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The table below shows some basic occlussal terms; please take a look at them
before proceeding with this lecture, most of the concepts depends on it.



When were relaxed (mouth is open ) the mandible will
be in its Muco-Skeletal Position of the Joint ( MS )
within the glenoid fossa . This position is defined as :
The most orthopedically stable joint position , it happens
when the condyles are in their most superior-anterior
position with the disk in between and the head of the
condyle is touching distal slope of the articular emeicne
or the CR/RCP position .
The MS positon of the mandible is considered the most stable position, because on
the slope of the glenoid fossae the bone is very thick (1) and it consists of a
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cortical bone (2) which makes it the ideal stable and load-bearing area. ( see figure
1 )
So when were relaxed (not chewing or doing any function with the mouth) the
mandible relaxes, but the muscles will pull the mandible in order to reach the MS
position of the mandible .

Now what happens when we close our mouth (as when were eating), the mouth
will close and the occlusion for a brief time would be cusp to cusp, now cusp to
cusp is not an occlussally stable position but rather considered as an occlussal
interference, so here the body is not looking for the Muco-Skeletal position
anymore, but rather it is looking for the most stable occlussal position to solve the
problem of the interference that occurred upon closure of the mouth .
In order for the body to solve this interference and achieve maximum intercusption
(MCP/ICP ) ( occlussal stable position during function ) and change the position
to cusp to groove which is occlusally far more stable than cusp to cusp. The
muscles will contract ( especially the lateral pyerydoid muscle ) with this action of
the muscles the mandible will move a little forward and thus achieving cusp to
groove or the MCP/ICP .

Now what happens when were eating (functioning) , while we chew we dont eat
in the CR but rather we function around the ICP ; meaning that at the end of the
mastictory cycle a brief contact between cusps would happen ( this brief contact is
essential to incise food ) meaning that we dont function exactly at the ICP because
we dont eat food by opening and closure but rather by doing lateral movements ,
so were functioning AROUND ICP .

Now the above senieros hold true for 90% of the population, meaning that 90% of
us will have occlussal interference upon closure and their mandible will move
forward a little bit to accommodate and solve those interference by going cusp to
grove ( ICP /MCP ) , the other 10% have different screnrieros ; theyre always on
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their MS position because they dont have occlussal interferences and thus the
body didnt feel the need to change positions and move the mandible a little
forward; meaning that their ICP is the same as their CR .

Now a question rises , the joint position in 90% of us while closing and chewing is
not in its orthopedically stable position ( the MS ) , why didnt we develop any
problems in the TMJs ? here, the condyles new position that the body made which
is a little bit forward is still compatible with the health , unless there are unusual
movements or loading thats happening in the joint ( e.g. burixisim , clenching )


Theres a concept called Mutually Protected Occlusion, in simple words this
concept means that: anterior teeth protect the posterior during protrusion and
posterior teeth protect the anterior teeth during mouth closure in maximum inter-
cusption .

The anteriors will prevent the premature contact of the postieror teeth during
protrusioin and thus protecting them , and the posteriors are more vertically placed
and have more roots thus the force applied to them would be more than the anterior
and thus theyll protect the anteriors ; theyll withstand more force than the
anteriors.
Any interference that disturbs this mutually protected occlusion will lead to tliting
and occlusion interference during function and protrusive movements, thats why
most restorations and prosthesis (crowns and bridges ) are made to conform to
patients existing ICP , meaning that we must have the maximum number of
contacts ( every tooth wither its sound or restored must have an opposing
contact on the other arch ) in order to preserve this mutually protected occlusion.
Consider the following examples:
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- A dentist might be presented with single high crown prosthesis; hell suggest
that trimming this high crown will resolve the case. But what will actually
happen is that supra-eruption of the opposing teeth in the other arch will
occur. (So the mutually protected occlusion concept is damaged, here when
the patient would protruded hell have occlussal interference at the back) this
might lead to either breakage of the crown or in the most severe cases TMJ
problems.
- A dentist who had just finished doing a restoration, he didnt check to see if
its high in occlusion (high spot) or not. Now whenever the patient is
chewing on that side the
muscle will contract to
prevent him from hitting
that spot every time, at the
long run the muscles will
be tired and TMJ
problems will occur (again
the mutually protected
occlusion is damaged).

