Clinical Oral Investigations (2023) 27:2299–2310

https://doi.org/10.1007/s00784-023-04963-x

RESEARCH

Quantitative and qualitative condylar changes following stabilization

splint therapy in patients with temporomandibular joint disorders
Mazen Musa1,2   · Qianqian Zhang3 · Riham Awad4   · Wenfang Wang1   · Madiha Mohammed Saleh Ahmed1,5   ·
Yunshan Zhao1   · Abeer A. Almashraqi6 · Xi Chen1   · Maged S. Alhammadi7

Received: 6 September 2022 / Accepted: 19 March 2023 / Published online: 11 April 2023
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023

Abstract
Objective  This study aimed to explore the quantitative and qualitative condylar changes following stabilization splint (S.S)
therapy, including condylar position, morphology, and bone mineral density (BMD) in subjects with temporomandibular
disorders (TMD).
Materials and methods  In this retrospective clinical study, we enrolled 40 TMD subjects (80 joints) aged 18 to 35 years, for
whom a S.S was used to treat TMD. The 80 TMD consists of 32 masticatory muscle disorders (myalgia) and 48 TMJ disor-
ders (arthralgia). Cone beam computed tomography (CBCT) was used to scan the TMJs of subjects pre- and post-treatment
for three-dimensional analysis (3D). Using Mimics software v.21.0, quantitative (3D condylar and joint spaces dimensions
parameters were measured using linear measurements in millimeters, according to the Kamelchuk method and Ikeda method,
while the assessment of anteroposterior condyle position within the glenoid fossa was based on the method of Pullinger
and Hollender), and qualitative (a round bone tissue with an area of 2 m ­ m2 in three representative areas according to the
Kamelchuk method to measure condylar BMD) pre- and post-treatment. Intra- and inter-group statistical comparisons were
performed using the Wilcoxon signed ranks and the Kruskal–Wallis test, respectively.
Results  The course of treatment was 6–12 months, with an average of 9.1 months. For the pre- and post-treatment quantita-
tive comparisons, there was a statistically significant difference in the anterior joint space (AJS) and coronal medial space, as
well as the condyle length in the myalgia group and condylar width in the arthralgia group. For qualitative measurements, a
significant difference was observed in the posterior slope of the myalgia group and the arthralgia group’s anterior, superior,
and posterior slopes. The inter-group comparisons revealed significant differences in AJS, condylar length, and anterior
slope density.
Conclusion  In short-term follow-up, the S.S influenced patients with TMD from different origins; it changes anterior and
coronal medial joint space, condyle length in myalgia, and width in arthralgia. Furthermore, it improved the condyle bone
density more evidently in arthralgia.
Clinical relevance  This study highlights the influence of S.S on symptomatic populations with TMD of different origins from
a qualitative and quantitative perspective.

Keywords  Arthralgia · Cone beam computed tomography (CBCT) · Myalgia · Bone mineral density · TMJ diseases · TMJ
myofascial pain syndrome · Craniomandibular disorders

Introduction

The temporomandibular joint (TMJ) is a crucial and com-

Mazen Musa and Qianqian Zhang contributed equally to this work,
and they are considered as joint first authors.
* Xi Chen
13038598996@163.com
Extended author information available on the last page of the article
plex joint involved in numerous processes, such as chewing,
swallowing, and speaking [1].
The American Academy of Orofacial Pain (AAOP)
defines temporomandibular disorders (TMD) as “a collective
term that embraces several clinical problems that involve the
masticatory muscles, the (TMJ) and associated structures”;

