Occlusal Splint/ Occlusal Device/ Orthotics: “Any
removable artificial occlusal surface used for diagnosis or therapy affecting
the relationship of the mandible to the maxillae. It may be used for occlusal
stabilization, for treatment of TMJ disorders, or to prevent wear of the
Its usually made of hard acrylic, that fits over the occlusal and incisal
surfaces of teeth in one arch, creating precise occlusal contact with the
teeth of opposing arch
Splint therapy may be defined as the art and science of establishing
neuromuscular harmony in the masticatory system and creating a
mechanical disadvantage for parafunctional forces with removable
A properly constructed splint supports a harmonious relation among the
muscles of mastication, disk assemblies, joints, ligaments, bones, teeth, and
Most occlusal splints have one primary function: to alter an occlusion so they do
not interfere with complete seating of the condyles in centric relation.
When and why are splints(orthotics) indicated?
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.
In stabilizing the occlusion in patients with anterior open bites and other
Distribution of occlusal forces
Reduction of wear
Stabilization of unopposed teeth
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).
- Splints allowing the condyle to seat in centric relation
What is CR – GPT “A clinically determined relationship of the mandible to the
maxilla when the condyle disk assemblies are positioned in their most
superior position in the mandibular fossae and against the distal slope of the
Occlusion hit and slide can create muscle
incoordination when occluding.
How do muscle and joint disorders affect occlusal stability and Centric
- All joints, including the temporomandibular joints, undergo remodeling throughout life
with thinning of the disc and remodeling(flattening) of the head of the condyle and
As the disc space diminishes, the elevator muscles continue to seat the condyle in the
fossa resulting in greater wear of the posterior molars.
In patients with oral habits of clenching and bruxing, a progression of excessive occlusal
wear, excessive interproximal wear, crowding of the mandibular teeth will be seen. With
interproximal wear, the arch shortens and a malocclusion may result and even an anterior
- Sustained muscle contraction in clenching and bruxing can lead to muscle co-contraction
and a shortened resting muscle length.
- Chronic and acute overloading of the condyle/disk assembly when it is out of its
normal physiologic position contributes greatly to the catch-all term
temporomandibular disorder. Temporomandibular joints are load bearing and
susceptible to overload.
The key rule is, “do not adjust the occlusal of the teeth in any patient with muscle
pain or muscle or TMJ dysfunction.” “Resolve the muscle and joint pain first with a
splint or other reversible procedure or modality,e.g.stress management, and then
reevalualte the occlusion.”
Centric relation is the optimal arrangement of joint, disk, and muscle.
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
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 apnea
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.
Karolyi, a German, introduced an occlusal splint in 1901 for the
treatment of bruxism.
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
They are designed to eliminate noxious occlusal contacts and promote harmonious
masticatory muscle function. The primary function of these splints is to alter the occlusion so
that teeth do not interfere with complete seating of the condyles and to control muscle forces.
These represent the flat-plane appliances. The two classic designs of permissive splints are
anterior midpoint contact splints and full contact splints.
Directive splints (Pull forward splint or Anterior Repositioning Splint)
These Are designed to position the mandible in a specific relationship to the maxilla. The sole
purpose of a directive splint is to position or align the condyle-disk assemblies. Thus directive
splints should be used only when a specifically directed position of the condyles is required
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
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
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.
Anterior midpoint contact permissive splints are designed to disengage all teeth
except the incisors. This accomplishes several objectives:
-- It removes occlusal interferences to complete joint seating on closure.
-- Simultaneously, it allows freedom for full seating of the mandibular condyles when
the elevator muscles contract on closure.
-- It encourages release of the lateral pterygoid and anterior neck positioning
muscles on closure.
It has been shown through electromyography that molar contact allows 100%
clenching force; cuspid contact permits approximately 60% maximum clenching force;
and incisor contact minimizes elevator muscle clenching force to 20% to 30% of
maximum clenching force.
Therefore, muscle clenching forces are reduced significantly when contact is
isolated exclusively on the incisors. The width of the midpoint contacting
platform is limited to the width of the 2 lower incisors, measuring 8 mm to 10
Eliminating posterior teeth contact significantly reduces noxious sensory
feedback, through the trigeminal afferents, from previously sore temporalis
muscles, which can evoke sympathetic vascular changes intracranially. This is the
premise of the nociceptive trigeminal inhibition (NTI) splint
NTI (nociceptive trigeminal inhibition) anterior midpoint
contact permissive splint.
-- Other examples of anterior midpoint contact permissive splints include the Lucia jig (Great Lakes
Orthodontics, LTD, Tonawanda, NY) and the B splint.
Lucia jig anterior midpoint contact permissive splint.
B Splint (bruxism) anterior midpoint contact permissive
Lower full arch permissive
Upper full arch permissive
Gibbs et al found that the highest recorded bite force during bruxism was 975 lbs. and
that can be as much as 6 times to that of the nonbruxer. The average maximum biting force
measured during clenching is 162 lbs. This data indicates why the forces generated during
night activity can destroy the dentition. A splint not balanced in CR will show increased
Holmgren et al have shown that splints do not stop bruxism but do redistribute the load
borne by the teeth and masticatory system.
Piper recommended using a 12- to 15-mm-thick splint (incise edge to incisal edge) to
decrease clenching efficiency. A thick splint should be considered for chronic bruxers with
morning muscle pains.
