Tooth mobility: therapeutic strategies
Plan
- Introduction
- Therapeutic strategy according to the situation
- The restraint
- Definition
- Principles of restraint
3-2-1- Basic mechanical principles
3-2-2- Biological principles
- Indications and contraindications
- Classification of restraints
- Different types of restraint
3-5-1- Direct restraints
3-5-2- Indirect restraints
- Occlusal adjustment
- Conclusion
- Bibliographic references
- Introduction :
Pathological mobility of one or more teeth causes discomfort in life and can increase periodontal disease by making hygiene methods difficult. In addition, this mobility does not allow for effective periodontal therapies. Thus, therapeutic strategies ranging from occlusal adjustment to different retentions have been proposed in order to stabilize mobile teeth.
- Therapeutic strategies according to the situation:
Lidhe proposed different therapeutic strategies according to five situations that can be encountered in daily practice.
- Situation 1 : presence of dental mobility or widening of the alveolar-dental ligament (LAD) but without alveolar lysis:
These types of situations occur when there is an overflowing restoration or a poorly fitting crown, causing occlusal trauma. Thus Lidhe suggests that an occlusal adjustment alone will allow the return to normal and the elimination of mobility.
- Situation 2: presence of dental mobility or alveolar bone loss and widening of the LAD are observed:
After treatment of moderate to severe periodontitis cases, the return to periodontal health allows the stability of teeth with a reduced periodontium. If a tooth with a reduced periodontium is exposed to excessive forces this can produce tooth mobility. In this case it is an occlusal trauma and an occlusal adjustment allows to eliminate this mobility.
- Situation 3 : presence of dental mobility with reduced periodontium and without widening of the LAD:
When tooth mobility is the result of a reduced periodontium but without widening of the LAD, an occlusal adjustment will not solve the problem. In this case, if the mobility does not interfere with function, abstention is the best therapeutic choice. Otherwise, when the mobility interferes with function (mastication, phonation, etc.), a retainer must be put in place.
- Situation 4 : Increasing dental mobility of a tooth due to progressive widening of the reduced LAD:
It often happens that in advanced periodontitis, tissue destruction has reached such a level that the extraction of one or more teeth cannot be avoided.
In such a situation, the teeth still available for periodontal treatment may, after therapy, exhibit such a high degree of mobility that the forces exerted during function mechanically disrupt the remaining components of the LAD and lead to tooth loss.
It will be possible to maintain these teeth only by means of a retainer.
- Situation 5 : presence of dental mobility despite the presence of a retainer:
In the most severe cases of periodontitis, tooth mobility persists despite the installation of a retainer or a retention bridge. This mobility can be accepted if it does not interfere with function and the periodontal disease is stable. In the most extreme cases, extraction of these teeth may be considered.
Tooth mobility: therapeutic strategies
- The restraint :
3-1- Definition:
Retention means “to hold with”. Temporary, semi-permanent or permanent, it is intended to secure and hold teeth in place using fixed equipment.
3-2- Principle of restraint:
3-2-1-Basic mechanical principles :
- Roy’s principle of planes (1923): there are three planes per arch, a sagittal plane which passes through the incisors, a frontal plane which passes through the premolars and molars and an intermediate plane which passes through the canines. A retention is more effective if it unites, by a non-deformable means, contiguous teeth belonging to two planes of different mobility.
- Containment polygon (Fourel and Falabragues, 1980): a material system that has a fixed point can rotate around all axes passing through this point; a system that has two fixed points can rotate around the axis connecting these points; a material system that has three non-aligned points is immobile in all cases in the plane concerning these three points. Increasing the number of non-aligned support points therefore improves the equilibrium conditions by limiting the number of axes of rotation.
- Terminal tooth principle : more exposed to exogenous forces, it is important to ensure that the terminal tooth has sufficient stability .
- Direction of chewing forces: in the mandible, these forces are centripetal and in the axis of the tooth; in the maxilla, they are centrifugal and perpendicular to the axis of the teeth. The risks of fractures are therefore greater in the maxilla than in the mandible, hence the need to strengthen the contention in the maxilla.
