OCCLUSAL SPLINTS

Presented by:
Guided by:
Dr. SHILPA JAIN Anubhuti Dubey
MDS 3rd Year
 CONTENTS
 Introduction
 Requirements of an Ideal Splint
 Indications and Contraindications of Splints
 Functions of splints
 Goals of occlusal splint therapy
 Classification of splints
 Permissive splints
 How Permissive splint work?

2
 Anterior Deprogramming splints
 Abuse of Anterior Deprogramming splints
 Fabrication of splints
 Upper v/s lower splints
 Principles of full occlusal splint design
 Directive splints
 Superior repositioning splints
 Anterior bite plane
 Posterior bite plane
 Pivoting appliance
3
 Soft or resilient appliance
 Flat plane stabilization appliance
 Kois deprogrammer
 Hydrostatic appliance
 Splints materials
 Common treatment considerations of appliances therapy
 Conclusion
 References

4
 INTRODUCTION
 Treatment of occlusal-related disorders is often a challenge for both
the dentist and the patient. These disorders are often difficult to
diagnose, as the presenting symptoms can be variable. Occlusal
splint design and function can be considered an example of the art
and science of dentistry.

 Once the cause of occlusal-related disorders is identified, this

reversible, non-invasive therapy provides both diagnostic
information and relief without the problems that often accompany
other approaches to care, i.e., surgery and extended drug.

5
 Occlusal splints are defined as “Any removable artificial occlusal
surface affecting the relationship of the mandible to the maxilla
used for diagnosis or therapy; uses of this device may include, but
are not limited to, occlusal stabilization for treatment of
temporomandibular disorders, diagnostic overlay prior to extensive
intervention, radiation therapy, occlusal positioning and prevention
of wear of the dentition or damage to brittle restorative materials
such as dental porcelain. ” – GPT 9

6
 Traumatize tooth
during
application

Neither damage
Fulfill aesthetic
gingiva nor to
demand
caries

Requirements of Ideal splint

Interfere with
Interfere with
endodontic
occlusion
treatment
7
INDICATIONS
 Interfere with (or prevent the development of) abnormal orofacial
habits

 TMJ disorders

 Retention following orthodontic treatment

 Adjunct to fixed orthodontic appliances

8
INDICATIONS
 For treatment of dento-alveolar and mandibular fractures.

 To stabilize moderate to advanced tooth mobility that cannot

be used by any other means.

 To stabilize teeth after acute dental trauma.

Example; Subluxation

9
CONTRAINDICATIONS
 Insufficient number of firm or sufficiently firm teeth to stabilize
mobile teeth.

 Prior occlusal adjustment cannot be done on teeth with occlusal

trauma or occlusal interference.

 Patients who do not maintain good oral hygiene.

10
 FUNCTIONS OF SPLINT

Properly fabricated splints have at least 6 functions, including the

following:

1. Relaxing the muscles- Tooth interferences to CR or in excursion

cause muscle hyperactivity and myalgia which is relieved by splint.

2. Allowing the condyle to seat in CR: For the condyle to properly seat
the SLP should be relaxed. If it is hyperactive, the disc is pulled
anteromedially and there is overloading of joint and leads to TMD.

11
4. Protecting teeth and associated structures.

5. Mitigates PDL 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 patterns to protect teeth from overload. A splint can balance
proprioception and even lessen it to mitigate proprioceptive output.

12
6. Reducing cellular hypoxia levels - In a study by Nitzan,
pressure was measured in the superior joint space of patients with
articular disk displacements. When they clenched maximally,
recorded 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.

13
GOALS OF OCCLUSAL SPLINT THERAPY

1. To protect the TMJ discs from dysfunctional forces, which

may lead to perforations or permanent displacements.

2. To improve jaw muscle function and to relieve associated

pain by creating stable balanced occlusion.

14
What Occlusal Splints Do?

 Stabilization of weak teeth: An occlusal splint can effectively stabilize weak

or hypermobile teeth by the adaptation of the splint material around the
axial surfaces.

 Distribution of occlusal forces

 Reduction of wear

 Stabilization of unopposed teeth

15
 Alteration of the dental occlusion

 Reduction of muscle contraction and associated forces

 Repositioning of the TMJ

 Splints are effective in reducing musculoskeletal pain (myalgia,

myofascial Pain, osteoarthritis and systemic arthritis (RA)

16
 What Occlusal Splints Cannot Do?

 Occlusal splint does not unload the

condyles. They cannot cause effects that
are in violation of mechanical laws. The
popular claim that a posterior occlusal
splint serves as a pivot for the distraction
of the condyles is in violation of facts of
anatomy, laws of physics, and clinical
data.

17
CLASSIFICATION
According to Okeson

Other types:
1. Orthopedic repositioning 3. Soft/resilient appliance
appliance/anterior repositioning
appliances
4. Anterior bite plane
2. Stabilization appliance which
reduces muscle activity/ muscle 5. Pivoting appliance
relaxation appliance.

18
 According to Dawson:

 1. Muscle deprogrammer or permissive splints

 2. Directive splints or non-permissive splints

 3. Pseudo permissive splints, for example, soft splints.

19
20
arch as long as it frees the mandible to slide to centric relation.
The smooth surface can face either the lower arch or the upper
• the condyles can slide back and
up the eminentiae to complete
seating into centric relation.
• have a smooth surface on one
side
• allows the muscles to move the
mandible without interference
PERMISSIVE OCCLUSAL SPLINTS
 DIRECTIVE OCCLUSAL SPLINTS

 Direct the lower arch into a specific

occlusal relationship that in turn directs
the condyles to a predetermined position.

