TMJ

Intra-articular and Muscle Symptoms and Subjective

Relief During TMJ Internal Derangement Treatment
with Maxillary Anterior Repositioning Splint or SVED
and MORA Splints: A Comparison with Untreated
Control Subjects
Simona Tecco, D.D.S.; Sergio Caputi, D.D.S.; Stefano Teté, D.D.S.;
Giovanna Orsini, D.D.S.; Felice Festa, M.D., D.D.S., M.S., Ph.D.

0886-9634/2402-
119$05.00/0, THE
JOURNAL OF ABSTRACT: Discomfort associated with wearing an intraoral splint represents a problem in the man-
CRANIOMANDIBULAR
PRACTICE, agement of temporomandibular joint (TMJ) internal derangement. This study evaluated whether the use
Copyright © 2006 of a mandibular splint during the day and a maxillary splint at night could be more comfortable and there-
by CHROMA, Inc.
fore as efficacious in internal derangement treatment as a maxillary splint (AR splint). Fifty (50) patients
(average age 28.8; range 14-63) with confirmed internal derangement in at least one TMJ were divided
Manuscript received
November 12, 2003; into three groups: 20 patients treated with AR splint (Group I); 20 patients treated with a SVED (Sagittal
revised Vertical Extrusion Device) and a MORA (Mandibular Anterior Repositioning Splint) (Group II); and 10
manuscript received
June 6, 2005; accepted patients who underwent no treatment (Control Group). Joint noise, pain intensity and its character (as
October 19, 2005 constant or chewing/biting pain), muscular pain, and subjective relief were evaluated monthly before
Dr. Simona Tecco treatment began (T0) and for six months thereafter. The following results were found: 1. Subjects in
Via Le Mainarde, 26
65121 Pescara Group I and Group II displayed a significant decrease in joint pain (p<0.001), constant pain (p<0.001),
Italy chewing/biting pain (p<0.001), joint noise and muscle pain from the beginning through the sixth month
E-mail: [email protected]
follow-ups; 2. At T1 and T2, subjects in Group II reported significantly lower discomfort associated with
the devices than subjects in Group I. The use of two splints seems to be as efficacious as the use of an
AR maxillary splint; however an AR splint is considered more comfortable by patients, especially during
the first months of therapy.

D
isplacement of the disk in one or both of the tem-
poromandibular joints (TMJ) is found in a major-
ity of patients with symptoms of temporo-
mandibular disorders (TMD). 1 In about half of these
patients, the displaced disk can be held in a normal
Dr. Simona Tecco received her D.D.S. (reduced) relationship with the condyle by anterior posi-
degree in 1999 from the Faculty of tioning of the mandible. With the mandible held in ante-
Dentistry, University of Chieti, Italy. Since
1999, she has been a staff member of the rior position, clicking and locking are eliminated, and
Department of Orthodontics and pain relief is usually obtained within a few days.
Gnathology, School of Dentistry at the Consequently, anterior mandible repositioning using
University of Chieti. She is currently
working toward a Ph.D. in oral science at maxillary appliances with pull-forward ramps has been
the same university. used to treat reducing disk displacement.2-3
In a literature review of long-term treatment findings,
the anterior repositioning splint (AR splint) proved supe-
rior to flat occlusal splints and when compared with a
control group in reducing or eliminating joint noise
(clicking), joint pain, and associated muscle symptoms.4

