Int. J. Oral Maxillofac. Surg.

2008; 37: 424–427

doi:10.1016/j.ijom.2008.01.022, available online at http://www.sciencedirect.com

Clinical Paper
TMJ Dysfunction

Does the use of soft or hard C. Alpaslana, S. Kahramana,

B. Günerb, S. Culac
a
Department of Oral and Maxillofacial

splints affect the short-term Surgery, Faculty of Dentistry, Gazi University,

Turkiye; bAnkara Oral Health Center,
Department of Oral and Maxillofacial Surgery,
Turkiye; cBaþkent University Faculty of

outcome of temporomandibular Commercial Sciences, Insurance and Risk

Management, Turkiye

joint arthrocentesis?
C. Alpaslan, S. Kahraman, B. Güner, S. Cula: Does the use of soft or hard splints affect
the short-term outcome of temporomandibular joint arthrocentesis?. Int. J. Oral
Maxillofac. Surg. 2008; 37: 424–427. # 2008 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Arthrocentesis is an effective treatment modality for temporomandibular

joint (TMJ) disc displacement without reduction (DDw/oR), especially in patients
who do not respond to non-surgical methods, and is nowadays regarded as a
first-line treatment. Soft and hard stabilizing splints have also been used to treat
TMJ disorders, but no data are available regarding the use of splints following
arthrocentesis.
The aim of this study was to compare the effect of the use of soft or hard
stabilizing splints versus no appliance following TMJ arthrocentesis on the
prognosis of the treatment. Forty-five patients with DDw/oR were included in the
study. Pain was measured on a visual analog scale, and maximal mouth openings,
lateral jaw movements and tenderness were recorded before arthrocentesis.
Following arthrocentesis hard splints were fabricated for 22 patients, soft splints for
9 patients, and 14 patients without any splint served as controls. All the
measurements were repeated 1 day, 1 month, 3 months and 6 months after
Keywords: TMJ; arthrocentesis; stabilisation
arthrocentesis. Improvement in mouth opening was significant as well as decrease in splints; hard splints; soft splints.
pain in all groups regardless of the use of splints (P < 0.05). Arthrocentesis alone is
a successful procedure in the treatment of DDw/oR; the use of splints as an Accepted for publication 25 January 2008
additional therapy does not affect the short-term prognosis. Available online 19 March 2008

Temporomandibular joint (TMJ) disc dis- closed a high incidence of clenching and reaching very high levels during clench-
placement without reduction (DDw/oR), grinding6,12. Intra-articular pressure mea- ing.12 High intra-articular joint pressure
where limited mouth opening is the chief surements in the upper compartment of the likely causes an increase in the viscosity of
complaint, is one of the main presentations temporomandibular joint during rest posi- synovial fluid thereby interfering with the
of temporomandibular disorders. The ana- tion, maximal mouth opening and clench- smooth action of the joint, and the disc
lysis of patients with closed lock has dis- ing demonstrated a fluctuating range, adheres to the fossa at the posterior slope

0901-5027/050424 + 04 $30.00/0 # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Splint use following TMJ arthrocentesis 425

