TMD

Enhanced CPD DO C

Martin James

Funmi Oluwajana, Charles Crawford, Emma Foster-Thomas and A Johanna Leven

Temporomandibular Disorders.
Part 4: Appliance Therapy
Abstract: Appliances have been used in the management of temporomandibular disorders (TMD) for many years, and over this time
designs have waxed and waned in popularity. The majority of appliance designs have few studies to support their use and what evidence
is available, is often of low quality. This article, the fourth in a series of six, reviews the mechanisms of action, evidential support for, and
provides advice on when to use commonly used appliance designs.
CPD/Clinical Relevance: There are a plethora of splint designs in use, but it is essential that the evidence supporting each is understood so
that the most appropriate design is used for each individual situation.
Dent Update 2022; 49: 536–544

Appliance therapy has been used in TMD The literature on this topic is with a diagnosis of myofascial pain.
management for over a century, and heterogeneous in terms of methodology In general, they are used alongside
despite being commonly prescribed, there and outcome measures, and this variation other conservative measures such as
remains a lack of conclusive evidence continues into the use of nomenclature. To self-management, physical therapies
to support the efficacy of one design avoid ambiguity and misunderstanding, and pharmacological treatments.2
over another.1 The aim of this article standardized terms are used throughout Unfortunately, the literature on
is to describe and discuss the most this article (Table 1). SS not only varies in quality, but is
commonly used occlusal appliances in difficult to interpret and presents
the management of TMDs, to present contradictory outcomes.3,4
their supporting evidence and to provide Stabilization splint (SS) A Cochrane review of 12 randomized
some pragmatic guidance to general SS are considered by many as the gold controlled trials (RCTs) showed no
dental practitioners. standard of appliance therapy for patients significant advantage of an SS over any
other active treatment (acupuncture, bite
plates, biofeedback/stress management,
visual feedback, relaxation, jaw exercises
Martin James, BDS(Hons), MJDF RCS (Eng), FHEA, MPerio RCSEd, Specialty Registrar and placebo appliance) and only weak
in Restorative Dentistry, University Dental Hospital of Manchester. Funmi Oluwajana, evidence for their effectiveness versus
BDS(Hons), MFDS RCSEd, Specialty Registrar in Restorative Dentistry, University no treatment.3 Another Cochrane review,
Dental Hospital of Manchester. Emma Foster-Thomas, BDS (Hons), MFDS RCS (Glasg), this one identifying five suitable RCTs
Academic Clinical Fellow, in Restorative Dentistry, University Dental Hospital of investigating splint therapy for sleep
Manchester. Charles Crawford, BDS MSc MFGDP(UK) PGCT&L, Lead Clinician TMD Clinic, bruxism, showed SS had no benefit
University Dental Hospital of Manchester. Emma Foster-Thomas, BDS(Hons), MFDS over other treatments (placebo splints,
RCPS(Glasg), Academic Clinical Fellow in Restorative Dentistry, University Dental Hospital mandibular advancement device
of Manchester. Peter Clarke, BDS(Hons), MFDS RCPS(Glasg), M Perio RCSEd, Specialty and transcutaneous electric nerve
Registrar in Restorative Dentistry, University Dental Hospital of Manchester. A Johanna
stimulation) or no treatment.5
Leven, BDS, MFDS RCSEd, FDS (Rest Dent) RCSEd, Consultant and Honorary Senior
With the lack of high-quality
Lecturer in Restorative Dentistry, University Dental Hospital of Manchester.
randomized controlled clinical trials,
email: martin.james6@nhs.net
lower-level evidence must be considered

