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CRANIO®The Journal of Craniomandibular & Sleep Practice

ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20

Treatment of Joint Pain and Joint NoisesAssociated with a Recent TMJ InternalDerangement: A Comparison of an AnteriorRepositioning Splint, a Full-Arch MaxillaryStabilization Splint, and an Untreated ControlGroup

Simona Tecco, Felice Festa, Vincenzo Salini, Ettore Epifania & MicheleD’Attilio

To cite this article: Simona Tecco, Felice Festa, Vincenzo Salini, Ettore Epifania & MicheleD’Attilio (2004) Treatment of Joint Pain and Joint Noises Associated with a Recent TMJ InternalDerangement: A Comparison of an Anterior Repositioning Splint, a Full-Arch MaxillaryStabilization Splint, and an Untreated Control Group, CRANIO®, 22:3, 209-219

To link to this article: http://dx.doi.org/10.1179/crn.2004.026

Published online: 30 Jan 2014.

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0886-9634/2203-209$05.00/0, THE JOURNAL OF CRANIOMANDIBULAR PRACTICE,Copyright © 2004by CHROMA, Inc.

ABSTRACT: Pain and joint noises associated with temporomandibular joint (TMJ) internal derangementare often treated by using an intra-oral splint. This study evaluated whether an anterior repositioningsplint (AR splint) could be more effective in the treatment of these symptoms than a full-arch maxillarystabilization splint (FAMS splint), because of its capability to re-establish immediately the normalcondyle/disk relationship. The authors treated 40 patients (average age 16.8; range 8.0-24.0) with con-firmed internal derangement, joint pain, and joint noises in at least one TMJ for at least two months, withAR splint (20 subjects) or FAMS splint (20 subjects); 10 untreated patients comprised the control group.Joint noise, joint pain, and the intensity of pain were assessed using a visual analogic scale (VAS), andthe pain was characterized (i.e., constant or chewing/biting pain) and evaluated monthly for eightmonths. Significantly fewer AR splint patients experienced pain after four months of treatment. A signifi-cantly lower intensity of pain was experienced by the AR splint patients after two months of treatment.Significantly fewer AR splint patients experienced chewing/biting pain after eight months of treatment.The frequency of joint noises decreased over time, with no significant differences between the groups.In conclusion, the AR splint seems to be more effective in decreasing pain, but it seems to make no dif-ference in the treatment of joint noises.

Dr. Simona Tecco received her D.D.S.degree in 1999 from the Faculty ofDentistry, University of Chieti, Italy. Sincethen she has been a staff member in theDepartment of Orthodontics andGnathology at the same university. Dr. Tecco is attending working toward aPh.D. degree in oral science.

It is well documented that factors affecting degenera-tion in human temporomandibular joints (TMJ) canbe divided into intra-articular variables (mostly artic-

ular disk position and specific joint components) andgeneral factors (gender, age, and tooth loss).l Wide con-sensus seems to exist regarding the role of increasing age2

and abnormal disk position (internal derangement),3-5

both of which have been reported to significantly affectTMJ degeneration. Several studies have indicated that theelapsed time since a disk displacement has occurred is animportant factor in determining the pathologic state of theTMJ at treatment, since the earlier the disk displacementhas occurred, the more severe is the disk deformation.6

Disk displacement without reduction is considered amore advanced condition than disk displacement withreduction, and it may in some cases be a precursor ofosteoarthrosis.7-8 Articular disk displacement without any

Treatment of Joint Pain and Joint Noises Associatedwith a Recent TMJ Internal Derangement: A Comparison of an Anterior Repositioning Splint, a Full-Arch Maxillary Stabilization Splint, and anUntreated Control Group

Simona Tecco, D.D.S.; Felice Festa, M.D., D.D.S., M.S., Ph.D.; Vincenzo Salini, M.D.Ettore Epifania, D.D.S.; Michele DÕAttilio, D.D.S.

