Evaluation of disk capture with a splint repositioning appliance

Clinical and critical assessment with MR imaging

Hiroshi Kurita, DDS, PhD, a Kenji Kurashina, DDS, PhD, a Hiroo Baba, DDS, b Akiko Ohtsuka,
DDS, b Akira Kotani, DDS, PhD, c and Sigvard Kopp, DDS, PhD, d Matsumoto, Japan, and
Huddinge, Sweden
SHINSHU UNIVERSITY AND KAROLINSKAINSTITUTET

Objective, The purpose of this study was to evaluate disk repositioning clinically and through use of magnetic resonance imaging
after the insertion of a disk repositioning appliance.
Study design. Seventy-four patients with 82 temporomandibular joints showing middle to late opening movement click and clos-
ing movement click near maximum intercuspation were treated with a mandibular full-coverage repositioning splint. These joints
were assessed clinically and by means of magnetic resonance imaging for disk recapture.
Results. According to clinical assessment, 75.6% (62/82) of the joints were treated successfully; no click was observed from the
splinted mandibular position. When compared with the results of magnetic resonance imaging assessment, clinical assessment
showed an accuracy rate of 91.5%, although the incidence of the false negatives was high (40%).
Conclusions. The results of this study showed that about 70% of reducing displaced disks were captured with use of the disk repo-
sitioning appliance. And it was also suggested that magnetic resonance imaging is helpful to evaluate disk repositioning therapy.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:377-80)

Disk displacement of the temporomandibular joint
(TMJ) may cause TMJ pain and dysfunction and can
lead to actual progression of disorders. 1,2 Previously,
many surgical or nonsurgical methods of treatment
have been reported to restore a correct disk-condylar
relationship. Mandibular protrusive repositioning
splint therapy (often called a disk repositioning splint)
is one type of treatment and to gain a "normal" disk-
condyle relationship. 3,4
Many investigators point out that there is no assur-
ance that the articular disk is recaptured by insertion of
an anterior repositioning appliance. 4-1° Preparation and
placement of a disk repositioning appliance is usually
performed based on clinical findings. Some investiga-
tors think that it is necessary to confirm splint recapture
by means of imaging modalities. However, there have
been few studies that ascertained disk recapture after
the application of the disk repositioning appliance using
imaging modalities. 5-1°
The purpose of this article is to evaluate disk recap-
turing just after the application of a disk repositioning
aAssistant Professor, Department of Dentistry and Oral Surgery,
Shinshu University School of Medicine,
bResearch Associate, Department of Dentistry and Oral Surgery,
Shinshu University School of Medicine,
cprofessor, Department of Dentistry and Oral Surgery, Shinshu
University School of Medicine.
dprofessor, Department of Clinical Oral Physiology, School of
Dentistry, Karolinska Institutet.
Received for publication, Feb. 3, 1997; returned for revision, April
24, 1997 and Aug. 8, 1997; accepted for publication, Nov. I8, 1997.
Copyright © 1998 by Mosby, Inc.
1079-2104/98/$5.00 + 0 7112187816
splint. In this study, we used the distinct inclusion crite-
ria stated below. The disk recapturing was assessed clin-
ically and through use of magnetic resonance imaging
(MRI). The success rate of disk splint capture and the
reliability of clinical assessment for disk capture are
discussed.
MATERIAL A N D METHODS
This study was performed at the Department of
Dentistry and Oral Surgery in Shinshu University
Hospital during the period from 1990 to 1995. During
this time, 450 patients were referred for the treatment of
temporomandibular disorders (TMDs). Mandibular
full-coverage disk repositioning appliances (Fig. 1)
were used for the purpose of disk recapturing in 74
patients who were clinically determined to have anteri-
or displaced TMJ disks with reduction. These were
patients who had joint clicking that occurred at both
middle to late opening and late closing (near maximum
cuspation) of the mandible; most of them were later
proved by MRI to have displaced disk. Protrusive posi-
tioning eliminated the clicks on clinical examination.
The patients had also complained of joint pain, the exis-
tence of intra-articular interference to condylar move-
ment, or both. The patients who had no symptoms other
than joint clicking and the patients who required pro-
trusion to edge-to-edge position or further anteriorly to
eliminate reciprocal clicking were not included accord-
ing to the suggestion of an earlier report.11 Of the result-
ing 74 subjects, 55 were women and 19 were men. The
mean age was 26.2 _+ 9.2 [standard deviation (SD)]

