The Use of Fibre Reinforced Composites (Frcs) in

Periodontal Splinting & the Natural Tooth Pontic (NTP)

in the Management of Advanced Periodontal Disease
Ian Kerr – BDS, (U’Ncle)
Member of the British Endodontic Society and British Society of Restorative Dentistry
StoneRock Dental Care, Kent, UK – info@stonerock.co.uk

ABSTRACT
This article uses a series of case studies to examine the use of fibre reinforced composite splints in the management of
advanced gum disease that has led to mobility and imminent exfoliation of teeth. The case studies show the various
techniques for producing a durable aesthetic splint and how to use these principles in the production of a natural
tooth pontic.

KEYWORDS
Fibre reinforced composites, Periodontal Splints, natural tooth pontics, Mobility.

INTRODUCTION
Knowledge of the anatomy of the root-canal system The
treatment of periodontal disease is one of the mainstays of
modern dentistry and has been shown to have a massive
impact on patients’ ability to keep their teeth for much
longer than they may have done without care.1 At the
heart of periodontal treatment is the understanding of the
relationship to the build-up of plaque on a patients tooth
and the response of the host periodontium to that plaque.2
With this in mind periodontal treatment has developed
as a two pronged approach that relies on Periodontal
Maintenance by the dental team and home care by the
(Fig. 1) Advanced periodontal disease
patient.3 The position paper on Periodontal Maintenance,
September 20034 states that the patients with periodontal
disease show lower tooth loss and disease progression
when they adhere to a PM schedule, sadly it also reports
that over a ten year period compliance was as low as
45%. It is assumed throughout this article that this essential
approach to periodontal treatment if carried out to the full;
neither splints nor NTPs offer an alternative to this care,
they act merely as adjuncts to it.
Conventional Periodontal Therapy without the
opportunity for splinting (Figs 1,2).
(Fig. 2) Post initial therapy
Background information on FRC splints and Case Studies
examining how Fiber Reinforced Composite (FRC) result in tooth loss. It is in these advanced stages we see
splints and Natural Tooth Pontic (NTP) can assist in the then most need for the use of splints and NTPs. In the
management of advanced gum disease; author’s opinion mild (grade1-2) mobility is usually best
managed by conventional periodontal treatment only
Advanced gum disease is characterised by severe bone and splints are not normally needed.5 In fact some would
loss that can result in increased mobility and drifting argue that in cases of mild mobility splints are contra-
of teeth. This increased mobility and drifting can be indicated as they can mask the extent of improvement
uncomfortable and unsightly and can limit function in the natural condition and can hide any early signs of
and can impede the patient’s ability to clean their teeth a worsening condition. Where the disease has reached
effectively. Eventually the bone loss, if severe enough, will advanced levels, however, and the mobility is at such a

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point that cleaning and function is impaired splints can
provide an excellent adjunct to conventional therapy and
can positively influence retention of teeth to a significant (Fig. 4)
level.6 Indeed it has been stated by researchers that Measure required
splints can help retain mobile teeth to an almost limitless length of fibre
level, so long as they are used in combination with
conventional treatment.7 In the author’s experience in
cases of severe mobility (Grade3+) we see the best
results where splints are fitted prior to conventional
periodontal therapy as they give patient’s the confidence (Fig. 5)
to clean firmly and effectively around the teeth which is Etch all surfaces
clearly an essential part of the treatment.8

The use of splinting for mobile teeth is certainly not

new in dentistry and there are a bewildering array of
splint designs and materials reported in the literature.9
Whilst there is some evidence to support the use of cast (Fig. 6)
metal splints10 the majority of splints provided in general Apply bond according
practice rely on either metal ligature wire bonded to the to instructions
teeth or fibre reinforced composite splints.

This article will look at examples of FRC splints as these

represent the only aesthetic option and the one that
can be developed into NTPs if needed. Probably the (Fig. 7)
two most commonly used FRC materials for this work Place an uncured layer
are the everStick range from StickTech™ ltd Finland of flowable
and the Ribbond™ system. The everStick Perio system
incorporates a unidirectional e type glass fibre in a
PMMA resin that exhibits an InterPenetrating Polymer
network that has been shown to dramatically increase
its bond strength.11 Ribbond™ uses polyethylene (Fig. 8)
fibres locked in a cross-link leno weave to encourage Take pre cut fibre
multidirectional integrity. The flexural strength of the length Composite
everStick® fibre (1280MP) is as high as that of cast
chromic cobalt metal, whereas glass fibre reinforced
structures are not completely stiff as their elastic modulus
is very close to that of a dentin.12 The elasticity of the
glass fibres may be beneficial to the periodontal tissue
because the surrounding supportive tissues are loaded
more naturally by different occlusal forces than in the
totally rigid construction. Studies have demonstrated that
fibre reinforcement increases the flexural strength and (Figs. 9 & 10) Tack cure the fibres for 5 seconds per tooth into
flexural modulus of composite resins and do not impact the uncured resin
negatively on the bond strengths achieved.13,14

It is beyond the scope of this article to contrast clinical

outcomes of either product but I would encourage
readers to try each product and find which they find more
manageable as ultimately this is likely to have a profound
(Figs. 11 & 12) Place a thin layer of composite and cure 40
impact on the outcome of the splints (Figs 3-13).
seconds per tooth

