The Journal of the American Dental Association
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

J Am Dent Assoc, Vol 137, No 8, 1108-1114.
© 2006 American Dental Association
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Conti, P. C. R.
Right arrow Articles by de Araujo, C. d. R. P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Conti, P. C. R.
Right arrow Articles by de Araujo, C. d. R. P.
Related Collections
Right arrow Endodontics

COVER STORY

The treatment of painful temporomandibular joint clicking with oral splints

A randomized clinical trial



Paulo César Rodrigues Conti, DDS, PhD, Carlos Neanes dos Santos, DDS, MS, PhD, Evelyn Mikaela Kogawa, DDS, MS, Ana Claudia de Castro Ferreira Conti, DDS, MS, PhD and Carlos dos Reis Pereira de Araujo, DDS, MS, PhD


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. The authors compared the efficacy of bilateral balanced and canine guidance (occlusal) splints in the treatment of temporomandibular joint (TMJ) pain in subjects who experienced joint clicking with a nonoccluding splint in a double-blind, controlled randomized clinical trial.

Methods. The authors randomly assigned 57 people with signs of disk displacement and TMJ pain into three groups according to the type of splint: bilateral balanced, canine guidance and nonoccluding. The authors followed the groups for six months using analysis of a visual analog scale (VAS), palpation of the TMJ and masticatory muscles, mandibular movements and joint sounds. They used repeated analysis of variance and a {chi}2 test to test the hypothesis.

Results. The type of guidance used did not influence the pain reduction, yet both occlusal splints were superior to the nonoccluding splint, on the basis of the VAS. Despite similar outcomes in relation to opening, left lateral and protrusive movements, TMJ and muscle pain on palpation, subjects who used the occlusal splints had improved clinical outcomes. The frequency of joint noises decreased over time, with no significant differences among groups. Subjects in the groups using the occlusal splints reported more comfort.

Conclusion. The type of lateral guidance did not influence the subjects’ improvement. All of the subjects had a general improvement on the VAS, though subjects in the occlusal splint groups had better results that did subjects in the nonoccluding splint group.

Key Words: Temporomandibular disorders; occlusion; occlusal splints

Temporomandibular disorders (TMDs) have signs and symptoms that affect the masticatory muscles, temporomandibular joint (TMJ) or both. These signs and symptoms include complaints of facial and TMJ pain, tenderness to palpation on the face and TMJ, uncoordinated mandibular movement and the presence of joint sounds.

The full-coverage occlusal splint is one of the therapies most frequently used in the treatment of these problems. A recent systematic review concluded that stabilization splints are beneficial for reducing pain when compared with no treatment.1 The authors, however, suggested the need for well-conducted randomized clinical trial (RCT).

Despite reports of high rates of clinical success of full-coverage occlusal splints on the reduction of TMD signs and symptoms, little is known about their efficacy, especially concerning the effects of lateral and protrusive guidance.

Researchers have proposed several mechanisms of action to explain the reported effectiveness of this therapy, including increasing the vertical dimension of occlusion, incorporating the "ideal" occlusion pattern, muscle relaxation, cognitive awareness and use of a placebo.2

Many studies have shown that the presence of canine guidance is crucial for the success of both natural occlusion and splints.3–14 D’Amico4 stated that "when the canines are in contact, there is an immediate interruption on the tension of the temporal and masseter muscles, therefore reducing the magnitude of force."

On the other hand, some researchers believe that occlusal contacts on the nonworking side might provide an advantage for the treatment of painful TMJs.15–18 For example, Kahan16 observed that symptomatic subjects with and without disk displacement had significantly smaller amounts of nonworking side contacts compared with asymptomatic subjects. In 1990, Minagi and colleagues18 evaluated 430 dental students and observed a highly significant correlation between the absence of contacts on the nonworking side and the increase of joint sounds with age. Moreover, other studies19,20 indicate that nonworking side contacts may protect the TMJ at the same side.

