A Common-sense Approach to Splint Therapy

INTRODUCTION

Practitioners appreciate a practical approach to allaspects of treatment; splint therapy is no exception.The purpose of this article is to review the currentunderstanding of how splints work, describe varioussplint types and their uses, and suggest how to ensuretheir proper design, fabrication, and adjustment.

Splint therapy may be defined as the art and scienceof establishing neuromuscular harmony in the mastica-tory system and creating a mechanical disadvantage forparafunctional forces with removable appliances. Aproperly constructed splint supports a harmoniousrelation among the muscles of mastication, disk assem-blies, joints, ligaments, bones, teeth, and tendons.

SPLINT TYPES AND FUNCTIONS

All splints are classified as either permissive or non-permissive. A permissive splint1 allows the teeth tomove on the splint unimpeded, which in turn allowsthe condylar head and disk to function anatomically.A nonpermissive splint has a ramp or “indentations”that position the mandible inferiorly and anteriorlyand secure it there. Examples of permissive splintsinclude bite planes (anterior jigs, Lucia jig, anteriordeprogrammer) (Fig. 1) and stabilization splints (flatplane, Tanner, superior repositioning, and centricrelation [CR]) (Fig. 2). An example of a nonpermis-sive splint is a repositioning splint (anteriorrepositioning appliance [ARA]) (Fig. 3). Soft splintsand hydrostatic splints (Aquilizer; Jumar Corp,Carefree, Ariz.) could be considered pseudo-permis-sive splints, as their functions are extremely differentthan those of the permissives.

Properly fabricated splints have at least 6 functions,including the following: (1) to relax the muscles, (2)to allow the condyle to seat in CR, (3) to provide diag-nostic information, (4) to protect teeth and associatedstructures from bruxism, (5) to mitigate periodontalligament proprioception, and (6) to reduce cellularhypoxia levels.

Relaxing the muscles

It has been well documented that tooth interfer-ences to the CR arc of closure hyperactivate the lateralpterygoid muscle2; posterior tooth interferences duringexcursive mandibular movements cause hyperactivity ofthe closing muscles3; and the elimination of posteriorexcursive contacts by anterior guidance significantly

A common-sense approach to splint therapy

Tim J. Dylina, DDSa

Merced, Calif.

Splint therapy is a proven modality for alleviating the pain of many types of temporomandibulardisorders and bruxism, though questions still remain regarding how splints work. In this article, areview of the literature is used to determine an effective splint design for the different degrees oftemporomandibular problems. Sufficient credible literature exists to help provide an understand-ing of and a treatment protocol for the use of splints for temporomandibular disorders andbruxism problems. (J Prosthet Dent 2001;86:539-45.)

aPrivate practice.

NOVEMBER 2001 THE JOURNAL OF PROSTHETIC DENTISTRY 539

Fig. 1. Anterior deprogrammer to separate posterior teethwith smooth function on anterior teeth.

Fig. 2. Occlusal view of mandibular stabilization appliance.

reduces elevator muscle hyperactivity.4 It follows that asplint with equal-intensity contacts on all of the teeth,with immediate disclusion of all posterior teeth by theanterior teeth and condylar guidance in all movements,will relax the elevator and positioning muscles. The neu-romuscular harmony that follows provides optimalfunction and predictability to the system. The splint maybe thought of as an exquisitely balanced arch of teeththat must function in a similar manner. The literaturereveals that very small (50 µm) occlusal interferencescan cause changes in coordinated muscle activity.5 Themore balanced and frictionless the splint, the better theopportunity for reducing muscle hyperactivity. A musclethat is fatigued through ongoing muscle hyperactivitycan present with pain. If the hyperactivity is stopped, thepain caused by this activity usually will disappear.6

Occlusal splints are a means of reversibly altering theocclusion to reduce masticatory muscle activity. Fuchs7

reported the advantages of splint therapy in the reduc-tion of nocturnal EMG masseter activity in patientswith temporomandibular disorder (TMD). Beard andClayton8 also reported reductions in muscle symptomswith splint therapy. Okeson et al9 found that acute or

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chronic symptoms of muscle hyperactivity were less-ened significantly with 24-hour splint wear. Theeffectiveness of splint therapy in reducing pain indexesand muscle hyperactivity is well documented.10-13

Allowing the condyle to seat in centricrelation

No report on splints would be complete without anunderstanding of the role of CR to the healthy sto-matognathic system. The Glossary of ProsthodonticTerms defines centric relation as “A clinically deter-mined relationship of the mandible to the maxillawhen the condyle disk assemblies are positioned intheir most superior position in the mandibular fossaeand against the distal slope of the articular emi-nence.”14

