227 Perio 2004: Vol 1, Issue 3: 227235

CLINICAL AND RESEARCH REPORT

Predictability of Resin-bonded Splints in the
Treatment of Patients with Periodontitis:
a Retrospective Study
Yves Samama, Lala Lboukili, Rosita Purer
A long-term retrospective analysis of clinical and radiographic data was carried out to determine
the interest and value of splint therapy for stabilizing clinical conditions after periodontal treat-
ment. The study population was composed of 51 patients enrolled in periodontal maintenance.
Patients were selected for splint therapy (splints or combined splint-fixed partial dentures)
because of residual tooth mobility in the anterior area following completion of periodontal treat-
ment. The follow-up period comprised between 2 to15 years.
During the observation period, 2 out of the 308 abutment teeth were lost and a small number
of complications (3 pulpal incidents, 9 debondings) occurred. The mean percentage of bone loss
calculated on periapical radiographs was 0.27% in the group 510 years after splinting and
0.40% in the group 1015 years after splinting.
The results of this study demonstrate that when modern adhesive techniques are applied, resin-
bonded splints and fixed partial denture splints can be viable alternatives to conventional com-
plete coverage prostheses in the treatment and maintenance of patients with periodontal dis-
eases.
Key words: periodontitis, resin-bonded splints, periodontal maintenance
INTRODUCTION
Advances in research over the last 30 years have
greatly enhanced our knowledge of periodontal
diseases. A better understanding of the relation-
ship between the bacterial etiology of periodontal
diseases and the host response has led to more
sophisticated diagnostic procedures and treatment
concepts. However, prosthodontic pro c e d u re s
which involve some degree of hard and soft tissue
invasion are still required to replace missing teeth,
to improve comfort and aesthetics, and to stabilize
some clinical situations in periodontal patients.
In addition to the considerable loss of tooth struc-
ture, the construction of conventional fixed partial
dentures is often associated with problems such as
pulp necrosis or periodontal complications due to
subgingival preparations in the anterior region
(Randow et al, 1986). Therefore, alternative meth-
ods of fixed tooth replacements have been pro-
posed. One of them is the adhesive pro s t h e s i s ,
which was also introduced as a less aggre s s i v e
method of splinting teeth with reduced periodontal
s u p p o rt (Rochette, 1973). However, this technique
has suff e red a series of failures related to a poor
understanding of the indications for its use and to
the mediocre perf o rmance of the first bonding
agents under occlusal and salivary stre s s e s
(Marinello, 1987, 1988).
The problems indicated by these initial failure rates
have been addressed by improving not only the
preparation protocol of the retaining teeth but also
the quality of the bonding agents (Samama, 1995;
R o m b e rg et al, 1995; Wood et al, 1996)
It has been demonstrated that resin-bonded splints
and fixed partial denture splints provide long term
e fficiency (Livatidis et al, 1982; MacLaughlin,
1981), the primary clinical criterion being the length
of time that restorations remained bonded. However
only few studies on the periodontal response to this
type of re c o n s t ructions are available (Freilich et al,
1990; Marinello et al, 1990; Quirynen, 1999)
They all show that, despite the possibly altered con-
tour of the abutment teeth and the resulting higher
f requency of plaque retention, this pro s t h o d o n t i c
a l t e rnative did not seem to change the periodontal
status in long-term evaluations.
The purpose of this study is to investigate the value
of this minimally invasive prosthodontic approach
for stabilizing clinical conditions after periodontal
disease treatment, using both clinical and radi-
ographic criteria.
STUDY DESIGN AND RESULTS
Resin-bonded splints were used according to the
protocol described by Samama (1995). The suc-
cess of this protocol depends on a good under-
standing of the interface mechanisms and stresses
on the bonded joints. The necessity of tooth prepa-
ration has proven to be of great importance in
countering the major stresses on the bonded joints
related to tooth mobility. Four types of stress have
been described: tearing and cleavage, peeling,
traction, and traction-shearing (Samama, 1995)
(Fig. 1).
