Journal of Oral Rehabilitation 2001 28; 651±657
A study of factors for successful splint capture
of anteriorly displaced temporomandibular joint disc
with disc repositioning appliance
HIROSHI KURITA*, AKIKO OHTSUKA*, KENJI KURASHINA* & SIGVARD KOPP²
*Department of Dentistry and Oral Surgery, Shinshu University School of Medicine, Matsumoto, Japan and ²Department of Clinical Oral
Physiology, School of Dentistry, Karolinska Institutet, Huddinge, Sweden
SUMMARY The purpose of this study was to analyse
the factors which in¯uenced the success of disc
recapture by the insertion of a disc repositioning
appliance. Fifty-one joints with joint clicking that
occurred at both middle to late opening and late
closing (near maximum cuspation) of the mandible
were splinted with a mandibular full-coverage repo-
sitioning appliance. The clinical and MR ®ndings
were compared between the joints with successful
and unsuccessful splint disc capture. Thirty-two
clicking joints with reducibly displaced discs
(DDWR) had successful disc recapture, while six of
19 joints with displaced disc without reduction
Introduction
Treatment of patients with disc displacements of the
temporomandibular joint (TMJ) using disc reposition-
ing therapy, aimed at restoring a normal physiologic
relationship between the condylar head of the man-
dible and the articular disc, has been controversial.
Some studies that advocate the use of disc repositioning
therapy reported that a repositioning splint is more
effective both in the resolution of the articular click and
of the pain compared with the use of ¯at plane occlusal
splint (Anderson et al., 1985; Lundh et al., 1985, 1988;
Santacatterina et al., 1998). Simmons and Gibbs (1995)
and Summer and Westesson (1997) also reported that a
greater degree of relief may be achieved in the recap-
turing of discs and so in reducing internal derange-
ments.
Other investigators have reported lower successful
rates in regaining a proper disc to condylar relationship
ã 2001 Blackwell Science Ltd
(DDWOR). Unsuccessful joints with DDWOR had
signi®cantly higher prevalence of deformed disc and
joint effusion, higher VAS quantitative pain score,
and severe disc displacement especially in medial
part of the joint (P < 0á05). From the results of this
study joints with DDWR can be expected to have
successful disc recapture with the insertion of the
appliance. In joints with DDWOR, presence of
in¯ammatory conditions, changed disc morphology
and extensive disc displacement in medial part of
the joint are negative factors.
KEYWORDS: TMJ, disc repositioning appliance, disc
1 displacement, disc recapture
than those above and have recorded situations where
the disc is not captured by use of a disc repositioning
appliance (Manzione et al., 1984; Manco & Messing,
1986; Kirk, 1991; Orenstein, 1993). However, these
researchers did not describe critical inclusion and
exclusion criteria in their disc repositioning treatment.
In a previous study, Kurita et al. (1998a) evaluated disc
repositioning using magnetic resonance imaging (MRI)
after insertion of a disc repositioning appliance. It was
concluded that about 70% of the anteriorly displaced
discs that showed both middle to late opening move-
ment click and closing movement click near maximum
intercuspation were recaptured by the insertion of the
appliance. It was also suggested that de®nitive inclusion
criteria may be important for the success of the disc
repositioning therapy. However, there are no published
studies of the speci®c conditions under which the disc
repositioning therapy could be expected to be ef®ca-
cious.
651
652 H . K U R I T A et al.
The purpose of this study was to analyse the
conditions under which disc capture could be obtained
by the insertion of a disc repositioning appliance.
Anterior repositioning appliance (ARA) therapy was
to be employed, sometimes accompanied with mandib-
ular manipulation (Farrer & McCarty, 1982), to regain a
normal disc to condylar relationship. Disc recapture was
evaluated by using MRI, and the factors which in¯u-
enced successful or non-successful splint disc capture
are discussed.
Materials and methods
This study was performed at the Department of Den-
tistry and Oral Surgery, in Shinshu University Hospital
during a 6-year period (April 1990±September 1996). A
total of 492 consecutive patients were referred for
the treatment of temporomandibular disorders (TMDs).
Disc repositioning therapy was used in 80 patients, who
had joint clicking that occurred at both middle to late
opening and late closing (near maximum cuspation) of
the mandible and patients who re-experienced the
clicking after an application of mandibular manipula-
2 tion technique (Farrer & McCarty, 1982). Protrusive
positioning of the mandible eliminated the clicks on
clinical examination. The patients had also complained
of joint pain and/or disturbed condylar movement.