 Directive splints have very limited use.

They should be reserved for specific
conditions involving intracapsular TMDs.

21
 HOW PERMISSIVE OCCLUSAL SPLINTS WORK

 Most occlusal splints have one primary function: to alter an

occlusion so it does not interfere with complete seating of the
condyles.

 This can be accomplished by separation of all posterior teeth,

allowing only anterior tooth contact against a smooth flat surface, or
by allowing any segment or all of the occlusal surfaces to freely slide
against a smooth surface.

22
 As long as the temporomandibular joints (TMJs) are intact and able
to comfortably accept loading, any device that permits complete
seating of the condyles during clench closure of the mandible will
effectively eliminate the need for lateral pterygoid resistance to the
elevator muscles.

 This release of lateral pterygoid contraction is the point at which

relief of the discomfort is affected.

23
 ANTERIOR DEPROGRAMMING SPLINTS

 It is the simplest type of permissive splint.

 If there are no intracapsular structural disorders in the TMJs, a

correctly made deprogramming splint is close to 100 percent
effective in getting patients comfortable, usually within minutes or
hours.

24
ANTERIOR DEPROGRAMMERS

 It is a hard acrylic appliance worn over the maxillary teeth

providing contact only with the mandibular anterior teeth.

 It is primarily intended to disengage the posterior teeth.

 By disengaging, it eliminates the influence on the function of the

masticatory system.

25
An occlusal interference such as a high crown or deflective tooth permissive (smooth) anterior splint separates the interfering molar from
incline activates muscle hyperactivity. Pain is often focused in the contact, thus permitting the condyle-disk assemblies to seat up into centric
masticatory muscles to give the impression of a TMD. A high per relation. This eliminates the trigger for muscle activity and allows the inferior
centage of misdiagnosed TMDs are occluso-muscle disorders that lateral pterygoid muscle to release. Peaceful, comfortable muscle activity
are readily resolvable. resumes quickly. Complete separation of posterior teeth actually causes most
of the elevator muscles to completely release contraction.

26
 INDICATIONS

 Muscle disorders related to

orthopedic instability or an acute
change in the occlusal condition.

27
DISADVANTAGES

 If the appliance is worn continuously for several weeks or

months, there is a great likelihood that the unopposed
mandibular posterior teeth will supraerupted and the result
will be an anterior open-bite.

 Hence, therapy must be closely monitored and used only for

short periods.

28
 LUCIA JIG

 It promotes neuromuscular reprogramming of the masticatory

system and allows the stabilization of the mandible without the
interference of dental contacts, maintaining the mandible position
in harmonic condition with the musculature in normal subjects or
in patients with temporomandibular dysfunction.

 It makes jaw manipulation easier and provides relaxation of

muscles.

 Indications: - Deprogramming of muscles in full mouth

rehabilitation cases. 29
ABUSE OF ANTERIOR DEPROGRAMMING SPLINTS

 Failure to recognize the simple permissive action of anterior

deprogramming splints has led to overuse of flat anterior devices as
a substitute for correction of occlusal interferences.

 Dentists should recognize that such devices can be an important aid

in diagnosis of orofacial pain, migraine headaches, and other
masticatory system pains; but such devices are not treatment
devices as much as they are diagnostic devices.

30
 They are very effective in diagnosing whether deflective occlusal
interferences are the cause of occluso-muscle pain.

 Using such devices as treatment over an extended time period may

cause intrusion of the covered teeth and supraeruption of the
separated teeth. The same is true of any segmental occlusal
appliance.

31
 FABRICATION OF OCCLUSAL SPLINTS

 Many occlusal splints fail to achieve a peaceful neuromusculature. Three very

common reasons for this are:

1. The splint does not fit the teeth properly, so it is uncomfortable or loose, or it
rocks in place.
2. The occlusal contacts on the splint are not in harmony with centric relation.
By far, most of the occlusal splints have occlusal interferences to centric relation
and/or excursions, so they cause displacement of the TMJs and a resultant
stimulus to muscle activity rather than a reduction of muscle activity.
3. An intracapsular structural disorder was not diagnosed, so centric relation
was not achievable.
32
Take a verified centric relation bite
record.

Mount the casts in centric relation with a

facebow.

Outline the coverage area of the base.

33
Fabricate a Biostar vinyl base on the cast

34
Remove the excess from the base, but do not
remove it from the cast.

Put the cast and base back on the articulator.

Open the pin enough to separate all posterior
teeth from any contact with the base.
Because the casts were mounted with a
facebow, this change of vertical dimension
does not affect centric relation.

35
Mix resin (A) and position it on the base just
behind the upper an terior teeth. Put enough
resin to contact and be slightly indented by the
lower anterior teeth in centric relation.

B, Allow the resin to set. Flatten the resin down to

the level of the incisor indentations. This surface
must be smooth and polished for equal contact of
the lower incisors against the resin surface

(C). The canines may also contact.

36
Remove the base and smooth the edges.
Remove undercuts into interproximal areas.

The completed splint should fit perfectly and

require almost no adjustment.

If done carefully, this indirect method saves a

serious amount of chair time.
37
38
UPPER OR LOWER SPLINT?
 upper splint  lower splint
 More stable and covers more tissue.  Easier for the patient to speak with it in
 More retentive and less likely to break. place.
 More versatile, allowing opposing  More aesthetic.
contacts to be achieved in all skeletal and
molar relationships.
 Helps to locate the MS relationship of the
condyles in the fossae.

