Evaluation of the single and combined therapeutic effects of individually manufactured earplug therapy in patients with myogenous temporomandibular disorders: A randomized controlled clinical trial

OBJECTIVE

To evaluate the effect of individually manufactured earplug therapy on pain intensity (PI), symptom severity (SS), and maximum mouth opening (MMO), in patients with myogenous temporomandibular disorders (TMD).

METHODS

One-hundred-twenty patients were randomly allocated to six groups: Groups EP (earplug), OS (occlusal splint), EX (exercise), EPO (earplug with occlusal splint), EPE (earplug with exercise), and C (control). Outcomes were PI (assessed with a visual analog scale (VAS)), SS (assessed with the modified Symptom Severity Index Questionnaire (mSSI)), and MMO (evaluated with a digital caliper). Measurements were performed at T0 (before the therapy), T1 (1-month follow-up), and T2 (3-month follow-up). Data were analyzed using one-way analysis of variance (ANOVA), Tukey's HSD, and chi-square tests (alpha = 0.05).

RESULTS

At T1 and T2, the greatest VAS and mSSI reduction was detected for the groups EPE (VAS = 5.3 ± 1.05, 3.3 ± 0.7; mSSI = 38.2 ± 2.27, 43.6 ± 3.94) and EPO (VAS = 5.2 ± 0.91, 3.2 ± 0.78; mSSI = 36.3 ± 3.97, 42.2 ± 3.19), respectively (p < 0.05). At T1, occlusal splint groups (groups OS (34.8 ± 2.97 mm) and EPO (33.8 ± 3.49 mm)) gave the highest MMO values, while T2 values did not constitute a significant difference with T1 (p > 0.05).

CONCLUSIONS

The short-term use of combined earplug therapy resulted in a decrease in both PI and SS. Improvement in MMO in participants using occlusal splints was observed in the 1st month and was maintained through the 3rd month.

CLINICAL RELEVANCE

Earplug therapy can be applied as a complementary therapy to occlusal splint and exercise treatments to decrease PI and SS in patients with myogenous TMD. To achieve functional recovery such as MMO, its combined use with splints should be taken into consideration by clinicians.

Recommendations on the Use of Oral Orthotic Occlusal Appliance Therapy for Temporomandibular Joint Disorders: Current Evidence and Clinical Practice

Background

'Temporomandibular joint disorders (TMDs)' denote an umbrella term that includes arthritic, musculoskeletal and neuromuscular conditions involving the temporomandibular joint, the masticatory muscles, and the associated tissues. Occlusal devices are one of the common treatment modalities utilized in the conservative management of TMDs. The indications for the available 'oral splints' or 'oral orthotic occlusal devices' remain ambiguous.

Methods

A joint international consortium was formulated involving the subject experts at TMJ Foundation, to resolve the current ambiguity regarding the use of oral orthotic occlusal appliance therapy for the temporomandibular joint disorders based on the current scientific and clinical evidence.

Results

The recommendations and the conclusion of the clinical experts of the joint international consort has been summarized for understanding the indications of the various available oral orthotic occlusal appliances and to aid in the future research on oral occlusal orthotics.

Conclusion

The use of the oral orthotic occlusal appliances should be based on the current available scientific evidence, rather than the archaic protocols.

3D Resin-coated pressure sensor response for bite force assessment: A pilot study

Background

Occlusal splints with sensors help in the bruxism diagnosis and monitoring, by recording the patient's bite force. The aim of this study was to evaluate the accuracy of a pressure sensor when it is covered with different thicknesses of a 3D printing resin (Anycubic 405nm Translucent Green UV Resin, Anycubic, UK).

Methods

In this preliminary study, the evaluated sensor (FlexiForce A201 Sensor, Tekscan) was firstly calibrated without any type of cover material, and later tested with 3D printing resin with different thicknesses (1 mm, 1.15 mm, 1.4 mm and 1.6 mm). The load tests were performed by a force tester (MultiTest 2.5 dV, Mecmesin).

Results

When the pressure sensor was covered with resin of 1mm and 1.6 mm thick specimens, a higher difference was found between the applied load and the corresponding sensor reading.