119
COMPARISON OF SPLINT TREATMENT FOR INTERNAL DERANGEMENT TECCO ET AL.

However, one of the most important clinical problems study, and suspected internal derangement in the subjects
with this type of therapy is the discomfort during swal- was confirmed. Where internal derangement was clini-
lowing, talking, eating, and drinking. Since the splint cally diagnosed on both sides (32 subjects), the radiolo-
must be worn daily for many hours, especially during the gist did not always confirmed this data. In 21 subjects,
first months of therapy, the discomfort is a serious clini- internal derangement was confirmed by MRI on one side
cal problem. Therefore, at the University of Chieti, Italy, only; however, these subjects were included in the sample
subjects were treated using two different splints con- because the clinical examination confirmed the presence
structed with the same wax in an advanced mandible of TMJ sounds. It was assumed that TMJ disk displace-
position. Since the most important symptoms associated ment was present.
to TMD are joint noises and/or pain and muscular pain, Occlusal splints are often used in the management of
the authors wanted to investigate the frequency and inten- TMD. The intent of this study was to evaluate the influ-
sity of the symptoms in subjects treated with the two ence of the type of occlusal splint used in these cases. Ten
splints. patients were chosen as a control group. Forty (40)
The SVED (Sagittal Vertical Extrusion Device)5 and patients were randomly divided into two homogeneous
the MORA (Mandibular Anterior Repositioning Splint),6 groups, based on the criteria of the Kolmogorov-Smirnov
were used alternatively during night and day, respec- test, in age distribution (Table 1). No significant differ-
tively, and the results were compared with an untreated ences were found in the variables considered among
group of subjects and a group of patients treated using an the three groups before treatment began. Since there is no
AR splint. 2 The authors also evaluated psychological literature on a standard therapeutic method for the man-
and/or physical stress associated with wearing the devices agement of internal derangement, the authors used SVED
and experienced by the subjects at baseline and during and MORA in Group II and an AR splint in Group I. In
the treatment. Psychological and/or physical stress expe- both Group I and Group II, the treatment consisted of
rienced by a patient leads to increased activity of the mas- anterior mandibular repositioning by means of oral
ticatory muscles, 7-8 and masticatory muscle activity orthopedics. No drugs or physical therapy were pre-
increases with stress, often resulting in, or exacerbating, scribed. The patients were not instructed in exercises or
symptoms of craniomandibular disorder.9 This hypothe- home care and were not told to change their diets. The
sis is supported by a stress-related concept of myofascial primary reason for the lack of adjunctive therapies was to
pain dysfunction (MPD), based on studies which have more accurately assess the effects of one treatment made
found a high incidence of other “psychosomatic” disor- at a time.
ders in MPD subjects. It was found that 135 MPD sub-
jects had more frequent low back and neck pain, nervous Group I: Anterior Repositioning Splint
stomach, asthma, and a history of ulcers than control sub- An anterior repositioning splint is commonly used in
jects.10 the management of anterior disk displacement with
reduction to re-establish the normal condyle-disk rela-
Material and Methods tionship (Figure 1). The primary goal in protrusive splint
treatment is the elimination of joint sounds by recaptur-
The sample was selected from a group of subjects ing the disk. A smooth, coordinated, painless range of
referred for evaluation of complaints of TMJ pain and motion often can be obtained if the disk is recaptured. In
dysfunction. Symptoms included: joint tenderness and this way, mandible deviation, joint noises, and pain can
pain on palpation; joint pain during masticatory move- be eliminated.11-12 For each patient, a full-coverage AR
ments and abnormal noises, such us popping and click- splint was constructed for the maxillary arch using clear
ing; tenderness and pain in masticatory muscles during self-curing acrylic resin as described by Okeson.13 The
palpation. Subjects were included based on the following base of the occlusal splint is prepared on a model and
criteria: 1. if they presented joint pain and joint noise in at fitted to the maxillary teeth. An acrylic ramp is placed in
least one TMJ; and 2. if suspected internal disk derange- the anterior palatal area so that during normal occlusion,
ment was confirmed on magnetic resonance images the mandibular anterior teeth contact with the protrusive
(MRI). Fifty (50) subjects were included, 28 males and guiding ramp. Occlusal contacts are constructed position-
22 females (average age 28.8; range from 14.0 to 63.0). ing the mandible forward to a jaw position that is effec-
Internal disk derangement was assessed with MRI with tive in decreasing pain and to where the joint noise
two sequences using dual coil capability. The sequences disappears. The later the opening clicking sound occur-
were performed using a proton density image technique. red, the less the trend for mandibular protrusion to obtain
The MRI was read by an oral radiologist, blind to the acceptable condyle-disk position. The subjects were

120 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE APRIL 2006, VOL. 24, NO. 2
TECCO ET AL. COMPARISON OF SPLINT TREATMENT FOR INTERNAL DERANGEMENT

Table 1
Mean Distribution of Age and VAS Assessments of Joint Pain
(Mean, SD, Median and Range) According to the Type of Therapy
Group I (N=20) Group II (N=20) Control group (N=10)
Vs Vs Vs
Mean SD Median Range Grp II Mean SD Median Range Cont Grp Mean SD Median Range Grp I
Age 26.70 5.8 28.5 14.2-58.8 NS 28.20 6.5 27.5 18.2-63.4 NS 27.8 7.2 28.4 15.3-58.2 NS
T0 66.00 15.94 67.5 35-90 NS 67.25 15.09 67.5 40-90 NS 64.5 18.77 60.0 40-95 NS
T1 37.75† 17.28 40.0 0-85 * 20.25† 23.92 12.5 0-85 *** 60.5§ 17.71 55.0 40-50 *
T2 19.25† 17.64 22.5 0-50 NS 14.00‡ 17.29 0 0-50 60.0 15.63 55.0 40-85 ***
T3 13.70‡ 13.46 17.5 0-39 NS 11.20§ 13.45 0 0-39 *** 58.5 16.67 55.0 30-85 ***
T4 4.75‡ 8.66 0 0-25 NS 4.00‡ 8.37 0 0-25 *** 51.5 23.46 55.0 0-80 ***
T5 3.50 7.27 0 0-20 NS 3.50 7.27 0 0-20 ** 46.5§ 22.86 50.0 0-75 **
T6 1.50 4.62 0 0-15 NS 1.50 4.62 0 0-15 ** 46.0§ 22.83 47.5 0-75 **
*p<0.05; **p<0.01; ***p<0.001 in the transversal analysis
†p<0.001; ‡p<0.01; §p<0.05 in the longitudinal analysis

