Occlusal Splint Design & Fabrication

Charles J. Arcoria, DDS, MBA

Materials & Issues

Should we use hard acrylic or soft rubber?
Crystal Clear from OrthoSource

Understand the importance of Splint design regarding the development of occlusion Potential stimulation of the PDL Control, and lack of control, regarding the vertical dimension using soft acrylic

Soft Athletic Mouthguard

This is not an effective Occlusal Splint

Construction of the Splint in the Maxillary or Mandibular Arch?

Generally, either design is acceptable Other considerations regarding arch placement:
Timing of patients pain Stability, missing teeth Speech Eating Comfort

General Goals of Splint Therapy

To decrease pain and increase range of motion
A baseline should be established at the initial exam

Can the patient close firmly into maximum intercuspation without pain?
Can the muscles relax? Is there the potential for decreased pressure within the joint apparatus?

If your splint stops bruxism, you just got lucky.

- Bruxism reduction is never a treatment goal

Designed primarily as a diagnostic tool

Splint Design
Stabilization
Relax muscles, change point of pressure within the joint apparatus, protect the teeth and existing restorations Typically, a splint is the long-term design to which you should lead the patient

Anterior Bite Plane Splint (NTI) Anterior Positioning Splint Pivoting Splint

Stabilization Appliance
Treatment of muscle pain This splint is sometimes beneficial for joint pain Can be fabricated for either the maxillary or mandibular arch Guides the patient and the practitioner to an orthopedically stable joint position Ideal for long-term wear

Stabilization Appliance
Posterior tooth contacts should be heaviest Anterior tooth contacts lighter (primarily passive) Extra placement of acrylic at the lateral-facial and anterior-facial of the canines will provide for disocclusion of posterior teeth Centric contacts for all teeth are on a flat surface without any incline contact Anterior guidance occurs during all excursive movements

Stabilization Appliance
Determining the appropriate amount of Vertical Dimension Muscle soreness
Change muscle working length Avoid grinding through

Disc dislocation or displacement Posterior tooth contacts at centric relation position Presence of plunging cusps from maxillary molars Ability to achieve anterior guidance Open articulator just enough to break the occlusal plane

Four Types of Permissive Splints

A = anterior bite plane B = molar contacting point C = flat plane, stabilization device D = flat plane, anterior open bite

Anterior Bite Plane Splint

Anterior Bite Plane (NTI)

Contact occurs only at maxillary and mandibular central incisors Intended to separate posterior teeth and eliminate their influence on TMD symptoms This is best designed and suited for the maxillary arch Patient needs to be observed very closely to prevent super-eruption of posterior teeth

Anterior Bite Plane (NTI)

Overused by many practitioners, because it is easy to design and construct Works for muscle soreness approximately 80% of the time For some patients, it does not decrease muscle activity

Anterior Bite Plane (NTI)

Short-term use only
Must convert these patients to having a stabilization appliance placed

Supereruption of posterior teeth Patients will exhibit joint loading and pressure Sore incisors are probable

Anterior Positioning Appliance

To temporarily move mandible anterior to the maximum intercuspation position To treat an articular disc derangement which will comfortably and reliably reduce Allows for slow adaptation of retrodiscal tissues. Eventually, the patient must be converted to a stabilization appliance

Anterior Positioning Appliance

Unfortunately, the data shows that it will not permanently realign a displaced articular disc A side effect of this splint is the potential shortening of lateral pterygoid muscle fibers

Pivoting Appliance
Suitable for treating unilateral disc displacement without reduction Allows for healing of retrodiscal tissues Will not improve the condyle/disc relationship For short-term use only; patient should be converted to a stabilization appliance as soon as possible

8 7 6

2 3 4

Contralateral Loading Test Joint Pressure Determination

Having the patient bite with a tongue blade on their right side will load the left TMJ, and vice versa.

Pivoting Appliance
Unilateral pivot Strategically placed contact on posterior portion of the splint

Suitable for treating unilateral disc displacement without reduction Allows for healing of retrodiscal tissues Will not improve condyle/disc relationship Short-term use only, convert to stabilization appliance

Stabilization Appliance
Main issues to consider
All mandibular facial cusps should contact the maxillary splint in an even manner The established plane should be as flat as possible The incisal pin should be contacting the table The red arrows indicate anterior guidance

Improper Posterior Contact Removal

Flat Plane Reduction on Posterior portion of the Splint

Building the Anterior Segment

Add acrylic to the anterior portion in 2 stages: 1) to achieve passive centric contacts, and 2) to create anterior ramp.

