1

The Circumferential Splint Reinvented

Gerald Wank, DDS, PC
Paul Springs, DMD
INTRODUCTION
Periodontally compromised anterior teeth often complicate comprehensive treatment, as
patient esthetics, hygiene, immobilization, and cost must all be balanced. While many
treatment modalities address some of these criteria, the modified circumferential splint is a
long-term treatment that reliably satisfies them all.In clinical practice, extensively
periodontally compromised patients often paradoxically show determination to maintain their
remaining dentition only once the remaining periodontal support precludes most types of
restoration. The authors preferred modality in such cases incorporates circumferential
periodontal splinting, short-period recalls and thorough homecare instruction, allowing
preservation and strengthening of teeth otherwise so periodontally unsupported as to be
considered non-restorable 1. In each case reviewed herein, the patients chief complaints
entailed missing or hopeless anteriors with adjacent mobile teeth. Both cases were
complicated by patient unwillingness to consider extracting further mobile teeth.
Additionally, fixed prosthesis was contraindicated by a poor periodontal prognosis. In both
cases, Type II occlusal trauma caused mobility of the anterior teeth, patient discomfort and
masticatory inefficiency, making immobilization a necessity2,3.
For many clinicians, a fixed bridge is the only method of splinting that is ever considered.
This technique allows superior three-dimensional rigidity, relative control of esthetics, and
profitability, but its downsides include occasionally prohibitive crown-to-root ratio
requirements, significant tooth reduction, cost to clinician and patient, and periodontal
involvement complicating hygiene and tissue health. Historically, cast lingual splints were
undertaken to avoid these limitations, but inordinate technique sensitivity, chairtime

inefficiency, retention problems and expense often restrict their application. Consequently,
many clinicians use medium-term fiber-reinforced lingual composite splints. This modality
leverages improved bonding chemistry for relatively inexpensive and technique-insensitive
single-visit direct fabrication with limited pontic incorporation4,5. Still, a lingual-only splint
cannot adequately dissipate the facially-directed forces of occlusion to the maxillary
anteriors. Additionally, lingual bulk and esthetic difficulties rarely justify the materials cost,
and intracoronally retained fiber-reinforced techniques require sizeable preparations for
predictable survival rates6,7.
In the authors experience, no long-term immobilization method of occlusally traumatized
anteriors outperforms circumferential splinting. It meets all the clinicians requirements:
three-dimensional rigidity rivalling a solder joints, ideal interproximal embrasures allowing
simplified patient hygiene, relative technique simplicity, and single-visit speed8,10. Patients
love its efficiency, minimal expense, and esthetics and feel rivaling any lab-fabricated
prosthesis. The restoration is rigid enough to allow incorporation of a pontic on abutments
whose only alternative would be a removable prosthesis. Moreover, circumferential splints
require minimal removal of tooth structure, yet withstand the test of decades, with easy
access for material repairs or restoration of adjacent caries indefintitely3. Although all
restorations have their most likely complications, clinical trials show the complications of
braided stainless steel and composite bonded ligatures are most easily repaired among splint
types9-16. In general, circumferential splinting demonstrates excellent long-term survival
rates with the least preparation necessary for favorable long-term success rates 11-16.

TABLE 1: Comparison of splinting methods

Splint
Criterion
Three-Dimensional Rigidity10
Esthetics10
Cost4,5,10
Technique Insensitivity4,510,11-16
Conservative Preparation10,11-16
Embrasure Form4,5,10
Pontic Inclusion4,10
Root Support Required18,19
Clinical Efficiency4,5,9,10
Long-Term Success,5,11-15,18,19
Easy Repair/Revision9,11-16

FPD

+++
++
--+
-+++
---++
--

Cast

+++
---+
+
--------

Fiber-Reinforced

Circumferential

Circumferential

Lingual

Dacron

Wire

+
+
+++
+++
+
+
+++
-++

++
+++
+++
++
+++
+++
++
+++
++
+++
+++

+++
+++
+++
++
++
+++
+++
+++
++
+++
+++

Once all data are evaluated and Type II occlusal trauma is diagnosed, prognostic factors must
be discussed before the teeth are immobilized through splinting17. After splinting, scaling and
any necessary periodontal therapy is completed, as stabilized teeth exhibit improved healing
and periodontal pocket reduction2. Optionally, minor tooth movement before splinting can be
used to optimize alignment, cleansability and occlusal relationships of traumatized teeth. This
is often necessary when anterior splaying and loss of vertical dimension follow occlusal
trauma secondary to lost posterior support. In such cases, the splint acts as a fixed retainer.
Elimination of malocclusions that would transmit excessive forces to the relatively healthy
abutments when splinted is an essential part of pre-treatment diagnosis, particularly when a
circumferential splint will support a pontic8. As such, thorough occlusal evaluation and
establishment of a mutually protective occlusion are a necessity.
PROCEDURE
The circumferential groove preparation resembles a horizontal slice of an ideal PFM prep,
with facial 1.5mm reduction to allow composite thickness for esthetic blockout of the
ligature, and up to 1mm on all other surfaces, just enough to incorporate and cover the