of the eminence causing a limitation in application, and 5 patients were recom- months and 6 months after arthrocentesis.
mouth opening11. mended splints in other centers before Preoperative and postoperative results
Arthrocentesis is a minimally invasive arthrocentesis. Such non-surgical treat- were analyzed statistically by repeated
treatment option for cases with DDw/oR ment does not seem to have affected the measures analysis of variance for all
that fail to respond to non-surgical treat- outcome of arthrocentesis in this study. groups at a 5% level of significance.
ment. It is thought to be important to For the measurement of pain level,
eliminate or minimize overloading to patients were asked to rate their pain on
Results
avoid progression of the disorder or a visual analog scale (100 mm), 0 indicat-
relapse. In a previous study it has been ing no pain and 10 severe pain. Maximal Forty-five patients (41 female, 4 male) of
shown that insertion of an intraoral appli- mouth opening was measured between the the initial 67 patients, 22 in the hard splint
ance decreases the intra-articular pressure edges of the upper and lower central inci- group (mean age 29.8  11.1 years; range
by 81.2% during clenching12. sors by a millimeter ruler. Horizontal dis- 18-50 years), 9 in the soft splint group
In a prospective study, stabilization tance between the midpoints of the upper (mean age 31.6  10.5 years; range 19-44
splints provided effective therapy in and lower incisors during left and right years) and 14 patients without a splint
patients with DDw/oR18. In another study excursions was measured in the same way, (mean age 28.9  11.3 years; range 18–
by the same authors evaluating the effects and recorded as lateral jaw movements. 51 years), completed the 6-month follow-
of combination therapies, a significantly Patients were scheduled for arthrocent- up period. No complications or complaints
greater increase in maximum jaw opening esis to be followed by insertion of either a were noted during or after arthrocentesis.
was obtained in patients with splints and soft or hard appliance. Patients without Twelve patients were excluded from this
receiving supplementary medical therapy any splint served as controls. Written con- prospective study because of the lack of
compared to patients treated solely with sent forms were obtained from patients some data in the follow-up period. Eleven
occlusal splints. Medical therapy consist- before the procedure. patients in the hard and 6 patients in the
ing of 400 mg ibuprofen three times a day All treatment procedures were per- soft groups, and 7 of those without any
and a 5-mg dose of diazepam once a day formed by the same oral and maxillofacial splints had a history of bruxism.
had a positive influence on the outcome of surgeons. For the arthrocentesis proce- There was a reduction in pain in all
patients with anterior DDw/oR19. dure, two 21-gauge needles were intro- groups (P < 0.05) starting from the 1st
This prospective study was designed to duced into the superior joint space after day following arthrocentesis. There was
observe whether a combination therapy of nervus auriculotemporalis block. The joint no difference between the 3 groups in the
arthrocentesis and splints would affect the was irrigated with at least 100 ml lactated decrease in pain. There was an increase in
outcome of the treatment, and if there is a Ringer’s solution. Following arthrocent- maximal mouth opening and lateral jaw
difference between the uses of hard or soft esis, patients were randomly allocated to movements in all groups (P < 0.05) fol-
splints versus no splint. the soft or hard appliance group. A full- lowing arthrocentesis at all time intervals.
coverage soft or hard splint was fabricated Between-group analysis did not show any
and adjusted following arthrocentesis. differences (Figs. 1–4).
Materials and methods
Some patients received no splints after There was a decrease in tenderness in all
Patients were selected from those referred arthrocentesis and served as controls. groups (p < 0.05) following arthrocent-
with signs and symptoms of temporoman- Patients were instructed to wear their esis until the 6-month follow up
dibular disorder and orofacial pain. His- splint at night during sleep. All the mea- (Fig. 5). Between-group analysis showed
tory was taken and clinical examination surements were repeated 1 day, 1 month, 3 that tenderness of the TMJ on palpation
carried out in all patients. In cases where
diagnosis could not be confirmed, further
evaluations with MRI were made. Sixty-
seven patients with a clinical diagnosis of
DDw/oR with or without synovitis and
with maximal mouth opening 20–35 mm
were included in the study. A clinical
diagnosis of synovitis was made according
to the pain on palpation localized to the
TMJ. The primary inclusion criterion was
the presence of DDw/oR, regardless the
presence of synovitis. Among the patients Fig. 1. Comparison of pain level between groups.
who were included, some presented at a
very early stage of closed lock, as early as
1 day, while some had experienced inter-
mittent locking for a period of 1.5 years.
The average duration of closed lock was
201.94 days, but all patients were admitted
in acute closed lock condition.
Arthrocentesis was planned as a first-
line therapy in all patients, i.e. non-surgi-
cal treatment was not tried first in this
study. Some patients with a long duration
of symptoms and intermittent locking had
received medical therapy, such as heat Fig. 2. Comparison of maximal mouth opening between groups.
426 Alpaslan et al.

