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SYSTEMATIC APPROACH TO ORAL SPLINTS – AN OPINION

PAPER: PART 1 – FUNDAMENTAL ISSUES

Gregor Slavicek

1a*

, Anastasia Novitskaya

1,2b

, Florian Slavicek

Orehab Minds GmbH, DE-70567 Stuttgart, Germany

Dental Clinic Smiletime, RU-14106 Podolsk, Moscow Region, Russia

MD, DDS, MSc, CEO and Head; e-mail: g.slavicek@orehab-minds.com; ORCIDiD: https://orcid.org/0000-0003-2454-4048

DDS, CEO; e-mail: anastasia.novitskaya@gmail.com; ORCIDiD: https://orcid.org/0000-0003-3446-3866

BSc; e-mail: f.slavicek@orehab-minds.com; ORCIDiD: https://orcid.org/0000-0003-4245-7829

Background Oral Splints are controversially discussed in dentistry. Although scientic ndings cannot yet

provide a denitive statement on ecacy and mechanism of action, dentists apply occlusal splints in large

numbers.

Objectives This series of articles aims to bring together the discrepancy between ndings from studies and

clinical reality. In addition, the contradictory terminology will be discussed.

Conclusion The practicing dentist and his interdisciplinary team strive to provide the best possible treatment

for the patient. The treatments focus on the long-term eect, using a causal therapeutic approach. Occlusal

splints can be used in dierent situations. This requires the indication to be dened precisely, the parameters

of the splint to be tailored to the individual patient, and a realistic picture, including a realistic prognosis

regarding the expected eect, to be developed together with the patient.

ABSTRACT

Orthognathic Surgery; Titanium miniplates; Plate removal; Risk factors; Infection.

1. INTRODUCTION

Oral Splints are controversially seen in dentistry.

Practicing dentists use this therapeutic option

frequently and regularly [1,2]. Academic opinion

leaders reject the use of oral splints, citing the paucity

of studies that show little evidence for these forms of

therapy [3]. A constantly increasing number of over-

the-counter devices (OTC) and similar commercially

available devices indicate that consumers, aected

persons, and unsatised patients demand these

products a lot [4]. A wide range of other treatment

methods, some of which are part of so-called

conventional medicine but others that go far beyond

it, make it dicult to form a clear opinion and dene

the best way to relieve aected patients [5,6].

Dental treatments aim to improve the patient's

situation in the long term. Often, the patient

requires intervention from the dental team because

of a symptom such as pain. The approach is either

causal or symptomatic. Causal therapy is preferable

in many respects. Dentists must take these situations

seriously and are in charge of developing the best

possible treatment. Any treatment requires an

open mind without premature and preconceived

diagnoses. An unbiased diagnosis needs systematic

examinations and neutral conclusions. Weighing

up the facts and the patient's preferences can now

be combined with the scientic evidence. The most

suitable therapy will be implemented after weighing

the risk-benet prole. The dental team must

consider scientic information (the evidence) and

match all parameters while developing a treatment

plan. However, if the evidence for a particular therapy

(e.g., occlusal splints) is weak (low), the conclusion

must not be to rule out this treatment method. The

dentist's expertise and the patient's autonomous

freedom of choice are equally important factors in

evidence-based medicine [7]. (Fig. 1)

KEYWORDS

OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.

Peer-Reviewed Article

Citation: Slavicek G, Novitskaya A, Slavicek F. Systematic Approach to Oral Splints – an opinion paper Part 1: Fundamental Issues. Stoma Edu J.

2024;11(1-2):65-71.

Received: April 01, 2024; Revised: April 30, 2024; Accepted: May 02, 2024; Published: May 04, 2024.

*Corresponding author: Professor Gregor Slavicek, MD, DDS, MSc, CEO and Head; Orehab Minds GmbH, Address: Zettachring 2, DE-70567 Stuttgart,

Germany; Tel./Fax: +49-7307-24922-11; e-mail:

g.slavicek@orehab-minds.com

https://doi.org/10.25241/stomaeduj.2024.11(1-2).art.6

OCCLUSION AND TMJ

Figure 1. Evidence-based medicine (EBM). Scientific evidence is an

important, but not the only element in decision making. Only the

combination between the clinical expertise of the dental team and the

patients’ priorities allows the establishment of the best treatment strategy.