536 DentalUpdate July/August 2022

 TMD

Term Synonyms
Stabilization splint (SS) Michigan splint, Tanner splint, hard acrylic splint, occlusal
splint, Fox appliance, centric relation appliance
Soft splint Vacuum-formed splint, soft bite raising appliance, bite guard,
night guard, soft acrylic splint
Bilaminar splint Armadillo splint, dual laminate splint
Anterior bite splint Anterior bite plane, anterior discluding appliance, Hawley
(ABS) bite plane, Sved appliance, Nociceptive Trigeminal Inhibition
Tension Suppression System (NTI-tss), Sleep Clench Inhibitor
(Sci, Sci+, SCi+ Dual Arch Sliders), B-splint, Relax appliance
Figure 1. A balanced stabilization splint: static
Anterior re-positioning Orthopedic repositioning appliance, mandibular orthopaedic contacts are present on each tooth on TMH/in
splint (ARPS) repositioning appliance (MORA) CR, marked in blue, and dynamic contacts with
Table 1. Nomenclature used in the article. anterior guidance shared by the incisors and
lateral guidance on the canines, marked in red.

Splint type/mechanism of action SS Soft/ ABS ARPS LOIS

Positioning the mandibular
condyles centrally in the
glenoid fossa
Positioning of the mandible where
the muscles are at their most
relaxed position
Eliminating posterior interferences
that cause deviations or hinder
harmonious jaw movement
Reduction of neuromuscular activity E
Creation of stable occlusal
relationships with uniform
tooth contacts
Sharing the occlusal forces
throughout the dental arch
Increased cognitive awareness
Central changes to pain anticipation
and processing
Increase in the occlusal
vertical dimension
Prevention of sleep bruxism
Prevention of awake bruxism
Protection of teeth and restorations
Improvement in OSA
The placebo effect
Table 2. Possible actions of common splint designs.3,13,38-44 SS: Stabilization splint; ABS: anterior bite
splint; ARPS: anterior re-positioning splint; LOIS: localized occlusal interference splint; OSA: obstructive
sleep apnoea; T: theorized effect only; E: experimental evidence to support effect.
to support clinical decision-making.
Fricton et al4 undertook a more inclusive
systematic review and meta-analysis of 47
bilaminar
splint appliance (covering the palatal aspect
of the teeth and not interfering with
T
the static or dynamic occlusal contacts).
Interestingly, the same study found the
difference between SS therapy and no
T treatment to be non-significant.
SS can be difficult and time
consuming to fabricate, fit and adjust
E E E correctly. They are, therefore, infrequently
constructed in UK general dental
practice.6 Step-by-step guides are
available and the features well defined
E E to effectively provide a temporary and
T T removable ideal, mutually protected,
occlusal scheme.7 In summary these:
 Should be constructed on the
arch with the least teeth to
T T T
allow the maximum number of
occlusal contacts;
E E E E E  Provide full occlusal coverage
E E E E E with contact on every tooth
simultaneously on the terminal hinge
axis (THA)/in centric relation (CR);
T T T T T  Provide posterior disclusion in
anterior and lateral excursions;
E T  Provide canine guidance in lateral
excursions where achievable or group
E function on the first premolar if not;
T T T  Provide shared incisal guidance in
anterior excursions (Figure 1).
E
The reasons why SS may cause relief of
E E E E E TMD symptoms is less clear, but possible
actions are summarized in Table 2.
Even conservative treatments have
complications, and there are isolated case
reports of anterior open bite development
during SS wear.8 A plausible mechanism
RCTs: they found a statistically significant for this rare complication is a change to
difference with SS, almost 2.5 times more the rest position of the condyle through
likely to improve symptoms than a placebo changes in the disc position and/or resting

