- Email: [email protected]
Temporary splinting for multiple mobile teeth
Temporary splinting for multiple mobile teeth Marvin Simring,* D.D.S., and Jack L. Thaller,f D.D.S., Brooklyn
economy of construction; (3) stability and efficiency; (4) accessibility to hy gienic procedures by patient; (5) non irritation to the gingival and oral tissues; ( 6) noninterference with other perio dontal treatment; (7) applicability to all parts of the mouth and ( 8) esthetic acceptability.
Periodontal treatment is difficult in a mouth with many mobile teeth. Splint ing frequently provides the stability nec essary for such procedures as scaling, curettage, occlusal equilibration and periodontal surgery. Efficient mastication and effective toothbrushing and home care are facilitated by splinting. A simple, rapid, efficient and economical method of splinting multiple loose teeth, as an aid to periodontal therapy, is described. The suggested method is applicable to all quadrants of the mouth, and most nearly fulfills the requirements of an ideal tem porary splint. Applicability to all parts of the mouth is desirable because of the great stabiliza tion attainable by splinting around the arch. The mechanical and physio logic values of splinting around the arch have been emphasized.1 Experimental evidence2 indicates that the stabilizing power of the splint is directly propor tional to the distance between the abut ments in the direction of the stress. M u l tidirectional splinting around the arch provides maximum resistance against the multidirectional forces which occur in the mouth1 (Fig. 1). AN
ID E A L
TEM PO RARY
S P L IN T
The use of the temporary splint is indi cated in the following circumstances: 1. Where mobility of the teeth exists, so that physiologic rest can be effected. 2. Where mobility exists to such a degree that effective periodontal treat ment and procedures cannot otherwise be executed properly. 3. As a diagnostic aid to evaluate the prognosis before instituting extensive per manent splinting. 4. To improve the morale of the pa tient with mobile teeth.
‘ Assistant professor, departm ent of periodontia and oral medicine, New York University College of Den tistry. In charge o f periodontics departm ent, Jewish Hospital o f Brooklyn. fForm erly, assistant, periodontics departm ent, Jewish Hospital of Brooklyn. A t present, instructor, departm ent of periodontia and oral medicine, New York University College o f Dentistry. 1. Simring, M . S plinting: theory and practice. J.A .D .A . 45:402 Oct. 1952. 2. Smyd, E. S. Principles o f foundational capacity of dental investing tissues. (A bst.) J.D.Res. 31:498 Aug. 1952.
S P L IN T
An ideal splint should possess the follow ing qualities: ( 1) simplicity and facility of construction and application; ( 2) 429
430 • TH E JO U R N A L O F T H E A M ER IC A N DEN TAL A SSO C IA TIO N
L IM IT A T IO N S O TH ER
OF
S P L IN T IN G
T E C H N IC S
Each of the other splinting technics— permanent splinting, wire ligatures, re movable splints, orthodontic bands and intradental splinting — has important limitations. Permanent Splinting1'*’ * * The time re quired to construct a permanent splint may delay unduly the necessary perio dontal procedures. Such delay may lead to eventual loss of teeth. Permanent splinting may not be necessary for man agement of the problem. Time and con siderable effort are required to prepare multiple mobile teeth for fixed splinting. Finally, the permanent splint is costly to construct. Wire Ligatures 113-5 • The use of wire ligatures is restricted to the anterior re gion of the mouth, unless the posterior teeth have constricted necks or heavy roots, or unless self-curing acrylic resin is used to engage the wire, as suggested by Simring.1 Other limitations of wire liga tures are that they are unesthetic, they may loosen or fray, and they cannot be added to or extended easily to include