Splinting Natural Teeth to Implants: What Strategies Work?

Dr. G. asks:
I am a prosthodontist and have done many cases over the years where I have splinted natural teeth to natural teeth and implants to implants. I have never splinted natural teeth to implants. I have encountered a number of cases where this could produce a better prosthetic result if I can be confident that splinting natural teeth to implants can be successful or at least not inherently a practice that would lead to eventual and certain failure. What are your thoughts on this? What has been your experience? What strategies work? I have heard some speakers recommend using a telescope crown on the natural tooth and cementing with resin cement?

32 thoughts on “Splinting Natural Teeth to Implants: What Strategies Work?

  1. There is a common misconception that you should not splint natural tooth to an implant – this however is very wrong.

    Although ideally you want an implant splinted to an implant, splinting natural tooth to an implant works predictably.
    Paul Fugazzotto has an article published which shows hundreds of cases with high clinical success. That said, in about 3% of implant – tooth splinted cases, you tend to get intrusion of the natural tooth in what’s called the ‘natural tooth intrusion phenomena.’ To minimize the chance of this occuring, it’s recommended that a cement that does not ‘wash out’ be used to cement both the dental implant and the tooth, in addition to using rigid connection only.

  2. Agreed. I have connected natural teeth with implants on many occasions and have yet to encounter a problem (knock on wood!). I’ve done this mostly in the anterior region for esthetic purposes although sometimes finances have played a roll. My reasoning for doing so is fairly straight forward. As far as I’m concerned, the issue with teeth failing post-restoration is relative to the amount of undue force put on them. We’ve all splinted two mobile teeth with crowns to have them lend each other stability. Well, once an implant is integrated is there anything in a patient’s mouth that is as stable? My feeling is if you connect a natural tooth to an implant, you are provided as much protection from undue forces as possible. That is, if the occlusion is correct. Now to be honest, I have never heard of “natural tooth intrusive phenomena” and it’s something that I am going to have to look into. If anyone has more info on that, perhaps you can post it here?

    • Natural tooth intrusion is well known and well documented. Several studies suggest placing copings on the natural tooth in the event that intrusion occurs. Professor Richard Palmer et al. has carried out several studies with very positive results for a single Astra implant in a distal extension saddle area connected to a premolar. I have used this on several occasions with a 3-10 follow-up and it works well. Intrusion does not always occur but also cannot be predicted. Hope this helps

  3. What I’d been taught was that it risks the implant if the tooth is mobile. Say a three-unit bridge with an implant and a mobile tooth as abutments. You’re potentially placing a 2-unit cantilever on the implant, if the tooth isn’t supporting it’s end of the bridge, coping or not.
    If the tooth is not mobile, you might get intrusion.

    • Similar prosthetic principle applies to an implant-tooth bridge as it does for a tooth-tooth bridge. Would you make a bridge on 2 mobile natural teeth? I hope not. Then, why would anyone splint implant to a mobile tooth. (Yes, a healthy natural tooth has a minute degree of mobility compared to none for an integrated implant – so what – is it clinically significant?). Anyway, in general, a tooth-implant bridge should be no more than a 3-unit bridge (ie 1 pontic maximum). There are exceptions, but with full understanding of increased risks.

      • //(Yes, a healthy natural tooth has a minute degree of mobility compared to none for an integrated implant – so what – is it clinically significant?). //

        Yes it is clinically significant. An implant does not move AT ALL, and the tooth NEEDS to move on a microscopic level. Physiologically, it is very important to allow that natural tooth to move, the lack of which is the cause of intrusion.

        Even if intrusion only happens 3% of the time, why risk harm to a patient for a cosmetic outcome??? Health and safety should ALWAYS be a higher priority than appearance. A full denture looks very pretty, but I’d never suggest it to a healthy patient with crooked teeth!

  4. I have never seen the intrusion of teeth when splinted to implants. I usually place copings on the natural teeth when doing so. I cement the copings with glass ionomer cement and the bridge with polycarboxylate or zinc phosphate cement. I have been doing this for 20 years without any issues. The intrusion is most likely something that is most rare at best.