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Evidence-based medicine is the conscientious,

explicit, and judicious use of current best evidence

in making decisions about the care of individual

patients. Low evidence should not be interpreted

as a rejection of a therapy. Rejection implies the

risk of harming a patient by withholding a possible

helpful therapeutic regime. [8] Rejection requires

evidence as well. A paradigm shift is methodically

and ethically sound if a clear alternative exists and

the evidence demonstrates the superiority of the

alternative [9-11].

This series of three articles discusses the discrepancy

between scientic evidence and clinical expertise

regarding occlusal splints (oral devices). If the main

dierences in the view on occlusal splints (scientic

vs. practical) are understood, an improved application

of occlusal splints, merging evidence with expertise

and patients' characteristics to improve the patient's

quality of life.

2. CONFUSING TERMINOLOGY

TIn medicine and dentistry, "splint" refers to measures

to connect, stabilize, and fix two or more parts

together to enable or improve the healing process.

A rigid or exible device maintains the corrected

position of displaced parts to keep these parts in

place. Such splinting devices usually restrict motions

or immobilize joints. Splinting in dentistry refers to

connecting two or more teeth, forming a rigid unit to

reduce the mobility of the single tooth [12].

In (muscle) physiology, a prolonged muscle

contraction that inhibits or prevents movement of a

body part is called muscle splinting, an involuntary

contraction of a muscle (total or partially) to avoid

particular movements causing severe pain sensations.

The location of the pain to be avoided by the splinting

is not necessarily located directly in the muscle but

in joints, joint capsules, ligaments, and tendons.

Resistance to passive stretch of the muscle with partial

muscle relaxation at rest is typical for such situations,

also called protective muscle contraction [13-15].

Today, the term splint is still used, although the main

idea of occlusal splints is not to connect and to x

two parts. Occlusal splints are removable intraoral

devices covering the occlusal surfaces and aecting

the relationship of the mandible to the maxillae.

Blocking mandibular movements and limiting TMJ

movements are not intended by prescribing occlusal

splints; here, the term splint should not be interpreted

in a sense, as mentioned earlier, of xing two or more

moveable parts [16].

The use of occlusal splints may include, but is not

limited to, occlusal stabilization, initial therapy prior

to extensive intervention, or prevention of wear of

the dentition or damage to brittle restorative dental

materials. Such occlusal appliances (occlusal splints)

are designed in manifold variations. A unique and

characteristic feature of occlusal splints is the articial

occlusion, allowing reversible alterations of dental

structures and the interaction of upper and lower

teeth. Oral splints allow alterations of mandibular

position, vertical dimension, and joint position

without irreversible changes in dental structures [16].

The terms occlusal splints, occlusal appliances, and

occlusal splints are generally used as synonyms. The

term night guard is misleading and should be used

only for particular indications, which is usually the

parafunctional activity of the patient. Such devices

are used during sleep to avoid the adverse side eects

of bruxing and clenching. Night guard implies that

these devices should be used during sleep (during

the night) only. Today, awake bruxism also requires

attention, and such protection guards are also helpful

during the awake state. Bruxism was (and sometimes

still is) seen as a harmful movement disorder. [Sleep

medicine] On the other hand, the positive eects of

these (physiological) occlusal functions are described:

breathing suspension and increased salivation [17,

18], hormonal regulation, and stress relief [19]. The

visualization of the tooth contacts, occurring due to

grinding or pressing teeth in an awake or asleep state,

helps the patient to understand these unconscious

occlusal functions and supports the dental team

in integrating this information into the diagnostic

findings (not only "bruxing yes or no" but also

which teeth, which segments of the dental arches

are involved, correlated to other ndings such as

periodontal breakdown, chipping, class V lesions,

pain and alterations of mandibular movements).

[18] Sleep bruxism is not only an issue for the adult.

Clinical attention should be placed on children and

adolescents to support the development of the

stomatognathic system and occlusal functions. [20].

3. UNCLEAR INTENTIONS OF ORAL SPLINTS

A general description for oral splints can best be

described as follows: Occlusal splints are removable

devices, usually made of hard acrylic, covering the

occlusal and incisal surfaces of all teeth in one dental

arch and inuencing the relationship of the upper

and lower jaw. The labels (names) for such devices

that emerged over the last decades (1950 till now)

are not uniform and often conicting and, therefore,

confusing. Unclear synonyms potentially provoke

misunderstandings, leading to problems with the

indication and application [21,22].

