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Classification of periodontal diseases

June 2, 2024

Orthopaedic intervention in treatment of periodontal diseases. Treating of traumatic occlusion. Temporary and permanent splinting. Designs of removable and fixed splint.

Classification of periodontal diseases

1. Gingivitis

There are two main groups of periodontal diseases: gingivitis and periodontitis. Gingivitis is recognised by gums that show classic signs of inflammation, redness and swelling, but without involvement of the periodontium. The periodon-tium includes the gingiva, cementum, periodontal ligaments, connective tissue, and the alveolar bone. Periodontitis occurs when inflammation spreads to the periodontium, causing one of the following conditions: (1) the gingiva detaches from the affected tooth along its root, creating a periodontal pocket; or (2) gingival recession, where the gingiva recedes along its root line, affecting the whole thickness of the gum. In both cases, alveolar bone loss hidden by ginvi-val inflammation is what matters most. When bone loss is extensive, the teeth can become loose and eventually fall out. Periodontal destruction is induced by the deleterious effects of inflammatory mediators occurring because of bacterial plaque build-up around the tooth. Periodontal diseases can be subdivided into 2 sub-groups: juvenile and adult. Periodontal diseases observed in young people are usually associated with neu-trophil dysfunction; in adults, they are caused mostly by an accumulation of bacterial plaque around the teeth and their roots. Certain lifestyles, health conditions or states of health, and systemic diseases are also factors that can increase the severity of periodontitis.

Why should physicians be concerned with periodontal diseases?

1. An accumulation of bacterial plaque around the teeth is the main aetiology involved in periodontal diseases; however, different lifestyles, systemic diseases, health statuses, as well as certain genetic factors can either enhance the risk of periodontal diseases or modify their prognosis.

2.Some periodontal diseases are caused by bacterial (linear gingival erythema), viral (primary herpetic gingivos-tomatitis) or fungal (histoplasmosis) infections, presenting an additional risk for the pathogen to be transmitted through direct contact with the mouth and saliva.Osteoporosis and periodontitis are diseases that affect a wide range of men and women in the worldwide, with incidence increasing with advancing age. Osteoporosis is a skeletal disorder characterized by compromising bone strength predisposing to increased risk of fracture, with bone strength characterized by bone density and bone quality.

3. In some cases, periodontal diseases may negatively affect a patient’s overall health.

4. The major risk factors associated with periodontal diseases (smoking, diabetes, oral hygiene, stress, etc.) are also associated with other conditions or systemic disease.

5. Some medications can affect the health of the periodontium.

6. Women are more susceptible to peri-odontal diseases because of the hormonal changes they experience during different stages of life: at puberty, during the menstrual cycle or pregnancy, when taking oral contraceptives, or during menopause. For example, during pregnancy, the immune response is weaker and concentrations of progesterone and oestrogen are at least.

2. Periodontitis.

ten-fold higher; consequently any accumulation of bacterial plaque, no matter how small, can induce a disproportionate inflammatory response in the periodon-tium. Therefore, it is important to encourage pregnant women and women who plan on becoming pregnant to maintain good dental hygiene.

Two risk factors of greater concern for periodontal diseases

Smoking

Smokers are afflicted more often with peri-odontitis thaon-smokers and often experience a higher rate of bone loss. Conversely, smokers’ gums tend to bleed less when they brush due to the vasocon-strictive effect of tobacco, which masks the presence of periodontal disease. Moreover, smokers are exposed to a particularly destructive and painful type of periodontal disease, acute necrotizing ulcerative gingivitis (ANUG). Smoking may constitute a contraindication to gingival grafts and dental implants; in addition, prognosis of periodontal treatment in smokers is often less favourable.

Diabetes

Diabetes (types 1 and 2) increases the risk of periodontal diseases because the biochemical processes linked to diabetes reduce blood flow to the gums and blunt the immune response. Therefore, poorly controlled diabetes can enhance periodon-tal destruction in people with periodontitis.

The risk of smokers developing a periodontal disease is fivetimes higher than among non-smokers; the risk for a diabetic smoker is 20 times higher. Diabetic patients who show signs of microcomplications associated with diabetes (e.g. retinopathy) are more susceptible to periodontal diseases.

Two systemic complications: hypotheses

Cardiovascular diseases

Some studies suggest that having a peri-odontal disease can increase the risk of atherosclerosis, coronary disease, and myocardial infarction. At this time, four main mechanisms are suspected:

1. The direct effects of the infectious agents involved in periodontal diseases on atheroma formation;

2. The indirect effect of the immune response induced by a periodontal infection;

3. Common genetic predispositions between periodontal diseases and atherosclerosis;

4. Common risk factors linked to lifestyle. The production of protein such as C-reactive protein and fibrinogen seems to be particularly significant. Several pathogenic agents involved in periodontal diseases can also affect the heart, if bacteraemia occur; the classic example is infective endocarditis.

Preterm low-weight babies:

Some studies seem to indicate that peri-odontitis in a pregnant woman can affect the foetus’s health, especially if her peri-odontal condition worsens during her pregnancy.

Periodontitis is an inflammation of the supporting tissue of the teeth, usually leading to loss of bone and periodontal ligament and is a major cause of tooth loss and edentulousness in adults .

Periodontal diseases are associated with a number of chronic diseases including Osteoporosis.

Osteopenia and osteoporosis are systemic skeletal diseases characterized by low bone mass and microarchitectural deterioration with a consequent increase in bone fragility and susceptibility to fracture .

According to the World Health Organization, osteoporosis is considered to be present when bone mineral density (BMD) is 2.5 standard deviations (SD) below the young normal. Osteopenia is defined as bone density levels between 1 SD and 2.5 SD below normal BMD.

In the 3rd National Health and Nutrition Examination Survey (NHANES III) the prevalence of osteoporosis when assessed at the femoral neck was 20% of postmenopausal white women.

The risk factors for osteoporosis can be divided into non-modifiable and modifiable risk factors,

The non-modifiable include sex, age, early menopause, thin or small body frame, race, and heredity. Lack of calcium intake, lack of exercise, smoking, and alcohol are modifiable risk factors. Low bone mass, certain medications (corticosteroid or anticonvulsant), propensity to fall, and systemic diseases such as hyperparathyroidism are modifiable to some extent (Fig.3). The risk factors for osteoporosis include many risk factors associated with advanced periodontal disease. Since both osteoporosis and periodontal diseases are bone resorptive diseases, it has been hypothesized that osteoporosis could be a risk factor for the progression of periodontal disease. The data gathered on the mostly cross-sectional studies appears to indicate a relationship between systemic BMD and oral BMD. Additional data from ongoing longitudinal studies will further elaborate this relationship.

Menopause, osteoporosis and periodontal diseases Female life expectancy to 80 years old, 40 % of her life in menopause which is associated with decline in the hormonal levels due to decrease in the ovarian functions. All these hormonal changes will lead to psychological, oral and systemic health changes. Oral changes that can be seen may include: thinning of oral mucosa, desquamation of gingival epithelium, burning mouth, gingival recession, xerostomia and alveolar bone loss & ridge resorption.

Bone loss in women occurs most rapidly in the years immediately following menopause wheatural levels of estrogen are greatly reduced. In most women, bone mass reach its peak level at third decade of life and decline thereafter. This decline accelerate with the onset of menopause. While estimates the rate of menopausal bone loss may differ by population and measurement technology a rate on the order of 0.5% to 1.0% per year has been reported.

Association between Osteoporosis and periodontal diseases A growing body of literature has accumulated regarding the role of osteoporosis in the onset and progression of periodontal disease and tooth loss. The association between these two diseases is biologically plausible as well. However, most studies are crosssectional uncontrolled, consist of small samples, and are largely restricted to postmenopausal women. Cross-sectional studies have an inherent limitation in establishing causation, since bias, confounding, and temporality are difficult to establish and control. Loss of alveolar bone as a feature of periodontal disease may be easily confounded by other factors such as gender, hormone intake, smoking, race, age, stress and distress, diet, body mass, and exercise. Many of the studies to date inadequately address these issues. Most studies are relatively small and make control of confounding and assessment of effect modification difficult.

Potential mechanisms and biological aspects

Based upon our knowledge of osteopenia and periodontal disease and the risk factors that affect both, it is reasonable to propose the following hypothesis: periodontitis results from bacteria that produce factors which cause loss of collagenous support of the tooth, as well as loss of alveolar bone. Osteopenia results in loss of BMD throughout the body, including loss in the maxilla and mandible. The resulting local reduction of BMD in the jawbones would set the stage for more rapid alveolar crestal height loss since a comparable challenge of bacterial bone-resorbing factors could be expected to result in greater alveolar crestal loss than a non-osteopenic individual. There are, in addition, systemic risk factors such as smoking, diabetes, diet, and hormone levels that affect systemic bone loss and may also affect periodontitis.

Although periodontal disease has historically been thought to be the result of an infectious process, others have suggested that periodontal disease may be an early manifestation of generalized osteopenia. Evidence in support of this concept is limited and evaluation of the independent role of generalized osteopenia on periodontal disease requires further study. Bone loss associated with osteoporosis occurs when there is an imbalance between bone resorption and formation, favoring resorption. Calcium balance, vitamin D metabolism, estrogens, and aging are interrelated factors in the causation of osteoporosis. Chronic negative calcium balance reduces bone mineral content. Decrease in calcium intake and decrease in intestinal calcium absorption with age contribute to a negative calcium balance in older women. Both estrogen and vitamin D are known to affect intestinal calcium absorption. Vitamin D3 supplementation has been shown to reduce new vertebral fractures in postmenopausal women compared to women supplemented with calcium that contribute to bone loss include suboptimal skeletal development in early adulthood and age-related bone loss. Hormone dependent increases in bone resorption and accelerated loss of bone within 10 years after menopause have been reported to be the main pathogenic factors in primary osteoporosis in women. Estrogen deficiency appears to play a major role in osteopenia and accelerated bone loss, a concept which is supported by the higher prevalence of osteopenia in women than men. Also, a meta-analysis of the effect of estrogen replacement therapy on reduction of osteoporotic hip fractures in postmenopausal women estimated a 25% reduction in hip fracture in estrogen users compared to non-users, supporting a major role of estrogen in hip fracture and presumably osteoporosis prevention.

Treatment of osteoporosis and periodontitis

Regarding the treatment of osteoporosis include decrease the risk factors through many treatment options such as adding protective factors of a Ca & vit. D rich diet + supplementation, weight bearing exercises, hormonal replacement therapy (HRT)-(ERT), drug therapy such as: alendronate (Fosamax^®), calcitonin, selective estrogen receptor modulators and parathyroid hormone.

HRT as one of the treatment modalities for osteoporosis had been showed that patient on HRT show regaining bone mass to pre menopause level & in preventing / reversing postmenopausal osteoporotic changes in long bones & spine and has a beneficial effect on tooth loss, mandibular bone density & gingival bleeding.

Clinical consideration and management of periodontal disease for an osteoporisis patient If the patient is osteoporosis susceptible and due to the changes in alveolar bone level or oral manifestation for a menopause woman; close monitoring of periodontal maintenance, informing the patient regarding the potential risks of hormone depleting on the oral tissue and consulting the patient’s physician about the current medication & the replacements to treat osteoporosis.

Every treatment modality in periodontal therapy can be done for osteoporotic patient from scaling and root planing, different periodontal and implant surgery so we can say from the scientific evidences that osteoporosis is not a contraindication for different periodontal surgery (guided tissue regeneration and implant) in spite of the lack for more controlled prolonged studies in that field

Regarding dental Implant osteoporosis is not likely a risk factor for failure of osseointegrated implants, dental implant placement in edentulous area aid in maintaining the height & density of alveolar bone. osteoporotic bone does not heal differently than more dense bone and the prognosis of osseointegrated implants can be improved in O.P patient who received treatment such as (Fosamax^®)

New evidences and precautions for oseoporotic patient who are on certain medication and need a huge periodontal and implant’s surgical intervention Ruggiero and colleagues reported in the August 2004 issue of the Journal of Oral and Maxillofacial Surgery the observation of an osteonecrosis syndrome reminiscent of osteoradionecrosis in certain patients taking bisphosphonate drugs. Patients developed osteoradionecrosis-like lesions soon after extraction of teeth for periodontal, endodontic, or prosthetic reasons; from 2001 to 2003, they saw 63 cases, of which approximately two-thirds of the osteonecrosis cases occurred in the mandible. All patients had been receiving various forms of bisphosphonate therapy (primarily zoledronic acid and pamidronate) for a variety of metastatic cancers. Also in CHICAGO – April 11, 2006 – The patient of a periodontist in private practice in New Orleans, LA, developed osteonecrosis of the jaw (ONJ), a condition that can cause severe, often irreversible and debilitating damage to the jaw, following periodontal surgical therapy. Two years prior to surgery, the patient had started receiving IV

bisphosphonate therapy, or bone-sparing drugs commonly used in the treatment of osteoporosis and metastatic bone cancer to help decrease associated pain and fractures, following treatment for breast carcinoma .

So it will be wise enough after all these continuous observation to start with a small periodontal surgical intervention for those patient who are osteoporotic on intravenous bisphosphenate therapy or bone spring drugs and see the prognosis and the healing before we go for more advances and complicated surgical interventions).

Conclusion

From the literature we had, it appeared that there is an association of osteporosis with onset and progression of periodontal diseases in humans, also the studies revealed that Low bone mass independently associated with loss of alveolar crest height & tooth loss.

1.The limitations of the studies that investigate the aspects of the relation between osteoporosis and periodontal diseases include: small sample size 2.Limited control of other profounding factors 3.V arying definitions of periodontal diseases & O.P.

Finally there is a demanding issue to better understanding and investigation for the potential mechanisms between periodontal diseases and systemic problems including osteoporosis.

Gingivitis and periodontitis are the 2 major forms of infamma-tory diseases affecting the periodontium. Their primary etiology is bacterial plaque, which can initiate destruction of the gingi-val tissues and periodontal attachment apparatus. Gingivitis is infammation of the gingiva that does not result in clinical attachment loss. Periodontitis is infammation of the gingiva and the adjacent attachment apparatus and is characterized by loss of connective tissue attachment and alveolar bone. Each of these diseases may be subclassifed based upon etiology, clinical presentation, or associated complicating factors.

Gingivitis is a reversible disease. Therapy is aimed primarily at reduction of etiologic factors to reduce or eliminate infam-mation, thereby allowing gingival tissues to heal. Appropriate supportive periodontal maintenance that includes personal and professional care is important in preventing re-initiation of infammation.

Therapeutic approaches for periodontitis fall into 2 major categories: 1) anti-infective treatment, which is designed to halt the progression of periodontal attachment loss by removing etiologic factors; and 2) regenerative therapy, which includes anti-infective treatment and is intended to restore structures destroyed by disease. Essential to both treatment approaches is the inclusion of periodontal maintenance procedures.⁴

Infammation of the periodontium may result from many causes (eg, bacteria, trauma). However, most forms of gingivitis and periodontitis result from the accumulation of tooth-adherent microorganisms. Prominent risk factors for development of chronic periodontitis include the presence of specifc subgingival bacteria, tobacco use, diabetes,age, and male gender. Furthermore, there is evidence that other factors can contribute to periodontal disease pathoge-nesis: environmental, genetic, and systemic (eg, diabetes).

treatments discussed should not be deemed inclusive of all possible therapies, or exclusive of methods of care reasonably directed at obtaining good results. The ultimate decision regarding the appropriateness of any specifc procedure must be made by the practitioner in light of the circumstances presented by an individual patient.

Plaque-induced Gingivitis

Therapy for individuals with chronic gingivitis is initially directed at reduction of oral bacteria and associated calcifed and noncalcifed deposits. Patients with chronic gingivitis, but without signifcant calculus, alterations in gingival morphology, or systemic diseases that affect oral health, may respond to a therapeutic regimen consisting of improved personal plaque control alone. The periodontal literature documents the short-and long-term effects following self-treatment of gingivitis by personal plaque control. However, while it may be possible under controlled conditions to remove most plaque with a variety of mechanical oral hygiene aids, many patients lack the motivation or skill to attain and maintain a plaque-free state for signifcant periods of time. Clinical trials also indicate that self-administered plaque control programs alone, without periodic professional reinforcement, are inconsistent in providing long-term inhibition of gingivitis.

Many patients with gingivitis have calculus or other associated local factors (eg, defective dental restorations) that interfere with personal oral hygiene and the ability to remove bacterial plaque. An acceptable therapeutic result for these individuals is usually obtained when personal plaque control measures are performed in conjunction with professional removal of plaque, calculus, and other local contributing factors.

Removal of dental calculus is accomplished by scaling and root planing procedures using hand, sonic, or ultrasonic instruments. The therapeutic objective of scaling and root planing is to remove plaque and calculus to reduce subgingival bacteria below a threshold level capable of initiating clinical infammation.The success of instrumentation is determined by evaluating the periodontal tissues following treatment and during the maintenance phase of therapy.

The use of topical antibacterial agents to help reduce bacterial plaque may be benefcial for the prevention and treatment of gingivitis in some patients.

A number of these agents in oral rinses and dentifrices have been tested in clinical trials.²⁸ However, to be accepted by the American Dental Association (ADA) Council on Dental Therapeutics as an effective agent for the treatment of gingivitis, a product must reduce plaque and demonstrate effective reduction of gingival infammation over a period of at least 6 months. The agent must also be safe and not induce adverse side effects.

Three medicaments have been given the ADA Seal of Acceptance for the control of gingivitis. The active ingredients of one product are thymol, menthol, eucalyptol, and methyl salicylate. Active ingredients in the other two are chlorhexidine digluconate and triclosan.²⁹ If properly used, the addition of a topical anti-plaque agent to a gingivitis treatment regimen for patients with defcient plaque control will likely result in reduction of gingivitis.³⁰ However, experimental evidence indicates that penetration of topically applied agents into the gingival crevice is minimal.³¹ Therefore, these agents are useful for the control of supragingival, but not subgingival plaque. Among individuals who do not perform excellent oral hygiene, supra-gingival irrigation with and without medicaments is capable of reducing gingival infammation beyond that normally achieved by toothbrushing alone. This effect is likely due to the fushing out of subgingival bacteria.

If gingivitis remains following the removal of plaque and other contributing local factors, thorough evaluation should be undertaken of systemic factors (eg, diabetes, pregnancy, etc.). If such conditions are present, gingival health may be attained once the systemic problem is resolved and plaque control is maintained.

Acute Periodontal Diseases

NUP involves debridement which may be combined with irrigation with antiseptics (eg, povidone iodine), antimicrobial mouth rinses (eg, chlorhexidine), and administration of systemic antibiotics. There is also evidence that HIV-immune defciency may be associated with severe loss of periodontal attachment that does not necessarily present clinically as an ulcerative lesion.⁴⁰ Although not an acute disease, linear gin-gival erythema (LGE) occurs in some HIV-infected individuals and does not appear to respond to conventional scaling, root planing, and plaque control. Antibiotic therapy should be used in HIV-positive patients with caution due to the possibility of inducing opportunistic infections.

The oral manifestations of a primary herpes simplex virus type I infection often include gingivitis. By the time gingivitis is present, patients are usually febrile, in pain, and have lymph-adenopathy. Diagnosis is generally made from the clinical appearance of the oral soft tissues. Although not performed routinely, a viral culture may provide defnitive identifcation of the infective agent. In otherwise healthy patients, treatment for herpetic gingivitis consists of palliative therapy. The infection is self-limiting and usually resolves in 7 to 10 days. Systemic antiviral therapy with acyclovir is appropriate for immunocompromised patients with herpetic gingivitis.