additional teeth in the splint, if this should be desired after the splint has been placed. Also, wire ligatures may irritate the soft tissues of the mouth, and may act as a food trap. Removable Splints1- 3,4 • The use of the removable type of splint generally is limited to one small segment of the mouth because of varying axial inclinations of the teeth. Vertical forces are generally not resisted adequately by this type of splint. Repeated removal and insertion of the appliance may further loosen previously mobile teeth. The bulkiness of the appli ance may be irritating to the patient. Orthodontic Bands6' 1 • Lack of proper contact is inherent in the use of ortho
dontic bands. They may require separa tion of teeth, and they are unesthetic unless covered by acrylic resin. Intradental Splinting8 • In the intra dental splinting technic devised by Obin and Arvins, the teeth are notched and undercut, and self-curing acrylic resin is painted into the notches. This technic involves destruction of tooth structure and is applicable only if permanent fixed splinting will be undertaken ultimately. S O L U T IO N
The method proposed here involves simple ligation of the teeth followed by application of a self-curing acrylic resin so that the ligature becomes embedded in the resin. The resin engages the occlusogingival curvature of the teeth to prevent the splint from slipping gingivally or occlusally; by using the ligature alone, such slipping might occur. Liga tion is done in separate segments accord ing to the anatomy of the teeth; the ligated segment is affixed to the other units in the arch with self-curing acrylic resin. A continuous fixed splint around the entire upper or lower arch may be accomplished, if necessary. Materials • The materials used in the temporary splint for multiple mobile teeth are white, braided, silk ligature or braided, dead, soft, stainless steel ligature (U.S.P. size 0 ) ; self-curing acrylic resin: straight and contra-angle sable brushes
3. M üler, S. C. Textbook of periodontia, ed. 3. Philadelphia, Blakiston Co., 1950. 4. Sorrin, S. Use o f fixed and removable splints in the practice o f periodontia. A m .J.O rthodont. & O ra! Surq. (Ora! Surg. Sect.) 31:354 June; correction 454 July !945. 5. H irschfeld, L. Use o f wire and silk liqatures. J.A .D .A . 41:647 Dec. 1950. 6. Chaiken, B. S. Temporary splinting in periodontal therapy. Alpha Omegan 47:97 Sept. 1953. 7. Friedman, N. Temporary splin tin g. An adjunct in periodontal therapy. J .Periodont. 29:229 O ct. 1953. 8. O bin, J. N., and Arvins, A. N. Use o f self-curing resin splints fo r the tem porary stabilization o f m obile teeth due to periodontal involvement. J.A .D .A . 42:320 March 1951.
SIM R IN G —TH A LLER . . .V O L U M E 53, O CTO BER 1956 • 431
i (size 00) , and single strand, dead, soft, stainless steel ligature 0.007 inches in diameter. Technic • The teeth are ligated with either the braided wire or silk. A ligature of braided wire is stronger than one of silk, and tends to remain cleaner; how ever, it is much more difficult to manipu late. For the posterior teeth, the ligature is placed at the height of contour (the greatest buccolingual diameter), circling each tooth twice in a double loop which provides added retention for the acrylic resin. Excessive tightness of the ligature should be avoided lest it slip subgingivally. It may be necessary to insert tem porarily a supraocclusal wire, 0.007 inches in diameter, to hold the arch wire in place during placement of the braided ligature and application of the acrylic resin. Such supraocclusal wire is removed on completion of the resin application (Fig. 2). For the anterior teeth, the ligature, wound around the teeth in a figure eight manner, is placed incisally to the cingulum but gingivally to the contact point (Fig. 3, above). An alternate method of
s». *///
FO R C E
T®
i
Y )
la « - A —►
<-------
R.
