Internal derangements of the temporomandibular joint. III. Anterior repositioning splint therapy

Can anterior repositioning splint effectively treat temporomandibular joint disc displacement?

The aim of this study was to determine whether anterior repositioning splint (ARS) can effectively treat temporomandibular joint (TMJ) anterior disc displacement with reduction (DDwR) in juvenile Class II patients. This study investigated disc repositioning clinically and through use of MRI with 12-month follow up. Patients with skeletal Class II malocclusions and DDwR diagnosed by magnetic resonance imaging (MRI) were treated with ARS. The efficacy of ARS was assessed clinically and by means of MRI before treatment (T0), immediately after bite registration (T1), at the end of treatment (T2), and at 12 months after functional appliance treatment (T3). Improvement in TMJ pain, TMJ noises, and range of mandibular movement were assessed. MRI evaluation was based on disc-condylar relationship in parasagittal images. Seventy-two juvenile patients with 91 joints were included in this study. The average age was 15.7 years old (range, 10–20 years) at first visit. There were statistically significant reductions in TMJ pain, disability in daily life and TMJ clicking (P < 0.01). MRI at T2 indicated that the success rate was 92.31% (84/91), but decreased to 72.53% (66/91) at T3. The unsuccessful splint disc capture was mainly observed in late adolescence, especially over 18 years old. Using MRI results as the gold standard, we found that clinical assessment had an accuracy rate of 75.82% at 12-month follow-up. In conclusion, although success rate for ARS treatment decreased over time, both clinical findings and MRI examination indicate that the ARS is relatively effective in repositioning the DDwR, especially for patients in early puberty. However, further and larger studies are needed to evaluate the outcome with ARS.

Metrical analysis of disc-condyle relation with different splint treatment positions in patients with TMJ disc displacement

OBJECTIVE

To evaluate the effect of bite positions characterizing different splint treatments (anterior repositioning and stabilization splints) on the disc-condyle relation in patients with TMJ disc displacement with reduction (DDwR), using magnetic resonance imaging (MRI).

MATERIAL AND METHODS

37 patients, with a mean age of 18.8±4.3 years (7 male and 30 females) and diagnosed with DDwR based on the RDC/TMD, were recruited. MRI metrical analysis of the spatial changes of the disc/condyle, as well as their relationships, was done in three positions: maximum intercuspation (Position 1), anterior repositioning splint position (Position 2), and stabilization splint position (Position 3). Disc/condyle coordinate measurements and disc condyle angles were determined and compared.

RESULTS

In Position 1, the average disc-condyle angle was 53.4° in the 60 joints with DDwR, while it was -13.3° with Position 2 and 30.1° with Position 3. The frequency of successful "disc recapture" with Position 2 was significantly higher (58/60, 96.7%) than Position 3 (20/60, 33.3%). In Positions 2 and 3, the condyle moved forward and downward while the disc moved backward. The movements were, however, more remarkable with Position 2.

CONCLUSIONS

Anterior repositioning of the mandible improves the spatial relationship between the disc and condyle in patients with DDwR. In addition to anterior and inferior movement of the condyle, transitory posterior movement of the disc also occurred.

Physiological effects of anterior repositioning splint on temporomandibular joint disc displacement: a quantitative analysis

Anterior repositioning splints (ARS) are used primarily for the management of temporomandibular joint (TMJ) anterior disc displacement with reduction (ADDwR). However, the exact physiological effects of ARS are still unclear. This study investigated the short and long-term effects of ARS on disc and condyle angles/positions by metric analysis. Twenty-two subjects diagnosed with ADDwR were recruited. Maxillary full-coverage ARS were fabricated, and MRI of TMJs was obtained before splint treatment, immediate post-insertion and 6 months after splint treatment. Disc-condyle relationship was determined by disc-condyle angle measurement. Disc and condyle positions were described as X-Y coordinates with the summit of glenoid fossa as the origin of the coordinates. Thirty-two TMJs were classified as ADDwR and 12 were normal. Upon ARS insertion, all TMJs with ADDwR got normal disc-condyle relationships. The condyles moved significantly forward and downward, while the discs moved significantly backward and upward. MRI at 6 months after treatment (without ARS insertion) indicated that only 40·6% (13/32) of the joints were maintained in the normal disc-condyle relationship. The majority of condyles returned to their pre-treatment positions, while the discs generally moved anteriorly again. The use of ARS resulted in forward and downward condyle movement, and a concurrent backward movement of the disc resulting in ideal spatial disc-condyle relationship. The stability of this relationship, however, could not be maintained in the majority of TMJs upon ARS removal. Findings explain the good short-term clinical outcomes with ARS and their relatively lower efficacy in the long term.

