J Oral Maxillofac Surg

63:1295-1303, 2005

Conservative Therapy in Patients With

Anterior Disc Displacement Without
Reduction Using 2 Common Splints: A
Randomized Clinical Trial
Marc Schmitter, DDS,* Mona Zahran, DDS, PhD,†
Jean-Marc Phu Duc, DDS,‡ Volkmar Henschel, PhD,§
and Peter Rammelsberg, DDS, PhD储
Purpose: We performed a comparative evaluation of different types of splint therapy for anterior disc
displacement without reduction (ADDWR) of the temporomandibular joint.
Patients and Methods: Seventy-four patients agreed to participate (65 females and 9 males). All
patients were examined using a clinical temporomandibular joint disorder examination protocol, includ-
ing muscle palpation, mandibular range-of-motion measurement, and joint sound detection. Additionally,
the patients marked their pain (during chewing, mandibular movements, and rest position) and limitation
levels on a visual analog scale. Bilateral magnetic resonance images were acquired, confirming ADDWR
in at least one joint. After clinical examination and imaging, randomized splint therapy was provided: 38
patients received a centric splint, while 36 received a distraction splint. After 1, 3, and 6 months of
therapy, outcome was evaluated using the Wilcoxon signed rank test for matched pairs. Success after 6
months was defined as improvement in active mouth opening of greater than 20% and pain reduction (on
chewing) of at least 50%. Success was statistically verified using logistic regression test.
Results: The improvements in mouth opening were significant in both groups. The improvements in
pain on chewing, pain during other functions, pain at rest, functional limitation on chewing, and other
functions were also comparable in both groups. However, the logistic regression test suggested that
patients using centric splints were treated more successfully than the others (confidence interval, 1.014
to 8.741, odds ratio ⫽ 2.785).
Conclusions: Centric splints seem to be more effective than distraction splints. Therefore, before the
surgical treatment of ADDWR, centric splints should be used instead of distraction splints.
© 2005 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 63:1295-1303, 2005

Temporomandibular joint (TMJ) disorders (TMDs) have

*Assistant Professor, Department of Prosthodontics, University of
Heidelberg, Heidelberg, Germany.
†Formerly, Assistant Professor, Department of Prostnodontics,
University of Munich, München, Germany; Currently, Palm
Springs, NV.
‡Assistant Professor, Department of Prosthodontics, University
of Munich, München, Germany.
§Assistant Professor, Institute of Medical Biometrics, University
of Heidelberg, Heidelberg, Germany.
储Director, Department of Prosthodontics, University of Heidel-
berg, Heidelberg, Germany.
Address correspondence and reprint requests to Dr Schmitter:
Department of Prosthodontics, University of Heidelberg, Im Neuen-
heimer Feld 400, 69120 Heidelberg, Germany; e-mail: Marc_
Schmitter@med.uni-heidelberg.de
© 2005 American Association of Oral and Maxillofacial Surgeons
0278-2391/05/6309-0008$30.00/0
doi:10.1016/j.joms.2005.05.294
come to take their place among major dental diseases
with a high prevalence,1 representing an umbrella term
for myogenic and arthrogenic complaints.
In the past 2 decades, clinical examination of the
TMJ has been supplemented by magnetic resonance
imaging (MRI). This diagnostic modality has the dis-
tinct advantage of depicting both soft and hard tissue2
and therefore visualizes the position of the articular
disc of the TMJ.3 Thus, a clinical suspicion of anterior
disc displacement can be confirmed with ease.
There are various stages and types of internal de-
rangements, each with its own degree of severity.
Anterior disc displacement without reduction (AD-
DWR) is one of the advanced stages of internal de-
rangement of the TMJ.4 This intracapsular disorder is
one that manifests itself with severe pain and func-
tional limitation, most easily observed by restriction
in the mouth opening capability.5

1295
1296
Different treatment strategies for patients with AD-
DWR have been described: physiotherapy,6,7 differ-
ent kinds of splint therapy,8,9 surgical interventions,10
and even abandonment of any therapy have been
proposed.11 The most common conservative therapy
is splint use; physical therapy seems to be insufficient
in patients with ADDWR.12
However, the use of different types of splints may
result in different outcomes as different mechanisms
of action are underlying. The outcome of the conser-
vative splint therapy is important for the planning of
surgical interventions as some patients do not benefit
enough from conservative therapy and consequently
ask for surgical interventions. Thus, the selection of
the splint seems to be essential for reducing the num-
ber of surgical treatments.
