Which is the Best Dental Splint? [SPLINTEMBER] – PDP038

Like this is such a big question which splint is your go-to splint and basically you know you’re gonna hear about my journey with splints. People who have influenced me mentored me but I’m gonna get right into it very quickly when i was gonna tell you what are the factors which i look for to determine which is the best splint for a patient i have so since i posted about Splintember on Facebook and Instagram everyone’s been sending me a lot of love and everyone’s looking forward to it which has been so amazing it’s a really confusing topic for me, my interest in splints grew out of frustration I’ll talk about that in a moment but thank you so much for everyone sending their love. One of the listeners Taha Alibi actually messaged me on Instagram say no i really like the splinter idea but for october can you do Orthooctober or Orthodontober to try and get all the orthodontic systems to sort of almost debate against each other to see which is the best orthodontic system and I thought that’s pretty clever it’s a great idea but I might say that until next year for example when everyone has enough time to prepare and stuff but thank you so much everyone for your suggestions.

The Protrusive Dental Pearl even though it’s a splint episode I’m going to give you like a a non-splint appeal and this is something i posted on my Instagram just a few days ago check out @jazzygulati for the Instagram and this is how I like to remove temporary crowns and temporary onlays. I use a hemostat or mosquitoes or archery forceps lots of words for them and if it’s a posterior one like to use the curved ones and basically you squeeze your temporary crown or temporary only and that breaks apart any bonds that you have so for example for an onlay I would use a zinc polycarboxylate cement such as duralon for example is a popular brand and I would squeeze the only that would just compress it and that compression actually causes tensile stress at your sort of bond layer or the cement layer and that just gets really weak and suddenly you can just so very easily shake it off if you’ve got a really thick crown you know like normal even if you use conventional techniques like you know using what i used to use like a big excavator a mitchells a carver or something like that and try and flick up it’s not so pleasant it’s not so successful in my hands and sometimes just i’m able to get the temporary crown off so you have to section it so sometimes for a really thick crown you’ll struggle and also be careful with thin teeth like lower incisors or quite weak teeth because you don’t want to put all those sort of talking loads especially for a crown rather than only those are so much easier to you know with their innate lack of resistance form. So I hope that Protrusive Dental Pearl helped you and i look forward to sharing more with you. 

So let’s go straight to the episode now right so which is the best dental splint so i was incredibly confused by splints for many years and to some degree there’s so much about splints you know that we all still have so much to learn as a profession the evidence base for splints is poor and i think that’s a big reason why that we as a profession get so confused about splints and why there’s so much opinion out there so i i think it starts at dental school where if you go to your restorative lectures, your lecturer will tell you that the Michigan or the Tanner splint is the best and that’s the only acceptable appliance there is any time ever that’s it and if you don’t know what any of these appliances mean any ones I mentioned don’t worry we’re going to cover all those in future episodes so yeah restorative will tell you that the Michigan and Tanner is great and restorative will tell you that anyone who gives an anterior only appliance so let’s call them anterior midpoints stop appliances so AMPSA is an evil dentist and bad things will happen to the patient. Patient will spontaneously combust or get an AOB for sure and temporary mandibular disorder and all that sort of stuff you know so I was always taught that you know stay away from anterior only appliances. 

Now in that same dental school when you had your oral surgery sort of sessions or oral medicine sessions and they would make the diagnosis of “TMD” then everyone would get a soft splint and the Maxfacts or surgery department would swear that you know it’s a partly raising appliance and it has a very high success rate and you don’t really need anything else so already coming out of Dentistry school we have these mixed signals and then coming into practice and actually trying to make appliances because you want to best serve your patients you want to sort of help them out you think they’re bruxing and you think that the splint might even stop them bruxing so that’s what you think you know give them a splint and they’ll stop brexit even patients say it patients say to you oh I had an appliance once or i was given a splint once to help me stop bruxing and I correct the patients I said you know what nothing will stop you bruxing except maybe fixing the root cause but I don’t go that deep with them we’ll talk about the root causes of bruxism and Parafunction and that sort of stuff only because it’s interesting it only helps you and I say this to a patient it only helps you to manage your grinding you’ll still grind but to do it on a piece of plastic is so much better than doing it on your own teeth so that’s why I say to patients. Trialing splints on patients and having some failures early on failures all sorts of different types of failures and we’ll cover the different type of failures there are and then really losing faith in splints and then really still being so confused as to which is the best splint and then you come across some very well-respected clinicians and lecturers who educate on anterior-only appliances and you think have on a minute this is the same splint that dental school told me to stay away from what is going on so before I go any deeper I just want to pay respect to some of the the splint mentors I have some of the people who have influenced my thinking on appliances some people who really mentored me and helped me and helped me to understand a lot. 

