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4/9/11 9:51 AM
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General Dentistry: Occlusal Splints From the Beginning to the Present
J.S. DuPont, Jr. D.D.S.; C.E. Brown, D.D.S. Volume 24 Issue 2 April 2006 Abstract:
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In his text outlining the various splint modalities in use today, Bledsoe,l defines a splint as a removable oral device fitted between the maxilla and the mandible. Its functions may include stabilizing the temporomandibular joint to reduce the muscle activity of the craniomandibular complex, or to reduce the attrition of the teeth to the parafunctional forces of occlusion or to trauma. Since much literature exists to support the efficacy of this modality of care, a perspective look at splint therapy in dentistry can most simply be reduced to a review of the type of material used for such orthotic devices. Now, argument is made as to which style of splint and what kind of material would be most helpful to the profession. History The original inventor of the forerunner of modern splints will probably never be known. With the development and patenting of vulcanite rubber in 1855, Charles Goodyear,2 provided dentists with a material that could be molded for many different oral applications. One of the early medical uses of vulcanite was by dental surgeons for splinting of broken jaw bones. In November 1862, Thomas Gunning,3 a practicing surgeon, used vulcanite to fabricate a custom fitting splint to treat himself for a broken jaw. He wore the splint for two months and discarded it when he considered himself healed. Another dentist, James Bean,4 working independently from Gunning, used a vulcanite device for jaw fractures while in the service of the Confederate Army. His splint had cup-like depressions to fit over the crowns of teeth. The Gunning vulcanite splint, Figure 1, is remarkably similar to appliances used today to treat temporomandibular disorders. Additionally, his double arch splint, Figure 2, very closely resembles early orthodontic positioners, snoring and sleep apnea appliances in use today. In 1887, twenty-five years after Gunning's development, Kingsely,5 published an article discussing the use of soft vulcanized rubber to make an obturator. Then in 1888, Farrar,6 discussed the use of a splint to disarticulate the teeth for the purpose of increasing the eruption of selected teeth. He also recognized the changes in what he calls the inferior maxilla and its articulation. Karolyi,7 a German, introduced an occlusal splint in 1901 for the treatment of bruxism. Since that time, a variety of different splint designs have been developed and treating theories postulated. Hawley,8 in 1919, and then Monson,9 in 1921, each suggested that bruxism led to a loss of occlusal vertical dimension, which gave rise to occlusal disorders. The use of a removable bite plane to extrude posterior teeth was advocated. Several years later, in 1925, Washburn10 published an article discussing the history and evolution of occlusion. He discussed the melange of splint contrivances used since the mid-19th century. Articles by Goodfriend11 in 1933, Costen12 in 1934 and Block13 in 1947 suggested treatment modalities to increase vertical dimension for the treatment of TMD symptoms. Sved,14 in 1944, was using appliances to extrude posterior teeth to increase vertical dimension. To this day, our therapies continue to carry forward many of these pioneers’ treatment concepts. Resilient Appliances It was not until the 1940s that several articles began appearing in the literature discussing the use of soft appliances to treat oral conditions. Some early soft resilient appliances were possibly made of vulcanite or soft vulcanized rubber. One of the first references to the use of a soft appliance is by Matthews15 in 1942, for the treatment of bruxism. He advocated a technique for using soft latex rubber to make a splint because he believed that acrylic was harmful to mouth tissues. Four years later, in 1946, Kesling's16 article discussed using a maxillary soft occlusal appliance in order to maintain the
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Postulating that resilient occlusal guards were the best treatment for bruxism. in 1971. and the variability in reporting. have minimal wear. These included an inability to eliminate contacts in excursive movements. In summary. soft rubber and plastics. Ingersoll and Kerens. subjective evaluations. He felt that these appliances must be easy to fabricate. Also using a resilient material for splints. Harkins38 showed an effective treatment using a soft splint design during a 10-20 day treatment plan in patients with a clicking TMJ with pain and dysfunction. we read that Williams46 liked the use of a soft splint for a patient with an edentulous ridge opposing an arch of natural dentition during sleep at night. The present trend in clinical use appears to be that of a hard acrylic http://cranio. In 1988.44 in 1997. they settled on a mandibular appliance to make use