www.jglobaloralhealth.

org Print-ISSN 2643-4709

Online-ISSN 2643-4695
Volume 3 • Issue 1 • January-June 2020

JOURN;ALOF

GLOBAL
ORAL HEALTH

Journal of Global Oral Health

Official Publication of
ACADEMY OF DENTISTRY
INTERNATIONAL (ADI)
Estd. 1974

Review Article

Occlusal splint therapy in TMD pain management: A review

Subachanya Ramalingam1, Saravana Priyan G L2
Department of General Dentistry, Vivekanandha Dental College for Women, Namakkal, 2Department of General Dentistry, Balaji Dental and Craniofacial
1

Hospital, Chennai, Tamil Nadu, India.

ABSTRACT
The temporomandibular joint (TMJ) acts as a hinge that connects the mandible to the skull. TMJ dysfunction
can lead to difficulty chewing, clicking sounds while opening and closing the jaw, pain, discomfort, and locking
of the jaw joint. American Academy of Orofacial Pain stated that temporomandibular disorder (TMD) is
referred to as a combined term of clinical problems that involve the masticatory musculature, the TMJ, and its
*Corresponding author: associated structures. A variety of treatment modalities have been proposed for the management of TMDs, such
Subachanya Ramalingam, as behavioral therapy, physiotherapy, intraoral appliances, orthopedic stabilization, and collective treatment. This
Department of General topic aims to provide insight and detailed information regarding the various types and functions of occlusal splint
therapy in TMD pain management.
Dentistry, Vivekanandha Dental
College for Women, Namakkal, Keywords: Occlusal splints, TMD, Intraoral appliances, Orofacial pain, TMJ pain
Tamil Nadu, India.
[email protected]
INTRODUCTION
Received: 13 January 2022
Accepted: 09 June 2022 The temporomandibular joint (TMJ) is interrelated with neuromuscular components (nerve and
EPub Ahead of Print: 09 August 2022
Published: 06 January 2023 muscle fibers). Defects of any of these components preventing them from working in harmony
could lead to temporomandibular disorders (TMDs). The American Academy of Orofacial Pain
DOI classifies TMD broadly into intra-articular and extra-articular, both of which can be present at the
10.25259/JGOH_2_2022 same time, making diagnosis and treatment more difficult (Kafas and Leeson, 2006). TMDs have
Quick Response Code:
a multifactorial etiology with bruxism, psychological illness, traumatic injuries from mastication,
extreme mouth opening, and dental treatments. Some of the conditions causing pain and dysfunction
in the TMJ include temporomandibular dysfunction syndrome, myofascial pain dysfunction
syndrome, and facial arthromyalgia. TMDs are characterized by clicking sound and pain while
opening and closing the jaw, either confined to the TMJ region or radiating to the eyes, shoulder,
and neck. Common symptoms include headache, earache, facial pain, jaw deviation, and limited
mouth opening. Symptoms range from minor to disabling. Pain is the most significant symptom, for
which patients seek medical care promptly. Management of TMD includes conservative and surgical
treatments. Examples of conservative treatments are physical therapy, localized steam application,
external muscle massage, occlusal adjustment, analgesia, splint therapy, and jaw exercise alternative
therapies such as acupuncture, ultrasound, soft laser, diathermy, and infrared radiation. Surgical
treatments include meniscoplasty and meniscectomy with disk replacement using the Proplast-
Teflon interpositional implant (Tolvanen et al., 1988, Peltola et al., 2000).[1]
In general, occlusion splint therapy is a challenge for both the dentist and the patient. Occlusion-related
disorders are often difficult to diagnose and deliver proper treatment because symptoms presented
by the patients may be varied. Once the cause of occlusal-related disorders is identified, occlusal

is is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others
to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
©2022 Published by Scientific Scholar on behalf of Journal of Global Oral Health