instructed to wear the same splint both at night and during so that increases in occlusal vertical dimension were kept
the day. The proper instructions for wearing the AR splint to a minimum. The amount of anterior repositioning in
were given during each of the monthly appointments. The bites averaged 4.5 mm, with a range of 2-6 mm, measured
importance of wearing the splint at all times, as instructed, in anterior teeth. During the treatment, all patients were
was impressed on the patients in order to guarantee the fitted with removable day and night appliances. They
correct repositioning of the mandibular condyle. were told to wear the MORA or SVED at all times and to
be very careful not to bite down when changing appli-
Group II: SVED and MORA ances. Proper instructions for wearing the AR splints
Subjects in Group II were treated using two types of were given during each of the monthly appointments. The
appliances: a SVED and a MORA (Figure 2a, 2b). The importance of wearing the splint at all times, as instructed,
MORA was worn during daytime, while the SVED was was impressed on the patients in order to guarantee the
worn alternatively, at night. At the initial examination, a correct repositioning of the mandibular condyle.
polyvinylsilozane putty construction bite was established The MORA (Figure 2a) is a frequently used partial
in mandibular position, which effectively eliminated clin- coverage splint positioned on the maxillary or mandibu-
ical signs of disk displacement and reduction by forcing lar teeth that has high patient acceptance because of the
the mandible to open and close along an anterior trajec- relatively comfortable design. When used on the lower
tory. Contact of the natural anterior teeth was maintained arch, it is a modified Gelb splint.14-15 Acrylic covers the
occlusal and lingual surfaces of the mandibular posterior
teeth, from the canines to the most distal molar bilater-
ally. There is a lingual anterior metal bar. The incisal
edges of the lower anterior teeth are left uncovered, and
the upper incisors do not contact the splint. Total occlusal
contact of the posterior teeth, including canine guidance,
is established with the appliance. The use of two posterior
segments allows incisal function of the natural anterior
teeth and avoids interfering with tongue position. The
appliance is made with prominent pull-forward inclines
located over the lingual side of the premolar area (so that
they engage the mesial facing slope of the lingual cusp of
the maxillary first premolar) and the lingual side of the
most distal mandibular molars (so that they engage the
mesial facing slope of the palatal cusp of the terminal
Figure 1
maxillary molar). In this study, all subjects had the
Example of AR splint used in Group I mandible advanced to approximately an edge-to-edge

APRIL 2006, VOL. 24, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 121
COMPARISON OF SPLINT TREATMENT FOR INTERNAL DERANGEMENT TECCO ET AL.

that the anterior ramp is constructed behind the canine

area and specifically engages the anterior mandibular
teeth, preventing mandibular movement in a posterior
direction. Thus the mandible is anteriorly braced even
when the mouth is open. The anterior ramp used in this
study was carefully adjusted so that it forced the mandible
to open and close on the same trajectory supported by the
inclines of the daytime appliance. Both appliances were
balanced in centric occlusion and into right lateral and
left lateral excursions. When the patients first received
their appliances, they were instructed to return to the
office only if they noticed some dramatic relief of symp-
toms within a week.
Figure 2
Examples of appliances/splints used in Group II: a. (above) Man- All subjects in the three groups were monitored monthly
dibular Anterior Repositioning Splint (MORA), occlusal view; from the beginning of the treatment (T0) for a total period
b. (below) Sagittal Vertical Extrusion Device, occlusal view. of six months (Tl, T2, T3, T4, T5, T6).
1. Joint noise. The presence of joint noise (clicking)
was investigated by the same clinician using a stetho-
scope. Each subject was listed as having or not
having joint noise each month. Based on clinical
evaluation and on the patient’s referred history, the
patient was classified as having (yes) or not having
(no) joint noises. Patients with a unique joint noise,
during the opening or closing of the mouth, were
classified as having joint noises.
2. Intensity of joint pain. The intensity of pain was
assessed daily by each subject with a 100 mm Visual
Analogical Scale (VAS) rated from no pain to worst
pain possible. Each subject was asked to record the
intensity of pain (VAS score) daily in a personal day-
incisal relationship, with a mild anterior open bite created book. The mean value of the daily scores during each
by the minimal thickness of the acrylic required to cover month was used as the VAS scores for that month.
the posterior teeth. Gelb 14 notes that the mandibular 3. Kind of joint pain. Each patient was asked to describe
orthopedic repositioning appliance, which is constructed the kind of pain as constant pain or pain when chew-
to cover only the lower posterior teeth has a lot of advan- ing/biting, 16 using two descriptors based on the
tages: 1. it provides the patient with functional comfort in McGill Pain Questionnaire. For each type of joint
the shortest period of time; 2. it is hygienic and comfort- pain, a daily note of the intensity (VAS score) was
able; and 3. phonetically, it can be checked to see that it recorded by patients. The mean value of those daily
does not invade the freeway space. values during each month was used as the VAS
In the current study, when the appliance was placed in score for that month.
the patients’ mouths, it was balanced in centric occlusion. 4. Muscle pain. Muscle pain was assessed during pal-
Centric stops were then incorporated into the occlusal pation using the Travell17 method. Muscle pain was
topography of the acrylic appliance, and the patient’s bite rated based on a 4-point scale from 0-3.18 (0: no pain;
was guided into right lateral and left lateral excursions. 1: discomfort, aching or suffering; 2: pain; 3: patient
Finally, the patient was instructed to move into a protru- shows lachrymation or asks to the clinician to not
sive relationship with optimal contact on the last molar palpate that point). Because of the small samples and
only. Subjects were requested to wear the appliance in order to increase the power of statistical analysis,
during daytime. During the first week, the appliance had patients were finally classified as having or not
to be worn for short periods of time, then the time was having muscle pain upon palpation.
increased until it became a full day in the second week. 5. Subjective relief. The VAS was also adapted and
All patients were given a SVED (Figure 2b)5 to use employed to assess subjective status associated with
during sleeping. The primary advantage of the SVED is disturbing articulation, occlusion, or muscle function

