Occlusal Splints Used In Prosthetic Management Of Tmj Disorders

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Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders CONTENTS • I NTRODUCTI ON • DEFI NI TI ON • PURPOSE  WHAT OCCLUSAL SPLI NTS CAN DO? AND CANNOT DO? •  VARI OUSUNEXPLAI NED THERAPEUTI C CLAI MS • CLASSI FI CATI ON • GENERALCON ONSI DERATI ONS • MUSCLERELAXATI ON APPLI ANCE  ANTERI OR REPOSI TI ONI NG APPLI ANCE •  ANTERI OR BI TE PLANE • • POSTERI OR BI TEPLANE • PI VO OT TI NG APPLI ANCE • SOF OFT/RESI LI ENTAPPLI ANCE • RELATED ARTI CLES • SUMM MMARY DEPT. OF PROSTHODONTICS  114 114 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders • BI BLI OGRAPHY DEPT. OF PROSTHODONTICS  115 115 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders OCCLUSALSPLI NTSUSED I N PROSTHETI C MANAGEMENT OFTMJDI SORDERS I NTRODUCTI ON:  An occl usalappl i ance ( of t en cal l ed a spl i nt )i sa r emov abl e devi ce,usual l ymadeofhar dacryl i c,t hatfit sovert heoccl usaland i nci salsur f aces oft eet hi n one arc h,cr eat i ng pr eci se occl usal cont actwi t ht het eet hofopposi ngar ch. I ti scommonl yr ef err ed t oasabi t eguar d,ni ghtguar d,i nt er oc c l us alappl i anc e s,i nt r aor a lar t ho t i c ,ore v e nor t hopae di cde v i c e .  Thesear eext ensi v el yusedi n managementofTMJdi sor der s .  The y shown consi der abl ec ont r oli n my of aci alpai n,howe v er no cl earhypot hesi saboutt hemechani sm ofact i onhasbeenpr oved. I thas mor e ofdi agnost i c val ue,f or exampl e,i fa pat i ent r espondsf avor abl et oan occl usaldevi cet hen t her esponset ot he same r es t or at i ve per manentt r eat mentshoul d be posi t i ve .So i t ser ve s as an i mpor t antdi agnost i c val ue bef or e goi ng t o an fixed pr o s t ho dont i ct he r a py . DEFI NI TI ONS  Tempor omandi bul arj oi nt : DEPT. OF PROSTHODONTICS  116 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders  The ar t i cul at i on be t ween t he t empor al bone and t he mandi bl e .I ti sadi ar t hr o i dal ,bi l at e r alg i ngl y musar t hr oi dalj oi nt .  Thear t i cul at i on oft hecondyl arpr ocessoft hemandi bl eand t hei nt er art i cul ardi sk wi t ht hemandi bul arf ossaoft hesqumous por t i on oft empor albone;mov ementi n upperj oi ntcompart menti s most l yt r ansl at i onal ,wher eas i nt he l owerj oi ntcompart menti s mos t l yr o t at i onal .  The j oi ntc onnect st he mandi bul arcondyl et ot he ar t i cul ar f os sa of t he t empor al bone wi t h t he t empor omandi bul ar di s c i nt erposed.  Tempor omandi bul arDi sor der s: “ Abnormal ,i ncompl et e,ori mpai r edf unct i onofTMJ” . Occl usalSpl i nt /Occl usalDevi ce/Or t hoti cs: “ Any r emovabl ear t i fici aloccl usalsurf aceused f ordi agnosi s or t her apy affec t i ng t he r el at i onshi p of t he mandi bl et ot he max i l l ae .I tma ybeus e df o roc c l us als t abi l i z a t i o n,f o rt r e at me nto f  TMJdi sor der s,ort opr ev entwearoft hedent i t i on. ” Occl usalPi vot : “ An el evat i on pl aced on t heoccl usalsur f ace,usual l yi nt he mol ar r eg i on, des i gned t o act as a f ul cr um, t hus l i mi t i ng mandi bul arcl osur eandi nduci ngmandi bul arr ot at i on” . Occl usalPr emat ur i t y: DEPT. OF PROSTHODONTICS  117 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders “ Anycont actofopposi ngt eet ht hatoccur sbef or et hepl anned ar t i cul at i on” . Br uxi sm/Toot hGr i ndi ng/Occl usalNeur osi s: “ Thepar af unc t i o nalg r i ndi ngo ft e e t h” . “ An or al habi t consi s t i ng of i nv ol unt ar y r hyt hmi c or spasmodi cnonf unct i onalgnashi ng,gri ndi ngorcl enchi ngoft eet h, i n ot hert han c he wi ngmov ement sofmandi bl e,whi c h mayl eadt o occl usalt r auma” . PURPOSE:  The pur pose of occl usal t r eat ment i st o make t he t ee t h c onf or mt oac or r e c ts ke l e t onr e l at e dpos i t i ono ft hec ondy l araxi s .  The pur pose ofoccl usalspl i nt si st o pr ovi de an i ndi r ect met hod f or al t er i ng t he occl usi on unt i lt he cor r ect ness of t he condyl araxi sposi t i oncanbedet er mi nedandconfir med.  WHAT OCCLUSALSPLI NTSCAN DO? 1.St abi l i zat i on ofweak t eet h:An occl usalspl i ntcan effect i vel y st abi l i zeweak orhyper mobi l et eet h byt headapt at i on oft he s pl i ntmat e r i alar oundt heax i als ur f ac e s . 