The effect of a mandibular advancement appliance on cervical lordosis in patients with TMD and cervical pain

AIMS

A preliminary study to compare cervical lordosis by means of cervical cephalometric analysis, before and after six months of continuous mandibular advancement appliance (MAA) use, and to show how physical therapy posture re-education would improve the cervical lordosis angle.

METHODOLOGY

Twenty-two female patients with temporomandibular disorders (TMD) and cervical pain with lordosis <20° were included. Patients had to have a muscle pain history for at least six months, and with an intensity ⩾6, measured by means of a visual analog scale (a horizontal 0-10 numeric rating scale with 0 labeled as 'no pain' and 10 as 'worst imaginable pain'). Patients had to present the angle formed by the posterior tangents to C2 and C7 of equal or less than 20°. Cephalometric and clinical diagnostics were performed initially (baseline) and at the end of the study period (six months). During the third month with MAA treatment, a physical therapist evaluated the postural deficit and performed a program of postural re-education. Angular and linear dimension data presented a normal distribution (P>0·05; Shapiro Wilk Test), so the paired comparison of the cephalometric measurements was made by t-test for dependent samples.

RESULTS

Angle 1 (OPT/7CVT); angle 3 (CVT/EVT) and angle 4 (2CL/7CL) showed a significant increase in the cervical lordosis. Angle 2 (MGP/OP), angle 5 (HOR/CVT) and the distances C0-C2 and Pt-VER, presented no significant changes.

CONCLUSIONS

The increase in cervical lordosis implies that six months of continuous MAA use, together with a program of postural re-education, promotes the homeostasis of the craniocervical system.

Occlusal rehabilitation of pseudo-class III patient

To treat a patient with anterior crossbite, the clinician should first assess if it is a genuine class III or a pseudo-class III malocclusion. Cephalometric analysis is important; however, registering a patient's centric relation (CR) is simple, quick, and costless and can play a decisive role in a differential diagnosis for this type of patient profile. This clinical report depicts a patient clinically diagnosed as class III. After mandible manipulation in CR, it was noted that the patient in question was a pseudo-class III. The treatment was based on the pseudo-class III diagnosis. Therefore, the patient was rehabilitated by occlusal adjustments and conventional and implant-supported prostheses and without the need for invasive orthognathic surgery.

Splint therapy for disc displacement with reduction of the temporomandibular joint. part I: modified mandibular splint therapy

The aims of this preliminary study were to present a modified mandibular splint together with a treatment regimen and to evaluate their effects on the treatment of reciprocal joint sounds of the temporomandibular joint (TMJ). The study participants were recruited from 312 consecutive patients in the temporomandibular disorder clinic of a medical center in Taiwan from January 2003 to December 2003. From among these, 59 cases with typical reciprocal clicking were selected for this study. All participants were treated with a modified mandibular splint and then followed up for 6 months. Successful treatment was defined as leading to the disappearance of the joint sounds of TMJ, as described by patients. Based on clinical evaluation, the overall success rate was 71.2% (42/59) with minimal temporary complications. Patients with clicking at less than 3.5 cm of interincisal opening had a success rate of 92.5%, which was higher than the success rate of patients with clicking at a mouth opening of 3.5 cm or more. This study showed that a modified mandibular splint can be used to treat reciprocal clicking of the TMJ effectively and encouraged us to conduct further study on the efficacy of this splint to treat disc displacement with reduction of TMJ using magnetic resonance imaging examination.

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.

Internal derangements of the temporomandibular joint

This article discusses several types of internal derangements of the temporomandibular joint. It includes definitions, clinical characteristics, and management options. Nonsurgical and surgical treatment strategies are discussed taking into consideration the latest evidence-based literature.

Nonsurgical treatment as an adjunct to surgery

Although some temporomandibular joint problems require surgical intervention, nonsurgical modalities are essential in the treatment of most joint afflictions, including internal derangements, inflammatory conditions, and arthritides. These approaches are crucial for presurgical management of these conditions and are an important adjunct in postsurgical care.

