Occlusal Splints Used in Prosthetic Management of TMJ Disorders

Seminar - IVOcclusal Splints Used in Prosthetic Management of TMJ Disorders CONTENTS  INTRODUCTION  DEFINITION  PURPOSE  WHAT OCCLUSAL SPLINTS CAN DO? AND CANNOT DO? VARIOUS UNEXPLAINED THERAPEUTIC CLAIMS  CLASSIFICATION  GENERAL CONSIDERATIONS  MUSCLE RELAXATION APPLIANCE  ANTERIOR REPOSITIONING APPLIANCE  ANTERIOR BITE PLANE  POSTERIOR BITE PLANE  PIVOTING APPLIANCE  SOFT/ RESILIENT APPLIANCE  RELATED ARTICLES  SUMMARY DEPT. OF PROSTHODONTICS 114 Seminar - IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders  BIBLIOGRAPHY DEPT. OF PROSTHODONTICS 115 They shown considerable control in myofacial pain. intra-oral arthotic. however no clear hypothesis about the mechanism of action has been proved. for example.Seminar . DEFINITIONS Temporomandibular joint: DEPT. night guard. It has more of diagnostic value. It is commonly referred to as a bite guard. usually made of hard acrylic. that fits over the occlusal and incisal surfaces of teeth in one arch. creating precise occlusal contact with the teeth of opposing arch. So it serves as an important diagnostic value before going to an fixed prosthodontic therapy. OF PROSTHODONTICS 116 . if a patient responds favorable to an occlusal device then the response to the same restorative permanent treatment should be positive.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders OCCLUSAL SPLINTS USED IN PROSTHETIC MANAGEMENT OF TMJ DISORDERS INTRODUCTION: An occlusal appliance (often called a splint) is a removable device. inter occlusal appliances. These are extensively used in management of TMJ disorders. or even orthopaedic device. The joint connects the mandibular condyle to the articular fossa of the temporal bone with the temporomandibular disc interposed. incomplete.Seminar .” Occlusal Pivot: “An elevation placed on the occlusal surface. designed to act as a fulcrum. usually in the molar region. thus limiting mandibular closure and inducing mandibular rotation”. OF PROSTHODONTICS 117 . It may be used for occlusal stabilization. whereas in the lower joint compartment is mostly rotational. or to prevent wear of the dentition. movement in upper joint compartment is mostly translational. or impaired function of TMJ”. Occlusal Splint/ Occlusal Device/ Orthotics: “Any removable artificial occlusal surface used for diagnosis or therapy affecting the relationship of the mandible to the maxillae. for treatment of TMJ disorders. bilateral ginglymus arthroidal joint.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders The articulation between the temporal bone and the mandible. The articulation of the condylar process of the mandible and the interarticular disk with the mandibular fossa of the squmous portion of temporal bone. Temporomandibular Disorders: “Abnormal. It is a diarthroidal. Occlusal Prematurity: DEPT. WHAT OCCLUSAL SPLINTS CAN DO? 1. The purpose of occlusal splints is to provide an indirect method for altering the occlusion until the correctness of the condylar axis position can be determined and confirmed. 2. Distribution of occlusal forces 3. in other than chewing movements of mandible.Seminar . Stabilization of weak teeth: An occlusal splint can effectively stabilize weak or hypermobile teeth by the adaptation of the splint material around the axial surfaces. “An oral habit consisting of involuntary rhythmic or spasmodic non-functional gnashing.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders “Any contact of opposing teeth that occurs before the planned articulation”. Bruxism/ Tooth Grinding/ Occlusal Neurosis: “The parafunctional grinding of teeth”. PURPOSE: The purpose of occlusal treatment is to make the teeth conform to a correct skeleton-related position of the condylar axis. OF PROSTHODONTICS 118 . grinding or clenching of teeth. which may lead to occlusal trauma”. Reduction of wear DEPT. Seminar . Occlusal splints can cause a ‘purging of system poisons’ 4. and clinical data.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders 4. Stabilization of unopposed teeth WHAT OCCLUSAL SPLINTS CANNOT DO? Occlusal splints cannot cause effects that are in violation of mechanical laws. Thus an occlusal splint does not unload the condyles. The popular claim that a posterior occlusal splint serves as a pivot for distraction of the condyles is in violation of facts of anatomy. Occlusal splints increase the wearer’s strength 2. Occlusal splints cause remission of unrelated diseases 3. OF PROSTHODONTICS 119 . laws of physics. TYPES: According to Okeson 1) Muscle relaxation appliance/ stabilization appliance used to reduce muscle activity 2) Anterior repositioning appliances/ orthopedic repositioning appliance DEPT. VARIOUS UNEXPLAINED THERAPEUTIC CLAIMS: 1. Occlusal splints cause a ‘regulation of multiple bodily functions’. The condyles are then allowed to return to their correct seated position in centric relation if the condition of the articular components permits. OF PROSTHODONTICS 120 . A directive splint Permissive Splints: Are designed to unlock the occlusion to remove deviating tooth inclines from contact. Permissive splints/ muscle deprogrammer 2.g Soft splints. A permissive splint or 2.