CLINICAL STUDY
Assessment of Occlusal Appliance for the Reposition
of Temporomandibular Joint Anterior Disc
Displacement With Reduction
Pei Shen, MS, Xinwei Chen, MS, Qianyang Xie, MS,
Shanyong Zhang, MD, and Chi Yang, MD
Abstract: The aim of our study was to evaluate the success rates
and prognoses of patients treated with occlusal appliances used to
reposition the temporomandibular joint anterior disc displacement
with reduction (ADDWR). A sample of 144 consecutive patients
(210 joints) diagnosed with ADDWR based on MRI were included
in our study. Disc recapture was confirmed in a mandible-anterior
position to eliminate joint clicking based on magnetic resonance
imaging (MRI). Anterior repositioning appliance (ARS) was
applied to keep the mandible in this position. The occlusal surface
of the ARS was ground down by 1 mm approximately every 4 weeks
for bite reconstruction. MRI was carried out before treatment,
6 months after the start of treatment, at the end of the treatment,
and at their last follow-up visit. A Cox regression model was used to
estimate the risk of failure of the treatment. The mean treatment
duration was 9.52.6 months. A total of 177 joints (84.3%) were
successfully repositioned at the end of splint treatment according to
MRI. Regular follow-up indicated that almost 53% of the patients
had normal disc–condyle relationships after 2 years. Sex, age,
treatment duration, and orthodontics used were included in the
final Cox regression model, with hazard ratios of 1.375, 1.141,
0.396, and 0.364, respectively. ARS is inferior for recapturing
ADDWR in the long-term. It is thus better to explore other more
effective methods to reposition the displaced disc in patients with
ADDWR.
From the Department of Oral Surgery, Ninth People’s Hospital, College of
Stomatology, Shanghai Jiao Tong University School of Medicine,
Shanghai Key Laboratory of Stomatology & Shanghai Research
Institute of Stomatology, Shanghai, People’s Republic of China.
Received August 8, 2018.
Accepted for publication October 31, 2018.
Address correspondence and reprint requests to Dr. Chi Yang, Department
of Oral Surgery, Ninth People’s Hospital, Collage of Stomatology,
Shanghai Jiao Tong University School of Medicine, Shanghai Key
Laboratory of Stomatology, Shanghai Research Institute of Stomatol-
ogy, No. 639, Zhi Zao Ju Rd, 200011 Shanghai, People’s Republic of
China; E-mail: yangchi63@hotmail.com; Shanyong Zhang,
E-mail: zhangshanyong@126.com
This study was supported by the Youth Program of National Natural Science
Foundation of China (81601915), doctoral Innovation Fund of Shanghai
Jiaotong University School of Medicine (CBXJ201809), Science and
Technology Commission of Shanghai Municipality Science Research
Project (14DZ2294300), and the Project of Western Medicine Guidance
of Shanghai Municipality (16411960800).
PS and XC contributed equally to the work.
The authors report no conflicts of interest.
Copyright # 2019 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000005210
1140 The Journal of Craniofacial Surgery  Volume 30, Number 4, June 2019
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Key Words: Anterior disc displacement with reduction, disc
repositioning, occlusal appliances, temporomandibular joint
(J Craniofac Surg 2019;30: 1140–1143)
T emporomandibular joint (TMJ) anterior disc displacement
(ADD) is one of the most common TMJ disorders with a high
incidence. Patients with ADD can be divided into those with
anterior disc displacement with reduction (ADDWR) and those
with anterior disc displacement without reduction (ADDWoR)
based on the positional relationship between the disc and the
condyle when opening the mouth.1 Patients with ADD mainly
complain of symptoms such as clicking, joint pain, limited range
of mouth opening, masticatory difficulty, and mandible dysfunc-
tion, which seriously disturb their lives.
Many treatments have been suggested for ADD,2,3 including
occlusal appliances, medications, physical therapy, arthrocentesis,
and disc repositioning. However, the appropriate treatment proce-
dure for ADD remains controversial. Occlusal appliances have
recently received attention from many TMJ specialists. Lin et al4
have reported that flat-plane splints with vertical thicknesses of
3 mm and 5 mm can effectively improve the symptoms of
ADDWoR, especially in patients with joint crepitus and those with
TMJ arthralgia. Zhang et al5 have reported that splint therapy can
increase maximal mouth opening and reduce both pain intensity and
the frequency of clicking in patients with TMJ disorders. Although
many reports indicate that splints can more or less improve the
clinical symptoms of ADD, most of these studies have focused on
the symptoms rather than the positional relationship between the
disc and the condyle. Kurita et al6 have reported that all of the 32
joints with ADDWR were successfully recaptured following the use
of occlusal appliance. However, no follow-up data from this
population have been reported. Furthermore, the above study con-
tained no information regarding the stability of the splint treatment
in the short or long term. To our knowledge, there are few studies
paying attention to the prognosis of splint on recapturing the
displaced disc.
To evaluate the success rates and prognoses of patients treated
using splints for the repositioning of ADDWR, we assessed the
positional relationship between the disc and the condyle in these
patients at different times. In this study, we only focused on the
relationship between the disc and the condyle rather than changes in
clinical symptoms.
MATERIAL AND METHODS
Patients
Consecutive patients who visited the TMJ Clinic at the Depart-
ment of Oral Surgery at Shanghai Ninth People’s Hospital from
August 2009 to June 2016 for splint treatment were reviewed in our
study. The inclusion criteria were as follows: ķ diagnosis with
The Journal of Craniofacial Surgery  Volume 30, Number 4, June 2019 Assessment of Occlusal Appliance