For the condyle to completely seat under the disk inthis anterosuperior position, the lateral pterygoid mustcompletely relax because of its attachment to the diskthrough the superior belly. If this muscle stays contract-ed after hyperactivity, the disk will be pulledanteromedially (along the direction of the muscle origin)and will not seat completely over the condyle. When thedisk is loaded in a power bite or through parafunctionalactivities, the disk, attached muscle, condylar head,condylar ligaments, and retrodiscal tissues can sustainexcess force loads and be damaged if the condyle/diskassembly is not properly related to the fossa. Chronic andacute overloading of the condyle/disk assembly when itis out of its normal physiologic position contributesgreatly to the catch-all term temporomandibular disorder.Temporomandibular joints are load bearing15-17 andsusceptible to overload. When splints were placed inmonkeys in one study, a lateral deviation from the CRarc of closure resulted, as did bone density changes inthe condyles that were not found when CR splints wereused.18 This has led to cartilage breakdown and arthri-tis in the condylar heads.19

Centric relation is the optimal arrangement of joint,disk, and muscle. A person can function if the arrange-ment is anterior to this position, but the condyle anddisk must be allowed by the dentition to return unim-peded to perform their load-bearing function. Thisposition is consistently repeatable because of theboney stop for the condyle/disk assembly as thecondyle hinges on its axis through the medial pole. Itis not muscle braced as would be the case if thecondyle/disk were down and forward against thearticular eminence. To maintain a mechanical advan-tage, maximal clenching must be performed in thisposition. Splint therapy must use CR as the ultimatetreatment position except in situations where inflam-mation of the joint makes this position uncomfortable.The patient may use his/her anteroinferior condylarposition until the inflammation subsides (approxi-mately 7 days) and be reintroduced to the CR position

A

Fig. 3. A, Repositioning appliance locking condyle intoanteroinferior position. B, Occlusal view of appliance withindentations in acrylic.

B

before permanent changes in the muscle, disk, or sup-porting tissues take place.

Providing diagnostic information

Splint therapy can be an important diagnostic tool todetermine wear patterns, bruxism habits, and TMD sta-tus. Wear patterns that exist on the splint arereintroduced into the natural dentition when the splintis not worn. A horizontal “grazing” pattern would indi-cate a different occlusal scheme than a vertical“chopping” bite. Bruxism habits also leave their markon the surface of the hard acrylic resin splints. In a studyby Holmgren et al,20 indentations indicated isometricclenching in 13% of subjects, bilateral mandibularclenching in 71%, unilateral excursion in 13%, and pro-trusive movements in 3%. Information gained fromwear patterns on splints helps determine occlusal con-figurations, material choice, cusp heights and shapes,guidance angulations, axial loads, the envelope of func-tion, and the neutral zone (Fig. 4).

The anatomic and physiologic status of the joint alsocan be evaluated in part by splint wear. If a patientrapidly becomes comfortable with a splint, it may be anindication that the disorder is muscular. If symptomsworsen with permissive splint wear, this may indicate aninternal derangement (disk) problem (perhaps causedby free reign of the condylar head back to the retrodis-cal tissues without housing by the disk) or an error inthe initial diagnosis. In and of itself, this informationhas limitations. However, with a thorough TMD andocclusal examination, such information can be aninvaluable piece of the diagnostic puzzle.

Protecting teeth and associated structuresfrom bruxism

A CR–balanced nocturnal permissive splint can pro-tect teeth from extensive wear caused byparafunctional activity (bruxism). Studies suggest thatbruxism exists in 6.5% to 88% of the population.21

Gibbs et al22 found that the highest recorded biteforce during bruxism was 975 lbs. and that bitestrength in some bruxer-clenchers can be as much as 6times that of the nonbruxer. The average maximumbiting force measured during clenching is 162 lbs.23

This data indicates why the forces generated duringnight activity can destroy the dentition. A splint notbalanced in CR will show increased localized wear(usually in the posterior of the splint) (Fig. 5). Thesleeper’s attempt to get to CR (the most superiorbone-braced position) with the help of the elevatormuscles is interrupted by the splint.