When considering the occlusal design of splints, Fitins and Sheikholeslam5 found that incorporating the canine-protection scheme seemed to cause a significant decrease in the electromyographic activity of elevator masticatory muscles. Other investigators have also used mutually protected occlusion21 and extreme canine-protected occlusion with limited lateral movement22 designs in the treatment of patients with TMD. Gray and colleagues23 did not find significant differences when they compared stabilization splints and splints with a localized occlusal interference in patients with TMJ pain. They concluded that the success of the splint therapy is independent of its occlusal design.

We conducted a double-blind, controlled RCT to evaluate the efficacy of stabilization splints with bilateral balanced guidance in the treatment of painful TMJ clicking compared with a traditional splint with canine guidance and a nonoccluding splint.


   SUBJECTS, MATERIALS AND METHODS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Population sample. We selected 60 subjects (mean age 29.9 years) from a pool of patients attending the Orofacial Pain Center, Prosthodontics Department, Bauru Dental School, University of São Paulo, Brazil, who met the inclusion criteria and entered them into the study. The inclusion criteria were the presence of TMJ reciprocal clicking, subjects’ report of TMJ pain for at least three months and joint tenderness on palpation on at least one side. We excluded people with systemic conditions, arthritis, or a history of TMJ surgery or TMD treatment. We also excluded people who had a dental prosthesis or who had more than two posterior missing teeth (except for third molars and teeth extracted for orthodontic reasons).

We obtained informed consent from all of the subjects. The university’s ethics committee approved the study.

Experimental procedure. An experienced dentist (C.R.P.A.) examined all of the subjects according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD).24 We included in the study subjects who met the diagnosis criteria for Group II (disk displacement) and Group IIIa (arthralgia). We then randomly assigned the 55 female and five male subjects to three groups described below (which we matched for aging) using a stratification method; that is, we placed the subjects into different groups according to the severity of the initial pain that was measured using a visual analog scale (VAS) and the tenderness of the TMJ on palpation. We used a table generated by a computer to perform the randomization.

A second experienced dental practitioner (C.N.S.) inserted the splints, without mentioning the type of splint and its expected mechanism to the subject. The dentist instructed the subjects to wear their splints only at night, while sleeping.

We treated the subjects in group I (mean age 28.9 years) with a modified acrylic stabilization (balanced) splint on the maxillary arch. With this design, the mandibular buccal cusps and incisal edges contacted a flat surface, even contacts on posterior and anterior regions, allowing for simultaneous contact of the mandibular teeth in all segments of the splint during excursive movements (right lateral, left lateral and protrusion excursions) (Figure 1Go).


Figure 1
View larger version (99K):
[in this window]
[in a new window]
  		Figure 1. Frontal view of the bilateral balanced stabilization splint. Note the posterior contacts during the protrusive movement.

 
We treated group II (mean age 31.3 years) with a conventional acrylic full-covered stabilization splint with canine guidance on the maxillary arch (Figure 2Go). This design allowed disocclusion of all posterior teeth by the contact between canines during lateral movements and between anterior teeth during protrusive movement.


Figure 2
View larger version (100K):
[in this window]
[in a new window]
  		Figure 2. Canine guidance stabilization splint.

 
Subjects in group III (mean age 29.5 years) received a nonoccluding splint on the mandibular arch. We built this appliance with acrylic over buccal and lingual surfaces, with no interferences on the subject’s occlusion (Figure 3Go).


Figure 3
Figure 3
View larger version (191K):
[in this window]
[in a new window]
  		Figure 3. A. Lateral view of the nonoccluding splint. Note the noninterference with the intercuspal position. B. Occlusal view of the nonoccluding splint.

 
We did not provide counseling on any sort of therapy to the subjects during the trial period. Three subjects left the study: two from group III owing to lack of remission of symptoms and one from group I owing to a change in address.

We monitored and evaluated all subjects at 15 days, one month, three months and six months after the insertion of the splints. A third examiner (P.C.R.C.), who was blinded for group distribution, performed these follow-up examinations. To compare the groups, we used the subjects’ pain reports from the VAS, TMJ and muscle palpation (temporal and masseter),25,26 analysis of the active mandibular range of motion and TMJ manual inspection for joint sounds. We also evaluated the subjects’ self-reports as to the progression of joint sounds, changes in occlusion and comfort levels.

