Journal of Oral Rehabilitation 2005 32; 474–479
Comparative prospective study on splint therapy of anterior
disc displacement without reduction
M. STIESCH-SCHOLZ, J. KEMPERT, S. WOLTER, H. TSCHERNITSCHEK &
A . R O S S B A C H Department of Prosthetic Dentistry, Hannover University Medical School, Hannover, Germany
SUMMARY A prospective randomized study was car-
ried out to compare the therapeutic success of two
different types of splint in patients with painful
anterior disc displacement of the temporomandib-
ular joint. The patients in Group I (n = 20) received
stabilization splint therapy and the patients in
Group II (n = 20) pivot splint therapy. Clinical
investigation of the craniomandibular system was
performed before and 1, 2 and 3 months after
therapy and this was accompanied by subjective
evaluation by the patients of their symptoms, using
a validated questionnaire with visual analogue
scales (VAS). There was a significant increase in
maximum jaw opening and a significant reduction
in subjective pain in both groups during the course
of therapy (Wilcoxon test, P < 0Æ05). Active jaw
Introduction
Anterior disc displacement is an arthrogenic cranio-
mandibular disorder, characterized by a change in the
position of the Discus articularis in relation to the
condyle. As the aetiology of disc displacements is
multifactorial (1, 2) and there is frequent coincidence
with myogenic and arthrogenic abnormalities in the
whole locomotor system (3, 4), an interdisciplinary
treatment concept must be the goal (5). The dental
component of this therapy is usually occlusion splint
therapy, aimed at a reduction in the leading symptoms,
such as restricted mobility of the lower jaw and joint
pain. Many different splint designs have been discussed
in the literature (6).
The splints may be classified into three major groups
on the basis of their hypothesized function: the relax-
ation/stabilization splints, the distraction splints and the
ª 2005 Blackwell Publishing Ltd
opening increased by a mean of 8Æ05 mm in the
group of patients treated with a stabilization splint
(Group I). The comparable figure with pivot splint
therapy (Group II) was 8Æ26 mm. The VAS scale
value in Group I was reduced by 30Æ54 units and in
Group II by 39Æ36 scale units. However, neither of
these differences between the groups was statisti-
cally significant (Mann–Whitney U-test, P > 0Æ05). It
can be concluded that both types of splint provided
effective therapy in patients with anterior disc
displacement.
KEYWORDS: temporomandibular joint, craniomandib-
ular disorders, disc displacement, occlusion, occlusal
splint, therapy
Accepted for publication 8 August 2004
reposition splints. The latter have been described for the
therapy of painful disc displacement with reduction.
However, the indication is limited, induction of irre-
versible changes in the masticatory system is possible
and the prognosis of the condition is uncertain (5–7).
The suggested functions of the stabilization splints are
the stabilization of physiological static and dynamic
occlusion, relaxation of the masticatory musculature
and stabilization of the physiological stress relationships
in joint structures (8). There is evidence, that an
occlusal stabilization splint is more effective in patients
with craniomandibular disorders than a control non-
occluding appliance (9). In another study with random-
assignment in patients with disk displacement without
reduction, stabilization splint therapy showed signifi-
cant more pain reduction than therapy with transcu-
taneous electric nerve stimulation (10). Other authors
found that the use of occlusal stabilization appliances in
474
 SPLINT THERAPY OF ANTERIOR DISC DISPLACEMENT
managing arthralgia is sufficiently supported by evi-
dence in the literature (11).
The hypothesized function of the distraction splint is
the reduction of the stress on the joint structures, by
causing caudal displacement of the condyle, accom-
panied by vertical widening of the joint space. This is
aimed at reducing pain and at protecting the involved
tissue. Pivot splint therapy, as described by Sears (12), is
a special form of distraction splint therapy. For this
purpose, a pivot is assembled in the region of the
second molar, so that the mandible can rotate in the
anterior cranial direction, resulting in caudal move-
ment of the condyle (6, 12). There are no reliable
published data from randomized comparative studies
with these different types of splint.
The present prospective, randomized study includes
patients suffering from painful disc displacement of the
temporomandibular joint (TMJ) and compares the suc-
cess of treatment with the two types of splint – the pivot
splint and the stabilization splint. The pivot splint was
used as the treatment and the stabilization splint as the
active control.
Materials and methods
Patient Selection
The study was approved by the Ethics Committee of
Hannover University Medical School. The study was
undertaken with the understanding and written con-
sent of each subject.