2.Di s t r i but i onofo cc l us alf o r c e s 3.Reduct i onofwear DEPT. OF PROSTHODONTICS  118 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders 4.St abi l i zat i on ofunopposedt eet h  WHAT OCCLUSALSPLI NTSCANNOT DO? Occl usalspl i nt scannotcauseeffect st hatar ei n vi ol at i on of mec hani call aws.Thus an oc cl usalspl i nt does not unl oad t he condyl es.Thepopul arcl ai mt hatapost eri oroccl usalspl i ntserves asa pi v o tf ordi s t r ac t i on o ft hec ondy l e si si nv i ol at i on o ff ac t so f anat o my ,l a wsofphy s i c s ,andc l i ni c aldat a.  VARI OUSUNEXPLAI NED THERAPEUTI C CLAI MS: 1.Occl usalspl i nt si ncr easet hewear er ’ sst r engt h 2.Occl usalspl i nt scauser emi ssi onofunr el at eddi seases 3.Occl usalspl i nt scancausea‘ pur gi ngofsyst em poi sons’ 4.Occ l usal spl i nt s cause a ‘ r egul at i on of mul t i pl e bodi l y f unc t i ons ’ .  TYPES:  Accor di ngt oOkeson 1)Muscl er el axat i on appl i ance/st abi l i zat i on appl i anceused t o r educemuscl eact i vi t y 2)Ant er i or r eposi t i oni ng appl i ances/ ort hopedi cr eposi t i oni ng appl i ance DEPT. OF PROSTHODONTICS  119 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders Ot hert ypes: a)Ant eri orbi t epl ane  b)Pi v ot i ngappl i ance c )Sof t /r e s i l i e ntappl i anc e  Accor di ngt oDawson: 1.Per mi ss i v es pl i nt s/musc l edepr ogr ammer 2.Di r e c t i v es pl i nt s /no npe r mi s s i v es pl i nt s 3.Ps e udope r mi s s i v es pl i nt s( e . gSof ts pl i nt s ,Hy dr os t at i cs pl i nt ) MORA–mandi bul aror t hopedi cr eposi t i oni ngappl i ance  TypesofOccl usalSpl i nt s: 1.Aper mi ssi vespl i ntor 2.Adi r e c t i v espl i nt e desi gned t o unl oc kt he oc cl usi on t o  Per mi ssi ve Spl i nt s: Ar r emovedevi at i ngt oot hi ncl i nesf r om cont act .Thecondyl esar et hen al l o we dt or e t ur nt ot he i rc or r e cts eat e d pos i t i oni nc ent r i cr e l at i on i ft hec ondi t i o no ft hear t i c ul arc ompone nt spe r mi t s . Per mi ssi v e spl i nt s ar e of t en r ef er r ed t o as muscl e depr ogr ammer s.A pr oper l ymadecent r i cr el at i on occl usalspl i nti s ape r mi s s i v es pl i nt . DEPT. OF PROSTHODONTICS  120 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders I fa cent r i cr el at i on spl i nt i s made wi t h deep f ossae and i nc l i ne st hata r et o os t e e p,i tc a n bet ur ne di nt oadi r e c t i v es pl i nt t hatl i mi tc ondy l ara cc es st oc ent r i cr e l at i ononl y . e des i gned t o posi t i on t he mandi bl ei na Di rect i ve spl i nt s:Ar s pe c i ficr e l at i ons hi pt ot hemax i l l a.Theso l epur po seo fadi r e c t i v e spl i nti st o posi t i on or al i gn t he condyl edi sk assembl i es.Thus di r ect i vespl i nt sshoul d beused onl ywhen a speci fical l y di r ect ed pos i t i ono ft hec ondy l e si sr e qui r e d. Cont r ai ndi c at i onsf orDi r ec t i v eSpl i nt s: 1.Thecondyl eandt hedi skcanbeal i gnedcorr ect l y . 2.Thecor r ect l yal i gnedcondyl edi skassembl i escanmovet ot he mos t super i or posi t i on agai ns tt he emi nent i ae wi t hout der ange ment . 3.The di sks can mai nt ai nt hei ral i gnmentwi t ht he co ndyl es dur i ngf unc t i on.  Ver i ficat i on t hatt he condyl edi sk assembl i es ar e capabl e of normalf unct i oni nt hemostsuper i orposi t i oncanbeachi ev edona t e nt at i v ebas i sbyt e s t i ngi nt hef o l l o wi ngmanne r : 1.Lo adt e s t i ngt hej oi nt swi t hbi l at e r a lpr e s s ur e DEPT. OF PROSTHODONTICS  121 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders 2.Cl encht est i ngwi t ht het eet hseparat ed 3.Doppl erauscul t at i on Superi orReposi t i oni ngSpl i nt s:  Thepur poseofant er i orr eposi t i oni ngt her apyi sf ul fil l e dwhen t he r e t r odi skal t i ss ues hav e heal ed suffici ent l y t o r eg ai n a  bac kwar dpul lon t hedi sk.Howev er ,ei t hert hecondyl eort hedi sk mayhavedi fficul t ymovi ngbackt ocent r i cr el at i on af t erbei nghel d f orwar d. Ther ei sr eason t o suspect t hat t he i nf er i or l at er al pt er y goi d musc l e i s shor t ened by l ongt er m use of ant er i or r eposi t i oni ngdevi ces.Thi smakesi tmor edi fficul tf ort hemuscl es t or e l e as et hec ondy l e st ot he i rmos ts upe r i o rpo si t i o n.De f o r mi t yof t hedi spl aced di skmayal sor equi r et i met oadapt i vel yr emodelt oa s t abl econt our .  