So before I continue any further, I want to thank Dr Pav Khaira from the UK who sort of started to get me think that anterior only appliances or AMPSAs are not as bad as people say they are. Then i was influenced by Jim Boyd and Barry Glassman who I believe they’re the ones who came up with the NTI appliance so I placed a lot of those and that they really influenced me they had a lot of sort of educational content for free on youtube and whatnot which at the time maybe four or five years ago when I started getting into this that was all there was really i’m hoping to change that obviously but that was really helpful for me at the time also helpful to me has been Dr Michael Melkers, okay? Who’s obviously coming to November for occlusion 2020 at the end of november that’s 27th and 28th of november for occlusion 2020 program two-day workshop which we’re really looking forward to but what he you know taught me about splints is you know just unparalleled with anything else. He really took out that next level for me and also clarified a few designs which I use very commonly now so Dr Melkers, thank you so much I know you listen to this so thanks so much for helping me in my journey with splints and lastly Dr Kushal Gadhia, who’s a restorative consultant here in the UK who taught you know everything I know about michigan splints you know it comes from him and he’s taught me so much so well on his courses but I love that he’s so humble because when I met him on his course, he knew that I was doing a lot of anterior only appliances and instead of like some of the consultants that I’ve come across for who really you know look down on you and poo poo he really kept an open mind you know he said ‘Jaz , you know i’m gonna listen to any episodes and try and figure it out even though I don’t provide anterior only appliances’. He really wanted to understand my viewpoint and my experiences and sort of was happy to do that myth busting session i think it was episode eight myth busting about anterior only appliances do they call it AOBs and whatnot. So i respect that so much that someone at his level will give up some time to try and understand where young dentist is coming from with his experience of splints so a massive shout out to him we need more people like you Kushal, who will keep an open mind. 

Now before we dive into the meat of the episode I’m gonna tell you straight up which is the best splint a lot of the sort of best way to think about splints was actually covered in episode 15 ‘your occlusion questions answered by Dr Michael Melkers’ and I’m going to play you this two minute or three minute extract from this episode where Dr Michael Melkers gives the best summary for splints I really want you to hear again it’s just fantastic so listen to this bit and it’ll get you get you thinking about what is the role of a splint.

One thing i want to speak about before we talk about your upcoming program is splint therapy my gosh people are so confused about splints. It’s one of the most controversial topics it gets a lot of questions when anytime anyone posts on social media about splints and there are like all parts of dentistry and occlusion as well there are very polarizing views and we can go into the whole anterior midpoint stop appliances and those who are really against it and whatnot but but one thing i want to kind of just talk to you about is that or tell you is that your DAASA so dual arch anterior midpoint stop line protocols that you showed were was amazing and the way the cases that you showed and the application of confirming centric relation prior to rehabilitation and you talked about the different indications that was great and I’ve been using that in you know in a lot of my patients and it’s been a real game changer for me so

[Michael] I’m glad you’ve had success with that

[Jaz] I’m using that all the time in practice you know in the right indications and seeing great success with it so can you tell us just you know briefly to anyone who’s not familiar with these sort of appliances is why you think they have a place in practice. Is that too broad?

[Michael] No, but i would actually probably even want to make it broader is why would you use any appliance to begin with it’d be and that’s where i always want to start i always want to start with the why. We get into arguments as you say and we get into disagreements because people have their what and their how and they want everybody to do their same how like you have to do my how, you have to use my how, my appliance is the right one my mind this this but in so many of those discussions we’re missing the why. So why do we use orthotics, why do we use occlusal splints, why do we use bite guards and night guards whatever you want to call them there are just a few very simple reasons why we use them. We use them to get people out of pain, we get use them to help protect things and we use them to help figure things out. Palliative, Protective, Diagnostic. 