F ig . I • R esistance to b u c c o lin g u a l fo r c e is re la tiv e ly p o o r w hen s p lin t runs fro m fir s t b ic u s p id to se co n d m o la r b eca u se o f sm all d is ta n c e ( A ) in b u c c o lin g u a l d ir e c tio n b e tw e e n second m o la r a n d fir s t b ic u s p id . W h e n s p lin t is e x te n d e d to c e n tra l in c is o r, e ffe c tiv e b u c c o lin g u a l d is ta n c e is in cre a se d to (B ), w hich is m uch g r e a te r th a n ( A ) a n d , th e re fo re , p ro v id e s s u p e rio r re sista n ce to fo r c e in a la te ra l ( b u c c o lin g u a l) d ire c tio n
F ig . 2 • L e ft: B ra id e d , d e a d , so ft, stainless steel lig a tu r e p la c e d a b o u t te e th . S u p ra o c c lu s a l w ire re ta in s lig a tu re . C e n te r: S e lf-c u rin g a c ry lic resin a p p lie d w ith sable h a ir brush to c o v e r b ra id e d b u c c o lin g u a l lig a tu re s . S u p ra o cclu sa l w ire s a re n o t c o v e re d . N o te r ig h t a n g le brush. R ig h t: S u p ra o c c lu s a l w ire s c u t o ff, a n d a c ry lic resin trim m e d a n d p o lis h e d to p ro v id e fin is h e d s p lin t. This s e c tio n fo rm s p a r t o f s p lin t illu s tra te d in Figures 7 a n d 8
432 • TH E JO U R N A L OF TH E A M ERICA N DENTAL ASSO CIA TIO N
F ig . 3 • A b o v e : L ig a tio n o f lo w e r a n te r io r re g io n in fig u r e e ig h t m a n n e r p r io r t o a p p lic a tio n o f a c ry lic re sin . B elo w : A lte r n a te m e th o d o f lig a tio n in w h ic h se ve ra l te e th o f s im ila r a n a to m y have b een e n c irc le d b y th e lo o p s o f lig a tu re in ste a d o f e ach to o th b e in g e n c irc le d in d iv id u a lly
Fig. 4 • Sillt lig a tu re a p p lie d to u p p e r r ig h t p o s te rio r te e th a c c o rd in g to a lte rn a te te c h n ic illu s tra te d in F ig u re 3, b e lo w
ligation may be used in which a double loop is tied to encircle two or three teeth of comparable anatomy (Fig. 3, below). For convenience, a separate piece of liga ture may be used for each loop. For the posterior teeth, the ligature is placed at the buccolingual height of contour and gingivally to the contact point. This fairly simple technic is of particular value in relatively inaccessible regions, but it produces a rather bulky splint (Fig. 4 and 5). Where the contact point between teeth is tight or inaccessible, a loop of fine spring steel wire, 0.006 inches in diameter, may be used to pull the ligature between the teeth (Fig. 6). This procedure util izes the principle of the blind man’s needle threader. Acrylic resin is applied by the nonpressure method.0 Right-angle sable hair brushes, size 00, are useful in reaching the distal surfaces of molars (Fig. 2, center). Where it appears likely that the acrylic resin may impinge on the interproximal gingiva, wax may be packed into the interproximal regions before the resin is applied; the wax may be removed later, as suggested by Shack.10 A com pleted splint after application of the acrylic resin is shown in Figure 5. A dry field of operation is essential to permit effective intermingling of the acrylic resin with the fibers of the ligature. An antisialogogue may be used for this purpose. Either 100 mg. of methantheline bromide (Banthine Bromide) or 0.01 grain of atropine sulfate may be given the patient 45 minutes before treatment. Limitations • The limitations of this method of splinting are as follows: 1. The splint is subject to fracture unless extreme caution is exercised in checking the occlusion.
F iq . 5 • C o m p le te d s p lin t a fte r a p p lic a tio n s e lf-c u rin g a c ry lic resin
of
9. Nealon, F. H. A crylic restorations: operative nonpressure procedure. New York J. Den. 22:201 May 1952. 10. Shack, Aaron. Personal communication.
SIM RIN G —TH A LLER . . . VOLUM E 53, O CTO BER 1956 • 433
2. The splint makes it difficult to clean the teeth and massage the gingival tissues. Décalcification of the teeth has been observed in a few patients whose splints were left on for very long periods of time. 3. Temporomandibular joint disturb ance due to occlusal aberration may result from the rigidification of a mobile tooth in supraocclusion. With several patients, failure to adjust the occlusion induced a “click” in the temporomandibular joint; the occlusal interference and the tem poromandibular joint disturbance were alleviated by grinding.
