Etiology of Tooth Mobility
Weakening of the periodontium due to tissue loss from periodontal disease can lead to secondary migration or tooth mobility, which is stressful for patients who are afraid of losing their teeth and see splinting as a way to keep them. However, mobility is not a prognostic factor nor an index of severity; it is only a symptom of an etiology, and it can be broadly attributed to the following factors:
Carrying out splinting as a first-line treatment, without treating the etiology, will certainly “reassure” patients temporarily, because they will no longer feel the mobility, but it will not prevent the progression of the pathology. It is preferable to treat the etiology first and then use splinting if still necessary.1
Often, the patient needs to be reassured: “No, you are not going to lose your teeth!” Then the clinician can advise the patient to resume rigorous brushing of the inflamed area to help improve periodontal health.
Occlusal disorder
An occlusal disorder alone will only result in an increase in the volume of the periodontal ligament and not in the destruction of the alveolar bone. These parafunctions will therefore cause a physiologic adaptation of the periodontium, which in the absence of cofactors (such as inflammation or infection), will be entirely reversible.
These parafunctions are often the consequence of secondary migrations frequently observed in cases of periodontitis. Due to the widening of the periodontal ligament, the tooth may have increased mobility. The use of articulating paper allows these interferences to be highlighted and corrected in static and dynamic occlusion in order to restore undisturbed function. However, this can only be considered if the mesial and distal contact points are preserved.2
On the other hand, in cases of underlying inflammation or infection (unless the patient is unable to close the mouth), occlusal correction should be avoided until the primary cause of the mobility has been resolved. In many cases, resolution of the underlying inflammatory or infectious cause will make it possible to reduce or even eliminate the mobility, and the tooth will naturally, in a certain number of cases, return to its correct location. A correction of the occlusion can always be performed as a second-line treatment. The lingual forces on a reduced periodontium also can lead to ectopic positions that cannot be managed by splinting alone. They must be rehabilitated
Underlying inflammation
Underlying inflammation causes enlargement of the periodontal ligament, which can lead to tooth mobility. Often, patients do not dare to brush their teeth anymore, resulting in an accumulation of even more biofilm, which is responsible for the inflammation, therefore making it worse. Patients will then often ask for immediate splinting in order to stop the mobility. However, unless there is terminal bone loss, mobility is a direct result of the inflammatory conditions, and resolution of the inflammation usually results in stability of the teeth. Patients need to be reassured that they can brush the area and that the tooth will not fall out. It is important to warn them that the tooth will move during brushing for the first few days, but they will quickly feel improvements. If the patient is not satisfied with the results, splinting can always be considered at a later stage.
Inflammation is the primary cause of mobility and is reversible. A tooth never moves by chance, and treatment of the etiology is often sufficient to resolve the mobility.3
Endodontic and/or periodontal infection
As the endodontic infection can spread through the periodontium, it can lead to endodontic-periodontal lesions and abscesses. In these cases, very severe mobilities up to axial mobility (Mühlemann type IV4) might be observed. Reduction of the bacterial load, coupled with etiologic treatment, can lead to a reduction in mobility and even its disappearance depending on the volume of residual bone.
Once again, splinting will provide very little benefit in these situations and should only be considered secondary to resolution of the etiology. Reduction in mobility will be an encouraging sign in the resolution of the etiology and cannot be achieved with splinting.
Terminal bone loss
Terminal loss of periodontal support results in tooth mobility within the remaining tissues.
Indications for Periodontal Splinting
The indications for periodontal splinting are limited, and it can often be avoided. The splinting is plaque retaining and masks recurrences or related problems by blocking the mobility of the tooth, which is not a serious sign but rather a warning sign.
The only splinting we perform today in periodontics is for emergency restoration when the periodontium is too weakened and we decide to retain the teeth, initially, for esthetic reasons or to maintain space. This gives us time to think about stabilizing the periodontal disease and then reassess the overall situation to decide whether or not to retain the teeth (Fig 13-1). These restorations, which can be fiber-reinforced (Fig 13-2) or done with the aid of a splint grid (Fig 13-3) or a splinting wire, often have a life span of a few months or a few years because of the shearing forces that are applied to the reduced periodontium.
Comfort splints (for the patient) can also be considered but will pose the problem of being highly retentive of dental plaque.
Periodontal splinting without prior orthodontics is no longer a recommended therapy. On the contrary, using splinting too soon can limit secondary migrations and could prevent the recovery of a more physiologic position of the tooth in the periodontium. It is more appropriate to manage the causes and treat the etiology before the symptoms. Patients need to be reassured about what they are experiencing. Validation that the tooth is moving but will remain in the mouth is usually enough to reassure the patient and allow the therapies discussed earlier to be implemented to achieve stable results over time.
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