122 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE APRIL 2006, VOL. 24, NO. 2
TECCO ET AL. COMPARISON OF SPLINT TREATMENT FOR INTERNAL DERANGEMENT

during the follow-up period. Subjects were asked to month of therapy (T1) and in 70% of the subjects after the
estimate their mood of nervousness (i.e., depression fourth month of therapy (T4). In Group I, clicking was
or aggressiveness), the comfort they felt wearing observed in 100% of subjects at T0, disappeared in 35%
splints while working or studying, and how they of subjects after the third month of therapy (T3), and in
experienced the state of their home life at the base- 40% of subjects after the fifth month (T5). Clicking dis-
line and during treatment. The VAS was a 100-mm appeared in 20% of subjects soon after the first month of
line with the endpoints of no complaints and the therapy (T1). In the control group, clicking was observed
highest possible intensity of complaints. in 100% of patients during the entire period of follow-up.
Chi-square analysis revealed that the percentage of sub-
Statistical Analysis jects reporting clicking was statistically lower in Group II
compared with the control Group at T5 and T6 (p<0.01),
This study focused on the distribution and the intensity Figure 3.
of pain and joint noises and the influence of the kind of
splint on these variables. Variables were used to show the Joint pain: Intensity of Pain on VAS
influence of using an orthopedic device and the particular Descriptive statistics are shown in Table 1. The
type of device. The three groups were preliminarily Friedman two-way analysis of variance (ANOVA)
screened for homogeneity of age distribution using a showed a highly significant effect over time, and separate
Kolmogorov-Smirnov test, resulting in age homogeneity Wilcoxon testing between the assessments of months 1,
in the three groups (Table 1). Simple descriptive statis- 2, 3, 4, 5, and 6 revealed significant therapeutic effects in
tics were assessed and differences in frequencies between the two study groups throughout the assessment period
groups were analyzed using Pearson’s chi-square. Due to (p<0.001). In Group II, the mean value of pain intensity
the possibility of skewed data, non-parametric statistics decreased approximately 70% from T0 to T1 (p<0.001).
(Kruskal-Wallis and Dunnett’s T3) were computed to test It then continued to decrease over time (Table 1) with
significant differences between groups according to the statistically significant differences between T2 and T1
VAS score assessment. In order to investigate the repeated (p<0.01); T3 and T2 (p<0.05); and T4 and T3 (p<0.01).
pain assessments, a Friedman’s two-way analysis of vari- In Group I, the intensity of pain showed a similar pattern
ance (ANOVA) between measurements was calculated (Table 1). There was a significant drop of about 45% in
and the differences were estimated with the Wilcoxon’s mean scores after one month from the start of treatment
signed rank test. All statistical analyses were performed (p<0.001) and also between T2 and T1 (p<0.001); T3 and
using the SPSS Ver. 9 (SPSS, Inc., Chicago, IL) and the T2 (p<0.01); and T4 and T3 (p<0.01). After T4, the inten-
level of significance was set at p<0.05. sity of pain continued to decrease and the mean score
became clinically irrelevant in both Groups I and II. The
Results most important finding regarding joint pain was that a
significant difference between groups was observed at
All subjects completed the study. Subjects reported T1, as a lower intensity of joint pain was recorded in
joint pain and joint noise in at least one TMJ on average Group II than in Group I (Table 1) (p<0.05). However,
for the past 24 months at mean (range 8 months to 28 there was no significant difference between the two study
months). No statistical analyses were performed in this groups at T0 or at the other follow-ups (T2, T3, T4, T5
regard. Occlusal features included different types of mal- and T6, Table 1). This is why therapy with SVED and
occlusion: 48% showed class II molars at one side or MORA seemed to be more efficacious during the first
bilaterally; 20% showed class III molars at one side or month of therapy than the therapy with the AR splint in
bilaterally; 12% showed the absence of one or more teeth decreasing joint pain. Untreated subjects in the control
in the posterior zone; 4% showed a genesis of one or group showed no significant decrease in joint pain from
more permanent teeth. T0 to T6, with the exception of between T1 and T0
(p<0.05); T5 and T4 (p<0.05); and T6 and T5 (p<0.05.
Joint Noises These differences were not clinically significant.
The frequency of joint noises was investigated by the
clinician while the subject was not wearing a splint. The Kind of Joint Pain: Chewing-Biting Pain
frequency decreased over time in the two study groups. In The intensity of chewing-biting pain significantly
Group II, the frequency of clicking decreased from 100% decreased over time in the two study groups (p<0.001)
of subjects at T0 to 25% of subjects at T6. Interestingly, but not in the control group, Table 2. In the control
clicking disappeared in 25% of subjects after the first group, the intensity of chewing/biting pain increased over