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders Other types: a) Anterior bite plane b) Pivoting appliance c) Soft/ resilient appliance According to Dawson: 1. A properly made centric relation occlusal splint is a permissive splint. Hydrostatic splint) MORA – mandibular orthopedic repositioning appliance Types of Occlusal Splints: 1.Seminar . Permissive splints are often referred to as muscle deprogrammers. Directive splints/ non-permissive splints 3. Pseudo permissive splints (e. DEPT. The condyle and the disk can be aligned correctly. Load testing the joints with bilateral pressure DEPT. The correctly aligned condyle-disk assemblies can move to the most superior position against the eminentiae without derangement.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders If a centric relation splint is made with deep fossae and inclines that are too steep.Seminar . 3. Directive splints: Are designed to position the mandible in a specific relationship to the maxilla. Contraindications for Directive Splints: 1. The sole purpose of a directive splint is to position or align the condyle-disk assemblies. OF PROSTHODONTICS 121 . Verification that the condyle-disk assemblies are capable of normal function in the most superior position can be achieved on a tentative basis by testing in the following manner: 1. The disks can maintain their alignment with the condyles during function. it can be turned into a directive splint that limit condylar access to centric relation only. 2. Thus directive splints should be used only when a specifically directed position of the condyles is required. Doppler auscultation Superior Repositioning Splints: The purpose of anterior repositioning therapy is fulfilled when the retrodiskal tissues have healed sufficiently to regain a backward pull on the disk. either the condyle or the disk may have difficulty moving back to centric relation after being held forward. OF PROSTHODONTICS 122 . you can eliminate the reflex and the mandible can have free access to the seated position.Seminar . However.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders 2. There is reason to suspect that the inferior lateral pterygoid muscle is shortened by long-term use of anterior repositioning devices. Clench testing with the teeth separated 3. The goal is a true skeletal relationship of the mandible to the maxilla and not one that is influenced by the maximum DEPT. Deformity of the displaced disk may also require time to adaptively remodel to a stable contour. The purpose of a superior repositioning splint is to eliminate the effect of the neuromuscular reflex that directs the mandible to close repetitively into the maximum intercuspation position. By covering the occlusal surfaces with plastic to provide a smooth surface. This makes it more difficult for the muscles to release the condyles to their most superior position. Even when the disk will not be released all the way to centric relation. It is especially important that the anterior guidance on the splint must disclude all posterior teeth in all jaw positions except centric relation.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders intercuspation of the teeth. It offers an alternative when the disk cannot stay aligned and the patient elects against reparative surgery. Prolonged anterior disk displacement often results in shortening of the superior lateral pterygoid muscle.Seminar . the superior repositioning splint may be beneficial. OF PROSTHODONTICS 123 . The purpose of the superior repositioning splint is to establish the correct skeletal relationship before the correct occlusal relationship is determined. The determining factors appear to be related to the amount of deformity of the recaptured disk. It may occur in a few days. GENERAL CONSIDERATIONS: DEPT. or it may take several months. and the condition of the inferior and superior bellies of the lateral pterygoid muscles. which controls the alignment of the disk. The fabrication of a superior repositioning splint is identical to the centric relation splint. The time required to achieve superior positioning of the condyle-disk assembly varies from patient to patient. Tanner (mandibular).Seminar . Superior repositioning Muscle Deprogramming. the condyles are in their most DEPT. Share (maxillary).IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders Appliance therapy has several favorable qualities that render it extremely helpful for the treatment of many TM disorders. When it is in place. When a malocclusion is suspected of contributing to a TM disorder. The success or failure of occlusal appliance therapy depends on the selection. and adjustment of the appliance and on patient cooperation. An appliance can affect a patient’s symptoms in several ways. Occlusal appliances are equally helpful in ruling out certain etiologic factors. occlusal appliance therapy can quickly and reversibly introduce a more desirable occlusal condition. OF PROSTHODONTICS 124 . fabrication. 