Tooth mobility: etiology - classification Therapeutic strategy

Tooth mobility: etiology – classification Therapeutic strategy

Introduction : One of the signs that most frequently brings a patient with periodontitis to consult is dental mobility, a consequence of the destruction of the supporting tissues of the dental organ by periodontal disease. If the goal of periodontal therapy has, for many years, consisted essentially in reducing dental mobility in order to restore the patient’s functional integrity with regard to his masticatory power, it is quite obvious that at present development has considerably broadened our therapeutic field, increasingly directing our activities towards prevention.

1-Generalities:

-teeth have a certain range of mobility, that of single-rooted teeth is greater than that of multi-rooted teeth and that of incisors is the greatest.

– mobility occurs mainly in the horizontal direction, it also occurs in the axial direction.

– mobility is greatest when waking up, probably due to the slight extrusion that occurs in the absence of function during the night, and it decreases during the day, probably due to the intrusion caused by chewing and swallowing food.

2-Definition of mobility : mobility is often defined as the amplitude of movement of the tooth on the arch, in a horizontal and/or vertical plane.

3-Classification of mobility

Physiological mobility: normal mobility varies from one individual to another. It is due, on the one hand, to the shock-absorbing role of the alveolar ligament (compressible space between the root and the alveolar bone, and on the other hand to the elasticity of the alveolar bone.

Pathologic (abnormal) mobility: Mobility that occurs beyond the physiological range is called abnormal or pathologic mobility because it exceeds the limits of normal mobility values and not because the periodontium is necessarily diseased at the time it is examined.

4-Etiology : Pathological mobility is caused by one or more factors:

1-loss of alveolar bone , desmodont and support: the degree of mobility depends on:

-the severity and distribution of tissue loss on each side of the root

-the length and shape of the roots

-the size of the root in relation to the crown

A tooth that has short, tapered roots is more likely to mobilize than a tooth that, with the same degree of bone loss, has normal-sized or bulbous roots.

2-Occlusal trauma : An injury caused by excessive occlusal forces and contracted during abnormal occlusal habits such as bruxism and clenching which are aggravated by emotional tension, is a common cause of tooth mobility.

3-The extension of the inflammation of the gum in the desmodontium causes degenerative transformations that increase mobility. The transformations usually occur during the more advanced stages of periodontal disease, but tooth mobility is sometimes observed in severe cases of gingivitis.

4-Mobility is increased during pregnancy and is sometimes associated with menstrual cycles or the use of hormonal contraceptives .

5 -Mobility is also increased for a short period following periodontal surgery.

6-Apical lesion of endodontic origin

7-periodontal inflammation of bacterial origin

Apart from periodontal disease, mobility can also be increased by orthodontic treatment, periapical infections and tumor processes. The search for the cause is always essential.

Tooth mobility: etiology – classification Therapeutic strategy

5-Phases of dental mobility:

The initial or intra-alveolar phase : during this phase the teeth move within the limits of the desmodont. This phenomenon is related to the viscoelastic distortion of the ligament and the redistribution of periodontal fluids, the content located between the bundles and the fibers.

The secondary phase : it appears gradually and causes the elastic deformation of the alveolar bone in response to the increase in horizontal forces. The tooth itself is also deformed by the impact of a force that is applied to its crown, but to a degree that is not clinically significant.

6-Indices : the classification of mobility most often used as a reference is that established by Mühleman in 1954. This involves measuring dental mobility between two rigid instruments and noting the amplitude of tooth movement after applying a force of 100g.

Type 0: imperceptible mobility

Type 1: Perceptible mobility

Type 2: mobility with a horizontal amplitude of around 1 mm

Type 3: mobility with a horizontal amplitude greater than 1 mm

Type 4: mobility with movement in the vertical direction.

Contention

Retention should not be systematic and does not constitute in any case a treatment for periodontal diseases. It intervenes after periodontal treatment, on reduced periodontium and is intended to stabilize teeth whose mobility is not compatible with the maintenance of periodontal health.

Its production meets essential biomechanical criteria and its indications and contraindications are precise.

1-Definition : retention is a symptomatic therapeutic procedure which allows dental organs to be immobilized temporarily while awaiting consolidation, or permanently when mobility has become irreversible.

