Effect of occlusal splints on TMJ symptomatology

Comparative evaluation of occlusal splint therapy and muscle energy technique in the management of temporomandibular disorders: A randomized controlled clinical trial

Background:

Contradicting evidence regarding the effects of occlusal splint therapy in the management of Temporomandibular disorder (TMD) and promising results shown by muscle energy technique.

Aim:

To determine and compare the effects of occlusal splint therapy, muscle energy technique, and combined treatment with education for self-management and counseling in the management of TMD.

Study Design and Settings:

Randomized clinical trial.

Methodology:

A total of 160 participants diagnosed with TMD according to Diagnostic Criteria/TMD axis I were randomly allocated into four treatment groups with equal allocation ratio using random numbers table. The main inclusion criteria were the presence of pain in the preauricular area, TMJ and/or muscles of mastication and maximum mouth opening <40 mm. Group A participants received muscle energy technique, Group B participants received occlusal splint therapy, Group C participants received combined treatment, and Group D participants received education for self-management and counseling (control). Control group treatment was provided to all the trial participants.

Statistical Analysis:

Intragroup comparison was made using Friedman test and Wilcoxon test while intergroup comparison was done using Kruskal–Wallis test and Mann–Whitney U test.

Results:

Intensity of pain on a visual analog scale and maximum mouth opening were measured at baseline, at 1 week, at 2 weeks, at 1 month, and after 3 months.

Conclusion:

Muscle energy technique, occlusal splint therapy and combined treatment significantly reduce pain compared to controls and muscle energy and combined treatment are superior to other groups for mouth opening improvements in patients with TMD.

Effect of arthrocentesis on the clinical outcome of various treatment methods for temporomandibular joint disorders

Background

We evaluated the improvement of pain and the increase in mouth opening after temporomandibular joint arthrocentesis and the possible association with various factors such as previous splint treatment, medication, and diagnosis.

Results

We studied 57 temporomandibular joint disorder patients who underwent arthrocentesis at Korea University Anam Hospital. These patients (24 males and 33 females, aged between 15 and 76 years) underwent arthrocentesis that was performed by one surgeon. The degree of mouth opening (assessed using the maximum mouth opening: MMO) and pain (assessed using the visual analog scale: VAS) were assessed pre- and post-arthrocentesis. The study also investigated whether treatment modalities other than arthrocentesis (medication and appliance therapy) were performed. Statistical analysis revealed that there was a significant difference in mouth opening and pain after temporomandibular joint arthrocentesis. Preoperative appliance therapy affected the results of arthrocentesis, but it was not statistically significant. With regard to pain relief, preoperative diagnosis did not show a significant difference. However, with regard to maximum mouth opening, patients with disc displacement without reduction with limited mouth opening (closed lock) showed the highest recovery (11.13 mm).

Conclusion

The average of MMO increase after arthrocentesis was 9.10 mm, and patients with disc displacement without reduction with locking (closed lock) showed most recovery in maximum mouth opening and it was statistically significant. The average pain relief of patients after arthrocentesis was 3.03 in the VAS scale, and patients using anterior repositioning splint (ARS) preoperatively showed the most pain relief.

The Effect of Clenching and Occlusal Instability on Body Weight Distribution, Assessed by a Postural Platform

The purpose of this research project was to investigate whether or not clenching and occlusal instability of Angle's Class I malocclusion have an effect on body weight distribution in healthy adult subjects. Twenty adults (fourteen males and six females, ages 27-40, mean age 31.7 years, SD 3.32) were included in this study. The MatScan (Tekscan Inc., Boston, MA) system was used to measure the body weight distribution changes of the subjects. Four body weight distribution measurements were taken for each subject while (1) the mandible was in the rest position (no tooth contact) (RES), (2) subject was clenching (maximum intercuspation of the teeth with heavy occlusal forces) (CL), (3) subject was clenching on the right side (with 1 mm disocclusion on the left side) (CLR), and (4) subject was clenching on the left side (with 1 mm disocclusion on the right side) (CLL). The lateral and the anteroposterior body weight distribution changes during the different clenching conditions (both sides, right, and left) were compared to those at which the mandible was at the rest position. The statistical significance of these results was tested with a Chi-Squared test (p<0.05). Based on the findings of the present study it was concluded that clenching and occlusal instability are associated with lateral body weight distribution changes.

The Effect of Flat Dual-Cure Stabilizer Occlusal Splint in Pain Relief of Individuals Suffering from Migraine Headaches

Background:

No study on the effect of dual-cure stabilizer splint without canine ramp in migraine patients is present.

Objective:

This study was conducted to determine the effects of maxillary flat dual-cure stabilizer occlusal splint on severity, frequency and episodes of headaches in individuals suffering from a migraine.

Methods:

In this interventional clinical trial, 30 eligible patients were divided into 2 groups (case and control); each group consisted of 8 men and 7 women. Dual-cure stabilizer splint was made for patients in the case group and they used the adjusted splint 20 hours a day for 6 weeks. The severity, frequency and episodes of migraine attacks before and after using the splint were determined. For grading pain, severity visual analogue scale was used. The data were analyzed using SPSS 20 and Kolmogorov-Smirnov test and paired t-test.

Results:

The severity, frequency, and episodes of migraine attacks before and after using the splint were reduced by 56%, 68%, and 72%, respectively. The reduction was statistically significant (p < 0.05).