Journal of Global Oral Health • Volume 5 • Issue 2 • July-December 2022 | 102

 Ramalingam and Priyan: R-Splint therapy in TMD pain management

splint therapy is useful for the diagnosis and management of muscle deprogrammers and represent the flat plane appliance.
various masticatory system disorders.[2] Occlusal adjustment The two classic designs of permissive splints are anterior
involves repositioning the mandible to a centric occlusion using midpoint contact splints [Figure 2] (anterior bite planes and
orthodontic appliances. Intraoral occlusal splints are designed anterior deprogrammer) and full contact splints [Figure 3]
to provide even and balanced occlusion without forcefully (centric relation, flat plane, tanner, and superior repositioning)
altering the mandibular rest position. A splint is worn on the [Figures 2 and 3].
teeth such as a retainer or a removable denture.
Non-permissive splints/directive splints
OCCLUSAL SPLINTS AND THEIR TYPES
Non-permissive splints do not allow free movements of the
“Splint” can be several apparatus, appliances, or devices mandible. These have slopes or indentations on the occluding
employed to provide stabilization or support of teeth or bones, surface that helps in limiting the movements of the mandible.
or generally to resist motion or displacement of fractured or These are also called “directive splints,” because these
injured structures (Glossary of orthodontic terms).[3] appliances guide the mandible in a specific relationship to the
maxilla. The sole purpose of the directive splint is to position
“Occlusal splint therapy can be defined as the art and science
or align the condylar-disk assemblies to a more stable
of establishing neuromuscular harmony in the masticatory
position. It includes an anterior repositioning appliance and
system by creating a mechanical alteration of centric
a mandibular repositioning appliance.
occlusion with a removable appliance.”[4]
“An occlusal splint is a removable appliance which covers Pseudo permissive splints
the occlusal surfaces of the teeth in either the maxillary or
mandibular arches [Figure 1]. The ideal occlusal splint is Two splints are given below, that is, soft splints and
made from acrylic resin which should cover the occlusal hydrostatic splints are considered pseudo-permissive
surfaces of all the teeth in one arch or both arches.” It is also
called an occlusal appliance, interocclusal appliance, bite
guard, and night guard.

TYPES OF OCCLUSAL SPLINTS

According to Dawson splint classification
1. Permissive splints/muscle deprogrammer.
2. Non-permissive splints/directive splints
3. Pseudo permissive splints (e.g., Soft splints and hydrostatic
splints).

Permissive Splints/muscle deprogrammer

The permissive splints allow the teeth to glide unhindered

over the biting or contact surface.[5] The primary function Figure 2: Anterior midpoint contact splint.
of these splints is to alter the occlusion so that the teeth do
not interfere with the complete seating of the condyles and
to control muscle forces. Hence, these splints are also called

Figure 1: Intraoral maxillary occlusal splint. Figure 3: Full contact splint.

