Occlusal splints

Occlusal splints, known by various names such as bite guards, oral orthotics, and oral
appliances, find common usage within the field of dentistry. These dental devices serve
multiple purposes, including the relaxation of jaw muscles, the prevention of
temporomandibular jaw trauma, the protection of dentition, and the management of
headaches. However, the effectiveness of occlusal splints remains a subject of scrutiny.
Current laboratory methods for manufacturing occlusal splints rely on a range of manual
techniques and processes. These methods often vary between different laboratories, leading to
inter laboratory differences in the final products. For instance, when mounting casts onto
articulators to establish a hinge for adjusting the interocclusal distance, the orientation can be
visually determined. Alternatively, either the upper or lower cast may be placed against the
flat surface of a mounting jig. This variability can result in the occlusal plane being defined
by the three highest points on the dentition, which can significantly alter the arches'
orientation. Additional inaccuracies stem from how the technician positions the cast on the
mounting jig, influencing the hinge's orientation relative to the cast and the axis incisal
distance.

Moreover, intra-laboratory variations occur during the manual trimming process to create the
functional contact surface. Typically, acrylic is cured between articulated casts, and a
technician manually grinds down the acrylic around the tooth impressions left by the contact
arch. Consequently, the final contact surface contains residual tooth impressions, which result
from the technician's subjective judgment of smoothness. Clinically, these indexing
impressions tend to restrict patient movement and hinder the free motion required to
effectively deprogram muscles. Consequently, the existing methods of splint fabrication
practically guarantee that the same splint will never be replicated exactly, even when
produced by the same technician for the same patient.

In contrast, digitally based manufacturing offers several advantages, including consistency,

precise quantitative control, and efficiency compared to manual techniques. When applied to
medical and dental devices, flexible design software must be utilized to accommodate natural
biological variations. The goal of this applied research endeavor was to develop a digital
system for designing and producing occlusal splints. This system is akin to other dental
computer-aided design (CAD) and computer-aided manufacturing (CAM) systems,
encompassing scanning, specialized CAD software, and digitally driven fabrication.
Rapid prototyping (RP) technology enables the direct digital fabrication of plastic and metal
parts. In orthodontics, RP is used for producing plastic tooth setups for sequential positioners
in systems like the Invisalign System. RP has also been employed for crafting customized
lingual brackets and surgical splints as part of computer-assisted orthognathic surgery. In the
context of CAD/CAM for occlusal splints, specialized CAD software is utilized to articulate
and design these splints. This report focuses on the pioneering computer-based design and
production of flat-plane splints and splints with guidance ramps, presenting an overview of
the process and highlighting its key features.

The overarching approach in this developmental endeavor aimed to minimize the reliance on
custom hardware and software, instead leveraging readily available scanning and machining
equipment, albeit with customized versions of commercially available software. Custom
software played a pivotal role in the articulation and design of splints.

The process initiates with stone casts affixed to standard mounting plates, which are then
subjected to laser scanning using a Minolta VIVID 910 camera from Konica Minolta Sensing
in Ramsey, NJ. Geomagic Studio software, developed by Geomagic in Research Triangle
Park, NC, is employed to operate the camera and manipulate the scan data. Six scans, each
taken at 60° intervals, are merged into a unified object. The scanning system undergoes
calibration to precisely define the position of the casts relative to the mounting plate. For
cases with mounted stone casts, this calibration facilitates the digital positioning of the casts
in a manner that replicates their physical placement on a traditional articulator.

Fig1 . A combination scan or 3D bite record, used to locate the maxillary arch after using the mandibular arch to
locate a hinge axis (for unmounted cases).

In instances where stone casts are not initially mounted, a 3-dimensional (3D) digital bite
record, termed a "combination scan," is generated. This is accomplished by conducting a
single laser scan of both the maxillary and mandibular casts in conjunction with the provided
centric-relation bite registration, as depicted in Figure1. This 3D relationship between the
arches serves to determine the position of the maxillary arch following the establishment of a
hinge axis through the use of the mandibular arch.

