Management of Periodontally Involved Anterior Teeth by Glass Fiber-Reinforced Composite Splinting: A Clinical Report With 5-Year Recall

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DOI:10.21276/sjodr.2016.1.2.

Saudi Journal of Oral and Dental Research ISSN 2518-1300 (Print)


Scholars Middle East Publishers ISSN 2518-1297 (Online)
Dubai, United Arab Emirates
Website: http://scholarsmepub.com/

Case Report

Management of Periodontally Involved Anterior Teeth by Glass Fiber-


Reinforced Composite Splinting: A Clinical Report with 5-Year Recall
Dr. Sandeep Anant Lawande1, Dr. Gayatri Sandeep Lawande2
1
Assistant Professor, Department of Periodontics, Goa Dental College & Hospital, Bambolim, Goa, India
2
Consultant Periodontist & Director, Sai Multispecialty Dental Clinic & Research Centre, Porvorim, Goa, India

*Corresponding Author:
Dr. Sandeep Anant Lawande
Email: drsanlaw@rediffmail.com

Abstract: Periodontal disease results in attachment loss and damage to the supporting alveolar bone leading to tooth
mobility. In majority of cases, the mandibular incisors are the teeth showing the first signs of mobility. The clinical
management of periodontally involved teeth remains a challenge to the clinician. Splinting may be indicated for
individual mobile tooth as well as for the entire dentition. The main objectives of splinting include decreasing patient
discomfort, increasing occlusal and masticatory function, enhancing esthetics and improving the periodontal prognosis of
mobile teeth. Fiber-reinforced composites provide one of the better alternatives for splinting of teeth. This clinical report
describes a technique of splinting of periodontally involved mandibular anterior teeth using glass fiber-reinforced
composite resin with a follow-up period of five years.
Keywords: periodontal splinting, tooth mobility, fiber-reinforced composite, splint, periodontally involved teeth

INTRODUCTION support from stronger teeth. This prolongs the life


Periodontal disease is characterized by expectancy of the loose teeth, gives stability for the
gingival inflammation, loss of connective tissue periodontium to reattach, and improves comfort,
attachment and destruction of alveolar bone. function and aesthetics [8].
Progressive attachment loss around the involved teeth
eventually results in increased mobility [1]. Over the years, different methods have been
employed for splinting teeth. The most conservative of
According to Tarnow & Fletcher, the primary these involve use of adhesives and composite resins. In
reasons to control tooth mobility with periodontal the past, direct stabilization and splinting of teeth using
splinting are primary occlusal trauma, secondary an adhesive technique required the use of wires, pins, or
occlusal trauma, and progressive mobility, migration mesh grids. These materials could only mechanically
and pain on function [2, 3]. Primary occlusal trauma is lock around the resin restorative. Because of this there
defined as injury resulting from excessive occlusal was the potential of creating shear planes and stress
forces applied to a tooth or teeth with normal concentrations that would lead to fracture of the
periodontal support. Secondary occlusal trauma is composite and premature failure. When the splint failed,
injury resulting from normal occlusal forces applied to a the clinical problems that occurred included traumatic
tooth or teeth with inadequate periodontal support [4]. occlusion, progression of periodontal disease and
Tooth mobility has been shown to contribute to recurrent caries. With the introduction of fiber-
decreased masticatory and occlusal function, as well as reinforced technology, many of the problems with older
patient discomfort when eating. Clinical prognosis of types of reinforcement were solved [9, 10]. A variety of
periodontally compromised teeth many times hinges on reinforcement fibers such as glass fibers, polyethylene
the presence of tooth mobility [5, 6]. fibers, carbon fibers etc. are available in different
widths and sizes for the purpose of tooth splinting [8,
Splinting is a common practice to stabilize 11-14].
mobile periodontally involved teeth. The Glossary of
Prosthodontic Terms defines splinting as the joining of This clinical report describes a technique of
two or more teeth into a rigid unit by means of fixed or splinting of periodontally involved mobile mandibular
removable restorations or devices [7]. Splinting teeth to anterior teeth using glass fiber-reinforced composite
each other allows distribution of forces from mobile resin and the follow-up for a period of five years.
teeth to their immobile neighbours, thereby gaining