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TMD is either (1) muscle-related (myogenous), or (2) joint-
related (arthrogenous) [2],  and according to Diagnostic
Criteria for TMD (DC/TMD) terminology (myalgia) and
(arthralgia) [3].
Pain, popping, clicking, limited opening, mandibular
deviation on opening and closure, muscle discomfort, head-
aches, and earaches are symptoms of TMDs [4]. TMDs are
common in adults between 20 and 40 years old and are more
prevalent in women than men [5]. TMDs significantly influ-
ence patients’ daily lives due to psychological distress, phys-
ical impairment, and orofacial system functional restrictions
that reflect patients’ chewing or eating, oral hygiene, and
sleep [6]. It has a multifactorial etiology. Stress, hereditary
and psychological factors, including personality type [7],
jaw clenching, bruxism, and other musculoskeletal problems
that strain the jaw joint and trauma may cause TMD [8].
Because of the TMJ’s complicated biomechanical articu-
lar system, radiographic investigations are difficult to per-
form, and a good diagnosis suggests using multiple types
of radiographic imaging [9]. Traditional two-dimensional
(2D) radiography was the primary method for examining
the TMJ. However, due to the overlap of nearby structures
and the limited sensitivity to changes in both condylar and
temporal bone components, this 2D approach is unreliable
[10]. The development of three-dimensional (3D) and mag-
netic resonance imaging (MRI) imaging made it possible to
analyze TMJ much more precisely [11].
Cone beam computed tomography (CBCT) exposes
patients to less radiation than conventional computed tomog-
raphy CT. Its high-resolution imaging can reach excellent
performance in terms of accuracy when examining the TMJ
[12, 13].
Currently, methods of TMD treatment include an occlusal
splint, physiotherapy, pharmacotherapy, local, topical, and
systemic medications, or in combination, psychotherapy,
functional exercise, and surgery. The conservative and
reversible occlusal splint effectively relieves TMD symp-
toms [14].
Jeffrey Okeson was the first author to describe the
occlusal appliance or stabilization splints (S.S) in its mod-
ern form. He stated many features that may explain why
occlusal splints reduce the symptoms associated with TMDs,
such as alteration of the occlusal condition, alteration of the
condylar position, increase in the vertical dimension, cogni-
tive awareness, a change in peripheral input to the central
nervous system, natural musculoskeletal recovery, placebo
effect, and regression to the mean [15].
Recent meta-analyses have suggested that S.S could have
a key role in treating TMDs [14]; another study found no
evidence of the splint’s effectiveness in treating TMD [16].
At the same time, there is no evidence to back up or invali-
date the use of S.S for TMD treatment [17], while a rand-
omized trial revealed a comparable reduction in the pain
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Clinical Oral Investigations (2023) 27:2299–2310
factor (PF) in the two groups that were evaluated, regardless
of the device employed; with or without canine guidance;
and a comparable effectiveness in terms of boosting pain
resilience at the examined points was found [18].
Ricketts was the first to propose joint space measure-
ments [19]. The radiographic joint space is a radiolucent
area between the mandibular condyle and the temporal bone.
The condylar position is determined by this relative dimen-
sion of the radiographic joint spaces between the glenoid
fossa and the mandibular condyle [20]. Joint space within
the normal range is essential for the TMJ to function well
without limitation or pain [21].
Many methods are used to measure bone mineral density
(BMD), including dual-energy X-ray absorptiometry (DXA)
[22], quantitative computerized tomography (QCT) [23],
and CBCT measured in the Hounsfield unit (HU) [24, 25].
Many efforts have been undertaken to examine TMJ posi-
tion, morphology [1, 26, 27], and BMD [24, 28, 29], and
their clinical significance has long been a source of con-
troversy. It is not simple to standardize position, morphol-
ogy, and BMD because of the TMJ’s inherent diversity and
TMJ’s constant process of adaptability in response to time
and pathological changes. Although position, morphology,
and BMD have already been investigated, a knowledge
gap was observed regarding the source of TMD pre- and
post-treatment with S.S and its effect on condyle position,
morphology, and remodeling. Despite its expanding clinical
use, S.S has not been adequately explored in the Chinese
population.
Study hypothesis that S.S’s does not have any influence
on symptomatic populations with TMD of different origins
regarding the condylar position, morphology, and BMD.
The objective of the present study was to evaluate quan-
titative and qualitative condylar changes following S.S ther-
apy, including condylar position, morphology, and BMD in
patients with TMD.
Material and methods
Study design
The ethics committee of First Affiliated Hospital of Xi’an
Jiaotong University, China, approved this retrospective
clinical study (No. XJTU1AF2022LSK-027). The study
included a group of TMD subjects drawn from the popula-
tion of patients who came to the Department of Stomatol-
ogy, First Affiliated Hospital of Xi’an Jiaotong University,
China, from July 2017 to January 2022 with TMJ condition.
Informed consent was obtained from all subjects, and their
identifications were treated with confidentiality. Moreover,
all methods were carried out following the principles of the
Declaration of Helsinki.
Clinical Oral Investigations (2023) 27:2299–2310 2301
Sample size
The sample size was calculated using G*Power (V. 3.1.9.4),
with an alpha value of 0.05 and a power of 80%, based on a
pilot study in which the changes in the anterior joint space
(AJS) of the myalgia group were 0.194 ± 0.533 mm. The
resulting sample size was a minimum of 27 joints. This num-
ber was increased later to a minimum of 32 joints in each
included group.
Selection criteria
A total of 40 adult TMD patients were included. Subjects’
inclusion criteria for TMD were done after detailed history
taking, clinical examination, and radiographic findings. In
line with the latest version of the DC/TMD [3], all cases
were diagnosed with TMD. CBCT (KaVo 3D eXam cone,
Germany) was employed to observe the bony alterations in
the condylar surface after recommended S.S therapy.
The following inclusion criteria were applied: (1) 18 to
35 years old; (2) subjects suffering from symptoms of disc
derangement disorders, joint sounds with pain, intermittent
or chronic interlocking of the TMJ, mandibular deviation
during opening and closing coinciding with a click, limited
mouth opening, and joint pain radiating to the head and neck
region, and masticatory muscle disorders myalgia; (3) sub-
jects whose treatment plan included maxillary S.S with full
permanent dentition (not including the third molar) to meet
retention requirements; (4) CBCT clearly shows bilateral
condyles; and (5) the condyle displacement index shows that
