|Year : 2016 | Volume
| Issue : 1 | Page : 50-57
Management of tooth mobility in the periodontology clinic: An overview and experience from a tertiary healthcare setting
Clement Chinedu Azodo1, Paul Erhabor2
1 Department of Periodontics, University of Benin, Benin City, Edo, Nigeria
2 Department of Periodontics, University of Benin Teaching Hospital, Benin City, Edo, Nigeria
|Date of Web Publication||10-Jun-2016|
Clement Chinedu Azodo
Department of Periodontics, University of Benin Teaching Hospital, Room 21, 2nd Floor, Prof. Ejide Dental Complex, P.M.B. 1111 Ugbowo, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
Background: Tooth mobility, considered as the extent of horizontal and vertical tooth displacement created by examiners force, is caused trauma and periodontal disease. It is a common presenting complaint in periodontal clinic and may result in occlusal instability, dietary restriction, masticatory disturbances, esthetic challenge, and impaired quality of life. The treatment of tooth mobility involves a combination of treatment of the etiology usually by nonsurgical and surgical periodontal treatment, occlusal adjustment, and splinting. This article reviewed occlusal adjustment and splinting in the management of tooth mobility and reported our experience in University of Benin Teaching Hospital, Benin City, Nigeria on tooth mobility managed with 0.5 mm hard stainless steel wire reinforced composite splint. Results: Composite splinting reinforced with 0.5 mm HSS wire facilitates healing of periodontally compromised teeth with mobility after they have been treated with nonsurgical periodontal therapy and occlusal adjustment. Conclusion: Splinting is a well-accepted integral part of holistic periodontal treatment which results in morale boost, improved patient comfort, and oral functions.
Keywords: Composite resin, hard stainless steel wire, occlusal adjustment, splint, tooth mobility
|How to cite this article:|
Azodo CC, Erhabor P. Management of tooth mobility in the periodontology clinic: An overview and experience from a tertiary healthcare setting. Afr J Med Health Sci 2016;15:50-7
|How to cite this URL:|
Azodo CC, Erhabor P. Management of tooth mobility in the periodontology clinic: An overview and experience from a tertiary healthcare setting. Afr J Med Health Sci [serial online] 2016 [cited 2019 Jan 19];15:50-7. Available from: http://www.ajmhs.org/text.asp?2016/15/1/50/183893
| Introduction|| |
Periodontitis, which is an advanced form of periodontal disease, causes destruction of both soft and hard tissue components of the tooth supporting structures leading to tooth mobility. Tooth mobility is considered as the extent of horizontal and vertical tooth displacement created by examiners force. Assessment of tooth mobility is considered as an integral part of periodontal assessment because it is one of the important signs in the diagnosis of periodontal diseases. Hence, the reduction of tooth mobility is one of the prime objectives of periodontal therapy.
Tooth mobility is usually graded into Grade 1, 2, and 3 in periodontal healthcare delivery using Miller tooth mobility index because it has bearing on the choice of treatment and prognosis prediction. The mechanism through which periodontitis cause tooth mobility include inflammatory disruption of the periodontal tissues, widening of the periodontal ligament, attachment loss, alveolar bone loss, and occlusal trauma. The occlusal trauma here is considered as secondary occlusal trauma because the tissue destruction occurs in the presence of normal occlusal forces on the mobile tooth due to the weakened supporting tissues. Branschofsky et al. reported that secondary trauma from occlusion is frequently seen in periodontally compromised patients.
Tooth mobility results in occlusal instability, masticatory disturbances, and impaired quality of life. The continued movement of the mobile tooth during oral function further damages the periodontium, accelerating the disease process thereby leading to tooth loss. The initial awareness of tooth mobility in patients may be from tooth tenderness experience on mastication followed by pain on sudden tooth displacement when biting on hard foods or from inadvertent trauma. The anterior labial or lateral tooth displacement that results in fanning and elongation of clinical crown with poor appearance is the esthetic challenge associated tooth mobility. Individuals experiencing tooth mobility may resort to unilateral mastication and dietary restriction as their coping mechanisms. Teeth cleaning is also difficult thereby leading to the worsening of oral hygiene status by plaque accumulation. These factors trigger a positive feedback mechanism which will be truncated only if appropriate treatment is rendered or the untreated tooth is lost [Figure 1].