Holmgren et al20 have shown that splints do not stopbruxism but do redistribute the load borne by the teethand masticatory system. Their study duplicated the find-ings of Gentz24 and Kydd and Daly.25 Piper26

recommended using a 12- to 15-mm-thick splint (incisal

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NOVEMBER 2001 541

edge to incisal edge) to decrease clenching efficiency. Athick splint should be considered for chronic bruxerswith morning muscle pains (Fig. 6). Studies of pos-tural position11 tend to support Piper’s contention.

Fig. 4. Centric indentations and lateral excursive indents onsplint in mouth less than 1 week.

Fig. 5. Heavier wear on posterior of splint. Marker used forvisualization.

Fig. 6. Thick splint used to decrease muscle strength duringbruxism.

Mitigating periodontal ligamentproprioception

Proprioceptive fibers contained in the periodontalligaments of each tooth send nerve messages to thecentral nervous system. They indicate the amount offorce on individual teeth and can trigger muscle pat-terns to protect teeth from overload. A splint canbalance proprioception and even lessen it to mitigateproprioceptive output. Hellsing27 has shown experi-mentally how muscle changes immediately with toothcontact and that periodontal afferent feedback (propri-oception) must be responsible for this rapid adaptation.Hannam et al28 also found that in cats, stimulation ofpressure receptors in the periodontal membrane led toa jaw-opening reflex. This helps clarify why the teethmust be kept in balance with the condyle/disk assem-bly to maintain neuromuscular harmony in theassociated muscles.

Reducing cellular hypoxia levels

In a study by Nitzan,29 pressure was measured inthe superior joint space of patients with articular diskdisplacements. When they clenched maximally, record-ed pressures reached up to 200 mm Hg. When a flatplane appliance was placed, no significant pressure (nocapillary hyperfusion pressure) was recorded. Thislends credence to stabilization splint therapy from amolecular point of view.

SPLINT CHARACTERISTICS

The characteristics of a successful splint shouldinclude stability; balance in CR; equal intensity stopson all teeth; immediate posterior disclusion; a “skatingrink” surface; smooth transitions in lateral, protrusive,and extended lateral excursions (crossover); comfortduring wear; and reasonable esthetics. Patient compli-ance also contributes to splint success.

A splint that moves in the mouth cannot providethe stability necessary for a definitive, immobile sur-face prepared for heavy forces from all directions. Thelaboratory must fabricate a splint so that it comes onand off with a slight undercut to ensure a firm fit. Thepatient should feel no sense of tightness on any of theteeth when the splint is seated; if that is not the case,tooth hypersensitivity usually will follow. The length ofthe splint on the lingual and buccal is dependent onthe need for retention as a result of tooth size andshape. The shorter and thinner the splint is on the lin-gual, the better the patient compliance, the moredistinct the speech, and the more comfortable thetongue posture will be. The buccal flanges must bethick enough to be strong but not impinge on theneutral zones. Thinness can create discomfort or lip“trapping.”

Fabrication in a hard, heat-polymerized acrylic

resin will facilitate the establishment and adjustmentof contact points. Orthodontic acrylic resin is user-friendly, easy to adjust, and soft enough not tohyperactivate periodontal ligaments. It also can bepolished to a high luster for a low-friction surface.Methyl methacrylates are relatively easy to work withbut maintain a strong odor and exhibit a granularcomposition that is harder to polish and adjust. Thesoft rubber resilient materials used for sports guardspossess none of the characteristics important tosplint therapy and have no effective use in this arena.The literature has shown that they may even increasebruxism.30 Hydrostatic “pseudo” splints work toseparate the teeth and reduce muscle hyperactivityfor short periods while full-coverage splints arebeing fabricated. Long-term use of the former is notrecommended. Ultra splint resin (Astron DentalProducts, Lake Zurich, Ill.) is suggested for patientswith allergies to orthodontic acrylic resins.

The laboratory needs explicit instructions for thefabrication of any intraoral appliance. Maxillary andmandibular appliances have completely differentdesigns, though they function the same. All teethcontact in CR on a maxillary appliance. A mandibu-lar appliance often will have cuspid-to-cuspidcontact in CR, with the maxillary anterior teeth nottouching. Many TMD patients have a significanthorizontal overlap; to extend the mandibular acrylicresin to contact the maxillary teeth would beunsightly, physically uncomfortable, and unneces-sary. Since the oral cavity is a dynamic system andthe movement of the jaw is nearly always forward,the anterior teeth will be in constant contact with the splint. This area must be balanced by hav-ing the patient move in protrusive, lateral, andmediolateral movements, marking the areas, andestablishing anterior guidance principles alreadymentioned.

