Muscle deprogramming /certified fixed orthodontic courses by Indian dental academy


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Muscle deprogramming /certified fixed orthodontic courses by Indian dental academy

  1. 1. Muscle Deprogramming & Splint Therapy INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Muscle Deprogramming & Splint Therapy
  3. 3.  The key to treating TMD/ Bruxism patients is to reduce the patient's tendency to clench and grind their teeth. Even if, when the teeth are closed together, and the joints do not line up properly, all the symptoms tend to fade away if the patient does not tend to keep the teeth together with the forces characteristic of bruxing. The most common, and least expensive treatment for TMD is the construction of a hard acrylic bruxing guard/ interocclusal splint.
  4. 4.  These are horseshoe shaped plastic appliances which fit over (usually) the top teeth and have a smooth surface on the underside so the lower teeth can slide over the plastic without resistance. This prevents the teeth from locking together, and relieves a lot of the force placed on the teeth and joints.
  5. 5.  Unfortunately, these splints still allow the patient to clench against the guard. Since clenching is associated with overuse of the temporalis muscle, patients may still experience tension headaches even though they wear their guard religiously.
  6. 6.  Bruxing guards work even better if they are built so that when the lower teeth contact the plastic, the joints are forced to sit in their most relaxed positions in the most superior part of the socket. This position can be determined quite easily by a simple trick called deprogramming in which a piece of plastic is inserted over the top front teeth that does not allow the posterior teeth to make any contact. Usually, within an hour or so of wearing one, the jaw "drops" into a relaxed position with the joints in a more desirable position.
  7. 7.  A bite registration is taken with the deprogramming device (deprogrammer) in place so the new bruxing guard can be built to the new bite-adjusted jaw position which corresponds to a more physiologically acceptable joint position. Deprogrammer has an additional advantage in that it will relieve the symptoms very quickly and can be worn until the deprogrammed bruxing guard can be built.
  8. 8. Deprogrammers  The concept of deprogramming is based on the reflexive relaxation of the lower jaw when the posterior teeth are not permitted to engage. The various muscles that open and close the jaw learn and remember the level of contraction needed to perform their movements in a coordinated, comfortable way.
  9. 9.  They learn which positions of these muscles cause pain, and which don't, and store all the information in your brain in the form of "engrams" which are similar to automatic, unconscious computer programs that our body uses each time we open or close our mouth. In persons with TMJ, these movements can be quite complex.
  10. 10.  The relief of symptoms is the result of a forced relaxation of the muscles of mastication, which in turn brings about relief of pressure on all anatomic structures including the TMJ, the muscles of mastication, the teeth and supporting structures. Deprogramming frequently brings about a shift in the position of the lower jaw leaving the joints in a more relaxed functional position which probably corresponds fairly closely to Dawson's definition of centric relation. The condyles thus occupy a more centric and relaxed position in the fossae. This position is reproducible without forceful manipulation by the dentist.
  11. 11. Why Deprogram?  An anterior midline contact produces minimal temporalis contraction intensity and minimal joint strain, and tends to allow the TMJ to translate slightly forward to rest against the eminence. Furthermore, an attempt to brux against an anterior midline discluding element produces sore lower incisors, which discourages further bruxing. Thus deprogramming is a simple trick to produce a forced relaxation of the temporalis, masseter and pterygoid muscles allowing the TM Joints to rest in a functionally comfortable position in the fossa.
  12. 12.
  13. 13.  Masseter and Temporalis are the key players in the action of mastication. Muscular activity is independent of the occlusal scheme. However, the occlusal scheme modifies the forces generated by the muscular activity.
  14. 14.   The best application of the occlusal splint seems to be in its application prior to any occlusal adjustment. It is important to bring the patient to ‘round zero’ lowering EMG activity in the masster and temporalis muscles, and then proceed with further treatment. It is imperative to understand that results of splint therapy are temporary and recurrent symptoms are likely to show up within 4 wks of discontinuing the splint.
  15. 15.  Thus use of splints is symptomatic treatment and for an orthodontist it acts to accomplish the balance within the muscles, can also facilitate procedures such as occlusal analysis or an adjustment to a patients bite. Thus in the second phase the orthodontic treatment would relieve the occlusal dysfunction.
  16. 16.  The deprogrammer, followed by a bruxing guard built using the new functional (deprogrammed) bite registration can bring about immediate and permanent relief of pain in a majority of TMD cases. Symptoms relieved include a reduction in tension headaches, ear aches and the neck stiffness associated with parafunction. Sensitive teeth and "phantom toothaches" in otherwise healthy teeth frequently respond to this form of treatment. Crepitus and popping of the temperomandibular joints may be lessened or relieved.
  17. 17. The deprogrammer accomplishes three goals  1. The deprogrammer brings about nearly immediate relief of acute symptoms. In general, pain is reduced or eliminated within one or two hours of insertion of the deprogrammer. Muscle relaxants, analgesics or other drugs are generally not necessary.
  18. 18.  2.The butterfly deprogrammer helps to confirm the diagnosis of TMD, and the appropriateness of jaw repositioning as a treatment. In cases where the deprogrammer does not bring about sufficient relief from pain, the construction of a functional appliance will be of little benefit. While this does not mean that jaw repositioning therapies are entirely inappropriate, it does imply that the practitioner should rule out other causes for the patient's pain before proceeding with expensive therapies.