Conclusion

It was concluded that it is possible to use this type of pressure sensor and that it showed better accuracy with the 1.15 mm and 1.4 mm 3D printing resin covering.

Effect of manual physical therapy on sleep quality and jaw mobility in patients with bruxism: A biopsychosocial randomized controlled trial

This study aimed to investigate the effects of deep-stripping and trigger-point pressure release massage on the Pittsburgh Sleep Quality Index (PSQI), jaw mobility, and pressure pain threshold (PPT) of masticatory muscles in patients with sleep bruxism. A randomized controlled trial was conducted among 45 patients diagnosed with sleep bruxism. The patients were randomly assigned to three groups. Group I was the control group and included five men and 10 women; Group II was the deep-stripping massage group, which included two men and 13 women; and Group III was the pressure release group, which involved four men and 11 women. Patients were tested two times, before and after 6 weeks. Group I received transcutaneous electrical nerve stimulation and passive stretching; Group II received a deep-stripping massage; and Group III received a trigger-point pressure release massage. Findings revealed significant improvements in PSQI (p = 0.0001), jaw opening (p = 0.0001), jaw protrusion (p = 0.0001), jaw left lateral movement (p = 0.004), jaw retraction (p = 0.0001), right temporalis PPT (p = 0.0001), left temporalis PPT (p = 0.0001), right master PPT (p = 0.001), left master PPT (p = 0.001), right lateral pterygoid PPT (p = 0.001), left lateral pterygoid PPT (p = 0.001), right digastric muscle PPT (p = 0.001), and left digastric muscle PPT (p = 0.001) in the post-test condition in Group II compared with Group I and Group III. Deep-stripping massage improved PSQI, jaw mobility, or PPT of the masticatory muscles compared with trigger-point pressure release massage and traditional treatment techniques in patients with sleep bruxism.

Lingual treatment of an adult patient with an iatrogenic class II anterior open bite: Report of a case with a non-surgical orthodontic approach

INTRODUCTION

The treatment of adult patients presenting an open bite is a real challenge for orthodontists due to the complexity of the malocclusion. The diagnosis is essential to identify aetiological factors and establish the best aesthetic and functional therapeutic prognosis. Among the aetiological factors, iatrogenic treatment history has to be considered. It is the case here where a regrettable unsuitable splint for bruxism treatment forced an open bite to appear.

MATERIAL AND METHOD

This case report presents an adult women with a large open bite due to an occlusal splint not covering the last mandibular molars. It was not really a vertical skeletal excess but more a mandibular clockwise rotation linked to the molar extrusions, which created a dento-alveolar open bite and labio-mental contractions during lip closure. Treatment objectives were the intrusion of the third and second molars, the extrusion of incisors to obtain a counter clockwise mandibular rotation. The patient was treated with an aesthetic and customized lingual appliance with no orthognathic surgery. A physiotherapy was followed by the patient when the open bite was closed in order to facilitate and stabilize the intercuspation.

RESULTS

A complete closing of the open bite was reached after two years of treatment. The superimposition showed the anticlockwise mandibular rotation. The levelling with posterior intrusion and the incisors extrusion reduced the vertical dimension with success. After 3years of retention, the occlusal stability was obtained.

CONCLUSION

The intrusion of the molars associated with a counter clockwise mandibular rotation made it possible the incisor extrusion. The occlusal balance with physiotherapy and patient compliance maintained the closure. In this way, the iatrogenic effects of the poorly designed bite splint were repaired.

Is Biofeedback through an Intra-Aural Device an Effective Method to Treat Bruxism? Case Series and Initial Experience

Biofeedback was reported as an effective concept for bruxism treatment, through increasing patient's awareness of the habit. During bruxing both ear canals become tighter, therefore, an in-ear device can provide biofeedback. The in-ear device is fitted to the ear canal in physiological status, during bruxing the ear-canal tightens resulting in stress on the canal walls and unpleasant feeling. Subsequently, patients stop their bruxing habit. The aim of this study is to provide first clinical evidence that in-ear devices have a positive impact on relieving bruxism in patients. Despite the low number of patients, this early study was designed as a controlled prospective study. The trial included seven female patients with a median age of 47.3 years (23-64 years). Only two patients implemented their devices for eight and seven months, respectively. One patient reported a relief in her symptoms, like headaches and pain intensity during the night, by 50% after three month and 80% after six months. Despite the limited number of participants, the study reflects a potential of Intra-aural devices as effective biofeedback devices in treating bruxism.