Discussion:

Despite the effect of occlusal devices on the migraine disorder is controversial, the most researchers agree that using these appliances can be effective in reducing headache in migraine patients.

Conclusion:

Given the favorable effects of dual-cure stabilizer splint on reducing the severity, frequency and episodes of migraine headaches, the device can be used as an effective alternative therapy besides common pain-relieving methods.

Comparative evaluation of clinical performance of different kind of occlusal splint in management of myofascial pain

Purpose:

To determine the efficacy of hard, liquid, and soft splints in the management of myofascial pain dysfunction syndrome.

Materials and Methods:

In this randomized clinical trial, 45 patients with myofascial pain were diagnosed and were randomly assigned into three groups of 15 patients each. Group 1 - subjects were given hard splint, Group 2 - soft splint, and Group 3 - liquid oral splint for 3 months. Subjective pain analysis using Modified Symptom Severity Index (Mod-SSI) and objective pain analysis muscle palpation was performed at 7 days, 1 month, 2 months, and 3 months after splint insertion. The changes in mean pain value by both methods, in all three groups, were analyzed with Tukey test and Kruskal–Wallis H-test, respectively (P < 0.05).

Results:

Both Mod-SSI and palpation scores showed statistically significant reduction in pain for all three groups at the end of 3 months. However, the hard splints proved to be very effective in a shorter period of time, followed by liquid splints and finally soft splints.

Conclusion:

The result of this study advocates the use of any one of the three types of the occlusal splints in the therapeutic management of myofascial pain due to temporomandibular disorders.

Efficiency of pivot splints as jaw exercise apparatus in combination with stabilization splints in anterior disc displacement without reduction: a retrospective study

OBJECTIVE

To evaluate efficiency of pivot splints in jaw exercises, in combination with stabilization splints, in cases of anterior disc displacement without reduction of temporomandibular joint.

SUBJECTS AND METHODS

Twenty-three patients who referred to the prosthodontics clinic in 1995-1997 were included in the study, where anterior disc displacement without reduction of temporomandibular joint was diagnosed using magnetic resonance imaging and clinical examination. Pivot splints were used for jaw exercises for five minutes long; five times/day and stabilization splints were used at all other times. The patients were followed for 24 weeks. Lateral and protrusive excursions along with maximum mouth opening and were evaluated at each control. Bilateral palpation of temporal, masseter, sternocleidomastoid muscles and TMJ was assessed for pain perception before and after treatment. Data were statistically analyzed using Paired sample t-test and Independent Samples t-test (p < .05).

RESULTS

Mean mandibular range of motion measurements increased from 28.74 mm prior to 49.17 mm on maximum opening; right/left lateral excursion from 7.61 mm to 12.04 mm and 4.09 mm to 7.3 mm on protrusion after treatment. All changes observed before and after treatment were found to be statistically significant. (p < .001) Pain symptoms were eliminated at the end of 24 weeks of treatment in all patients.

CONCLUSION

Using pivot splints as an exercise regimen along with a stabilization splint may be a viable treatment option for patients with anterior disc displacement without reduction; as normal mandibular range of motion was established and pain was eliminated.

Treatment of Joint Pain and Joint Noises Associated with a Recent TMJ Internal Derangement: A Comparison of an Anterior Repositioning Splint, a Full-Arch Maxillary Stabilization Splint, and an Untreated Control Group

Pain and joint noises associated with temporomandibular joint (TMJ) internal derangement are often treated by using an intra-oral splint. This study evaluated whether an anterior repositioning splint (AR splint) could be more effective in the treatment of these symptoms than a full-arch maxillary stabilization splint (FAMS splint), because of its capability to re-establish immediately the normal condyle/disk relationship. The authors treated 40 patients (average age 16.8; range 8.0-24.0) with confirmed internal derangement, joint pain, and joint noises in at least one TMJ for at least two months, with AR splint (20 subjects) or FAMS splint (20 subjects); 10 untreated patients comprised the control group. Joint noise, joint pain, and the intensity of pain were assessed using a visual analogic scale (VAS), and the pain was characterized (i.e., constant or chewing/biting pain) and evaluated monthly for eight months. Significantly fewer AR splint patients experienced pain after four months of treatment. A significantly lower intensity of pain was experienced by the AR splint patients after two months of treatment. Significantly fewer AR splint patients experienced chewing/biting pain after eight months of treatment. The frequency of joint noises decreased over time, with no significant differences between the groups. In conclusion, the AR splint seems to be more effective in decreasing pain, but it seems to make no difference in the treatment of joint noises.

Oral surgery: part 3. Temporomandibular disorders

Temporomandibular disorders (TMDs) are a collection of conditions affecting the temporomandibular joint (TMJ), the muscles of mastication and/or associated structures. They are probably one of the most commonly presenting chronic orofacial pain complaints to the dental profession. TMDs are recognised as a chronic illness and exert biopsychosocial effects on the patient and should therefore be managed in a biopsychosocial manner. This chapter will firstly cover the basic anatomy of the TMJ and its associated structures and then go on to discuss the signs and symptoms, aetiology, diagnosis, and broad management options for TMDs.

Effect of simultaneous therapy of arthrocentesis and occlusal splints on temporomandibular disorders: anterior disc displacement without reduction

Objectives

This study sought to evaluate the effect of simultaneous application of arthrocentesis and occlusal splint.

