Accepted Manuscript

Evaluation of the role of splint therapy in the treatment of temporomandibular joint

pain on the basis of MRI evidence of altered disc position

Yoko Hasegawa, D.D.S. & Ph.D., Associate Professor, Naoya Kakimoto, D.D.S.
& Ph.D., Seiki Tomita, D.D.S. & Ph.D., Masanori Fujiwara, D.D.S. & Ph.D., Reichi
Ishikura, MD. & Ph.D., Hiromitsu Kishimoto, D.D.S. & Ph.D., Kosuke Honda, D.D.S. &
Ph.D.

PII: S1010-5182(17)30022-7
DOI: 10.1016/j.jcms.2017.01.011
Reference: YJCMS 2572

To appear in: Journal of Cranio-Maxillo-Facial Surgery

Received Date: 21 June 2016

Revised Date: 29 November 2016
Accepted Date: 16 January 2017

Please cite this article as: Hasegawa Y, Kakimoto N, Tomita S, Fujiwara M, Ishikura R, Kishimoto H,
Honda K, Evaluation of the role of splint therapy in the treatment of temporomandibular joint pain on
the basis of MRI evidence of altered disc position, Journal of Cranio-Maxillofacial Surgery (2017), doi:
10.1016/j.jcms.2017.01.011.

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 ACCEPTED MANUSCRIPT 1

Evaluation of the role of splint therapy in the treatment of temporomandibular joint pain on the

basis of MRI evidence of altered disc position

Yoko Hasegawa1, 2 D.D.S. & Ph.D., Naoya Kakimoto3＊D.D.S. & Ph.D., Seiki Tomita3 D.D.S. & Ph.D.,

Masanori Fujiwara1 D.D.S. & Ph.D., Reichi Ishikura4 MD. & Ph.D., Hiromitsu Kishimoto1 D.D.S. &

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Ph.D., Kosuke Honda1 D.D.S. & Ph.D.

1) Department of Dentistry and Oral Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho,

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Nishinomiya Hyogo 663-8501, Japan

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2) Division of Oromaxillofacial Regeneration, Osaka University Graduate School of Dentistry, Osaka

565-0871, Japan

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3) Department of Oral and Maxillofacial Radiology, Osaka University Graduate School of Dentistry,
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Osaka 565-0871, Japan

4) Departmant of Radiology, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya Hyogo

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663-8501, Japan
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*: Co-first author
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Address correspondence to: Yoko Hasegaw, Associate Professor, Department of Dentistry and Oral
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Surgery, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan

Phone: +81-798-45-6677, Fax: +81-798-45-6679

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E-mail: cem17150@hyo-med.ac.jp
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Funding: This study was supported by a grant from the Ministry of Education, Science and Culture of

Japan (grant numbers 25463043 and 15K20464).

 ACCEPTED MANUSCRIPT
Summary

Objective: To clarify whether altering temporomandibular joint (TMJ) condyle and disc

positions by occlusal splint (splint) therapy relieves TMJ pain and to determine whether

splint therapy facilitates improvement of the ranges of condyle and articular disc motions.

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Study Design: A total of 150 joints of 75 patients admitted with TMJ pain/discomfort were

evaluated. A visual analog scale for TMJ pain was administered during visits following the

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start of splint treatment. At the start of splint treatment, MRI was performed with/without

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splint insertion, after which condyle/disc movements were evaluated. Disc position and

function, disc configuration, joint effusion, osteoarthritis, and the bone marrow were

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evaluated. Pearson’s correlation coefficients, linear regression, and multiple regression
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analyses were used for statistical analysis.
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Results: Splint-related anterior movement of the condyle was related to TMJ pain. With a

biconvex disc and/or bone marrow abnormality, splint treatment was ineffective for reducing
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TMJ pain.
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Conclusion: Splint therapy was not likely to be successful for any kind of TMJ abnormalities,
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such as bone marrow abnormalities and/or a biconvex disc appearance on MRI.

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Key words: pain, temporomandibular joint, magnetic resonance imaging, occlusal splints,

longitudinal survey.

