Early in my career, I became frustrated with splint therapy. In the clinical area it was working. In theory, it made sense to me that I should be able to take the appliance back through well-articulated CR casts and ultimately to my patient’s mouth.

Turned out, patients treated with splints were not beating down my door for definitive dentistry. Like Mick Jagger, I Couldn’t Get No Satisfaction. A decade later, I have experienced something magical happening and am singing a new Rolling Stones song in my head, Time is On My Side. (Yes it is!)

Time and Splint Therapy

Perhaps I was not waiting on my patients or more than likely they were waiting on me. I have hundreds of splints on unrestored patients that visit me a couple of times a year. They bring along the plastic to have it ultrasonically cleaned, sometimes tweaked, sometimes repaired.

There was a time when I believed the transition to treatment was a given once the appliance was well-adjusted on a patient willing to trust me with their investment in therapy. (I mean geez, that happens every time for the folks who taught me how to make one, right?) The presentation of the next phase was a conversation that probably sounded a whole lot like a sales pitch and generally fell flat on its face.

Time is on our side. I’ve grown to realize the virtue of patience and listening. Specifically, I listen for compliments, appreciation of the appliance, and sometimes simply a statement of dependency on the plastic. Sometimes this takes years. This is the time to ask, “Would you like to discuss dentistry that can make your teeth feel this way?” Sometimes they outright ask me.

Time is on our side. Appliance therapy is a seed. Our caring attention is a well-nurtured garden. Patients will bloom when they are ready.

My experience with splint therapy was like most dentist’s prior to developing the skills taught at Pankey. In fact, my appliance was not really therapy at all. Perhaps just a shot in the dark “helmet” that protected teeth against collisions with very little intention.

Throughout the years there have been many facets of my experience I value greatly in guiding patients to health using plastic:

Splint Therapy and Appliance Design

Appliance design is a provisional analog (that is, a practice replacement) for any changes we make to the teeth and ultimately the stomatognathic system. The splint is a great diagnostic tool that is capable of healing, but it’s also an iconic part of the behavioral interaction between the provider and the patient.

Aside from physically being an orthotic analog, the splint is a training tool, maybe even the greatest reversible “do-no-harm” in our profession. Case by case, each patient experiences changes and familiarizes themselves with my touch and caring.

Month by month and year by year dentists educate themselves and develop an understanding of bite relationships by using therapy. This happens case by case too, much like waxing cars and painting fences for Mr. Miyagi. As the experiences compile, sometimes our questions do as well. Sometimes we turn to our mentors for answers, much like the Karate Kid.

For the learning dentist, different parts come together when bringing splint therapy from the classroom to the operatory. There is the initial understanding of the “why” that can be conceptualized in theory, but not realized in practice until the “how” of the technical piece arrives through experiential understanding.

Each provider comes into their own by developing skills to have patients relate needs and eventually invite them confidently to enter appliance therapy.

There’s more to come in Part 2! What challenges have you faced in splint therapy techniques to ease patient discomfort? 

Current digital splint technology requires workarounds to make it a feasible option for clinically exceptional dentistry. In Part 1 of this series, I described the challenges and opportunities of digital dental technology and explained some details of my preferred protocol. Here, I continue this explanation:

An Effective Digital Splints Protocol

In my practice, I mount digitally printed models using a centric relation record and a protrusive record for condylar inclination adjustments. This is just like we have done in the past with stone models. 

The lab technician can transfer this into the computer exactly as we have it in our hands. They do this with the use of a tabletop scanner. It’s important to note that the technician can now register original files for the impressions into position for the best accuracy. The greatest benefit today is the accuracy of these original scans (20-30 microns). 

The design portion comes next in this process. Communication with the technician can be done in real time online. My technician and I have been working with different settings in the software that give me the best chance of skipping the reline procedure patients don’t enjoy. 

I can also evaluate and do final adjustments on the mounted digital models and analog articulator. We have been successful about 80% of the time getting a splint that is rock solid and has an intimate fit on the occlusal surfaces. This is critical for fine-tuning adjustments and fracture resistance. 

If it ends up as an ill-fitting or loose-fitting splint, we can still reline just like we always have because it is a milled PMMA material (as dense as a denture tooth). 

Areas of Improvement for Digital Splints

My opinion at this time on digital splints is mixed:

Pro: We can produce a very high quality PMMA splint that lasts longer and generally gives the patient a better experience.

Con: We still need digital counterparts to essential analog skills that provide for all situations. 

Pro: I believe we will have printed materials that outperform current milled materials in the near future (this will lower the cost to produce splints). 

Con: It is frustrating that we are not getting better support from companies selling us  expensive equipment.

I am proud to be part of the Pankey family because our community encourages the use of technology to enhance good dentistry. 

The new challenge facing us in dentistry is how to incorporate technology into our daily practice. Digital splints specifically are a subject I have been working on for about a year. 

