Establishment of a Temporomandibular Physiological State with Neuromuscular Orthosis Treatment Affects Reduction of TMD Symptoms in 313 Patients

Barry C. Cooper, D.D.S.; Israel Kleinberg, Ph.D., D.D.S., D.Sc.:  Journal of Craniomandibular Practice, April 2008, Vol. 26, No. 2, pp 104-117.


ABSTRACT: 
The objective of this investigation was to test the hypothesis that alteration of the occlusions
of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly,
rather than anatomically based, would result in reduction or resolution of symptoms that characterize the
TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD
symptoms were examined for neuromuscular dysfunction, using several electronic instruments before
and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement
of the activities of the masticatory muscles during rest and in function, tracking and assessment of various
movements of the mandible, and listening for noises made by the TMJ during movement of the
mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of
the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate
location of a physiological rest position for the mandible. TENS also made it possible to select positions
of the mandible that were most relaxed above and anterior to the rest position when the mandible
was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position
was recorded in the form of a bite registration, which was subsequently used to fabricate a removable
mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated
retention and stabilization of the mandible in its new-found physiological position, which was confirmed
by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions
achieved remained intact and were associated with improved resting and functioning activities of
the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of
headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for
assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this
study and that taking patients from a less to a more physiological state is an effective means for reducing
or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

Anterior Repositioning Splint in the Treatment of TMJ with Reciprocal Clicking

H. Lundh, P.L. Westesson, S. Koop, and B Tillstrom: Anterior repositioning splint in thre  treatment of tempormandibular joints with reciprocal clicking.  Comparison with a flat occlusal splint and an untreated control group. Oral Surg. Oral Med. Oral Pathol. 60: 131, 1985. 

ABSTRACT:
The anterior repositioning splint is widely used to treat temporomandibular joints with reciprocal clicking. The aim of this prospective study was to evaluate the effect of an anterior repositioning splint in the treatment of patients with reciprocal temporomandibular joint clicking.

Seventry patients referred because of  pain and dysfunction in the masticatory system were selected for this study.  In a random assignment, 24 patients were treated with an anterior repositioning splint, 23 with a flat occlusal splint, and 23 served as a control group.

The anterior repositioning splint, designed to keep the mandible in the anterior position and, thereby, eliminate reciprocal clicking, was placed on the maxillary teeth of the patients in the first group.  This anterior position was maintained through inclines on the splint which allowed the mandibular teeth to occlude withthe splint only in the anterior position.  The flat occlusal splint only in the anterior position.  The flat occlusal splint for the second group was adjusted to maximal occlusal contact in centric relation and centric occlusion, to group contact in laterotrusion, and to anterior guidance on protrusion.  The patietns in the control groups did not receive any treatment.

The anterior repositioning splint decreased joint pain at rest, during chewing,  and during protrusion.  Reciprocal clicking was eliminated and palpatory tenderness of the  joint and muscles was reduced.  This favorable effect was of short duration.  The majority of the patients reported pain and clicking and demonstrated tenderness following removal of the splint after six weeks' treatment.  the flat occlusal splint decreased joint tenderness but did not affect clicking or muscle tenderness.  In the control group, the clicking remained and the frequency of muscle tenderness increased.

The  results suggest thattemporomandibular  joints with reciprocal clicking can be treated successfully by positioning the mandible anteriorly.  Since the symptoms returned when the splint was removed, it seems necessary to stabilize the mandible permanently in an anterior position, thereby maintaining the recaptured disk in a normal relationship to the condyle.