of gravity for improved retention. Later that same year. some patients in the soft appliance actually showed an increase in muscle activity. Gecker and Weill24 discussed the use soft splints for bruxism because they believed this material produced less trauma on the teeth. as he liked the cushioning effect it had to occlusal trauma. Ingerslev. he was able to relieve most initial symptoms quickly but noted that some splints were destroyed by the powerful muscle activity in these children. published articles slowly began to offer more comparison of the use of splints made of some resilient material with those made of a hard acrylic material now becoming more popular with practitioners. Zarrinnia. He cautioned about the disadvantages of soft appliances. a softer material produced less trauma to the tissue and teeth in the arch opposing this material. Though splint designs and materials used have varied considerably during the past 150 years. undertook a study to compare the effectiveness of hard and soft bite plates to manage bruxism. Quayle and Gray41 showed that soft splints helped with vascular type of headaches but did not with tension style headaches.33 used a latex material in his splint treatment. Kaner18 published an article describing the use of a combination acrylic-vulcanite splint in the treatment of bruxism. They concluded that hard splints are likely to be more effective in reducing hyperactive muscles. Anthony43 advocated that a hybrid design using soft vinyl fused to a hard acrylic might get the best of both worlds. they must be used as a transition therapy toward one using a hard acrylic material. problems with adjustments. Okeson.37 compared the used of hard splints with soft splints in a pool of patients showing nocturnal bruxism. Dawson. he did admit that after just eight weeks of treatment some excessive tooth mobility was noted in his patients. That same year. the efficacy of splint therapy for treatment of signs and symptoms of TMD and occlusal disharmonies is well documented.28 in 1972. He cited the use of soft splints for patients with a bruxing habit as well as for patients with a click in the TMJ. Ramfjord and Ash. This patient had previously clenched against the ridge causing a traumatic ulcer. By the 1980s. Hicks39 showed a technique for fabricating a soft splint chairside to gain quick relief for his patient and then gain time to move to a hard splint design for long-term care. He advocated the use of a hard appliance. suggested that bruxism was one of the first activities patients engage in when the “vicissitudes of life become excessive. it was "selfadjusting" and as such changed with the changing joints. in 1987. not the vulcanite or latex rubber of the past. Campbell20 described his approach that used a soft appliance to treat patients who bruxed their teeth or had joint pain. His appliances were constructed out of vinyl material.32 told of care that he provided for a population of children who showed signs of parafunctional occlusal habits. Moore's19 article outlined a technique for using a soft rubber bite positioner for nighttime use for bruxism in 1956. That same year.22 in 1961. authored a paper discussing the treatment of occlusal trauma using a semi-soft vinyl resin appliance made of vinolin. However. suggested that maxillary arch appliances were most effective and that they need not cover the palatal area. Then in 1999. But. Echoing this thought the following year. A literature review by Boero40 at the end of the decade. They reported that 74% of their patients had total or almost complete remission of non-specific TMD symptoms after six weeks. Since the soft material equally distributed occlusal load. In 1990. His suggestion was to use a soft splint for immediate relief and as a diagnostic guide for patients with a reducible disk derangement. Verban.” He went on to outline a technique for treatment using a splint of soft latex rubber that was painted over a cast to the desired thickness and allowed to dry. Wright42 used a soft splint effectively during a short 4-11 week treatment study. Hutchins and Elkins. In 1984. Writing in 1983. maybe even resulting in an additional bruxing habit. Block and Laskin31 found that resilient appliances were effective in treating TMJ dysfunction symptoms with complete or almost complete joint reduction. but complained that comparison of results was difficult due to the various outcome scales. offered a review of the literature evaluating splint therapy for treatment of TMD. He felt the appliance acted as a cushion to prevent excessive tooth pressure. Al Quran and Lyons47 performed an electromyographic study investigating the immediate effects of hard and soft splints. The patient was slowly equilibrated using this approach. In 1974. The splint offered a protective cushion. Also.30 in 1975. Shanahan. Also in 1984. They concluded that the hard bite guards were slightly more effective for managing these disorders.35 in 1986. They also noted that soft appliances were difficult to adjust and