July/August 2022 DentalUpdate 537

TMD

muscular tension.9,10 There is also evidence a

from small sleep studies that an SS may
increase the number of apnoeic/hypopnoeic
events in patients with obstructive sleep
apnoea (OSA), but the clinical relevance
of this is questionable.11 Considering the
significant morbidity associated with OSA,
it would be prudent to screen patients and
liaise with the general medical practitioner
prior to provision of an SS. b
Although the evidence supporting SS Figure 2. A Nociceptive Trigeminal Inhibition
is equivocal, most experts agree that their Tension Suppression System appliance in situ:
static and dynamic contacts are only present
use is at least anecdotally beneficial and
anteriorly due to the partial coverage design.
patients are generally accepting of wearing
Image courtesy of Hussain Rashid.
an SS so long as the treatment protocol
is explained. This is particularly true if
they have not had sufficient symptomatic
control from other conservative measures. failed to detect a difference between SS,
Patients who do not get symptomatic soft splints or homecare instruction alone, Figure 3. (a,b) An anterior re-positioning splint in
relief from a well-made SS should be although this outcome may have been situ: the appliance is retained on the mandibular
further assessed, ideally by an experienced due to insufficient participants.16 Comfort arch by friction, and 1–2-mm deep indentations
clinician, to confirm the diagnosis and, if for the maxillary teeth guide the mandible
and compliance is an often-cited reason
necessary, for alternative treatment options repeatedly into a forwards postured position with
for a preference for soft splints; however,
to be considered. the disc ‘recaptured’.
this is not borne out in the literature, with

Soft and bilaminar splints

Soft splints are usually constructed out
of thermoplastic polyvinyl material using
a vacuum or pressure former over the
study model. Owing to the simplicity of
construction, they are very popular.12
Nevertheless, there are concerns about
both their resilience and texture, which may
potentially encourage increased bruxism
and thus worsen symptoms.13 Clinically, it
should be confirmed that the appliance is
well fitting and provides full coverage, but
no occlusal adjustments are conducted.
Regular review is essential to assess
compliance, effectiveness and identify
complications early.
Significant improvements in signs and
symptoms have been reported in patients
with TMD following treatment with a
soft splint.14 There are also completely
contradictory reports of soft splints
increasing muscular activity.15 Studies
on both sides of the argument generally
have small sample sizes and short-term
follow-up, therefore cannot be relied
upon to support an evidence-based
recommendation. The possible mechanisms
of action of soft and bilaminar splints are
summarized in Table 2.
Considering the significant difference
in clinical and laboratory time and skill
required to construct SS, there have been
investigations of various qualities to
discover whether similar results can be
Table 3. Less common splint designs with no experimental evidence.
achieved with simpler designs. One RCT
Name
Placebo splint or non-
occluding splint
Flat plane splint
Gelb appliance/Gelb-
MORA (mandibular
orthopaedic
repositioning appliance)
Posterior pivot appliance
or decompression splint
Hydrostatic appliance
Neuromuscular
appliance/orthotic
Design and function
Any appliance that does not interfere with the static or
dynamic occlusion and therefore is reliant on increased
cognitive awareness and the placebo effect
A full coverage hard acrylic appliance with contact on every
tooth on THA/in CR but with no anterior guidance; aiming to
provide a similar effect to an SS, but with less compromise on
aesthetics and function to enable full-time wear
A partial-coverage hard acrylic ARPS that covers the
mandibular molar teeth only. Designed to be worn full time,
this appliance cannot be recommended due to the risk of
occlusal derangement
A hard acrylic appliance that provides a single posterior
contact in each quadrant, theoretically pulling the condyles
downward when clenching, decompressing the joint and
allowing the disc to re-assume a normal position. The effect
is impossible to produce anatomically as the insertions of
the masticatory muscles are posterior to the dentition and
therefore cannot act anterior to the pivot
Bilateral water-filled chambers sit between the posterior teeth
theoretically allowing the mandible to optimally position
itself
Proponents of this appliance use EMG-based devices to
‘locate’ the optimal position of the mandible. An orthotic
appliance is designed to position the jaw and is usually
followed by a full occlusal rehabilitation to make the new
position ‘permanent’. Validity studies have concluded
that EMG is not sensitive/specific enough to be used as a
diagnostic tool in TMD

538 DentalUpdate July/August 2022

TMD

38% compliance reported after only

9 weeks.17
The bilaminar splint is similar in design
and construction to the vacuumed-
formed soft splint, with the exception
that the blank used in production is a
two-layered ethylene-vinyl acetate, one
soft and the other hard. This results in a
splint that is as simple in the clinical and
laboratory stages as a soft splint, but is
more durable.18
Even with little high-quality evidence
to support their use, there is a role for soft
or bilaminar splints, but they cannot be
applied as a panacea. Their role probably
lies in emergency TMD management
when time will be needed to execute
a more definitive strategy, and in the
protection of teeth or restorations from
parafunctional activity.