APRIL 2006, VOL. 24, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 123
COMPARISON OF SPLINT TREATMENT FOR INTERNAL DERANGEMENT TECCO ET AL.

time (p<0.01) with a statistically significant difference 37.5; p<0.01) and at T2 (respectively 11.0 and 21.5;
between T1 and T0 (p<0.05). Patients in Groups I and II p<0.05). In the control group, the intensity of constant
reported a significantly lower intensity of chewing/biting pain increased over time from T0 (63.5) to T4 (73.0),
pain compared with the control group since T1 (p<0.001). although Wilcoxon testing revealed a significant de-
These differences were highly significant for the two crease between T1 and T0 (p<0.05). After T4, pain inten-
groups until T6 (p<0.001 both groups). Interestingly, sity (VAS) decreased until T6 (65.5), with a significant
subjects in Group I showed a significantly lower intensity difference between T5 and T4 (p<0.01). However, this
of chewing/biting pain at T1, compared with subjects in pain reduction cannot be considered clinically relevant
Group II (p<0.001), although no significant differences since all the subjects included in the control group asked
were observed at T2, T3, T4, T5 and T6. for all therapy after the sixth month study.
Cross-sectional analysis revealed a significantly lower
Kind of Joint Pain: Constant Pain intensity of constant pain in Group II and Group I com-
At T0, in each of the three groups, constant pain dis- pared with the Control Group at T1 (respectively, p<0.001
played a lower intensity than chewing-biting pain and p<0.01), and T2, T3 and T4 (p<0.001 for both study
(p<0.001). The intensity of constant pain significantly groups). In addition, although a significant reduction of
decreased over time in the two study groups (p<0.001) constant joint pain between T5 and T4 was recorded in
but increased in the control group, Table 3. There were the Control Group (p<0.01), pain intensity in the two
no significant differences between groups at T0. In Group study groups continued to be significantly lower at T4
II, the intensity of pain decreased approximately 85% and T5, compared with the control group (p<0.001).
from 62.5 (mean VAS score at T0) to 4.00 (mean VAS In both study groups, the frequency of muscle pain was
score at T3) after three months of therapy and became significantly lower than that observed in the control
clinically irrelevant after the third month of therapy group (p<0.05) at T5. At T6, no statistical analysis was
(range from 0.00 to 15.00 at T4, T5 and T6). In Group I, performed, since no muscle pain was recorded in either of
a similar pattern was found as the intensity of pain the two study groups, Figure 4.
decreased form 65.0 (mean VAS score at T0) to 5.25 No significant difference was observed between sub-
(mean VAS score at T3) after three months of therapy jects from the two study groups at T0 when they inserted
and became clinically irrelevant after the third month of the splints in their mouths for the first time. All the sub-
therapy (range from 0.00 to 30.0 at T4, T5 and T6). jects reported a severe discomfort (Figure 5), mostly
Although a statistically significant and clinically relevant associated with difficulty in phonetic function and swal-
reduction of pain intensity was observed in both the study lowing. They also reported difficulty in maintaining cor-
groups, this reduction was more evident in Group II, as rect oral hygiene. Soon after the beginning of treatment,
the mean value of VAS score was significantly lower in at T1 and T2, subjects in Group II reported a significant
Group II than in Group I at T1 (respectively 28.75 and decrease in discomfort (p<0.001). At the same time, sub-