Joint intracapsular disorders: diagnostic and nonsurgical management considerations

This article reviews common intracapsular temporomandibular disorders encountered in the dental practice. It begins with a brief review of normal temporomandibular joint anatomy and function followed by a description of the common types of disorders known as internal derangements. The etiology, history, and clinical presentation of each are reviewed. Nonsurgical management is presented based on current long-term scientific evidence.

Natural course of disc displacement with reduction of the temporomandibular joint: changes in clinical signs and symptoms

PURPOSE

The goal of this study was to examine the natural course of disc displacement with reduction in the temporomandibular joint (TMJ).

PATIENTS AND METHODS

This retrospective study involved 24 patients who had been diagnosed with disc displacement with reduction of the TMJ, but who had not undergone any treatment. The extent of maximal mouth opening, protrusion, lateral excursions, noise of the TMJ, pain of the TMJ, and tenderness of masticatory muscles were recorded monthly for a mean of 25.8 months.

RESULTS

Maximal mouth opening, protrusion, and lateral excursions remained unchanged during follow-up. TMJ pain decreased by 15.7% (P >.05). Clicking decreased by 20.8% (P <.05), and tenderness of masticatory muscles decreased by 33.3% (P <.05). Reciprocal clicking remained unchanged in 19 patients (79.2%) and disappeared in 5 patients (23.8%). Four patients (16.7%) in whom clicking disappeared had a normal mouth opening, but locking developed in 1 patient (4.2%).

CONCLUSIONS

In patients with disc displacement with reduction who do not undergo treatment, range of movement remains unchanged over time. Tenderness of masticatory muscles tended lessen, but reciprocal clicking and TMJ pain tended to remain. Clicking did not progress to locking in most patients.

Multifactorial comparison of disk displacement with and without reduction to normals according to temporomandibular joint hard tissue anatomic relationships

STATEMENT OF PROBLEM

There is disagreement about the predictive value of temporomandibular joint tomographic anatomy in the diagnosis of internal derangements.

PURPOSE

This study aimed to identify multifactorial temporomandibular hard tissue relationships that differentiate disk displacement with reduction and disk displacement without reduction from normals.

MATERIAL AND METHODS

Temporomandibular joint tomograms from females diagnosed with unilateral disk displacement with (n=84) or without (n=78) reduction were compared to 42 asymptomatic normal joints with the use of 14 linear and angular measurements and 8 ratios. A validated classification tree model was tested for accuracy with sensitivity, specificity, goodness of fit, and the amount of log likelihood accounted for. The tree model was compared with a multiple logistic regression model and univariate testing.

RESULTS

The disk displacement with reduction tree model consisted of 3 disease and 2 normal pathways with interactions between fossa width to depth ratio, condyle position, and linear posterior joint space. This class was characterized by either a much wider- and shallower-than-average fossa shape and/or by a moderately posterior condyle position when the fossa shape was average to deeper and/or narrower. The logistic regression and univariate models also suggested wider and/or shallower fossae, as well as longer eminence length. The disk displacement without reduction tree model consisted of 2 disease pathways and 1 normal pathway. Interactions characterized this class by either a posterior to very posterior condyle position or by a much deeper than average fossa depth when the condyle position was concentric to anterior. The logistic regression model emphasized greater fossa depth and width versus normals. The tree models conservatively predicted the disease classes: Rescaled Cox and Snell R(2) 37.0%, sensitivity 70.2%, and specificity 90.5% for disk displacement with reduction; R(2) 28.8%, sensitivity 66.7%, and specificity 85.7% for disk displacement without reduction.

CONCLUSION

Within the limitations of this study, hard tissue relationships revealed by central tomogram sections were able to model notable differences between disk displacement with reduction and disk displacement without reduction versus asymptomatic normals when temporomandibular joints were examined as a multifactorial system typified by interactions of fossa width to depth proportions and condyle position. While substantial, the hard tissue predicted only part of the biology. The model could be broadened by additional factors and interactions.