|Figure 1: Effects of periodontitis associated tooth mobility with positive feedback|
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Periodontal diseases have remained one of the major causes of tooth loss in Nigeria and globally despite numerous technological advances in prevention and management of oral diseases. Tooth mobility is one of the terminal presentations of periodontal disease before tooth loss. The adoption of proper and adequate steps in the management of tooth mobility will definitive help in increasing the longevity of the tooth and preventing edentulism. The treatment of tooth mobility involves a combination of treatment of the etiology usually by nonsurgical and surgical periodontal treatment, occlusal adjustment, and splinting. Although other causes of tooth mobility exist; however, this review was limited to tooth mobility due to periodontitis. This article reviewed occlusal adjustment and splinting in the management of tooth mobility and reported our experience in University of Benin Teaching Hospital, Benin City, Nigeria on tooth mobility managed with 0.5 mm hard stainless steel wire reinforced composite splint.
Treatment of tooth mobility
The treatment of periodontitis-associated tooth mobility may involve specific treatment for the stage of periodontitis, occlusal therapy and splinting., Splinting is not a substitute for periodontal treatment as a real reduction in tooth mobility occurs from healing that follows the treatment of the periodontitis., The treatment of the periodontitis usually involves nonsurgical and surgical periodontal treatments but sometimes may be limited to only the nonsurgical periodontal treatment. The treatment of the periodontitis and sometimes occlusal adjustment is usually enough to strengthen the supporting tissue and re-establish function, especially in Miller Grade 1 tooth mobility. However, splinting is needed in cases of Miller Grade 2 tooth mobility in addition to the treatment of the periodontitis and occlusal adjustment. Splinting is sometimes indicated in cases of Miller Grade 3 tooth mobility where tooth extraction is not acceptable or contraindicated. Although splinting provides some beneficial distribution of occlusal forces that cause tooth mobility, occlusal adjustment alleviate these occlusal forces by removing destructive contacts and creating proper occlusal clearance.,
Occlusal adjustment also known as selective grinding is the modification of the occluding surfaces of teeth through grinding to create harmonious contact relationships between the maxillary and mandibular teeth. The aim of occlusal adjustment is to establish and maintain stable occlusal relationships and to restore an optimal occlusal function. It is known that proper occlusal management assists in maintaining comfort during function and health of the natural dentition. Ramfjord and Ash  stated that occlusal therapy is required to enhance occlusal stability at any stage of periodontitis but is most often necessary in advanced periodontitis. The treatment of occlusal discrepancies is considered an important factor in the overall treatment of periodontal disease because it has been reported to significantly reduce the progression of periodontal disease., Occlusal equilibration helps to offset persistent impaired function, diminished comfort, or unacceptable esthetics after inflammatory process has been controlled. Report of statistically greater clinical periodontal attachment gains when occlusal adjustment was included as a component of periodontal therapy exists in the literature. The indications and contraindications for occlusal adjustment listed by The 1989 World Workshop in Periodontics  are as follows:
Indications for occlusal adjustment
- To reduce traumatic forces to teeth that exhibit: (a) Increasing mobility or fremitus to encourage repair within the periodontal attachment apparatus and (b) discomfort during occlusal contact or function
- To achieve functional relationships and masticatory efficiency in conjunction with restorative treatment, orthodontic, orthognathic surgery, or jaw trauma when indicated
- As adjunctive therapy that may reduce the damage from parafunctional habits
- To reshape teeth contributing to soft tissue injury
- To adjust marginal ridge relationships and cusps that are contributing to food impaction.
Contraindications to occlusal adjustment
- Occlusal adjustment without careful pretreatment study, documentation, and patient education
- Prophylactic adjustment without evidence of the signs and symptoms of occlusal trauma
- As the primary treatment of microbial-induced inflammatory periodontal disease
- Treatment of bruxism based on a patient history without evidence of damage, pathosis, or pain
- When the emotional state of the patient precludes a satisfactory result
- Instances of severe extrusion, mobility, or malpositioning of teeth that would not respond to occlusal adjustment alone.