Table 2
VAS Assessments of Chewing-Biting Pain
(Mean, SD, Median and Range) According to the Type of Therapy
Group I (N=20) Group II (N=20) Control group (N=10)
Vs Vs Vs
Mean SD Median Range Grp II Mean SD Median Range Cont Grp Mean SD Median Range Grp I
T0 73.00 8.34 70.0 60-90 NS 73.50 7.27 72.5 65-90 NS 66.5 18.72 62.5 40-95 NS
T1 34.50† 6.67 35.0 20-45 *** 43.25† 7.30 42.5 30-60 *** 72.0§ 16.87 72.5 45-95 ***
T2 31.00‡ 4.76 30.0 20-40 NS 34.75† 5.95 35.0 25-50 *** 73.0 16.87 72.5 45-95 ***
T3 28.50‡ 4.32 30.0 20-35 NS 29.95‡ 5.03 30.0 20-40 *** 74.0 15.60 72.5 50-95 ***
T4 17.75† 9.66 20.0 0-25 NS 16.50† 9.33 20.0 0-30 *** 75.0 14.53 72.5 55-95 ***
T5 11.75‡ 8.47 15.0 0-20 NS 12.50‡ 9.25 15.0 0-25 *** 75.5 12.35 72.5 60-90 ***
T6 5.25‡ 6.17 0 0-15 NS 7.00‡ 6.96 10.0 0-20 *** 76.5 12.92 75.0 60-95 ***
*p<0.05 **p<0.01 ***p<0.001 in the transversal analysis
†p<0.001 ‡p<0.01 §p<0.05 in the longitudinal analysis

124 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE APRIL 2006, VOL. 24, NO. 2
TECCO ET AL. COMPARISON OF SPLINT TREATMENT FOR INTERNAL DERANGEMENT

Table 3
VAS Assessments of Constant Pain
(Mean, SD, Median and Range) According to the Type of Therapy
Group I (N=20) Group II (N=20) Control group (N=10)
Vs Vs Vs
Mean SD Median Range Grp II Mean SD Median Range Cont Grp Mean SD Median Range Grp I
T0 65.00 8.76 65.0 50-80 NS 62.50 6.59 62.5 50-70 NS 63.5 18.57 62.5 40-95 NS
T1 37.50† 8.81 40.0 20-50 ** 28.75† 5.35 30.0 20-40 *** 67.0§ 16.53 67.5 45-95 **
T2 21.50† 10.53 25.0 0-35 * 11.00† 11.65 7.5 0-30 *** 68.0 13.58 70.0 50-95 ***
T3 5.25‡ 10.06 0 0-30 NS 4.00§ 7.54 0 0-25 *** 72.0 11.83 72.5 55-95 ***
T4 4.25 9.39 0 0-30 NS 2.50 5.26 0 0-15 *** 73.0 11.35 75.0 55-95 ***
T5 3.75 9.30 0 0-30 NS 1.50 3.66 0 0-10 *** 68.5‡ 11.80 70.5 50-90 ***
T6 3.75 9.30 0 0-30 NS 1.00 3.08 0 0-10 *** 65.5 8.64 67.5 50-80 ***
*p<0.05 **p<0.01 ***p<0.001 in the transversal analysis
†p<0.001 ‡p<0.01 §p<0.05 in the longitudinal analysis

jects using the AR splint (Group I) continued to describe pain intensity and joint noises and, consequently, began
a severe discomfort caused by difficulties during speak- to wear the splints only for a few hours during the day.
ing, probably associated with the presence of the anterior Because of this decrease, patients in Group I reported sig-
ramp on the splint. However, subjects treated with SVED nificantly less discomfort than in Group II at T5 and T6
and MORA described no difficulty in speaking when (p<0.05).
they wore the MORA (during the day) and said they felt
comfortable while wearing the MORA while working or Discussion
studying. Because of the improvement of adaptation to
the devices, subjects in Group II showed a significantly Joint pain and joint sounds were strongly associated
lower discomfort at every follow up from T1 to T4, com- with joint abnormal morphology. The presence of pain
pared with subjects usng the AR splint (Group I), Figure was associated with MRI evidence of joint effusion19 and
5. At T3 and T4, subjects using the AR splint showed a reciprocal clicking was consistently associated with disk
significant decrease of discomfort, Figure 5 (p<0.05 displacement with reduction.20-21 Pereira, et al.,22 in TMJ
between T4 and T3 and p<0.001 between T5 and T4), autopsy studies which correlated symptoms before death
derived from the fact that they experienced a decrease of to anatomical examination of the joints, concluded that

Figure 3
Graphic representation of patients
reporting joint noise (as % of the
whole sample) treated by using the
AR splint (AR: N=20), SVED and
Gelb splint (SVED and GELB:
N=20) or nontreated control subjects
(Control: N=10), from the baseline
recording (T0) to month six (T6)
after the start of treatment.
Significant differences between
groups indicated by brackets.

APRIL 2006, VOL. 24, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 125
COMPARISON OF SPLINT TREATMENT FOR INTERNAL DERANGEMENT TECCO ET AL.

