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Temporary Splinting in secondary trauma
from occlusion followed by vestibular
extension: A case report
Harinder Gupta1, Shreya Joshi2
Department of Periodontology, Punjab government dental college and hospital
Department of Periodontology, Professor & HOD (Harinder Gupta)
Department of Periodontology, MDS student (Shreya Joshi)
ABSTRACT: Background: A 27 year old female
patient presented with the chief complaint of pain
and mobility in mandibular anterior teeth. An
extremely shallow vestibule with less width of
attached gingiva was observed with marginal
gingival recession in 31, 32 and 41. Secondary
trauma from occlusion was observed clinically with
respect to 31.
Methods: After adequate oral prophylaxis, the
trauma from occlusion on 31 was relieved by
selective grinding. The mobile mandibular anterior
teeth were splinted with a temporary splint material
(26 gauge stainless steel wire). The mandibular
labial vestibule was extended using the lip switch
procedure or the Edlan-Mejchar technique.
Results: The procedure yielded a considerable gain
in the width of the attached gingiva, which
maintained itself even 9 months after the surgical
procedure. Mobility was reduced with complete
resolution of injury to the supporting tissues
leading to improved function of the mandibular
anterior teeth.
Conclusion: Patients presenting with secondary
trauma from occlusion and a shallow vestibule,
treatment options such as oral prophylaxis,
selective grinding, splinting combined with Edlan-
Mejchar technique leads to complete resolution of
mobility along with maintenance of the width of
the attached gingival for a considerable period of
time.
KEYWORDS: Vestibular extension, Trauma from
occlusion, Splinting.
INTRODUCTION
The goals of periodontal therapy include
maintenance of health of periodontal tissues,
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prevention of recurrence of periodontal disease
with desirable esthetics and harmonious
functioning of the entire masticatory apparatus.
Excessive occlusal forces do not initiate but can
modify pathway of periodontal destruction.
Secondary trauma from occlusion is an occlusal
force which itself may not necessarily be abnormal
but is excessive when it acts on the reduced or
weakened periodontium.2
Splinting is carried out to immobilise or stabilise
the injured or diseased parts which in turn increases
the resistence to the applied force by increasing the
effective root surface area for the dissipation of
forces and providing reciprocal antagonism.
Although the force remains the same but the
resistance is increased.10
The presence of an adequate width of attached
gingiva has been considered essential for the
protection of periodontium from injury caused by
frictional forces during mastication and also to
dissipate the muscle pull of adjacent alveolar
mucosa on the marginal gingiva. This facilitates
subgingival plaque accumulation due to improper
closure of periodontal pocket thus facilitating
apical spread of plaque due to decreased tissue
resistance which in turn favors attachment loss and
soft tissue recession.11 A situation that is commonly
seen on the labial aspect of the mandibular anterior
teeth is a shallow vestibule that may also impede
proper oral hygiene measures by hampering the
proper placement of a tooth brush.
One of the mucogingival surgical procedures
advocated for the correction of this defect include
denudation techniques.4, 12, 18 The main
disadvantage of this technique is alveolar bone
resorption due to its exposure17 and severe
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postoperative pain. The split flap procedure
removes only the superficial portion of the oral
mucosa leaving the bone covered by periosteum13,
14, 15, 19
so that there is less severe bone resorption
and loss of crestal bone height due to retention of
thick layer of connective tissue on the bone
surface.5
Thus, this case report describes a vestibular
extension technique by Edlan and Mejchar6 that
increases vestibular depth and keratinized tissue on
the labial side of mandibular anterior teeth.
Temporary splinting was carried out to reduce
mobility in mandibular anterior teeth due to
secondary trauma from occlusion.
CASE REPORT
A 27-year-old female patient reported to the
Department of Periodontics at Punjab Government
Dental College and Hospital, Amritsar with the
chief complaint of localised dull pain and mobility
in lower front teeth. Intraoral examination revealed
grade II mobility of 31 and grade I mobility of 41.
Miller's class II recession was present wrt 31(6
mm) and wrt 41(4mm). [Figures 1 and 2]. The
width of the attached gingiva was reduced in this
region, measuring 2 mm. Grade 2 calculus (Oral
hygiene simplified) with marginal gingivitis was