Mandibular appliances are the popular choice foractive patients who wear splints 24 hours per day, asthey do not show or affect speech as much as maxil-lary appliances. On the other hand, the maxillaryappliance is an attractive choice for night wear, as allof the teeth are in contact with equal intensity, andthe 13% of the population that bruxes isometricallywill have these forces more equally balanced. Otherreasons for the choice of one arch over the otherinclude arch irregularities, the patient’s profession,and the potential for gagging. It is appropriate forthe patient to have a mandibular appliance for daywear and a maxillary appliance for the night (Fig. 7).

Twenty-four–hour splint wear is recommendedbecause of the forces generated when teeth cometogether during swallowing and chewing.Swallowing forces exceed chewing forces,23 occurapproximately 2000 times per day, and happen all



day. If possible, the splint should be worn when thepatient eats.

Anterior repositioning splints were originallydesigned to “recapture” the disks by protruding themandibular jaw forward until the condyle poppedback on the disk and “locked” it into position.Although the disk may have been temporarily betteraligned with the condyle out of the fossa, the physi-ologic parameters necessary for the functioning ofthe lateral pterygoids and the retrodiscal tissues (vas-cular knee) were not addressed. Clark31 found goodclinical success with this modality, and Anderson etal32 even suggested its superiority to flat plane appli-ances. Longer studies by Lundh and Westesson33

have shown that the clicking that initially stoppedwith these appliances returned in a large percentageof the patients, which indicates that the intendedfunction of anterior repositioning splints was notaccomplished. In patients who did not experiencefurther clicking, the disk may have been permanent-ly pushed out to the side on the lateral pole insteadof recapturing the disk.

Success in alleviating pain with these appliances canbe impressive, but it also can be explained. If the jawis brought down and forward, the condyle will notimpinge on the inflamed retrodiscal tissues, which area major source of pain. Anterior repositioning splintsmay be a valid treatment for short-term use (no morethan 10 days) in trauma cases when stabilization splintstend to increase pain by allowing the condyle freeaccess to inflamed tissues in the retrodiscal area.However, anterior repositioning splints tend to intro-duce posterior open bites in long-term wearers (whenthe appliance does not cover the anterior teeth), andheroic orthodontics or restorative dentistry is requiredto close the teeth into their new anteroinferior muscle-braced position (Fig. 8). One would have to discountthe anatomic and physiologic principles of the masti-catory system to believe that an anterior repositioningappliance should be a standard modality for TMD dis-orders of any kind (other than acute short-termtrauma).

CHOOSING THE CORRECT SPLINT

Determination of the appropriate type of splint therapydepends on the specific diagnosis of the temporo-mandibular disorder and a thorough understanding of theanatomy of the condyle/disk complex.

Muscle incoordination is determined by muscle pal-pation, joint loading, range-of-motion measurements,joint palpation, occlusal evaluation, and Dopplerdiagnosis. Patients present with painful symptoms inthe facial muscles, headaches, limited ranges ofmotion, frequent joint inflammation, and occlusalinterferences to CR; infrequent clicking on jaw move-ment also may be present. This anatomic asymmetry

is reversible if caught in time and treated with biteplane therapy or permissive splint therapy in Phase I(reversible treatment) and with appropriate Phase IItherapy (additive or subtractive occlusal therapy,restorative dentistry, orthodontics, maxillofacialsurgery, and segmental alveolar surgery) to restorebalance from/to the CR position.


NOVEMBER 2001 543

Fig. 7. A, Maxillary stabilization appliance for night wear.B, Mandibular splint for day wear.

A

B

Fig. 8. Posterior open occlusion developed after anteriorrepositioning appliance was worn for 7 years.

Muscle and disk incoordination has the same signsand symptoms as muscle incoordination except recip-rocal clicking or a history of reciprocal clicking thatstops. Diagnosis may include sagittally correctedtomograms. Patients often present with the medialpole of the condyle intact under the disk with the lat-eral pole of the disk damaged from loading orstretching and subsequent ligament laxity. Most symp-toms may be reversible if caught in time, though thereversibility of clicking depends on the shape of thedistorted disk and the fibrosis of the lateral pterygoidmuscle. Treatment usually includes permissive splinttherapy and Phase II therapy for stabilization becauseof the weak ligament structure.

With advanced muscle and disk incoordination,symptoms may be the same as in previous stages,though jaw locking, painful joint noises, and increasesin pain with splint therapy may be evident. Thesepatients often have a long history of joint noises with-out pain that have become painful. Pain on loadingwith bimanual manipulation is evident and may beextreme. Diagnostic techniques include sagittally cor-rected tomograms and magnetic resonance images.Surgical intervention may be necessary depending onthe location and degree of displacement of the disk.These stages are irreversible but may be managed to apain-free state with appropriate medications, splinttherapy, and Phase II therapy.

