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OCCLUSAL SPLINT THERAPY-REVIEW ARTICLE

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International Journal of Dental Practice & Medical Sciences ISSN -2319 -5029

Review Article - Occlusal Splint Therapy

1 2
Suryakant C. Deogade Girish Nazirkar
1
Reader, Department of Prosthodontics, Hitkarini Dental College & Hospital, Jabalpur, Madhya Pradesh,India.
2
Prof.head, Department of Prosthodontics, SMBT Dental College & Hospital,Sangamner,india.
Abstracts: AbstractOcclusal splint therapy has been used for many years for the diagnosis and
treatment of various disorders of the masticatory system. It is recommended in oral Para function,
unstable occlusion, stress related pain symptoms, occlusal interferences, and in extensive restorative
treatment. The goal of this article is to familiarize readers of the basic principles of occlusal splint
therapy for treating temporomandibular disorder (TMD), bruxism, and some forms of headache. Also it
will familiarize the reader with basic splint designs and explain how to use these effectively.
Key Words:bite splint, occlusal splint, occlusal device, occlusal appliance, temporomandibular
dysfunction.

Author for correspondence: Dr. Suryakant C. Deogade, MDS

Department of Prosthodontics, Hitkarini Dental College & Hospital, Jabalpur, Madhya Pradesh,India.

Introduction Main reasons for occlusal splint therapy

Occlusal splint therapy may be defined Occlusal splint therapy has been shown to be
as “the art and science of establishing useful for the diagnosis and management of
neuromuscular harmony in the masticatory various masticatory system disorders.2 A
system by creating a mechanical disadvantage common reason for prescribing an occlusal
for parafunctional forces with removable splint is to protect the teeth from excessive
appliances”.1 wear in patients with bruxism. Splints are also
used frequently to treat patients with internal
Occlusal splint is a diagnostic, relaxing, derangement and other TMDs with associated
repositioning and reversible device. According symptoms, such as tension headache and
to the Glossary of Prosthodontic Terms [8th cervical, neck and oral/facial pain.3-6
ed.], “occlusal splint is defined as any
removable artificial occlusal surface used for A common goal of occlusal splint treatment is
diagnosis or therapy affecting the relationship to protect the TMJ discs from dysfunctional
of the mandible to the maxilla. It may be used forces, which may lead to perforations or
for occlusal stabilization, for treatment of permanent displacements. Other goals of
temporomandibular disorders, or to prevent treatment are to improve jaw-muscle function
wear of the dentition.” and to relieve associated pain by creating a
stable balanced occlusion.
A bite splint can be a valuable diagnostic and
treatment aid in carefully selected cases if Occlusal splint therapy can be recommended
properly made, adjusted and maintained. A for the following purposes:
properly constructed splint supports a
harmonious relation among the muscles of 1. To protect oral tissues in patients with oral
mastication, disc assemblies, joints, ligaments, parafunction
bones, teeth and tendons. It provides a 2. To stabilize unstable occlusion
relatively easy, inexpensive and non-harmful 3. To promote jaw muscle relaxation in patients
way to make reversible changes in the with stress related pain symptoms like tension
73

occlusion headache and neck pain of muscular origin

4.To eliminate the effects of occlusal
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interferences

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5. To test the effect of changes in occlusion caused by it will usually disappear. A splint
on the TMJ and jaw muscle function before with equal intensity contacts on all of the teeth,
extensive restorative treatment with immediate disclusion of all posterior teeth
by the anterior guidance and condylar
guidance in all movements, will relax the
How do splints work? elevator and positioning muscles.10