Materials and Methods

A retrospective study of 43 patients (3 males, 40 females) whose symptoms had improved was conducted at the Department of Oral and Maxillofacial Surgery, Dong-A University Hospital between 2008 and 2010. Subjects were divided into three groups: Group A (17 patients with arthrocentesis and occlusal splints simultaneously applied), Group B (13 patients whose symptoms did not improve with occlusal splints, undergoing arthrocentesis after occlusal splint use for 8 weeks), and Group C (13 patients that only used occlusal splints). We compared these groups in maximum comfortable opening (MCO) and the visual analogue scale of pain and noise. Follow-up was performed at 1 week, 1 month, 3 months, and 6 months.

Results

The improvement of symptoms was noted in all three groups, but Group A had a quicker improvement than the other groups, in terms of pain reduction and MCO increases.

Conclusion

The simultaneous application of arthrocentesis and occlusal splints can reduce patient discomfort more quickly.

Correlation between centric relation&#x2013;maximum intercuspation discrepancy and temporomandibular joint dysfunction

OBJECTIVE

To investigate the relationship between centric relation-maximum intercuspation (CR-MI) discrepancy and temporomandibular joint dysfunction (TMD) in pre-treated orthodontic patients.

MATERIAL AND METHODS

The study involved an experimental group of 107 pre-treated orthodontic patients with signs and symptoms of TMD aged 18-32 years, and a control group of 70 students with no signs and symptoms of TMD aged 20-30 years. The psychological condition of subjects was evaluated using two standard questionnaires, and a clinical examination performed to assess masticatory musculature and temporomandibular joint (TMJ) function, and to establish the presence or absence of TMD. Helkimo indices, the anamnestic dysfunction index (Ai) and the clinical dysfunction index (Di), were determined. Dental casts were mounted on a semi-adjustable articulator in CR using a CR bite record taken by bilateral manipulation and verified by load testing and face bow records. Differences in condylar position between CR and MI in the three planes of space were determined using the condyle position indicator.

RESULTS

A positive CR-MI discrepancy, defined as a discrepancy exceeding 1 mm in the vertical or horizontal planes or 0.5 mm in the transverse plane, was found in 72.9% of the experimental and 11.4% of the control group. Comparison of the groups showed a significant difference (χ² = 22.67, P < 0.001). CR-MI discrepancy was significantly correlated with Di and Ai in all subjects (P < 0.01).

CONCLUSIONS

There was CR-MI discrepancy in most of the pre-treated patients with signs and symptoms of TMD. This discrepancy may be a contributory factor to the development of TMD in these patients.

Patient responses to vacuum formed splints compared to heat cured acrylic splints: pilot study

OBJECTIVE

Vacuum formed and heat cured acrylic splints have been used in the diagnosis and treatment of temporomandibular disorders. The aim of this study was to evaluate patient's preference to either the vacuum formed or the heat cured acrylic splint.

MATERIAL AND METHODS

Twenty patients planned to receive splints were chosen from the dental school. Both types of occlusal splints were fabricated for each of them. Each patient used the splints alternatively on a nightly basis for 3 weeks. After 3 weeks, each patient completed a questionnaire regarding the comfort, fit, retention, occlusal contact, taste, gingival and lip irritation, smoothness and smelling. Statistical analysis was conducted by the MacNemar's Chisquare test.

RESULTS

There was no statistical difference in patient's responses to the different splint materials except for the comfort of wearing through the night.

CONCLUSION

The vacuum formed and heat cured acrylic splint may be equally worn in patient preference for treatment of temporomandibular disorders.

Oral appliances in the management of temporomandibular disorders

Various types of oral appliances (OAs) have been used for over half a century to treat temporomandibular disorders (TMDs), but there has been considerable debate about how OAs should be designed, how they should be used, and what they actually do therapeutically. However, there is enough information in the scientific literature at this time to reach some evidence-based conclusions about these issues. The main focus of this review is on the materials and designs of various OAs in terms of their proposed mechanisms of action and their claimed clinical objectives. Based on current scientific evidence, an analysis is presented regarding the role that OAs can or cannot play in the management of TMDs. Finally, the concept that OAs may be an effective treatment modality for some TMDs owing to their potential for acting as an elaborate placebo rather than any specific therapeutic mechanism is considered.

The treatment of painful temporomandibular joint clicking with oral splints

BACKGROUND

The authors compared the efficacy of bilateral balanced and canine guidance (occlusal) splints in the treatment of temporomandibular joint (TMJ) pain in subjects who experienced joint clicking with a nonoccluding splint in a double-blind, controlled randomized clinical trial.

METHODS

The authors randomly assigned 57 people with signs of disk displacement and TMJ pain into three groups according to the type of splint: bilateral balanced, canine guidance and nonoccluding. The authors followed the groups for six months using analysis of a visual analog scale (VAS), palpation of the TMJ and masticatory muscles, mandibular movements and joint sounds. They used repeated analysis of variance and a chi(2) test to test the hypothesis.

RESULTS

The type of guidance used did not influence the pain reduction, yet both occlusal splints were superior to the nonoccluding splint, on the basis of the VAS. Despite similar outcomes in relation to opening, left lateral and protrusive movements, TMJ and muscle pain on palpation, subjects who used the occlusal splints had improved clinical outcomes. The frequency of joint noises decreased over time, with no significant differences among groups. Subjects in the groups using the occlusal splints reported more comfort.