So if someone is hurting and they could be hurting in their teeth they could be hurting in their muscle or they can be hurting in their joint they need a palliative splint. I don’t care what design it is. If someone is breaking their teeth or breaking their restorations and they want to keep those restorations intact then they need a protective splint. Now if we need to figure something out whether it’s in other camps that want to figure out chewing patterns or my approach if we want to figure out parafunctional patterns or if it is important a joint position then it is a diagnostic approach and you can use full arch appliances for all of those applications and you can use anterior midpoint stops for all of those applications it goes back to the exact same thing that we were talking about at the beginning of this chat is we have a lot of tools but we have to have goals and then we have to balance efficiency with them.

[Jaz] So there we are protective, palliative, diagnostic that’s it. If you can just categorize your splints in those three sections everything becomes so much easier so almost the sort of the you know people a lot of people on the Protrusive Dental Community ask for a flowchart of this and you’ll see in this episode why it’s so complex to make a flowchart but at the very top you should always bear that in mind whether your split is protective, palliative or diagnostic and we’ll get into that a little bit more as the weeks come by so doctor. Thank you Dr Michael Melkers for inspiring us with that so it’s just a simple and beautiful sort of viewpoint on how to choose the best splint. So the best dental splint in the world is called a G-splint the G stands for my surname Gulati and i’ll be telling you all about the G-splint. I’m very much against having giving blanket prescriptions or splints but hear me out for a second why the g splint may be the best splint. Okay so in no particular order let’s look at the first factor i would consider, again this is random order i’ve got you know four or five different points which makes the best dental splint. 

Okay so number one the g splint is the best splint because it’s the one that actually addresses the diagnosis. So too many people give blanket prescriptions of everything you know i will do a vertical preparation for all preparations because they are the most conservative or whatever or i will do a one specific type of procedure for every scenario because it works in my hands or whatever, so a lot you know dentists who will only ever give a michigan or a tanner and that’s it nothing else and you know what they’ll have a reasonably high success rate in general but you have to ask yourself is that practitioner sort of prescribing it based on individual needs and diagnoses or out of habit. So the first thing is diagnosis like is it a joint ,is it a bony issue, is it a muscle issue or are you trying to just put something between the teeth to protect them. So what are you trying to achieve maybe it’s two or all three of those things and maybe they’re just completely asymptomatic and they are just chipping and wearing away their teeth and they’re concerned. So really it depends on your diagnosis the health of the joint, health the muscles, the sort of initiating factors. Are they a daytime or a nighttime para functional patient, are they bruxing during the day? Night? All these factors are part of your diagnosis and that’s an important thing to consider don’t you think?

Number two, compliance. Now this is a huge one okay many years ago i used to do lots of michigan splints and tanner splints and you know once again if you don’t know what these are these are full coverage appliances, hard acrylic traditionally. Now you can actually do the Bilaminar type a lot of dentists are against these but they’re soft on the inside and hard on the outside and have the whole canine ramps for disclusion and whatnot but essentially you know these splints are supposed to be made ideally using a face bow and you know two or three long appointments to get them perfectly equilibrated but the number of appliances that I’ve seen that patients own that come from other practices you know and i asked them oh you know tell me about how this splint was made it was oh yeah just one appointment they gave it to me i went home that’s it done and you checked their bite and they’ve almost got like an AOB on this splint and you know it’s supposed to be a michigan retainer so how many of these appliances are actually really truly and properly equilibrated i don’t think very many.

So compliance is a huge factor when i used to give these michigan and tanner appliances with all the best intentions, all the best experience and really trying to get the best for my patient it was so disheartening and embarrassing for both me and the patient when the patient would come back for recall and i’d be like hey how you getting along with that splint we spent a good few hours on that you know we checked your bite over ever again. How are you getting on with it and then you know they say you know i tried for the first couple of weeks and and too fair i you know i couldn’t get myself to wear anymore. I kept removing it in the middle of night and now I don’t even know where it is anymore. So compliance is such a huge factor because you can have the best splint in the world, the best equilibrate splint in the world if your patient doesn’t wear it then it’s completely pointless so that is another factor to consider. So the g-splint will be the one that will also help with compliance for the patient and and that depends on patients. Some patients will comply better than others and that might be a personality type trait. That might be just something innate about them so something to you want to suss out about them.