F ig . 6 • Fine w ire lo o p used to e asily th ro u g h t i g h t c o n ta c t p o in t
d ra w
lig a tu re
4. The patient may be annoyed by the bulkiness of the splint. 5. The appliance may act as a food trap, resulting in horizontal food impac tion, which in turn may create an edema tous shelf of tissue (Fig. 7 ). Home Care • The patient must cooperate in the treatment. Diligent home care is essential. A modified Charter’s toothbrushing technic is demonstrated to the patient. For cleanliness, lavage is neces sary; the patient is advised to irrigate the splinted teeth with a stream of water from a commercial spray attachment, the head of which has been removed, as advised by Miller.11 Rubber tip stimula tion interdentally is imperative. A regular checkup is essential. The splint should be removed after not more than four months, and a thorough pro phylaxis and examination performed. A new splint may then be applied if neces sary.
F ig . 7 • P a la ta l le d g e o f e d e m a to u s g in g iv a l tissue fo rm e d as a re s u lt o f fo o d s lo d g in g b e tw e e n b u lk y s p lin t a n d g in g iv a w hen p a tie n t's p r o p h y la c tic p ro c e d u re s w ere in a d e q u a te
RESU LT
The simple new method of splinting described makes firm and stable all mem bers of the dental arch, to permit effective periodontal procedures (Fig. 8). The gingival tissues may assume normal, healthy tone, color and form as inflamma tory signs vanish.
F ig. 8 • L ig a tu re a n d a c ry lic s p lin t s u p p o rtin g a ll te e th in p a tie n t w ith a d v a n c e d p e rio d o n ta l disease w ith m o b ility o f a ll te e th
434 • THE JO U R N A L O F THE A M ERIC A N DENTAL A SSO C IA TIO N
SU M M A R Y
A simple, rapid, efficient and economical method of splinting multiple loose teeth as an aid in periodontal therapy is de scribed. The method is applicable to all quadrants of the mouth, and most nearly
fulfills the requirements temporary splint. 2566 O cean A venue
2.
of
an
ideal
II. M iller, S. C. O ral diagnosis and treatm ent, ed. Philadelphia, Blaiciston Co., 1946, p. 357.
Endodontics : selection of cases and treatment procedures Harry J. Healey, D.D .S., Indianapolis
The purpose of this paper is to call at tention to factors which enter into the selection or rejection for treatment of pulpally involved teeth. It will also dis cuss well directed and effective treatment procedures which supplement the re quired initial selection. S E L E C T IO N
OF CASES
A favorable prognosis for any restorative or replacement procedure depends pri marily on an accurate analysis of condi tions initially present. A consideration of indications or contraindications for the planned restoration or appliance is de manded to assure efficiency in the final result. Many failures in the mouths of patients can be attributed to injudicious initial planning of the treatment. The selection of cases for endodontic therapy is also of utmost importance in the ultimate success or failure of endodontically treated teeth. The commend able attitude of those who are willing to attempt to maintain pulpally involved teeth in the mouth by root canal therapy
can be nullified by unwise selection of cases for treatment. A knowledge of con ditions that are favorable or unfavorable for treatment is gained through expe rience. The importance of selection of cases for endodontic treatment has been pointed out and discussed in the litera ture by Appleton,1 Blayney,2 Coolidge,3 Grossman,4 Jasper5 and others. Experience— whether pleasant or un pleasant— and the utilization of the knowledge and experience of others as expressed in the literature, make it pos sible to determine criteria for selection of teeth for endodontic treatment. In essence, these criteria require an appraisal
Professor of operative dentistry, chairman, division o f endodontics, Indiana University School o f Dentistry. 1. Appleton, J. L. T., Jr. A report on an a ttem pt to form ulate a policy on the management o f the pulpless tooth. D. Cosmos 75:50 Jan. 1933. 2. Blayney, J. R. Root-canal therapy, diagnosis and therapeutics. D. Cosmos 70:380 A p ril 1928. 3. C oolidge, E. D. C linical pathology and treatm ent o f the dental pulp and periodontal tissues, ed. 2. Philadelphia, Lea & Febiger, 1946, p. 78. 4. Grossman, L. I. Root canal therapy, ed. 3. Phila d elphia, Lea & Febiger, 1950, p. 177. 5. Jasper, E. A. Root-canal therapy in modern den tistry. D. Cosmos 75:823 Sept. ^1933.
economy of construction; (3) stability and efficiency; (4) accessibility to hy gienic procedures by patient; (5) non irritation to the gingival and oral tissues; ( 6) noninterference with other perio dontal treatment; (7) applicability to all parts of the mouth and ( 8) esthetic acceptability.