Thepur poseofasuper i orr eposi t i oni ngs pl i nti st oel i mi nat e t heeffectoft heneur omuscul arr eflext hatdi r ect st hemandi bl et o cl ose r epet i t i vel yi nt ot he maxi mum i nt er cuspat i on posi t i on.By cove r i ng t he occl usalsur f aces wi t h pl ast i ct o pr ovi de a smoot h sur f ace ,you can el i mi nat et her eflex and t hemandi bl e can hav e f r e eac c es st ot hes e at e dpos i t i on.  Thegoali sat r ueskel e t alr el at i onshi poft hemandi bl et ot he max i l l a and not one t hat i s i nfluence d by t he max i mum DEPT. OF PROSTHODONTICS  122 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders i nt er cuspat i on of t he t ee t h. The pur pose of t he super i or r e pos i t i oni ngs pl i nti st oe s t abl i s ht hec or r e cts ke l e t alr e l at i ons hi p  bef or et hecor r ectoccl usalr el at i onshi pi sde t er mi ned.  Thef abr i cat i on ofa super i orr eposi t i oni ngs pl i nti si dent i cal t ot he c e nt r i cr e l at i on s pl i nt .I ti se s pe c i al l yi mpor t antt hatt he ant e r i o rg ui danc eon t hes pl i ntmus tdi s c l udeal lpos t e r i o rt e e t hi n al lj aw pos i t i onsexc eptc ent r i cr e l at i on.  The t i me r equi r ed t o ac hi ev e super i or posi t i oni ng of t he condyl edi skassembl yvari esf r om pat i entt opat i ent .I tmayoccur i n af ew day s,ori tmay t ake se ve r almont hs.The de t er mi ni ng f act or s appeart o be r el at ed t ot he amountofdef or mi t y oft he r ecapt ur ed di sk,and t he condi t i on oft he i nf er i or and super i or  bel l i esoft hel at er alpt er ygoi dmuscl es. Pr ol onge d ant er i or di sk di spl ace ment of t en r es ul t s i n short eni ngoft hesuperi orl at er alpt erygoi dmuscl e,whi ch cont r ol s t heal i gnmentoft hedi sk. Evenwhent hedi skwi l lnotber el easedal lt hewayt ocent r i c r el at i on,t he super i or r eposi t i oni ng spl i nt may be benefici al .I t offer s an al t er nat i v e when t he di sk cannotst ay al i gned and t he pat i e nte l e ct sag ai ns tr e par a t i v es ur g e r y . GENERALCONSI DERATI ONS: DEPT. OF PROSTHODONTICS  123 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders  Appl i ancet her apyhassev er alf av or abl equal i t i est hatr ender i text r emel y hel pf ulf ort he t r eat mentofmany TM di sor der s.An appl i ance can affecta pat i ent ’ s sympt oms i n sev er always.I ti s ext r emel yi mpor t antt hatwhen i tr educe s sy mpt oms t he pr ec i se causeandeffect r el at i onshi p be i dent i fied bef or e i r r ever si bl e t her apyi sbegun. Oc c l us alappl i anc e sar eeq ual l yhe l pf uli nr ul i ngo utc e r t ai n et i ol ogi cf act ors.When amal occl usi on i ssuspect edofcont r i but i ng t o a TM di sor der , oc cl usalappl i ance t her apy can qui ckl y and r e v e r s i bl yi nt r o duc eamo r ede s i r abl eoc c l us alc ondi t i o n.  The y ar ea r ev er si bl e noni nv asi v e modal i t yt hatcan hel p manage t he sympt oms ofmany TM di sor der s.The success or f ai l ur e ofoccl usalappl i ance t her apy depends on t he sel ect i on, f abr i cat i on, and adj us t ment of t he appl i anc e and on pat i ent c oo pe r a t i on. 1. MUSCLE RELAXATI ON APPLI ANCE/ Fl at Pl ane, Shar e ( maxi l l ary) ,Tanner( mandi bul ar) ,Superi orr eposi t i oni ngMuscl e Depr ogr ammi ng,orCR Spl i nt : Des cr i pt i on andTr eat mentGoal s:  Themuscl er el axat i onappl i ancei sgener al l yf abr i cat edf ort he maxi l l aryarc h.When i ti si n pl ace,t hecondyl esar ei nt hei rmost DEPT. OF PROSTHODONTICS  124 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders muscul oskel et al l y st abl e posi t i on att he t i me t hatt he t eet h are cont act i ng evenl yand si mul t aneousl y .Cani nedi soccl usi on oft he post er i or t ee t h dur i ng ec ce nt r i c mov ement i s al so pr ovi ded.  Tr eat mentgoalel i mi nat e any or t hopedi ci ns t abi l i t y be t ween t he oc c l us alpos i t i onandt hej oi ntpo si t i on. I ndi cat i ons: 1)Tr eatmuscl ehyper act i vi t y 2)Decr easet hepar af unct i onalact i vi t y 3)Br uxi sm 4)Localmuscl esor enessormyosi t i s 5)Ret r odi sci t i ssecondaryt ot r auma. Si mpl i fiedf abri cat i on t echni que:  An al gi nat ei mpr essi on i s made oft he maxi l l ar y ar c h.I ti s pour ed i mmedi at el y wi t h a sui t abl e gy psum pr oduct . Wi t h a pr ess ur eorv acuum adapt er ,2mmt hi ckhar d,cl earr esi n shee tof mat e r i ali sadapt e dt ot hecas t .  