A common-sense approach to splint therapy

Tim J. Dylina, DDSa

Merced, Calif.
Splint therapy is a proven modality for alleviating the pain of many types of temporomandibular
disorders and bruxism, though questions still remain regarding how splints work. In this article, a
review of the literature is used to determine an effective splint design for the different degrees of
temporomandibular problems. Sufficient credible literature exists to help provide an understand-
ing of and a treatment protocol for the use of splints for temporomandibular disorders and
bruxism problems. (J Prosthet Dent 2001;86:539-45.)

INTRODUCTION
Practitioners appreciate a practical approach to all
aspects of treatment; splint therapy is no exception.
The purpose of this article is to review the current
understanding of how splints work, describe various
splint types and their uses, and suggest how to ensure
their proper design, fabrication, and adjustment.
Splint therapy may be defined as the art and science
of establishing neuromuscular harmony in the mastica-
tory system and creating a mechanical disadvantage for
parafunctional forces with removable appliances. A
properly constructed splint supports a harmonious
relation among the muscles of mastication, disk assem-
blies, joints, ligaments, bones, teeth, and tendons.
Fig. 1. Anterior deprogrammer to separate posterior teeth
SPLINT TYPES AND FUNCTIONS with smooth function on anterior teeth.
All splints are classified as either permissive or non-
permissive. A permissive splint1 allows the teeth to
move on the splint unimpeded, which in turn allows
the condylar head and disk to function anatomically.
A nonpermissive splint has a ramp or “indentations”
that position the mandible inferiorly and anteriorly
and secure it there. Examples of permissive splints
include bite planes (anterior jigs, Lucia jig, anterior
deprogrammer) (Fig. 1) and stabilization splints (flat
plane, Tanner, superior repositioning, and centric
relation [CR]) (Fig. 2). An example of a nonpermis-
sive splint is a repositioning splint (anterior
repositioning appliance [ARA]) (Fig. 3). Soft splints
and hydrostatic splints (Aquilizer; Jumar Corp,
Carefree, Ariz.) could be considered pseudo-permis-
sive splints, as their functions are extremely different Fig. 2. Occlusal view of mandibular stabilization
than those of the permissives. appliance.
Properly fabricated splints have at least 6 functions,
including the following: (1) to relax the muscles, (2)
to allow the condyle to seat in CR, (3) to provide diag-
Relaxing the muscles
nostic information, (4) to protect teeth and associated
structures from bruxism, (5) to mitigate periodontal It has been well documented that tooth interfer-
ligament proprioception, and (6) to reduce cellular ences to the CR arc of closure hyperactivate the lateral
hypoxia levels. pterygoid muscle2; posterior tooth interferences during
excursive mandibular movements cause hyperactivity of
the closing muscles3; and the elimination of posterior
aPrivate practice. excursive contacts by anterior guidance significantly

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THE JOURNAL OF PROSTHETIC DENTISTRY
A when the condyle disk assemblies are positioned in
B condylar ligaments, and retrodiscal tissues can sustain
Fig. 3. A, Repositioning appliance locking condyle into
anteroinferior position. B, Occlusal view of appliance with
indentations in acrylic.
reduces elevator muscle hyperactivity.4 It follows that a
splint with equal-intensity contacts on all of the teeth,
with immediate disclusion of all posterior teeth by the
anterior teeth and condylar guidance in all movements,
will relax the elevator and positioning muscles. The neu-
romuscular harmony that follows provides optimal
function and predictability to the system. The splint may
be thought of as an exquisitely balanced arch of teeth
that must function in a similar manner. The literature
reveals that very small (50 µm) occlusal interferences
can cause changes in coordinated muscle activity.5 The
more balanced and frictionless the splint, the better the
opportunity for reducing muscle hyperactivity. A muscle
that is fatigued through ongoing muscle hyperactivity
can present with pain. If the hyperactivity is stopped, the
pain caused by this activity usually will disappear.6
Occlusal splints are a means of reversibly altering the
occlusion to reduce masticatory muscle activity. Fuchs7
reported the advantages of splint therapy in the reduc-
tion of nocturnal EMG masseter activity in patients
with temporomandibular disorder (TMD). Beard and
Clayton8 also reported reductions in muscle symptoms
with splint therapy. Okeson et al9 found that acute or
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DYLINA
chronic symptoms of muscle hyperactivity were less-
ened significantly with 24-hour splint wear. The
effectiveness of splint therapy in reducing pain indexes
and muscle hyperactivity is well documented.10-13
Allowing the condyle to seat in centric
relation
No report on splints would be complete without an
understanding of the role of CR to the healthy sto-
matognathic system. The Glossary of Prosthodontic
Terms defines centric relation as “A clinically deter-
mined relationship of the mandible to the maxilla
their most superior position in the mandibular fossae
and against the distal slope of the articular emi-
nence.”14
For the condyle to completely seat under the disk in
this anterosuperior position, the lateral pterygoid must
completely relax because of its attachment to the disk
through the superior belly. If this muscle stays contract-
ed after hyperactivity, the disk will be pulled
anteromedially (along the direction of the muscle origin)
and will not seat completely over the condyle. When the
disk is loaded in a power bite or through parafunctional
activities, the disk, attached muscle, condylar head,
excess force loads and be damaged if the condyle/disk
assembly is not properly related to the fossa. Chronic and
acute overloading of the condyle/disk assembly when it
is out of its normal physiologic position contributes
greatly to the catch-all term temporomandibular disorder.