1. They are a reversible non-invasive modality that can help manage the symptoms of many TM disorders. MUSCLE RELAXATION APPLIANCE/ Flat Plane. It is extremely important that when it reduces symptoms the precise cause-and-effect relationship be identified before irreversible therapy is begun. or CR Splint: Description and Treatment Goals: The muscle relaxation appliance is generally fabricated for the maxillary arch. Simplified fabrication technique: An alginate impression is made of the maxillary arch. clear resin sheet of material is adapted to the cast. Treatment goal eliminate any orthopedic instability between the occlusal position and the joint position.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders musculoskeletally stable position at the time that the teeth are contacting evenly and simultaneously. OF PROSTHODONTICS 125 . DEPT. Indications: 1) Treat muscle hyperactivity 2) Decrease the parafunctional activity 3) Bruxism 4) Local muscle soreness or myositis 5) Retrodiscitis secondary to trauma. The lingual border of the appliance extends 10 to 12 mm from the gingival border of the teeth throughout the lingual portion of the arch. Canine disocclusion of the posterior teeth during eccentric movement is also provided. With a pressure or vacuum adapter. The labial border of the appliance terminates between the incisal and middle thirds of the anterior teeth. 2-mm-thick hard.Seminar . The cut is made at the level of the interdental papilla on the buccal and labial surfaces of the teeth. It is poured immediately with a suitable gypsum product. The outline of the appliance is then cut off the cast with a separating disk. DEPT. If a distal inclination exists on the stop. clenching will force the mandible posteriorly away from the musculoskeletally stable position. away from the most musculoskeletally stable position. It is added to the occlusal surface of the anterior portion of the appliance. The contact on the anterior stop is marked with articulating paper and adjusted so it provides a stop that is perpendicular to the long axis of the mandibular tooth being contacted. In the other technique.Seminar . because the clenching will tend to reposition the condyle forward. This acrylic will act as the anterior stop. It is approximately 4 mm wide and should extend to the region where a mandibular anterior central incisor will contact. The anterior stop should not be mesially inclined and create a forward shift or slide of the mandible. Locating the musculoskeletally stable position: Bilateral manual manipulation technique. a stop is placed on the anterior region of the appliance and the muscles are used to locate the musculoskeletally stable position of the condyles. OF PROSTHODONTICS 126 .IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders A small amount of clear self-curing acrylic resin is mixed in a dappen dish. (This technique uses the same principles employed with the leafgauge). The mandibular teeth should sink into the soft acrylic until the incisors contact the anterior stop. The acrylic surrounding the pencil marks is removed so the relatively flat occlusal surface will allow eccentric freedom. The appliance is then returned to the mouth.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders Developing the Occlusion: When the CR position has been located. both anterior and posterior. and the patient either closes or is guided into CR. Adjusting the CR Contacts: The occlusal surface of the appliance is best adjusted by first marking the deepest area of each mandibular buccal cusp tip and incisal edge with a pencil. All contacts. The appliance is removed from the mouth and self-curing acrylic is added to the remaining anterior and posterior regions of the occlusal surface. should be carefully refined so they will occur on flat surfaces with equal occlusal force. Instructions are given to tap on the anterior stop.Seminar . OF PROSTHODONTICS 127 . the patient should become familiar with it by wearing the appliance for a few minutes. Adjusting the eccentric guidance: DEPT. not the mandibular central and lateral incisors.to 45-degree angulation to the occlusal plane and allow the canines to pass over in a smooth and continuous manner during protrusive and laterotrusive excursions. is the goal. Eccentric contacts of the mandibular central and lateral incisors also must be eliminated so the predominant marks are those of the mandibular canines. guidance by the maxillary canines. During a protrusive movement. OF PROSTHODONTICS 128 .Seminar . the canines will restrict mandibular movement and may aggravate an existing muscle disorder. If the angulation of the prominences is too steep. Final criteria for the muscle relaxation appliance: The following eight criteria must be achieved before the patient is given the muscle relaxation appliance: DEPT. It is important that the mandibular canines move freely and smoothly over the occlusal surface of the appliance.