Mounted cases are articulated within the software environment, simulating the mechanical
articulators commonly employed in dental practice. Utilizing the mounting plate as a
reference point, the casts are digitally arranged in a manner mirroring their physical
arrangement on a mechanical articulator. Notably, this software allows for individual control
over condylar inclination angle, eminence curves, and the Bennet angle. Such control enables
the accurate simulation of protrusive and lateral excursions, crucial for designing guidance
ramps in occlusal splints.

Fig2 . Section of the articulation software used to locate a hinge axis. Either standard averages or patientspecific
(custom) values are used to locate a centricaxis for unmounted cases.

For cases involving unmounted stone casts, the lower cast is used to determine the hinge axis.
A standard articulation method is applied, initially defining a mandibular occlusal plane and
subsequently orienting it at a 15° angle to the horizontal plane. The hinge axis is established
at an axis-incisal distance of 100 mm and a vertical height of 50 mm. Importantly, the
software provides independent control over the mandibular occlusal plane angle, axis-incisal
distance, and vertical height. Figure 2 illustrates a portion of the articulation software
interface used for inputting these values.

While the software is capable of accepting patient-specific values, the current source of such
data is limited to cephalograms. Future plans include the incorporation of published data
specific to various population groups and enhancing the precision of articulation for cases
involving unmounted stone casts. In cases with mounted casts, similar condylar control
software is applied, maintaining consistency across both scenarios.
Splint design

The cast designated to receive the occlusal splint is referred to as the "splint" cast, while the
opposing arch is termed the "contact" cast. The process of splint design encompasses the
specification of several critical parameters, including the interocclusal distance, placement of
contact points, dimensions of flat-plane shelves, configuration of anterior and canine ramps,
and the overall perimeter or shape of the splint.

The initial step involves adjusting the interocclusal distance to the desired setting. It is
advisable to record a centric-relation bite at the intended interocclusal distance to minimize
the need for significant adjustments later on. Generally, the clinician should be able to
observe through the occlusion to ensure an adequate thickness of plastic and the absence of
lateral interferences.

Contact points on the contact cast are defined within the software by selecting specific
locations on the cast's surface. Due to the inherent difficulty in pinpointing these locations
precisely, software optimization techniques are employed to relocate these points to ideal
positions. This optimization process serves to ensure consistency in design and allows the
designer to focus on determining which cusps should be in contact.

For cases characterized by relatively normal curves of Spee, point optimization is based on
the occlusal plane of the contact cast. This method automatically adjusts the chosen position
to the point on the tooth closest to the occlusal plane. In cases where a tooth extends above
the plane, the point on the tooth farthest from the plane is used. Subsequently, a surface
normal is computed for each contact point, and a circular "island" of controlled diameter,
oriented perpendicularly to the surface, is constructed around each point. The collection of
islands is then used to establish a contact plane, which is the flattest possible surface that
passes through all the contact points. The functional surface of the splint is derived from a
horseshoe-shaped portion of this contact plane, covering the teeth of the opposing arch where
contact is intended. In situations necessitating adaptation based on the arc of closure,
optimization entails repositioning the initial point to the location on the tooth that is first
intersected by a plane rotated about the centric axis.
Fig 3. Mandibular arch with contact points, surface normals, and the perpendicular circular islands. A, Best-fit
contact plane passing through the islands curves down from the canine to the premolar island. Red guidance
markers indicate the extent of the canine ramp. B, Arcoptimized points in red and plane-optimized points in
green in a patient with a large curve of Spee. The contact plane passes smoothly through all the contact islands.

