CLINICIAN'S CORNER

Three-dimensional retraction of anterior teeth

with orthodontic miniplates in patients with
temporomandibular disorder
Gerald Nelson,a Hyo-Won Ahn,b Sung-Hee Jeong,c Jun-Shik Kim,d Seong-Hun Kim,e and Kyu-Rhim Chungf
San Francisco, Calif, and Seoul, Pusan, and Suwon, Korea

Vertical dimension control is critical for adults with Class II high-angle malocclusions. If the patient has a temporomandibular disorder, this requirement is exacerbated. When extraction is planned, the treatment challenge is
further increased. This article reports on a new biomechanical design (C-therapy) appropriate for anterior segment retraction with excellent control of the vertical dimension, even in a Class II high-angle patient with a temporomandibular disorder. Maximum retraction of the maxillary anterior segment can be achieved with a lingual
retractor and a palatal miniplate without appliances on the maxillary posterior segments. Mandibular anterior vertical height was well controlled by a second miniplate in the mental region. This device also contributed to mandibular anchorage reinforcement. A patient with temporomandibular disorder symptoms treated with this
approach is shown. (Am J Orthod Dentofacial Orthop 2012;142:720-6)

s the incidence of adult orthodontic treatment

increases, orthodontists learn more about
conducting such treatment safely and with improved outcomes. The risks are higher than with a growing adolescent, especially when extractions are involved,
because treatment time is extended and resistance to
periodontal breakdown is lower. In some patients, extractions are a necessity for a reasonable outcome. Orthodontic specialists know that a hyperdivergent
skeletal pattern poses some barriers to a good esthetic
outcome.1 The use of temporary skeletal anchorage devices has renewed enthusiasm for a more dependable result when treating such patients.2-4 Improper treatment
a
Clinical professor and acting chair, Division of Orthodontics, Department of Orofacial Science, University of California, San Francisco.
b
Clinical fellow, Department of Orthodontics, College of Dentistry, Kyung Hee
University, Seoul, Korea.
c
Assistant professor, Department of Oral Medicine, School of Dentistry, Pusan
National University, Pusan, Korea.
d
Postgraduate student, Department of Orthodontics, College of Dentistry, Kyung
Hee University, Seoul, Korea.
e
Associate professor and chairman, Department of Orthodontics, College of Dentistry, Kyung Hee University Medical Center, Seoul, Korea.
f
Professor and chairman, Department of Orthodontics, School of Medicine, Ajou
University, Suwon, Korea.
The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article.
Reprint requests to: Seong-Hun Kim, Department of Orthodontics, College of
Dentistry, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul
130-701, Republic of Korea; e-mail, bravortho@gmail.com.
Submitted, June 2011; revised and accepted, July 2011.
0889-5406/$36.00
Copyright 2012 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2011.07.029

720

planning or faulty treatment mechanics can result in

backward mandibular rotation and an unesthetic
increase in anterior facial height.5 Any change in the vertical height of the dentoalveolar complex as a result of
orthodontic therapy can aggravate the temporomandibular disorder symptoms.3 The ideal method of anchorage
control in these patients allows the desired tooth movement without noxious inuences on the temporomandibular joint complex. This concept is particularly
valuable in adults, because they will have no compensatory growth in posterior facial height.
Clinicians have proposed a wedge hypothesis to the
effect that extraction treatment plans facilitate bite closure.6,7 However, recent studies have shown that, even
though molars move mesially out of the wedge, they
also extrude, keeping pace with an increase in facial
height.8,9 Thus, careful planning is necessary to
control any increase in the anterior vertical dimension
that would degrade the esthetics of chin contour.10
Common strategies for resisting an increase in anterior vertical dimension and anchorage reinforcement include headgear, a low-hanging transpalatal arch, the
Nance holding appliance, and interocclusal bite coverage. Even with these extra measures, we still see minor
increases in the mandibular plane angle and moderate
loss of posterior anchorage.2,11 To compensate for
a loss of posterior anchorage, clinicians often follow
up with Class II elastics to achieve a Class I outcome.
Unfortunately, in a skeletally hyperdivergent patient,
the use of Class II elastics will extrude the mandibular