39
 PRINCIPLES OF FULL OCCLUSAL SPLINT DESIGN
 The design must incorporate four main principles:

 1. The splint should allow uniform, equal-intensity contacts of all teeth

against a smooth splint surface when the joints are completely seated in
centric relation.
 2. The splint should have an anterior guidance ramp angled as shallow as
possible for horizontal freedom of mandibular movement.
 3. The splint should provide immediate disclusion of all posterior teeth in all
excursive jaw movements from centric relation.
 4. The splint should fit the arch comfortably and have good stable retention.

40
HOW LONG MUST THE SPLINT BE WORN?
 The splint should be worn until the following requirements are
attained:

 1. All related pain is gone.

 2. The joint structure is stable.
 3. The bite structure is stable.

 All three of these requirements are related to perfection of the

occlusion.

41
 Depending on how much remodeling of the TMJs must occur, the
occlusion will require follow-up adjustments until the joints
stabilize.

 At that point, it will be evident because further occlusal corrections

will become unnecessary.

 Occlusal splints for therapy must be worn 24 hours a day except to

eat and brush until the occlusion and the TMJs become stable.

42
 Stability is determined by three verifications:

 1. Elimination of painful symptoms

 2. Verification of centric relation by load testing
 3. Stability of the bite on the splint over the course of a few days (or
weeks if joint damage has occurred).

 For occluso-muscle disorders, these results are usually achieved in

a matter of days (not months or years). The average length of splint
therapy for occluso-muscle disorders is two to four weeks to
achieve a stable occlusion.

43
WHAT IS THE NEXT STEP AFTER OCCLUSAL SPLINT
THERAPY?

 Successful splint therapy achieves a correct, stable position for the

TMJs. It is not a cure for the occlusal disharmony.

 The common practice of removing the splint without correcting the

occlusion is counterproductive, as the original cause of the problem
is still present.

 In time, the uncorrected occlusal interferences will reactivate the

problems. The proper next step is to correct the occlusion when the
occlusal splint is discarded.
44
SUPERIOR REPOSITIONING SPLINT (SRS)

 a srs splint is a full arch hard acrylic appliance.

 Interocclusal appliance that provides an occlusal relationship in the

masticatory system that is considered optimal.

 the teeth are contacting simultaneously and musculoskeletally; the

condyles will be in their most stable position.

45
 There is canine disocclusion of posterior teeth during eccentric
movement.

 It can be given in both the arches, but maxillary arch provides more
stability.

 The SRS is a full coverage splint, and it incorporates a full occlusal

scheme with incisal guidance.

 The anterior inter-occlusal acrylic is balanced to allow lateral and

protrusive movements with incisal guidance.
46
INDICATIONS

 Muscle hyperactivity,

 myospasms or myositis and

 parafunctional activity associated with increased level of emotional

stress.

47
FABRICATING THE APPLIANCE

 The fabrication of a maxillary occlusal appliance involves several

steps:

 1. An alginate impression is made of the maxillary arch. This should

be free of bubbles and voids on the teeth and palate.

 poured immediately with a suitable gypsum product (preferably

die stone).

 When the stone is adequately set, the cast is withdrawn from the
impression.
48
49
50
 Anterior contact marked & observed to
Contact of lower incisors only on anterior stop
be flat and perpendicular to long axis of
mand. incisor

51
Autocuring acrylic is added to the occluding surface of the appliance. B, All occluding areas except the
contact on the anterior stop have bee covered. The setting acrylic is dried with an air syringe and the rinsed
in warm water before it is placed in the patient's mouth.

52
A, The appliance with the setting acrylic is placed in the mouth
and the mandible is closed into centric relation on the anterior
stop.

B, Once the mandibular teeth have made impressions in the

setting acrylic, the appliance is immediately taken out of the
mouth and allowed to set completely on the counter. All the
mandibular teeth have made impressions in the setting acrylic.

53
ADJUSTING THE CR CONTACTS

 Mark with pencil the deepest area of each mandibular buccal cusp
tip and incisal edge

 The acrylic surrounding the pencil marks is removed so that the flat
occlusal surface allows for freedom in eccentric movements

 Anterior and posterior contacts should be carefully refined so that

they will occur on flat surfaces and occlusal forces are equalized.

54
55
56
ADJUSTING THE ECCENTRIC GUIDANCE

 The acrylic prominences labial to the mandibular canines is

smoothed.

 They should exhibit about a 30-45° angulation to the occlusal plane

and allow the canines to pass over in a smooth and continuous
manner during protrusive and laterotrusive excursions.

 Mandibular canines should move freely and smoothly over the

occlusal surface of the appliance.

57
58
59
60
CRITERIA FOR THE MUSCLE RELAXATION
APPLIANCE
 The following eight criteria must be achieved before the patient is
given the muscle relaxation appliance:

 1. In CR, all posterior mandibular buccal cusps must contact on flat

surfaces with even force

 2. It must accurately fit the maxillary teeth, with total stability and
retention when contacting the mandibular teeth and when checked by
digital palpation

 3. During any lateral movement, only the mandibular canine should

exhibit laterotrusive contact on the appliance 61
 4. During protrusive movements, the mandibular canines must contact the appliance
with even force. The mandibular incisors may also contact it but with less force than
the canines.

 5. There should be no imprints of mandibular cusps on the occlusal surface of the

appliance. Surface should be flat

 6. Only in the CR closure, the mandibular posterior teeth must contact the appliance

 7. Posterior teeth must contact the appliance more prominently than the anterior
teeth during the alert feeding position

 8. The appliance should be polished so that it will not irritate any adjacent soft tissues .

62
 INSTRUCTIONS AND ADJUSTMENTS

 The patient is instructed in proper insertion and removal of the

appliance.

