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in CASE REPORT
ISSN No-2321-1482

DJAS 4(III), 195-200, 2016

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Dental JOURNAL
of A d v a n c e S t u d i e s

“CATCH IT RIGHT”-A CASE REPORT ON OCCLUSAL SPLINT

Monika Makkar1, Poonam Pathania2, Swati Sharma3
1
Professor, Department of Prosthodontics, Swami Devi Dyal Dental College and Hospital, Haryana, India
2
Post graduate student, SDDHC, Haryana, India
3
Post graduate student, SDDHC, Haryana, India

ABSTRACT

TMDs have a multifactorial etiology varying from bruxism, psychological illness and traumatic injuries
from mastication ,extreme mouth opening ,or faulty dental restorations.The present case study highlights the
importance of right diagnosis of the patients problem as this forms the foundation to formulate a
comprehensive treatment plan which further ensures the right solution to the stated patient problem along
with long term maintenance of healthy stomatognathic system. An hard occlusal splint has been indirectly
fabricated on the semiadjustable articulator. Occlusal splint used in treatment of TMDs is designed to provide
even and balanced Occlusal contacts without forcefully altering the mandibular rest position or permanently
altering the dentition. One case of fabrication of mandibular occlusal splint and its therapeutic role is
discussed in this case report. The splint successfully relieved the patient TMD signs and symptoms, when
used over four months.
Keywords: Bruxism, Occlusal splint, TMDs, TMJ disorders,

INTRODUCTION ensures the solving of the stated patient

Natural teeth and related dental problem along with long term
problems are not as simple to understand maintenance of healthy stomatognathic
and treat as these appear to be because of system.
the fact that dentition forms one of the part TMDs have a multifactorial etiology
of stomatognathic system. The three varying from bruxism, psychological
components of stomatognathic system are illness and traumatic injuries from
the neuromusculature, Temporomandibular mastication, due to extreme mouth
joint(TMJs) and the teeth.1 All the three opening, or faulty dental restorations.
components must be in harmony with TMDs are characterized by clicking and
each other so as to maintain long term pain, either confined to the TMJ region or
health and function of TMJ and teeth. radiating to the eyes, shoulder, and neck.
Defects of any of these components Headaches, tinnitus, jaw deviation,
prevent them from working in harmony locking, and limited mouth opening are
and thus vicious cycle develops that could common symptoms. Pain is the most
lead to Temporomandibular disorders crucial symptom for which patients seek
(TMDs). Further, dental changes are more medical care. Management of TMD
easily noticed as compared to changes in includes conservative and surgical
the TMJ assembly by a dentist, which interventions. Conservative treatments
Corresponding Author: could be manifesting symptomatically are physical therapy, localized steam
Monika Makkar
E-mail: later. In view of this, a thorough diagnosis application, external muscle massage,
[email protected] of a clinical case is crucial, to formulate a occlusal adjustment, analgesia,
th
Received: 12 September 2016
Accepted: 2 December 2016 comprehensive treatment plan which
nd psychotropic medication, splint therapy,
Online: 20th January 2017

