J. Maxillofac. Oral Surg.

(Apr–June 2022) 21(2):678–683

https://doi.org/10.1007/s12663-020-01508-7

ORIGINAL ARTICLE

Evaluating the Efficacy of the Occlusal Splint on the Muscle

Activity with the Transducer in Patients
with Temporomandibular Joint Dysfunction Syndrome
Sathyabama Vijayarangan1 • M. Veerabahu1 • Ajit Chandrasekar2 •

Veeraragavan Narayanan1 • Nivedhini Priya1

Received: 31 January 2020 / Accepted: 30 December 2020 / Published online: 13 January 2021
Ó The Association of Oral and Maxillofacial Surgeons of India 2021

Abstract region seen as a repetitive motion disorder of the masti-

Aim A prospective study was designed to evaluate the catory system, most of them which can be treated non-
effectiveness of occlusal splint therapy for the management surgically. These disorders are associated with clinical
of temporomandibular joint disorder. complex of symptoms including headache, pre-auricular
Objective This study recorded the activity of anterior pain [2], articular noises, orofacial pain generally located
temporalis and masseter muscles in patients with TMD over masseter and anterior temporalis muscle regions,
using a transducer before and after conservative manage- cervical spine dysfunction and also associated with dizzi-
ment with splint therapy. ness, burning tongue and tinnitus resulting in a diagnostic
Results The results suggested that VAS mean dropped dilemma for the clinician. Though the exact aetiology of
from 21.2 to 11% for temporalis and from 12.6 to 7% for the disease is insufficiently studied and remains unspeci-
masseter. fied, the factors contributing to TMD include occlusal
Conclusion The study concludes that the occlusal splints abnormalities, psychological stress, orthodontic treatment,
has a prominent action on muscles of mastication and can chronic micro-trauma [2] and joint laxity.
be effectively used in early stages of TMD. Occlusal disharmony [3] selectively influences the pro-
gression of TMJ dysfunction leading to neuromuscular
Keywords TMD
Temporomandibular disorders
incoordination, muscle spasm and pain. Occlusal splints [4]
Transducer
Occlusal splint
TMJ dysfunction are reversible nonsurgical options to treat temporo-
mandibular joint disorders and are most commonly adopted
choice of treatment for the functional disturbances of TMJ.
Introduction It reduces the pathologic symptoms around TMJ by alter-
ing the excessive occlusal pressure and by recapturing the
Temporomandibular disorders (TMDs) are among the most condyle disc fossa position. The purpose of this study is to
challenging diseases of today’s society occurring in clinically evaluate the role of occlusal splints and their
approximately 25% of the population. Temporomandibular effects on the masticatory system by using indigenously
disorders (TMDs) include broad spectrum of clinical designed transducers.
problems affecting the temporomandibular joint (TMJ),
myofascial muscles and its associated structures [1]. They
are often the major cause of nondental pain in the orofacial Materials and Methods

A prospective clinical study included a total of 15 patients

& Sathyabama Vijayarangan
[email protected]
diagnosed with untreated temporomandibular dysfunction
between 18 and 60 years of age. This clinical study was
1
Department of Oral and Maxillofacial Surgery, Ragas Dental conducted in Ragas Dental College and Hospital in the
College and Hospital, Chennai, Tamilnadu, India Department of Oral and Maxillofacial Surgery during the
2
Christian Medical College, Vellore, India period of December 2016 to November 2018. The study

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was accepted by the Institutional Review Board (IRB) on the final scores to assess the degree of improvement. The
December 2016. All the participants were taken written initial examination was conducted to find out the location
consent to participate in the study until the study concludes and the distribution of the pain the aggravating and
and to abide by the rules of the study. relieving factors. The deviation or deflection of the
Pain was evaluated with Fonseca questionnaire of TMD mandible with the amount of mouth opening was measured
(Table 1) and recorded with VAS (Visual Analogue Scale) to compare with the end results. The relation between
(Table 1). Patients with stage I and II of internal gender, parafunctional habits and impacted third molar was
derangement between 18 and 60 years of age group were evaluated.
chosen. Pain in and around the TMJ, patients with inter- An initial orthopantomogram was taken followed by
mittent locking and joint sounds were included in the MRI in an open and closed mouth technique to evaluate the
study. position of the disc and the degree of anterior displacement
Patients with structural abnormalities within the joint and also to elicit any structural alterations such as a per-
and those with a staging greater than stage III of Wilkes foration or laxity of the disc [5]. The anterior dislocation of
staging of internal derangement were excluded from the the disc as noted in the MRI marked with arrows as shown
study. Patients with cognitive impairment and those with in Fig. 1 of the Annexure satisfied the inclusion criteria as
loss of posterior dental height were excluded from the suggested by the study. MRI which showed disc perfora-
study. Patients with other systemic illness such as osteo- tion was eliminated from the study. The MRI used was 1.5
porosis, rheumatoid arthritis, with a history of previous T, Echelon Oval, Hitachi.
fracture or temporomandibular joint surgery were excluded A Novotek indigenously designed transducer was used
too. to detect the force exerted by muscle activity during con-
traction and relaxation and this output is connected to a
microcontroller, Arduino version 1.8.7, whose digital out-
Methodology put is recorded using CamStudio open source software.
The splint utilized in the study was a deprogramming
Case report and an informed consent form were explained splint in Fig. 2, and the patients were found to be having a
to the patient and signed before starting any other proce- good compliance in wearing the splint throughout the
dure. A detailed clinical history was taken regarding the study. Some were found to be using it even after 20 months
causative factor for the pain. If the patient satisfied all the of usage. The patient was asked to clench his/her teeth, and
factors for the inclusion criteria, he or she was consented the bulk of masseter that contracted was palpated on both
and was included in the study. The consent form was then sides and the two electrodes (red and black—Figs. 3 and 4)
asked to be signed. were placed as in the given figure. The third blue elec-
The Visual Analogue Scale for pain was explained to the trode—the reference electrode was placed on the forearm.
patient with degrees ranging from 0–10, and all patients Once the output system was set up and the recording
were assessed at the clinical examination on their first visit. software CamStudioTM had been set up, the participant was
The scoring as subjectively described by the patient was asked to follow the following four instructions:
recorded on their individual sheets. The association and
1. To open the mouth
then they were considered to be participants in the study.
2. To close the mouth
They were given the VAS scoring chart and were asked to
3. To do a right lateral excursion
fill up the form. Then, the Fonseca questionnaire was filled
4. To do a left lateral excursion
by them. The findings of these scores were compared with

