DDSWally

Articles

A New Look at an Old Bite Splint

A Passion for Healing

Healing Ministry of Dentistry

PDFs

The Bicuspid Buildup as an Alternative in Phase II Treatment of Craniomandibular Dysfunction

The Biscuspid Buildup: As a Diagnostic Aid in TMJ and Muscular Dysfunction—A Followup Study

A New Look at an Old Bite Splint

For Dentists

Occlusal Screening, Tests, and Bite Splint Adjustments

A New Look at an Old Bite Splint

By Walter W. Niemann, DDS
Edited by Martha Niemann Hlavin
August 14, 2011

Abstract

The purpose of this article is to explain a broader rationale for the use of the classic "bite splint" in general dental, orthodontic and other specialty practices. The author's motivation for writing comes from over 50 years of diagnosing the indications for a splint, and developing variations in the design, fabrication, delivery and adjustments to it. Techniques for diagnosis and fabrication as well as patients' feedback are included.

Introduction

Figure 1

Figure 1

Bite splints and other removable appliances have been used since Dr. N. W. Kingsley first reported on them in 1887.1 Over the years, there have been many variations of splints, from the hard acrylic, upper full palate Hawley type the author has used since 1955 (see Figure 1), to what is commonly called a "night guard," to the upper full tooth coverage splint, to the "NTI" anterior disclusion splint, to the soft plastic athletic mouth guards sold in sporting good stores today.

Advertisements in the print, broadcast media and dental journals promote splints to solve TMJ problems, prevent sports injuries and recently, address sleep apnea. There are hundreds of thousands internet websites featuring bite splints and mouth guards. It is good that information and products are accessible to the general public as it has increased awareness of the need for bite splints and mouth guards. Against this backdrop, there is reason for dental professionals to explore and broaden the use of bite splints in their practices.

Looking Beyond Historical Indications

Figure 2

Figure 2

Figure 3

Figure 3

Historically, indications for bite splints have been wear facets, tooth breakage, tooth sensitivity, recession, night grinding, clenching and the symptoms associated with Temporomandibular Joint (TMJ) Dysfunction. (See examples of wear in Figures 2 and 3.)

Additionally, porcelain veneers, crowns, bridges and implants are also at risk of wear and breakage when unrelenting biting forces go undiagnosed and untreated. Initially, it was assumed that most tooth wear was done during the night, hence the name "night guard" to prevent it. Over time, some medical and dental professionals began tying other physical symptoms to bite dysfunctions, including headaches, neck soreness, facial asymmetries, sleep disorders, muscle weakness and chronic pain in hands, arms and shoulders.

Paradigm Shift

The Hawley flat plane splint such as the Anterior Bite Plane described by Philip Wiygul, D.D.S., M.S.2, was first used by the author in the 1950's to counteract effects of tooth wear, sensitivity, and recession. In the 1970's, lectures by Janet Travell, M.D.3, President Kennedy's personal physician, pointed out the possible connection of the mouth to neck and shoulder muscle pain and introduced the author to a broader awareness of physical symptoms that might be related to bite disorders.

Figure 1

Figure 4

In Dr. Travell's electromyography (EMG) studies of the sternocleidomastoid muscle (SCM m.), she noted that other muscles fired or contracted when the teeth "touched." She labeled the SCM m. also as a chewing muscle. Identifying the SCM m. as a muscle related to chewing was an addition to temporalis and digastric muscles that dental professionals knew were involved. Dr. Travell also considered other neck muscles as auxiliary chewing muscles because they are "recruited" to stabilize the head when biting, chewing and swallowing. She identified the levator scapulae muscle (LS m.) in Figure 4 as one of those related neck muscles.

The levator scapulae muscle traverses from the scapula across the shoulder, and up the spinal cord attaching to the top four cervical vertebrae. The bilateral attachments of LS m. are responsible for turning the head left and right, as well as for raising the shoulders. In her research into myofacial pain and dysfunction, Dr. Travell dubbed the LS m. the "stiff neck muscle."4 This same muscle is also engaged in the dental dysfunctions of clenching and grinding of teeth.