Enamel micro-shoulders were designed to counter
peeling stress, while an arrangement of cingulum
pins was intended to reduce traction stre s s e s
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Samama et al Predictability of Resin-bonded Splints in the Treatment of Patients with Periodontitis: a Retrospective Study
Fig. 1 Effects of the 4 types of stress on the bonded
joint.
Fig. 2 Enamel microshoulders are designed to counter
peeling stress.
Fig. 3 Tooth mobility leads to significant traction stress
on bonded joints, accounting for the debonding of
mobile teeth in splints. The arrangement of cingulum pins
helps to limit traction stress on mobile teeth with reduced
periodontal conditions.
Fig. 4 The inner surface of a maxillary splint with cingu-
lum pins (elaborated on the base of the preparation
shown in Fig. 3), before bonding.
(Figs. 24). All the abutment teeth were prepared
but the exact number of preparations for each
tooth depended on tooth mobility, the extent of the
edentulous zone and on the occlusal conditions
o b s e rved in each patient. All restorations were
designed to be supragingival and to respect pulpal
conditions. A chemically activated re s i n
(Superbond, Sun-Medical, Shiga, Japan) was used.
Characteristics of the Population Studied
The study was limited to the anterior sector of the
arch, where function and aesthetics are equally
important. Clinical data including prosthetic and
endodontic complications and radiographic data
from 51 patients (38 females and 13 males),
ranging in age from 18 to 64 years, were used in
this study. Each patient had periodontal disease
requiring anterior teeth to be splinted or treated
with combined splint fixed partial dentures.
At the first clinical examination by a periodontist,
and according to periodontal and radiographic
parameters, 6 patients were diagnosed with initial
chronic periodontitis and 35 with moderate to
severe chronic periodontal disease (Armitage,
1999). Only 10 patients were diagnosed with
aggressive periodontitis. Following periodontal
treatment, patients were referred for prosthodontic
stabilization with resin-bonded splints or with com-
bined splint-fixed partial dentures. All patients
were maintained in parallel supportive periodontal
care by their periodontists for a period of 2 to 15
years and followed regular maintenance visits,
including periodontal screening, prophylaxis and
oral hygiene instructions. Patients were recalled at
3 to 12 month intervals on average.
Clinical and Radiographic Analysis
The subjects were analyzed according to specific
clinical and radiographic parameters.
For the clinical evaluation: the study population
was divided into 3 groups based on the time span
of the follow-up period after splinting: 25 years
(n=7), 510 years (n=9), and 1015 years
(n=35). For each patient, the following clinical data
w e re collected: type of periodontal treatment, ort h o-
dontic treatment needs, nature of retention (splint or
fixed partial denture splint), number of teeth
involved in bonding, number of teeth lost during
o b s e rvation period; number of debonding i n c i d e n t s
during observation period, and frequency of pulp
disease incidents during observation period.
For the radiographic evaluation: only 2 groups
were established based on the availability of their
radiographic status: 510 years after splinting
(n=29) and 1015 years after splinting (n=16).
The radiographic assessments did not correspond
exactly in time with clinical evaluations. These two
analyses were thus considered as parallel studies.
Periapical radiographs, applying the long cone
paralleling technique, taken before and after
splinting were used to analyze the evolution of
bone loss around the anterior splinted teeth. For
each patient, the mean percentage of bone loss
was calculated between the initial status and the
follow-up status. Measurements were taken with a
magnifying glass graded to one tenth of a mil-
limeter and allowing a magnification of ten. All
analyses were undertaken by the same examiner
under standardized conditions, using an illuminat-
ed light box. Radiographs were separated so that
the initial and final sets from each patient were not
read at the same session. To ensure that bone loss
was consistently measured, 10 randomly selected
radiographs were re-measured. There was an
exact correspondence between the original and
the repeated measurements in 93% of cases, indi-
cating that the reproducibility of this technique for
assessing alveolar bone loss was good.
Interproximal alveolar bone heights were assessed
using a modified version of the technique of She
et al (1959) as described by Linden (1988). The
cemento-enamel junction (CEJ) was chosen as the
coronal reference point since it is more reliable
than the most occlusal point (Selikowitz et al,
1981). When the CEJ was not visible due to the
presence of a restoration, the most apical point of
the restoration was used. The alveolar crest, which
constituted the second reference point, was con-
sidered as the most coronal level when the peri-
odontal membrane retained its normal width.