There is no general agreement about if or why Allowing the condyles to seat in centric
splint treatment may have a beneficial effect. relation: For the condyles to seat completely
Following are few concepts, which explain how under the disc in anterosuperior position, the
occlusal splints can help. Preventing the superior belly of lateral pterygoid should obtain
patient to close in maximal intercuspal position: its full extension. When the lateral pterygoid is
By occlusal splint, the patient is obliged to triggered to hyperactivity through occlusal
place his mandible in a new posture, thus stimuli, the disc is pulled anteromedially toward
resulting in a new muscular and articular the origin of muscle, resulting in displacement.
balance. The patient, disturbed in his habits Overloading of condyle/disc assembly when
will not clench his teeth any more, like before not in normal physiologic position contributes
and protect his TMJ and teeth.7 towards TMJ disorders. A properly balanced
splint results in an occlusion associated with
Distribution of forces: The forces generated relaxed positioning and elevator muscles,
during bruxism can be as much as six times allowing the articulator disc to obtain its antero-
the maximal force generated by normal superior position over the condylar head.
chewing.8 The splints distributes these forces
across the masticatory system. These Increase in the vertical dimension of occlusion:
appliances can decrease the frequency of Occlusal splints can be adjusted with a vertical
bruxing episodes but not the intensity.9 height that exceeds the physiologic
interocclusal distance. Temporary use of
Normalising periodontal ligament: occlusal splints with a vertical height exceeding
proprioception: Proprioceptive fibres contained the physiologic rest position does not cause
in the periodontal ligament of each tooth send increase in tonus or hyperactivity of jaw
message to central nervous system, triggering muscles. Studies have shown that elongation
muscle patterns that protect them from of elevator muscles to or near the vertical
overload. An occlusal splint functions to dimension of least electromyographic activity
dissipate the forces placed on individual teeth by means of occlusal splint are effective in
by utilizing a larger surface area covering all producing neuromuscular relaxation.11, 12
teeth in the arch. Thus a splint balances the
load and allows for muscle symmetry. Cognitive awareness theory: According to
this theory, the presence of the splint as a
Relaxing the muscles: Tooth interferences to foreign object in the mouth would likely change
the CR arc of closure hyperactivate the lateral the oral tactile stimuli, decrease the oral
pterygoid muscles and posterior tooth volume and space for the tongue and make the
interferences during excursive mandibular patient conscious about the position and
movements cause hyperactivity of the closing potentially harmful use of their jaw. As
74

muscles. A muscle that is fatigued through cognitive awareness is increased, factors that
ongoing muscle hyperactivity can present with contribute to the disorder are decreased. The
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pain. If the hyperactivity is stopped, the pain result is a decrease in the symptoms.

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Permissive splints are often referred to as

Placebo effect: A positive placebo effect may muscle deprogrammers. The two classic
result from the competent and reassuring designs of permissive splints are anterior
manner in which the doctor approaches the midpoint contact splints and full contact splints.
patient and provides the therapy. This Examples of anterior midpoint contact splints
favorable doctor-patient relationship, include nociceptive trigeminal inhibition (NTI)
accompanied by an explanation of the problem splint, Lucia jig and the B splint, and the
and reassurance that the appliance will be example of full contact splint is centric relation
effective, often leads to a decrease in splint.
emotional stress experienced by the patient,
which may be the significant factor responsible Directive splints: Are designed to position the
for the placebo effect. mandible in a specific relationship to the
maxilla. The sole purpose of a directive splint
Increased peripheral input to the central is to position or align the condyle-disc
nervous system: Nocturnal muscle assemblies. The jaw to jaw relationship that
hyperactivity appears to have its source in the results from maximum intercuspation with the
CNS. When an occlusal splint is placed splint determining where the condyles must be
between the teeth, it provides a change in at the intercuspal position. Thus directive
peripheral input and thus decreases CNS- splints should be used only when a specifically
induced bruxism. All these concepts overlap directed position of the condyles is required.
and are not mutually exclusive. Anterior repositioning splint is a directive splint.