Nelson et al

molars and prop open the mandible. Independent

treatment of the maxillary and mandibular arches can
help to prevent these side effects.
When compared with headgear anchorage, temporary skeletal anchorage devices have been reported to
predictably distalize or intrude the maxillary and mandibular molars12-14 and achieve better results in the
treatment of maxillary dentoalveolar protrusion.11
Many reports support the advantages of temporary skeletal anchorage devices: eg, greater retraction of the
maxillary anterior teeth, less anchorage loss of the maxillary posterior teeth, and even molar intrusion, followed
by counterclockwise rotation of the mandible, resulting
in a decreased sagittal jaw discrepancy.12,13
In this article, we introduce new biomechanical designs appropriate for Class II high-angle patients with
temporomandibular disorder, to avoid the use of intermaxillary mechanics. Our target approach has a goal to
maintain the vertical dimensions by introducing minimum or no change to the maxillary posterior teeth. No
appliances are placed in the maxillary posterior segments. Retraction of the maxillary anterior segment
with a palatal miniplate tethered to a lingual retractor
was done independently of the maxillary posterior teeth.
Mandibular anterior vertical height was controlled during retraction with a special miniplate (C-tube) in the
symphysis-menton area.
MATERIAL AND METHODS

In the maxillary arch, the lingual appliance (C-retractor) is made of 0.036-in 18-8 stainless steel wire soldered to mesh pads, consolidating the 6 anterior teeth
into 1 physical unit (Fig 1). This bonded splint has 2 lever
arms extending into the palatal vault, usually extended
from a point distal to the central incisors. The palatal
plate has a wide horizontal arm (C-plate; Jin Biomed,
Bucheon, Korea). It is xed to the cortical bone of the
palate with up to 4 titanium screws (5-6 mm) placed adjacent to the median palatal suture. This temporary skeletal anchorage device provides maximum anchorage
with no need for attachments on the teeth of the posterior buccal segment. We have used this setup for both
pure orthodontic retraction and corticotomy-assisted retraction or osteotomy patients.15,16
The desired length of the retractor lever arms can be
determined by estimating the center of resistance to retraction of the maxillary anterior teeth.17,18 If bodily
movement is needed, a long lever arm is chosen
(about 10 mm into the palate from the facial-axis
point on the lingual surface of these teeth). For
a controlled tipping movement (with the incisor's
apical tip as the center of rotation), a shorter lever arm
(about 7 mm) is effective.

721

In the mandibular arch, a smaller miniplate (C-Tube;

Jin Biomed) is placed on the facial surface of the symphysis. This miniplate is smaller than most and has an
adjustable leg ending in a tube that is easily opened to
form a hook, if desired. The small size and I-shape design
of the C-Tube plate (Fig 1, B) make its surgical placement procedure simple enough that an orthodontic specialist can do it.19 Here is a brief description of the
procedure. After palpation of the symphyseal area,
a 5-mm vertical incision is made along the midline
(Fig 2, A). Detach the periosteum with an elevator (Fig
2, B). Position the I-type C-tube and anchor it with 2 titanium screws (1.5-mm diameter, 4-mm length). The
tube-shaped head part remains exposed to the oral cavity (Fig 2, C). One or 2 sutures are recommended after
xation of the miniplate (Fig 2, D). This system provides
good esthetics, rapid and controlled space closure without deepening the overbite, and reasonable comfort
(Fig 3). During the retraction period, no intermaxillary
elastics were applied. After the en-masse retraction,
full xed orthodontic appliances can be bonded to the
maxillary teeth for nishing details.
Clinical application