  19. 19.  3.The butterfly deprogrammer brings about relaxation of masticatory structures, and allows for the determination of a functional centric jaw relation and the construction of a "deprogrammed" bite appliance. Any symptoms of TMD that have been relieved by the use of the deprogrammer should be also be corrected by a properly fabricated deprogrammed bruxing guard. Unfortunately, bruxing guards, even deprogrammed guards, do not always relieve tension headaches since the patient can still clench against the guard. Even so, patients often experience a reduction in the frequency and intensity of tension headaches.
  20. 20. Butterfly Deprogrammer
  21. 21.
  22. 22. Nocireceptive Trigeminal Inhibition
  23. 23. Taking and using a bite registration  The patient should be allowed to wear the deprogrammer on and off for several days prior to taking a bite registration. Just before the bite is to be registered, the patient should wear the deprogrammer continuously all day until the appointment time. Schedule this appointment for the morning instructing the patient to sleep with the deprogrammer in place and remove it only to eat and brush the teeth. Otherwise, the patient's posterior occlusion should be discluded for as long as possible before the appointment.
  24. 24.  With the deprogrammer in place, have the patient sit in an upright position and gently tap the lower teeth against the bite ramp a few times. NOT HARD! when the dentist is satisfied that the position of contact of the ramp with the lower teeth is stable and reproduced with each tap, have the patient hold the lower teeth gently against the ramp. Now begin injecting the Blue Mousse (or Regisil) between the teeth starting on the posterior teeth on one side, and continuing anteriorly being sure to overlay the buccal cusp tips and incisal edges of all teeth while injecting around the arch to the posterior teeth on the other side.
  25. 25.   With the deprogrammed bite in hand, remove the deprogrammer and take alginate impressions of upper and lower teeth. Then mount the teeth using the Regisil bite, and not to change the vertical dimension when building the bruxing guard. A hard acrylic flat plane guard for heavy bruxers can be used, although the newer Thermoflex or ValPlast materials make fitting the guard much easier since warm water softens the plastic and allows the appliance to self adjust to any discrepancies in the exact fit to the teeth.
  26. 26.  Hence, Interocclusal orthopedic appliances are routinely used in the treatment of disorders of the temporomandibular joint (TMJ) and masticatory system. Hard or soft removable acrylic appliances covering the teeth have been used to eliminate occlusal disharmonies, prevent wear and mobility of the teeth, reduce bruxism and parafunction, treat masticatory muscle dysfunction, and correct derangements of the TMJ. Mandibular orthopedic repositioning appliances (MORA’s) have been recommended for increased strength and athletic performance.
  27. 27. History of Splints   With the development and patenting of vulcanite rubber in 1855, Charles Goodyear provided dentists with material that could be molded for many different oral appliances. In November 1862, Thomas Gunning , a practicing surgeon, used vulcanite to fabricate a custom fitting splint to treat himself for a broken jaw.
  28. 28.   The Gunning vulcanite splint, is remarkably similar to appliances used today to treat TMD. Additionally, his double arch splint, very closely resembles early orthodontic positioners, snoring and sleep apnoea appliances in use today. In 1887, twenty five yrs after Gunning’s development, Kingsley, published an article discussing the use of soft vulcanized rubber to make an obturator.
  29. 29.   In 1888, Farrar, discussed the use of a splint to disarticulate the teeth for the purpose of increasing the eruption of selected teeth. Karolyi, a German, introduced an occlusal splint in 1901 for the treatment of bruxism.
  30. 30.  Hawley, in 1919, and then Monson, in 1921, each suggested that bruxism led to a loss of occlusal vertical dimension, which gave rise to occlusal disorders.
  31. 31. Resilient appliances   One of the first reference to the use of a soft appliance is by Matthews in 1942, for the treatment of bruxism In 1946, Kesling’s article discussed using a maxillary soft occlusal appliance in order to maintain the mandible in predetermined relationship to the maxilla.
  32. 32.   Ingersoll and Kerens, in 1952, authored a paper discussing the treatment of occlusal trauma using a semi soft vinyl resin appliance made of vinolin. In 1957, Campbell described soft appliance approach for treating bruxism.
  33. 33.   Shore, in 1959, provided an outline for treating TMJ pain and facial pain. He cautioned about the disadvantages of the soft appliances, such as perforations, functioning like orthodontic appliances.
  34. 34. Splint Types        Stabilization splint Repositioning splint Pivot splint Soft splint Bite plate splint Hydrostatic splint Mandibular orthopedic repositioning appliances (MORA)
  35. 35. Stabilization splints  Stabilization splints are commonly used for treatment of masticatory dysfunction signs and symptoms such as muscular pain, TMJ pain, clicking, crepitus, limitation of motion and incoordination of movement. This type of splint is constructed with even posterior occlusal contact in centric relation with the condyles "seated", separation of posterior teeth in protrusive or lateral movements (anterior disclusion) and canine rise in lateral excursions. It can cover the maxillary or mandibular dentition.
  36. 36.  Carraro and Caffesse (1978) described the response of 170 TMJ patients treated only with a full coverage stabilization splint. Eighty-two percent of subjects responded favorably to the splint therapy. Symptoms of TMJ pain, muscle pain or dysfunction all improved. Thirty-seven percent of the patients were cured and 45 percent improved. Pain symptoms were significantly more likely to be cured than dysfunction symptoms. Clicking was the most difficult dysfunctional symptom to eliminate.