Surgical interventions (arthrocentesis, disc repair
or disc repositioning, discectomy) are described to
provide some benefit to patients with ADDWR, espe-
cially in patients who do not respond to nonsurgical
treatments.
The effect of occlusal splint therapy is the increase
of the vertical dimension of occlusion and the possi-
bility for spatial change in mandibular postural posi-
tion.13 The described effectiveness of splint therapy
has theoretically been attributed to decreased loading
of the TMJs14 and reduction of neuromuscular reflex
activity,15 besides the placebo effect.16 It has also
been suggested that the splint removes the influence
of teeth on the joint position by slight distraction of
the joint, which in turn enables the tissue to heal.17
To intensify this distraction of the joint, distraction
splints have been recommended.18 However, the clin-
ical effectiveness of this additional distractive effect is
not proved, although one study showed that there is
a verifiable distractive effect using MRI.19
Occlusal splint therapy does produce muscle har-
mony and coordination and is useful in evenly redis-
tributing occlusal forces and preventing wear and
mobility of teeth.20 Consequently, it aims at a reduc-
tion in bruxal activity and myofascial pain.
Forsell et al21 concluded that evidence for the use
of occlusal adjustment is lacking and postulated an
obvious need for well-designed controlled studies to
analyze the current clinical practice. This finding also
applies to the use of centric and distraction splint
therapy: the confusion about the effectiveness of dif-
ferent forms of occlusal splint therapy is general. For
the therapy of ADDWR, both centric and distraction
splints seemed to be suitable, as both splint types
reduce pressure on the joint structures.22,23
The effect of different surgical interventions are
based upon the lysis of adhesions (in the anterior,
medial, and posterior walls),24 capsular release,25 par-
tial or total discectomy,26 at which no statistically
SPLINT THERAPY
significant differences between the effects of any of
these treatments were shown.10
As mentioned, differences between the efficiency
of different splints (distraction splint and stabilization
splint) in the therapy of ADDWR are still unclear.
Therefore, the decision of which splint should be
used before a surgical intervention is problematic.
However, this decision is decisive for the numbers of
patients needing/asking for a surgical intervention.
Thus, the aim of this study was to compare the suc-
cess of 2 common splints (randomized clinical trial) in
the therapy of ADDWR.
Materials and Methods
The study was approved by the Review Board of
the University Medical Board (approval No. 142-98)
and informed consent was obtained from all partici-
pants by signing a consent form.
Patients visiting the department of prosthodontics
for problems of the masticatory muscles/TMJ within a
period of 15 months (n ⫽ 483) were screened to rule
out those patients who did not have TMD and/or did
not require treatment for their complaints and/or pre-
senting with no antagonistic molar contact at 1 and/or
2 sides. For this reason, a detailed clinical examination
procedure including muscle and joint pain assess-
ment and mandibular mobility measurements was es-
tablished (according to the recommendations of the
German Dental Association). Only patients presenting
a clear-cut clinical diagnosis of ADDWR were includ-
ed: (subjectively) limited mouth opening with deflec-
tion and limited lateral movement of the incisors
and/or pain had to be found. Additionally, patients
had to present at least one antagonistic molar contact
on each side. This was necessary to ensure the sup-
port of the splint in the posterior region by natural
teeth.
All examinations were performed by 4 investiga-
tors, and were calibrated beforehand for the linear
measurements.
To verify the clinical finding, magnetic resonance
images in opened and closed mouth positions were
acquired before splint insertion. A 1.0-T system (Im-
pact; Siemens, Erlangen, Germany) including a TMJ
surface coil was used. All scans were performed with
a 2-dimensional FLASH-sequence with a flip angle of
35 degrees. Opened mouth position was stabilized
using a mechanical mouth opener (Burnett BiDirec-
tional TMJ Device; Medrad, Inc, Indianola, PA), to
reduce blurred images. The MRI protocol is given in
Table 1. Thus, 74 patients (65 female and 9 male)
fulfilled the previously described criteria and agreed
to participate in this study. All of the subjects pre-
sented with complete anterior disc displacement
without reduction.
