Periodontology 2000, Vol.

4, 1994, 15-22 Copyright 0 Munksgaard 1994

Printed in Denmark . All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713

Tooth mobility and the biological -

rationale for splinting teeth

STURER . NYMAN P. LANG
& NIKLAUS

For many years dentistry was influenced by a series
of paradigms based predominantly on mechanical
concepts. In this respect, the fear for occlusal over-
load and the presumptive sequelae of trauma from
occlusion often led to meticulous replacement of
any missing tooth and the incorporation of a large
number of abutment teeth into fixed bridge recon-
structions. Also, increased tooth mobility in itself
was always considered to be a sign of pathology
jeopardizing the longevity of the tooth. These
thoughts manifested themselves in a claim (1) that
was adopted as a therapeutic law for fixed recon-
structive dentistry for more than half a century.
Ante (1) postulated that “the total periodontal mem-
brane area of the abutment teeth must equal or ex-
ceed that of the teeth to be replaced”. Similar state-
ments reiterated the mechanical approaches to
restorative dentistry; for example, “the length of the
periodontal membrane attachment of an abutment
tooth should be at least one half or two thirds of that
of its normal root attachment” (18, 19). Conse-
quently, a number of teeth with reduced periodontal
support could no longer serve as abutments for fixed
bridgework but had to be extracted and, hence, re-
placed. Such concepts easily led to overtreatment.
re-establishment of periodontal health after success-
ful treatment, persisting hypermobility used to be
regarded as pathological. However, if the height of
the supporting tissues is reduced but the width of
the periodontal ligament is unchanged, it should be
realized that the amplitude of root mobility within
the remaining periodontium is the same as in a
tooth with normal height of the periodontal bone
height (Fig. 1).Hence, the so-called hypermobility of
a periodontally healthy tooth with reduced support
but normal width of the periodontal ligament should
be considered physiological tooth mobility (10).
The second determining factor for increased tooth
mobility is a widening of the periodontal ligament.
This is the result of uni- or multi-directional forces

Tooth mobility
Since teeth are not ankylotically anchored but sus-
pended in the jaw bone by a network of collagenous
fibers, they exhibit a certain degree of mobility. This
mobility is usually assessed as the amplitude of
crown displacement resulting from the application
of a defined force (such as 0.1 N) (8). The magnitude
of this amplitude has then been used to distinguish
between physiological and pathological tooth mo- Fig. 1. Schematic drawing illustrating the relationship be-
tween tooth mobility and the height of the alveolar bone.
bility. In teeth with non-inflamed periodontal
An applied force (arrow) will result in a greater amplitude
tissues, two basic factors determine the degree of of crown displacement if the bone height is reduced. How-
tooth mobility: the height of the supporting tissues ever, within the periodontal ligament, the amplitude of
and the width of the periodontal ligament. Following the root displacement remains the same.