REHABILITATIVE MEDICINE

Manuscript receivedMarch 17, 2003; revisedmanuscript receivedAugust 4, 2003; acceptedSeptember 17, 2003

Address for reprintrequests:Dr. Simona TeccoVia Le Mainarde 2665121 PescaraItalyE-mail: simtecc@tin.it

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treatment can accelerate osseus degenerative joint changesand become a chronic dysfunction.5 Patients with thispathology seem to experience more pain, more signs ofmandibular dysfunction, more hard tissue changes, andmore frequent perforation and deformation of the diskwhen compared to patients with disk displacement withreduction who do not progress to disk displacement with-out reduction.7,9 In 58 randomly selected autopsy speci-mens of the TMJ, Westesson, et al.6 showed that in jointswith a partial anterior disk position (disk displacementwith reduction), disk deformation occurred in 31% andwas consistently located in the part of the disk that wasanteriorly displaced. Joints with completely anteriorlypositioned disks (disk displacement without reduction)showed disk deformation in 77% and irregularities of thearticular surfaces in 65%.

Based on these findings, internal derangement is con-sidered an ascending degenerative condition of the TMJthat is conducive, when the biochemical integrity of theextracellular matrix is compromised, to progressive dis-integration of the articular surfaces, fibrillation, and split-ting.10,11 The disintegration starts at the surface of a jointcomponent and subsequently increases in severity by pro-gressively involving deeper layers of the articular carti-lage and then spreading tangentially along the articularsurface. Kurita, et al.12 examined histological disksobtained at autopsy from ten symptom-free subjects andcompared the findings with observations involving 17surgically removed disks. The normal disks were bicon-cave, whereas the surgically removed disks were de-formed and thicker than the normal disks. Chondrocytes,a surface layer of proliferative connective tissue, a highermaximal density of fibroblasts and vessels, and splittingwere seen in the surgically removed disks but not in thenormal specimens.

The factor of time since the pathology occurred seemsto be of great importance in determining the prognosisand the state of the disease. However, although manystudies have been done in order to show the more effec-tive therapy for disk displacement,13-15 these studies havenever included as selection criteria, the elapsed time sincethe symptoms started. Presumably, the time of pathologycould also affect the severity of symptoms and the capa-bility and the speed of healing. The aim of this study wasto compare different occlusal splints for the treatment ofTMD symtoms which had been occurring for at least sixmonths. The criteria of time since symptoms occurredwas critical in the selection of subjects. Since the mostimportant symptoms associated with TMJ damage areabnormal joint sounds and pain, the authors wanted tostudy the frequency and the intensity of these symptomsin subjects treated with an anterior repositioning splint

(AR splint) or a full-arch maxillary stabilization splint(FAMS splint) and to compare the results with those of anuntreated group of subjects. In a literature review of long-term treatment findings for anterior disk displacementwith reduction, the AR splint proved superior to the flatocclusal splint, when compared with a control group, inreducing or eliminating joint noise (clicking), joint pain,and associated muscular symptoms.15

Material and Methods

The sample was selected from a group of patients whowere referred for evaluation of complaints of TMJ painand dysfunction in a private study in Pescara, Italy.Complaints included the following symptoms: joint ten-derness and pain on palpation, joint pain during mastica-tory movements, and abnormal noises (i.e., popping andclicking). Subjects were included in the study sampleaccording to the following criteria: 1. joint pain and jointnoise in at least one TMJ for at least six months; 2.memory of the precise event that caused the onset ofsymptoms; and 3. internal disk derangement confirmedon magnetic resonance images (MRI). Using this criteria,50 subjects were selected, 28 males and 22 females (aver-age age 28.8 age, range from 14-63). Internal diskderangement was assessed on MRI: two sequences usingdual coil capability; the sequences were performed usingproton density image technique. The MRI were read byan oral radiologist who was blinded to the study, and whowas told that all subjects were suspected of having inter-nal derangement which he was to confirm. All the sub-jects were considered to have been asymptomatic untilthe initial event occurred; 22 patients had been evaluatedfor orthodontic treatment and were not diagnosed withTMJ dysfunction; 17 wore orthodontic appliances; 28subjects had never been evaluated by an orthodontist andhad only been seen by a general dentist; none of thepatients were diagnosed with TMD. All patients wereevaluated using MRI and were referred for treatment forinternal disk displacement.