Gingival Enlargement

Chronic gingival infammation may result in gingival enlargement. This overgrowth of gingiva may be exaggerated in patients with genetic or drug-related systemic factors (eg, anticonvul-sants, cyclosporine and calcium channel blocking drugs).Among individuals taking phenytoin, gingival overgrowth may be minimized with appropriate personal oral hygiene and professional maintenance. However, root debridement in patients with gingival overgrowth often does not return the periodontium to normal contour. The residual overgrowth may not only complicate the patient’s ability to adequately clean the dentition, but it may also present esthetic and functional problems.

For patients with gingival overgrowth, the modifcation of tissue topography by surgical recontouring may be undertaken to create a maintainable oral environment. Postoperative management following tissue resection is important. The benefts of surgical reduction may be lost due to rapid proliferation of the tissues during the post-therapy phase.Recurrence is common in many patients with drug-induced gingival overgrowth.⁵¹ For these patients, consultation with the patient’s physician is advisable to determine if it is possible to use an alternative drug therapy that does not induce gingival overgrowth. If not, then repeated surgical and/or non-surgical intervention may be required.

Chronic Periodontitis

Appropriate therapy for patients with periodontitis varies considerably with the extent and pattern of attachment loss, local anatomical variations, type of periodontal disease, and therapeutic objectives. Periodontitis destroys the attachment apparatus of teeth resulting in periodontal pocket formation and alteration of normal osseous anatomy. The primary objectives of therapy for patients with chronic periodontitis are to halt disease progression and to resolve infammation. Therapy at a diseased site is aimed at reducing etiologic factors below the threshold capable of producing breakdown, thereby allowing repair of the affected region. Regeneration of lost peri-odontal structures can be enhanced by specifc procedures. However, many variables responsible for complete regeneration of the periodontium are unknown and research is ongoing in this area.

Scaling and Root Planing

The benefcial effects of scaling and root planing combined with personal plaque control in the treatment of chronic peri-odontitis have been validated. These include reduction of clinical infammation, microbial shifts to a less pathogenic subgingival fora, decreased probing depth, gain of clinical attachment, and less disease progression.

Scaling and root planing procedures are technically demanding and time-consuming. Studies show that clinical conditions generally improve following root planing; nonetheless, some sites still do not respond to this therapy. The addition of gingival curettage to root planing in the treatment of generalized chronic periodontitis with shallow suprabony pockets does not signifcantly reduce probing depth or gain clinical attachment beyond that attained by scaling and root planing alone. The following factors may limit the success of treatment by root planing: root anatomy (eg, concavities, furrows etc.), furcations, and deep probing depths.

Several weeks following the completion of root planing and efforts to improve personal plaque control, re-evaluation should be conducted to determine the treatment response. Several factors must be considered at sites that continue to exhibit signs of disease. If the patient’s daily personal plaque control is not adequate to maintain gingival health, then additional instruction and motivation in personal plaque control and/or the use of topical chemotherapeutics (eg, mouthrinses, local drug delivery devices) may be indicated. Anatomical factors that can limit the effectiveness of root instrumentation or limit the patient’s ability to perform personal plaque control (eg, deep probing depths, root concavities, furcations) may require additional therapy including surgery. Host response may also have an effect on treatment outcome and patients with systemic conditions (eg, diabetes, pregnancy, stress, AIDS, immunodefcien-cies, and blood dyscrasias) may not respond well to therapy that is directed solely at controlling local factors. In such patients, it is important that attempts be made to control the contributing systemic factors.

Pharmacological Therapy

Pharmacotherapeutics may have an adjunctive role in the management of periodontitis in certain patients. These ad-junctive therapies are categorized by their route of administration to diseased sites: systemic or local drug delivery.

Surgical Therapy

Surgical access to facilitate mechanical instrumentation of the roots has been utilized to treat chronic periodontitis for decades. A surgical approach to the treatment of periodontitis is utilized in an attempt to: 1) provide better access for removal of etiologic factors; 2) reduce deep probing depths; and 3) regenerate or reconstruct lost periodontal tissues.

Clinical trials indicate that both surgical and nonsurgical approaches can be effective in achieving stability of clinical attachment levels. Flap refection is capable, however, of increasing the effcacy of root debridement, especially at sites with deep probing depths or furcations.

Nevertheless, complete calculus removal, even with surgical access, may not always be achieved. The addition of osseous resection during surgical procedures appears to produce greater reduction of probing depth due to gingival reces-sion, particularly in furcations. Regardless of the type of therapy, furcated teeth are problematic since they are still more likely to lose clinical attachment thaonfurcated teeth.While these overall fndings are helpful, the practitioner should base specifc decisions for therapy on fndings for each individual patient.

Regenerative Surgical Therapy

The optimal goal of therapy for individuals who have lost a signifcant amount of periodontal attachment is regeneration of lost tissues. While root debridement in combination with plaque control has demonstrated effcacy in resolving infam-mation and arresting periodontitis, healing typically results in the formation of a long junctional epitheliumwith remodeling of the alveolus. Similarly, surgical debride-ment alone does not induce signifcant amounts of new connective tissue attachment. However, some bone fll may occur in selected sites.

Clinical trials suggest that obtaining new periodontal attachment or regenerating lost tissues is enhanced by the use of adjunctive surgical technique devices and materials. Chemical agents that modify the root surface, while promoting new attachment, have shown variable results when used in humans. Bone grafting and guided tissue regeneration (GTR) techniques, with or without bone replacement grafts,may be successful when used at selected sites with advanced attachment loss. The use of biologically engineered tissue inductive proteins (eg, growth factors, extracellular matrix proteins, and bone morphogenic proteins) to stimulate periodontal or osseous regeneration has also shown promise. Literature reviews on periodontal regeneration and mucogingival therapy provide additional information regarding these therapies.

Regenerative therapy and other treatment modalities can be affected by several risk factors (eg, diabetes and tobacco use) which can diminish periodontal treatment outcomes. In this regard, cigarette smoking is associated with a high risk for progressive periodontitis and treatment for periodontitis may be less effective in smokers thaon-smokers. These factors are reviewed in more depth in the Academy’s position paper Tobacco Use and the Periodontal Patient. To maximize effective prevention and treatment of periodontitis, patients should be encouraged to stop smoking and to stop using smokeless tobacco.

Occlusal Management

Several studies indicated that excessive occlusal forces do not initiate plaque-induced periodontal disease or connective tissue attachment loss (periodontitis). However, other investigations suggest that tooth mobility may be associated with adverse effects on the periodontium and affect the response to therapy with respect to gaining clinical attachment. With regards to treatment, occlusal therapy may aid in reducing tooth mobility and gaining some bone lost due to traumatic occlusal forces.Occlusal equilibration also may be used to ameliorate a variety of clinical problems related to occlusal instability and restorative needs. Clinicians should use their judgment as to whether or not to perform an occlusal adjustment as a component of periodontal therapy based upon an evaluation of clinical factors related to patient comfort, health and function.

Periodontal Maintenance Procedures

Periodic monitoring of periodontal status and appropriate maintenance procedures should be part of the long-term treatment plan for managing chronic periodontitis. Although experimental studies have demonstrated very successful treatment outcomes when patients are professionally maintained at 2-week intervals, such a program is impractical for most chronic periodontitis patients. Therefore, to maximize successful therapeutic outcomes, patients must maintain effective daily plaque control. It also appears that in-offce periodontal maintenance at 3 to 4 month intervals can be effective in maintaining most patients.⁴ A more comprehensive review on this subject can be found in the American Academy of Periodontology’s position paper entitled

Conclusion

Finally there is a demanding issue to better understanding and investigation for the potential mechanisms between periodontal diseases and systemic problems including osteoporosis.

Plaque-induced Gingivitis

The use of topical antibacterial agents to help reduce bacterial plaque may be benefcial for the prevention and treatment of gingivitis in some patients.

A number of these agents in oral rinses and dentifrices have been tested in clinical trials. However, to be accepted by the American Dental Association (ADA) Council on Dental Therapeutics as an effective agent for the treatment of gingivitis, a product must reduce plaque and demonstrate effective reduction of gingival infammation over a period of at least 6 months. The agent must also be safe and not induce adverse side effects.

Three medicaments have been given the ADA Seal of Acceptance for the control of gingivitis. The active ingredients of one product are thymol, menthol, eucalyptol, and methyl salicylate. Active ingredients in the other two are chlorhexidine digluconate and triclosan. If properly used, the addition of a topical anti-plaque agent to a gingivitis treatment regimen for patients with defcient plaque control will likely result in reduction of gingivitis.³⁰ However, experimental evidence indicates that penetration of topically applied agents into the gingival crevice is minimal.³¹ Therefore, these agents are useful for the control of supragingival, but not subgingival plaque. Among individuals who do not perform excellent oral hygiene, supra-gingival irrigation with and without medicaments is capable of reducing gingival infammation beyond that normally achieved by toothbrushing alone. This effect is likely due to the fushing out of subgingival bacteria.

Acute Periodontal Diseases

Necrotizing ulcerative gingivitis (NUG) is associated with specifc bacterial accumulations occurring in individuals with lowered host resistance. NUG usually responds rapidly to the reduction of oral bacteria by a combination of personal plaque control and professional debridement. If lymphadenopathy or fever accompanies oral symptoms, administration of systemic antibiotics may be indicated. The use of chemotherapeutic rinses by the patient may be benefcial during the initial treatment stages. After the acute infammation of the NUG lesion is resolved, additional intervention may be indicated to prevent disease recurrence or to correct resultant soft tissue deformities. Necrotizing ulcerative periodontitis (NUP) manifests as rapid necrosis and destruction of the gingiva and periodontal attachment apparatus. It may initiate gingival bleeding and pain, and it usually represents an extension of necrotizing ulcerative gingivitis in individuals with lowered host resistance. NUP has been reported among both HIV-positive and negative individuals, but its true prevalence is unknown. Management of NUP involves debridement which may be combined with irrigation with antiseptics (eg, povidone iodine), antimicrobial mouth rinses (eg, chlorhexidine), and administration of systemic antibiotics. There is also evidence that HIV-immune defciency may be associated with severe loss of periodontal attachment that does not necessarily present clinically as an ulcerative lesion.⁴⁰ Although not an acute disease, linear gin-gival erythema (LGE) occurs in some HIV-infected individuals and does not appear to respond to conventional scaling, root planing, and plaque control. Antibiotic therapy should be used in HIV-positive patients with caution due to the possibility of inducing opportunistic infections.

Gingival Enlargement

Chronic Periodontitis

Scaling and Root Planing

Pharmacological Therapy

Systemic Drug Administration

Numerous investigations⁷³ have assessed the use of systemic antibiotics to halt or slow the progression of periodontitis or to improve periodontal status. The adjunctive use of systemically delivered antibiotics may be indicated in the following situations: patients with multiple sites unresponsive to mechanical debridement, acute infections, medically compromised patients, presence of tissue-invasive organisms and ongoing disease progression.The administration of antibiotics for the treatment of chronic periodontitis should follow accepted pharmacological principles including, when appropriate, iden-tifcation of pathogenic organisms and antibiotic sensitivity testing.

Considerable research efforts have focused on systemic application of host modulating agents such as non-steroidal anti-infammatory drugs (NSAIDS) and subantimicrobial dose doxycycline. Investigators have reported some beneft when these medications are incorporated into treatment proto-cols.Recently [year 2000], the United States Food and Drug Administration (FDA) approved the use of a systemically delivered collagenase inhibitor consisting of a 20-mg capsule of doxycycline hyclate as an adjunct to scaling and root planing for the treatment of periodontitis. Benefts included a statistically signifcant reduction in probing depths, a gain in clinical attachment levels and a reduction in the incidence of disease progression. Overall, the data suggest that use of subantimi-crobial dose doxycycline as an adjunct to scaling and root planing provides defned but limited improvement in periodontal status.

It is important to consider the potential benefts and side effects of systemic pharmacological therapy. Benefts may include the ability to treat patients unresponsive to conventional therapy or an individual with multiple sites experiencing recurrent periodonitits. In contrast, potential risks associated with systemically administered antibiotics include development of resistant bacterial strains,⁸⁵ emergence of opportunistic infections, and possible allergic sensitization of patients.With regard to the prolonged administration of NSAIDS, harmful effects may include gastrointestinal upset and hemorrhage, renal and hepatic impairment, central nervous system disturbances, inhibition of platelet aggregation, prolonged bleeding time, bone marrow damage, and hypersensitivity reactions. At present, the incidence of negative side effects reported after root planing with or without administration of subantimicrobial dose doxycy-cline has been similar. In general, since patients with chronic periodontitis respond to conventional therapy, it is unnecessary to routinely administer systemic medications such as antibiotics, NSAIDS, or subantimicrobial dosing with doxycycline.

Local Delivery

Controlled delivery of chemotherapeutic agents within peri-odontal pockets can alter the pathogenic fora and improve clinical signs of periodontitis. Local drug delivery systems provide several benefts; the drug can be delivered to the site of disease activity at a bactericidal concentration and it can facilitate prolonged drug delivery. The FDA has approved the use of an ethylene vinyl acetate fber that contains tetracy-cline, a gelatin chip that contains chlorhexidine⁹³ and a minocycline polymer formulationas adjuncts to scaling and root planing. The FDA has also approved doxycycline hyclate in a bioabsorbable polymer gel as a stand-alone therapy for the reduction of probing depths, bleeding upon probing, and gain of clinical attachment.

Local delivery systems have potential limitations and benefts. If used as a monotherapy, problems associated with local delivery can include allergic reaction, possible inability to disrupt bioflms, and failure to remove calculus. The benefts include the ease of application, selectively targeting a limited number of diseased sites that were unresponsive to conventional therapy, and possibly enhanced treatment results at specifc locations. Local delivery modalities have shown benefcial clinical improvements with regard to probing depth reduction and gain in clinical attachment. Furthermore, there are limited data to suggest that local delivery of antibiotics may also be benefcial in preventing recurrent attachment loss in the absence of maintenance therapy.

Utilization of antibiotics at an individual site will depend on the discretion of the treating therapist after consultation with the patient. The greatest potential of local delivery devices may be to enhance therapy at sites that do not respond to conventional treatment. Ultimately, the results of local drug delivery must be evaluated with regard to the magnitude of improvement that can be attained relative to disease severity. A more complete review of local drug delivery can be found in the American Academy of Periodontology position paper The Role of Controlled Drug Delivery for Periodontitis.

Surgical Therapy

Regenerative Surgical Therapy

Occlusal Management

Periodontal Maintenance Procedures

It is important to consider the potential benefts and side effects of systemic pharmacological therapy. Benefts may include the ability to treat patients unresponsive to conventional therapy or an individual with multiple sites experiencing recurrent periodonitits. In contrast, potential risks associated with systemically administered antibiotics include development of resistant bacterial strains, emergence of opportunistic infections, and possible allergic sensitization of patients.With regard to the prolonged administration of NSAIDS, harmful effects may include gastrointestinal upset and hemorrhage, renal and hepatic impairment, central nervous system disturbances, inhibition of platelet aggregation, prolonged bleeding time, bone marrow damage, and hypersensitivity reactions. At present, the incidence of negative side effects reported after root planing with or without administration of subantimicrobial dose doxycy-cline has been similar. In general, since patients with chronic periodontitis respond to conventional therapy, it is unnecessary to routinely administer systemic medications such as antibiotics, NSAIDS, or subantimicrobial dosing with doxycycline.

Local delivery systems have potential limitations and benefts. If used as a monotherapy, problems associated with local delivery can include allergic reaction, possible inability to disrupt bioflms, and failure to remove calculus. The benefts include the ease of application, selectively targeting a limited number of diseased sites that were unresponsive to conventional therapy, and possibly enhanced treatment results at specifc locations. Local delivery modalities have shown benefcial clinical improvements with regard to probing depth reduction and gain in clinical attachment.Furthermore, there are limited data to suggest that local delivery of antibiotics may also be benefcial in preventing recurrent attachment loss in the absence of maintenance therapy.

specifc subgingival bacteria, tobacco use, diabetes,age, and male gender. Furthermore, there is evidence that other factors can contribute to periodontal disease pathoge-nesis: environmental, genetic, and systemic (eg, diabetes).

This paper primarily reviews the treatment of plaque-induced gingivitis and chronic periodontitis, but there might be some situations where the described therapies will not resolve disease or arrest disease progression. Furthermore, the treatments discussed should not be deemed inclusive of all possible therapies, or exclusive of methods of care reasonably directed at obtaining good results. The ultimate decision regarding the appropriateness of any specifc procedure must be made by the practitioner in light of the circumstances presented by an individual patient. Numerous investigations⁷³ have assessed the use of systemic antibiotics to halt or slow the progression of periodontitis or to improve periodontal status. The adjunctive use of systemically delivered antibiotics may be indicated in the following situations: patients with multiple sites unresponsive to mechanical debridement, acute infections, medically compromised patients, presence of tissue-invasive organisms and ongoing disease progression.The administration of antibiotics for the treatment of chronic periodontitis should follow accepted pharmacological principles including, when appropriate, iden-tifcation of pathogenic organisms and antibiotic sensitivity testing.

Local delivery systems have potential limitations and benefts. If used as a monotherapy, problems associated with local delivery can include allergic reaction, possible inability to disrupt bioflms, and failure to remove calculus. The benefts include the ease of application, selectively targeting a limited number of diseased sites that were unresponsive to conventional therapy, and possibly enhanced treatment results at specifc locations. Local delivery modalities have shown benefcial clinical improvements with regard to probing depth reduction and gain in clinical attachment.^91-94 Furthermore, there are limited data to suggest that local delivery of antibiotics may also be benefcial in preventing recurrent attachment loss in the absence of maintenance therapy.⁹⁰

Dental braces

Dental braces (also known as orthodontic braces, or simply braces) are devices used in orthodontics that align and straighten teeth and help to position them with regard to a person’s bite, while also working to improve dental health. They are often used to correct underbites, as well as malocclusions, overbites, cross bites, open bites, deep bites, crooked teeth, and various other flaws of the teeth and jaw. Braces can be either cosmetic or structural. Dental braces are often used in conjunction with other orthodontic appliances to help widen the palate or jaws and to otherwise assist in shaping the teeth and jaws.

How braces work

The application of braces moves the teeth as a result of force and pressure on the teeth. There are four basic elements that are needed in order to help move the teeth. In the case of traditional metal or wire braces, one uses brackets, bonding material, arch wire, and ligature elastic, also called an “O-ring” to help align the teeth. The teeth move when the arch wire puts pressure on the brackets and teeth. Sometimes springs or rubber bands are used to put more force in a specific direction. Braces have constant pressure, which over time, move teeth into their proper positions. Occasionally adults may need to wear headgear to keep certain teeth from moving. When braces put pressure on one’s teeth, the periodontal membrane stretches on one side and is compressed on the other. This movement needs to be done slowly otherwise the patient risks losing his or her teeth. This is why braces are commonly worn for approximately two and a half years and adjustments are only made every three or four weeks.

This process loosens the tooth and theew bone grows in to support the tooth in its new position which is technically called bone remodeling. Bone remodeling is a biomechanical process responsible for making bones stronger in response to sustained load-bearing activity and weaker in the absence of carrying a load. Bones are made of cells called osteoclasts and osteoblasts. Two different kinds of bone resorption are possible which are called direct resorption, starting from the lining cells of the alveolar bone, and indirect or retrograde resorption, which takes place when the periodontal ligament has become subjected to an excessive amount and duration of compressive stress.^[4] Another important factor associated with tooth movement is bone deposition. Bone deposition occurs in the distracted periodontal ligament and without bone deposition, the tooth will loosen and voids will occur distal to the direction of tooth movement. A tooth will usually move about a millimeter per month during orthodontic movement, but there is high individual variability. Orthodontic mechanics can vary in efficiency, which partly explains the wide range of response to orthodontic treatment.