74
Lawande SA & Lawande GS.; Saudi J. Oral. Dent. Res.; Vol-1, Iss-2(Jun-Aug, 2016):74-79
CLINICAL REPORT 3M ESPE, USA) for a period of 30 seconds (Figure 4).
A female patient aged 45 years presented with Care was taken so that the etchant flows in the
the chief complaint of mobile lower central incisors and interdental areas of the teeth to be splinted. The teeth
discomfort while eating. On clinical examination, were then copiously irrigated to remove all acid
periodontal pocket depths ranged from 4 to 6 mm residues, gently dried and isolated. A resin adhesive
involving the proximal aspects of mandibular right (Single Bond, 3M ESPE, USA) was applied to the
lateral incisor and extending to the left first premolar. etched enamel surfaces and light-cured for 10 seconds.
Grade II mobility in relation to 31 and grade I mobility
of 41 were recorded according to the Miller’s index. A thin layer of microhybrid composite resin
Gingival recession of 2 to 4 mm was noted in relation to (Filtek Z250, 3M ESPE, USA) was placed on the
the involved teeth (Figure 1). Further examination also lingual surfaces of the teeth and extended slightly to the
revealed positive tension test indicating presence on an proximal surfaces of each tooth. The wetted fiber splint
aberrant labial frenal attachment in relation to the section was gently pressed into the composite resin and
mandibular incisor region. Difficulty in maintaining any excess resin was adapted for achieving a smooth
plaque control was evident with the presence of plaque surface. It was then light-cured for 40 seconds for each
and calculus in this area. Radiographic examination tooth from the lingual and proximal directions (Figure
revealed over 50% bone loss in relation to the 5). A smoothening layer of composite resin was applied
mandibular central incisors (Figure 2). No relevant over the surface especially covering loose ends of the
medical history was revealed by the patient. fiber splint to prevent fraying and then light-cured for
20 seconds for each tooth. The occlusion was checked
A treatment plan was formulated to include for any interference and adjusted. Esthetic contouring
scaling and root planing, periodontal splinting to allow was done with the help of finishing burs and diamonds.
stabilization for the mobile teeth followed by Finishing and polishing were performed using
periodontal surgery of the involved teeth. At the initial aluminium oxide sandpaper discs (Sof Lex, 3M ESPE,
consultation, the plan of extending the splint from USA) and composite resin polishing paste (Figure 6).
canine to canine in the mandibular region was carefully
explained to the patient but the patient consented to the Once the teeth were stabilized, open flap
compromised treatment plan of getting only the central debridement was performed for the involved teeth. In
incisors splinted. addition to this, the management of aberrant labial
frenum was accomplished by performing a frenectomy
Periodontal therapy started with an initial procedure, which involved complete removal of the
preparation phase which consisted of scaling and root frenum including its attachment to the underlying bone
planing and minor occlusal adjustment. The patient was (Figure 7). A week later, the patient was recalled, suture
educated on the importance of maintaining a strict removal performed and the healing was noted to be
plaque control. Three weeks later, as the condition uneventful (Figure 8). The patient was given strict
improved with a favorable plaque control, it was instructions on maintaining meticulous oral hygiene by
decided to perform periodontal splinting using glass using an interdental brush on a daily basis, in addition
fiber-reinforced composite involving the mobile central to routine oral hygiene practices.
incisors as described in the following procedure.

The teeth were cleaned on the facial and


lingual surfaces using a prophylaxis cup with a non-
fluoridated pumice paste. The teeth were then
thoroughly rinsed and dried. The proximal tooth
surfaces were prepared using medium-grit finishing
strips. As per the manufacturer’s instructions, a channel
of about 0.5 mm deep and 2 mm wide was prepared on
the lingual aspect of each tooth (Figure 3). A piece of
dental floss was laid onto the lingual surface at the level
of the proximal contacts and cut to required length.
With the cut floss, section of fiber splint (Interlig®,
Angelus, Brazil) was taken and cut to an equal length as
the floss using a sterile scissor. Fig 1: Pre-treatment facial view