Statistical analysis. We conducted statistical analyses using repeated measurements analysis of variance, a Friedman test and a {chi}2 test. We considered probability levels of 5 percent (P ≤.05) to be significant.


   RESULTS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Our analysis showed a significant decrease in the VAS for all of the groups studied (P < .05). For group I, the mean initial value of the VAS was 63.2 millimeters and the final value at six months was 10.5 mm (Table 1Go and Figure 4Go). For group II, the mean initial value of the VAS was 68.0 mm and the final value was 9.5 mm. For group III, the mean initial value of VAS was 62.7 mm and the final value was of 27.2 mm.


View this table:
[in this window]
[in a new window]
  		TABLE 1 Pain reports at different examinations.

 

Figure 4
View larger version (55K):
[in this window]
[in a new window]
  		Figure 4. Pain reports at different times. VAS: Visual analog scale.

 
As measured by VAS, the mean improvement was 52.7 mm (83.4 percent) for group I, 58.5 mm (86 percent) for group II and 35.5 mm (56.6 percent) for group III. We found a significant difference between groups II and III (P < .05). Despite the differences between groups I and III, the significance level of .05 was not achieved (P = .064). Indeed, our intragroup analysis showed a significant improvement for the whole sample (P < .05) regardless of the group studied. This significant improvement occurred earlier with the occlusal splints and was more gradual with the nonoccluding splints (Figure 4Go).

As for mandibular movement, we observed a significant difference only for the right lateral movement between groups I and III (P < .05). The results were similar among the three groups for the amount of left lateral and protrusive movement.

We observed a reduction in frequency of joint sounds for the entire sample (P < .05) (Table 2Go). Although the reduction was more pronounced for group II, we found no significant differences among the groups.


View this table:
[in this window]
[in a new window]
  		TABLE 2 Joint sounds detected at different examinations.

 
Indeed, we found no significant difference among groups for TMJ pain on palpation on both the lateral and posterior aspects of the left and right TMJs. The intragroup analysis for this variable over time showed a decrease in joint sounds for the whole sample. We detected a better outcome, however, for groups I and II.

Reduction in muscle tenderness on palpation was similar for the whole sample. We found significant differences in anterior temporalis muscles and the body of masseter muscles among groups (P < .05), with better results from the occlusal splint groups (Table 3Go).


View this table:
[in this window]
[in a new window]
  		TABLE 3 Intragroup analysis of muscle tenderness on palpation after six months.

 
None of the subjects reported changes in their bites. Subjects wearing the occlusal splints reported more comfort and reduction in the frequency of joint sounds than did those in group III.


   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
The use of occlusal splints is one of the most widely accepted methods of treatment for the signs and symptoms of TMD.2,8,27–31 Clinical reports suggest that stabilization splints are useful for treatment of pain on TMJs,32–35 masticatory muscles30,36,37 or both. Researchers do not agree, however, on how the splints work or which would be a better occlusal design.25,33,38

In our study, the bilateral balanced splint design used in group I did not seem to influence the improvement in subjects’ pain reports as measured by the VAS when compared with the canine guidance splint design used in group II. Indeed, despite the absence of a difference between groups I and III (P = .064), we found that the change in the group I subjects’ pain reports to be much more significant, since 14 of the 19 subjects in group I reported some discomfort and pain judged as "0" (absence of pain) on the VAS, whereas just five of the 18 subjects in group III marked "0." The rate of improvement was 83.4 percent for group I and 56.6 percent for group III.

Regarding the presence of joint sounds, we found no significant difference among the groups over time. The percentages, however, suggest a mild reduction in the number of subjects with joint sounds in all groups; the reduction was slightly higher in subjects in group II (Table 1Go). We also observed a reduction in muscle tenderness for most of the muscle spots we evaluated, which could reflect a decreased co-contraction after the improvement of the TMJ pain, which was the chief complaint,38 and one of the inclusion criteria for the study.