TherapyOcclusal splints are often used in the management of

craniomandibular disorders. In this study, the therapyincluded the use of an occlusal splint. The intent of thisstudy was to evaluate the influence of the type of occlusalsplint used in these cases. Since there is no literaturerelating to a standard therapeutic method for the manage-ment of recent internal derangement, the author used aFAMS splint or an AR splint. Ten subjects out of the 50decided against therapy for differing reasons, but they didagree to undergo a control visit by the clinician monthly

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and were used as the control group. The patientsÕ andcontrol subjectsÕ joint noises, joint pain, and pain inten-sity were assessed using a Visual Analogic Scale (VAS).All subjects were monitored and evaluated monthly foreight months. The data were collected and included in thestatistical analysis.

Full-Arch Maxillary Stabilization (FAMS) SplintSplints provide a useful tool for the elimination of

occlusal interferences to reduce neuromuscular activityand to obtain stable occlusal relationships with uniformtooth contact throughout the dental arch (Figure 1).16 Foreach subject, a full-arch maxillary stabilization occlusalsplint was made of transparent thermopolymerizingacrylic resin (with flat occlusal surfaces and uniform,simultaneous, and multiple occlusal contacts at centricrelation-centric occlusion). The increases in the verticaldimension of occlusion produced by the splints rangedfrom 4-5.5 mm measured in the central incisor region.The subjects were asked to wear the splint 24 hours a dayfor a period of a few months. When the appliance wasfitted for the first time, it was balanced for parafunctionalexcursions. The appliance was first balanced in centricocclusion, then after centric stops were definitively incor-porated into the occlusal plane of the acrylic appliance,lateral excursions were recorded. The patient was guidedinto right lateral and then left lateral excursions.

The patient was then asked to move into a protrusiverelationship with optimal contact and finally, the mandiblewas retruded to the terminal hinge position to removecentric relation prematurities. The appliance was adjustedon a continuing basis over the course of the therapy.

Anterior Repositioning (AR) SplintAn anterior repositioning splint (Figure 2) is com-

monly used in the management of anterior disk displace-ment with reduction to re-establish the normal condyle-disk relationship. The major goal in protrusive splinttreatment is the elimination of joint sounds by recaptur-ing the disk. A smooth, coordinated, painless range ofmotion often can be obtained if the disk is recaptured. Inthis way, mandibular deviation, joint noises, and pain canbe eliminated.17,18 For each patient, a full coverage ARsplint was constructed for the maxillary arch using clearself-curing acrylic resin as described by Okeson.19 Thebase of the occlusal splint was prepared on a model, theanterior stop was constructed, and the splint was fitted tothe maxillary teeth. A ramp of acrylic was placed in theanterior palatal area so that during normal closure, themandibular anterior teeth contacted in the protrusiveguiding ramp. The anterior ramp of the splint did not dis-clude the posterior teeth but allowed full contact. Occlusal

contacts were constructed positioning the mandible for-ward to a position that was effective in decreasing painand to where the joint noise disappeared. The later inopening the click occurred, the greater was the trend formandibular protrusion to obtain acceptable condyle-diskposition. With the splint inserted in the mouth, the patientwas able to see the facial change and feel the differenceon palpation through the external auditory meati, as wellas a diminution in tenderness in some of the masticatoryand neck muscles. The click at closing also disappearedafter the splint was inserted, which convinced the patientsof its efficacy. The subjects were instructed to wear thesplint 24 hours per day. The subjects were treated withthe AR splints for eight weeks.20 After this period, thesplint was modified to allow the mandible to return grad-ually to its original more posterior position.

Figure 1Full-arch maxillary stabilization spint.

Figure 2Anterior repositioning splint.

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VariablesAll the subjects in the three groups (FAMS splint

group, AR splint group, and the control group) were mon-itored each month from the start of treatment for a periodof eight months. The presence of joint noise (clicking)was investigated by the same clinician using a stetho-scope. Each subject was listed as having or not havingany joint noise at each monthÕs evaluation. Based on theclinical evaluation by the clinician and on the referredhistory of each subject, the subjects were included eachmonth in one of three categories: a constantjoint noisegroup, a sometimejoint noise group, or a neverjoint noisegroup. Subjects in the first category were still experienc-ing joint noises during the eighth month; subjects in thesecond category often showed joint noises during theeighth month, but not always; and finally, subjects in thethird category had no joint noises by the eighth month.Relative to pain, the subjects were asked at each monthÕsevaluation whether they had pain or not in the joint areaduring clinical examination. Subjects with a constantpain and those with pain during function, mostly chewing(chewing/bitinggroup), were included together as sub-jects with pain. Then each patient characterized his/herpain using one of two descriptors based on the McGillPain Questionnaire, i.e., constant painor pain whenchewing/biting.21 The extent of the pain was assesseddaily by each subject using a 100 mm Visual AnalogicScale (VAS) with a rating from no painto worst painpossible. Each subject was asked to daily note the inten-sity of pain (VAS score) in a personal day-book. Themean of the daily values indicated by patients, during thecurrent month, were used as VAS scores of the currentmonth being considered.