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 comparison between horizontal splint and repositioning splint in the treatment of 'disc dislocation with reduction'. Literature meta-analysis

We reviewed the literature from 1985 to 1996 concerning the preliminary treatment of disc dislocation with reduction (DDWR) by means of occlusal splints, pinpointing two main methods. The conflicting results of many papers induced us to make a literature meta-analysis of those articles with the necessary requirements in order to verify the effectiveness of the two therapeutic means more frequently used in DDWR; the repositioning splint and the bite plane. A statistical comparison between the two kinds of treatment has demonstrated that the repositioning splint is more effective both in the resolution of the articular click and of the pain at a level of P < or = 0.00001, which is noteworthy and highly significant.

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.

Management of temporomandibular disorders: concepts and controversies

STATEMENT OF PROBLEM

Controversy continues in the area of epidemiology, etiology, diagnosis, and management of temporomandibular disorders (TMD). The field is replete with testimonials and clinical opinion, but it has been lacking in scientific foundation.

PURPOSE

This article reviews the recent temporomandibular disorder and orofacial pain literature and summarizes the concepts published in the 1993 and 1996 American Academy of Orofacial Pain guidelines. Temporomandibular disorders rarely occur as single entities but rather as multiple problems with overlapping symptoms.

CLINICAL SIGNIFICANCE

The multicausal nature of these problems and the number of conditions with similar signs and symptoms demand an effective differential diagnostic process. Diagnostic criteria are used from an operational standpoint to establish specific diagnoses based on a multiaxial diagnostic model.

CONCLUSION

Because little is known about the natural course of the various classifications of temporomandibular disorders, and because most treatment approaches are reported to be equally effective, a conservative, noninvasive management program is endorsed. The emphasis is on a medical multidisciplinary model similar to ones used for other musculoskeletal disorders that involve the patient in the physical and behavioral management of his or her own problem. This article concludes that a majority of temporomandibular disorder patients achieve good relief of symptoms with noninvasive reversible therapy.

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.

Mandibular repositioning can be effective in treatment of reducing TMJ disk displacement. A long-term clinical and MR imaging follow-up

In order to evaluate the long term clinical and morphologic results of recapture of a displaced TMJ disk, we recalled for follow-up MR imaging 75 patients who had been treated by attempted disk recapture based on pre-treatment MR imaging 1-6 years earlier. The treatment included a day appliance with inclines to guide the mandible into the therapeutic position and a telescopic night appliance which prevented retrusion of the mandible during sleep. Appliance treatment was followed by rebuilding or resurfacing the posterior teeth of one arch to permanently support the mandible in the therapeutic position. After treatment of 115 joints with displaced disks, 52% of the disks were normally positioned, 23% were improved in position, and 25% showed persistent disk displacement. Symptom relief was 92% in patients with normalized (recaptured) disks, 84% in patients with improved disk position, and 49% in patients with persistent disk displacement. Failure to improve disk position occurred in 7% of the joints with anterior disk displacement and in 44% of the joints with a transverse (sideways) component to the displacement. Forty-five percent of the recaptured-disks improved in contour. We concluded that anterior mandibular repositioning was effective in the treatment of patients with reducing displaced disks primarily when the disks were displaced only in an anterior direction. This treatment can be recommended in anterior disk displacements if the patient has failed more conservative treatment measures, permanent occlusal reconstruction can be justified, and the patient understands that long-term use of a night appliance may be necessary. Anterior mandibular repositioning appears much less effective in cases with a transverse component to the disk displacement.

Anterior mandibular repositioning in a patient with temporomandibular disorders: a clinical and tomographic follow-up case report

A 42 year old female with temporomandibular disorders (TMD) was treated by anterior mandibular repositioning which was followed-up clinically and tomographically. The authors tomographically reconfirmed the mandibular repositioning and discovered a type of condyle remodeling which they had not seen previously. Although clinical signs and symptoms of TMD were removed and the condyle was centered tomographically by the anterior repositioning, the MRI image indicated the disk was displaced anteriorly and laterally. The results suggest that image analysis of temporomandibular joint (TMJ) is beneficial and careful application of the treatment for anterior repositioning is recommended.

Temporomandibular disorders. 2. Non-surgical treatment

There are many treatment modalities for temporomandibular disorders (TMD), most of which are effective in controlling symptoms, at least in the short term. The non-surgical treatment of temporomandibular disorders continues to be the most effective way of managing over 80 per cent of patients who present with symptoms of temporomandibular pain and dysfunction. In this, the second article in the series, a general overview of the current non-surgical treatment strategies for TMD will be presented.

