Journal of Oral Rehabilitation 1998 25; 8188

Review A comparison between horizontal splint and repositioning splint in the treatment of disc dislocation with reduction. Literature meta-analysis
A . S A N T A C AT T E R I N A , M . P A O L I , R . P E R E T T A , A . B A M B A C E & A . B E L T R A M E Department of Dentistry, University of Padua, Italy

SUMMARY

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 conicting 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 000001, which is noteworthy and highly signicant.

Introduction
One of the most frequent clinical signs in the range of craniomandibular disorders (CMD) is the presence of an articular click which is a manifestation, mainly during the initial phase of mouth opening, of the temporary loss of the anatomico-functional unity of the condyle-disc complex. This phenomenon is generally known as disc dislocation with reduction (DDWR) (Zarb et al., 1994). Authors who have carried out clinical research on DDWR therapy adopt differing therapeutic approaches; the distinctive signs can be found not only in the choice of either a horizontal splint (bite plane) or a mandibular repositioning splint, but above all in the particular importance they give to the clinical history, the aetiology and, depending upon this, the therapy chosen. Through a careful analysis of the literature on the subject, we have identied two main groups: the repositioners and the functionalists.
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The repositioners state that every therapeutic effort must be made to guarantee the restitutio ad integrum of the correct intra-articular anatomy, continually sought by means of repositioning splints. The rationale of this stream of thought, of which Tallents et al. (1985, 1986) are amongst the main representatives, is based upon the following assumptions: (i) the clinical history of CMD with intra-articular origin is invariably progressive; (ii) the click, even if it causes no pain, must be considered as a pathological symptom; (iii) the repositioning splint is a basic therapeutic means in the case of condylo-meniscal incoordinations; the clinical disappearance of the articular noise is always associated with the anatomic recapture of the disc; (iv) the nal therapeutic position, reached at the end of the temporary occlusal treatment, must be constantly stabilized by means of permanent rehabilitation (xed prosthesis, orthodontics, etc.). Many clinical trials have actually proved how the