Splinting, which is a procedure by which a tooth resistance to an applied force, is increased by joining it, to a neighboring tooth or teeth, is a well-accepted clinical treatment used to control irreversible tooth mobility through mechanical stabilization. It has the advantage of stabilizing mobile teeth by forming a firm unit, minimizing tooth mobility, and greatly improving the occlusal function of the teeth. Splinting is considered an important component of a periodontal treatment plan because of its ability to provide coaptive stability to the teeth and greatly improve the outcome and prognosis of teeth affected by periodontal disease. Splinting is valuable in ensuring the retention of periodontally compromised tooth and positively affecting the longevity. Splinting is regarded as an integral part of periodontal therapy because it is used to maintain periodontally migrated teeth that have been repositioned and also used before periodontal surgery to stabilize mobile teeth during postsurgical healing as such stabilization creates a more favorable environment for periodontal repair. Chalifoux  stated that splinting saves a significant number of mobile teeth but requires a high degree of clinical skill and diagnostic expertise. The success in splinting therefore depends heavily on the ability of the clinician to make an accurate diagnosis concerning the etiology of the functional disturbance. The technical elements in splinting include achievement of marginal fit, contour, cleansibility, occlusion and aesthetics, retention, and adequate thickness or bulk of the splint and good solder joints.
The overall objective of splinting is to create an environment where the tooth movement can be contained within physiological limits, thereby improving patient comfort and the restoration of function. Splinting is known to improve patient's comfort during mastication by evenly distributing the masticatory and occlusal forces in the arch., Zhang asserted that splints help redirect force to other teeth when occluding thereby protecting the mobile tooth, reducing traumatism, and facilitating periodontal tissue repairing and regeneration. Vályi et al.[3w0] reported that the stabilization of mobile teeth with splint allow the same healing like a nonmobile teeth. Splinting has also been shown to promote healing following periodontal surgery in localized aggressive periodontitis with resultant significant bone gain. Splinting boost the morale of patients with tooth mobility by increasing their confidence while eating and reducing the fear of tooth loss in them.
The rationale for splinting
The rationale for splinting which are mainly for protection of tissue, restoration of physiologic occlusion, distribution of force, ensuring functional comfort during mastication are listed below.
- To protect the investing structures of the teeth
- To protect the pulp
- To control forces and stress
- To establish physiologic occlusion
- To serve as an evaluating procedure
- To serve as anchorage and stabilizer in cases requiring minor tooth movement
- To treat periodontal cases which required both restorative and periodontal therapy to be executed simultaneously or required immobilization or to maintain periodontal result
- To establish the prognosis of a questionable teeth as it affects the final treatment plan
- To enhance stabilization in postacute trauma
- To prevent drifting in normal dentition during occlusal therapy
- To provide functional comfort by preventing mobility in disease dentition.
Indications for splinting
The main purposes of splinting are to provide rest where wound healing is in process and permits function where the tissues alone cannot perform adequately. Indications for splinting include ,,,:
- To maintain periodontally migrated teeth that have been repositioned
- It is usually required in addition to occlusal adjustment in moderate to severe periodontitis when trauma from occlusion is progressive
- Moderate to advanced tooth mobility that cannot be reduced by other means and which has not responded to occlusal adjustment and periodontal therapy and when there is interference with normal function and patient comfort
- In cases where nonsurgical and surgical periodontal procedures are difficult in the absence of tooth stabilization. It facilitates treatment of extremely mobile teeth by splinting them before periodontal instrumentation and occlusal adjustment procedures
- Splinting is used to eliminate movements in the healing area after periodontal surgery since micromovement of the surgical site may inhibit repair to take place in the healing area
- Tooth splinting may be indicated for individual mobile teeth as well as for an entire dentition in cases where extraction and implant therapy is not a viable alternative
- Prevention of teeth drifting after orthodontic treatment or when a tooth is missing
- Prevention of mobility after acute trauma as in subluxation and avulsion. von Arx  stated that splinting of traumatized teeth is an important step in the treatment of periodontally injured teeth and a precondition of healing of the periodontal tissues and also listed medicolegal reasons, patient comfort and avoidance of additional trauma during periodontal healing as other reasons for splinting in such situations.
