General Dentistry: Occlusal Splints From the Beginning to the Present

General Dentistry: Occlusal Splints From the Beginning to the Present

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General Dentistry: Occlusal Splints From the Beginning to the Present

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J.S. DuPont, Jr. D.D.S.; C.E. Brown, D.D.S.  Volume 24 Issue 2 April 2006

 Abstract: In his text outlining the various splint modalities in use today, Bledsoe,l defines a splint sp lint as a removable oral device fitted between the maxilla and the mandible. mandible. Its functions may include stabilizing the temporomandibular temporomandibular joint to reduce red uce the muscle activity of the craniomandibular complex, complex, or to reduce the attrition of the teeth to the parafunctional forces forces of occlusion or to trauma. Since Sinc e much literature exists to support the efficacy of this modality of care, a perspective perspective look at splint therapy in dentistry can most simply be reduced to a rev iew iew of the type of material used for such orthotic devices. Now, argument argument is made as to which style of splint and what kind of material would be mo st helpful to the profession. History  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 splinting of broken jaw bones. bones. In November 1862, Thomas Gunning,3 Gunning,3 a practicing surgeon, surgeon, used vulcanite to fabricate 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 temporomandibular disorders. Additionally, 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 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. postulated. Hawley,8 in 1919, and then Monson,9 in 1921, each suggested that bruxism 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 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 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 mouth tissues. Four Four years later, later, in 1946, Kesling's16 article discussed using a maxillary soft occlusal appliance in order order to maintain the

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General Dentistry: Occlusal Splints From the Beginning to the Present

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mandible in a predetermined relationship to the maxilla. Ingersoll and Kerens,17 in 1952, authored a paper discussing the treatment of occlusal trauma using a semi-soft vinyl resin appliance made of vinolin. They thought that splints made of hard acrylic or vulcanite caused trauma to the opposing dentition, but that vinolin, a softer material produced less trauma to the tissue and teeth in the arch opposing this material. Experimenting with several different designs, they settled on a mandibular appliance to make use of gravity for improved retention. Later that same year, Kaner18 published an article describing the use of a combination acrylic-vulcanite splint in the treatment of bruxism. Moore's19 article outlined a technique for using a soft rubber bite positioner for nighttime use for bruxism in 1956. He felt the appliance acted as a cushion to prevent excessive tooth pressure. Then in 1957, Campbell20 described his approach that used a soft appliance to treat patients who bruxed their teeth or had joint pain. Shore's21 book in 1959 provided an outline for treating TMJ and facial pain. He cautioned about the disadvantages of soft appliances, such as perforations functioning like orthodontic appliances. In one of the most eloquently penned definitions of bruxism reviewed, Shanahan,22 in 1961, suggested that bruxism was one of the first activities patients engage in when the “vicissitudes of life become excessive.” 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. The patient would wear the splint day and night for one week except when eating. If a perforation appeared, the occlusal prematurity was reduced and a new coat of latex was applied. The splint was again worn until supporting tissues returned to normal or other perforation appeared and the above process was repeated. The patient was slowly equilibrated using this approach. Posselt and Wolff,23 in 1963, undertook a study to compare the effectiveness of hard and soft bite plates to manage bruxism. They concluded that the hard bite guards were slightly more effective for managing these disorders. That same year, Gecker and Weill24 discussed the use soft splints for bruxism because they believed this material produced less trauma on the teeth. Postulating that resilient occlusal guards were the best treatment for bruxism, Kessler25 in 1964, suggested that maxillary arch appliances were most effective and that they need not cover the palatal area. His appliances were constructed out of vinyl material, not the  vulcanite or latex rubber of the past. He felt that these appliances must be easy to fabricate, have minimal wear, and be easy to clean and of acceptable taste. Also using a resilient material for splints, Krogh- Poulsen and Olsson26 treated craniomandibular parafunction in 1968. However, just three years later, in 1971, Ramfjord and Ash,27 stated that soft appliances were not effective in treating bruxism because the patient played with the appliance, maybe even resulting in an additional bruxing habit. They also noted that soft appliances were difficult to adjust and polish. Shulman,28 in 1972, related that bite appliances have been made