3-2-2- Biological principles:
Biological principles arise directly from the notions of preservation of supporting tissues. A retainer must therefore be compatible with good plaque control and must not irritate the surrounding tissues. The volume of the devices must not disrupt physiological occlusion or hinder oral functions or mandibular postures.
Tooth mobility: therapeutic strategies
3-3- indications and contraindications:
- Indications:
According to the American Academy of Periodontology , a retainer is a device designed to stabilize mobile teeth whose extraction is postponed or not planned and which have a poor response to treatment.
The periodontal indications for retainers are as follows:
– Interference of the mobile tooth(s) with chewing and/or patient comfort in a context of stable occlusion,
– Risk of migration of the mobile tooth(s),
– Risk of worsening of mobility despite the disappearance of inflammatory signs, on a reduced and healthy periodontium, but which no longer supports occlusal loads,
– Risk of worsening of mobility after root planing or periodontal surgery.
- Contraindications:
The purpose of retention is to stabilize mobile teeth , but with the objective of performing periodontal treatment. Thus, the patient’s non-compliance with their periodontal treatment can be considered as a hindrance, a contraindication to the performance of this retention. In the same spirit, the lack of oral hygiene or an inadequate diet promoting the development of carious pathologies remain limitations to the realization of these retention systems.
More pragmatically, decayed teeth that cannot be included in the preparation for maintaining the retention system may contraindicate this treatment.
3-4- Classification of restraints:
- Temporary or semi-permanent retention : indicated for very mobile teeth before or after periodontal treatment
- Semi-permanent or permanent retention : can be used for extremely mobile teeth that interfere with chewing.
- Permanent retention : indicated during complex oral rehabilitation when the abutments are very mobile or when a few abutments must support the entire prosthesis, especially if these abutment teeth have a very reduced periodontium but have benefited from effective periodontal treatment. If such teeth are not solidified they will become increasingly mobile.
3-5- Different types of restraint:
3-5-1- Direct restraints:
- Metal ligature:
Figure 8 or ladder are retention systems that are valid for a few weeks at most. They are currently rarely used because they are unsightly.
- Glued retainers:
These retainers are in the form of metal wire (braided or not), fiberglass strip or Elman metal grid and will be glued lingually. Bonding can be done by simply applying the retainer to the lingual surfaces, retention being ensured by bonding points with composite masses.
3-5-2- Indirect restraints:
Indirect retention is performed in the laboratory and therefore requires enamel preparation and impression taking. Its use is justified by the greater precision of the devices: cast-bonded splints, fiber composite or zirconium splints, retention bridges.
Tooth mobility: therapeutic strategies
- Occlusal adjustment:
Occlusal adjustment is done by selective grinding. The application of simple rules allows the elimination of premature contacts in centric occlusion , the harmonization of lateral occlusions and the elimination of contacts on the swinging side.
Selective grinding is done by small diamond grinding wheels in the shape of a wheel, flame and ball.
The tooth surfaces are thoroughly dried and then premature contacts and interferences are marked with articulating papers of different colors for simple contact and for sliding.
Tooth mobility: therapeutic strategies
- Conclusion :
Periodontal retention of mobile teeth is an effective therapeutic aid to provide comfort to the patient . These retentions complement periodontal treatments which, with regular maintenance, remain effective therapies to stop bone loss at the origin of these dental mobilities.
- Bibliographic references:
[1] Bercy, Tenembaum, Periodontology from diagnosis to practice, Edition de boeck, 2000.
[2] Bartala Michel, Micheau Charle, Periodontal retention, Clinical reality, 2024.
[3] Clara Joseph, Frédéric Courson, Sophie-Myriam Dridi, Restraint in all cases…, Clinical Reality No. 2, June 2015.
[4] s. Campana, k. Nasr, r. Esclassan,T. Canceill, a. Galibourg, b. Arcaute,O. Chabreron, l. Raynaldy, s. Laurencin, Creation of a periodontal retention splint by CAD/CAM using hybrid material, prosthesis notebooks, 2019.
[5] Lidhe Jan, Niklaus P. Lang, Clinical periodontology and implant dentistry, sixth edition, Wiley Blackwell, 2015.