NeuroQuantology |February 2023 | Volume 21 | Issue 4| Page 234-247| Doi: 10.48047/NQ.2023.21.4.

NQ23021
Suresh Rajendiran et al/Deprogrammers- A Review of Literature

Deprogrammers- A Review of Literature

Suresh Rajendiran
MDS, Associate Professor, Department of Dentistry, Meenakshi Medical College Hospital & Research
Institute, Enathur, Kanchipuram-631552. INDIA
Faculty of Medicine, Meenakshi Academy of Higher Education & Research (MAHER) Deemed to be
University, Chennai-600078. INDIA
Email ID: [email protected]

ABSTRACT
Deprogrammers are dental devices that help to reduce or eliminate occlusal interferences by
temporarily separating the upper and lower teeth. This technique is used to diagnose, treat, and
prevent various dental problems, including temporomandibular joint disorders (TMJ), bruxism (teeth
grinding), and occlusal trauma. In dentistry, deprogrammers are often used in combination with
other treatment modalities, such as orthodontics and restorative dentistry, to achieve optimal
outcomes. Deprogrammers are custom-made appliances that are fabricated based on individual
patient needs. They are typically made of acrylic and designed to fit over the teeth in a specific way,
allowing for the separation of the upper and lower arches. The use of deprogrammers in dentistry is
considered a minimally invasive and reversible approach, making it a popular treatment option for
patients who are hesitant to undergo more invasive procedures. The benefits of using
deprogrammers in dentistry are numerous. For instance, they help to alleviate the symptoms of TMJ,
which can include pain, discomfort, and limited jaw mobility. They can also help to reduce teeth 234
grinding and clenching, which can cause tooth damage and other dental problems. Additionally,
deprogrammers can help to prevent future dental issues by identifying and correcting occlusal
interferences early on. Overall, deprogrammers are a valuable tool in modern dentistry. They offer a
non-invasive and effective way to diagnose, treat, and prevent various dental problems. With
continued advancements in dental technology, it is likely that deprogrammers will continue to play
an important role in the field of dentistry for years to come.
Keywords: Deprogrammers, TMD, Centric relation
DOINumber:10.48047/nq.2023.21.4.NQ23021 NeuroQuantology2023;21(4):234-247

INTRODUCTION muscles cause them to become patterned to

Recording the Centric Relation1 is one of the the deviated closure and these memorized
most critical steps in fabricating the prosthesis patterns of muscle activity are called muscle
or in diagnosing the extent of malocclusion. It splinting or “engrams “. This muscle activity
is the most stable and reproducible position to may prevent the condyles from seating
reconstruct the dentition. Muscles may appropriately when taking a centric relation
change the position of the jaw in the presence registration2. The ability of occlusion to
of occlusal interferences in an attempt to program muscle function through
3
protect the interfering teeth from potentially proprioceptive input has been termed
absorbing the entire force of contracting “occlusal programming” by Guichet. This same
musculature. The constant repetition of the phenomenon is described as the “favorable
proprioceptive trigger receptors to the reflex action” by Kronfeld, the “proprioceptive
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engrams system” by Dawson, and “muscle device has on the patient’s occlusion and
engrams” by Okeson. One idea is to combine resultant muscle activity found that when a
various devices to help relax inherent muscle device was placed in the anterior part of the
engrams, an action referred to as occlusion, muscle activity under light or heavy
deprogramming and the device used for loads decreased significantly.
deprogramming is a deprogrammer.
Regardless of what appliance is used, the goal
NEED is to get the upper and lower posterior teeth
Through deprogramming the neuromuscular separated to erase the muscle closure
system is given the opportunity to place the patterns and relieve the compensatory muscle
mandible in a position independent of patterns. The device should guide the muscle
occlusion. The resultant mandibular position is into a symmetrical, bilateral, easy muscle
influenced only by the activity of the contraction that creates a smooth hinge
antagonistic muscle groups attached to the action and proper bilateral orthopedic
mandible. Deprogramming can have a positioning of condyle.
significant effect on the position of the
mandible only if there is truly a discrepancy A number of deprogramming techniques are
between the nonmanipulated centric and being used in dentistry prior to making a
habitual centric condylar positions there are centric registration; the actual effectiveness of
no musculoskeletal impediments some of the techniques has not yet been
(constrictions of the muscles or the joint tested scientifically. Among these are
capsule). relaxation on cotton rolls or an anterior bite
jig, relaxation on an equalizer, use of the Myo-
CONCEPT monitor, use of acupuncture, use of hypnosis,
The concept of deprogramming is based on use of biofeedback procedures, opening and
the reflective relaxation of the lower jaw closing movements without tooth contact.
when the posterior teeth are not permitted to
engage. The various muscles that open and CLASSIFICATION 4
close the jaw learn and remember the level of
contraction needed to perform their Deprogramming devices are categorized as
movements in a coordinated, comfortable either active or passive. If the patient has to 235
way. By increasing the vertical dimension and use his or her muscle power to hold the device
separating posterior teeth, the occlusal between the teeth, the device is considered
interferences to centric occlusion are active. The active devices are Dawson
removed. deprogrammer and Leaf gauge
deprogrammer.
TECHNIQUES
If the device can be inserted and snapped over
For years clinicians have struggled to find the the heights of contour of the teeth or it uses
correct device or appliance to help deprogram another retention mechanism that does not
the muscle engrams of patients who present use any action of the patient’s muscles, it is
for minor and major dental reconstruction4. considered passive. Examples of passive
The classic approach directed clinicians to devices are Lucia jig/ Pankey deprogrammer,
insert something between the upper and Nociceptive Trigeminal Inhibition device, Kois
lower anterior teeth to separate them. Several deprogrammer, Cranham deprogrammer,
studies on the effects that location of the
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Mini deprogrammer, B-splint and Release appliance.