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indiscriminate application of these principles does not always ensure a satisfactory percentage of long-term success, and, furthermore, the patients are submitted to a considerable risk of over-treatment (Orenstein, 1993). Even the theoretical basis of these principles has often been questioned (Adler, 1986; Okeson & Hayes, 1986; Salonen, Hellden & Carlsson, 1990). The classic study by Moloney and Howard (1986) reported that for a sample of 241 patients treated with the repositioning splint method, the percentage of successful results was 70% when examined 1 year after the conclusion of the therapy, 53% after 2 years and only 36% after 3 years. In the same period, by means of arthrograpy Manzione et al. (1984), and by means of the CT (computed tomography) Manco and Messing (1986), both demonstrated that 46 and 42%, respectively, of the articulations in which the meniscus had successfully been clinically recaptured actually did not show a correct condylo-meniscal relation. In a recent study (de Leeuw et al., 1994), a sample of 99 individuals who, 30 years earlier, had already been treated with completely conservative methods to solve a problem of internal derangement were reviewed. These researchers could verify that, in general, no important changes had occurred in the clinical state of the patients during this long period of time, and, furthermore that, had there been any change at all, it was not signicant enough to compromise the well-being and the masticatory capacity of the patients in a pronounced way. This and other scientic evidence have created difculty for certain foundations of the radical repositioners theory and have given rise to a generation of clinicians that we dene as selective repositioners. These authors, Okeson, 1988; Moloney & Howard, 1986 are among the most representative, feel that although the repositioning splint must still be considered as a main therapeutic procedure; nevertheless, it is not to be applied indiscriminately, but only after a careful selection of the patients. They suggest that the articular click requires treatment only in cases where it causes pain or an articular dysfunction, and its disappearance does not necessary guarantee that the treatment of the dysfunctional patient has been successful. Permanent occlusal rehabilitation must be used sparingly and in carefully selected patients for whom the risk : benet and cost : benet ratios in such an exacting treatment are denitely favourable. In a survey Okeson (1988) analysed a sample of patients who had been treated with the repositioning splint method and walk-back therapy and estimated the percentage of successful results 2.5 years after the end of the treatment. When considering the parameter articular noise, only 35% had successful results. On the other hand, if the parameters were exclusively pain or mouth-opening capability, the percentage then reached 65%. The functionalists differ from the repositioners in a clinical approach based upon the particular attention they pay to neuromuscular and psychological factors. The authors who join this stream of thought criticize the excessive interest in the articular aspect of craniomandibular dysfunctions. They prefer to think that: (i) the anatomic recapture of the disc is today no longer absolutely necessary since all patients with this problem can effectively be cured without taking into consideration the disc position. This concept is generally summed up in the expression treating-off the disc (Orenstein, 1993); (ii) the articular click is often a benign condition, present without progressive worsening in a large part of the population (De Kanter et al., 1992, 1993); (iii) the bite plane is a conservative therapy that may sometimes be replaced by alternative methods (physical therapy, psychological therapy, placebo). The main objective of the therapy is to create the best conditions for the organism to recover, and to allow the TMJ to be remodelled and thus be able to perform its function even without an optimum condilar position (Greene & Laskin, 1988); (iv) more exacting therapies such as, for example, extensive rehabilitation and surgery are carried out exclusively for those patients who are totally refractory to any other treatment (Sidelsky & Clayton, 1990). In 1988 Greene and Laskin, two of the most important authors in this stream of thought, published the results of research they had carried out on 190 patients who suffered from DDWR and had been treated with no attempts at disc recapturing. Their treatment in general had been very conservative; physical therapy, psychological support, occlusal splints, etc. The researchers could verify that, after 5 years, 63% of the patients no longer suffered from the click or, at least, could observe an attenuation of the symptom. In terms of global symptomatology, 76% of the patients noticed an improvement (Greene & Laskin, 1988). These results, surprising in themselves, become even more interesting when they are compared to those already reported by Okeson (1988). As regards global
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T R E AT M E N T O F D I S C D I S L O C AT I O N W I T H R E D U C T I O N
Table 1. Papers selected Anderson O.C., Schulte J.K. & Goodkind R.J. Lundh H., et al. (1985) (1985) Comparative study of two treatments methods for internal derangements of the TMJ Anterior repositioning splint in the treatment of temporomandibular joints with reciprocal clicking: comparison with a at occlusal splint and an untreated control group Disk repositioning onlays on treatment of TMJ disk displacement: comparison with a at occlusal splint and with no treatment Long-term follow-up after occlusal treatment to correct abnormal TMJ disk position Internal derangement of the TMJ. III: anterior repositioning splint Long-term treatment of disk interference disorders of the TMJ with anterior repositioning occlusal splints Evaluation of arthrographically assisted splint therapy in treatment in TMJ disk displacement Arthrographically assisted splint therapy: a 6 month follow-up Use of protrusive splint therapy in anterior disk displacement of the temporo-mandibular joint: a 13 year follow-up The treatment of internal derangement of the temporomandibular joint: a survey of 300 cases Journal of Prosthetic Dentistry, 53, 392. Oral Surgery, Oral Medicine, Oral Pathology, 60, 131.

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(1988)

Oral Surgery, Oral Medicine, Oral Pathology, 66, 155. Oral Surgery, Oral Medicine, Oral Pathology, 67, 2. Australian Dental Journal, 31, 30. Journal of Prosthetic Dentistry, 60, 611.

Lundh H. & Westesson P.L. Moloney F. & Howard J.A. Okeson J.P.

(1989) (1986) (1988)

Tallents R.H., et al. Tallents R.H., et al. Tallents R.H., et al.

(1985) (1986) (1990)

Journal of Prosthetic Dentistry, 53, 836. Journal of Prosthetic Dentistry, 56, 224. Journal of Prosthetic Dentistry, 63, 336. Journal of Craniomandibular Practice, 5, 120.

Williamson E.H.

(1987)

symptomatology, the results overlap, whereas the data concerning the click are even better although the treatment adopted is much more conservative. The analysis of the literature concerning this subject shows that the two different trends found in DDWR therapy the rst mainly based upon intervention and asserting the necessity of intra-articular restitutio ad integrum and the second denitely more conservative and functionalist actually do not achieve substantially different percentages of success. The aim of this work is to revise the literature concerning preliminary therapy with occlusal splints and, by means of meta-analysis, make a comparison between the clinical effectiveness both of the repositioning splint and of the bite plane in the treatment of DDWR.