They all had no history of previous treatment. The
patients who had no symptoms other than joint clicking
and the patients who required protrusion to edge-
to-edge position or further anteriorly to eliminate
reciprocal clicking were excluded according to the
suggestion of a previous report (McNeil, 1990). Subse-
quently, because 35 patients did not consent to MRI
study or discontinued their treatment, 45 patients
were available for this study. They were fully informed
and agreed to take part in the study. Of these, 34 were
women and 11 were men. The mean age was 25á5 years,
with a range of 14±56 years. Six patients had joint
clicking on both sides, and thus, 51 joints were assessed.
Clinical examination was performed at their ®rst
visit. The patients were asked about experience of
reciprocal clicking, joint locking, and/or pain. The TMJ
pain was scored by the patients on 100 mm visual
analogue scales ranging from 0 to 100. The distance
from 0 to the patient's mark was measured in mm.
Disability in daily life, including jaw locking, sleep
disturbance, disability on chewing and absence from
work because of TMJ symptoms, was also scored using
ã 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 651±657
the same method. The patient's maximum mouth
opening capacity was measured between the edge of
the upper and the lower incisors in mm.
The patients were splinted with a mandibular full-
coverage disc repositioning appliance (often called as
ARA). The splints were constructed as an of®ce proce-
dure. The splint positioned the mandible anterior
enough to eliminate the reciprocal clicking upon mouth
opening. The disc was then thought to be captured by
the splint. The position of the mandible to be obtained
by the splint was determined in the following way.
The patients were instructed to open fully, beyond the
opening click and then close in a protrusive position.
The mandible was then retruded to a position just
before the late click would happen. This `splinted
position' was obtained by a minimum of opening and
protrusive movement. The patients were instructed
to wear the appliance 24 h a day for 2 months. The
patients who could reduce mandibular closed lock by
themselves and understood the mechanism of the
splint therapy were allowed to remove the splint when
brushing their teeth and chewing if necessary. After the
successful splint therapy of 2 months, permanent
occlusal rehabilitation procedure was to be employed.
The MRI assessment of the TMJ was carried out
within a few weeks after initiation of the splint therapy.
MRI was performed with a 1á5-T system (General
Electric Medical Systems, Milwaukee, WI, USA) using a
TMJ surface coil (6á0 cm in diameter). At ®rst, the TMJ
was scanned without insertion of ARA for the purpose
of con®rming the presence of a displaced disc. An initial
axial localizer was performed with a repetition time
(TR) of 300 ms, an echo time (TE) 16 ms, a ®eld of view
of 24 cm, a slice thickness of 5 mm and 256 ´ 192
matrix. Five, orthogonal sagittal images of TMJ, with a
3-mm image slice thickness, were obtained with the
jaw in the intercuspal position and then at the maximal
opened position. Then, ARA was placed on the man-
dibular teeth after the patient opened the mouth fully,
beyond the opening click (if necessary, the mandibular
manipulation technique was applied). An axial localizer
was performed again, and ®ve corrected sagittal images,
with a 3-mm image slice thickness, were obtained with
the jaw in the splinted position and in maximal opened
position. Scanning parameters for these sagittal images
were TR 500 ms, TE 15 ms, ®eld of view of 24 cm and
256 ´ 192 matrix.
The MRI was analysed by a trained radiologist and
one of the authors regarding splint disc capture and

the parameters listed below. If their assessments were
different, they were discussed until consensus was
reached.
Splint disc capture
Splint disc capture was de®ned as the intermediate zone
of the disc being located between the articular surface
of the condyle and the anterior wall of the articular
fossa. When the anteriorly displaced disc was corrected
by the splint and the posterior band of the disc was
de®ned at the superior position relative to the condyle,
the disc capture was designated to be successful. In the
cases where the anteriorly displaced disc was not
captured by the splint, unsuccessful splint capture was
reported.
Position of the disc and disc reduction
In the sagittal images without insertion of the splint, the
disc position was classi®ed as normal if the posterior
band was at the apex of the condyle (12-o'clock
position) in the closed-mouth projection (Rao et al.,
1993). Any forward displacement of the disc constitu-
ted anterior displacement. The displaced disc was
further categorized as displacement with reduction if
the disc assumed a normal relationship with the
condyle in an opened-mouth position. However, if
the displaced disc remained in an anterior position
relative to the condyle in an opened-mouth position, it
was classi®ed as displacement without reduction.