When widening of the cervical part of the peri-
odontal membrane space was present, it was
scored as bone loss only if evidence of oblique
resorption was also present (Albandar et al,
1987). The CEJ, the apex and the alveolar bone
margins of each splinted tooth were identified and
marked on the periapical radiographs. The latter
were considered as acceptable only if the CEJ,
restoration margin, interdental bone crest, and
apex were clearly visible.
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Samama et al Predictability of Resin-bonded Splints in the Treatment of Patients with Periodontitis: a Retrospective Study
The optimal bone level was taken as extending to
1mm below the CEJ. The mean percentage of
bone loss was calculated for the mesial and distal
sites of each splinted tooth as follows:
% of bone loss:
[ (CEJ-MBL) 1 / (CEJ-apex) 1 ] x 100
where MBL is the marginal bone level.
To measure the diff e rence in bone loss, the re a d-
able score for each post-splinting site was subtract-
ed from the initial radiograph score for each site.
Clinical Observations
In our study population, 8 patients received surgi-
cal treatment after initial therapy and 35 patients
received orthodontic treatment before splinting.
From the 51 patients, 32 patients received resin-
bonded metallic splints (26 in the maxilla, 3 in the
mandible and 3 in both the maxilla and the
mandible); 18 patients received splint fixed partial
d e n t u res (12 in the maxilla and 6 in the
mandible); and 1 patient received a fixed partial
denture splint in the maxilla to replace the upper
right central incisor and a metal splint in the
mandible. In total, the number of resin-bonded
splinting devices was 55 constructed on 308
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Samama et al Predictability of Resin-bonded Splints in the Treatment of Patients with Periodontitis: a Retrospective Study
Fig. 5 Distribution of splints, prostheses and retainers in
the study population (clinical evaluation).
Fig. 6 Example of the repair work debonded elements:
the debonded element is separated from the rest of the
splint. The latter is preserved. New preparations are
elaborated within the metallic elements of the splint adja-
cent to the tooth.
Fig. 7 A new small splinting device is elaborated,
reuniting the debonded tooth with the rest of the initial
splint.
Fig. 8 The newly elaborated splint is bonded onto the
tooth surface and onto the adjacent metal surface, the
former having been pre-treated with sandblasting and the
application of a primer (Sun Medical).
Observation 25 years 510 years 1015 years
p e r i o d
Total No. of 7 9 3 5
p a t i e n t s
No. of splints 6 9 * 2 1 * *
No. of fixed 1 1 1 6
partialdenture
s p l i n t s
No. of retainers 4 3 5 4 2 1 1
* One patient received a splint in the maxilla and in the
m a n d i b l e
** Two patients were treated each with a splint in the
maxilla and in the mandible, and one patient received a
fixed partial denture splint in the maxilla and a metal
splint in the mandible
teeth. The number of splints, prostheses, and units
of the splints/prostheses in each group is present-
ed in Figure 5.
Due to periodontal complications, 2 out of the
308 teeth (1 lower lateral incisor and 1 upper
central incisor) were lost during the 1015 year
observation group. No tooth loss was recorded in
the 25 year group or the 510 year group.
Nine debonding incidents occurred in 7 patients
in the 1015 year group (211 total retainers in
35 patients), resulting in 7 repairs and 2 remakes.
One single debonded unit was observed in 5
patients; 2 patients presented 2 debonded units
each, thus resulting in 4 debonded units. No
debonding was observed in the 25 year group
or the 510 year group (97 retainers in 16
patients). Figures 6, 7 and 8 illustrate an example
of splint repair.
Only 3 pulpal incidents on 3 different patients (1
lower lateral incisor, 1 upper lateral incisor and 1
canine) were observed among the 3 groups.