Temporomandibular joints are load bearing15-17 and
susceptible to overload. When splints were placed in
monkeys in one study, a lateral deviation from the CR
arc of closure resulted, as did bone density changes in
the condyles that were not found when CR splints were
used.18 This has led to cartilage breakdown and arthri-
tis in the condylar heads.19
Centric relation is the optimal arrangement of joint,
disk, and muscle. A person can function if the arrange-
ment is anterior to this position, but the condyle and
disk must be allowed by the dentition to return unim-
peded to perform their load-bearing function. This
position is consistently repeatable because of the
boney stop for the condyle/disk assembly as the
condyle hinges on its axis through the medial pole. It
is not muscle braced as would be the case if the
condyle/disk were down and forward against the
articular eminence. To maintain a mechanical advan-
tage, maximal clenching must be performed in this
position. Splint therapy must use CR as the ultimate
treatment position except in situations where inflam-
mation of the joint makes this position uncomfortable.
The patient may use his/her anteroinferior condylar
position until the inflammation subsides (approxi-
mately 7 days) and be reintroduced to the CR position
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before permanent changes in the muscle, disk, or sup-

porting tissues take place.
Providing diagnostic information
Splint therapy can be an important diagnostic tool to
determine wear patterns, bruxism habits, and TMD sta-
tus. Wear patterns that exist on the splint are
reintroduced into the natural dentition when the splint
is not worn. A horizontal “grazing” pattern would indi-
cate a different occlusal scheme than a vertical
“chopping” bite. Bruxism habits also leave their mark
on the surface of the hard acrylic resin splints. In a study
by Holmgren et al,20 indentations indicated isometric
clenching in 13% of subjects, bilateral mandibular
clenching in 71%, unilateral excursion in 13%, and pro- Fig. 4. Centric indentations and lateral excursive indents on
trusive movements in 3%. Information gained from splint in mouth less than 1 week.
wear patterns on splints helps determine occlusal con-
figurations, material choice, cusp heights and shapes,
guidance angulations, axial loads, the envelope of func-
tion, and the neutral zone (Fig. 4).
The anatomic and physiologic status of the joint also
can be evaluated in part by splint wear. If a patient
rapidly becomes comfortable with a splint, it may be an
indication that the disorder is muscular. If symptoms
worsen with permissive splint wear, this may indicate an
internal derangement (disk) problem (perhaps caused
by free reign of the condylar head back to the retrodis-
cal tissues without housing by the disk) or an error in
the initial diagnosis. In and of itself, this information
has limitations. However, with a thorough TMD and
occlusal examination, such information can be an
invaluable piece of the diagnostic puzzle.
Fig. 5. Heavier wear on posterior of splint. Marker used for
Protecting teeth and associated structures visualization.
from bruxism
A CR–balanced nocturnal permissive splint can pro-
tect teeth from extensive wear caused by
parafunctional activity (bruxism). Studies suggest that
bruxism exists in 6.5% to 88% of the population.21
Gibbs et al22 found that the highest recorded bite
force during bruxism was 975 lbs. and that bite
strength in some bruxer-clenchers can be as much as 6
times that of the nonbruxer. The average maximum
biting force measured during clenching is 162 lbs.23
This data indicates why the forces generated during
night activity can destroy the dentition. A splint not
balanced in CR will show increased localized wear
(usually in the posterior of the splint) (Fig. 5). The
sleeper’s attempt to get to CR (the most superior
bone-braced position) with the help of the elevator Fig. 6. Thick splint used to decrease muscle strength during
muscles is interrupted by the splint. bruxism.