TYPES
LUCIA JIG / PANKEY DEPROGRAMMER4,5,6,16

In 1964, Lucia and Pankey created a device degrees posteriorly and superiorly from the
that attaches to the teeth using a hard setting occlusal plane.
bite registration material, compound17, or cold
cure acrylic. It can be made directly in the Fabrication
mouth or on a maxillary cast. The jig covers Dry orthodontic foil is well adapted to the
the maxillary central incisors and a small of maxillary central incisors, and the tooth
the palate with minimal internal spacing. Its contact position in centric relation is checked
outer surface is adjusted so that a lower in order to accurately estimate the amount of
central incisor contacts the smooth lingual interocclusal opening that will be necessary to
incline of the jig at only one point. The jig’s avoid tooth contact during registration. A
incline must stop the closure of the mandible cotton roll is placed between the teeth to
before posterior tooth contact, and this interrupt the proprioceptive mechanism while 236
lingual slope should be angled 45 to 60 the acrylic resin is being mixed.

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The cotton roll is removed, the doughy mix of acrylic resin trimmed to cover only the central
self curing acrylic resin is placed over the incisors. All tooth indentations are erased, the
incisors, the patient is bimanually manipulated jig is replaced in the mouth and using 237
into centric relation but without making tooth bimanual manipulation technique plus
contact, and the mandibular incisors are articulating ribbon, adjustment is carried out
brought into contact with the acrylic resin. until one point on one of the mandibular
Just before the acrylic resin finally sets it is incisors near the midline contacts one point
removed to ensure that it is not engaged in on the jig. The interocclusal opening should be
any undercuts. It is then repeatedly replaced enough to permit from tooth contact and
and removed until set, so that the teeth are placement of an occlusal recording material
not over heated. The jig is removed from the between the arches.
mouth, orthodontic foil extricated, and the

LEAF GAUGE DEPROGRAMMER4,6,7

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238

The leaf gauge deprogrammer was advocated by the addition or removal of leaves.
by V.O.Long in 1973. It is perhaps the most Previously, leaf gauges were made from
useful and practical alternative to the Lucia unexposed panoramic x ray film, which was
Jig. The leaf gauge, similar to a “feeler gauge”, developed to remove the emulsion coating,
consists of multiple sheets of plastic, one or thus providing a clear film. The film was then
more of which is placed between the incisors cut into 1 cm x 5 cm sections and bound
at an upward angle. The dentist can create together by some type of screw-post
anterior resistance at any vertical dimension fasteners.

Recently, a more sophisticated leaf gauge was provide a convenient measure and record of
described. It is made out of a thinner, more exact vertical opening between the incisors.
pliable plastic. The leaves are a uniform 0.1 Narrow more firm paper disposable leaf
mm thick and sequentially numbered to gauges are described by Woelfel.