The following (incomplete) list intends to illustrate

this problem, particularly from the perspective of the

reader of specialist articles and publications:

- Positioning:

- What should be positioned?

- From which position (start) to which position

(desired)?

- Repositioning:

- What should be repositioned?

- From which position (start) to which position

(desired)?

- Positioning and Repositioning:

- Are there dierences in the intention and in the

design of the splint?

Slavicek G, et al.

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Systematic Approach to Oral Splints: Part I

- Are there dierences in the meaning?

- Stabilization:

- What has to be stabilized?

- Why does something has to be stabilized?

- What was the reason for becoming unstable?

- Are there particular and clinically relevant

dierences between Stabilization and Positioning?

- Is the stabilization an active (via splint elements) or

a passive (via muscle coordination and relaxation)

operation?

Names (labels) of splints refer to typical design

features (e.g., mandibular advancement splint), may

refer to the proposed eect (mandibular stabilization

splint), or refer to particular diagnostic ndings (disc

(re-) positioning splint). Are these devices dierent to

justify dierent names, or is it one type of splint, and

further subdivisions do not lead to more clarity but

create more misunderstandings? On the other hand,

if this labeling makes sense and is helpful in clinical

decision-making, are such dierentiators recognizable

in the evidence-based conclusions?

Four terms are often used concerning occlusal splints

and may be considered to refer to fundamental

intentions when using such oral devices.

* Stabilization usually refers to stabilizing the mandible.

Occlusal structures (relief and particular elements) of

the splint occlusal surface are used to implement the

stabilization eect. A harmonization and improved

coordination of the muscles of the chewing organ is

a possible mechanism for stabilization or a positive

eect of the achieved mandibular stability. The term

stabilization splint is frequently used in clinical trials

[23,24].

* Relaxation usually refers to relaxation of the

neuromuscular system. The relaxation eect of oral

splints (stabilization, Positioning) is often not explicitly

mentioned but can probably be read between the

lines. Relaxation techniques seem to be the domain

of non-splint therapeutical regimes. However, the

eects of stabilization splints and applied relaxation

techniques are not different; both show similar

eectiveness in treating pain [25]. However, if the

patient receives two or more therapies, and dierent

disciplines are involved, the outcome of the therapy

should be better compared to the outcome of a single

therapy. (Fig. 2)

* Oral devices for short-term masticatory muscle

relaxation can be summarized in one group with only

partial occlusal contacts (often frontal teeth, but also

premolars). Jig, anterior bite plate, and interceptor

are familiar names.

* Positioning refers to Mandibular Position. An active

positioning requires the fabrication of the splint in

the programmed articulator. A passive positioning:

the CMS System dominates over occlusion. The terms

active and passive are here used from the dentist's

perspective: active implies decision and construction

elements, and passive means the dentist allows the

stomatognathic system to position the mandible as

soon as the splint separates the existing occlusion.

* Re-capturing refers to the articular disc in cases

with partial or total anterior disc dislocation with

reduction. A re-capturing occlusal device aims to bring

the articular disc back into its physiological position

in relation to the condyle. A re-capturing splint is

applied to move the articular disc from partial or total

displacement back to the physiological position in

relation to the condyle. The terms Disc-Repositioning

and Disc Re-Capturing are used synonymously.

What is known today as internal derangement of

TMJ structures has been described by W. Farrar in

1978: the condyle-disc relationship is temporarily

(anterior Disc Displacement with Reduction aDDwR)

or permanently (anterior Disc Displacement without

Reduction aDDwoR) disturbed. In both situations, the

articular disc is anteriorly positioned in relation to the

condyle, with possible lateral or median shifts. The

anterior dislocation of the disc remains during the

opening movement in aDDwoR, with the condyle-

disc relationship restored during the opening in

aDDwR. The reduction of the disc and the luxation

of the disc are often accompanied by joint noises,

usually described as clicking noises. Clinically, the

term reciprocal click is used to summarize the

opening and closing sounds. Mandibular movements

can be aected quantitatively and qualitatively; the

mandibular range of motion (MROM) may be reduced

for opening, protrusion, and laterotrusion, deviation,

and deections during mandibular movements can be

described as well. The aDDwoR and reduced opening

capacity are summarized as acute (often accompanied

by joint pain) and chronic (often without joint pain,

but with muscle pain, stiness, or fatigue) locked joint

(mouth) phenomena [26,27].

