TRATAMIENTO LUXACION DISCAL

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Journal of Oral Rehabilitation 1998 25 ; 8188

ReviewA comparison between horizontal splint and repositioningsplint in the treatm ent of disc dislocation w ith reduction.Literature meta -an alysisA . S A N TA C ATTE R I N A , M . P A O L I , R . P E R E TTA , A . B AM B A C E &A . B E LTR A M E Department of Denti str y, Un iversity of Padua, Ital y

SUMMARY We reviewed the literature from 1985 to1996 concerning the preliminary treatment of disc dislocation with reduction (DDWR) bymeans of occlusal splints, pinpointing two mainmethods. The conicting results of many papersinduced us to make a literature meta-analysis of those articles with the necessary requirementsin order to verify the effectiveness of the two

Introduction

One of the most frequent clinical signs in th e range ofcraniomandibular disorders (CMD) is the presence ofan articular click w hich is a manifestation, mainlyduring the in it ia l phase of mouth opening , of thetemporary loss of the anatomico-functional unity of thecondyle-disc complex. This phen omeno n is generally

know n as disc dislocat ion w ith reduction (DDWR) (Zarbet al., 1994).

Authors who have carried out clinical research onDDWR therapy adopt differing therapeutic approaches;the distinctive signs can be foun d no t on ly in th e choiceof either a h orizontal splint (bite plane) or a man dibularrepositioning splint, but above all in the particularimportance they give to the clinical history, the aetiologyand , depending upon this, the th erapy chosen. Througha careful analysis of the literature on the subject, wehav e identi ed tw o main groups: the repositioners andthe functionalists.

1998 Blackwell Science Ltd 81

therapeutic means more frequently used in DDWR;the repositioning splint and the bite plane. Astatistical comparison between the two kinds of treatment has demonstrated that the repositioningsplint is more effective both in the resolution of the articular click and of the pain at a levelof P 000001, which is noteworthy and highlysignicant.

The repositioners state tha t every th erapeutic effortmust be made to guarantee the restitutio ad integrum ofthe correct intra-articular anatomy, continually soughtby mean s of repositioning splints. The rationa le of th isstream of th ought, of w hich Tallents et al. (1985, 1986)are amongst the main representatives, is based uponthe follow ing assumptions:

(i) th e clinical history of CMD w ith intra-articular

origin is invariably progressive;(ii) the click, even if i t causes no pain, must be

considered as a pathological symptom;(iii) the repositioning splint is a basic therapeutic

mean s in the case of condylo-meniscal incoordina tions;the clinical disappearan ce of the a rticular n oise is alwa ysassociated w ith th e a natomic recapture of the disc;

(iv) the nal therapeutic position, reached at theend of the temporary occlusa l t rea tment, must beco nst an tly st abilized by m ea n s o f perm a nen trehabilitation ( xed prosthesis, orthodo ntics, etc.).

Many clinical trials have actually proved how the


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82 A . S A N TA C ATTE R I N A et al.

indiscriminate application of these principles does notalw ays ensure a satisfactory percentage of long-termsuccess, and, furthermore, the patients are submitted

to a considerable risk of over-treatment (Orenstein,1993) . Even t he theoretical basis of th ese principles hasoften been questioned (Adler, 1986; Okeson & Hayes,1986; Sa lonen , Hellden & Carlsson, 1990). The classicstudy by Moloney a nd How ard (1986) reported that fora sample of 241 patients treated with the repositioningsplint method, the percentage of successful results was70% when examined 1 year after the conclusion of thetherapy, 53% after 2 years and only 36% after 3 years.In the same period, by means of arthrograpy Manzioneet al. (1984) , and by means of the CT (computed

tomography) Manco and Messing (1986), bothdemonstrated that 46 an d 42%, respectively, of thearticulations in w hich the meniscus ha d successfullybeen clinically recaptured actually did not show a correctcondylo-meniscal relation. In a recent study (de Leeuw et al ., 1994), a sample of 99 individuals w ho, 30 yearsearlier, had already been treated w ith completelyconservative methods to solve a problem of internalderangemen t w ere reviewed. These researchers couldver ify tha t , in genera l, no important changes hadoccurred in the clinical state of the patients during thislong period of time, and, furthermore that, had therebeen any change at all , i t was not signicant enoughto compromise the w ell-being and the masticatorycapacity of the patients in a pronounced way.