ADDWR based on magnetic resonance images (MRI); ĸ no

history of conservative or surgical treatment for TMJ;
Ĺ confirmation of the disc recapture in a mandible-anterior posi-
tion to eliminate joint clicking when opening the mouth based on
MRI; and ĺ acceptance of appliance treatment. Patients who
discontinued treatment and those lost to follow-up during the
treatments were excluded from our study.

Treatment Process
Patients who were diagnosed with ADDWR were required to
undergo MRI in a protrusive edge-to-edge position fixed using wax
(Fig. 1). If the MRI findings confirmed that the disc could be
recaptured, a full-coverage anterior repositioning appliance (ARS)
was produced in this anterior position (Fig. 2). The patients were
instructed to wear the ARS 24 hours per day for 6 months. The
occlusal surface of the ARS was ground by 1 mm approximately
every 4 weeks for bite reconstruction. When the upper and lower
molars touched in the required anterior position after taking off the
ARS, bite reconstruction was deemed complete and the treatment
was finished. Patients were required to attend regular follow-up
visits after finishing their treatments. Fixed orthodontics were
recommended depending on the patients’ main complaints.

MRI Evaluation
All the included patients underwent MRI examinations before
treatment, 6 months after they began to wear ARS, at the end of
splint treatment, and at their follow-up visits. The MRIs were
obtained using a 1.5 T imager (Signa; General Electric; Milwaukee,
WI) with dual phased-array dedicated TMJ surface coil receivers
using a routine sequence. For each patient, 3 sagittal and 3 coronal
MR images obtained in the same position before, during, and after
treatment were compared at 3 different levels. The evaluation
criteria described by Zhang et al7 were used to evaluate the out-
comes: ķ repositioning in 3 sagittal planes was considered excel-
lent, ĸ repositioning in 2 planes was considered good, and
FIGURE 2. A typical case of splint recapturing the anterior displaced disc in
anterior disc displacement with reduction. (A) The occlusion before anterior
repositioning appliance (ARS) treatment. (B) Magnetic resonance imaging
(MRI) showed that the disc was anteriorly displaced on the first visit. (C) The
occlusion of wearing the ARS. (D) MRI showed that the disc became normal in a
mandible protrusive edge to edge position. (E) The occlusion after ARS
treatment. (F) MRI showed that the disc remained in the normal position after
splint treatment.
Ĺ repositioning in less than 1 plane or a change to ADDWoR
was considered poor. Excellent and good evaluations were regarded
as successes.