Journal of Global Oral Health • Volume 5 • Issue 2 • July-December 2022 | 103

 Ramalingam and Priyan: R-Splint therapy in TMD pain management

splints. These splints can exacerbate bruxism, possibly due (5) To mitigate periodontal ligament proprioception, and
to premature posterior contacts associated with the very fact (6) To reduce cellular hypoxia levels.
that these splints cannot be balanced.[6]
RELAXING THE MUSCLE
Hydrostatic appliance
The bite force is considered an important indicator of
It has a bilateral water-filled chambers on posterior teeth, masticatory function, which is exerted by the elevator
thereby giving cushioning effect to redistribute the occlusal muscles and is regulated by the nervous, muscular, skeletal,
forces. These chambers are attached to the acrylic palatal and dental systems. Therefore, the muscle spindle plays the
plates. These splints are working based on a new application of most important role in relaxing the muscle during occlusal
a physical law of nature called Pascal’s Law, which states that splint therapy. Masseter and anterior temporalis muscle
an enclosed fluid will apply equalized fluid pressure regardless and its muscle spindle show a high degree of functional
of the shape of the splint. It employs water to balance the adaptability after splint therapy. Muscle spindles play a
biting pressure, treat malocclusion, and relieve TMJ pain role in maintaining the posture of the mandible (Brill and
and symptoms associated with TMDs.[7,8] It is inserted either Tryde, 1974; Broekhuijsen and van Willigen, 1983) and
in the upper or lower jawbone.[8] Its commercial name is jaw movements during masticatory function. Therefore,
Aqualizer. It is available as Aquasplint mini, Aquasplint jaw muscle spindles could be the receptors responsible for
classic, and Aquasplint ultra [Figure 4]. the perception and maintenance of the occlusal vertical
dimension (OVD) and the control of jaw movements during
Soft rubber splint [Figure 4] normal masticatory function.[10] Most splints alter the vertical
dimension of occlusion and increase the functional length of
The soft appliance is a device fabricated of resilient material muscles. The muscular length develops maximum tension at
that is usually adapted to the maxillary teeth [Figure 5]. the resting position. The vertical dimension at the clinical rest
These appliances have been recommended for patients who position (postural position) has a minimal muscle strain. The
experience high levels of clenching and bruxism which will elevator muscles are presumed to be the most relaxed at rest.
reduce pain, discomfort, and myalgia of joints. However, these The nature of the occlusal system and specific tooth contact
appliances can exacerbate the bruxism probably due to the influences muscle function while opening and closing the jaw.
inability to achieve balanced contact with posterior teeth.[9]
The splint therapy can control teeth interferences and
mandibular movement. This will modify the muscle
FUNCTIONS OF OCCLUSAL SPLINTS [FIGURE 5]
hyperactivity by helping the OVD masticatory muscle get
Fabricated splints have six functions, including the following: relaxed. The tooth interferences to the centric relation arc
(1) To relax the muscles, of closure activate the lateral pterygoid muscles.[11] Posterior
(2) To maintain centric relations, tooth interferences during excursive mandibular movements
(3) To provide diagnostic information, cause hyperactivity of the closing muscles (masseter,
(4) To protect the occlusal surfaces teeth and associated temporalis, and medial pterygoid).[12] A muscle that is in a
structures from bruxism, fatigued and hyperactive state can present with pain.

Figure 4: Hydrostatic occlusal splint. Figure 5: Soft splint.