In the above two examples you now realize how
important is to maintain this mutually protected
balance, and now you realize why we love to have
maximum number of contacts on each and every
tooth , thats why most restorations and prosthesis
(crowns and bridges ) are made to conform to
patients existing ICP . for this to be an appropriate
form of treatment ICP must be stable and occlussal
anatomy of all restorations must be carefully
shaped to reproduce correct contacts; meaning that
we must have the maximum number of contacts
(every restorations or prosthesis must not
damage the mutually protected occlusion , or in
other words , a restoration or a prosthesis in the
back must not interfere upon protrusion and a
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prosthesis or restoration in the front must not also interfere upon closure ) .
(see figure 2 : A: a contact in the back prevented lead to less stable postion in the
articular and thus TMJ problems , B : good crowns/restorations show no
interference and thus good position in the articular was achieved and no problems
were found )
The question that rises now is how do we manage those patients who have
interferences? Or how do we restore the mutually protected occlusion? The answer
is we give them occlussal splint, consider figure 3 and 4 , in 3 notice how a faulty
crown is damaging the mutually protracted occlusion and that the lateral pyerydoid
muscle is always contracting and notice in 4 how we added an occlussal splint or
an antieror guidance that relaxed the hyperactive muscle.
After weve covered the basic concepts of occlusion physiology and mutually
protected occlusion, and after weve understood the need behind occlussal splints
well talk about them for the rest of this lecture.



The definition of the occlussal splints is: Any removable artificial occlussal
surface used for diagnosis or therapy affecting the relationship of the mandible to
the maxillae. It may be used for occlussal stabilization, for treatment of
temporomandibular disorders , or to prevent wear of the dentition GPT-8

Okoson defined it as follows: it is a removable device usually made of hard
acrylic , that fits over the occlussal and incisal surfaces of the teeth in one arch ,
creating precise occlussal contact with the teeth of the opposing arch .

So, the occlussal splints devices can be used to either stabilize the occlusion, treat
TMJ problems or aid in diagnosis.
But how exactly can we achieve a diagnosis with occlussal splints? Consider the
following example, you made a new bridge work for your patient and inserted into
his mouth, couple of weeks later the patient is complaining of a pain in his jaws,
youre suspecting that a high spot in your bridge is that cause of this but still you
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need to confirm that. What youre going to do is that youre going to make him an
occlussal splint (a night guard) and ask him to use it, the patient reported back that
hes now happy and no pain is found, so you concluded that the high spot on that
bridge work was the cause, so here the occlussal splint was used as a diagnostic
tool.
Occlussal splints can have many different names like (refer to the slides to have the
full list ) :
anteiror reprogramming splint
anterior postioning splint
annterio repostioing splint
flat occlusal splint
bite splint
mandibular advancement device
muscle deprogramming splint
occlusal protecting splint
Lucia Gig
Orthopedic deprogramming device
Occlussal correcting splint
Distal push splint
Buccal separator
discluding splint


Its indicated in the following cases :
Temporomandibular disorders ( first line of treatment )
Myofascial pain
Disc displacement disorders
Arthritides of the TMJ
Headache/migrane
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Sleep burxism
Sleep apnea
Parckinsons disease
Oral tardive dyskinesia
Its applications are as follow:
Occlussal rehabilitation :
o Ortothodontics
o Periodontics
o Prosthodontics
Establishemnt of CR (where we cant determine CR )
Protection of new restorations ( like in the case of vnerees and
all ceramic restorations )
Creating space for restorations
o Phantom bite ( where the patient cant determine a bite ) .
o Others :
Diurnal burixism
Sports
Cheek/ fingernail biting
Electroconvulsive therapy
Lip commissure burn
Esophageal reflux
Sinusitis
Diagnosis of possible cause of TMD



Splints are indicated to reduce harmful effects :
o Teeth : attrition , fractures and mobility or pain
o TMJ : pain , traumatic arthritis , degenerative remodeling
o Muscles : pain or spasm
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Note that splints can not cure bruxism because it is a centrally mediated disorder .
Howevere it can reduce its effects through :
Providing a softer surface to wear ( its hard acrylic and it wont wear teeth )
Redistribute the tramtic forces over larger number of teeth
Splinting teeth together and provide ideal occlussal contacts.