Materials and methods

We carried out the analysis of international literature from 1985 to 1996 by means of the MEDLINE database. A careful selection, especially based on the exhaustive description of the study, the reliability of the reported data and the homogeneity of the sample employed,
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has allowed us to identify 10 publications (Anderson, Schulte & Goodkind, 1985; Lundh et al., 1985, 1988; Lundh & Westesson, 1989; Moloney & Howard, 1986; Okeson, 1988; Tallents et al., 1985, 1986, 1990; Williamson, 1987) (Table 1). Using a correct methodology, they explain the clinical trials performed to verify the effectiveness of the two kinds of splint used in DDWR. We have discarded three of these publications (Moloney and Howard (1986), Lundh and Westesson (1989), Tallents et al. (1990)), because they reported the data only after denitive occlusal therapy, As for Williamson (1987), all the symptoms it describes were gathered by asking patients certain questions, but this method is not sufciently reliable and objective. Finally, we have selected a sample of six studies, divided into two groups: group 1, studies comparing the repositioning splint and bite plane; and group 2, studies concerning the repositioning splint only (Table 2). The six studies have satised the need to compare the use of the repositioning splint (adopted in all cases) and that of the bite plane (analysed only in the three articles of the rst group) in the treatment of DDWR. In all samples, apart from Tallents et al. (1985), the click caused physical pain. The studies of Lundh et al. (1985,

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Table 2. Papers included in the meta-analyis Sample 20 patients divided in 2 groups of 10 70 patients divided in 3 groups with random procedure Group A: bite plane Type of dysfunction Treatment Duration 5 months

Group Author

Anderson O.C., Schulte J.K. & Goodkind R.J. (1985)

Lundh H., et al. (1985)

Disk dislocation with reduction: reciprocal click with articular and muscular pain Disk dislocation with reduction

6 weeks

Lundh H., et al. (1986)

63 patients divided in 3 groups with random procedure

Disk dislocation with reduction

6 months

II II II

Tallents R.H., et al. (1985) Tallents R.H., et al. (1986) Okeson J.P. (1988)

82 patients 40 patients 40 patients

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Disk dislocation with reduction Disk dislocation with reduction Disk dislocation with or without reduction

Group B: repositioning splint Group A: not treated (controls) Group B: bite plane (nigth only) Group C: repositioning splint (all day long) Group A: not treated (controls) Group B: bite plane (nigth only) Group C: repositioning onlay in an arthroscopically determined position Repositioning splint Repositioning splint Repositioning splint and then walkback therapy

310 weeks 6 months 2 months

T R E AT M E N T O F D I S C D I S L O C AT I O N W I T H R E D U C T I O N
Table 3. Effectiveness of repositioning splint for click Authors Lundh H., et al. (1985) Lundh.et al. (1988) Anderson O.C., Schulte J.K. & Goodkind R.J. (1985) Okeson J.P. (1988) Tallents et al. (1985) Tallents et al. (1986) Meta-analysis Treatment duration 17 weeks 6 months 5 months 2 years, 5 months 310 weeks 6 months Patients 24 20 10 25 82 51 212 Successful 5 19 8 20 57 49 158 % Successful 2083 950 800 80 6951 9607 7453 95% Condence interval 537% 85100% 55100% 6496% 6079% 91100% 6980%

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1986), describe a control group, in addition to the two test groups, composed of patients who had been treated only by means of reassurance and advice; this method proved to be very signicant. The surveys expressed by means of Helkimos (1974) clinical dysfunction index, and presented in Anderson et al. (1985), have been converted into percentages that consider the improvement of a symptom as a successful result and its persistence or worsening as a failure. To sum up, by means of meta-analysis (LAbbe , Detsky & O Rourke, 1987; Cohen, 1992) we calculated the percentages of success and the relevant condence interval (95%) in order to examine the effectiveness of each type of splint with respect to the click and to pain. In the same way, by means of a meta-analytic method, we have made statistical comparisons among the various degrees of therapeutic effectiveness on the same symptoms. This was made possible due to the three studies of the rst group, and to the data supplied by the meta-analyses described above. The calculation was performed by means of two-tailed Students t-test. The minimum level of statistical signicance was set at P 005.

