/. Periodontal Res.

9: 121-126

Periodontal conditions in patients

treated with dental bridges
V. Effects of splinting adjacent abutment teeth

JOHN SILNESS AND ELISABETH OHM

Department of Prosthodontics, School of Dentistry, University of Bergen,
Bergen, Norway

The periodontal condition of 162 splinted approximal abutment tooth surfaces was com-
pared with that of 162 contralateral tooth surfaces which were not fastened together.
The Plaque Index (Silness & Loe 1964), the Gingival Index (Loe & Silness 1%3), and
the Margin Index (Silness 1970a) were recorded. Pocket depths were measured as explained
by Glavind and Loe (1967). In bridge recipients who had received periodontal treatment
and instruction to improve oral hygiene and who had no subgingival retainer margins in
the embrasure areas between the splinted teeth, the periodontal condition was no better or
worse than that of the contralateral area with which it was compared. Bridge recipients
who had not been systematically influenced to change the tooth cleansing habits and who
had subgingival retainer margins in the embrasure area between the splinted teeth, showed
a considerable deterioration of the periodontal condition as compared to that of the con-
tralateral area.

(Received for publication Feb. 11, 1974, accepted Mar. 13, 1974)

levered mesially or distally. Furthermore,

Introduction
fixed permanent splints are frequently con-
One of the guiding principles in the design structed to provide stability for mobile teetb
of fixed bridges is that the abutment teeth which have lost much of the periodontal
must provide adequate periodontal support support. They are also utilized to retain
for the bridge. Even though "adequate peri- teeth after they have been moved ortho-
odontal support" is not well defined it is dontically.
generally accepted that due to periodontal The retainers of the adjacent abutments
disease or because of the anatomical shape for the different types of bridges and fixed
of the roots bridges must often be extended permanent splints are usually united by
to include two adjacent teeth at tbe end rigid connectors. Tbe effects of sucb proce-
of the bridge when support is lacking. dures on the periodontal condition of the
Further, in cases with one missing tooth it embrasure area between the splinted abut-
is frequently necessary to choose between ments were not reported in the previous
three-units bridges abutted at each end and publications of tbis series (Silness 1970a,b,c,
cantilever bridges. The latter design requires 191 A). The present paper reports on some of
that two adjacent teeth are splinted and the tbese effects.
pontic replacing the missing tooth canti-
122 SILNESS
Materials and Methods
The material consisted of 81 fixed bridges
made for 81 individuals by students. The
constructions had been in the mouth 1-6
years. All the 81 bridges had two adjacent
end abutments rigidly fastened together by
a soldered or cast connector. There were 52
three-units bridges with mesially or distally
cantilevered pontics, 14 four-units bridges,
and 15 five-units bridges.
The periodontal condition was assessed by
recording the Plaque Index (Silness &
Loe 1964, the Gingival Index (Loe & Sil-
ness 1963) and by measuring pocket depth
according to Glavind and Loe (1967). The
position of the proximal retainer margins
was registered by using the Margin Index
(Silness 197()a). The present study was based
on comparison between the joint approximal
abutment surfaces and the contralateral ap-
proximal surfaces which were not tied to-
gether.
The selected sample consisted of two
groups:
Group I was selected from bridge recipi-
ents who had received treatment for peri-
odontal disease and instructed to practice
A C
Group I
Figs. 1 & 2. Diagrammatic representation of the embrasure area between two splinted end abutments. The Xi
surface is the approximal surface situated nearest to the pontic and X2 the surface most distant from pontic.
Non-subgingival retainer margins in Group I and subgingival margins in Group II.
A = abutment tooth, C = connector, R = pontic.
AND OHM
thorough oral hygiene with tooth brush and
wood points prior to bridge construction.
Supervision of the oral hygiene had been
maintained for variable lengths of time. The
other criterion for the selection of partici-
pants belonging to Group I was related to
the location of the retainer margins and the
restoration margins of the control tooth
surfaces: the retainer margins of the ap-
proximal, connected abutment surfaces
should not extend subgingivally (MI <: 2,
Fig. 1). Likewise, the contralateral control
surfaces should be devoid of subgingival
restorations. Group I comprised 38 bridges
placed in 38 individuals (22$, 16(5) with an
average age of 48 years (range 30-63 years).
The distribution of approximal surfaces on
tooth types is shown in Table 1.
Group II was selected from bridge recip-
ients who had not been influenced sys-
tematically to change their tooth cleansing
habits. The retainer margins of the ap-
proximal, connected abutment surfaces were
all subgingival (MI = 3, Fig. 2). The con-
trol surfaces carried fillings with and with-
out subgingival margins, and several sur-
faces were devoid of fillings. Group II con-
sisted of 43 bridges made for 43 individuals
Group
 P E R I O D O N T A L C O N D I T I O N S A N D S P L I N T I N G 123