Holmgren et al20 have shown that splints do not stop
bruxism but do redistribute the load borne by the teeth edge to incisal edge) to decrease clenching efficiency. A
and masticatory system. Their study duplicated the find- thick splint should be considered for chronic bruxers
ings of Gentz24 and Kydd and Daly.25 Piper26 with morning muscle pains (Fig. 6). Studies of pos-
recommended using a 12- to 15-mm-thick splint (incisal tural position11 tend to support Piper’s contention.

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Mitigating periodontal ligament
proprioception
Proprioceptive fibers contained in the periodontal
ligaments of each tooth send nerve messages to the
central nervous system. They indicate the amount of
force on individual teeth and can trigger muscle pat-
terns to protect teeth from overload. A splint can
balance proprioception and even lessen it to mitigate
proprioceptive output. Hellsing27 has shown experi-
mentally how muscle changes immediately with tooth
contact and that periodontal afferent feedback (propri-
oception) must be responsible for this rapid adaptation.
Hannam et al28 also found that in cats, stimulation of
pressure receptors in the periodontal membrane led to
a jaw-opening reflex. This helps clarify why the teeth
must be kept in balance with the condyle/disk assem-
bly to maintain neuromuscular harmony in the
associated muscles.
Reducing cellular hypoxia levels
In a study by Nitzan,29 pressure was measured in
the superior joint space of patients with articular disk
displacements. When they clenched maximally, record-
ed pressures reached up to 200 mm Hg. When a flat
plane appliance was placed, no significant pressure (no
capillary hyperfusion pressure) was recorded. This
lends credence to stabilization splint therapy from a
molecular point of view.
SPLINT CHARACTERISTICS
The characteristics of a successful splint should
include stability; balance in CR; equal intensity stops
on all teeth; immediate posterior disclusion; a “skating
rink” surface; smooth transitions in lateral, protrusive,
and extended lateral excursions (crossover); comfort
during wear; and reasonable esthetics. Patient compli-
ance also contributes to splint success.
A splint that moves in the mouth cannot provide
the stability necessary for a definitive, immobile sur-
face prepared for heavy forces from all directions. The
laboratory must fabricate a splint so that it comes on
and off with a slight undercut to ensure a firm fit. The
patient should feel no sense of tightness on any of the
teeth when the splint is seated; if that is not the case,
tooth hypersensitivity usually will follow. The length of
the splint on the lingual and buccal is dependent on
the need for retention as a result of tooth size and
shape. The shorter and thinner the splint is on the lin-
gual, the better the patient compliance, the more
distinct the speech, and the more comfortable the
tongue posture will be. The buccal flanges must be
thick enough to be strong but not impinge on the
neutral zones. Thinness can create discomfort or lip
“trapping.”
Fabrication in a hard, heat-polymerized acrylic
542
DYLINA
resin will facilitate the establishment and adjustment
of contact points. Orthodontic acrylic resin is user-
friendly, easy to adjust, and soft enough not to
hyperactivate periodontal ligaments. It also can be
polished to a high luster for a low-friction surface.
Methyl methacrylates are relatively easy to work with
but maintain a strong odor and exhibit a granular
composition that is harder to polish and adjust. The
soft rubber resilient materials used for sports guards
possess none of the characteristics important to
splint therapy and have no effective use in this arena.
The literature has shown that they may even increase
bruxism. 30 Hydrostatic “pseudo” splints work to
separate the teeth and reduce muscle hyperactivity
for short periods while full-coverage splints are
being fabricated. Long-term use of the former is not
recommended. Ultra splint resin (Astron Dental
Products, Lake Zurich, Ill.) is suggested for patients
with allergies to orthodontic acrylic resins.
The laboratory needs explicit instructions for the
fabrication of any intraoral appliance. Maxillary and
mandibular appliances have completely different
designs, though they function the same. All teeth
contact in CR on a maxillary appliance. A mandibu-
lar appliance often will have cuspid-to-cuspid
contact in CR, with the maxillary anterior teeth not
touching. Many TMD patients have a significant
horizontal overlap; to extend the mandibular acrylic
resin to contact the maxillary teeth would be
unsightly, physically uncomfortable, and unneces-
sary. Since the oral cavity is a dynamic system and
the movement of the jaw is nearly always forward,
the anterior teeth will be in constant contact
with the splint. This area must be balanced by hav-
ing the patient move in protrusive, lateral, and
mediolateral movements, marking the areas, and
establishing anterior guidance principles already
mentioned.
Mandibular appliances are the popular choice for
active patients who wear splints 24 hours per day, as
they do not show or affect speech as much as maxil-
lary appliances. On the other hand, the maxillary
appliance is an attractive choice for night wear, as all
of the teeth are in contact with equal intensity, and
the 13% of the population that bruxes isometrically
will have these forces more equally balanced. Other
reasons for the choice of one arch over the other
include arch irregularities, the patient’s profession,
and the potential for gagging. It is appropriate for
the patient to have a mandibular appliance for day
wear and a maxillary appliance for the night (Fig. 7).