Okay number three, the best splint is the one that will also consider their orthodontic status. Now, so many of our patients receive orthodontics like did you know in the uk when they sort of budget in the national health system and they allocate some funds to to children’s braces and orthodontics under the NHS they budget that one in three children will require orthodontics. One in three, that’s huge. So imagine the patient of tomorrow one in three of them will have had some comprehensive orthodontics from the NHS and a significant chunk of patients would have paid privately because maybe they didn’t meet the criteria for IOTN so maybe up to 40% of our patients in the future may have had some degree of orthodontics at some stage so don’t you think before you give an appliance that you should ask if they’re currently wearing retainers at the moment whether they have had orthodontics before and whether they need retention or not and perhaps an appliance or a splint that not only addresses the diagnosis the the sort of the reason for giving a splint is diagnostic, is it palliative, is it protective but also factors in a degree of orthodontic retention if it’s necessary. So that’s another thing that the best splint will actually address. Does the patient need orthodontic retention?

The next one’s also very important to consider is it’s airway, you know i recorded some episode episodes ago with professor Ama Johal about airway and our role our growing role in the future in dentistry to help patients with airway issues and there’s a huge correlation between airway issues. I’m talking sleep apnea, the inability to get enough oxygen when you’re sleeping because it collapses the airway the soft tissue airway and basically this is one of the implicated theories of why people brux and parafunction because if you’re not able to get the air in then your muscles mastication they sort of go all over the place to try and allow you to get more air inside and the other thing is a gas gastric esophageal reflux disease is also implicated in bruxim and parafunction because it’s trying to move your jaw around to get more saliva so these are some of the theories but there’s a huge link that if you treat someone’s airway with a CPAP for example one of those positive continuous air machines that they all stop parafunctioning, isn’t that so fascinating. 

So shouldn’t you consider that yes you have a dental appliance you want to give it to them but their airway is important because if it’s their airway causing the issue then perhaps going down that path and perhaps them not even needing an appliance anymore or if you just ask him and typically if it’s like a 50 year old man who’s looking a little bit thick around the neck and then you sort of discuss with them and you have to sometimes be frank and ask them if you already have it in your questionnaire then great but if you don’t have it you sometimes have to ask them do you snore and then a lot of times they’ll say yes. It’s a huge problem in my life my wife is about to divorce me because of it or whatever it’s a massive massive issue usually for the spouse rather than the patient actually snores but it is actually as you know a marriage breaker and if i find out from my patient that snoring is a huge issue and i’m seeing signs of parafunction then at the very least i might offer them an anti-snoring appliance because hey if that’s in the way of the teeth then they can’t damage their teeth anymore. If they can help their snoring and help their spouse get a better night then the g-splint will be one that also considers their airway. 

So have a think about that in the future i mean i think one of the reasons in the UK and we discussed this in the previous episodes is that we lack we really sort of lagging behind Australia and the USA in terms of managing airway and dentistry is that we don’t have the correct pathways or referral pathways set up like we always have to send to the GP first who may not know much about sleep apnea and they are the ones responsible to send them to ENT or something and they might just say to the patient oh you know just lose some weight or whatever which is good advice but it’s not going to be a you know helping these sleep studies which i needed and all these sort of issues. So i think that’s why we sort of lag behind the UK. So there’s so much more i need to learn about airway as well but something i would definitely consider when choosing the best splint so consider the airway when you’re prescribing the best appliance for your patient.