Types of Occlusal Splints Specific Uses of Different Types of Splints

STABILIZATION SPLINT:
According to Okeson13
Stabilization appliance Stabilization splint is also known as the
Anterior repositioning appliances superior repositioning splint, the Tanner
appliance, the Michigan splint, the Fox
appliance or the centric relation appliance. The
Other types: stabilization splint is a hard acrylic splint that
Anterior bite plane provides a temporary and removable ideal
Posterior bite plane occlusion. Providing an ideal occlusion by the
Pivoting appliance use of splint therapy reduces abnormal muscle
Soft/resilient appliance activity and produces neuromuscular
balance.15 It is suggested that patients should
According to Dawson14 wear the splint only at night. The splint needs
Permissive splints/ muscle deprogrammer to be adjusted (rebalancing of the splint to the
Directive splints/ non-permissive splints new position of the jaw by grinding some of its
surface points, since the lower jaw will adopt a
Permissive Splints: Are designed to unlock the new position as a result of wearing the splint)
occlusion to remove deviating tooth inclines over several visits as the masticatory muscles
from contact. This eliminates the cause and relax until a consistent jaw relationship is
effect of muscle in co-ordination. The condyles reached. The patient should be reviewed at
75

are then allowed to return to their correct regular intervals. After a period of successful
seated position in centric relation if the splint therapy (between 2 to 3 months),
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condition of the articular components permits. patients can be weaned off the splint.

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relationship of the disc condyle complex.19, 20

A stabilization splint provides centric The anterior repositioning splint places a
relation occlusion, eliminates posterior patient‟s mandible and TMJ into an anterior
interference, provides anterior guidance and position so as to reduce a TMJ click that
gives stable occlusal relationships with uniform occurs on opening and closing of the jaw. The
tooth contacts throughout the dental arch. anterior repositioning splint is typically placed
(Fig.1) on the maxillary arch with an anterior ramp that
first engages mandibular teeth on initial closure
Indications: and shifts the jaw forward into final closure,
The stabilization splint is most efficacious when all mandibular teeth contact the splint.
for masticatory myalgia and TMJ arthralgia, (Fig.2) This position provides a more favorable
especially if the pain is worse upon awakening. condyle-disc relationship in the fossa so that
This type of splint can also be used during the normal function can be established. The goal is
day for oral habit management. Such splints to eliminate the signs and symptoms
are designed to provide postural stabilization associated with disc-interference disorders.
and to protect the TMJ, muscles, and teeth.
The centric relation splint is generally used The treatment goal is not to alter
to treat muscle hyperactivity.16 Studies17, 18 permanently a mandibular position but ideally
have shown that wearing it decreases to alter only temporarily while normal condyle-
parafunctional muscle activity. Patients with disc complex function returns. Once the
myospasms or myositis are best treated with function is again optimal, treatment consists of
centric relation splint. gradually eliminating the splint and returning
The symptoms of patients who experience the patient to preexistent normal condition.
trauma or suffer an inflammatory joint disorder
and have a co-existent factor of parafunctional Indications
activity are managed successfully with centric
relation splint therapy. Anterior repositioning splints can be efficacious
It is also used in reducing symptoms from for intermittent jaw locking with limited range of
parafunctional activity associated with motion, especially upon awakening, or for
increased levels of emotional stress. persistent TMJ arthralgia not responsive to
other therapy (including a stabilization splint).
Careful adjustment of the stabilization They are recommended only for short-term use
splint is an important step as muscle activity because they can cause occlusal changes if
changes and edema subsides. Acute pain can worn continuously or chronically.
be caused by inflammation in intracapsular Anterior repositioning splints are used
TMJ tissues. They may swell or shrink during primarily to treat disc-interference disorders.
different stages of the disease period. Patients with joint sounds such as single
Repeated adjustments may have to be made or reciprocal clicks can sometimes be
for quite long periods. effectively treated with this type of splint.
Intermittent or chronic locking of the joint
ANTERIOR REPOSITIONING SPLINT Inflammatory disorders (e.g. retrodiscitis)

The anterior repositioning splint induces a ANTERIOR BITE PLANE

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therapeutic mandibular position, forward to the

maximum intercuspation position of the patient The anterior bite plane is a hard acrylic
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and affects the physiological-topographical appliance worn over the maxillary teeth that