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INTRODUCTION

Occlusal appliance (splint) therapy has been recommended as a reversible nonsurgical

option for management of many temporomandibular disorders (TMD) (Dylina, 2001; Dao

and Lavigne, 1998; Dao et al., 1994; Wenneberg et al., 1988). It has been suggested that

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splint therapy can reduce pain in the temporomandibular joint (TMJ) caused by excessive

occlusal pressure. In this manner, the splint restores blood circulation to the TMJ by

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maintaining a wide gap between the mandibular condyle (condyle) and the mandibular fossa

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(Ettlin et al., 2008; Moncayo, 1994). While the majority of patients experience symptomatic

relief in response to a splint (Clark, 1984), approximately 30% of patients do not experience

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any improvement in temporomandibular arthrosis (Sasaki et al., 1994).
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In a previous study, we quantitatively evaluated changes of condyle and articular disc

positions on magnetic resonance imaging (MRI) taken at the start of splint therapy
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(Hasegawa et al., 2011). We showed that the condyle moves anteroinferiorly and rotates
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mouth opening, but the discs are difficult to move with splints in patients suffering from pain
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in the TMJ. However, it has been reported that splint therapy combined with therapeutic

exercise shows satisfactory results for patients whose TMJ pain was induced by articular disc
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disorders (Chortis et al., 2006; Moraes et al., 2013; Wright and North, 2009; Kurita et ail.,

2001), since the TMJ pain is often associated with restricted mouth opening due to disc
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displacement. On the other hand, one report found that placebo splint therapy was nearly
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equal to specific splint therapy in efficacy (Proceedings, 1997). We must choose treatments

based on the scientific evidence. Therefore, further studies are required to clarify the effects

of splint therapy for the TMJ pain associated with disc disorders. Splint therapy should not be

used indiscriminately, so that irreversible occlusal changes can be avoided.

The objectives of the present study were to clarify whether altering mandibular condyle

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and disc positions by splint therapy reduces TMJ pain and to determine whether long-term

splint therapy facilitates improvement of the ranges of motion of the condyle and disc.

SUBJECTS AND METHODS

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Subjects

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Fifty-one women and twenty-four men (mean age 38.4 years, range 17-70 years) with a

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history of clicking, catching, or restricted mouth opening and unilateral or bilateral joint pain

who had been referred to Osaka University Dental Hospital and Hyogo College of Medicine

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Hospital from February 2009 to January 2013 and gave informed consent were enrolled in the
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study. The study was approved by the ethics committee of the Osaka University School of

Dentistry (H21-E4) and Hyogo College of Medicine (No.887).

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Trial of splint therapy

All patients were treated with a hard acrylic resin stabilization splint with a flat surface
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that covered all of the upper teeth. An impression of the upper and lower jaws was made, and
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models were created. Subjects were then placed in a supine position to recreate the
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maxillo-mandibular relationship and were instructed to gently bite into the wax after

confirmation that the occlusal vertical dimension between the cervix of the central incisors of

the maxilla and the mandible was 5 mm. The reason for choosing the thickness was to

prevent cuspal interference, except for guides in the canine region in all subjects, and to

normalize the experimental conditions by specifying the splint thickness. In addition, we

adopted the same thickness as in our previous study to facilitate comparison of the results

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(Hasegawa et al., 2011). The wax impression was used to mount the upper and lower models

on the articulator. The splint was fabricated with fluid resin (Palapress Vario, Heraeus Kulzer

GmbH. & Co. KG, Wehrheim/Ts, Germany). The splints were adjusted to have contact points

with all of the opposing teeth with the patient in the supine positon. The occlusal vertical

dimension between the central incisors of the maxilla and the mandible was maintained at 5

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mm. The occlusal splint is illustrated in Figures 1A and 1B. Patients were instructed to wear

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the splint only during sleep, and they visited the hospital 1 week, 1 month, 2 months, and 3

months after splint insertion for evaluation; a visual analog scale (VAS) was used to evaluate

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TMJ pain at each visit. Patients were asked to grade pain felt, with zero indicating “no pain”

and 100 indicating “the worst pain possible”, during the following times: A, at rest; B, when

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the mouth was opened and closed; and C, while eating. The maximum level of pain at A, B,
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and C at each visit was set as the VAS level at the day of the visit. From the VAS data
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obtained, relative value units (RVU) were calculated based on the VAS data as TMJ pain

before (pre) and after (post) splint therapy as follows:

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RVU = (VASpost-VASpre) / VAS pre

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Namely, if the RVU value is positive, it means that TMJ pain has worsened after
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splint therapy as compared to before splint treatment; if the RVU value is negative, it shows

that the symptom has remitted after treatment compared to before treatment.
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MRI examination

On the day the splints were given to the patients, they were assessed with/without splints

in the mouth open and closed positions using MRI. MRI was performed with the patient in

the supine position with a 1.5-T MR scanner using TMJ surface coils. MRI was used to

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examine the positions of the condyle and disc, as well as the configuration of the disc. Proton

density-weighted images (repetition time (TR) (msec) / echo time (TE) (msec) / number of

excitations (NEX) = 2500/20/2) with the fast spin echo sequence were obtained in the oblique

sagittal plane in the closed mouth position with or without a splint in place. When the splint

was in place, the subjects were asked to make light contact with the splint using their teeth.

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Other proton density-weighted images (TR/TE/NEX = 800/24/2) with the fast spin echo

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sequence were obtained in the sagittal plane in the closed and opened mouth positions to

assess disc reduction. The field of view was 10 cm × 10 cm, slice thickness was 3 mm with

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0.5-mm inter-slice spacing, and matrix size was 256×160. Two oral and maxillofacial

radiologists (N.K. and S.T.) interpreted the MR images and performed the analyses.

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First, the 150 joints evaluated in this study were classified into 5 categories, as reported

by Tasaki et al. (1996), with some modifications: partial anterior disc displacement with
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reduction (PADDWR), partial anterior disc displacement without reduction (PADDWOR),

complete anterior disc displacement with reduction (ADDWR), and complete anterior disc
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displacement without reduction (ADDWOR). Diagnosis of partial or complete anterior

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displacement was made from the oblique sagittal MRIs of each joint (right and left) in the
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closed mouth position. Assuming that no displacement was observed on more than 1 oblique

sagittal MRI, it was regarded as “partial displacement”. The joint in which every oblique
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sagittal MRI showed anterior disc displacement was considered “complete displacement” and,
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thus, “ADDWOR”. Joints showing no anterior disc displacement on every oblique sagittal

MRI were judged to be “normal discs (NDs)”.

The subjects were classified into three groups according to the position of the disc

(balance of the discs) on MRI to examine the balance of the left and right TMJ conditions:

the bilateral normal disc (ND) group, the unilateral ADD group, and the bilateral ADD group.

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This classification method is based on our previously reported paper (Hasegawa et al., 2011).

Second, disc configuration was classified into five categories, as reported by Murakami et

al. (1993), including biconcave, biplanar, hemiconvex, biconvex, and folded. Joint effusions

were classified into three categories according to Larheim et al. (2001b): none or minimal

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fluid, moderate fluid, and marked or extensive fluid. Osteoarthritis, as demonstrated by

condylar osteophytes or erosion, was classified into two categories, negative or positive

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according to Kirk (1994). Bone marrow abnormalities of the condyle, or osteonecrosis, as

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described by Larheim et al. (1999), were classified into two categories, negative or positive.

Third, displacement of the condyle and disc achieved by placing the splint was

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quantified according to the method of Kurita et al. (1998) using an image analysis software
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program (Analyze®, Biomedical Imaging Resource, Overland Park, KS, USA). Figure 1

shows the reference points. Evaluations were performed according to the methods of
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Hasegawa et al. (2011). The slice through the center of the horizontal long axis of the
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mandibular condyle was selected for measurement (measuring image). Analytical methods
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used to assess changes in disc and condyle positions are shown in Figure 1 (C-E). A tangent

line was drawn from the lower edge of the tubercle (T) to the upper edge of the external
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auditory meatus (P). Then, a perpendicular line was drawn from this line passing through the

posterior border of the condyle. The point where this line intersected the TP line was defined
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as C. Similarly, a perpendicular line was drawn from the posterior edge of the disc to the TP
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line, and the intersection of this line and the TP line was defined as D. The position of the

condyle was expressed as the ratio of the distance between T and C and the distance between

T and P, and the position of the disc was expressed as the ratio of the distance between T and

D and the distance between T and P. Reference points with an accent mark (´) represent the

positions when a splint was in place.