Joint loading depends on the splint design.25,39–43 Several studies have concluded that part of the occlusal force applied on the teeth is transmitted to the TMJ14,35,44–50; yet the more anterior the tooth contact on the splint is, the higher the load that is transferred to joint.14,35,44–50 It also has been reported that the TMJ is submitted to tension forces (compression and distraction) during unilateral clenching,19,20,42 and that the force applied to the contralateral joint side is reduced highly when simultaneous contacts are established at both working and non-working sides.17,19,20

On the basis of the assumption that people with disk displacement may have a reduced capacity to absorb occlusal loading,51 we believe that the use of balanced splints could help them protect the joint.

Studies have found that the load transmitted to the TMJ at the contralateral side is higher owing to the leverage action caused by the canine guidance on the working side.17,20 Therefore, a contact on the nonworking side would provide more stability to the joints, especially during tooth clenching on the canine edge-to-edge position, which would decrease joint loading. This decreased joint loading could improve and enhance the healing process and, consequently, result in faster healing in people with signs and symptoms of TMJ pain.

The role of the canine guidance in splints to decrease muscle activity and pain has to be considered. Other studies have found that mechanoreceptors in the periodontal ligaments of canine teeth could produce a measurable reduction in the contraction of elevator muscles.7,9,25 This observed reduction in muscle contraction, if caused by these receptors, could be responsible for the decreased intra-articular pressure in patients using bilateral balanced splints to levels similar to what the mechanical configuration of the canine guidance splints could produce.

Our discussion is about the role of canine guidance in splints to treat TMJ pain. The function of this feature in the natural dentition to protect posterior teeth from lateral forces is important and should be considered when establishing occlusal patterns for orthodontic treatment or full-mouth rehabilitation.

Clinicians should consider mechanisms other than splints. A natural and progressive adaptation of TMJ structures to loading may explain the general improvement for most of the subjects in our study, regardless if they used the occlusal splints. It is suggested that the formation of a retrodiskal fibrosis and the establishment of a pseudodisk seem to be the natural progression of TMJ with displaced disks and pain.52,53

People with joint pain and clicking with no treatment had a significant recovery after the six-month follow-up in a one-year controlled study when compared with people who received stabilization and repositioning splints.54 There is a regression to the mean for most people, which characterizes the benign aspect of these conditions.

The acceptable outcome in patients using nonoccluding splints in our study also can be explained by the fact that the patients’ belief that the treatment will be effective plays a vital role in placebo response.2,51 The patient’s personal relationship with the professional and his or her feeling of being "under treatment" are important influences on the final outcomes of most pain management therapies. The presence of the splint as a foreign object in the mouth would change the oral tactile stimuli and make the patient aware of the potentially harmful use of the jaw.2

When considering the presence of joint clicking, we found a general improvement. Although it is considered to be one of the goals of TMD treatment, the resolution of TMJ clicking no longer is the primary objective of using oral splints. In a one-year controlled study with a sample comparable to that used in our study, Conti and colleagues54 found similar outcomes for improvement of joint noises between subjects wearing oral splints and subjects in a no-treatment group.

As the goal of the splints used in our study was not to re-establish a "normal" disk-condyle relationship, the improvement observed for the presence of clicking probably is due to morphological alterations and remodeling in the joint structures over time (disk, ligaments and retrodiskal tissues), diminishing the physical obstruction for the condyle translation and, consequently, decreasing the sound. To substantiate this statement, however, the use of more sophisticated diagnostic tools, set as the gold standard, would be necessary (for example, magnetic resonance imaging, which we did not use in our study). This overall reduction on joint clicking did not influence the overall result (that is, decrease in pain and dysfunction).


   CONCLUSIONS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
As our results suggest, TMJ pain and clicking seems to subside over time, regardless of the type of oral splint used. We found that the occlusal splints provided earlier improvement compared with the nonoccluding splint, when we considered subjects’ pain reports and TMJ tenderness on palpation.