15
Nvman & L a m
Fig. 2. Reversibility of bone loss resulting from traumatic
forces. A. Normal periodontiurn with normal height of
supporting bone prior to the application of traumatic
forces. B. Loss of crestal bone resulting from the appli-
cation of jiggling forces. Observe that no loss of connec-
to the crown, high and frequent enough to induce
resorption of the alveolar bone walls in the pressure
zones. This phenomenon is well known in orthodon-
tic therapy. In a series of controlled animal experi-
ments in periodontally healthy teeth (6, 171, the al-
veolar bone resorption induced by such forces
resulted in increased tooth mobility but not in loss
of connective tissue attachment, irrespective of the
height of the supporting bone. Other studies on the
effect of occlusal trauma on healthy periodontal
tissues (2, 16) have documented the reversibility of
this bone loss following neutralization of the applied
forces (Fig. 2). Later it has been suggested that bone
resorption as a result of so-called traumatic forces
may only represent demineralization of the bone,
and remineralization occurs when the forces are dis-
continued (4, 15). The results of these studies, show-
ing that the application of traumatic forces to peri-
odontally healthy teeth does not result in the loss of
connective tissue attachment, and furthermore, that
the alveolar bone loss is reversible following discon-
tinuation of the forces allow the conclusion that
increased tooth mobility as a result of a widened
periodontal ligament, usually diagnosed radio-
graphically, is a physiological adaptation to altered
functional demands and not a sign of pathology (7).
I6
tive tissue attachment has occurred. C. Following discon-
tinuation of the traumatic forces, crestal bone regrowth
has occurred. Photomicrographs courtesy of Kantor et al.
J Periodont 1976: 47: 687-695.
Occlusal therapy influencing tooth mobility
Tooth mobility can be reduced by occlusal adjust-
ment and/or splinting teeth. In this chapter, the in-
fluence of occlusal therapy on tooth mobility is dis-
cussed only in relation to teeth with non-inflamed
periodontal tissues. For the rationale and the selec-
tion of the two occlusal treatment modalities, the
different reasons for the increased tooth mobility
must be recognized: to diagnose whether the reason
is a widened periodontal ligament, reduced height
of the supporting tissues or a combination of these
two factors. If hypermobility is the result of a wid-
ened periodontal ligament, it may be reduced by oc-
clusal adjustment, that is, elimination of occlusal in-
terferences. Such treatment reduces the stress on the
actual tooth and thereby normalizes the width of the
periodontal ligament, consequently stabilizing the
tooth. On the other hand, if the reason for increased
tooth mobility is exclusively a reduced height of the
supporting tissues, occlusal adjustment will not af-
fect the degree of mobility. In such situations, reduc-
tion of mobility can only be obtained by joining
teeth together in a splint. Since increased tooth mo-
bility due to reduced height of the periodontal sup-
port should be considered as physiological mobility,
 Tooth mobilitv and the biological rationale for splinting teeth
Fig. 3. A. 43-year-old male patient after periodontal ther-
apy. A certain degree of hypermobility of the front teeth
persisted following treatment. This, however, did not dis-
as discussed above, splinting in such situations is
only indicated if the mobility disturbs the patient’s
masticatory function or chewing comfort (Fig. 3A, B).
If a combination of a widened periodontal liga-
ment and a reduced height of the periodontal sup-
port is the reason for the increased mobility, occlusal
adjustment may be sufficient to reduce the mobility
to an acceptable degree. However, if the patient’s
subjective chewing comfort is still disturbed, splint-
ing may be considered.
In final stages of periodontal disease, the pro-
gressive breakdown of the supporting tissues may
have reached such an apical level that, despite
proper periodontal treatment and occlusal adjust-
ment, the remaining periodontal tissues can no
longer withstand the masticatory forces. In such
situations, a gradual resorption of the remaining al-
veolar bone will occur and single teeth or groups of
remaining teeth may yield a gradually increasing or
progressive mobility. As an ultimate consequence,
the remaining periodontal ligament components
may be disrupted and the teeth extracted by other-
wise normal, functional forces (Fig. 4A). The only
way of preserving such dentitions is to use the teeth
as abutments for a fixed splint of cross-arch design
(Fig. 4B, C). The objective of such a bridge construc-
tion is to create a situation in which the mobility of
the entire bridge is either “normal” or at least non-
progressive. A cross-arch design of a fixed bridge sig-
nificantly reduces the lever effect of the occlusal
forces. Hence, the stability of the entire bridge is as-
sured and the mobility of the individual teeth before
bridge installation is no longer a pertinent problem
(Fig. 4D, E) (9).
It should also be realized that teeth with such
minimal amounts of remaining, healthy periodon-
turb the masticatory function or the patient’s comfort. B.
20 years later, no further loss of periodontal support has
occurred.
tium as in the patient described (Fig. 4A) cannot be
used as abutments for a unilateral bridge. Such a
bridge would most likely be luxated and the abut-
ment teeth extracted as the result of functional
forces of normal magnitude. Since such teeth cannot
serve as individual chewing units either, similar ef-
fects would also be expected if they were incorpor-
ated in a conventional partial, removable denture. In
fact, if these teeth are to be maintained in the jaw,
they must serve as abutments for a fixed bridge of
cross-arch design (Fig. 4D, E) (11). This is in direct
contrast with previous paradigms of reconstructive
dentistry.
The present treatment concept is based on scien-
tific evidence from longitudinal clinical trials (3, 5,
13, 14). In these studies, the successful maintenance
of abutment teeth with severely reduced periodontal
support has been documented. In fact, in over 50%
of the bridges presented by Nyman & Ericsson (14)
after an observation period of 8-11 years, the total
periodontal membrane area of the abutment teeth
was more than 50% less than required by Ante’s law
(l), and yet the periodontal support around the
abutments remained unaffected. Of course, the pa-
tients subjected to the type of treatment discussed
were selected based on their oral hygiene standards.
Furthermore, they were incorporated in a mainten-
ance care program including professional tooth
cleaning at regular intervals.
Occlusal aspects of fixed
bridgework and splints
As discussed above, functional forces exerted on a
cross-arch splint are evenly distributed over the en-
17
Nyman & Lang

