FAQ

There are many clinical situations where either the maxillary or the mandibular deprogrammer can be used. In these cases, the considerations are simple: which one is easier to fit and which one permits free lateral mandibular movement?

Irregular incisal edges are more common in the lower arch, and covering them with the splint helps avoid the necessity of reducing them. (It can be interesting to use a felt tip pen to “blacken” the edges you would need to adjust and show the patient with a mirror. Frequently they will want you to adjust them.)

A mandibular deprogrammer will eliminate canine contact, even with long lower canines and extreme lateral mandibular movement. This can be important with headache patients.

Lip closure is always possible with a mandibular splint. Many patients therefore find it more comfortable than a splint that adds contour to the labial of the maxillary incisors.

A palatal inclination of the maxillary central incisors can make it difficult to achieve adequate retention of a maxillary deprogrammer, although this is naturally dependent on the embrasure form and the tooth contours as well.

There was also another consideration with the mandibular splint. Classic deprogrammers only cover the central incisors and are therefore quite simple to fit with a chairside technique. Our maxillary splint widens the indication by including palatal coverage of the canines but sometimes we want simplicity: acute TMJ pain is one example. By inverting the mandibular splint and using it in the maxillary arch this “hole” in the indications is closed.

An overbite of more than four millimeters is (usually) a contradiction for the mandibular deprogrammer. It will increase the vertical dimension quite dramatically. Obviously, it also is not suitable for Class II occlusion in general, whether Division 1 or 2.

Gary Unterbrink DDS

Sometimes but not very often. When you think about the antagonist contacts on the splints, the critical retentive areas are labial on the maxillary splint and lingual on the mandibular splint. Retentive areas might be the cervical of the teeth or the embrasures.

If too much is taken away during chairside relining, the resins are still chemically active. A light curing flowable composite can be used, with a small amount placed in the retentive area and cured in the mouth directly through the FOS.

Dimethacrylates will not bond well to old relining resin, so at recalls the classic temporary C+B materials with monomethacrylate liquid and PMMA powder work best. Here again use only small amounts placed selectively.

Gary Unterbrink DDS

This is a very difficult question because there are very few comparative studies. There is no doubt that for many patients any splint would help. Two symptoms can be used to give general guidelines: headaches and TMJ pain.

• TMJ pain without headaches or TMJ pain with occipital headache location: a classic relaxation splint.
• Temporal or frontal headaches with or without TMJ pain: a deprogrammer.
• Acute TMJ pain: a mandibular advancement splint such as a BiteSoft or others (which is then converted to a deprogrammer or a relaxation splint during the course of treatment).

Gary Unterbrink DDS

Observations over a period of more than fifteen years of deprogrammer use would indicate that the overwhelming majority of patients do not protrude during the night. Rather than reduce the labial extension in 98% of cases (to permit lip closure) it seemed sensible to eliminate the extension.

For the few patients who do protrude it would be immediately noticeable to them (pain) and with the FOS it is fairly simple to use thermal welding to extend the splint labially.

I do believe it is important to have bilateral contacts on the lower incisiors but am not convinced that there is any major difference whether it is only the two centrals or all four.

Gary Unterbrink DDS

The first priority during the design phase was to provide axial loading of the antagonistic incisiors without extensive adjustment of the splint. There is no conclusive evidence that would indicate that the occlusal plane is a valid reference for splint therapy. Classic full coverage splints automatically duplicate the occlusal plane, so perhaps this factor is just carried over from tradition.

Gary Unterbrink DDS

Any eccentric load on a tooth during chairside relining can lead to this. (With a laboratory fabrication technique this will not happen if the impression was accurate.) Internal adjustment of the splint before relining to have a single stable position is important, then seat the splint during relining quickly and release all pressure while the relining material goes into the elastic phase.

If a single tooth under the splint is sensitive at recall you can use a fit-checking silicone to find the pressure spot but it is not as easy as with a crown. We still need undercuts for retention, and it is difficult to know which “perforations” in the silicone are causing the unpleasant pressure. If it is more

than one tooth the most efficient method is to remove the reliner until the splint fits passively and then reline it again.

The key to avoiding this problem is avoiding pressure during the relining technique. The first factor is achieving a stable position of the FOS before relining through internal adjustment of the spots allowing the splint to “rock” back and forth or side to side – it should fit passively but in one single stable position before you reline it. During relining, use fairly firm pressure to seat it immediately in the predetermined position and then release all pressure while waiting for the elastic phase. I do keep my fingers on it to be sure it doesn’t move. (This is another reason why I do not let the patient bite down to hold it in place during polymerization.)

Gary Unterbrink DDS

First check to make sure the tooth is loaded axially when the patient bites on the FOS. If this is the case, the tooth or teeth in question are probably in excessive contact during an excursive movement. Direct observation as the patient “slowly” glides their teeth in different directions on the splint is the easiest method to find this position, and then it can be marked with articulating foil.

You should also make sure the sensitive tooth does not “catch” on an edge anywhere.

Tip: Sensitivity with finger pressure from labial but not from palatal or lingual means the responsible contact loads the tooth toward the labial. The sensitivity is always caused by a contact loading the tooth in the opposite direction of the pressure causing pain.

Gary Unterbrink DDS

The main reason is that development of the elastic phase is much more gradual and the length of this phase longer. They also are more flexible than dimethacrylate composites. (Undercuts in our crown preparations tend to be minor.)

There is no contraindication for their use, they are simply more technique sensitive. If you do prefer to use them, you will need to use a dimethacrylate bonding agent for thermal welding: theoretically any dentin or enamel bonding agent would work fine. Test your combination first on the outer surface of an FOS to be sure it functions properly.

Gary Unterbrink DDS