Statisficial AnalysesThis study focused on the follow-up of the distribution

and the intensity of pain and joint noises and on the influ-ence of the type of splint (FAMS splint, AR splint, andcontrol groups) on these variables. Therefore, in theanalyses, the variables were used separately and/or aggregated to show the influence derived from the useof an orthopedic device and a particular type of thedevice. Simple descriptive statistics were used andbetween group differences in frequencies were analyzedwith PearsonÕs chi-square and, where the number of patients was too small, with the Fisher exact test. Dueto the skewed data, nonparametric statistics (Kruskal-Wallis and Dunnett) were computed to test significantdifferences between groups according to the VAS scoreassessment. In order to investigate the repeated painassessments, a FriedmanÕs two-way analysis of variancebetween measurements was calculated, and the differ-

ences were estimated with a WilcoxonÕs signed rank test.All statistical analyses were performed with the SPSSsoftware program (Microsoft Corp. Ver. 9.0), and thelevel of significance was set at p<0.05.

Results

All participating subjects completed the study. Subjectspresented joint pain and joint noise in at least one TMJfor two months at mean (range from one month to sixmonths). The most frequent answers relating to the onsetof the pain were: a macro-trauma (motor vehicle acci-dents, a blow to the head or face due to a fall or a fight); along dental visit; a gape; an industrial accident; or no par-ticular event. No statistical analysis was performed on theanswers. Occlusal features included different types ofmalocclusion: 42% showed class II molar on one side orbilaterally; 26% showed class III molar on one side orbilaterally; 16% showed the absence of one or more teethin the posterior zone; and 8% showed agenesia of one ormore pemanent teeth.

Follow-up and Pain TreatmentAt the beginning of treatment all the subjects reported

pain. Figure 3 shows the number of subjects reportingpain from T0 (the initial visit) to month eight. A largemajority of subjects reported pain during the first month(95% in the FAMS splint group; 90% in the AR splintgroup; 100% in control group). At month two, the numberof subjects treated with an AR splint and reporting paindropped to nine (45%), while 95% of subjects treatedwith the FAMS splint, and 100% of control subjects con-tinued to report pain. At month eight from the start oftreatment, 16 subjects (80%) in the FAMS splint groupstill were experiencing pain, and nine subjects (90%) inthe control group reported pain. Significantly more sub-jects treated with FAMS splint or in the control groupexperienced pain during months 4, 5, 6, 7, and 8.

Pain IntensityThe intensity of pain showed a similar pattern (Figure

4A-B). There was a significant drop in mean scores aftertwo months from the start of treatment in subjects treatedwith the AR splint compared with the FAMS splint andthe control subjects (p<0.001) (Figure 4A). The differ-ences in scores between the AR splint subjects and theother groups at months 3, 4, 5, 6, 7, and 8 were statisti-cally significant (p<0.001 and p<0.01) (Figure 4A). Alsoat month eight, the subjects treated with FAMS splintsshowed significantly lower pain intensity when com-pared with control subjects (p<0.05) (Figure 4A). TheFriedman two-way analysis of variance showed a highly

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Figure 3Graph showing joint pain reported bypatients (as a percentage of the wholesample) treated with an AR splint(AR, n=20); FAMS splint (FAMS,n=20); or untreated control group(CONTROL, n=10) from baselinerecording (0) to month eight (8) oftreatment.

Figure 4AGraph showing pain intensityreported by patients (as VASscore: mean value and SD) treatedwith an AR splint (AR, n=20);FAMS splint (FAMS, n=20); oruntreated control group (CON-TROL, n=10) from baseline re-cording (0) to month eight (8) oftreatment. Significant differencesbetween groups are indicated inbrackets {} and * (p<0.05),**(p<0.01), *** (p<0.001).