   FOOTNOTES
 

Dr. Paulo César Rodrigues Conti is an associate professor, Bauru School of Dentistry, University of São Paulo, Brazil. Address reprint requests to Dr. Paulo César Rodgrigues Conti at Al. Dr. Octávio Pinheiro Brisolla, -9-75, Villa Universitária, Bauru–São Paulo, Brasil CEP 17012-901, e-mail "pcconti{at}fob.usp.br".


Dr. Santos is a graduate student, Bauru School of Dentistry, University of São Paulo, Brazil.


Dr. Kogawa is a clinical professor, Catholic University of Brasília, Taguatinga-Distrito Federal, Brazil.


Dr. Ana Claudia de Castro Ferreira Conti is a clinical professor, Paulista University, Bauru-São Paulo, Brazil.


Dr. de Araujo is a clinical professor, Bauru School of Dentistry, University of São Paulo, Brazil.


This study was supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq BRAZIL) grant 14164312000-5.


   REFERENCES
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. Al-Ani Z, Gray RJ, Davies SJ, Sloan P, Glenny AM. Stabilization splints therapy for the treatment of temporomandibular myofascial pain: a systematic review. J Dent Educ 2005;69(11):1242–50.[Abstract/Free Full Text]

  2. Dao TT, Lavigne GJ. Oral splints: the crutches for temporomandibular disorders and bruxism? Crit Rev Oral Biol Med 1998;9(3):345–61.[Abstract/Free Full Text]

  3. Borromeo GL, Suvinen TI, Reade PC. A comparison of the effects of group function and canine guidance interocclusal device on masseter muscle electromyographic activity in normal subjects. J Prosthet Dent 1995;74(2):174–80.[Medline]

  4. D’Amico A. The canine teeth-normal functional relation of the natural teeth of man. J South Calif Dent Assoc 1958;26:6–23; 49–60; 127–42; 175–82; 194–208; 239–41.

  5. Fitins D, Sheikholeslam A. Effect of canine guidance of maxillary occlusal splint on level of activation of masticatory muscles. Swed Dent J 1993;17(6):235–41.[Medline]

  6. Graham GS, Rugh JD. Effect of splint occlusal guidance on masticatory muscle EMG activity (abstract 16). J Dent Res 1984;63:172.

  7. Graham GS, Rugh JD. Maxillary splint occlusal guidance patterns and electromyographic activity of the jaw-closing muscles. J Prosthet Dent 1988;59(1):73–7.[Medline]

  8. Major PW, Nebbe B. Use and effectiveness of splint appliance therapy: review of literature. Cranio 1997;15(2):159–66.[Medline]

  9. Manns A, Chan C, Miralles R. Influence of group function and canine guidance on electromyographic activity of elevator muscles. J Prosthet Dent 1987;57(4):494–501.[Medline]

  10. Miralles R, Bull R, Manns A, Roman E. Influence of balanced occlusion and canine guidance on electromyographic activity of elevator muscles in complete denture wearers. J Prosthet Dent 1989;61(4): 494–8.[Medline]

  11. Shan SC, Yun WH. Influence of an occlusal splint on integrated electromyography of the masseter muscles. J Oral Rehabil 1991; 18(3):253–6.[Medline]

  12. Shupe RJ, Mohamed SE, Christensen LV, Finger IM, Weinberg R. Effects of occlusal guidance on jaw muscle activity. J Prosthet Dent 1984;51(6):811–8.[Medline]

  13. Williamson EH, Lundquist DO. Anterior guidance: its effect on electromyographic activity of the temporal and masseter muscles. J Prosthet Dent 1983;49(6):816–23.[Medline]

  14. Brehnan K, Boyd RL, Laskin J, Gibbs CH, Mahan P. Direct measurement of loads at the temporomandibular joint in Macaca arctoides. J Dent Res 1981;60(10):1820–4.[Abstract/Free Full Text]

  15. Donegan SJ, Christensen LV, Mckay DC. Canine tooth guidance and temporomandibular joint sounds in non-patients and patients. J Oral Rehabil 1996;23(12):799–804.[Medline]

  16. Kahan J. Prevalence of dental occlusal variables and intra-articular temporomandibular disorders: molar relationship, lateral guidance and nonworking side contacts. J Prosthet Dent 1999;82:410–5.[Medline]

  17. Korioth TW. Simulated physics of the human mandible. In: McNeill C, ed. Science and practice of occlusion. Chicago: Quintessence; 1997:179–86.

