Labs are often asked a variety of questions regarding occlusal guards, splints, such as:
What design type to use?
What materials are best?
What clinical records should be taken?
The goal of this article is to highlight what are desirable occlusal guard designs and what clinical records are required to achieve the desired end results. This article will provide a concise checklist for clinical records and Rx instructions for the lab. The basic design considerations will be covered; however, there is no such thing as a benign occlusion appliance. Any change to occlusion can affect the TMJ, head/neck muscles, and even the airway. By following some basic design rules you can safely and effectively deliver an occlusal guard on asymptomatic patients.
What You Will Learn In This Article
What are desirable occlusal guard designs
Basic design considerations
Why consider an occlusal guard as a treatment
Purposes of occlusal guards
Types of occlusal guards
Recommended designs
Appliances to consider using
Occlusal therapy is both an art and a science.
Every "Night Guard" should be regarded as a form of occlusal therapy. We must remember that any alteration of occlusion affects the entire mastication system and has potential effects on overall health. One size fits all does not exist!
Occlusal therapy is both an art and a science. Many patients will adapt and tolerate virtually anything you put in their mouth. However, on many other patients, you may have to use a series of appliances to discover that patient's specific appliance formula. This can be a diagnostic process.
Basic Design Principles
On Which The Majority of Clinicians Agree
- Occlusal Guards should be fabricated on a flat plane occlusion with minimal interferences.
- No posterior function - at most, light contact at rest and immediate disclusion in lateral.
Options that some clinicians prefer:
- Anterior glide plane - parallel to the occlusal plane - Kois Deprogrammer
- Maxillary Lingual ramp to restrict lingual movement of mandible - BiteSoft
- "Cuspid guidance" - to facilitate posterior disclusion - Ruiz
Why consider an occlusal guard as a treatment?
It is estimated that nearly one-third of people in North America are bruxers and clenchers. The forces generated during bruxism can be as much as six times the maximal force generated by normal chewing. Signs or symptoms of bruxism should be countered with a nocturnal CR-balanced splint prior to and after any restorative intervention.
Purposes of Occlusal Guards Include:
- Protect new ceramic restorations like porcelain veneers.
- Intercept or prevent damage caused by bruxism.
- Treat TMD
(The purpose of this article is only to address "protective" occlusal guards. We will address the treatment of symptomatic TMD and Sleep Apnea in later articles. You should consider screening for sleep apnea and TMD. If patients present with symptoms of these conditions, they will require an advanced approach and may require the involvement of a medical professional in order to fully diagnose and treat.)
Types of Occlusal Guards
Clinical Records Required
Recommended - Use a deprogrammer in order to take a CR Bite; Use Lucia Jig
Take a bite in CR Relationship
Use leaf gauge (see image below), Lucia Jig or cotton roll seat in their most anterior-superior position (CR).
With the patient in this open centric relation, inject bite registration into the posterior and anterior openings.
Construction bite
Vertical opening to where you want the final appliance made - (3-6 mm anterior open bite, 1-2 mm posterior)
Impression
Accurate, void-free impression of both arches. For a precise fit, ensure that no tears or bubbles are present in the impression material. Alginate replacement PVS is recommended as it allows the lab to make duplicate models for verification of fit. Increase accuracy by using light body PVS on the occlusal surfaces to capture more details.
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Recommended Designs
Facilitates condyles seating in their most anterior-superior position (that is centric relation (CR).
Anterior Glide plane table - Smooth occlusal surface removes sensory feedback from interfering with tooth contacts and allows elevator muscles to move the mandible so that the condyles can slide posteriorly for complete seating in CR.
The guard should not have any occlusal or cuspal indentations into which opposing teeth can lock and exert heavy lateral or thrusting forces.
Provides posterior disclusion ("canine guidance") NO posterior contact in excursions.
Maxillary guards are preferred as they are better tolerated, more stable, avoid crowding the tongue, and achieve occlusal contact with all opposing teeth regardless of the maxillomandibular relationship.
Posterior open 1.2 to 2 mm. - anterior open 3-6 mm. (May need to be more in symptomatic patients.)
Optimal Designs
Maxillary anterior repositioning ramp, to minimize the possibility of the mandible moving lingual and restricting the airway.
Appliances for Consideration
Kois Deprogrammer (no posterior occlusion, anterior glide plane)
Ruiz Golden Rule Night Guard (equal occlusal contact spots, canine guidance - posterior disclusion in excursive)
BiteSoft® - (with lingual ramp & anterior glide plane)
Occlusal guards are very important considerations for restorative and cosmetic treatment plans. A very high percentage of patients have some sort of para-functional activity. A well-designed occlusal guard can facilitate a longer life for restorations and reduce the probability of future bruxism-related occlusal disease.
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