SCHMITTER ET AL
Table 1. MAGNETIC RESONANCE IMAGING PARAMETERS
TE TR
(ms) (ms) Matrix
Sagittal Oblique 14.0 420 256 ⫻ 256
Abbreviations: TE, time of echo; TR, time of repetition.
Schmitter et al. Splint Therapy. J Oral Maxillofac Surg 2005.
After MRI, centric splints or distraction splints were
randomly assigned. 38 patients received a centric
splint while 36 obtained a distraction splint. The pa-
tients were blinded to the type of splint. Age distri-
bution for both splint groups is given in Figure 1. As
the differences between the centric splint and the
distraction splint are obvious for experienced exam-
iners, no blinding of the investigators was possible.
The baseline examination included the following
items:
● Initial visual analog pain scales (VAS) at chewing,
at rest, and other functions
● Functional limitation assessment on eating, talk-
ing, and other functions
● Assessment of painful muscle sites on palpation
● Initial active and passive mouth opening mea-
surement
● Initial mandibular excursive movement measure-
ment
● Description of the opening movement
FIGURE 1. Age distribution in both splint groups. Circles denote
outliers.
Schmitter et al. Splint Therapy. J Oral Maxillofac Surg 2005.
1297
Field of Slice
View Thickness Acquisition
(mm) (mm) Time (min)
120 ⫻ 120 3 7.3
● Measurement of distance between centric rela-
tion and centric occlusion
● Number of missing nonreplaced posterior teeth
(excluding the wisdom teeth)
After clinical examination, magnetic resonance im-
age acquisition, and splint assignment, impressions
were made, bite was registered, and the splints were
fabricated and inserted. Using alginate impression ma-
terial (Blueprint Cremix; Dentsply Ltd, DeTray Divi-
sion, Surrey, England), an impression was made for
the maxillary jaw and 2 for the mandibular jaw, as the
cast may be destroyed during splint fabrication. The
impressions were poured in dental stone. A bite reg-
istration of the relation of the mandibular teeth to the
maxillary teeth was made using wax and alu-wax in
the region of the centrals and first molars, followed by
zinc-oxide eugenol paste. For this purpose, the man-
dible was gently (not forcefully) guided by hand into
the centric position. It is worth mentioning that this
did not result in a physiologic relation between disc
and condyle because the disc was located anteriorly.
All splints were supported in the posterior area by
natural teeth. A facebow (SAM Gesichtsbogen; SAM
Praezisionstechnik GmbH, Munich, Germany) regis-
tration of the relation of the maxilla to the cranium
was made, and used for mounting the maxillary cast
to the articulator (Artikulator SAM 2; SAM Praezision-
stechnik GmbH). The mandibular cast was mounted
with the use of the bite registration placed on the
maxillary cast.
The stabilization splint was constructed using au-
topolymerizing acrylic resin (Orthochryl; Dentaurum,
Ispringen, Germany) with even bilateral occlusal con-
tacts on the flat splint surface (Fig 2). During lateral
movements, only the cuspid was in contact with the
splint.
The distraction splint (occlusal contacts are located
predominantly in the posterior part of the splint; Fig
3) was constructed so that both joints were distracted
by 0.5 mm in both a caudal and an anterior direction.
This was effected by placing tin foils of 0.5 mm
thickness (Fig 4) on the posterior and superior surface
of the condylar house in the articulator (SAM 2 Praezi-
sionstechnik). Hugger et al19 showed that the effect
1298
FIGURE 2. Occlusal contacts on the stabilization splint.
Schmitter et al. Splint Therapy. J Oral Maxillofac Surg 2005.
of this kind of splint with respect to a distractive
effect in the TMJ is obvious using MRI.
After centric splint insertion, splint-to-tooth con-
tacts were verified for each tooth with 8-␮m shim
stock (Hanel-GHM-Dental GmbH, Nuetintingen, Ger-
many) with the condyles physiologically seated in the
mandibular fossae. The anterior guidance of the cen-
tric splint was adjusted so that all posterior teeth
disoccluded during eccentric movements, as deter-
FIGURE 3. Occlusal contacts on the distraction splint.