CONCLUSION

The type of lateral guidance did not influence the subjects' improvement. All of the subjects had a general improvement on the VAS, though subjects in the occlusal splint groups had better results that did subjects in the nonoccluding splint group.

Anterior midline point stop device (AMPS) in the treatment of myogenous TMDs: Comparison with the stabilization splint and control group

Two occlusal splints, the full-arch stabilization splint and the anterior midline point stop (AMPS) device, were evaluated for their efficiency in relieving myogenous temporomandibular disorders (TMD). One hundred and fourteen patients with myogenous TMD were distributed into 3 groups. The first group was treated with the AMPS device, the second with the stabilization splint, and the third group was the control group. Pain intensity was scored using the visual analogue scale before treatment and 1 month and 3 months after treatment. Statistical Package for the Social Sciences (SPSS, Chicago, Ill) and multiple comparisons tests were used to compare results before and after treatment and to compare the groups. The use of AMPS device in the first group resulted in a significant improvement after 1 month and 3 months (P < or = .001) and showed a 56.66% pain reduction. A significant improvement was also noticed in the second group (P = .001) with a 47.71% pain reduction. Although pain reduction percentage appeared more in the first group, this was not statistically significant. There was a highly significant difference between groups treated with both kinds of splints and the control group. It was concluded that both types of occlusal splints are beneficial to patients with myogenous TMD.

Clinical factors affecting the outcome of occlusal splint therapy of temporomandibular joint disorders

The purpose of this study was to test the hypothesis that (1) the presence of a clinical temporomandibular joint-related disorder has effects on short-term changes in temporomandibular joint pain, and that (2) clinical variables of time since pain onset predict treatment outcomes of occlusal splint therapy. The study comprised 76 patients with unilateral temporomandibular joint pain. The clinical disorder subgroup included 47 patients with a clinical pain side-related diagnosis of internal derangement type I (n = 16), internal derangement type III (n = 19), and degenerative joint disease (n = 12). The clinical non-disorder subgroup consisted of 29 patients without a temporomandibular joint disorder. A logistic regression analysis was used to compute the odds ratio for the clinical variables of time since pain onset, adjusted for age, gender, pretreatment pain level, and clinical subgroup. For the temporomandibular joint pain measurements there was no significant 'session'/'clinical subgroup' interaction (P = 0.470). Significant increase in benefit of a successful outcome of 'pain reduction >70%' occurred with a time since pain onset of <or=6 months (15.1 odds ratio) (P = 0.003). The odds ratio that a patient with a time since pain onset of >2 years might belong to the unsuccessful treatment group of 'pain reduction <30%' was strong (6.0) and significant (P = 0.026). Diagnosis of temporomandibular joint disorder proved not to be linked to changes in therapeutic outcome measures of temporomandibular joint pain. Time since pain onset was an important prognostic determinant of successful occlusal splint therapy.

Efficacy of stabilization splints for the management of patients with masticatory muscle pain: a qualitative systematic review

This study aimed at providing an answer to two clinical questions related to patients with masticatory muscle pain: 1) Does the use of a full-coverage hard acrylic occlusal appliance (stabilization splint) lead to a significant decrease of symptoms? and 2) Is the treatment success achieved with a stabilization splint more pronounced than the success attained with other forms of treatment (including placebo treatment) or no treatment? A systematic search was carried out in different electronic databases, supplemented by handsearch in four selected dental journals and by examination of the bibliographies of the retrieved articles. Thirteen publications, representing nine controlled clinical studies, could be identified. Reporting quality of most studies as assessed with the Jadad score ranged from 1 to 5. Based on the currently best available evidence it appears that most patients with masticatory muscle pain are helped by the incorporation of a stabilization splint. Nevertheless, evidence is equivocal if improvement of pain symptoms after incorporation of the intraoral appliance is caused by a specific effect of the appliance. A stabilization splint does not appear to yield a better clinical outcome than a soft splint, a non-occluding palatal splint, physical therapy, or body acupuncture. The scarcity of current external evidence emphasizes the need for more and better clinical research.

Electromyographic evaluation of masseter and anterior temporalis muscles in patients with temporomandibular disorders following interocclusal appliance treatment

The purpose of this study is to evaluate the interocclusal appliance efficiency in patients with temporomandibular disorder (TMD), by using computerized electromyographic (EMG) evaluation in the rest position of the mandible. Twenty-two patients (male and female) with TMD symptoms, between 18 and 53 years of age, were examined. EMG evaluations were performed before the treatment and during the 90th, 120th and 150th day of using the interocclusal appliance therapy. In the 90th and 120th day, inserting canine guidance and group function disclusion, respectively, changed interocclusal appliance. The results showed that group function disclusion caused shorter EMG activity in the mandible rest position for the anterior temporalis muscle.