Table 1
Distribution of approximal abutment tooth surfaces (X) on the various tooth types

Group 1 Group II

Upper jaw Lower jaw Upper jaw Lower jaw

m d m d m d m d

Central incisors _ 4 _ 2 _ 4 _
Lateral incisors 4 8 2 6 2 6 - -
Canines 8 16 6 2 8 13 _ 8
First premolars 16 - 2 - 13 4 8 3
Second premolars - - - - 4 5 3 -
First molars - - - - 5 - - -

28 28 10 10 32 32 11 11

m = mesial, d = distal.

(26$, 17(3). Average age of the group was
39 years (range 23-60 years). The distribu-
tion of approximal surfaces on tooth types
is shown in Table 1.
The significance of differences between
paired observations was tested by the t-test
for paired observations (Chilton 1967).
The different surfaces of the experimental
teeth (X) and the control teeth (C) were des-
ignated as follows (see Figs. 1 and 2):
Oral hygiene - Group I
For the approximal surfaces of the abut-
ments which were rigidly connected, the
mean Plaque Index was 1.37 for the Xj
surfaces and 1.42 for the X2 surfaces. For
the contralateral control surfaces the mean
values were 1.42 for the Cj surfaces and
1.32 for the Cg surfaces. The analysis re-
vealed no statistically significant differences
between the surfaces which were compared.

X] = the approximal surface between the Gingival health - Group I

abutments situated nearest to the
pontic
Xg = the approximal surface between the
abutments situated most distant from
the pontic
Ci = the control surface contralateral to
the X] surface
C-> = the control surface contralateral to
the X.2 surface
An equal number of experimental surfaces
and control surfaces were available.
Results
The results are summarized in Table 2 and
Table 3.
The mean Gingival Index for the united sur-
faces was 1.00 for the Xi surfaces and 1.10
for the X2 surfaces. The corresponding
values for the control surfaces Cj and C2,
were 1.10 and 1.05 respectively. Comparison
between the various surfaces showed that
none of the differences were statistically
significant.
Pocket depth - Group I
The mean pocket depth of the splinted
abutment surfaces was 2.84 mm for the Xj
areas and 3.00 mm for the Xo areas. For
the control surfaces the values were 3.05
mm for Cj and 3.10 mm for Co. The com-
parison showed that the mean pocket depth
value of the Cj areas was significantly
124 SILNESSANDOHM

Table 2
Mean Plaque Index, Gingival Index and Pocket Depth ofthe approximal surfaces compared

Tooth ^ No of Plaque Index Gingival Index Pocket Depth

Group ^ _ 1 _
surface surfaces y cc- y C;F- X ^F—

Cl 1 38 1.42 0.109 1.10 0.091 3.05 0.124

Cz 1 38 1.32 0.104 1.05 0.083 3.10 0.131

Cl + C2 1 76 1.37 0.076 1.08 0.060 3.07 0.088

Xi 1 38 1.37 0.119 1.00 0.091 2.84 0.096

Xz 1 38 1.42 0.137 1.10 0.074 3.00 0.117

X, + Xz 1 76 1.39 0.090 1.05 0.059 2.92 0.076

Cl 2 43 1.86 0.052 1.58 0.076 3.16 0.096

Cz 2 43 1.82 0.076 1.60 0.077 3.19 0.097

Cl + C2 2 86 1.84 0.049 1.59 0.053 3.17 0.070

Xi 2 43 2.16 0.055 1.93 0.052 3.42 0.137

Xz 2 43 2.11 0.053 1.91 0.050 3.44 0.113

Xi + X2 2 86 2.13 0.043 1.92 0.037 3.43 0.074

Table 3
Table of d~ - and " t " values for test of significance of differences between the
approximai surfaces compared

