Occlusal splints have been generallyrecommended for temporomandibulardisorder (TMD) therapy and to mitigatethe occlusal effects of bruxism. Duringbruxism, if posterior interferences (ie,protrusive, working, and balancing con-tacts) are present, the maxillary musclesexhibit significantly greater contractileforce than when disclusion is guided by asingle canine or maxillary central incisorsduring protrusion, whether it is a normalfunctional or a parafunctional movement.1

When only the canine or the incisorscontact in lateral movement, there is aneurologic feedback mechanism that pre-vents excessive muscular contraction (themore teeth that contact the greater thepossible contractile stress and thus mus-cular overload). Also, because the ante-rior teeth are farther from the fulcrum(the temporomandibular joint in thisinstance), there is a mechanical disadvan-tage relative to molars. This means thesame contractile force in the maxillarymuscles exerts proportionally less stresswith respect to farther-anterior toothcontact. Combining all of these concepts:(1) fewer teeth in contact during excur-sions; (2) moving excursive contact farther

to the anterior; and (3) creating caninedisclusion in lateral movements—becausethe canine has the longest root and largestcross-sectional area of the anterior teethwhich makes it more favorable to absorblateral stress—has been one of the basictenents of occlusal theory.2 These exces-sive uncontrolled forces generated byposterior interferences contribute to amultitude of problems and acceleratedfailure cycles. Excessive wear and jointproblems, muscular issues, and toothsensitivity all increase as a result of theseexcess forces. Recessions, fractures of allmaterials, and early marginal failure allincrease under additional loads. Treatmentoptions for malocclusion, includingorthodontics with attention to func-tional occlusion, proper occlusal adjust-ment, and equilibration can aid in theprevention of these force-flex-failure is-sues, but a well-fabricated and well-ad-justed splint can be an important treat-ment in preventing future problems.

The first part of this article covered therationale for and potential uses of asplint and gave the tools necessary forsuccessful patient education and motivation,as patient compliance is a mandatory part

of long-term treatment outcomes.2 Theobjective of the second part of this articleis to discuss the fabrication of a hard,durable, repairable, maxillary neutralsplint/retainer. In the authors’ experience,this clear composite maxillary splint isvery stable and rarely needs adjustment.It can be made in the office in an hour,but there are some important clinicalconsiderations, including:

• Passive fit (no tooth movement orforce on teeth) on the maxillary arch.

• Retention through close fit and 1 mmto 2 mm of buccal overhang (cuspidthrough second-to-the-last tooth).

• Neutral intercuspal (flat contact, noindentations) relationship in solidcentric relation; adjust to neurologic/muscular release (free “clomp, clomp,clomp” sound).

• Mild cuspid rise and cuspid protec-tion (posterior contacts are just spots,not slides).

MATERIALS AND EQUIPMENTThe composite splint featured in thisarticle is fabricated out of a 2-mm thicklight-cure composite tray/base material

(Triad® TranSheet™ Colorless, DENTSPLYInternational, York, PA). It is cured in aTriad 2000™ Visible Light Curing Unit(DENTSPLY International) (Figure 1).Triad Model Release Agent (MRA,DENTSPLY Trubyte, York, PA) is theseparating agent used for lubricating thecast that does not interfere with futureadditions or bonding. Add to this list anybonding liquid and brush, pigtail explorer,scalpel, your favorite laboratory acrylicbur, and articulating paper and you have

LABtaLkLaboratory perspectives from the inside out.

88 INSIDE DENTISTRY—JANUARY 2008

Splints Are Not Just for TMJ TherapyPart II: Fabrication TechniqueGreg Vigoren, DDS; and Edward A. McLaren, DDS

Edward A. McLaren, DDSDirector

Center for Esthetic Dentistry

Founder and DirectorUCLA Master Dental Ceramist Program

Adjunct Associate ProfessorUCLA School of Dentistry

Los Angeles, California

Private Practice limited to Prosthodonticsand Esthetic Dentistry

Greg Vigoren, DDSPrivate Practice

Newport Beach, California

Adjunct FacultyUCLA Center for Esthetic Dentistry

Los Angeles, California

Figure 1 Sealed transparent sheet of the Triadtray material along with the MRA.

Figure 2 Standard splint fabrication arma-mentarium.

Figure 3 Properly poured and trimmed cast. Figure 4 A sheet of the Triad material tried onthe maxillary cast to verify that the size of thematerial will be adequate.

...THIS TYPE OF SPLINT IS FABRICATED WITH NO

ARTICULATOR; THE PATIENT AND IN-THE-MOUTH

ADJUSTMENTS REPLACE THIS STEP. THEREFORE,

NO OPPOSING IMPRESSION, NO OPPOSING MODEL, NO

INTEROCCLUSAL RECORD AND NO FACEBOW ARE NECESSARY.

LabTalk_V4N1_3rd.qxd 12/13/07 4:08 PM Page 88

all the necessary materials and equip-ment (Figure 2).

One of the strengths in this techniqueis that some of the steps associated withtraditional splint techniques are not needed(eg, opposing mandibular impressionsand casts, interocclusal jaw registrationrecords, facebow transfer records, a sophis-ticated articulator or correlator). This isan in-office procedure, thus you do notneed to send this out to a laboratory or

wait for its return. There is no laboratorybill. This technique was first used in theauthors’ practice 15 years ago in an emer-gency situation involving a patient needinga splint and leaving on an extended tripthe next day. This first experimental useof this technique involved less time fromstart to finish than the normal adjustingtime alone of the standard laboratory-processed acrylic splint that had beenmounted on an articulator using a face-

bow and interocclusal records. Thousandshave been successfully done using thistechnique since.