  18. Minagi S, Watanabe H, Sato T, Tsuru H. Relationship between balancing-side occlusal contact patterns and temporomandibular joint sounds in humans: proposition of the concept of balancing-side protection. J Craniomandib Disord 1990;4(4):251–6.[Medline]

  19. Baba K, Yugami K, Yaka T, Ai M. Impact of balancing-side tooth contact on clenching induced mandibular displacements in humans. J Oral Rehabil 2001;28(8):721–7.[Medline]

  20. Ito T, Gibbs CH, Marguelles-Bonnet R, et al. Loading on the temporomandibular joints with five occlusal conditions. J Prosthet Dent 1986;56(4):478–84.[Medline]

  21. Kimmel SS. Temporomandibular disorders and occlusion: an appliance to treat occlusion generated symptoms of TMD in patients presenting with deficient anterior guidance. Cranio 1994;12(4):234–40.[Medline]

  22. Willis WA. The effectiveness of an extreme canine-protected splint with limited lateral movement in the treatment of temporomandibular dysfunction. Am J Orthod Dentofacial Orthop 1995;107(3):229–34.[Medline]

  23. Gray RJ, Davies SJ, Quayle AA, Wastell DG. A comparison of two splints in the treatment of TMJ pain dysfunction syndrome: can occlusal analysis be used to predict success of splint therapy? Br Dent J 1991;170(2):55–8.[Medline]

  24. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6(4):301–55.[Medline]

  25. Pertes RA, Gross SC. Clinical management of temporomandibular disorders and orofacial pain. Chicago: Quintessence; 1995:197–209.

  26. Conti PC, Ferreira PM, Pegoraro LF, Conti JV, Salvador MC. A cross-sectional study of prevalence and etiology of signs and symptoms of temporomandibular disorders in high school and university students. J Orofac Pain 1996;10(3):254–62.[Medline]

  27. Clark GT. A critical evaluation of orthopedic interocclusal appliance therapy: design, theory and overall effectiveness. JADA 1984;108(3):359–64.

  28. Gray RJ, Davies SJ. Occlusal splints and temporomandibular disorders: why, when, how? Dent Update 2001;28(4):194–9.[Medline]

  29. Kreiner M, Betancor E, Clark GT. Occlusal stabilization appliances: evidence of their efficacy. JADA 2001;132(6):770–7.

  30. Rubinoff MS, Gross A, McCall WD Jr. Conventional and nonoccluding splint therapy compared for patients with myofascial pain dysfunction syndrome. Gen Dent 1987;35(6):502–6.[Medline]

  31. Tsuga K, Akagawa Y, Sakaguchi R, Tsuru H. A short-term evaluation of the effectiveness of stabilization-type occlusal splint therapy for specific symptoms of temporomandibular joint dysfunction syndrome. J Prosthet Dent 1989;61(5):610–13.[Medline]

  32. Carraro JJ, Caffesse RG. Effect of occlusal splints on TMJ symptomatology. J Prosthet Dent 1978;40(5):563–6.[Medline]

  33. Goharian RK, Neff PA. Effect of occlusal retainers on temporomandibular joint and facial pain. J Prosthet Dent 1980;44(2):206–8.[Medline]

  34. Pruim GJ, de Jongh HJ, ten Bosch JJ. Forces acting on the mandible during bilateral static bite at different bite force levels. J Biomech 1980;13(9):755–63.[Medline]

  35. Spear FM. Fundamental occlusal therapy considerations. In: McNeill C, ed. Science and practice of occlusion. Chicago: Quintessence; 1997:421–34.