377
378 Kurita et al.
Fig. 1. Mandibular full-coverage disk repositioning appliance
set in position.
years, with a range of 14 to 56 years. Ten patients had
joint clicking on both sides, and thus 84 joints were
assessed. The subjective experience of reciprocal click-
ing was noted for less than 2 years in 48 of 84 joints
with an average of 34.3 ___42.2 (SD) months.
Splints were constructed as an office procedure. The
splint positioned the mandible anteriorly far enough to
eliminate the reciprocal clicking on mouth opening. The
disk was then thought to be captured by the splint. The
patients were instructed to open fully, beyond the open-
ing 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 continuously for 2 months. The patients were
allowed to discontinue only when brushing their teeth
and during meals if necessary.
One or 2 weeks after the disk repositioning appliance
was inserted, each joint was reevaluated clinically. In
case the condyle translated beyond the articular emi-
nence and the joint had no clicking from the splinted
position, splint capture was judged to be successful. In
those cases when the joint occasionally (one or two
times per day) had clicking, (e.g., on awaking in the
morning), splint capture was judged to be nearly suc-
cessful. When the joint had persistent clicking or the
condyle did not translate under the articular eminence,
splint capture was judged to be unsuccessful.
The subjects also had MRI assessment of the TMJ
within a period of a few weeks after initiation of the
splint therapy. MRI was performed with a 1.5-tesla sys-
tem (General Electric Medical Systems, Milwaukee,
Wisc.) with a TMJ surface coil (6.0 cm in diameter). At
first, the TMJ was scanned without insertion of the disk
repositioning appliance for the purpose of confirming
the presence of a displaced disk. An initial axial local-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 1998
Complete splint capture Partial splint capture No splint capture
Fig. 2. Schema of criteria of MRI assessment of disk capture.
izer was performed with a repetition time (TR) of 300
msec, an echo time (TE) 16 msec, a field of view of 24
cm, a slice thickness of 5 mm, and a 256 x 192 scanning
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, the appliance was placed on the
mandibular teeth after the patient opened his or her
mouth fully, beyond the opening click. An axial localiz-
er was performed again, and five corrected sagittal
images again with a 3-ram 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 msec, TE 15 msec,
field of view of 24 cm, and a 256 x 192 scanning
matrix.
The MRI was assessed by a trained radiologist and
one of the authors separately. If their assessments were
different, they were discussed until consensus was
reached. Both were blinded as to the result of clinical
assessment. Disk capture was defined as the intermedi-
ate zone of the disk being located between the articular
surface of the condyle and the anterior wall of the artic-
ular fossa. When the anteriorly displaced disk was cor-
rected by the splint and the posterior band of the disk
was clearly defined at the superior position relative to
the condyle, the disk capture was designated to be com-
plete. In the cases in which the anteriorly displaced
disk was corrected by the splint but the posterior band
of the disk was somewhat anterior to the superior posi-
tion relative to the condyle, the disk capture was desig-
nated partial. In the cases where the anteriorly displaced
disk was not captured by the splint, no splint capture
was reported (Fig. 2).
RESULTS
The results of clinical assessment of splint capture
were as follows. Two patients (two joints) complained
of the appliance giving discomfort and stopped the
treatment within a week. Of the 82 joints examined,
clinical examination revealed that splint capture was
successful in 45 (54.9%) of these joints. In 17 (20.7%)
of these joints, the splint capture was thought to be
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Kurita et al. 379
Volume 85, Number 4

Table I. Comparison of the result of clinical versus

MRI assessment of splint capture
Results of
clinical Results of MRI assessment
assessment Complete or
(no. of joints) partial capture No capture Not scanned
Successful or 40 2 20
nearly successful
Unsuccessful 2 3 15

False positive, 2 of 42 or 4.7%.

False negative, 2 of 5 or 40%.
Accuracy, 43 of 47 or 91.5%.