Moreover, the design of splints with guidance ramps, both anterior and canine, aims to
facilitate posterior disocclusion when the patient protrudes or engages in lateral jaw
movements. The lateral extent of these ramps is determined by placing four markers on the
line connecting the contact points. The anterior ramp lies between the two mesial markers,
while the canine ramps are situated between the two sets of distal markers. The software
allows control over the length and angle of each ramp. Typically, the initial calculation
establishes the ramp angle required for zero disclusion, followed by a 5° increase to ensure a
gradual disclusion rate. The width of horizontal shelves associated with the ramps can be
directly specified in millimeters. For example, in a maxillary Dawson design, a 1-mm shelf
lingual to the ramp may be specified.

In cases involving the design of flat-plane splints, it is crucial to specify the width of the
surface both anterior and posterior to the contact points. This specification is particularly
important for cases with significant horizontal overlaps to ensure an adequate shelf length for
protrusion.

Finally, the perimeter or shape of the splint is determined by selecting a series of points on
the splint cast, allowing for customization of its configuration. Figure 4 illustrates the design
of a maxillary flat-plane splint, with visualized contact points from the mandibular arch,
anteriorand canine guidance ramps, and a close-up lingual view.
Fig 4. Flat-plane maxillary arch splint. A, Contact points from the mandibular arch; B, with anterior and canine
guidance ramps. The splint has a 2-mm shelf extending lingually from the anterior contact points. The canine
and anterior ramps blend smoothly into each other. C, Lingual view shows contact points and canine and
anteriorramps.

Splint fabrication

Splints are manufactured through a machining process involving the removal of excess
acrylic material applied to the splint cast. The finalized splint design is saved as a 3D surface
file, which is then directly imported into PowerMILL Computer-Aided Manufacturing
(CAM) software developed by Delcam PLC, headquartered in Birmingham, United
Kingdom. The splint cast, covered with acrylic, is securely mounted within a high-speed
vertical machining center manufactured by Haas Automation, Inc., located in Oxnard,
California. Carbide ball end mills of varying diameters are employed for the machining
process, with an emphasis on using the largest possible tool diameters to ensure the creation
of the smoothest possible surface finish.

It is noteworthy that the underlying tooth anatomy of the splint does not require machining,
as this surface is accurately replicated by the acrylic material. This feature substantially
reduces the size of the digital files and simplifies the machining operation. Since splints often
exhibit general similarities in their shapes, similar cutting strategies can be applied to most
cases. However, regions of the contact surface containing contact points necessitate
meticulous machining down to meet the designed surface. Smaller cutting tools are
specifically used in these areas to precisely follow the contour of the surface. Figure 5
illustrates the PowerMILL CAM software interface, showcasing regions with contact points
that have been selected for finer machining, identifiable by white outlines. The software
employs raster-type tool paths within each selected region. The splint's surface is represented
as a series of four-sided patches, with each patch defined by intersecting nonuniform rational
B-splines. This approach ensures a continuously curved machining surface, as opposed to a
faceted polygonal one.

To withstand the forces generated during machining, robust mountings are essential.
Mounting stone, rather than plaster, is utilized due to its superior strength. The milling
process can be adapted to accommodate standard wire clasps inside appliances by adjusting
tool paths within the CAM software. Remarkably, the contact surface is consistently
machined to an accuracy level of less than 10 μm, obviating the need for additional finishing
steps.

Fig 5. Screenshot of CAM software. Three sets of nonuniform rational B-spline patches on the contact surface
have been selected for finer machining. The complete machining tool paths fora 1/8-in diameter tool are shown.