In dentistry, retention is a device designed to stabilize mobile teeth (definition proposed in 2001 by the AAP). It helps maintain the results of periodontal and orthodontic treatments by preventing recurrences of dental migrations and limiting residual mobility.

2-History:

-Contention splints have continued to benefit from progress made in the field of biomaterials and particularly in that of bonding.

-Until the end of the 1960s, restraint devices were purely mechanical.

-In 1973, Rochette introduced a new concept in fixed prosthesis, that of tissue economy, by eliminating the need for preparation of prosthetic pillars. Indeed, he proposed the bonding of perforated metal fins on unprepared teeth using a polymethylmethacrylate resin. Then, a few years later, to increase the retention and longevity of these systems and to broaden their indications, Livaditis modified the technique by returning to a superficial preparation of the teeth and by carrying out a surface treatment of the metal.

-The 1990s were the years of progress in biomaterials and technology. These advances allowed dentistry to enter the era of adhesive dentistry with the use of new materials (tissues, fibers, composite, amelodentin adhesive) and new processes (polymerization, surface treatment).

3-Goals:

-obtain chewing comfort-

-maintain mobile teeth in good functional position pending natural consolidation or definitive retention.

– permanently maintain in good functional position teeth whose mobility is considered irreversible and preserve the periodontium from traumatic overloads.

– immediately relieve before any treatment the patient whose pain is caused by tooth mobility.

-psychological, when mobility represents the patient’s major concern.

-facilitate certain therapeutic procedures such as scaling.

-reduce postoperative hypermobility in a patient with very reduced bone support.

-stabilize orthodontic treatment by preventing relapses of migration

-replace a missing tooth, in the more or less long term, when there are economic imperatives or a very poor prognosis for a more elaborate restoration.

4-Principles of retention : the teeth to be retained must be joined together using certain methods in order to ensure artificial consolidation and to distribute occlusal loads likely to irritate the supporting tissues.

Mechanical principles : a certain number of mechanical principles govern any retention system, of which it should not be forgotten that the main aim is to bring the teeth together in order to artificially reduce their mobility and to distribute the occlusal forces likely to damage the supporting tissues.

Roy’s Principle : Roy established 3 mobility plans for an arcade:

-A sagittal mobility plane for the incisors

-a frontal mobility plane which forms a 90° dihedral angle with the previous plane: this is the mobility plane of the PM and M.

-an intermediate right and left mobility plane, for the canines: the latter being the bisecting plane of the two preceding ones.

The contention is ensured if the teeth of one mobility plane are preferably joined by a rigid and non-deformable means to other teeth which belong to another mobility plane making an angle of at least 90° with the first plane.

The greater the number of teeth involved, and the more mobility planes used, the better the retention.

Tooth mobility: etiology – classification Therapeutic strategy

Terminal tooth principle : The least protected dental organs in a retention system are the terminal teeth of that system, because they are only attached to the retention system on one side, which exposes them more to exogenous forces.

It will be necessary to check that the terminal teeth of any retention system have some stability, and the retention may sometimes have to include one or more additional dental organs to terminate at a tooth with relatively strong supporting tissue.

Principle of the retention polygon : it is desirable to include the maximum number of dental organs in a retention system to obtain better efficiency of this system. In addition, the forces applied to the arch must necessarily be included within the polygon that circumscribes the entire retention system.

Biological principles:

-Minimal hindrance to oral hygiene : bacterial plaque being the main cause of periodontal disease, itself the cause of pathological tooth mobility requiring a retention system, it is appropriate that this device minimally hinders the control of bacterial plaque during oral hygiene procedures in order to avoid any recurrence of periodontal disease.

Perfect occlusal equilibration : particular care should be taken with occlusal equilibration when fitting a retention system, and a summary preliminary occlusal equilibration should always be carried out before fitting a temporary retention.

Maximum comfort for the patient : the primary objective of a retention system is to improve the patient’s masticatory function, some of whose dental organs present pathological dental mobility hampering their masticatory efficiency. If, under this pretext, the device used is the cause of a certain number of other inconveniences for the patient, the desired goal is far from being achieved. It is therefore advisable to check when making a retention system:

-that it is not irritating to the surrounding tissues (marginal periodontium, cheeks, tongue and lips)

-that it does not modify or distort the patient’s speech

-that it is as unsightly as possible.

