Stretch Beyond Your Expectations.®

STEP 1.

Call our toll-free number and ask for your local sales consultant

STEP 2.

Fax the following information:

Patient information

Insurance information (include copy of insurance card)

Rx and/or Certificate of Medical Necessity (CMN)

Most recent chart notes

HOW TO ORDER DYNASPLINT® SYSTEMS:

The Dynasplint® Trismus System aids in restoring physical function and more importantly, quality of life to patients suffering from joint stiffness and limited range of motion in the posterior mandibular or temporomandibular region. Limitations in mandibular motion can be caused by TMJ dysfunction, radiation therapy, infection, surgery, trauma, or burns. In preliminary clinical trials the Dynasplint® Trismus System has been successful in treating these limitations. The key to its effectiveness is the low-load, prolonged-duration stretch (LLPS) technology that delivers a correct biological stimulus to create a permanent length change in shortened connective tissue.

Dynasplint Systems, Inc., the pioneer and market leader in dynamic splinting since 1981, has successfully treated more than a quarter of a million patients utilizing the proven principles of LLPS. Dynasplint® Systems are simple, yet reliable in design and function. Developed for home use they are an ideal adjunct to doctors‘ and therapists’ standard protocols.

As a direct result of our years of industry experience, our professional sales consultants provide comprehensive support to health care providers. This support includes product fitting and instruction, follow-up care, splint adjustment and protocol development. Dynasplint Systems, Inc. also assists with administrative responsibilities including insurance verification and direct billing.

Experience, Reliability, Knowledge, Service, Support—Results. Stretch Beyond Your Expectations. ®

L L PS (L ow-L oad, Prolonged-D uration S tretch) technology has successfully treated limitations of mandibular motion

E asy to use

B alancing barsprov ide hands free application

H igh patientcompliance

B iomechanicallycorrect

S imple, adjustable and reproducible bilateral tensioning system

Mouthpiece is padded to prov idemaximum comfort and safety

Av ailable forrent or purchase

C lin ic a l Ad v a n t a g e s o f t h e Dy n a s p lin t ® Tr is m u s Sy s t e m • U tilizes the clinically proven approach of “ Low-Load, Prolonged-Duration Stretch” (LLPS) — C onstantly seeks new end range to increase RO M. — U tilizes the T.E.R.T. principle (Total End Range Time) — G radually remodels the connective tissue• Does not require or rely on the patient to squeeze the unit to apply tension• C an be used for exercise & passive RO M• Approved by “ Medicare” • C an be “ customized” for individual patient requirements with “ oral impression” materials • Dynasplint Systems, Inc. handles all insurance processing• Dynasplint Systems, Inc. clinical sales consultants perform patient fittings

V ariable & fully reproducible tension settings: 0 – 2 .3 ft./lb. or 0 – 3 1.5 kg/cmWeight of U nit: .7 5 lb. without counter balance bars 1.3 5 lb. with counter balance barsRange of Motion / O ral O pening: Type I: 15 mm – 5 0 mm Type II: 9mm – 5 0 mmPatent # U S 6 ,4 13 ,2 3 1

C orporate H eadq uarters:8 00.6 3 8 .6 7 7 1 toll-free8 00.3 8 0.3 7 8 4 fax

C anada:8 00.6 6 8 .9 13 9 toll-free9 05 .8 5 1.3 4 9 4 fax

www.d y n a s p lin t .c o m

Europe:+ 3 1 (0)4 5 .5 23 .04 18 phone

+ 3 1 (0)4 5 .5 23 .13 03 fax

What are Dynasplint® Systems?

Dynasplint Systems, Inc. is the pioneer and market leader of dynamic splinting. Since 1981, Dynasplint® has aided patients in restoring physical function and gaining range of motion during rehabilitation.

What is Trismus?

Trismus is an involuntary contraction caused by damage to the muscles of mastication, temporomandibular joint and the oral and peri-oral connective tissues causing a restriction of the mouth opening. Trismus occurs when the muscles and connective tissue become damaged and shortened by physiologic structural changes. Significant functional disabilities associated with Trismus include: difficulty with eating and chewing, dysphagia, speech and articulation problems, compromised oral hygiene and difficulty in the fabrication, use and maintenance of oral prosthesis. Who is appropriate for the Dynasplint® Trismus System?