Efficacy of TMJ radiographs in terms of expected versus actual findings

OBJECTIVES

The purpose of this study was to measure the amount of new information contributed by temporomandibular joint tomograms beyond that anticipated by the patient's clinical presentation.

STUDY DESIGN

The results of a clinical examination and history, including a video of patient interview, and dental casts of 105 patients with a temporomandibular disorder were presented to a panel of general dentist evaluators with some experience in temporomandibular disorders. These evaluators then described the radiographic findings they anticipated. Lastly they examined temporomandibular joint tomograms for each of the study patients and scored their findings.

RESULTS

The temporomandibular joint tomograms revealed unanticipated osseous changes in 61% of case judgments of condyles and 47% for the temporal bone or 34% and 22%, respectively, when subtle changes were excluded. Unexpected condyle positional findings were revealed in 31% of the patients. When stratified by clinical class, osteoarthritis and internal derangement, false-positive and false-negative interpretations were 12.1% and 25.5%, respectively, for osteoarthritis, and 12.2% and 17.3% for derangement.

CONCLUSIONS

The fairly high rate of unexpected new osseous and positional findings supports the need for tomograms in patients with a clinical diagnosis of derangement or osteoarthritis.

Anterior repositioning appliances when used for anterior disk displacement with reduction--a critical review

Anterior repositioning appliances are commonly used for treating patients with an anterior disk displacement with reduction. The goal is to regain a proper disk to condyle relationship. Several questions immediately arise: Does the absence of joint noise indicate that the disk is properly positioned over the head of the condyle? Does this anterior position promote healing of the ligaments surrounding the disk?; and, is this anterior position merely therapeutic, or should the mandible be kept in this forward position? This review of the literature is intended to explore how anterior repositioning appliances are used in temporomandibular joint dysfunction (TMD) patients. Hopefully, it will answer questions and also raise more questions about our treatment objectives when dealing with dysfunctional patients.

The relationship between level of mandibular pain and dysfunction and stage of temporomandibular joint internal derangement

Temporomandibular joint internal derangement (TMJ ID) is the most common intra-articular TM disorder and can progress from TMJ ID with reduction to TMJ ID without reduction. It is not known whether this anatomical progression is associated with increasing levels of mandibular dysfunction. The objective of this study was to determine whether the level of clinically detectable mandibular dysfunction was related to the stage of TMJ ID. Two clinicians examined 42 subjects prior to bilateral TMJ arthrographic evaluation. The level of mandibular dysfunction was calculated by Helkimo's Clinical Dysfunction Index (Di) and the Craniomandibular Index (CMI). Statistical analysis revealed that the level of mandibular dysfunction as determined by the Di and CMI was not related to the arthrographic presence or absence of TMJ ID. Therefore, the clinician cannot assume that the level of mandibular dysfunction is directly related to the absence or presence of TMJ ID. Epidemiologically, the CMI and Di can be used only for estimation of the degree of mandibular dysfunction, since they do not provide direct information on a specific TM disorder.

Etiologic theory and the prevention of temporomandibular disorders

Over the last 75 years, a variety of etiologic factors has been suggested as the cause of pain and dysfunction in the temporomandibular system. The earliest and still-popular etiologic theory proposed that temporomandibular disorders are induced by abnormal structure, usually described as a malocclusion of the teeth or jaws. The fact that this theory was based on mechanical concepts, ignored biologic diversity, and had limited factual experimental evidence to support it as well as extensive evidence in opposition did not seem to matter to its proponents. In the late 1960's and early 1970's, the structural occlusal model for TM Disorders was challenged and has yielded ground to a more multifactorial model of TMD causation. Other etiologic factors for TM disorders--such as anatomical susceptibility of TM tissues to trauma, polyarthritic diseases, joint laxity, repetitive parafunctional behaviors, and stress-related muscle dysfunction--need to be recognized and quantified. Unfortunately, many practicing dentists demonstrate a very poor understanding of and often fail to recognize these etiologic factors as agents that produce TM disorders. This failure is largely due to the fact that the dental profession has spent the last 90 years dealing with a variety of misconceptions about the etiology of temporomandibular disorders. In the 1990's, one of the more formidable challenges we face is acquiring the ability to segregate and define validly the specific TM Disorder of concern and then correctly identify and measure the specific etiologic factors that produce it. Until these problems are solved, it is unlikely that we will be able to prevent disease of the TM apparatus.

