Muscle Deprogramming / Orthodontic Courses by Indian Dental Academy

Muscle Deprogramming &
Splint Therapy

INDIAN DENTAL ACADEMY

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Muscle
Deprogramming &
Splint Therapy
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 necessary.
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.
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.
Butterfly Deprogrammer
Nocireceptive Trigeminal Inhibition
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.
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.
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.
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 (MORAs) have been
recommended for increased strength and athletic
performance.

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.
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 Gunnings
development, Kingsley, published an article
discussing the use of soft vulcanized rubber to make
an obturator.
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.
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.
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, Keslings article discussed using a maxillary
soft occlusal appliance in order to maintain the
mandible in predetermined relationship to the
maxilla.
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.
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.
Splint Types

Stabilization splint
Repositioning splint
Pivot splint
Soft splint
Bite plate splint
Hydrostatic splint
Mandibular orthopedic
repositioning appliances (MORA)

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.


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.

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.

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 disc-
condyle 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.


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.

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.


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 step-
back procedure. No occlusal changes were
attempted.


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.

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.

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.


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.

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.


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.

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.

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.


The splints were worn full time for 1020 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.


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.

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.
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.

Hydrostatic splint
Design: Fluid filled reservoir
covering the teeth.
It equalizes the biting pressure.
Aqualizer
The Aqualizers 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 Pascals Law, meaning that when you bite
down on the Aqualizer, the fluid is evenly
distributed across the entire bite.
The Aqualizer is unique. Its revolutionary floating
action enables the body to find and restore its own
systemic function and balance. The Aqualizers
built-in fluid system automatically eliminates the
occlusal imbalances that trigger the patients
symptoms. This fluid system works by freeing up the
patients muscles so they can reposition the jaw to its
most comfortable position, which takes the
uncertainty out of reestablishing the correct bite.
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.
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.


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.


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.


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.

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.


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.

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
fibers isometric tension is enhanced by elongation
and loading.


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.

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.

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.
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.

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 low-
angle 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.
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.

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.
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.

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.
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.
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.

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.

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.

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.

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.

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.
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.

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.

Patients who experience difficulty adjusting to the
appliance should return 2 weeks after the 1-week
visit.

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.

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.

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.

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.

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.
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.

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.

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.

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.

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.

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.
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.
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.
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
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.
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.

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.
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.
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.

LITERATURE REVIEWED: The authors evaluated
four placebo-controlled studies, several randomized
wait-list controlled studies and several random-
assignment 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.
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.
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.
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.
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.
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.
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.
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
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.
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 non-
invasive, 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.
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