Before and After Photos following Orthodontic Treatment – Teeth Braces

Types of braces

· Traditional metal wired braces are stainless steel, sometimes in combination with titanium, and are the most widely used. These include conventional braces, which require ties to hold the archwire in place, and newer self-tying (or self-ligating) brackets. Self-ligating brackets may reduce friction between the wire and the slot of the bracket, which in turn might be of therapeutic benefit.

· “Clear” braces serve as a cosmetic alternative to traditional metal braces by blending in more with the natural colour of the teeth or having a less conspicuous or hidden appearance. Typically, these brackets are made of ceramic or plastic materials and function in a similar manner to traditional metal brackets. Clear elastic ties and white metal ties are available to be used with these clear braces to help keep the appliances less conspicuous. Clear braces have a higher component of friction and tend to be more brittle than metal braces. This can make removing the appliances at the end of treatment more difficult and time consuming.

“Clear” braces

· Gold-plated stainless steel braces are often employed for patients allergic to nickel (a basic and important component of stainless steel), but may also be chosen because some people simply prefer the look of gold over the traditional silver-coloured braces.

· Lingual braces (examples of which are SureSmile QT, Incognito Braces) are custom made fixed braces bonded to the back of the teeth making them invisible to other people. In lingual braces the brackets are cemented onto the backside of the teeth making them invisible while in standard braces the brackets are cemented onto the front side of the teeth. Hence, lingual braces are a cosmetic alternative to those who do not wish the braces to be visible.

· Titanium braces resemble stainless steel braces but are lighter and just as strong. People with allergies to the nickel in steel often choose titanium braces, but they are more expensive than stainless steel braces.

Traditional braces are mostly used in treating children, as well as adults. They consist of a small bracket that is glued to the front of each tooth and the molars are adjusted with a band that encircles the tooth. An advantage is one can eat and drink while wearing the brace but a disadvantage is that one must give up certain foods and eating habits while wearing them, such as, chewing gum and potato chips. Another disadvantage is they have to be periodically tightened by your orthodontist causing increased amounts of discomfort.

· Customized Orthodontic Treatment Systems (an example of which is Suresmile) combine high-technology including 3-D imaging, treatment planning software and a robot to custom bend the wire. Customized systems such as this offer faster treatment times and more efficient results. Treatment can be more expensive and is not available at all orthodontists.

· Progressive, clear removable aligners (examples of which are Invisalign, Originator, and ClearCorrect) may be used to gradually move teeth into their final positions. Aligners are generally not used for complex orthodontic cases, such as when extractions, jaw surgery, or palate expansion are necessary. These braces are the most recent type of braces. Many orthodontists do not use these braces because they feel they do not produce the best corrective results compared to traditional braces, but opinions vary from person to person. The braces are hardly noticeable on the teeth and work to gradually move the teeth into their right position without the need for wires or tightening. Like traditional braces, they do require an improvement in the amount of oral hygiene because they have to be removed to eat and one must brush and floss after every meal.

· For less difficult cases, spring aligners are also an option that can cost much less than braces or Invisalign (one example is NightShiftOrtho) and still align primarily the front six top and bottom teeth.

· Smart brackets are the latest concept under investigation. The smart bracket contains a microchip that measures the forces that act on the bracket and subsequently, the tooth interface . The aim of these braces is to reduce the duration of orthodontic therapy and the related expenses and discomfort to the individual.

· A-braces are another new concept in dental appliances. In the shape of a capital letter A, A-braces are applied, adjusted, removed and completely controlled by the user. At the ends of the A’s arms are angled knobbed bits that the user bites down over. The width between the bits is adjusted by turning the crossbar, housed across the arms, outside the mouth. A user never has to experience pain because the pressure is so easy to control. Though they are not designed or recommended for wearing while sleeping, A-braces may serve as self-adjustable retainers and palate expanders.

Orthodontic services may be provided by any licensed dentist trained in orthodontics. In North America most orthodontic treatment is done by orthodontists, dentists in diagnosis and treatment of malocclusions—malalignments of the teeth, jaws, or both. A dentist must complete 2–3 years of additional post-doctoral training to earn a specialty certificate in orthodontics. There are many general practitioners who also provide orthodontic services.

The first step is to determine whether braces are suitable for the patient. The doctor consults with the patient and inspects the teeth visually. If braces are appropriate, a records appointment is set up where X-rays, molds, and impressions are made. These records are analyzed to determine the problems and proper course of action. The use of digital models is rapidly increasing in the orthodontic industry. Digital treatment starts with the creation of a three-dimensional digital model of the patient’s arches. This model is produced by laser-scanning plaster models created using dental impressions. Computer-automated treatment simulation has the ability to automatically separate the gums and teeth from one another and can handle malocclusions well. This software enables clinicians to ensure, in a virtual setting, that the selected treatment will produce the optimal outcome, with minimal user input.

Typical treatment times vary from six months to two and a half years depending on the complexity and types of problems. Orthognathic surgery may be required in extreme cases. About 2 weeks before the braces are applied, orthodontic spacers are required to spread apart back teeth in order confirm enough space for the bands.

Teeth to be braced will have an adhesive applied to help the cement bond to the surface of the tooth. In most cases the teeth will be banded and then brackets will be added. A bracket will be applied with dental cement, and then cured with light until hardened. This process usually takes a few seconds per tooth. If required, orthodontic spacers may be inserted between the molars to make room for molar bands to be placed at a later date. Molar bands are required to ensure brackets will stick. Bands are also utilized when dental fillings or other dental work make securing a bracket to a tooth infeasible.

An archwire will be threaded between the brackets and affixed with elastic or metal ligatures. Ligatures are available in a wide variety of colors, and the patient can choose which color they like. Archwires are bent, shaped, and tightened frequently to achieve the desired results.

Dental braces, with a transparent power chain, removed after completion of treatment.

Modern orthodontics makes frequent use of nickel-titanium archwires and temperature-sensitive materials. When cold, the archwire is limp and flexible, easily threaded between brackets of any configuration. Once heated to body temperature, the archwire will stiffen and seek to retain its shape, creating constant light force on the teeth.

Brackets with hooks can be placed, or hooks can be created and affixed to the archwire to affix rubber bands to. The placement and configuration of the rubber bands will depend on the course of treatment and the individual patient. Rubber bands are made in different diameters, colors, sizes, and strengths. They are also typically available either colored or clear/opaque.

When applying another type of dental brace, such as Invisalign, the process is quite different but there are similarities like the initial steps of molding the teeth before application. With Invisalign, impressions of the patient’s teeth are sent for evaluation. After viewing and determining the best course of action for the patient, their series of trays are created. The patients dentist or orthodontist receives the trays which fit to the patients mouth almost like a protective mouthpiece.

There are some forms of braces in which the brackets are placed in a special form which are customized to the patients mouth. This reduces the application time for the traditional type of braces. The form contains the metal brackets which are placed in the patients mouth like a mouth guard, drastically reducing the application time.

In many cases there is insufficient space in the mouth for all the teeth to fit properly. There are two main procedures to make room in these cases. One is extraction: teeth are removed to create more space. The second is expansion: the palate or arch is made larger by using a palatal expander. Expanders can be used with both children and adults. Since the bones of adults are already fused, expanding the palate is not possible without surgery to unfuse them. An expander can be used on an adult without surgery, but to expand the dental arch, and not the palate.

Every three to six weeks, the braces must be adjusted. This helps shift the teeth into the correct position. When they get adjusted, the orthodontist removes the colored or metal ligatures keeping the archwire in place. The archwire is then removed, and may be replaced or modified. When the archwire has been placed back into the mouth, the patient may choose a color for the new elastic ligatures, which are then affixed to the metal brackets. The adjusting process may cause some discomfort, which is normal.

Post-treatment

In order to avoid the teeth moving back to their original position, retainers may be worn once the treatment with braces is complete.

Patients may need post-orthodontic surgery, such as a fiberotomy or alternatively a gum lift, to prepare their teeth for retainer use and improve the gumline contours after the braces come off.

Retainers

Main article: Retainer (orthodontic device)

Hawley retainers are the most common type of retainers. This picture shows retainers for the top and bottom of the mouth.

In order to prevent the teeth moving back to their original position, retainers may be worn once the treatment with braces is complete for the patient depending on their specific needs. Retainers help in maintaining and stabilizing the position of teeth long enough to permit reorganization of the supporting structures after active phase of orthodontic therapy.If the patient does not wear the braces appropriately for the right amount of time, the teeth may move towards their previous position. For regular traditional braces Hawley retainers are used. They are made of metal hooks that surround the teeth and are enclosed by an acrylic plate shaped to fit the patient’s palate. For invisalign braces an Essix retainer is used. They are similar to the regular invisalign braces and is a clear plastic tray that is firmly fitted to the teeth that stays in place. There is also a bonded retainer where a wire is permanently bonded to the lingual side of the teeth, usually the lower teeth only. Doctors will sometimes refuse to remove this retainer, and it may require a special orthodontic appointment to have it removed.

Malocclusion is a common finding, although it is not usually serious enough to require treatment. Those who have more severe malocclusions may require orthodontic and sometimes surgical treatment (orthognathic surgery) to correct the problem. Correction of malocclusion may reduce risk of tooth decay and help relieve excessive pressure on the temporomandibular joint. Orthodontic treatment is also used to align for aesthetic reasons.

Malocclusions may be coupled with skeletal disharmony of the face, where the relations between the upper and lower jaws are not appropriate. Such skeletal disharmonies often distort sufferer’s face shape, severely affect aesthetics of the face and may be coupled with mastication or speech problems. In these cases the dental problem is, most of the time, derived from the skeletal disharmony.[citatioeeded] Most skeletal malocclusions can only be treated by orthognathic surgery.

Malocclusions can be divided mainly into three types, depending on the sagittal relations of teeth and jaws, by Angle’s classification method. However, there are also other conditions e.g. crowding of teeth, not directly fitting into this classification.

Many authors have tried to classify or modify Angle’s classification. This has resulted in many subtypes.

Edward Angle, who is considered the father of modern orthodontics, was the first to classify malocclusion. He based his classifications on the relative position of the maxillary first molar. According to Angle, the mesiobuccal cusp of the upper first molar should align with the buccal groove of the mandibular first molar. The teeth should all fit on a line of occlusion which is a smooth curve through the central fossae and cingulum of the upper canines, and through the buccal cusp and incisal edges of the mandible. Any variations from this resulted in malocclusion types. It is also possible to have different classes of malocclusion on left and right sides.

Class I: Neutrocclusion Here the molar relationship of the occlusion is normal or as described for the maxillary first molar, but the other teeth have problems like spacing, crowding, over or under eruption, etc.

Class II: Distocclusion (retrognathism, overjet) In this situation, the upper molars are placed not in the mesiobuccal groove but anteriorly to it. Usually the mesiobuccal cusp rests in between the first mandibular molars and second premolars. There are two subtypes:

Class II Division 1: The molar relationships are like that of Class II and the anterior teeth are protruded.

Class II Division 2: The molar relationships are class II but the central are retroclined and the lateral teeth are seen overlapping the centrals.

Class III: Mesiocclusion (prognathism, negative overjet) In this case the upper molars are placed not in the mesiobuccal groove but posteriorly to it. The mesiobuccal cusp of the maxillary first molar lies posteriorly to the mesiobuccal groove of the mandibular first molar. Usually seen as when the lower front teeth are more prominent than the upper front teeth. In this case the patient very often has a large mandible or a short maxillary bone.

Crowding of teeth is where there is insufficient room for the normal complement of adult teeth.

Cause

Extra teeth, lost teeth, impacted teeth, or abnormally shaped teeth have been cited as causes of malocclusion. Ill-fitting dental fillings, crowns, appliances, retainers, or braces as well as misalignment of jaw fractures after a severe injury are other causes. Tumors of the mouth and jaw childhood habits such as thumb sucking, tongue thrusting, pacifier use beyond age 3, and prolonged use of a bottle have also been identified as causes.

A 2011 paper suggested that “the changes in human skulls are more likely driven by the decreasing bite forces required to chew the processed foods eaten once humans switched to growing different types of cereals, milking and herding animals about 10,000 years ago.”

Treatment

Crowding of the teeth is treated with orthodontics, often with tooth extraction, dental braces, followed by growth modification in children or jaw surgery (orthognathic surgery) in adults. Surgery may be required on rare occasions. This may include surgical reshaping to lengthen or shorten the jaw (orthognathic surgery). Wires, plates, or screws may be used to secure the jaw bone, in a manner similar to the surgical stabilization of jaw fractures. Very few people have “perfect” alignment of their teeth. However, most problems are very minor and do not require treatment.

Other kinds of malocclusions are due to vertical discrepancies. Long faces may lead to open bite, while short faces can be coupled to a deep bite. However, there are many other more common causes for open bites (such as tongue thrusting and thumb sucking), and likewise for deep bites.

Malocclusions can also be secondary to transverse skeletal discrepancy or to a skeletal asymmetry.

Oral habits and pressure on teeth or the maxilla and mandible are etiological factors in malocclusion.

In the active skeletal growth mouthbreathing, finger sucking, thumb sucking, pacifier sucking, onychophagia (nail biting), dermatophagia, pen biting, pencil biting, abnormal posture, deglutition disorders and other habits greatly influence the development of the face and dental arches.

Pacifier sucking habits are also correlated with otitis media.

Dental caries, periapical inflammation and tooth loss in the deciduous teeth alter the correct permanent teeth eruptions.

If traumatic occlusion is not treated on time the chances of periodontal disease increase greatly. This is because of those teeth which are not straight or properly aligned. The biting pressure exerted by other teeth makes them become loose and eventually become diseased. Proper identification of this condition is necessary in order to treat it rightly. People who are in a habit of biting their nails or sucking their thumb are often victims of traumatic occlusion. If proper treatment is not provided, it leads to the next stage of this condition known as occlusal trauma, which can be primary or secondary.

Traumatic occlusion is mostly treated by a procedure called occlusal equilibration in which the chewing and biting surfaces of teeth are grinded to achieve balance and proper alignment. By doing so the pressure on individual teeth is lessened, thereby making them less susceptible to becoming weak or contaminated. Other than occlusal equilibration, occlusal restoration is also sometimes prescribed to correct the alignment of teeth. Crooked teeth are replaced or reconstructed through restorative procedures in order to improve the normal functioning of the mouth.

Appliances known as jaw repositioners are also used for the treatment of traumatic occlusion. These devices are worn like braces and need to be adjusted and tightened after regular intervals of time until a desired tooth position is achieved. These appliances provide a temporary solution and may require other complex treatments to permanently correct the problem. These treatments include orthodontics, occlusal adjustment and orthognathics. In some cases all of these treatments are required to correct the alignment of different teeth and completely cure traumatic occlusion.

Orthognathics is a term used to describe the correctness of upper and lower jaw alignment and the treatment is called orthognathic surgery. This type of surgery is intended to correct the bone relationship rather than straightening of the teeth. If there is a need to straighten the teeth, orthodontics (braces) are used. Occlusal or bite adjustment is similar to occlusal equilibration. How much adjustment is required is determined by using computer-based occlusal analysis. This type of adjustment is needed when there are loose or shifting teeth, severe grinding or clenching during sleep, and sensitivity to temperature. If you suffer from constant headache due to misalignment of your jaw, you should opt for one of the above-mentioned treatments to prevent further damage.

Periodontitis /ˌ p ɛr i oʊ d ɒ n ˈ t aɪ t ɪ s / or pyorrhea /ˌ p aɪ ə ˈ r i ə / is a set of inflammatory diseases affecting the periodontium, i.e., the tissues that surround and support the teeth. Periodontitis involves progressive loss of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and subsequent loss of teeth. Periodontitis is caused by microorganisms that adhere to and grow on the tooth’s surfaces, along with an overly aggressive immune response against these microorganisms. A diagnosis of periodontitis is established by inspecting the soft gum tissues around the teeth with a probe (i.e., a clinical exam) and by evaluating the patient’s x-ray films (i.e. a radiographic exam), to determine the amount of bone loss around the teeth.[1] Specialists in the treatment of periodontitis are periodontists; their field is known as “periodontology” or “periodontics”.

The word “periodontitis” comes from the Greek peri, “around”, odous (genitive odontos), “tooth”, and the suffix -itis, in medical terminology “inflammation”.

Classification

The 1999 classification system for periodontal diseases and conditions listed seven major categories of periodontal diseases, of which the last six are termed destructive periodontal disease because the damage is essentially irreversible. The seven categories are as follows:

Gingivitis

Chronic periodontitis

Aggressive periodontitis

Periodontitis as a manifestation of systemic disease

Necrotizing ulcerative gingivitis/periodontitis

Abscesses of the periodontium

Combined periodontic-endodontic lesions

Moreover, terminology expressing both the extent and severity of periodontal diseases are appended to the terms above to denote the specific diagnosis of a particular patient or group of patients.

Extent

The extent of disease refers to the proportion of the dentition affected by the disease in terms of percentage of sites. Sites are defined as the positions at which probing measurements are taken around each tooth and, generally, six probing sites around each tooth are recorded, as follows:

· mesiobuccal

· mid-buccal

· distobuccal

· mesiolingual

· mid-lingual

· distolingual

If up to 30% of sites in the mouth are affected, the manifestation is classification as localized; for more than 30%, the term generalized is used.

Severity

The severity of disease refers to the amount of periodontal ligament fibers that have been lost, termed clinical attachment loss. According to the American Academy of Periodontology, the classification of severity is as follows:[3]

Mild: 1–2 mm of attachment loss

Moderate: 3–4 mm of attachment loss

Severe: ≥ 5 mm of attachment loss

Signs and symptoms

In the early stages, periodontitis has very few symptoms; and in many individuals the disease has progressed significantly before they seek treatment.

Symptoms may include the following:

Redness or bleeding of gums while brushing teeth, using dental floss or biting into hard food (e.g. apples) (though this may occur even in gingivitis, where there is no attachment loss)

Gum swelling that recurs

Spitting out blood after brushing teeth

Halitosis, or bad breath, and a persistent metallic taste in the mouth

Gingival recession, resulting in apparent lengthening of teeth. (This may also be caused by heavy handed brushing or with a stiff tooth brush.)

Deep pockets between the teeth and the gums (pockets are sites where the attachment has been gradually destroyed by collagen-destroying enzymes, known as collagenases)

Loose teeth, in the later stages (though this may occur for other reasons as well)

Patients should realize that the gingival inflammation and bone destruction are largely painless. Hence, people may wrongly assume that painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that patient.

Effects outside the mouth

Periodontitis has been linked to increased inflammation in the body such as indicated by raised levels of C-reactive protein and Interleukin-6.It is through this linked to increased risk of stroke, myocardial infarction, and atherosclerosis. It also linked in those over 60 years of age to impairments in delayed memory and calculation abilities.Individuals with impaired fasting glucose and diabetes mellitus have higher degree of periodontal inflammation, and often have difficulties with balancing their blood glucose level owing to the constant systemic inflammatory state, caused by the periodontal inflammation. Although no causative connection was proved yet, a recent study revealed an epidemiological association between chronic periodontitis and erectile dysfunction.

Causes

Periodontitis is an inflammation of the periodontium, i.e., the tissues that support the teeth. The periodontium consists of four tissues:

· gingiva, or gum tissue;

· cementum, or outer layer of the roots of teeth;

· alveolar bone, or the bony sockets into which the teeth are anchored;

· periodontal ligaments (PDLs), which are the connective tissue fibers that run between the cementum and the alveolar bone.