Anterior bite splint (ABS)

This category of appliances contains a vast
range of designs, but importantly, they all
share the common feature of providing
static and dynamic occlusal contacts on
the anterior teeth only (Figure 2). The
most popular proprietary variant is the
Nociceptive Trigeminal Inhibition Tension
Suppression System (NTI/NTI-tss; NTI-TSS
Inc, Mishawaka, IN, USA), known in the UK
as the Sleep Clench Inhibitor (Sci, S4S (UK)
Ltd, Sheffield), which can be fabricated
chairside or in a laboratory (Sci+).19 NTI
was first described as a treatment for
migraines and tension-type headaches
and showed benefit compared to a
placebo appliance (whitening tray).20
While not fully understood, several
mechanisms of action of ABS have been
proposed/tested (Table 2).
Several RCTs have investigated the
effect of various ABS against SS with
inconsistent findings ranging from no
difference21 to the superiority of the SS.22
Full-time wear of an ABS should be
actively discouraged alongside regular
review. This is due to the risk of occlusal
changes of which there are reports from
both normal clinical practice and well-
supervised controlled trials demonstrating
how rapidly this may occur.22,23 Occlusal
derangements caused by partial coverage
splints can be exceptionally difficult
to manage.24 There are also isolated
reports of increased tooth mobility
and sensitivity.21
Very serious complications of medical
emergencies resulting specifically from
NTI wear have also been reported with
Figure 4. Diagrammatic representation of anterior disc displacement with reduction. (a) Mandible
at rest with the condyle sat on the posterior band of the disc (not the avascular centre). (b) Partial
opening with the disc pulled further anteriorly by the lateral pterygoid and impeding further
translation of the condyle; the patient may report some restriction to further opening at this point
(and closed locking if there is disc displacement without reduction). (c) Full opening with the disc
recaptured and the avascular centre of it sitting over the condyle; the patient may report a click at
this point as the elastic retro-discal tissues cause sudden recapture. (d) Closing of the mandible into
a protrusive position (as if wearing an ARPS) with the avascular centre of the disc still sitting over the
condyle; the patient will have no clicking or restriction when opening from this position.
four cases of aspiration21 and one of muscular activity is desirable;
ingestion, which became lodged in the  There is insufficient evidence to show
oesophageal entrance.25 advantage or equivalence with SS;
An evolution of the ABS exists  Given the risk of catastrophic occlusal
whereby the anterior device is affixed changes, aspiration and ingestion,
to a full coverage vacuum-/pressure- extreme caution needs to be exercised
formed appliance, similar to an Essix when using partial coverage devices.
retainer, and addition of a vacuum-/
pressure-formed splint in the opposing
arch. This splint type is sometimes Anterior re-positioning
referred to as a B-Splint or an SCi+ splints (ARPS)
Dual Arch Slider by its proponents. This
The primary mechanism by which an
modification theoretically reduces the
ARPS functions is to hold the mandible
risk of occlusal changes and aspiration/
in an anterior position (Figure 3) to
ingestion; however, although there are
‘recapture’ the articulatory disc so that
mentions of this splint design in reviews,26
it lies in the correct relationship with
experimental evidence is elusive.
the condyle, allowing its attachments to
General conclusions on this splint remodel to this new position (Figure 4).
design echo that of a systematic review This action has been confirmed with
on the subject:23 magnetic resonance imaging (MRI)
 There is sufficient evidence for studies27. Potential additional effects are
the role of ABS for emergency listed in Table 2.
TMD management in those with Devices to position the mandible
severe trismus, precluding full arch anteriorly have been advocated as a
impressions, in whom reduced treatment for various different reasons,