Morphologic appearance of the disc
Disc morphology was judged in closed-mouth projec-
tions in the sagittal plane and categorized as being a
normal (biconcave), biplannar, biconvex, folded or
amorphous (Hasson et al., 1990; Katzberg & Westesson,
1991). The disc morphology was examined at repre-
sentative medial, centre and lateral depth.
Joint effusion
We judged a presence of a joint effusion by the criteria
reported by Westesson and Brooks (1992). On
T2-weighted images, joint effusion was identi®ed as
an extended area of high signal intensity in the region
of the upper or lower joint spaces.
ã 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 651±657
APPLIANCE FOR DISPLACED TM DISC 653
Morphologic appearance of the condyle
The condyle morphology was assessed in both the
opened-and closed-mouth projections in the sagittal
plane and judged whether proliferative changes inclu-
ding ¯attening, spurring or eburnation were seen (Rao
et al., 1990).
The images were also measured using the method for
describing the disc and the condyle position which we
reported before (Kurita et al., 1998b). A tangent from
lower edge of the articular tubercle (T) to upper edge of
the porus acustics externus (P) is drawn (TP). Perpen-
dicular lines are drawn from either the posterior edge of
condyle or the posterior band of disc to the tangent
(C and D). Distance of TP, TC and TD are measured in
mm. The condylar and disc position were calculated
and expressed as TC/TP and TD/TP, respectively
(Fig. 1). The position of the disc was evaluated at
representative medial, central and lateral depth, and
the position of the condyle at representative centre
depth. Degree of the disc displacement and condylar
position without ARA were recorded. In addition, the
amount of the condylar dislocation after the insertion of
ARA was calculated.
The student's or Welch's t-test was used to test for
differences in clinical variables and measurements in
Fig. 1. Measurements of the position of condyle and TMJ disc. A
tangent from lower edge of articular tubercule (T) to upper edge of
the porus acusticus externus (P) is drawn (TP). Perpendicular lines
are drawn from either the posterior edge of condyle or the
posterior band of disc to the tangent (C and D). Distance of TP, TC,
and TD are then measured in mm.
654 H . K U R I T A et al.
MR images between the groups with and without splint
disc capture. With regard to other nominal data, the
chi-square, Fisher's probability test, or goodness test of
®t for chi-square test was used. All P-values <0á05 were
considered statistically signi®cant.
Results
In the MRI examination, the imaging which was taken
without insertion of the splint showed that an anteri-
orly displacement of the disc was seen in all joints (with
reduction in 32 joints and without reduction in 19
joints). According to the criteria, 45 out of the 51 joints
were found to have disc recapture by the splint. In the
remaining six joints, the disc was not captured.
Comparison as to the date in the clinical examination
between the joints with successful and unsuccessful
splint disc capture is shown in Table 1. There was no
statistically signi®cant difference for VAS quantitative
pain score and disability in daily life between the
groups. On the other hand, the patients with unsuc-
cessful joints showed signi®cantly smaller maximum
mouth opening than the patients with successful joints
(Student's t-test; P < 0á05). The patients with unsuc-
cessful joints also revealed signi®cantly shorter duration
of either their joint clicking, the joint locking, or pain
(Welch's t-test; P < 0á01).
Comparison in the MRI assessment is shown in
Table 2. The unsuccessful joints had signi®cantly higher
prevalence of either disc displacement without reduc-
tion or proliferative condylar changes than the success-
ful joints (chi-square test; P < 0á01 and P < 0á05,
respectively). There was also signi®cant difference in
Result of splint disc capture
Successful
Female:male 34:11
Mean age 25á2 ‹ 10á0
TMJ pain (VAS; 0±100) 27á7 ‹ 24á1
Disability in daily life (VAS; 0±100) 41á0 ‹ 24á7
Maximum mouth opening (mm) 41á3 ‹ 9á4
Length of experienced joint clicking (month) 38á4 ‹ 43á1
Length of experienced joint locking and/or 16á1 ‹ 24á8
pain (month)
NS: No signi®cance.
*Fisher's probability test.
²
Student's t-test.
³
Welch's t-test.
disc morphology (goodness test of ®t for chi-square test;
P < 0á01).
In the measurements of the MR images, it was shown
that the discs which failed in recapture were displaced
more severely than those with successful recapture.