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provides contact with only the mandibular PIVOTING SPLINT

anterior teeth. It is primarily intended to
disengage the posterior teeth and thus The pivot splint is also known as distraction
eliminate their influence in the function or splint. The pivot splint was introduced by
dysfunction of the masticatory system. Anterior Krough-Poulsen. It is a hard acrylic appliance
jig, Lucia jig, Hawley with bite plane, anterior that covers one arch and usually provides a
deprogrammer and Sved plate21 are types of single posterior contact in each quadrant. This
anterior bite plane. contact is usually established as far posteriorly
as possible. The proposed effect is that the
Indications condyles are pulled downward upon clenching
Treatment of muscle disorders related to on the pivot, thereby relieving traumatic load
orthopedic instability or an acute change in the and giving the disc freedom to reassume a
occlusal condition. normal position.
Parafunctional activity associated with
unfavorable posterior tooth contacts can also The pivoting splint was originally
be treated but only for short periods. developed with an idea that it would create a
If the appliance is worn continuously for decrease in interarticular pressure, thus
several weeks or months, it is likely that the unloading the articular surface of the joint. This
unopposed mandibular teeth will supraerupt. was thought to occur when the anterior teeth
When this occurs and the appliance is moved closer together, creating a fulcrum
removed, it results in an anterior open bite. around the second molar and pivoting the
Anterior bite plane therapy must be closely condyle downward away from the fossa.
monitored and used only for short periods.
However, this can occur only if the forces
POSTERIOR BITE PLANE that close the mandible are located anterior to
the pivot. Unfortunately, the forces of the
The posterior bite plane is usually fabricated elevator muscles are located primarily
for the mandibular teeth and consists of areas posterior to the pivot, which therefore does not
of hard acrylic located over the posterior teeth allow any pivoting action. It was originally
and connected by a cast metal lingual bar. The suggested that the therapy was helpful in
treatment goals of the posterior bite plane are treating joint sounds. It now appears, however,
to achieve major alterations in vertical that the anterior repositioning splint is more
dimension and mandibular repositioning. The suitable for this purpose since it provides more
Gelb (Gelb-MORA [mandibular orthopedic controlled re-positional changes. In fact, the
repositioning appliance]) splint22 is a type of pivoting appliance has been advocated for the
posterior bite plane. (Fig.3) treatment of symptoms related to degenerative
joint diseases of the temporomandibular joint.
Indications It has even been suggested that the splint be
Severe loss of vertical dimension. inserted and elastic bandages be wrapped
When major changes in anterior from the chin to the top of the head to
positioning of the mandible are needed. decrease forces in the joint.
The major concern with this appliance is
potential supraeruption of the unopposed teeth Indications
77

and the intrusion of the occluded teeth. To unload the articular surface of the joint
Constant and long term use is discouraged. caused by decrease in inter-articular
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pressure.

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Treating joint sounds. limits.

For the treatment of symptoms related to
degenerative joint diseases. BITE SPLINT ACCORDING TO SHORE

SOFT OR RESILIENT SPLINT This splint has a design similar to the

stabilization splint but does not extend onto the
The soft splint is an appliance fabricated from facial or buccal surfaces of the teeth, and
resilient material and usually adapted to the covers the entire palatal area. It may be
maxillary teeth. Treatment goals are to achieve preferred by some patients who need to use
even and simultaneous contact with the the splint during daytime, for esthetic reasons,
opposing teeth. It is quick to fabricate and can because it can be made less visible. In some
be provided as „emergency treatment‟ for a patients with parafunctional tongue activities,
patient who presents with an acute TMD. The such a palatal extension may be felt more
only record needed is an upper alginate comfortable. A centric relation splint can easily
impression. These appliances are generally be changed into this type by removing facial
worn only at night and if they are successful, and buccal extensions, adding palatal cover
will produce symptomatic relief within 6 weeks. and, if needed, securing adequate retention
They should be replaced after 4 – 6 months as with clasps.
they lose their resilience with the passage of
time. CAP SPLINT