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Two lines were drawn parallel to the TP line, a tangent line passing through the roof of the

mandibular fossa on the measuring image (point F) and a tangent line passing through the

surface of the condyle (point S). The shortest distance between these two lines was defined as

the vertical change of the condyle and was expressed as the ratio of the distance between T

and P. The anteroposterior movement of the condyle caused by the splint was evaluated by

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subtracting T´C´/T´P´ (with splint) from TC/TP (without splint). Vertical movement was

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evaluated by subtracting F´S´/T´P´ (with splint) from FS/TP (without splint). The

anteroposterior movement of the disc was evaluated by subtracting T´D´/T´P´ (with splint)

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from TD/TP (without splint). The rotational angle of the condyle was determined by

superimposing the condyle on the measuring image with a splint and the condyle on the

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measuring image without a splint and by expressing this parameter as the angle between the
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lines TP and T´P´. These measurements were performed in a blinded manner by two
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radiologists.
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Statistical analysis
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Relationships between RVU values and continuous variables (movement of the

condyle/disc due to splint insertion and age) were evaluated by Pearson’s correlation
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coefficients. To evaluate RVU, a one-sample t-test was used.

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For identification of the factors affecting TMJ pain, a generalized linear model with the

variables explained in methods as the descriptive variables and RVU as the objective variable

was used. Then, multiple regression analysis was performed with RVU as the objective

variable and the explanatory variables with P<0.05 on linear regression, assuming age and

sex as moderator variables (stepwise). The level of significance was set to 5% for all analyses,

which were performed with IBM SPSS 22.0 J (IBM SPSS Statistics, Version 22.0.0 for

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Windows; SPSS, Chicago, IL).

RESULTS

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A summary of the 150 joints in the 75 patients is presented in Table 1; quantitative

image analysis of MRIs could not be performed for 19 joints due to patient movement during

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MRI examination, and image interpretation was impossible for 4 joints having a poorly

defined disc on the MRI.

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The mean RVU of all patients was –32.1 (confidence interval –62.2 to –2.4; P=0.04).

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There were weak significant negative correlations between age (R=−0.18, P=0.03) and RVU
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and between anterior-posterior condyle movement and RVU (R=−0.19, P=0.03) (Table 2).

These results showed that older patients and patients with anterior condyle movement had
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less TMJ pain when wearing the splint. In contrast, patients with superior-inferior condyle
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movement, anterior-posterior movement, and rotational disc movement did not have less joint
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pain when wearing the splint.

Table 3 shows the results of simple and multiple regression analyses related to TMJ
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pain. Age, biconvex articular disc configuration, and positive bone marrow abnormality were
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identified as significant variables by the simple/multiple linear regression analyses. These

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results suggest that the TMJ pain level was likely to increase easily in cases in which the

articular disc configuration was biconvex and a bone marrow abnormality was found.

DISCUSSION

Splint therapy has very frequently been indicated for treating TMD. The most

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common conditions are masticatory myalgia, TMJ arthralgia, and TMJ dysfunction (Dao et

al., 1994; Ekberg et al., 1998). Four well-known American dental organizations, the National

Institutes of Health-National Oral Health Information Clearing House (NIH-NOHIC), the

American Academy of Oral Pain (AAOP), the American Association of Oral and

Maxillofacial Surgeons, and the American Academy of Craniofacial Pain (AACFP)

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recommend short-term splint therapy without any occlusal changes as treatment for TMD

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(Clark and Minakuchi, 2006). However, there is insufficient scientific evidence showing that

splint therapy helps reduce myalgia or arthralgia. Namely, it has not been determined which

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type of TMD would most likely respond to splint therapy. The therapeutic advantage of splint

therapy, especially stabilization appliances, lies in producing stability of occlusion and equal

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distribution of abnormal forces causing overload of the masticatory muscles and the TMJ.
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However, this theory raises the question of how splint therapy reduces myalgia or arthralgia.
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Assessments of efficacy of splint therapies on improvement of TMJ conditions have relied on

attending doctor’s judgment based on patient’ subjective symptoms. However, objective

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clarification of failure with splint therapy may be meaningful for clinicians if joint symptoms
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are not relieved. Therefore, objective evidence that splint therapy is useful to lessen myalgia

or arthralgia is very important.

