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INTRODUCTION
Practitioners appreciate a practical approach to all
aspects of treatment; splint therapy is no exception.
The purpose of this article is to review the current
understanding of how splints work, describe various
splint types and their uses, and suggest how to ensure
their proper design, fabrication, and adjustment.
Splint therapy may be defined as the art and science
of establishing neuromuscular harmony in the mastica-
tory system and creating a mechanical disadvantage for
parafunctional forces with removable appliances. A
properly constructed splint supports a harmonious
relation among the muscles of mastication, disk assem-
blies, joints, ligaments, bones, teeth, and tendons.
Fig. 1. Anterior deprogrammer to separate posterior teeth
SPLINT TYPES AND FUNCTIONS with smooth function on anterior teeth.
All splints are classified as either permissive or non-
permissive. A permissive splint1 allows the teeth to
move on the splint unimpeded, which in turn allows
the condylar head and disk to function anatomically.
A nonpermissive splint has a ramp or “indentations”
that position the mandible inferiorly and anteriorly
and secure it there. Examples of permissive splints
include bite planes (anterior jigs, Lucia jig, anterior
deprogrammer) (Fig. 1) and stabilization splints (flat
plane, Tanner, superior repositioning, and centric
relation [CR]) (Fig. 2). An example of a nonpermis-
sive splint is a repositioning splint (anterior
repositioning appliance [ARA]) (Fig. 3). Soft splints
and hydrostatic splints (Aquilizer; Jumar Corp,
Carefree, Ariz.) could be considered pseudo-permis-
sive splints, as their functions are extremely different Fig. 2. Occlusal view of mandibular stabilization
than those of the permissives. appliance.
Properly fabricated splints have at least 6 functions,
including the following: (1) to relax the muscles, (2)
to allow the condyle to seat in CR, (3) to provide diag-
Relaxing the muscles
nostic information, (4) to protect teeth and associated
structures from bruxism, (5) to mitigate periodontal It has been well documented that tooth interfer-
ligament proprioception, and (6) to reduce cellular ences to the CR arc of closure hyperactivate the lateral
hypoxia levels. pterygoid muscle2; posterior tooth interferences during
excursive mandibular movements cause hyperactivity of
the closing muscles3; and the elimination of posterior
aPrivate practice. excursive contacts by anterior guidance significantly
Mitigating periodontal ligament resin will facilitate the establishment and adjustment
proprioception of contact points. Orthodontic acrylic resin is user-
friendly, easy to adjust, and soft enough not to
Proprioceptive fibers contained in the periodontal hyperactivate periodontal ligaments. It also can be
ligaments of each tooth send nerve messages to the polished to a high luster for a low-friction surface.
central nervous system. They indicate the amount of Methyl methacrylates are relatively easy to work with
force on individual teeth and can trigger muscle pat- but maintain a strong odor and exhibit a granular
terns to protect teeth from overload. A splint can composition that is harder to polish and adjust. The
balance proprioception and even lessen it to mitigate soft rubber resilient materials used for sports guards
proprioceptive output. Hellsing27 has shown experi- possess none of the characteristics important to
mentally how muscle changes immediately with tooth splint therapy and have no effective use in this arena.
contact and that periodontal afferent feedback (propri- The literature has shown that they may even increase
oception) must be responsible for this rapid adaptation. bruxism. 30 Hydrostatic “pseudo” splints work to
Hannam et al28 also found that in cats, stimulation of separate the teeth and reduce muscle hyperactivity
pressure receptors in the periodontal membrane led to for short periods while full-coverage splints are
a jaw-opening reflex. This helps clarify why the teeth being fabricated. Long-term use of the former is not
must be kept in balance with the condyle/disk assem- recommended. Ultra splint resin (Astron Dental
bly to maintain neuromuscular harmony in the Products, Lake Zurich, Ill.) is suggested for patients
associated muscles. with allergies to orthodontic acrylic resins.