Table 1 Distribution of the

S. No Aetiology Male (n = 5) Female (n = 10)
sample based on the variables
1. Habits Present 4 8
Absent 1 2
2 Impacted 3rd molar Present 3 9
Absent 2 1
3 Nature of occlusion Class 1 2 1
Class 2 2 8
Class 3 1 1
4 Wilkes staging Stage I 0 2
Stage II 5 8

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Fig. 1 MRI of the TMJ

EXTERNAL ACOUSTIC MEATUS CONDYLE LATERAL PTERYGOID

ARTICUAR DISC

Fig. 2 Fabricated deprogramming splint

The mandibular movements were performed, and the

corresponding output values T0 were recorded. The ante-
rior temporalis was palpated during clenching of the teeth,
and in a similar manner T0 values were recorded. The
recordings were subsequently done 1 month (T1), at
2 months (T2) and at 3 months (T3) after delivering of the Fig. 3 Muscle force transducer: top blue cable—output to computer;
prescribed splint. middle black box—transducer; bottom coloured cables—input to the
transducer–surface sensor electrodes

had parafunctional habits as described by the Pie chart in

Results
Fig. 8 and Table 1.
The transducer recorded the muscle activity preopera-
The patient distribution pattern was found to have 86.6% of
tively before the use of splints and later after the use of
them in Wilkes stage II, and the rest were in stage I of the
splints at 1, 2 and 3 months, respectively. As the variables
disease. It was found that 66.7% were female, 80% had
of the masseter and anterior temporalis followed normal
impacted third molar, 66.7% had angles class II, and 80%

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Discussion

Temporomandibular joint dysfunction is one of the most

common musculoskeletal disorders in an adult population
that severely compromises the quality of life. Multiple
factors influencing TMJ disorders can be of traumatic,
physiologic, pathologic, genetic, environmental and beha-
vioural, out of which the most common are loss of posterior
teeth, parafunctional habits [6], stress, abnormal occlusion
and adverse oral habits. The accurate cause for TMJ dis-
orders is not well documented and remains unclear
(Fig. 8).
Fig. 4 Transducer electromyographic activity analysis of the mas- Occlusal disturbances account for 10–20% of the spec-
seter and the anterior temporalis muscle trum of contributing factors for TMD. With oestrogen
influencing the regulative mechanism of pain, TMD has a
striking female predilection [7] than male with a ratio of
distribution, to analyse the data at different time periods, 10:1. The quality of life of these patients was found to be
repeated measures of ANOVA was applied. compromised due to the longevity of the problem.
The masseter baseline point improved from a base value The treatment of TMD can be categorized into nonin-
of 9.7 to 5.16 at 3-month interval after the use of splint, but vasive, minimally invasive and invasive. The most com-
for temporalis the mean dropped from 21.2% to 11% monly employed nonsurgical treatments [8] are physical
showing a significant improvement in the muscle spasm therapy [9], occlusal splints [10], pharmacological agents
associated with the temporomandibular joint dysfunction [11] and electrophysical modalities such as transcutaneous
as shown in Figs. 5, 6. electric nerve stimulation (TENS) [12], ultrasound and
The Visual Analogue Scale had a mean score of 6.2 at laser. Minimally invasive procedures are arthrocentesis
the time of presentation of the complaint with a maximum [13], arthroscopy, sodium hyaluronate and corticosteroid
at 9.0 and minimum at 2.0, but 1 month after splint therapy injections, while a combination of both injections has
the mean score dropped to 2.06 with 1.0 as the minimum showed faster and longer effect on reducing TMD symp-
score and 5.0 as the maximum. This is depicted in Fig. 7 of toms. Studies on injection therapy show both regenerative
the annexure. Most patients had an asymptomatic second and degenerative responses and make their use controver-
and third month scorings. sial. Long-term research is advocated to study the benefits