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In the present study, patients with internal derangements were objectively evaluated
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on the basis of MRI evidence while a splint was worn and followed clinically. TMJ
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abnormalities cannot be reliably assessed on the basis of clinical examinations. MRI can

visualize joint abnormalities not seen on other modalities and is thus the best method for

diagnostic assessments of TMJ status (Bertram et al., 2001). The image analysis method used

in the present study (Hasegawa et al., 2011) was an application of the method used by Kurita

et al. (1998), with high usability in carrying out quantitative analysis of TMJ movement. The

predominant TMJ finding in patients with TMD referred for diagnostic imaging is internal

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derangement related to disc displacement (Bertram et al., 2001). This finding is significantly

more frequent in affected patients than in asymptomatic volunteers, occurring in up to 80% of

individuals consecutively referred for TMJ imaging (Katzberg et al., 1996; Larheim et al.,

2001a; Paesani et al., 1999; Ribeiro et al., 1997; Tasaki et al., 1996). Moreover, certain types

of disc displacement appear to occur more frequently in TMD patients, namely complete disc

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displacement that does not decrease on mouth opening (Larheim et al., 2001b; Tasaki et al.,

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1996) In the present study, “balance of the articular discs” was evaluated with the aim of

investigating TMJ balance bilaterally.

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The present study showed that patients with reduction of pain were observed to show

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anterior movement of the condyle while wearing a splint. This is probably because this led to
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joint space expansion, and elastic tissues in the deeper layer expanded the inner space of the

plexus, increasing its blood supply (Kino et al., 1993). In addition, if a biconvex disc was
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found at the beginning of splint therapy, it was difficult to decrease TMJ pain. Honda et al.

(2008) reported that disc displacement on mouth closing and opening with the biconvex discs
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was somewhat greater than with biconcave or biplanar discs. Accordingly, pain in the joints
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with biconvex type discs may be induced through various complicated processes, almost
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irrespective of disc displacement. For instance, the articular cavity was narrowed by

parafunction, and synovial fluid production was reduced, leading to increased friction,
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limitation of condylar motion, and mechanical injury to the articular soft tissue layer. For the
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treatment of the joint pain induced by such a biological mechanism, the effect of splint

therapy is less known, although it has been advocated in patients with pain of muscular origin.

Further studies are required to clarify the effects of splint therapy for pain of joint origin.

It is known that condyle bone marrow abnormalities are pain-producing factors.

Sano et al. (2000) also reported that the degree of pain was greater in joints with abnormal

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bone marrow than in joints with normal bone marrow signals on MRI scans. On the other

hand, there are reports that bone marrow abnormalities do not always depend on the

pathologic state of the TMJ (Larheim et al., 1999). The present study did not find that splint

therapy was effective in the treatment of TMJ pain in patients with bone marrow

abnormalities. Furthermore, our previous study indicated that there was no difference in

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improvement with arthrocentesis between the joints with and without bone marrow changes

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(Honda et al., 2011). Therefore, it is important in future studies to determine which types of

bone marrow abnormalities tend to cause joint pain based on the characteristics of the disc

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and condyle dislocation in the TMJ.

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Clinical implications
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Surgical treatments are necessary for TMD if conservative approaches are

unsuccessful. However, aggressive surgical procedures can cause permanent musculoskeletal

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changes of the TMJ (1996). The present study may give a clue to elucidating the pathogenesis
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of internal derangement of the TMJ associated with lack of coordination of the articular disc
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and condyle, and it is very meaningful for clinicians, who should take great care in the

selection of surgical procedures. Moreover, the possibility exists that over treatment with
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surgery may be prevented.

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Study Limitations

The present study has some limitations. First, the type of pain (myalgia or arthralgia,

spontaneous pain or induced pain) was not evaluated, and the time over which symptoms

developed was not taken into account. Moreover, the duration of symptoms and treatment

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methods prior to the start of splint therapy could not be evaluated. The results of the present

study included several phenomena that cannot be explained by movement of the TMJ due to

splint insertion alone, such as the fact that the VAS level decreased more readily in patients

with regressive changes of the TMJ, and reduction was more difficult in patients suffering

from diseases other than TMD. Further investigation is necessary to address these issues, and

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it is necessary to ascertain the therapeutic benefit of stabilization splints in relation to various

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parafunctional habits.