polish.com/volume24/issue2/general-dentistry-occlusal-splints-from-the-beginning-to-the-present/ Page 2 of 4 . argued that a soft splint allowed the patient to reach a comfortable TMJ location.23 in 1963. If a perforation appeared. Major and Nebbe. Kessler25 in 1964. which then allowed for the natural reorganization of damaged tissue. but that vinolin.General Dentistry: Occlusal Splints From the Beginning to the Present 4/9/11 9:51 AM mandible in a predetermined relationship to the maxilla. Krogh-Poulsen and Olsson26 treated craniomandibular parafunction in 1968. Then in 1957. The patient would wear the splint day and night for one week except when eating. while the soft splints did not. Shore's21 book in 1959 provided an outline for treating TMJ and facial pain. He confirmed reports of problems with resilient splint materials as lacking durability and posing problems with adjustments in follow-up care. In fact. They thought that splints made of hard acrylic or vulcanite caused trauma to the opposing dentition. the following year. Clark34 offered an evaluation of all of the orthopedic interoccusal appliances being used to date. In one of the most eloquently penned definitions of bruxism reviewed. Thorp. Experimenting with several different designs. The next year. His article reviewed various hard splint designs and concluded that the best modality of care would be with a full arch occlusal stabilizing splint made of a hard material.27 stated that soft appliances were not effective in treating bruxism because the patient played with the appliance.17 in 1952. He concluded that the hard splints significantly reduced this hyperactivity of the muscles. Posselt and Wolff. such as perforations functioning like orthodontic appliances. They concluded that much data supports efficacy of this modality. Shulman. He then transitioned these patients to a hard splint for long-term care. related that bite appliances have been made of many different materials such as vulcanite.36 cautioned that while soft splints were useful for immediate relief of acute pain. As the 90s came to a close. However. He related that patients wore a maxillary and mandibular appliance at night. Maybe Okeson's37 earlier results of increased muscle activity with soft appliances might explain Quayl's41 conclusion. The splint was again worn until supporting tissues returned to normal or other perforation appeared and the above process was repeated. but that these materials have many disadvantages. He switched to a hard splint material for those cases in order to complete his study. just three years later. the occlusal prematurity was reduced and a new coat of latex was applied. Writing in 1978. Over a 10-15 week period. strong arguments can be made that effective treatment can be attained with an interocclusal appliance. distortion and poor retention.29 suggested the use of soft appliances to cushion the posterior teeth in subjects with chronic sinusitis. and be easy to clean and of acceptable taste. suggested that soft splints do help in the short-term but definitely have problems with the ability to be adjusted and with uncontrolled changes in tooth position. he noted equally effective results with each type of splint. Pettengill45 designed a study using 18 patients to test the efficacy of hard and soft appliances in treating TMD. Using a soft splint. described a technique of combining hard and soft (Molloplast B) material to produce an appliance to use in the treatment of bruxism. In 1995.
Hutchins M. Clark G: A critical evaluation of orthopedic interoccusal appliance therapy: design. 10:7-8. Gray R. Laskin DM: The use of a resilient rubber bite appliance in the treatment of MPD syndrome [Abstract 71].: Appli-cation of soft occlusal splints in patients suffering from clicking temporomandibular joints. 108:359-364. Dent Cosmos 1933. Dawson PE: Evaluation. In: Schwartz L. Cueva O. J Periodont 1956. Leff A: Bruxism and clenching. Dent Cosmos 1925. 23. Quayle A. 40. 29. JADA 1987. 32:285. Al Quran F. 5. 43:115. Kesling HD: Coordinating the predetermined pattern and tooth position with conventionl treatment. Washburn HB: History and evolution of the study of occlusion. Dental Cosmos 1888. J Houston Dist Dent Soc 1987. 79(2):165-168. Wright E. occlusal treatment. Nebbe B: Use and effectiveness of splint appliance therapy: a review of the literature. 30:527. 31. Romm S: Thomas Brian Gunning and his splint.General Dentistry: Occlusal Splints From the Beginning to the Present 4/9/11 9:51 AM appliance covering the full arch of teeth. 61(1):48-50. 26. Plast and Reconstrut Surg 1986. 38. 24. Verban E: A self-adjusting TMJ appliance. J Dent Child 1983. 3rd ed. et al. 114:788-791. 82:116. St. Campbell J: Extension of the temporomandibular joint space by methods derived from general orthopedic procedures. Chayes CM. 28. 1971. eds. Besen GH. 46. Zarrinnia K. J Clin Orthod 1984. 22. Block LS: Diagnosis and treatment of disturbances of the temporomandibular joint especially in relation to vertical dimension. diagnosis and treatment. Nat Dent Ass J 1921. a rationale of therapy. 