Schmitter et al. Splint Therapy. J Oral Maxillofac Surg 2005.
SPLINT THERAPY
FIGURE 4. Tin foil placed in the condylar house.
Schmitter et al. Splint Therapy. J Oral Maxillofac Surg 2005.
mined by articulating tape. If sliding contacts devel-
oped, the occlusal surfaces were modified to reestab-
lish immediate disocclusion of the posterior teeth.
After the insertion of the distraction splint, care
was taken to verify and/or create contacts in only the
posterior part (molars) of the splint. Therefore, the
major difference between these 2 types of splints is
the location of occlusal contacts (Figs 2, 3). These
differences in occlusion have been thought to have
effects on the TMJ.19
Patients were instructed to wear the splint 18 hours
a day.27 Directions as to the care of the splint were
given.
After 1 and 3 months, patients were to provide
their subjective evaluation by filling out the VAS form,
thereby recording any change in their pain level or
functional performance level. Additionally, the man-
dibular range of motion was recorded and the occlu-
sion between the centric splint and opposing dental
arch was checked for even simultaneous bilateral con-
tact in centric occlusion, and any posterior eccentric
contacts were eliminated. In each splint group, 1
patient had moved and therefore missed the 3-month
follow-up appointment.
After 6 months, the last follow-up appointment was
made. Four patients from the centric splint group and
5 patients from the distraction splint group missed
this follow-up appointment (due to being out of reach
or having no interest in participating any longer).
Objective evaluation of progress was recorded by
determination of success criteria. Success was defined
as the improvement of active mouth opening of
greater than 20% (of baseline opening) and pain re-
duction (on chewing) of more than 50%. Patients
were to provide their subjective evaluation by filling
out the VAS form, thereby recording any change in
their pain level or functional performance level.
SCHMITTER ET AL
FIGURE 5. Pain on chewing (initial, after 1 month, after 3 months,
and after 6 months) in patients wearing a centric splint or a distraction
splint. Circles denote outliers.
Schmitter et al. Splint Therapy. J Oral Maxillofac Surg 2005.
STATISTICS
The Wilcoxon signed rank test for matched pairs
was used to assess the effectiveness of the splint
within the groups.
Additionally, the logistic regression test was used to
isolate factors of prognostic relevance (initial mouth
opening, initial pain level, type of splint, gender, etc)
with respect to the success of the splint therapy. This
specific statistical procedure analyzes the data, taking
into account the values of the variables acquired at
the initial examination. Therefore, the result of this
statistical test makes it possible to assign to each
subject a prognosis for the improvement of his or her
complaints on the basis of the initial findings and
weighs the influence of each variable on success
(odds ratio).
Results
BASELINE FINDINGS
The VAS values marked initially by patients in each
group separately appeared to be very similar. Pain on
chewing (Fig 5) and with other functions (Fig 6), such
as yawning exhibited a median value of 6 in the
centric splint group and 5.5 in the distraction splint
group. Pain at rest was limited to 1 to 1.5 for both
groups. Functional limitation on chewing (Fig 7) was
marked by a median value of 7 in both splint groups.
Talking did not score a high value in limitation by
either group, where 0 was the median for the centric
1299
splint group, whereas 1 was that for the distraction
splint patients. Yawning or functions other than eat-
ing were rated as 5.5 and 5 for the centric and dis-
traction splint groups, respectively (Fig 8).
Analysis restricted to the joints diagnosed on MRI as
having anterior disc displacement without reduction
revealed that 57% of the right TMJs (n ⫽ 42) and 31%
of the left joints (n ⫽ 51) did not exhibit tenderness
to joint palpation, whether dorsally or laterally.
Joints involved in anterior disc displacement with-
out reduction gave the result that tenderness or pain
upon muscle palpation of the respective side was
absent in 38% and 25% of the right and left sides,
respectively.
Initial measurements of the active mouth opening
in all patients (n ⫽ 74) revealed a range between 20
mm and 52 mm, with a median of 33 mm. Individu-
ally, the median of the centric and distraction splint
group was 30.5 mm and 33.5 mm, respectively.