 When bruxism is the problem night time use is essential, while day
use may not be as important.

 When the disorder is retrodiscitis, the appliance may need to be

worn most of the time.

63
 It has been demonstrated that myogenous pain disorders respond best to
part-time use (especially night time use) while intracapsular disorders
are better managed with continuous use.

 If wearing causes increased pain, the patient should discontinue wearing

and report the problem immediately for evaluation and correction.

 On certain occasions fabrication of a mandibular muscle relaxation

appliance may be desirable. Evidence suggests that maxillary and
mandibular appliances reduce symptoms equally.

 The primary advantages of the mandibular type are that it affects speech
less and esthetics may be better.

64
 ANTERIOR REPOSITIONING SPLINTS

 An interocclusal device that encourages the

mandible to assume a position more anterior than
the intercuspal position.

 Useful for the management of certain disc

derangement disorders

since anterior positioning of the condyle may help

to provide a better condyle-disc relationship, thus
allowing a better opportunity for tissue
adaptation or repair.
65
 The goal of treatment is not to alter the mandibular position
permanently but only to change the position temporarily so as to
enhance adaptation of the retrodiscal tissues.

 Once tissue adaptation has occurred, the appliance is eliminated,

allowing the condyle to assume the musculoskeletally stable
position and painlessly function on the adaptive fibrous tissues.

66
 INDICATIONS

 1. To treat disc derangement disorders. Patients with joint sounds

(e.g., a single or reciprocal click) can sometimes be helped by it.

 2. Intermittent or chronic locking of the joint (e.g.,retrodiscitis).

 3. Some inflammatory disorders are symptomatically treated as the

slight anterior position is more comfortable position for mandible.

67
A. The anterior positioning appliance causes the mandible to
assume a more forward position, temporarily creating a more
favorable condyle disc relationship

B. During normal closure, the mandibular anterior teeth contact in

the anterior guiding ramp provided by the maxillary appliance.

C. As the mandible closes into occlusion, the ramp causes it to

shift forward into the desired position. This position eliminates
the disc derangement disorder. At the desired forward position,
all teeth contact to maintain arch stability

68
SIMPLIFIED FABRICATION TECHNIQUE

 Like the muscle relaxation appliance, the anterior repositioning

appliance is a full-arch hard acrylic device that can be used in either
arch.

 The anterior stop is constructed and the appliance is fitted to the

maxillary teeth.

69
FABRICATING AND FITTING THE APPLIANCE

 The initial steps identical to those in fabricating a

stabilization appliance.

 The anterior stop is constructed and the appliance

is fitted to the maxillary teeth. Since the acrylic
extending over the labial surfaces of the maxillary
teeth is not needed for occlusal purposes, it can be
removed to improve esthetics.

 This may be important if the patient has to wear the

appliance during the day.

70
 LOCATING THE CORRECT ANTERIOR POSITION

 The key to successful anterior repositioning appliance fabrication is

finding the most suitable position for eliminating the patient’s
symptoms.

 The anterior stop is used to locate it. The patient is instructed to

protrude slightly and to open and close in this position.

 The joint is revaluated for symptoms and the anterior position that
spots the clicking, is located and marked with red marking paper.

71
 Locating the desirable anterior position

A, Relationship of the anterior teeth to the anterior stop in centric relation,

B, The patient's mandible protrudes slightly until an opening and closing movement
occurs that eliminates the painful clicking. The contact area marked with articulating
paper in this position.

C. The mark labeled as CR is the musculoskeletal stable position of the condyle

(centric restion), and the mark labeled AP is the anterior therapeutic position of the
condyle that eliminates the TMJ clicking.
72
 This contact is grooved approximately 1 mm
deep with a small round bur.

 Self-curing acrylic is added to the remaining

occlusal surface so all occlusal contacts can be
established.

 The anterior stop must not be covered by the

acrylic. This position is verified by opening
and closing a few times

73
 ADJUSTING THE OCCLUSION

 The difference with this appliance is the anterior guiding ramp, which
requires the mandible to assume a more forward position to
intercuspal position.

 Flat occlusal contacts are developed for the posterior teeth, and the
large lingual ramp in the anterior region is only smoothed.

 The ramp is developed into a smooth sliding surface so as not to

promote catching or locking of the teeth in any position.

74
75
FINAL CRITERIA FOR THE ANTERIOR
REPOSITIONING APPLIANCE

 The following four criteria should be met by the anterior

repositioning appliance before it is given to the patient:

 1. When in contact with the mandibular teeth, it should accurately

fit the maxillary teeth with total stability and retention. In the
established forward position all the mandibular teeth should
contact it with even force

 2. The forward position established by the appliance should

eliminate the joint symptoms during opening and closing to and
from that position 76
 3. In the retruded range of movement the lingual retrusive guidance
ramp should contact and upon closure it should direct the mandible
into the established forward position

 4. The appliance should be polished with smooth surfaces and

compatible with adjacent soft tissue structures.

77
 INSTRUCTION AND ADJUSTMENTS
 During the day the appliance should not be worn so that normal function of the
condyle will promote the development of fibrotic connective tissue in the
retrodiscal tissue.

 The patient should be provided with physical self-regulation instructions so as to

reduce loading of joint structures during the day.

 If the patient reports pain during the day, the appliance may be worn for short
periods of time throughout the day to reduce the pain.