Okay the next point to consider for the best appliance is how much do you trust your patient and how much does your patient trust you and what i mean by that is obviously we want to have a very trusting patient-dentist relationship but not all of your patients trust you as much as your favorite patient maybe and you don’t trust all your patients as much as you trust your favorite patient. If that makes sense so trust varies amongst different patients and how much the patients trust you like they might trust you enough to do a composite on the lower six but they might not trust you enough to do a full month rehab for example or anything cosmetic whatever. So trust is a huge factor because if you’re going to prescribe an appliance that has very specific instructions for example only where this appliance at nighttime not in the day then can you trust your patient to follow this advice because if the proverbial hits the fan and things go wrong then you want to be able to have a patient that actually followed the instructions because when patients follow the instructions of an appliance and you have put thought and care into the correct prescription of the correct appliance for that patient and you’re not going to run into any issues but when there’s a lack of trust i.e between you not trusting the patient to do things correctly or massive one is patient not trusting you. If i have a patient in front of me and i’m getting these vibes that you know they’re listening to me but i don’t think they’re taking anything in so for example one of those patients there that you show them their photos and you show them all their signs of severe parafunction completely flat incisors that you know four millimeters of you know incisor height left and then they’re looking at you they’re listening but they’re not trusting you they’re not buying into it they don’t agree maybe this is the first time maybe that you know someone’s telling them about their bruxism habit and they don’t know whether to trust you or not so that patient who might not certainly might not necessarily trust you if something was to go wrong because you know any appliance can cause a occlusion changes any appliance can cause changes in the temporomandibular joint and at the dental level so be careful when prescribing any type of appliance not just anterior only ones and so if the patient doesn’t trust me i might give them the cheapest most simple appliance that is the safest and not likely to cause any issues because it might just do enough for the patient because the patient doesn’t trust me that i don’t want to give them my everything because if things go wrong then already you’re on the back foot. So trust actually is an important factor when it comes to prescribing the best appliance for your patient.

Okay the next one is an interesting one is ease of access and access in general for example the other week i had an 80-something year old delightful lady just an absolute comedian. She was just brilliant, full of life and so funny but she did have early to moderate alzheimer’s disease and her son would bring her in and she lives a fair distance away and really we you know we spoke with her and her son and we thought that because of the distance she lives away she her main goal is to stay stable and to do the least amount of denristry possible but also to minimize the need for her to come to the surgery. So minimize and emergencies and whatnot and other than lots of wear on her teeth which you may expect It’s common but not normal like you know she’s obviously been parafunctioning at high rate throughout her life and she knew it i mean it’s one of those patients that tell you one of those rare patients that tell you that they’ve been grinding a lot and she actually came with a a chipped composite on the anterior which i fixed for her and then i spoke to her son i spoke to her and we decided to go for a splint. I’ll tell you in the future why we did this and how we did this. We decided to splint that was really low maintenance easy to wear and will not need many adjustments because if she lives a long while away and she depends on her son and she really wants to minimize the number of appointments and number of times she has to see me and i want a low maintenance appliance that doesn’t need a lot of close sort of reviews and just checking how things are developing. So for her which is a protective appliance which i’ll describe in future episodes hopefully with except with some examples i can show you these types of appliances but the g splint for my patient there was one that factors in the fact that this patient cannot come to see me for stringent follow-up protocols and i need to give a plug-and-play appliance that’s going to be easy for her to wear and compliance is almost guaranteed So how far away your patient lives and how how easily they’re able to access your care will also affect which is the best splint for that patient. 

The next one is one that considers if your patient will be requiring any further dental work in the near future like you don’t want to be giving appliances to your patients who you know have poor oral hygiene, have lots of large restorations with constantly fracturing cusps. You want to get your patients stable enough so that they’re not going to be you know you’re not anticipating in doing lots of treatment on them in the future. You’ve stabilized all the caries, you’ve got everything pretty much stable enough because you don’t want to give an appliance and spend so much time on it and then suddenly you know three months down the line they need a new crown and then restoration and a root canal and then things keep changing and a lot of appliances once things change they don’t fit so well or they need a lot of work and it’s not as predictable they’re better off just having a new appliance. So you need to get a patient who is stable most of the time now sometimes if they’ve got lots of work that’s required but all of it is conformative so we’re sort of sticking to their occluding scheme and all of that work is going to be posteriorly for example and maybe you need an appliance just to prevent them for doing any further damage then maybe in that case an anterior only appliance may be the best splint that could be the g-splint for the patient So factor in that if they will be likely in need or maybe they’ve already got a treatment plan that they need to complete and just being a little bit slow but that’s all planned treatment So think about the type of treatment that they may or will need in the future and how that may impact a constant need for new appliances is there a clever way that you can do it so for example one of the appliances i’ll talk about in future episodes called the FOS appliance, F-O-S and i love it because if i’m going to be doing a DAHL type case where i’m building up the anteriors I just gouge it out once i’ve built up their teeth and realign it to their teeth it’s the same splint they’re already used to it but now i’m able to do new dentistry for them yet still keep them on the same appliance. So have a think about if they need any further work. Are they stable? We should really be doing appliances for most time appliances on stable patients

