Pantographic records on TMJ dysfunction subjects treated with occlusal splints: A progress report

Nelson Roura, D.M.D., M.S.,* and Joseph A. Clayton, D.D.S., M.S.**

The University o/Michigan, School o~ Dentistry, Ann Arbor, Mich.

R e p r o d u c i b l e mandibular border movements can .be recorded graphically, by means of a pantograph, on subjects with apparently "normal" muscle and temporomandibular joint (TMJ) function. 1"~ If a subject cannot reproduce the border movements, one cause might be T M J dysfunction. G's A subject's ability to control muscles is involved in making border movements. One aspect of T M J dysfunction may also involve muscle control, and therefore, muscle dysfunction and border movements may be interrelated. Electromyography (EMG) reflects the activity in a muscle and the relative time of activation of different muscles. EMG has been used as an aid to diagnose muscle dysfunction. 9"~ Occlusal bite splints have been recommended as a possible treatment for T M J dysfunction.7, s, 10, 14, 1;-to The effectiveness of bite-splint therapy has been studied by several investigators, t4, ts, 20, 21 and results have varied widely. The purposes of this study were: (1) to observe mandibular movements on subjects with T M J dysfunction as recorded by a pantograph and (2) to observe the effect of therapy with occlusal bite splints on the subjects' T M J dysfunction and on their ability to reproduce border movements.

MATERIALS AND METHODS

Five subjects with T M J dysfunction and one "normal" subject were selected according to clinically demonstrable signs and symptoms. Presented before the American Academy of Crown and Bridge Prosthodontics, Chicago, Ill. Condensed from a thesis presented in partial fulfillment for the degree of Master o! Science in Restorative Dentistry at The University of Michigan. This study vas supported in part by United States Public Health Service Grants No. DE-0231-01s GRS No. 012713, and RR No. 0521-13. ~Assistant Professor, Restorative Sciences Division, University of Puerto Rico, School of Dentistry. **Professor, Crown & Bridge Department, The University of Michigan, School of Dentistry.

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Fig. 1. Photographs of the type of occlusal bite splint used for 30 day therapy in this study. (A) The splint is designed so that all the mandibular teeth contact (buccal cusp tips or incisal edges) the splint in centric position. Guidance ramps are placed from canine to canine to separate the posterior occlusion in excursive movements. (B) The splint is designed to stabilize the maxillary teeth. The teeth cannot erupt or shift during the 30 day therapy. The splint is adjusted to rill-mandibular positions.

Table I. The reproducibility of the border movement tracings was evaluated according to the number of points",of measurement (loci) at which more than one line was observed. An arbitrary evalu'ationscale was made to facilitate a comparison: excellent (0), good ( 1 to 2), fair (3 to~9)-, poor (10 to 19), and very poor (20+) There are 36 possible loci for a set of mandibular movement tracings (see Fig. 2 )

Subject i
"Normal" I 2 3 4 5

Visit 1 (initial)
Excellent Poor Fair Fair Fair Fair

Visit 2 (inserted splint)

Excellent Very poor Poor Excellent Good Fair

Visit 3 (4 to 7 days [rom splint)

Excellent Very poor Very poor Excellent Fair Excellent

Visit 4. (30 days from splint)

Excellent Very poor Poor Good Excellent Excellent

Initially, subjects were surveyed radiographically, electro,nyographically, and pantographically. EMG was used to help in determining the presence or absence of muscle dysfunction. The pantograph was used to observe mandibular border movements. Diagnostic casts were made and mounted on a H a n a u semiadjustable articulator.* Occlusal bite splints were waxed and then processed in clear heat-cured acrylic resin 19 (Fig. 1). At the second visit, EMG records were obtained before and after splint insertion. Then standardized pantographic records were attempted. One week after splint insertion, E M G records were obtained with the splint in the mouth and after removal of the splint. Pantographic records were also obtained. The same procedure was repeated one month after splint insertion. Clinical symptoms were assessed on each visit. As a control, pantographic records were obtained on the "normal" subject at four comparable visits.
*Hanau Engineering Company, Inc., Buffalo, N. Y.