 As soon as the pain is resolved, the use of the appliance is limited to nighttime
only.
78
REFERENCES
References

1. Dawson PE. Evaluation, Diagnosis and Treatment of Occlusal Problems, 2nd ed. St.
Louis: Mosby; 1989. p.380-392.
2. Okeson JP. Management of temporomandibular disorders and occlusion. 8th ed.
Elsevier Mosby, St Louis, Missouri; 2014. p 375-398.
3. Dylina TJ. A common-sense approach to splint therapy. J Prosthet Dent.
2001;86(5):539-45.
4. Srivastava, Rahul et al. “Oral splint for temporomandibular joint disorders with
revolutionary fluid system.” Dental research journal. 2013;10(3): 307-13.
5. Alqutaibi AY, Aboalrejal AN. Types of Occlusal Splint in Management of
Temporomandibular Disorders (TMD). J Arthritis. 2015;4(11): 176-180.

79
6.Yadav S, Karani J. The Essentials of Occlusal Splint Therapy-Review article. Int J.
Prosthet Dent. 2011;2(1)12-21.
7.Bharadwaj K. The Basics of Occlusal Splints- A Review. Int. J. Adv. Res 2017;5(11):1239-
42.
8.Okeson JP. Orofacial Pain: Guidelines for assessment, diagnosis and management for the
American Academy of Orofacial Pain Differential Diagnosis and management
considerations of temporomandibular disorders. Quintessence Pub Chicago,III
1996;11(5):120-2.
9.M S Lakshmi, Sufiyan M K, Mehta R, Bhangdia M, Rathore K, Lalwani V. Occlusal splint
therapy in temperomandibular joint disorders. An update review. J Int Oral Health. 2016;
8(5):639-45.

80
THANK YOU

81
ANTERIOR BITE PLANE
 The anterior bite plane is a hard acrylic appliance
worn over the maxillary teeth, providing contact
with only the mandibular anterior teeth.

 It is primarily intended to disengage the posterior

teeth and thus eliminate their influence on the
function of the masticatory system.

82
 INDICATIONS

 1. Muscle disorders related to orthopedic instability or an

acute change in the occlusal condition.

 2. Parafunctional activity may also be treated with it, but only

for short periods.

83
 Major complications - when an anterior bite plane or any appliance
is used that covers only a portion of one arch.

 The unopposed posterior teeth have the potential to supraerupt. If

the appliance is worn continuously for several weeks or months,
there is a great likelihood that the unopposed mandibular posterior
teeth will erupt.

 When this occurs and the appliance is removed, the anterior teeth
will no longer contact and the result will be an anterior open bite.

84
85
86
 The ideal appliance should have maximal effectiveness with
minimal adverse effects and also be cost-effective.

 The profession is responsible for scientifically determining

effectiveness and risk factors before it embraces a new treatment
method.

 Ease of fabrication should be considered only after effectiveness

and risk factors have been found to be equal to or better than a
standard time-tested therapy.

87
POSTERIOR BITE PLANE
 Usually fabricated for the mandibular teeth
and consists of areas of hard acrylic
located over the posterior teeth and
connected by a cast metal lingual bar.

 The treatment goals of the posterior bite

plane are to achieve major alterations in
vertical dimension and mandibular
positioning.

88
INDICATIONS

 Advocated in cases of severe loss of vertical dimension or when

there is a need to make major changes in anterior positioning of the
mandible.

 Some therapists have suggested that this appliance be used by

athletes to improve athletic performance. At present, however,
scientific evidence does not support this theory.

89
 The use of this device may be helpful for certain disc derangement disorders, although
this appliance has not been studied well for this condition.

 As with the anterior bite plane, the major concern surrounding this appliance is that it
occludes with only part of the dental arch and therefore allows potential supraeruption
of the unopposed teeth and/or intrusion of the occluded teeth.

 Constant and long-term use should be discouraged. In most cases, when disc
derangement disorders are treated, the entire arch should be included, as with the
anterior positioning appliances.

90
91
PIVOTING APPLIANCE

 The pivoting appliance is a hard acrylic device that covers one arch and usually provides
a single posterior contact in each quadrant.

 This contact is usually established as far posteriorly as possible. When superior force is
applied under the chin, the tendency is to push the anterior teeth close together and
pivot the condyles downward around the posterior pivoting point.

92
93
INDICATIONS
 The pivoting appliance was originally developed with the idea that it would reduce
interarticular pressure and thus unload the articular surfaces of the joint.

 This was thought to be possible when the anterior teeth moved closer together, creating
a fulcrum around the second molar and pivoting the condyle downward and backward
away from the fossa.

 However, such an effect can occur only if the forces that close the mandible are located
anterior to the pivot.

94
 Unfortunately the forces of the elevator muscles are located primarily posterior to the
pivot, which therefore disallows any pivoting action.

 Whereas it was originally suggested that this therapy would be helpful in treating joint
sounds, it now appears that the anterior positioning appliance is more suitable for this
purpose, since it provides better control of positional changes.

 Perhaps one positive effect that a pivoting appliance may offer in a patient with disc
displacement or dislocation is that the pivot does not restrict the mandibular position;
therefore the patient may close and position the mandible more downward and forward
to avoid the pivot.

95
96
 If this occurred, the condyle would be positioned off of the retrodiscal tissues, providing
a therapeutic effect on the disorder. This thought is very speculative and further
research is needed to better determine if this appliance has any use in dentistry.

 The pivoting appliance has also been advocated for the treatment of symptoms related
to osteoarthritis of the TMJs. It has also been suggested that the device be inserted and
elastic bandages wrapped from the chin to the top of the head to decrease forces on the
joint. Manual extraoral force to the chin can also be used to decrease intra-articular
pressure.

