the restraint
1- definition:
In periodontics, retention is “a symptomatic therapeutic procedure which allows dental organs to be immobilized temporarily while awaiting consolidation or permanently when mobility has become irreversible.” (BARRELLE)
2- Historical reminder:
- The Egyptians, 2500 years BC, already used retainers to keep loose teeth. The gold wire ligature discovered by Junker is evidence of this.
- Hippocrates recommended fixing loose teeth with gold wire in the Middle Ages, Albucassis, then in the 16th century , Ambroise Paré represents the same methods.
- It was not until the 18th century that a host of French dental surgeons began to make up for the delays that had accumulated since antiquity.
- It was Château who, in 1907, first laid the scientific foundations for a method of treating periodontal disease by immobilization through his work on the “prosthetic treatment of pyorrhea”.
3- Objectives:
Retention consists of joining one or more mobile teeth, together or with less mobile teeth, so that:
- Occlusal forces are distributed such that teeth whose
Periodontal support is reduced so that they are less stressed.
- Preventing pathological migrations
- Stabilize mobile teeth during therapy by promoting the
tissue regeneration during healing
- functional (relief of pain and discomfort due to mobility) and psychological purpose.
4- Indications / contraindications:
a- Indications:
Retention is indicated as a symptomatic treatment for dental mobility regardless of its origin. For example:
– periodontitis, whatever its severity, causing tooth mobility.
– radiologically the altered radiological crown-root ratio may lead us to propose a retention.
– indicated after surgical treatment to limit the resulting mobility
– after orthodontic treatment to stabilize the teeth and prevent relapse.
– indicated for functional purposes for good distribution of occlusal forces.
b- Contraindications:
- Absolute contraindications:
– uncooperative patient
– Predisposition to caries
– Altered psychological profile
– Dental malpositions.
– Presence of diastemas.
- Relative contraindications:
– Aesthetic factor.
– Pulp volume (for intra-coronary contention)
– The cost of certain types of restraint.
5- Principles of restraint:
a- Mechanical principles:
a-1- ROY principle (1935):
The teeth present a preferential direction of vestibulolingual mobility. From this observation, ROY determined 3 planes of dental mobility for an arch.
– a retention will be more effective if it unites by a non-deformable means contiguous teeth belonging to 2 different mobility planes.
– The greater the number of teeth integrated into the retention system, the more effective the retention will be.
The restraint
The restraint
a-2- Principle of resistance of the posterior pillars:
Posterior abutments must be strong to be included in a retention system, i.e. have little or no periodontal damage at their level.
a-3- Principle of resistance of posterior anchors:
To ensure the stability of a restraint, the anchoring methods considered at the level of the posterior pillars must be the least traumatic and resistant. In descending order, the most used anchors are
1- Tenon crowns.
2- The Richmonds
3- Simple crowns.
4- Tenon onlays
5- The inlays.
a-4- Integration into physiological occlusion:
The volume of the devices must be integrated into the physiological occlusion in order to avoid the appearance of craniomandibular dysfunction, worsening of mobility or simply fracture of the contention.
b- Biological principles:
– Respect for the vestibular and lingual embrasures in order to free the interdental papilla.
– Respecting cervical limits and avoiding creating undercut areas.
– Promote hygiene.
– The gum must be freed from any compression.
– Do not disturb or modify phonation.
– Be as unsightly as possible.
6- Moments of restraint:
Before periodontal treatment (emergency):
– To relieve the patient from the pain of dental mobility.
– Facilitate periodontal sanitation later.
During periodontal treatment:
– Facilitate scaling during initial therapy.
– Facilitate surgery.
– It facilitates occlusal equilibration.
During the final stages of treatment:
– Stabilize loose teeth after surgery so as not to compromise healing.
After treatment:
– Helps to hold teeth together for a long time.
7- The different restraint systems:
a- Temporary restraint:
Temporary restraint is carried out either as an emergency or during initial therapy and its aim is to relieve:
- The pain
- Disabling functional gene
- and to facilitate the performance of other therapeutic procedures such as scaling or surgery performed on loose teeth
→ Fixed systems:
● Ligatures:
A- ligature with silk thread:
- Advantage :
– Very quick to make.
– Almost invisible.