Twenty-four–hour splint wear is recommended
because of the forces generated when teeth come
together during swallowing and chewing.
Swallowing forces exceed chewing forces,23 occur
approximately 2000 times per day, and happen all
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day. If possible, the splint should be worn when the

patient eats.
Anterior repositioning splints were originally
designed to “recapture” the disks by protruding the
mandibular jaw forward until the condyle popped
back on the disk and “locked” it into position.
Although the disk may have been temporarily better
aligned with the condyle out of the fossa, the physi-
ologic parameters necessary for the functioning of
the lateral pterygoids and the retrodiscal tissues (vas-
cular knee) were not addressed. Clark31 found good
clinical success with this modality, and Anderson et
al32 even suggested its superiority to flat plane appli- A
ances. Longer studies by Lundh and Westesson 33
have shown that the clicking that initially stopped
with these appliances returned in a large percentage
of the patients, which indicates that the intended
function of anterior repositioning splints was not
accomplished. In patients who did not experience
further clicking, the disk may have been permanent-
ly pushed out to the side on the lateral pole instead
of recapturing the disk.
Success in alleviating pain with these appliances can
be impressive, but it also can be explained. If the jaw
is brought down and forward, the condyle will not
impinge on the inflamed retrodiscal tissues, which are B
a major source of pain. Anterior repositioning splints
may be a valid treatment for short-term use (no more Fig. 7. A, Maxillary stabilization appliance for night wear.
than 10 days) in trauma cases when stabilization splints B, Mandibular splint for day wear.
tend to increase pain by allowing the condyle free
access to inflamed tissues in the retrodiscal area.
However, anterior repositioning splints tend to intro-
duce posterior open bites in long-term wearers (when
the appliance does not cover the anterior teeth), and
heroic orthodontics or restorative dentistry is required
to close the teeth into their new anteroinferior muscle-
braced position (Fig. 8). One would have to discount
the anatomic and physiologic principles of the masti-
catory system to believe that an anterior repositioning
appliance should be a standard modality for TMD dis-
orders of any kind (other than acute short-term
trauma).
CHOOSING THE CORRECT SPLINT
Determination of the appropriate type of splint therapy
depends on the specific diagnosis of the temporo- Fig. 8. Posterior open occlusion developed after anterior
mandibular disorder and a thorough understanding of the repositioning appliance was worn for 7 years.
anatomy of the condyle/disk complex.
Muscle incoordination is determined by muscle pal-
pation, joint loading, range-of-motion measurements, is reversible if caught in time and treated with bite
joint palpation, occlusal evaluation, and Doppler plane therapy or permissive splint therapy in Phase I
diagnosis. Patients present with painful symptoms in (reversible treatment) and with appropriate Phase II
the facial muscles, headaches, limited ranges of therapy (additive or subtractive occlusal therapy,
motion, frequent joint inflammation, and occlusal restorative dentistry, orthodontics, maxillofacial
interferences to CR; infrequent clicking on jaw move- surgery, and segmental alveolar surgery) to restore
ment also may be present. This anatomic asymmetry balance from/to the CR position.

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Muscle and disk incoordination has the same signs
and symptoms as muscle incoordination except recip-
rocal clicking or a history of reciprocal clicking that
stops. Diagnosis may include sagittally corrected
tomograms. Patients often present with the medial
pole of the condyle intact under the disk with the lat-
eral pole of the disk damaged from loading or
stretching and subsequent ligament laxity. Most symp-
toms may be reversible if caught in time, though the
reversibility of clicking depends on the shape of the
distorted disk and the fibrosis of the lateral pterygoid
muscle. Treatment usually includes permissive splint
therapy and Phase II therapy for stabilization because
of the weak ligament structure.
With advanced muscle and disk incoordination,
symptoms may be the same as in previous stages,
though jaw locking, painful joint noises, and increases
in pain with splint therapy may be evident. These
patients often have a long history of joint noises with-
out pain that have become painful. Pain on loading
with bimanual manipulation is evident and may be
extreme. Diagnostic techniques include sagittally cor-
rected tomograms and magnetic resonance images.
Surgical intervention may be necessary depending on
the location and degree of displacement of the disk.
These stages are irreversible but may be managed to a
pain-free state with appropriate medications, splint
therapy, and Phase II therapy.