  37. 37. Repositioning splints  Along with change in tooth contact and muscle function, splints can influence the temporomandibular joint. The proper position of the condyle to the meniscus and fossa is generally thought to be necessary for normal function. While there is some variation in condylar position in an asymptomatic population, derangement of the disc with displacement of the condyle is implicated in disturbances of motion and degenerative joint changes. Splints may affect the joint in two ways: alter the stress or loading of the joint, and recapture or change condyle-disc fossa position.
  38. 38.  Most clicking is caused by a rapid change in position of the condyle or disc, sometime during condylar translation. Since the direction of pull of the external pterygoid is anterior and medial, in derangements the meniscus is usually dislocated forward and inward. Conceptually, keeping the mandible forward with a splint would "recapture" the normal disccondyle orientation and eliminate the clicking. The initial enthusiasm for repositioning was supported by studies showing good clinical success. Comparisons with flat plane splint treatment showed the superiority of repositioning appliances.
  39. 39.  Increasing the length of the splint therapy does not improve the treatment result. Following six months or more of active repositioning splint therapy, control of noise and pain was achieved in 70 percent of 241 patients. (Moloney et al 1986) 53% were successful after two years, and by the end of three years only 36%were successfully treated. The later the click occurred in opening, the poorer the long term prognosis. 14 of the successfully treated cases were occlusally reconstructed and 34 had orthodontic treatment to maintain the altered jaw position. 43% of the restored patients and 50%of the orthodontic patients had return of clicking.
  40. 40.  Ronqillo et al, (1988) studied the relationship between the pretreatment position of the condyle in the fossa to unsuccessful protrusive splint therapy. Of 142 patients with internal derangements, 72 were arthrographically confirmed to be suitable for repositioning therapy. The initial condylar position was measured on CO tomograms. The patients were followed from six months to five years. Seventy-one percent of the patients in the sample were successfully treated while 29 percent had return of clicking, locking and/or return of pain. Whether the condyle was anteriorly, centrally or posteriorly positioned before splint therapy had no bearing on the success of treatment.
  41. 41.  Okeson (1988) took a retrospective look at 40 patients treated for eight weeks with anterior repositioning splints. All patients had a primary diagnosis of a disc-interference disorder: disc displacement associated with distinct single joint sounds (n=25), a history of locking with recapture (n=8), and permanent dislocation (locking without recapture, n=8). After eight weeks of therapy 80 percent of the patients were free of pain, clicking and locking. The splints were phased out with a stepback procedure. No occlusal changes were attempted.
  42. 42.  Two and one-half years later 66% of the successfully treated patients had a return of joint sounds. 23% reported joint pain. The average maximal interincisal opening improved from 37 millimeters to 43 millimeters. 18% had decreased opening. This study would conclude that repositioning therapy permanently resolves joint sounds only one-third of the time but reduces long term pain three-quarters of the time.
  43. 43.  The author used the same data to evaluate success under differing criteria. The success rate was 25 percent if the patients were free of pain, clicking and locking. Accepting painless joint sounds, the success rate was 55 percent. Seventy-five percent were successful if only pain resolution was considered and 80 percent were better according to the patient. Therefore, if resolution of pain is the primary objective, repositioning has a good long term prognosis. If elimination of all signs of dysfunction is the goal, repositioning splint therapy is of limited value.
  44. 44.  The enthusiasm and the high success rate reported initially for anterior repositioning is not supported by carefully controlled long term studies. Successful recapture of a displaced disc depends on readaption of stretched or torn ligamentous attachments and repair of the retrodiscal tissue. The disc displacement may also be of a type that is impossible to recapture. (Leidberg 1988) Return of clicking after successful treatment means that the joints are not repairing themselves or that the original clicking was not caused by disc displacement.
  45. 45. Pivot splints  Treating an injured or painful articulation with traction is common in physical medicine. The pivot splint is a hard splint with single posterior contact on each side. The contact is usually on the most posterior tooth. If the mandible rotates forward around the fulcrum of the pivots, the condyle is distracted from the fossa and the joint is unloaded.
  46. 46.  Theoretically, unloading should be desirable in patients with internal derangements and intracapsular inflammations. In the craniofacial configuration of most patients the elevator muscles lie on or posterior to the most distal tooth. Therefore, contraction of the closing muscles does not result in joint unloading. The closing vector must be anterior to the pivot.
  47. 47.  Lous (1978) published the results in a study of 60 clicking patients treated with pivots. Previous traditional treatment methods had been unsuccessful. In these cases splint wear was supplemented with vertical pull headgear attached to a chin strap. The average treatment lasted three to four weeks with a three month follow-up. 72% of the patients had elimination of symptoms. 17% had improvement but reoccurring symptom episodes.
  48. 48.  Another limitation of this splint is that because of the limited occlusal contact with this splint there is a possibility of change in tooth position. The clinician has better control of the occlusion with a full coverage splint. For treatment of internal derangements, the anterior repositioning splint would give the therapist more control over condylar position. If joint unloading is the object of therapy, auxiliaries must be considered.
  49. 49. Soft splints  Soft, resilient splints are easily constructed. They may even be prefabricated. Their value for protection from trauma in athletics is well substantiated; their use to reduce parafunctional clenching and grinding is not. Harkins and Marteney (1986) tested prefabricated soft splints (a modified Doubleguard appliance) in one-half of a sample of 84 dysfunction patients who had clicking and pain. The other half served as controls.