pain is on average 80%, with a range of condence between 72 and 87% (Table 5), whereas the bite plane average effectiveness on the same symptom is 33% with a range of condence between 18 and 49% (Table 6). The statistical comparison between the percentages of success in the two kinds of treatment has demonstrated that the repositioning splint method is more effective both in the case of articular click and of the pain deriving from it; this occurring at a level of P 000001, which is highly signicant (Tables 7 and 8)

Discussion
The aim of this study was to perform reliable comparisons among the various studies that reect the wide range of opinions concerning the treatment of CMD. We are not aware of any meta-analysis having been performed previously on this subject In fact, the decision to limit the study to the comparison between the effectiveness of the two kinds of occlusal splints in the treatment of DDWR, as well as the strict homogeneity of the data and the methodological rigour that meta-analysis requires, have reduced further than anticipated the number of articles considered in the study. It was actually very surprising to ascertain the incompleteness and often even the omission of some essential data in many of the studies initially reviewed but not selected for meta-analysis. These missing data included, for instance, the dimension and conguration of the sample, the method followed in the treatment and its duration, the use of control groups, and so on. In addition to this we had to consider the lack of unequivocal and accepted criteria of success in the therapy of CMD. However, we must emphasize

Results
In the studies that we have examined the percentage of success in the treatment of the articular click using the repositioning splint is, on average 75%, with a range of condence between 69 and 80% (Table 3). The bite plane, instead, is characterized by much lower values, an average of 17% with a range of condence between 7 and 27% (Table 4). Similarly, the percentage of success of the repositioning splint method in the treatment for physical
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Table 4. Effectiveness of bite plane for click Authors Treatment duration Patients Successful % Successful 95% Condence interval

Lundh H., et al. (1985) Lundh H., et al. (1988) Anderson O.C., Schulte J.K. & Goodkind R.J. (1985) Meta-analysis

17 weeks 6 months 5 months

23 21 10 54

2 5 2 9

869 238 200 17

020% 642% 045% 727%

Table 5. Effectiveness of repositioning splint on pain Authors Lundh H., et al. (1985) Lundh H., et al. (1988) Anderson O.C., Schulte J.K. & Goodkind R.J. (1985) Okeson J.P. (1988) Tallents et al. (1985) Tallents et al. (1986) Meta-analysis Treatment duration 17 weeks 6 months 5 months 2 years, 5 months 310 weeks 6 months Patients 9 12 10 32 51 114 Successful 2 9 6 27 47 91 % Successful 2222 750 60 8437 9216 7982 95% Condence interval 049% 5099% 3090% 7297% 85100% 7287%

Table 6. Effectiveness of bite plane on pain Authors Lundh H., et al. (1985) Lundh H.et al. (1988) Anderson O.C., Schulte J.K. & Goodkind R.J. (1985) Meta-analysis Treatment duration 17 weeks 6 months 5 months Patients 9 17 10 36 Successful 4 7 1 12 % Successful 4444 4117 100 3333 95% Condence interval 1277% 1865% 029% 1849%

Table 7. Relative effectiveness on click of two kinds of splint Authors Treatment duration % Successful on articular click Difference between percentage 12% 71% 60% 58% P

Lundh H., et al. (1985) Lundh H., et al. (1988) Anderson O.C., Schulte J.K. & Goodkind R.J. (1985) Meta-analysis *, Not signicant.

17 weeks 6 months 5 months

Bite-plane 9% Repositioning splint 21% Bite-plane 24% Repositioning splint 95% Bite-plane 20% Repositioning splint 80% Bite-plane 17% Repositioning splint 75%

025728 * 000004 000226 000001

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T R E AT M E N T O F D I S C D I S L O C AT I O N W I T H R E D U C T I O N
Table 8. Relative effectiveness on pain of two kinds of splint Authors Treatment duration % Successful on articular pain Difference between percentage 22% 34% 50% 47% P

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Lundh H., et al. (1985) Lundh H., et al. (1988) Anderson O.C., Schulte J.K. & Goodkind R.J. (1985) Meta-analysis *, Not signicant.