Most occlusal devices used in clinical studies can be

allocated to one of the above-mentioned terms.

The length of the plates in the mandible was used

as an indicator for the advancement of the lower

jaw. A BSSO with plate lengths of 8 mm or less was

considered as a small advancement (574 patients),

while plate lengths of more than 8 mm were

considered as a big advancement (573 patients).

In the patient group with a small advancement 31

patients needed plate removal, 41 patients in the big

advancement group (P=.221). Of the 1147 patients

Figure 2. Multi- and Interdisciplinary treatments. in a multidisciplinary

approach, the collaboration of disciplines leads to the sum of the effects of

the disciplines. In an interdisciplinary collaboration, the concerted

approach leads to an increased therapeutic effect. [adapted from: Slavicek

G., Interdisciplinary - A Historical Reflection 2012, Int.J.Humanities&Social

Science Vol.2/20].

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Slavicek G, et al.

with a lower jaw osteotomy, 86 patients had a rotation

of the mandible. Patients with a rotation of the lower

jaw had more plates removed than patients with a

symmetrical osteotomy (P=.010).

According to the patient les 47 out of 1252 patients

smoked (3.8%). Only 2 of these 47 patients had plates

removed (2.6%, P=.965). Smoking was more frequent

among female patients (70.2%), versus 29.8% for male

patients.

4. THE ORIGIN OF MANY OF TODAY'S COMMON

NAMES FOR OCCLUSAL SPLINTS

The rst systematic use and description of occlusal

devices dates back to Ramord and Ash in the 1950s

[28,29]. At that time, stabilization and splinting teeth

were strategies in periodontal treatment.

The splinting was not performed with occlusal devices

but as temporary splints using bonding techniques.

Stabilization refers, in this context, to reducing

tooth mobility. An additional option for treating

periodontal patients and reducing occlusal loads on

mobile teeth was called bite-planes. Occlusal trauma

and periodontal stress due to bruxism were primary

indications, intending to stabilize mobile teeth and

prevent tooth migration. Positive eects of such

devices on temporomandibular joint discomfort

and muscle pain were observed (positive adverse

events) and were subsequently used therapeutically.

Before orthodontic re-positioning of migrated teeth,

bite planes were used if permanent splinting was

impossible. Ramord and Ash described maxillary

bite-planes with at occlusal surfaces, centric stops

for all opposing teeth, and anterior and canine

guidance for posterior Disclusion in lateral and

protrusive mandibular movements. "This appliance

will decrease the occlusal load for single teeth and

also decrease the total muscle activity" [28]. The terms

splinting, stabilization, positioning and repositioning

have emerged already, but they are based on dierent

meanings and intentions.

Knowledge of the original texts by Ramord and Ash

helps a lot to understand the nomenclature of occlusal

splints in use today: to splint – to reduce occlusal

forces aecting single teeth; to stabilize – reduce tooth

mobility; to reposition – orthodontic movement of

migrated teeth back to their original position. These

terms are still in use, but the meaning and the target

structures have significantly changed. Occlusal

Splints are used to reduce and distribute occlusal

forces better; Occlusal Splints are used to stabilize

the mandible by alternating mandibular-maxillary

relationship and to allow the neuromuscular system

to reduce activity and to harmonize mandibular

statics and dynamics; Occlusal Splints are used to (re-)

position the mandible and to improve TMJ position,

including the condyle-disc relation [29].

Today, the term stabilization splint is frequently used.

A splint is used to stabilize (but not immobilize) the

chewing organ or parts of it if occlusion does not

perform stabilization. [GPT-9] In the 1980s, the term

stabilization splint became popular and refers to

splints fabricated in semi-adjusted articulators to

stabilize the mandible. Often, such splint designs

are called Michigan splints. Upper and lower teeth

are separated by a at occlusal surface with centric

contacts and anterior guiding elements (laterotrusive

and protrusive). Indication for stabilization of the

mandible is an unstable lower jaw due to occlusal

deficits of an individual. Occlusal structures are

not able to stabilize the mandible. Today, the term

“stabilization” with an occlusal splint implies the

following intentions in the specialist literature: to

develop a stable status, to maintain the stable status,

to protect other parts of the stomatognathic system

due to instability of the mandible, to secure and to

reinforce elements of the craniomandibular system.