The laboratory needs explicit instructions for the
Reducing cellular hypoxia levels
fabrication of any intraoral appliance. Maxillary and
In a study by Nitzan,29 pressure was measured in mandibular appliances have completely different
the superior joint space of patients with articular disk designs, though they function the same. All teeth
displacements. When they clenched maximally, record- contact in CR on a maxillary appliance. A mandibu-
ed pressures reached up to 200 mm Hg. When a flat lar appliance often will have cuspid-to-cuspid
plane appliance was placed, no significant pressure (no contact in CR, with the maxillary anterior teeth not
capillary hyperfusion pressure) was recorded. This touching. Many TMD patients have a significant
lends credence to stabilization splint therapy from a horizontal overlap; to extend the mandibular acrylic
molecular point of view. resin to contact the maxillary teeth would be
unsightly, physically uncomfortable, and unneces-
SPLINT CHARACTERISTICS
sary. Since the oral cavity is a dynamic system and
The characteristics of a successful splint should the movement of the jaw is nearly always forward,
include stability; balance in CR; equal intensity stops the anterior teeth will be in constant contact
on all teeth; immediate posterior disclusion; a “skating with the splint. This area must be balanced by hav-
rink” surface; smooth transitions in lateral, protrusive, ing the patient move in protrusive, lateral, and
and extended lateral excursions (crossover); comfort mediolateral movements, marking the areas, and
during wear; and reasonable esthetics. Patient compli- establishing anterior guidance principles already
ance also contributes to splint success. mentioned.
A splint that moves in the mouth cannot provide Mandibular appliances are the popular choice for
the stability necessary for a definitive, immobile sur- active patients who wear splints 24 hours per day, as
face prepared for heavy forces from all directions. The they do not show or affect speech as much as maxil-
laboratory must fabricate a splint so that it comes on lary appliances. On the other hand, the maxillary
and off with a slight undercut to ensure a firm fit. The appliance is an attractive choice for night wear, as all
patient should feel no sense of tightness on any of the of the teeth are in contact with equal intensity, and
teeth when the splint is seated; if that is not the case, the 13% of the population that bruxes isometrically
tooth hypersensitivity usually will follow. The length of will have these forces more equally balanced. Other
the splint on the lingual and buccal is dependent on reasons for the choice of one arch over the other
the need for retention as a result of tooth size and include arch irregularities, the patient’s profession,
shape. The shorter and thinner the splint is on the lin- and the potential for gagging. It is appropriate for
gual, the better the patient compliance, the more the patient to have a mandibular appliance for day
distinct the speech, and the more comfortable the wear and a maxillary appliance for the night (Fig. 7).
tongue posture will be. The buccal flanges must be Twenty-four–hour splint wear is recommended
thick enough to be strong but not impinge on the because of the forces generated when teeth come
neutral zones. Thinness can create discomfort or lip together during swallowing and chewing.
“trapping.” Swallowing forces exceed chewing forces,23 occur
Fabrication in a hard, heat-polymerized acrylic approximately 2000 times per day, and happen all
Muscle and disk incoordination has the same signs put in their mouths yet stop improving after the initial
and symptoms as muscle incoordination except recip- 1 to 2 weeks. If the interferences on the splint are con-
rocal clicking or a history of reciprocal clicking that tinually chased by rebalancing into CR, the patient will
stops. Diagnosis may include sagittally corrected grow comfortable and stay that way. The more skilled
tomograms. Patients often present with the medial the practitioner becomes with this balance and timing,
pole of the condyle intact under the disk with the lat- the more rapidly the patient can progress. The tech-
eral pole of the disk damaged from loading or nique inevitably works; however, lack of attention to
stretching and subsequent ligament laxity. Most symp- detail or the skill level of the doctor may influence suc-
toms may be reversible if caught in time, though the cess.
