1. a b c d 9. a b c d2. a b c d 10. a b c d3. a b c d 11. a b c d4. a b c d 12. a b c d5. a b c d 13. a b c d6. a b c d 14. a b c d7. a b c d 15. a b c d8. a b c d 16. a b c d

PERSONAL CERTIFICATION INFORMATION:

Last Name (PLEASE PRINT CLEARLY OR TYPE)

First Name

Profession / Credentials License Number

Street Address

Suite or Apartment Number

City State Zip Code

Daytime Telephone Number With Area Code

Fax Number With Area Code

E-mail Address

/

Dentistry Today is an ADA CERPRecognized Provider.

Approved PACE Program ProviderFAGD/MAGD Credit Approvaldoes not imply acceptanceby a state or provincial board ofdentistry or AGD endorsement.June 1, 2009 to May 31, 2011AGD Pace approval number: 309062

Documents

Tooth Stabilization