Plaque Index Gingival Index Pocket Depth

Paired surfaces Group
d- d- "t" d- "t"

C/Cz 1 0,10 0,95 0.05 0,59 0,05 0,36

X1/X2 1 0,05 0,50 0,10 1,10 0,16 1,45

Ci/X, 1 0,05 0,63 0,10 1,21 0,21 2,08

Cz/Xz 1 0,10 1,36 0,05 0,76 0,10 0,71

C,/C2 2 0,05 1,07 0,02 0,23 0,03 0,22

Xi/Xz 2 0,05 0,86 0,02 0,49 0,02 0,17

Ci/X, 2 0,30 4,24 0,35 4,33 0,26 2,34

Cz/Xz 2 0,29 3,55 0,31 4,02 0,25 2,26

p < 0,05 t = 2,02, p < 0,025 t = 2,33. for d . f. 37.

p<0,05 t = 2,01, p < 0,025 t = 2,32, p < 0,001 t = 3,53 for d . f. 42.

higher than the value for the X] areas Oral hygiene - Group II
(p < 0.05). No other statistically significant The mean Plaque Index of the connected
differences occurred. approximal abutment areas was 2.16 for the
 PERIODONTAL CONDITIONS A N D SPLINTING 125

Xi surfaces and 2.11 for the X2 surfaces. lost teeth. In individuals who had received
The corresponding values for the C^ and Ca periodontal treatment and instruction prior
areas were 1.86 and 1.82. The statistical data
to bridge construction and who had no sub-
showed that the mean Plaque Index value gingival retainer margin in the embrasure
of the Xj surfaces was significantly higher area (Group I), the periodontal condition
than the mean value for the Ci surfaces was no better or worse than in the contra-
(p < 0.001). Likewise, the mean Plaque In- lateral area which served as control. This
dex value of the X.2 areas was significantly finding indicates that the standard of
higher than the value for the C2 areas (p < hygiene and gingival health of embra-
0.001). The results of the remaining com- sure areas between splinted teeth may be
parisons (XI/XQ, C1/C2) revealed no signifi- kept at a level comparable to that of
cant differences. non-splinted teeth, provided there are no
subgingival restoration margins. The re-
Gingival health — Group II duction in pocket depth (X^ < C{) for
The mean Gingival Index value of the Xi Group I should probably not be interpreted
areas was 1.93 and for the Xo areas 1.91. as being an effect of splinting, but rather
The control surfaces scored 1.58 for the be viewed in the light of an earlier study,
Cl areas and 1.60 for the C2 areas. The showing that loss of teeth may cause pocket
mean value of the X] surfaces was signifi- depth reduction on both approximal aspects
cantly higher than the one for the C] sur- of the adjacent teeth (Silness, Hunsbeth &
faces (p < 0.001). Similarly, the mean index Figenschou 1973). It has also been shown
value of the X2 surfaces was significantly that this effect of tooth loss may be re-
higher than the value for the C2 surfaces tained when lost teeth are replaced by fixed
(p < 0.001). The results of the two other bridge pontics (Silness 191 A).
comparisons were negative. {Xx/X^., C1/C2). The embrasure areas between the splinted
teeth in bridge recipients who had received
Pocket depth - Group II no periodontal treatment or instruction prior
The mean pocket depth of the joint abut- to bridge construction, and which areas had
ment surfaces was 3.42 mm for the X^ both retainer margins located subgingivally
surfaces and 3.44 mm for the X2 surfaces. (Group II) showed periodontal conditions
TTie control surfaces C\ measured 3.16 mm significantly poorer thati the areas with
and the C2 surfaces 3.19 mm. The X] pock- which they were compared. Considerable
ets were significantly deeper than the Cj amounts of soft deposits could be seen with
pockets (p < 0.025) and so were also the the naked eye and/or collected from the
X2 pockets as compared to the C2 pockets pockets by probe. Concomitantly, all papil-
(p < 0.05). The comparisons X]/X2 and lae, with 3 exceptions, started bleeding on
2 showed no significant differences. gentle pressure with the probe. Experimen-
tal histological and epidemiological studies
have shown that artificial crown margins
Discussion placed subgingivally may deteriorate the