  50. 50.  The splints were worn full time for 10–20 days. 10% of the patients stopped clicking, 64%had less clicking, 7% increased and 19% had no change. Myalgia did not change or worsened in 26% of patients. Minor occlusal changes were noted in 67%. There was no change in the controls.
  51. 51.  Okeson (1987) tested the response of a soft splint and a hard splint on the same bruxing patient. Soft splints might be useful on a temporary basis for relief of symptoms but because of the resilient material, adjustment of the occlusal contacts is difficult. Also, uncontrolled changes in tooth position may occur.
  52. 52. Bite plate Splint    Design: A maxillary or mandibular hard splint allowing contact of only one or more anterior teeth. The posterior teeth do not contact. Other names: Anterior jig, Luca jig, Hawley with bite plate or anterior deprogrammer. It interrupts mandibular position sense, eliminate proprioceptive feedback from the posterior teeth and / reduce muscle activity.
  53. 53. Mandibular Orthopedic repositioning appliance    Design: Hard mandibular posterior coverage splint usually with a lingual bar connecting the posterior segments. Also known as Gelb Splint It increases the strength and athletic performance, change posterior occlusal contact , eliminate anterior tooth contact or restore vertical dimension.
  54. 54. Hydrostatic splint   Design: Fluid filled reservoir covering the teeth. It equalizes the biting pressure.
  55. 55. Aqualizer™   The Aqualizer™’s revolutionary water system is different than other products in the market. While most splints 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 functional balance. The Aqualizer™ applies a physical law of nature called Pascal’s Law, meaning that when you bite down on the Aqualizer™, the fluid is evenly distributed across the entire bite.
  56. 56.
  57. 57.  The Aqualizer™ is unique. Its revolutionary “floating action” enables the body to find and restore its own systemic function and balance. The Aqualizer™’s built-in fluid system automatically eliminates the occlusal imbalances that trigger the patient’s symptoms. This fluid system works by freeing up the patient’s muscles so they can reposition the jaw to its most comfortable position, which takes the uncertainty out of reestablishing the correct “bite.”
  58. 58.  Diagnosis no longer wastes valuable chair time. Simply remove the Aqualizer™ from its package and insert it into the mouth. The Aqualizer™ ’s perfect occlusal balance starts treatment instantly! No impressions, lab work, or time consuming adjustments needed! It is truly an “instant splint.”
  59. 59. Occlusal changes  The nature of the occlusal scheme and specific tooth contact influences behavior of the muscles. The splint therapist has control over which teeth contact in the various mandibular functions. It is important to understand the changes in muscle behavior that accompany alterations in occlusal patterns so that better decisions can be made in the design of a splint.
  60. 60.  With cemented maxillary splints adjusted for different tooth contact patterns, Wood (1984) monitored the activity of the masseter, the anterior temporal and posterior temporal muscles. Clenching with full contact of all teeth on the splint increased EMG activity 17 percent, predominately in the masseter. If the second molar occlusal contact on the same side was removed, electrical activity dropped 20 percent. EMG activity decreased 13 percent with only canine to canine contact.
  61. 61.  Different occlusal protrusive functions also influence elevator muscle activity. Protrusion reduces elevator muscle activity but the number of teeth contacting appears to be the most significant factor in this reduction. Whether muscular inhibition emanates from the TMJ, the muscles or the periodontal membrane is unclear. In cats, stimulation of the pressure sensors in the periodontal membrane leads to a jaw opening reflex. Bruxing may override normal neuromuscular feedback so muscle activity may not be reduced.
  62. 62.  The clinical benefits of anterior guidance were demonstrated by Williamson and Lundquist. A splint limiting excursive contacts to the anterior teeth shut down the masseter and anterior temporal activity that normally occurred with posterior tooth contact. They concluded that anterior guidance was necessary to reduce muscle activity. However, in their experiment the variable of change in vertical dimension with the splint was not controlled.
  63. 63.    The following principles based on the above studies would apply to the use of different occlusal schemes in splint therapy: 1. Bilateral, even contact allows maximal muscle effort, balances right and left muscle contraction and reduces pain of muscle origin. 2. Reducing the number of teeth in contact does not reduce clenching effort if bilateral balance is maintained.
  64. 64.   3. In protrusive and lateral function, reducing the number of contacting teeth reduces muscle activity. 4. The anterior-posterior location of the working side tooth contact in lateral excursions is not the critical factor in reducing muscle activity.
  65. 65. Vertical dimension  Most splints alter the vertical dimension of occlusion and increase the functional length of muscles. The muscular length that develops maximum tension is defined by physiologists as the resting length. A fiber’s isometric tension is enhanced by elongation and loading.
  66. 66.  It has been assumed that clinical rest position (postural position) would be the vertical dimension of minimal muscle effort. In other words the elevator muscles would be the most relaxed at clinical rest. Rugh and Drago,(1981), determined that the mean vertical of minimal masseteric activity was 8.6 millimeters between the anterior teeth. The average postural position was 2.1 millimeters. Testing the masseter, posterior temporal and anterior temporal over the full range of mandibular opening, Manns showed the minimal EMG activity of the temporals at 12 millimeters and the masseter at 10 millimeters.