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders The acrylic prominences labial to the mandibular canines are smoothed. They should exhibit about a 30. In CR all posterior mandibular buccal cusps must contact on flat surfaces with even force. 4. OF PROSTHODONTICS 129 . with total stability and retention when contacting the mandibular teeth and when checked by digital palpation. In the alert feeding position the posterior teeth must contact the appliance more prominently than the anterior teeth. It must accurately fit the maxillary teeth.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders 1. 7. The occlusal appliance is polished so it will to irritate any adjacent soft tissues. Instructions and adjustments: DEPT. 2. 3. 5. The mandibular incisors may also contact it but not with more force than the canines. The mandibular posterior teeth must contact the appliance only in the CR closure. The occlusal surface of the appliance should be as flat as possible with no imprints for mandibular cusps. 6.Seminar . In any lateral movement only the mandibular canine should exhibit laterotrusive contact on the appliance. During protrusive movement the mandibular canines must contact the appliance with even force. 8. On certain occasions fabrication of a mandibular muscle relaxation appliance may be desirable. the patient should discontinue wearing and report the problem immediately for evaluation and correction. When bruxism is the problem nighttime use is essential while day use may not be as important. OF PROSTHODONTICS 130 .IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders The patient is instructed in proper insertion and removal of the appliance. Finger pressure is used to align and seat it initially. ANTERIOR REPOSITIONING APPLIANCE Description and Treatment Goals: DEPT. the appliance may need to be worn most of the time. Removal is most easily accomplished by catching it near the first molar area with the fingernails of the index fingers and pulling the distal ends downward. Evidence suggests that maxillary and mandibular appliances reduce symptoms equally. The primary advantages of the mandibular type are that it affects speech less and aesthetics may be better.Seminar . It has been demonstrated that myogenous pain disorders respond best to part-time use (especially nighttime use) while intracapsular disorders are better managed with continuous use. When the disorder is retrodiscitis. If wearing causes increased pain. . Simplified fabrication technique: Like the muscle relaxation appliance.g. The goal of treatment is not to alter the mandibular position permanently but only to change the position temporarily so as to enhance adaptation of the retrodiscal tissues. However. a single or reciprocal click) can sometimes be helped by it. Patients with joint sounds (e.g. the maxillary arch is preferred because a guiding ramp can be more easily fabricated to direct the mandible into the desired forward position. its goal is to provide a better condyledisc relationship in the fossae so normal function will be reestablished. Indications: To treat disc derangement disorders.. OF PROSTHODONTICS 131 . retrodiscitis).IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders The anterior repositioning appliance is an interocclusal device that encourages the mandible to assume a position more anterior than the intercuspal position. the anterior repositioning appliance is a full-arch hard acrylic device that can be used in either arch. Fabricating and fitting the appliance: DEPT. Intermittent or chronic locking of the joint (e.Seminar . The anterior stop is constructed and the appliance is fitted to the maxillary teeth. The appliance is then returned to the mouth and the patient locates the groove and taps into it. The joint is reevaluated for symptoms and the anterior position that spots the clicking is located and marked with red marking paper as the patient taps on the stop. The anterior stop is used to locate it. Acrylic extending over the labial surfaces of the maxillary teeth is not needed for occlusal purposes.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders The initial step in fabricating a maxillary anterior repositioning appliance is identical to that in fabricating a muscle relaxation appliance. DEPT. Locating the correct anterior position: The key to successful anterior repositioning appliance fabrication is finding the most suitable position for eliminating the patient’s symptoms. The patient is instructed to protrude slightly and to open and close in this position. There should be no joint sounds during opening and closing.Seminar . the appliance is removed and the area of the contact is grooved approximately 1 mm deep with a small round bur. Joint pain during clenching should also be reduced or eliminated. OF PROSTHODONTICS 132 . Once this has been marked. Myogenous pain originating from the superior lateral pterygoid. With the teeth resting together. When the anterior teeth are felt to contact in the groove on the anterior stop.