NOCICEPTIVE TRIGEMINAL INHIBITION DEVICE (NTI )8

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The Lucia Jig was modified by Boyd, a adaptation of the Lucia Jig to provide for
researcher who discovered that if the canines mandibular movements while still suppressing
are considered part of posterior tooth clenching intensity.
complex and a device minimized any contact
on these teeth, unwanted elevator muscle The NTI is a pre-fabricated matrix that
activity could be eliminated. Thus he created eliminates all of the laboratory work and most
the Nociceptive Trigeminal Inhibition (NTI) of the chair side procedures(about 75%). Upon
device. This device offers narrowed anterior final delivery of an NTI device, incisal guidance
stop portions and discluding elements when should be ensured such that the Incisor edge
compared with the original Lucia/Pankey contact only on the Discluding Element (DE) --
device. no canine or posterior contacts in any position
and the degree of condylar translation and
The NTI is a tension suppression system that rotation kept to a miminum in all excursive
uses the body’s natural reflex protection when and protrusive positions. There is a risk of a 239
being used during waking hours. At night it lower canine contacting the DE of an upper
prevents and reduces the muscular NTI device .This is best prevented by a
component of migrane, chronic headache and mandibular device, with smooth transitioning
jaw disorders by preventing parafunctional through lateral, protursive and retrusive
contacting of canine and molar teeth. excursions.
The device is small, clear, taco shell- shaped Suppression of temporalis contraction
appliance that fits over the upper two front (clenching) can be achieved by exploiting the
teeth. Attached on the incisal edges of the nociceptive trigeminal inhibition reflex, also
taco shell is a bump or a bar that extends known as the jaw-opening-reflex. Direct
anteriorly and posteriorly to provide the point pressure stimulation of the mandibular
stop. NTI stands for Nociceptive Trigeminal incisor's periodontal ligament activates a
Inhibition. This is a technical way of saying the reflex loop which suppresses the temporalis'
jaw opening is a reflex, and this device contraction intensity (conversely,
provides a way to suppress the elevating anesthetization of the mandibular incisors
muscles of mastication. The NTI is the PDL's allows clenching intensity to increase.

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240

Historically, an anterior deprogrammer (such with the anterior-point-stop allows for

as a Lucia jig) or an anterior-point-stop has occluding of the posterior teeth, again
been advocated to establish and record allowing for high intensity clenching. Clearly,
optimal condylar position (CR) and to suppress all mandibular excursive positions, not just
acute muscular symptoms on a short term centric, must be considered when attempting
basis. Each is effective in clenching to suppress temporalis clenching. Modifying
suppression in centric positions. However, for an anterior point stop by extending the point
the deprogramming jig, excursive movements contact both anteriorly and distally provides
of the mandible can allow for a mandibular clenching suppression in all mandibular
canine to contact the device, allowing for movements (a prefabricated, retrofitable
ipsilateral near-maximal clenching and joint device - NTI)
strain. Protrusive movement of the mandible

KOIS DEPROGRAMMER4

The Kois deprogrammer is a Hawley bite central incisors and slightly discludes all teeth.
plane with a discluding element that contacts The design of Kois deprogrammer is not
the lower incisors on one point. It features a intended for nocturnal use, unless its
small anterior stop contacting the lower discluding element is extended labially to
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accommodate for protrusive parafunction. anterior’s cingulum, and not compress into
The palatal acrylic must be tooth borne by the palatal mucosa.

CRANHAM DEPROGRAMMER

241

The Cranham deprogrammer can be used for incisors and slightly discludes all the teeth. It is
equilibriation, centric relation records, or as a comfortable for the patient, requires no
night guard. This appliance features a small retention clasping, and is easy to use.
anterior stop contacting the lower central

MINI DEPROGRAMMER

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The Mini deprogrammer is designed with an disharmony and allows the condyles to
242
anterior bite plane, the appliance takes properly seat. A flat bite plane option is also
posterior teeth slightly out of contact to move available but will require a greater anterior
any interference that can cause muscle opening.

B-SPLINT9

The B-SPLINT is used for rapid harmonization studies consistently show up to 80% reduction
of occluso muscle disorders. Its effectiveness in elevator muscle activity due to clenching. It
is due to decreased muscle activity of the is designed on the same principle as the classic
lateral pterygoids, medial pterygoids, anterior deprogrammer but can be used for an
masseters and temporalis muscles created by indefinite period of time when managed
malocclusion and / or parafunction. Clinical properly.

