Bite Splints

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Technique for Construction of a Maxillary Stabilization Splint.

Part 1

Pei Feng Lim BDS, MSDiplomate of the American Board of Orofacial PainFellow of the American Academy of Orofacial PainDirector, Oral & Maxillofacial Pain ProgramUNC at Chapel Hill, School of [email protected]

Occlusal Splint Therapy1. Lecture: Bruxism & Occlusal Splint Therapy2. Lecture: Technique for Construction of a Maxillary

Stabilization Splint. Part 13. Clinic: Maxillary impression & model4. Clinic: Splint construction 15. Lecture: Technique for Construction of a Maxillary

Stabilization Splint. Part 26. Lecture & Lab: Masticatory Muscle & TMJ disorders7. Clinic: Splint construction 28. Clinic: Splint construction 3

Types of Splints

• Stabilization Splint / Muscle Relaxation Splint• Anterior Positioning or Repositioning Splint /

Orthopedic Repositioning Splint• Anterior Bite Plane• Posterior Bite Plane• Pivoting Splint• Soft Splint• Etc.

Stabilization Splint

• When splint is in place, condyles in musculoskeletally stable position, teeth contact evenly & simultaneously

• canine guidance• AIM: eliminate orthopedic instability between occlusal

position & TMJ position

Stabilization Splint• maxillary / mandibular

Advantages of Maxillary stabilization splint1. Covers more tissue → > stable, > retentive, < likely to break2. Easier to achieve occlusion in Class II & III3. Lower teeth contact on flat surface → > stable4. Easier to locate CR position

Advantages of Mandibularstabilization splint1. Aesthetics

Contraindications1. Mixed dentition 2. Orthodontic treatment

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Criteria for Stabilization Splint1. Good fit, stability & retention2. In CR, mandibular buccal cusps

contact flat surfaces evenly3. Protrusion on canines4. Laterotrusion on canines5. Mandibular posterior teeth

contact splint only in CR6. Upright position, posterior occlusion

more prominent than anterior7. Splint occlusal surface is flat8. Splint polished

Many Techniques

• None better than the other• Indirect (lab) Vs Direct (chair side)

techniques• Technique sensitive

The best technique is the technique you are most experienced in & most comfortable with

Indirect TechniqueLess chair-side time (more popular)

1. Maxillary & Mandibular impression & models

Indirect Technique

2. Bite Registration

Indirect Technique

3. Face-bow record

Indirect Technique

4. Send to Laboratory

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Indirect Technique

5. Finished product from Lab

Indirect Technique

6. Splint delivery

Direct Technique

• Is what you will learn in this course• Disadvantage: chair time • Advantage: if you can do this, you can make

any splint with any technique on any planet

Technique Outline1st visit• Patient assessment• Maxillary impression

Laboratory Phase

2nd Visit• Splint delivery

3rd Visit (follow-up)• Splint adjustment

Visit 1: Patient Assessment Demographics• Name • Date • BP• Pulse• Age• Sex• Medical Hx: Bruxism secondary to medical condition

(neurodegenerative disorders? Parkinsons? Epilepsy? Sleep disorder? Anxiety disorder? Chronic pain conditions? TMD?)

• Current Meds: Bruxism secondary to Rx/drug use• Allergies:

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Chief Complaint• “I have soreness in my jaw when I wake up in the

morning”• “Mom thinks I am grinding my teeth in my sleep”

• “3 of my back teeth have fractured in the past month. Do you think I am grinding my teeth?”

• “I have fibromyalgia. My rheumatologist thinks I have TMD and he said a bite splint should help”

• “I have had the TMJ for many years. Lately, my headaches have worsened. My neurologist says maybe I’m grinding my teeth. Will a bite splint help?”