SPLINT DESIGN WITH FUNCTIONAL
CONSIDERATIONS
Understanding the function of the masticatory sys-
tem provides an excellent basis for splint design. A set
of teeth (the splint) is needed that has equal intensity
contact on all the teeth, provides immediate posterior
disclusion by the anterior teeth and condylar guidance,
and is as frictionless as possible for neuromuscular har-
mony and subsequent healing. The stabilization splint
meets these needs.1 It can be placed on either arch as
long as the basic requirements are met. The splint
must allow the condyle to achieve the CR position.
This can be achieved with bimanual manipulation,
which was fostered by Dawson34 and has proven to be
the most reliable and repeatable35 method for achiev-
ing CR with inexperienced practitioners.
A stabilization splint is not unique if the teeth
and/or inflammation result in an incomplete condylar
seating. The splint could be considered a set of teeth
with occlusal interferences. Therefore, the splint must
be continually monitored and adjusted. When the
muscle relaxes and/or inflammation subsides, the
position of the teeth on the splint changes. When
readjustment on the splint to the CR position is
accomplished, the teeth and condyle/disk assembly
achieve neuromuscular harmony. This explains why
patients feel some initial relief from almost anything
544
DYLINA
put in their mouths yet stop improving after the initial
1 to 2 weeks. If the interferences on the splint are con-
tinually chased by rebalancing into CR, the patient will
grow comfortable and stay that way. The more skilled
the practitioner becomes with this balance and timing,
the more rapidly the patient can progress. The tech-
nique inevitably works; however, lack of attention to
detail or the skill level of the doctor may influence suc-
cess.
In a study by Holmgren et al,20 changes were seen
on the splint (in the form of indents) in 61% of
patients at every 2-week evaluation. The remaining
39% of the patient pool experienced changes from
time to time. The majority of splint wearers need to be
seen more often than every 2 weeks for initial adjust-
ments. A suggested protocol would include adjustments
at 24 hours, 54 hours, 7 days, 2 weeks, and 1 month
after seating. When no movement on the splint is seen
at adjustment appointments and symptoms are
reduced, the intervals between adjustments can be
extended as long as any reversal of symptoms is coun-
tered with an immediate adjustment appointment.
After 3 months with no changes on the splint, a com-
fortable musculature, and no pain on loading, the
patient is ready for evaluation of phase II therapy.
SPLINT FABRICATION
Practitioners beginning a career in treating bruxers
or TMD patients may become frustrated while trying
to seat a new splint in a reasonable period of time.
Laboratories often provide a prosthesis from a maxi-
mum intercuspation (MI) occlusion that presents high
on the distal of the splint and ends up having a hole
ground all the way through the acrylic resin in an
attempt to balance the occlusal relation. Without an
accurate CR occlusal record, accurate models of all
occluding surfaces, and a reliable face-bow transfer,
seating time will be longer and occasionally impossible
because of excessive or inadequate acrylic resin. With
precise laboratory instruction and records, seating and
adjusting should take no longer than 10 minutes. In-
house fabrication allows the practitioner to quickly and
efficiently develop the prosthesis that the diagnosis
demands. If this is not possible, precise communica-
tion with a commercial dental laboratory is necessary
to provide the quality prosthesis mandatory for treat-
ment success.
WHAT SPLINTS CANNOT DO
Splints cannot do 3 basic things: unload the joint,
prevent bruxism, or “heal” the patient. Some authors
and lecturers have stated that splints function to
unload the joints and therefore take pressure off the
disk. This theory has been disproved by Kuboki et al36
and cannot be explained anatomically or physiological-
ly. The elevator muscles are located behind the most
VOLUME 86 NUMBER 5
DYLINA
posterior tooth and therefore ensure that the joint will
always be loaded when the elevators contract. The
unloading theory is probably used to protect the valid-
ity of splint designs that are ineffective in their
theorized function. Such splints open the vertical
dimension and minimally decompress the condylar
head when not loaded to reduce superior tissue pres-
sures. They also may increase temporomandibular
joint loading37 that results from greater maximum
muscle efficiency.
Splints do not prevent bruxism; they balance the
force distribution to the entire masticatory system.
They can decrease the frequency but not the intensity
of bruxing episodes.20 Splints also do not heal
patients; they give patients the opportunity to heal
themselves. The patient pays not for the fabrication of
a splint only but also for the care, skill, and judgment
of the practitioner whose goal is to enable healing
through appropriate design, monitoring, and adjust-
ment.
SUMMARY
There is sufficient credible literature to support the
use of splint therapy to reinstitute neuromuscular har-
mony in a compromised masticatory system. Dental
practitioners have a responsibility to understand and
provide this treatment, monitor the condition, and
refer the patient to another practitioner if necessary.
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