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1
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
2
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
3
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:
4
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
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
5
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
6
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
7
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
8
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 patient’s name on base of model
Faculty signature
9
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
10
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
11
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
12
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
Building the Occlusion
• Seat splint in the mouth
• Guide mandible to CR. Patient close till lower incisors hit anterior stop
13
Building the Occlusion
Leave splint on model to allow acrylic to polymerize
WHY??
Recapitulation 23 Feb 8-10am
Recapitulation 23 Feb 8-10am Recapitulation 23 Feb 8-10am
Recapitulation 23 Feb 8-10am Recapitulation 23 Feb 8-10am
14
Recapitulation 23 Feb 8-10am
Up next,23 Feb Clinic 8-10amMaxillary impression