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders however. The anterior stop must not be covered by the acrylic. the position is verified by opening and closing a few times. the appliance is taken out of the patient’s mouth and self-curing acrylic is added to the remaining occlusal surface so all occlusal contacts can be established. OF PROSTHODONTICS 133 . DEPT. When the joint symptoms have been eliminated and verified by the anterior stop. This will adapt the resin to the lingual surfaces of the mandibular anteriors and provide the needed ramp for guiding the mandible into the forward position. will not be eliminated since this muscle is active during clenching. the patient should gently place his tongue on the setting resin lingual to the anterior teeth and press.Seminar . and the large lingual ramp in the anterior region is only smoothed. In the established forward position all the mandibular teeth should contact it with even force. with total stability and retention when in contact with the mandibular teeth and when checked by digital palpation. It should accurately fit the maxillary teeth. DEPT. The forward position established by the appliance should eliminate the joint symptoms during opening and closing to and from that position.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders Adjusting the occlusion: The difference with this appliance is the anterior guiding ramp. 2. which requires the mandible to assume a more forward position to ICP. The ramp is developed into a smooth sliding surface so as not to promote catching or locking of the teeth in any position.Seminar . Final criteria for the anterior repositioning appliance: The following four criteria should be met by the anterior repositioning appliance before it is given to the patient: 1. OF PROSTHODONTICS 134 . Flat occlusal contacts are developed for the posterior teeth. In the retruded range of movement the lingual retrusive guidance ramp should contact and upon closure direct the mandible into the established forward position. ANTERIOR BITE PLANE/ ANTERIOR JIG LUCIA JIG. Indications: DEPT.Seminar . On occasion a patient may need to wear this appliance all the time depending on the severity of the symptoms. It is primarily intended to disengage the posterior teeth and thus eliminate their influence on the function of the masticatory system. HAWLEY WITH BITE PLANE/ ANTERIOR DEPROGRAMMES: Description and Treatment Goals: The anterior bite plane is a hard acrylic appliance worn over the maxillary teeth providing contact with only the mandibular anterior teeth. Instruction and Adjustments: Instructions regarding insertion and removal of the anterior repositioning appliance are given. Instructed to wear the appliance at night and during the day as needed to reduce symptoms. OF PROSTHODONTICS 135 . The appliance should be smoothly polished and compatible with adjacent soft tissue structures.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders 3. 4. Some therapists have suggested that this appliance be used by DEPT. Indications: Severe loss of vertical dimension or when there is a need to make major changes in anterior repositioning of the mandible. there is a great likelihood that the unopposed mandibular posterior teeth will supraerupt.Seminar . The treatment goals of the posterior bite plane are to achieve major alterations in vertical dimension and mandibular repositioning. Disadvantages: If the appliance is worn continuously for several weeks or months. When this occurs and the appliance is removed.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders Muscle disorders related to orthopedic instability or an acute change in the occlusal condition. POSTERIOR BITE PLANE Description and treatment goals: The posterior bite plane is usually fabricated for the mandibular teeth and consists of areas of hard acrylic located over the posterior teeth and connected by a cast metal lingual bar. OF PROSTHODONTICS 136 . the anterior teeth will no longer contact and the result will be an anterior open-bite. Anterior bite plane therapy must be closely monitored and used only for short periods. scientific evidence does not support this theory. Disadvantages: Potential supraerutpion of the unopposed teeth and/or intrusion of the occluded teeth.Seminar . Unfortunately. Constant and long-term use should be discouraged. PIVOTING APPLIANCE The pivoting appliance is a hard acrylic device that covers one arch and usually provides a single posterior contact in each quadrant. When superior force is applied under the chin. the forces of the elevator muscles are located primarily posterior to the pivot. which therefore disallows any pivoting action. This contact is usually established as far posteriorly as possible. the tendency is to push the anterior teeth close together and pivot the condyles downward around the posterior pivoting point. However. DEPT. OF PROSTHODONTICS 137 .IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders athletes to improve athletic performance. Indications: The pivoting appliance was originally developed with the idea that it would lessen interarticular pressure and thus unload the articular surfaces of the joint. 