540 DentalUpdate July/August 2022


Figure 5. A localized occlusal interference splint
in situ. Static contact is onto the stainless steel
ball clasps on the canines only; however, the
patient may be able to achieve tooth–tooth
contact in extreme excursions; the appliance
is retained by wrought clasps between
the premolars.
although they are now generally
only used in the management of disc
displacements. Disc displacements are
generally stable, asymptomatic and
not functionally limiting. Even painful
or functionally limiting displacements
generally improve spontaneously.
There is, therefore, rarely a need for
active treatment.28 A diagnosis of disc
displacement is often comorbid with
myofascial pain due to the insertion of
the superior belly of the lateral pterygoid
into the articular disc; spasm of this
muscle may cause joint clicking and
myalgia masquerading as arthralgia.
It is for this reason that it is prudent
to manage myofascial pain prior to
considering ARPS therapy for an isolated
disc derangement.
The spontaneous improvement in
disc displacements makes proving the
efficacy of any therapy more difficult.
Without a non-treatment control group, it
is impossible to prove that any outcome is
due to the effect of an appliance, and not
just the passage of time. RCTs by Lundh
et al29 and Conti et al30 found 6 weeks full
time ARPS wear to successfully resolve a
joint click in 91% of cases (significantly
better than either an SS or no treatment)
and gave an 81% reduction in joint pain
(significantly better than counselling
only). The former study, however, also
showed that at 11 and 46 weeks after
treatment the click had returned in
86% of those successfully treated, so at
1 year, there was no significant difference
from the no-treatment group. Relapse
is variable and dependent upon the
outcome measure. Up to 90% of patients
self-reported continued symptomatic
July/August 2022 DentalUpdate 541
control at 3 years, but only 40% of
discs remained in the optimal position
when examined by MRI 3 months
after treatment.27,31
An ARPS is fabricated in a
mandibular position that ‘recaptures’
the disc and, therefore, can only be
constructed for patients with disc
displacement with reduction, but not
without.32 The appliance must also only
be used in patients who have ceased
growth as otherwise the ARPS would act
as a functional orthodontic appliance
leading to a reduced overjet, creation
of a reverse overjet and/or bilateral
posterior open bite. The wear regimen
of an ARPS is critical, with a significantly
better success rate after 3 months of
full-time wear than either daytime only
or night-time only.33
In summary, the ARPS is a
useful appliance for improving joint
clicking and pain in patients with
disc displacement with reduction.
The appliance, however, is bulky,
uncomfortable, requires full-time wear
and has unpredictable long-term results.
In general, spontaneous improvements
in disc displacement occur, therefore the
ARPS should be reserved for patients
who have a severe click that is affecting
their quality of life, and where there
has been exclusion or management of
myofascial pain.
Localized occlusal
interference splint (LOIS)
Also known as an interceptor splint, the
localized occlusal interference splint
(LOIS) is primarily used in patients with
signs or symptoms of awake bruxism
and it functions as a habit breaker. The
simple design uses stainless steel ball
clasps to create contact on the canine
or premolar teeth only, preventing all
other teeth from touching (Figure 5).
This theoretically increases the force
on the proprioceptive fibres of the
periodontal ligaments, which makes
parafunctioning uncomfortable and
hence, discouraged. Other modes of
action may also contribute (Table 2).
LOIS will be unsuccessful in patients who
parafunction in extreme excursions. The
splint should be worn all day initially to
allow identification of the times of day
when parafunctioning occurs, and then
the splint wear can be tailored to those