- Disadvantages:
– Fragile and can only remain in place for a short time.
– The thread becomes soaked in saliva and oral fluids and becomes loose.
- Technique:
– We take a 30cm wire.
– We make a double turn at the neck of the 1st tooth and stabilize it with a double knot.
The following teeth are surrounded above the cingulum, each time making a double proximal knot.
– We finish on the last tooth as on the first .
B-metal ligatures:
We use:
– A flexible nickel-chromium wire, 0.3mm thick
– Crushed tongs
– Crown scissors.
– Flat jaw pliers.
There are three types: figure eight, ladder step and sewing machine.
Sewing machine stitch binding
- Indications:
– Teeth not too mobile
- Advantage :
– Easy to make.
– less disruptive to hygiene and stable
The restraint
- Inconvenience :
– Unrepairable, the breakage of the wire requires the complete repair of the ligature
- Technique:
– We make a double turn around the premolar.
– We keep 2 free strands of unequal length.
– The shorter strand is pressed against the lingual surface while the longer strand serves as a shuttle and blocks the lingual wire in the interdental space between each tooth.
– This movement is continued until the opposite PM, where the 2 strands are then twisted.
Figure eight ligature:
- Indication:
– Used for immobilization not to exceed one week.
- Advantage :
– Easy and quick to make.
- Disadvantages:
– Unsure
– Slides very easily
– Often loosens
- Technique:
It is similar to the floss ligature, but instead of making an interdental knot, we simply cross the strands, each one being successively vestibular and lingual.
Ladder ligature:
- Benefits :
– Solid, it can stay in place for a long time.
– Easily adjustable and changeable.
– Allows you to obtain a precise position of the teeth.
- Disadvantages:
– The strands can be irritating and prevent proper interdental hygiene.
- Technique:
– A metal wire of 0.2 to 0.3 mm is used.
– First, we position the uprights, which we fix by tightening the ends of the wires very loosely.
– 5cm long portions of wire are slipped and twisted into the interdental spaces (incomplete tightening), to bring the uprights together. -the tightening of the bars is carried out alternately and progressively. -the strands must be folded back in the occlusal direction.
Some authors suggest covering the ligature with self-polymerizing acrylic resin of the same shade as the ligated teeth for better aesthetics and good functional performance.
● Temporary composite splints:
Bonding of loose teeth using composite is a retention system reserved for very short periods.
A- Extra coronal bonding:
If it is necessary to stabilize mobile teeth for the duration of one session, simply bonding a composite resin bar to the vestibular surfaces may be sufficient.
B-dental-dental bonding:
The bonding is done around the contact point.
The realization is quite quick and practically invisible.
- fixed orthodontic appliances
We distinguish:
– passive fixed orthodontic appliances, especially in cases of loss of contact points between teeth.
– orthodontic braces.
→ Removable systems:
● Hawley plate:
– This appliance consists of a vestibular arch made of steel wire, fixed to a palatal plate or to a lingual band made of acrylic resin.
– It limits the vestibulolingual movement of the incisors which are clamped between the wire and the plate.
● Occlusal splint:
– These are removable devices, placed between the dental arches, used temporarily to modify and reestablish the dento-dental relationships, and intended to correct occlusal dysfunctions or deficient mandibular functions.
b- Ambivalent restraint (semi-permanent)
Ambivalent restraints are carried out in cases where the indication for restraint has been definitively established:
– In the case of a complex treatment plan, an ambivalent retention can be carried out pending a final reassessment at the end of all the oral cavity care.
– Its lifespan can be from a few months to several years.
→ U-shaped splint:
The U-brace connects the teeth closely together using U-shaped steel wires, sealed in calibrated wells.
The restraint
● Indications:
– It is particularly suitable in the upper incisor-canine area.
● Advantages:
– It offers great resistance by ensuring containment in 2 planes of space, horizontal and vertical.
– It has the particularity of bringing the teeth together one by one and therefore best meets our concern to limit the extent of the contention to the minimum number of teeth.
● Disadvantages:
– It is difficult to perform on the mandibular incisors because of the pulp risk.
→ Ceria-Cerosi splint:
To correct tooth mobility, a lingual, palatal or occlusal groove (PM-MOL) is made at their levels to place a steel orthodontic wire or a polyethylene fiber mesh.