the maximum intercuspation-centric relation MI-CR con-
dyle displacement exceeds the physiological range Meas-
ures Condyle Displacement device (MCD) value of verti-
cal dimension > 1 mm and transverse dimension > 0.5 mm.
The following exclusion criteria were followed: (1) subjects
with a history of congenital or developmental disorders; (2)
TMJ injury or surgery; (3) rheumatoid arthritis and other
autoimmune diseases affecting TMJ idiopathic condylar
resorption; (4) osteoarthritis; (5) under medication affect-
ing bone metabolisms, such as calcitonin and hormone or
other systemic diseases; (6) history of orthodontic and/or
orthognathic treatment; (7) prosthetic replacement of teeth
(partial or complete denture); (8) open bite patients; and (9)
visible skeletal mandibular asymmetry.
CBCT assessment
CBCT was acquired (KaVo company, Germany); the
applied parameters were set at 120 kV, 5 mA, field of view
(23 cm × 17 cm), and 17.8-s exposure time, with a voxel size
of 0.3 mm, the slice thickness was 2 mm; all images were
obtained under the same conditions by the same experienced
radiologist. Subjects were asked to sit and place their heads
in the center of the headrest, then positioned parallel to the
floor with the Frankfurt plane. Afterward, the subjects were
told to bite their teeth into the maximum intercuspal position
(MIP), and the center beam was lined up with the sagittal
plane. The CBCT scan data were transferred into Digital
Imaging and Communication in Medicine (DICOM) file
format and afterward imported into Mimics 21.0 software
(Materialize Company, Belgium) for 3D reconstruction. The
CBCT was done at two-time points: pre-treatment (T0) and
post-treatment (T1).
Reoriented TMJ to reference planes and images resliced
to identify the axial view make the sagittal line perpendicu-
lar to the long condyle axis and pass through the condyle
center (Fig. 1).
The 3D anatomical landmarks, reference planes, TMJ
spaces, 3D condylar position, and mandibular measurements
were done according to methods described by Alhammadi
et al. [30, 31].
Landmark digitization was performed on the 3D module
under the guidance of slice locators (sagittal, axial, and coro-
nal) for more accurate 3D localization.
Treatment protocol
1st appointment—day 1: clinical examination DC/TMD,
radiographic examination CBCT, all subjects were
examined for mandibular range of motion assessment
and limitation measured in millimeters, opening pattern,
opening, and closing movement, whether there was pain,
noises, and whether there were obstacles in mandibular
extension, retraction, and lateral movement, joint area,
and muscle palpation. Clinical evaluation was performed
again after the treatment to verify the absence of TMD
symptoms.
2nd appointment—day 7: informing the subjects of the
diagnosis based on the DC/TMD, possible etiological fac-
tors, and prevalence; describing and demonstrating the
normal range of the TMJ and abnormalities found. After
neuromuscular deprogramming using manual bilateral
manipulation, centric relation was recorded, followed by
registering the maximum intercuspation (MIC); then, a
face bow was established to record the relationship of the
upper teeth to the anatomical reference area and trans-
fer this relation to a semi-adjustable articulator (AD 2®;
Advanced Dental Designs Inc, Riverside, CA, USA). The
horizontal and vertical condylar positions (CPs) were
evaluated using a single MCD and MIC wax record.
MCD measures the three-dimensional position of the
condyle in the MIP.
3rd appointment—day 14: installation and polishing of
the S.S, which was fabricated in a colorless thermopolym-
erized acrylic resin of 3-mm thickness. Adjustment of the
occlusal contacts. Instructions for the user include the fol-
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2302
Fig. 1  Image processing show-
ing (A) the coronal view; (B)
the axial view; (C) the sagittal
view; and (D) the three-dimen-
sional view
lowing: wearing the splints at least 20 h a day [32], except
during eating and brushing their teeth and, keeping good
hygiene of self and the S.S, coming to appointments on
time to ensure optimal success. During all appointment
periods, they were checked on how the symptoms were
progressing, recorded the palpation index of the joint area
and muscle tenderness each time, and had the splint read-
justed, if necessary.
4th appointment—day 21: occlusal contacts were reas-
sessed once their occlusal contacts were stabilized; fol-
lowing the fourth appointment, the follow-up intervals
expanded to 15, 30, and 60 days [33]. S.S was progres-
sively reduced until the MIC was achieved [34].
The course of treatment was 6–12 months, with an aver-
age of 9.1 months. The subjects in this study were instructed
to depend on S.S as the only treatment; no medication or
physical therapy was applied.
Evaluation of treatment was not based solely on patient
reports; after the test showed that the condyles were close to
the CR, reached a stable TMJ position, and the TMD symp-
toms improved in three consecutive follow-up visits, with
a careful, gradual weaning-off period—where the amount
of time without the splint is gradually increased—then the
patient was instructed to stop wearing the appliance.
Quantitative outcomes assessment
The linear measurements of radiographic joint spaces in
the sagittal plane were measured in millimeters, according
to the Kamelchuk method [35], while in the coronal plane,
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Clinical Oral Investigations (2023) 27:2299–2310
we followed the Ikeda method [36] (Table 1, Fig. 2A, B).
The assessment of anteroposterior condyle position within
the glenoid fossa was based on the method of Pullinger
and Hollender [37].
Anatomical landmarks are described in Supplementary
information no. 1. The determining quantitative landmarks
and reference line as described by Hilgers [38] Condyle
length (CL 1), width (CL 2), height (CH), fossa height
(FH), the slope of the anterior condyle (β), the inclination
of the articular eminence (θ), and the condylar process-
articular socket relationship (β-θ) are described in Table 1
and presented in Fig. 2C, D, E, F.
Qualitative outcomes assessment
The qualitative landmarks were determined according to
the Kamelchuk method [35] (Supplementary information
1; Fig. 2G). To restore the contrast limits, all data sets
were subjected to Hounsfield unit calibration within the
micro-CT program and standardized to achieve a consist-
ent threshold difference. We selected a bone threshold
value range of 226 to 3071 HU [24]. Using the Mimics
software function Density in Ellipse, a round bone tissue
with an area of 2 ­mm2 was selected in the anterior slope
(AS), superior slope (SS), and posterior slope (PS), and
the condyle center is adjacent to the correct sagittal posi-
tion. The bone density of ten continuous sections (thick-
ness of 0.3 mm) was measured, and the average value was
finally taken to represent the unit bone density of each
slope of the condyle.
Clinical Oral Investigations (2023) 27:2299–2310 2303