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CONCLUSION

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The conclusions of the present study are as follows. 1) Splints causing anterior movement of

the condyle had a weak relationship with TMJ pain reduction. 2) There was a high probability
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that splint therapy would not be successful in patients with visible abnormalities such as bone

marrow abnormalities and biconvex disc configuration of the TMJ.

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ACKNOWLEDGMENTS
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The authors would like to express their sincere appreciation to K. Yoshikiyo, M. Shiramizu,
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and K. Yasukawa for their tremendous support.

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Conflicts of interest: none

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134-139, 2013.

25. Murakami S, Takahashi A, Nishiyama H, Fujishita M, Fuchihata H. Magnetic resonance

evaluation of the temporomandibular joint disc position and configuration. Dento maxillo

facial radiology 22: 205-207, 1993.

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26. Paesani D, Salas E, Martinez A, Isberg A. Prevalence of temporomandibular joint disk

displacement in infants and young children. Oral surgery, oral medicine, oral pathology,

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oral radiology, and endodontics 87: 15-19, 1999.

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27. Ribeiro RF, Tallents RH, Katzberg RW, Murphy WC, Moss ME, Magalhaes AC, Tavano

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O. The prevalence of disc displacement in symptomatic and asymptomatic volunteers
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aged 6 to 25 years. J Orofac Pain 11: 37-47, 1997.

28. Sano T, Westesson PL, Larheim TA, Takagi R. The association of temporomandibular
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joint pain with abnormal bone marrow in the mandibular condyle. Journal of oral and
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maxillofacial surgery 58: 254-257; discussion 258-259, 2000.

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29. Sasaki K, Watanabe M, Tanabe T, Kikuchi M, Inai T, Huh J-I, Tsuboi A, Hattori Y,

Meguro O, Satoh I, Hiramatsu S, Okugawa H. Clinical Evaluation of Occlusal Therapy

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Based on EMG Biofeedback Occlusal Examination in Craniomandibular Disorders.

C

Journal of Prosthodontic Research 38: 340-351, 1994.

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30. Tasaki MM, Westesson PL, Isberg AM, Ren YF, Tallents RH. Classification and

prevalence of temporomandibular joint disk displacement in patients and symptom-free

volunteers. American journal of orthodontics and dentofacial orthopedics 109: 249-262,

1996.

31. Wenneberg B, Nystrom T, Carlsson GE. Occlusal equilibration and other stomatognathic

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treatment in patients with mandibular dysfunction and headache. The Journal of

prosthetic dentistry 59: 478-483, 1988.

32. Wright EF, North SL. Management and treatment of temporomandibular disorders: a

clinical perspective. The Journal of manual & manipulative therapy 17: 247-254, 2009.

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Table 1. Subjects’ characteristics

N (%)
Sex Male 48 (32.0)
Female 102 (68.0)

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Disc position
Bilateral ND 35 (46.7)
Unilateral ADD 15 (20.0)

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Bilateral ADD 23 (30.7)
Not recognize 2 (2.6)
Articular disc position and function

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ND 73 (48.7)
PADDWR 19 (12.7)
PADDWOR 4 (2.7)
ADDWR 18 (12.0)

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ADDWOR 32 (21.3)
Not recognize 4 (2.7)
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Articular disc configuration
Biconcave 48 (32.0)
Biplanar 48 (32.0)
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Hemiconvex 20 (13.3)
Biconvex 11 (7.3)
Folded 19 (12.7)
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Not recognized 4 (2.7)

Joint effusion
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None or minimal 103 (68.7)

Moderate 26 (17.3)
Osteoarthritis
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Negative 114 (76.0)

Positive 36 (24.0)
Bone marrow abnormality
Negative 121 (80.7)
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Positive 29 (19.3)
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Data show the number of subjects and percent in each category.

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Table 2. Relationship between condyle/disc movement and pain/discomfort of the

temporomandibular joint

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Value Rpain P-value

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Age 38.4 ± 17.0 -0.18 0.03

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Condyle and Disc movement

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Condyle_anteroposterior (%) 2.75 ± 3.35
AN -0.19 0.03

Condyle_vertical (%) -0.58 ± 0.69 0.88 0.37

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Disc_anteroposterior (%) 0.39 ± 3.75 -0.07 0.47

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Rotational angle (°) 2.58 ± 1.57 0.01 0.88

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Means and standard deviation.