nearly successful. In the remaining 20 (24.4%) joints,

the splint capture was thought to be unsuccessful
according to our clinical criteria.
Because 16 patients did not consent to MRI study or
discontinued their visits, 41 patients with 47 joints were
available for the MRI assessment. By MRI, an anterior-
ly displaced disk was confirmed in all joints without
insertion of the appliance (Fig. 3, A and B). According
to the MRI assessment, 35 (74.5%) of the 47 splinted
joints were found to have complete disk recapture by
the splint (Fig. 3, C and D). Seven (14.9%) joints were
found to have partially captured disks. In the remaining
5 (10.6%)joints, the disk was not captured at all.
The results of clinical assessment were compared
with the results of MRI assessment (Table I). Of 42
joints that were judged as successfully or nearly suc-
cessfully recaptured by the clinical assessment, 40
joints had their displaced disks recaptured by the splint
and two joints did not. Of five joints that were clinical-
ly judged as unsuccessful, the disk was not captured in
three joints and was captured in two joints. With respect
to a splint capture, clinical assessment showed an accu-
racy rate of 91.5% (MRI and clinical examination
showed agreement in 91.5% of the joints), two false
positives (4.8%, 2 of 42) and two false negatives (40%,
2 of 5).
DISCUSSION
The results of this study indicated that about 70% of
the anteriorly displaced disks were captured by the
splint, because 75.6% (62 of 82 joints) were judged as
successful or nearly successful in the clinical assess-
ment, and because our clinical assessment of disk cap-
ture showed an accuracy rate of 91.5% when compared
with the results of the assessment with MRI.
Unfortunately, we cannot compare this rate with those
of previous studies, because there have been no such
studies to the best of our knowledge.
The patients did not have a pretreatment MRI study
and the possibility exists that we overdiagnosed or
Fig. 3. MRIs of patient with or without disk repositionmg
appliance revealed that occasionally displaced disk was suc-
cessfully captured by insertion of appliance. A, Mouth clos-
ing without appliance. B, Mouth opening without appliance.
C, Mouth closing with appliance. D, Mouth opening with
appliance.
underdiagnosed internal derangement before treatment.
However, the main aim of the study was to compare the
position of the disk with and without the splint as
assessed by MRI and clinical examination and thereby
estimate the ability of the splint to reduce disk dis-
placement. The joints were therefore scanned without
the appliance in position and with the appliance set in
position. This consecutive study showed that anteriorly
displaced disks were captured with the insertion of the
appliance.
In this study, of 42 joints that were judged as suc-
cessfully or nearly successfully treated by the clinical
assessment, 40 (95.2%) joints were also successfully
recaptured disk according to MRI assessment. This rate
is much higher than that of previous reports. Manzione
et al., 8 using arthrographic examination, found that disk
capture by the splint was unsuccessful in 26 (46.4%) of
56 patients who were splinted in a position clinically
thought to reduce an anterior displacement of the TMJ
disk. Manco and Messing, 6 using direct sagittal com-
puted tomography, also found that in 41.8% of joints,
anterior displacement still existed with the disk reposi-
380 Kurita et al.
tioning. However, these previous reports included
patients who were referred from several dental practi-
tioners of various institutes and did not describe indica-
tions and methods for construction of the splint. In addi-
tion, there was no information about the criteria used
for inclusion or exclusion of patients or the clinical cri-
teria for successful splint capture. In this study, the sub-
jects were chosen at our hospital on the basis of a defin-
itive inclusion criteria and j u d g e d according to our
distinct clinical criteria for disk capture. We think the
inclusion and exclusion criteria may be the factors most
responsible for the high positive predictive ability of the
clinical assessment.
The results of this study showed a high incidence of
false negatives as j u d g e d by clinical examination.
Because m a n y cases that were clinically j u d g e d as
unsuccessful in splint capture unfortunately did not par-
ticipate in the M R I study, we could not obtain a reliable
rate of false negative results. In the two false-negative
joints, although joint clicking remained with the splint,
the MR[ study revealed the disk was captured by the
splint. On the other hand, it is also reported that elimi-
nation of joint clicking or limitation of condylar trans-
lation m a y not necessarily mean that the disk is suc-
cessfully captured over the head of the condyle. The
disk displaced to that extent would not create clicking
and interfere with condylar translation any longer. 12,13
These facts suggest that disk recapture after splint treat-
ment is not accurately judged by clinical examination
alone. Therefore we think that posttreatment and (if
possible) pretreatment MRIs are helpful in evaluating
the result of disk recapture treatment.
CONCLUSIONS
F r o m the results of this study, it is concluded that
about 70% of the anteriorly displaced disks that showed
both middle to late opening movement click and closing
m o v e m e n t click near m a x i m u m intercuspation were
recaptured b y the insertion o f a disk repositioning
splint. However, because there was a high incidence of
false-negative treatment results, it is also suggested that
M R I is necessary to evaluate this kind of disk reposi-
tioning therapy.
We wish to thank the doctors in the Department of
Radiology, Shinshu University School of Medicine, for their
assistance in MRI study of TMJ.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 1998
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Reprint requests:
Hiroshi Kurita, DDS, PhD
Department of Dentistry and Oral Surgery
Shinshu University School of Medicine
Asahi 3-1-1, Matsumoto, 390, Japan
e-mail: hkurita@gipac.shinshu-u.ac.jp