Radiographic Observations
The mean interval between radiographs was
6.54 years (range 58 years) for the 510 year
o b s e rvation group and 10.94 years (range
1015 years) for the 1015 year group. Due to
interpretation difficulties, 6 out of a possible 308
surfaces were not included in the first group and 5
out of a possible 174 surfaces were not included
in second group.
Bone loss scores were obtained for 302 sites in
the 510 year group and 169 sites in the 1015
year group. Figures 9 and 10 represent the aver-
age bone loss for each patient before and after
splinting for both study groups. Figures 11 and 12
show the distribution in bone loss during the study
period. In the 510 year observation group, it
ranged from a mean bone gain of 5.48% and a
mean bone loss of 6.10%; the median bone loss
being around 2.27%. In the 1015 year group,
the change ranged was from a mean bone gain
of 3.63% to a mean bone loss of 19.55%; the
median bone loss being around 0.52%. The aver-
age percentage of interproximal bone resorption
was 0.27% per year in the first group and 0.40%
per year in the second group.
DISCUSSION
The results of this study support the use of re s i n -
bonded splints and splinted fixed partial denture s
for maintaining patients with moderate to advanced
periodontal diseases. This prosthodontic technique
has the advantage of limiting the functional pro b-
lems caused by periodontal diseases and extend-
ing tooth longevity with reduced periodontal sup-
p o rt using minimally invasive pro c e d u re s .
F u rt h e rm o re, splinting is often necessary for post-
o rthodontic maintenance in periodontal patients.
The present results corroborate the few existing
studies on the periodontal response to resin-bond-
ed splints and fixed partial denture splints
(Marinello, 1988; Freilich, 1990; Marinello et al,
1990; Quirynen et al, 1999), showing an over-
all favorable result. They also confirm the findings
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Samama et al Predictability of Resin-bonded Splints in the Treatment of Patients with Periodontitis: a Retrospective Study
Fig. 9 Representation of bone loss for each patient
before and after treatment in the 510 year observation
group.
Fig. 10 Representation of bone loss for each patient
before and after treatment in the 1015 year observa-
tion group.
of Wood et al (1996) who concluded that caries
was not associated with resin-bonded fixed partial
dentures.
Aesthetic problems due to the dark metal giving a
grayish appearance to the incisal third of the abut-
ment teeth are also resolved by adding opaquers
to the formerly translucent resins.
In general two means of evaluation are applied to
assess the rate of periodontal disease progression
and the effectiveness of possible therapeutic inter-
ventions: namely tooth loss and the amount of
bone loss around the remaining teeth. Tooth loss
can be defined as the number of teeth lost during
a period of more than 10 years, resulting in a total
tooth loss score of 0.65%. The score of tooth loss
per patient and per year is 0.001 respectively.
This result compares well with those generally
obtained in the literature, varying from 0.02 to
0.24, with an average of 0.07 (Hirshfeld et al,
1978; McFall, 1982; Lindhe et al, 1987; Becker
et al, 1984; Goldman et al, 1986; Wood et al,
1989; McGuire, 1991; Brgger et al, 1992).
However, it is important to emphasize that these
studies included mono- and pluri-radiculated teeth,
whereas in the present investigation, only anterior
teeth were examined.
A radiographic assessment of alveolar bone loss
in patients with periodontitis can be used to meas-
ure the progression of bone loss on a longitudinal
basis. In this study, the average percentage of
interproximal bone resorption was 0.27% per
year and 0.40% per year in the 510 year and
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Samama et al Predictability of Resin-bonded Splints in the Treatment of Patients with Periodontitis: a Retrospective Study
Fig. 13 View of palatal preparations with pins in place,
ready for impression. This is a young patient with
aggressive periodontitis, who had undergone multidisci-
plinary treatment (periodontal care followed by orthodon-
tic and prosthodontic treatment).
Fig. 14 Lingual view of a splint cast made with a noble
alloy. The inner surface of the splint was silica coated.
Fig. 11 Distribution of the difference in bone loss in the
510 year observation group.
Fig. 12 Distribution of the difference in bone loss in the
1015 year observation group.
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Samama et al Predictability of Resin-bonded Splints in the Treatment of Patients with Periodontitis: a Retrospective Study
Fig. 15 The use of opaque powder eliminates the
unaesthetic grayish aspect widely observed with metallic
splinting.