Contraindications for splinting
- When the treatment of inflammatory periodontal disease has not been addressed
- When occlusal adjustment to reduce trauma and/or interferences has not been previously addressed
- When the sole objective of splinting is to reduce tooth mobility whose etiology could be ascertained.
Biomechanics of the splint
In periodontitis associated tooth mobility, occlusal forces, lateral, mesiodistal, and intrusive forces play roles in further tissues destruction as the forces are not directed on the long axis of the tooth as the center of rotation of affected tooth is altered. Before splinting, tooth mobility reduction is achieved by decreasing the occlusal forces through occlusal adjustment. Splinting increases the total area of root resistance, periodontal resistance, and the resistance to mesiodistal forces by creating a multirooted unit and altering the center of rotation of each tooth. Splinting ensures better distribution of force by directing the force over the splinted area that has adequate periodontal support. Consequent upon this, masticatory function would then be directed toward the area of most convenient and efficient for function as a result of conditioned reflex activity. between the abutments of the splint are necessary to avoid tipping (lateral) forces on forceful biting. Th e distribution of mesiodistal force is better when two single rooted teeth are splinted together. In splinted areas, intrusive forces are very well tolerated because the impact of the force spread over a maximal number of principal periodontal fibers. Splinting extends around the arch to connect posterior and anterior segments or to engage teeth in the opposite side of the arch so that anteroposterior forces and faciolingual forces are counteracted to achieve a favorable stabilization in the faciolingual and mesiodistal direction.
Disadvantages of splinting
The primary disadvantage of splinting is that it compromises plaque control by making oral hygiene access difficult thus instructing the patient about enhanced measures for oral hygiene after splinting is essential for the improved longevity of the connected teeth. This is based on the fact that plaque accumulation at the splinted margins can lead to gingival irritation and further periodontal breakdown in a patient with already compromised periodontal support. Syme and Fried  stated that periodontal and caries risk assessment, periodontal debridement, and preventive interventions during professional follow-up are critical to splint longevity. Other disadvantages of splinting included loose or fractured crown, splint interference with phonetics, normal interproximal wear, and mesial drift. Splinting is known to cause further deterioration in periodontal health if incorrectly performed. The following requirements have been outlined to overcome such potential negative consequences and achieve maximal positive outcome.
Ideal splinting requirements
Splints will achieve the indicated purpose for the fabrication and application when the ideal requirements listed below are given due consideration.
- It should incorporate as many firm teeth as is necessary to reduce the extra load on individual teeth to a minimum
- It should hold the teeth rigid and not impose torsional stresses on any incorporated teeth
- It should extend around the arch so that anteroposterior forces and faciolingual forces are counteracted
- It should not interfere with the occlusion
- If possible, gross tooth disharmonies should be eliminated before the application of the splint
- It should not irritate the pulp
- It should not irritate the soft tissues, gingiva, cheeks, lips, or tongue
- It should be designed to be comfortable and easy to keep clean for the patient
- Interdental embrasure spaces should not be blocked by the splint
- It should be readily available, relatively inexpensive, and medically acceptable
- Ease of fabrication and maintenance
- Capable of removal and insertion
- Esthetically acceptable.
Classification of splints
There are many techniques for splinting teeth. They can be classified based on their purpose and duration of use, the location of the splinted teeth in the jaw and the way of fabrication. Ferencz classified splints into short-term splints, provisional splints, and long-term splints according to their expected length of service.