A 22-year-old woman came to the outpatient clinic

of Kyung Hee University Dental Hospital with a chief
complaint of mouth protrusion. There were no signicant temporomandibular joint symptoms, but a mild degenerative bony change of the condyle was evident on
the panoramic view. However, the complication in this
patient was a large sagittal centric occlusion-centric relation discrepancy. The pretreatment intraoral photographs showed Class I molar and canine relationships,
but in centric relation, the occlusion was Class II molar
and canine with a large 6-mm overjet (Fig 4). The pretreatment photographs show the everted thick upper
and lower lips, lip incompetency, skeletal Class II, and
dental Class I mouth protrusion. The dental midline coincided with the facial midline. There was no obvious
crowding. An open-bite tendency and a shallow overjet
were observed, and the patient's swallowing pattern included an anterior thrust. She had no missing teeth and
4 impacted third molars. A panogram (not shown)
showed root dilaceration of the maxillary second premolars. The cephalometric analysis (in centric occlusion)
showed a slight skeletal Class II relationship (ANB,
4.8 ) with a normodivergent facial pattern. Labioversion
of the maxillary and mandibular incisors (U1 to FH,
120.5 ; IMPA, 110.3 ) and a reduced interincisal angle
(106.3 ) were observed. The patient was diagnosed
with skeletal Class II malocclusion with bidentoalveolar
protrusion and temporomandibular disorder with a large
centric occlusion-centric relation discrepancy.

American Journal of Orthodontics and Dentofacial Orthopedics

November 2012  Vol 142  Issue 5

Nelson et al

722

Fig 1. A, Arrows indicate the force vectors produced by the lingual C-therapy system. The radiograph
shows the lingual retractor, the palatal plate, and the mandibular miniplate in the symphysis area; B,
detail of the C-tube miniplate placed on the symphysis; C and D, schematic illustrations of the biomechanics of the C-therapy lingual retraction method. There were no appliances on the posterior teeth.

Fig 2. Surgical procedures for miniplate placement on

symphysis area: A, a 5-mm incision along the midline;
B, periosteal elevation; C, positioning of the I-type Ctube plate xated with 2 mini-plate anchoring screws,
1.5 mm in diameter and 4 mm in length, with the tubeshaped head part remaining exposed to the oral cavity;
D, 1 or 2 stitches after xation of the miniplate.

The centric occlusion-centric relation discrepancy

was conrmed after a 5-month period of splint wear
and adjustment. Three more months of splint therapy
established a stable centric relation, so orthodontic
treatment could commence. To determine the appropriate teeth for extraction, the cast mounted in centric relation position (Fig 4, A-C) was adjusted by occlusal
reduction of the posterior teeth for bite closure (Fig 4,

November 2012  Vol 142  Issue 5

Fig 3. A, The palatal system caused a minor imprint on

the tongue, which did not bother the patient and resolved
after removal of the plate, and the low tongue position was
improved with tongue exercises; B, the tip of the mandibular C-tube miniplate exits the tissue in the attached
gingiva, so there is no inammation or hypertrophy.

D-F). After occlusal adjustment, the Class II dental relationship was evident. Therefore, a Class II extraction pattern was chosen (maxillary rst premolars and
mandibular second premolars).
The maxillary anterior teeth were splinted into 1 unit
with the C-lingual retractor, and the palatal C-plate provided temporary skeletal anchorage. Nickel-titanium coil
springs provided gentle retraction forces (Fig 5, A-C). A
total of 400 g was initially loaded on the C-plate by the 2
sides of the lever arm (200 g each). The maxillary rst
molars were intruded by using a power chain (Forestadent, Pforzheim, Germany) between a bonded transpalatal arch and the horizontal arm of the miniplate. In

American Journal of Orthodontics and Dentofacial Orthopedics

Nelson et al

723

Fig 4. Dental casts mounted in centric relation: A-C, Class II molar and canine relationships and large
overjet and open bite were observed; D-F, occlusal adjustment of the casts to close the bite conrms
the extent of the Class II occlusion and excess overjet.