Periodontal treatment is difficult in a mouth with many mobile teeth. Splint ing frequently provides the stability nec essary for such procedures as scaling, curettage, occlusal equilibration and periodontal surgery. Efficient mastication and effective toothbrushing and home care are facilitated by splinting. A simple, rapid, efficient and economical method of splinting multiple loose teeth, as an aid to periodontal therapy, is described. The suggested method is applicable to all quadrants of the mouth, and most nearly fulfills the requirements of an ideal tem porary splint. Applicability to all parts of the mouth is desirable because of the great stabiliza tion attainable by splinting around the arch. The mechanical and physio logic values of splinting around the arch have been emphasized.1 Experimental evidence2 indicates that the stabilizing power of the splint is directly propor tional to the distance between the abut ments in the direction of the stress. M u l tidirectional splinting around the arch provides maximum resistance against the multidirectional forces which occur in the mouth1 (Fig. 1). AN
ID E A L
TEM PO RARY
S P L IN T
The use of the temporary splint is indi cated in the following circumstances: 1. Where mobility of the teeth exists, so that physiologic rest can be effected. 2. Where mobility exists to such a degree that effective periodontal treat ment and procedures cannot otherwise be executed properly. 3. As a diagnostic aid to evaluate the prognosis before instituting extensive per manent splinting. 4. To improve the morale of the pa tient with mobile teeth.
‘ Assistant professor, departm ent of periodontia and oral medicine, New York University College of Den tistry. In charge o f periodontics departm ent, Jewish Hospital o f Brooklyn. fForm erly, assistant, periodontics departm ent, Jewish Hospital of Brooklyn. A t present, instructor, departm ent of periodontia and oral medicine, New York University College o f Dentistry. 1. Simring, M . S plinting: theory and practice. J.A .D .A . 45:402 Oct. 1952. 2. Smyd, E. S. Principles o f foundational capacity of dental investing tissues. (A bst.) J.D.Res. 31:498 Aug. 1952.
S P L IN T
An ideal splint should possess the follow ing qualities: ( 1) simplicity and facility of construction and application; ( 2) 429
430 • TH E JO U R N A L O F T H E A M ER IC A N DEN TAL A SSO C IA TIO N
L IM IT A T IO N S O TH ER
OF
S P L IN T IN G
T E C H N IC S
Each of the other splinting technics— permanent splinting, wire ligatures, re movable splints, orthodontic bands and intradental splinting — has important limitations. Permanent Splinting1'*’ * * The time re quired to construct a permanent splint may delay unduly the necessary perio dontal procedures. Such delay may lead to eventual loss of teeth. Permanent splinting may not be necessary for man agement of the problem. Time and con siderable effort are required to prepare multiple mobile teeth for fixed splinting. Finally, the permanent splint is costly to construct. Wire Ligatures 113-5 • The use of wire ligatures is restricted to the anterior re gion of the mouth, unless the posterior teeth have constricted necks or heavy roots, or unless self-curing acrylic resin is used to engage the wire, as suggested by Simring.1 Other limitations of wire liga tures are that they are unesthetic, they may loosen or fray, and they cannot be added to or extended easily to include additional teeth in the splint, if this should be desired after the splint has been placed. Also, wire ligatures may irritate the soft tissues of the mouth, and may act as a food trap. Removable Splints1- 3,4 • The use of the removable type of splint generally is limited to one small segment of the mouth because of varying axial inclinations of the teeth. Vertical forces are generally not resisted adequately by this type of splint. Repeated removal and insertion of the appliance may further loosen previously mobile teeth. The bulkiness of the appli ance may be irritating to the patient. Orthodontic Bands6' 1 • Lack of proper contact is inherent in the use of ortho