This and other scienti c evidence have createdd ifcu lty for ce rta in founda t ions o f the rad ica lrepositioners theory a nd h ave given rise to a generationof clinicians that we dene as selective repositioners.These aut ho rs, Okeson, 1988; Moloney &How ard, 1986are among the most representative, feel that althoughthe repositioning splint must still be considered as amain therapeutic procedure; nevertheless, it is not to

be applied indiscriminately, but only after a carefulselection of th e patients. They suggest tha t the articularclick requires treatment only in cases where it causespain or an articular dysfunction, and its disappearancedoes not necessary guaran tee that the treatment of thedysfunctional patient has been successful. Perman entocclusal rehabilitation must be used sparingly and incarefully selected patients for whom the risk : benetand cost : benet ratios in such an exacting treatmentare denitely favourable. In a survey Okeson (1988)analysed a sample of patients who had been treatedw ith the repositioning splint method and w alk-back

1998 Blackw ell Science Ltd, Journal of Oral Rehabilitation 25 ; 8188

therapy and estimated the percentage of successfulresults 2.5 years after th e end of the treatment. Whenconsidering the parameter articular noise, only 35%

had successfu l resu lts. On the o ther hand, if theparameters w ere exclusively pain or mouth-openingcapability, the percentage then reached 65%.

The functionalists differ from the repositioners in aclinical approach based upon the particular attentionthey pay to neuromuscular and psychological factors.The authors w ho join th is stream of th ought criticizethe excessive in terest in the ar ticu lar aspect ofcraniomandibular dysfunctions. They prefer to thinkthat:

(i) the anatomic recapture of the disc is today no

longer absolutely necessary since all patients w ith th isproblem can effectively be cured without taking intoconsideration th e disc position. This concept is genera llysummed up in the expression treating-off the disc(Orenstein, 1993);

(ii) the articular click is often a benign condition,present without progressive worsening in a large partof the population (De Kanter et al., 1992, 1993);

(iii) the bite plan e is a conservative therapy tha t ma ysometimes be replaced by alternative m ethods (physicaltherapy, psychological therapy, placebo). The mainobjective of the therapy is to create the best conditionsfor the organism to recover, and to a llow the TMJ tobe remodelled and thus be able to perform its functioneven w ithout an optimum condilar position (Greene &Laskin, 1988);

(iv) more exacting therapies such as, for example,extensive rehabilitation and surgery are carried outexclusively for those patients who are totally refractoryto a ny other treatment (Sidelsky &Clayton, 1990).

In 1988 Greene an d Laskin, tw o of the most importantauthors in this stream of thought, published the resultsof research they had carried out on 190 patients who

suffered from DDWR and had been treated w ith noattem pts at d isc recapturing. Their treatm ent in generalhad been very conse rva tive; physica l therapy,psychological support, occlusal splints, etc. Theresearchers could verify that, after 5 years, 63% of thepatients no longer suffered from the click or, at least,could observe an attenuation of the symptom. In termsof global symptomatology, 76% of the patients noticedan improvement (Greene &Laskin, 1988).

These results, surprising in t hem selves, becom e evenmore interesting w hen they are compared to thosealready reported by Okeson (1988). As regards global


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TR E ATM E N T O F D I S C D I S L O C ATI O N W I TH R E D U C TI O N 83

Table 1. Papers selected

Anderson O.C. , Schulte J .K. (1985) Compara t ive study of two t rea tments methods for Journ al of Prosthetic Dentistry , 53,

& Goodkind R.J . in terna l derangements of the TMJ 392.Lundh H., et al. (1985) Anterior repositioning splint in the treatment of Oral Surgery, Oral Medicine, Oral

temporom an dibular joints w ith reciprocal clicking: Pathology , 60, 131.comparison with a a t occ lusa l spl in t and anuntreated control group

Lundh H., et al. (1988) Disk repositioning onlays on treatment of TMJ disk Oral Surgery, Oral Medicine, Oral displacement: compa rison with a at occlusal splint Pathology , 66, 155.and with no treatment

Lundh H. &Westesson P.L. (1989) Long-term follow-up af te r occ lusa l t rea tment to Oral Surgery, Oral Medicine, Oral correct abno rmal TMJ disk position Pathology , 67, 2.