of many different materials such as vulcanite, soft rubber and plastics, but that these materials have many disadvantages. These included an inability to eliminate contacts in excursive movements, problems with adjustments, distortion and poor retention. He advocated the use of a hard appliance. In 1974, Dawson,29 suggested the use of soft appliances to cushion the posterior teeth in subjects with chronic sinusitis. Thorp,30 in 1975, described a technique of combining hard and soft (Molloplast B) material to produce an appliance to use in the treatment of bruxism. He related that patients wore a maxillary and mandibular appliance at night. Writing in 1978, Block and Laskin31 found that resilient appliances were effective in treating TMJ dysfunction symptoms with c omplete or almost complete joint reduction. They reported that 74% of their patients had total or almost complete remission of non-specific TMD symptoms after six weeks. By the 1980s, 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. Writing in 1983, Ingerslev,32 told of care that he provided for a population of children who showed signs of parafunctional occlusal habits. Using a soft splint, he was able to relieve most initial symptoms quickly but noted that some splints were destroyed by the powerful muscle activity in these children. He switched to a hard splint material for those cases in order to complete his study. In 1984, Zarrinnia,33 used a latex material in his splint treatment, as he liked the cushioning effect it had to occlusal trauma. However, he did admit that after just eight weeks of treatment some excessive tooth mobility was noted in his patients. Also in 1984, Clark34 offered an evaluation of all of the orthopedic interoccusal appliances being used to date. He cited the use of soft splints for patients with a  bruxing habit as well as for patients with a click in the TMJ. He confirmed reports of problems with resilient splint materials as lacking durability and posing problems with adjustments in follow-up care. 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. Verban,35 in 1986, argued that a soft splint allowed the patient to reach a comfortable TMJ location, which then allowed for the natural reorganization of damaged tissue. Since the soft material equally distributed occlusal load, it was "self adjusting" and as such c hanged with the changing joints. But, the following year, Hutchins and Elkins,36 cautioned that while soft splints were useful for immediate relief of acute pain, they must be used as a transition therapy toward one using a hard acrylic material. Also, in 1987, Okeson,37 compared the used of hard splints with soft splints in a pool of patients showing nocturnal bruxism. He concluded that the hard splints significantly reduced this hyperactivity of the muscles, while the soft splints did not. In fact, some patients in the soft appliance actually showed an increase in muscle activity. In 1988, 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. He then transitioned these patients to a hard splint for long-term care. His suggestion was to use a soft splint for immediate relief and as a diagnostic guide for patients with a reducible disk derangement. Echoing this thought the following year, 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. A literature review by Boero40 at the end of the decade, 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. In 1990, Quayle and Gray41 showed that soft splints helped with vascular type of headaches but did not with tension style headaches. Maybe Okeson's37 earlier results of increased muscle activity with soft appliances might explain Quayl's41 conclusion. In 1995, Wright42 used a soft splint effectively during a short 4-11 week treatment study. That same year, Anthony43 advocated that a hybrid design using soft vinyl fused to a hard acrylic might get the best of both worlds. Major and Nebbe,44 in 1997, offered a review of the literature evaluating splint therapy for treatment of  TMD. They concluded that much data supports efficacy of this modality, but complained that comparison of results was difficult due to the various outcome scales, subjective evaluations, and the variability in reporting. The next year, Pettengill45 designed a study using 18 patients to test the efficacy of  hard and soft appliances in treating TMD. Over a 10-15 week period, he noted equally effective results with each type of splint. As the 90s came to a close,  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. This patient had previously clenched against the ridge causing a traumatic ulcer. The splint offered a protective cushion. Then in 1999, Al Quran and Lyons47 performed an electromyographic study investigating the immediate effects of hard and soft splints. They concluded that hard splints are likely to  be more effective in reducing hyperactive muscles. In summary, the efficacy of splint therapy for treatment of signs and symptoms of TMD and occlusal disharmonies is well documented. Though splint designs and materials used have varied considerably during the past 150 years, strong arguments can be made that effective treatment can be attained with an interocclusal appliance. The present trend in clinical use appears to be that of a hard acrylic http://cranio.com/volume24/issue2/general-dentistry-occlusal-splints-from-the-beginning-to-the-present/