present in all mandibular anterior teeth.
A diagnosis of chronic generalised marginal
gingivitis with localised periodontitis in the region
of the mandibular incisors was made. The patient
was in good systemic health with no
contraindications for periodontal surgery. She was
explained about the surgery and written informed
consent was taken by the patient.
A thorough oral prophylaxis i.e phase-I therapy
was carried out with ultrasonic instruments.
MANAGEMENT OF MOBILE MANDIBULAR
INCISORS:
The mandibular anterior region was isolated with
cotton rolls labially and lingually, followed by
appropriate etching and application of a bonding
agent on the lower anterior teeth. A 26 guage
stainless steel wire was used for splinting adapted
lingually to the mandibular anterior teeth and
secured with flowable composite resin material
which was then light cured. [ Figure 4]
VESTIBULAR EXTENSION PROCEDURE:
Two weeks after phase I therapy, the patient was
planned for surgical procedure. Prior to the surgical
procedure, a calibrated periodontal probe was
placed on the labial aspect of the mandibular
central incisors to measure the distance between the
gingival margin and mucogingival junction. This
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measurement was recorded at subsequent follow up
intervals every 3 months postoperatively upto a
period of 9 months.
Patient was scrubbed with 7.5% povidone iodine
solution after a pre procedural rinse with 0.2%
chlorhexidine mouthwash. Bilateral mental nerve
block was administered using 2% lignocaine with
1:1, 00,000 adrenaline.
Incision: Mesial to one of the mandibular canines
and starting at the junction of the attached and free
gingiva, an incision was made with a 15c surgical
blade for a distance of 10 to 12 mm extending on to
the lower lip. A similar incision was made on the
contralateral mandibular canine. These two
incisions were joined by a horizontal incision
across the midline.
The mucosa included within this incision was
reflected from the underlying muscular tissue using
sharp dissection with the surgical blade. This
resulted in a loose flap of labial mucosa with its
base on the gingiva. [Figure 5]
Incision and reflection of the periosteum: The
loose flap of labial mucosa was folded upward and
a horizontal incision was made on the periosteum,
which had now become visible. This incision was
made so that it extended between the two initial
vertical incisions mesial to the canines. The
incision of the periosteum was extended in a
vertical direction at its ends. The periosteum was
then separated from the bone, forming a second
flap with its base on the apical portion of the
mandible.
Transposition of the two flaps: The loose flap of
labial mucosa was folded back and placed on the
bone from which the periosteum had been
removed. It was fixed with interrupted 3-0 black
silk sutures to the inner surface of the periosteum,
which had been removed from the bone. The upper
edge of the periosteum was also sutured to the
mucous membrane of the lip to cover the area
denuded by the reflection of the labial mucosal
flap.
A periodontal dressing COE pack (Coe
Laboratories Inc., Chicago, IL) was placed to
protect the operated area. An antibiotic amoxicillin
500 mg TDS and anti-inflammatory Brufen 400mg
BD for 5 days were prescribed to the patient in
addition to 0.2% chlorhexidine rinse twice daily for
two weeks. Other postsurgical instructions included
intermittent cold fomentation on the first
postoperative day, soft/liquid diet for one week,
and maintenance of good oral hygiene. The patient
was recalled after one week.
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Postoperative recall: The one week postoperative
examination revealed excellent healing (by first
intention) and a considerable gain in the width of
the attached gingiva and depth of the vestibule (up
to 7 mm). The patient was subsequently placed on a
recall programme and her periodontal condition
was periodically reviewed. No loss of width of the
attached gingiva was observed throughout the
recall period.
DISCUSSION
Several changes in the periodontal tissues are
caused by trauma from occlusion.
Secondary trauma from occlusion was seen as a
contributing factor for the destructive processes
initiated by bacterial periodontal inflammation
similar to that stated by William W. Hallmon.8 The
lowered tissue resistance or tissue integrity leads to
faster progression of the bacterial inflammation of
the periodontium. Clinically, trauma from
occlusion occurs as premature contacts with
fremitus in the suspected teeth and
radiographically, a widening of the periodontal
space can be seen.2 [Figure 3]
In the absence of inflammation, the changes seen in
trauma from occlusion are believed to be reversible
which is consistent with the study by Geramy et al.1