M oloney F. &Howa rd J . A. (1986) Int erna l derange me nt o f the TM J . I II : a n ter io r Australian Dental Journal , 31, 30.repositioning splint

Okeso n J .P. (1988) Lo ng-t erm t rea tm en t o f disk in terferen ce d iso rd ers Journal of ProstheticDentistry , 60, 611.of th e TMJ w ith a nterior repositioning occlusalsplints

Tallen ts R.H., et al. (1985) Evaluation of arthrographically assisted splint Journ al of Prosthetic Dentistry , 53,therapy in t rea tment in TMJ disk displacement 836.

Tallen ts R.H., et al. (1986) Arthrographically assisted splint thera py: a 6 mon th Journ al of Prosthetic Dentistry , 56,follow -up 224.

Tallen ts R.H., et al. (1990) Use of protrusive splint therapy in anterior disk Journ al of Prosthetic Dentistry , 63,displacement of the temporo-mandibular joint: a 336.13 y ear follow -up

Willia mso n E.H. (1987) Th e trea tm en t of in tern al dera ngem en t o f th e Journal of Cran iomandibu lar Practice ,temporomandibular joint: a survey of 300 cases 5, 120.

symptomatology, the results overlap, w hereas the dataconcerning the click are even better although thetreatment adopted is much more conservative.

The an alysis of th e literature concerning th is subjectshows that the two different trends found in DDWRtherapy the rst m ainly based upon intervention andasserting the necessity of intra-articular restituti o ad integrum and the second denitely more conservativeand functionalist actually do not achieve substantiallydifferent percentages of success.

The a im of th is w ork is to rev ise the litera tureconcerning preliminary therapy w ith occlusal splints

and, by means of meta-analysis, make a comparisonbetween the clin ica l e ffect iveness both o f thereposit ioning sp lin t and of the b ite p lane in thetreatment of DDWR.

Materials and methods

We carried out the analysis of international literaturefrom 1985 to 1996 by m eans of th e MEDLINE data base.A careful selection, especially based on the exhaustivedescription of the study, the reliability of the reporteddata and the h omogeneity of the sample employed,


has allow ed us to identify 10 publications (Anderson,Schulte & Goodkind, 1985; Lundh et al ., 1985, 1988;Lundh & Westesson, 1989; Moloney & How ard, 1986;Okeson, 1988; Tallents et al . , 1985, 1986, 1990;Williamson, 1987) (Table 1). Using a correctmethodology, they explain the clinical trials performedto verify the effectiveness of the two kinds of splintused in DDWR. We have discarded three of thesepublications (Moloney a nd How ard (1986), Lund h a ndWestesson (1989), Tallen ts et al. (1990)), because th eyreported the data only after denitive occlusal therapy,As for Williamson (1987), all the symptoms it describes

w ere gathered by asking patients certain questions, butthis method is not sufciently reliable and objective.Finally, w e ha ve selected a sam ple of six studies, dividedin to two groups: group 1, studies comparing therepositioning splint and bite plan e; an d group 2, studiesconcernin g th e repositioning splint o nly (Table 2).

The six studies have satis ed th e need to comparethe use of th e repositioning splint (adopted in all cases)and that of the bite plane (analysed only in the threearticles of the rst group) in the treatment of DDWR.In a ll sam ples, a part fro m Tallents et al. (1985), t he clickcaused ph ysical pain. The stu dies of Lundh et al. (1985,


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Table 3. Effectiveness of repositioning splint for click

Authors Trea tment dura tion Patients Successful % Successful 95% Con dence interva l

Lundh H., et al. (1985) 17 w eeks 24 5 2083 537%Lundh. et al. (1988) 6 months 20 19 950 85100%Anderson O.C., Schulte J .K. 5 months 10 8 800 55100%

&G oodkind R.J. (1985)Okeson J .P. (1988) 2 years, 5 months 25 20 80 6496%Talle nt s et al. (1985) 310 w eeks 82 57 6951 6079%Talle nt s et al. (1986) 6 months 51 49 9607 91100%Meta-analysis 212 158 7453 6980%

1986), describe a control group, in addition to the twotest groups, composed of patients wh o ha d been treatedonly by means of reassurance and advice; this methodproved to be very signicant.

The surveys ex pressed by mea ns o f Helkimos (1974)clinical dysfunction index, and presented in Andersonet al. (1985), ha ve been converted into percentages thatconsider the improvemen t of a symptom a s a successfulresult and its persistence or worsening as a failure.