  36. Greene CS, Laskin DM. Long-term evaluation of treatment for myofascial pain-dysfunction syndrome: a: a comparative study. JADA 1983;107(2):235–8.

  37. 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(1):79–82.[Medline]

  38. Lundh H, Westesson PL, Kopp S, Tillstrom B. Anterior repositioning splint in the treatment of temporomandibular joint with reciprocal clicking: comparison with a flat occlusal splint and an untreated control group. Oral Surg Oral Med Oral Pathol 1985;60(2):131–6.[Medline]

  39. Kuboki T, Azuma Y, Orsini MG, Hirooka T, Yatani H, Yamashita A. The effect of occlusal appliances and clenching on the temporomandibular joint space. J Orofac Pain 1997;11(1):67–77.[Medline]

  40. Leib AM. The occlusal bite splint: a noninvasive therapy for occlusal habits and temporomandibular disorders. Compend Contin Educ Dent 1996;17(11):1081–90.[Medline]

  41. Nitzan DW. Intraarticular pressure in the functioning human temporomandibular joint and its alteration by uniform elevation of the occlusal plane. J Oral Maxillofac Surg 1994;52(7):671–9.[Medline]

  42. dos Santos J Jr, Nowlin TP. The effect of splint therapy on TMJ position measured by the Gerber Resiliency Test. J Oral Rehabil 1992;19(6):663–70.[Medline]

  43. Wood WW, Tobias DL. EMG response to alteration of tooth contacts on occlusal splints during maximal clenching. J Prosthet Dent 1984;51(3):394–6.[Medline]

  44. Barbenel JC. Analysis of forces at the temporomandibular joint: during function. Dent Pract 1969;19:305–10.

  45. Erhardson S, Sheikholeslam A, Forsberg CM, Lockowandt P. Vertical forces developed by the jaw elevator muscles during unilateral maximal clenching and their distribution on teeth and condyles. Swed Dent J 1993;17(1–2):23–34.[Medline]

  46. Hekneby M. The load of the temporomandibular joint: physical calculations and analyses. J Prosthet Dent 1974;31(3):303–12.[Medline]

  47. Katona TR. The effects of cusp and jaw morphology on the forces on teeth and the temporomandibular joint. J Oral Rehabil 1989;16(2):211–9.[Medline]

  48. Koolstra JH, van Eijden TM, Weijs WA, Naeije M. A three-dimensional mathematical model of the human masticatory system predicting maximum possible bite forces. J Biomech 1988;21(7):563–76.[Medline]

  49. Nelson SJ, Hannam AG. A biomechanical simulation of the craniomandibular apparatus during tooth-clenching (291). J Dent Res 1982;61:211.

  50. Smith DM, McLachlan KR, McCall WD Jr. A numerical model of temporomandibular joint boarding. J Dent Res 1986;65(8):1046–52.[Abstract/Free Full Text]

  51. Israel HA. Current concepts in the surgical management of temporomandibular joint disorders. J Oral Maxillofac Surg 1994;52(3): 289–94.[Medline]

  52. Mills DK, Daniel JC, Herzog S, Scapino RP. An animal model for studying mechanisms in human temporomandibular joint disc derangement. J Oral Maxillofac Surg 1994;52(12):1279–92.[Medline]

  53. Scapino RP. Histopathology associated with malposition of the human temporomandibular joint disk. Oral Surg Oral Med Oral Pathol 1983;55(4):382–97.[Medline]

  54. Conti PCR, Miranda JES, Conti ACCF, Pegoraro LF, Araujo CRP. Partial time use of anterior repositioning splints in the management of TMJ pain and dysfunction: a one-year controlled study. J Appl Oral Sci 2005;13(4):345–50.





This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Conti, P. C. R.
Right arrow Articles by de Araujo, C. d. R. P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Conti, P. C. R.
Right arrow Articles by de Araujo, C. d. R. P.
Related Collections
Right arrow Endodontics

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS