SPLINT THERAPY

Question 1

Pre-
authorize
as
needed
(2)

Answer 1

Some insurance plans
require pre-authorization
before making the splint
or occlusal orthotic
State Medical/Dental
coverage benefits should
be known by your
treatment coordinator
and billing manager

Question 2

Private Insurance

Answer 2

Is an occlusal orthotic covered
Is TMD covered under the plan
What is the cost (if ANY) to the
patient (a co-payment)

Question 3

State Insurance Plan

Answer 3

Is an occlusal orthotic covered
for specific TMJ condition?
Is it not covered for Bruxism- if
not, do NOT include Bruxism in
your diagnosis

Question 4

In California, Medi-Cal Dental
(D7880)
◦ — device is a benefit for all
members
◦ Requires corrected — or a
radiological report
◦ Requires written documentation that must include:
(3)
◦ A benefit for diagnosed TMJ dysfunction
◦ Not a benefit for the treatment of —

Answer 4

Occlusal orthotic
lateral tomography

1. specific TMJ conditions addressed by the
   procedure, 2. the rationale demonstrating the
   need, and 3. any pertinent history

bruxism

Question 5

Orthopedic
Appliance
Therapy
◦ Commonly referred to as:
(8)

Answer 5

◦ Nightguards
◦ Occlusal guards
◦ OCCLUSAL ORTHOTIC DEVICE
◦ Interocclusal splints
◦ Bite guards or bite planes
◦ Orthotics or orthoses
◦ Bruxism appliances
◦ Splints

Question 6

Orthopedic Appliance
Therapy
(5)

Answer 6

Routinely used
in treatment
of TMD
Removable
acrylic resin
appliances
Covers the
teeth on one
arch
Alters occlusal
relationships
Redistributes
occlusal
forces

Question 7

Centric Relation (CR) = Retruded
Contact Position (RCP):

Answer 7

Point of initial tooth contact when
the condyles are guided along the
posterior slope of the articular
eminence into their most superior
position on jaw closure
Synonyms: centric relation
occlusion, retruded contact
position

Question 8

Centric Occlusion (CO)
= Intercuspal Position
(ICP):

Answer 8

mandibular position
with the most complete
interdigitation of
opposing teeth
independent of
condylar position
Synonyms: maximum
intercuspal position
(MIP), maximum
intercuspation,
intercuspal position

Question 9

Impressions versus Intraoral
Scans
(3)

Answer 9

Take Alginate
impressions of
Maxillary and
Mandibular arch
Pour up in dental
stone
Impressions MUST
be taken within 2
weeks of turning
models into lab
due to teeth
shifting

Question 10

skip
Bite Registration – in MIP (ICP)
(4)

Answer 10

Dentsply TRUBYTE wax (type II regular)
Dip into warm water bath
Fold wax in half & press on hard surface
Cut to size of maxillary arch

Question 11

Laboratory
Mount upper/lower
casts using wax bite
registration or other
registration type
Turn in mounted
models of
maxillary/mandibular
arches to lab
Have primary
attending faculty fill
out & sign lab slip
LAB INSTRUCTIONS: Posterior splint
thickness = 3-4mm
MAY Add – ball
clasps OR make a
FLEX liner or all
acrylic or dual
laminate

Answer 11

4

Question 12

Trios Scanner
Bite registration needs to
open posterior bite by –
mm POSTERIORLY
Can use SomnoMed bite
fork with or with-out
horseshoe wax to obtain
bite

Answer 12

3

Question 13

Functions of Appliance
Therapy
(4)

Answer 13

Treats masticatory muscle & TMJ pain and
dysfunction
Alters functional relationships in the TMJ
Prevents tooth wear & mobility
Reduces bruxism & parafunction ? NO

Question 14

BRUXISM DEFINITIONS
◦ Two differentiating definitions published in the widely recognized
2018 International Consensus on the Assessment of Bruxism [8]:
* Sleep bruxism (SB) is

Answer 14

a masticatory muscle activity during
sleep that is characterized as rhythmic (phasic) or non-
rhythmic (tonic) and is not a movement disorder or a sleep
disorder in otherwise healthy individuals.

Question 15

• Awake bruxism is

Answer 15

a masticatory muscle activity during
wakefulness that is characterized by repetitive or sustained
tooth contact and/or by bracing or thrusting of the mandible
and is not a movement disorder in otherwise healthy
individuals.