Craniofacial pain and motor function: pathogenesis, clinical correlates, and implications

Many structural, behavioral, and pharmacological interventions imply that favorable treatment effects in musculoskeletal pain states are mediated through the correction of muscle function. The common theme of these interventions is captured in the popular idea that structural or psychological factors cause muscle hyperactivity, muscle overwork, muscle fatigue, and ultimately pain. Although symptoms and signs of motor dysfunction can sometimes be explained by changes in structure, there is strong evidence that they can also be caused by pain. This new understanding has resulted in a better appreciation of the pathogenesis of symptoms and signs of the musculoskeletal pain conditions, including the sequence of events that leads to the development of motor dysfunction. With the improved understanding of the relationship between pain and motor function, including the inappropriateness of many clinical assumptions, a new literature emerges that opens the door to exciting therapeutic opportunities. Novel treatments are expected to have a profound impact on the care of musculoskeletal pain and its effect on motor function in the not-too-distant future.

The short-term effect of stabilization-type splints on local cross-sectional dimensions of muscles of the head and neck

STATEMENT OF PROBLEM

Patients with temporomandibular disorders may have a cluster of joint and muscle disorders characterized primarily by pain, joint sounds, and irregular or deviating jaw function.

PURPOSE

This study evaluated changes in local cross-sectional dimensions of muscles of the head and neck associated with short-term application of "splint therapy" using the diagnostic approach of high resolution gray-scale ultrasonography.

MATERIAL AND METHODS

The study included 15 subjects with signs and symptoms of temporomandibular disorders, 10 in the internal derangement type (IDT) III-a group, and 5 in the myalgia type I (MT I) and myalgia type II (MT II) group. Ultrasonographic investigation was performed with a linear (B-scan) 7.5 MHz small-part transducer to visualize the anterior temporalis, anterior and deep masseter, anterior and posterior digastric, and sternocleidomastoid muscles. The absolute asymmetry index was used to assess local muscle asymmetry patterns and to evaluate the respective effect of occluding splints, with the mean maximum muscle diameter of the respective right and left sides calculated from 3 consecutive measurements before and after splint therapy.

RESULTS

A comparison of pretreatment with 2-month follow-up values revealed a slight decrease in the overall mean local cross-sectional dimensions in the internal derangement type III-a group (0.3 mm) and a moderate decrease in the myalgia type I/II group (3.3 mm). With an overall mean pretreatment absolute asymmetry index of 1.3% for the internal derangement type III-a group and 0.5% for the myalgia type I/II groups, the 2-month follow-up showed the internal derangement type III-a group to be associated with a moderate (1.2%) and the myalgia type I/II groups with a slight (0.1%) decrease in the respective overall mean pretreatment absolute asymmetry indices.

CONCLUSION

This study suggests that stabilization-type splints are effective in the reduction of local muscle thicknesses and asymmetries. Further studies are necessary to evaluate muscle-site specific effects in patient and nonpatient groups and to relate these effects to variables such as bite force, preferred chewing side, facial structure, and occlusion.

Oral splints: the crutches for temporomandibular disorders and bruxism?

Despite the extensive use of oral splints in the treatment of temporomandibular disorders (TMD) and bruxism, their mechanisms of action remain controversial Various hypotheses have been proposed to explain their apparent efficacy (i.e., true therapeutic value), including the repositioning of condyle and/or the articular disc, reduction in the electromyographic activity of the masticatory muscles, modification of the patient's "harmful" oral behavior, and changes in the patient's occlusion. Following a comprehensive review of the literature, it is concluded that any of these theories is either poor or inconsistent, while the issue of true efficacy for oral splints remains unsettled. However, the results of a controlled clinical trial lend support to the effectiveness (i.e., the patient's appreciation of the positive changes which are perceived to have occurred during the trial) of the stabilizing splint in the control of myofascial pain. In light of the data supporting their effectiveness but not their efficacy, oral splints should be used as an adjunct for pain management rather than a definitive treatment. For sleep bruxism, it is prudent to limit their use as a habit management aid and to prevent/limit dental damage potentially induced by the disorder. Future research should study the natural history and etiologies of TMD and bruxism, so that specific treatments for these disorders can be developed.

A pilot study comparing the efficacy of hard and soft stabilizing appliances in treating patients with temporomandibular disorders

STATEMENT OF PROBLEM

Soft and hard stabilizing appliances have been used to treat temporomandibular disorders. No data exist to suggest whether a hard or soft appliance is beneficial.

PURPOSE

This study compared soft and hard acrylic resin stabilizing appliances in the reduction of masticatory muscle pain in patients with temporomandibular disorders.

MATERIALS AND METHODS

Twenty-three patients with at least one clinical sign from the list of diagnostic subgroups of temporomandibular disorders were alternately assigned a hard or soft appliance for temporomandibular disorder treatment. No other temporomandibular disorder treatment (self-care, physical therapy, biofeedback, or muscle or joint injections) was rendered. Each patient was seen by two dentists at each visit. One dentist initially fabricated the appliance and adjusted the appliance on each visit and an examining dentist examined the patient each visit and recorded signs of temporomandibular disorders. The appliance material (soft or hard) was not disclosed to the examining dentist, only to the dentist who fabricated and adjusted the appliance. Patients were examined and appliances were adjusted every 2 to 3 weeks for a minimum of 10 weeks. Masticatory muscles were palpated and charted on each visit. Data were analyzed and subjected to nonparametric Mann-Whitney test.

RESULTS

Eighteen of the initial 23 patients, 7 in the hard appliance group and 11 in the soft appliance group finished the study over 10- to 15-week period. Soft and hard appliances performed the same in reduction of masticatory muscle pain.