Aesthetic principles : respect for dental morphology, particularly the anterior sectors.

5-Indications:

-if the patient complains of loose teeth preventing him from speaking or eating.

-if there is a real risk of accidental dislocation or avulsion, for example when chewing.

-if it is observed that the mobility of the teeth increases over time despite the disappearance of the inflammatory signs, in this case the periodontium, which has become healthy but reduced, no longer supports normal occlusal loads.

-if dental migration following periodontal disease has been corrected by orthodontics, the retention splint prevents relapse, which is often inevitable.

-high mobility of a tooth whose periodontium is particularly affected.

-functional deficiency of the mobile tooth responsible for a transfer of loads from one place to another onto other teeth less able to bear them.

6-Contraindications:

-lack of hygiene and non-cooperation of the patient.

– predisposition to caries or poor quality of enamel

-dilapidated teeth or teeth with fillings that cannot be included in the preparation

-aesthetic problem in the presence of a significant diastema.

-unfavorable occluso-articular relationship at the level of the antero-superior sector.

7-Maintenance : in order for the retentions produced to prove their effectiveness, it is essential to combine clinical monitoring of the device with periodontal or therapeutic support maintenance. This includes all the care that can stop the progression of periodontal disease. The absence of maintenance is often synonymous with relapse, loss of attachment and early loss of teeth.

8-Operating protocols :

Direct technique : the direct technique allows the retention device to be produced extemporaneously. This requires the use of biomaterials that can be manipulated in the mouth in order to achieve the result during the session. This technique is often the most economical in terms of tissue and finances. Its production is sometimes delicate and its longevity is less (temporary or semi-temporary) compared to retention by indirect technique.

Indirect technique : indirect splints are retention systems described as “permanent” which almost always require dental preparations which highlight their irreversible nature from a tissue point of view.

Tooth mobility: etiology – classification Therapeutic strategy

9-Different types of restraint:

1-Temporary retention: its purpose is to ensure the immobilization of the teeth for a certain time . It is therefore preferable to use simple, quick and inexpensive methods

-Mobile temporary retention: the teeth are trapped between the acrylic plate and the continuous vestibular support wire. This easy retention method is only used for night retention because the somewhat bulky device can be considered annoying. This prosthesis can temporarily replace certain missing teeth.

– Fixed temporary retention: it is more used and has more indications. It includes all ligature procedures:

Flossed silk ligature : used for short-term immobilization of anterior teeth and most often to facilitate scaling. These ligatures undergo alterations in the salivary environment.

Wire ligature : These have the same stabilizing effects but using an unalterable material such as nickel-chrome wires. Can be kept in place for several weeks to several months.

a-Ladder ligature : this is the most durable process because it is the least vulnerable. The ligature consists of two heads, a vestibular head and a lingual head which correspond to each of the two uprights of the ladder. Small interdental wires which will join the two uprights will constitute the rungs of the ladder.

b-sewing machine stitch binding: easier to execute, less visible but less robust. It can however be satisfactory in the majority of cases and last if it is well executed.

b-sewing machine stitch binding : easier to execute, less visible but less robust. It can however be satisfactory in the majority of cases and last if it is well executed.

c-cast ligatured splint: a lingual or palatal splint made of cast metal and held in place by means of a ligature on each affected tooth is a retention method used for long-term retention. The arch is made in the laboratory on a model (in precious metal or not). Two small stirrups on the PM or canines prevent it from sliding towards the neck. This arch must have a triangular section so as to be applied to the teeth by a simple edge, which will facilitate prophylaxis. It is placed just above the cingulum and wires individually intertwining each of the crowns of the teeth to be stabilized will thus ensure, by connecting each tooth to the arch, rigid and durable immobilization

d-Glued wire : widely used by orthodontists, this technique helps stabilize an orthodontic result.

Indicated in adolescents without periodontal pathology, and in adults with healthy periodontium.