  5. In my opinion, splinted natural teeth to implants will increase the failing rate of the implant. There will be intrusion, but the amount of force acted on an implant is unpredictable. When we doing bridge work on the natural teeth, the immediate mobility acted on both abutments, therefore the force distributed evenly.
    The bridge make on a natural tooth and an implant, when the force acted on the brigde, the natural tooth have immediated mobility but the implant is not. Therefore the implant will take more forces acted upon.

    Another risk factor is the natural teeth, how long does it last while it still there. Would we jeopardise the implant for this natural tooth.

    There are many factors involve why the patient lost their teeth in the first place. So splinted natural teeth to implants will increase the risk factor.

    These issues still debatable.

  6. Hi John,
    Richard answered the question for you about why we use gold copings. This prevents leakage beneath the bridge on the tooth if intrusion does occur (at least the tooth is still covered with the coping). Hoang I don’t think any of us are suggesting that this is a routine plan of action when treatment planning cases but we are just saying that it can be considered occasionally when other options are exhausted. Like I said there are several favorable studies showing good 10 year + success with a 3 unit bridge.

    • Hi zak, how does putting a coping on a tooth prevent leakage under a bridge? I never heard this before. And if there is an intrusion for the natural tooth and its covered by the coping, that makes it better? The bridge is no longer supported on one end if the tooth has intruded, whether it has a coping or not. So i’m removing the bridge at that point. So, i still dont get why a coping is necessary.

      And, dr. Hughes shouldnt use polycarboxylate cements on implant prosthesis – it reacts with the Titanium and makes it rust. At least thats what the label on duralon says.

  7. Hi John, The gold coping is cemented on with permanent cement onto the tooth. It acts like a thimble protecting the tooth IF it intrudes. The bridge is then cemented over this with another cement. The bridge abutment fitting over the gold coping can usually have some form of groove or slot (precision or other) for improved retention and the bridge is then cemented with whatever cement you prefer. I personally don’t use Polycarboxylate cement but rust shouldn’t be an issue as you are only using it beneath the bridge on the tooth not over the implant. I believe this is what Richard meant. As I mentioned intrusion does not always occur but if it does then there may be an issue with the cantilever that you mention. HOwever in my hands this has worked well. You could easily get a document disc from AstraTech that has several papers on this. Hope that makes sense.

  8. why would you splint natural teeth and implants? In the last 25 years I have seen and heard it all, flexible splinting, precision and semi precision attachements, coping and fixed splinting, and in the end Its not good for the implant and will in same cases hurt the natural teeth. Just remember that cantilevers are not really indicated in implants and that is what you are doing when splinting with teeth.
    JUST DONT. Is better to place an extra implant and live relaxed

  9. I will try to clarify my previous statement. When cementing bridges with copings, I use the harder of the two cements for the coping and the softer cement for the bridge. Example: glass ionomer for the copings and Zinc phosphate or polycarboxylate or ZOE for the bridge. If the bridge becomes lose at least it should not affect the cementation of the coping. The copings are usually used on the natural abutments and sometimes on the implant abutments depending on the implant modality used.

  10. Dr kong: I don’t believe most people would consider using a mobile tooth as an abutment for a final restoration. I have treated mibile teeth periodontally and grafted with Osteogen mixed with PRP in the related periodontal defect and used PRF as a membrane. Then splint with a provisional bridge. This produced fantastic results ( stabilized the tooth and the perio defect regenerated). When you mentioned rust, did you actually mean tarnish. It may be possible the implant prosthetic components were not Ti alloy.

  11. I don’t believe most people would consider using a mobile tooth as an abutment for a final restoration. I have treated mibile teeth periodontally and grafted with Osteogen mixed with PRP in the related periodontal defect and used PRF as a membrane. Then splint with a provisional bridge. This produced fantastic results ( stabilized the tooth and the perio defect regenerated). When you mentioned rust, did you actually mean tarnish. It may be possible the implant prosthetic components were not Ti alloy.