The appliance is generally made out of 2 - A cap splint

4 mm polyvinyl sheet. If a thinner splint is can be described as an intermediary between
required, laboratory can be instructed to a splint and a bridge. It is useful for temporary
overheat the material before vacuum forming reconstruction before final decision about
and if a thicker appliance is required (for design, vertical dimension, etc., can be made.
patient with an anterior open bite), then layers It is often made with metal with the occlusal
can be added in certain areas (i.e. anteriorly) surface in hard acrylic.
to ensure even occlusal contact. (Fig.4)
HYDROSTATIC APPLIANCE
Indications: (Commercial name: Aqualizer)
-In reducing symptoms of temporomandibular
disorders (joint dysfunction and myalgia). It employs water to balance the biting
Protective device for persons likely to receive pressure, to treat malocclusion and to relieve
trauma to their dental arches (athletic splint) TMJ pain and symptoms associated with
-To prevent bruxism and clenching TMDs.23, 24 When the hydrostatic cell is
For relief of extremely sensitive posterior teeth inserted between the arches, a sequence of
due to chronic or repeated sinusitis. reorganization spreads throughout the
stomatognathic system, and all occlusal
The soft splints are less likely to cause disharmonies are compensated automatically
significant occlusal changes that are by distribution of fluid within the cell. Occlusal
sometimes noted with hard occlusal splint. forces to every tooth contacting the cell there
They have low density and amorphous by becomes systematically equalized and
78

structure, therefore they are compressed or axially oriented.

worn before the masticatory muscles are
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stretched or stressed beyond their physiologic The volume of fluid within the cells is

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adjusted to obtain the desired degree of in bruxers, Several variations of splints are
increase in the vertical dimension of occlusion. designed to protect cheeks
and tongue in patients with oral parafunctions
Occlusal forces that normally arise (such as cheek biting or tongue thrust). These
individually as the result of many maxillary and patients may benefit from a splint with
mandibular tooth contacts now are created as extensions or enlargements designed in a way
a whole within the hydrostatic cell and that keeps the cheeks from being pinched or
distributed to each tooth that contacts the cell. the tongue from pressing against the lingual
The occlusal forces transmitted to each tooth surfaces of the teeth.
are hypothesized thereby to become optimal,
these forces now arise simultaneously and are COMBINATION SPLINTS
perfectly equalized (in accordance with
Pascal‟s law which states that an enclosed Missing teeth can easily be replaced by adding
fluid distributes forces equally and artificial teeth to the splint. A Shore splint can
simultaneously in all directions) and function as a temporary partial denture by
horizontally displacing contacts are reoriented adding artificial teeth. There are numerous
axially. combinations of splint and orthodontic
appliances. A removable bionator appliance
The hydrostatic appliance is worn 24 can act both as an orthodontic and as a
hours and removed only while eating, for a repositioning appliance (Fig.6).25 An “invisible
period ranging from several weeks to years. retainer” can simultaneously act as a soft
The cells retain their fluid an average of about acrylic splint.
two weeks. A new cell is installed when the
enclosed fluid escapes. LOCATION OF SPLINT: MAXILLARY OR
MANDIBULAR
NTI (Nociceptive Trigeminal Inhibition) Tension
Suppression System Presumably it is possible to obtain the same
(By Dr. James Boyd) results regardless of the situation of the
occlusal splint but the choice of the individual
The direct stimulation of the periodontal situation depends on a few basic principles. If
ligament of the lower incisors activates a teeth are missing, the splint is usually made in
feedback loop, which significantly limits the the jaw where most teeth are lost to increase
contraction intensity of the closing muscles. the stabilizing effect by creation of additional
This is because of the nociceptive trigeminal occlusal points. If molars and premolars are
inhibition (NTI) reflex. missing in both jaws, it may be advisable to
make both upper and lower splint or to first
The NTI appliance takes advantage of this restore occlusion in at least one jaw with
reflex via an acrylic guard worn on either the prosthodontic reconstruction.
mandibular or maxillary incisors. Stock NTIs
are relined with self-cure acrylic. (Fig.5) In case of significantly increased incisor
overjet, as in case of severe Angle Class II, an
SPLINTS FOR PROTECTION OF ORAL occlusal splint on the maxillary arch is
TISSUES preferred because it is difficult to achieve
79

proper anterior contacts and guidance with a

The most common reason for making a splint mandibular splint.
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is to protect the teeth from excessive abrasion