17 weeks 6 months 5 months

Bite-plane 44% Repositioning splint 22% Bite-plane 41% Repositioning splint 75% Bite-plane 10% Repositioning splint 60% Bite-plane 33% Repositioning splint 80%

033669* 008141* 003148 000001

that meta-analysis is an effective method which can bring forward reliable conclusions even from a limited number of studies (LAbbe ` et al., 1987; Cohen, 1992). Many authors (e.g. Orenstein, 1993) have critically reconsidered the possibility of a permanent occlusal rehabilitation after treatment with a splint, yet asserting that it must be offered exclusively to those patients who are totally refractory to any other treatment. The results of the present study do not give sufcient indications concerning the long-term effects of permanent rehabilitation in dysfunctional patients. This is due to the fact that the studies examined, apart from some exceptions (e.g. Okeson, 1988), consider a follow-up period no longer than 6 months, so as to include only the period of temporary treatment with splints. Therefore, the results of this study exclusively concern the phase of temporary occlusal therapy performed by means of the splints, but do not give any information about the denitive treatment. We must therefore underline the necessity of further research, extending over a longer period of time, and of a correct initial denition of the methods.

The meta-analysis of the literature on this subject has shown the good results obtained with the repositioning splint against the main symptoms of disc dislocation, namely articular noise and physical pain, as well as its being more effective (statistically very signicant), when compared with the bite plane. Thus, all the results achieved show that, under the present conditions of scientic knowledge, a correct treatment with the repositioning splint is the best procedure to follow in cases of DDWR. In the treatment of this clinical occurrence, we consider that the systematic employment of the bite plane, athough this device has proved to be easier to use and more easily accepted by the patients, is not supported by the necessary scientic evidence.

References
ADLER, R.C. (1986) A comparison of long-term post-management results of condylar-repositioned patients. Journal of Dental Research, 65 (special issue), 339. ANDERSON, O.C., SCHULTE, J.K. & GOODKIND, R.J. (1985) Comparative study of two treatments methods for internal derangements of the TMJ. Journal of Prosthetic Dentistry, 53, 392. COHEN, P.A. (1992) Meta-analysis: application to clinical dentistry and dental education. Journal of Dental Education, 56, 172. DE KANTER, R.J.A.M., KAYSER, A.F., BATTISTUZZI, P.G.F.C.M., TRUIN, G.J. & VANT HOF, M.A. (1992) Demand and need for treatment of craniomandibular dysfunction in the Dutch adult population. Journal of Dental Research, 71, 1607. DE KANTER, R.J.A.M., TRUIN, G.J., BURGERSDIJK, R.C.W., VANT HOF, M.A., BATTISTUZZI, P.G.F.C.M., KALSBEEK, H. & KAYSER, A.F. (1993) Prevalence in the Dutch adult population and meta-analysis of signs and symptoms of temporomandibular disorder. Journal of Dental Research, 72, 1509. DE LEEUW, R., BOERING, G., STEGENGA, B. & DE BONT, L.G.M. (1994) Symptoms of temporomandibular joint osteoarthrosis and