97
 The only appliance that can routinely distract a condyle from the fossa is a unilateral
pivot appliance. When a unilateral pivot is placed in the second molar region, closing
the mandible on it will load the contralateral joint and slightly distract the ipsilateral
one (i.e., increase the discal space).

 The biomechanics of this appliance might appear to be indicated for the treatment of an
acute unilateral disc dislocation without reduction. However, there is no scientific
evidence at present that such a treatment is effective in reducing the disc. This device
should not be used longer than 1 week since it is likely to intrude the second molar used
as the pivot.

98
99
SOFT OR RESILIENT APPLIANCE

 The soft appliance is a device fabricated of resilient material that is usually adapted to the
maxillary teeth.

 Treatment goals are to achieve even and simultaneous contact with the opposing teeth.

 In many instances this is difficult to accomplish, since most of the soft materials are
difficult to adjust precisely.

 These appliances are generally worn only at night and if they are successful, will produce
symptomatic relief within 6 weeks. Generally made out of 2 - 4 mm polyvinyl sheet.

100
INDICATIONS

 1. Protective device for persons who are likely to

receive trauma to their dental arches

 2. Protective athletic splints decrease the likelihood of

damage to the oral structures when trauma is
received

 3. Clenching and bruxism.

101
 Okeson demonstrated that nocturnal masseter EMG activity was increased in 5 of 10
subjects with a soft appliance. In the same study, 8 of the 10 subjects had significant
reduction of nocturnal EMG activity with a hard stabilization appliance.

 (Only one subject showed reduction of activity with the soft appliance.) Other studies
evaluating the effectiveness of hard and soft appliances on symptoms showed that
although soft appliances can reduce symptoms, hard appliances seem to reduce
symptoms more quickly and effectively.

 Hard appliances seem to reduce the EMG activity of the masseter and temporalis
muscles more than soft appliances while the teeth are controllably clenching.

102
 Soft appliances have been less documented in the scientific literature, but a few more
recent studies suggest that they may be helpful in some patients for short-term use.

 Soft appliances have been advocated for patients who suffer from repeated or chronic
sinusitis, resulting in extremely sensitive posterior teeth.

 In some cases of maxillary sinusitis the posterior teeth (with roots extending into the
sinus area) become extremely sensitive to occlusal forces. A soft appliance may help
decrease the symptoms while definitive treatment is directed toward the sinusitis.

103
FLAT PLANE STABILIZATION APPLIANCE
(MICHIGAN SPLINT)
 The splint allows free and smooth movement of upper
teeth over lower teeth while helping muscle to break the
habit of clenching or grinding.

 Also known as the gnathologic splint, Michigan splint, or

muscle relaxation appliance. this appliance is generally
fabricated for the maxillary arch but, for esthetics and
avoid interference with a speech; some clinicians have
recommended that it could be placed for the mandibular
arch.

104
 Indications: Anterior disc dislocation with reduction, severe bruxism, establishment of
optimal condylar positions in centric relation prior to definitive occlusal therapy.

 the purpose of stabilization appliance as outlined by the American Academy of Orofacial

Pain guidelines is to “provide joint stabilization, protect the teeth, redistribute the
occlusal forces, relax the elevator muscles, and decrease bruxism.” Additionally, it is
stated that “wearing the appliance increases the patient’s awareness of jaw habits and
helps alter the rest position of the mandible to a more relaxed, open position”.

 It is the most commonly used type of occlusal appliance, and it has the least adverse
effects to the oral structures when properly fabricated

105
KOIS DEPROGRAMMER
 The Kois Deprogrammer (KD) is a palatal-coverage
maxillary acrylic device with a flat plane lingual to
the anterior teeth. It separates the dental arches and
provides a single lower-central incisor contact
against the anterior bite plane.

106
APPLICATIONS OF THE KOIS DEPROGRAMMER

 Numerous clinical applications for the KD have been determined. It can be used for
simplifying difficult bite registrations and for accurate mounting of diagnostic casts, for
patients that are difficult to manipulate into CR, and for facilitating occlusal adjustments
(during which time it is worn).

 The KD can be used as a diagnostic tool to determine if the mandible needs to move in
the anterior or posterior direction to reach CR from maximal intercuspal position (MIP).

107
 The device is also used to differentiate among three types of
abnormal occlusal attrition:

 Constricted path of closure (CPC): Attrition occurs during closure

into MIP when anterior interferences create a distal thrust that
moves the condyles distal to Cr.

 Occlusal dysfunction: Occlusal attrition as a result of excessive

grinding triggered by interferences on the posterior teeth.

 Parafunction (true bruxism): Occlusal wear as a result of excessive

grinding triggered by the brain. It has no functional purpose.

108
 FEATURES AND BENEFITS OF THE KOIS
DEPROGRAMMER
 The KD appliance is designed such that it can be worn for extended periods of time, as long as it
does not exceed 20 hours per day. It is worn until the necessary muscle deprogramming is
accomplished and can be worn for days or weeks if necessary (the usual course is for one week).

 If the patient is not completely deprogrammed by that time, it may be necessary for the patient to
wear the deprogrammer for up to 24 hours per day (except when eating).

 In this case the duration should be limited, preferably no longer than one week. This is to prevent
potential supraeruption of the posterior teeth or intrusion of the contacting incisor.