There are several significant differencesand advantages between this splint tech-nique and the more traditional laboratorytechnique. This type of splint is fabricatedwith no articulator; the patient and in-the-mouth adjustments replace this step.Therefore, no opposing impression, noopposing model, no interocclusal record

and no facebow are necessary. The mate-rial is easy to use, easy to repair or modify,and, overall, less costly in both time andlaboratory expense.

TECHNIQUEAt the first patient visit, make a maxillaryalginate impression with attention to lin-gual, occlusal, and incisal detail. You canuse an alginate substitute like Penta™Quick (3M ESPE, St. Paul, MN) or AlgiNot(Kerr Corporation,Orange,CA).The patientmay then either wait for fabrication afterthe cast sets, return later that day, or comeback for a separate appointment.

Pour the single maxillary impressionin plaster or die stone with or withoutslurry and trim the cast appropriately(Figure 3). Lubricate the stone cast withMRA (Figure 4), then place a TranSheet onthe maxillary cast and outline the finalform with excess extending over the ante-riors (Figure 5). Double up the anteriorarea in the TranSheet by folding under(Figure 6). Set the material back on thecast and cut the posterior relief, then cutoff any excess material (Figure 7).

Using your fingers, press down the traymaterial without thinning it and form itto the cast (Figure 8). Cut off any excessmaterial at the incisal of the four anteriorsand remove any excess material off thebuccal of the most posterior molar, givinga 1-mm to 2-mm overhang on the facialof the cuspid to the first molar and a palataloutline form (Figure 9). Light-cure in theoven for 30 seconds, tease the blank upand down, cure for an additional 30 sec-onds, and then remove from the cast(Figure 10). Light-cure for an additional5 minutes off the cast (the color will changefrom a yellow tint to white) (Figure 11).Relieve the interior in the embrasure areasand along the facial flange of retention(facial overhang); this material shrinkslingually into the bulk of the material(Figure 12). Remove rough edges andsmooth (Figure 13).

Return the patient to the chair. Fit thesplint passively on the upper arch, re-lieve any tight or pressure points (Figure14). Using a pencil, mark the mesial anddistal of the lower cuspids on the uppersplint. This allows you to identify/makea panographic tracing (mild cuspid rise)of the lower cuspids on the splint be-tween these lines (Figure 15). Adjust theinterarch occlusion; use articulation pa-per until even occlusion is achieved (mul-tiple contacts/all teeth, only one pertooth is necessary in centric occlusion)(Figure 16).

Reline the buccal overhang with a smallamount of bonding liquid and a 1-mmroll of splint composite material (this isthe only retention feature necessary). Seatthe splint and have the patient bite downwith force, remove the excess with anexplorer, and then set up the reline mate-rial with the light source (Figure 17 andFigure 18). Remove the splint from themouth; trim, smooth, and polish (Figure19). Return to the mouth and finalize

90 INSIDE DENTISTRY—JANUARY 2008

Figure 5 Placing the MRA. It is then spreadthin with a finger.

Figure 9 View after final trimming of material,before polymerization.

Figure 13 Sharp edges are rounded andsmoothed.

Figure 14 The initial try-in of the splint. Figure 15 The desired canine disclusion pathis marked with a pencil.

Figure 16 Occlusal adjustments are made untilthere is a simultaneous point of contact on all teeth.

Figure 10 The splint is cured for 30 secondson the cast and then slightly separated from thecast and cured for another 30 seconds.

Figure 11 The splint is cured for 5 more minutesoff the cast.

Figure 12 Potential binding areas in embra-sures are lightly relieved.

Figure 6 The anterior segment is folded underto make the material thicker in the anterior toallow for anterior guidance.

Figure 7 The material is split down the middleto the center of the palate to allow individualforming on the right and left sides of the arch.

Figure 8 The material is pressed and formedand smoothed using fingers.

LabTalk_V4N1_3rd.qxd 12/13/07 4:08 PM Page 90

occlusal contacts, make posterior spots assmall as possible; remember, they are pointson a flat surface, not slides or indenta-tions. Deliver the splint to the patientwith instructions, reinforcement, home-care, and in an orthodontic retainer case(Figure 20).

DISCUSSIONThis two-part article presented a simpli-fied, in-office splint technique and the

associated philosophy of use that addres-ses many of the concerns over splint use.The verbal skills necessary to motivatepatients to use this valuable adjunctiveprocedure were covered in Part 1. Thetechnique demonstrated in Part 2 makesit simple to fabricate a well-fitting, oc-clusally well-adjusted appliance that, inthe authors’ experience, overcomes mostof reasons for lack of acceptance or lackof compliance in using a splint.

REFERENCES1. Williamson EH. The role of craniomandibu-

lar dysfunction in orthodontic diagnosis and

treatment planning. Dent Clin North Am.

1983;27(3):541-560.

2. Vigoren G, McLaren EA. Splints are not just

for TMD therapy. Inside Dentistry. 2007;

3(10):92-94.

INSIDE DENTISTRY—JANAURY 2008 91

Figure 17 Triad material is added in the canineregion bilaterally and trimmed. This is done toincrease the retention in this area.

Figure 18 This addition is light-cured.

Figure 19 Final adjustments are made andthen the splint is polished.

Figure 20 The finalized and polished splintis delivered to the patient in an orthodonticretainer case.

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