Long-term results of appliance therapies in anterior disk displacement with reduction: a review of the literature

The diagnosis and management of temporomandibular disorders (TMD) have been a source of controversy in the dental community for decades. This controversy has been especially acute in the management of patients with anteromedial disk displacement (ADD) with reduction. This article presents a review of the literature specifically concerning the long-term results of appliance therapy in ADD with reduction patients. The literature review identified the failure of many past investigators to conduct scientifically well-designed studies or to use comparable criteria. However, from the evidence examined, both appliances seem to be able to decrease muscle and joint pain and increase mandibular function. The anterior repositioning splint seems to be superior to the flat-plane occlusal splint in eliminating reciprocal clicking and palpatory tenderness of the temporomandibular joint. The recapture of the disk is permanent in only a small percentage of patients suggesting that the use of irreversible procedures must be carefully evaluated.

Treating TM disorders: a survey on diagnosis, etiology and management

This survey of five dental groups revealed that the dental profession still is far from reaching a consensus about temporomandibular disorders. Despite a great deal of research that has clarified many issues in this field, clinicians often cling to outdated concepts and practices. However, many respondents did give answers that demonstrated their awareness of modern TMD diagnostic and treatment guidelines.

A clinical evaluation of temporomandibular joint disk plication surgery

Clinical and radiographic examinations were performed preoperatively and an average of 18 1/2 months postoperatively on 33 patients who had undergone TMJ disk plication surgery because of significant TMJ dysfunction symptoms that had not been resolved by previous conservative therapy. The results indicated that the disk plication procedure reduced the overall frequency of symptoms by 75%. The frequency of TMJ intracapsular, otologic, and head and shoulder symptoms was reduced by more than 80% after surgery whereas dental symptoms such as bruxing and clenching showed only a 28% reduction in incidence. Of the sample 77% were either free of pain or experiencing only mild symptoms at their postoperative recall, with only nine joints still experiencing moderate or severe symptoms, compared with the 31 joints that were in this category before surgery.

A dynamic model of etiology in temporomandibular disorders

A dynamic model is proposed to depict the etiology of temporomandibular disorders. A balance is described between destructive factors in the masticatory system that result in dysfunction, and adaptive factors that tend to return it homeostatically to normal. Five factors that cause or potentiate muscle hyperfunction are included on one side of the model with five other factors that affect the ability of the system to adapt on the other side. Relationships among the etiologic factors are discussed, and literature support for each is cited.

Use of protrusive splint therapy in anterior disk displacement of the temporomandibular joint: a 1- to 3-year follow-up

Sixty-eight patients, who were determined clinically (by the presence of audible and palpable-joint sounds) and arthrographically to have meniscus displacement with reduction, had protrusive splints constructed, and the results were evaluated for a minimum of 1 year to a maximum of 3 years. Eighteen additional patients, arthrographically determined to have meniscus displacement with reduction, served as a nontreatment group for comparison. Odds ratios were calculated to compare the proportions of subjects who experienced follow-up symptoms on the two regimens. Results indicated that with splint therapy there was a statistically significant reduction of the intensity of jaw joint pain, temporal headache, ear pain, and pain in front of the ear, and there was a decrease in the probability of a closed lock condition developing. Splint therapy is less likely to reduce frontal headache, neck pain, and clenching of teeth.

Do occlusal factors play a part in temporomandibular dysfunction?

This article sets out to explore the relationship between occlusal factors and temporomandibular dysfunction. Various studies have been reviewed and some confounding difficulties identified. A rationale for treatment, based on current knowledge, is presented.

Long-term follow-up after occlusal treatment to correct abnormal temporomandibular joint disk position

Fifteen patients with temporomandibular joint disk displacement in whom a normal condyle-disk relationship could be established were treated with occlusal changes to maintain the disk in a recaptured position. Occlusal changes were achieved by prosthodontics in 11 patients and by orthodontics in four patients. Follow-up after about 3 years showed that joint function was improved, intensity of pain was reduced, and joint and muscle tenderness were less frequent than before treatment. Intermittent locking, use of analgesics, sleep disturbances, and absence from work because of temporomandibular joint symptoms were also less frequent. Radiographic examination performed in 11 patients at follow-up demonstrated anteroinferior condylar position in the majority of the patients, but only minor hard tissue changes. Arthrography showed the disk to be in a correct position relative to the condyle in 82% (9 of 11) of the patients. These results suggest that permanent change of the occlusion with the objective of eliminating abnormal disk position may be effective treatment for disk displacement when conventional methods of treatment have failed to alleviate the symptoms. The extent of dental treatment needed to maintain the disk in a correct position should, however, be considered relative to the severity of the symptoms.