Table 1  Definitions of the selected TMJ measurements

Measurement parameters Abbreviation Definition

Quantitative measurements
  Anterior joint space (mm) AJS The vertical distance from the anterior-most mandibular condyle point
(AC) to the glenoid fossa
  Superior joint space (mm) SJS The vertical distance from the most superior condyle point (SC) to the
most superior point of the glenoid fossa
  Posterior joint space (mm) PJS The vertical distance from the posterior-most mandibular condyle point
(PC) to the glenoid fossa
  Coronal medial joint space (mm) CMS The vertical distance from the coronal medial point (CM) of the con-
dyle to the glenoid fossa
  Coronal lateral joint space (mm) CLS The vertical distance from the lateral coronal point (CL) of the con-
dyle to the glenoid fossa
  Condyle length (mm) CL 1 The vertical distance from the posterior-most condylar point (PCp) to the
anterior-most condylar point (ACp)
  Condyle width (mm) CL 2 The vertical distance from the medial condyle point (MCp) to the lateral
condyle point (LCp)
  Condyle height (mm) CH The vertical distance from the most superior aspects of the condyle (SC)
to the reference line (L)
  Fossa height (mm) FH The vertical distance from the highest point of the fossa (SF) to the refer-
ence line (L)
  The slope of the anterior condyle ( ° ) β The angle formed between the line passing the tangent of the anterior
slope of the condyle to point (SF) and the reference line (L)
  The inclination of the articular eminence ( ° ) θ The angle formed between the line passing through the tangent of the
anterior wall of the articular eminence to point (SF) and the reference
line (L)
  Condylar process—articular eminence relationship β-θ The difference between the slope of the anterior condyle and the tangent
( ° ) of the anterior wall of the articular eminence
Qualitative measurements
  Anterior slope (Hu) AS Anterior cortical bone density was measured in an area of ­2mm2 ellipse
in shape bone tissue representing the anterior slope
  Superior slope (Hu) SS Superior cortical bone density was measured in an area of ­2mm2 ellipse
in shape bone tissue representing the superior slope
  Posterior slope (Hu) PS Posterior cortical bone density was measured in an area of ­2mm2 ellipse
in shape bone tissue representing the posterior slope

Statistical analysis Results

Statistical analysis was performed using SPSS 25.0 soft-
ware (IBM, Chicago Inc., USA). The measurements of
CBCT were re-estimated by two different observers who
reanalyzed the cases within 2 weeks to ensure intra- and
inter-examiner reliability of the measurements in 20 ran-
domly selected cases. After data assessment for normality
showed that the data did not obey a normal distribution
using Shapiro–Wilk’s test, the Wilcoxon signed ranks test
was performed to test the statistical significance of the
mean changes between pre- and post-treatment measure-
ments in the same group. For intergroup comparisons, the
Kruskal–Wallis test was used. Mean and standard devia-
tions were calculated using 0.05 as the significance level.
Forty adult TMD subjects treated with S.S participated in
our study, aged between 18 and 35 years, with a mean age
of 22.2 years and 2 months. This study included 80 TMD
consisting of 32 masticatory muscle disorders (myalgia) and
48 TMJ disorders (arthralgia). The intra- and inter-observer
reliabilities for all the TMJ landmarks outcomes ranged from
0.88 to 0.95 (Supplementary information 2).
Quantitative outcomes
Compared to pre-treatment, the proportion of posterior
positioned condyles decreased, and the ratio of the anterior
and concentric positions increased. While the proportion