- Splints are classified as metallic, nonmetallic, and combination of metallic and nonmetallic type on the basis of material. Metallic types are usually made of stainless steel, chrome cobalt, and cast metals, whereas nonmetallic types are made of acrylic and composites
- Splints are classified as fixed and removable on the basis of way of fabrication 
- Splints are classified as extra coronal and intracoronal on the basis of the location of the splinted teeth in the jaw 
- Extracoronal splints: Here, stabilizing wire, fiber-reinforced ribbon, or similar stabilization device is bonded to the outside of the teeth like a fixed orthodontic retainer. Other examples include tooth-bonded plastic, night guard, and welded bands
- Intracoronal splints: Here, a slot is milled into the affected teeth, and the stabilizing device is inserted into the slot and bonded in place. This makes this type of splint less visible with esthetic superiority. Examples include inlays and nylon wire
- Splints are classified as temporary, provisional, or permanent on the basis of duration and purpose ,
- Temporary splints: Temporary splints are those which are used less than 6 months during periodontal treatment and may or may not lead to other types of splinting. It is used to reduce unfavorable occlusal forces for a limited time in postacute trauma, in supportive measure in the treatment of advanced periodontal disease, and for anchorage in orthodontic therapy. Temporary splints can be removable, fixed external, and fixed internal types. Examples of removable temporary splint are cast metal splint of Elbrecht, the acrylic Hawley or other types of orthodontic appliance, the bite guards or night guards. Examples of fixed external types are (1) Annealed 0.010 or 0.012 inches stainless steel ligature wire, single or double, bonded to the teeth facially, lingually, and sometimes incisally.(2) The splint of wire combined with acrylic.(3) Orthodontic bands welded together (4) cast splints of gold or chrome nickel alloy cemented to the teeth and the facial and lingual parts tied together with ligature wire.(5) The most popular temporary splint is the one made with acid etch, self-polymerizing resin, and composite material.(6) Acrylic reinforced with the orthodontic grid material or cast metal framework
- Example of fixed internal type metal wires with acrylic reinforced placed in interproximal box preparation with mark retention to hold the teeth together Provisional splints: Provisional splints may be used from several months to years for diagnostic purposes, and usually lead to more permanent types of stabilization. Amsterdam and Fox  defined provisional splinting as the phase of restorative therapy utilizing a biomechanical combination of tooth dressing coverages and stabilization of teeth on an immediate and temporary basis. They are used in borderline cases in which the final result of the periodontal treatment cannot be predicted with certainty during the initial treatment planning. They provide information as to whether splinting will offer benefits before planning comprehensive treatment. Examples include ligature wires, nightguards, and interim fixed prosthesis, composite resin splints (with or without wire and fiber support)
- Permanent splints: Permanent splints are worn indefinitely and could be fixed or removable. They are intended to increase functional stability and improve esthetics on a long-term basis. They are usually placed only after completion of periodontal therapy and achievement of occlusal stability. Examples include Pin ledge type of abutment, clasped supported partial denture.
| Case Reports|| |
A 24-year-old male undergraduate who is a Christian and Urhobo by tribe. He presented with a complaint of a desire to replace a missing tooth lost 6-year ago. The missing tooth was as a result of a head-on collision, he sustained while cutting his hair in a barbing saloon. There was associated tooth mobility which patient noted was progressing. On examination, the following were noted: The upper left central incisor (21) and lower left lateral incisor (32) were missing. There was Grade 3 mobility with supra-eruption of the two lower central incisors (31, 41), Simplified-Oral Hygiene Index (OHI-S) was 4.7 with heavy calculus deposits around the mobile teeth. There were gingival inflammation and recession around the affected teeth with severe clinical attachment loss. Treatment done were scaling of all the quadrants, selective grinding of the lower central incisors, and reinforced composite splint [Figure 2]. At 3 months postoperative review, the tooth mobility has reduced, and there was radiographic evidence of minimal bone deposition.
A 38-year-old female hairdresser who is a Christian and Benin by tribe. She presented with a complaint of mobile lower left central incisor (31) of about 2 years duration. The mobility was progressively increasing in severity. There was no history of trauma to affected tooth, but history of associated recession of the gingiva in the lower anterior segment was obtained. On examination, the following were noted: Grade 2 mobility of the lower left central incisor (31). OHI-S was 1.3. There were gingival inflammation and recession around the lower left central incisor (31), lateral incisor (32), first premolar (34), lower right central incisor (41), lateral (42), and first premolar (44) with clinical attachment loss. Periapical radiograph reveals horizontal bone loss with enlarged periodontal ligament space of the lower left central incisor (31). An impression of chronic periodontitis of the lower left central incisor (31) was made. Treatment done were scaling of all the quadrants, root planing, and selective grinding of the lower left central incisor (31) with composite reinforced with 0.5 mm HSS splint [Figure 3]. Oral hygiene instruction was given, and patient was placed on doxycycline 100 mg 12 hourly for 14 days. On 3 months recall visit, mobility has reduced with some level of alveolar bone deposition.