There were signi®cant differences of the disc position
between the groups at every representative depth
(student's t-test; P < 0á01 for medial plane, P < 0á05
for central and lateral plane). However, there was no
signi®cant difference in the condylar position between
the groups, or in the amount of condylar movement
through the insertion of ARA.
Because all joints with disc displacement with reduc-
tion (DDWR) were successful in disc recapture, we
picked up the 19 joints with disc displacement without
reduction (DDWOR) and compared the clinical and MR
®ndings between the joints with successful and unsuc-
cessful splint disc capture (Table 3). There were statis-
tically signi®cant differences in the distribution of disc
morphology and in the prevalence of joint effusion
(P < 0á01; goodness test of ®t for chi-square test and
P < 0á05; Fisher's probability test). There were also
signi®cant differences for VAS quantitative pain score
and disc position in the medial plane between the
groups (both P < 0á05; Student's t-test).
Discussion
The purpose of this paper was to analyse the conditions
under which splint disc capture could be obtained by
the insertion of the disc repositioning appliance. Disc
repositioning therapy was employed for the patients
according to the de®nitive inclusion and exclusion
Table 1. Comparison of clinical data
between the joints with successful
Unsuccessful and unsuccessful splint disc capture
(mean ‹ s.d.)
6:0 NS*
21á5 ‹ 11á6 NS²
42á3 ‹ 11á9 NS²
49á3 ‹ 19á4 NS²
31á8 ‹ 11á5 P < 0á05²
2á4 ‹ 1á9 P < 0á01³
1á7 ‹ 1.6 P < 0á01³
ã 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 651±657
 APPLIANCE FOR DISPLACED TM DISC 655

Table 2. Comparison of MR ®ndings and measurements between Table 3. Comparison of factors between successful and unsuc-
the joints with successful and unsuccessful splint disc capture cessful splint disc capture in the joints with disc displacement
without reduction
Result of splint disc capture
Result of splint disc capture
Successful Unsuccessful
Successful Unsuccessful
Disc reduction (n) P < 0á01²
With reduction 32 0 TMJ pain 20á5 ‹ 16á6 42á3 ‹ 11á9 P < 0á05²
Without reduction 13 6 (VAS; 0±100)

Disc morphology* (n) P < 0á01³ Disc morphology* (n) P < 0á01³
Biconcave 46 5 Biconcave 9 5
Biplannar 46 0 Biplannar 13 0
Convex 38 6 Convex 15 6
Folded 2 2 Folded 2 2
Amorphous 3 5 Amorphous 0 5

Joint effusion (n) NS² Joint effusion (n) P < 0á05§

+ 11 4 + 1 4
) 34 2 ) 12 2

Proliferative condylar change (n) P < 0á05² Disc position (TD/TP; mean ‹ s.d.)
+ 4 3 Medial plane 0á43 ‹ 0á10 0á31 ‹ 0á12 P < 0á05²
) 41 3 Central plane 0á36 ‹ 0á09 0á29 ‹ 0á13 NS
Lateral plane 0á35 ‹ 0á13 0á25 ‹ 0á09 NS
Disc position (TD/TP; mean ‹ s.d.)
Medial plane 0á44 ‹ 0á09 0á31 ‹ 0á12 P < 0á01§ NS: No signi®cance.
Central plane 0á40 ‹ 0á09 0á29 ‹ 0á13 P < 0á05§ *Sum total of representative three depth (medial, central and
Lateral plane 0á35 ‹ 0á10 0á25 ‹ 0á09 P < 0á05§ lateral plane).
²
Condylar position (TC/TP; mean ‹ s.d.) Student's t-test.
³
Central plane 0á66 ‹ 0á06 0á68 ‹ 0á04 NS¶ Goodness test of ®t for chi-square test.
§
Fisher's probability test.
Amount of condylar dislocation through the insertion of the disc
repositioning appliance (mean ‹ s.d.)
Central plane 0á08 ‹ 0á07 0á05 ‹ 0á04 NS¶
The results of this study showed that the clicking
joints with displaced discs can be expected to obtain disc
NS: No signi®cance. recapture with the use of ARA. All joints with DDWR
*Sum total of representative three depth (medial, central and
were successful in disc recapture. On the other hand,
lateral plane).