Fig. 16 Initial radiographs of a patient with aggressive
periodontal disease. Lateral incisors were extracted.
Fig. 17 Palatal view of the 6-unit resin-bonded fixed
partial denture, replacing the lateral incisors after peri-
odontal treatment.
Fig. 18 Radiographic view 10 years after placement of
resin-bonded prosthesis. Dental and periodontal condi-
tions were stable.
1015 year groups respectively. These values are
slightly lower than those presented by Rohner et al
(1983), who recorded a mean bone loss of
0.51% per year over a period of 414 years, in
a population of patients under periodontal main-
tenance. In our two study groups, 10 patients pre-
sented a mean bone loss of about 0.46% per year
during the 510 year period with a comparable
figure of 0.5% per year during the 1015 year
period. However, this annual bone loss score
should not be interpreted as a slow, continuous
rate of destruction on a truly annual basis because
of the great variability observed among the sub-
jects and among different sites within the same
patients: interproximal alveolar bone change
ranged from an individual mean gain of 5.48% to
a mean loss of 6.10% in the 510 year group and
f rom a mean gain of 3.63% to a mean loss of
19.55% in the 1015 year group. It should thus be
kept in mind that the results of any clinical investi-
gation indicate only the average occurrence and
may not be applied to every individual subject.
The clinical and radiographic results of this study
demonstrate the value of resin-bonded splints and
splinted fixed partial dentures, which improve aes-
thetics and may extend tooth longevity. Figures
1315 provide an example of a maxillary splint,
illustrating the quality of the aesthetic result achiev-
able with this technique. Figures 1618 show the
clinical and radiographic aspects of a maxillary
splinted fixed partial denture 10 years after peri-
odontal and prosthodontic treatment, and indicate
the long term stability of this technique.
With most of its initial problems re s o l v e d
(Marinello et al, 1987, 1988; Samama, 1995;
Romberg et al, 1995; Wood et al, 1996), adhe-
sive prostheses may now be considered as true
alternatives for the conventional prosthodontic
treatment of periodontal patients. The develop-
ment of fiber-reinforced composite technology
over the last decade has also opened avenues in
the field of rapid, aesthetic and non-invasive direct
tooth replacements and splints using this type of
material (Rada, 1999; Meiers et al, 1998,
1999) (Fig. 19). These techniques would seem to
represent good alternatives to metal adhesive
prostheses if their long-term durability is proven.
However, treatment planning must be undertaken
with care given the current state of ignorance on
the progression rates of periodontal diseases and
the influence of host susceptibility and other risk
factors such as stress, smoking habits, and gener-
al health status. With these factors in mind, final
decisions must be made on a multivariate level for
each patient. Depending on patient age, the type
of periodontal disease, the extent of periodontal
damage, and the occlusal profile, other treatment
modalities such as implant placement may be
appropriate.
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Samama et al Predictability of Resin-bonded Splints in the Treatment of Patients with Periodontitis: a Retrospective Study
CONCLUSIONS
Out of the total 55 resin-bonded splinting
devices applied to 51 patients on 308
teeth, only nine debonding incidents were
managed with minor repairs. Only 2 out of
the 55 splinting devices had to be re m a d e .
During the 1015 year observation period,
2 out of 308 teeth were lost due to peri-
odontal complications. No tooth loss was
re c o rded during the shorter observ a t i o n
periods. Only 3 pulpal incidents in 3 dif-
f e rent patients were observed among the
3 gro u p s .
The average percentage of annual bone
loss around splinted teeth is comparable to
that observed in the general population by
other authors (Rohner et al, 1983). Some
d e g ree of variability was re p o rted in alve-
olar bone resorption among individuals in
the population studied.
Fig. 19 Example of mandibular splint in fiber-reinforced
composite.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the assistance
provided by all the periodontists that carried out
the periodontal treatment and maintenance of the
patients featured in this study,
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Reprint requests:
Yves Samama
3, place du 18 juin 1940
Paris 6me
Paris, France
E-mail: [email protected]
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