Figure 4BGraph showing pain intensityreported by patients (as VASscore: mean value and SD) treatedwith an AR splint (AR, n=20);FAMS splint (FAMS, n=20); oruntreated control group (CON-TROL, n=10) from baseline re-cording (0) to month eight (8) oftreatment. Significant intra-groupdifferences observed over time are indicated in brackets {} and *(p<0.05), **(p<0.01), ***(p<0.001).

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significant effect over time, and separate Wilcoxon testsbetween the assessments of months 1, 2, 3, 4, 5, 6, 7, and8 revealed significant effects for the total group through-out the assessment period. Analyzing the groups sepa-rately, the results were not significant based on the VASscores between months 5 and 6, between months 6 and 7,between months 7 and 8 for the AR group (Figure 4B);and were not significant between months 2 and 3, months3 and 4, months 6 and 7 or months 7 and 8 for the controlsubjects (Figure 4B). Thus, the analyses indicated thatthe changes in pain assessments were clearly perceivableamong the study groups but not in the control group.

Characterizing Pain.All the subjects described the character of pain as a

constant pain or as pain during chewing/biting. Less than40% of subjects experienced a constant pain during thefirst three months, with the exception of month one when50% of the control subjects reported constant pain (Figure5). This frequency decreased during months 3, 4, and 5when less than 30% reported constant pain, except atmonth three when 35% of subjects treated with the FAMSsplint reported constant pain (Figure 5). The frequencydecreased again during months 6, 7, and 8, when less than20% of subjects experienced constant pain (Figure 5). Amajority of subjects in the control group and the FAMSsplint group reported chewing/biting pain after only onemonth of treatment (Figure 6). The frequency of chew-ing/biting pain decreased after the second month of treat-ment to less than 30% at the third month and less than20% at months 4, 5, and 6 (Figure 6). During months 7and 8, it was less than 10%. After eight months from thestart of treatment, significantly fewer patients treatedwith AR splints experienced chewing/biting pain com-pared with patients treated with FAMS splints (p<0.05).

Joint NoisesThe frequency of joint noises decreased over time.

More than 50% of the subjects in the three groups experi-enced a constant joint noise at month three (Figure 7). Atmonth five, a constant joint noise was observed only inabout 30% of subjects treated using the AR splint, whilemore than 50% of patients in the control group and theFAMS splint group continued to suffer a constant jointnoise. There was another evident decrease in the fre-quency of constant joint noise in the AR splint groupduring months 6, 7, and 8. In fact, at month eight, only10% of the subjects in the AR splint group showed a con-stant joint noise, while 50% of the control subjects con-tinued to have that symptom (Figure 7). The frequencyof subjects reporting joint noise sometimesshowed anincreasing value over time, but remained less than 50% ineach group at month eight, except for month seven, when50% of subjects in the AR splint group experienced jointnoise (Figure 8). The frequency increased over time inthe three groups, predominantly in the AR splint group(about 15% at month one and 40% at month eight), whilethe frequency in the FAMS splint group and the controlgroup remained between 10% and 30% (Figure 8). Thefrequency of subjects included in the category never jointnoiseincreased over time in the three groups, mostly inthe AR splint group (from 5% at month one to 50% atmonth eight) and the FAMS splint group (from 5% to40%) (Figure 9). Instead, more than 70% of control sub-jects showed joint noises (90% at month one; 70% atmonth eight) (Figure 9). No significant differences wereobserved in the distribution of frequencies of joint noisesamong the three groups.

Figure 5Graph showing constant pain reportedby patients (as a percentage of thewhole sample) treated with an ARsplint (AR, n=20); FAMS splint(FAMS, n=20); or untreated controlgroup (CONTROL, n=10) frombaseline recording (0) to month eight(8) of treatment. There were no signifi-cant differences.

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Figure 6Graph showing chewing/bitingpainreported by patients (as a percentageof the whole sample) treated with anAR splint (AR, n=20); FAMS splint(FAMS, n=20); or untreated controlgroup (CONTROL, n=10) frombaseline recording (0) to month eight(8) of treatment. Significant differ-ences between groups are indicatedwith brackets {}.