Also in the 1970's, a Scandinavian researcher, T. Magnusson, wrote about patients with TMJ Dysfunctions and recurrent headaches.5 Magnusson recommended that patients with chronic unresolved head pain should have a dental consultation. Unfortunately, then and still today, it is rare that physicians refer patients to dentists for headaches or neck pain. Sometimes, patients are referred to dentists by otolaryngologists for unresolved ear pain to check for possible TMJ/D related problems. More often, patients consult with physicians, neurologists, chiropractors, acupuncturists, osteopathic doctors, massage therapists and physical therapists for head, neck and shoulder pain. When no solutions are found there, many times patients are referred to psychiatrists or psychologists for further evaluation of chronic pain.

Dr. Travell's research and writings clearly connected the mouth and teeth to neck and shoulder muscles not previously associated with them. Dr. Magnusson's work connected TMJ to headaches and he also found the same problems with denture wearers. This information led the author to broaden his thinking in his own dental practice. It became evident to him, that the mouth was part of the person's overall health and well-being, and that there was a need to take a different and expanded diagnostic and treatment approach to all patients, whether they exhibited the usual dental indications for bite splints or not.

Thus began the author's career-long study in TMJ dysfunctions and related chronic pain, with mentors like Doctors Gelb, Stack, Moffet, Mongini, Okeson, Whitzig, Stall, Levy, Stenger and Fonder. Over the years, the author documented hundreds of patient cases and presented many case studies in dental journals and at dental meetings in an effort to encourage both general dentists and specialists to broaden their approach to the use of bite splints.

Why?

Why should the use of bite splint be broadened? Simply answered: for the good of the patients. Additionally, because it represents another valuable service the practitioner can provide which can lead to growth in the practice while giving the practitioner more professional gratification in solving patients' problems.

Commonly, patients wearing upper flat plane splints/night guards have reported improvements ranging from reduced TMJ pain, better sleep, less neck stiffness, reduction in headaches, less snoring, night clenching and grinding, less tooth sensitivity. Some patients even opt to wear the splints during the day to reduce stress while driving, sewing, or working at the computer. By wearing a splint, many patients find relief from prolonged clenching and grinding and the associated chronic muscle contraction and related pain in jaw, neck and shoulders.

In a letter dated July 25, 2009, a patient, age 59, related, "I'm actually surprised to find I'm sleeping through the night (most nights). That's never been the case before. Also, my husband says I'm no longer making strange noises when I sleep!"

Another patient was happy to report that wearing the splint gave relief that allowed her to chew steak again and return less frequently to have anterior veneers crown reattached after breaking under the constant pressure of her clenching.

The bottom line is that the tooth contact of clenching/grinding, whether there is food in your mouth or not, recruits supporting muscles to contract, in turn, producing pain, stiffness, tiredness, fatigue and general dysfunction of the affected muscles.

Important Diagnostic Techniques

Three diagnostic tools are essential for the dentist or specialist to employ in order to broaden the use of the bite splint for both new and returning patients:

  • Expanded written patient health history.
  • Personal and confidential dialogue with the patient.
  • Expanded dental examination and physical observations.

Expanded Health History

Today, most dental practices give new patients a health history to fill out. Additionally, recall patients are asked general questions about any changes in health status or medications since their last visit. The new patient health history and follow-up questions for recall patients need to be expanded if non-typical conditions related to bite disorders are to surface. The results of the questions may reveal problems the patient never thought to be related to dental conditions or treatments.

Example questions include: "Do you have headaches? Neck aches? Back aches?" "What medications do you take?" Any over-the-counter drugs such as Aspirin, Aleve, Tylenol, or Ibuprofen?" "How often do you take all these medications? Please be specific."