Digital splints offer a notable advantage in terms of the smoothness of their contact surfaces
when compared to conventionally produced splints. Traditional splints often exhibit residual
indexing impressions left by the contact cast, which can interfere with the movement of teeth
over the splint surface. In contrast, digitally produced splints are free of such divots,
facilitating unimpeded tooth movement. Figure 6 provides scanning electron micrographs at
equal magnification (20 times) for both manually produced laboratory splints and digitally
produced splints, highlighting the remarkable surface smoothness achieved through digital
fabrication. Clinical contacts on digitally produced splints manifest as fine markings or points
rather than larger marks caused when articulating paper is drawn into tooth impressions by
the opposing arch. This streamlined contact surface simplifies the equilibration process, as
adjustments can be made precisely at the contact points, minimizing the need for excessive
material removal.
A key advantage of digital splint design is the ability to select contact points that yield the
flattest overall surface, particularly important for molar contact points. Designers can add or
remove contact points while observing the resultant impact on the shape of the contact plane.
This dynamic feature enables the attainment of the flattest possible surface consistent with
the required contact points. Moreover, for unmounted cases, clinicians can input patient-
specific articulation parameters to customize designs. These parameters can be derived from
either direct clinical measurements or published statistical data accounting for variations
related to factors such as race, age, or sex. The nature of the occlusal plane influences the
placement of contacts on the splint, with a flat curve of Spee allowing for optimal contact
points based on the occlusal plane. However, it became evident during beta testing that as the
curve of Spee increased, the occlusal plane was no longer suitable for optimizing contact
points. This led to the development of the capability to optimize points based on the arc of
closure.

Fig 6. Equal magnification scanning electron micrographs of splint surfaces. A, Manually produced splint shows
2 typical tooth impressions; B, digital splint shows a smooth surface that also has 2 contact points.

The ramp angle is another parameter of significance, with the software initially employing a
standard 20° condylar inclination angle and average eminence curves consistent with fully
adjustable articulators. For patients with significant changes in condylar angle or joint
remodeling (e.g., delta bruxers), additional design information is necessary to construct an
appropriate ramp that minimizes the disclusion angle. Another clinically important
consideration is the fit of the appliance over the teeth, which should readily seat over the
teeth before equilibration procedures commence. The splint's design must account for dental
anatomy to ensure a secure fit. For example, flared anterior teeth dictate that the splint should
seat passively over them and rely on posterior teeth for retention. During beta testing, two
designs were evaluated: one with complete overlap of buccal and facial surfaces and palatal
coverage, and the other with the occlusal third of the buccal and palatal surfaces of the teeth,
featuring 2 to 4 ball clasps for retention. Ultimately, the latter design, which provided ball-
clasp retention, was deemed superior in terms of ease of placement.

The arc of closure influences the location of initial contacts in an anteroposterior direction. If
the splint is designed with an axis-incisal distance that is too short, initial contacts will occur
anteriorly on the splint, whereas excessive distance will result in posterior initial contacts.
However, it is essential to note that most cases received by dental laboratories today are
unmounted, lack facebow recordings, and feature interocclusal records of varying thickness
and type. Consequently, a standard axis-incisal distance of 100 mm is employed in the
software to address these cases. Although a true hinge axis recording with an accurate
centric-relation record yields the most precise representation of the arc of closure, this
practice is not yet widespread in dental offices. Many cases in dental offices utilize an
arbitrary facebow recording with a centric record, which can produce reasonably accurate
representations of the arc of closure as long as the interocclusal record does not exceed 3 mm
in thickness.

During beta testing, two methods were used to record interocclusal distance: bimanual
manipulation and the Power-Bite method with a Lucia jig and silicone impression material.
The Lucia jig offered advantages in controlling the posterior interocclusal space and
establishing a stable bite position for injecting silicone bite material. This method eliminates
the need for significant changes in bite opening during splint design and is particularly crucial
for unmounted cases, where rotation occurs on an arbitrary hinge and may introduce errors.
In contrast, when using wax bites, controlling the posterior interocclusal space is more
challenging.

While digitally produced splints offer distinct advantages over conventional ones, precise bite
registration recordings by clinicians remain crucial for the clinical success of such prostheses.

In conclusion, a novel digital procedure for the fabrication of occlusal splints has been
successfully developed. This innovative method aligns with established CAD/CAM systems,
encompassing scanning, CAD-based design, and machining stages. It offers a level of
precision and consistency in digital management of articulation, appliance conceptualization,
and production. There are future plans to expand the core technology into other domains of
appliance construction and surgical planning. This advancement holds significant potential
for enhancing the field of orthodontics and related areas.