Fig. 5 Masseter muscle activity

seen with a transducer

BLUE – PRE SPLINT THERAPY – POST SPLINT THERAPY

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682 J. Maxillofac. Oral Surg. (Apr–June 2022) 21(2):678–683

Fig. 6 Anterior temporalis

muscle activity seen with a
transducer

– PRE SPLINT THERAPY – POST SPLINT THERAPY

joint reconstruction [14], discectomy and disc repositioning

[15] when nonsurgical forms of treatment have failed [16].
The role of botulinum toxin (BTX) injection’s [17] to
the masticatory muscles remains controversial as it
improves the muscle size recovery but not the contractile
function. Osteopathic manipulative treatment can induce
changes in the stomatognathic dynamics, offering a valid
support in the clinical approach to TMD ‘‘the combination
of orofacial myofunctional therapy and an occlusal splint
can be beneficial for patients with TMD-hypermobility’’.
Current trends have driven towards tissue engineered
Fig. 7 Vas score of pre-op and post-op values of masseter and [18] replacement by native tissues which offers permanent,
anterior temporalis natural solution to regain function. The success of tissue
engineering lies on understanding appropriate cell sources,
of arthroscopic surgery and arthrocentesis. Invasive pro-
biochemical and biomechanical signals and scaffolding for
cedures are surgical interventions performed such as total
developing condylar and disc cartilage.

Fig. 8 Distribution on
participants based on findings

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Conclusion 2. Mercuri LG, Campbell RL, Shamaskin RG (1982) Intra-articular

meniscus dysfunction surgery. Oral Surg 54:613
3. Granger Ernest R, Mount Vernon NY (1958) Occlusion in tem-
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aetiology; rather, they are multifactorial whose onset can- 4. Newton AV (1969) Predisposing causes for temporomandibular
not be predicted. Perfect harmony between the teeth, joint dysfunction. J Am Prosthet Dent Assoc 22(6):647–651
5. Sanromán JF, Gómez González JM, del Hoyo JA (1998) Rela-
muscles, nerves, TMJ and supporting tissues must be
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established to provide health, functional efficiency, stabil- temporomandibular joint dysfunction: an MRI and CT prospec-
ity and aesthetics to the entire stomatognathic system. tive study. J Cranio Maxillofacial Surg 26(1):35–42
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joint: review of 214 patients following meniscectomy. Can J Surg
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required longer period of occlusal splint therapy. Thus, it is
8. Benson B, Keith D (1985) Patient response to surgical and non-
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toms of TMD. However, the use of splint therapy alone is mandibular joint. J Oral Maxillofac Surg 43:770–777
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Funding The authors did not receive support from any organization the examination, diagnosis and management of temporo-
for the submitted work. No funding was received to assist with the mandibul. J Am Dent Assoc 106:75
submission of the manuscript. No funding was received for con- 12. Wessberg GA, Carroll WL, Dinham R, Wolford LM (1981)
ducting this study. No funds, grants or other support was received. Transcutaneous electrical stimulation as an adjunct in the man-
agement of my ofascial pain-dysfunction syndrome. J Prosthet
Compliance with Ethical Standards Dent 45:307–313
13. Carvajal WA, Laskin DM (2000) Long-term evaluation of
Conflict of interest The authors do not have any potential conflict of arthocentesis for the temporomandibular joint. J Oral Maxillofac
Interest and did not receive any funding for any of the done project Surg 58:852–855
either for conducting the study or for the submission of the 14. Sidebottom Andrew (2009) Current thinking in temporo-
manuscript. mandibular joint management. Br J Oral Maxillofac Surg
47:91–94
15. Nyberg J, Adell R, Svensson B (2004) Temporomandibular joint
Human Rights The human participants were well informed about
discectomy for treatment of unilateral internal derangements–a
the project that was performed and gave a written consent form for the
5 year follow-up evaluation. Int J Oral Maxillofac Surg.
MRI taken and the graphs that were produced using the transducer
33(1):8–12
attached to the masseter muscle and the anterior temporalis. The study
16. Marciani R, Ziegler R (1983) Temporomandibular joint surgery:
was approved by the Institutional Review Board of Ragas Dental
a review of 51 operations. Oral Surg 56:472
College and Hospital, Uthandi, Chennai, with Approval number:
17. Chen YW, Chiu YW, Chen CY, Chuang SK (2015) Botulinum
ECR/1163/Inst/TN/2018.
toxin therapy for temporomandibular joint disorders: a systematic
review of randomized controlled trials. Int J Oral Maxillofac Surg
Informed Consent Every patient was explained about the procedure,
44(8):1018
and an informed consent was taken to have the study done as well as
18. Detamore MS, Athanasiou KA (2003) Structure and function of
to go ahead with the publication of the data involving their pictures
the temporomandibular joint disc: implications for tissue engi-
and figures that are relevant to the study for publication.
neering. J Oral Maxillofac Surg 61:494

Publisher’s Note Springer Nature remains neutral with regard to

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