Using EMA bloc material (available from Frantz Design Incorporated), block out any bridgework to prevent dislodging. If there are very few undercut areas, help cool the impression material with an air syringe before removing from teeth; if there are large undercut areas do not let the material cool as long. Remove and reseat the trays as thermoplastic material is cooling to avoid the tray fitting too tight. The trays should snap on and off the patient's teeth when completely cooled. If one of the trays come off too easily, see below. If trays fit too tight, reheat & reseat trays often as cooling, this will remove undercuts.

1) Heat ceramic cup full of water in microwave to 175 – 185º Fahrenheit, if water boils, cool 4 minutes.

2)  Drop one level scoop of thermoplastic material in cup of hot water.

3) When the beads are clear, remove from hot water with a cement spatula. (Wearing gloves protects your hands and keeps material from sticking to your skin)

4) Make a rope of thermoplastic material long enough to fill the lower tray from end to end.

5)  Immediately place lower tray (with pull-tab) in patient's mouth. Spring tray out toward cheeks before seating to avoid an abrupt edge at end of tray, which would irritate the tongue. Push down until lower teeth hit the bottom of the tray. Allow the material to cool on the patient's teeth 30 seconds. Remove and trim excess material at edge of tray with curved scissors to avoid soft tissue impingement. Replace lower tray before placing upper tray so trays will hit evenly when the patient bites down.

6)  Repeat steps 2 - 5 for upper tray. When seating upper tray, make sure teeth are in the middle of the tray. Trim thermoplastic material as on lower tray. Remove and replace both trays several times before cooling. You can smooth any sharp edges of thermoplastic with a blow pipe flame.

*** Trays will seem to fit too loose until completely cooled. Cool tray under running cold tap water until white. If after completely cooled, tray is too loose, place a very small amount of thermoplastic material in hot water to prepare an additional thin rope 1/8 to 3/16 of an inch in diameter. While thermoplastic material is heating and immediately prior to making rope, hold the loose fitting tray in cup of hot water to soften the exterior portion of the loose tray - approximately 10 seconds. Place the hot thin rope over the tooth imprints and re-seat on patient's teeth. Cool material with an air syringe. While in patient's mouth, remove and re-seat several times to make sure tray does not fit too tight. Once the trays fit properly, the patient can wear the temporary device for several weeks. Advise the patient not to reheating the device.

7)  With the fitted trays in place, have the patient bite down in centric occlusion (all the way posterior). Using an indelible pen, place a mark by the hole closest to the pin on upper tray. Have the patient protrude the mandible to his maximum. Place a mark by hole closest to this maximum protrusion.

8)  Have patient start "treatment" with pin in a hole half way between holes marked so mandible is 50% protruded. Caution patient of possible TMJ pain and the necessity of reporting any discomfort to you.

9)  Have patient continue to protrude mandible by moving pin forward to the next largest numbered hole. When patient's symptoms disappear, take impressions for a custom appliance. Note on patient's chart how many mm's mandible was protruded when symptoms disappeared. The holes are 3 mm apart.