Statistics Analysis
Statistical analysis was performed with R Core Team (2015) (R
Foundation for Statistical Computing; Vienna, Austria). A Cox
proportional hazard regression model was used to estimate the risk
of failure. Successfully treated joints were censored at the time of
their last available follow-up. The initial assessment was subjected
to univariate analysis, with continuous variables evaluated as
nontransformed, log-transformed, or best-fit fractional polynomial
transformations. Transformation did not significantly improve the
model fit for any variable. Therefore, nontransformed data were
used. Multivariate model development involved covariate assess-
ment based on statistical significance and clinical importance.
Variables and interaction terms were entered into multivariate
models if the univariate P value was <0.05.

RESULTS

FIGURE 1. Magnetic resonance imaging (MRI) and clinical evaluation of the

temporomandibular joint disc displacement with reduction. (A) MRI showed
the disc was anterior displacement in a mouth closed position. (B) MRI
demonstrated that the disc returned to its normal position when opening the
mouth. (C) The patient made his mandible protraction in an edge-to-edge
position to eliminate the joint clicking upon month opening and fixed by a wax.
(D) MRI was performed in this protrusive position and confirmed that disc could
return to its normal position.
Description of Patients
A total of 153 patients (223 joints) were enrolled in the present
study, although 9 patients (13 joints) dropped out of the study during
their treatments. The study thus included 210 joints from 144
patients (107 female patients and 37 male patients), whose ages
ranged from 9 to 53 years at the time of the initial visit (19.5  7.1
years). The treatment duration ranged from 6 to 16 months, with a

# 2019 Mutaz B. Habal, MD 1141

Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Shen et al The Journal of Craniofacial Surgery  Volume 30, Number 4, June 2019

TABLE 1. Demographics of Patients in the Study TABLE 3. The Follow-up Results of Splint in Treating ADDWR

Variables Patients Percentage Follow-up Period, Success Joints/Total Success

mo Follow-up Joints Rate
Sex
Male 37 25.7% 3–6 39/46 84.8%
Female 107 74.3% 7–12 42/56 75.0%
Age, y 13–24 31/43 72.1%
20 98 68.1% >24 17/32 53.1%
21–35 39 27.1%
36 7 4.8% ADDWR indicates anterior disc displacement with reduction.
Disc position
Bilateral ADD 66 45.8%
the hazards ratio (HR) for each variable. Results of the multivariate
Unilateral ADD 78 54.2%
analyses are shown in Table 4. Sex, age, treatment duration, and
Orthodontics 52 36.1%
orthodontics use were included in the final Cox regression model,
and had HRs of 1.375 (0.92, 2.05), 1.141(0.98, 1.33), 0.396(0.29,
ADD indicates anterior disc displacement.
0.54), and 0.364(0.23, 0.58), respectively (Table 4 and Fig. 3).

DISCUSSION
mean duration of 9.5  2.6 months. The shortest follow-up duration ADD is one of the most common TMJ disorders and occurs in
was 3 months and the longest follow-up duration was 50 months patients of all ages, although it has a high prevalence in adoles-
(14.9  11.2 months). Fifty-two patients accepted the use of fixed cents.8,9 There are different opinions regarding the natural course of
orthodontic appliance after splint treatment (Table 1). TMJ ADD. Schiffman et al10 reported that ADD had progressed in
almost 15% of patients after 8 years of follow-up. However, some
Success Rate of Splint Repositioning for the studies indicate that the joint condition with ADD likely deterio-
rates during its natural course.11 Lei et al12 observed a high
Treatment of ADDWR prevalence of degenerative TMJ with recent-onset ADD in ado-
MRI findings indicated that 177 joints (84.3%) were success- lescents and young adults. Schellhas et al13 have reported that ADD
fully repositioned at the end of splint treatment, and that 33 joints is associated with decreased ramus height and maxillofacial abnor-
(15.7%) were not recaptured during or at the end of the splint malities. These studies suggest that early disc repositioning is
treatment, as determined based on our evaluation criteria. The
outcomes of splint repositioning in patients with ADDWR in the
TABLE 4. Multivariate Analyses of the Success Rate by COX Regression Model
different groups are shown in Table 2. The success rates in patients
younger than 20 years, those aged 21 to 35 years, and those older Variables Hazard ratio 95% CI P
than 36 years were 84.72%, 84.21%, and 77.78%, respectively. The
success rates in female and male patients were 87.01% and Sex—M vs F 1.375 0.92, 2.05 0.119
76.79%, respectively. Age 1.141 0.98, 1.33 0.099
Treatment duration 0.396 0.29, 0.54 0.0001
Orthodontics – Y vs N 0.364 0.23, 0.58 0.0001
Assessment Splint Treatment for ADDWR for
Different Follow-up Durations CI indicates confidence interval.
To assess the stability of splints, MRI results from the 177
successfully treated joints were evaluated at the time of the last
follow-up after splint treatment. The joints were divided into 3 to 6
months, 7 to 12 months, 13 to 24 months, and >24 months’ MRI
follow-up after the end of treatment. The success rates in these 4
groups were 84.8%, 75.0%, 72.1%, and 53.1%, respectively
(Table 3). Cox regression analysis was then performed to evaluate