Patients who have range of motion (ROM) limitations as a result of impaired muscles of mastication and the TM are appropriate for the Dynasplint®. Mandible jaw limitation can be caused by cancer treatments such as: radiation therapy and/or head and neck surgery; oral and maxillofacial surgery, degenerative TM disease, chemical and thermal burns and any traumatic injury to the muscles of mastication and TMJ.

When can patients start using the Dynasplint® Trismus System?

The Dynasplint® Trismus System can be used as soon as the doctor releases the patient for passive range of motion. The sooner after onset, injury, surgery or radiation treatment the device is implemented; the faster results can be expected.

When is the Dynasplint® Trismus System applied?

Patients take the Dynasplint® home and use it 3 times a day for up to 30 minutes per session. Dynasplint® Trismus therapy is suggested 7 days a week.

Where is the Dynasplint® Trismus System applied?

The Dynasplint® Trismus is easily worn in the anterior part of the mouth while the patient relaxes. Proper placement is essential for the ideal stretch of the masticatory muscles. The patient can hand-hold the device or attach the counterbalance bars for hands-free therapy.

Why should a doctor choose a Dynasplint® Trismus System?

The Dynasplint® Trismus System is the most advanced home therapy treatment available. It is far superior to the commonly used tongue depressors. The Dynasplint® actively stretches the muscles of mastication and can be used for patients with openings as small as 9mm. Patients find it easy and comfortable to use.

How does the Dynasplint® Trismus System work?

The Dynasplint® Trismus System is based on low-load, prolonged-duration stretch (LLPS) technology. It is spring loaded for simple, adjustable, reproducible tension at each therapy session. This correct biological stimulus has been clinically proven to permanently lengthen and remodel shortened connective tissue.

Stretch Beyond Your Expectations.®

DY N A SP L IN T® TR ISM U S SY STE M

LANDMARKM E D I C A L

A Division of Dynasplint Systems, Inc.

CERTIFICATE OF MEDICAL NECESSITYCorporate Headquarters: 770 Ritchie Hwy, Suite W-21 Severna Park, MD 21146 Tel: 800-638-6771

Patient Name_______________________________________________________ M F Date______________

D.O.B.___________________________ Date of Onset of Illness/Injury/Surgery:_________________________________

Length of Time Needed: 1 month 3 months 6 months Other______________________________

Dynasplint Systems aid in restoring physical function to patients with joint stiffness and limited range of motion. The key

to its effectiveness is the low-load, prolonged-duration stretch (LLPS) that delivers a correct biological stimulus to create a

permanent length change in shortened connective tissue. Dynasplint Systems have been clinically proven to reduce time

and cost associated with range of motion rehabilitation– in many cases by more than 50 percent.

Fill as ordered. NO substitutions:

Trismus Dynasplint® System

Diagnosis/Cause of Trismus (limited oral opening)

Arthritis of Joint (ICD-9 Code)__________________________________

Congenital Deformity (ICD-9 Code)__________________________________

Cancer of the Head & Neck (ICD-9 Code)__________________________________

Radiation Induced (ICD-9 Code)__________________________________

Neurological (ICD-9 Code)__________________________________

Trauma (accident, surgery, etc.) (ICD-9 Code)__________________________________

Other:_______________________________ (ICD-9 Code)__________________________________

Current oral opening Range of Motion: (Active/Passive) _______/_______ mm (Adult Average is 45-50mm)

Does patient require a customized mouthpiece: Yes No

IS THE PATIENT CURRENTLY INVOLVED IN ANY THERAPY PROGRAM? Yes No

Physician Name:___________________________________________________________________________________

U.P.I.N.#______________________Phone:_____________________________Fax:_____________________________

Address:_________________________________________________________________________________________

________________________________________________________________________________________________

Physician Signature:_______________________________________________________________________________

Attending Therapist:___________________________ Sales Consultant: ______________________________________

This form is needed to bill the patient’s insurance. Please complete and return.

Fax to: Attn:___________________________ Sales Consultant: ___________________________

(Last, First, MI)

Stretch Beyond Your Expectations.®

Revision 2/06

T

800-380-3784