  67. 67.  So these authors concluded that as the vertical dimension increases from occlusal contact, muscular effort decreases. Presumably at the opening of minimal EMG, passive tissue stretch maintains mandibular position. With greater opening, stretch receptors become activated and muscle contraction increases.
  68. 68. Mandibular rest position and electrical activity of the masticatory muscles.  Michelotti A, Farella M, Vollaro S, Martina R. The objectives of this study were to analyze the relation between mandibular rest position and electrical activity of masticatory muscles and to compare clinical and electromyographic rest position in subjects with different vertical facial morphologic features.
  69. 69.  Clinical rest position and electromyographic rest position were investigated in 40 subjects. Electromyographic rest position ranged from 0.4 to 12.7 mm (average 7.7 +/- 2.7 mm). Clinical rest position ranged from 0.1 to 4.4 mm (average 1.4 +/1.1 mm). The average difference between electromyographic rest position and clinical rest position was 6.3 +/- 2.5 mm (range 0.3 to 10.3 mm). Sixteen subjects were selected according to the Frankfort mandibular plane angle and separated in two groups having a mandibular plane angle > or = 28 degrees.
  70. 70.  RESULTS: Rest position was significantly greater in the low-angle group (2 +/- 1.3 mm) than in the high angle group (0.8 +/- 0.8 mm). Electromyographic rest position did not differ between subjects with different facial morphologic features (8.1 +/- 1.7 mm lowangle group; 7.6 +/- 4.1 mm high angle group). By varying the vertical dimension millimeter by millimeter, masseter and anterior temporal electromyographic activity demonstrated a considerable decrease over an interocclusal distance of 3 to 4 mm.
  71. 71.  Further mandibular opening up to 18 mm corresponded to small changes in postural activity. This study suggests that a jaw posture with a few millimeters of interocclusal distance involves a great reduction of masticatory muscle activity.
  72. 72. Integrated electromyography of the masseter on incremental opening and closing with audio biofeedback: a study on mandibular posture.  Gross MD, Ormianer Z, Moshe K, Gazit E. The purpose of this study was to test the hypothesis of a minimum electromyographic (EMG) rest position based on masseter surface EMG recordings of incremental opening and closing of the mandible with simultaneous audio EMG biofeedback.
  73. 73.  Nineteen alert subjects in an upright seated position opened and closed the mandible in 1-mm increments 20 mm interincisally. An electronic recording device allowed each subject to maintain the vertical dimension of each increment while simultaneously reducing right masseteric muscle activity to the minimum possible level using audio EMG biofeedback. Integrated EMG masseteric activity was recorded at each static opening and closing increment.
  74. 74.  RESULTS: Analysis of variance for repeated measures showed no difference in opening and closing EMG levels and no interaction between opening, closing, and change in vertical dimension. CONCLUSION: These results, with those of other studies, raise questions regarding the validity of the concept of a unique physiologic rest position of the mandible with the masseter or associated muscles at minimum muscle activity. The idea of overlapping postural ranges appears to be more appropriate.
  75. 75. The indications for the splints     patients with TMD. differential diagnosis in patients with signs and symptoms that imitate TMD. patients with bruxism and parafunction. patients with moderate to severe occlusal/incisal teeth wear.
  76. 76.       stabilization of mobile teeth. treatment of periodontal trauma from occlusion. temporary stabilization of the occlusion for orthodontic purposes. establishing the optimum position of the mandible to the maxilla in centric relation before definitive occlusal therapy. postsurgical occlusal/jaw stabilization. treatment of headaches caused by masticatory muscle tension.
  77. 77. Maxillary Occlusal Device-Indications and Advantages The maxillary occlusal device is the treatment of choice over the mandibular occlusal device because:  ideal occlusal contacts in centric relation can be established for all lower buccal cusps tips and incisal edges.  ideal anterior guidance can be established.  it covers more lingual soft tissue and is less likely to fracture.  it is more easily tolerated during non work and nonsocial situations.
  78. 78.   it does not cause flaring of the maxillary incisors, especially during episodes of bruxism, which is a concern with mandibular occlusal devices. Some dentists argue that “speech difficulties” may be encountered with the maxillary occlusal device.
  79. 79. Mandibular Occlusal Device– Indications and Advantages   The mandibular occlusal device is recommended in patients who: object to acrylic resin that will be visible on a maxillary occlusal device which provides anterior guidance, especially in “open bite cases.”
  80. 80.   do not want to display any amount of anterior clear acrylic resin on maxillary devices. exhibit a severe gag reflex with the maxillary occlusal device.
  81. 81. Characteristics of ideal splint      1. Accurately fits the maxillary teeth, with no rock.” 2. Adequate retention, no tighter than removable partial denture. 3. All mandibular buccal cusp tips and incisal edges contact on flat surfaces in the centric relation position. 4. In protrusive jaw excursions, only the lower incisors are in contact. Anterior guidance is no steeper than 45 degrees. 5. A long centric of 0.5 mm sometimes may be necessary, especially for class II jaw relation patients.
  82. 82.    6. In lateral jaw excursions, only the mandibular canines are in contact. 7. In the upright position, the posterior teeth contact more prominently than the anterior teeth in the centric relation position (maximum intercuspation). 8. It is polished to prevent soft-tissue irritation.