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alternative therapies such as acupuncture, as well as more tender as compared to left side. Right and left
treatment modalities such as ultrasound, soft laser, lateral pterygoids were found to be tender on intraoral
diathermy, and infrared radiation. palpation. Detailed evaluation of TMJ was done by
Case Report using Fonseca's Questionnaire which gave score of 70
(details of the questionnaire ahead in the text). Dental
A 43yrs old male patient named Ravinder Kumar
examination showed generalized attrition of teeth
reported in the department of Prosthodontics, crown
(Figure 3,4) with loss of anterior guidance .Occlusal
and bridge and oral implantology with a chief
examination showed the posterior teeth contacts in
complaint of moderately severe pain on the right side of
protrusive mandibular movements (Figure 5) and there
his lower jaw and mild pain on left side ,since three to
were contacts present on non working side during
four months. History of present illness revealed the
lateral excursions (Figure 6).
pain was less at rest and increased while eating routine
food, yawning. The pain was sharp with feeling of jaw Dental orthopantanogram of the patient (Figure 2),
deviation towards right side and backwards. The showed bilateral subcondylar sclerosis. Bilateral
patient discontinued eating hard food since then and Spruing of angle of mandible, suggested of massesteric
started taking analgesics for a week as was prescribed hyperactivity.
and reported back with no relief in pain. Clicking in
right TMJ was present on opening the mouth. The
patient reported the habit of clenching and grinding his
teeth while in anger.
Medical History revealed that patient is a
controlled diabetic and was on medication since two
years. The patient had cardiovascular problem three
and a half years ago. The patient suffered from
breathlessness and swelling in joints which was
relieved after medication. The patient was first
diagnosed of hyperthyroidism but later it was negated
after tests. Patient was taking muscle relaxants and Figure 2: Orthopantanogram of the patient
analgesics for TMJ pain. There was a history of
emotional stress as well as habits of clenching and
bruxism during driving and at night.
Extraoral examination revealed bilateral massetric
hypertrophy along with the loss of vertical dimension
(Figure 1). The palpation of
TMJ revealed tenderness,
more so on right side. There
was pain especially in right
TMJ, while opening of the
mouth wide. Clicking was
present on both sides. No
deviation of movement was
Figure 3: Incisal and occlusal wear
seen while opening of the
mouth. On muscle
Provisional Diagnosis of occlusal instability leading to
examination, right side
TMD along with muscle hyperactivity due to clenching
elevator muscles were found Figure 1: Bilateral Massetric
muscle hypertrophy or bruxism was extracted .

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TREATMENT PLAN
The foremost goal of the treatment plan was to
achieve the joint stability by establishing bilateral
balanced occlusal contacts along with proper anterior
guidance. Stabilization splint was planned at adapted
centric relation position. Occlusal splint therapy for
joint stabilization and relief of symptoms was given.
Follow up visits and required correction of splint
several times over 3-4 months was planned. Then the
definitive occlusal reconstruction for long term joint
stability was to be performed.
Initially, diagnostic casts were fabricated by
Figure 4: Occlusal wear pouring impressions made with Irreversible
hydrocolloid (Zelgan 2002 Densply) and then facebow
transfer was done on the semiadjustable articulator
(Hanau wide vue ). After deprogramming the jaw
muscle engrams by using cotton rolls, a centric
interocclusal record as well as protrusive record was
made with Aluwax (AluwaxTM dental bite). This was
required to mount the mandibular cast (Figure 7) and
record and transfer the condylar guidance on the
articulator, respectively. A centric stabilization splint
(Figure 8) was fabricated with self activated clear
acrylic resin (DPI-RR cold cure)at increased vertical
dimension and anterior guidance was established on the
bite splint on programmed articulator (Figure 7). The
splint was found to be well adapted and stable in mouth
and adjusted for uniform posterior occlusal contacts in
Figure 5: Posterior teeth contacts in protrusive movement
centric relation position first on articulator and, then in
patients mouth. Centric stops were established only on

Figure 6: Nonworking contacts in left and

Figure 7: Mounted diagnostic casts and indirect
right lateral movement
splint fabrication on programmed Hanau Wide Vue

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Figure 8: Occlusal splint

Figure 10: Patients frontal view before and after,
showing decreased masseter mass after 3 months
functional cusps. Posterior disclusion on protrusion of splint wearing
and shallow canine guidance for lateral excursions, was
3
established on the splint (Figure 9). Fonseca 's questionnaire for TMD
The patient was instructed to use the splint for S. Questions Day After one After 3
maximum number of hours as possible and report next No. 1 month months
1. Is it hard for you to open 10 0 0
day for any aggravated symptoms.The sign and your mouth?
symptoms were anaylsed according to fonseca's 2. Is it hard for you to move 10 0 0
questionnaire3 for TMD over 3 days, 1 month, 3 months your mandible from side to
side?
3. Do you get tired/have 10 0 0
muscular pain while
chewing?
4. Do you have frequent 10 0 0
headaches?
5. Do you have pain on the nape 0 0 0
or stiff neck
6. Do you have ear aches or 10 4 0
pain in craniomandibular
joints
7. Have you noticed any TMJ 0 0 0
Clicking while chewing or
when you open your mouth?
8. Do you clench or grind your 10 0 0
teeth?
9. Do you feel your teeth do not 10 10 10
articulate well
Figure 9: Protrusive and Nonworking contacts in right 10. Do you consider yourself a 10 8 10
lateral movement after splint insertion tense (nervous)person?
Total score 70 22 20
on scale 0 to 10. Patient also reported that feeling of
right TMJ shifting on opening was not there after
Clinical index classification-Fonseca
wearing of this splint. Patient also did not have to
pursue muscle relaxants and analgesics after wearing Total between 0 and 15 points No TMD
the splint. Total between 20 and 40 points Mild TMD
Almost all the symptoms of TMD in the patient got Total between 45 and 65 points Moderate TMD
reduced effectively alongwith the progressive
Total between 70 and 100 points SevereTMD
reduction of massester muscle mass (Figure 10).

