Figure 1 - First appointment
After diagnosis of bruxism, instruct the patient to close into centric relation to verify midline position and bite.
Figure 2 - First appointment
Place two cotton rolls behind the cuspids and instruct the patient to close until resistance is felt.
Figure 3 - First appointment
You could also place softened wax over the anterior molars and have the patient close to the desired 3 mm opening.
Figure 4 - First appointment
With the patient closed into this open bite, inject bite registration into the posterior openings of both quadrants.
Figure 5 - First appointment
Inject bite registration material into the anterior opening to capture a complete open construction bite.
Figure 6 - First appointment
Using a properly fitting impression tray, take upper and lower alginate impressions using correct water-to-powder ratios.
Figure 7 - Fabrication of the splint
Upper and lower models with bite mounted in place. Note the open bite between anterior teeth.
Figure 8 - Fabrication of the splint
The upper or lower model is used in the Erkoform-3d to thermoform the splint and create the flat bite table.
Figure 9 - Fabrication of the splint
After thermoforming, the splint is trimmed and polished with carbide burs, felt wheels and acrylic polish.
Figure 10 - Second appointment
Seat the splint, and evaluate fit, retention and occlusion. Adjust with a carbide bur and polish if necessary.
Figure 11 - Second appointment
After completely seating splint, check bite using marking tape to identify any premature occlusion.
Figure 12 - Second appointment
Instruct the patient to care for his or her splint by rinsing with water after every use and storing dry.
You can see my assistant has filled the tray with AlgiNot™ material (Kerr). This brand is probably the best name in dentistry for an alginate replacement product.
My assistant puts a little extra material on her index finger and smears it on the occlusal surfaces of the posterior teeth.
The material is also smeared along the incisal edges of the anterior teeth. These are the areas that we have to capture on an occlusal splint impression.
My assistant takes the adjustable tray that has been filled with the AlgiNot material, which is a fast-set material, and she seats the tray into place.
There are three key areas where the occlusal splint needs to fit. These are the areas we really need to focus on to achieve good definition on the impression and the model: the occlusal surfaces of the posterior teeth, the occlusal third of those posterior teeth, and the incisal third of the anterior teeth. It's not a big deal if you take an impression and get a bubble along the gingival, a molar or a bicuspid, or if you have a pull on the anterior tooth by the gingival or the frenum — these areas will not affect the final fit of the occlusal splint.
My assistant fills the tray with AlgiNot for the lower opposing impression. In fact, at the lab, we use alginate replacements, like AlgiNot, for all of our impressions. It's kind of one of my pet peeves when dentists send in, let's say, a case with eight crowns — a case that costs roughly $8,000 to the patient — and with it they include a really cruddy opposing model that was taken in alginate.
For a splint like this, it isn't a big deal. But if you spend a little bit more on the material to ensure a great impression that's going to be stable over time, can be poured multiple times and is extremely accurate, you are doing a great service to your patients.
Let's take a closer look at the lower, or opposing, impression. Again, by spending a little bit more money on impression material and tray to get a good impression of the opposing model, we are going to end up with a nice result.
We're going to end up with a nice accurate model on the lower. You can see how good it looks!
Now because this is a splint, it's not going to come anywhere near the palate. My dental assistant always knows not to place any material in the palate. Remember, the occlusal splint is going to follow the outline of the teeth, and it's going to come up about a third of the way on the facial surfaces of the teeth.
The splint is going to cover the entire lingual, so we're looking around the lingual to make sure that we got all the detail along the lingual. We just need the incisal third of those anterior teeth; that is where the splint is going to fit. We get the junction of the tooth and the gingival on the lingual, as we come all the way along here. When you pour this up and look at the stone model, the detail on these teeth is really pretty amazing. This is why I have chosen to stick with alginate replacement materials like AlgiNot.
My dental assistant has finished taking the impressions for the occlusal splint. That's one of the things I love about providing occlusal splints for my patients: A well-trained dental assistant can practically do the entire procedure by him or herself.