Building the Anterior Segment

Protrusive guidance should be even, symmetrical, bilateral. Ramps just steep enough to disocclude the posterior teeth.

Building the Anterior Segment

Make the anterior guidance as smooth as possible. There should not be a bump as the patient attempts to move anteriorly or laterally.

Steps in Fabricating Anterior Bite Plane

A = embed mandibular anterior teeth into acrylic B = examine lingual and facial areas to remove C = trim lingual flange, then decrease the steepness of the facial ramp D = centric contact seen with excursive ramp

Acrylic prominence at Canine level

Height of canine ramp is not obtrusive

Canine Disocclusion during mandibular left lateral movement

No posterior tooth contact should be evident

Laterotrusive and Protrusive Contacting Guidances Initial

Incomplete protrusive and lateral excursion Contact may be evident on a posterior tooth

Laterotrusive and Protrusive Contacting Guidances Final

Right Side of Splint Occlusal Contacts

P = Protrusive LT = Laterotrusive contact CR = Contacts in MI MT = Mediotrusive contact

Common Problems During Splint Fabrication

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Distortion is present, especially if the cold-cure splint is fabricated as one solid unit (posterior and anterior at the same time) Your appliance is too thin on the occlusal surface, leading to perforations and fractures. The appliance is seldom too thick on the occlusal surface. Flat enough? Most splints have too many wells that allow for the mandibular facial cusps to sit in a key-and-lock fit Inadequate palatal coverage, eventually causing posterior fracture Inadequate thickness of the facial perimeter, causing posterior splint fracture Inadequate anterior guidance. It is rare to have too great of an anterior guidance ramp, but this can be alleviated with some trimming

Communication
Information given to the patient before any treatment begins will help to define patient expectations.
Always impress upon the patients that this is not a cure (it is self-limiting treatment) feeling better? Discern their improvement levels patient compliance. They must have it in the mouth for it to work referral additional care

Finish and Polish Procedure

5. Finish perimeter

6. Exo-wheel

8. Acrilustre

7. Pumice

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Be careful lifting the splint from the cast to prevent fracture and/or distortion

Submitting the Final Product

Splints should be cleaned and scrubbed Deliver in a bag of plastic box for the patient to take home

Finished Splint with Contacts

Splint Delivery Appointment

Patient positioning (slightly supine position) Stable fit
Discern any warpage or distortion Should have a retentive, yet passive fit
Ball clasps may be placed in the acrylic to increase retentiveness

Reline of a loose splint

Protect composite resins during reline Usually, not very successful. Best to remake splint

Splint Delivery Appointment

Occlusion First, establish tooth contacts in centric closure
all posterior teeth must contact evenly Contacts must occur on the flat posterior surfaces posterior contacts should be predominant

Splint Delivery Appointment

Second, check the lateral excursions Third, check the protrusive excursion Finally, comfort should be increased when closing on a well-designed splint

Patient Follow-up
Re-evaluate all splint patients at 2-7 Days
Ask patient about pain Muscle palpation Occlusion on splint Thereafter, reappoint in accordance with pain level If no pain, then every 2 weeks until occlusion is stabilized

Guidelines regarding length of treatment

Characterize muscle pain Protection of restorations Identification of clenching or bruxism

Typical Treatment Time

Muscle Soreness
8 hours per day Muscle problems should resolve in 2-3 weeks Decrease wear as patient becomes symptom-free

Joint Problems
8-16 hours per day Joint problems take longer, typically 3-6 months May decrease wear somewhat as patient becomes symptomfree

Patient Follow-up
May decrease wear time with joint problems, depending on the goal:
Inflammed retrodiscal tissue Disc displacement

Why do some patients grind through their splints?

The splint is too thin at delivery Incorrect acrylic material used Bruxism patient

Why do splints work?

Occlusion is stabilized Condyles are stabilized Vertical dimension is increased Patient awareness Placebo effect Regression to the mean

Splint Design & Fabrication

The End