CONCLUSION

This study suggests, based on the limited number of participants, that soft and hard stabilizing appliances may be equally useful in reducing masticatory muscle pain in short-term appliance therapy.

Effect of anterior repositioning splints on the electromyographic activities of masseter and anterior temporalis muscles

The effect of anterior repositioning (AR) splint therapy on masticatory muscle activity was investigated in seventeen patients with internal derangement; disk displacement with reduction in particular. Integrated electromyography (EMG) recordings from the masseter and anterior temporalis muscles were analyzed quantitatively during maximal biting in intercuspal position before and after eight week treatment period, EMG recordings were taken for each subject prior to the beginning of clinical therapy and final EMG recordings were made without AR splint to provide a standard for comparison. The results of the investigation revealed the following: 1. AR splint therapy did not cause any significant modification of the EMG activity in the recorded muscles during maximal biting in intercuspal position; 2. Before and after treatment the EMG activity from the masseter muscle was less than from the temporal muscle; 3. AR splint therapy resulted in reduction of the pain (88.2%) and jaw joint sounds (64.7%) and mean vertical opening which was 42.17 mm before treatment increased to 45.06 mm.

Clinical effect of full coverage occlusal splint therapy for specific temporomandibular disorder conditions and symptoms

PURPOSE

The purpose of this retrospective study was to evaluate the effect of maxillary full-coverage occlusal splint (stabilization splint) therapy for specific temporomandibular disorders and their symptoms/signs.

MATERIAL AND METHODS

This study assessed the outcome of 232 patients who were suffering from chronic pain on movements, joint noise except reciprocal clicking, and difficulty of mouth opening. All were treated with the stabilization splint alone.

RESULTS

The total remission rate was 41% and, including those reporting some improvement, the rate was 84%. The presence of displaced disk significantly decreased the success rate. However, the presence or absence of radiographic changes in the temporomandibular joint did not influence the treatment outcome.

CONCLUSION

From this study, it is suggested that the stabilization splint therapy may be a useful treatment modality in treatment of temporomandibular disorders, especially for the patients without clinical evidence of displaced disk.

Use and effectiveness of splint appliance therapy: review of literature

Interocclusal orthopedic appliances of varied design and application have been employed in the treatment of myofascial pain dysfunction (MPD) and temporomandibular joint disorders (TMD). These appliances provide the practitioner with a non-invasive, reversible form of intervention to manage the patient's symptoms. Literature on the use and effectiveness of these appliances has become readily available and now requires retrospective evaluation. However, comparison of results from studies making use of interocclusal orthopedic appliance therapy is difficult due to the employment of various outcome measurement scales, subjective evaluation of patient outcome, and variability in reporting of treatment outcomes. The aim of this paper is to review the effects and success rates of the various appliances reported in the literature and provide the practitioner with useful information that may be of assistance in the prediction of outcome and success of splint appliance therapy.

Evidence-based care of musculoskeletal facial pain: implications for the clinical science of dentistry

The authors assert that advancement of dentistry as a clinical science has been hampered by a failure to practice evidence-based care, which incorporates principles derived from clinical epidemiology. The schism between the cultures of researcher and practitioner was most evident at a recent National Institutes of Health Technology Assessment Conference on the Management of Temporomandibular Disorders.

Elongated styloid process in a temporomandibular disorder sample: prevalence and treatment outcome

An elongated styloid process is an anatomic anomaly present in 2% to 30% of adults; it is occasionally associated with pain. Its prevalence among patients with classic temporomandibular disorder pain symptoms is unknown. The effect of conservative treatment on patients who have symptoms of temporomandibular disorders and an elongated styloid process is also unknown. The objectives of this study were to determine the prevalence of the elongated styloid process in a sample of patients with temporomandibular disorders and to compare patients with and without the elongated styloid process on initial presenting signs and symptoms and treatment outcome. A total of 100 panoramic radiographs of patients with symptomatic temporomandibular disorders were examined to ascertain the presence or absence of an elongated styloid process. All patients participated in a conservative treatment program of biofeedback and stress management and a flat-plane intraoral appliance. Initial symptoms and treatment outcome of patients with and without an elongated styloid process were compared by use of multivariate analysis of variance on several oral-paraoral and psychosocial-behavioral methods. The prevalence of an elongated styloid process in this clinic sample of temporomandibular disorders was 27%. The patients with or without an elongated styloid process were not significantly different in pretreatment symptoms, and both groups exhibited substantial treatment gains. However, patients with an elongated styloid process showed significantly less improvement on unassisted mandibular opening without pain than did patients who did not have an elongated styloid process. This suggests that an elongated styloid process may place structural limitations on pain-free maximum mandibular opening. The results support conservative management of patients with symptoms of temporomandibular disorders when an elongated styloid process is present.

Effects of occlusal splints on the asymmetry of masticatory muscle activity during maximal clenching

The effects of stabilization splints on the electromyographic activity patterns of the masseter and anterior temporal muscles during maximal clenching in healthy subjects and subjects with different types of stomatognathic dysfunction syndrome were investigated. No marked effect of splints on the asymmetry of muscle activity during bilateral clenching was revealed immediately after splint insertion. During unilateral clenching in the intercuspal position (ICP), the relative asymmetry index (rAI) of the masseter muscles, detecting the imbalance of left and right muscular activity, was significantly increased. The use of splints suppressed the asymmetry of masseter muscle activity during unilateral clenching. This result suggests that the use of a splint is a method of suppressing clench-caused aggravation of stomatognathic dysfunction in the presence of an imbalance between left and right muscle activities.

