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