Theout l i neoft heappl i ancei st hen cutoff t hecas twi t ha separ at i ng di sk.The cuti s made att he l ev eloft he i nt er dent al papi l l ao nt hebuc c alandl abi als ur f ac e soft het e e t h.  Thel i ngualbor deroft heappl i ancee xt ends10t o12mm f r om t hegi ngi valbor deroft het eet ht hr oughoutt hel i ngualport i on of t hear ch.Thel abi alborderoft heappl i ancet ermi nat esbet weent he i nc i s alandmi ddl et hi r dsoft heant e r i ort e e t h. DEPT. OF PROSTHODONTICS  125 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders  Asmal lamountofc l earsel f cur i ngacr yl i cr esi ni smi xedi na dappen di sh.I ti s added t ot he occl usalsur f ace oft he ant er i or por t i onoft heappl i anc e.Thi sac r yl i cwi l lac tast heant e r i ors t op.I t i sappr oxi mat el y4mm wi deandshoul dext endt ot her egi onwher e amandi bul arant e r i orc e nt r ali nc i s orwi l lc ont ac t . Locat i ngt hemuscul oskel et al l yst abl eposi t i on: Bi l at er almanualmani pul at i ont echni que. I nt heo t he rt e c hni q ue ,as t o pi spl ac e do nt heant e r i o rr e g i on of t he appl i ance and t he muscl es ar e used t o l oc at e t he muscul oskel et al l y st abl eposi t i on oft hecondyl es.( Thi st echni que usest hesamepr i nci pl esempl oyedwi t ht hel eaf gauge) .  Thecont acton t heant er i ors t op i smar ked wi t h ar t i cul at i ng paperand adj ust ed so i tpr ovi desa st op t hati sper pendi cul art o t hel ongaxi soft hemandi bul art oot hbei ngcont act ed. I fa di s t ali nc l i nat i on e xi s t son t hes t op,c l e nc hi ngwi l lf or c e t he mandi bl e post er i or l y away f r om t he muscul oskel et al l y st abl e posi t i on.The ant er i or st op shoul d notbe mesi al l yi ncl i ned and cr eat eaf or war d shi f t or sl i de of t he mandi bl e, because t he cl enchi ngwi l lt endt or eposi t i ont hecondyl ef orwar d,awayf r om t he mos tmus c ul o ske l e t al l ys t abl epo si t i on. DEPT. OF PROSTHODONTICS  126 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders Devel opi ngt heOccl usi on:  Whe nt heCR posi t i on hasbeen l ocat ed,t hepat i entshoul d  becomef ami l i arwi t hi tbywear i ngt heappl i ancef oraf e w mi nut es. I ns t r uc t i o nsar egi v e nt ot apont heant e r i ors t op.  The appl i ance i sr emov ed f r om t he mout h and sel f cur i ng acryl i ci sadded t ot her emai ni ngant eri orand post eri orr egi onsof t heoc c l us als ur f ac e .  Theappl i ancei st henr e t ur nedt ot hemout h,andt hepat i ent ei t hercl osesori s gui ded i nt o CR.The mandi bul art ee t h shoul d si nk i nt ot he sof tacryl i c unt i lt he i nci sors cont actt he ant eri or s t op.  Adj ust i ngt heCR Cont act s:  Theoccl usalsur f aceoft heappl i ancei sbe s tadj us t edbyfir s t mar ki ngt hedee pestar eaofeac h mandi bul arbucc alcuspt i p and i nc i s ale dg ewi t hape nc i l .  Theacr yl i csur r oundi ngt hepenci lmar ksi sr emov ed sot he r e l at i v e l yflatoc cl us als ur f ac ewi l lal l o we cc ent r i cf r e e dom.  Al lcont act s,bot h ant er i orand pos t er i or ,shoul d becar ef ul l y r efinedsot heywi l loccuronflatsur f aceswi t hequaloccl usalf orce.  Adj ust i ngt heeccent r i cgui dance: DEPT. OF PROSTHODONTICS  127 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders  Theacr yl i cpr omi nencesl abi alt ot hemandi bul arcani nesar e smoot hed.Theyshoul dexhi bi tabouta30-t o45degr eeangul at i on t ot he occ l usalpl ane and al l ow t he cani nes t o pass ov er i na smoot h and c ont i nuous manner dur i ng pr ot r usi v e and l at e r o t r us i v ee xc ur s i ons . I ti si mpor t antt hatt hemandi bul arcani nesmovef r eel yand smoot hl y ov er t he occ l usal sur f ace of t he appl i ance .I ft he ang ul at i o no ft hepr o mi ne nc e si st o os t e e p,t hecani ne swi l lr e s t r i c t mandi bul ar mov ement and may aggr avat e an exi s t i ng muscl e di s or der . Ecc ent r i c cont act s of t he mandi bul ar ce nt r al and l at er al i nci sor s al so mus tbe el