times. It is essential that the appliance is
TMD
not worn at night, as conscious discomfort
is required to prevent damage.
There is little experimental evidence on
the effectiveness of the LOIS; however, its
use has been shown by electromyography
(EMG) studies to reduce masticatory muscle
activity similar to an ABS.34 Additionally,
an RCT of 68 patients with myofascial
pain treated with LOIS compared with SS
found no significant difference in patient-
reported symptom control.35
Given the simplicity of construction
and the evidential support for the LOIS,
albeit small, its role in TMD management
is exclusively in patients with myofascial
pain, awake parafunction and self-reported
worsening of symptoms throughout the
day or at specific timepoints.
Other intra-oral appliances
The field of appliance therapy for TMD
is heavily based on expert opinion
owing to the general lack of high-quality
experimental evidence.36 This environment
is probably the main reason for the huge
range of appliance designs that have been
suggested in the literature. Table 3 presents
a non-exhaustive list of less-common splint
designs that lack experimental evidence.
Extra-oral appliances
Intra-aural inserts (IAI) are a novel TMD
treatment, previously marketed as
Cerezen (which has been removed from
the market). The theorized mechanism
of action is that when opened, the
mandibular condyles move away from
the external acoustic meatus causing an
increase in the canal volume. Filling the
canal with a hard material in its enlarged
state exerts a small amount of pressure on
the walls of the ear canal when the jaw is
closed, discouraging clenching.37
The only experimental evidence
investigating IAI is a single RCT that
concluded there was no statistically
significant difference between IAI, SS
therapy or physiotherapy within the short
follow-up.37 There is, however, a high risk
that there were insufficient participants
to detect a difference between the
treatments and, therefore, until further
data become available, IAI use cannot be
routinely recommended. They may have
a role in the management of those who
struggle to wear an intra-oral appliance
on the understanding that they are
currently unproven.
TMD
Conclusion
This article has described the appliances
used in the management of TMD that have
some experimental evidence to support
their use, and also briefly described those
that do not. The literature in this field is
heterogeneous due to:
 Recruitment: variation in case
definitions and inclusion of single or
multiple diagnoses;
 Methodology: inconsistency in the
description of the appliances, placebos
and the control of confounding factors
such as analgesia and physiotherapy;
 Outcome measures: different
combinations of signs and symptoms.
These factors make it challenging to
quantitatively compare or combine trials in
a meaningful way.
In many cases, the limited evidence
must be combined with clinical experience
to select the most appropriate appliance
therapy; this should only be undertaken
when a definitive diagnosis has been
established, and simple conservative
measures have failed to achieve
symptomatic control.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Turp JC, Komine F, Hugger A. Efficacy of
stabilization splints for the management
of patients with masticatory muscle pain:
a qualitative systematic review. Clin Oral
Investig 2004; 8: 179–195. https://doi.
org/10.1007/s00784-004-0265-4
2. Durham J, Aggarwal V, Davies S, Harrison
S. Temporomandibular disorders (TMDs):
an update and management guidance for
primary care from the UK Specialist Interest
Group in Orofacial Pain and TMDs (USOT).
RCS England 2013.
3. Al-Ani MZ, Davies SJ, Gray RJ et
al. Stabilisation splint therapy for
temporomandibular pain dysfunction
syndrome. Cochrane Database Syst
Rev 2004: CD002778. https://doi.
org/10.1002/14651858.CD002778.pub2
4. Fricton J, Look JO, Wright E et al.
Systematic review and meta-analysis of
randomized controlled trials evaluating