Now obviously if you’re trying to deprogram them like a diagnostic appliance so get their sort of muscles relaxed prior to centric relation records for a future rehabilitation that’s different and again if this is a mumbo-jumbo to you don’t worry we’re going to cover it slowly and shortly in the next few episodes but bear in mind at the need for any future dental work and the last point to consider i’m sure there are more and i’ll probably cover them throughout the next few episodes in splintember but the last one i want to consider is the best splint is the one that actually gets the job done and what i mean by that is i mean a recent patient experience triggered this sort of point and it’s a patient i saw recently who has a lower left molar which is pretty much last chance saloon like it’s so weak and every year she comes in she breaks it and it gets restored and she saw me as an emergency so the first time i saw her and i said look this tooth really needs to come out and she’s like look i’m so desperate she’s about 23. ‘I really don’t want to lose this tooth, it’s not causing me any pain please please please can you patch it up again?’ I’m not into patch up dentistry you know i already try and convince my patients that look let’s get it sorted once and for all now. She’s a child minder and and funds are not in the best place at the moment so we think what can we do to minimize the risk of this tooth continually breaking away. 

Now she’s really good at not eating on that tooth which i know is a massive shame and i really hope she gets it fixed properly but she wears an appliance as well and her main issue is got she’s large muscle mastication and she’s a you know a strong parafunction or very strong signs of bruxism and she’s aware of it. Again one of those places that really know you know they really do it when they’re aware of it right? 

So her appliance is an upper one so it just doesn’t make sense if her weak tooth is lower one, lower molar and her appliance is the upper one that when she’s parafunctioning that weak tooth even though she’s protecting it during the day by not eating on it. That weak tooth is parafunctioning on plastic but it’s still receiving the lateral loads of parafunction because she showed me the appliance and i had a look and every time she’d grind left to right she’s grinding on that weak tooth no wonder it’s breaking away despite her being so careful on it. So for that patient don’t you think a lower appliance to actually cover over gently that very vulnerable tooth would have been the better appliance? So it’s got to be something that gets the job done. So those are some of the seven or eight factors which i think are important and those are all the things that make up the g splint. 

So if you haven’t started already i was only joking there’s no g-splint yet i’m joking. There isn’t, there’s no Gulati splint that was like an analogy, a comparison a way to think. So the g-splint is one that suits your patients needs the g splint is individual to every patient that’s what i was trying to get to basically there’s no one splint for every situation and now all those people that ask for a flow chart i’ll still try and make you a flow chart but can you see the problem with having a flowchart in this sort of topic? Because there’s so many different variables and i think I’ve only just scratched the surface with this episode about which is the best appliance because I’m going to talk about in-depth each and every appliance in the future episodes coming very soon but can you see the complexities and how even if i make a flow chart there’s too many ifs and buts and you know how far away do they live? Have they had orthodontics before? Do they snore i mean these are things that are so unique to every individual to decide which is the best appliance for that individual. 

So really i hope that gives you food for thought about which makes the best splint, it’s the g-splint it’s the one that’s best for your patient in front of you based on their individual needs so i hope you found that useful and check out the next few episodes of splintember I’ve got so much lined up for October as well I’m recording a couple times this month as well for future content to come out in November hey if you’re looking to come to the Michael Melkers course 27th and 28th november please check out occlusion2020.com and let me know i’m still recording these in september as i’m going along so if you want to know anything specific about splints please help me to to sort of add that content in to the sort of series on splints probably three or four episodes to come this month and i hope you’re enjoying splintember and join me for rest. 

Thanks so much for tuning in all the way to the end on this episode which i know wasn’t what you were expecting you were expecting me to say the michigan’s splint or a b splint or whatever is the best splint but no there’s so much more to it than that and that’s what makes this field so exciting and just for getting to too much i think but in the future episodes bear in mind that splints are great and they can really help your patient but you don’t want to be doing splints and that’s it you want to be doing the rehabs well you’re going to you want to be doing the fun dentistry splints are just part of it because guess what every time a really well known dentist does a full mouth rehab they’re pretty much always getting a splint afterwards.

So splints are also important but they’re not something that quite often is it you know have the splint and you’ll be sorted for life although it they can work that way a lot of times the patient still need our dentistry so that sort of flavor will be going in the future episodes and please subscribe to the newsletter on protrusive.co.uk. Thanks so much for listening all the best