mandibular disorders suggested that the

use of occlusal splints may be of some
benefit4. An evidence-based review of
intraoral splints also revealed that stabili-
zation splints can reduce TMJ pain com-
pared to non-occluding splints, and are as
effective as physical medicine, behavioral
medicine and acupuncture. There was
some evidence to suggest that soft splints
Fig. 3. Comparison of left lateral excursion between groups.
are effective in reducing TMJ pain com-
pared to placebo controls5.
Arthrocentesis has a high success rate
especially in patients with DDw/oR1,2,13.
There is also evidence that arthrocentesis
is an excellent treatment in patients who
have recent onset of painful limitation of
mandibular opening14. In a meta-analysis
of surgical treatments for temporomandib-
ular articular disorders, arthrocentesis was
shown to be effective in patients with
closed lock, refractory to non-surgical
Fig. 4. Comparison of right lateral excursion between groups. therapies17. Success occurs more quickly
with arthrocentesis than non-surgical
treatment in patients with DDw/oR. In
some or most cases it is the first-line
therapy depending on the view and experi-
ence of the surgeon.
The rate of clenching and/or bruxism
among patients with TMJ internal
derangements is very high10. The disc
and retrodiscal tissue are subject to com-
pression during clenching. Stress in the
retrodiscal tissue is approximately five
Fig. 5. Comparison of tenderness between groups. times greater in the symptomatic joint
and stress relaxation does not occur com-
pared to the asymptomatic joint7. The aim
Table 1. Statistical results for tenderness of using splints in this study was not to
help re-establish a normal disc–condyle
Within-group analysis (P) Between-group analysis (P)
relationship, but to evaluate whether pro-
Preop–day 1 0.001 0.026 tecting the joint structures from excessive
Preop–day 30 0.00 0.031 bite forces affects the success of arthro-
Preop–3 months 0.00 0.027
centesis during a 6-month follow-up per-
Preop–6 months 0.00 0.032
Day 1–30 0.00 0.009 iod. No significant difference was found
Day 1–3 months 0.00 0.004 between patients with splints and without
Day 1–6 months 0.00 0.003 splints during the overall follow-up per-
Day 30–3 months 0.045 0.015 iod, regarding decrease in pain and
Day 30–6 months 0.00 0.021 improvement of mandibular dysfunction.
3–6 months 0.026 0.015 Both experimental and retrospective
studies suggest a link between parafunc-
was statistically different (P = 0.002 < also have an impact on treatment outcome. tions and pain in temporomandibular dis-
0.05) in the soft splint group; the hard- Today, arthrocentesis is regarded as the order patients, but there have been some
splint group and patients without splints first-line therapy in cases of DDw/oR. This contradictory results. The rate of bruxism
showed the same reduction in tenderness study evaluated whether the use of splints, was found to be 68% among patients who
(P = 0.14 > 0.05). Statistical results were hard or soft, affects the outcome of the underwent arthrocentesis for the treatment
significantly different between the soft– treatment. The results show that arthro- of TMJ internal derangements in a pre-
hard appliance (P = 0.001 < 0.05) and centesis decreases pain and improves vious study. The 5-year retrospective eva-
soft–without appliance groups (P = mandibular dysfunction in patients with luation interestingly demonstrated that,
0.036 < 0.05) (Table 1). DDw/oR, regardless of whether and what although both preoperative and follow-
type of splint is used. up pain scores were higher in patients with
Soft and hard splints have been used bruxism, there was not a significant dif-
Discussion widely for non-surgical treatment of TMJ ference in the outcome when compared to
internal derangements. A qualitative sys- non-bruxers1.
The hypothesis was tested that adverse tematic review of randomized controlled In another study by IWASE et al.,8 self
joint loading that causes DDw/oR may trials of occlusal treatments in temporo- reporting of clenching and pain level was
 Splint use following TMJ arthrocentesis 427

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Disc Displacement Without Reduction
Splints are used to reduce bruxism, and Unresponsive to Nonsurgical Treatment: Faculty of Dentistry
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