Long-term treatment of disk-interference disorders of the temporomandibular joint with anterior repositioning occlusal splints

Forty patients with three different types of symptomatic disk-interference disorders were treated with anterior repositioning splint therapy for 8 weeks. At the end of that period 80% of the patients were free of joint sound and pain. Each patient's splint was then gradually modified until the patient's original occlusal condition was reestablished. Each patient was then allowed to function in that position. The patients were reevaluated an average of 2 1/2 years later. Seventy-five percent of the patients had no joint pain and 66% had a return of joint sounds. Sixty-six percent of the patients did not find the need to seek additional treatment for jaw pain and dysfunction.

Temporomandibular joint disk displacement: arthrographic and tomographic follow-up after 6 months' treatment with disk-repositioning onlays

Eighteen patients with an arthrographic diagnosis of temporomandibular joint disk displacement with reduction were treated with disk-repositioning onlays for 6 months. Arthrograms and tomograms were obtained before and after treatment. The arthrographic examination after treatment showed that the disk remained in the superior position in twelve but was again displaced in six patients. Three of the patients with disk displacement manifested no clinical signs, such as clicking or locking; two showed signs of locking; and one had reciprocal clicking. The patients with clicking or locking had more symptoms than the other patients. A retrospective analysis of the pretreatment arthrograms suggested that there could have been a medial component to the disk displacement in four of the six patients in whom the disk became displaced again during treatment. Medial disk displacement were not seen in the patients with a successful treatment outcome. This study suggests that recurrence of symptoms during treatment with disk-repositioning onlays is frequently associated with recurrent disk displacement. The study further suggests that medial displacement of the disk is more difficult to treat.

Long-term status of TMJ clicking in patients with myofascial pain and dysfunction

This study evaluated the long-term changes in TMJ clicking and general TM disorder symptoms in 190 subjects originally treated by conservative, nonsurgical modalities that were not specifically directed to the problems of TMJ noise or disk derangement. The findings are detailed and support the concept that if the symptoms of pain and dysfunction in patients with clicking can be treated successfully by conservative, nonsurgical modalities, it is generally not necessary to correct the internal derangement with surgery.

Disk-repositioning onlays in the treatment of temporomandibular joint disk displacement: comparison with a flat occlusal splint and with no treatment

Sixty-three patients with an arthrographic diagnosis of disk displacement with reduction were randomly assigned to three treatment groups: (I) onlays to maintain disk repositioning, (II) flat occlusal splint, or (III) untreated controls. Guidance for construction of the disk-repositioning onlays was established during arthrography to obtain a recaptured disk position relative to the condyle. The onlays were cemented to the teeth and maintained the new intercuspal position anteriorly and inferiorly. The flat occlusal splint was used at night only and was adjusted to maintain a maximal occlusal contact in centric relation and centric occlusion. Clinical examinations were performed before and after 6 months of treatment. The disk-repositioning onlays improved joint function and reduced joint and muscle pain when compared with the flat occlusal splint and with nontreatment. The signs and symptoms in the flat occlusal splint group were no different from those in the control group. It is concluded that disk-repositioning onlays are effective in reducing pain and dysfunction associated with disk displacement with reduction in patients in whom the disk can be maintained in a normal relationship to the condyle with the aid of such onlays. The symptoms, however, returned when the onlays were removed after 6 months; this raises the question of whether a permanent change in the intercuspal position is necessary for long-term success.

Bilateral arthrographic evaluation of unilateral temporomandibular joint pain and dysfunction

A group of 20 subjects with symptoms of unilateral TMJ and/or associated muscular problems was clinically assessed and the condition of the symptomatic and asymptomatic joints was investigated by using an arthrographic technique. The assumption that asymptomatic TMJs have a normal condyle/disk relationship is now in question.