Long-Term Results of Appliance Therapies in Anterior Disk Displacement with Reduction: A Review of the Literature Abstract OCTOBER 1991, Iginio Zamburlini, D.M.D., David Austin, D.D.S. The diagnosis and management of temporomandibular disorders (TMD) have been a source of controversy in the dental community for decades. This controversy has been especially acute in the management of patients with anteromedial disk displacement (ADD) with reduction. This article presents a review of the literature specifically concerning the long-term results of appliance therapy in ADD with reduction patients. The literature review identified the failure of many past investigators to conduct scientifically well-designed studies or to use comparable criteria. However, from the evidence examined, both appliances seem to be able to decrease muscle and joint pain and increase mandibular function. The anterior repositioning splint seems to be superior to the flat-plane occlusal splint in eliminating reciprocal clicking and palpatory tenderness of the temporomandibular joint. The recapture of the disk is permanent in only a small percentage of patients suggesting that the use of irreversible procedures must be carefully evaluated Dr. Iginio Zamburlini received his dental degree in 198S from The Universita degli Studi di Milano, Milan, lay. He was in private practice in his hometown, Como, Italy. and worked in a local general hospital ‘weating temporomandibuiar joint and orofacial pain patients until 1989 {In 1990 he completed the fist year of a two-year continuing education program in the Diagnosis and Management of Orofaial Pain and Tem. Poromandibular Joint Pair/Dysfunction atthe University of Medicine and Dentsry-New Jersey Dental School in Newark, New Jersey. Curent). he mainians a private practice in Comma and a part-time position in local ‘general hospital dealing mainly with temporomandibular disorder and ‘orofacial pain patients, Dr. David G. Austin compete a fellowship in orofacial pin in 1990 atthe University of Medicine and Dentistry: New Jersey (UMDNJ) Destal Schools Center for TMJ Disorders and Orofacial Pain Management Cur rently he is a master’s degree candidate atthe UMDNJ-Graduate School ‘of Biomedical Sciences. A'1977 graduate of Ohio State University College fof Dentistry, Dr. Austin is a past dental consultant and founder of a ‘nonprofit volunteer health service foundation, He is presently involved in several research endeavors, one of which has a patent pending. In Sep ‘ember 1990, Dr. Austin began a practice dedicated solely tothe treatment ‘of temporomandibular joint disorders and orofacial pain in Columbus, Ohio. VOL. 9, NO. 4 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 361TMJ the diagnosis and management of temporoman- dibular disorders (TMD) can be difficult and has been a source of controversy in the dental com- ‘munity for decades ‘The precise etiology of these disorders remains un- clear because of the difficulty in experimental model design and the paucity of well-designed studies.'~? ‘Comparable and equivalent studies are basically non- existent. Past investigators have failed to use identical criteria for the definition of TMD, patient selection, treatment modalities, study duration, definition of suc- cess, and the use of control groups. There are many treatment methods that seem to have equal success. However, none have been studied through the scien- tific method to properly differentiate their respective efficacy. Therefore, dental practitioners, the insurance industry, and patients have been swept into a mael- strom of confrontation and confusion over the many conflicting treatment modalities and methodologies. ‘Temporomandibular disorders present with a wide and variable degree of severity. The temporomandib- ular joint (TMJ) and surrounding structures may dis- play a variety of signs and symptoms. The list of patient complaints may include arthralgic pain in the ‘TMS, auricular pain, muscular pain or dysfunction, neck pain, tinnitus, dizziness, nausea, and headache. Noises on mandibular movement may also be a patient complaint. These noises may range from clicks to thuds to the sound of sandpaper slowly being rubbed together (commonly referred to as crepitus). Mandibular move~ ‘ment may also be limited. Considering the broad spec- trum of presentations, it is not surprising to see the corresponding spectrum of treatment methodologies. Anteromedial disk displacement (ADD) with re- duction is one of the most frequent diagnoses made in patients with TMD. Itis characterized by reciprocal clicking and deviation of the mandible. Sometimes the click can be detected in the affected joint during con- tralateral excursive movement and protrusion. The click ‘often disappears by having the patient open and close with the mandible in a more protrusive position. Pain can also arise from the TMJ capsule and re~ trodiskal tissue, Masticatory muscles can also be dys- functional and be a source of limitation and pain. The pain from the masticatory muscles may arise from ‘muscle spasm or trigger point formation due to para- functional activity, such as clenching and bruxism, Muscle splinting may also occur and limit mandibular ‘movement, ‘A critical issue for practitioners is whether oF not to change the condyle-disk relationship and perhaps irreversibly alter the maxillomandibular relationship. 362 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 0886-96349 1 0904.0361803.000, ‘THE JOURNAL OF CRANIOMANDIBULAR PRACTICE Copygit 1991 by Willams & Wilkin In the management of ADD with reduction, appliance therapy is commonly used to reposition the mandible anteriorly and so pethaps reestablish the normal con- dyle-disk relationship.