  83. 83. Appliance wear for Bruxism Patients  During the insertion visit, patients are given a written explanation of the purpose, use, and care of the appliance. Bruxism patients, or those with severe teeth wear, are instructed to wear the prosthesis while they sleep. They should wear it during daylight hours when there is a tendency to clench the teeth. Bruxism patients should return to the office 1 week after insertion to check the device in the mouth and to further refine the occlusion.
  84. 84.  Patients who experience difficulty adjusting to the appliance should return 2 weeks after the 1-week visit.
  85. 85. Appliance wear for TMD Patients   Patients being treated for TMD, including muscle and TMJ pain, are instructed to wear the appliance continuously, except when eating and for cleaning. Patients are cautioned not to clench their teeth without the appliance in the mouth. After 1 week, these patients are scheduled for a postinsertion visit where changes in TMD signs and symptoms are recorded.
  86. 86.  Slight changes in jaw and joint position usually require occlusal refinement to the appliance in centric relation and in excursive movements. These changes may be the result of reduced edema, reduced inflammation, and/or reduced muscle splinting/tonicity. Patients are seen at 2 to 4 week intervals until the TMD signs and symptoms have markedly disappeared.
  87. 87.   Ideally, the patients should be “weaned” off of the splint, first during the day and then during sleeping hours. If modest to good improvement is not made within 4 weeks, patients should be referred to a TMD specialist.
  88. 88. Adjunctive TMD Therapy   Over a limited time, splint therapy may be all that is needed to eliminate bruxism and/or TMD signs and symptoms. Adjunctive therapy that may help in TMD therapy includes, but is not limited to, physical therapy, counseling, nonsteroidal anti-inflammatory drugs, biofeedback, and selective occlusal equilibration therapy.
  89. 89.  It has been shown that some patients who did not obtain complete relief of their bruxism and/or TMD symptoms after prolonged use of a splint, did improve when selective occlusal equilibration was added to their therapy. However, dentists should attempt to equilibrate the occlusion only if they possess the appropriate knowledge and skill.
  90. 90.  If modest to good TMD improvement is not made within 4 weeks of initiating therapy, patients should be re-evaluated or referred to a TMD specialist. In this instance, other diagnoses and factors should be considered including chronic pain behavior, misdiagnosis, and TMJ internal derangements.
  91. 91. Complications of Occlusal Device Therapy   Tooth caries, gingival inflammation, and/or mouth odors are the result of poor compliance by the patient to maintain cleanliness of the device and the underlying teeth and gingivae. A few patients may complain that the device interferes with the tongue space. This problem is corrected by locating the lingual areas of the occlusal device that restrict tongue movement in function.
  92. 92.   Pressure- indicating paste is applied to the occlusal device and then inserted into the mouth. The patient is asked to swallow and then speak a few words. The occlusal device is removed from the mouth, and the areas on the device where paste has been rubbed off are thinned and/or shortened with a carbide denture bur. In the bruxism patient, occasional minor teeth discomfort, masticatory muscle myalgia, and/or an uncomfortable “bite” may be reported. These problems are resolved by refinement of the occlusal device to produce a more stable, mutually protected occlusion.
  93. 93.   Patients with TMD who report no improvement on postinsertion visits should be reevaluated. The first step is to refine the mutually protected occlusion on the occlusal device. If discomfort persists at future visits, refer the patient for adjunctive TMD therapy. Some patients may develop a psychological addiction or dependence to wearing the occlusal device. It is the responsibility of the dentist to monitor these patients for as long as they continue to wear the device to ensure there are no irreversible changes in the interocclusal relations.
  94. 94. An electromyographic study of aspects of 'deprogramming' of human jaw muscles.   Donegan SJ, Carr AB, Christensen LV, Zieber GJ. (1990) Surface electromyograms from the right and left masseter and anterior temporalis muscles were used to detect peripheral correlates of deprogramming, of jaw elevator muscles. Putative deprogramming was attempted through the clinically recommended use of a leaf gauge, placed for 15 min between the maxillary and mandibular anterior teeth and disoccluding the posterior teeth by about 2 mm.
  95. 95.  Use of the leaf gauge did not affect normalized postural activity (about 4%), the duration (about 900 ms) and static work efforts of clenching (about 1200 microV.s), the time to peak mean voltage of clenching (about 400 ms), and the peak mean voltage of clenching (about 300 microV). Activity and asymmetry indices showed that the studied motor innervation patterns were not changed by the leaf gauge.
  96. 96. Occlusal splint on the temporal and masseter muscles in patients with functional disorders and nocturnal bruxism.   Sheikholeslam A, Holmgren K, Riise C. (1986) The postural activity of the temporal and masseter muscles in thirty-one patients with signs and symptoms of functional disorders were studied: before, during and after 3-6 months of occlusal splint therapy. The fluctuating signs and symptoms, as well as the postural activity of the temporal and masseter muscles were significantly reduced after treatment.
  97. 97.  After cessation of the splint therapy the signs and symptoms recurred to the pre-treatment level within 1-4 weeks in about 80% of the patients. The results indicate that an occlusal splint can eliminate or diminish signs and symptoms of functional disorders and re-establish symmetric and reduced postural activity in the temporal and masseter muscles, which can facilitate procedures, such as functional analysis and occlusal adjustment.