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In case of a deep curve of Spee,

mandibular splint is preferred. Mandibular Anterior bite splints are worn continuously
occlusal splint also offers the advantage of but for a very limited time, wearing it for more
encouraging a better rest place for tongue than 2 weeks may be hazardous in case
(which is anterior palate). intracapsular pathology because of
compression risk. It is proposed for emergency
Extensions on the facial surfaces of the treatment, or very short duration and
incisors should be avoided. Besides not being musculorarticular symptoms of an acute form.
aesthetic, it may prevent adequate lip seal.
Hard splints cannot be used in the
DURATION OF USAGE children for more than short periods because
they may not fit after a relatively short time and
Most patients use their splints only during therefore interfere with the normal growth
sleep to protect them from the effects of pattern.
involuntary parafunctional motor activities like
bruxing, clenching, tongue pressure, etc. The effective monitoring of the patients by
Those who cannot control such habits when the practitioner at 2,4,8 and possibly
awake may need to use the splint during the sometimes 12 weeks is essential to
daytime hours. There are no fixed rules for the accompany rehabilitation and to evaluate the
length of time that a conservative splint (a affect of treatment. Dylina TJ has suggested a
splint that doesn‟t change the jaw relations protocol, which include adjustments at 24hrs, 3
except for a minimal increase of vertical) days, 7 days, 14 days, 21 days and 1 month.
should be used. Some patients can discard When no movement on the splint is seen at
them after a few months; others may need to adjustment appointments and symptoms are
continue them for decades. Generally wearing improving, then interval between adjustments
must not exceed a few months because with can be extended.
his parafunctional habits, the patient gets used
to occlusal splint and a negative dependence Regular supervision is important and a
can be created. If the patient is aware that their splint should never be delivered without
TMD are correlated with stressful situation securing that the patient can and will come
such as examination or sporting events, back for regular check-ups. The dentist also
episodic daytime wearing is advisable during has to ensure that he or she is able to see the
these periods. In patient with frequent patient any working day during the first weeks
parafunctional habits which abrade their teeth after delivery.
or put in danger their prosthetic reconstructions
or implants, permanent nocturnal wearing of Acute pain can be caused by
the occlusal splint is recommended. inflammation in intracapsular TMJ tissues.
They may swell or shrink during different
Splints that do not cover all teeth with stages of the disease period. Repeated
balanced contacts with opposing teeth should adjustments may have to be made for quite
not be used for longer period than 4-6 weeks. long periods.
During that period they should be continuously
worn for 24hrs a day and removed only when The worsening symptoms require immediate
80

brushing the teeth. Irreversible changes may revaluation in order to provide explanations,
occur in the occlusion if they are used for corrections or necessary adjustment but also
Page

periods longer than 6 weeks. revaluation of the diagnosis.

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CONCLUSION

Occlusal splint therapy has been used for

many years for the diagnosis and treatment of
various disorders of the masticatory system.
Many designs are
described in the literature. The different types
of splint are used to treat different conditions. A
proper examination and differential diagnosis is
necessary to lead to a decision regarding the
appropriate role of splint therapy for each Fig.3- Gelb MORA splint
problem. After reading this article, clinicians
should be better equipped to successfully
implement splint therapy into their
armamentarium of treatment options in
managing masticatory system disorders.

Figures

Fig.4- Athletic mouth guard

Fig.1- Upper stabilizing splint

Fig.5- NTI splint

81

Fig.2- Anterior repositioning splint

Page

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9. Holmgren K, Sheikholeslam A, Ruse C.

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10. Williamson EH, Lundquist DO. Anterior

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IJDPMS Vol (1) Issue (2) Jan – Apr 2013

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