Occlusal Splints can be classified according to :
1- Material of construction:
Hard
Soft
Bilaminar

2- Coverage:
They could be full coverage or partial coverage

3- Function :
Stabilization
Repositioning

4- Position :
They could be maxillary
or mandibular




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1- Hard acrylic is the most common used
material, which is:

1- chemically cured or heat/pressure
processed
2- hard on both occlusal and fitting surface
3- Durable
4- Easy to repair
5- More retentive
6- Less prone to change in color & plaque
accumulation.

2- Soft or resilient plastic night guard:
Giving a patient with tempomandibular disfunction (TMD) a soft night guard is
just like giving him/her a chewing gum and ask him to chew it!! Thus; instead of
making the muscles relaxed you're making the condition worse !
So ,what is the use of soft night guard ?!
They're just used in emergency cases, if someone has acute pain and you want
something to open his bite to relax the muscles , you should give him soft night
guard for few days then make him a full hard night guard .. JUST in Emergency
cases
3- Bilaminar ( dual laminated) :

- The side toward the teeth is soft ,and the one toward the occlusal side is
hard .
- Can maintain a stable occlusion
Other properties mentioned in the
slides:

Vacumformed vinyl splint
Soft on both surfaces
Not durable
Cannot maintain stable occlusion
Helpful in emergencies but might
lead to increased muscle activity
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Partial coverage :1- Anterior bite plane
2- Posterior bite plane.
Anything you wear for more then 4-6 weeks with
partial coverage will lead to irreversible changes in
the occlusion, that's why full coverage is
preferable.
If a patient uses a posterior bite plane and wear it continuously for 4-6 weeks
,there will be supra eruption for anterior teeth ,and ends up with posterior openbite.
And the same with anterior bite plane where you will end up with anterior openbite
within 4-6 weeks.
These are types of irreversible damage, thats why
we hate partial coverage splint !!

Other examples of partial coverage splints include
1- Lucia Gig
2- Nociceptive Trigeminal Inhibition Tensin
Supression System (NTI).
3- The Anterior Medline Point Stop (AMPS)
devices.
If you used them you have to strictly tell
the patients not to wear them continuously,
otherwise well have supra-eruption and
end up with an openbite .
Lucia Gig
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1- Stabelization (permissive) ,the one we will
fabricate in the clinic which is called (Michigan
or stabilization appliance) (figure 6 : A)
It has flat occlussal surface with the opposing
teeth ,doesn't have indentation ,it's called
stabilization because it puts the mandible in a
muscoskeletal stable (MS) position ,it puts the
condyle in its anterior superior position.
2-Repositioning device,, it has indentations, I
will take the bite in anterior position , in order to
unload the disk, the idea is unload the disk if I
have the loading on the retrodiscal tissue and the
patient has extensive pain Ill ask the patient to
protrude and take a bite and make an anterior
bite plane for him which will relieve that pain (figure 6 : B)
Can be used as first line emergency treatment only to reduce acute pain , so
its only used in short periods of time
Can lead to irreversible change in occlusion
which will cause a disaster after a while.
3-Pivoting concept : they thought that putting a
partial coverage posteriorly by using a bite plane (
the pivot ) , that it will bring the condyle downward
upon clenching on the pivot thus reliving the
traumatic load and allowing the disc to resume the
normal position . But it has proven that this concept
is not true.(figure 7)


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Could be maxillary or mandibular.
1- Maxillary appliances :
have more coverage less likely to break
more stable
better retention
More versatile

2- Mandibluar appliance :
are used for class III occlusion &posterior crossbite
they have minimal show on the patient
easier to speak with


The splint therapy is effective in reducing the pain in 70-90 % of the TMD
patients, although they do work their true mechanism of action is still not known,
there are some proposed theories concerning their mechanism of action:
The table below summarizes these theories :
Dental reasons for efficacy Nondental reasons for efficacy
Alteration of the occlusal condition Cognitive awareness
Alteration of the condylar position Placebo effect
Increase in the vertical dimension of
occlusion
Increased peripheral input to the central
nervous system decreases motor activity
Regression to the mean(natural
fluctuation of symptoms)
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- The most convincing one is cognitive awareness (nondental), when you give
a patient a night guard you remind him not to chew , to reduce bruxism .
- Placebo effect ,whenever you put anything between his teeth he feels that you
care for him this why he will feel better , theres a dentist who did a research
on three different groups . The first one had a real night guard that the sample
wore for 2 hrs , the second sample had a fake one where the night guard only
covered the palatal surface and the last sample didnt recive and night guards
but instead they were treat with a compasinte and a caring way via the dentist .
Surprisingly all the three groups showed decreased TMD symptoms.
- Increased peripheral input to the central nervous system so decrease motor
activity
- regression to the mean (natural fluctuation of symptoms) : Which means that if
a person has a stressful life event in a specific period of time he will suffer
from TMJ problems ,but when this stress goes away his condition will be
resolved and the TMJ will come back to the natural relaxed state.