Temporomandibular disorders: improving outcomes using a multidisciplinary approach

Patients with temporomandibular disorders (TMD) can become very complex. This article aims to highlight the importance of the multimodal and multidisciplinary approach in this type of patients to improve clinical outcomes. At present we have innumerable techniques and tools to approach this type of patients from a biopsychosocial model where active and adaptive type treatments are fundamental. There are various health professions that have competence in the treatment of TMD, however, although in the most complex cases should be treated simultaneously, still too many patients receive unique treatments and only from one point of view. This review exposes the treatments available from a clinical-scientific perspective and also emphasizes the importance of working in specialized units with those professionals who have competencies on the different conditions that may occur.

Gap arthroplasty with active mouth opening exercises using an interocclusal splint in temporomandibular joint ankylosis patients

Background

Temporomandibular joint (TMJ) ankylosis during early childhood may lead to disturbances in growth and facial asymmetry and to serious difficulties in eating as well as in breathing during sleep. The purpose of this study is to describe the effectiveness of an interocclusal splint (IOS) for active mouth opening exercises in the treatment of TMJ ankylosis.

Methods

A total of nine patients with 13 instances of TMJ ankylosis from 2008 to 2010 were included in this study, of which five patients were male and four patients were female. Five patients demonstrated unilateral ankylosis, while five patients showed bilateral symptoms. Ankylosed mass resection with coronoidectomy, fibrotic scar release, and resection of stylohyoid ligament calcification was performed with gap arthroplasty without an interpositional graft, and all patients were assessed for maximum mouth opening (MMO) during a mean 6.6-year follow-up period.

Results

All patients were subjected to postoperative mouth opening exercises from the day of the operation with the help of an IOS, which was based on an impression taken during surgery. All patients were sufficiently comfortable moving their mandible according to the IOS's guiding plane and impingement, and satisfactory results were achieved, in which MMO was improved by 35 mm more than 6 years after surgery.

Conclusions

Complete and adequate resection of the ankylosed mass and postoperative active mouth opening exercises are essential in the treatment of TMJ ankylosis. Moreover, a more comfortable mouth opening guide and interdigitation can be achieved using an IOS, and newly organized fibrosis in the gap space between the newly made resected condylar head and temporal fossa can be suggested.

Interdisciplinary Management of an Orthodontic Patient with Temporomandibular Disorder

A 21-year-old female patient presented with temporomandibular disorder, skeletal Class II, Angle Class II division 2 malocclusion, gummy smile, and incomplete overbite was managed successfully by splint therapy and orthodontic camouflage with miniscrew anchorage and extraction. She was treated with occlusal splint to alleviate signs and symptoms of anterior disc displacement without reduction and the associated masticatory dysfunction and revealed the true malocclusion before orthodontic treatment. Computer software facilitated the formulation of visual treatment objective (VTO) and occlusogram which guided the whole arch intrusion, retraction of the upper anterior segment, mesialization of lower left dentition, and distalization of lower right dentition. In this case report, the rationale and importance of preorthodontic splint therapy and specific considerations in orthodontic mechanics for managing this patient were discussed.

Do patients with malocclusion have a higher prevalence of temporomandibular disorders than controls both before and after orthognathic surgery? A systematic review and meta-analysis

PURPOSE

The aim of this study was to identify, through meta-analysis, whether patients who require orthognathic surgery have a higher prevalence of temporomandibular disorders (TMDs) than controls, both before treatment and after.