18
 Tooth mobility and the biological rationale for splinting teeth
Fig. 4. A. Radiographs obtained after periodontal treat-
ment and preparation of preserved teeth as abutments for
cross-arch splintslbridges in a 28-year-old patient. B. Fix-
ed splints of cross-arch design were incorporated. Despite
pronounced hypermobility of most of the individual abut-
ment teeth, the splintslbridges were stable at the time of
cementation. C. Radiographs obtained 5 years after incor-
poration of the bridges. D. Radiographs obtained 18 years
after periodontal and restorative treatment. No further
loss of periodontal support is observed. E. 21 years after
completion of therapy and following regular maintenance
care, periodontal health and bridge stability are main-
tained.
tire extension of the splint and the lever effect of the
forces is substantially reduced. Hence, overloading
of abutment teeth with very reduced periodontal
support is unlikely, especially when the number and
the distribution of the abutment teeth are favorable
in relation to the bridge extension. Quite another
situation exists when a unilateral bridge is placed on
abutment teeth with reduced periodontal support
and increased mobility. Such bridgework will not
provide a multidirectional splinting effect, and
hence, the bridge may show the same degree of mo-
bility as the individual abutment teeth. However, as
mentioned before, an increased mobility of a single
tooth due to reduced height of the periodontal sup-
port can be accepted, provided that the mobility
does not disturb the patient’s masticatory function
and comfort. Likewise, an increased bridge mobility
due to reduced height of the support around the
abutment teeth may also be tolerated. Fig. 5A shows
a unilateral bridge extending from 13 to 15. Follow-
ing periodontal therapy, both abutment teeth ex-
hibited hypermobility due to a reduced height of the
supporting tissues. Since such a bridge does not pro-
vide a splinting effect on the abutment teeth in the
buccolingual direction, the total bridge has the same
degree of hypermobility as the individual abutment
teeth. It is then important to design the occlusion in
such a way that no further increase of the mobility
occurs: that is, that the functional forces do not wid-
en the periodontal ligaments. If so, the bridge mo-
bility might increase to a degree that is no longer
tolerable. To prevent this from occurring, the pre-
treatment degree of overbite of the abutment teeth
should be reduced and the overjet increased. This
reduces the lever effect on the abutments during lat-
eral movements of the mandible and minimizes the
risk for progressive bridge mobility. Radiographs ob-
tained 20 years after insertion of the bridge shown
in Fig. 5A (Fig. 5B) reveal no widening of the peri-
odontal ligaments around the abutment teeth, and
the bridge mobility has not increased over the years.
Similar thoughts should govern the treatment
planning in patients with, for example, reduced peri-
odontal support around the teeth in the maxillary
front region. It is well known that functional forces
of normal magnitude may induce protrusive mi-
gration of such teeth. Stabilization of the front teeth
may not be obtained by merely joining them to-
gether, since in cases with advanced loss of the peri-
odontium around the teeth, the entire front segment
may tilt in the frontal direction. Stabilization of such
front teeth can only be obtained by extending the
splintlbridge posteriorly, thereby neutralizing the
anterior lever effect of the functional forces. In situ-
ations where posterior teeth are missing, this can be
achieved by using posterior cantilever extensions ri-
gidly joined together with the anterior segment. Fig.
6A and B show a maxillary dentition with lack of
teeth posterior to the canines. The front teeth have
lost more than 70% of the periodontium and have
also migrated out in the frontal direction. The peri-
odontal support around these teeth is reduced to the
extent that it can no longer withstand the patient’s
normal functional forces. A splint encompassing
only the 6 front teeth would most likely not be suf-
ficient to prevent anterior tilting of the entire seg-
ment, since the functional forces would almost ex-
clusively be acting in the anterior direction. These
19
Nyman & Lang
forces can be neutralized by creating counteracting
forces in the posterior region. This, in turn, can be
accomplished by the use of posterior cantilever seg-
ments, rigidly joined with the anterior bridge.
In the present patient, the front teeth were retrud-
ed to their original position and stabilized by means
of a temporary reconstruction after extraction of
tooth 22. Following periodontal treatment, the per-
manent reconstruction encompassed a fixed bridge
with bilateral two-unit cantilever segments (Fig. 6C,
D). The occlusion was designed to obtain a balanced
load on each site of the fulcrum of bridge mobility.
In other words, simultaneous occlusal contacts must
be established in the anterior and posterior regions,
not only in centric occlusion but also during frontal
excursion of the mandible from a retruded to pro-
truded contact position. This, in turn, implies that
the palatal surfaces of the crowns in the front region
are given a functional anatomy with horizontal
20
Fig. 5. k Unilateral bridge 13-15 inserted following peri-
odontal treatment. The bridge does not provide a splint-
ing effect on the abutment teeth and has the same mo-
bility as the individual abutment teeth 13 and 15 before
bridge insertion. B. Radiographs obtained 20 years follow-
ing treatment.
shelves providing gliding contacts in the protrusive-
retrusive mandibular movement; that is, the func-
tional forces establish a balance on the bridge (12).
In lateral excursions of the mandible, the guiding
contacts were placed on the canines to avoid work-
ing and non-working side contacts on the cantilever
pontics (5).Fig. 6E documents a stable occlusal and
periodontal situation 8 years after treatment with no
widening of the periodontal ligaments and no loss
of supporting tissues.
It is important to realize that reconstructive ther-
apy in patients with severe loss of periodontal sup-
port can only be successful if the treatment prin-
ciples described are followed. Since each patient
presents a different situation, the precise analysis of
the individual functional pattern is a prerequisite for
predictable outcome of the treatment. Finally, it
should be kept in mind that utilization of polyunit
cantilevered fixed bridges involves a number of tech-
Tooth mobility and the biological rationale for splinting teeth