Fig 5. Three time points in treatment: A-C, immediately after the maxillary rst and mandibular second
premolar extractions; D-F, at 14 months; G-I, at 16 months, the maxillary posterior teeth were bonded
for detailing.

the mandibular dentition, the goal was reciprocal space

closure, so it was treated with conventional labial xed
appliances. A steel closing loop archwire was used in
the mandibular arch. Five months later, there was
a need to control the vertical height of the mandibular
incisors, so a C-tube miniplate was placed in the mandibular symphysis area (Fig 5, D-F). At 14 months, space
closure of the mandibular arch was almost completed.
The maxillary retraction was completed at 16 months,
and the lingual retractor was removed. To detail the

occlusal relationships, a 0.022-in slot preadjusted edgewise appliance was placed (Fig 5, G-I). Leveling and further nishing were continued, including nal root
angulation on the maxillary canines. The total active
treatment period was 20 months.
Class I canine and molar relationships, ideal overjet,
and ideal overbite were obtained after treatment
(Fig 6). The centric occlusion-centric relation discrepancy
was resolved, and a stable condylar position in harmony
with the occlusion was achieved. The posttreatment

American Journal of Orthodontics and Dentofacial Orthopedics

November 2012  Vol 142  Issue 5

Nelson et al

724

Fig 6. Posttreatment extraoral photographs.

facial photographs show a dramatic decrease of lip protrusion and and improvement of facial esthetics. The
lip-volume change was also obvious, and the lip incompetency disappeared. The facial midline coincided with
the dental midline. Superimposition of the pretreatment
and posttreatment tracings showed controlled tipping
and intrusion of the maxillary anterior teeth with reduction of the gummy smile (Fig 7). In the mandible, the incisors were tipped back around the apex without
extrusion, and the molars shifted bodily to the mesial
aspect, facilitating achievement of the Class I molar relationship. There was no reduction in lower face height or
the mandibular plane angle, even when the mandible was
seated into centric relation. Because of poor cooperation
during the nishing stage, the appliances were removed
before the ideal outcome. Some space remained at the
mandibular extraction sites, but root retraction in the
extraction sites was appropriate. The occlusion remained
stable 4 years after removal of the orthodontic appliances. The mandibular third molars were removed 3 years
after debonding. In general, the dentition and the centric
relation were stable, and tissue health was good with
xed retention (Table). There were no temporomandibular disorder symptoms.
DISCUSSION

Orthodontic diagnosis and treatment planning for an

adult patient typically includes evaluation of the temporomandibular joints and the possibility of detrimental effects to them from comprehensive orthodontic
treatment. Asymptomatic patients with advanced degenerative bone changes or disc displacements are at risk.
In patients with no signicant centric occlusioncentric relation discrepancy, a prudent diagnosis includes
locating the centric relation, since guarded muscle

November 2012  Vol 142  Issue 5

Fig 7. Superimposition of the pretreatment (solid line)

and posttreatment (dotted line) tracings.

function might prevent the clinician from discerning

the degree of sagittal discrepancy.20 Mechanisms by
which centric occlusion-centric relation discrepancies
can contribute to temporomandibular disorders have
been proposed by Dawson21 and Roth.22 An occlusal interference that causes deection of the condyles away
from centric relation might trigger muscle hyperactivity
and contribute to the development of a temporomandibular disorder.
Some clinicians have found that stabilization splints
are effective in moderating temporomandibular disorder
symptoms and identifying centric relation positions.23-26
Mechanisms of action have been proposed to explain

American Journal of Orthodontics and Dentofacial Orthopedics

Nelson et al

725

Table. Cephalometric survey

SNA ( )
SNB ( )
ANB ( )
PFH/AFH (%)
Sum
Articular angle ( )
FMA ( )
FH-UI ( )
IMPA ( )
FMIA ( )
Interincisal angle ( )
UL-E plane (mm)
LL-E plane (mm)
Nasolabial angle ( )