  98. 98. Occlusion in temporomandibular disorders: treatment after occlusal splint therapy   Hobo S (1996) The concept of using the condylar path as the reference for occlusion is questionable for the patient whose temporomandibular joint has pathological changes because the condylar path of TMD patient deviates greatly. After occlusal splint therapy it is suggested that the patient's occlusion be treated using the Twin-Stage Procedure which does not require measurement of the condylar path
  99. 99.  The research findings that occlusion controls the condylar path seems to support the concept that if the dentist creates the occlusion properly, the condylar path may be corrected and thereby minimise the micro-trauma which causes TMD.
  100. 100. Critical evaluation of orthopedic interocclusal appliance therapy   Clark GT. (1984) This paper reviewed the effectiveness of occlusal splints on specific symptoms that are often associated with TM disorders. The research has shown the clicking TMJ is sometimes helped but not cured by the traditional stabilization interocclusal appliance and that TMJ clicking is the least responsive to treatment. Questions have been raised about the need to specifically treat the clicking joint; more research on this issue is necessary.
  101. 101.  Painful TMJs have been shown to respond to occlusal appliance therapy, but questions still exist about the effectiveness of interocclusal appliances for this symptom. There is little scientific proof available about the ability of splints to effectively slow down or reverse degenerative TMJ changes that are evident on radiographs. Masticatory muscle pain is by far the symptom that has the best experimental evidence to support occlusal splints as a highly effective method of treatment. These changes are probably mediated via an alteration in the patient's muscle activity patterns.
  102. 102.  Those patients with more severe symptoms are less likely to be helped with splints as a sole treatment modality. The effect of occlusal appliances in muscle trismus has been discussed but not effectively evaluated in the literature. Occlusal splints have been shown to have a distinct influence on improving mandibular muscle coordination. Inter-occlusal splints are a commonly used method of controlling attrition and adverse tooth loading, and few questions have been raised in the literature about this therapeutic application.
  103. 103. Occlusal stabilization appliances - Evidence of their efficacy   Kreiner M, Betancor E, Clark GT (2001) BACKGROUND: There is substantial controversy regarding the value of occlusal appliances for managing temporomandibular joint disorders. This article specifically assessed whether the evidence is sufficient to judge occlusal appliances as being efficacious for the management of localized masticatory myalgia, arthralgia or both. A major confounder is that few studies have measured or evaluated whether subjects had strong, ongoing parafunctional activity (such as clenching or grinding) and whether appliances influenced this behavior.
  104. 104.  LITERATURE REVIEWED: The authors evaluated four placebo-controlled studies, several randomized wait-list controlled studies and several randomassignment treatment-comparison studies. Data from the wait-list condition studies vs. those from the occlusal appliance condition studies consistently suggested that the latter treatment's effect on patient symptom level is far more than that of no treatment on a wait-list group's condition. In contrast, the studies on placebo-controlled vs. occlusal appliance studies yielded a mix of data: two showed a positive benefit of occlusal vs. nonoccluding appliances, and two showed a null effect or no difference.
  105. 105.  CONCLUSIONS: Considering all of the available data (pro and con), the authors concluded that the use of occlusal appliances in managing localized masticatory myalgia, arthralgia or both is sufficiently supported by evidence in the literature. CLINICAL IMPLICATIONS: The mechanism of action by which occlusal appliances affect localized myalgia and arthralgia probably is behavioral modification of jaw clenching. However, if the behavior continues unabated, even the best splint will not work.
  106. 106. Clinical comparison between two different splint designs for temporomandibular disorder therapy.   Jokstad A, Mo A, Krogstad BS (2005) OBJECTIVE: To compare splint therapy in temporomandibular disorder (TMD) patients using two splint designs. MATERIAL AND METHODS: In a double-blind randomized parallel trial, 40 consenting patients were selected from the dental faculty pool of TMD patients. Two splint designs were produced: an ordinary stabilization (Michigan type) and a NTI (Nociceptiv trigeminal inhibition). The differences in splint design were not described to the patients. All patients were treated by one operator.
  107. 107.  A separate, blinded, examiner assessed joint and muscle tenderness by palpation and jaw opening prior to splint therapy, and after 2 and 6 weeks’ and 3 months' splint use during night-time. The patients reported headache and TMD-related pain on a visual analog scale before and after splint use, and were asked to describe the comfort of the splint and invited to comment. RESULTS: Thirty-eight patients with mainly myogenic problems were observed over 3 months.
  108. 108.  A reduction of muscle tenderness upon palpation and self-reported TMD-related pain and headache and an improved jaw opening was seen in both splint groups. There were no changes for TM joint tenderness upon palpation. No differences were noted between the two splint designs after 3 months for the chosen criteria of treatment efficacy. CONCLUSION: No differences in treatment efficacy were noted between the Michigan and the NTI splint types when compared over 3 months.
  109. 109. The use of a deprogramming appliance to obtain centric relation records.  The purpose of this study was to investigate the effect of an anterior flat plane deprogramming appliance (Jig) in 40 subjects for whom centric relation (CR) records were obtained before and after the use of the appliance. Incisal overbite and overjet dimensions and three-dimensional instrument condylar representation using the Panadent condylar path indicator (CPI) were recorded from maximum intercuspation and centric relation. Subjects were assessed subjectively to determine the degree of difficulty manipulating the mandible to obtain the centric relation record.