For initial mandibular excursive movement mea-
surements, a range between 1 mm and 13 mm was
measured for right lateral movement of the incisors,
initially in all patients (n ⫽ 74), with a median of 7
mm. Left lateral movement of the incisors had a range
of between 0 mm (one subject was not able to move
his mandible to the left) and 15 mm, with a median of
8.25 mm. As for protrusion, the initial measurement
lay between 1 mm and 12 mm; the median was 7 mm.
The description of the opening movement demon-
strated that joints diagnosed as having ADDWR
showed a predominance of deflection. Deviation was
FIGURE 6. Pain during other functions (initial, after 1 month, after 3
months, and after 6 months) in patients wearing a centric splint or a
distraction splint. Circles denote outliers.
Schmitter et al. Splint Therapy. J Oral Maxillofac Surg 2005.
1300
FIGURE 7. Limitation on chewing (initial, after 1 month, after 3
months, and after 6 months) in patients wearing a centric splint or a
distraction splint. Circles denote outliers.
Schmitter et al. Splint Therapy. J Oral Maxillofac Surg 2005.
not a common finding. Thirty-two percent of the total
number of patients (n ⫽ 74) did not reveal any slide
from centric relation to centric occlusion. Fifty-three
percent of the patients had no missing teeth in all 4
quadrants (excluding the wisdom teeth). The greatest
number of nonreplaced teeth was 6, appearing in
FIGURE 8. Limitation on other functions (initial, after 1 month, after 3
months, and after 6 months) in patients wearing a centric splint or a
distraction splint. Circles denote outliers.
Schmitter et al. Splint Therapy. J Oral Maxillofac Surg 2005.
SPLINT THERAPY
FIGURE 9. Active mouth opening (initial, after 1 month, after 3
months, and after 6 months) in patients wearing a centric splint or a
distraction splint. Circles denote outliers.
Schmitter et al. Splint Therapy. J Oral Maxillofac Surg 2005.
only 3 patients (4%) of the whole group. All patients
who participated in this study had anterior disc dis-
placement without reduction in at least one joint, as
confirmed by MRI. The number of patients whose
opposing joint was deemed to be normal was 36. The
number of those diagnosed as having anterior disc
displacement with reduction or without reduction in
the other joint were 19 in each of these subdivisions.
EFFECT OF THERAPY AFTER 1, 3, AND 6 MONTHS
Active mouth opening (Fig 9) showed a great im-
provement even after 1 month of centric splint ther-
apy, with a median value of 5.0 mm, reaching a
current median value of 36 mm. This improvement
continued to proceed steadily over the following
months, but at a lower rate than after the first month.
In comparison, the distraction splint wearers exhib-
ited only a 2.5-mm median improvement after 1
month therapy, reaching a current median value of
35.0 mm. The increase in active mouth opening pro-
ceeded to advance gradually at a rate almost similar to
that observed in the centric splint wearer group. The
Wilcoxon signed rank test for matched pairs was used
to compare the initial values of the active mouth
opening with those at each follow-up and gave the
result that a statistical significance (P ⬍ .001) existed
when both splint groups were combined. Analysis of
the centric splint group showed a statistically signifi-
cant difference of P ⬍ .001 when comparing the
recall active mouth opening measurements with the
initial measurement.
SCHMITTER ET AL
FIGURE 10. Passive mouth opening (initial, after 1 month, after 3
months, and after 6 months) in patients wearing a centric splint or a
distraction splint. Circles denote outliers.
Schmitter et al. Splint Therapy. J Oral Maxillofac Surg 2005.
After 1 month of therapy, the centric splint wearer
group showed a median increase of 3.0 mm in passive
mouth opening (Fig 10), which corresponded to a
current median value of 39.0 mm. The distraction
splint patients showed a minimal improvement in
passive mouth opening after 1 month of therapy,
attaining a median increase of 1.5 mm, equivalent to
a current median value of 38.5 mm. The Wilcoxon
signed rank test for matched pairs demonstrated a
statistically significant difference of P ⬍ 0.001 for all
follow-up appointments for centric splint wearers. In
the case of the distraction splint, a statistical signifi-
cance of P ⱕ .005 was found at all follow-up appoint-
ments.
Pain on chewing (Fig 5) decreased in both groups
after 1 month in a similar way (VAS decrease dropped
by a median of 2.5 to 3 points), reaching a median
value of 3 points after 1 month. After 3 months, the
current median was 2 points, and after 6 months, the
centric splint group reached a median of 0.5, and the
distraction splint group, a median of 0.