i mi nat ed so t he pr edomi nantmar ks ar e t hoseoft hemandi bul arc ani nes. Dur i ng a pr ot r usi v e mov ement ,gui danc e by t he maxi l l ar y cani nes,nott he mandi bul ar cent r aland l at er ali nci sor s,i st he g o a l . Fi nalcri t eri af ort hemuscl er el axati onappl i ance:  The f ol l owi ng ei ght cr i t er i a mus t be ac hi e v e d bef or et he pat i e nti sg i v e nt hemus c l er e l axat i o n appl i anc e : DEPT. OF PROSTHODONTICS  128 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders 1.I tmus tac c ur at e l yfitt hemax i l l ar yt e e t h,wi t ht o t als t abi l i t y and r e t ent i on when co nt act i ng t he mandi bul ar t ee t h and  whenc hec kedbydi gi t alpal pat i on. 2.I nCR al lpost er i ormandi bul arbucc alcuspsmustcont acton flats ur f ac e swi t he v e nf or c e . 3.Dur i ng pr ot r usi v e mov ementt he mandi bul arcani nes mus t cont act t he appl i ance wi t h ev en f or ce . The mandi bul ar i nci sor smayal socont acti tbutnotwi t h mor ef or cet han t he c ani ne s . 4.I n anyl at er almov ementonl yt hemandi bul arc ani neshoul d e xhi bi tl at e r o t r us i v econt ac tont heappl i anc e . 5.The mandi bul arpos t er i ort ee t h mus tc ont actt he appl i ance onl yi nt heCR cl osur e. 6.I nt heal ertf eedi ngposi t i on t hepost eri ort eet h mustcont act t heappl i ancemor epr omi nent l yt han t heant er i ort eet h. 7.The occ l usalsur f ace oft he appl i anceshoul d be as flatas possi bl ewi t hnoi mpr i nt sf ormandi bul arcusps. 8.The occl usalappl i ance i s pol i shed so i twi l lt oi rr i t at e any adj ac ents of tt i s sue s. I nst r uct i onsandadj ust ment s: DEPT. OF PROSTHODONTICS  129 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders  Thepat i enti si ns t r uct ed i n pr operi nser t i on and r emov alof t heappl i anc e . Fi ng e rpr e s s ur ei sus e dt oal i g n ands e ati ti ni t i al l y .Re mo v al i smosteasi l yaccompl i shedbycat chi ngi tneart hefir stmol ararea  wi t ht hefinger nai l soft hei ndexfinger sandpul l i ngt hedi s t alends downwar d.  Whe nbr uxi sm i st hepr obl em ni ght t i meusei sessent i alwhi l e day use may not be as i mpor t ant . When t he di sor de ri s r et r odi sci t i s,t heappl i ancemayneedt obewornmostoft het i me.I t has bee n demons t r at ed t hatmy og enous pai n di so r der sr es pond  bes tt opar t t i meus e( e speci al l yni ght t i meuse)whi l ei nt r acapsul ar di sor der s ar e be t t er managed wi t h cont i nuous use .I f wear i ng causesi ncr easedpai n,t hepat i entshoul ddi scont i nueweari ngand r eportt hepr obl em i mmedi at el yf oreval uat i on andcorr ect i on. On ce r t ai n occ asi ons f abr i cat i on ofa mandi bul ar musc l e r el axat i on appl i ance may be des i r abl e.Evi dence sugge st st hat maxi l l ar y and mandi bul ar appl i ance sr educe sy mpt oms equal l y .  Thepr i mar yadv ant agesoft hemandi bul art ypear et hati taffect s speechl essandaest het i csmaybebet t er .  ANTERI OR REPOSI TI ONI NG APPLI ANCE Descr i pti on andTr eat mentGoal s: DEPT. OF PROSTHODONTICS  130 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders  Theant er i orr eposi t i oni ngappl i ancei sani nt er occl usalde vi ce t hatencour agest hemandi bl et oassumea posi t i on mor eant er i or t hant hei nt e r c us palpos i t i on.i t sgoali st opr o vi deabe t t e rc ondy l e di sc r el at i onshi p i n t he f oss ae so nor mal f unct i on wi l l be r eest abl i shed.Thegoaloft r eat menti snott oal t ert hemandi bul ar posi t i on per manent l y butonl yt o changet heposi t i on t empor ari l y s oast oenhanc eadapt at i ono ft her e t r o di s c alt i s s ue s . I ndi cat i ons:  To t r eat di sc der angement di sor der s. Pat i ent s wi t h j oi nt sounds( e. g. ,asi ngl eorreci pr ocalcl i ck)can somet i mesbehel ped  byi t .I nt er mi t t entorc hr oni cl oc ki ngoft hej oi nt( e. g. ,r e t r odi sci t i s) . Si mpl i fiedf abr i cati ont echni que: Li ke t he muscl e r el axat i on appl i ance , t he ant er i or r e po si t i oni ngappl i anc ei sa f ul l ar c h har d ac r y l i cde v i c et hatc a n  be used i n ei t herar c h.Howev er ,t he maxi l l ar y ar c hi s pr ef er r ed  becauseagui di ngr ampcan bemor eeasi l yf abr i cat edt odi r ectt he mandi bl ei nt ot hedesi r