dontic bands. They may require separa tion of teeth, and they are unesthetic unless covered by acrylic resin. Intradental Splinting8 • In the intra dental splinting technic devised by Obin and Arvins, the teeth are notched and undercut, and self-curing acrylic resin is painted into the notches. This technic involves destruction of tooth structure and is applicable only if permanent fixed splinting will be undertaken ultimately. S O L U T IO N
The method proposed here involves simple ligation of the teeth followed by application of a self-curing acrylic resin so that the ligature becomes embedded in the resin. The resin engages the occlusogingival curvature of the teeth to prevent the splint from slipping gingivally or occlusally; by using the ligature alone, such slipping might occur. Liga tion is done in separate segments accord ing to the anatomy of the teeth; the ligated segment is affixed to the other units in the arch with self-curing acrylic resin. A continuous fixed splint around the entire upper or lower arch may be accomplished, if necessary. Materials • The materials used in the temporary splint for multiple mobile teeth are white, braided, silk ligature or braided, dead, soft, stainless steel ligature (U.S.P. size 0 ) ; self-curing acrylic resin: straight and contra-angle sable brushes
3. M üler, S. C. Textbook of periodontia, ed. 3. Philadelphia, Blakiston Co., 1950. 4. Sorrin, S. Use o f fixed and removable splints in the practice o f periodontia. A m .J.O rthodont. & O ra! Surq. (Ora! Surg. Sect.) 31:354 June; correction 454 July !945. 5. H irschfeld, L. Use o f wire and silk liqatures. J.A .D .A . 41:647 Dec. 1950. 6. Chaiken, B. S. Temporary splinting in periodontal therapy. Alpha Omegan 47:97 Sept. 1953. 7. Friedman, N. Temporary splin tin g. An adjunct in periodontal therapy. J .Periodont. 29:229 O ct. 1953. 8. O bin, J. N., and Arvins, A. N. Use o f self-curing resin splints fo r the tem porary stabilization o f m obile teeth due to periodontal involvement. J.A .D .A . 42:320 March 1951.
SIM R IN G —TH A LLER . . .V O L U M E 53, O CTO BER 1956 • 431
i (size 00) , and single strand, dead, soft, stainless steel ligature 0.007 inches in diameter. Technic • The teeth are ligated with either the braided wire or silk. A ligature of braided wire is stronger than one of silk, and tends to remain cleaner; how ever, it is much more difficult to manipu late. For the posterior teeth, the ligature is placed at the height of contour (the greatest buccolingual diameter), circling each tooth twice in a double loop which provides added retention for the acrylic resin. Excessive tightness of the ligature should be avoided lest it slip subgingivally. It may be necessary to insert tem porarily a supraocclusal wire, 0.007 inches in diameter, to hold the arch wire in place during placement of the braided ligature and application of the acrylic resin. Such supraocclusal wire is removed on completion of the resin application (Fig. 2). For the anterior teeth, the ligature, wound around the teeth in a figure eight manner, is placed incisally to the cingulum but gingivally to the contact point (Fig. 3, above). An alternate method of
s». *///
FO R C E
T®
i
Y )
la « - A —►
<-------
R.