reversibility of clicking depends on the shape of the In a study by Holmgren et al,20 changes were seen
distorted disk and the fibrosis of the lateral pterygoid on the splint (in the form of indents) in 61% of
muscle. Treatment usually includes permissive splint patients at every 2-week evaluation. The remaining
therapy and Phase II therapy for stabilization because 39% of the patient pool experienced changes from
of the weak ligament structure. time to time. The majority of splint wearers need to be
With advanced muscle and disk incoordination, seen more often than every 2 weeks for initial adjust-
symptoms may be the same as in previous stages, ments. A suggested protocol would include adjustments
though jaw locking, painful joint noises, and increases at 24 hours, 54 hours, 7 days, 2 weeks, and 1 month
in pain with splint therapy may be evident. These after seating. When no movement on the splint is seen
patients often have a long history of joint noises with- at adjustment appointments and symptoms are
out pain that have become painful. Pain on loading reduced, the intervals between adjustments can be
with bimanual manipulation is evident and may be extended as long as any reversal of symptoms is coun-
extreme. Diagnostic techniques include sagittally cor- tered with an immediate adjustment appointment.
rected tomograms and magnetic resonance images. After 3 months with no changes on the splint, a com-
Surgical intervention may be necessary depending on fortable musculature, and no pain on loading, the
the location and degree of displacement of the disk. patient is ready for evaluation of phase II therapy.
These stages are irreversible but may be managed to a
SPLINT FABRICATION
pain-free state with appropriate medications, splint
therapy, and Phase II therapy. Practitioners beginning a career in treating bruxers
or TMD patients may become frustrated while trying
SPLINT DESIGN WITH FUNCTIONAL
to seat a new splint in a reasonable period of time.
CONSIDERATIONS
Laboratories often provide a prosthesis from a maxi-
Understanding the function of the masticatory sys- mum intercuspation (MI) occlusion that presents high
tem provides an excellent basis for splint design. A set on the distal of the splint and ends up having a hole
of teeth (the splint) is needed that has equal intensity ground all the way through the acrylic resin in an
contact on all the teeth, provides immediate posterior attempt to balance the occlusal relation. Without an
disclusion by the anterior teeth and condylar guidance, accurate CR occlusal record, accurate models of all
and is as frictionless as possible for neuromuscular har- occluding surfaces, and a reliable face-bow transfer,
mony and subsequent healing. The stabilization splint seating time will be longer and occasionally impossible
meets these needs.1 It can be placed on either arch as because of excessive or inadequate acrylic resin. With
long as the basic requirements are met. The splint precise laboratory instruction and records, seating and
must allow the condyle to achieve the CR position. adjusting should take no longer than 10 minutes. In-
This can be achieved with bimanual manipulation, house fabrication allows the practitioner to quickly and
which was fostered by Dawson34 and has proven to be efficiently develop the prosthesis that the diagnosis
the most reliable and repeatable35 method for achiev- demands. If this is not possible, precise communica-
ing CR with inexperienced practitioners. tion with a commercial dental laboratory is necessary
A stabilization splint is not unique if the teeth to provide the quality prosthesis mandatory for treat-
and/or inflammation result in an incomplete condylar ment success.
seating. The splint could be considered a set of teeth
WHAT SPLINTS CANNOT DO
with occlusal interferences. Therefore, the splint must
be continually monitored and adjusted. When the Splints cannot do 3 basic things: unload the joint,
muscle relaxes and/or inflammation subsides, the prevent bruxism, or “heal” the patient. Some authors
position of the teeth on the splint changes. When and lecturers have stated that splints function to
readjustment on the splint to the CR position is unload the joints and therefore take pressure off the
accomplished, the teeth and condyle/disk assembly disk. This theory has been disproved by Kuboki et al36
achieve neuromuscular harmony. This explains why and cannot be explained anatomically or physiological-
patients feel some initial relief from almost anything ly. The elevator muscles are located behind the most
posterior tooth and therefore ensure that the joint will 14. The glossary of prosthodontic terms. J Prosthet Dent 1999;81:39-110.