edf orwar dposi t i on. Fabr i cati ngandfit t i ngtheappl i ance: DEPT. OF PROSTHODONTICS  131 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders  The i ni t i al s t ep i n f abr i cat i ng a maxi l l ar y ant er i or r e po si t i oni ngappl i anc ei si de nt i c alt ot hati nf abr i c at i ngamus c l e r el axat i on appl i ance.The ant er i or st op i s const r uct ed and t he appl i anc ei sfit t e dt ot hemax i l l ar yt e e t h.Ac r y l i ce xt e ndi ngo v e rt he l abi alsur f aces oft he maxi l l ary t eet hi s notneeded f or occl usal pur poses. Locat i ngthecor r ectant eri orposi t i on:  The ke y t o successf ul ant er i or r eposi t i oni ng appl i ance f abr i c at i on i sfindi ngt hemo s ts ui t abl epo si t i o nf ore l i mi nat i ngt he pat i e nt ’ ss ympt oms .Theant e r i ors t opi sus e dt ol oc at ei t .  Thepat i enti si ns t r uct edt opr ot r udesl i ght l yandt oopenand c l o sei nt hi spo si t i on.Thej o i nti sr e e v al uat e df ors y mpt omsandt he ant e r i o rpo si t i o nt hats po t st hec l i c ki ngi sl o cat e dandmar ke dwi t h r edmarki ngpaperast hepat i entt apsont hest op. Oncet hi shasbee nmar ked,t heappl i ancei sr emov edandt he ar ea oft he cont acti s gr oov ed appr oxi mat el y 1 mm de ep wi t ha smal lr oundbur .Theappl i ancei st henr e t ur nedt ot hemout h and t hepat i e ntl oc at e st hegr oo v eandt apsi nt oi t .  Ther eshoul dbenoj oi ntsoundsdur i ngopeni ngandcl osi ng.  Joi ntpai n dur i ngcl enc hi ngshoul d al sober educ ed orel i mi nat ed. Myogenous pai n ori gi nat i ng f r om t he super i or l at er alpt er ygoi d, DEPT. OF PROSTHODONTICS  132 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders however ,wi l lnotbe el i mi nat ed si ncet hi smuscl ei sact i veduri ng c l e nc hi ng .  Whe nt hej oi ntsympt omshav ebe en el i mi nat ed and v er i fied  by t he ant er i ors t op,t he appl i ance i st aken outoft he pat i ent ’ s mout h and sel f cur i ng acryl i ci sadded t ot her emai ni ng occl usal s ur f ac esoal lo cc l us alc ont ac t scanbee s t abl i s he d.  Theant er i ors t opmus tnotbecov er e dbyt heacr yl i c.  Whe nt heant er i ort ee t h ar ef el tt o cont acti nt hegr oov eon t heant eri orst op,t heposi t i on i sveri fied byopeni ngand cl osi nga f e wt i me s .Wi t ht het e e t hr e s t i ngt og e t he r ,t hepat i e nts ho ul dg e nt l y pl ac ehi st ong ueo nt hes e t t i ngr e s i nl i ng ualt ot heant e r i o rt e e t h and pr ess.Thi swi l ladaptt her esi nt ot hel i ngualsurf acesoft he mandi bul arant er i or sandpr ovi det henee dedr ampf orgui di ngt he mandi bl ei nt ot hef orwar dposi t i on. DEPT. OF PROSTHODONTICS  133 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders  Adj ust i ngt heoccl usi on:  The di ffer ence wi t ht hi s appl i ance i st he ant er i or gui di ng r amp, whi c hr equi r es t he mandi bl et o assume a mor ef or war d pos i t i ont oI CP . Fl atoccl usalcont act s ar e devel oped f ort he post eri ort eet h, andt hel argel i ngualr ampi nt heant er i orr egi on i sonl ysmoot hed.  Ther amp i sdev el ope di nt oa smoot h sl i di ngsur f acesoasnott o pr o mo t ec at c hi ngorl o c ki ngoft het e e t hi nanypo si t i o n. Fi nalcri t eri af ort heant eri orr eposi t i oni ngappl i ance:  The f ol l owi ng f our cr i t er i a shoul d be me t by t he ant er i or r e pos i t i oni ngappl i anc ebe f or ei ti sgi v e nt ot hepat i e nt : 1.I ts houl dac c ur at e l yfitt hemaxi l l ar yt e e t h,wi t ht o t als t abi l i t y andr et ent i onwheni ncont actwi t ht hemandi bul art ee t hand  whe nc hec kedbydi gi t alpal pat i on.I nt hees t abl i shedf or war d posi t i on al lt hemandi bul art eet h shoul dcont acti twi t h even f o r c e . 2.The f or war d posi t i on es t abl i shed by t he appl i ance shoul d el i mi nat et hej oi ntsympt omsdur i ngopeni ngand cl osi ngt o andf r om t hatposi t i on. DEPT. OF PROSTHODONTICS  134 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders 3.I nt he r e t r uded r ange of mov ement t he l i ngual r e t r usi v e gui dancer amp shoul d cont actand upon cl osur edi r ec tt he mandi bl ei nt ot hee s t abl i s he df or war dpo si t i o n. 4.The appl i anceshoul d be smoot hl y pol i shed and co mpat i bl e  wi t hadj ac entsof tt i ssues t r uct ur es. I nst r uct i on andAdj ust ment s: I nst ruct i onsr egar di ng i nsert i on and r emovaloft heant eri or r eposi t i oni ngappl i ancear egi ven.I nst ruct ed t oweart heappl i ance atni ghtand dur i ng t hedayasneeded t or educesympt oms.On occasi on a pat i entmay nee dt o weart hi s appl i anceal lt he t i me dependi ngont hesev er i t yoft hesympt oms.  