SPLINT DESIGN WITH FUNCTIONALCONSIDERATIONS

Understanding the function of the masticatory sys-tem provides an excellent basis for splint design. A setof teeth (the splint) is needed that has equal intensitycontact on all the teeth, provides immediate posteriordisclusion by the anterior teeth and condylar guidance,and is as frictionless as possible for neuromuscular har-mony and subsequent healing. The stabilization splintmeets these needs.1 It can be placed on either arch aslong as the basic requirements are met. The splintmust allow the condyle to achieve the CR position.This can be achieved with bimanual manipulation,which was fostered by Dawson34 and has proven to bethe most reliable and repeatable35 method for achiev-ing CR with inexperienced practitioners.

A stabilization splint is not unique if the teethand/or inflammation result in an incomplete condylarseating. The splint could be considered a set of teethwith occlusal interferences. Therefore, the splint mustbe continually monitored and adjusted. When themuscle relaxes and/or inflammation subsides, theposition of the teeth on the splint changes. Whenreadjustment on the splint to the CR position isaccomplished, the teeth and condyle/disk assemblyachieve neuromuscular harmony. This explains whypatients feel some initial relief from almost anything

put in their mouths yet stop improving after the initial1 to 2 weeks. If the interferences on the splint are con-tinually chased by rebalancing into CR, the patient willgrow comfortable and stay that way. The more skilledthe practitioner becomes with this balance and timing,the more rapidly the patient can progress. The tech-nique inevitably works; however, lack of attention todetail or the skill level of the doctor may influence suc-cess.

In a study by Holmgren et al,20 changes were seenon the splint (in the form of indents) in 61% ofpatients at every 2-week evaluation. The remaining39% of the patient pool experienced changes fromtime to time. The majority of splint wearers need to beseen more often than every 2 weeks for initial adjust-ments. A suggested protocol would include adjustmentsat 24 hours, 54 hours, 7 days, 2 weeks, and 1 monthafter seating. When no movement on the splint is seenat adjustment appointments and symptoms arereduced, the intervals between adjustments can beextended as long as any reversal of symptoms is coun-tered with an immediate adjustment appointment.After 3 months with no changes on the splint, a com-fortable musculature, and no pain on loading, thepatient is ready for evaluation of phase II therapy.

SPLINT FABRICATION

Practitioners beginning a career in treating bruxersor TMD patients may become frustrated while tryingto seat a new splint in a reasonable period of time.Laboratories often provide a prosthesis from a maxi-mum intercuspation (MI) occlusion that presents highon the distal of the splint and ends up having a holeground all the way through the acrylic resin in anattempt to balance the occlusal relation. Without anaccurate CR occlusal record, accurate models of alloccluding surfaces, and a reliable face-bow transfer,seating time will be longer and occasionally impossiblebecause of excessive or inadequate acrylic resin. Withprecise laboratory instruction and records, seating andadjusting should take no longer than 10 minutes. In-house fabrication allows the practitioner to quickly andefficiently develop the prosthesis that the diagnosisdemands. If this is not possible, precise communica-tion with a commercial dental laboratory is necessaryto provide the quality prosthesis mandatory for treat-ment success.

WHAT SPLINTS CANNOT DO

Splints cannot do 3 basic things: unload the joint,prevent bruxism, or “heal” the patient. Some authorsand lecturers have stated that splints function tounload the joints and therefore take pressure off thedisk. This theory has been disproved by Kuboki et al36

and cannot be explained anatomically or physiological-ly. The elevator muscles are located behind the most



posterior tooth and therefore ensure that the joint willalways be loaded when the elevators contract. Theunloading theory is probably used to protect the valid-ity of splint designs that are ineffective in theirtheorized function. Such splints open the verticaldimension and minimally decompress the condylarhead when not loaded to reduce superior tissue pres-sures. They also may increase temporomandibularjoint loading37 that results from greater maximummuscle efficiency.

Splints do not prevent bruxism; they balance theforce distribution to the entire masticatory system.They can decrease the frequency but not the intensityof bruxing episodes.20 Splints also do not healpatients; they give patients the opportunity to healthemselves. The patient pays not for the fabrication ofa splint only but also for the care, skill, and judgmentof the practitioner whose goal is to enable healingthrough appropriate design, monitoring, and adjust-ment.