Thick splint used to decrease muscle strength during
Anterior Deprogrammer type splints
“Do not use them if the patient continues to clench and or grind on the anterior
deprogrammer type appliance and scratches are seen on the appliances.” “This will
cause injury to the TMJs.” “If a patient continues to clench on an anterior bite plane,
the biting forces will be directed onto the disc causing injury.
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.
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.
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
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.
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.
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
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
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.
Dr. N.R. Krishnaswamy (7th IOS P.G. Convention) outlined the objectives of Splint therapy as
•To find the “true” anatomic relationship of the mandible to the maxilla by “deprogramming” the muscle
to eliminate the neuromuscular reflexes.
•To test the patient’s response to a change in the occlusion
•To determine if the craniomandible relationship can be stabilized.
Prepare the model Place a sheet of Isofolan spacer in place of separating medium
Position the model in the pellets Enter the heating time of 25 seconds into the Biostar
after heating cycle is complete, swing the
chamber over the model. Lock the chamber to activate
the pressure and the cooling cycle
At the end of the cooling phase, evacuate the air pressure
from the chamber and Slide the clamping frame to the left
to release the material and swing the chamber
back to its open position.
Trim the excess material
a piece of 1.5mm splint Biocryl material is used to
fabricate an anterior
Place the material on the pressure chamber Enter the heating time of 50 seconds into the Biostar
Once the heating cycle is complete, swing the
chamber over the model
Remove the matrix from the machine and shake off
Trim excess material With a lab knife, remove the splint Biocryl from the model.
Peel away and discard the Isofolan spacer.
Place the trim-line at
With a carbide taper bur in a lab handpiece, trim the
Biocryl to the reference lines
halfway down the labial surface of
the anterior teeth and
at the gingival margin of the labial surface of the posterior
For the direct technique, try the Biocryl matrix on the
patient to make sure it’s comfortable
With 50 micron aluminum oxide, air-abraide the anterior
section from the first premolar to the first pre-molar where
the bite plane will be formed
Apply a light cure bonding agent to the anterior section
cure it according to the instructions for the bonding agent.
Light-cure rope material is used to form the bite plane.
With fingers, mold the light cure material to the basic fl
plane form from first pre-molar to first pre-molar. The
bonding agent can be used to smooth the bite plane to
reduce trimming time.
Prepare a Whale Tail with a thin layer of petroleum jelly.
This will be used to form the flat plane. Place the
appliance into the patient’s mouth and slide the Whale Tail
across the bite plane
Ask the patient to close very lightly into the bite plane so
that the lower six anterior teeth just come in contact with
the bite plane.
Use a light cure gun to cure the bite plane With a pencil, mark where the lower anteriors made
contact with the bite plane.
The goal is to trim the bite plane as flat as possible Insert the appliance in the patient’s mouth. Use blue o
black articulating paper to
check the contacts.
If all anterior teeth are not contacting the bite plane, lightly
trim marks and repeat the
process until all anterior teeth are in contact
Once all the anterior contacts are visible, choose a
different color articulating paper to mark excursive
After excursive movements are marked,
use the black or blue articulating paper
to mark the centric contacts
Remove the appliance.
Check to ensure contacts trimming and finishing procedures
Determination of the appropriate type of splint therapy depends on the specific
diagnosis of the temporomandibular disorder and a thorough understanding of the
anatomy of the condyle/disk complex.
Muscle incoordination is determined by muscle palpation, joint loading, range-of-
motion measurements, joint palpation, occlusal evaluation, and Doppler diagnosis.
Patients present with painful symptoms in the facial muscles, headaches, limited
ranges of motion, frequent joint inflammation, and occlusal interferences to CR;
infrequent clicking on jaw movement also may be present.
This anatomic asymmetryis reversible if caught in time and treated with
bite plane therapy or permissive splint therapy in Phase I (reversible treatment) and
with appropriate Phase II therapy (additive or subtractive occlusal therapy, restorative
dentistry, orthodontics, maxillofacial surgery, and segmental alveolar surgery) to restore
balance from/to the CR position.
Muscle and disk incoordination has the same signs and symptoms as muscle
incoordination except reciprocal clicking or a history of reciprocal clicking
that stops. Diagnosis may include sagittally corrected tomograms. Patients
often present with the medial pole of the condyle intact under the disk with
the lateral pole of the disk damaged from loading or stretching and
subsequent ligament laxity.
Most symptoms may be reversible if caught in time, though the
reversibility of clicking depends on the shape of the distorted disk and the
fibrosis of the lateral pterygoid muscle.
Treatment usually includes permissive splint therapy and Phase II therapy
for stabilization because of the weak ligament structure.
With advanced muscle and disk incoordination, symptoms may be the
same as in previous stages, though jaw locking, painful joint noises, and
increases in pain with splint therapy may be evident. These patients often
have a long history of joint noises without pain that have become painful.
Pain on loading with bimanual manipulation is evident and may be
Diagnostic techniques include sagittally corrected tomograms and
magnetic resonance images. Surgical intervention may be necessary
depending on the location and degree of displacement of the disk.
These stages are irreversible but may be managed to a pain-free state
with appropriate medications, splint therapy, and Phase II therapy.
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2) J Appl Oral Sci 2004; 12(3): 238-43
3) Anterior Deprogrammer Fabrication Technique
4) DeWitt C. Wilkerson, DMD Senior Faculty/Lecturer, Dawson Academy Adjunct
Professor, University of Florida College of DentistryPartner, International Center for
Complete Dentistry, St. Petersburg, Florida.
5) J Adv Prosthodont 2014;6:103-8
6) J tnd Orthod Soc 2002; 35:113·117
7) J Prsthet Dent 2001;86:539-45.