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Fig. 2  The studied TMJ

measurements (1) Quantita-
tive measurements of (A)
AJS: anterior joint space,
SJS: superior joint space, PJS:
posterior joint space; while (B)
CMS: coronal medial space,
CLS: coronal lateral space. (C,
D, E, F) Measurement of TMJ
morphology measurement: (C)
CL1: condyle anteroposterior
diameter; (D) CL2: condyle
mediolateral diameter; (E)
CH: condyle height, FH: fossa
height; (F) β: condylar slope, θ:
inclination of the articular emi-
nence. (2) Qualitative measure-
ments of (G) the bone mineral
density (BMD) of the condyle
in the three selected sites AS:
anterior slope, SS: superior
slope, PS: posterior slope. A—
anterior direction, P—posterior
direction, T—top direction,
B—bottom direction, R—right
direction, L—left direction

of the condyles on the medial side increased, the cen- A statistically significant difference between pre- (T0) and
tral position slightly decreased, and the lateral remained post-treatment (T1) was observed in AJS and CMS of myal-
unchanged; however, the differences were insignificant gia (Table 3). In addition, significance was observed in AJS
(Table 2). between the myalgia and arthralgia treatment effect (Table 5).

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Clinical Oral Investigations (2023) 27:2299–2310 2305

Table 2  Comparison of condyle position in the glenoid fossa in the Discussion

sagittal and coronal section pre-and post-treatment; (No.) = 80

Position in sagittal section (No.) Total p-value TMJ is a unique joint with a biomechanically complicated
Posterior Concentric Anterior articular system; its clinical examinations are operator sensi-
T0 29 37 14 80 tive; considering this obstacle, TMJ pathology is evaluated
T1 18 38 24 80  0.074 utilizing a range of imaging modalities.
Position in coronal section (No.) CBCT is less costly and has a lower radiation dose. In
Lateral Central Medial addition to these advantages, CBCT provides a three-dimen-
T0 30 44 6 80 sional image of TMJ. CBCT is efficient in diagnosing several
T1 30 38 12 80 0.295 bone changes (quantitative) in TMJ. CBCT measurement is
accurate and reliable in determining alveolar bone quality
No., number of study sample per (joint); *p-value of < .05 statistically
(qualitative) [39].
significant; **p < 0.01; ***p < 0.001
This study intended to assess the quantitative and quali-
tative condylar changes following S.S therapy, including
Only the CL 1 in myalgia and CL 2 in arthralgia showed condylar position, morphology, and BMD in subjects with
statistically significant differences between pre- and post- TMD from different origins (myalgia or arthralgia) using
treatment (Tables  3 and 4). Moreover, CL  1 showed a CBCT imaging.
statistical difference between the myalgia and arthralgia For the quantitative outcomes; the current study showed
treatment effects (Table 5). that averages of AJS and CMS were reduced compared
with pre-treatment in both myalgia and arthralgia TMD
Qualitative outcomes subjects, which was statistically significant in myalgia only;
at the same time, SJS increased, which suggests a forward
A statistically significant difference between pre- (T0) and post- and downward movement mostly on the medial trajectory.
treatment (T1) was observed in the PS of the myalgia. Also, in Hasegawa et al. [40] used S.S, and Ramachandran et al. [41]
the AS, SS, and PS of the arthralgia (Tables 3 and 4). Further- used anterior deprogrammer, and both studies concluded
more, A significant difference was observed in the treatment that the splint resulted in the anteroinferior displacement
effect between the myalgia and arthralgia in the AS (Table 5). of the condyle.

Table 3  Comparison of Measurement standard Mean ± SD Mean ± SD Mean different Δ p-value

quantitative and qualitative
measurements pre-and post- T0 (No. = 32) T1 (No. = 32) T1 – T0 (No. = 32)
treatment in the myalgia group
Quantitative measurements
  AJS (mm) 1.99 ± 0.62 1.68 ± 0.60  − 0.31 0.002**
  SJS (mm) 2.44 ± 0.48 2.59 ± 0.75 0.15 0.150
  PJS (mm) 1.87 ± 0.61 2.03 ± 0.60 0.16 0.145
  CMS (mm) 2.32 ± 0.74 2.09 ± 0.89  − 0.23 0.024*
  CLS (mm) 1.93 ± 0.67 2.09 ± 0.89 0.16 0.231
  CL 1 (mm) 7.87 ± 1.26 8.27 ± 1.15 0.4 0.005**
  CL 2 (mm) 16.18 ± 2.34 16.14 ± 2.46  − 0.04 0.086
  CH (mm) 8.32 ± 0.98 8.44 ± 0.92 0.12 0.308
  HF (mm) 6.14 ± 1.44 5.88 ± 1.28  − 0.26 0.607
  β ( ° ) 63.96 ± 7.91 62.60 ± 7.94  − 1.36 0.318
  θ ( ° ) 47.35 ± 6.84 46.24 ± 7.15  − 1.11 0.441
  β − θ ( ° ) 16.61 ± 6.57 16.36 ± 6.18  − 0.25 0.614
Quantitative measurements
  AS (Hu) 314.61 ± 103.8 322.24 ± 94.2 7.63 0.135
  SS (Hu) 273.33 ± 99.7 291.59 ± 98.19 18.26 0.178
  PS (Hu) 262.95 ± 107.2 287.09 ± 125.4 24.14 0.003**