(Fig. 3)
Clean surfaces to
be bonded
(Fig. 13 a&b) A lingual view and radiograph of a typical
splint completed by the author using the above technique

Smile Dental Journal | Volume 8, Issue 4 - 2013 | 33 |

 The great advantage that FRC splints have over their
metal counterparts is aesthetics. This can be of particular
importance when teeth have started to drift and spacing
has developed. The example below shows how the
above technique can be used to extend the splint across
interproximal spaces in an aesthetically acceptable manner.
Example of splint placement technique using everStick
Perio fibres: (Figs 14,15) (Fig. 16) Preop shot of lower splint

(Fig. 14) Preop shot of lower splint (Fig. 17) Buccally placed everStick fibres in place

(Fig. 15) Aesthetic splint in place (Fig. 18) Direct splint in place

We also have the option to incorporate our splinting in to

direct composites on the buccal facing of upper anterior (Fig. 19)
teeth which has the obvious advantage of avoiding any Amalgam fillings
potential occlussal interferences that can occur when present
splinting on the palatal surfaces of upper incisors. In this
case the upper left lateral incisor had become mobile
and the patient was unhappy with the appearance of
her upper left central and lateral incisor compared to
the ceramic crown on the upper right central incisor,
which she was very fond of. She did not want to make (Fig. 20)
any changes to the appearance of her teeth on the right Cavities cut
hand side of her smile. A decision was made to splint
the upper left central and lateral incisor together with the
upper left canine using a direct everStick splint and direct
composite “veneering” (Figs 16-18).

Traditional wire splints are on occasions not well (Fig. 21)

tolerated when used to help stabilise posterior teeth. Fibres imbedded in
Here again FRC splints can be of value as they can be cavities
incorporated into the restoration so generating much
less bulk. In the case below, the lower right second molar
was showing grade 3 mobility despite excellent specialist
periodontal care and home maintenance. The decision
was made to splint the tooth to the firm and much less (Fig. 22)
affected lower right first molar. The splint was replaced Final restorations
at 5 years due to decay in the second molar; it has
remained in function for the past 18 months since the
splint was replaced (Figs 19-23).

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 (Fig. 23)
OPG review at 3 years
(Fig. 27)
Bone level pre-splinting

A similar approach was used in these premolars as part of a

strategy to delay the loss of the upper posterior teeth for as
long as possible. This was a strategy that lasted for almost
12 years until all posterior teeth were electively removed at a
time that suited the patient to do so (Figs 24-26).

(Fig. 28)
Bone level after 4 years of
splinting

(Figs. 24 & 25) Root filled premolar teeth splinted using

everStick Crown and Bridge fibre

facing the usual decisions regarding replacement options

and none of them are ideal in patients with advanced
bone loss and adjacent mobile teeth. If the teeth are
splinted then the natural tooth pontic can be utilised.
This approach offers us an immediate solution that is
cost effective, minimally invasive and aesthetically very
pleasing (Figs 29-35).

(Fig. 26) OPG of same case taken 3 years prior to removal of

remaining posterior teeth

The timing of the loss of teeth is a very important

consideration when managing patient’s advanced (Fig. 29)
periodontal disease. It is a decision that often reflects a Pre-op radiograph
far greater emotional attachment to the teeth than any
physical one. The loss of confidence that goes along
with a worsening state of edentulousness cannot be
overestimated and it is important that we are able to offer
simple non-invasive, cost effective ways of delaying the
loss of teeth for patients so they can plan for replacement
options at a time of life that is most acceptable to them.

As previously stated one of the concerns regarding the

use of splints is that they can mask symptoms such as
worsening mobility which can fool both patients and
clinicians in to believing the periodontitis is under control.
In patients with poor compliance and contributing health (Fig. 30) Pre-operative clinical view
problems the rate of bone loss under splints can be
alarming. The case below shows a splint over a four year
period in a patient who was a heavy (20 or more per day)
smoker and poorly controlled insulin dependent diabetic.
The home care was intermittent and professional cleaning
kept to a minimum at the patient’s request (Figs 27,28).

Where bone loss has reached a point where infection

can no longer be controlled then the loss of the tooth is (Fig. 31) A not too challenging extraction
almost inevitable. If the tooth is extracted then we are left

Smile Dental Journal | Volume 8, Issue 4 - 2013 | 35 |

 (Fig. 32)
Root resection and
seal. Root length cut (Fig. 39)
to allow socket fit 2-week review
approximately 3mm
subgingival

(Fig. 33)
(Fig. 40)
Rubber dam with
“pontic hole” 3 month review

(Fig. 34) (Fig. 41)

Pre-etched pontic in Addition to NTP at
place gingival level

CONCLUSION
(Fig. 35) The aesthetic periodontal splint has been shown to enhance
Immediately placed outcome in tooth retention and can improve patients’
Natural Tooth Pontic confidence along with their ability to chew and to clean
and Splint their teeth. The natural tooth pontic offers an immediate,
cost effective way of restoring a smile in such a way that the
patient may not feel that they have really lost a tooth. The
techniques involved are easily mastered and are simple to
An alternative technique for the natural tooth pontic learn via hands on training course; they can form a regular
can be used where an existing splint is functioning and productive part of any general dental practice.
adequately. In this case there was an existing lingual
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