Technique for Construction of a Maxillary Stabilization Splint.

Part 1
Pei Feng Lim BDS, MS
Diplomate of the American Board of Orofacial Pain Fellow of the American Academy of Orofacial Pain Director, Oral & Maxillofacial Pain Program UNC at Chapel Hill, School of Dentistry peifeng_lim@dentistry.unc.edu

Occlusal Splint Therapy

1. 2. 3. 4. 5. 6. 7. 8. Lecture: Bruxism & Occlusal Splint Therapy Lecture: Technique for Construction of a Maxillary Stabilization Splint. Part 1 Clinic: Maxillary impression & model Clinic: Splint construction 1 Lecture: Technique for Construction of a Maxillary Stabilization Splint. Part 2 Lecture & Lab: Masticatory Muscle & TMJ disorders Clinic: Splint construction 2 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 splint
1. Covers more tissue > stable, > retentive, < likely to break
2. Easier to achieve occlusion in Class II & III 3. Lower teeth contact on flat surface > stable 4. Easier to locate CR position

Contraindications
1. Mixed dentition 2. Orthodontic treatment

Advantages of Mandibular stabilization splint 1. Aesthetics

Criteria for Stabilization Splint

1. 2. 3. 4. 5. 6. 7. 8. Good fit, stability & retention In CR, mandibular buccal cusps contact flat surfaces evenly Protrusion on canines Laterotrusion on canines Mandibular posterior teeth contact splint only in CR Upright position, posterior occlusion more prominent than anterior Splint occlusal surface is flat 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 Technique
Less chair-side time (more popular)

Indirect Technique

1. Maxillary & Mandibular impression & models 2. Bite Registration

Indirect Technique

Indirect Technique

3. Face-bow record

4. Send to Laboratory

Indirect Technique

Indirect Technique

5. Finished product from Lab

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 Outline
1st 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:

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 Im 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

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

History of past treatment: multiple splints, tx for

TMD, tx failures

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: intercuspal position, working contacts, non working contacts, protrusive contacts
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 -----------------------------------------------------------------------------------32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Clinical Examination
Examine current splint (if present) Splint description: maxillary/mandibular, partial/fullcoverage, soft/acrylic Fit Retention Stability Occlusion: centric stops, lateral guidance, protrusive guidance 1. 2. 3. 4. 5. 6.

Additional Tests
Questionnaire
Has anyone heard you grinding your teeth at night? Is your jaw ever fatigued or sore on awakening in the morning? Are your teeth or gums ever sore on awakening in the morning? Do you ever experience temporal headaches on awakening in the morning? Are you ever aware of grinding your teeth during the day? Are you ever aware of clenching your teeth during the day?

>2 positive responses => bruxer

Additional Tests
Polysomnogram

Additional Tests
EMG Recording

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

Additional Tests Imaging

Summary of Findings
Clinical Impression:
Nocturnal bruxism? Daytime parafunctions?

Contributing Factors:
Psychosocial stressors? Caffeine?

Treatment Plan
1. Advised stress mx & reduce caffeine intake 2. Maxillary stabilization splint

Maxillary Impression

Armamentarium

A good quality impression accurately capturing 1. all teeth 2. hard palate

Maxillary Impression

Making a Maxillary Impression

Look at the palatal arch

Select tray

Check Impression
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 Faculty signature

Armamentarium

Stone Model

Check Model
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

Faculty signature

Draw Splint Outline

Armamentarium

Draw Splint Outline

Buccal & labial extension at level of interdental papilla

Draw Splint Outline

Buccal & labial extension at level of interdental papilla

Draw Splint Outline

Buccal & labial extension at level of interdental papilla

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 patients name on base of model

Faculty signature

Wrap Stone Model

Draw Splint Outline

Recapitulation 23 Feb 8-10am

Recapitulation 23 Feb 8-10am

Recapitulation 23 Feb 8-10am

Lab Sheet Instructions

use hard/soft material follow splint outline drawn on model create anterior stop

Anterior Stop

5mm 10mm 5mm

Lab Procedure

Finished Product from Lab

Checklist Splint, model, case for storing splint Correct hard/soft material Anterior stop

Finished Product from Lab

Checklist Splint outline Fit Retention Stability

Poor retention & unstable

Faculty signature

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Visit 2: Splint Delivery

Armamentarium

Check splint in the mouth

Checklist Fit Retention Stability

Locating the CR position

Musculoskeletally stable position

Locating the CR

Locating the CR

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Check splint in the mouth

Check posterior separation

Checklist Checklist Anterior stop perpendicular to lower incisor Posterior teeth separation ~2mm.

Occlusal surface of splint

2mm

Anterior stop

Last molar

Inferior surface perpendicular to lower incisor

Checklist Posterior teeth separation ~2mm. ** If >2mm, reduce vertical height of anterior stop
** If <2mm, add acrylic to increase vertical height of anterior stop

Lubricate acrylic restorations with vaseline

Building the Occlusion

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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Building the Occlusion

Recapitulation 23 Feb 8-10am

WHY??

Leave splint on model to allow acrylic to polymerize

Recapitulation 23 Feb 8-10am

Recapitulation 23 Feb 8-10am

Recapitulation 23 Feb 8-10am

Recapitulation 23 Feb 8-10am

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Recapitulation 23 Feb 8-10am

Up next, 23 Feb Clinic 8-10am Maxillary impression

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