Journal of Global Oral Health • Volume 5 • Issue 2 • July-December 2022 | 104

 Ramalingam and Priyan: R-Splint therapy in TMD pain management

Occlusal splint promotes the elimination of posterior the wear occurs against the splint. Furthermore, the splints
excursive contacts by anterior guidance and condylar reduce stress on the individual tooth due to more teeth
guidance which will relax the elevator muscle and positioning contacts of equal intensity.[19] It is important to remember that
muscle allowing the condyles to seat in centric relation: For splints do not prevent night grinding; rather, they distribute
the condyles to seat completely under the articular disk in the force across the masticatory system. These appliances can
the anterosuperior position, the superior belly of the lateral decrease the frequency but not the intensity of the bruxing
pterygoid should obtain its full extension. When the lateral episodes.[20]
pterygoid is triggered to hyperactivity through occlusal force,
the disk is pulled anteromedially toward the origin of the MITIGATING PERIODONTAL LIGAMENT
muscle, resulting in displacement. Overloading of condyle/ PROPRIOCEPTION
disk assembly when not in normal physiologic position
contributes to TMJ disorders. A properly balanced splint Proprioceptive fibers contained in the periodontal ligament
results in an occlusion associated with relaxed positioning of each tooth send messages to the central nervous system,
and elevator muscles, allowing the articulator disk to obtain triggering muscle patterns that protect them from overload.
its anterosuperior position over the condylar head. Thereby, An occlusal splint functions to dissipate the forces placed on
chronic symptoms of muscle hyperactivity were lessened individual teeth by utilizing a larger surface area covering all
significantly within 24-h of splint wear. The effectiveness teeth in the arch. Thus, a splint balances the proprioception
of splint therapy in reducing pain indexes and muscle and allows for muscle symmetry.[21] Hannam et al.[22] also
hyperactivity is well documented[13-16] from the 1st day to found that in cats, stimulation of pressure receptors in the
8 weeks time period. periodontal membrane led to a jaw-opening reflex. This helps
in clarifying why the teeth must be kept in balance with the
TO MAINTAIN THE CENTRIC RELATION condylar disk assembly to maintain neuromuscular functions
in the associated muscles.
The basic function of the occlusal splint is to prevent the
existing occlusion from controlling the maxillomandibular REDUCING CELLULAR HYPOXIA LEVELS
relationship at maximum intercuspation (centric relation).
The Glossary of Prosthodontic Terms defines centric relation In a study by Nitzan,[23] pressure was measured in the superior
as “A clinically determined maxilla-mandibular relationship, joint space of patients with articular disk displacements.
in which condylar disk articulate in their anterosuperior While clenching maximally, recorded pressures reached up
position in the mandibular fossae and against the distal slope to 200 mm Hg. When a flat plane appliance was placed, no
of the articular eminence.”[17] Splint therapy can utilize centric significant pressure (no capillary hyper fusion pressure) was
relation as a physiologic treatment position. Whenever recorded.
rearrangement of the occlusion is required, it is essential to
do restorative procedures with a period of splint therapy to CHOOSING THE CORRECT OCCLUSAL SPLINT
ensure that a stable relationship has been obtained.
Determination of the appropriate type of splint therapy
PROVIDE DIAGNOSTIC INFORMATION depends on the specific diagnosis of TMD.
1. If the patient reports bruxism and headaches, the use of
Splint therapy can be an important diagnostic tool to a full-coverage splint at night, in which acrylic covers
determine wear patterns, bruxism habits, and the anatomic an entire arch of teeth, is often adequate to protect the
and physiologic status of the joint and TMD status.[18] If teeth. A minimum of a 4-mm splint thickness increase
a patient becomes comfortable with a splint immediately, in vertical dimension is necessary to protect bruxism
it may be an indication that the disorder is muscular. If patients. If the patient is wearing a 4 mm thickness splint
symptoms worsen with permissive splint wear, this may and still experiences muscular tenderness, headache,
indicate an internal disk derangement problem or an error in and/or facial muscle tightness immediately after waking,
the initial diagnosis.[4] splint thickness should be increased incrementally
until symptoms disappear[4,24] When a muscle disorder
PROTECTING OCCLUSAL SURFACES OF is suspected in TMD patients, minimal invasive may
TEETH AND ASSOCIATED STRUCTURES FROM be used like bite planes which will separate the teeth
BRUXISM and allowing the muscles to relax. In general, muscle
disorders are effectively treated with appropriate splint
Patients who are prone to nocturnal bruxism (the grinding therapy (bite planes and stabilization appliances).[4,18,24]
or clenching of teeth) should routinely wear occlusal splints 2. If the combination of muscle and disk disorders is
at night because the splints protect the teeth against wear as identified (i.e., clicking sound with muscle pain),

Journal of Global Oral Health • Volume 5 • Issue 2 • July-December 2022 | 105

 Ramalingam and Priyan: R-Splint therapy in TMD pain management

stabilization bite splints are the treatment of choice. They 1974;89:1351-7.