To sum up, by mean s of meta -ana lysis (LAbbe , Detsky& O Rourke, 1987; Cohen, 1992) we calculated thepercentages of success and the relevant con denceinterval (95%) in order to examine the effectiveness ofeach ty pe of splint w ith respect to th e click and to pain.In the same way, by means of a meta-analytic method,w e have made statistical comparisons amo ng the variousdegrees of therapeutic effectiveness on the samesymptoms. This w as m ade possible due to the threestudies of the rst group, and to the data supplied bythe meta-an alyses described a bove. The calculation w asperformed by means of tw o-tailed Students t -test. Theminimum level of statistical signi cance w as set atP 005.

Results

In the studies that w e have examined the percentageof success in the treatment of the articular click usingthe repositioning splint is, on average 75%, w ith arange of condence between 69 an d 80% (Table 3).The bite plane, instead, is characterized by much low ervalues, an average of 17% with a range of condencebetw een 7 an d 27% (Table 4).

Sim ila rly, t he percen ta ge o f su ccess o f t herepositioning splint method in the treatment for physical


pain is on average 80%, with a range of condencebetw een 72 and 87% (Table 5), w hereas the bite plan eaverage effectiveness on the same symptom is 33%with a r ange o f condence between 18 and 49%(Table 6).

The statistical comparison betw een the percentageso f su ccess in t he t w o kin ds o f t rea tm en t h asdemonstrated that the repositioning splint method ismore effective both in the case of articular click and ofthe pain deriving from it; this occurring at a level ofP 000001, w hich is highly signi can t (Tables 7 an d 8)

Discussion

The a im o f th is study was to per fo rm reliablecomparisons am ong th e various studies that reect thewide range of opinions concerning the treatment ofCMD. We are not aware of any meta-analysis havingbeen performed previously on this subject

In fact , the decision to limit the study to thecomparison between the effectiveness of the two kindsof occlusal splints in the treatment of DDWR, as wella s t he st rict h om ogen eit y o f t he d at a a n d t he

metho dological rigour that meta-an alysis requires, ha vereduced further than anticipated the number of articlesconsidered in th e study. It w as actua lly very surprisingto ascertain the incompleteness and often even theomission of some essential data in ma ny of the studiesinitially reviewed but not selected for m eta-ana lysis.These missing da ta in cluded, for instan ce, the dimen sionand conguration of the sample, the method followedin the treatment and its duration, the use of controlgroups, an d so on. In add ition to this we h ad to con siderthe lack of un equivocal an d a ccepted criteria of successin the therapy of CMD. However, we must emphasize


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Table 4. Effectiveness of bite plane for click

Authors Trea tment dura tion Patients Successful % Successful 95% Con dence in terva l

Lundh H., et al. (1985) 17 w eeks 23 2 869 020%Lundh H., et al. (1988) 6 months 21 5 238 642%Anderson O.C., Schulte J .K. 5 months 10 2 200 045%

&G oodkind R.J. (1985)Meta-analysis 54 9 17 727%

Table 5. Effectiveness of repositioning splint on pain


Lundh H., et al. (1985) 17 w eeks 9 2 2222 049%Lundh H., et al. (1988) 6 months 12 9 750 5099%Anderson O.C., Schulte J .K. 5 months 10 6 60 3090%

&G oodkind R.J. (1985)Okeson J .P. (1988) 2 years, 5 months 32 27 8437 7297%Talle nt s et al. (1985) 310 w eeks Tallen ts et al. (1986) 6 months 51 47 9216 85100%Meta-analysis 114 91 7982 7287%

Table 6. Effectiveness of bite plane on pain


Lundh H., et al. (1985) 17 w eeks 9 4 4444 1277%Lundh H. et al. (1988) 6 months 17 7 4117 1865%Anderson O.C., Schulte J .K. 5 months 10 1 100 029%&G oodkind R.J. (1985)

Meta-analysis 36 12 3333 1849%

Table 7. Relative effectiveness on click of tw o kinds of splint

Auth ors Trea tmen t dura tion % Successful on a rticula r click Differen ce betw een P percentage

Lundh H., et al. (1985) 17 w eeks Bite-plane 9% 12% 025728 *Repositioning splint 21%

Lundh H., et al. (1988) 6 months Bite-plane 24% 71% 000004Repositioning splint 95%

An derson O.C., Sch ulte J .K. 5 mon th s B ite-pla ne 20% 60% 000226& Goodkind R.J . (1985) Repositioning splin t 80%

Bite-plane 17% 58% 000001Meta-analysis Repositioning splint 75%

*, Not signica nt.