ligature without changing the tooth contour. The circumferential groove is prepared with any
parallel-sided bur, as horizontally as possible while incorporating the level of the contact
points of the abutment teeth. Undermining enamel for macroretention is contraindicated in
such high-surface-area resin-bonded restorations. Optionally, long bevels in short span cases
can increase microretention while eliminating undermined enamel and marginal transitions.
The prepared teeth are isolated, selective etched and bonded using a self-etching adhesive to
maximize chemical retention while eliminating intra-operative anesthesia and post-operative
sensitivity.
Wire ligature offers superior rigidity, though it necessitates additional attention to detail for
ideal esthetic results. When proximal contacts are large and/or the involved teeth are less
mobile, braided translucent white Dacron ligature (Dupont) facilitates simpler esthetics.
Whether wire or Dacron is used, the macroretention offered by braided ligature improves
interfacial composite retention8,10. After treating the preparations and two to three dead soft .
010 stainless steel wires for bonding, the wires are braided together using needle holders and
threaded through the first contact. The decision between two or three wires is based on the
rigidity and retention required, with considerations including number of pontics/abutments,
degree of bone loss, and interproximal contact size8,10. With the ligatures midpoint cinched
against the axial wall of the first groove preparation, the wire is crossed over itself in the next
interproximal space before a thixotropic microfill composite is injected, engulfing the ligature
and slightly overfilling the entire preparation. Once light cured, the initial increment of
composite tacks the wire firmly in place, enabling repetition of the process for each tooth.
The pontic is prepared identically to the abutments whether it is prefabricated, custom made,
or an extracted tooth. The only exception is pontics must be carefully positioned and checked
against the opposing occlusion and gingivial tissue before definitive curing to ensure occlusal

harmony and gingival cleansability. Once the process is repeated to the final abutment, the
two free ends of wire are twisted flush against the preparation and engulfed in flowable
composite to complete the stabilization. The long-term success of this restorative splint rivals
a PFM bridges but its greatest advantages are its minimal preparation, minimal debonding
potential, easily cleansable and repairable finish line locations9, and contour and form
identical to natural teeth with no gingival involvement.
CASE 1
These advantages are demonstrated by the following patient, presenting with a desire to save
his compromised teeth at any cost. Based on preoperative records, #25 was diagnosed as
periodontally hopeless, requiring imminent replacement (Figure1&2). From a periodontal
perspective, a fixed bridge was contraindicated, and a removable prosthesis would not
provide the fixation necessary to improve the mobile adjacents prognoses. The hopeless
incisor was extracted, but was retained for use as an ovate pontic. The necessary shade of
injectable resin was chosen, and the level of the proximal contacts marked with a pencil
(Figure3). Once the teeth had been rough prepared with a circumferential groove, the
gingival level was marked on #25(Figure4). After atraumatic extraction, the alveolus was
degranulated (Figure5). The root was debrided of soft tissue, resected apical to the gingival
margin line, recontoured to ideal ovate pontic shape, and sealed with a thin layer of glassionomer cement (Fuji I [GC America]) (Figure6). Once detoxified and polished to a high
gloss, the glass ionomer both sealed off endodontic portals of exit, and created a favorable
soft-tissue interface. The pontics positioning was checked intraorally, confirming both stable
occlusion, and gingival cleansability (Figure7).

The braided wire was surface treated with a universal, metal-priming adhesive (Scotchbond
Universal [3M]), air thinned and dried. Next, the preparations were isolated, and the
marginal enamel etched with 37% phosphoric acid gel (Kerr). After selective etching, selfetching resin adhesive (BeautiBond [Shofu]) was vigorously scrubbed into the dentin and
enamel, air-thinned and cured, and the midpoint of the braided wire was wrapped around the
distal of #27 and crisscrossed between #27 and 26 (Figure8). Next, the wire was closely
adapted to the axial wall, and a non-slumping flowable microfill (Tetric EvoFlow [Ivoclar])
was injected to completely encompass the wire and slightly overfill #27. Following light
curing, the ligature was left passively stabilized on the distal of #26, and the same process of
adapting the wire, crossing it interproximally, overfilling the preparation, and complete
curing while holding the wire in place was repeated on #26. Once reached, the pontics ideal
occlusal and gingival positioning was confirmed while it was splinted to its neighbors using
wire, but before it was tacked in place (Figure9). Upon reaching the final abutment, the wire
ends were twisted together until stable but passive, and the excess wire clipped off within the
groove before the preparation was filled with flowable composite and cured. Next, proper
occlusion and guidance on all units were confirmed in maximal intercuspation and all
excursions using 8 articulating foil (TrollFoil [Troll Dental]). This step was especially
important as occlusal trauma was the chief etiologic agent2. With functionality assured, the
composite was finished and polished until the restoration was made invisible. (Figure10)
CASE 2
The patient in Figure11 presented with Type II occlusal trauma and significant periodontal
involvement. Lack of available bone precluded implant-retained or fixed bridges, but the
patient requested a definitive restoration without the loss of any more teeth. Radiographs
revealed abutment support inadequate for a conventional fixed bridge, which would require