The centric splint group initially gave a greater
reduction in pain during other functions (Fig 6), such
as yawning, and stabilized at the median difference
value of ⫺4 until the 3-month follow-up. The distrac-
tion splint group showed similar pain reduction after
1 month but did not reach the values of the centric
splint group after 3 and 6 months. The current re-
corded median values after 6 months were 1 and 2
points for the centric and distraction splint groups,
respectively. The Wilcoxon signed rank test for
1301
matched pairs revealed a highly statistically significant
difference (P ⬍ .001) when comparing initial values
and those of each follow-up for pain during other
functions other than chewing. This observation was
found in both splint groups when tested individually
and when combined.
Pain at rest did not show an initial high value, so
that any reduction was expected to be minimal (me-
dian value, 1.5 points for the centric splint group and
1 point for the distraction splint group).
The centric splint group revealed a reduction in
functional limitation on chewing (Fig 7), attaining a
median difference of ⫺3 after 1 month. The distrac-
tion splint group also showed an initial median reduc-
tion of ⫺3, and both splint groups registered the same
median current value of 4 points after 1 month. The
median difference of ⫺5.5 was observed in the cen-
tric splint group after 6 months; however, the distrac-
tion splint group recorded a current median value
reduction of ⫺5 points in comparison to the centric
splint group. Using the Wilcoxon signed rank test for
matched pairs to compare the initial values and those
of each follow-up, a statistically significant difference
(P ⬍ .001) was observed in both splint groups when
tested individually and combined.
Functional limitation on talking was very limited
(initial median value for the centric splint group was
0, and for the distraction group, 1.5 points); there-
fore, any reduction that was to be noticed was not
great.
Both splint groups experienced an identical reduc-
tion in functional limitation during performance of
other functions other than chewing and talking until
the 6-month follow-up, where the median difference
obtained was about ⫺5 to ⫺4. The current median
value recorded by the patients was 3 points for both
groups after 1 month. Using the Wilcoxon signed
rank test for matched pairs to compare the initial
values and those of each follow-up, a statistically sig-
nificant difference (P ⬍ .001) was observed when
both splint groups were combined for all recall
appointments.
DIFFERENCES IN THE EFFICIENCY BETWEEN THE
2 SPLINTS
After 6 months, the success of splint therapy was
assessed. Success was defined as pain reduction on
chewing (at least 50%) and improvement of active
mouth opening (at least 20%). Logistic regression test
demonstrated P ⫽ .0528 for the centric splint group.
The 95% profile likelihood confidence limits ranged
from 1.01 to 8.74 with an odds ratio of 2.875.
As the lower limit of the confidence interval is
greater than 1 for the centric splint, this kind of splint
might be up to 2.875 times more effective than the
other splint.
1302
Discussion
In the present study, the use of both splints re-
sulted in pain reduction and increases in the mandib-
ular range of motion. Both splints increased the mean
active mouth opening. This result is comparable to
those of previous investigations, especially with those
of Stiesch-Scholz et al.28 They found that both splints
resulted in an improvement, whereas the centric
splint users displayed slightly greater improvements.
However, they did not differentiate between anterior
disc displacement with and without reduction.
Sato et al29 compared patients using a stabilization
splint with a control group. They found no statisti-
cally significant differences between the control
group (no treatment) and the study group (patients
with disc displacement). However, Sato et al29 de-
scribed a success rate of 41.9% for the natural course
group and 55.0% for the stabilization splint group.
Therefore, the use of the stabilization splint group
may reduce the number of patients asking for surgical
intervention. This finding was also described by Mi-
nakuchi et al30 for the comparison of other nonsurgi-
cal treatment strategies and the abandonment of ther-
apy for patients with ADDWR: they found no
significant difference but described a better success in
mouth opening in the splint group (splint group: 29.1
at the initial visit and 39.8 after 8 weeks; control: 32.5
at the initial visit and 38.5 after 8 weeks).