SD, standard deviation; No., number of study sample per (joint); mm, millimeters; °, degree; Hu, Houns-
field unit; T0, before treatment; T1, after treatment; *p-value of < .05 statistically significant; **p < 0.01;
***p < 0.001

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Table 4  Comparison of Measurement standard Mean ± SD Mean ± SD Mean different Δ p-value

quantitative and qualitative
measurements pre-and post- T0 (No. = 48) T0 (No. = 48) T1 – T0 (No. = 48)
treatment in the arthralgia group
Quantitative measurements
  AJS (mm) 2.24 ± 0.68 2.12 ± 0.56  − 0.12 0.132
  SJS (mm) 2.43 ± 0.48 2.61 ± 0.66 0.18 0.097
  PJS (mm) 1.81 ± 0.66 2.01 ± 0.64 0.2 0.73
  CMS (mm) 2.47 ± 0.74 2.29 ± 0.78  − 0.18 0.114
  CLS (mm) 2.27 ± 0.75 2.29 ± 0.78 0.02 0.969
  CL 1 (mm) 7.85 ± 1.47 7.96 ± 1.6 0.11 0.272
  CL 2 (mm) 6.02 ± 2.74 16.20 ± 2.7 10.18 0.019*
  CH (mm) 8.57 ± 1.28 8.50 ± 1.2  − 0.07 0.361
  HF (mm) 6.11 ± 1.11 6.13 ± 1.2 0.02 0.845
  β ( ° ) 64.83 ± 1.40 63.69 ± 9.9  − 1.14 0.295
  θ ( ° ) 46.85 ± 8.22 47.07 ± 8.9 0.22 0.704
  β − θ ( ° ) 17.97 ± 1.16 17.33 ± 6.4  − 0.64 0.108
Quantitative measurements
  AS (Hu) 369.11 ± 104 397.98 ± 120 28.87 0.005**
  SS (Hu) 335.20 ± 112 357.5 ± 128 22.3 0.013*
  PS (Hu) 310.6 ± 130 341.8 ± 124 31.2 0.003**

SD, standard deviation; No., number of study sample per (joint); mm, millimeters; °, degree; Hu, Houns-
field unit; T0, before treatment; T1, after treatment; *p-value of < .05 statistically significant; **p < 0.01;
***p < 0.001

The optimum positioning prevents the condyle from artic-

Table 5  Comparison of quantitative and qualitative measurements of
treatment effect between the myalgia and the arthralgia groups ulating with the posterior attachment, which is a vascular-
ized and well-innervated retrodiscal area [42], especially in
Measurement standard Myalgia Arthralgia p-value
the case of anterior disk displacement (ADD) (Fig. 3). When
(No. = 32) (No. = 48)
comparing the treatment effect between myalgia and arthral-
T1 – T0 T1 – T0
gia groups, only statistical significance was observed in AJS,
Quantitative measurements indicating that the effect of S.S differs in AJS regarding the
  AJS (mm)  − 0.31  − 0.12 0.039* TMD source.
  SJS (mm) 0.15 0.18 0.969 Regarding the condylar morphology, the CL 1 in myalgia
  PJS (mm) 0.16 0.2 0.945 and CL 2 in arthralgia TMD showed statistically significant
  CMS (mm)  − 0.23  − 0.18 0.530 differences between pre- and post-treatment, and the CL 1
  CLS (mm) 0.16 0.02 0.371 differed in the intergroup comparison, indicating potential
  CL 1 (mm) 0.4 0.11 0.041* reconstructive changes that took place in the condylar sur-
  CL 2 (mm)  − 0.04 10.18 0.458 faces as a result of the treatment which may alter the intra-
  CH (mm) 0.12  − 0.07 0.118 articular mechanical dynamics. This can be explained by the
  HF (mm)  − 0.26 0.02 0.840 ability of the splint to modify the occlusal contacts and alter
 β(°)  − 1.36  − 1.14 0.821 mandibular position [15]; downward movement of the con-
 θ(°)  − 1.11 0.22 0.806 dyle relieves pressure and maintain a gap between the con-
  β − θ ( ° )  − 0.25 0.64 0.637 dyle and its fossa, which restore better blood circulation [40]
Qualitative measurements at the same time muscle contract and stretch force work on
  AS (Hu) 7.63 28.87 0.005** mandibular condyle and its cartilage which will change its
  SS (Hu) 18.26 23.3 0.095 growth environment, leading to gradual changes in condyle
  PS (Hu) 24.14 31.2 0.806 morphology (musculoskeletal recovery). In myalgia, the
No., number of study sample per (joint); mm, millimeters;°, degree;
muscle has a hyperactivity status and is uncoordinated, with
Hu, Hounsfield unit; T0, before treatment; T1, after treatment; excessive contraction and starching causing micro-trauma
*p-value of < .05 statistically significant; **p < 0.01; ***p < 0.001