significant sacrifice of abutment structure in any case. This patients periodontal compromise
was less advanced than in Case 1, hence a predictable and esthetic circumferential splint was
possible using a braided Dacron ligature. Conveniently, Dacrons decreased stiffness allowed
simplified placement of the entire ligature at once. This increases both efficiency and
simplicity of the procedure, but limits rigidity in a way that is inadvisable in cases with more
advanced periodontal involvement, weak contact areas, or multiple pontics8. The restoration
technique was otherwise unchanged from Case 1 (Figures12, 13), except the pontic of choice
was a denture tooth. The patient loved the appearance and stability of the result (Figure14),
and the author was confident the splint would stabilize the occlusion, eliminate traumatic
inflammation, and increase patient comfort,1,2 restoring the patients masticatory function18,19.
DISCUSSION
Splinting reduces the overfunction of compromised teeth by axial force alignment and force
distribution to abutments, reducing mobility and resultant inflammation2,3,18,19. Additionally,
proximal contacts are stabilized, impaction zones eliminated, and individual tooth mobility,
tipping, migration, or supraeruption prevented. Consequently, splinting prevents the jiggling
of hypermobile teeth during mastication, eliminating patient discomfort and periodontal
truma2,3.. Splints must distribute masticatory forces efficiently on the remaining abutment
teeth, because when the force on one tooth exceeds its periodontal adaptive capacity, occlusal
trauma results, and when excess occlusal forces are applied to a splinted tooth, injurious force
is dissipated throughout the periodontal tissue of all splinted members. Hence, a sustainable
occlusion, designed during treatment planning and confirmed intraorally post-operatively, is
crucial2,17. This technique can transitionally splint traumatized teeth being evaluated for
FPDs, as the procedure is atraumatic, economical, and esthetic, with minimal preparations
that do not prematurely commit the patient to full coverage.16 It is periodontally hygienic,

non-inflammatory, non-cariogenic, easily repairable and rigid1,8. It is strong and distributes

the forces of occlusion3,8. Furthermore, the technique allows future emergency resection of
abutment teeth if necessary without compromising arch continuity. Case analysis is the most
important aspect of any treatment. The dentist must establish criteria for success for
traumatized periodontia17. When severe bone loss is present and re-establishment of a sound
periodontium is the prime goal, splinting is indicated. The modified circumferential splint is
utilized as an esthetic, hygienic splint for periodontally involved anterior teeth, either as a
transitional splint or a permanent restoration, depending on the clinicians diagnosis and the
patients treatment goals10,17.

Figure1&2: Preoperative records of hopeless #25, with questionable neighbors

Figure3: Preparatory marking of the preparation level
Figure4: Rough preparations with gingival level marked for the future pontic
Figure5: Final preparations and pontic site following socket degranulation
Figure6: #25 debrided and sealed with glass ionomer, ready for finishing and polishing
Figure7: Confirmed pontic placement
Figure8: Ligature in place for composite tacking
Figure9: Pontic position being checked before fixation
Figure10: Post-operative
Figure11: Case 2, preoperative
Figure12: Completed, etched preparations
Figure13: Single-step Dacron ligature placement
Figure14: Postoperative

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Dr. Wank is a Clinical Professor and former Postgraduate Director of periodontia and
implantology at NYU College of Dentistry, and is in private practice in Manhattan. He is
a former consultant at Coler-Goldwater Specialty Hospital and at the VA Hospital in
Manhattan. Dr. Wank holds fellowships with the American College of Dentistry,
International College of Dentistry, Academy of Oral Medicine, New York Academy of
Dentistry, American Public Health Association, and Academy of General Dentistry. He
lectures nationally and internationally and has written extensively in several dental
journals. He can be reached at gwank@aol.com.

Dr. Springs was graduated from Rutgers Dental School and the GPR at Coler-Goldwater
Specialty Hospital and Bellevue Hospital in New York City. A former Student President
of the New Jersey AGD, he currently serves as Board Member At Large of the New York
AGD and its New Dentist Committee, and is in private practice in Brooklyn and Queens.
He can be contacted at paul.a.springs@gmail.com.

Disclosure: Doctors Wank and Springs report no disclosures.

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