Thus the oral prophylaxis i.e scaling and root
planning was carried out first before splinting to
eliminate source of infection that led to
inflammation in the tissues of the periodontium.
Mobility may either cause or accelerate the
progression of periodontal disease and inhibit
periodontal tissue repair.7 Stabilization which in
this case was achieved by temporary splinting
decreased mobility leading to increase in function 3,
16
that was beneficial for the patient and thus
allowed repair during periodontal treatment.
A modification of the Kazanjian technique9 of
vestibular extension was used for the present case.
This technique has the advantage that healing
occurs by first intention and no bone is left exposed
which reduces the chances of bone resorption and
further recession. In the present case, an excellent
clinical result was obtained which was maintained
even 9 months after surgery.
The patient maintained good plaque control
throughout the follow-up period, thus the plaque
did not have any influence on the final stable
attachment level that was achieved.
Thus, based on the findings of the present case it
can be concluded that in cases with secondary
trauma from occlusion having mobility in
mandibular anterior teeth; thorough oral
prophylaxis followed by temporary splinting of
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teeth for stabilisation gives an opportunity for
healing of the underlying periodontal tissues.
[Figure 6] The technique for vestibular extension
advocated by Edlan and Mejchar to increase
shallow vestibule depth and narrow width of
attached gingiva on the labial aspect of mandibular
anterior teeth provides a predictable way in which
gingival health can be achieved and maintained.
REFERENCES
1. Allahyar G, Faghihi S. Secondary trauma
from occlusion: Threedimensional
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Quintessence international. November
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2. Branschofsky M, Beikler T, Schfer R,
Flemmig FT, Lang H. Secondary trauma
from occlusion and periodontitis.
Quintessence International. June 2011;
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3. Clark J, Weatherford T, and Mann W. The
wire ligature- acrylic splint. J Periodontol
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4. Corn H. Periosteal separation its clinical
Significance. J Periodontol 1962; 33:140
152.
5. Costich ER, Ramfjord SF. Healing after
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6. Edlan A and Mejchar B. Plastic surgery of
the vestibulum in periodontal therapy. Int
Dent J 1963; 13: 593-596.
7. Fleszar JT, Knowles JW, Morrison CE,
Burgett GF, Nissle RR, Ramfjord PS.
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8. Hallmon WW. Occlusal Trauma: Effect
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Periodontol 1999; 4:102-107.
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10. Lemmerman KJ. Rationale for
Stabilization. J. Periodontol. July 1976:
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11. Lindhe J, Karring T, Lang PN. Clinical
Periodontology and Implant Dentistry. 4th
ed. Blackwell; 2003. 576p.
12. Ochsenbein C. Newer concept of
mucogingival surgery. J Periodontol 1960;
31: 175185.
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13. Pfeifer JS. The reaction of alveolar bone
to flap procedures in man. Periodontics
1965; 3: 135140.
14. Staffileno H, Levy S, Gargiulo A.
Histologic study of cellular mobilization
and repair following a periosteal retention
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surgery. J Periodontol 1966; 37: 117131.
15. Staffileno H, Wentz F, Orban BJ.
Histologic study of healing of split
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Periodontol 1962; 33: 5669.
16. Stern I. The status of fixed splinting
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Figure 2 showing preoperative intraoral depth of
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17. Wilderman MN, Wentz FM, Orban BJ. gingival recession on distal of 31
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Figure 3. preoperative radiograph showing

decreased and uneven alveolar bone levels due to
inflammatory disease along with widening of PDL
space in 31

Figure 1 showing preoperative intraoral depth of

gingival recession on mesial of 31

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International e-Journal For Medical And Research-2017

Figure 4. intraoral splinting of mandibular Figure 6. post operative radiograph showing

anterior teeth with 26 gauge stainless steel wire decrease in the width of PDL space and
and flowable composite resin improvement of levels of alveolar bone

Figure 5. vestibuloplasty by edlan mejchar

technique in mandibular labial vestibule

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