3) Clenching and bruxism Okeson demonstrated that nocturnal masseter EMG activity was increased in 5 to 10 subjects with a soft appliance. the pivoting appliance has been advocated for the treatment of symptoms related to osteoarthritis of the TMJs. For the treatment of an acute unilateral disc dislocation without reduction.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders In fact.Seminar . Treatment goals are to achieve even and simultaneous contact with the opposing teeth. in the same DEPT. SOFT OR RESILIENT APPLIANCE Description and Treatment Goals: The soft appliance is a device fabricated from resilient material that is usually adapted to the maxillary teeth. Indications: 1) Protective device for persons likely to receive trauma to their dental arches 2) Protective athletic splints decrease the likelihood of damage to the oral structures when trauma is received. OF PROSTHODONTICS 138 . Cognitive awareness 5. Placebo effect: 40% of the patients suffering from certain TM disorders respond favorably to such treatment.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders study 8 of the 10 subjects had significant reduction of nocturnal EMG activity with a hard muscle relaxation appliance. Before any permanent therapy is begun. Alteration of the condylar position 3. Common Treatment Considerations of Appliance Therapy: However. 1. Increase in the vertical dimension 4. one needs to be aware that there are six general features common to all devices that may be responsible for decreasing muscle activity and symptoms. DEPT. OF PROSTHODONTICS 139 . much controversy exists over the exact mechanism by which occlusal appliances reduce symptoms.Seminar . Alteration of the occlusal condition 2. Most conclusions are that they decrease muscle activity (particularly parafunctional activity). Increased peripheral input to the CNS: Any change at the peripheral input level seems to have an inhibitory effect on this CNS activity. 6. The clinician also needs to consider that 40% of patients suffering from TMD demonstrate favorable response to therapy from a placebo effect. The clinician is encouraged to evaluate fully each particular patient case in an effort to develop a differential diagnosis that leads to effective management plan. there is still a plethora of documentation that intra-oral appliance when used in the management plan accurately. As with any treatment. the clinician should be confident that the patient will benefit from the therapeutic approach. Before commencing any appliance therapy for a TMD. DEPT. can contribute to the relief of TMD symptoms. It can contribute to a positive and favorable response to intraoral occlusal splint therapy.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders SUMMARY Despite the unanswered questions on the physiologic mechanisms that explain the effectiveness of intra-oral appliances on reducing symptoms of TMD.Seminar . a good patient-dentist relationship and concomitant with patent education. If the symptoms reduced that will provide additional diagnostic information. can alloy patient feelings and anxieties. OF PROSTHODONTICS 140 .  Fundamentals of fixed prosthodontics. 50:700-709. Theory and practice of fixed prosthodontics. diagnosis and treatment of occlusal problems. Oral Medicine. 3 rd edition. Hubo. Mc Nail.  Journal of Prosthetic Dentistry 1985. 53 : 717-721. Whitshell. Occlusal correction. Koth. 45 : 438-445.  Journal of Prosthetic Dentistry 1980. 59:165-180.  Journal of Prosthetic Dentistry 1981. 3rd edition. Principle and Practice.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders BIBLIOGRAPHY:  Management of temporomandibular disorders and occlusion. DEPT.  Journal of Prosthetic Dentistry 1983. 4 th edition. Rosenstiel. 44:324-335.  Journal of Prosthetic Dentistry 1982 48 : 708-712.  Science and practice of occlusion. Land.  Cranio 1993. 88:67-75. Fujimoto.  Albert Solonit/ Cornutte. Dawson.Seminar .  Berkit’s. 8 th edition. 11:184-191.  Journal of Prosthetic Dentistry 2001.  Contemporary fixed prosthodontics. 86(5):539. Shillenberg. OF PROSTHODONTICS 141 . Malone.  Evaluation. Bracketti.  Aust Dent J 1990.  Tylman.  Journal of Prosthetic Dentistry 1989. Jeffrey O Okeson. Jacob.  Journal of Prosthetic Dentistry 1980. 35 : 266-276.  Journal of Prosthetic Dentistry 1990. 83 : 2. OF PROSTHODONTICS 142 . DEPT. 63:52.IV Occlusal Splints Used in Prosthetic Management of TMJ Disorders  Journal of Prosthetic Dentistry 2000.Seminar .