intraoral orthopedic appliances for
temporomandibular disorders. J Orofac Pain
2010; 24: 237–254.
542 DentalUpdate July/August 2022
5. Macedo CR, Silva AB, Machado MA et al.
Occlusal splints for treating sleep bruxism
(tooth grinding). Cochrane Database
Syst Rev 2007: CD005514. https://doi.
org/10.1002/14651858.CD005514.pub2
6. Patel K, Hemmings KW, Vaughan
S. The provision of occlusal splints
in primary dental care. Prim Dent
Care 2000; 7: 109–113. https://doi.
org/10.1308/135576100322694196
7. Moufti A, Lilico J, Wassell R. How to make a
well-fitting stabilization splint. Dent Update
2007; 34: 398–408.
8. Magdaleno F, Ginestal E. Side effects of
stabilization occlusal splints: a report of
three cases and literature review. Cranio
2010; 28: 128–135. https://doi.org/10.1179/
crn.2010.018
9. Al-Ani Z, Davies S, Sloan P, Gray R. Change
in the number of occlusal contacts
following splint therapy in patients with a
temporomandibular disorder (TMD). Eur J
Prosthodont Restor Dent 2008; 16: 98–103.
10. Fujii T, Torisu T, Nakamura S. A change of
occlusal conditions after splint therapy
for bruxers with and without pain in the
masticatory muscles. Cranio 2005; 23: 113–
118.
11. Nikolopoulou M, Ahlberg J, Visscher CM et
al. Effects of occlusal stabilization splints
on obstructive sleep apnea: a randomized
controlled trial. J Orofac Pain 2013; 27: 199–
205. https://doi.org/10.11607/jop.967.
12. Wassell RW, Verhees L, Lawrence K et al.
Over-the-counter (OTC) bruxism splints
available on the Internet. Br Dent J
2014; 216: E24. https://doi.org/10.1038/
sj.bdj.2014.452
13. Gray R, Davies S. Occlusal splints and
temporomandibular disorders: why, when,
how? Dent Update 2001; 28: 194–199.
14. Wright E, Anderson G, Schulte J. A
randomized clinical trial of intraoral
soft splints and palliative treatment for
masticatory muscle pain. J Orofac Pain 1995;
9: 192–199.
15. Okeson JP. The effects of hard and soft
occlusal splints on nocturnal bruxism. J Am
Dent Assoc 1987; 114: 788–791. https://doi.
org/10.14219/jada.archive.1987.0165.
16. Truelove E, Huggins KH, Mancl L, Dworkin
SF. The efficacy of traditional, low-cost and
nonsplint therapies for temporomandibular
disorder: a randomized controlled trial.
J Am Dent Assoc 2006; 137: 1099–1107;
quiz 1169. https://doi.org/10.14219/jada.
archive.2006.0348
17. Feinmann C, Harris M. Psychogenic facial
pain. Part 2: Management and prognosis.
Br Dent J 1984; 156: 205–208. https://doi.
org/10.1038/sj.bdj.4805304
18. Longridge N, Milosevic A. The bilaminar
(dual-laminate) protective night guard. Dent
Update 2017; 44: 648–654.
19. Blumenfeld A, Bender S, Glassman B,
Pinto A. Patterns of use for an enhanced
nociceptive trigeminal inhibitory splint.
Inside Dentistry 2011; 7: e1.
20. Shankland W. Migraine and tension-type
headache reduction through pericranial
muscular suppression: a preliminary report.
Cranio 2001; 19: 269–278.
21. Jokstad A, Mo A, Krogstad B. Clinical
comparison between two different splint
designs for temporomandibular disorder
therapy. Acta Odontol Scand 2005; 63: 218–
226.
22. Magnusson T, Adiels A-M, Nilsson H,
Helkimo M. Treatment effect on signs and
symptoms of temporomandibular disorders-
-comparison between stabilisation splint
and a new type of splint (NTI). A pilot study.
Swedish Dent J 2004; 28: 11–20.
23. Stapelmann H, Türp J. The NTI-tss device for
the therapy of bruxism, temporomandibular
disorders, and headache–Where do we
stand? A qualitative systematic review of the
literature. BMC Oral Health 2008; 8: 22.
24. Bereznicki T, Barry E, Wilson NHF.
Unintended changes to the occlusion
following the provision of night guards.
Part two: management. Br Dent J 2019; 226:
649–656. https://doi.org/10.1038/s41415-
019-0261-3
25. Fleten A, Gjerdet N. Accidental
swallowing of an incisal splint. Den Norske
tannlaegeforenings tid 2004; 114: 638–639.
26. Yadav S, Karani J. The essentials of occlusal
splint therapy. Int J Prosthet Dent 2011; 2:
12–21.
27. Chen HM, Liu MQ, Yap AU, Fu KY.