The effect of occlusal splint therapy on different curve parameters of axiographic TMJ tracings

Computerized axiography was used as an objective instrumental method of evaluating the response of patients with temporomandibular joint (TMJ) symptomatology to occlusal splint therapy. Diagnosis was performed in a standardized manner by systematically analyzing TMJ path tracings obtained by computerized axiography. Thirty-six patients were axiographed before and after therapy with full-arch occlusal stabilizing appliances, followed by assessing the effect of therapy on various path curve parameters. The data obtained for the patient group treated with splints was compared to that of six patients also axiographed, but left untreated for a period of six weeks before a second TMJ tracing was obtained. The results show that splints have a certain effect on reciprocal TMJ clicking (response rate 67%). Retral stability and path characteristics are also substantially improved (response rates 44% and 40%). Less influence was noted on hypomobile joint paths (response rate 29%), the quality of movements (response rate 28%) and Bennett angle values (response rate 23%). Patients with disk displacements without reduction were not treated with splints, they underwent surgery. Their results will be reported later. By contrast, TMJ tracings in the control group remained essentially unchanged.

The efficacy of oral splints in the treatment of myofascial pain of the jaw muscles: a controlled clinical trial

Oral splints are widely used in the treatment of myofascial pain of masticatory muscles, even though their mechanism of action is unknown. The present study evaluated the therapeutic efficacy of splints using a parallel, randomized, controlled and blind design. Following a sample size estimation, 63 subjects were recruited and assigned to 3 groups: (1) passive control: full occlusal splint worn only 30 min at each appointment; (2) active control: palatal splint worn 24 h/day; and (3) treatment: full occlusal splint worn 24 h/day. On each of 7 visits over 10 weeks, subjects rated on 100 mm visual analogue scales their pain intensity and unpleasantness at rest and after experimental mastication. The effect of pain on the quality of life was also rated on category scales. All pain ratings decreased significantly with time, and quality of life improved for all 3 groups. However, there were no significant differences between groups in any of the variables. These data suggest that the gradual reduction in the intensity and unpleasantness of myofascial pain, as well as the improvement of quality of life during the trial, was non-specific and not related to the type of treatment.

Effects of intraoral appliance and biofeedback/stress management alone and in combination in treating pain and depression in patients with temporomandibular disorders

To assess the differential efficacy of two commonly used treatments for temporomandibular disorders (TMD), intraoral appliances (IAs) and biofeedback (BF), separately and in combination, two studies were conducted. The first study directly compared IA treatment, a combination of biofeedback and stress management (BF/SM), and a waiting list control group in a sample of 80 TMD patients. Both treatments were determined to be equally credible to patients, ruling out this potential threat to the validity of the results obtained. The results demonstrated that the IA treatment was more effective than the BF/SM treatment in reducing pain after treatment, but at a 6-month follow-up the IA group significantly relapsed, especially in depression, whereas the BF/SM maintained improvements on both pain and depression and continued to improve. The second study examined the combination of IA and BF/SM in a sample of 30 TMD patients. The results of this study demonstrated that the combined treatment approach was more effective than either of the single treatments alone, particularly in pain reduction, at the 6-month follow-up. These results support the importance of using both dental and psychologic treatments to successfully treat TMD patients if treatment gains are to be maintained.

Measuring the impact of a dental practice on TM disorder symptoms

This article describes a practical, quantitative method of measuring changes in temporomandibular disorder (TMD) symptoms in a dental practice. It applies the TMJ Scale to produce a number of clinically important measures of treatment effectiveness. Those measures include pre- and post-treatment symptom severity, percent of patients improved, level of improvement, and percent of patients converting to non-symptomatic after treatment. All of these outcome parameters were applied to a sample of the practice and to subgroups based on age, sex and problem length. The treated patients were compared to a group of diagnosed but untreated patients. The specific target symptoms of TMD are analyzed including pain, palpation pain, joint dysfunction and limited range of motion of the mandible. In addition, the overall symptom severity of the TM disorder, psychological factors and stress are studied, leading to an assessment of symptom change. The results support the concept that patients with acute problems are more treatment responsive than are patients with chronic problems. This suggests that careful screening and earlier detection of TMD may have an important impact on ultimate treatment outcome.

Passive eruption in the treatment of craniomandibular dysfunction: a posttreatment study of 151 patients

There is sparse posttreatment evaluation of craniomandibular dysfunction (CMD). This study describes the use of an orthopedic interocclusal appliance with passive eruption for the treatment of CMD. The clinical results of 151 patients treated using the passive eruption procedures were assessed at a follow-up time averaging 1.75 years after treatment with a highly structured telephone interview questionnaire. The treated patient population was chronic, averaging 2.58 years in pain and 2.25 previously ineffective treatments for their CMD. Although this was a subjective inquiry, the treated patients confirmed significant reductions in symptoms, a decrease in pain and interference ratings, and reduced health care utilization. A subgroup of 38 patients who previously had no relief with flat-plane therapy exhibited similar positive results. Treatment failures were also assessed but were low. The results are discussed in terms of the patients' support of the efficacy of the passive eruption procedure, including the need for future research.