Figure 7Graph showing constantjointnoise reported by patients (as apercentage of the whole sample)treated with an AR splint (AR,n=20); FAMS splint (FAMS,n=20); or untreated controlgroup (CONTROL, n=10) frombaseline recording (0) to montheight (8) of treatment. No signif-icant differences were noted.

Figure 8Graph showing sometimejointnoise reported by patients (as apercentage of the whole sample)treated with an AR splint (AR,n=20); FAMS splint (FAMS,n=20); or untreated controlgroup (CONTROL, n=10) frombaseline re-cording (0) to montheight (8) of treatment. No signif-icant differences were noted.

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Discussion

The SampleThe criteria of time since the onset of symptoms was

critical in the selection of the sample. In fact, joint painand joint sounds were strongly associated with abnormaljoint morphology. The presence of pain was previouslyassociated with MRI evidence of joint effusion,22 and rec-iprocal clicking was consistently associated with disk dis-placement with reduction.23,24 However, Pereira, et al.,25

who, in TMJ autopsy studies, correlated symptoms beforedeath to anatomical examination of the joints after death,concluded that the association between pain and/or dys-function and joint morphology was complex and thatgross morphologic alterations could be present in theabsence of those symptoms. However, since the primaryreasons for consulting a clinician are pain and jointnoises, in this study we simply assessed the existence ofpain and joint noises and monitored over time the pres-ence of these symptoms without assessing morphologicalalteration of TMJs seen on MRI.

Joint PainThe primary finding of this study was that subjects

treated with AR splints experienced significantly lessjoint pain from month four to month eight (p<0.05 atmonth 4, 5, and 6 and p<0.01 at months 7 and 8) com-pared with the control subjects and with the subjectstreated with the FAMS splint. After two months of ther-apy, abscence of pain was reported in 55% of patientstreated with AR splints. This result does not agree withthat of Hersek, et al.,26 who reported the same conditionan elimination of joint pain in about 88.2% of patients.However Hersek26 did not mention the method used toassess TMJ pain in their study. Although the results in

that study were different in conclusion, they also sup-ported the use of AR splints, because of the reduction inpain and symptoms. Based on this point of view, our con-clusions can be considerd in accord with those of theHersek study.26

Our findings are also in agreement with those ofLundh, et al.,15 who compared patients with reciprocalclicking treated with an anterior repositioning splint, aflat occlusal splint, and an untreated control group. Theanterior repositioning splint decreased joint pain at rest,during chewing, and during protrusion, and it completelyeliminated reciprocal clicking.l5 The flat occlusal splintdecreased joint tenderness but did not affect clicking. Inthe control group, the clicking remained.15

Our findings also agree with those of Lundh, et al.,27

who compared 63 patients with an arthrographic diagno-sis of disk displacement with reduction treated with: 1. onlays to maintain disk repositioning, constructedusing arthrography to obtain a recaptured disk positionrelative to the condyle; 2. or a flat occlusal splint; and 3.an untreated control group. Clinical examinations wereperformed before and after six months of treatment. Thedisk repositioning onlays improved joint function andreduced joint pain when compared with the flat occlusalsplint and with no treatment.27 The signs and symptomsin the flat occlusal splint group were no different fromthose in the control group.27

Pain IntensityIn the current study, the reduction of joint pain included

not only the decreasing of the frequency of reported pain,as shown in Figure 3, but also a reduction of the intensityof pain, assessed by VAS score, as shown in Figure 4Aand Figure 4B. A significant decrease in pain in the ARsplint subjects was already evident at month two after the

Figure 9Graph showing patients whoreported no joint noises (as apercentage of the whole sample)treated with an AR splint (AR,n=20); FAMS splint (FAMS,n=20); or untreated controlgroup (CONTROL, n=10) frombaseline recording (0) to montheight (8) of treatment. Nosignificant differences werenoted.

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start of treatment (p<0.001), compared with both theFAMS splint group and the control subjects (Figure 4A).The differences continued to be significant until montheight (Figure 4A). These results seem to suggest that areduction of joint pain symptoms was evident first as adecreasing of pain intensity (at month two) (Figure 4A)and then as a disappearance of pain (at month four)(Figure 3).