Average
(female)*
81.6
79.2
2.4
66.8
395.7
146
24.3
116.0
95.9
59.8
123.8
0.9
0.6
98.0

Pretreatment
80.0
75.2
4.8
65.6
393.8
158.0
22.9
120.5
110.3
46.8
106.3
2.2
6.1
93.4

Posttreatment
79.9
75.7
4.2
65.7
394.0
157.8
21.6
109.8
93.9
64.7
134.0
0.0
0.3
97.7

*For Korean women: data from the Korean Association of Orthodontists.36

their efcacy, including relaxing the muscles and seating

the condyles in centric relation.21,27-29
On the other hand, Pullinger and Seligman30 and
Seligman and Pullinger31 showed no correlation between
occlusion and temporomandibular disorder, and claimed
that single occlusal variables can hardly be used to identify patients with a temporomandibular disorder. They
concluded that occlusal slides from a retruded cuspal position to a maximum intercuspal position can increase
the risk of temporomandibular disorders only when
they exceed 5 mm. However, Crawford20 contended
that a centric occlusion-centric relation discrepancy exceeding 1.0 mm in the vertical or horizontal plane and
0.5 mm in the transverse plane is likely to be associated
with temporomandibular joint problems. The controversy is alive and well in regard to the exact range of centric occlusion-centric relation discrepancy that
contributes to a temporomandibular disorder. Many orthodontic specialists pursue the goal of eliminating occlusal interferences and achieving functional
agreement between centric relation and maximum intercuspal position.
Dentofacial morphology in patients with a temporomandibular disorder also should be evaluated carefully,
because it can be inuenced by orthodontic treatment.32
Structurally compromised joints, such as temporomandibular joint disc displacement or a compromised
cortical surface of the condyle, might respond in an
unfavorable and pathologic manner to orthodontic
treatment when the functional environment of the
temporomandibular joint and its adaptive capacity are
altered by treatment.33-35 Backward rotation of the
mandible can occur during orthodontic treatment,
especially in a skeletally hyperdivergent patient.

Clinicians try to avoid such a change in mandibular

position with high-pull headgears and transpalatal
arches.
We focus on maintaining the vertical position in
these patients by avoiding interarch treatment mechanics. In the example, once centric relation position was
conrmed, the Class II molar relationship was veried.
In the mandibular arch, the use of loop closing mechanics and the C-tube skeletal anchor provided control of
incisor extrusion and assisted the anchorage power of
the mandibular anterior teeth during mesial translation
of the molars. This device allows an easier and cleaner
method of molar protraction compared with bilateral
skeletal anchors, which tend to are the posterior teeth
buccally during protraction.
In the maxilla, maximum anchorage was the goal.
The C-lingual retractor and C-plate achieved the desired
amounts of intrusion and retraction of the maxillary incisors without a change in position of the maxillary posterior teeth. In this patient, molar bonding was done to
intrude the molars and allow forward mandibular rotation. The initial cephalogram was taken in centric occlusion. If it had been taken in centric relation, the
mandibular plane would have measured a few degrees
steeper, so molar intrusion was important to maintain
the lower facial height after treatment. Although we
were concerned about the roots of the central incisors
in this situation, root resorption did not progress significantly during retraction. Perhaps the rigid splinting of
the C-lingual retractor helped to moderate this risk,
since the force was evenly distributed among the 6 anterior teeth. Since the maxillary molars did not extrude
during the retraction, there was no change in the mandibular plane angle. No intermaxillary elastics were used
during the treatment period. Anterior and posterior vertical heights were well controlled by the independent
arch mechanics with C-therapy. The treatment results
were well maintained, as shown in the 4-year followup records. As one would expect, choosing an extraction
pattern of the maxillary rst premolars and the mandibular second premolars caused some tooth-size discrepancies.
CONCLUSIONS