F ig . I • R esistance to b u c c o lin g u a l fo r c e is re la tiv e ly p o o r w hen s p lin t runs fro m fir s t b ic u s p id to se co n d m o la r b eca u se o f sm all d is ta n c e ( A ) in b u c c o lin g u a l d ir e c tio n b e tw e e n second m o la r a n d fir s t b ic u s p id . W h e n s p lin t is e x te n d e d to c e n tra l in c is o r, e ffe c tiv e b u c c o lin g u a l d is ta n c e is in cre a se d to (B ), w hich is m uch g r e a te r th a n ( A ) a n d , th e re fo re , p ro v id e s s u p e rio r re sista n ce to fo r c e in a la te ra l ( b u c c o lin g u a l) d ire c tio n
F ig . 2 • L e ft: B ra id e d , d e a d , so ft, stainless steel lig a tu r e p la c e d a b o u t te e th . S u p ra o c c lu s a l w ire re ta in s lig a tu re . C e n te r: S e lf-c u rin g a c ry lic resin a p p lie d w ith sable h a ir brush to c o v e r b ra id e d b u c c o lin g u a l lig a tu re s . S u p ra o cclu sa l w ire s a re n o t c o v e re d . N o te r ig h t a n g le brush. R ig h t: S u p ra o c c lu s a l w ire s c u t o ff, a n d a c ry lic resin trim m e d a n d p o lis h e d to p ro v id e fin is h e d s p lin t. This s e c tio n fo rm s p a r t o f s p lin t illu s tra te d in Figures 7 a n d 8
432 • TH E JO U R N A L OF TH E A M ERICA N DENTAL ASSO CIA TIO N
F ig . 3 • A b o v e : L ig a tio n o f lo w e r a n te r io r re g io n in fig u r e e ig h t m a n n e r p r io r t o a p p lic a tio n o f a c ry lic re sin . B elo w : A lte r n a te m e th o d o f lig a tio n in w h ic h se ve ra l te e th o f s im ila r a n a to m y have b een e n c irc le d b y th e lo o p s o f lig a tu re in ste a d o f e ach to o th b e in g e n c irc le d in d iv id u a lly
Fig. 4 • Sillt lig a tu re a p p lie d to u p p e r r ig h t p o s te rio r te e th a c c o rd in g to a lte rn a te te c h n ic illu s tra te d in F ig u re 3, b e lo w
ligation may be used in which a double loop is tied to encircle two or three teeth of comparable anatomy (Fig. 3, below). For convenience, a separate piece of liga ture may be used for each loop. For the posterior teeth, the ligature is placed at the buccolingual height of contour and gingivally to the contact point. This fairly simple technic is of particular value in relatively inaccessible regions, but it produces a rather bulky splint (Fig. 4 and 5). Where the contact point between teeth is tight or inaccessible, a loop of fine spring steel wire, 0.006 inches in diameter, may be used to pull the ligature between the teeth (Fig. 6). This procedure util izes the principle of the blind man’s needle threader. Acrylic resin is applied by the nonpressure method.0 Right-angle sable hair brushes, size 00, are useful in reaching the distal surfaces of molars (Fig. 2, center). Where it appears likely that the acrylic resin may impinge on the interproximal gingiva, wax may be packed into the interproximal regions before the resin is applied; the wax may be removed later, as suggested by Shack.10 A com pleted splint after application of the acrylic resin is shown in Figure 5. A dry field of operation is essential to permit effective intermingling of the acrylic resin with the fibers of the ligature. An antisialogogue may be used for this purpose. Either 100 mg. of methantheline bromide (Banthine Bromide) or 0.01 grain of atropine sulfate may be given the patient 45 minutes before treatment. Limitations • The limitations of this method of splinting are as follows: 1. The splint is subject to fracture unless extreme caution is exercised in checking the occlusion.
F iq . 5 • C o m p le te d s p lin t a fte r a p p lic a tio n s e lf-c u rin g a c ry lic resin
of
9. Nealon, F. H. A crylic restorations: operative nonpressure procedure. New York J. Den. 22:201 May 1952. 10. Shack, Aaron. Personal communication.
SIM RIN G —TH A LLER . . . VOLUM E 53, O CTO BER 1956 • 433
2. The splint makes it difficult to clean the teeth and massage the gingival tissues. Décalcification of the teeth has been observed in a few patients whose splints were left on for very long periods of time. 3. Temporomandibular joint disturb ance due to occlusal aberration may result from the rigidification of a mobile tooth in supraocclusion. With several patients, failure to adjust the occlusion induced a “click” in the temporomandibular joint; the occlusal interference and the tem poromandibular joint disturbance were alleviated by grinding.