Question 16

Splint therapy for TMD
Treatment
slide 18

Question 17

Splint Therapy: 4 TYPES
(4)

Answer 17

Soft splint
Stabilization
splint
Anterior
repositioning
splint
Anterior Bite
splint (NTI)

Question 18

1. Acrylic flat plane stabilization
   splint

Answer 18

◦ Treats muscle and TMJ Disorders :
myalgia, myofascial pain,
arthralgia and clenching

Question 19

2. Anterior Repositioning Splint:
   (2)

Answer 19

◦ Treats anterior disc displacement
without reduction & intermittent
non-reduction by unloading
posterior attachment
◦ Has indexing or indentations
holding jaw anteriorly to reduce
inflammation on the posterior
attachment reducing acute pain

Question 20

Splint therapy – full
coverage appliance
(3)

Answer 20

◦ The full-coverage flat plane stabilization appliance,
also known as the Michigan splint, is custom-made for
either the maxillary or mandibular arch. 8
◦ The optimal positioning of a stabilizing appliance
should result in only slight modification to the
maxillomandibular relationship, apart from the minimal
effect caused by the thickness of the appliance’s
material.8
◦ This kind of oral appliance is the most widely used, and
when constructed accurately, it carries the smallest
risk of negative consequences to the oral structures.8

Question 21

Splint therapy – full
coverage appliance
◦ A retrospective study aimed to determine the impact of using a maxillary
full-coverage occlusal splint (also known as a stabilization splint) on certain
temporomandibular disorders and their associated symptoms and signs. 11
➢ The study involved 232 patients who were experiencing chronic pain
during jaw movements, joint sounds other than reciprocal clicking, and
restricted mouth opening. 11
➢All patients received treatment exclusively with the stabilization splint. 11
➢The study found that 41% of patients experienced complete remission,
and when including those who saw partial improvement, the success rate
rose to 84%.11
➢ It was observed that patients with a displaced disk had a lower success
rate with this therapy. However, the presence of radiographic changes in
the temporomandibular joint did not appear to affect the treatment
results. 11
➢The findings suggest that stabilization splint therapy could be an effective
option for managing temporomandibular disorders, particularly for
patients with no clinical signs of a displaced disk.11

Question 22

Stabilization Splint
Indications:
(5)

Answer 22

◦ Myalgia or Myofascial Pain
◦ Capsulitis/synovitis
◦ Osteo/Rheumatoid Arthritis
◦ Anterior disc displacement with reduction
◦ Attrition prevention

Question 23

Stabilization
Splint
Patient
Instructions
(3)

Answer 23

When removing splint from
mouth, tell patient that it
may take a few minutes to
“find their normal bite”
The patient should be
accustomed to appliance
within 1 to 2 weeks
Pain & Symptoms should
begin to improve within 3 to
4 weeks (but may take
longer)

Question 24

Stabilization
Splint Patient
Instructions
(3)

Answer 24

◦ Keep appliance in case when
not wearing
◦ Keep appliance moist by
placing small amount of
water in case
◦ HIDE from DOGS

Question 25

SPLINTS
FOR
ADULTS
(2)

Answer 25

SHOULD BE CUSTOM MADE
BY DENTIST
OVER THE COUNTER SPLINTS
ARE SOFT- THE PATIENT BOILS
THE APPLIANCE AND BITES
INTO IT WHILE WARM
THEREFORE CALLED “BOIL &
BITE” NIGHT GUARD

Question 26

Stabilization
Appliance
(flat plane,
gnathologic,
or muscle
relaxation
splints)
1. Acrylic (hard) splint with flat-
plane occlusion;
2. Must cover
3. — appliance reduces
symptoms more quickly &
effectively than — splint
4. Good for —
5. Reduces symptoms in —% of
TMD’s

Answer 26

clasps add
retention OR acrylic with flex
liner (hard/soft splint)
all of the maxillary or
mandibular teeth
Hard, soft
bruxism/clenching
70-90

Question 27

Stabilization Appliance
Functions
(5)

Answer 27

Provide joint
stabilization
Relax the elevator
(closing) muscles
Provide stable
occlusion
Increases awareness
of jaw habits
Alters rest position of
jaw to a more
relaxed, open
position

Question 28

Stabilization
Splint
Patient
Instructions
(4)

Answer 28

Wear 8 to 12 hours per day
Wear night time if pain is worse on
awakening
Wear daytime if pain is worse during
day or at end of day BUT remove at
mealtime
Clean appliance with toothbrush, toothpaste or
soak in Efferdent or orthodontic retainer solution
UNLESS there is a soft liner inside the appliance

Question 29

Symptom Improvement
Failure to show
an initial positive
response may be
related to:
(5)

Answer 29

Noncompliance
Chronic painbehavior/bruxism
Degree of TMJ pathology
Misdiagnosis

Question 30

Anterior Repositioning
Appliance
◦ Also known as:
(2)

Answer 30

◦ Anterior positioning splint
◦ Mandibular orthopedic repositioning
appliance (MORAs)