Physiological effects of anterior
repositioning splint on temporomandibular
joint disc displacement: a quantitative
analysis. J Oral Rehabil 2017; 44: 664–672.
https://doi.org/10.1111/joor.12532
28. Naeije M, Te Veldhuis A, Te Veldhuis E et
al. Disc displacement within the human
temporomandibular joint: a systematic
review of a ‘noisy annoyance’. J Oral Rehabil
2013; 40: 139–158.
29. Lundh H, Westesson PL, Kopp S, Tillstrom
B. Anterior repositioning splint in the
treatment of temporomandibular joints
with reciprocal clicking: comparison with a
flat occlusal splint and an untreated control
group. Oral Surg Oral Med Oral Pathol 1985;
60: 131–136. https://doi.org/10.1016/0030-
4220(85)90280-4
30. Conti PC, Correa AS, Lauris JR, Stuginski-
Barbosa J. Management of painful
temporomandibular joint clicking with
TMD
different intraoral devices and counseling:
a controlled study. J Appl Oral Sci 2015; 23:
529–535. https://doi.org/10.1590/1678-
775720140438
31. Davies SJ, Gray RJ. The pattern of splint
usage in the management of two common
temporomandibular disorders. Part III:
Long-term follow-up in an assessment of
splint therapy in the management of disc
displacement with reduction and pain
dysfunction syndrome. Br Dent J 1997;
183: 279–283. https://doi.org/10.1038/
sj.bdj.4809495
32. Eberhard D, Bantleon HP, Steger W. The
efficacy of anterior repositioning splint
therapy studied by magnetic resonance
imaging. Eur J Orthod 2002; 24: 343–352.
https://doi.org/10.1093/ejo/24.4.343
33. Davies SJ, Gray RJ. The pattern of splint
usage in the management of two common
temporomandibular disorders. Part I: The
anterior repositioning splint in the treatment
of disc displacement with reduction. Br
Dent J 1997; 183: 199–203. https://doi.
org/10.1038/sj.bdj.4809466
34. Manns A, Miralles R, Pena M. The effect
of different occlusal splints on the
electromyographic activity of elevator
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muscles: A comparative study. J Gnathol
1988; 7: 61–73.
35. Gray R, Davies S, Quayle A, Wastell D.
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: 55–58.
36. Rinchuse DJ, Rinchuse DJ, Kandasamy
S. Evidence-based versus experience-
based views on occlusion and TMD.
Am J Orthod Dentofacial Orthop 2005;
127: 249–254. https://doi.org/10.1016/j.
ajodo.2004.02.012
37. Tavera AT, Montoya MC, Calderon EF et
al. Approaching temporomandibular
disorders from a new direction: a
randomized controlled clinical trial of the
TMDes ear system. Cranio 2012; 30: 172–
182. https://doi.org/10.1179/crn.2012.027.
38. Baad-Hansen L, Jadidi F, Castrillon E et
al. Effect of a nociceptive trigeminal
inhibitory splint on electromyographic
activity in jaw closing muscles during
sleep. J Oral Rehabil 2007; 34: 105–111.
https://doi.org/10.1111/j.1365-
2842.2006.01717.x
39. Daud A. TMD treatment – a splint
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alterantive. Dentistry Magazine. 2017:36.
40. Ernst M, Schenkenberger AE, Domin M et al.
Effects of centric mandibular splint therapy
on orofacial pain and cerebral activation
patterns. Clin Oral Investig 2020; 24: 2005–
2013. https://doi.org/10.1007/s00784-019-
03064-y
41. Lim J, Lasserson TJ, Fleetham J, Wright
J. Oral appliances for obstructive
sleep apnoea. Cochrane Database
Syst Rev 2006: CD004435. https://doi.
org/10.1002/14651858.CD004435.pub3
42. Lotze M, Lucas C, Domin M, Kordass
B. The cerebral representation of
temporomandibular joint occlusion and its
alternation by occlusal splints. Hum Brain
Mapp 2012; 33: 2984–2993. https://doi.
org/10.1002/hbm.21466
43. Raphael K, Marbach J, Klausner J et al. Is
bruxism severity a predictor of oral splint
efficacy in patients with myofascial face
pain? J Oral Rehabil 2003; 30: 17–29.
44. Solberg WK, Clark GT, Rugh JD. Nocturnal
electromyographic evaluation of bruxism
patients undergoing short term splint
therapy. J Oral Rehabil 1975; 2: 215–223.
https://doi.org/10.1111/j.1365-2842.1975.
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