F ig . 6 • Fine w ire lo o p used to e asily th ro u g h t i g h t c o n ta c t p o in t
d ra w
lig a tu re
4. The patient may be annoyed by the bulkiness of the splint. 5. The appliance may act as a food trap, resulting in horizontal food impac tion, which in turn may create an edema tous shelf of tissue (Fig. 7 ). Home Care • The patient must cooperate in the treatment. Diligent home care is essential. A modified Charter’s toothbrushing technic is demonstrated to the patient. For cleanliness, lavage is neces sary; the patient is advised to irrigate the splinted teeth with a stream of water from a commercial spray attachment, the head of which has been removed, as advised by Miller.11 Rubber tip stimula tion interdentally is imperative. A regular checkup is essential. The splint should be removed after not more than four months, and a thorough pro phylaxis and examination performed. A new splint may then be applied if neces sary.
F ig . 7 • P a la ta l le d g e o f e d e m a to u s g in g iv a l tissue fo rm e d as a re s u lt o f fo o d s lo d g in g b e tw e e n b u lk y s p lin t a n d g in g iv a w hen p a tie n t's p r o p h y la c tic p ro c e d u re s w ere in a d e q u a te
RESU LT
The simple new method of splinting described makes firm and stable all mem bers of the dental arch, to permit effective periodontal procedures (Fig. 8). The gingival tissues may assume normal, healthy tone, color and form as inflamma tory signs vanish.
F ig. 8 • L ig a tu re a n d a c ry lic s p lin t s u p p o rtin g a ll te e th in p a tie n t w ith a d v a n c e d p e rio d o n ta l disease w ith m o b ility o f a ll te e th
434 • THE JO U R N A L O F THE A M ERIC A N DENTAL A SSO C IA TIO N
SU M M A R Y
A simple, rapid, efficient and economical method of splinting multiple loose teeth as an aid in periodontal therapy is de scribed. The method is applicable to all quadrants of the mouth, and most nearly
fulfills the requirements temporary splint. 2566 O cean A venue
2.
of
an
ideal
II. M iller, S. C. O ral diagnosis and treatm ent, ed. Philadelphia, Blaiciston Co., 1946, p. 357.
Endodontics : selection of cases and treatment procedures Harry J. Healey, D.D .S., Indianapolis
The purpose of this paper is to call at tention to factors which enter into the selection or rejection for treatment of pulpally involved teeth. It will also dis cuss well directed and effective treatment procedures which supplement the re quired initial selection. S E L E C T IO N
OF CASES
A favorable prognosis for any restorative or replacement procedure depends pri marily on an accurate analysis of condi tions initially present. A consideration of indications or contraindications for the planned restoration or appliance is de manded to assure efficiency in the final result. Many failures in the mouths of patients can be attributed to injudicious initial planning of the treatment. The selection of cases for endodontic therapy is also of utmost importance in the ultimate success or failure of endodontically treated teeth. The commend able attitude of those who are willing to attempt to maintain pulpally involved teeth in the mouth by root canal therapy
can be nullified by unwise selection of cases for treatment. A knowledge of con ditions that are favorable or unfavorable for treatment is gained through expe rience. The importance of selection of cases for endodontic treatment has been pointed out and discussed in the litera ture by Appleton,1 Blayney,2 Coolidge,3 Grossman,4 Jasper5 and others. Experience— whether pleasant or un pleasant— and the utilization of the knowledge and experience of others as expressed in the literature, make it pos sible to determine criteria for selection of teeth for endodontic treatment. In essence, these criteria require an appraisal
Professor of operative dentistry, chairman, division o f endodontics, Indiana University School o f Dentistry. 1. Appleton, J. L. T., Jr. A report on an a ttem pt to form ulate a policy on the management o f the pulpless tooth. D. Cosmos 75:50 Jan. 1933. 2. Blayney, J. R. Root-canal therapy, diagnosis and therapeutics. D. Cosmos 70:380 A p ril 1928. 3. C oolidge, E. D. C linical pathology and treatm ent o f the dental pulp and periodontal tissues, ed. 2. Philadelphia, Lea & Febiger, 1946, p. 78. 4. Grossman, L. I. Root canal therapy, ed. 3. Phila d elphia, Lea & Febiger, 1950, p. 177. 5. Jasper, E. A. Root-canal therapy in modern den tistry. D. Cosmos 75:823 Sept. ^1933.