The primary etiology (cause) of gingivitis is poor oral hygiene which leads to the accumulation of a mycotic and bacterial matrix at the gum line, called dental plaque. Other contributors are poor nutrition and underlying medical issues such as diabetes. New finger nick tests have been approved by the Food and Drug Administration in the US, and are being used in dental offices to identify and screen patients for possible contributory causes of gum disease such as diabetes.

In some people, gingivitis progresses to periodontitis –- with the destruction of the gingival fibers, the gum tissues separate from the tooth and deepened sulcus, called a periodontal pocket. Subgingival microorganism (those that exist under the gum line) colonize the periodontal pockets and cause further inflammation in the gum tissues and progressive bone loss. Examples of secondary etiology are those things that, by definition, cause microbic plaque accumulation, such as restoration overhangs and root proximity.

Smoking is another factor that increases the occurrence of periodontitis, directly or indirectly, and may interfere with or adversely affect its treatment.

Ehlers-Danlos Syndrome is a periodontitis risk factor.

If left undisturbed, microbic plaque calcifies to form calculus, which is commonly called tartar. Calculus above and below the gum line must be removed completely by the dental hygienist or dentist to treat gingivitis and periodontitis. Although the primary cause of both gingivitis and periodontitis is the microbic plaque that adheres to the tooth surface, there are many other modifying factors. A very strong risk factor is one’s genetic susceptibility. Several conditions and diseases, including Down syndrome, diabetes, and other diseases that affect one’s resistance to infection also increase susceptibility to periodontitis.

Another factor that makes periodontitis a difficult disease to study is that human host response can also affect the alveolar bone resorption. Host response to the bacterial-mycotic insult is mainly determined by genetics; however, immune development may play some role in susceptibility.

According to some researchers periodontitis may be associated with higher stress.

Prevention

Daily oral hygiene measures to prevent periodontal disease include:

Brushing properly on a regular basis (at least twice daily), with the patient attempting to direct the toothbrush bristles underneath the gum-line, to help disrupt the bacterial-mycotic growth and formation of subgingival plaque.

Flossing daily and using interdental brushes (if there is a sufficiently large space between teeth), as well as cleaning behind the last tooth, the third molar, in each quarter.

Using an antiseptic mouthwash. Chlorhexidine gluconate-based mouthwash in combination with careful oral hygiene may cure gingivitis, although they cannot reverse any attachment loss due to periodontitis.

Using periodontal trays to maintain dentist-prescribed medications at the source of the disease. The use of trays allows the medication to stay in place long enough to penetrate the biofilms where the microorganism are found.

Regular dental check-ups and professional teeth cleaning as required. Dental check-ups serve to monitor the person’s oral hygiene methods and levels of attachment around teeth, identify any early signs of periodontitis, and monitor response to treatment.

Typically dental hygienists (or dentists) use special instruments to clean (debride) teeth below the gumline and disrupt any plaque growing below the gumline. This is a standard treatment to prevent any further progress of established periodontitis. Studies show that after such a professional cleaning (periodontal debridement), microbic plaque tend to grow back to pre-cleaning levels after about 3–4 months. Nonetheless, the continued stabilization of a patient’s periodontal state depends largely, if not primarily, on the patient’s oral hygiene at home as well as on the go. Without daily oral hygiene, periodontal disease will not be overcome, especially if the patient has a history of extensive periodontal disease.

Periodontal disease and tooth loss are associated with an increased risk of cancer.

Contributing causes may be high alcohol consumption or a diet low in antioxidants.

The cornerstone of successful periodontal treatment starts with establishing excellent oral hygiene. This includes twice daily brushing with daily flossing. Also the use of an interdental brush is helpful if space between the teeth allows. For smaller spaces a product called “Soft Picks” are an excellent manual cleaning device. Persons with dexterity problems such as arthritis may find oral hygiene to be difficult and may require more frequent professional care and/or the use of a powered tooth brush. Persons with periodontitis must realize that it is a chronic inflammatory disease and a lifelong regimen of excellent hygiene and professional maintenance care with a dentist/hygienist or periodontist is required to maintain affected teeth.

Initial therapy

Removal of microbic plaque and calculus is necessary to establish periodontal health. The first step in the treatment of periodontitis involves non-surgical cleaning below the gumline with a procedure called scaling and debridement. In the past, Root Planing was used (removal of cemental layer as well as calculus). This procedure involves use of specialized curettes to mechanically remove plaque and calculus from below the gumline, and may require multiple visits and local anesthesia to adequately complete. In addition to initial scaling and root planing, it may also be necessary to adjust the occlusion (bite) to prevent excessive force on teeth that have reduced bone support. Also it may be necessary to complete any other dental needs such as replacement of rough, plaque retentive restorations, closure of open contacts between teeth, and any other requirements diagnosed at the initial evaluation.

Reevaluation

Multiple clinical studies have shown that non-surgical scaling and root planing is usually successful if the periodontal pockets are shallower than 4–5 mm (See articles by Stambaugh RV, Int J Periodontics Rest Dent, 1981 or Waerhaug J, J Periodontol, 1978). It is necessary for the dentist or hygienist to perform a reevaluation 4–6 weeks after the initial scaling and root planing, to determine if the patient’s oral hygiene has improved and inflammation has regressed. Probing should be avoided at 4–6 weeks, and an analysis by gingival index should determine the presence or absence of inflammation. Three monthly reevaluation of periodontal therapy should involve periodontal charting as a better indication of the success of treatment, and to see if other courses of treatment can be identified. Pocket depths of greater than 5-6mm which remain after initial therapy, with bleeding upon probing, indicate continued active disease and will very likely lead to further bone loss over time. This is especially true in molar tooth sites where furcations (areas between the roots) have been exposed.

Surgery

If non-surgical therapy is found to have been unsuccessful in managing signs of disease activity, periodontal surgery may be needed to stop progressive bone loss and regenerate lost bone where possible. There are many surgical approaches used in treatment of advanced periodontitis, including open flap debridement, osseous surgery, as well as guided tissue regeneration and bone grafting. The goal of periodontal surgery is access for definitive calculus removal and surgical management of bony irregularities which have resulted from the disease process to reduce pockets as much as possible. Long-term studies have shown that in moderate to advanced periodontitis, surgically treated cases often have less further breakdown over time and when coupled with a regular post-treatment maintenance regimen are successful iearly halting tooth loss iearly 85% of patients.

Maintenance

Once successful periodontal treatment has been completed, with or without surgery, an ongoing regimen of “periodontal maintenance” is required. This involves regular checkups and detailed cleanings every three months to prevent re-population of periodontitis-causing microorganism, and to closely monitor affected teeth so that early treatment can be rendered if disease recurs. Usually periodontal disease exists due to poor plaque control, therefore if the brushing techniques are not modified, a periodontal recurrence is probable.

Alternative treatments

Periodontitis has an inescapable relationship with subgingival calculus (tartar). The first step in any procedure is to eliminate calculus under the gum line, as it houses destructive anaerobic microorganisms that consume bone, gum and cementum (connective tissue) for food.

Most alternative “at-home” gum disease treatments involve injecting anti-microbial solutions, such as hydrogen peroxide, into periodontal pockets via slender applicators or oral irrigators. This process disrupts anaerobic microorganism colonies and is effective at reducing infections and inflammation when used daily. A number of potions and elixirs that are functionally equivalent to hydrogen peroxide are commercially available but at substantially higher cost. However, such treatments do not address calculus formations, and so are short-lived, as anaerobic microorganism colonies quickly regenerate in and around calculus.

Additionally, Periodontitis can be treated in a noninvasive manner by means of Periostat, an FDA-approved, orally-administered drug that has been shown to reduce bone loss. Its mechanism of action in part involves inhibition of Matrix metalloproteinases (such as collagenase), which degrade the extracellular matrix under inflammatory conditions. This ultimately can lead to reduction of aveolar bone-loss in patients with periodontal disease (as well as patients without periodontitis).

Prognosis

Dentists and dental hygienists measure periodontal disease using a device called a periodontal probe. This is a thin “measuring stick” that is gently placed into the space between the gums and the teeth, and slipped below the gum-line. If the probe can slip more than 3 millimeters below the gum-line, the patient is said to have a gingival pocket if no migration of the epithelial attachment has occurred or a periodontal pocket if apical migration has occurred. This is somewhat of a misnomer, as any depth is in essence a pocket, which in turn is defined by its depth, i.e., a 2 mm pocket or a 6 mm pocket. However, it is generally accepted that pockets are self-cleansable (at home, by the patient, with a toothbrush) if they are 3 mm or less in depth. This is important because if there is a pocket which is deeper than 3 mm around the tooth, at-home care will not be sufficient to cleanse the pocket, and professional care should be sought. When the pocket depths reach 6 and 7 mm in depth, the hand instruments and cavitrons used by the dental professionals may not reach deeply enough into the pocket to clean out the microbic plaque that cause gingival inflammation. In such a situation the bone or the gums around that tooth should be surgically altered or it will always have inflammation which will likely result in more bone loss around that tooth. An additional way to stop the inflammation would be for the patient to receive subgingival antibiotics (such as minocycline) or undergo some form of gingival surgery to access the depths of the pockets and perhaps even change the pocket depths so that they become 3 mm or less in depth and can once again be properly cleaned by the patient at home with his or her toothbrush.

If a patient has 7 mm or deeper pockets around their teeth, then they would likely risk eventual tooth loss over the years. If this periodontal condition is not identified and the patient remains unaware of the progressive nature of the disease then, years later, they may be surprised that some teeth will gradually become loose and may need to be extracted, sometimes due to a severe infection or even pain.

According to the Sri Lankan tea labourer study, in the absence of any oral hygiene activity, approximately 10% will suffer from severe periodontal disease with rapid loss of attachment (>2 mm/year). 80% will suffer from moderate loss (1–2 mm/year) and the remaining 10% will not suffer any loss.

Periodontitis is very common, and is widely regarded as the second most common disease worldwide, after dental decay, and in the United States has a prevalence of 30–50% of the population, but only about 10% have severe forms.

Like other conditions that are intimately related to access to hygiene and basic medical monitoring and care, periodontitis tends to be more common in economically disadvantaged populations or regions. Its occurrence decreases with higher standard of living. In Israeli population, individuals of Yemenite, North-African, South Asian, or Mediterranean origin have higher prevalence of periodontal disease than individuals from European descent.

There are 2 types of Dental Splints:

Fixed Dental Splints

Removable Dental Splints

These are divided into types based on their property of allowing movement to the Dental Structures. These are used to immobilize the Oral structures to aid in the healing process.

Fixed Dental Splints:

Fixed Dental Splints are further divided into types:

Sectional acrylic cap splint

Vacuum / pressure formed splints

Interdental Wiring

Arch Bar

Sectional Acrylic Cap Splint:

Synonyms: stout’s or ribbon splint.

Uses:

Immobilization of dento alveolar structures

Mandibular fractures.

Advantages:

Simplicity of the appliance

Little lab equipment is required for its construction.

Sectional Acrylic Cap Splint

Procedure Of Splinting Using Sectional Acrylic Cap Splint:

It consists of acrylic band or flange.

Undercuts need not be eliminated.

By embracing the crown and more especially the interdental spaces excellent retention is obtained.

1cm in diameter is situated on the buccal aspect of splint.

If displacement is present then obtain a working model, correcting this my dividing the model to wire connectors are adapted.

From half round1.25 mm diameter of stainless steel wire around the distal aspect and then splint is fabricated in wax.

Wire ends are left long in order to obtain retention.

An essential component of this splint is the formation of wax button approximately 1cm in diameter is situated on the buccal aspect of splint.

The model with wax splint is then invested making sure that the wire inserts are secured in the plaster matrix.

Following separation of two halves the flask, the wax is boiled out and the plaster surface painted with cold mould seal.

If splint is urgently requires then cold cure acrylic is used.

When processed, splint is removed from plaster, trimmed and polished.

Splint is sectioned vertically retaining the button, longitudinally along any edentulous spaces.

Allows splint to be opened out and sprung into position on the model.

Fixation into the mouth is obtained by passing a soft stainless steel wire around the vertically divided button and through holes drilled horizontally through any edentulous areas.

This will firmly adapt the splint into all the retaining sites to obtain adequate stability and immobilization.

Vacuum / pressure formed splints

Uses:

Fixation of dento alveolar fractures.

Advantages:

Method of construction is extremely simple and not time taking.

Highly plasticised polymeric material in sheet form can be used.

Two basic techniques:

Vacuum forming (suck down)

Pressure forming ( blow down).

Procedure Of splinting Using Vacuum / Pressure formed Splints:

Impression of both arches are taken and working models are prepared.

Displaced teeth should be ligated together in order to restore the original arch form.

Gingival margins around the teeth are trimmed.

Large tooth undercuts should be blocked out with plaster to provide a common path.

With both methods of adapting the splint material it is advisable to trim the edges of the base of the model to the full depth of sulcus

The working model is placed on top plate of machine and a suitable shaped dry sheet of appropriate material is located and clapped beneath the heating section.

Following cooling the splint is carefully eased from the model and the gingival margins are trimmed.

The contoured splint is fitted back to the working model to check the relationship of the edges of splint o the gingival margin and occlusion with the opposing model.

Interdental Wiring:

Thin soft stainless tell wires are used for this type of fixation.

It is important that the ligatures are applied to several adjacent teeth on both sides of traumatized area to achieve sufficient stabilization.

For additional stability cold cure acrylic can be placed around the interdental ligatures.

The stabilization properties of this ligature are limited due to lack of rigidity especially when the wires become to stretch.

So interdental wiring should be limited to fixation of a single traumatized tooth

Arch Bars

Metal bars fitted to the dental arch and ligated to the individual teeth are commonly used

Most often a semi-circular soft metal bar is manually shaped to fit the dental arch

This is used for immobilization of avulsed and partially displaced tooth

Disadvantage:

The correct positioning of traumatized teeth is ofteot obtained because of difficulties in exact adaptation of the dental arch.

Removable Splints:

Occlusal splints : They are used in tempero-mandibular disorder patients. They are Divided into 2 groups

· Auto-repositioning

· Anterior – repositioning

Auto-repositioning :

It is mostly used to treat muscle problems & eliminate tmj pain .

This splint allows full arch dental contact with the condyles in more posterior retruded position .

This also allows the patient to seek a comfortable muscle & joint position without excessive influence of occlusion.

Ex: Patient with Class II malocclusion & significant overjet complain of muscular sympotms & describe a feeling that they do not have a consistent repeatable bite relationship.

Anterior –repositioning :

Used for temporary relief in rare cases & long term cure for anterior disc displacement .

In this case the anterior position is determined by protrusion of mandible necessary to produce proper disc & condoyle relationships .

These are usually worn 24 hours a day for several months .

These splints are generally effective in producing permanent reduction of disc displacement

SVED Splints:

It is a removable appliance fabricated in acrylic .

It is constructed such that the acrylic extends over the occlusal / incisal surface of the tooth thereby fixing & stabilizing it .

1. Measure and cut the fibre

Measure the length of fibre needed by using, for example, a periodontal probe or dental floss. Cut the appropriate amount of the ever StickPERIO fibre with the silicone bed using sharp scissors

2. Clean the teeth

The entire length of the fibre splint must be bonded to tooth surfaces. Clean the tooth surfaces and approximal areas with a paste of pumice and water, rinse and air-dry the area. Place wedges in the interdental spaces as necessary, so that the spaces to be cleaned are not filled with composite. If you are working without wedges, be careful not to block these spaces with composite.

3. Etch the tooth surfaces

In the area of the splint etch the tooth surfaces and approximal areas thoroughly with ortho-phosphoric acid. Preferably etch a slightly wider area thaecessary rather than too little. The recommended enamel etching time for surface-retained areas is 45 to 60 seconds. Rinse with water and air-dry the tooth surfaces after etching. As with all bonded restorations, a dry operating field is absolutely necessary. A rubber dam isolation is highly recommended.

4. Bond the tooth surfaces

Use the adhesive bonding technique for bonding teeth according to the instructions

of the bonding agent manufacturer. Apply the bonding agent to the entire area to be

bonded. Light-cure the bonding agent as described by the manufacturer.

5. Apply flowable composite

Apply a continuous thin layer of flowable composite (for example, StickFLOW) on the teeth including the approximal areas. Leave enough space for cleaning the interdental spaces. Do not cure the composite during this hase.

6–7. Position and light-cure the fibre

Place the fibre bundle on top of the uncured flowable composite. Aim to place the fibre as incisally as possible in the anterior area. Make sure that it will not be in occlusion. Position one end of the fibre bundle first by pressing it down with the StickSTEPPER instrument. Pre-cure the fibre in place, one tooth at a time, for about five seconds, using a curing light. The wide-tipped StickSTEPPE instrument shields the rest of the fibre from light. As the fibre is made of light-conducting material, it is recommended to direct thelight-curer away from the uncured fibre bundle. Press the fibre into the approximal areas as well. Make sure that the interdental spaces are not blocked with fibre and composite.

8. Cover and finish the splint

After pre-curing, cover the entire fibre splint with a thin layer of composite. Note that in surface-retained areas the fibre bundle can be coated with a thin layer (0.5 mm) of flowable composite. Then light cure the whole retainer for 40 seconds, one tooth or coverage area of the light-curer at a time. Be careful not to cut the fibre when finishing/polishing the splint.

Intra-coronal periodontal splinting of anterior and posterior teeth

The steps for the intra-coronal splint are the same as for the surface retained splint except for that a masial-to-distal groove is prepared in the teeth to be splinted.

Aesthetic periodontal splint-bridge

When teeth are lost for periodontal reasons, there are different options as to how they may be replaced and the remaining teeth stabilised. Sometimes the missing teeth can be used as pontics, sometimes other solutions are necessary. When the natural teeth cannot be used, composite replacements are possible. For some cases this is considered very time consuming. Denture teeth can be used as a faster alternative. The case on this page is a good example of how to do that. Two central incisors of this 60-year-old patient were missing, and the lateral incisors showed increased mobility.

The patient had stage II mobility in the remaining front teeth, and wanted treatment to save them. The missing teeth were not available to make a splint-bridge.

Small retention holes were prepared in the teeth. A model was produced from an impression, the future outline of the prosthesis was marked and the denture teeth were adjusted and fixed with wax.

Undercuts were prepared on the proximallingual surfaces to enhance the connection with the Ribbond framework.

The correct length for the Ribbond fibres was established with the help of tin foil. Then the entire lingual surfaces of the denture teeth were wetted with a monomer of heat curable resin and dried. Single Bond adhesive was then applied to these surfaces and light cured.

Then the proper length of Ribbond fibre is positioned onto a thin first layer of uncured Z100 restorative. The fibre is pressed into the composite for optimum wetting. The composite was then light cured.

A second layer of the composite was applied to smooth the exposed surfaces.

The lingual view of the teeth prior to 8placement of the splint-bridge. The tooth surfaces were prepared by proper application of Single Bond adhesive which was light cured.

The bridge was then placed with a thin layer of Z100 restorative, which was cured through the bridge. This is the labial view 6 months after placement.

A radiograph of the restoration shows the weave of the fibres and the thicker areas of composite in the undercut.

Bite Splints in General Dental Practice

This handout is not supposed to be the only basis for working with bite splints. It has to be complemented with information from instructors assigned to help in clinics.