The Michigan type and similar splint designs are

often applied in splint studies. Systematic reviews

show that no clear evidence exists to support the

provision of splints for the various subtypes of

TMD or bruxism. However, the conclusions drawn

from such meta-analysis are based on the studies,

which used substantial dierences in three crucial

factors: 1) diagnoses, 2) splint type, and 3) outcome

measurement/reporting [3].

A common indication and inclusion criteria in clinical

trials is pain, referring to the (R)DC/TMD criteria [30].

Pain is an unspecic symptom. Craniomandibular

disorder (CMD) is a collective term that summarizes

signs and symptoms. Pain often goes along with

dysfunction. The treatment needs of CMD patients

are controversially discussed. Causal or symptomatic

approaches are possible. Pathomechanism, especially

the role of occlusion and occlusal function as a cause

for CMD, is the subject of ongoing debate [11,14,

31]. J.B. Costen described the effect of occlusal

alterations, loss of vertical dimension of occlusion,

and reduction of lower facial height in 1934 [32]. The

description of this clinical picture, known today as

Costen's syndrome, is a predecessor to today's CMD

interpretation. Pain alone or combined with other

signs and symptoms is often used as an inclusion

criterion in (randomized) clinical trials of occlusal

splints versus other therapeutic regimens [22]. The

results are inconclusive and do not allow a final

conclusion as to whether splints are superior to other

forms of therapy [34]. Pain, dysfunction, and bruxism

are often combined in these studies, which makes it

dicult to quantify the eects [35-37].

5. CONCLUSION

Rejection of (potentially helpful) splint therapy for

individual patients due to a lack of scientic evidence

carries the risk of withholding eective therapies

and prolonging or worsening the patient's situation.

Experimentation and trial and error approaches are

contraindicated. A supercial diagnosis, often focused

only on one symptom (pain or dysfunction), leads to

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symptomatic applications of oral devices that perform

equally or even worse in direct comparison with other

methods.

A causal approach is required in contemporary

dentistry. However, the causality of occlusion in the

development and emergence of masticatory organ

dysfunctions, cranial Mandibular Dysfunctions, and

Myoarthropathy is still controversially discussed.

There are two completely contradictory points of

view for and against occlusal causality; the dentist

has to make the decision based on systematic clinical

and instrumental functional analysis. The goal of a

splint therapy is a causal approach. Here, special

attention has to be made to multifaceted problems

of the patient. If the patient´s situations does not

allow a clear assignment to a particular discipline, or

the diagnostic ndings clearly show that more facets

need to be considered, a one-splint therapy is very

apt to fail. Patients with various problem should not

fall between two stools (disciplines). (Fig. 3)

Application of occlusal splints for individual patients

is eective and ecient in treating patients in daily

dental practice, not only to reduce or eliminate

symptoms, but also to serve as basis for oral

rehabilitation [37]. However, the scientic evidence

of these positive eects still needs to be completed.

From the authors' point of view, the following factors

contribute signicantly to this:

* one type of splint for (almost) all indications

* general splint parameters for each patient, without

considering the individual patient's skeletal class and

skeletal pattern

* only limited information regarding instructions for

the patient who and when to use the appliance

* almost no information regarding follow-up (short-

term check-up) and how to monitor the course of the

treatment

* no information if the occlusal splint has to be

adapted and equilibrated

* expectations are formulated in a very general

manner (pain reduction)

The complexity of the stomatognathic system requires

special attention. Successful therapeutical regimes

require a clear and systematic clinical sequence

of dental diagnostics followed by an initial splint

therapy [37,38] A classical gnathological triangle

demonstrates the interaction between occlusion, TMJ

and neuromuscular system (Fig. 4).

Nevertheless, the complexity of the masticatory

organ is not reected in this conclusive graphic. If

the masticatory organ is understood as a cybernetic

system, more complex interactions can be derived.

The role of occlusion in this system is recognized

less by separated independent factors (interference)

and more by dynamic occlusal function (chewing,

swallowing, speaking, grinding, clenching) (Fig.