    • Dr.Hughes, I’m impressed you are able to treat and stabilize mobile teeth using osteogen, PRF and PRP. I recommend adding eye of newt to that next time – it’s even more fantastic than your fantastic results.

      I think we’re in agreement that mobile teeth should not be used as abutment teeth.

      I believe most Implants/parts are Titanium/alloy (the implant, the abutment, etc.). If you read the manufacturer’s instructions for Duralon, it clear states “not suitable for cementing Titanium.” Durelon is found to CORRODE (not tarnish) titanium and the effect could related directly to the implant abutment, implant body and surrounding tissues.

  12. Hi Zaki , welcome , I have splinted only twice and used gold copings both times exactly as you have stipulated . One case now 10 years plus the implants were placed in the tuberosities and linked to the upper second premolars ( the patient absolutely refused the notion of sinus augmentation ) . There have been no issues and minimal bone loss ( less than 1 mm) and although cemented with tempbond has neither has be-bonded .
    Peter

  13. Hi Peter, Thanks for your post. Glad you have found success doing this. You had a situation that indicated this and it worked well for you and I have also found indications that necessitated this approached for one reason or another. It has also worked well for me. I have some cases that were done during my Masters training in Implant Dentistry 13 years ago…no intrusion so far. Dr Berg and John, we are not suggesting this should be considered all the time but for those rare cases where you are scratching your head about what to do next, it is worth considering.

  14. Dr.Hughes, if you’re referring to the eye of newt comment, I was being sarcastic.

    It’s just that your comment about “regenerating periodontal defect” made me roll my eye. You don’t treat gum disease by stuffing everything under the sun into a periodontal defect – it is very different from an osseous defect. The fact that you mixed bone (or in your case HA) w/ PRP is very telling. There is no evidence that shows it enhances “periodontal regeneration” let alone “bone fill.”

  15. Dear Dr Kong,

    This subject keeps recurring regularly on this website. Some will say this is a terrible concept but this position is based on Dogma and not on evidence. In fact there is quite a lot of evidence confirming that connecting a natural tooth to an implant for purposes of constructing a bridge can be and is a highly successful process. I will copy and paste my prior comments on this subject as there appears to be new people in this discussion

    “A free standing implant bridge is always preferable for the obvious reasons of potential stress transference to the implant as a consequence of movement of the natural abutment due to the compression of the periodontal ligament. However a short-span bridge anchored to a both a solid root and a solid implant can be a viable service particularly when the patient is placed at unnecessary risk or morbitity such as can occur in the area of the mental foramen.

    For joining a natural tooth abutment to an implant abutment, the protocols which I follow are:

    • The implant abutment should be of substantial size and should be placed in type II bone to best withstand the increase in shear forces that can arise from this type of hybrid bridge system.
    • The pontic should have a short span, preferably only a single tooth, to minimize torque forces on the abutments.
    • The natural root abutment should have good stability, preferably with no mobility and the tooth should preferably be multi-rooted to minimize tooth displacement.
    • Both abutment connectors should have a rigid connector design. Nonrigid attachments should be avoided as they are associated with an incidence of root intrusion.
    • If telescopes or copings are used, avoid temporary cements; in particular, avoid the no-cement coping technique, as loss or absence of a rigid connection will induce the highest incidence of intrusion.
    • Use highly retentive cements with superior design features for retentive preparation at the abutment to resist cementation failure.
    • Eliminate or minimize unbalanced tooth contacts in excursive movements as well as in centric.
    • Consider bruxism as a risk factor; if present, manage bruxism with an anti-bruxism splint, preferably placed on the arch that contains the bridge.”

  16. Dr Kong, the fact remains that the treatment I used does work. Why should it not work? One flaps the area, deb rides the site(defect), detoxified the defect and root, decorticates the internal aspect of said defect and places Osteogen w or wo PRP. Educate me and others if this is so wrong!

  17. I’m looking from” the outside in “, in this situation, but can it not be as simple as ; splint only to very sound teeth, in the appropriate candidate. This has worked well for us. Never splint to a compromised tooth, just as you wouldn’t abut a fixed partial to one. Again, some things rarely change! Bv

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