109
 The KD has a number of features and benefits that make it an ideal protocol for
obtaining CR or managing a number of occlusal issues:

 It allows for the patient to deprogram over time. It has been has shown that in patients
with a centric prematurity introduced for a short period of time, a percentage of them
may take days or weeks to lose the muscular discoordination in the muscles of
mastication once the prematurity is removed. This explains why some patients will not
deprogram instantly or in a few hours. In these cases, an accurate record cannot be
taken until they have been completely deprogrammed.

110
 The jaw is not manipulated into CR, but is determined by the patient and
is reproducible. This is a key criterion to determine if the patient is
deprogrammed. The patient must be able to close into the same position
every time, passively, without any guidance or external force.

 The patient can be observed when closing into a reproducible CR mark.

This position can again be verified when the bite registration is taken.
The patient should make the same mark on the appliance during the
bite registration as was made during the initial recording.

 The bite registration is taken with the appliance in place. This allows
great control of the vertical dimension of occlusion (VDO) during bite
registration.

111
 It is used to facilitate an occlusal adjustment once the deprogramming is complete. The same
appliance can be used. Use of the KD ensures that the deprogramming will be maintained during
the occlusal adjustmen.

 It can be worn at a minimally opened VDO of approximately 1 mm in the molar region. This
closed position is often more comfortable than appliances that require a much greater VDO. This
also makes the appliance more esthetic if needed for daytime use.

 It is self-adjusting. There is only one incisor tooth contact against the appliance. As the muscles
relax, the condyles are free to move with no obstacles to prevent them from achieving an
equilibrium position in CR. This saves multiple adjustment appointments.

112
 HOW DOES IT WORK?

 Proprioceptors in the periodontium provide feedback that programs the muscles to close in MIP.
Without reinforcement through repeated tooth contact, the feedback and the influence of the
dentition on the condylar position is lost.

 Tooth-deflecting inclines can trigger discoordination of the masticatory muscles. Until these
muscles relax and function in a coordinated manner, the patient may be incapable of achieving a
CR position.

 The KD breaks this cycle by discluding the teeth and allows the muscles to return to normal
function. The KD protocol also verifies that the muscles of mastication are deprogrammed. This
ensures that the condyles are allowed to “move” to the CR position, being unaffected by
uncoordinated muscles, tooth interferences, or operator error

113
HYDROSTATIC APPLIANCE (AQUALIZER)

Self-adjusting oral splint in occlusion

114
 The Aqualizer™ has unique water system that
immediately optimizes biomechanics,
supports the jaw in a comfortable position,
removes the teeth from dominance, placing
bite and body in harmony, straightens the bite
to maximize other structures, enables
systemic function and balance, allows the
body to naturally balance itself, finds perfect
occlusal balance after starting the treatment
immediately.

115
 Relief of pain usually occurs within 5-10 min after insertion of the Aqualizer™,
particularly in the episodic sufferer. Instruct the patient to wear the Aqualizer™
continuously for the next 48 h, except when eating or brushing teeth. At the end of this
period, re-examine the patient.

 If the patient's bruxism improves after wearing the bite splint, occlusal treatment is
indicated. If the patient's symptoms do not improve significantly, they are most likely
not occlusal in origin and occlusal treatment alone is unlikely to be successful. Patients
should not exceed 8 h of Aqualizer™ wear per 24-h period.

116
 Aqualizer works by allowing the muscles to automatically reposition the jaw. For TMJ
pain relief, restoring this balance is essential.

 The Aqualizer self-adjusting oral splint allows the body to unravel bite distortions and
establish optimal systemic function and balance.

 While most dental mouth guards simply disable the bite long-term and guess at optimal
occlusion, the Aqualizer takes the guesswork out of treatment by allowing the body to
naturally find TMJ pain relief and functional balance.

117
 The Aqualizer is a new application of a basic physical law of nature called Pascal's law,
which states that that an enclosed fluid will apply equalized fluid pressure regardless of
where pressure is applied to the fluid.

 In other words, biting down on the Aqualizer™ causes the fluid to distribute bite forces
evenly across the bite, reducing TMJ pressure and pain and ensuring relief.

118
OCCLUSAL APPLIANCES (SPLINTS) MATERIALS

 Commonly there are two different materials, based upon consistency, which are used in
the fabrication of occlusal appliances.

 TНere are hard acrylic resin Occlusal appliances that are either self cured (by chemical
reaction) or heat cured, resulting in hard and rigid tooth-borne and occlusal surface.

 In other hand, there are soft or resilient occlusal appliances, the soft appliance are
somewhat flexible and pliable tooth-borne and occlusal surface.

119
 A third variation of material known as dual laminated, as its occlusal surface consists of
hard acrylic resin and the tooth-borne surface consist of a soft material. TНis produces
an occlusal appliances with advantages of a soft material (fitting well and providing
comfort for the supporting teeth), and an adjustable occlusal surface of the hard acrylic
resin.

 Hard acrylic resin occlusal appliances can be either custom fabricated at chairside or
indirect fabrication in the dental lab rotary by use of stone casts. the soft occlusal
appliances can be purchased readily from dental supply houses this type of occlusal
appliance (“boil and bite”) is molded and adapted by boiling the product in water and
then placing the material intra-orally with a biting force to establish the preferred
correct occlusion

120
 Another variation of the soft occlusal appliance is a dental office fabricated type, in
which the material is vacuum formed to fit stone casts, and then the occlusion is later
established at chairside.

 A third variation involves a similar processing technique which occurs at a commercial

laboratory and then the occlusion established once again at chair side.