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'oIoD poOm~laU~I "vaam~ D leUO!l~NT "S~ln nu!Aj!unetu qttto'- ~ q~sne~t:l: I "JII~D 'mloq~uv '-dzo D a~u~(i ~. 'ss~IAT 'Xou!n~ quamnalsu! lu~!p~ut ss~aD~.

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April, 1975

Fig.. 5. Subject 2 made thri~e guided attempts to move along the border positions at (a) the initial .app0intment and "(b) 30 days_after wearing an occlusal splint. Note the multiple centric points and multiple lateral tracings (a). "/'his subject appears to have less reproducibility after 30 days of occlusal splint therapy (b).

with a scale in-tenths of a millimeter) at 36 standardized points on the tracings. Whenever more-than a single line was recorded at a particular point of measurement, the widths of the two.or three lines p!us-the distance between the lines were included in_the:-rrfeasureme~nt (Fig. 2). The values measured for the initial and final-visits for the five subjects were ianalyzed statistically to determine if-the tracings were, reproducible.,, A pairwise-t statistical comparison and a four-point multivariate test were made.
RESULTS Borcler movement. Reproducibility of mandibular border movements was based upon the ability of the subject to retrace the same line at the 36 points of measurements on three repeated guided lateral excursions. Reproducible, pantographic, border-movement tracings for comparable visits were recorded from the "normal" subject (Fig. 3). After bite-splint therapy, three of the subjects showed an improve-

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T M f dysfunction treated with occlusal splints

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ment in reproducing the tracings, and two subjects did not show improvement (Table I and Figs. 4 to 8). A pairwise t statistical comparison showed that for only two o f the 36 pairs compared was the difference of means significant at a level of 0.1. The multivariate analysis showed that the mean for the set of values of the final visit was not significantly closer to zero than was that of the initial visit. Electromyography. Electromyographically, four of the five subjects showed slight muscle improvement through bite-splint therapy. Four subjects showed a decrease in muscle activity at rest, three showed a slight improvement in chewing, and two showed an improved muscle synchrony during lateral sliding. None of the subjects showed any noticeable change in swallowing pattern. The suprahyoid muscles showed an increase in resting activity when the occlusal splint was inserted (Fig. 9). After 30 days of ocelusal splint therapy, however, the subjects showed a decrease in resting activity at the final visit without the splint in the mouth (Fig. 10).

448

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Symptoms. Four of .the..~ubjects who had pain initially showed improvement of

clinical symptoms. Subject ~ . . ~ i a l symptoms of clicking and popping of the joint only, did not show an improvemen"t~in-~mptoms.
DISCUSSION

Thro.u.gh 30 days of treatment with occlusal bite splints, o " ~ l ~ b j e c t impro'eed to t h e point of making reproducible border movements ("exc~.llent~ rating in Tabie"~I).z-..Tl-id rdlSr6ducibility of these tracings was comparable to that of the tracings from th'~e 'normal" patient and to that described by Cohen 1 and Clayton and associatesY The pairwise t statistical test showedih"at;-- t ~ o s t of the points measured for initial and final visits, there were no statistically stgmfieant changes inline, width. The multivariate analysis demonstrated that there did not s ~ b e - a n ~ v statistical trend as to change in reproducibility of border tracings with the use of this m~e m----' sure~ ment system, biat the lines traced differed significantly enough to justify an analysis. A decrease in muscle activity at rest and slight improvement in chewing'"' '' and in muscle synchrony ~ suggest improvement in the muscle dysfunction. On the basis of these facts alone, however, and since atypical swallowing patterns did not improve,