Conclusions
The analysis of the literature on the treatment of disc dislocation with reduction (DDWR) has highlighted the fact that the various clinical opinions on this subject can actually be gathered into two different lines of thought: the repositioners who believe in the therapeutic necessity of re-connecting the right condyledisc relations, and the functionalists who emphasize instead the possibility of clinical healing, even in cases where the condylo-meniscal relation is not optimum.
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internal derangement 30 years after non-surgical treatment. Journal of Craniomandibular Practice, 13, 81. GREENE, C.S. & LASKIN, D.M. (1988) Long-term status of TMJ clicking in patients with myofacial pain and dysfunction. Journal of American Dental Association, 117, 461. HELKIMO, M. (1974) Studies on function and dysfunction of the masticatory system. II. Index for anamnestic and clinical dysfunction and occlusal state. Swedish Dental Journal, 67, 101. LABBE, K.A., DETSKY, A.S. & OROURKE, K. (1987) Meta-analysis in clinical research. Annals of Internal Medicine, 107, 224. LUNDH, H., WESTESSON, P.L., KOPP, S. & TILLSTROM, B. (1985) Anterior repositioning splint in the treatment of temporomandibular joints with reciprocal clicking: comparison with a at occlusal splint and an untreated control group. Oral Surgery, Oral Medicine, Oral Pathology, 60, 131. LUNDH, H., WESTESSON, P.L., JISANDER, S. & ERIKSSON, L. (1988) Disk repositioning onlays on treatment of TMJ disk displacement: comparison with a at occlusal splint and with no treatment. Oral Surgery, Oral Medicine, Oral Pathology, 66, 155. LUNDH, H. & WESTESSON, P.L. (1989) Long term follow-up after occlusal treatment to correct abnormal TMJ disk position. Oral Surgery, Oral Medicine, Oral Pathology, 67, 2. MANCO, L.G. & MESSING, S.G. (1986) Splint therapy evaluation with direct sagittal computed tomography. Oral Surgery, Oral Medicine, Ora1 Pathology, 61, 5. MANZIONE, J.V., TALLENTS, R., KATZBERG, R.W., OSTER, C. & MILLER, T.L. (1984) Arthro-graphically guided splint therapy for recapturing the temporomandibular joint meniscus. Oral Surgery, Oral Medicine, Oral Pathology, 57, 235. MOLONEY, F. & HOWARD, J.A. (1986) Internal derangement of the temporomandibular joint. III: anterior repositioning splint therapy. Australian Dental Journal, 31, 30. OKESON, J.P. & HAYES, D.K. (1986) Long-term results of treatment for temporo-mandibular disorders: an evaluation of patients. Journal of American Dental Association, 112, 473. OKESON, J.P. (1988) Long term treatment of disk interference disorders of the temporomandibular joint with anterior repositioning occlusa1 splints. Journal of Prosthetic Dentistry, 60, 611. ORENSTEIN, E.S. (1993). Anterior repositioning appliances when used for anterior disk displacement with reduction a critical review. JournaI of CraniomandibuIar Practice, 11, 141. SALONEN, L., HELLDEN, L. & CARLSSON, G.E. (1990) Prevalence of signs and symptoms of dysfunction in the masticatory system: an epidemiologic study in an adult Swedish population. Journal of Craniomandibular Disorders, Facial and Oral Pain, 4, 241. SIDELSKY, H. & CLAYTON, J.A. (1990) A clinical study of joint sounds in subjects with restored occlusions. Journal of Prosthetic Dentistry, 63, 58086. TALLENTS, R.H., KATZBERG, R.W., MILLER, T.L., MANZIONE, J.V. & OSTER, C. (1985) Evaluation of arthographically assisted splint therapy in treatment of TMJ disk displacement. Journal of Prosthetic Dentistry, 53, 836. TALLENTS, R.H., KATZBERG, R.W., MACHER, D.J., MANZIONE, J., ROBERTS, C., SOMMERS, E. & MESSING, S. (1986) Arthrographically assisted splint therapy: a six month foIIow-up. Journal of Prosthetic Dentistry, 56, 224. TALLENTS, R.H., KATZBERG, R.W., MACHER, D.J. & ROBERTS, C.A. (1990) Use of protrusive splint therapy in anterior disk displacement of the TMJ: a 13 year follow up. Journal of Prosthetic Dentistry, 63, 336. WILLIAMSON, E.H. (1987) The treatment of internal derangement of the temporomandibular joint: a survey of 300 cases. Journal of Craniomandibular Practice, 5, 120. ZARB, G.A., CARLSSON, G.E., SESSLE, B.J. & MOHL, N.D. (1994) Temporomandibular Joint and Masticatory Muscle Disorders, 1st edn. Munksgaard, Copenhagen. Correspondence: Dr Antonio Santacatterina, Via Baccarini No. 9, 36015 Schio (Vicenza), Italy.

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