It consists of gluing a shaped wire with composite studs. The wire can be formed directly in the mouth or preformed on a model made from an impression. The enamel is etched with orthophosphoric acid, then with a composite the splint is bonded to the teeth previously covered with adhesive.

e- Ellman grid : it has long been the most popular direct technique in periodontics, it is also the one on which we have the most experience. It is an extra-coronal technique which consists of gluing a metal grid on the lingual surface of the teeth using composite and adhesive materials. It is indicated in situations of weakened periodontium associated with dental mobility. It increases the comfort and effectiveness of scaling-root planing by ensuring the support points. It can also be indicated in the event of temporization in the event of extraction of an incisor, to allow alveolar healing before the creation of a definitive implant-supported prosthesis.

This technique, using adhesive systems, requires the installation of a suitable surgical field. The material used is a very thin, very flexible steel grid, offering a great grip to the composite. It is cut to the desired length in the mouth, placed approximately 1 mm from the free edges of the incisors, and applied so as to best follow the dental anatomy by faithfully matching the cingulate bulges. The edge must clear the embrasures. The position of the teeth is checked and maintained using a silicone key made beforehand. While being sufficiently coated with composite, the grid is most often located outside the occlusal impacts. For this reason, it is more suitable for the mandible than the maxilla. It is considered by some authors as a semi-permanent splint. Its ability to be repaired and its reversibility make it an adaptable and practical instrument in our therapeutic arsenal.

2- ambivalent restraint : this restraint can be used for two purposes:

-As a temporary measure when a long-term retention is decided in order to leave the periodontium under observation after treatment. In the event that the tissue reactions prove favorable, the ambivalent temporary retention which can remain for 1 to 2 years will give way to a definitive retention.

-Definitively, when the treatments could not be instituted until too late, all hope of long-term preservation of the teeth has been lost.

Two procedures are known:

a-The Ceria Cerosi splint : made of a twisted nickel-chromium wire. This wire is fixed using self-polymerizing acrylic, in a retentive trench that runs along an entire arch on the lingual surface of the teeth. This trench can be made with a turbine or with a diamond wheel grinder that digs a groove made resonant by an inverted cone burr that widens the bottom

After having previously tried and then removed the twisted wire in its trench, the acrylic that will ensure the connection with the teeth must be prepared. It will be of a fairly liquid consistency in order to spread well throughout the interior of this trench. A small fine brush will be used. Then the twisted wire is immediately placed. We then continue filling the cavity using a final supply of acrylic and wait for it to polymerize. Clear the interdental spaces clogged with acrylic with a very fine diamond wheel. Polish.

Disadvantages of this method: This process can last a long time, if it is executed well. Twisted wire is a very economical means of connection but a little too flexible. In addition, if a loosening occurs even on a small portion of the arch, everything has to be started again, repairs being impossible.

b-The Berliner splint : the idea is the same but the process is a little different. The teeth, instead of being joined along the entire length of an arch, are only joined two by two by their proximal faces by means of a small splint also embedded in self-polymerizing acrylic.

-the fiberglass preparation must have a fluid consistency , it is applied with a brush in the groove that it must fill.

-the wire is soaked in fairly liquid fiberglass and introduced into the groove. A supplement of this material is then added not only to perfectly fill the groove but also to wrap the splint at the point of contact of the teeth concerned.

Splints made step by step can thus ensure the retention of part of the teeth in an arch, or even the retention of all the teeth in the arch.

This method is very effective, very aesthetic, relatively resistant if the execution technique is good. In the event of a splint becoming loose, it is always possible to redo it without harming the rest of the retention. Any extension of retention is possible. However, the duration of such a device must not exceed a few years, as infiltrations can occur and cause deep caries. The fiberglass is in fact subjected to forces that promote its detachment from the walls, which is the cause of the infiltrations.

In principle, retention using this ambivalent method is only possible if all the teeth in the arch are present. However, if just one of them is missing, it can be replaced very effectively.

Tooth mobility: etiology – classification Therapeutic strategy

c- “Fibered” composite splint : fibered splints are extra coronal composite devices reinforced with polyethylene or glass fibers. The position of the teeth is recorded in occlusion using a vestibular key made of high viscosity, fast-setting silicone. After cleaning the dental surfaces, etching is carried out and then an adhesive system is applied.