Question 31

Anterior Repositioning Splint
made from Trios scans
(3)

Answer 31

Indexing holds jaw anteriorly to unload posterior attachment,
improve pain and Possibly improve
Disc position to seat onto condyle

Question 32

BITE REGISTRATION IS TAKEN BY MOVING MANDIBLE FORWARD BY 1-2 MM.
LISTEN WITH STETHOSCOPE TO SEE IF CLICK IS ELIMINATED TEMPORARILY WITH
OPENING & CLOSING.
MANDIBULAR ANTERIOR REPOSITIONING SPLINT:
(2)

Answer 32

HAS INDEXING ON OCCLUSAL SURFACE TO HOLD
MANDIBLE FORWARD. MAY IMPROVE DISC CATCHING
OR
LOCKING OF THE DISPLACED DISC BUT NO GUARANTEE

Question 33

Anterior Repositioning Splint
Indications
(3)

Answer 33

Anterior disc displacement without reduction with
significant pain in TMJ
Anterior disc displacement with intermittent non-
reduction (catching)
Primarily indicated for ACUTE TMJ pain associated with
disc displacement with reduction

Question 34

Anterior
Repositioning
Appliance
MAY Affect
TMJ Disc
Displacements
in 3 Ways:
Alters
Alters
Reduce

Answer 34

Alters adverse
loading in the
TMJ (unloads
the posterior
attachment)
Alters the
structural
condyle-disc
relationship
Reduce
associated
muscle
splinting

Question 35

Anterior
Repositioning
Splint
Not always successful in..
Night time wear is indicated if..
Day time wear is indicated if…
Replace with stabilization splint in
– weeks once joint
pain/dysfunction is controlled

Answer 35

recapturing disc or eliminating
TMJ noises
jaw locking primarily occurs on
awakening
locking with pain primarily occurs
in daytime
6-12

Question 36

Anterior
Repositioning
Appliance
MAY Affect TMJ Disc Displacements
in 3 Ways:

Answer 36

Alters adverse loading in the TMJ
(unloads the posterior attachment)
Alters the structural condyle-disc
relationship
Reduces associated muscle
splinting

Question 37

Partial
Coverage
◦ NTI : (2)

Answer 37

called the Nociceptive
Trigeminal Inhibition Tension
Suppression System (NTI-tss),
which involves a small segment
of the maxillary anterior teeth,
typically 2 to 4 incisors.
◦ The Risk of negative dental
effects from the use of the NTI-
tss over an extended and
continuous duration is
considerable. 8

Question 38

Splint therapy – partial coverage appliance
(NTI-tss)
(6)

Answer 38

➢may lead to irreversible changes in the occlusion over time if not
adequately supervised by a dental professional.13
➢a chance for the overeruption of the unopposed premolars and
molars which may lead to anterior open bite. The open bite could also
happen from the intrusion of the anterior teeth which hold the NTI-tss. 8
➢Mobility of the mandibular anterior teeth may also result. 8
➢Occlusal forces may lead to the displacement of the
maxillary anterior teeth which hold the NTI.8
➢ may lead to mouth dryness during sleep, as it can keep the mouth
slightly open. 13
➢it could be swallowed or inhaled, which could be life-threatening;
such severe incidents have been reported. 13

Question 39

Evaluation of the efficacy of the full
coverage stabilization splint and the
partial coverage appliance (NTI-tss)
◦ A double-blind randomized trial was conducted to evaluate the efficacy
of two different types of splints in treating patients with
temporomandibular disorder. 13
➢The study involved 40 participants and focused on comparing a
stabilization splint (of the Michigan design) with a NTI-tss splint.13
➢ An examiner who was unaware of the treatment specifics measured joint and
muscle sensitivity and recorded jaw opening measurements at the beginning of
the treatment, and then again at intervals of 2 weeks, 6 weeks, and 3 months
after starting the use of the splint at night. 13
➢ The patients also rated their TMD-related pain severity on a scale prior to and
after beginning the use of the splint. They also provided feedback on the
comfort of the splint. 13
➢ Over a three-month period, patients, primarily those with myogenic TMD
symptoms, demonstrated a decrease in muscle tenderness when palpated, a
reduction in both self-reported TMD pain and headaches, and an improvement
in jaw opening. 13
➢ After 3 months,

Answer 39

there were no noted differences in treatment outcomes between
the two types of splints.13

Question 40

Partial
Coverage
Splints
(3)

Answer 40

NEVER done at UMKC SD
Do not evenly distribute
loading forces
May cause occlusal
problems (i.e. super-eruption
of teeth not covered by
acrylic)

Question 41

Soft Splint
(6)