With the increased awareness of sleep apnea and other sleep disturbances, questions about patients' sleep patterns or problems need to be included in health history. Sleep issues may come to the surface in answers about medications if a patient is taking prescribed sleep aids. A recent 2008 sleep study by Dr. Rosetti and colleagues shows there is a "relationship between rhythmic masticator muscle activity during sleep and myofacial pain."6

Questions about the use of phones, cell phones, computers and other new technology, musical instruments and crafts are also pertinent as they often entail repeated motions or positions. Posture, tilt of head, the twist of shoulders and the repetition of such positions can add strain to neck and shoulder muscles, just as repeated computer use has lead to widespread complaints of wrist and hand muscles. The proliferation of hand held devices and constant computer use has lead to an increase of complaints of head, neck and jaw muscles.

A basic set of "Occlusal Screening Procedures" is attached at the end of this article. These questions and interpretations were created by Dr. Joseph Gantz, D.D.S., a colleague of the author and fellow member of the American Academy of Oral Facial Pain, and can be included in current new patient health history forms and questions for recall patients.

Patient and Dentist Face-to-Face Consultation

Figure 1

Figure 5

The importance of a personal, confidential patient and dentist face-to-face dialogue is visually summed up in Figure 5. This patient dialogue approach is also espoused in an editorial by Michael Glick, DMD and editor of the Journal of the American Dental Association. "Use of a health history form reflects a practitioner's knowledge. It can promote dialogue with the patients to screen medical conditions they may not be aware of."7 Dr. Glick's statement reemphasizes the need to listen to patients and include the patients' comments in their health history files.

This dialogue approach, which the author used throughout his career, frequently reveals other patient concerns, anxieties, fears, pains and past discomforts, including chronic, debilitating problems seemingly unrelated to their jaws or teeth. With further investigation, a connection between these discomforts and the teeth and jaw functions often becomes evident.

It is important to ask questions using the information provided in the health history form. The dentist repeats the questions and often obtains additional clarification. For example, "Do you have headaches?" The patient may say "no." Dentist says, "On your health form you indicate taking over-the- counter medication…what do you take that for?" The patient says, "For my headaches." Dentist's response, "You just said you didn't have headaches." The patient has often responded, "Oh! You mean those headaches." Additionally, when discussing prescription medications, it is important to learn what they are taken for as they can mask pain symptoms that may be related to grinding, clenching and TMJ dysfunction and thus complicate dental diagnosis.

This thorough and in-depth verbal history, in a face-to-face setting, especially as part of the dentist's first encounter with a new patient, can be very satisfying for a patient because the patient is treated as a person and not "just a mouthful of teeth". A relationship of trust is established before the patient sits in the vulnerable and fear-filled position in a dental chair. While this dialogue takes time, and "time is money" in any practice, it is time well spent for the diagnosis and treatment of individual patients and as a "practice builder" for the dentist. In this age of "hurry up" care, a face-to-face diagnostic dialogue demonstrates the dentist's care and interest in the patient as well as the dentist's professional competence.

Expanded Physical Examination

With the information gathered through expanded health history questions and the face-to-face patient-dentist dialogue, the dentist then conducts the physical examination. Take a set of impressions to make study models which will shed additional light on the patient's dental condition not easily observed directly in the mouth. Making a diagnostic wax bite relationship of the jaws in a more "normalized position" (often called the "as if" position) to helps the patient visualize and evaluate improved facial and general appearance changes in this new posture. Also check the patient's head, neck and body posture while standing and take photos of the face and teeth from different angles.

The patient needs to be "looked at" and observations noted such as overbite, overjet, profile, posture, etc. One rule of thumb the author has used, "The more normal the look, the more normal the function…the more abnormal the look, the more abnormal the function, with its related pain." The expanded physical evaluation is definitely "hands on," with the palpation of muscles and joints of the jaw, head, neck and shoulders and written notes of presence and intensity of pain.

What Next?