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appliance covering the full arch of teeth. References 1. Bledsoe S: Intraoral Orthotics. Vol. 1, No.2; Williams & Wilkins Publishing, 1991. 2. Romm S: Thomas Brian Gunning and his splint. Plast and Reconstrut Surg 1986; 18(2):252-258. 3. Fraser-Moodie W: Gunning and his splint. Br J Oral Surg 1969: 7:112. 4. Covey EN: The interdenal splint. Richmond Med J 1866; 1:81. 5. Kingsely NW: An experiment with artifical palates. Dent Cosmos 1887; 19:231- 238. 6. Farrar IN: Irregularies of the teeth and their correction. Dental Cosmos 1888. 7. Karolyi M: Beobacchtungen uber pyorrhea alveolaris.Oesterreichungarische Vieteljahrs-schrift fur Zahnheilkunde 1901; 17:273. 8. Hawley CA: A removal retainer. Internat J Orthodon 1919; 5:291. 9. Monson GS: Impaired function as a result of closed bite. Nat Dent Ass J 1921; 8:833. 10. Washburn HB: History and evolution of the study of occlusion. Dent Cosmos 1925;67:331. 11. Goodfriend DJ: Symptomology and treatment of abnormalities of the mandibular articulation. Dent Cosmos 1933; 75:844-852, 1106-1111. 12. Costen JB:A syndrome of ear and sinus symptoms dependent upon function of the temporomandibular joint. Ann Otol Rhinol Laryngol 1934; 43:115. 13. Block LS: Diagnosis and treatment of disturbances of the temporomandibular joint especially in relation to vertical dimension. JADA 1947; 34(2):253-260. 14. Sved A: Changing the occlusal level and a new method of retention. Am J Orthod Oral Surg 1944; 30:527. 15. Matthews EA: Treatment for the teeth-grinding habit. Dent Record 1942; 62:154-155. 16. Kesling HD: Coordinating the predetermined pattern and tooth position with conventionl treatment. Am J Orthod Oral Surg 1946; 32:285. 17. Ingersoll WB, Kerens EG: A treatment for excessive occlusal trauma of bruxism. JADA 1952; 44:22-27. 18. Kaner A, Besen GH, Armstrong RH: Bruxism. US Armed Forces Med J 1952; Oct (3): 1539-1544. 19. Moore DS: Bruxism, diagnosis and treatment. J Periodont 1956; 27:281. 20. Campbell J: Extension of the temporomandibular joint space by methods derived from general orthopedic procedures. J Prosthet Dent 1957; 7:386399. 21. Shore NA: Temporomandibular joint dsyfunction and occlusal equilibration. Philadelphia: JB Lippincott C, 1959:249. 22. Shanahan TEJ, Leff A: Bruxism and clenching, occlusal treatment. NY Dent J 1961; 27:401-403. 23. Posselt U, Wolff IB: Treatment of bruxism by bite guard and bite planes. Can Dent Assoc 1963; 29:733. 24. Gecker L, Weill R: Bruxism, a rationale of therapy. JADA 1963; 66:14. 25. Kessler SJ, Zweig JM: Rapid fabrication of effective bruxism guard. J NJ Dent Soc 1964; 36(10):59-61. 26. Krogh-Poulsen WG, Olsson A: Management of occlusion of the teeth. In: Schwartz L, Chayes CM, eds. Facial pain and mandibular dysfunction. Philadelphia: WB Saunders 1968: 236-280. 27. Ramfjord SR, Ash MM: Occlusion. 3rd ed. Philadelphia: WB Saunders Co. 1971. 28. Shulman J: Bite modification appliances-planes, plates and pivots. VA Dent J 1972; 49(6):29-30. 29. Dawson PE: Evaluation, diagnosis and treatment of occlusal problems. St. Louis: CV Mosby Co. 1974. 30. Throp PDE: An appliance to be worn at night for the heavy tooth grinder. Dent Tech 1975; 28:144-145. 31. Block LS, Apfel M, Laskin DM: The use of a resilient rubber bite appliance in the treatment of MPD syndrome [Abstract 71]. J Dent Rest 1978; 57(special issue):92. 32. Ingerslev H: Functional disturbances of the masticatory system in school children. J Dent Child 1983; 50(6):446-450. 33. Zarrinnia K, Lang K: A therapeutic method for selected TMJ dysfunction patients. J Clin Orthod 1984; 18:35-37. 34. Clark G: A critical evaluation of orthopedic interoccusal appliance therapy: design, theory and overall effectiveness. JADA 1984; 108:359-364. 35. Verban E: A self-adjusting TMJ appliance. CDS Review 1986; 79(9):38-39. 36. Hutchins M, Elkins W: Pathophysiology of masticatory muscle disorders and occlusal splint therapy. J Houston Dist Dent Soc 1987; 10:7- 8. 37. Okeson J: The effect of hard and soft splints on nocturnal bruxism. JADA 1987; 114:788- 791. 38. Harkins S, Marteney J, Cueva O, et al.: Appli-cation of soft occlusal splints in patients suffering from clicking temporomandibular joints. J Craniomandib Pract 1988; 6:71- 75. 39. Hicks N: An effective method for constructing a soft interoccusal splint. J Prosthet Dent 1989; 61(1):48- 50. 40. Boero R: The physiology of splint therapy: a literature review. Angle Orthod 1989; 59(3):165-169. 41. Quayle A, Gray R, Metcalfe R, Guthrie E, Wastell D: Soft occlusal splint therapy in the treatment of migraine and other headaches. J Dent 1990; 18(3):123-129. 42. Wright E, Anderson G, Schulte J: A randomized clinical trial of intraoral soft splints and pallative treatment for masticatory muscle pain. J Orofac Pain 1995; 9(2):116-130. 43. Anthony T: Soft thermoplastics in bruxism appliances. Trends and Techniques 1995; 12(7):32-36. 44. Major P, Nebbe B: Use and effectiveness of splint appliance therapy: a review of the literature. J Craniomandib Pract 1997; 15(2):159-166. 45. Pettengill C, et al.: A pilot study comparing the efficacy of hard and soft stabilizing appliances in treating patients with temporomandibular disorders. J Prosthet Dent 1998; 79(2):165-168. 46. Williams R: Occlusal guard for the maxillary edentulous patient. J Prosthet Dent 1999; 82:116. 47. Al Quran F, Lyons M: The immediate effect of hard and soft splints on EMG activity of the masseter and temporalis muscles. J Oral Rehabil 1999; 26:559-564.

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Dr. John DuPont has published a number of articles and manuals on the diagnosis and treatment of temporomandibular joint disease. 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). Dr. Chris Brown practices in New Orleans, Louisiana. 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). Also, he serves as an adjunct clinical professor to the senior class patient clinic at the Louisiana State University School of Dentistry. ORDER ARTICLE

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