TABLE 2. Outcomes of splint repositioning TMJ ADDWR in different groups

Success Failure
One Joint Success and
Factors Bilateral Unilateral Bilateral Unilateral the Other Failure

Age group, y
20 39 43 6 9 1
21–35 14 18 2 3 2
36 2 3 0 2 0
Sex
Female 41 50 4 10 2
Male 14 14 4 4 1

ADDWR indicates anterior disc displacement with reduction; TMJ, temporoman- FIGURE 3. The Cox proportional hazard regression model to estimate the risk of
dibular joint. failure in their prognosis of occlusal appliance repositioning the disc in patients
with disc displacement with reduction.

1142 # 2019 Mutaz B. Habal, MD

Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 30, Number 4, June 2019
necessary to avoid deterioration of the disc and decreases in
condylar height.
TMJ ADD is a disease, which is concerned with craniomax-
illofacial system, such as tense muscles or dental occlusion.14,15
Thus, ARS is usually used in patients with ADDWR to relieve
muscle tension and to correct malocclusion to recapture the anterior
displaced disc.16 In the present study, we only focus on the effect of
ARS to require a normal disc–condylar relationship. Previous
studies have shown that ARS has uncertain outcomes in recapturing
the disc in patients with ADDWR. Huang e al17 reported that the
overall success rate of ARS in recapturing the anterior displaced
disc in patients with ADDWR was 71.2% based on clinical exam-
inations. However, this group’s study did not include MRI exam-
inations. Kurita et al6,18 reported that the disc can be recaptured in
patients with ADDWR using occlusal appliances, although they
have not reported any follow-up data. Ma et al19 reported that the
TMJ space was well-distributed and there was adaptive remodeling
in the TMJ in patients with ADDWR treated using ARS. However,
the authors only focused on the effects of ARS on space changes
rather than the relationship between the disc and the condyle.
In the present study, although we confirmed that the disc could
be recaptured in all the included patients using MRI before ARS
treatment, only 84.3% of the joints were successfully repositioned
at the end of the splint treatment. Comparing the success rates of
different groups revealed a slightly higher failure rate in older
patients than in younger patients. There was also a weak correlation
between sex and success rate, such that male patients had lower
success rates than female patients. These findings may be explained
by inferior adaptive capacity in the older patients and stronger
masticatory muscles in the male patients.
We followed up the patients with the 177 successfully recap-
tured joints to assess the stability of ARS. After 2 years follow-up,
53% of the joints had a normal disc–condyle relationship as
assessed using MRI. COX regression analysis revealed that sex,
age, treatment duration, and orthodontics use were correlated with
treatment stability. The female patients had better prognoses than
the male patients. In addition, the younger patients had better
treatment stability. Our results also indicated that longer treatment
duration led to better outcomes. This may be because using the
appliance for a longer period can lead to sufficient adaptive
remodeling of the TMJ. Patients who underwent orthodontic treat-
ment following splint treatment had better prognoses.
CONCLUSION
In conclusion, the long-term effectiveness of ARS in recapturing
ADDWR is inferior, as ARS had a success rate of 53%. It would
thus be better to explore other more effective methods to reposition
the displaced disc. However, ARS is recommended for young
patients with ADDWR, as orthodontics therapy after the use of
ARS may increase the long-term stability of ARS treatment.
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