An occlusal splint has been fabricated for our 27-year-old male patient. Before we insert the splint, make necessary adjustments and deliver it to the patient, I want to provide you with a closer look of the patient's teeth.
His lower anterior teeth already have some wear, as do the lower cuspids.
We can see some chips on the incisal edges of the lowers.
Here you can see the ragged look of the maxillary anteriors. Otherwise, the patient's teeth look pretty decent. You can tell he's not 60 or 70 years old, but he has quite a bit of wear for his age group.
The patient is the perfect candidate for an occlusal splint, and he is exactly the kind of patient where we say: "Hey, look, here's what's going on in your mouth."
The patient holds a mirror and looks on as we show him how the upper and lower cuspids come together, which is what they're supposed to do. As you can see, the lower lateral hits the upper lateral, which is part of the wear pattern there. We are in the group function — the first bicuspid is hitting the lower, first bicuspid. We check the other and show him what it looks like. As he bites together, it fits like puzzle pieces!
With two cuspids hitting each other, and the laterals hitting each other as well, the patient is going to continue to wear these teeth down. Why not offer him an occlusal splint, an opportunity to save the wear and tear on his teeth for the next 20 years? Place the responsibility of saving the teeth in the patient's hands.
The splint is in the patient's mouth. This is a Comfort H/S™ Hard Soft Bite Splint, and I can't think of one time where the splint hasn't fit (provided you take an accurate impression). So we're trying the splint in here with a couple of cotton rolls.
We place articulating paper on both sides, and then we make some marks and take it out. You want to have one opposing tooth mark for each of the opposing teeth and an occlusal stop for each opposing tooth.
I adjust the Comfort H/S Hard Soft Bite Splint using a pear-shaped bur in an electric handpiece. The splint is made from acrylic material, so it's very easy to work with. I prefer using a high-torque, low-speed handpiece, but this can also be done chairside with a high-speed handpiece.
We make one more small set of adjustments here, and then we go ahead and check the excursions and see how the splint looks there. The cuspids obviously can handle a lot of stress in the lateral direction, but we check to see if we have the desired cuspid rise. We do, so we're OK, but we'd still like to see the cuspid disclusion on both sides of the splint.
It's rare for the splint not to fit. But if it doesn't seem to want to go into place, we put it in some really hot (but not boiling) water for 30-45 seconds. After 45 seconds, remove it, shake it a few times and push it onto the patient's teeth. The soft material on the inside will readapt itself around the patient's teeth.
We check the anterior one more time. The patient bites down together for us so that we can check how the marks look here. Then we go ahead and make our final adjustments before polishing the splint.
We can see some nice spots in the area of the cuspids. As the patient slides forward, I can see some marks going forward on the anterior teeth as well. So this is pretty much doing what we wanted to do for the patient. Again, this is a preventive occlusal splint. The patient does not have temporomandibular joint issues. So, we just want to keep the teeth apart and have him grind on the plastic, if he grinds on anything.
This green disc you see me using is a Lisko-S disc. This disc is available from Glidewell Direct — I don't know of anybody else who actually sells them in the U.S. I use the Lisko-S disc because it does a great job on this acrylic, and other acrylics, in terms of polishing. It is not extremely abrasive, and it can smooth any marks made with a carbide bur from an electric handpiece. If you feel a strong desire to polish the splint to a high shine, as you would a veneer or crown, keep in mind that the patient is going to be grinding on this surface. A high shine is not necessary.
We make sure the patient knows how to put in and take out the Comfort H/S Bite Splint.
My dental assistant discusses with the patient how to take care of the splint, how to maintain it and when to wear it. And we tell pretty much every patient the same thing: We want them to wear the splint every night, and even during the day when experiencing high levels of psychological stress.
I would not be fabricating such a high volume of occlusal splints if not for the Comfort H/S Hard Soft Bite Splint. If you have shied away from providing your patients with occlusal splints because you were worried about comfort, I suggest you make a Comfort H/S Hard Soft Bite Splint for you or a staff member. Wear it to see just how much this splint lives up to its name!