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Recall Visit: patient was checked next day after The splint design has flat posterior surface with only
insertion of the prosthesis. All the signs and symptoms supporting cusp tips touching. These should be
were significantly reduced. .There was decrease in preserved to minimize the stimulation of periodontal
symptom of pain within 24 hours. Patient was kept at proprioceptors that provoke the muscular
monthly follow-ups for about four consecutive months. hyperactivity.7 This also allowed the condyles to be
The patient also reported the discontinuation of the seated in the most anterosuperior position
analgesics. Reduction in muscle mass of masseter was progressively .
obvious during each recall visit. The occlusion developed on the splint varies
DISCUSSION according to the requirements of the patient. In most
The use of dental occlusal splint followed by instances, multiple occlusal contacts in maximum
permanent occlusal adjustments has been the main intercuspation at terminal hinge position of the
stays of TMD treatment. A common goal of occlusal mandible and in eccentric jaw positions, concept of
splint treatment is to protect the TMJ Discs from canine guidance was followed.8
dysfunctional forces a well as to improve the jaw Bimanual method of mandibular guidance was
muscle function to relieve associated signs and used to adjust the splint in centric relation position.
symptoms by creating harmonious occlusion.4 The Anterior guidance was kept shallow at the same time
appliance can be made to cover the occlusal surfaces of allowing for posterior disclusion on protrusive
maxillary or mandibular teeth and can be fabricated movement and right and left canine guidance was
from many different materials, like a hard splint of established on the working side. The splint was
acrylic resin or soft splint of polyacetamide fabricated at the vertical dimensions guided by
thermoplastic sheet.5 Occlusal splint is beneficial to retruded contact point (i.e just keeping optimum
reduce or eliminate unfavorable loading forces by thickness of interocclusal recording medium sufficient
breaking the muscle engrams and gradually returning enough to keep Retruded Contact Point (RCP) free
the jaw to its most unstrained centric relation position. from occlusion. The incorporation of Curve of Wilson
This slowly alleviates the masticatory muscle pain, facilitated the working side disclusions by keeping
TMJ pain, TMJ noises, restricted jaw mobility and all lower lingual cusps slightly shorter than lower buccal
the other signs and symptoms of the TMDs. cusp.2
One of the important factors that play a role in the The shallow anterior guidance on splint also
longevity and stability of restorative results is the status ensured preventing premature anterior contact during
of tempromandibular joint and neuro musculature clenching which further prevents distalization of
system. Bite splint therapy can be effective way to condyle and comfort of retrodiscal tissues and that
manage signs and symptoms of TMDs both resulted in the reduction of pain.
intracapsular and neuromuscular. For the present case, In this above discussed case, relief for the
the two goals to be achieved with occlusal splint were; symptoms was achieved almost overnight. The pain in
1. To eliminate /improve patient's symptoms joint and muscles was reduced and mouth opening
2. Stability of occlusion with splint for atleast 2-3 improved. The credit for this in major part lies with the
months. Splint allows healing, remodelling and patient's self motivation to follow the instructions and
adaption of joint structures by controlling forces to the his compliance to regular follow ups after the splint
TMJs with properly bite splint design.6 Hard acrylic therapy.
material was chosen for its precise fit and easy to adjust. CONCLUSION
The mandibular splint was preferred as it was more Over the past 10-20 years, the conceptual basis for
camouflaged by the lower lip as well as it interferes less using oral appliance in treating TMDs and bruxism has
during speech. been dramatically redefined. Currently, Occlusal splint

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Source of Support: Nil, Conflict of Interest: None Declared

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