Introduction A bite splint (synonyms: occlusal splint, bite plane, night guard) is a removable appliance, usuallyfabricated of resin, most often designed to cover allthe occlusal and incisal surfaces of the teeth in the upperor lower jaw. It is being used frequently in treatment of patients with temporomandibular joint disorders (TMD) and related diseases such as tension headache function, and jaw muscle function affects the way the TMJ functions. Therefore changes in the patient’s occlusion will at least sometimes have some effect on the jaw muscles and the TMJ structures. The effect can be direct by changing the relations between the intracapsular TMJ elements or indirect by affecting the muscles’ working conditions. In extreme condition changes in occlusion may lead to displacement and destruction of the TMJ disks. Occlusal interferences may thus cause internal TMJ derangement.

Plane maxillary splint. The articulator paper markings are from contacts with mandibular cusps and incisal edges. It is desirable that all supporting cusps make contact with the splint at jaw closing.

Schematic drawing showing the outline of a maxillary bite splint of Michig antype. and neck pain. One advantage with bite splints is that hey provide a relatively easy, inexpensive and nonharmful ay to make reversible changes in theclusion. The goal for bite splint treatment ismainly to improve jaw muscle and TMJ functiod to relieve pain related to dysfunction of those ystems. The most common reason for bite splint rescription is, however, bruxism. o evaluate the possible role of occlusion in he etiology of TMD and jaw muscle dysfunction in atient examination it is necessary to have a good nderstanding of functional jaw muscle and TMJ natomy. Occlusion affects the way jaw muscles nternal derangements such as disk displacement may ertainly be caused by a number of other factors,for instance trauma to the jaw. Such a displacement ay change the occlusion and make it unstable with bservable interferences. The role of interferences s complex and there is no general agreement about role of interferences in TMD etiology. here is no general agreement about if and hy splint treatment may have a beneficial effect. ome researchers have found that about 80% oftheir patients received some benefit from splint herapy. Some claim, however, that the only effect is lacebo. With such a divergence in opinions about he value of splint treatment, it is understandable that his figure illustrates the importance of ooking at occlusion, jaw muscles, and he temporomandibular joint (TMJ) as nits which are dependent upon each ther in function. That is we need to ave good knowledge about all units to reat any of them and preserve optimalfunction of the stomathognathic system. no consensus has been reached about pros and cons of different designs. Numerous variations in design, and explanations for its possible effect, have been published since Karolyi 1901 described his splint. It is difficult to prove or disprove the advantages of one type or another. There are often large discrepancies between the signs observed by the therapist and the symptoms described by the patients. Most of what we know about splint design and use is based on “clinical experience”. Still, the clinician should not hesitate in suggesting conservative splint treatment when he/she sees a reason for it. Compared to most other treatment modalities, it is an inexpensive, non- invasive, reversible procedure which, according to most clinically experienced authors, has a high success rate. A reasonable assumption seems to be that rigid rules for the design of a splint are less justified and that a splint, following a few basic principles, is well justified for the following purposes:

To protect the teeth in bruxing patients.

To protect the cheek and/or tongue in patients with oral parafunctions.

To stabilize unstable occlusion.

To promote jaw muscle relaxation in patients with stress related pain symptoms like tension headache and neck pain of muscular origin.

To test the effect of changes in occlusion on the TMJ and jaw muscle function before extensive restorative treatment.

To eliminate the effect of occlusal interferences.

Sagittal sections through one TM joint with the disk iormal position (left) and another oint with the disk displaced anteriorly (right).So called repositioning splints were for a while often used in attempts to help the disk go back and stay in a normal position.

The well known Posselt-diagram shows the so called border movements of the lower jaw (mandible). Impaired ability to perform such movements is an important sign of TMJ dysfunction. It is important to make notes about the patient’s ability to perform jaw movements before and during bite splint treatment. RC=rotation center (center for the hinge axis movement when the first part of jaw opening occurs without translation of the condyle). CO=central occlusion or the position of maximal intercuspidation. CR=centric relation. MOR=maximal opening without translation. MORT=maximal opening with rotation and translation. HCP=habitual closing path. MP=maximal protrusion.(Modified after Ramfjord & Ash, 1983).

This coronal (frontal) section through the area of the third molar shows some of the most important jaw closing muscles, the masseter (M) and the temporalis (T) muscles. Pain in those muscles are important signs in TMJ muscle dysfunction and a common reason for bite splint treatment. Note especially the insertion of the temporalis muscle into the coronoid process (CP). Tenderness in this area is often found at intraoral palpation on

TMD patients To unload the TMJ in patients with acute TMJ pain of intracapsular origin Bite splints can be classified according to • Material used for fabrication. • Location of placement. • Design of area for contact with opposing teeth. • Effects on condylar position at clenching. • Specific purposes.

Sagittal section through a plane maxillary splint illustrating one of the important principles namely that all supporting cusps in the lower jaw should make contact with the splint.

Mandibular splint with the occlusal surface in soft cured acrylic. Splints may for instance be classified as follows: A) Splints which make balanced contacts with all opposing teeth at jaw closure a) Causing a minimal increase of vertical allowing the patient to close with a “hinge axis movement”. That is the rotation centers of the condyles are not changed. b) causing a more than minimal increase of the vertical but still without changing the condyles’ rotation centers. c) Increase the vertical and causing a translatory movement of the condyles at the final part of closure (thus changing the rotation centers). B) Splints that make contact only with parts of the opposing arch at jaw closure. a) Contacts only with the anterior teeth in the opposing arch. b) Contacts only with the molar and premolar teeth in the opposing arch. Splints in groups A.a, b have a minimal risk of causing permanent changes in occlusion. Splints in groups A.c and B can cause such changes if used for longer than a few (4-6) weeks. Examples of Group A.c splints for instance, are the so-called repositioning splints. Those have been tried to keep a repositioned disk in a normal position during healing. However, the risk for permanent detrimental changes in the occlusion make the use of repositioning splints less advisable. Long term use of splints that make contact only with some of the opposing teeth may cause serious irreversible changes in the occlusion. Splints where the only contacts are with the incisors may cause an anterior open bite. Splints with contacts only in the molar regions may cause intrusion of the teeth there. There are unfortunately quite a few TMD clinicians who advocate the long term use of such splints without first trying other possible remedies. Most patients use their splints only during sleep to protect them from the effects of involuntary parafunctional motor activities like bruxing, clenching, tongue pressure, etc. Those who caot control such habits when awake may need to use the splint during daytime hours. There are no fixed rules for the length of time that a conservative plane splint (a splint that does not change the jaw relations except for a minimal increase of vertical) should be used. Some patients can discard them after a few months; others may need to continue using them for decades. Splints that do not cover all teeth with balanced contacts with the opposing teeth, like Sved plates, repositioning splints, etc., should, however, not be used for longer periods than four to six weeks. During that time they may have to be used continuously and removed only when brushing the teeth. Irreversible changes may occur in the occlusion if a repositioning splint is used for longer periods than about six weeks. As a general rule a non-specialist should never encourage a patient to use any type of splint for more than a few months except for cases where the teeth need to be protected because of bruxing, clenching habits. Side effects from long term use of splints can be severe and non-reversible especially those from unsupervised mandibular advancement splints and splints covering only the molar and premolar areas. Splint Material Many metal materials have been tried in the past such as gold, silver, – even lead! Most splints are now made using heatcured acrylic. Splints can also be made in soft acrylic or using light cured composite. Soft acrylic splints are usually made for the lower jaw, can be made quickly by the dentist and are indicated for short time use in patients with acute pain and/or dysfunction symptoms caused by muscular hyperactivity or acute trauma. This type is also indicated in children with deciduous teeth if they have signs and symptoms of severe bruxism. Gnashing the teeth may serve the purpose to adjust the occlusion of the deciduous teeth while the jaws are growing. However, a splint may be indicated if the children develop pain symptoms, if the gnashing sounds are disturbing or if the permanent teeth are affected, showing signs of non-functional wear. Hard splints caot be used in children for more than short periods because they may not fit after a relatively short time and therefore interfere with the normal growth pattern. A soft splint may also be indicated in adult patients who caot adjust to a conventional splint because they feel it is too tight, creating tension.

Bite splint with pivot was introduced by Krogh-Poulsen and supposed to be helpful in patients with disk displacement. The proposed effect on the condyles (pulling them down at clenching) has been questioned by several authors and this splint type is now seldom used. A slightly different type of distraction splint has, however, been found beneficial in patients with juvenile rheumatoid arthritis Soft acrylic splint for daytime use are indicated in patients when night time use of a hard splint is not sufficient to relieve the symptoms or break the habit during daytime. A soft splint can be used during daytime to help in breaking the parafunctional habit, either alone or used in one jaw with a conventional hard splint in the other Soft splints do not last as long as those made in hard acrylic and have to be replaced when they are worn down or have lost their fit. They are simple to fabricate and are more easily adjusted to adequate contact patterns due to the softness of the occlusal surface. Replacing the occlusal contact area of a hard cured splint with soft cured acrylic makes a variation of the splint. Some patients prefer the cushion effect created by the soft acrylic.

Maxillary or mandibular splint? Most splints are maxillary. Many clinicians find it easier to make a stable splint with good retention and adequate cuspid guidance in the upper jaw. If the splint is to be used during daytime it may be preferred, for esthetic reasons, to make a mandibular splint which may be less visible. Extension onto the facial surfaces of the incisors should be avoided. Besides not being esthetic it may prevent adequate lipseal. Breakage of lipseal may lead to mouth breathing during sleep with harmful side effects. Extension onto the incisal facial surfaces is not needed for retention which can as well be obtained by extension onto the bucca surfaces of molars and premolars. Such coverage is not visible and does not prevent lipseal. If not enough retention can be obtained that way a couple of simple clasps may be added. A maxillary splint can also be made “invisible” in most cases if extension onto the facial surfaces is avoided. If teeth are missing the splint should be made for the jaw with the fewest teeth. This is especially important if molar support is lost. Some patients have successfully used splints in both the upper and the lower jaws. If molars and premolars are missing in both jaws it may be advisable to make both an upper and a lower splint or to first restore occlusion in at least one jaw with prosthodontic reconstruction. Without specific reasons for a mandibular placement, a splint should be made for the upper jaw. A mandibular splint encroaches more on the space normally occupied by the tongue. In patients with horizontal overjet, a mandibular splint has to be extended in the anterior direction to obtain anterior support. Such a “buttress” may interfere with normal lipseal and irritate the lower lip thereby triggering parafunctional activity in the orbicularis oris. Anterior contact may not be possible in all cases with large horizontal overjet.

Following here are descriptions of some of the most used types of splints. A Michigan (MI) type splint ( plane splint with cuspid guidance) is usually placed in the upper jaw covering all the maxillary teeth, giving the opposing mandibular teeth balanced, even contacts at habitual closure.

There are serious dangers with long term use of nonconservative splints, especially those making contacts with only some of the opposing teeth.In this case a splint which made contact only with the anterior mandibular teeth had been used for more than 10 years. Acute TMJ pain may be relieved but the risk for creating an anterior open bite should be explained to the patient before use.

In a MI splint all mandibular teeth, except the cuspids, are discluded at protrusive and lateral movements. This type is recommended in patients with signs and symptoms of jaw muscle hyperactivity (bruxism, clenching). If teeth are missing, the splint is usually made in the jaw where most teeth are lost. If molar support is lost in one jaw only, the splint should most often be made in that jaw with a saddle extended where teeth are missing. Some patients may feel that a mandibular splint is uncomfortable and a maxillary splint may then be tried in spite of lost mandibular occlusal support. Cuspid Guidance. A cuspid guidance is created to provide a rise in lateral and protrusive movements, so that the only contacts are between the mandibular cuspid apex and the cuspid guidance The mandibular cuspid should slide on a flat area inclined only in the sagittal plane during protrusive and in the coronal (frontal) plane during lateral movements Ideally cuspid guidance should be on the apex of the mandibular cuspid. It may be on the mesial cusp ridge of the mandibular cuspid during protrusive movement or on the distal cusp ridge of the mandibular cuspid during lateral movement. No guidance should be on the axial surface of the mandibular cuspid! There should be no posterior contacts in protrusive and balancing and no incisal contacts in protrusive. In the natural dentition a slide from CR to CO takes place mostly with a vertical and sometimes also with a lateral shift in the mandible’s position. One important goal in the fabrication of a plane splint is to create an area around the contacts at habitual closing which makes it possible for the mandibular teeth to move from CR to a CO position without such vertical or lateral shifts. It is considered by many clinicians that part of the beneficial effect of the plane bite splint is because of the elimination of such shifts. Plane splints without cuspid guidance. For esthetic reasons some patients may prefer to have splints without cuspid guidance. It is easier to make a plane splint “invisible” if that feature is excluded. A common feature to the above two types is that balanced contacts with all opposing supporting

In this case the patient had been given a splint which made contact only with the oppsing posterior teeth. Acute pain was relieved but returned and new layers of acrylic were added which may explain which seems to be intrusion of the posterior teeth and a posterior open bite. The patient had this type of splints for a period of about 10 years. She had chronic TMJ pain. Surgical and orthodontic consults deemed it not possible to recreate a stable occlusion. Study casts and/or photos showing the occlusion before start of bite splint treatment should be kept in the patient file but were in this, as in many similar others, not existing

cusps and the incisal anterior teeth edges should be achieved. There are, however, some clinicians with longtime experience from treating TMD patients who claim that better results are achieved if the anterior contacts (incisal areas) are very light or removed. Bite splint according to Shore. This splint has a design similar to the plane splint but does not extend onto the facial or buccal surfaces of the teeth, and covers the entire palatal area. It may be preferred by some patients who need to use the splint also during daytime, for esthetic reasons, because it can be made less visible. In some patients with parafunctional tongue activities, such a palatal extension may be felt more comfortable. A Michigan splint can easily be changed into this type by removing facial and buccal extensions, adding palatal cover and, if needed, securing adequate retention with clasps.

Relaxation plate (Sved plate). Only the opposing anterior teeth make contact with this splint. It is not recommended if the patient has acute pain in the TMJ or feels pain or soreness at palpation of those areas. It is easy to change a plane splint into a relaxation plate or vice versa. It is recommended that the relaxation type is tried in patients with acute or chronic muscle pain if the plane splint is without effect. It is usually placed on the upper teeth with an incline in the anterior part giving contact only with opposing cuspids and incisors. It should be used only during nighttime and not more than 10- 12 hours/day. There is a risk for intrusion of teeth, which has to be explained to the patient before splint delivery. Regular checkups are, as always, important.

Mandibular splint with lingual bar. Unlike the Sved plate, this type is supposed to be used during daytime. Its primary purpose is to help patients who caot control oral parafunctional activities when awake and do not feel comfortable with a splint of the Shore-type. The splint does not cover the cuspids or the incisors and should have balanced contacts in the premolar and molar areas both in CO and in CR. It is most often adjusted to achieve group contact on the working side at lateral movements. Precautions are the same as for the relaxation type splint.

The left splint was made in heat cured acrylic and the right one in light cured composite (LCC). LCC is an excellent alternative when treating patients with acute pain because the splint can be made “in house” and fabricated in about one hour after casts have been prepared. Some dentists fear the color makes the appearance less attractive. It is, however, not necessary to extend the splint onto the facial surfaces of the anterior teeth. Such coverage should instead be avoided in all splints because it may prevent lipseal and lead to mouth breathing during sleep. Retention can be secured by simple clasps if needed and there are no basis for believing that coverage is needed to keep the anterior teeth from “moving”.

Repositioning splints. Plane bite splints increase the vertical but should not in any other way affect the position of the mandible when habitual clenching occurs on the splint. Repositioning splints guide the mandible into a different position at closing, which is supposed to facilitate repositioning of the disk and reduce the load on retrodiscal pain sensitive areas. These splints are sometimes indicated for short-term use to keep a recaptured disk in a normal superior position for instance when a displaced disk has been recaptured by manipulation.

Bite splint with a pivot. This type was introduced by Krogh-Poulsen about 40years ago and was supposed to be helpful in patients with disk displacement. The proposed effect is that the condyles are pulled downwards upon clenching on the pivot, thereby relieving traumatic load and giving the disk freedom to reassume a normal position. Today it is seldom used because most patients find it uncomfortable.

Cap splints. A cap splint can be described as an intermediary between a splint and a bridge. It is useful for temporary reconstruction before final decision about design, vertical dimension, etc. It is often made in metal with the occlusal surface in hard acrylic.

Combination splint/partial denture and splint/orthodontic appliance. Missing teeth can easily be replaced by adding artificial teeth to the splint. A Shore splint may function as a temporary partial denture by adding artificial teeth. Another fringe area exists between occlusion and orthodontics. There are numerous combinations of splint and orthodontic appliances. An ‘invisible retainer’ may simultaneously function as a soft acrylic splint.

Others. Patients with oral parafunctions like cheek biting, tongue thrust, large diastemata, etc. may benefit from a splint with extensions or enlargements designed in a way that will keep the cheeks from being pinched or the tongue from pressing against the lingual surfaces of the teeth.

Cuspid guidance is a feature of the Michigan splint that has been found clinically useful when added to the plane splint. It functions by breaking all contacts, except for between the guidance and the apex of the mandibular cuspids, during lateral and protrusive movements. It is relatively difficult to create and should be avoided unless the dentist is willing to give enough time to careful adjustments. It is for instance important to establish contact only with the apex of the opposing cuspid and not with the axial surfaces during movement

Fabrication of splint

Many procedures can be left to a laboratory but any dentist more seriously involved in treating TMD patients should be able to make and deliver a splint shortly ( 1-2 hours) after taking impressions. This is especially important if patients have acute pain but also if they have to travel a long way for treatment. Using light cured composite for instance, a splint can be made “in house” and delivered about one hour after the casts have been mounted in articulator.

The main procedures are

Taking and pouring impressions

Face bow recording

Bite registration

Mounting of casts

Blocking out of undercuts

Waxing the splint or forming of composite

Curing of acrylic or composite

Delivery and maintenance of splint

Some of those procedures may be omitted without jeopardizing the end result. It is not always needed to make a face bow recording or bite registration. A few important points should be stressed. If impressions are taken using alginate they should be poured immediately, never waiting more than 1-2 minutes, to avoid dimensional changes. A high quality stone has to be used and mixed with the right proportions of powder and water. A most common mistake is mixing the plaster with too much water. A good choice is for instance Velmix which should be mixed with the proportions 100 g powder to 20 cc water. Other things to remember are that the tray should be large enough to go about 5 mm beyond the most posterior teeth. When placing the tray its essential to not have “break through”, and the thinnest alginate above the occlusal surfaces should be at least 2 mm. An accurate bite registration is difficult to make and deserves special attention. The material used

“Freedom of centric” means that the lower jaw is able to move from centric relation (CR) to centric occlusion (CO) without restrictions in an area with a diameter of 1-2 mm. In the natural dentition this movement has naturally a vertical component but a lateral slide should, according to some clinicians, be avoided and corrected if larger than 1-2 mm. In the Michigan splint the vertical component too should be eliminated. The goal is to let the mandibular supporting cusps slide between contact in splint centric (SCR) and in habitual contact position (CO) without vertical or latera shift.

(mostly wax) should not cover the facial surfaces of the incisors and should not make contact with the soft tissues. It is necessary to see the incisal edges of the anterior teeth to ensure that they are aligned the same way with and without checkbite. The wax should never touch the papillae. If it does those tissues are displaced and the wax will not fit on the cast. Centric relation (CR) caot be properly registered in most patients with acute signs and symptoms of TM disorders. It may even be contraindicated to try to make such a registration. Any pushing of the mandible in a patient with TMJ inflammation and/or internal derangement can increase the tissue injury. It is acceptable and often preferable to register only the position into which the patient habitually closes. Be especially careful with patients with lateral deviations after the first tooth contact at clenching. If the patient has a lateral slide-in-centric, check that the closing movement stops before any lateral slide takes place. Make sure that the wax is thick enough to register a position before the lateral slide

Always try to take a checkbite if:

• There is a large discrepancy between CR and CO.