13
Clinical Oral Investigations (2023) 27:2299–2310 2307
Fig. 3  Representation of the
bilaminar (retrodiscal tissues)
zone with condyle relation-
ship (A) without splint; an
anteriorly displaced disc with a
condyle that is painfully articu-
lating with the well-innervated
and supplied retrodiscal tissues;
(B) with splint condyle moved
forward and off the retrodiscal
tissues allowing the disc to go
back after stabilization splint
was installed. Reduces the ret-
rodiscal tissues’ loading, which
reduces the pain
over a long time. In addition, it reduces friction between the
condyle and articular eminence (bone to bone), which limits
the damage that leads to the peaking of the condyle in the
case of arthralgia [43].
This study adopts relative values for BMD for the quali-
tative measures, making the measurement method highly
reproducible [44]. To avoid the interference of measurement
errors, the MIMICS software bone threshold was used to
automatically identify bone tissue; it can accurately locate
the condyle cortical boundary through the three-dimensional
structure.
In this study, condylar bone density was assessed by
CBCT. When compared to established standard values,
Hounsfield values from the CBCT images were found to
be inaccurate assessments of bone density, according to
Campos et al. [45]; on the other hand, Reeves et al. [46]
and Cassetta et al. [47] reported that Hounsfield units could
be derived from the gray levels in dental CBCT scanners
using linear attenuation coefficients as an intermediate step
and that the results were as accurate as those with medical
computed tomography (CT) Hounsfield units.
Previous research [48] has suggested that the leading
cause of the various condylar bone densities was mandibular
asymmetry, which explains why we excluded any subjects
with skeletal asymmetry.
Statistical significance was observed in the AS, SS, and
PS in arthralgia and the PS of myalgia TMD pre- and post-
treatment; moreover, in AS for intergroup comparison was
also significant. This assumes that the lower bone density
before S.S therapy was an explanation for having arthralgia.
AS had the highest BMD, followed by SS, and PS had
the lowest BMD pre- and post-treatment in both myalgia
and arthralgia. This finding was unexpected since the AS of
the condyle is assumed to bear a heavy load during the man-
dibular function and by the contraction force of the external
pterygoid muscle attached to the anterior part of the condyle:
this causes resorption to take effect. However, Kawaguchi
et al. [49] hypothesized that increased condylar bone density
is associated with the imbalance of bone metabolism (forma-
tion and resorption). Kim. et al. [44] have reported similar
results. Another observation of this study regarding treat-
ment effect, PS has the highest treatment effect (T1-T0),
followed by the SS, and the AS was the lowest in myalgia.
In arthralgia, the PS also has the highest treatment effect,
followed by AS, and SS was the lowest.
Numerous studies [50, 51] found that the thickness of the
condyle cortical bone in subjects with TMD after S.S ther-
apy supports the results of this study. Finally, it’s important
to mention that Derwich et al. [52] believed that treatment
for TMD patients should not focus on the gnathological
concept of positioning the mandibular condyles in centric
relation since this relationship does not seem to be neces-
sary for optimal treatment outcomes in TMD patients.
The differences in the results of various studies may be
due to the complexity of the TMJ anatomy, or the wide
range of TMD patients, such as unilateral or bilateral
involvement of the disease, length of the disease, whether it
is accompanied by articular disc displacement, mandibular
function movement, sample size, research factors (such as
the methods used) will affect the results of the study.
This research is essential in clinical practice since it high-
lights the influence of S.S on symptomatic populations with
TMD of different origins from a qualitative and quantitative
perspective.
This study’s limitations include using small sample size and
unequal distribution of subjects. Another limitation is that the
disc position was not assessed using MRI, which may affect
the accuracy of the condylar movement with the TMJ. Future
prospective studies are required to assess the TMJ using both
CBCT and MRI to evaluate the TMJ bony structures and the
articular disc in the presence of the control group and T2
6–12 months later to see if those changes will disappear as
they resume their normal MIP occlusion. Another limitation
is the short-term evaluation of the treatment effect, and the
results might change if the long-term evaluation was done and
presented.
13