The present study has shown that the peri- periodontal condition of teeth (Waerhaug
odontal conditions as assessed by Plaque 1953, Marcum 1967, Karlsen 1970, Silness
Index, Gingival Index and pocket depth 1970c, Bergman, Hugoson & Olsson
measurements may vary in the embrasure 1971). It seems reasonable to assume that
areas between two rigidly connected end the periodonta! condition of the embrasure
abutments for fixed bridges made to replace area between splinted teeth in Group 11
126 S I L N E S S
should be attributed mainly to the presence
of subgingival retainer margins. The simul-
taneous impact of two subgingival crown
margins on the same papilla in the embra-
sure area may explain the considerable
changes which occurred in the area. On the
clinical examination it was also observed that
the soldered joint occasionally was over-
extended in a gingivo-occlusal direction.
This undoubtedly made the embrasures less
accessible to cleansing. This problem was
not as frequently encountered in bridge
recipients belonging to Group I. Probably
as a result of periodontal treatment, the
clinical crowns were often longer and the
embrasures wider. The soldered joints,
therefore, did not interfere with accessibility
to the same extent.
The results of the present study indicate
that when lost teeth are replaced by fixed
bridges, adjacent teeth should be splinted to
serve as abutments only when the retainer
margins will not be placed subgingivally and
the embrasures made wide enough to render
possible the use of tools suitable to promote
the hygiene of the embrasure area. The re-
sults discourage the use of bridge designs
with two or more end abutments in cases
where subgingival retainer margins have to
be used especially in recipients who do not
practice appropriate tooth cleansing meth-
ods.
References
Bergman, B., Hugoson, H. & Olsson, C.-O.
1971. Periodontal and prosthetic conditions
in patients treated with removable partial
dentures and artificial crowns. Acta Odontol.
Scand. 29: 621-638.
Chilton, N. W. 1967. Design and analysis in
A N D O H M
dental and oral research. J. B. Lippincott
Company. Philadelphia.
Glavind, L. & Loe, H. 1967. Errors in the
clinical assessment of periodontal destruction.
}. Periodontal Res. 2: 180-184.
Karlsen, K. 1970. Gingival reactions to dental
restorations. Acta Odontol. Scand. 28: 895-
904.
Loe, H. & Silness, J. 1953. Periodontal dis-
ease in pregnancy. I. Prevalence and severity.
Acta Odontol. Scand. 21: 533-551.
Marcum, J. S. 1967. The effect of crown mar-
ginal depth upon gingival tissue. /. Prosteth.
Dent. 17: 479-487.
Silness, J. & Loe, H. 1964. Periodontal dis-
ease in pregnancy. H. Correlation between
oral hygiene and periodontal condition. Acta
Odontol. Scand. 22: 121-135.
Silness, J. 1970a. Periodontal conditions in pa-
tients treated with dental bridges. /. Perio-
dontal Res. 5: 60-68.
Silness, J. 1970b. Periodontal conditions in pa-
tients treated with dental bridges. II. The
influence of full and partial crowns on
plaque accumulation, development of gin-
givitis and pocket formation. J. Periodontal
Res. 5: 219-224.
Silness, J., 1970c. Periodontal conditions in pa-
tients treated with dental bridges. III. The
relationship between the location of the
crown margin and the periodontal condition.
J. Periodontal Res. 5: 225-229.
Silness, J., Hunsbeth, J. & Figenschou, B.
1973. Effects of tooth loss on the periodontal
condition of neighbouring teeth. J. Perio-
dontal Res. 8: 237-242.
Silness, J. 1974. Periodontal conditions in pa-
tients treated with dental bridges. IV. The
relationship between the pontic and the peri-
odontal condition of the abutment teeth. J.
Periodontal Res. 9: 50-55.
Waerhaug, J. 1953. Tissue reactions around
artificial crowns. ./. Periodontol. 24: 172-185.
Address.
School of Dentistry
University of Bergen
Arstadvei 17
5000 Bergen, Norway