Fig. 6. A, B. Radiographs and clinical documentation of a

50-year-old woman before periodontal therapy. Severely
reduced periodontal support and pronounced hypermo-
bility of the front teeth. All posterior teeth were missing.
C, D. A cross-archbridge with bilateral two-unit cantilever
segments inserted following periodontal therapy. E.
Radiographs obtained 8 years after treatment. A stable oc-
clusion and periodontal health were maintained (courtesy
of J. Wennstrom, Goteborg).

nical and biophysical aspects. These aspects are dis-

cussed elsewhere in this volume by Lundgren & Lau-
re11 and Glantz & Nilner.

References
1. Ante I. The fundamental principles of abutments. Michi-
gan State Dent SOCBull 1926: 8: 14-23.
2. Kantor M, Polson AM, Zander HA. Alveolar bone regenera-
tion after removal of inflammatory and traumatic factors.
J Periodontol 1976: 47: 687-695.
3. Karlsen K. Traumatic occlusion as a factor in the propa-
gation of periodontal disease. Int Dent J 1972: 22: 387-393.
4. Karring T, Nyman S, Thilander B, Magnusson I. Bone re-
generation in orthodontically produced alveolar bone
dehiscences. J Periodont Res 1982: 17: 309-315.
5. Laurel1 L, Lundgren D, Falk H, Hugoson A. Long term
prognosis of extensive polyunit cantilevered fixed partial
dentures. 7 Prosthet Dent 1991: 66: 545-552.
6. Lindhe J, Ericsson I. The influence of trauma from oc-
clusion on reduced but healthy periodontal tissues in
dogs. 1 Clin Periodontol 1976: 3: 110-122.
7. Lindhe J, Nyman S. The role of occlusion in peridontal
disease and the biological rationale for splinting in treat-
ment of periodontitis. Oral Sci Rev 1977: 10: 1143.
8. Miihlemann HR. Tooth mobility. The measuring method.
Initial and secondary tooth mobility. J Periodontol 1954:
25: 22-29.
9. Nyman S, Lindhe J, Lundgren D. The role of occlusion for
the stability of fixed bridges in patients with advanced
periodontal disease. 1 Clin Periodontol 1975: 2: 53-66.
10. Nyman S, Lindhe 1. Persistent tooth hypermobility follow-
ing completion of periodontal treatment. I Clin Peri-
odontol 1976: 3: 81-93.
11. Nyman S, Lindhe J. Prosthetic rehabilitation of patients
with advanced periodontal disease. J Clin Periodontol
1976 3: 135-147.
12. Nyman S, Lindhe J. Considerations on the design of oc-
clusion in prosthetic rehabilition of patients with ad-
vanced periodontal disease. 7 Clin Periodontol 1977: 4:
1-15.
13. Nyman S, Lindhe 1. A longitudinal study of combined peri-
odontal and prosthetic treatment of patients with ad-
vanced periodontal disease. J Periodontol 1979: 50:
163-169.
14. Nyman S, Ericsson I. The capacity of reduced periodontal
tissues to support fixed bridgework. J Clin Periodontol
1982: 9: 409-414.
15. Nyman S, Karring T, Bergenholtz G. Bone regeneration in

21
 alveolar bone dehiscences produced by jiggling forces. J
Periodont Res 1982: 17: 316-322.
16. Polson AM, Meitner SW, Zander HA. Trauma and pro-
gression of marginal periodontitis in squirrel monkeys. IV.
Reversibility of bone loss due to trauma alone and trauma
superimposed upon periodontitis. J Periodont Res 1976:
11: 290-298.
22
17. Svanberg G. Influence of trauma from occlusion on the
periodontium of dogs with normal or inflamed gingivae.
Odontol Revy 1974: 25: 165-178.
18. Tylman SD, Tylman SG. Theory and practice of crown and
bridge prosthodontics. 4th edn. St. Louis: Mosby, 1960.
19. Tylman SD, Malone WE! Theory and practice of fixed
prosthodontics. 7th edn. St. Louis: Mosby, 1978.