Figure 4
Graphic representation of patients
reporting muscle pain (as % of the
whole sample) treated by using the
AR splint (AR: N=20), SVED and
Gelb splint (SVED and GELB:
N=20) or nontreated control subjects
(Control: N=10), from the baseline
recording (T0) to month six (T6)
after the start of treatment.
Significant differences between
groups indicated by brackets.

the association between pain and/or dysfunction and joint toms (sounds and pain), and these 21 subjects showed
morphology is complex and that gross morphologic alter- severe clinical symptoms, although symptoms were not
ations can be present in the absence of TMD symptoms. confirmed by MRI on one side. Additionally, since TMJ
However, since the primary symptoms for consulting a displacement on one side is often treated with the same
clinician are pain and joint noises, in the current study we therapeutic program as cases with both disks displaced,
simply assessed the existence of pain and joint noises and we decided to include these patients in our sample.
monitored over time the presence of symptoms without One difference between this study and other studies of
assessing any morphological alteration of the TMJ attempted disk recapture is that the SVED was used on all
observed on MRI. patients at night. The design of the SVED seems better
In the current study, we included 21 patients with disk able to maintain the anterior mandibular position. During
displacement confirmed only on one side by MRI and sleep, the anterior ramp may have served as protection to
with TMJ sounds in both joints. The primary inclusion the retrodiskal tissues against gravitational pulling of the
criteria in the study was the presence of clinical symp- mandible or to relieve the lateral pterygoids of the respon-

Figure 5
Graphic representation of subject
relief (as VAS score) (mean value
and SD) reported by patients treated
by using the AR splint (AR: N=20),
SVED and Gelb splint (SVED and
GELB: N=20) or nontreated control
subjects (Control: N=10), from the
baseline recording (T0) to month six
(T6) after the start of treatment.
Significant differences between
groups indicated by brackets.
*p<0.05 **p<0.01 ***p<0.001

126 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE APRIL 2006, VOL. 24, NO. 2
TECCO ET AL. COMPARISON OF SPLINT TREATMENT FOR INTERNAL DERANGEMENT

sibility of preventing mandibular retrusion. Reflex neuro- rior repositioning of the mandible in the treatment of TMJ
muscular protective mechanisms are most quiescent internal derangement.
during sleep, and the mandible assumes its most retrusive Subjects treated with the SVED and MORA showed a
posture when the body is fully reclined. significantly lower intensity of constant joint pain at T1
The primary finding with regard to joint pain in the and T2, compared to those treated with the AR splint,
current study was that no significant difference was Table 3. Longitudinal analysis showed a highly signifi-
observed in the amount of joint pain in the group of sub- cant decrease in constant joint pain at T1, T2 (p<0.001),
jects treated with the AR splint or SVED and MORA, and T3 (p<0.05), Table 3, while no significant decrease
except at T1 (one month after the start of treatment). At was observed at follow-up in subjects treated with the
T1, the subjects treated using the SVED and MORA SVED and MORA. This confirms that the greater thera-
reported a significantly lower intensity of joint pain peutic effect of the SVED and MORA mostly occurred
(p<0.05), compared with subjects treated with the AR during the first months of wearing the device. However,
splint, Table 1. This finding may be due to the fact that no conclusions could be made, since subjects treated with
subjects treated with the AR splint reported a signifi- the AR splint also experienced a highly significant
cantly greater discomfort associated with the device decrease in constant joint pain at T1, T2 (p<0.001), and
during the first month of therapy than subjects treated T3 (p<0.01), Table 3. This finding seems to confirm the
with the SVED and MORA (p<0.01) Figure 5. Subjects validity of that therapeutic device despite its discomfort.
treated with the AR splint did not wear the splint all night In the group of untreated control subjects, constant
and day and probably experienced a less evident thera- pain showed an increase in intensity until T4 (the increase
peutic effect. Instead, subjects treated with the SVED and was statistically significant at T1, p<0.05, Table 3), and
MORA experimented a higher decrease in discomfort at this finding was probably due to the absence of a thera-
T1 and T2 (p<0.001) Figure 5. More than likely these peutic program.
patients wore their splints without interruption and In the control group, the intensity of constant pain
obtained a greater therapeutic effect. Discomfort was showed a decrease at T5 and T4 (p<0.01), Table 3. The
probably associated with the presence of the anterior mechanism of this improvement of symptoms remains
ramp on the AR splint, which can make phonetic function unclear. Perhaps, this was due to the fact that subjects
and swallowing difficult. Subjects treated using the learned a new mode of pain perception. The perception of
SVED and MORA had to wear the SVED (with the ante- pain changed and the values became higher than in the
rior ramp) only at night, while the MORA (worn during first month. However, this finding cannot be considered a
the day) was more comfortable. They reported no diffi- sign of recovery as it was not clinically relevant.
culty in speaking when they wore the MORA (during the The distribution of chewing-biting pain (Table 2)
day) and were comfortable while wearing the MORA showed the same tendency compared with that of con-
while working or studying. In conclusion, the use of the stant pain (Table 3), since it showed significantly lower
SVED and MORA seems to be more efficacious com- intensity in subjects treated with the AR splint or the
pared with AR splint use in the treatment of joint pain SVED and MORA compared with the untreated control
during the first month of therapy because of the more subjects, from T1 to T6 (p<0.001). This finding seems to
comfortable therapeutic design. confirm the validity of jaw repositioning in the treatment
Longitudinal analysis showed that the intensity of joint of TMJ internal derangement. It must be noted that sub-
pain in subjects treated with the SVED and MORA jects treated with an AR splint experienced a more effica-
mostly decreased during the first month of therapy (from cious therapeutic effect at T1, compared with those
67.5 to 20.25; p<0.001, Table 1). This finding seems to treated with the SVED and MORA (p<0.001), since they
be in accord with the fact that subjects treated with the reported a lower chewing-biting pain intensity, Table 2.
SVED and MORA experienced a greater therapeutic Subjects in the control group experienced a progressive
effect during the first month of therapy. This disputes the increase of pain intensity from T1 to T6, Table 2. This
importance of subjective relief in the management of finding also confirms the validity of both of the compared
TMJ internal derangement. treatments.
It must be noted that no significant differences were The frequency of joint noise (Figure 3) became signif-
found between the study groups from T2 to T6 in the icantly lower in the groups of patients treated with the
intensity of joint pain and that subjects in both of the SVED and MORA at T5 and T6, compared to subjects
study groups showed a significantly lower intensity of treated with the AR splint and with the untreated control
joint pain from T1 to T6 compared to the control subjects patients (p<0.01). This seems to suggest that the SVED
(Table 1). This seems to confirm the validity of the ante- and MORA were more efficacious in the treatment of