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Table 8. Relative effectiveness on pain of two kinds of splint

Auth ors Trea tment dura tion % Successful on a rticula r pa in Differen ce betw een P

percentage

Lundh H., et al. (1985) 17 w eeks Bite-plane 44% 22% 033669*Repositioning splint 22%

Lundh H., et al. (1988) 6 months Bite-plane 41% 34% 008141*Repositioning splint 75%

An derson O.C., Sch ulte J .K. 5 m on th s B ite-pla ne 10% 50% 003148& Goodkind R.J . (1985) Repositioning splin t 60%

Bite-plane 33% 47% 000001Meta-analysis Repositioning splint 80%

*, Not signicant.

that meta-analysis is an effective method which canbring forw ard reliable conclusions even from a limitednumber of studies (LAbbe et al ., 1987; Coh en, 1992).

Many authors (e.g. Orenstein, 1993) have criticallyreconsidered the possibility of a permanent occlusalrehabilitation a fter treatment w ith a splint, yet assertingtha t it mu st be offered exclusively to th ose patients wh oare tota lly refractory to an y oth er treatmen t. The resultsof the present study do not give sufcient indicationsconcern ing the long-term effects of permanentrehabilitation in d ysfunctional patients. This is due tothe fact that the studies examined, apart from someexceptions (e.g. Okeson, 1988), consider a follow -upperiod no longer than 6 months, so as to includeonly th e period of temporary treatment w ith splints.Therefore, the results of this study exclusively con cernthe phase of temporary occlusal therapy performed bymeans of the splints, but do not give any informationabout the denitive treatment. We must thereforeunderline the necessity of further research, extendingover a longer period of time, and of a correct initialdenition of the methods.

Conclusions

The ana lysis of the literature on the treatment of discdislocation w ith reduction (DDWR) ha s highlighted th efact th at the various clinical opinions on this subjectcan actually be gathered into two different lines ofthough t : the reposit ioners who believe in thetherapeutic necessity of re-connecting the right condyle-disc relations, and the functionalists who emphasizeinstead the possibility of clinical healing, even in caseswhere the condylo-meniscal relation is not optimum.


The m eta-ana lysis of the literature o n this subject ha sshown the good results obtained with the repositioningsplint against the main symptoms of disc dislocation,namely articular noise a nd physical pain, as w ell as itsbeing more effective (statistically very signi cant ), wh encompared w ith the bite plane.

Thus, all the results achieved show that, under th epresent conditions of scientic knowledge, a correcttreatment w ith the repositioning splint is the bestprocedure to follow in cases of DDWR. In the treatm entof th is clin ica l occurrence , we consider tha t thesystematic employment of the bite plane, athough thisdevice has proved to be easier to use and more easilyaccepted by the pa tien ts, is not supported by thenecessary scientic evidence.

References

ADLER, R.C. (1986) A comparison of long-term post-managementresults of condylar-repositioned patients. Journal of Dental Research, 65 (special issue), 339.

ANDERSON, O .C ., SCHULTE , J .K. & GOODKIND, R .J . (1985)Comparative study of tw o treatments methods for internal

deran gements of th e TMJ. Journal of Prosthetic Denti stry , 53, 392.COHEN, P.A. (1992) Meta-analysis: application to clinical dentistryand dental education. Jour nal of Dental Education , 56, 172.

DE KANTER, R.J.A.M., KAYSER, A.F., BATTISTUZZI, P.G.F.C.M., TRUIN,G.J . &VANT HOF, M.A. (1992) Demand and need for treatmentof craniomandibular dysfunction in the Dut ch adult population.Journal of Dental Research , 71, 1607.

DE KANTER , R.J.A.M., TRUIN, G.J . , BURGERSDIJK, R.C. W., VANT HOF,M.A., BATTISTUZZI, P.G.F.C.M., KALSBEEK, H. &KAYSER, A.F. (1993)Prevalence in the Dutch adult population and meta-analysis ofsigns an d symptoms of temporomandibular disorder. Journal of Denta l Research , 72, 1509.

DE LEEUW, R., BOERING, G. , STEGE NGA , B . &DE BONT, L.G.M. (1994)Symptoms of temporomandibular joint osteoarthrosis and


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