A new biomechanical system (C-therapy) for managing adult patients who need maximum maxillary anterior
retraction is presented. Orthodontic treatment should be
carefully applied to skeletally hyperdivergent patients
with a temporomandibular disorder so as not to risk exacerbation of the syndrome. In the example presented,
a Class II malocclusion with a large centric occlusioncentric relation discrepancy, the use of a C-retractor
and C-plate combined with a C-tube demonstrated clear

American Journal of Orthodontics and Dentofacial Orthopedics

November 2012  Vol 142  Issue 5

Nelson et al

726

advantages in esthetics, comfort, and outcome. The Cretractor and C-plate system achieved maximum retraction of the maxillary anterior teeth, and the C-tube
achieved vertical and sagittal control of the mandibular
incisors and molars.
REFERENCES
1. Yoon HR, Choi YJ, Kim KH, Chung C. Comparisons of occlusal force
according to occlusal relationship, skeletal pattern, age and gender
in Koreans. Korean J Orthod 2010;40:304-13.
2. Yao CC, Lai EH, Chang JZ, Chen I, Chen YJ. Comparison of treatment outcomes between skeletal anchorage and extraoral anchorage in adults with maxillary dentoalveolar protrusion. Am J Orthod
Dentofacial Orthop 2008;134:615-24.
3. Kuroda S, Katayama A, Takano-Yamamoto T. Severe anterior
open-bite case treated using titanium screw anchorage. Angle
Orthod 2004;74:558-67.
4. Ahn SJ, Lee SJ, Kim TW. Orthodontic effects on dentofacial morphology in women with bilateral TMJ disk displacement. Angle
Orthod 2007;77:288-95.
5. Schendel SA, Eisenfeld J, Bell WH, Epker B. The long face syndrome: vertical maxillary excess. Am J Orthod 1976;70:398-408.
6. Isaacson JR, Isaacson RJ, Speidel TM, Worms FW. Extreme variation in vertical facial growth and associated variation in skeletal
and dental relations. Angle Orthod 1971;41:219-29.
7. Aras A. Vertical changes following orthodontic extraction treatment in skeletal open bite subjects. Eur J Orthod 2002;24:407-16.
8. Cusimano C, McLaughlin RP, Zernik JH. Effects of rst bicuspid
extractions on facial height in high-angle cases. J Clin Orthod
1993;27:594-8.
9. Chua AL, Lim JYS, Lubit EC. The effects of extraction versus
nonextraction orthodontic treatment on the growth of the lower
anterior facial height. Am J Orthod Dentofacial Orthop 1993;
104:361-8.
10. Gebeck TR, Merrield LL. Orthodontic diagnosis and treatment
analysis concepts and values: part II. Am J Orthod Dentofacial
Orthop 1995;107:541-7.
11. Lai EH, Yao CC, Chang JZ, Chen I, Chen YJ. Three-dimensional
dental model analysis of treatment outcomes for protrusive maxillary dentition: comparison of headgear, miniscrew, and miniplate
skeletal anchorage. Am J Orthod Dentofacial Orthop 2008;134:
636-45.
12. Melsen B, Bosch C. Different approaches to anchorage: a survey
and an evaluation. Angle Orthod 1997;67:23-30.
13. Moon CH, Lee JS, Lee HS, Choi JH. Non-surgical treatment and
retention of open bite in adult patients with orthodontic mini-implants. Korean J Orthod 2009;39:402-19.
14. Kim MJ, Park SH, Kim HS, Mo SS, Sung SJ, Jang GW, et al. Effects
of orthodontic mini-implant position in the dragon helix appliance
on tooth displacement and stress distribution: a three-dimensional
nite element analysis. Korean J Orthod 2011;41:191-9.
15. Kim SH, Lee KB, Chung KR, Nelson G. Severe bimaxillary protrusion with adult periodontitis treated by corticotomy and compression osteogenesis. Korean J Orthod 2009;39:54-64.
16. Kim HS, Lee YJ, Park YG, Chung KR, Kang YG, Choo H, et al.
Histologic assessment of the biological effects after Speedy Surgical Orthodontics in a beagle animal model: a preliminary study.
Korean J Orthod 2011;41:371-8.