provide long-term wear and also cover the entire dental 8. Lerman MD. The hydrostatic appliance: A new approach to the
arch, ensuring that the covered teeth do not move. If treatment of the TMJ pain-dysfunction syndrome. J Am Dent
advanced disk and muscle disorders are identified (jaw Assoc 1974;89:1343-50.
9. Okeson JP. The effects of hard and soft occlusal splints on
locking and/or noises, painful joints), stabilization
nocturnal bruxism. J Am Dent Assoc 1987;114:788-791.
splints are the treatment of choice, they must be worn
10. Yabushita T, Zeredo JL, Fujita K, Toda K, Soma K. Functional
continually for 24 h for as long as required to eliminate adaptability of jaw-muscle spindles after bite-raising. J Dent
the muscle, disk, ligament, and tooth symptoms. 3 Res 2006;85:849-53.
to 6 months of wear is required depending upon the 11. Ramford S, Ash M. Occlusion. 3rd ed. Philadelphia, PA: WB
patient.[24] Saunders Co.; 1983.
3. In acute trauma, an anterior repositioning appliance 12. Manns A, Rocabado M, Cadenasso P, Miralles R, Cumsille MA.
for 7–10 days is required to keep the condyle away The immediate effect of the variation of anteroposterior
from the retrodiscal tissues so that the inflammation laterotrusive contact on the elevator EMG activity. Cranio
can subside. 1993;11:184-91.
13. Manns A, Miralles R, Guerrero F. The changes in the electrical
activity of the postural muscles of the mandible upon varying
CONCLUSION the vertical dimension. J Prosthet Dent 1981;45:438-45.
14. Manns A, Miralles R, Santander H, Valdivia J. Influence of the
This article is a review of different types of splints that
vertical dimension in the treatment of the myofascial pain-
can be given to TMD patients for different problems and
dysfunction syndrome. J Prosthet Dent 1983;50:700-9.
selecting proper splints dentist should have a thorough 15. Clark GT, Lanham F, Flack VF. Treatment outcome results
an understanding of symptoms and carry out a complete for consecutive TMJ clinic patients. J Craniomandib Disord
assessment of TMJ and its associated problems. A perfect 1988;2:87-95.
appliance with fewer complications should be delivered. 16. Sheikholeslam A, Holmgren K, Riise C. A clinical and
electromyographic study of long-term effects of an occlusal
Declaration of patient consent splint on the temporal and masseter muscles in patients with
functional disorders and nocturnal bruxism. J Oral Rehabil
Patient’s consent not required as there are no patients in this 1986;13:137-45.
study. 17. Williamson EH, Lundquist DO. Anterior guidance and its
effect on electromyographic activity of the temporal and
Financial support and sponsorship masseter muscles. J Prosthet Dent 1983;49:816-23.
18. The glossary of prosthodontic terms. J Prosthet Dent
Nil. 1999;81:39-110.
19. Yunus N. Occlusal splints therapy: A review. Indian J Dent
Educ 2009;2:5.
Conflicts of interest
20. Holmgren K, Sheikholeslam A, Rüse C. Effect of a full arch
There are no conflicts of interest. maxillary occlusal splint on parafunctional activity during
sleep in patients with nocturnal bruxism and signs and
symptoms of craniomandibular disorders. J Prosthet Dent
REFERENCES 1993;69:293-7.
1. Seifeldin SA, Elhayes KA. Soft versus hard occlusal splint 21. Srivastava R, Jyoti B, Devi P. Oral splint for temporomandibular
therapy in the management of temporomandibular disorders joint disorders with revolutionary fluid system. Dent Res J
(TMDs). Saudi Dent J 2015;27:208-14. (Isfahan) 2013;10:307-13.
2. Kreiner M, Betancor E, Clark GT. Occlusal stabilization 22. Hannam AG, Wood WW, De Cou RE, Scott JD. The effects
appliance. Evidence of their efficacy. J Am Dent Assoc of working side occlusal interferences on muscle activity
2001;132:770-7. and associated jaw movements in man. Arch Oral Biol
3. Jacobson A. Glossary of orthodontic terms. Am J Orthod 1981;26:387-92.
Dentofacial Orthop 2002;122:335. 23. Nitzan DW. Intraarticular pressure in the functioning human
4. Dylina TJ. A common sense approach to splint therapy. temporomandibular joint and its alteration by uniform
J Prosthet Dent 2001;86:539-45. elevation of the occlusal plane. J Oral Maxillofac Surg
5. Boero RP. The physiology of splint therapy: A literature review. 1994;52:671-9.
Angle Orthod 1989;59:165-80. 24. Piper M. Manual for Intermediate to Advanced TMD
6. Okeson JP. Management of Temporomandibular Disorders and Treatment. St. Petersburg, FL: Center for Advanced Dental
Occlusion. Amsterdam, Netherlands: Elsevier Health Sciences; Study; 1999. p. 1-17.
2019.
7. Lerman MD. A complete hydrostatically derived treatment How to cite this article: Ramalingam S, Saravana Priyan GL. Occlusal splint
therapy in TMD pain management: A review. J Global Oral Health 2022;5:102-6.
of TMJ pain dysfunction syndrome. J Am Dent Assoc

Journal of Global Oral Health • Volume 5 • Issue 2 • July-December 2022 | 106