5). Searching for similarities between the occlusal

splints leads to two elements, both closely related

to occlusion: the existing occlusion is (reversibly)

changed, and the vertical dimension of the occlusion is

increased. The craniomandibular system can stabilize,

position, and relax without constantly conicting with

the existing occlusion. Splints usually lead to a new

lower jaw position.

The existing occlusion remains unchanged. The

subsequent oral rehabilitation task is to adapt the

occlusion to optimally support this new lower jaw

position and guarantee the long-term eect (Fig. 6).

Figure 3. Interdisciplinary dentistry. The allocation of a patient to a

special discipline is sometimes difficult, especially if the patient´s problems

affect several disciplines (indicated by the light grey area). This can

complicate the coordination of diagnostic and therapeutic tasks. [adapted

from: Slavicek G., Interdisciplinary - A Historical Reflection 2012,

Int.J.Humanities&Social Science Vol.2/20].

Figure 4. Mutual influences. The mutual positive and negative influences

of the temporomandibular joint, musculature and occlusion are clearly

recognizable and comprehensible in a pathogenetic model. However,

linear relationships are simplifying and not capturing the fundamental

complexity.

Figure 5. Cybernetic system. If the masticatory organ is viewed as an

integrated part of the organism, the relationships of structures, occlusal

functions and central/peripheral nervous system can be visualized. Psyche

and personality are elements that cannot be ignored. [adapted from:

Slavicek R. The Masticatory Organ, ISBN 3950126112, 9783950126112].

Figure 6. General splint effects. Most occlusal splints act via the

occlusion, which is reversibly altered, including an increase in the vertical

dimension of the occlusion. These alterations of occlusion allow the

neuromuscular system to relax, harmonize better, and carry out the

mandibular movements more cohesively. The jaw joint can assume a

centered position without being placed in an unfavorable position by the

occlusion.

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65-71

The beneficial effects of occlusal splints can be

significantly increased by considering individual

factors. Clinical application is based on adapting

the splint in many ways to the individual patient's

situation. These aspects are discussed and explained

in part 2 and part 3 of this article series.

AUTHOR CONTRIBUTIONS

All authors contributed to the concept, writing, analysis,

interpretation and critical revision of the manuscript.

CONFLICT OF INTEREST

Authors declare that there is no conict of interests.

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Dr. Slavicek is an MD, specialized in Dentistry. He is currently Director of the Steinbeis Transfer Institute Biomedical Interdisciplinary

Dentistry, Steinbeis University of Berlin. Since 2019, he has been CEO of Orehab Minds GmbH in Stuttgart, Germany. He

graduated from the University of Vienna (medicine and dentistry), also specializing in Clinical Research at the same university

(Master of Science). He attended additional postgraduate orthodontic training at the University of Aarhus (Denmark), with Prof.

B. Melsen, and postgraduate gnathological training at University of Florida (USA), with Prof. H. Lundeen and Prof. C. Gibbs. He is

an honorary member of the Italian Gnathological Society. He was awarded an honorary professorship by the Ukrainian Dental

Society. He was visiting professor at the rst medical state University in Moscow Sechenov (2014-2018).

Gregor SLAVICEK

MD, DDS, MSc, CEO, Head

Orehab Minds GmbH

DE-70567 Stuttgart, Germany

Questions

1. Systematic reviews report the level of evidence for splints studies for the various

subtypes of TMD or bruxism as follows:

qa. Strong;

qb. Low;

qc. Conrmed;

qd. Superior to alternative treatments.

2. Data from meta-analysis on occlusal splints often are unclear regarding the following

parameters:

qa. Diagnosis;

qb. Splint type and outcome measure;

qc. Diagnosis, Splint type and outcome measure;

qd. Outcome measure.

3. Typical Splint types do not refer to one of the following items:

qa. Posteriorizing;

qb. Stabilization;

qc. Positioning;

qd. Anterior repositioning.

4. Which statement is incorrect regarding the term re-capturing?

qa. Re-Capturing refers to the articular disc;

qb. Re-Capturing refers to aDDwR;

qc. Farrar description of the pathomechanism of the reciprocal click with a recapturing and a luxation of

the articular disc;

qd. Re-Capturing refers to the re-establishing the vertical dimension of occlusion.