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Fabrication

The appliance consists of a clear acrylic plate upper appliance/lingually on a lower

which is modified in the anterior region. appliance) to stay in contact when the
Orthodontic acrylic is mixed in a doughy stage mandibular incisors protrude out to an edge 243
and luted with liquid monomer to the incisor to edge position with the maxillary incisors. It
surface of the blank appliance. It is hand is very important that the platform be level
formed to create a platform that is thick with the bench top and thus create a
enough to discludes all teeth but the opposing perpendicular contacting surface for the
central incisors combined. It should be long opposing teeth. It is critical that no distalizing
enough to touch when the mandible is in the forces to the mandible be present when the
fully seated joint position as well as extended appliance is in place.
on a smooth horizontal surface(labially on an

DAWSON’S DEPROGRAMMER4,6

Dawson’s deprogrammer is the most basic cotton roll placed between the patient’s front
form of deprogrammer where in a simple teeth for 5 to 10 minutes before recording
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centric relation. For patients with minimal method works amazingly well.
amounts of muscle engrams to relax, this

RELEASE APPLIANCE4

244

Release appliance is a passive deprogramming The release appliance can be fabricated in the
device that respects the canines as part of the laboratory or in the dental office. It consists of
posterior group of teeth and narrows the a composite stop in the anterior covered with
platform. It allows the stop to be set at a a thin 1 mm thermoforming material. Further
desired occlusal vertical dimension, keeps the modification can be completed with the
upper and lower posterior teeth apart, and window record technique, where the molars
ultimately relaxes the muscle and eliminates are exposed to take the bite registration.
unwanted muscle engrams or compensations.

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Patient compliance is a vital part of the mandible’s position in the presence of occlusal
process. Typically, the appliance is delivered interferences owing to memorized patterns
late in the day, the day before the and proprioceptive sensory information. They
appointment to record the final restorative also hypothesize that the condyles are
245
OVD. Advise the patient to wear the appliance prohibited from being seated appropriately
as much as possible that night and schedule unless a deprogramming splint precedes CR
him or her to return the following morning. In bite registrations. Deprogramming splints are
the morning, the patient should remove the thought to provide a more physiological
appliance only to carry out normal oral muscular engram than what exists by allowing
hygiene and then reinsert the appliance. That the mastication muscles to mitigate
morning a liquid breakfast should be temporarily the proprioceptive errors caused
prescribed. by occlusal prematurities. Some orthodontic
gnathologists believe that patients, even
EFFECTS OF A DEPROGRAMMER patients without TMD, need to be
deprogrammed before their CR records are
The use of a deprogrammer strongly but obtained—sometimes for as long as three
temporarily decreased the masticatory muscle months. Some orthodontic gnathologists also
tone in all patients before recording centric argue that orthodontic patient diagnosis is not
relation.10,19,20 The use of deprogrammer has complete unless deprogramming splints and
no correlation on the terminal transverse articulator-mounted dental casts are used.
hinge axis of the mandible in healthy The need to ‘deprogram’ patients from their
patients.3,18 pre-existing occlusions with occlusal splints
before taking centric relation recordings is
USES OF DEPROGRAMMER6 controversial. Nonetheless, use of
The deprogrammer is used in the fabrication deprogramming splints lacks a true
of centric relation bite planes or splints, to physiological basis and the evidence to
make accurate centric relation jaw support it is equivocal. While some
records.14,15,16 NTI is used to treat chronic investigations have demonstrated a possible
cases of TMD13 benefit of deprogramming, others have not. In
addition, articles have discussed the
CONTROVERSIES11 techniques, benefits or both of
The need to "deprogram" patients from their deprogramming. Both sample studies used
pre-existing occlusions with occlusal splints deprogrammers for relatively short periods.
before taking CR recordings is controversial. Karl and Foley placed a "Lucia-type anterior
Gnathologists in general hypothesize that the deprogramming jig" (that is, anterior tooth
mastication muscles can affect adversely the contact without posterior tooth contact) in 40
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subjects with TMD for six hours and found The device that can be used by a dentist for a
differences of only fractions of a millimeter in particular patient depends on the clinical
centric registration when a deprogrammer situation and operator preferences or both.
was used; the difference may not be clinically
significant. Conversely, Kulbersh and REFERENCES
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