1- Stable with no rocking
2- Ease of placement
3- Smooth with no sharp edges
4- Reasonable esthetics
5- The contact should be
- Balanced in the centric relation; every single tooth has to have
centric stop. when you put the night guard in the patient mouth let
him bite and put a horseshoe articulating paper , every single tooth in
the lower should have a mark on its occlusal surface, if there are
marks on the posterior teeth but nothing on the anterior; supra
eruption of the anterior will result .If there is anterior contact without
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posterior contact supraeruption of the posterior will happen. If all
teeth have a contact except one tooth ,this tooth will supraerupt alone
and you will notice in those patients with night guard when they
wake up in the morning they will said that they bite on one tooth
,why ? due to supra eruption.

- Occlusal surface should be flat
- Immediate posterior disclusion on protrusion and lateral excrusion
- 0.5 mm freedom in centric


1- Take a full upper and lower alginate impression all teeth should be
recorded.
2- Bite registration on RCP preferably with facebow record ,take precentric
occlusal registration.
Upper and lower teeth should not touch when I take the bite ,, there
should be 2 mm separation posteriorly and about 3-4 mm separation
between the incisors anteriorly.
3- Mounting the casts using facebow record and the bite provided.
4- After the mounting do block out (very important )
If you do block out before mounting you can't mount the cast because the
cast will not stick to the bite .
Mount first then block out
Where you should put the plaster ?
- in pits and fissures,
- the embrasure area in the lingual side and cover the lingual gingival
margins.
- do not block out labial undercuts because you will use the labial
undercuts for the retention of your appliance .
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- Draw a line to determine the extent of the splint ,4-6 mm of the palatal
gingival margins ,2-3 mm from the labial surface of teeth.
5- Then do wax up using two layers of wax ,adapt them on the surface ,this will
produce indentations which you have to remove them later ,you just need a
flat surface.
6- Use an articulating paper to produce dots on all the occlussal surfaces there
must be marks ( contacts ) the dots showed be :
a. All teeth must show contacts in ICP
b. Only the canines contacts in lateral extrusions
c. Anterior guidance component showed be only on the canines (
preferable ) or canines and lower incisors
7- Add wax labial and mesial to lower canines to establish a Canine ramp or
just on one canine ,every doctor has his own way and both are correct
8- Then do flasking
9- Packing in heat cured acrylic

Inspect the appliance for sharp margins
Check for sever undercuts.
Carefully place the appliance in the mouth and don't force it into place and
don't allow the patient to insert it at this stage.
The splint should have a light comfortable pressure with a soft click.
Make sure that it's fully seated before you start adjusting the occlusion.
If the appliance is not stable or rocking or not retentive
- check for undercuts
- consider relining
- consider remaking
Use an articulating paper to check for occlusion ,first establish even contact
on all teeth at RCP,then check for canine guidance on lateral excursions and
protrusion, if you do the opposite it won't work .
Always check RCP first.
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give post operative instructions , the splint should be worn as recommended
by the dentist.
saliva flow will increase in the first two weeks ,which is normal of artificial
appliance.
It's normal to feel tightness for the first 2 minutes of wearing.
If it's not worn keep it in water (very important)
Regular check up is mandatory
Do Not wear the splint for more than 4-6 months without review
Brush the appliance with soap after meals
Dont bite or clench continuously on the appliance ,it's there to make you
relax

Review after 7 days to recheck the occlusal contacts.
Remember that if the patient is suffering from TMD it will be difficult to
establish centric relation record correctly from the first appointment so you
have to repeat it again .the patients will have pain on the first appointment
and their muscles are contracted so the RCP won't be correct at the
beginning ,so what to do ?
First fabricate the splint on RCP, then after one week if the muscles
improved the mandible will get backward a little bit, then test it another
time, till the signs and symptoms of muscular tenderness goes away .

If I want to use the position of the mandible for restorative purposes ,the
occlusion shouldnt be changed for at least two consecutive appointments
before I can go ahead.