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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 [email protected]
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
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
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
Contraindications
• maxillary / mandibular 1. Mixed dentition
2. Orthodontic treatment
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
Advantages of Mandibular stabilization splint 1. Aesthetics
1
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
Indirect Technique
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)
1. Maxillary & Mandibular impression & models 2. Bite Registration
Indirect Technique
Indirect Technique
3. Face-bow record
4. Send to Laboratory
2
Indirect Technique
Indirect Technique
5. Finished product from Lab
6. Splint delivery
Direct Technique
Technique Outline
• 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
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:
3
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?”
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
• “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 • • • •
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
4
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
Additional Tests Questionnaire
1. 2. 3. 4. 5. 6.
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
5
Maxillary Impression
Armamentarium
A good quality impression accurately capturing 1. all teeth 2. hard palate
Maxillary Impression
Look at the palatal arch
Making a Maxillary Impression
Select tray
Check Impression
Fabricate stone model
Criteria for good impression 1. All teeth captured 2. Hard palate captured 3. Good quality & accurate A good quality model accurately capturing 1. all teeth 2. hard palate Æ Faculty signature
6
Armamentarium
Check Model Criteria for good model 1. All teeth captured 2. Hard palate captured
Stone Model
Splint Outline • Buccal & labial extension – at level of interdental papilla • Distal extension – distal to last tooth (2nd molars) • Palatal extension – 15mm from gingiva
3. Good quality & accurate
Æ Faculty signature
Draw Splint Outline Armamentarium
Draw Splint Outline • Buccal & labial extension – at level of interdental papilla
7
Draw Splint Outline • Buccal & labial extension – at level of interdental papilla
Draw Splint Outline • Palatal extension – 15mm from gingiva
• Distal extension – distal to last tooth
Draw Splint Outline • Palatal extension – 15mm from gingiva
Draw Splint Outline (2nd
Draw Splint Outline • Buccal & labial extension – at level of interdental papilla
molars)
Write patient’s name on base of model
Æ Faculty signature
8
Wrap Stone Model
Draw Splint Outline
Recapitulation 23 Feb 8-10am
Recapitulation 23 Feb 8-10am
Lab Sheet Instructions
Recapitulation 23 Feb 8-10am •
use hard/soft material
•
follow splint outline drawn on model
•
create anterior stop
9
Anterior Stop
5mm 10mm 5mm
Finished Product from Lab
Lab Procedure
Checklist
Finished Product from Lab
•
Splint, model, case for storing splint
•
Correct hard/soft material
•
Anterior stop
Poor retention & unstable
Checklist •
Splint outline
•
Fit
•
Retention
•
Stability
Æ Faculty signature
10
Visit 2: Splint Delivery
Check splint in the mouth
Armamentarium
Locating the CR position Musculoskeletally stable position
Checklist •
Fit
•
Retention
•
Stability
Locating the CR
Locating the CR
11
Check splint in the mouth
Check posterior separation
Checklist •
Checklist •
Posterior teeth separation ~2mm.
Anterior stop perpendicular to lower incisor
Occlusal surface of splint
2mm
Anterior stop
Last molar
Inferior surface perpendicular to lower incisor
Checklist •
Lubricate acrylic restorations with vaseline
Posterior teeth separation ~2mm. ** If >2mm, reduce vertical height of anterior stop ** If <2mm, add acrylic to increase vertical height of anterior stop
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
12
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
13
Recapitulation 23 Feb 8-10am
Up next, 23 Feb Clinic 8-10am Maxillary impression
14
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
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
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
Contraindications
• maxillary / mandibular 1. Mixed dentition
2. Orthodontic treatment
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
Advantages of Mandibular stabilization splint 1. Aesthetics
1
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
Indirect Technique
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)
1. Maxillary & Mandibular impression & models 2. Bite Registration
Indirect Technique
Indirect Technique
3. Face-bow record
4. Send to Laboratory
2
Indirect Technique
Indirect Technique
5. Finished product from Lab
6. Splint delivery
Direct Technique
Technique Outline
• 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
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:
3
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?”
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
• “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 • • • •
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
4
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
Additional Tests Questionnaire
1. 2. 3. 4. 5. 6.
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
5
Maxillary Impression
Armamentarium
A good quality impression accurately capturing 1. all teeth 2. hard palate
Maxillary Impression
Look at the palatal arch
Making a Maxillary Impression
Select tray
Check Impression
Fabricate stone model
Criteria for good impression 1. All teeth captured 2. Hard palate captured 3. Good quality & accurate A good quality model accurately capturing 1. all teeth 2. hard palate Æ Faculty signature
6
Armamentarium
Check Model Criteria for good model 1. All teeth captured 2. Hard palate captured
Stone Model
Splint Outline • Buccal & labial extension – at level of interdental papilla • Distal extension – distal to last tooth (2nd molars) • Palatal extension – 15mm from gingiva
3. Good quality & accurate
Æ Faculty signature
Draw Splint Outline Armamentarium
Draw Splint Outline • Buccal & labial extension – at level of interdental papilla
7
Draw Splint Outline • Buccal & labial extension – at level of interdental papilla
Draw Splint Outline • Palatal extension – 15mm from gingiva
• Distal extension – distal to last tooth
Draw Splint Outline • Palatal extension – 15mm from gingiva
Draw Splint Outline (2nd
Draw Splint Outline • Buccal & labial extension – at level of interdental papilla
molars)
Write patient’s name on base of model
Æ Faculty signature
8
Wrap Stone Model
Draw Splint Outline
Recapitulation 23 Feb 8-10am
Recapitulation 23 Feb 8-10am
Lab Sheet Instructions
Recapitulation 23 Feb 8-10am •
use hard/soft material
•
follow splint outline drawn on model
•
create anterior stop
9
Anterior Stop
5mm 10mm 5mm
Finished Product from Lab
Lab Procedure
Checklist
Finished Product from Lab
•
Splint, model, case for storing splint
•
Correct hard/soft material
•
Anterior stop
Poor retention & unstable
Checklist •
Splint outline
•
Fit
•
Retention
•
Stability
Æ Faculty signature
10
Visit 2: Splint Delivery
Check splint in the mouth
Armamentarium
Locating the CR position Musculoskeletally stable position
Checklist •
Fit
•
Retention
•
Stability
Locating the CR
Locating the CR
11
Check splint in the mouth
Check posterior separation
Checklist •
Checklist •
Posterior teeth separation ~2mm.
Anterior stop perpendicular to lower incisor
Occlusal surface of splint
2mm
Anterior stop
Last molar
Inferior surface perpendicular to lower incisor
Checklist •
Lubricate acrylic restorations with vaseline
Posterior teeth separation ~2mm. ** If >2mm, reduce vertical height of anterior stop ** If <2mm, add acrylic to increase vertical height of anterior stop
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
12
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
13
Recapitulation 23 Feb 8-10am
Up next, 23 Feb Clinic 8-10am Maxillary impression
14
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