A 30-year-old female legal practitioner who is a Christian and Ibo by tribe. She presented with a complaint of mobile upper right first molar (16), upper left first molar (26), lower left central incisor (31), lateral incisor (32), first molar (36), lower right central incisor (41), and first molar (46) of about 1 year duration. The mobility started some 17 years ago but became worse a year ago. There was a history of associated recession of the gingival in the lower anterior segment. On examination, the following was noted: Grade 1 mobility of the upper right first molar (16), upper left first molar (26), lower left central incisor (31), first molar (36), lower right central incisor (41), and first molar (46) of about 1 year duration.; Grade 11 mobility of lower left lateral incisor (32). OHI-S was 0.4. There were gingival inflammation and recession around the lower left central incisor (31), and lower left lateral incisor (32) with clinical attachment loss. Full blood count was done and revealed an essentially normal blood profile. Orthopantomogram revealed bone loss. An impression of localized aggressive periodontitis was made. Treatment done was scaling of all the quadrants and root planing of the affected teeth was done along with irrigation with tetracycline solution. Patient was placed on 500 mg amoxicillin and 400 mg of metronidazole both 8-hourly for 10 days. On review, 3 weeks later, mobility was still be present with no reduction. Selective grinding of the lower left central incisor (31), lateral incisor (32), lower right central incisor (41), and lateral incisor (42) with composite reinforced with 0. 5 mm HSS splint was done [Figure 4]. Oral hygiene instruction was given. Patient defaulted on the follow-up appointment. However, on 4 months recall visit, mobility has reduced with some level of alveolar bone deposition.
A 37-year-old female trader who is a Christian and Benin by tribe. She presented with a complaint of mobile upper left central incisor (21) of about 3 weeks duration. The mobility is progressively increasing in intensity. Patients ascribed the mobility to the trauma from intimate partner violence. There is a history of associated supra-eruption of the affected tooth. On examination, the following were noted: Grade 2 mobility of the 21. OHI-S was 3.3. There was gingival inflammation around the upper left central incisor (21). Periapical radiograph reveals horizontal bone loss with enlarged periodontal ligament space of the upper left central incisor (21). Impression of chronic periodontitis was made. TTreatment done were scaling of all the quadrants root planing and selective grinding of the upper left central incisor (21) with composite reinforced with 0.5 mm HSS splint [Figure 5]. Oral hygiene instruction was given, and patient was placed on doxycycline 100 mg 12 hourly for 14 days. Patient defaulted on the follow-up appointment. However, on 4 months recall visit, mobility has reduced with some level of alveolar bone deposition.
| Discussion|| |
Tooth mobility may arise in different patients from different causes ranging from aggressive periodontitis, chronic periodontitis, periodontitis associated with systemic conditions, trauma, occlusal traumatism, and complication of periodontal surgery. The management of periodontitis associated tooth mobility necessitates the administration of nonsurgical and surgical periodontal treatment, occlusal adjustment, and splinting. The composite splinting reinforced with 0.5 mm HSS wire utilized in the cases reported is a fixed temporary extracoronal splint. Mismanagement using splint alone without removal of the underlying cause and subsequent healing often results in tooth mobility manifesting again when the splint is removed. It is therefore crucial to raise clinician's awareness in the appropriate way of managing tooth mobility. In the cases reported, the causes were chronic periodontitis and aggressive periodontitis. It is important to properly diagnose the cause of a particular patient's tooth mobility so as to know how to manage the patient. History taking is necessary for proper diagnosis; however, incomplete history given by the patient may misguide an unsuspecting dentist, especially in cases of trauma. Dental examination and intraoral radiography are usually helpful in confirming the cause. In this report, nonsurgical periodontal treatment and occlusal adjustment before splinting resulted in a good clinical outcome. The bone deposition may be due resolution of the inflammation, passive eruption following occlusal adjustment and improved healing from the splinting.
| Conclusion|| |
Splinting is a well-accepted integral part of holistic periodontal treatment which results in morale boost, improved patient comfort, and oral functions. Composite splinting reinforced with 0.5 mm HSS wire may be used to facilitate healing of periodontally compromised teeth with mobility after they have been treated with nonsurgical periodontal therapy and occlusal adjustment.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]