November 2012  Vol 142  Issue 5

17. Hong RK, Heo JM, Ha YK. Lever-arm and mini-implant system for
anterior torque control during retraction in lingual orthodontic
treatment. Angle Orthod 2005;75:129-41.
18. Kim JS, Kim SH, Kook YA, Chung KR, Nelson G. Analysis of lingual
en masse retraction combining a C-lingual retractor and a palatal
plate. Angle Orthod 2011;81:662-9.
19. Chung KR, Kim SH, Kang YG, Nelson G. Orthodontic miniplate
with tube as an efcient tool for borderline cases. Am J Orthod
Dentofacial Orthop 2011;139:551-62.
20. Crawford SD. Condylar axis position, as determined by the occlusion and measured by the CPI instrument, and signs and symptoms
of temporomandibular dysfunction. Angle Orthod 1999;69:
103-15.
21. Dawson PE. Functional occlusion: from TMJ to smile design. St
Louis: Mosby; 2006.
22. Roth RH. Functional occlusion for the orthodontist. J Clin Orthod
1981;15:32-51.
23. Kurita H, Ikeda K, Kurashina K. Evaluation of the effect of a stabilization splint on occlusal force in patients with masticatory muscle disorders. J Oral Rehabil 2000;27:79-82.
24. Tsuga K, Akagawa Y, Sakaguchi R, Tsuru H. A short-term evaluation of the effectiveness of stabilization-type occlusal splint therapy for specic symptoms of temporomandibular joint
dysfunction syndrome. J Prosthet Dent 1989;61:610-3.
25. Davies SJ, Gray RJ. The pattern of splint usage in the management
of two common temporomandibular disorders. Part III: long-term
follow-up in an assessment of splint therapy in the management of
disc displacement with reduction and pain dysfunction syndrome.
Br Dent J 1997;183:279-83.
26. Carraro JJ, Caffesse RG. Effect of occlusal splints on TMJ symptomatology. J Prosthet Dent 1978;40:563-6.
27. Dylina TJ. A common-sense approach to splint therapy. J Prosthet
Dent 2001;86:539-45.
28. Gray RJ, Davies SJ. Occlusal splints and temporomandibular
disorders: why, when, how? Dent Update 2001;28:194-9.
29. Al-Ani Z, Gray RJ, Davies SJ, Sloan P, Glenny AM. Stabilization
splint therapy for the treatment of temporomandibular myofascial
pain: a systematic review. J Dent Educ 2005;69:1242-50.
30. Pullinger AG, Seligman DA. Quantication and validation of
predictive values of occlusal variables in temporomandibular
disorders using a multifactorial analysis. J Prosthet Dent 2000;
83:66-75.
31. Seligman DA, Pullinger AG. The role of functional occlusal relationships in temporomandibular disorders: a review. J Craniomandib Disord 1991;5:265-79.
32. Ahn SJ, Lee SJ, Kim TW. Orthodontic effects on dentofacial
morphology in women with bilateral TMJ disk displacement. Angle
Orthod 2007;77:288-95.
33. Stegenga B, deBont LG, Boering G, van Willigen JD. Tissue
responses to degenerative changes in the temporomandibular
joint: a review. Oral Maxillofac Surg 1991;49:1079-88.
34. Luder HU. Articular degeneration and remodeling in human
temporomandibular joints with normal and abnormal disc position. J Orofacial Pain 1993;7:391-402.
35. Axelsson S. Human and experimental osteoarthrosis of the temporomandibular joint. Morphological and biochemical studies. Swed
Dent J 1993;92:1-45.
36. Korean Association of Orthodontists. Cephalometric norm of
Korean adults with normal occlusion. Seoul, Korea: Ji-Sung Publishing; 1998. p. 58995.

American Journal of Orthodontics and Dentofacial Orthopedics