MATERIAL AND METHODS

A systematic review and meta-analysis were conducted based on PRISMA guidelines, to address the study purposes. A search of major databases through PubMed, EMBASE, and Cochrane CENTRAL was performed to locate all pertinent articles published from inception to June 2016. Inclusion criteria were controlled clinical studies, either prospective or retrospective, and case-control studies comparing preoperative and postoperative signs and symptoms of TMDs in patients who undergo orthognathic surgery to those of a healthy volunteer population with no dentofacial deformities. The predictor variables were patients with dentofacial deformities who underwent orthognathic surgery and patients with no dentofacial deformities and with good maxillomandibular relations and normal occlusion. The outcomes variables were the weighted, prevalence rate (proportion) in signs and symptoms of TMDs in patients with dentofacial deformities and risk ratio (RR) of signs and symptoms of TMDs before and after orthognathic surgery, compared to the control group.

RESULTS

A total of 542 patients enrolled in 6 studies were included in this analysis. The overall pooled weighted rate or prevalence of TMDs for orthognathic surgery patients preoperatively was 32.5% (95% CI = 26.7%-38.9%). There was a significant difference between the 2 groups with respect to TMDs before surgery, but no significant difference in TMDs after surgery. The RR for patients who had dentofacial deformities before orthognathic surgery compared with a control group was 1.634 (95% CI = 1.216-2.194; P = 0.001). The RR for patients after orthognathic surgery compared with a control group was 1.262 (0.718; 95% CI = 0.805-1.979; P = 0.311).

CONCLUSION

The results of this study show that patients who are going to have a correction of their malocclusion by orthodontics and orthognathic surgery have a significant incidence of TMDs when compared to a control population, but that after treatment, the incidence of TMDs does not differ from a control population. The reasons for these findings are not clear.

Counseling and oral splint for conservative treatment of temporomandibular dysfunction: preliminary study

Abstract Introduction Temporoamndiular Disorders (TMD) involve the masticatory muscles, temporomandibular joint (TMJ) or both. The most common symptom is pain, which is usually located in the muscles of mastication, pre-auricular region, and / or ATM, especially during mandibular function. The main treatment for TMD is related to pain relief. Objective The purpose of this case report was to evaluate the reduction of pain symptoms using Visual Analogue Scale (VAS) of patients with TMD treated with counseling and use of occlusal splint (OS). Material and method 16 subjects had participated in this study, that was composed by 4 appointment with 7-day interval between each (CEP FOP / Unicamp – 137/2009). In the first, an examiner used the Research Diagnostic Criteria for Temporomandibular Disorders (RDC / TMD) to diagnose each patient and delivered a VAS to register the intensity of daily pain. In the second, counseling, molding of both dental arcs to fabricate the OS and the delivery of new VAS were performed. In the third, there was the installation and adjustment of the OS and the delivery of another scale, and in the last, possible adjustments on the OS were done. Data were analyzed by ANOVA two way and Tukey post-test at 5% significance level. Result There was significant difference when comparing the intensity of pain of individuals after installation of splint with the baseline data and after counseling (p = 0.05). Conclusion According to the result of this study, the treatment of TMD associating counseling occlusal splint is effective in reducing pain intensity.

Effects of massage therapy and occlusal splint therapy on electromyographic activity and the intensity of signs and symptoms in individuals with temporomandibular disorder and sleep bruxism: a randomized clinical trial

Introduction

Temporomandibular disorder (TDM) is the most common source of orofacial pain of a non-dental origin. Sleep bruxism is characterized by clenching and/or grinding the teeth during sleep and is involved in the perpetuation of TMD. The aim of the present study was to investigate the effects of massage therapy, conventional occlusal splint therapy and silicone occlusal splint therapy on electromyographic activity in the masseter and anterior temporal muscles and the intensity of signs and symptoms in individuals with severe TMD and sleep bruxism.

Methods

Sixty individuals with severe TMD and sleep bruxism were randomly distributed into four treatment groups: 1) massage group, 2) conventional occlusal splint group, 3) massage + conventional occlusal splint group and 4) silicone occlusal splint group. Block randomization was employed and sealed opaque envelopes were used to conceal the allocation. Groups 2, 3 and 4 wore an occlusal splint for four weeks. Groups 1 and 3 received three weekly massage sessions for four weeks. All groups were evaluated before and after treatment through electromyographic analysis of the masseter and anterior temporal muscles and the Fonseca Patient History Index. The Wilcoxon test was used to compare the effects of the different treatments and repeated-measures ANOVA was used to determine the intensity of TMD.