On the contrary, the FAMS splint subjects showed asignificant reduction of pain intensity compared withcontrol subjects only after eight months from the start oftreatment (p<0.05) (Figure 4A). While no significant dif-ferences were evident in the percentage of subjectsreporting pain between the FAMS splint and control sub-jects (Figure 3), the results suggest that the FAMS splintdecreased the patientsÕ pain but did not eliminate it.

Longitudinal analysis revealed a significant decreasein pain intensity over time for all groups, and for the threegroups separately, from the start of treatment to montheight (Figure 4B). The results seem to suggest that itcannot be overlooked that subjects treated with theFAMS splint and the untreated control subjects couldexperience a highly significant reduction of joint painover time after the initial contributing event. This pointneeds further studies of the influence on the healingprocess of general factors (i.e., age), various pathologicpre-existing conditions, or on the type of causal event.Previously, Kurita, et al.,28 in a prospective cohort study,indicated that approximately 40% of patients with symp-tomatic disk displacement without reduction were free ofsymptoms within 2.5 years, 33% improved, whereas only25% continued to be symptomatic. Although the currentstudy has a different follow-up and a different disease(disk displacement with reduction), our study seems toconfirm that a reduction of symptoms may be observedeven in the untreated control patients with disk displace-ment with reduction.

Pain CharacterizationThe most important finding in the current study was

that there were no significant differences among thegroups in the distribution of constant pain (Figure 5). Infact, the frequency of constant pain was less than 50% inthe three groups at T0 and at month one. It improved toless than 20% at month eight in every group (Figure 5).These results confirm that untreated patients could expe-rience an improvement of their symptoms. Althoughthere were no significant differences among the groups, itmust be noted that patients wearing an AR splint alwaysexperienced a lower frequency of constant pain than theuntreated control subjects or subjects treated with theFAMS splint (Figure 5). The authors think that this find-

ing can be explained as simply the result of the lower fre-quency of TMJ pain generally observed in the AR splintgroup (Figure 3). The distribution of chewing/biting painshowed a different tendency compared to that of constantpain (Figure 5 and Figure 6), since it increased over timein the FAMS splint group and in the control group. On thecontrary, in the AR splint group it decreased and wentfrom 55% at month one to 5% at month eight (Figure 6).In the FAMS splint group and the control group, it wasalways higher than 50% from month one to month eight(Figure 6). After eight months from the start of treat-ment, significantly fewer patients treated with the ARsplint showed chewing/biting pain than patients treatedwith the FAMS splint (Figure 6). One interesting pointwas that the frequency of constant pain tended to decreaseover time (Figure 5), while chewing/biting pain tended to increase, except in the AR splint group (Figure 6).This result was due in part to the fact that most of the sub-jects experiencing constant pain developed into subjectswith chewing/biting pain before becoming patients withno pain.

Joint NoiseThe most important finding was that the frequency of

a constantjoint noise decreased over time in the threegroups considered (Figure 7). The frequency of the sub-jects experiencing a joint noise sometimesor nevertended to increase over time in every group (Figure 8and Figure 9). This probably means that the presence ofjoint noise was disappearing over time and became asometimesjoint noise before completely disappearing.After two months of therapy, 15% of subjects in the ARsplint group were in the group called never joint noise,and this result does not agree with those of Hersek, et al.,26 who reported an elimination of joint noise in64.7% of subjects treated with the same splint used in thecurrent study.

One other important finding with regard to the distrib-ution of joint noise was that, since subjects treated withthe FAMS splint and the control subjects showed a simi-lar distribution, subjects in the AR splint group alwaysshowed a lower frequency of subjects reporting constantjoint noise (Figure 7) and a higher frequency in the dis-tribution of subjects reporting sometimesjoint noise orneverreporting joint noise (Figure 8 and Figure 9). Atmonth eight, 50% of the subjects treated with the ARsplint reported no joint noise and 40% showed joint noisesometimes(Figure 8 and Figure 9). At the same time,50% of control subjects showed constantjoint noise(Figure 7). These results seem to suggest that the ARsplint is more effective for treating recently occurringjoint sounds compared with the FAMS splint and the

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TMJ PAIN TREATED WITH DIFFERENT SPLINTS TECCO ET AL.