The fiber splint section was lightly wetted with


unfilled resin (Filtek Flow, 3M ESPE, USA). Then the
section was kept away from light until it could be
embedded into the composite resin on the teeth. Both
the proximal and lingual aspects of the teeth were acid
etched with 37% phosphoric acid (Scotchbond Etchant,

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Lawande SA & Lawande GS.; Saudi J. Oral. Dent. Res.; Vol-1, Iss-2(Jun-Aug, 2016):74-79

Fig 2: Radiographic view of mandibular incisors Fig 6: Facial view after splinting

Fig 7: Lingual view of completed fiber-reinforced


Fig 3: Channel preparation for splinting composite resin splint

Fig 4: Acid etching Fig 8: Post-surgical frontal view of healing after 1


month

Fig 5: Placement of glass fiber and light curing with


composite Fig 9: Splint at one-year recall

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Lawande SA & Lawande GS.; Saudi J. Oral. Dent. Res.; Vol-1, Iss-2(Jun-Aug, 2016):74-79
[4]. Tooth splinting may be indicated for individual
mobile teeth as well as for an entire dentition.
According to Quirynen et al.; it is an accepted practice
to splint mobile teeth, particularly lower incisors, to
maintain the patient’s natural dentition as long as
possible [15]. Nyman and Lang demonstrated that
severely periodontally compromised splinted dentitions
with greater than 50% attachment loss of each abutment
tooth, in absence of inflammation, could be maintained
for extended period of time, in some cases more than 20
years [16]. Pollack stated that severely mobile teeth, if
in health, can be retained almost indefinitely [17].
Fig 10: Splint at two-year recall
Fiber-reinforced composites provide one of the
better alternatives for splinting of teeth [10, 18]. The
splint used in the present case is a braided, intertwined
glass fiber impregnated with dental resin (Interlig®,
Angelus, Brazil). Glass fibers are esthetic having
translucency similar to castable glass-ceramics. Fibers
can enhance the efficacy of a composite splint by acting
as a stress-bearing component, which increases the load
enhancing effect of the otherwise brittle matrix
composite material and also with the crack stopping or a
crack deflecting mechanism, which in turn increases the
toughness of the material. The open weave pattern of
glass fibers has been shown to have an inherent ability
Fig 11: Splint at three-year recall to dissipate stresses and prevent crack propagation [8,
11, 19].

Kolbeck et al.; stated that the reinforcing effect


of glass fibers was more effective than that of
polyethylene fibers. This was attributed to the difficulty
in obtaining good adhesion between ultra-high modulus
polyethylene fibers and the resin matrix, thus requiring
surface treatment of polyethylene fibers to solve the
problem [20, 21].

The advantages of glass fiber reinforced


composite splinting include: easy and single-visit
procedure, fibers provide high flexural strength, fibers
Fig 12: Splint at four-year recall are easy to cut as special scissors are not required,
minimal tooth reduction making the technique
reversible and conservative, fibers are malleable and
easy to adapt to the tooth contours, no laboratory work
is needed, can be easily repaired or repeated in case of
fractured splint and moreover, high esthetic value due to
which patient’s esthetic expectations are met [3,8,11].

Clinical evaluations of glass fiber-reinforced


composite resin restorations for periodontal splinting,
fixed partial prostheses or orthodontic retention have
been clinically successful [8, 10-12, 22]. Strassler et al.;
have reported a clinical evaluation of polyethylene
Fig 13: Splint at five-year recall fibers used for splinting over 12 to 40 months. They
observed that all the periodontal splints were successful
DISCUSSION and none exhibited debonding or recurrent caries [23].
The mobility of teeth resulting from loss of In another case, Strassler reported a 12-year recall for a
supporting bone is common in patients with periodontal periodontally compromised dentition in which the teeth
disease. In the majority of cases, the mandibular were occlusally adjusted and splinted with polyethylene
incisors are the teeth showing the first signs of mobility

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Lawande SA & Lawande GS.; Saudi J. Oral. Dent. Res.; Vol-1, Iss-2(Jun-Aug, 2016):74-79
fibers as a part of periodontal therapy and observed an 2. Tarnow, D.P., & Fletcher, P. (1986). Splinting of
improved prognosis of splinted teeth [24]. periodontally involved teeth: Indications and
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