Condyle_anteroposterior: The anteroposterior movement of the condyle caused by the splint was
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evaluated by subtracting T´C´/T´P´ (with splint) from TC/TP (without splint)

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Condyle_vertical: The vertical movement was evaluated by subtracting F´S´/T´P´ (with splint)
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from FS/TP (without splint).

Disc_anteroposterior: The anteroposterior movement of the disc was evaluated by subtracting

T´D´/T´P´ (with splint) from TD/TP (without splint)

Rotational angle: The rotational angle of the condyle.

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R: Pearson’s correlation coefficients.

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Table 3. Relationship between TMJ pain and patient factors per patient unit and per TMJ

unit

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B1 P-value B2 P-value CI(lowe - upper )
a b
r

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Patient unit
Sex Male Referenc -
e

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Female 35.9 0.27
Age -1.9 0.03 -2.4 0.01 -4.8 - -0.6

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Disc position
Bilateral ND Referenc -
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e
Unilateral ADD -44.2 0.28
Bilateral ADD 21.4 0.55
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TMJ unit
Condyle and Disc movement
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Condyle_anteroposteri -3.7 0.36

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or (%)
Condyle_vertical -0.5 0.98
(%)
Disc_anteroposterior 3.6 0.33
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(%)
Rotational angle (°) 6.5 0.56
Articular disc position and
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function
ND Referenc -
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PADDWR 39.6 0.40
PADDWOR -62.9 0.51
ADDWR 62.8 0.20
ADDWOR -50.4 0.20
Articular disc configuration
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Biconcave Referenc -
e
Biplanar 46.9 0.21
Hemiconvex -12.4 0.80
Biconvex 121.3 0.05 191.1 0.004 63.9 - 318.4

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Folded -33.3 0.50
Joint effusion
none or minimal Referenc -

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e
moderate -22.7 0.58

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Marked or Extensive 16.0 0.72
Osteoarthritis
Negative Referenc -

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Positive 60.9 0.08
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Bone marrow abnormality
Negative Referenc -
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e
Positive 83.3 0.03 124.0 0.004 40.0 - 208.0
B1, Partial regression coefficient by the generalized linear model.
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Objective variable relative value unit (RVU) of TMJ-pain, explanatory variables as each factors.

ND: normal disc, ADD: unilateral anterior disc displacement, PADDWR: partial anterior disc
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displacement with reduction, PADDWOR: partial anterior disc displacement without reduction,
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ADDWR: anterior disc displacement with reduction, ADDWOR: anterior disc displacement
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without reduction.

B2, Non-standardized coefficients in the multiple regression analysis; only variables with P <0.05

are displayed.

Objective variable RVU, explanatory variables are those with P <0.05 for the generalized linear
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regression coefficient, assuming sex as moderator variables (stepwise).

a, P-value with the generalized linear model.

b, P-value on multiple regression analysis.

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CI, Confidence interval of the partial regression coefficient on multiple regression analysis. The

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abbreviations of condyle movements and disc displacement are the same as for Table 2.

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FIGURE LEGENDS

Figure 1. Test splints and image analysis methods

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A, B: Test splint. C-E: Image analysis of the anteroposterior (C), vertical (D), and rotational (E)

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angle with respect to the condyle. T, lower edge of the tubercle; P, upper edge of the porus

acusticus externus; C, perpendicular line drawn from the line passing through the posterior edge

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of the condyle and a point crossing this line and the TP line; D, perpendicular line drawn from

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the TP line to the posterior edge of the disc and a point crossing this line and the TP line; F, two
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lines parallel to the TP line passing through the deepest portion of the mandibular fossa; S, line

passing through the summit of the condyle; Angle, rotational angle of the condyle.
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Highlights

Investigation of whether splint therapy facilitates improvement of condyle and disc

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motions.

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Splint-related anterior movement of the condyle was associated with TMJ pain.

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Splint therapy was not likely to be successful for any kind of TMJ abnormalities.

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