121
 Hard acrylic resin occlusal appliances have several advantages over the soі appliances;
hardness and resistance of the acrylic resin enable easily and quickly adjustments,
easily repaired, the fit of a hard acrylic resin is more accurate, methods of fabrication is
more reliable and greater longevity, more color stable, less food debris accumulation
and more durable than that of the soft version.

 In contrary, the adjustment of soі material is more difficult and often results in a less
adequate occlusal scheme. And these appliances are more susceptible to wearing that in
turn result in occlusal changes.

122
 COMMON TREATMENT CONSIDERATIONS
OF APPLIANCE THERAPY
  Most occlusal splints have one primary function that is to alter an occlusion so they do not
interfere with complete seating of the condyles in centric relation.

 Following are few concepts, which explain how occlusal splints can help:

 Preventing the patient to close in maximal intercuspal position: By occlusal splint, the patient
is obliged to place his mandible in a new posture, thus resulting in a new muscular and
articular balance. The patient, disturbed in his habits will not clench his teeth any more, like
before and protect his TMJ and teeth.

123
 2. Distribution of forces: The forces generated during bruxism can be as much as 6
times the maximal force generated by normal chewing.The splints distribute these
forces across the masticatory system. These appliances can decrease the frequency of
bruxing episodes but not the intensity.

 3. Normalizing periodontal ligament proprioception: Proprioceptive fibers contained in

the periodontal ligament of each tooth send message to central nervous system,
triggering muscle patterns that protect them from overload. An occlusal splint functions
to dissipate the forces placed on individual teeth by utilizing a larger surface area
covering all teeth in the arch. Thus, a splint balances the load and allows for muscle
symmetry.

124
 4. Relaxing the muscles: Tooth interferences to the CR arc of closure hyper-activate the
lateral pterygoid muscles and posterior tooth interferences during excursive
mandibular movements cause hyperactivity of the closing muscles.

 A muscle that is fatigued through ongoing muscle hyper-activity can present with pain.
If the hyperactivity is stopped, the pain caused by it will usually disappear.

 A splint with equal intensity contacts on all of the teeth, with immediate disclusion of all
posterior teeth by the anterior guidance and condylar guidance in all movements, will
relax the elevator and positioning muscles.

125
 5. Allowing the condyles to seat in centric relation: For the condyles to seat completely
under the disc in anterosuperior position, the superior belly of lateral pterygoid should
obtain its full extension.

 When the lateral pterygoid is triggered to hyperactivity through occlusal stimuli, the
disc is pulled anteromedially toward the origin of muscle, resulting in displacement.
Overloading of condyle/disc assembly when not in normal physiologic position
contributes towards TMJ disorders.

 A properly balanced splint results in an occlusion associated with relaxed positioning

and elevator muscles, allowing the articulator disc to obtain its antero-superior position
over the condylar head.

126
 6. Increase in the vertical dimension of occlusion: Occlusal splints can be adjusted with
a vertical height that exceeds the physiologic interocclusal distance.

 Temporary use of occlusal splints with a vertical height exceeding the physiologic rest
position does not cause increase in tonus or hyperactivity of jaw muscles.

 Studies have shown that elongation of elevator muscles to or near the vertical
dimension of least electromyographic activity by means of occlusal splint is effective in
producing neuromuscular relaxation.

127
 7. Cognitive awareness theory: This theory can be applied to any or all of the appliances
utilized. The cognitive awareness theory is based on the concept that having an
interocclusal appliance in the mouth constantly reminds the patient to alter his/her
normal behavior so that the opportunity for harmful or abnormal muscle activity with
every closure of the teeth is decreased.

 The increased cognitive awareness of the patient regarding the positioning and use of
the jaw, the change in oral tactile stimuli, and the decrease in oral volume can all
influence the patient to learn what position or activities are harmful.

128
CONCLUSION

 Properly made occlusal splints are an important and practical treatment modality when
used for specifically designed purposes.

 The basis for their utilization should be a clear understanding of how the splint affects
the position and condition of the TMJs and/or the suppressive effect on muscle
hyperactivity.

129
REFERENCES
1. Dawson PE. Evaluation, Diagnosis and Treatment of Occlusal Problems, 2nd ed. St.
Louis: Mosby; 1989. p.380-392.
2. Okeson JP. Management of temporomandibular disorders and occlusion. 8th ed.
Elsevier Mosby, St Louis, Missouri; 2014. p 375-398.
3. Dylina TJ. A common-sense approach to splint therapy. J Prosthet Dent.
2001;86(5):539-45.
4. Srivastava, Rahul et al. “Oral splint for temporomandibular joint disorders with
revolutionary fluid system.” Dental research journal. 2013;10(3): 307-13.
5. Alqutaibi AY, Aboalrejal AN. Types of Occlusal Splint in Management of
Temporomandibular Disorders (TMD). J Arthritis. 2015;4(11): 176-180.

130
6.Yadav S, Karani J. The Essentials of Occlusal Splint Therapy-Review article. Int J.
Prosthet Dent. 2011;2(1)12-21.
7.Bharadwaj K. The Basics of Occlusal Splints- A Review. Int. J. Adv. Res 2017;5(11):1239-
42.
8.Okeson JP. Orofacial Pain: Guidelines for assessment, diagnosis and management for the
American Academy of Orofacial Pain Differential Diagnosis and management
considerations of temporomandibular disorders. Quintessence Pub Chicago,III
1996;11(5):120-2.
9.M S Lakshmi, Sufiyan M K, Mehta R, Bhangdia M, Rathore K, Lalwani V. Occlusal splint
therapy in temperomandibular joint disorders. An update review. J Int Oral Health. 2016;
8(5):639-45.

131
THANK YOU

132