The restraint
The restraint
● Advantages:
– Good stability
– Satisfactory aesthetic result.
– Inexpensive
● Disadvantages:
Coronal preparation, hence the risk of caries at the level of the trench if the anatomical precautions are not respected.
→ Berliner splint:
● Technique:
1: a curvilinear trench is made on the lingual surface, using an inverted cone bur.
2: presentation of the wire, twisted wire made with 2 strands of soft steel of 0.25mm.
3: placement of the sealing composite and placement of the wire held with fine plugs or screws which are placed in the
Loops of twisted metal wire.
4: we complete the filling of the trench with composite.
5: after hardening the wire is cut with the cutter.
The restraint
● Indications:
– This is a technique that is particularly suitable in the mandibular incisor-canine sector.
– For premolars and molars, the retention can be made in pre-existing amalgam fillings, therefore without tissue damage.
– It can very well be done to join teeth in relative malposition if we use the twisted soft ligature wires, because we can embed the twist in the groove with a plugger following the irregularities and malpositions.
● Advantages:
– Easy to make.
– Minimal tooth preparation.
– Ensures good stabilization of mobile teeth.
– Satisfactory aesthetic result.
– It is an economical process allowing the maintenance of teeth for a relatively long period.
● Disadvantages:
– Risk of unsealing.
– Risk of caries by infiltration: this is one of the reasons why the patient must remain under surveillance.
c- Permanent restraint:
→ Removable permanent restraints:
Various types of removable splints have been used to hold loose teeth, the best known being:
● Elbrecht splint:
The teeth are held by a metal frame with stabilizing fins that fit into corresponding proximo-occlusal cavities.
The restraint
→ Fixed permanent restraints:
This type of definitive contention is most often effective and most used thanks to current techniques.
● Cast and glued metal splints:
- Technique:
The teeth are prepared while preserving a layer of enamel as often as possible. The preparation is intended to:
- increase splint retention.
- Limit the possible axes of unsealing.
- Make it easier to position when trying on and sticking.
- Advantage :
– Quick realization.
– Saving of dentin tissue .
– Possibility of including attachments for an auxiliary prosthesis.
– This type of splint can be made before the end of periodontal treatment.
- Disadvantages:
– The use of metal has aesthetic and biological disadvantages.
– The enamel-dentin adhesives used are hydrolyzable, their lifespan is theoretically limited.
● Bonded bridges:
- Definition :
It is a fixed prosthesis composed of a metal structure glued to the palatal surface of the teeth, including an intermediate bridge and anchored with a composite resin to the etched enamel of the abutment teeth.
- Indications:
– Replace a single tooth, rarely two.
– Periodontal retention.
– Favorable occlusal relationship.
– Orthodontic indication: space maintainer.
- Benefits :
– Respect for the periodontium and contact points.
– Good aesthetics.
– Tissue economy.
- Disadvantages:
– Very limited number of teeth to replace.
– Need for teeth in good position.
– Risk of detachment.
– Taking impressions of loose teeth can be problematic.
● Barelle Inlay:
In this process, the teeth are joined together in pairs, using a double inlay which secures the proximal faces; a dentine tenon ensures retention.
This system offers many advantages:
- It is possible to initially support only one group of teeth and then, several years later, extend the retention to neighboring teeth.
- Parallelism issues are minimized.
- Repairing a faulty element does not require repairing the entire assembly.
- Overall, the aesthetic appearance is satisfactory.
● Contention by permanent headdresses:
When dental organs are dilapidated or when a tooth loss needs to be compensated, a bridge made of metallic or metal-ceramic coronal restorations is sometimes the most reliable definitive solution.
These restorations are only carried out after periodontal treatment and are preceded for a few months by a temporary prosthesis.
Dental crowns are used to restore the shape and function of a damaged tooth.
Bruxism, or teeth grinding, can cause premature wear and often requires wearing a retainer at night.
Dental abscesses are painful infections that require prompt treatment to avoid complications. Gum grafting is a surgical procedure that can treat gum recession. Dentists use composite materials for fillings because they match the natural color of the teeth.
A diet high in sugar increases the risk of developing tooth decay.
Pediatric dental care is essential to establish good hygiene habits from an early age.