In the present study, the mean active mouth open-
ing for the centric splint group after 6 months was
43.4 ⫾ 7.0 mm. In their study with 30 patients, Chung
and Kim31 showed with nonreducing discs that after
stabilization splint therapy, interincisal distance mea-
surements increased about 18.5 mm. Mongini et al32
showed that, after a conservative treatment period
ranging between 18 and 147 months, the mean
mouth opening of 68 patients with ADDWR was
42.85 mm, which in comparison with pretreatment
measurements was considered to be highly significant
(P ⬍ .01). Centric splints also increased passive
mouth opening in the present study. Comparable
results have not been published previously in other
investigations.
The distraction splint group, on the other hand,
gave a mean of 40.0 ⫾ 7.0 mm for active mouth
opening after 6 months. These results are comparable
with other studies.28 It is worth mentioning that this
group had a higher initial mean for active mouth
opening measurement (33.3 ⫾ 6.8 mm) than that of
the centric splint group (31.1 ⫾ 6.4 mm); however,
the amount of improvement in the active mouth
opening was not as great. Passive mouth opening
registered a mean value of 41.9 ⫾ 7.0 mm after 6
months.
SPLINT THERAPY
Ekberg et al33 presented a study based on self-
assessment of TMJ pain using the VAS over 10 weeks
to determine the effect of a stabilization splint in
comparison with a placebo splint in patients with
TMD of arthrogenous origin but without classification
of the exact diagnosis. A significant decrease in the
changes in the severity of TMJ pain was observed in
the splint group, suggesting that the stabilization
splint is effective in treating TMD of arthrogenous
origin. However, Kreiner et al16 concluded in their
study that additional information about TMD sub-
groups is needed when the benefit of occlusal appli-
ances is assessed. Another study30 tried to obtain this
additional information using MRI to diagnose patients
with ADDWR. A short-term follow-up of 8 weeks on 3
groups (no treatment; palliative treatment; and stabi-
lization splint group) did not show any superior re-
sults in reducing subjective intensity of pain and daily
living limitation, despite a remarkable improvement
in maximum mouth opening in the splint group.
Therefore, this study shows that the use of a splint
may increase the patient satisfaction (mouth opening)
in some cases and consequently may reduce the num-
ber of surgical interventions, although the differences
between the splint group and the control group were
not significant. The analysis of the recall values of the
VAS in the present study showed an improvement in
pain conditions with respect to pain level or func-
tional limitation in both splint groups. However, the
investigators were not blinded with respect to the
splint used, but as questionnaires were used to assess
the improvements with respect to pain, the nonblind-
ing of the investigators seems to be acceptable.
Application of the Wilcoxon signed rank test for
matched pairs to each splint group separately showed
that pain and functional limitation on chewing, and
with other functions, were the 4 main variables with
statistically significant differences. In another investi-
gation where the VAS was not used for pain assess-
ment, but with a similar type of pain classification, it
was found that the mean pain level dropped from
2.91 before conservative treatment for ADD without
reduction in 68 patients to 1.22 after treatment. A
statistically significant difference (P ⬍ .001) was
found between both readings.32 Dworkin and Mas-
soth34 concluded from examination of several studies
on TMD pain that changing levels of TMD pain were
not related to changing patterns in the most common
clinical signs of TMD, such as jaw opening or joint
sounds. A marginal relationship was found between
longitudinal patterns of TMD pain and masticatory
muscle tender to palpation. Also, change in the extent
of jaw opening was unrelated to pain grade over time.
Multivariate logistic regression showed that centric
splint use may be slightly more effective than distrac-
SCHMITTER ET AL
tion splint use, confirming previously reported re-
sults.28
As described earlier, Sato et al29 and Minakuchi et
30
al found no significant difference between a stabili-
zation splint group and a natural course group. How-
ever, Sato et al29 described that the stabilization splint
group was about 13% more successful than the natu-
ral course group, and Minakuchi et al30 found a better
improvement of the mouth opening in the splint
group. Therefore, some patients may benefit from the
use of stabilization splints.
The use of distraction splints was slightly less suc-
cessful in the present study than the use of stabiliza-
tion splints. Keeping in mind this finding and the
results of Sato et al29 and Minakuchi et al,30 the use of
a distraction splint might eliminate the little differ-
ence between patients using a splint and controls.
Thus, the use of the less successful distraction splint
cannot be recommended in the therapy of ADDWR,
as the number of patients demanding surgical inter-
ventions might increase.
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