We have had the technology available to mill a splint out of acrylic for a few years now. However, we have not had a good protocol that meets all our needs. 

Digital Splints: Challenges

Some of the problems we face are as follows:

1) Lack of digital articulators that make all of the movements we are able to with semi adjustable articulators, such as crossover transitions. 

2) Absence of centric relation record mountings in software on a computer.

3) No rotational path insertion we can achieve from relines in the mouth. 

4) Few materials that are as good or better than we have now.

I believe we are well on our way to solving these issues. The biggest problem I see is something Dr. Pankey was dealing with many years ago. He talked about how the majority of dentists are indifferent to good comprehensive care dentistry. Therefore, most of the manufacturers of our dental equipment and software are catering to a majority that does not share our own clinical demands. 

These companies give me answers like, “That sounds great doc but who will I be able to sell that to?” I think we have to find workarounds for now that will encourage development in these technologies. Keep in mind, all of the workarounds I will explain are in line with what we teach at the Pankey Institute. 

Digital Splints: Opportunities

We also need systems we can duplicate and teach without compromising the quality of care or experience for patients. I believe there is great potential for higher quality materials and great fitting splints without relines. These two potentials alone can create more value and better experiences for patients.

Today I have a protocol that is some digital and some analog. I intraoral scan our impressions with the TRIOS scanner. I believe most of the scanners on the market today work very well and produce very accurate files that can be printed into models. I also use the TRIOS because it communicates very well with the 3SHAPE units most labs use. 

Now that I have files and models I have to mount them. This is our first problem to solve. I still use an analog facebow or facial analyzer. I mount these models on an articulator like the Denar Mark 330 because this is an articulator model programmed into the 3SHAPE software. 

To be continued…

Forty five years ago, in the fall of 1972, the first class at The Pankey Institute was held. It’s easy to forget how much things have changed in the world of dental continuing education. Read on for an enlightening reminder of how far dentistry has come in the last few decades … 

Pankey History: Dr. Henry Tanner

Dr. John Anderson and Dr. Loren Miller each had sold their private practices and dedicated their careers to the creation of the Institute. In 1974, Dr. Anderson asked Dr. Henry Tanner to be assistant director of education. Dr. Tanner had been head of fixed prosthodontics at USC School of Dentistry and had made several significant contributions to dentistry.  

Many years earlier, Dr. Tanner had rebuilt the occlusion of Dr. Anderson, who then described Henry as “the finest restorative dentist in the world.” Dr. Henry Tanner is most often associated with the development of the Tanner Appliance.  

Dr. Tanner vividly recalled the first time he made a lower full arch appliance for a woman who was having severe head and face pain. She and her husband went to the hospital emergency room and she was given morphine and Demerol, yet she was not having much relief.

During an emergency visit at his office, Dr. Tanner made an acrylic wafer, placed it directly in her mouth, had her touch it gently with her upper teeth, and asked her to mold it with her tongue. After the acrylic got rubbery, he took it out of her mouth, let it harden, and refined it. She was out of pain the next day.

Within weeks of that experience, Dr. Tanner met a well-recognized orthodontist, Dr. Bob Ricketts, who was taking laminagraphs (sectional x-rays) of his splint patients to monitor condylar position and bony healing in the joint.  

To be continued ...

Splint therapy can be one of the best services we offer our patients, but plan poorly and your headaches will greatly increase as you decrease your patient’s.

We all want to provide our best stuff for our patients, yet sometimes we can find ourselves in a quagmire of complexity and not getting reimbursed for our efforts.

Through the years I’ve seen this scenario play out in my own practice and many others because we lack structure around our fees for splint therapy. If ever there was an example of the failure of unit fees to provide appropriate care and reimbursement, the one size (fee) fits all approach in splint therapy will leave you clenching and grinding.

How to Individualize Splint Therapy Fees

To be equitable for patient and practice, fees for splint therapy must be individualized. To do this, you’ll need to have a good idea of what your production per hour goals are and utilize that as a basis for your fee.

For example, if I have an anterior deprogrammer that requires very little follow up to simply protect the dentition and calm muscle, the fee would consist of a lab fee (I charge this fee even if I make it in house), the time for insert, and the amount of time for follow up, usually one or two short appointments.

For more complex TMD therapy I like to look at it this way: take the same basic fee structure illustrated above and add time for insertion (allow yourself enough time, knowing mandibular/condylar position is likely to change as you adjust), then add for follow up appointments based on your diagnosis and complexity.

Estimating Therapeutic Time

Here are some of the factors I consider when estimating the “therapeutic time.” I’ll routinely add time and/or appointments based on whether it involves:

1) an occluso-muscle disorder

2) an intracapsular disorder

3) the amount of degenerative change in the condyle disc assembly

4) the chronic or acute nature of the problem (acute problems I feel are generally harder to manage)

5) the presence of pain, both quantitative and qualitative

6) the duration of pain and complexity of pain pattern (pain emanating from multiple sources)

7) the behavioral and psychological dynamics involved with the patient

In closing, I’d remember to under-promise and over-deliver in direct proportion to the complexity of the problem. Evaluate, diagnose, and treat wisely and you’ll achieve pain reduction and stability for both you and your patient!