• There is a significant lateral deviation of the mandible on opening and closing.

• There is a significant lateral slide in centric.

Checkpoints for Centric wax bite registration

• No perforations of wax.

• Stable position on maxillary teeth and on casts.

Face bow registrations are not mandatory but the casts need to be mounted on an articulator, which makes it possible to have normal values of the distance between the casts and the condylar elements.

Taking a good impression may be the most important step in the bite splint fabrication because if the impression is bad nothing can later be done to provide a splint of the best quality. A common fault is to use too small trays and/or let the tray make contact with the teeth (causing a “break-through”). The alginate should not be thinner than 1-2 mm in any area. Break throug is acceptable if it occurs in a soft tissue area not to be cocvered by the splint. The flow of alginate beyond the lingual part of the tray as seen in this picture is not acceptable. It may cause the patient to gag and is easily avoided by tilting th tray at the insertion bringing it up to first make soft tissue contact in the posterior soft tissue areas and the bringing the anterior part of the tray up into its final position. Another important rule is to always pour alginate impressions immediately in high quality stone mixed with correct proportions of water and powder. It is a common mistake to mix the plaster too thin

Casts may be mounted in the position of maximal intercuspidation (CO). An accurate CR checkbite can hardly be made if the patient has acute pain and/or internal TMJ derangement. Many clinicians prefer to take a checkbite in “open vertical” especially if there is a large lateral slide from CR to CO or disk displacement with reduction. If a checkbite is made it is most important to not let the wax extend onto the facial surfaces of the anterior teeth or touch soft tissues. If the wax makes contact with soft tissues it will not fit on the cast. There are some commercially available large prefabricated waxrims which, if used, make it almost impossible to get an accurate recording.

Splint delivery

Freedom of Centric. Flat, “horizontal” area, 0.5 – 1.0 mm in diameter, allowing smooth slide without vertical component, between CR and CO. Use different colors of articulating paper for CO and CR. Borders of splint. Extension not more than 1 mm. in the horizontal plane beyond the occlusal surfaces of the maxillary teeth, minimal thickness adjacent to the second molars and minimal thickness labial to the

The checkbite for the above case was made using a prefabricated wax rim that covered large parts of the facial surfaces of the incisors and probably taken with the mandible in a protruded position. The left picture shows how the patient’s mandible at closing onto the finished splint has been guided into an anterior position. The right picture shows the same splint with the CR position achieved with assistance from the examiner. It is obvious that this splint could not give balanced contact with all mandibular teeth when closing into CR and may cause the patient to habitually go into a protruded position. Light cured composite can be used for fast splint fabrication The method is especially valuable when treating patients with acute TMD problems. For instance if a patients comes with acute disk displacement it is very important to place the splint immediately. The risk for irreversible changes caaturally be expected to increase more the longer the patient has to wait for the treatment splint.The composite is placed on the cast and adjusted on the articulator mounted casts. It can then be cured in a special unit which takes about 90 seconds

incisors. The finished splint should be smooth. Interproximal buccal areas are used for retention. If excessive they should be blocked out to avoid too much retention. Most important is to check the splint for not having too much retention. Especially undesirable are gross extensions onto the facial surfaces of the incisors. Such extensions are really not needed at all. Improved retention can, if needed, be achieved by adding simple ball clasps in the molar or premolar areas or by adding acrylic or composite in the molar interproximal areas on the lingual of the appliance. Mark occlusal contacts with thin (12 microns or less) articulating paper. Thick articulating paper gives enlarged, smudged markings. Check lateral and protrusive movements for interferences with thin articulating paper and with shimstock. When checking for CR and CO use different colors! Reduce the appliance as much as possible in the labial areas and check for lipseal. Avoid excess of acrylic in the external areas by “scalloping” into the buccal embrasures leaving about 1-mm thickness of irreversible changes can naturally be expected to increase more the longer the patient has to wait for the treatment splint.The composite is placed on the cast and adjusted on the articulator mounted casts. It can then be cured in a special unit which takes about 90 seconds.

After the delivery of a splint the dentist has to be ready to see the patient and make adjustments.The soft tissues in a TMJ with inflammation may swell or shrink causing loss of balanced contacts. Creating balanced contacts is supposed to protect the sensitive areas from mechanical pain producing pressure.

Polish all areas to a shiny, glossy finish except where the mandibular teeth cusps make contact. If those areas are polished after adjustment some contacts may be lost. Use a soft rag wheel with wet pumice and a low speed engine to avoid heating and warping of the acrylic. A final polish may be achieved with a rag wheel and Bendick®. Be sure the patient can place and remove the splint. Instruct the patient in the care and maintenance procedures. Reappoint the patient for splint adjustment within one to two weeks after insertion. Be ready to see the patient even earlier. Acute pain may be caused by inflammation in intracapsular TMJ tissues. They may swell or shrink during different stages of the disease period. As one beneficial effect of the splint is supposed to be its unloading effect it is important to maintain balanced occlusion. Therefore repeated adjustments may have to be made for quite long periods. Eliminating all posterior contacts and keeping the anterior may temporarily relieve pain symptoms. This is often only a short term effect and using such a splint for longer periods than 4-6 weeks may lead to extrusion of posterior teeth and/or intrusion of the anterior teeth. It is desirable but not always possible to make and maintain contacts with all opposing balancing cusps. The main goal in splint adjustment is to eliminate any unstable relations.

Checkpoints

• Splint fully seated.

• No rocking.

• adequate retention.

• Even bilateral and posterior contacts.

• No balancing contacts.

• No incisal protrusive contacts.

• Splint comfortable relative to bulk.

• Lipseal.

• Feather edge on palatal side.

• Check for splint centric and CR contacts.

• Do not polish the splint centric contacts.

Comparison of a new dental trauma splint device (TTS) with three commonly used splinting techniques

Abstract – Splinting is the standard of care for stabilization of replanted or repositioned permanent teeth following trauma. The pres- ent experimental study compared four dental trauma splints in 10 volunteers. The evaluated splints included a wire-composite splint (WCS), a button-bracket splint (BS), a resin splint (RS), and a new device (TTS.Titanium Trauma Splint) specifically developed for splinting traumatized teeth. All splints were bonded to the labial surfaces of the maxillary lateral and central incisors. Splints were left in place for 1 week. After splint removal, the next splint was placed after a 1-week rest period. The sequence of splint application was randomized for each individual. The following parameters were assessed: tooth mobility with horizontal and vertical Periotest values (PTV) before and after splint application and splint removal, respectively; probing depths, plaque and bleeding on probing indices before splint application and removal, and chair time needed for splint application and removal. After splint application, horizontal PTV were significantly lower in central incisors for BS compared to TTS (P.0.04), and for RS compared to TTS (P.0.005) and to WCS (P.0.006). Reduction of lateral tooth mobility (.splint effect) expressed by the difference between horizontal preand postoperative PTV was significantly greater in RS compared to TTS and WCS (P,0.05) for central as well as for lateral incisors. However, changes of vertical tooth mobility were not significant T. across the splinting techniques. Periodontal parameters remained unchanged, reflecting the excellent oral hygiene by the study subjects. The chair time needed for splint application was significantly shorter for TTS (P,0.01). In conclusion, all tested splints appeared to maintain physiologic vertical and horizontal tooth mobility. However, the latter was critically reduced in RS splints. Dislocation of teeth is a frequent finding following orofacial trauma. It has been estimated that three to four in 10 children sustain injuries to their primary teeth prior to school age. Approximately every third child will also suffer trauma to the permanent teeth before leaving school age (1–3). It is common practice that injured primary teeth are not splinted. Depending on the clinical situation, traumatically displaced primary teeth are left to heal spontaneously or, in case of severe dislocation, are normally extracted (4–6). The same authors also advocate that avulsed primary teeth should not be replanted to avoid damage to the developing permanent teeth. However, every effort should be undertaken to save traumatized permanent teeth. Traumatically dislocated

or avulsed permanent teeth are normally repositioned or replanted, respectively (7–9). Treatment outcome is influenced by several factors, such as degree of dislocation, concomitant dento-alveolar injuries, stage of root formation, time period between trauma and treatment and, for avulsed teeth, duration and medium of storage. An important issue in trauma therapy is the splinting method used for stabilization of injured teeth to support periodontal healing. A large variety of fixation or stabilization techniques have been reported in the literature (Table 1) (10–14). An ideal splint should be passive and semirigid, maintaining physiologic tooth mobility after splinting. In addition, the splint should be left in place for as short a period as necessary, i.e. 1–2 weeks. It has been shown in experimental studies that either rigid or prolonged splinting may lead to adverse effects, such as external root resorption and dento-alveolar ankylosis (15–19). In addition, trauma splints should have optimal properties for handling, application and removal. From the patient’s perspective, the splint should not interfere with occlusion, oral hygiene and speech. The authors have developed a new device for splinting traumatized teeth (20). The objective of this experimental study was to compare this new splint with three other splints recommended for stabilization of injured teeth.

Material and methods

The study was conducted in 10 volunteers recruited from the staff of our department. All subjects were female with a mean age of 21 years 6 months (range 17 years 6 months to 34 years 9 months). The study design was approved by the Ethics Commission of the Canton Berne (study-number: ZMK-OC-1/2000) and the clinical study was carried out according to the Helsinki Declaration. The individuals were given oral and written information about the materials and procedures used throughout the study. Prior to enrollment, each volunteer signed a written consent form.

Table 1. Reported techniques for splinting traumatized teeth

Stabilization to teeth

– wire-composite splint

– Kevlar, Fiberglas splint

– bracket splint

– porcelain veneer splint

– arch bar

– interdental ligature wiring Stabilization to gingiva/mucosa

– suture fixation

– vacuum-formed stent Stabilization to bone

– fixation to bone screw/plate

– fixation to bone wire

To be included in the study, subjects had to be healthy and presenting no medical contraindications for the planned procedures. All four maxillary incisors had to be free of caries and periodontal disease. Gingiva and oral mucosa adjacent to the maxillary incisors had to show no pathologic conditions. Four different splinting methods were evaluated in each individual, resulting in a total of 40 splints. The sequence of splint application was determined at random. Each splint was left in situ for 7 days. After removal, at least 1 week elapsed before the next splint was placed.

Preliminary experiments

Preliminary in vitro experiments were undertaken to test the bond strength after four applications of the adhesion procedure used later in the clinical investigation (see below). Between application and removal, the samples were aged for 7 days and thermocycled (300A) between 5. and 55 .C. The results showed no change of the bond strength during the whole period of 28 days. Splint application All splints were bonded to the labial aspect of all maxillary incisors. By placing the splints coronally, PeriotestA (Gulden, Bensheim, Germany) measurements could be taken in the cervical area of the teeth, and the splints were kept away from the gingival margin and the papillae. After placing cotton rolls in the vestibule, the maxillary incisors were dried with air. Etching of the enamel surface was performed with 35% phosphoric acid gel for 30 s (Ultra-EtchA, Ultradent Products Inc., South Jordan, UT, USA). Subsequently, the gel was rinsed off with water from the dental unit and the etched surfaces were dried again. A thin layer of bonding agent (OptibondA, Kerr, Scafati, Italy) was applied using a microbrush. The bonding agent was left for 20 s prior to polymerization with a light source for another 40 s. Finally, the splints were placed with the techniques described below.

Titanium Trauma Splint (TTS)

The TTS was cut to the desired length and manually bent to the facial aspects of the maxillary incisors. Per tooth, one rhombus of the TTS was filled with lightcuring composite (TetricA Flow Chroma, Vivadent, Schaan, Liechtenstein) (Fig. 1) with 30 s of polymerization.

Wire Composite Splint (WCS) A 0.16..A0.22.. wire (Standard Edgewise Wire, American Orthodontics, Sheboygan, WI, USA) was cut to the desired length. The wire was then adapted

TTS titanium trauma splint bonded to each maxillary incisor

with light-cured composite.

Wire-composite splint using a rectangular orthodontic wire (0.16..A0.22..) fixed with composite.

Bracket splint with bonded button brackets and braided 0.3-mm wire connecting the four maxillary incisors.

Resin splint bonded directly to the surfaces and connectingall four maxillary incisors.

to the curvature of the maxillary incisors using pliers. The splint was secured with identical light-curing composite. Bracket Splint (BS) Button brackets (Buttons for direct bonding flat base, Dentaurum, Ispringen, Germany) were bonded with the same light-curing composite. Thereafter, a 0.3- mm soft wire (RemaniumA, Dentaurum) was braided from button to button to connect the four incisors. Care was taken to avoid any orthodontic force when twisting the ligature wire. Finally, the wire was secured to each button with composite.

Resin Splint (RS.PTS)

The resin (ProtempAII, ESPE Dental AG, Seefeld, Germany) was mixed according to the manufacturer’s instructions. Using a syringe, the material was continuously applied to the facial crown aspects connecting all four maxillary incisors. The total working time from mixture initiation to complete set of the resin was 7 min. All splints were finished if necessary. Any sharp edges and afflux material were removed to prevent irritation of the adjacent soft tissues. Splint removal A high-speed bur was used to cut the wires and the resin at the interdental area to separate the splints. The TTS was not separated but rather ‘‘peeled off’’ from the tooth surfaces after grinding the composite down to the titanium. Button brackets were removed with debonding pliers. Any remaining composite was chipped off with a curette or a special bur (Adhesive remover H22; Brasseler-Komet, Lemgo, Germany). A thin residual layer of bonding material was sometimes not removed to avoid repeated damage to the enamel surface, until removal of the last splint. After each removal procedure, a 1% fluoride solution

When occlusal forces exceed the adaptive capacity of the periodontal tissues, the tissue injury results. This resultant injury is termed as trauma from occlusion i.e.”damage in the periodontium caused by, stress on the teeth produced directly or indirectly by the teeth of the opposing jaw”.

Occlusal Trauma: An injury to the attachment apparatus as a result of excessive occlusal force.

Occlusal trauma can be divided into :

1) Primary Occlusal Trauma:

Injury resulting from excessive occlusal forces applied to a tooth or teeth with normal support . Examples include high restorations, bruxism, drifting or extrusion into edentulous spaces, and orthodontic movement.

2) Secondary Occlusal Trauma:

Injury resulting from normal occlusal forces applied to a tooth or teeth with inadequate support .

Traumatogenic Occlusion:

Any occlusion that produces forces that cause an injury to the attachment apparatus .

Occlusal Traumatism:

The overall process by which a traumatogenic occlusion produces injury in the periodontal attachment apparatus

Note

Trauma from occlusion refers to the tissue injury, not the occlusal force. An occlusion that produces such an injury is called as traumatic occlusion

Types

i. Depending on the onset and duration.

ii. Depending on the cause:

Depending on the onset and duration:

a. Acute trauma from occlusion (TFO).

b.Chronic trauma from occlusion (TFO).

Acute trauma from occlusion: Results from the abrupt or sudden changes in the occlusal forces, such as that produced by biting on a hard object, in addition, could also be due to iatrogenic factors (faulty restorations prosthetic appliance).

Chronic trauma from occlusion: As a result of the gradual changes produced in the periodontium due to the tooth wear, drifting movement, extrusion of the teeth combined with parafunctional habits such as bruxism and clenching.

Depending on the cause

Changes produced by primary trauma from occlusion are usually reversible, may be because, the supracrestal gingival fibers are not affected and thus prevents the apical migration of junctional epithelium.

Primary trauma from occlusion

It is a tissue injury, which is elicited around a tooth with normal height of periodontium. (Healthy periodontium) i.e Occurs if trauma from occlusion is main etiologic factor in periodontal destruction and the only local alteration of tooth is from occlusion.

•Example:

1.Insertion of high filling.

2.Prosthetic appliance exerting excessive force.

3.Drifting movement or extrusion of teeth in to the spaces created by unreplaced missing tooth.

4.Orthodontic tooth movement.

Note:

•Primary trauma does not alter level of connective tissue attachment and do not initiate pocket formation.

• This is because it does not affect the supracrestal gingival fibers and therefore prevents apical migration of junctional epithelium.

Secondary trauma from occlusion

It is related to situations in which occlusal forces cause injury in a periodontium of reduced height e.g: Periodontitis.

* Decreased adaptive capacity of the tissues to occlusal forces is due to bone loss.

* Bone loss is due to marginal inflammation

Bone loss leads to decreased periodontal attachment

Etiology of occlusal trauma:

1- Occlusal disharmony

-Tooth drifting, tipping and overeruption following extraction of neighboring teeth results in occlusal interference.

-Failure to contour the cusps of restorations.

-Occlusal interference following orthodontic tooth movement.

2- Excessive occlusal stress as badly designed partial denture.

3- Parafunctional activity e.g, bruxism. Periodontal reaction to traumatogenic occlusion:

Forces applied to a tooth may be either of unilateral type as orthodontic force or jiggling type. The most complex type of force to which a tooth can be subjected is jiggling force. When jiggling force is applied to a tooth, the periodontium is subjected alternatively to both pressures and tensions in a very short period of time. This induces histopathological effects such as thrombosis, vascular exudation, and vessel proliferation in the ligament. There is also a compensatory increase in the width of the periodontal ligament space which, at its most coronal point, may appear radiographically as an angular bone defect (Crestal funneling).

The main clinical effect is an increase in tooth mobility which will continue to increase until the periodontal ligament has been adapted to the applied

force. As long as the intensity of force does not increase, the periodontal

ligament remains widened, but healed, and the mobility remains increased, but not increasing.

Periodontal reaction to traumatogenic occlusion include: 1- Histologically:

– Vascular exudation.

– Vessel proliferation.

– Thrombosis. 2- Radiographically:

1) Widened PDL space

Widening of periodontal ligament space especially at the alveolar crest resulting in angular bone defect. (Crestal funneling).

2) Bone loss (furcations; vertical; circumferential)

3) Root resorption

3- Clinically: Increased but not increasing tooth mobility. So, all these changes are considered as adaptive response allowing movement of the tooth out of trauma.

Diagnosis of occlusal trauma

Signs and Symptoms

When evaluating a patient suspected of having occlusal trauma there are a number of clinical and radiographic symptoms that may be present. These indicators of trauma from occlusion may include one or more of the following :

1) Mobility (progressive)

2) Pain on chewing or percussion

3) Fremitus(functional tooth mobility): It is considered as a pathogenomonic sign of occlusal trauma. Tooth mobility can be detected visually or on palpation while the tooth is subjected to occlusal contact.

4) Occlusal analysis: Occlusal prematurities/discrepancies

5) Wear facets in the presence of other clinical indicators

7) Chipped or fractured tooth (teeth)

8) Thermal sensitivity Asst .Prof. Dr. Hala Yassin

9) Widening of periodontal ligament space.

10) Angular bone defect.

f Remember:

Role of traumatogenic occlusion in periodontal disease:

1-Excessive occlusal forces do not initiate gingivitis or periodontitis

2-Excessive occlusal forces is a cofactor in the progressions of periodontitis. It could produce a lesion of occlusal trauma which could accelerate the progression of plaque-induced Periodontitis.

The tissue response to occlusal trauma occurs in three stages.

1. Stage 1 -Injury

2. Stage 2 -Repair

3. Stage 3 -Adaptation remodeling of the periodontium

Stage 1 -Injury

•Tissue injury is produced by excessive occlusive forces.