SUMMARY

There is sufficient credible literature to support theuse of splint therapy to reinstitute neuromuscular har-mony in a compromised masticatory system. Dentalpractitioners have a responsibility to understand andprovide this treatment, monitor the condition, andrefer the patient to another practitioner if necessary.

REFERENCES

1. Boero RP. The physiology of splint therapy: a literature review. AngleOrthod 1989;59:165-80.

2. Ramford S, Ash M. Occlusion. 3rd ed. Philadelphia: WB Saunders Co;1983.

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4. Williamson EH, Lundquist DO. Anterior guidance: its effect on elec-tromyographic activity of the temporal and masseter muscles. J ProsthetDent 1983;49:816-23.

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6. Mao J, Stein RB, Osborn JW. Fatigue in human jaw muscles: a review. JOrofac Pain 1993;7:135-42.

7. Fuchs P. The muscular activity of the chewing apparatus during nightsleep. An examination of healthy subjects and patients with functionaldisturbances. J Oral Rehabil 1975;2:35-48.

8. Beard CC, Clayton JA. Effects of occlusal splint therapy on TMJ dysfunc-tion. J Prosthet Dent 1980;44:324-35.

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10. Manns A, Miralles R, and Guerrero F. The changes in electrical activityof the postural muscles of the mandible upon varying the vertical dimen-sion. J Prosthet Dent 1981;45:438-45.

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13. Sheikholeslam A, Holmgren K, Riise, C. A clinical and electromyo-graphic study of long-term effects of an occlusal splint on the temporaland masseter muscles in patients with functional disorders and noctur-nal bruxism. J Oral Rehabil 1986;13:137-45.

14. The glossary of prosthodontic terms. J Prosthet Dent 1999;81:39-110.15. Boyd RL, Gibbs CH, Mahan PE, Richmond AF, Laskin JL. Temporomandibular

joint forces measured at the condyle of the Macaca arctoides. Am JOrthod Dentofacial Orthop 1990;97:472-9.

16. Hekneby M. The load of the temporomandibular joint: physical calcula-tions and analyses. J Prosthet Dent 1974;31:303-12.

17. Korioth TW, Hannam AG. Mandibular forces during simulated toothclenching. J Orofac Pain 1994;8:178-89.

18. Curtis DA, Nielsen I, Kapila S, Miller AJ. Adaptability of the adult primatecraniofacial complex to asymmetrical lateral forces. Am J OrthodDentofacial Orthop 1991;100:266-73.

19. Radin EL, Paul IL, Rose RM. Role of mechanical factors in pathogenesisof primary osteoarthritis. Lancet 1972;1:519-22.

20. Holmgren K, Sheikholeslam A, Riise C. Effect of a full-arch maxillaryocclusal splint on parafunctional activity during sleep in patients withnocturnal bruxism and signs and symptoms of craniomandibular disor-ders. J Prosthet Dent 1993;69:293-7.

21. Faulkner, KD. Bruxism: a review of the literature. Part I. Aust Dent J1990;35:266-76.

22. Gibbs CH, Mahan PE, Mauderli A, Lundeen HC, Walsh EK. Limits ofhuman bite strength. J Prosthet Dent 1986;56:226-9.

23. Gibbs CH, Mahan PE, Lundeen HC, Brehnan K, Walsh EK, HolbrookWB. Occlusal forces during chewing and swallowing as measured bysound transmission. J Prosthet Dent 1981;46:443-9.

24. Gentz R. Apparatus for recording of bruxism during sleep. Sven TandlakTidskr 1972;65:327-42.

25. Kydd WL, Daly C. Duration of nocturnal tooth contacts during bruxing.J Prosthet Dent 1985;53:717-21.

26. Piper M. Manual for intermediate to advanced TMD treatment. St.Petersburg (FL): Center for Advanced Dental Study; 1999. p. 1-17.

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34. Dawson P. Evaluation, diagnosis and treatment of occlusal problems.2nd ed. St. Louis (MO): Mosby; 1989. p. 41-6.

35. McKee JR. Comparing condylar position repeatability for standardizedversus nonstandardized methods of achieving centric relation. J ProsthetDent 1997;77:280-4.

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37. Manns A, Miralles R, Palazzi C. EMG, bite force, and elongation of themasseter muscle under isometric voluntary contractions and variationsof vertical dimension. J Prosthet Dent 1979;42:674-82.

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A Common-sense Approach to Splint Therapy