ANTERI OR BI TE PLANE/ ANTERI OR JI G LUCI A JI G,HAWLEY  WI TH BI TE PLANE/ANTERI OR DEPROGRAMMES: Descr i pti on andTr eat mentGoal s:  Theant er i orbi t epl anei sahar d acr yl i cappl i ancewor n ov er t he maxi l l ary t ee t h pr ovi di ng cont actwi t h onl yt he mandi bul ar ant e r i o rt e e t h.I ti spr i mar i l yi nt e nde dt o di s e ng ag et he po s t e r i o r t ee t h and t hus el i mi nat et hei ri nfluence on t he f unct i on oft he mast i cat orysyst em. I ndi cat i ons: DEPT. OF PROSTHODONTICS  135 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders Mus c l edi s or de r sr e l at e dt oo r t ho pe di ci ns t abi l i t yo ran ac ut e c hang ei nt heo c cl us alc ondi t i on. Di sadvant ages: I ft he appl i ance i s wor n cont i nuousl yf orsever alweeks or mont hs,t her ei sagr eatl i kel i hood t hatt heunopposedmandi bul ar post er i or t ee t h wi l l supr aer upt . Whe n t hi s oc cur s and t he appl i ancei sremoved,t heant eri ort eet h wi l lnol ongercont actand t her e s ul twi l lbeanant e r i oro pe nbi t e .  Ant er i orbi t e pl ane t her apy mus tbe c l osel y moni t or ed and us e do nl yf o rs hor tpe r i o ds . POSTERI OR BI TE PLANE Descr i pti on andt r eat mentgoal s:  The pos t er i or bi t e pl ane i s usual l y f abr i cat ed f or t he mandi bul art eet h andconsi st sofar easofhar dacryl i cl ocat edover t hepost er i ort eet h and connect edbya castmet all i ngualbar .The t r eat mentgoal s oft he post er i or bi t e pl ane ar et o achi ev e maj or al t e r a t i o nsi nv e r t i c aldi me ns i onandmandi bul arr e po si t i o ni ng . I ndi cat i ons: Sever el ossofver t i caldi mensi on orwhen t her ei sa need t o make maj or c hange si n ant er i or r eposi t i oni ng oft he mandi bl e. Some t her api st s hav e sugg es t ed t hatt hi s appl i ance be use d by DEPT. OF PROSTHODONTICS  136 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders at hl et es t o i mpr ove at hl et i c per f or mance. Howev er , sci ent i fic evi dencedoesnotsupportt hi st heory . Di sadvant ages: Pot ent i al supr aer ut pi on of t he unoppos ed t ee t h and/or i nt r usi onoft heoccl udedt eet h.Const antandl ongt er m useshoul d  bedi scour aged. PI VOTI NG APPLI ANCE  The pi v ot i ng appl i ancei sa har d acr yl i c devi cet hatcov er s one ar ch and usual l y pr ovi desa si ngl epost er i orcont acti n each quadr ant .Thi scont acti susual l yest abl i shed asf arpost er i orl yas poss i bl e. When super i or f or ce i s appl i ed under t he c hi n, t he t endencyi st opush t heant eri ort eet h cl oset oget herand pi vott he condyl esdownwardaroundt hepost er i orpi vot i ngpoi nt . I ndi cat i ons:  Thepi v ot i ngappl i ancewasor i gi nal l ydev el opedwi t ht hei dea t hati twoul dl esse ni nt er art i cul arpr essur e and t hus unl oad t he ar t i c ul ars ur f ac esoft hej oi nt . Unf o r t unat e l y ,t hef or c e so ft hee l e v at o rmus c l e sar el oc at e d pr i mari l y post er i or t ot he pi vot , whi ch t her ef or e di sal l ows any pi v ot i ngac t i on. DEPT. OF PROSTHODONTICS  137 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders I nf act ,t he pi vot i ng appl i ance has been advocat ed f or t he t r eat mentofsympt oms r el at ed t o ost eoart hr i t i s oft he TMJs.For t he t r eat ment of an acut e uni l at er al di sc di sl ocat i on wi t hout r e duc t i on. SOFTOR RESI LI ENTAPPLI ANCE Descr i pti on andTr eat mentGoal s:  The sof t appl i ance i s a de vi c ef abr i cat ed f r om r esi l i ent mat er i alt hati susual l yadapt ed t ot hemaxi l l aryt eet h.Tre at ment goal s ar et o achi e v e ev en and si mul t aneo us co nt act wi t ht he o ppo si ngt e e t h. I ndi cat i ons: 1)Pr o t e c t i v ede v i c ef o rpe r s onsl i ke l yt or e c e i v et r aumat ot he i r dent alarc hes 2)Pr o t e c t i v eat hl e t i cspl i nt sde c r e as et hel i ke l i ho odo fdamag et o t heor