•A tooth rotates around a fulcrum or axis of rotation under the forces of occlusion

a.Slightly excessive pressure

•Slightly excessive pressure stimulates alveolar bone resorption which results in widening of PDL space. Asst .Prof. •The body attempts to repair injury and restore periodontium •Repair is stimulated from trauma

•The damaged tissues are removed and new C.T. cells and fibers , bones and cementum are formed

•Buttressing bone formation is process in which thinned bony trabeculae is reinforced with new bone when the bone is resorbed by excessive occlusal forces

•Buttressing bone formation occurs in 2 places. They are:

•Within jaw – called as central buttressing

•On the bone surface – called as peripheral buttressing

•Peripheral buttressing occurs on facial and lingual surfaces of alveolar plate

•Peripheral buttressing may produce Lipping ( shelf like thickening of alveolar margin ) or a pronounced bulge in the contour of facial and lingual bone

Stage 3 – Adaptive Remodeling of the Periodontium

•The periodontium is remodeled if the repair process does not keep pace with destruction.

•The remodeling occurs in order to escape injurious forces

•This results in

i. -Thickened PDL which is funnel shaped at the crest ii.-Angular defects in bone with no pocket formation iii.-Mobility of involved tooth iv.- Increased vascularization.

1-Excessive occlusal forces do not initiate gingivitis or periodontitis

2-Excessive occlusal forces is a cofactor in the progressions of periodontitis. It could produce a lesion of occlusal trauma which could accelerate the progression of plaque-induced Periodontitis.

Management of occlusal traumatism (occlusal adjustment):

Aim:

1-Reduce mobility and fremitus and encourage repair of the periodontal attachment apparatus. Alveolar bone loss, widening of periodontal membrane space and tooth mobility are reversible ion plaque induced lesion if excessive forces applied to the tooth is removed.

2-Treat discomfort during function.

3- Treat parafunction.

4-Achieve functional relationship in conjunction with restorative dentistry.

Methods of Occlusal adjustment:

*Altering the occlusion through occlusal adjustment to reduce force on teeth under occlusal traumatic load can be accomplished by, subtraction procedure (selective grinding), addition procedure (occlusal restoration) or orthodontic treatment.

*Selective grinding entails reshaping of cusps, cuspal inclines, incisal edge and the guiding inclines of anterior teeth. It is essential that irreversible procedures such as selective grinding are only undertaken following careful diagnosis, treatment planning and trial adjustment on study models mounted on semi-adjustable articulator.

*Cast restorations are indicated for occlusal correction when selective grinding may be excessive or recapturing occlusal contact is necessary.

*Orthodontics can enhance occlusal result obtained by selective grinding and restoration if key teeth are malposed to a degree that restoration results in periodontal problem.

Prosthetic dentistry:

*The design of a chrome cobalt denture aims to distribute the occlusal load to many supporting teeth (as possible) using occlusal rests. It also aims to minimize the stress on abutment teeth by reciprocating the forces placed upon them by retention clasp. Badly designed partial denture causes excessive occlusal stress on abutment (refer to occlusal trauma).

fitting or inadequacy polished dentures will tend to act as foci for plaque collection and promote development of spirilla and spirochetes.

*Dentures which are tissue borne frequently sink into the mucosa and compress the gingival margins causing inflammation and tissue destruction.

Endodontic treatment:

*Perforation of root canals resulting in periodontal absecss may be due to:

*Extending posts deep into molar roots, especially those with significant mesial and distal concavities.

*Improper mechanical preparation.

Hypofunction

Definition:

*Dental medicaments when accidentally come in contact with the gingiva causes painful burns and white lesions.

It is the reduction or absence of functional stimulation due to loss of antagonist teeth.

Sequelae:

The periodontal tissues undergo degenerative changes (disuse atrophy):

-Periodontal ligament is thin formed mainly of unorganized fibers with loss of principle fibers.

-Alveolar bone proper is thin and the cancellous bone undergoes atrophy.

-The lack of self-cleansing effect of chewing and tilting of overerupted teeth predispose to plaque retention and make plaque removal difficult. Plaque and calculus accumulation on hypofunctional teeth is associated with gingival inflammation.

-Long term hypofunction results in increased tooth mobility.

N.B: Hypofunction is more detrimental than hyperfunction Removal of local irritating factors should be performed before restoring the tooth into function, otherwise the condition will be exacerbated.

Habits

a. Neurosis

b. Occupational habits
c.Miscellaneous habits:

Habits of significance in the etiology of periodontal disease are:

1-Neuroses:

Such as lip biting and cheek biting which would lead to extra functional positioning of the mandible, others include tongue thrusting, fingernail biting and occlusal neurosis.

a-Occlusal neuroses: bruxism, clenching and tapping.

b-Tongue thrusting

2-Occupational habits:

– Such as holding of nails in the mouth, e.g. carpenters ,Pressure of a reed during the playing of certain musical instruments.

3- Miscellaneous habit:

– Such as pipe or cigarette smoking, tobacco chewing, incorrect methods of tooth brushing, mouth breathing and thumb sucking.

Neuroses

i-Bruxism: It is grinding of the teeth when the individual is not chewing or swallowing.

ii-Clenching (clamping): strong contractions of the jaw muscles during eccentric lateral jaw movement or in maximum intercuspation.

iii-Tapping (clicking): tapping and tooth setting in a repetitive manner at isolated contact location.

Clenching and’ tapping in which the occlusal force is concentrated on single tooth or segment are more detrimental to the periodontium than bruxism.

Etiology:

l.Stress; The relationship between emotional states and muscle tension appears to be better understood. Increased stress level is strongly correlated with increased level of masseter muscle activity at night (nocturnal bruxism). Most people are not aware of bruxism habit at day time (diurnal bruxism).

2.Occlusal interference: centric prematurities or interference in lateral excursions triggers parafunctional habits.

Diagnosis

1-Wear facets on the teeth. 2-Widening of periodontal membrane space-3-Hypertonicity of the muscles of mastication. 4-Tempromandibular joint discomfort.

Cases in which there is premature contact of teeth, bruxism is injurious and manifested as progressive increasing tooth mobility.

Treatment:

Management of stress associated bruxism includes:

1-Medications for a few days aiming at altering sleep anxiety level.

2-Maxillary stabilization appliance to protect the tooth surface and to dissipate forces built up in the musculoskeletal system.

b- Tongue thrusting: Definition:

It is the persistent, forceful wedging of the tongue against the teeth. Instead of the dorsum of the tongue being placed against the palate with the tip behind the maxillary teeth during swallowing, the tongue is thrust forward against the anterior teeth.

Tongue thrusting causes excessive lateral pressure, which may be traumatic to the periodontium. It also causes spreading and tilting of the anterior teeth, which tilt and also spread laterally

Sequelae:

-Excessive lateral pressure on the periodontium which may be traumatic.

-Labial drifting of the anterior teeth. Antagonistic forces created by the lip tends to direct the tooth in inward direction resulting in tooth mobility.

– Spreading of the teeth with an open bite, the loss of the proximal contact leads to food impaction (refer to food impaction).

c- Mouth breathing

Definition:

-It is the prolonged exposure of the gingival tissue of the anterior area to the drying effect of inspired air.

Etiology:

-Blockage of nasal passage by adenoids. -Short upper lip. -Protruded maxilla.

•The gingiva is erythematous, edematous, shiny and may be hyperplastic.

•Signs of gingival inflammation in mouth breather is due to:

-Diminished normal cleansing action of saliva so that plaque accumulates.

-Impaired tissue resistance due to dehydration (Saliva contains numerous defensive components as IgA, lysozyme,…).

Definition:

It is the forceful wedging of the food into the periodontium by occlusal forces. Cusps that tend to forcibly wedge food interproximally are known as “Plunger cusps”.

food impaction can occur in the following conditions:

a. Uneven occlusal wear: It can lead to food impaction because deflection of food away from the proximal areas does not occur.

b.Loss of proximal contact: This is one of the most common cause for food impaction. It may be due to, periodontal disease, non-replaced missing teeth, proximal caries and abnormal biting habits. c.Congenital morphologic abnormalities of teeth. d.Improperly-constructed restorations.

Lateral food impaction: In addition to food impaction caused by occlusal forces, lateral pressure from the lips, cheeks, tongue may force food interproximally. This usually occurs when the gingival embrasure is enlarged by periodontitis or by recession.

The following signs and symptoms may occur in the association with food impaction: sequelae of food impaction

i.Feeling of pressure and urge to dig the material from between the teeth.

ii. Vague pain that radiates deep in the jaws.

iii. Gingival inflammation with bleeding and a foul taste in the involved
area.

iv. Gingival recession.
v. Periodontal abscess formation.

vi. Varying degrees of inflammatory involvement of periodontal ligament,
sensitivity to percussion.

vii. Destruction of the alveolar bone.

viii. Root caries.

xi. Interdental crater formation. Loss of interdental tissues and creation of dead space bounded by labial and lingual pseudopapillae and proximal sides of adjacent teeth.

x. Foul odour.

Unreplaced Missing Teeth

Failure to replace extracted teeth initiates a series of changes that produce various degrees of periodontal diseases. The pattern of changes that may follow, failure to replace missing first molars is characteristic . In extreme cases it consists of the following:

a.The second and third molars tilt, resulting in a decrease in the vertical dimension.

The pre-molars move distally and the mandibular incisors tilt or drift lingually

Chemical, Thermal, Mechanical Irritation and Radiation Chemical [non allergic and allergic)

-The use of strong mouth washes, topical application of aspirin and accidental contact with phenol results in acute inflammation with ulceration in the gingiva.

-Allergic inflammatory reaction that ranges from erythema to painful vesicles and ulcers may results from contact with innocuous mouthwashes, dentifrices or denture material.

Mechanical :

-Faulty oral hygiene practice. -Clasps of denture . -Excessive force during orthodontic treatment. Irradiation (soft and hard tissue changes):

Initially: there is erythema and desquamation of oral mucosa, including the gingiva. Late changes include a thin mucous membrane with a thin atrophic epithelium and dense fibrous connective tissue with a reduced number of blood vessels.

Hard tissue:

Irradiated bone demonstrates accellularity and avascularity with loss of osteoclasts and osteoblasts rendering the bone more susceptible to infection. Periodontal disease is considered a portal of entry for infection and development of osteoradionecrosis after radiation therapy.

Thermal, chemical and mechanical irritation and irradiation are not significant factors in the etiology of common forms of periodontal disease.

Margin Location:

*It was postulated that the cervical margins of all smooth surface (class V) restorations should be located subgingivally. The reasoning on which this concept was based was that an initial carious lesion could never occur on enamel that was covered by gingiva (extension for prevention).

*In fact, all subgingival restoration margins are covered by pathological altered gingiva because the margin itself represents an area of increased plaque accumulation.

*Margins of restorations should be located supragingival except for esthetic reasons, problem of retention or extensive carious lesions.

HEALTHY PERIODONTAL STRUCTURES AND OCCLUSAL FORCES

The healthy periodontal structures, including root cementum, periodontal ligament and alveolar bone, form a functional unit or organ. The periodontal ligament is a very specialised interface between tooth and the alveolar bone. It serves as a structural, sensory and nutritive unit supporting the normal oral functions of chewing, swallowing, speaking, etc. It has a very dense network of interconnecting fibres attached to the bone. The supra-crestal fibres are especially important because they maintain the relative position of the teeth in the arch. The collagen fibres in the periodontal ligament are very dense and represent up to 75% of the volume. These so-called ‘Sharpey fibres’ are apically oriented and embedded both in the alveolar bone and the root cement. The natural dentition has been compared, because of these interconnecting supracrestal fibres, to beads on a string. Teeth function together but have their individual mobility in the alveolus. The entire periodontal ligament has viscoelastic characteristics. The ligament provides tooth fixation, and also force absorption. The thickness of the periodontal ligament is directly related to the forces exerted on it.

The periodontal ligament has a rich and dense vascular and nervous network. The ligament contains pro-prioceptors for movement and positioning and mechano-receptors for touch, pain and pressure. They regulate muscle function and occlusal forces to avoid overload and damage of the teeth and the alveolar bone. The periodontal ligament distributes and absorbs forces. Under physiological conditions the occlusal forces are transferred to alveolar bone and further to the mandible, the maxilla and the entire skull. The alveolar process has a pronounced capacity for modelling and remodelling under functional loading. The alveolar process remodels at a rate of 20% per year. The basal bone does not have this capacity. The periodontal ligament and alveolar bone need the functional stimulus of the occlusion to maintain their physiological, healthy condition.

TOOTH MOBILITY

Physiological tooth mobility is the result of the histological characteristics of the periodontal ligament. Physiological tooth mobility, in the horizontal as well as in the vertical direction, is different between single root and multirooted teeth and is determined by the width, height and quality of the periodontal ligament (Fig. 9.1).

In the vertical direction, the displacement is 0.02 mm by small forces up to 1 N. Under larger vertical forces, the tooth is moved in an apical direction because venous fluid and blood of the periodontal structures is pushed towards the venous lacunae and the cancellous bone. It takes 1-2 minutes before the tooth returns to its normal position after releasing an applied occlusal force. This explains the fact that tooth mobility is decreased after chewing, and the tooth is then in a more apical position.

In healthy conditions, the teeth move in a horizontal plane, under a force of 500 g, as follows (Muhlemann 1960):

•incisors: 0.1-0.12 mm •canines: 0.05-0.09 mm •premolars: 0.08-0.1 mm •molars: 0.04-0.08 mm.

Tooth mobility can also be estimated using the Periotest (Siemens AG, Germany), an electronic device that measures the reaction of the periodontium to a defined percussion force.

Under higher occlusal loads, the forces are transmitted to the bone, with slight deformation of the alveolar process as a result. The force is also transmitted to neighbouring teeth through the interproximal contacts.

Evaluation of tooth mobility

The exact measurement of individual tooth mobility (periodontometry) is necessary for research purposes. Clinically, an estimation of tooth mobility is performed by loading the tooth in an anterolateral direction with two instruments.

Four possible grades of tooth mobility are considered: •grade 0: physiological mobility

•grade 1: increased mobility but less than 1 mm in total •grade 2: pronounced increase; more than 1 mm in total •grade 3: more than 1 mm displacement combined with

a displacement in vertical direction (tooth can be

intruded).

Increased mobility can also be observed on radiographs: there is a widening of the periodontal space without vertical or angular bone resorption and without increased probing depth of the periodontal pocket (Figs 9.2 and 9.3).

Aetiological factors of hyper- and hypomobility

Excessive occlusal forces or premature contacts on teeth are the primary aetiologic factors for hypermobility.

There is an increased mobility during pregnancy because of the increase in the fluid content of the periodontal structures, an increased vascularity and a proliferation of

capillaries into the periodontal tissues. Systemic diseases such as non-Hodgkin’s lymphoma, scleroderma and Cushing’s syndrome may lead to increased mobility Hypermobility may be observed in cases of severe periodontal inflammation (periodontitis), teeth with a healthy but reduced periodontal support (that is, in patients after successful periodontal treatment), or in the first weeks after periodontal surgery.

Normal physiological mobility is decreased in the elderly and in the absence of antagonist teeth. In cases of severe bruxism and clenching the mobility decreases (‘ankylosing effect’). Without antagonists and therefore without functional stimulation, teeth will either overerupt or become ankylosed. The periodontal ligament becomes thinner and non-functional.

Evaluation of the changes in occlusal mobility can be helpful in the diagnosis of occlusal dysfunction, parafunction and in the evaluation of occlusal treatment procedures.

TYPES OF OCCLUSAL FORCES

The reaction of the bone and ligament depends on the magnitude, duration and direction of the forces. Different types of occlusal forces can be recognised:

•Physiologically normal occlusal forces in chewing and swallowing: small and rarely exceeding 5 N. They provide the positive stimulus to maintaining the periodontium and the alveolar bone in a healthy and functional condition.

•Impact forces: mainly high but of short duration. The periodontium can sustain high forces during a short period; however, forces exceeding the viscoelastic buffer capacities of the periodontal ligament will result in fracture of tooth and bone.

•Continuous forces: very low forces (for example, orthodontic forces), but continuously applied in one direction are effective in displacing a tooth by remodelling the alveolus.

•Jiggling forces: intermittent forces in two different directions (premature contacts on, for example, crowns, fillings) result in widening of the alveolus and in increased mobility.

TRAUMA FROM OCCLUSION

Trauma from occlusion has been defined as structural and functional changes in the periodontal tissues caused by excessive occlusal forces. Some of these changes are adaptive, while others should be considered pathological. Occlusal trauma can be acute if caused by external impact forces or chronic if caused by internal occlusal factors (premature contacts, grinding). Chronic occlusal trauma can be understood as primary and secondary trauma.

Occlusal trauma is the overall process by which traumatic occlusion (that is, an occlusion that produces forces that cause injury) produces injury to the attachment apparatus.

Primary occlusal trauma

Primary occlusal trauma is caused by excessive and non-physiological forces exerted on teeth with a normal, healthy and non-inflamed periodontium. The forces may be exerted on the periodontal structures in one direction (orthodontic forces) or as ‘jiggling’ forces.

Forces in one direction: orthodontic forces

Forces in one direction cause tipping of the tooth in the opposite direction or tooth displacement parallel to the force resulting in a ‘bodily movement’.

In the periodontal ligament, zones of compression and zones of tension are found, inducing increased resorption. The clinical result is a (temporary) increased mobility. However, there are no changes in the supracrestal fibres, no loss of periodontal attachment, or an increased probing pocket depth. The increased tooth mobility is functional adaptation to the forces exerted on that tooth. If the forces are too high and above the adaptation level, an aseptic necrosis in the tension zone of the periodontal ligament occurs, characterised by hyalinisation. In the compression zone, pressure stimulates osteoclasts in the adjacent bone and the alveolar wall is resorbed until a new connection is formed with the hyalinised bone (‘undermining resorption’). In the tension zone, bone apposition and rupture of the collagen fibres occur. After removal of the force the perio-dontal ligament is reorganised and after some time develops a normal histological appearance. If the applied forces are too high, root resorption occurs in the middle of the hyalinised tissues. This resorption continues for a variable time, resulting in shorter roots, frequently seen after orthodontic treatment.

Jiggling forces

Jiggling forces, coming from different and opposite directions, cause more complex histological changes in the ligament. Theoretically the same events (hyalinisation, resorption) occur, however, they are not clearly separated.

There are no distinct zones of pressure and tension. Histologically, there is apposition and resorption on either side of the periodontal ligament, resulting in a widening of the periodontal space (Fig. 9.4). This may be observed on radiographs. This phenomenon explains the increased mobility without pocket formation, migration and tipping.

The clinical phenomena are not only dependent on the magnitude of the forces, but also on the crown-root relationship, the position in the arch, the direction of the long axis, and the pressure of tongue and cheek musculature (Fig. 9.5). The interarch relationship (for example, deep bite) influences the extent of the trauma caused by jiggling forces. The hypermobility is found as long as the forces are exerted on the tooth: there is no adaptation. Hypermobility is therefore not a sign of an ongoing process, but may be the result of a previous jiggling force.

The long-term prognosis of teeth with increased mobility is poor, and is a complicating factor if they are used as abutment in prosthodontic reconstruction.

Successful periodontal treatment leads to healthy but reduced periodontal structures. Jiggling forces exerted on the teeth in this condition result in a pronounced increase in tooth mobility because the point of rotation (fulcrum) is closer to the apex thaormal. This is uncomfortable for

the patient and might be an indication for splinting of teeth (Fig. 9.6).