  110. 110.  The mean overbite difference from maximum intercuspation (MI) to centric relation without (CR) and with (CRJ) the appliance were statistically significant and decreased 1.58 mm and 2.23 mm, respectively. The mean overjet values from MI to CR and CRJ were statistically significant and increased . 44 mm and .57 mm, respectively. Significant differences were determined on the Panadent articulator for the absolute vertical (Z) and absolute horizontal (X) values for centric relation with and without the appliance.
  111. 111.  The number of subjects who exceeded the threshold values of 2 mm for CPI recordings in either the horizontal or vertical direction was 7 (18%,) from MI to CR and 16 (40%) from MI to CRJ. The Lucia-type jig deprogramming appliance provides a centric relation record with greater displacement from MI than a centric relation record alone. This appliance may be a useful adjunct in a patient where mandibular manipulation in taking a centric relation bite registration is deemed not easy
  112. 112. Conclusion  Understanding the relationship between occlusion and functional disorders of the masticatory system is no easy task. The static, functional, and dynamic relationships of the occlusal condition to the signs and symptoms of masticatory dysfunction should be well understood. In TMJ therapy, as with most treatments, the patient's improvement is closely connected to a proper diagnosis based on sound physiologic principles.
  113. 113.  Interocclusal orthopedic appliances of varied design and application have been employed in the treatment of myofascial pain dysfunction (MPD) and temporomandibular joint disorders (TMD). These appliances provide the practitioner with a noninvasive, reversible form of intervention to manage the patient's symptoms. These appliances are often used in conjunction with other forms of treatment such as physiotherapy or medication.
  114. 114. References    Moloney and Howard: Internal derangements of the temporomandibular joint. III. Anterior repositioning splint therapy. Aust. Dent. J. 31:30, 1986. Ronquillo, Guay, Tallents, Katzberg, Murphy and Proskin: Comparison of condyle-fossa relationships with unsuccessful protrusive splint therapy. Cranio. 2:178, 1988. Okeson: Long term treatment of disc-interference disorders of the TMJ with anterior repositioning occlusal splints. J. Prosthet. Dent. 60:611, Nov 1988.
  115. 115.    Liedberg and Westesson: Sideways position of the temporomandibular joint disc: Coronal cryosectioning of fresh autopsy specimens. Oral Surg. Oral Med. Oral Pathol. 66:644, Dec 1988. Lous: Treatment of TMJ syndrome by pivots. J. Prosthet. Dent. 40:179, Aug 1978. Tallents, Katzberg, Millar, Manzione, Macher and Roberts: Arthrographically assisted splint therapy: painful clicking with a nonreducing meniscus. Oral Surg. Oral Med. Oral Pathol. 61:2, Jan 1986
  116. 116.    Okeson: The effects of hard and soft occlusal splints on nocturnal bruxism. J. Am. Dent. Assoc. 114:788, Jun 1987. Karl PJ, Foley TF. The use of a deprogramming appliance to obtain centric relation records. Angle Orthod. 1999 Apr;69(2):117-24; discussion 124-5. Wood and Tobias: EMG response to alteration of tooth contacts on occlusal splints during maximal clenching. J. Prosthet. Dent. 51:394, Mar 1984.
  117. 117.    Williamson and Lundquist: Anterior guidance: its effect on EMG activity of the temporal and masseter muscles. J. Prosthet. Dent. 49:816, 1983. Rugh and Drago: Vertical dimension: A study of clinical rest position and jaw muscle activity. J. Prosthet. Dent. 45:670, Jun 1981. Ramfjord, Ash: Occlusion , 3rd Edition, Philadelphia: WB Saunders Co 1971
  118. 118.    Donegan SJ, Carr AB, Christensen LV, Ziebert GJ.An electromyographic study of aspects of 'deprogramming' of human jaw muscles. J Oral Rehabil. 1990 Nov;17(6):509-18. Dylina TJ.A common-sense approach to splint therapy J Prosthet Dent. 2001 Nov;86(5):539-45. Clark GT. A critical evaluation of orthopedic interocclusal appliance therapy: effectiveness for specific symptoms.J Am Dent Assoc. 1984 Mar;108(3):364-8.
  119. 119.    Kreiner M, Betancor E, Clark GT. Occlusal stabilization appliances. Evidence of their efficacy. J Am Dent Assoc. 2001 Jun;132(6):770-7. Jokstad A, Mo A, Krogstad BS. Clinical comparison between two different splint designs for temporomandibular disorder therapy Acta Odontol Scand. 2005 Aug;63(4):218-26. Gray RJ, Davies SJ. Occlusal splints and temporomandibular disorders: why, when, how? Dent Update. 2001 May;28(4):194-9.
  120. 120.    Batra P, Rao L, Bhattacharya A, Duggal R, Prakash H: Muscle Deprogramming- An Orthodontist perspective. J Ind Orthod Soc 2002; 35; 113-117 Boero RP.The physiology of splint therapy: a literature review. Angle Orthod. 1989 Fall;59(3):16580 Du Pont J, Brown C: Occlusal slplints from beginning to the present. Journ Cran Mand Pract 2006 ; 24(2); 141-45
  121. 121.  Gross MD, Ormianer Z, Moshe K, Gazi E.Integrated electromyography of the masseter on incremental opening and closing with audio biofeedback: a study on mandibular posture.Int J Prosthodont. 1999 SepOct;12(5):419-25.  Michelotti A, Farella M, Vollaro S, Martina R.Mandibular rest position and electrical activity of the masticatory muscles. J Prosthet Dent. 1997 Jul;78(1):48-53.
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