alst ruct ur eswhent r aumai sr ecei ved. 3)Cl enc hi ngandbr uxi sm Okeson demons t r at ed t hatnoct ur nalmasse t erEMG act i vi t y  wasi ncr easedi n5t o10subj ect swi t hasof tappl i ance ;i nt hesame DEPT. OF PROSTHODONTICS  138 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders st udy8 oft he10 subj ect shad si gni ficantr educt i on ofnoct ur nal EMG act i vi t ywi t hahardmuscl er el axat i onappl i ance. CommonTr eat mentConsi der at i onsofAppl i anceTher apy: Howev er ,much cont r ove r syexi st sov ert heexactmec hani sm  bywhi c h occl usalappl i ancesr educesympt oms.Mos tconcl usi ons ar et hatt he yde c r e a s emus c l eac t i v i t y( par t i c ul ar l ypar af unc t i o nal act i vi t y ) . Bef or e any per manentt her apy i s begun,one ne eds t o be awar et hatt her earesi xgener alf eat ur escommont oal ldevi cest hat mayber esponsi bl ef ordecr easi ngmuscl eact i vi t yandsympt oms. 1.Al t e r at i o no ft heoc c l us alc ondi t i o n 2.Al t e r at i o no ft hec ondy l arp os i t i o n 3.I ncr easei nt hever t i caldi mensi on 4.Cogni t i veawar eness 5.Pl aceboeffect :40% oft hepat i ent ssuffer i ngf r om cer t ai n TM di sorder sr espondf avor abl yt osucht r eat ment . 6.I ncr eas ed per i pher ali nputt ot he CNS:Any c hangeatt he per i pher ali nputl evelseemst o havean i nhi bi t ory effecton t hi sCNSac t i v i t y . DEPT. OF PROSTHODONTICS  139 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders SUMMARY De spi t e t he unanswer ed ques t i ons on t he physi ol og i c mechani smst hatexpl ai nt heeffect i venessofi nt r aor alappl i ances on r e duci ng sympt oms of TMD, t her ei ss t i l l a pl e t hor a of document at i on t hat i nt r aor al appl i ance when us ed i n t he managementpl an accur at el y ,can cont r i but et ot her el i efofTMD sympt oms. The cl i ni ci an i s encour aged t o ev al uat ef ul l y each par t i cul ar pat i ent cas ei n an effor tt o dev el op a di ffer ent i al di agnosi st hatl eadst oeffect i vemanagementpl an. Bef or e commenci ng any appl i ance t her apy f or a TMD,t he cl i ni ci an shoul d beconfidentt hatt hepat i entwi l lbenefitf r om t he t her apeut i c appr oach.I ft he sympt oms r educed t hatwi l lpr ovi de addi t i onaldi ag nos t i ci nf or mat i on.  The cl i ni ci an al so ne eds t o consi der t hat40% ofpat i ent s suffer i ng f r om TMD demons t r at ef av or abl er es ponse t ot her apy f r om apl aceboeffect .Aswi t hanyt r eat ment ,agoodpat i ent dent i st r el at i onshi p and concomi t ant wi t h pat ent educat i on, can al l oy pat i e ntf e el i ng sandanxi e t i e s. I tc anc ont r i but et oapo si t i v eandf a v or abl er e s po ns et oi nt r aor a loc cl us als pl i ntt he r apy . DEPT. OF PROSTHODONTICS  140 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders BI BLI OGRAPHY: • t h Managementoft empor omandi bul ardi sor der sandocc l usi on,4 edi t i on,Jeffr eyO Okeson. • Eval uat i on, di agnosi s and t r eat ment of occl usal pr obl ems, Dawson. • Sc i e nc eandpr ac t i c eofo cc l us i o n.McNai l . • r d Cont empor aryfixedpr ost hodont i cs,3   e di t i on,Ros e ns t i e l ,Land, Fuj i mot o. • r d Fundament al s offixe d pr ost hodont i cs ,3   edi t i on,Shi l l e nbe r g , Hubo,Whi t shel l ,Jacob,Br acket t i . • Be r ki t ’ s .Or a lMe di c i ne . t h  Tyl man.Theor yandpr act i ceoffixedpr os t hodont i cs,8   e di t i on, • Mal one,Kot h.  Al ber t Sol oni t / Cor nut t e. Occl usal cor r ect i on; Pr i nci pl e and • Pr a ct i c e.  Jour nalofPr os t he t i cDent i s t r y2001;86( 5) : 539. •  Jour nalofPr os t he t i cDent i s t r y1989;59: 165180. • • Cr ani o1993;11: 184191.  Jour nalofPr os t he t i cDent i s t r y1980;88: 6775. •  Jour nalofPr os t he t i cDent i s t r y1980;44: 324335. •  Jour nalofPr os t he t i cDent i s t r y198248:708712. •  Jour nalofPr os t he t i cDent i s t r y1981;45:438445. •  Jour nalofPr os t he t i cDent i s t r y1983;50: 700709. •  Aus tDentJ1990;35:266276. •  Jour nalofPr os t he t i cDent i s t r y1985;53:717721. • DEPT. OF PROSTHODONTICS  141 Seminar - IV  Occlusal Splints Used in Prosthetic Management of TMJ Disorders  Jour nalofPr os t he t i cDent i s t r y2000;83:2. •  Jour nalofPr os t he t i cDent i s t r y1990;63: 52. • DEPT. OF PROSTHODONTICS  142