Secondary occlusal trauma

Secondary trauma from occlusion is defined as the trauma caused by excessive and premature occlusal forces on teeth with an inflamed periodontium. A number of animal experiments and clinical epidemiological studies investigated the role of occlusion in the pathogenesis of periodontitis. In his original studies in the 1960s, Glickman (Glickman & Smulow 1967) formulated the hypothesis that premature contacts and excessive occlusal forces could be a co-factor in the progression of periodontal disease by changing the pathway and spread of inflammation into the deeper periodontal tissues. Glickman hypothesised that the gingival zone was a ‘zone for irritation’ by the microbial plaque; the supracrestal fibres were then considered to be a ‘zone of co-destruction’ under the influence of a faulty occlusion (Fig. 9.7).

Clinically, vertical bone resorption and the formation of infrabony defects should be an indication for occlusal trauma.

Animal experiments

Animal experiments investigating the influence of a faulty occlusion on the progression of periodontal disease were published by Swedish investigators between 1970 and 1980 using the beagle dog model, and by American investigators using the squirrel monkey model. In spite of the many remaining questions and controversies, few animal studies have been published since then.

From these studies the following conclusions may be drawn:

•In the absence of marginal inflammation, jiggling forces do not induce more bone resorptioor a shift of the epithelial attachment in an apical direction.

•In the case of marginal inflammation (gingivitis), occlusal overload has no influence.

•Jiggling forces on teeth with periodontal disease result in more bone loss and more loss of connective tissue attachment (Ericsson & Lindhe 1982).

•Jiggling forces induce a faster shift of microbial plaque in the apical direction in the pocket.

•One single trauma does not influence the pathogenesis; the forces have to be chronic.

•Treatment of periodontal inflammation without elimination of the premature contacts results in decreased tooth mobility, an increase in bone density, but no change of bone level.

•After periodontal treatment with scaling and root-planing, the presence or absence of prematurities have no influence on the microbial repopulation of the deepened pockets.

It must be mentioned that some animal studies did not reach the same definitive conclusions, due to differences in experimental setup and different animal models. The results of experimental animal studies cannot therefore be directly extrapolated to the human situation.

Clinical epidemiological studies

Given the complexity of the occlusal and periodontal interaction and the multifactorial aspect of the pathology, very few human studies have been published. Most studies have a limited number of subjects and the results are analysed on a subject basis rather than on a tooth basis. The studies have been recently summarised by Hallmon (Hallmon 1999). A number of cross-sectional epidemiological studies found either no relationship between the presence of premature contacts and increased probing depth or bone loss, while others reported that mobility and radiographic evidence of a widened periodontal ligament were associated with increased pocket depth, attachment loss and bone loss (Jin & Cao 1992). More recent longitudinal studies (Harrel & Nunn 2001) found that teeth with premature contacts at initial examination had a deeper probing pocket depth, an increased mobility and a worse prognosis. At the 1 year examination, teeth without premature contacts originally, or teeth where premature contacts had been removed, showed a 66% reduced chance of a worsening periodontal situation. After a few months, teeth with prematurities showed an increased probing depth compared with the teeth receiving occlusal adjustment. It was concluded that premature contacts are a ‘catalyst’ in the progression of periodontal disease.

It has also been shown that in the same patient more periodontopathogens are found in pockets around hypermobile teeth, than in teeth with normal mobility. This can lead to the hypothesis that the increased mobility changes the ecosystem in the pocket, favouring growth of these bacteria.

TRAUMA FROM OCCLUSION AND IMPLANTS

Endosseous implants have no periodontal ligament as an intimate implant-alveolar bone contact exists (‘functional ankylosis’). Implant failure can occur not only because of bacterial infection (peri-implantitis) but also because of occlusal overload (biomechanical failure) in combination with immunological host factors (Esposito et al 1998).

Occlusal overload results in ‘osseodisintegration’ over the complete implant surface without clinically detectable pocket formation or signs of inflammation. Often the implant has no increased mobility in spite of pronounced bone resorption along its entire surface. Clinical measurement of implant mobility is not an accurate tool for evaluating osseointegration or disintegration of an implant until late in the pathological process. If increased implant mobility occurs, osseointegration is by then usually destroyed.

GINGIVAL TRAUMA FROM OCCLUSION

Gingival recession may be provoked by direct contact of the teeth with the gingiva, as in severe overbite, where the upper incisors damage the buccal gingiva of the lower incisors. This problem is not easy to solve and may involve orthodontic treatment, orthognathic surgery or extensive prosthetic rehabilitation requiring an increase in vertical dimension.

It has been stated that gingival recession occurs with functional overload and/or premature contacts, as in the buccal surface of upper canines where there is a steep lateral canine guidance. Those cervical surfaces also show enamel abfraction. There is still controversy regarding whether or not overload is an aetiological factor in the recession, and consequently whether or not the occlusion and the lateral guidance should be changed.

PRACTICAL CLINICAL CONCLUSIONS AND GUIDELINES

• In a healthy non-inflamed dentition, traumatic occlusion leads to hypermobility of some teeth; if hyper-mobility, radiological widening of periodontal ligament space or pronounced cervical abfraction is found, the occlusion should be analysed and corrected. Simple uncomplicated, non-time-consuming procedures are in most cases adequate to restore a physiological situation and to reduce hypermobility.

•In cases of a healthy but reduced periodontium, increased mobility may also be reduced by occlusal adjustment; it should be recognised that tooth mobility in such cases, based on the mechanical situation, is nevertheless increased. It may be necessary to splint the teeth to increase the functional comfort and to avoid direct fracture. This may include very mobile teeth with a healthy but reduced periodontium, but complicates the clinical procedures.

•In cases of secondary occlusal trauma, treating the inflammation is of primary importance and should be the first step in treatment planning. From the literature it can be concluded that prematurities may play a role in the progression of the periodontitis.

•Asimple correction of the occlusion, if necessary, should be included in the initial phase of periodontal treatment. This results in more gain in attachment level during periodontal treatment, and may contribute to better healing of periodontal tissues.

•There are some indications that removing premature tooth contacts improves the prognosis of periodontally involved tissues.

•If some teeth do not react to conventional periodontal treatment as expected, further investigation should not only include periodontal re-examination and microbiological testing, but also more extensive occlusal analysis.

• As implant overload leads to bone resorption without the warning signal of inflammation, deep peri-implantitis pockets or (in the early stage) increased mobility, evaluation of the occlusion and radiographs should be included in regular maintenance programmes.

Use and Abuse of Bite Splints

Bite splints (BS) are often used in the treatment of patients with oral parafunctions, temporomandibular joint (TMJ) dysfunction or temporomandibular disorders (TMD). The most common reasons for prescribing a BS are to protect the teeth in patients with bruxism, to improve jaw- muscle and TMJ function and to relieve related pain. The risk for negative side effects is small in conservative bite splint treatment. Complications from long-term use of splints, however, can be severe and irreversible. The risks are especially high when mandibular advancement splints, or splints that make contact only with parts of the opposing dentition, are used for more than 4 to 6 weeks without appropriate supervision. As a general rule, a dentist should not encourage a patient to use any type of splint for more than a few months except for cases in which the teeth need to be protected because of persistent oral parafunctions. Appropriate record keeping, including signed consent forms, is necessary; wheeglected it becomes difficult for the dentist to defend himself from false accusations of malpractice.

A bite splint (also called bite plane, deprogrammer, intraoral orthotic, night guard, occlusal splint) is a removable appliance, usually fabricated of acrylic or composite, most often designed to cover all the occlusal and incisal surfaces of the teeth in the upper or lower jaw.

Bite splints can be classified according to the material used for fabrication; the location of placement; and their purpose and effect on jaw muscles, condylar position, and occlusion.

This article briefly describes different types of splints, and discusses why and when a conservative splint may be useful and why non-conservative splints should be prescribed only in carefully selected cases and never without fully informing the patient about possible harmful effects.

Main Reasons for Bite Splint Treatment

A common reason for prescribing a bite splint is to protect the teeth from excessive abrasion in patients with bruxism (Figure 4). Splints are also used frequently to treat patients with internal TMJ derangement and other TMDs with associated pain symptoms, such as tension headache and cervical-, neck-, and oral/facial pain^{1-4. A common goal of bite splint treatment is to protect the TMJ disks from dysfunctional forces that may lead to perforations or permanent displacements (Figures 5 through 8). Other goals of treatment are to improve jaw-muscle function and to relieve associated pain by creating a stable balanced occlusion.}

An important advantage of bite splints is that they can be used to make reversible changes in the occlusion. Occlusion affects the way jaw muscles function, and jaw muscle function affects the way the TMJ functions. Therefore changes in the patient’s occlusion will always have some effect on the jaw muscles and the TMJ structures. A stable, balanced occlusion is important for maintaining normal jaw muscle and TMJ function.

The role of occlusion in TMD etiology, however, is complex, and there is no general agreement about its significance⁵–⁶. Many patients seem to have good TMJ and jaw-muscle function with no history of pain in spite of bad occlusion. Clearly patients react differently to having less-than-ideal occlusion. TMDs also can be caused by a number of other factors, such as head trauma or diseases that affect the internal TMJ tissues¹.

There is no general agreement about if or why splint treatment may have a beneficial effect. Too few clinical studies have used adequate control groups and/or standardized recording methods. There are those who claim that the only effect is placebo. However, by definition double-blind placebo studies are impossible to design because it should not be possible to find dentists who can deliver and adjust a bite splint without immediately recognizing if the splint is a “placebo type”.

Suggested indirect effects, difficult to prove or disprove, are that splints promote jaw muscle relaxation in patients with stress-related pain symptoms like tension headache and neck pain of muscular origin, and unload the jaw joints in patients with acute TMJ pain of intracapsular origin^7-9.

In spite of the present divergence in opinions about the value of splint treatment, it is reasonable to recommend it for the following purposes:

• to protect oral tissues in patients with oral parafunctions;

• to stabilize unstable occlusion;

• to eliminate the effect of occlusal interferences; and

• to test the effect of changes in occlusion on the TMJ and jaw muscle function before extensive restorative treatment.

Splint material

In the past several metal materials were used to fabricate bite splints including gold, silver, -even lead! Most splints today are made using heat- or light-cured acrylic^10-11.

Dentists who are frequently involved in treating TMD patients often like to be able to make and deliver a splint shortly (1 to 2 hours) after taking impressions rather than having them fabricated in a laboratory. This is especially important if patients have acute pain, but also if they have to travel a long way for treatment. Using light-cured composite, a splint can be made “in house” and delivered about 1 hour after the casts have been mounted in an articulator¹¹.

Some patients prefer the cushion effect created by the soft acrylic. A vacuum-formed soft vinyl “night guard” is easy to fabricate. However, it needs careful adjustment and supervision to avoid unwanted results¹².

Location

Without specific reasons for a mandibular placement, such as deep curve of Spee or substantial loss of mandibular teeth, some clinicians prefer the splint to be made for the upper jaw. Others prefer to place the splint in the lower jaw. If teeth are missing, the splint is usually made in the jaw where most teeth are lost. If molars and premolars are missing in both jaws, it may be advisable to make both an upper and a lower splint or to first restore occlusion in at least one jaw with prostho-dontic reconstruction.

Usage

There are no fixed rules for how long patients should continue to use splints. However, with few exceptions, non-conservative splints that often have to be worn 24 hours a day should not be used for more than 4 to 6 weeks to avoid the risk of irreversible occlusal changes.

Bite splints should be looked on as temporary solutions to be used only until a final diagnosis has been made and a curative treatment has been successfully performed. Unfortunately, it is sometimes not possible to reach those goals; in those occasions only should, a dentist can encourage a patient to use a splint indefinitely.

Patients who have conservative bite splints prescribed because of parafunctional motor activities like bruxing, clenching, and tongue pressure mainly use their splints only during sleep. However, those who caot control such habits when awake might need to use the splint during the day also.

Main types of splints

Conservative splints

Michigan- type splint. If properly designed and adjusted, this splint¹ is effective as a diagnostic and treatment device. It reduces muscle hyperactivity, thereby helping the condyles to reposition in a way that promotes healing of internal TMJ structures. It is usually placed in the upper jaw covering all the maxillary teeth, giving the supporting cusps of the opposing mandibular teeth and the edges of the mandibular incisal teeth balanced, even contacts with the splint at habitual closure. Cuspid guidance is created to provide a rise in lateral and protrusive movements, so that all mandibular teeth, except the cuspids, are discluded at protrusive and lateral movements. This splint is not a flat occlusal splint and it does not have incisal guidance.

Plane splints. For esthetic reasons, some patients may prefer to have splints without cuspid guidance. Balanced contacts with all opposing supporting cusps are mandatory but some clinicians believe that better results are achieved if the contacts between the incisors and the splint are very light or even removed. Thin splints are often too fragile for heavy bruxers. Thicker splints may also be made to compensate for “reduced vertical”. Finding the best vertical by adjusting a bite splint, before final large permanent restorations are made may significantly facilitate the dentist’s work.

Bite splint according to Shore. This splint has a design similar to the conventional plane splint but does not extend onto the facial or buccal surfaces of the teeth and it covers the entire palatal area. For esthetic reasons, it may be preferred by some patients who need to use the splint during the day because it can be made less visible.

Svedplate. Only the opposing anterior teeth make contact with this splint¹³. It is recommended for patients with acute or chronic muscle pain if the plane splint is ineffective. The Sved plate is usually placed on the upper teeth. It is mostly used only at night and not more than 10 to 12 hours a day. There is a risk for intrusion of teeth, which has to be explained to the patient before delivery. As always, regular checkups are important.

Gelb splint. The Gelb appliance is made in the lower jaw, covering only the premolar and molar teeth. It is used to correct mandibular displacement, reduce TMJ dysfunction and oral/facial pain, and to provide occlusal stability with the patient’s natural dentition serving as the anterior guid-ance. Some dentists fear that this splint can cause intrusion of the posterior teeth. The originator claims that what seems to be an intrusion is actually a postural change because of a corrected jaw imbalance.

Distraction splints. The pivot splint was introduced by Krogh-Poulsen about 40 years ago and was supposed to be helpful in patients with disk displacement. The proposed effect is that the con-dyles are pulled downward upon clenching on the pivot, thereby relieving traumatic load and giving the disk freedom to reassume a normal position . It is seldom used today because most patients find it uncomfortable. The distraction splint, used by Pedersen et al to achieve a similar effect, has been tried successfully to reduce the destructive effect of juvenile rheumatoid arthritis on internal TMJ structures.

Repositioning splints. Repositioning splints guide the mandible into a position different from (mostly anterior to) the habitual one at closing. The purpose is to facilitate repositioning of the TMJ disks and to reduce the load on retrodiscal pain-sensitive areas. These splints may be indicated for short-term use to keep a recaptured disk in a normal superior position (e.g., when a displaced disk has been recaptured by manipulation).

A repositioning splint is most often removable but can be fixed. Such a splint, often called a cap splint, can be described as an intermediary between a splint and a bridge. It is useful for temporary reconstruction before final decision about design, vertical dimension, etc. It is often made in metal with the occlusal surface in hard acrylic¹⁸.

Splints for protection of oral tissues. The most common reason for making a splint is to protect the teeth from excessive abrasion in bruxers. Several variations of splints are designed to protect cheeks and the tongue in patients with oral parafunctions (such as cheek biting or tongue thrust). These patients may benefit from a splint with extensions or enlargements designed in a way that keeps the cheeks from being pinched or the tongue from pressing against the lingual surfaces of the teeth.

Combination splints. Missing teeth can easily be replaced by adding artificial teeth to the splint. A Shore splint can function as a temporary partial denture by adding artificial teeth. There are numerous combinations of splint and orthodontic appliances. A removable bionator appliance can act both as an orthodontic and as a repositioning appliance. An “invisible retainer” can simultaneously function as a soft acrylic splint.

Sources of Errors in Bite Splint Treatment

Careful adjustment of the stabilization splint is an important step as muscle activity changes and edema subsides¹. Regular supervision, therefore, is important, and a splint should never be delivered without securing that the patient can and will come back for regular check-ups. The dentist also has to ensure that he or she is able to see the patient any working day during the first weeks after delivery.

Acute pain can be caused by inflammation in intracapsular TMJ tissues. They may swell or shrink during different stages of the disease period. Repeated adjustments may have to be made for quite long periods.

Conservative splints have a minimal risk of causing permanent changes in occlusion. The risks increase when splints are made to guide the mandible into an advanced position. Those splints can cause irreversible, possibly harmful changes if used for longer than a few (4 to 6) weeks without adequate supervision. Examples of such splints are the repositioning splints, which have been used to keep a repositioned disk in a normal position during healing²⁰.

Splints designed to have contact with only some of the opposing teeth may eliminate or reduce acute TMJ-related pain. However, this is often only a short term effect; using such a splint for longer than 4 to 6 weeks may lead to extrusion of some teeth and/or intrusion of other teeth, depending on where the contacts are. Splints with contacts only in the molar regions may cause intrusion of the posterior teeth (Figures 9A through 10B). Splints in which the only contacts are with the incisors may cause an anterior open bite (Figures 11A through 11C). Long term use of such splints should not be prescribed without first trying other possible remedies. It may be the treatment of choice when everything else fails and the patient suffers from chronic pain.

Bite splint fabrication is best learnt in hands-on courses, only a few details about the clinical and laboratory procedures will be discussed here. Keeping these details in mind can save a lot of chair time and help avoid frustrating remakes.

If using alginate, the impressions should be poured immediately, never waiting more than 1 to 2 minutes, to avoid dimensional changes. A high quality stone must be used and mixed with the right proportions of powder and water. A common mistake is to neglect the manufacturer’s instructions and mix wrong proportions of plaster and water. Often, the mix is too thin (too much water) which lowers the quality of the stone and increases the risk of getting a splint that will not fit. Some practitioners might be surprised at how thick the mix is when using a balance to get the right proportions.

When making a bite registration, the wax should not extend onto the facial surfaces of the anterior teeth because it is important to compare how the teeth are aligned with and without the check bite in place.

Unless there is a specific reason based on the diagnosis, the dentist should make only minimal changes of vertical. Extensions onto the facial surfaces of the incisors should be avoided the risk of preventing lipseal, which may induce mouth breathing during sleep. There is no basis for the assumption that facial coverage is needed to prevent movement of the anterior teeth. If needed, improved retention can, be achieved by adding simple ball clasps in the molar or premolar areas or by adding acrylic or composite in the molar interproximal areas on the lingual of the appliance.

It is a common mistake to let bite splint treatment drag on for years without making appropriate referrals. If the patient’s acute problems are not resolved within a few months or his or her conditions are at least improving, the dentist should acknowledge that something is missing in the diagnosis or treatment plan. If the patient has persistent oral parafunctions or if the splint changes the occlusion in a desirable way, the dentist should discuss a permanent restoration. If the patient caot afford this or if it is impossible for other reasons, then the patient can be encouraged to use the splint indefinitely if coming back for controls at least 1-2 times/year..

Some patients function well with a splint but report that symptoms return if they stop using the splint. Unfortunately, some practitioners therefore encourage most or all of their patients to retain their splints for years, maybe even for the rest of their lives. A patient may be used to and even dependant on the splint, which then functions as a psychological “crutch”. The dentist has the obligation to try to resolve the patient’s problems with alternative treatments and by appropriate referrals.

Dentists should protect themselves and the patients by doing the following;

1. making study-casts and taking photos of the dentitions before treatment starts;

2. making careful recordings of jaw movement range, clinical signs of TMD, and oral/facial pain before and during treatment;

3. providing the patient with oral and printed information relevant to the case; and

4. obtaining a signed consent form²¹ and giving the patient a copy to keep.

Many problems might be avoided if the dentist keeps all patient records indefinitely, especially in cases where non-conservative procedures were used.