25. Boero R: The physiology of splint therapy: a literature review. 41. Richmond Med J 1866. 29:733. 18. 35. 8:833.Oesterreichungarische Vieteljahrs-schrift fur Zahnheilkunde 1901. 18(3):123-129. Internat J Orthodon 1919. Covey EN: The interdenal splint. 17. 26:559-564. 12(7):32-36. 66:14. 1974.2. Apfel M. Ash MM: Occlusion. Gecker L. Williams & Wilkins Publishing. JADA 1947. Sved A: Changing the occlusal level and a new method of retention. Kaner A. 27. Major P. 45. Hawley CA: A removal retainer. Philadelphia: JB Lippincott C. Farrar IN: Irregularies of the teeth and their correction.67:331. Block LS. 5:291. Krogh-Poulsen WG. Can Dent Assoc 1963.com/volume24/issue2/general-dentistry-occlusal-splints-from-the-beginning-to-the-present/ Page 3 of 4 . 1106-1111. Monson GS: Impaired function as a result of closed bite. Marteney J. 10. Ramfjord SR. 33. J Prosthet Dent 1957. 18(2):252-258. 19:231. 39. Wolff IB: Treatment of bruxism by bite guard and bite planes. 47. 59(3):165-169. Metcalfe R. Facial pain and mandibular dysfunction. Philadelphia: WB Saunders 1968: 236-280. 44. 7:386399. Am J Orthod Oral Surg 1946. J Prosthet Dent 1999. Lang K: A therapeutic method for selected TMJ dysfunction patients. 34(2):253-260. J Dent 1990. J Craniomandib Pract 1988. 1:81. 75:844-852. CDS Review 1986. J Dent Rest 1978. JADA 1963. J Craniomandib Pract 1997. 2. Shore NA: Temporomandibular joint dsyfunction and occlusal equilibration. 9(2):116-130. Goodfriend DJ: Symptomology and treatment of abnormalities of the mandibular articulation. Ann Otol Rhinol Laryngol 1934. VA Dent J 1972. Oct (3): 1539-1544. Okeson J: The effect of hard and soft splints on nocturnal bruxism. JADA 1952. Trends and Techniques 1995. 57(special issue):92. 17:273. J Oral Rehabil 1999. Olsson A: Management of occlusion of the teeth. 49(6):29-30. Armstrong RH: Bruxism. 9. 1991. 32. 62:154-155. Kingsely NW: An experiment with artifical palates. 11. 50(6):446-450. Shanahan TEJ. 27:401-403. diagnosis and treatment of occlusal problems. 37. 6. Am J Orthod Oral Surg 1944. Shulman J: Bite modification appliances-planes. 8. Schulte J: A randomized clinical trial of intraoral soft splints and pallative treatment for masticatory muscle pain. Br J Oral Surg 1969: 7:112. Angle Orthod 1989. 16. Throp PDE: An appliance to be worn at night for the heavy tooth grinder. Philadelphia: WB Saunders Co. 43. Costen JB:A syndrome of ear and sinus symptoms dependent upon function of the temporomandibular joint. 18:35-37. References 1. Dent Cosmos 1887. Kessler SJ. US Armed Forces Med J 1952. 13. J Prosthet Dent 1998. Zweig JM: Rapid fabrication of effective bruxism guard. No. Matthews EA: Treatment for the teeth-grinding habit. Harkins S. J NJ Dent Soc 1964. 15. 6:71-75. J Prosthet Dent 1989. 28:144-145. Ingerslev H: Functional disturbances of the masticatory system in school children. 20. Williams R: Occlusal guard for the maxillary edentulous patient. 27:281. Weill R: Bruxism. NY Dent J 1961. Dent Tech 1975. 44:22-27. Anthony T: Soft thermoplastics in bruxism appliances. et al. 1959:249. Kerens EG: A treatment for excessive occlusal trauma of bruxism. Louis: CV Mosby Co. Guthrie E. theory and overall effectiveness. Pettengill C. 21. Moore DS: Bruxism. Lyons M: The immediate effect of hard and soft splints on EMG activity of the masseter and temporalis muscles. Bledsoe S: Intraoral Orthotics. 1. 14. Dent Record 1942.: A pilot study comparing the efficacy of hard and soft stabilizing appliances in treating patients with temporomandibular disorders. J Orofac Pain 1995. Ingersoll WB. 36. http://cranio. Hicks N: An effective method for constructing a soft interoccusal splint. 7. Karolyi M: Beobacchtungen uber pyorrhea alveolaris. 15(2):159-166. 79(9):38-39. Wastell D: Soft occlusal splint therapy in the treatment of migraine and other headaches. 3. 4. Elkins W: Pathophysiology of masticatory muscle disorders and occlusal splint therapy. Anderson G. Vol. 42. 36(10):59-61. plates and pivots. 19. Posselt U. Fraser-Moodie W: Gunning and his splint.238. 34. 30. JADA 1984. 12.
Dr. ORDER ARTICLE © 2009-2011: The Journal of Craniomandibular Practice. Site by Medium http://cranio.General Dentistry: Occlusal Splints From the Beginning to the Present 4/9/11 9:51 AM Dr. Chris Brown practices in New Orleans.com/volume24/issue2/general-dentistry-occlusal-splints-from-the-beginning-to-the-present/ Page 4 of 4 . Louisiana. He has diplomat status in the American Board of Forensic Dentistry (ABFD) and American Academy of Pain Management (AAPM) and fellowships in International College of Cranio-Mandibular Orthopedics (ICCMO) and the Academy of General Dentistry (AGD). His is a fellow-eligible member of the American Academy of Craniofacial Pain (AACP) and a diplomat of the American Academy of Pain Management (AAPM). John DuPont has published a number of articles and manuals on the diagnosis and treatment of temporomandibular joint disease. he serves as an adjunct clinical professor to the senior class patient clinic at the Louisiana State University School of Dentistry. Also.
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