218 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JULY 2004, VOL. 22, NO. 3

control subjects. A possible reason for this effect is thatthe AR splint may alter adverse loading in the joint andcorrect a pathological disk position while reducingmuscle splinting which affects the joint. However, previ-ous studies based on autopsy specimen observation indi-cated that joint sound is always a sign of joint abnormality,but that the absence of joint sound does not excludeintraarticular pathosis.24,29 Unfortunately, no conclusionscan be drawn as to the prognosis of the control subjectsand the effect on their healing process, because theyprobably had a history of clicking which was replaced by an internal derangement without reduction. The elimination of joint sounds may be a sign of an internalderangement without reduction. In a previous study of 61patients with a clinical and arthrographic diagnosis ofdisk displacement with reduction who were followed forsix months and received no treatment, progression toclosed lock (disk displacement without reduction)occurred in twelve patients (20%) based on clinical andarthrographic examination.9 Additionally, the retrospec-tive analysis of the findings at the first consultationrevealed that the intensity of TMJ pain during chewingand the degree of disrupted joint function were more pronounced, and the frequency of temporary locking was higher in the patients who progressed to closed lockwhen compared with those who did not progress to closed lock.

In another study with three years of follow-up, 70patients with reciprocal clicking were followed: recipro-cal clicking remained unchanged in fifty patients (71%)and disappeared in twenty patients (29%), and lockingdeveloped in six patients (9%). At the initial examination,these six patients had more pain, more frequent joint ten-derness, greater frequency of missing molar support andmore dental abrasion on the affected side than the patientswho developed no locking.30 These studies seem to sug-gest that reciprocal clicking does not usually progress tolocking; however, the disappearance of joint noise cannotbe considered a sign of recovery. This conclusion may besupported by the findings in the current study.

Conclusion

The AR splint seems to be more effective in the treatment of joint pain associated with recently occur-ring internal derangement, and this becomes evident after only four months of therapy. The difference with the FAMS splint continues to be evident until montheight. Constant pain, more frequent during the initialperiod, probably progresses to a chewing/biting painbefore disappearing. This was true in all three of thegroups studied.

Limits of the StudyThe study was limited by the amount of time the groups

were followed (eight months). Follow-up was concludedwhen only a part of subjects were asymptomatic. Becauseof this, the study must be considered a preliminary study.We do not know in how many subjects the pathologybecame chronic or how many completely recovered. Theinterruption in the study was due in part to the fact thatthe control subjects who experienced constantor chew-ing/biting pain throughout the eight months decided tobegin splint therapy and were subsequently treated withAR splints. Another limitation was that the VAS scorewas used to assess the quantity of pain, and this methodhas been shown to be influenced by a subjective percep-tion as to the level of pain intensity.31 This method is considered by McKay and Christensen32 to be a pseudo-scientific diagnostic technique. Finally, no MRIs weremade during the eight months of the study, and the studymust be considered only an analysis of the primary symp-toms associated with a recently occurring TMD.

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Dr. Felice Festa is the Director of the Department of Orthodontics andGnathology, School of Dentistry and a full professor of orthodontics atthe University of Chieti, Italy. He is also Director of the post graduatecourses in clinical gnathology and orthodontics at the same university.He received his M.D. degree from the University of Rome in 1979, aD.D.S. degree from the same university in 1982, and earned an M.S. inorthodontics in 1985 from the University of Cagliari. In 2001, he wasnominated National Referee Professor in Orthodontics at the ProfessorNational College. Dr. Festa has authored many clinical and researcharticles.

Dr. Vincenzo Salini received his M.D. degree in 1999 from the Facultyof Medicine, University of Chieti, Italy and degrees in orthopedics andsports medicine in 1996 and 2000, respectively. Dr. Salini is an orthope-dic doctor in the orthopedic division at the Hospital of Chieti, Italy.

Dr. Ettore Epifania is currently an associate professor at the Universityof Napoli. Dr. Epifania has written many clinical and research articles.

Dr. Michele DÕAttilio received his D.D.S. degree in 1987 from theFaculty of Dentistry, University of Chieti, Italy. He has been a researcherin the Department of Orthodontics at the University of Chieti, Italy, since2000 and is chairman of Orthodontics I. Dr. D’Attilio has written manyclinical and research articles.

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