2308
Conclusions
• S.S therapy influences patients with TMD from different
origins.
• S.S adjusted anterior and coronal medial joint space
and condyle length in myalgia and width in arthralgia.
• S.S therapy improved the condyle BMD, more evi-
dently in arthralgia in the anterior slope (AS), supe-
rior slope (SS), and posterior slope (PS), compared
with only the PS of the myalgia. Furthermore, only AS
was significant as a treatment effect between the two
groups.
• In long-term evaluation, the influence of S.S therapy on
joint space, morphology, and BMD in the TMJ requires
further studies to assess its long-term stability.
Abbreviations  TMD: Temporomandibular joint disorders; BMD: Bone
mineral density; S.S: Stabilization splints; CBCT: Cone beam com-
puted tomography; 3D: Three dimensions; MCD: Measures Condyle
Displacement device; MIC: Maximum intercuspation; MRI: Mag-
netic resonance imaging; HU: Hounsfield unit; AS: Anterior slope;
SS: Superior slope; PS: Posterior slope
Supplementary Information  The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00784-0​ 23-0​ 4963-x.
Acknowledgements  We wish to thank the New Medical Treatment
and New Technology of the First Affiliated Hospital of Xi’an Jiaotong
University, Shaanxi University Joint Project, for financially supporting
this study; Charles S Greene, Professor, University of Illinois Col-
lege of Dentistry, USA, for his insightful comments in reviewing the
manuscript; and Mohammed Elhoumed, Salma Izeldin, and Nahawand
Adil, Xi’an Jiaotong University, China, for their statistical assistance.
Author contribution  Mazen Musa and Qianqian Zhang: conception of
the study, definition of the methodology, drafting of the manuscript,
and analysis and interpretation of data for the work; Riham Awad and
Wenfang Wang: contributions to the conception and design of the work
and interpretation of data for the work, statistical analysis, and interpre-
tation of the data and clinical examination; Madiha Mohammed Saleh
Ahmed and Yunshan Zhao: substantial contributions to the acquisi-
tion of data sample recruiting and data collection; Abeer A. Almash-
raqi: grammatical, typo, and intellectual editing of the manuscript and
contributed to critical revision of the article; Xi Chen: supervision
and funding acquisition; Maged S. Alhammadi: contributions to the
conception and critical revision of the article and contributed to the
scope of the discussion. All authors approved the final version of the
manuscript.
Funding  This study was funded by the New Medical Treatment and
New Technology of the First Affiliated Hospital of Xi’an Jiaotong
University (XJYFY-2017ZD02), Shaanxi University Joint Project
(2020GXLH-Y-014).
Data availability  The data that support the findings of this study are
available from the corresponding author upon reasonable request.
13
Clinical Oral Investigations (2023) 27:2299–2310
Declarations 
Ethics approval  This retrospective clinical study was approved by the
ethics committee of Xi’an Jiaotong University, Xi’an Jiaotong Univer-
sity, China (No. XJTU1AF2022LSK-027).
Informed consent  For research involving human participants, informed
consent was obtained from all subjects. All methods were performed
following the relevant guidelines and regulations.
Competing interests  The authors declare no competing interests.
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Authors and Affiliations
Mazen Musa1,2   · Qianqian Zhang3 · Riham Awad4   · Wenfang Wang1   · Madiha Mohammed Saleh Ahmed1,5   ·
Yunshan Zhao1   · Abeer A. Almashraqi6 · Xi Chen1   · Maged S. Alhammadi7
1 5
Department of Stomatology, The First Affiliated Hospital
of Xi’an Jiaotong University, Xi’an 710061, Shaanxi,
People’s Republic of China
2
Department of Orthodontics, Al Tagana Dental Teaching
Hospital, Faculty of Dentistry, University of Science
and Technology Omdurman, Omdurman, 11111 Khartoum,
Sudan
3
Department of Stomatology, Shaan’xi Provincial People’s
Hospital, Xi’an, Shaanxi, People’s Republic of China
4
Department of Pediatrics Dentistry, College
of Stomatology, Xi’an Jiaotong University, Xi’an, Shaanxi,
People’s Republic of China
13
Clinical Oral Investigations (2023) 27:2299–2310
52. Derwich M, Pawlowska E (2022) Do the mandibular condyles
change their positions within glenoid fossae after occlusal splint
therapy combined with physiotherapy in patients diagnosed with
temporomandibular joint disorders? A prospective case control
study. J Pers Med 12(2). https://​doi.​org/​10.​3390/​jpm12​020254
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exclusive rights to this article under a publishing agreement with the
author(s) or other rightsholder(s); author self-archiving of the accepted
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such publishing agreement and applicable law.
Department of Orthodontics, Faculty of Dentistry, Aden
University, Aden, Yemen
6
Department of Pre‑Clinical Oral Health Sciences, College
of Dental Medicine, QU Health, Qatar University, Doha,
Qatar
7
Orthodontics and Dentofacial Orthopedics, Department
of Preventive Dental Sciences, College of Dentistry, Jazan
University, Jazan, Saudi Arabia