The installation of the fiber strip (or the “stick”, Evrstick ^R ) is the major difficulty. We prefer to use small width fibers (1 or 2 mm) to leave as much space as possible for the composite protecting the whole. The situation thus obtained allows the practitioner to make the splint without haste, step by step. The composite is applied, then polymerized. Enough composite is needed to coat the fiber strip, while respecting the embrasures. (Facilitate hygiene). The volume of composite must be sufficient to avoid exposure of the fiber. Its exposure to saliva denatures it, contaminates it, and its partial or total removal must be considered.

3-The final contention:

Fixed contention:

a-The inlay-contention splint :

Technical:

The size of the inlay-splint has the appearance of a double cavity which is prepared in two stages, one of the cavities will be cut on the mesio-occluso-lingual face and the other on the mesio-occluso-distal face.

The inlay size consists of a slice, a groove and two grooves for each tooth.

-the cavity is coated with microfilm and then an impression is taken using Kerr’s blue wax. The wax will be heated as appropriate and then allowed to flow by introducing it through the small fins.

-the wax is poured, while waiting for the inlay to be placed, the cavity will be temporarily filled using gutta cones.

-the inlay is cast, it is then tried after having cleared the cavity of its gutta, it is sealed using a sealing cement.

Directions:

-perfectly healthy teeth

-beautiful dental morphology encouraging to keep the teeth intact

– Complete anterior arch

Contraindications:

– cavities and very large pulp

b-Cast bonded splints : this is a metal structure that concerns the lingual and proximal faces of the teeth to be maintained. It can also replace one or more teeth. They require a low thickness of metal (3 to 7/10th ^of a mm) particularly at the connection areas.

First session:

The preparation is done under local anesthesia to create a preparation for the niche and tenon housing.

The dentinal wells are made using calibrated drills and their recording is done with the corresponding tenons. They are between 0.7 and 0.8 in diameter and 1.5 to 2 mm in depth. They ensure the multidirectional stability of the anchorage.

To avoid tooth sensitivity between sessions, the dentinal surfaces are filled with calcium hydroxide cement. A thermoformed tray made extemporaneously also ensures the stability of the teeth and their position in accordance with that of the impression.

Second session: the splint must be made within a relatively short period of time (7 to 10 days).

Fitting: under anesthesia, the prepared teeth are cleaned, the splint is then tried on, its proper adaptation is checked and the occlusion relationships are verified in static and dynamic mode.

Collage:

-the prosthetic intrados is treated by sandblasting.

-the tooth surfaces are cleaned and etched.

-the splint is assembled.

Finishing: Remove excess glue, check occlusion, and polish surfaces.

c-Bridge retention: these fixed devices are part of occlusal-functional restoration procedures. In addition to the retention of elements whose mobility is considered irreversible, they provide restoration of the arches by replacing missing teeth, correction of the occlusal plane and possibly that of the vertical dimension.

Mobile devices : this method of restraint does not represent the best process, but it is one that is easy to carry out and has a low cost.

Stellites:

Advantage :

-provide perfect stability

– provide valid support for several years

-provide very good prophylaxis since the interdental spaces are freed and the patient can remove it to clean and brush it.

-their cost price makes them accessible to modest budgets.

Disadvantages: Over time, the retainer becomes imperfect. The fact that it is removed by the patient sometimes leads to some negligence on his part.

Mobile devices : this method of restraint does not represent the best process, but it is one that is easy to carry out and has a low cost price.

Conclusion : In the context of the treatment of dental mobility, and depending on the treatment objectives, the practitioner can determine the type of retention that best meets his choices. However, it is appropriate to establish the precise indications for such treatment; the control of bacterial plaque and the surgical elimination of periodontal pockets remain the essential times of periodontal therapy.

Bibliography:

-A.DANIEL contention in periodontics biological principles and indications EMC 23604 A 10 5-1983

-Bercy .TENENBAUM Periodontology from diagnosis to practice De Boeck-University

-Irving Glickman clinical periodontology prevention, diagnosis and treatment of periodontal diseases in the context of general dentistry. Edition cdp 57, rue Dulong -75017 Paris

-JJBARELLE, Simon HIRSCH introduction to periodontology volume 2 Edition AGECD 26 Rue du tg saint jacques Paris XIV.

-pierre GENON, Christine ROMAGNA- GENON periodontal treatment

reasoned JPIO edition Cdp.

-Phillipe Bouchard

Tooth mobility: etiology – classification Therapeutic strategy