alq!anpoadaa l!uuad lou Ainu slu!o.f a~Inq!pueumsodmal ,slaa.fqns u!ulaaa jo saanleaj a!uaoleuu aql ~ettl OSle Al!l!q.tssod e s~ aaatl,L "luatuaaotu aoj A~pedu3 :to Al!a!lae aelnasntu aauanlju ! ltt~!tu ',(ltA!93u a.tqa/~sd puu ~,, ,~,'ss~a~s ol uogauaa ,:t'~ltlo~led jo ,uo!l!sod--se--qmas 'ssolaej aOtllO "pale~!lsa,xu[ ~q plnott s pa!pnls aldtuus aql m ~uauhsnfpe IUSnlaaO JO ~ao~a aqd~ "uogaunjsXp I'~.L ~,Xa[laa Xla~aldtuoa ol :lua}a~tns aq aou lq~ttU aUOle Rdtuotll lu!ids-al!q leSnlaaO letll palsa~ans ~edme.,tl!aM pue jngddn H pu:e =tpaofjtueR. "uo!launjsAp fIAI~ jo sadXl um,aaaa-"a;,,a!laa ala!aldt'uoa ol am!l ltta!aRjnr aq lou lqI~!tu ,(deaaql lu!lds-al!q [.esnlaaO jo tll-tmtu auo ~,'.~t.~le-.~p .~q ~. _pal~$~ns sv "luatuleaal.jo ocL(1 pue qa~ua[ Se tlans 's.a0aaeJ iuaoaos jo u0!]u~q!lsa,xu! ao uop, eaap!suoa pal!ma p .aaotu aoj paau atD lsa~,qns Xp,ns S!tll jo-sltnsaa aq.L ,r.'qnu"I puu 'soofl {s.qan~I pue sd~lO?A pue llaSSOd jo asoql tllD~ aaa~u sllnsaa aSatl.l. "luatuleaal q~noat[1 luataaaoadtu! paaxoqs .slcia.fqias aatj aql, jo anoj 'stuoldtu*s iua!u!la ol ~u!paoaav "uado tla~otu aqI daa-'I o~,. ~so~o---aelnasnu[ e sl~q-,ro_,QDaasu.t ~u!lds aaUe ~alasntt[ p!oXqtudns jo .x, iD!~ap-.aad,iH "papnlauoa aq ~ouuea uo!:latlnj'g~-p ~:X[.I. JO ja]Iaa a~aldtuoa

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movements. The results, of this ,,study suggest-that the. ability of ,a: subject to trace reproducible .mandibular border ' movements' on,~/pantograph might be a valuable aid in determining i'.normal" Or, abnormal~mandibular movementsl The value of the pantograph as a diagnostic aid shouldbe studied further.
CONCLUSIONS

Within the group of six patients studied the following conclusions were made: 1. A subject with no apparent clinical signs and symptoms of TMJ dysfunction c a n make reproducible mandibular border movement tracings as recorded by a pantograph. 2. Subjects with TMJ dysfunction may not be able to make reproducible mandibular border movement tracings. 3. One month of occlusal splint therapy relieved most of the signs and symptoms of TMJ dysfunction, when studied clinically and electromyographically. Complete relief of muscle dysfunction was not evident. 4. In a subject with TMJ dysfunction, one month of occlusal bite-splint therapy alone may not insure relief of symptoms to the point where the Subject can trace reproducible mandibular border movements.
SUMMARY