APRIL 2006, VOL. 24, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 127
COMPARISON OF SPLINT TREATMENT FOR INTERNAL DERANGEMENT TECCO ET AL.

joint noises than the AR splint. However, it must be noted made to eliminate compliance failures from the study.
that the frequency of joint noise decreased over time in
each of the two study groups, just from T1, while it Limits of the Study
remained at 100% until T6 in the control group. The dif-
ference observed from T1 to T4 between the two study This study was limited by the time considered. Follow-
groups and the control group, although not significant, up was concluded when only a part of the subjects were
might suggest that an efficacious therapeutic goal could considered asymptomatic. The study must be considered
be obtained with the use of each of the two types of ther- a preliminary study. We do not know how many subjects
apy. The fact that no differences were observed between became chronic in pathology or how many completely
the study and the control groups until T5 could be recovered. This interruption of the study was in part due
explained as a consequence of the small number of sub- to the fact that control subjects decided to begin the ther-
jects studied. apy with the splint and were treated with AR splints.
The findings relative to the frequency of muscle pain, Another limit was that VAS was used to assess the quan-
shown in Figure 4, confirmed the therapeutic efficacy of tity of pain. This method was shown to be influenced by
treatment with the SVED and MORA, as well as of with subjective perceived levels of pain intensity23 by McKay
the AR splint. Although significant differences were and Christensen24 and therefore, a pseudo-scientific diag-
observed at T4 and T5 between the two study groups and nostic technique. Finally, no MRIs were made during the
the control group (p<0.05), a decrease of the frequency of eight months, and the study must be considered only an
muscle pain was observed from T1 in both the study analysis of the primary symptoms associated with a
groups. In the control group, the frequency of muscle recently diagnosed TMD.
pain showed a progressive increase from T0 to T2 and
became 100% at T3. It then remained at 100% until T6. Conclusions
This seems to confirm the presence of a closed link
between muscular and skeletal apparatus and the pres- In the treatment of TMJ internal derangement, anterior
ence of joint pain and muscle pain in subjects with inter- jaw repositioning seems to be confirmed as an efficacious
nal derangement. therapeutic action, since subjects in the two study groups
One of the most important findings was that subjects showed a significant decrease in joint pain, constant joint
treated with the SVED and MORA experienced signifi- pain, and chewing-biting pain from the first month after
cant lower discomfort while wearing the splints from Tl, the start of therapy.
compared with subjects treated with the AR splint, In the treatment of TMJ internal derangement, the clin-
Figure 5. This could suggest that, although clinical ther- ical therapeutic efficacy of the anterior repositioning of
apeutic effect of the two compared types of therapy was the mandible seems to be confirmed at least until the sixth
almost equal, the SVED and MORA were more easily month after the start of treatment, since subjects in the
accepted by the patients. This is probably because the study groups showed a significantly lower intensity of
MORA did not interfere with swallowing or phonetic joint pain, constant joint pain, chewing-biting pain, from
function during the day. Instead, the main of discomfort the beginning to the sixth monthly follow-up.
associated with the AR splint was difficulty during Regarding the therapeutic protocol, the use of an infe-
speaking and swallowing. rior splint during the day (MORA) and a superior splint
No definite conclusions with regard to the SVED and during the night (SVED) showed a similar therapeutic
MORA therapy were possible. It is difficult to know how effect compared with the use of an AR splint in the man-
many symptoms during treatment were due to a failure of agement of TMJ internal derangement, and resulted in
compliance rather than a problem with anatomy or treat- more comfort to the patient. Since patients tended to wear
ment technique. Patients were told they must adhere to a these types of splints for a greater number of hours
strict protocol for appliance wear. Although they were because of the comfortable design, the splints seem to be
told to always wear the night appliance to sleep and not more efficacious during the first months of therapy.
remove the day appliances for eating, patients occasion-
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