Results

The inter-group analysis of variance revealed no statistically significant differences in median frequency among the groups prior to treatment. In the intra-group analysis, no statistically significant differences were found between pre-treatment and post-treatment evaluations in any of the groups. Group 3 demonstrated a greater improvement in the intensity of TMD in comparison to the other groups.

Conclusion

Massage therapy and the use of an occlusal splint had no significant influence on electromyographic activity of the masseter or anterior temporal muscles. However, the combination of therapies led to a reduction in the intensity of signs and symptoms among individuals with severe TMD and sleep bruxism.

Trial registration

This study is registered in August, 2014 in the ClinicalTrials.gov (NCT01874041).

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-014-0043-6) contains supplementary material, which is available to authorized users.

Computerized analysis of occlusal contacts in bruxism patients treated with occlusal splint therapy

PURPOSE

Occlusal splints are commonly used to prevent tooth wear caused by bruxism. However, the effects of splints on occlusion are still unclear. Although it is rarely alluded in literature, splints can provoke severe occlusal alterations and other complications. This study was aimed to identify differences in the responses of individuals with bruxism and healthy individuals to a full-arch maxillary stabilization splint in terms of occlusal changes.

MATERIALS AND METHODS

Occlusal contacts in 20 (5 male, 15 female) bruxism patients and 20 (5 male, 15 female) controls with normal occlusion were evaluated before and after occlusal splint therapy. T-Scan III, a computerized occlusal analysis system, was used to simultaneously measure occlusion and disclusion times as well as left-right and anterior-posterior contact distributions before splint therapy and 3 months after therapy. Wilcoxon and Mann-Whitney U tests were used for statistical analyses (α=.05).

RESULTS

No differences were found in the posterior contact of bruxism patients before and after stabilization splint treatment. However, differences in posterior contact were observed between bruxists and normal individuals prior to treatment, and this difference disappeared following treatment.

CONCLUSION

The results of this study showed the use of a stabilization splint may not have an effect on occlusion. However, the area of posterior occlusal contact among bruxists was found to be greater than that of normal individuals. According to this study, the clinical use of splints may be harmless.

Use of light-cured resin to manufacture occlusal splints: report of two cases

This article presents selected cases of patients with functional disorders of the stomatognathic system. This group of patients had a need to made different types of removable occlusal splints. In the past, occlusal appliances were made mostly using self-cured acrylate materials, which for many years had no replacements. The rapid development of dental materials technology led to creation of thermo-formable materials and resins, which can successfully replace traditional acrylic materials in daily clinical practice. A practical application of light-cured resin in the fabrication of the occlusal splints in two clinical cases is reported and discussed herein.

The dental occlusion as a suspected cause for TMDs: epidemiological and etiological considerations

The relationship between the dental occlusion and temporomandibular disorders (TMDs) has been one of the most controversial topics in the dental community. In a large epidemiological cross-sectional survey - the Study of Health in Pomerania (Germany) - associations between 15 occlusion-related variables and TMD signs or symptoms were found. In other investigations, additional occlusal variables were identified. However, statistical associations do not prove causality. By using Hill's nine criteria of causation, it becomes apparent that the evidence of a causal relationship is weak. Only bruxism, loss of posterior support and unilateral posterior crossbite show some consistency across studies. On the other hand, several reported occlusal features appear to be the consequence of TMDs, not their cause. Above all, however, biological plausibility for an occlusal aetiology is often difficult to establish, because TMDs are much more common among women than men. Symptom improvement after insertion of an oral splint or after occlusal adjustment does not prove an occlusal aetiology either, because the amelioration may be due to the change of the appliance-induced intermaxillary relationship. In addition, symptoms often abate even in the absence of therapy. Although patients with a TMD history might have a specific risk for developing TMD signs, it appears more rewarding to focus on non-occlusal features that are known to have a potential for the predisposition, initiation or perpetuation of TMDs.