Five subjects with T M J dysfunction showed difficulty in making reproducible mandibular border movements as recorded by a pantograph. These subjects were treated with occlusal bite splints, and muscle activity was studied by electromyography. After one month of treatment, most subjects showed relief of clinical symptoms and improved EMG muscular activity. Most of the subjects' mandibular movements did not improve to the point of making reproducible border movements on a pantograph. The length of time and the type of treatment may have had a significant effect on the results. This should be investigated further.
References
1. Cohen, R. : The Relationship of Anterior Guidance to Condylar Guidance in Mandibular Movement, J. PRosTHET. DENT. 6: 758-767, 1956. 2. Clayton, J. A., Kotowicz, W. E., and Myers, G. E. : Graphic Recordings of Mandibular Movements: Research Criteria, J. PROSTHET. Dv.Nr. 25: 287-298, 1971. 3. McCollum, B. B., and Stuart, G. E.: A Research Report, South Pasadena, Calif., 1955, Scientific Press. 4. Stuart, C. E.: Accuracy in Measuring Functional Dimensions and Relations in Oral Prosthesis, J. PRosTrtET. DENT. 9: 220-236, 1960. 5. Posselt, U.: Sagittal Condylar Guidance. Odontol. Revy 11: 32-36, 1960. 6. Guichet, N. F.: Occlusion: A Teaching Manual, Anaheim, Calif., 1970, Denar Corp. 7. Clayton, J. A.: Border Positions and Restoring Occlusion, Dent. Clin. North Am. 15: 525-542, 1971. 8. Huffman, R. W., Regcnos, J. W., and Taylor, R. R.: Principlesof Occlusion: Laboratory and ClinicalTeaching Manual, ed. 3, Columbus, Ohio, 1969, H & R Press. 9. Moller, E. : Clinical Electromyography in Dentistry, Int. Dent. J . 19: 250-266, 1.97~9. I0. Griffin, G. J., and Munro, R, R.: Electromyography of the Masseter and Anterior Temporalis Muscles in Patients With Temporomandibular Joint Dysfunction, Arch. Oral Biol. 16: 929-949, 1971.

Volume 33 Numher 4

TM] dys/unction treated with occtusal splints

453

11. Munro, R. R.: Electromyography of the Masseter and Anterior Temporalis Muscles in Subjects With Temporomandibular Joint Dysfunction, Aust. Dent. J. 17: 209-218, 1972. 12. Ramfjord, S. P. : Dysfunctional Temporomandibular Joint and Muscle Pain, J. PROSTHET. DENT. 11: 353-374, 1961. 13. Lous, I, A', Sheik-Ol'E~!am, A., and Moller, E.: Postural Activity in Subjects With Functional Disorders of the :CheWing Apparatus~ Seand. J. 'Dent. Res. 78: 404-410, i970. 14. Jarabak, J. "R.:~ Electromyographie Analysis of MUscular and Temporomandibular JointDisturbances Due to Imbalances of Occlusion, Angle Orthod. 26: 170-190, 1956. 15. Yemm, R." Comparison of the Activity of Left and Right Masseter Muscles of Normal Individuals and Patients With Mandibular Dysfunction During Experimental Stress, J. Dent. Res. 50: 1320-1323, I97I. 16. Yemm, R.: Temporomandibular Dysfunction and Masseter Muscle Response to Experimental Stress, Br. Dent. J. 127: 508-510, 1969. 17~ Perry, H. T.: Muscular Changes Associated With Temporomandibular Joint Dysfunction, J. Am. Dent. Assoc. 54: 644-653, 1957. 18. Posselt, U., and Wolff, I. B. : Treatment of Bruxism by Bite Guards and Bite Plates, J. Can. Dent. Assoc, 29: 773-778, 1963; I9. Ramfjord, S. P., and Ash, M. M.: Occlusion, ed. 2, Philadelphia, 1971, W. B. Saunders Company. 20. Huppauf, L., and Weitkamp, J.: Ergebnisse der Behandlung yon hunktionsbed~ngten Erkramkungen des Kausystems mit Aufbifsplatten, Dtsch. Zahnaerztl. Z. 24: 347-352, 1969. 21. Fuchs, P., Boos, W., and Laub, M.: Eperimentelle Untersuehungen zur Behandlung yon junktionellen Kiefergelenksbesehwerden mit Aufbifsplatten, Dtsch. Zahnaerztl. Z. 27: 383-393, 1972.
DR. ROURA CONDOMINIO Los ROBLES, 3-D Rio PIEDRAS, PUERTO RICO 00927
DR. CLAYTON
CROWN & BRIDGE DEPARTMENT SCHOOL OF DENTISTRY THE UNIVERSITY OF MICHIGAN ANN ARBOR, MICH. 48104