A comparative study of three therapeutic modalities in a temporomandibular disorder (TMD) population

A comparative study of three treatment modalities, pharmacologic, occlusal appliance, and their combined use, was conducted to test their therapeutic efficacy on 61 temporomandibular disorder (TMD) patients. Alprazolam (Xanax) was used for the pharmacologic treatment; the occlusal appliance therapy consisted of a flat maxillary stabilization splint. Of the 61 patients, 19 received Alprazolam, 30 received occlusal appliance therapy, and 12 received combined therapy. Subjects were examined at two-week intervals for two months. Only 42 patients attended all follow-up visits. Eight parameters were studied: severity of pain, periodicity of pain, self-evaluated stress, muscle sensitivity to palpation, joint sensitivity to palpation, joint noises, limitation of opening, and limitation of lateral movement. No significant difference was found between the treatment modalities for most of the parameters. All three proved to be effective. Alprazolam increased the restricted mandibular movement, was least effective on joint sensitivity to palpation, and had no effect on joint noises. The combined treatment approach not only failed to prove superior to the other treatments, but showed less improvement in some parameters, possibly due to the small sample.

A graphic evaluation of the intermaxillary relationship before and after therapy with the Michigan splint

The effect of the Michigan splint was evaluated graphically in a group of 19 patients. Gothic arch tracings were registered before and after a period of therapy of 4 months, and the two tracings were compared photographically. The position of the apex of the Gothic arch was displaced in most patients, while the shape of the arch was more regular in almost all patients. The validity of the use of the Michigan splint was confirmed.

Immediate electromyographic response in masseter and temporal muscles to bite plates and stabilization splints

The immediate influence on masticatory muscle activity of bite plates and stabilization splints was investigated in control subjects and patients with craniomandibular disorders. Electromyographic surface recordings were performed from the masseter and temporal muscles bilaterally with and without the appliances in situ. In the rest position, no significant change in average activity was registered in any muscle with either appliance. Activity during maximal biting on stabilization splints was not different from that without the appliance while bite plates caused a decrease in activity in both muscles in both groups. The reduced maximal activity was probably due to the smaller number and exclusively anterior positioned occlusal contacts on the bite plate.

A short-term evaluation of the effectiveness of stabilization-type occlusal splint therapy for specific symptoms of temporomandibular joint dysfunction syndrome

To clarify the short-term effectiveness of stabilization-type occlusal splint therapy, a specific symptom approach was used toward 30 temporomandibular joint dysfunction patients with more than two major symptoms (temporomandibular joint and/or masticatory muscle pain, temporomandibular joint sounds, and limitation of mandibular movement). Eighty-seven percent of the patients with pain responded with this therapy and more than 50% had complete relief of pain 4 weeks after insertion of the splint. Temporomandibular joint sounds and limitation of mandibular movement responded more slowly than pain. These results suggest that the stabilization-type occlusal splint should be selected as a first choice among several therapies and that temporomandibular joint pain is particularly susceptible to this therapy.

The immediate effect of splint-induced changes in jaw positioning on the asymmetry of submaximal masticatory muscle activity

Maxillary full-arch splints in the retruded position (RP) and in a right lateral occlusion (1.0-1.5 mm to the right of the retruded contact position) were fabricated for ten subjects. Surface electromyography of the masseter and anterior temporal muscles was performed during submaximal clenching in order to investigate the immediate effects of the splints on the activity patterns of these muscles relative to the patterns found with the subjects occlusion in the inter-cuspal position. The splints in the RP were found to have no effect on the asymmetry of the activity of the masseter and the anterior temporal muscles, while the splints in a right lateral occlusion resulted in relative increases in right anterior temporal muscle activity (P less than 0.005).

Comparison of arthrographic findings of the temporomandibular joint with palpation of the muscles of mastication

Two hundred five patients were examined for temporomandibular joint pain and dysfunction and specifically for tenderness to muscle palpation. Arthrograms were performed on 222 joints (188 unilateral and 17 bilateral). Significant findings were ascertained for the middle portion of the temporal muscle in "normal" patients versus "with and without meniscus reduction" patients. The superficial masseter muscle was more tender in "normal" patients and in "reducing meniscus" patients than in "without meniscus reduction" patients. The medial pterygoid muscle was more tender in "normal" patients and in "without meniscus reduction" patients than in "reducing meniscus" patients. Though there are some significant findings with respect to muscle palpation, by itself muscle palpation is not a specific indicator of temporomandibular joint internal derangement.

Acromegaly and resulting myofascial pain and temporomandibular joint dysfunction: review of the literature and report of case

The medical and dental literature about acromegaly is reviewed. Medical considerations as well as the improvement in surgical techniques and airway management are discussed in reference to the myofascial pain dysfunction syndrome, secondary to mandibular overgrowth. Successful treatment of a patient is described.

Long-term results of treatment for temporomandibular disorders: an evaluation by patients

In this study, 110 patients with temporomandibular disorders who had been treated 2 to 81/2 years earlier were asked to evaluate the treatment they received. Of the patients, 85.5% reported that they were not experiencing pain or that they were experiencing much less pain; 79.1% reported that the treatment they had received had helped them completely or considerably. Analysis of the data did not disclose a subgroup or factor that could be correlated with the reduction of pain or the patient's perception of the success of treatment.