How do you structure fees for splint therapy in your practice? We’d love to hear from you in the comments! 

(Link to Digital Bite Splints: Part 1)

If you’re hesitant to start testing out digital bite splints in your practice, read on to learn why one dentist prefers them for improved efficiency and accuracy.

In Part 1 of my thoughts on this topic, I explained the features I love when working with a lab to create digital bite splints. These bite splints have an incredible fit and allow for customizable retention. Below, I round out the rest of my perspective on why they’re a great option for many dentists.

Occlusal Schemes and Adjusting the Digital Bite Splint Design

I’ve played with different occlusal schemes for digital bite splints. I have utilized:

1. A universal flat plane appliance (upper or lower).

2. An anatomic retainer-type appliance we designed to have a little more detail.

3. One anterior repositioning appliance. It was created for a patient who had some recent trauma. We were trying to keep them from seating all the way for a short period of time.

The idea is that you can design the occlusal scheme any way you want. After we send the scan in and the lab does the initial design, they can send us back screenshots that show us what the design is.

When we look at those screenshots, we can make comments on them. If there’s a lot of change – if we want to shallow the guidance, steepen the guidance, or make it thicker/thinner – we can actually go online live with the lab as they enact the changes. We can watch it happen in real time.

Increasing Efficiency by Reducing Chair, Lab, and Adjustments Time

Digital bite splints are a nice, new way to do things. Personally, I think we’re getting a better result. It’s certainly saving us a ton of time, both in terms of lab time (model work time) and chair time because the patient doesn’t need a lot of reline time. Of course, keeping the nasty acrylic out of the mouth is another significant benefit.

You don’t have to spend a lot of time adjusting. The occlusal adjustments are nominal. If we get the records right with the scan, there is very little in terms of adjustments. In fact, that might be the downfall for some of us because we lose a portion of time for the patient to experience things. Sometimes, I’ll spend more time adjusting than I need to. I ensure the patient is engaged and experiencing what an even bite might feel like relative to their natural occlusion. But, in this case, I wouldn’t have to devote that time if I didn’t need to.

Digital bite splints are also really dense. Breakage is going to be a minor problem. They’re going to hold up and last a long time.

What technology are you considering using in your practice? Please leave your thoughts in the comments!

The future of dentistry is here: digital bite splints. I’ve used bite splint therapy in my practice successfully for years. I was comfortable with my preferred traditional process until I learned I could work more efficiently and more accurately with the latest technology.

There is no reason to fear implementation of a digital workflow in your practice. In this two part series, I’m going to lay out the reasons why I’ve chosen to switch to digital bite splints for goals like protecting teeth and restorations, deprogramming muscles, and treating TMD.

They’re the productivity solution you didn’t realize you needed.

Less Effective Splint Fabrication Methods

My past process for fabricating occlusal splints (bite splints) was traditional. It included making records, alginate impressions, facebow, mounting, and several bite records (protrusive and centric). We would design and fabricate with cold cure acrylic that we would make by hand, then adjust and modify as needed.

That process works great, which is why most dentists use it. Alternately, some dentists send them off to the lab and have the same process done, possibly in a cured acrylic. But the outstanding process we have transitioned to in my practice is a completely digital designed and fabricated bite splint.

Why I Love the Digital Bite Splint Fabrication Process

The first step for a digital bite splint is to do an intraoral scan of the patient’s dentition. Any scanner can be used. We then send the scans to a restorative lab, where a software package specifically made for appliance design is utilized. The lab designs the appliances to our specifications and then they are milled out of a solid block of acrylic. This leads to an amazingly dense result that polishes unbelievably well.

The fit is incredible because we can get such an accurate scan with no distortion. With an impression, we usually have distortion of the alginate, distortion of the stone, or distortion of the acrylic as it sets, which is why we have to reline them. I have only had to reline two CAD/CAM designed and milled splints since we’ve been doing them. These bite splints are easy to adjust and it’s easy to read the dots on them. They just drop right in with almost no adjustment needed.

You can also dial in the retention on the software, so we’ve played with it a little bit to figure out what we want in terms of retention. We’ve got it just about right where they’re not too loose and not too tight. They have a nice snug fit that’s stable and retentive enough, but doesn’t squeeze the teeth too much.

Keep your eye out for Part 2 of this digital bite splint blog series. Next week, I’ll describe how we play with different occlusal schemes and work with the lab on customization in real time.

What advancements in dental technology are you hesitant to implement in your practice and why? We’d love to hear your thoughts in the comments!

(Link to Digital Bite Splints: Part 2)