²
Fisher's probability test. only six of 19 joints with DDWOR were successful in
³
Goodness test of ®t for chi-square test. disc recapture. Simmons and Gibbs (1995) studied the
§
Student's t-test. splint recapture of the TMJ disc using ARA and reported
¶
Welch's t-test. that post-insertion MRI showed recapture of discs in
25 of 26 reducing displacements, but no recapture in
criteria. All joints had reciprocal clicking at the time of partially reducing or non-reducing joints. The results of
construction of the ARA and they had also been proven this study are compatible with their results. Our results
to have displaced disc in the MRI examinations. also showed that there are differences in maximum
Unfortunately, we did not have a pre-treatment MRI mouth opening, disc morphology, proliferative condy-
study of the joints. Therefore, the possibility exists that lar change, and disc position between joints with
we overdiagnosed or underdiagnosed internal derange- successful and unsuccessful splint disc capture. We
ment prior to treatment. However, the joints were think that the higher prevalence of DDWOR in the
scanned without the appliance in position and with group of unsuccessful splint disc capture is responsible
the appliance set in position. This consecutive study for these differences. This study indicates that the
showed that anteriorly displaced discs were captured reduction of the displaced disc seemed to be the most
with the insertion of the appliance. The success rate in important factor for the splint disc capture.
recapturing the displaced disc has already been reported According to the results of comparison in the joints
(Kurita et al., 1998a). with DDWOR, presence of joint in¯ammation seems to

ã 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 651±657

656 H . K U R I T A et al.
be an important factor in recapturing the displaced disc
without reduction. Our results showed the higher score
of TMJ pain and the higher prevalence of joint effusion
in the joints with unsuccessful splint disc capture. Joint
effusion was thought to appear as an in¯ammatory
component secondary to the disc displacement, and
strong correlation between joint pain and joint effusion
has been reported (Westesson & Brooks, 1992). There-
fore, this suggests that displaced discs that are involved
with in¯ammation are dif®cult to recapture.
It is interesting that the amount of disc displacement in
the medial plane was a factor for the success of disc
recapture. Unfortunately, we had not taken coronal MR
images in all joints, but the lower degree of disc displace-
ment in the medial plane than the central and lateral
planes implies an anteromedial displacement of the disc.
Westesson and Lund (1989) considered that medial
displacement of the disc is more dif®cult to treat. Katzberg
et al. (1996) suggested that the severity of disc displace-
ment without reduction is greater than disc displacement
with reduction. According to this study, totally displaced
discs, which sometimes show severe disc deformities, are
most dif®cult to capture with non-surgical treatments.
Our results also showed the difference in the length
of experienced joint clicking and joint locking and/or
joint pain between the groups. We cannot explain the
cause of the difference. However, the patients with
displaced TMJ disc who do not respond to conservative,
non-surgical treatments sometimes have acute onset
and acute progression of their symptoms.
This study demonstrated the conditions under which
the splint disc capture could be obtained by the
insertion of ARA. However, there remains the question:
what should one do after the successful splint disc
capture. It is advocated that the ®nal therapeutic
mandibular position that was reached at the end of
the temporary occlusal therapy must be constantly
stabilized by means of permanent occlusal rehabilit-
ation (prosthetics, orthodontics or surgical procedures).
This permanent stabilization procedure is potentially
irreversible, complex and expensive. Many researchers
considered that a permanent stabilization procedure
must be used sparingly and in carefully selected
patients for whom the risk:bene®t and cost:bene®t
ratios are de®nitely favourable (Moloney & Howard,
1986; Okesson, 1988; Orenstein, 1993). It is also true
that many clinicians have recognized that the disc
repositioning therapy is recommended in those who are
totally refractory to any other conservative treatment.
ã 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 651±657
The conditions under which disc repositioning therapy,
followed by the occlusal rehabilitation, would be
bene®cial in the long term remain controversial and
require further study. It was reported that the arthrog-
raphy at follow-up of about 3 years after a permanent
change of the occlusion to maintain the disc in a
recaptured position showed the disc to be in a correct
position relative to the condyle in 82% (9/11) of the
patients (Lund & Westesson, 1989).
Acknowledgements
We wish to thank the doctors in the Department of
Radiology, Shinshu University School of Medicine, for
their assistance in MR study of TMJ.
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Correspondence: Dr Hiroshi Kurita, Department of Dentistry and
Oral Surgery, Shinshu University School of Medicine, 3-1-1 Asahi,
Matsumoto 390-8621, Japan.
E-mail: hkurita@hsp.md.shinshu-u.ac.jp
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