The dentist now has extensive information and description of patients' symptoms. How does a dental practitioner, who is new to these ideas yet interested in helping their patients relieve pain and improve function, begin to decipher all the information gathered, then diagnose and treat their patients? Considering the myriad diagnostic results, the author suggests that if patients are diagnosed with wear facets, night grinding, clenching, and associated sore neck muscles and generalized headaches, start with the simplest treatment: an "upper flat plane bite splint."

Fifty years ago, when the author learned how to make the "upper flat plane bite splint," it was easy and continues to be so, Fabrication can be done by a laboratory or in your office lab, whichever is more convenient and cost-effective. Photographs and instructions at the end of the article describe how to fabricate, finish, deliver, adjust, and instruct the patient in the use and care of the simple upper flat plane.

The splint is constructed on the patient's upper study model. A wax bite relation is not necessary in the lab unless the case is more complicated, or the patient has an unusually large overjet. This would require a more precise positioning of articulated models, for placement of the upper acrylic flat plane. The more of the lower incisors and cuspids that contact the flat plane the better. Some times the lower anteriors are so uneven and crowded, one is fortunate to have only 2 cuspids contacting the upper flat plane, which is fine.

This flat plane splint is much simpler than the upper full tooth coverage-gnathological type splint , which requires much longer delivery time and follow up adjustments because of so many full lower arch tooth contacts on upper acrylic.

It is also reasonable to question the long time occlusal effects of splint wear. The authors overall assessment is good. Some current patients have worn splints consistently and successfully over 50 years while many others over 25 to 40 years. They show no adverse effects, occasionally needing adjustments, repair or replacement.

Conversely, many patients reported recurrence of symptoms years later and had to be reminded about the need for continued splint wear (especially at night). They usually opined with ,"it was lost in the trash"," the dog chewed it up", "I was cured and didn't need it any more ", "I misplaced it", etc. The author has said many times to patients "once a clencher always a clencher", so splint wear is literally forever. Patient's cooperation and/or noncompliance is a large factor in treatment success.

This brings up a critical point concerning tooth contact points on splints. Dr. Robert Moyers, who taught post graduate courses in Orthodontics to general dentists at the University of Michigan Kellogg Post Graduate Dental Institute in Ann Arbor, along with Dr. Tom Graber, when discussing splints, said, "I am opposed to full occlusal coverage because I believe that a trigger area exists for many patients who are bruxists and clenchers."8

This view of Moyers and Graber reinforces the view of disengaging the pterygomassetaric sling of muscles to a relaxed state, better known as muscle deprogramming. This effect tremendously relieves and reduces the signs and symptoms of TMJ/D disease and related head and neck dysfunction and pain.

This concept has been held by the author for many years, and was recently substantiated in a small Electromyography (EMG) study he conducted. The conclusions were presented in a "poster clinic" at the 2010 spring meeting of the American Academy of Orofacial Pain. "Conclusions are: 1) Changing bite relation from intercuspal position to an anterior position produced significant reduction in activity levels of all four muscles measured during clenching. 2) The clenching activity levels of the anterior temporalis muscles were significantly lower in the anterior bite position than in the posterior bite position."9

Another diagnostic nuance deserves further discussion, being that others may not be aware of the authors use of radiographs (discussed in the next paragraph) in the diagnosis and treatment of TMJ problems. The "therapeutic positioned wax bite" (discussed under wax bite in the "expanded physical exam" on pp. 8 of this article) is used for repositioning the patient's lower jaw to a more pleasing ideal "look" and treatment position. This patient's "birdseye" view in a hand mirror, results in actually seeing and visualizing the soft tissue facial and profile changes in the new therapeutic relationship. Functioning in this new position there is usually more mobility, less noise, pain and tenderness. These are good signs for the patient. It sets the stage for further case discussion and future treatment modalities carrying out the axiom as stated by Dr. Benjamin Moffett,"10 form and function are always correlated, always change is to a similar degree and never should be separated in our approach to the patient's problem." Therefore if we establish a more normal position anatomically, more normal function should follow.