Chief Complaint• Bruxism: clenching, grinding, other oral parafunctional habits

• Reported by bed partner• Jaw soreness/pain in the morning• Jaw muscles feel tired in the morning• TMJ clicking/crepitus

Chief Complaint• Restricted mouth opening• History of jaw locking• Jaw pain• Headaches

• History of past treatment: multiple splints, tx for TMD, tx failures

Psychosocial History• Caffeine• Alcohol• Nicotine• Sleep disorder: snoring, sleep apnea• Stressors: life events, lifestyle, anxiety

Clinical Examination• Mandibular Function & Provocation Tests• Palpation of Orofacial Muscles• Palpation of TMJ• Mandibular Range of Motion

Clinical Examination

• Intraoral Examination: tooth wear, tooth mobility, cheek indentation, tongue indentations

• Occlusion: intercuspalposition, working contacts, non working contacts, protrusive contacts

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Clinical ExaminationExamine current splint (if present)• Splint description: maxillary/mandibular, partial/full-

coverage, soft/acrylic• Fit • Retention• Stability• Occlusion: centric stops, lateral guidance, protrusive guidance

Additional TestsQuestionnaire

1. Has anyone heard you grinding your teeth at night?2. Is your jaw ever fatigued or sore on awakening in the

morning?3. Are your teeth or gums ever sore on awakening in the

morning?4. Do you ever experience temporal headaches on

awakening in the morning?5. Are you ever aware of grinding your teeth during the

day?6. Are you ever aware of clenching your teeth during the

day?

>2 positive responses => bruxer

Bader & Lavigne. Sleep Med Rev 2000;4(1)27-43

Additional TestsPolysomnogram

Additional TestsEMG Recording

Additional TestsImaging Summary of Findings

• Clinical Impression: Nocturnal bruxism? Daytime parafunctions?

• Contributing Factors: Psychosocial stressors? Caffeine?

• Treatment Plan1. Advised stress mx & reduce caffeine intake2. Maxillary stabilization splint

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Maxillary Impression

A good quality impression accurately capturing

1. all teeth

2. hard palate

Armamentarium

Maxillary Impression

Look at the palatal arch Select tray

Making a Maxillary Impression

Check Impression

Faculty signature

Criteria for good impression

1. All teeth captured

2. Hard palate captured

3. Good quality & accurate

Fabricate stone model

A good quality model accurately capturing

1. all teeth

2. hard palate

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ArmamentariumStone Model

Check Model

Faculty signature

Criteria for good model

1. All teeth captured

2. Hard palate captured

3. Good quality & accurate

Splint Outline

• Buccal & labial extension –at level of interdental papilla

• Distal extension – distal to last tooth (2nd molars)• Palatal extension – 15mm from gingiva

Draw Splint OutlineArmamentarium

Draw Splint Outline• Buccal & labial extension – at level of interdental papilla

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Draw Splint Outline• Palatal extension – 15mm from gingiva

Draw Splint Outline• Palatal extension – 15mm from gingiva

Draw Splint Outline• Distal extension – distal to last tooth (2nd molars)

Write patient’s name on base of model

Faculty signature

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Wrap Stone ModelDraw Splint Outline

Recapitulation 23 Feb 8-10am Recapitulation 23 Feb 8-10am

Recapitulation 23 Feb 8-10amLab Sheet Instructions

• use hard/soft material

• follow splint outline drawn on model

• create anterior stop

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Anterior Stop

5mm10mm

5mm

Lab ProcedureFinished Product from Lab

Checklist

• Splint, model, case for storing splint

• Correct hard/soft material

• Anterior stop

Finished Product from LabChecklist

• Splint outline

• Fit

• Retention

• Stability

Faculty signature

Poor retention & unstable

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Visit 2: Splint Delivery Armamentarium

Check splint in the mouthChecklist

• Fit

• Retention

• Stability

Locating the CR positionMusculoskeletally stable position

Locating the CR Locating the CR

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Check splint in the mouth

Checklist

• Anterior stop perpendicular to lower incisor

Check posterior separation

Checklist

• Posterior teeth separation ~2mm.

Checklist

• Posterior teeth separation ~2mm.

** If >2mm, reduce vertical height of anterior stop

** If <2mm, add acrylic to increase vertical height of anterior stop

Anterior stop

2mm

Last molar

Occlusal surface of splint

Inferior surface perpendicular to lower incisor

Lubricate acrylic

restorations with vaseline

Building the Occlusion

• Mix acrylic

• Place acrylic on occlusal surface of splint


• Seat splint in the mouth

• Guide mandible to CR. Patient close till lower incisors hit anterior stop

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Leave splint on model to allow acrylic to polymerize

WHY??

Recapitulation 23 Feb 8-10am



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Recapitulation 23 Feb 8-10am

Up next,23 Feb Clinic 8-10amMaxillary impression

Documents

Bite Splints