‘ The dental literature is re- plete with articles concerning this technique, which has been adopted by many practitioners as the treat- ment of choice. The dental relationship must be stabilized to maintain the new anterior mandibular po: sition. Stabilization is achieved through surgery,"*'S prosthetic devices,**'""!? orthodontics," or some combination thereof. Conservative, reversible prosthetic techniques in- clude removable overlay splints and partial den- tures." Inreversible techniques include orthodontics, "° surgery," or full-mouth reconstruction. '! Gradually ‘modifying the appliance to slowly walk the mandible posteriorly to its original habitual position is a more conservative management approach. If tolerated by the patient, this technique avoids the need to stabilize the dentition." Furthermore, in terms of the risk and cost involved in dental stabilization techniques, this conservative approach offers a viable alternative and should be considered. According to Bell'® and other authors," a normal disk position is essential for joint stability and func- tion, The importance of recapturing the disk can be ‘demonstrated easly in some patients with painful clicks by anteriorly repositioning the mandible. A smooth, ‘coordinated, painless range of motion often can be obtained instantaneously if the disk is recaptured. In this way, mandibular deviation, joint noise, and pain are eliminated. These signs and symptoms instantly recur by merely returning the mandible to its original, habitual posterior position, with resultant loss of the ‘Some authors#®-* point out that many joints display ‘an adaptive capacity to remodel themselves and con- tinue to function without ideal disk position. Accord- ing to some studies,'“"" progressive breakdown of the joint is uncommon in ADD with reduction. Au- topsy studies*"=? on variable-age populations suggest ‘a high incidence of adaptive change in ADD. TMJ tissues often have been shown to respond successfully to anatomical variation. Initial studies suggest that retrodiskal tissue has ex- cellent adaptive capacity. These studies support the pseudodisk hypothesis in which retrodiskal tissue transforms itself into disk-like tissue when subjected to constant, repetitive compressive forces, and load- ing. This pseudodisk is thought to have most of the physical properties of the disk. Some authors question the ability of anterior repositioning to recap- OCTOBER 1991, VOL, 9, NO. 4ZAMBURLINI_AND AUSTIN ture and maintain the disk-condyle relationship over the long term. 6-292. Retrodiskal tissue adaptabil- ity may help to explain why some patients can function without pain despite ADD. To determine the most appropriate treatment for ADD with reduction, it is important to examine long- term findings with various conservative therapies, Anterior Repositioning Splint Therapy Moloney and Howard” in 1986 provided some in- sight into the efficacy of long-term anterior reposi- tioning splint therapy. They studied 241 patients after three years of post-treatment. Treatment had consisted of an anterior repositioning splint for patients diag- nosed with ADD with reduction. The length of treat- ‘ment was usually six months. The criteria for success were (1) painless masticatory function, (2) discontin- ued use of the anterior repositioning splint, and (3) lock-free and click-free TMJ function. The authors reported a 70% success rate after one year, a 53% success rate after two years, and a 36% success after three years, Two years later, Okeson!” published the results of a two-and-one-half-year-long retrospective study in- volving 40 patients with a primary diagnosis of disk interference disorder. Each patient wore an anterior repositioning splint 24 hours a day for eight weeks. Initially, the splint was modified to allow the mandible to retum gradually to its original, more posterior po- sition, Repositioning occurred over a period of two to four weeks, during which time the patient was fol- owed closely to ascertain tolerance of the device and any potential return of symptoms. ‘At the first evaluation, eight weeks into treatment, 80% of the patients were free of TMJ pain, clicking, catching, and locking. However, long-term results showed a retum of joint sounds in 66% of the 35 patients who had received only anterior repositioning therapy. Three of the five patients who had received further treatment after anterior repositioning splint therapy also continued to report joint sounds. ‘There- fore, joint sounds were still present in 65% of the patients after two and one-half years Better results were obtained regarding joint or facial pain, with 77% of the patients being free of pain by the end of the study. Furthermore, 799% showed an increase in comfortable maximum opening, 6% re- ported no change, and 15% reported a decrease in opening.” According to Moloney and Howard, the chances of successful recapture of the disk are minimal when OCTOBER 1991, VOL. 9, NO. 4 APPLIANCE THERAPIES there is a laté opening click or no click at all, There- fore, anterior repositioning splint therapy is contrain. dicated in patients with such problems. Instead, these investigators suggest the use of centric-relation or cen- tric-occlusion splints. Such splints are reported to pro- duce a favorable outcome in approximately 70% of all cases.”” If Moloney and Howards criteria for success (cited previously) are applied in Okeson’s study, the success rate drops to 25%. However, Okeson’s success rate increases to 55% by including painless joint sounds and to 75% by including painless catching. Further- ‘more, as Okeson emphasized, using the patient's opin- ion of successful treatment outcome raises the success rate to 80%. 173° Williamson and Sheffield"? found a success rate of ‘90% in 300 patients with a primary diagnosis of ADD with reduction. This patient group was studied after three years of post-treatment. Treatment consisted of an anterior repositioning splint and subsequent ortho- dontics. The author's criterion for success was the absence of patient-reported pain and clicking, Splint Therapy ‘The dental literature contains numerous studies re- garding the treatment of TMD using full-coverage bite plane therapy alone or with other modalities, such as Physical therapy. counseling, medications, occlusal equilibration, and relaxation techniques. One of the first retrospective studies was published by Cohen in 1978. He conducted a telephone survey of 118 pa- tients after one year of post-treatment, recording only their subjective condition. Cohen found that 62% had no further problems, while another 254 had a minimal level of discomfort with their symptoms. (The latter felt better and thought their problems were under con- trol.) Thus, Cohen found an overall improvement rate of 87%. Mejersjo® also reported a success rate of 87% for group of 136 TMD patients examined after seven Years of post-treatment. Methods of treatment used on these patients were counseling, occlusal adjustment, splints, therapeutic exercises for the mandible, med- ications, physical therapy, and intra-articular ot intra- ‘muscular injections, Greene and Laskin” surveyed 175 patients with myo- fascial pain dysfunction (MPD) who had been man- aged with maxillary full-coverage occlusal flat plane appliances. Post-treatment surveys covered a period ranging from one t0 11 years. An initial success rate THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 363,