Further radiographic diagnostic evidence of dysfunctional fossa/ disk/condyle relationships can be detected by a difference in x-ray technique. Historically, three transcranial x-rays were taken of each TMJ joint. The first picture is taken in centric occlusion. The second view was to be taken biting hard in centric occlusion. I decided to take the second view in the "as if" or therapeutic wax bite position, without moving the head so the only thing changed is the patient's condyle/disc assemby and the lower jaw position. The third view is taken as usual with the jaw wide open. This represents a total of six transcranial views from the two joints.

The usual effect in comparing the first and second film is to note the condyle head has moved down and forward on the posterior slope of the eminence. A secondary but very important notation on the x-ray is the larger space created posterior to the condylar head or retrodisc space. This technique has been used by the author since early 80s. The "as if "or wax bite positioned, radiograph is further discussed in article11. Hopefully these additional facts will spur additional study by interested practitioners.

Dr Cliff Simmons12 in 1992 published with much evidence, the efficacy of using tomograms for condylar location and repositioning as a clue for diagnosis and prescription of repositioning appliances in treatment. I am sure that cone beam radiography will offer additional nuances in 3d of Tm/Joint relationships helping clinician's diagnostics.

When clinicians become familiar with the great therapeutic results that can be obtained simply, with the "upper flat plane bite splints", they may be motivated to do more difficult cases, including inclined plane splints, cuspid blocks daytime splints, bicuspid buildups, onlay-partial dentures, possible orthodontics and full mouth reconstruction as finishing solutions. These variations are topics for future articles or discussions by direct contact with the author at wwniemann@sbcglobal.net. , or send a stamped, self addressed CD mailer to Dr. W. Niemann at 620 Cliff's drive, Ypsilanti Michigan. USA 48198, to obtain for free a CD with over two hours of text, slides, videos, and narration by the author on subjects related to, the above article.


Bibliography

1. Kingsley, N.W. "An Experiment with Artificial Palates." Dent Cosmos 1887; 19: pp. 231-38.

2. Wiygul, J. Philip, D.D.S., M.S "Cranio Clinics International." Intraoral Orthodontics. Editor S. Bledsoe, Vol. 1, No. 2, pp. 42-45.

3. Travell, Janet and Simon, M.D., "Myofacial pain and dysfunction." The Trigger Point Manual. Williams and Wilkins copywrite 1983, 428 E Preston St. Baltimore, Md.

4. Travell, Janet, M.D., Lecture circa 1965.

5. Magnusson, T. "Recurrent Headaches in Relation to Temporomandibular Joint Pain Dysfunction," Acta Odontol Scand, 1978, 36: pp.333-338.

6. Rosetti et al, L.M.N., D.D.S., MSC, Ph.D., "Relationship between rhythmic masticatory muscle activity during sleep and myofacial pain." Journal of Orofacial Pain. Vol. 22, No. 3, 2008.

7. Glick, Michael, DMD. Editorial, "Use of a health history form reflects practitioner's knowledge." JADA. Jul. 2007.

8. Graber, T. Letter to Editor, "Occlusal Splints," JADA, Vol. 100, p. 171, Feb., 1980.

9. Niemann, Walter W., DDS, "Muscle Activity in Anterior and Posterior Bite Relations." Presented May 1, 2010 at the American Academy of Orofacial Pain. Data compiled and analyzed by John Radke, President of BioResearch Associates, Inc., Milwaukee, WI.

10. Moffett, Dr. Benjamin Lecture given at the American Academy of Craniomandibular Disfunction, Feb. 1988

11. Niemann, Walter W., DDS, "The Bicuspid Buildup as an Alternative in Phase II Treatment Of Craniomandibular Dysfunction." The Functional Orthodontist Sept,/Oct. 1992, p. 38-46.

12. Simmons, H Clifton, DDS, Guidelines for anterior repositioning appliance therapy for the management of craniofacial pain and TMD. The Journal of Cranial Mandibular Practice, October 2005, volume 23, number 4, pp. 300 - 305.