15. Boyd RL, Gibbs CH, Mahan PE, Richmond AF, Laskin JL. Temporomandibular
always be loaded when the elevators contract. The joint forces measured at the condyle of the Macaca arctoides. Am J
unloading theory is probably used to protect the valid- Orthod Dentofacial Orthop 1990;97:472-9.
ity of splint designs that are ineffective in their 16. Hekneby M. The load of the temporomandibular joint: physical calcula-
tions and analyses. J Prosthet Dent 1974;31:303-12.
theorized function. Such splints open the vertical 17. Korioth TW, Hannam AG. Mandibular forces during simulated tooth
dimension and minimally decompress the condylar clenching. J Orofac Pain 1994;8:178-89.
head when not loaded to reduce superior tissue pres- 18. Curtis DA, Nielsen I, Kapila S, Miller AJ. Adaptability of the adult primate
craniofacial complex to asymmetrical lateral forces. Am J Orthod
sures. They also may increase temporomandibular Dentofacial Orthop 1991;100:266-73.
joint loading37 that results from greater maximum 19. Radin EL, Paul IL, Rose RM. Role of mechanical factors in pathogenesis
muscle efficiency. of primary osteoarthritis. Lancet 1972;1:519-22.
20. Holmgren K, Sheikholeslam A, Riise C. Effect of a full-arch maxillary
Splints do not prevent bruxism; they balance the occlusal splint on parafunctional activity during sleep in patients with
force distribution to the entire masticatory system. nocturnal bruxism and signs and symptoms of craniomandibular disor-
They can decrease the frequency but not the intensity ders. J Prosthet Dent 1993;69:293-7.
21. Faulkner, KD. Bruxism: a review of the literature. Part I. Aust Dent J
of bruxing episodes.20 Splints also do not heal 1990;35:266-76.
patients; they give patients the opportunity to heal 22. Gibbs CH, Mahan PE, Mauderli A, Lundeen HC, Walsh EK. Limits of
themselves. The patient pays not for the fabrication of human bite strength. J Prosthet Dent 1986;56:226-9.
23. Gibbs CH, Mahan PE, Lundeen HC, Brehnan K, Walsh EK, Holbrook
a splint only but also for the care, skill, and judgment WB. Occlusal forces during chewing and swallowing as measured by
of the practitioner whose goal is to enable healing sound transmission. J Prosthet Dent 1981;46:443-9.
through appropriate design, monitoring, and adjust- 24. Gentz R. Apparatus for recording of bruxism during sleep. Sven Tandlak
Tidskr 1972;65:327-42.
ment. 25. Kydd WL, Daly C. Duration of nocturnal tooth contacts during bruxing.
J Prosthet Dent 1985;53:717-21.
SUMMARY 26. Piper M. Manual for intermediate to advanced TMD treatment. St.
Petersburg (FL): Center for Advanced Dental Study; 1999. p. 1-17.
There is sufficient credible literature to support the 27. Hellsing G. Functional adaptation to changes in vertical dimension. J
use of splint therapy to reinstitute neuromuscular har- Prosthet Dent 1984;52:867-70.
mony in a compromised masticatory system. Dental 28. Hannam AG, Wood WW, De Cou RE, Scott JD. The effects of working-
side occlusal interferences on muscle activity and associated jaw
practitioners have a responsibility to understand and movements in man. Arch Oral Biol 1981;26:387-92.
provide this treatment, monitor the condition, and 29. Nitzan DW. Intraarticular pressure in the functioning human temporo-
refer the patient to another practitioner if necessary. mandibular joint and its alteration by uniform elevation of the occlusal
plane. J Oral Maxillofac Surg 1994;52:671-9.
30. Okeson JP. The effects of hard and soft occlusal splints on nocturnal
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