Answer 41

Effective in
pediatric patients
Less effective in
adults
Protects teeth
from trauma
Does not
decrease bruxism;
may increase
bruxism in adults
May be helpful for
short-term use Inexpensive

Question 42

Soft Splint
(7)

Answer 42

Effective in pediatric
patients and used for
MIXED DENTITION
because it is SOFT and
will not block the
eruption of the
permanent teeth
Useful in treating:
Myalgia, Arthralgia,
and
clenching/bruxism
Less effective in adults
Protects teeth from
trauma
Does not decrease
bruxism; may increase
bruxism in adults
May be helpful for
short-term use
Inexpensive

Question 43

Why can ONLY a SOFT SPLINT
be used in pediatric patients?
(3)

Answer 43

The SOFT splint is very inexpensive but inform parents that after the
permanent teeth erupt, a new acrylic splint is needed so they know
the cost up front
An Acrylic splint is rigid and may block the eruption of the permanent
teeth and it will NOT fit after the teeth erupt.
Because the soft splint will not block the eruption of the permanent

Question 44

skip
Delivery of Nightguard:
Schedule 30-60 minute appt. to
insert appliance
Supplies:
(9)

Answer 44

◦ Occlude
◦ Mouth mirror
◦ cotton rolls
◦ Sterile gauze
Blue/red articulating
paper
◦ Articulating paper
holders (2)

◦ #4 or 6 round bur
◦ Pineapple acrylic
bur
◦ Slow speed
handpiece
◦ Forceps

Question 45

Appliance Home Care
Instructions
(5)

Answer 45

1. When the appliance is not being worn, please place it in the case provided and keep the appliance moist. You Can place a clean, small sponge in the case which has been dampened with water. Clean the case with a Lysol Wipe once per week.
2. Clean the appliance with a toothbrush. If it is hard on the inside, you may soak it in water with a Polident or Efferdent Denture disinfecting tablet. Follow the instructions on the box.
3. Put your appliance in your mouth at bedtime and remove it in the morning. You may ONLY drink water with the Appliance in your mouth. REMOVE the appliance to eat or drink other liquids.
4. Bring your appliance to each appointment with your dentist.
5. If you require any dental treatment, especially crowns or bridges, bring you appliance to your dentist BEFORE the dental work is started. Your dentist should send your appliance to the dental lab so that the dental technician can make the new crown or bridge to fit exactly to your appliance. If the crown is made in the office, the dentist must make the crown to fit your appliance.

Question 46

Splint Therapy “Do’s”
Always take an
occlusal record
Limit splint wear to —hours per day
Always have —
arch coverage
Experiment with
night or daytime
wear
Anterior
repositioning should
additionally be
worn in daytime for
– hours
Recheck occlusion
periodically to rule
out occlusal
changes from splint
wear

Answer 46

8 to 14
full
4

Question 47

Warn your patient
(2)

Answer 47

◦ Do NOT wear 24 hours per day on long-term basis
or Major changes in occlusion (OPEN BITE) may
occur
◦ Occurs especially with partial-arch coverage-
NOT RECOMMENDED

Question 48

Splint Follow-
up
Appointments:
(7)

Answer 48

◦ 2 weeks
◦ 1 month
◦ 3 months
◦ 6 months (as long as patient
wears splint)
◦ Check fit and occlusal balance
◦ Check fit and LOOK for
OCCLUSAL WEAR. Show patient
wear patterns- EDUCATION.
◦ Follow-up with pain & adjust
medications, f/u with physical
therapy …

Question 49

What to Look For During the
Adjustment
(3)

Answer 49

1.Wear patterns on the splint to determine how
heavily your patient is clenching or grinding. Side-
to- side markings indicate bruxism.
2. Fractures in splint due to heavy clenching.
3. Delamination of soft liner

Question 50

What are the complications
with excessive or incorrect use?
(6)

Answer 50

1. Occlusal changes (i.e. open bite)
2. Speech difficulties
3. Caries
4. Gingival inflammation
5. Malodor
6. Psychological dependence

Question 51

Splint Adjustments
WHY ADJUST ?
It is your LEGAL RESPONSIBILITY
To correct for changes in occlusion as pain, muscle activity, inflammation,
edema, or soft tissue relations change.
Malocclusion due to arthritis must be monitored once per month for —
months and the splint serves a diagnostic purpose to see if occlusal
contacts on splint are stable over time

Answer 51

6

Question 52

SUMMARY
FOR
SPLINTS:
Limit wear to — hours long term
May improve — but not
necessarily eliminate it
Do NOT promise the patient that it will
“cure” their symptoms
Should decrease (three)
Adjust splint on regular basis
Evaluate patient’s occlusion to ensure
that it is not changing due to splint wear

Answer 52

8-12
clicking
pain, tightness, &locking