Forty patients (35 female, five male) were enrolled in
this study who were suffering from symptoms in the
TMJ and who had visited the Department of Prosthetic
Dentistry in Hannover University Medical School for
this reason. The criteria for inclusion were the presence
of anterior disc displacement without reduction and a
normal complement of teeth. The definition of the
clinical diagnosis of anterior disc displacement was case
history information of a sudden onset of limited mouth
opening, restriction of condylar translation and TMJ
pain related to mouth opening or chewing (10, 13). For
confirmation of the clinical diagnosis, magnetic reson-
ance imaging (MRI) examinations were carried out
with the closed and open mouth positions in the
parasagittal section. For the MRI diagnosis the inter-
mediate zone criterion according to Orsini et al. (13)
was used. For inclusion in the study all mentioned
clinical and MRI criteria had to be fulfilled.
ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 474–479
475
Criteria for exclusion were prior surgery in the region
of the TMJ, the presence of systemic underlying
rheumatic disease, signs of psychosomatic illness, an
incomplete complement of teeth and a removable
dental prosthesis.
The patients were assigned to one of the two
treatment groups: Group 1 – Treatment with a stabili-
sation splint; Group II – Therapy with a pivot splint. A
computer-generated sequence randomly assigned
which of the two oral splints was to be worn by each
patient. The patients were distributed to this list in the
order of their first appearance.
Group one consisted of 18 female and two male
patients with an age range between 18 and 62 years
(mean 34Æ8
13Æ7), group two consisted of 17 female
and three male patients with an age range between 18
and 64 years (mean 32Æ5
15Æ8). The mean duration
of complaints before treatment was 15Æ3
13Æ8 weeks
in group one and 18Æ7
11Æ6 weeks in group two.
Fourteen patients in group one and 17 patients in group
two exhibited not only pain of the TMJ but also
myofascial pain. None of the patients showed a history,
which referred to a psychosocial diagnosis like psycho-
logical impairment or low perceived live control (1).
Therapeutic intervention
The patients in Group I received a stabilization splint,
which covered the whole upper dental arch. The splint
was prepared in the articulator, in accordance with the
recommendations of Ash (14). During the integration
of the splint, care was taken that it was properly fitted.
The occlusal contacts during static occlusion and the
canine guidance during dynamic occlusion were
checked intra-orally for balance.
The patients in Group II were given a pivot splint, as
described by Sears (12), with a bilateral pivot in the
region of the second molar. The fit was checked intra-
orally and the ipsilateral contacts to the pivot were
checked for balance. All splints were made by one
person.
The patients in both treatment groups were instruc-
ted to wear the splints day and night excluding
mealtimes for the whole period of the study
(3 months). At each follow-up visit, it was checked
that the contacts to the stabilization splint were
balanced and they were adjusted occlusally where
necessary. At the third follow-up visit (after 2 months),
the pivot of the pivot splint was removed and the splint
476 M . S T I E S C H - S C H O L Z et al.

was adjusted to even occlusal contacts in a comfortable
centric relation. There was no additional drug or
manual therapy in either of the two groups.
Evaluation of the success of the therapy
Before (initial visit) and one (first follow-up), four
(second follow-up), eight (third follow-up) and
12 weeks (fourth follow-up) after the beginning of
therapy, all patients underwent a clinical examination
according to the Craniomandibular Index of Fricton
and Schiffman (4). The examination included those
items that reflect TMJ tenderness and functional prob-
lems (limits in range of mandibular motion, deviation
in movements, pain during movement, TMJ noise, TMJ
tenderness) as well as those items that reflect the
symptoms of muscle tenderness (extra-oral and intra-
oral muscular tenderness). Also a clinical examination
of the dental situation was performed in order to
evaluate possible side effects of splint therapy such as
tooth intrusion, tooth loosening or sensitivity on biting.
Therefore an occlusal foil was placed between the teeth
in order to investigate, if all teeth were in occlusal
contact with their antagonists. In addition a measure-
ment of the mobility score of the teeth was made and
the patients were asked, if they had any sensitivity on
biting. A change of the number of teeth with occlusal
contact with their antagonists, the number of teeth
with sensitivity on biting or a change of the mobility
score between the follow-ups was assessed as a side
effect.
This was followed by subjective evaluation of pain of
the craniomandibular system with visual analogue
scales (VAS: 0 ¼ no pain, 100 ¼ extreme pain). In
each case, pain was measured at rest, during stress (e.g.
chewing) and during border movements (e.g. maximal
active opening of the mouth).
All examinations were carried out by one investi-
gator, who was blinded to the type of appliance each
subject was wearing. The patients were instructed not
to mention their group membership to this investigator,
to minimize bias. The investigation was monitored by
an individual who was not enrolled in the trial.
Data analysis
Documentation and statistical data analysis were per-
formed with the Windows data processing program
SPSS/PC (15). The non-parametric Wilcoxon test was
used for paired values before and after treatment. The
two groups were compared by using the non-paramet-
ric Wilcoxon–Mann–Whitney U-test for unpaired val-
ues. A P-value of < 0Æ05 was considered statistically
significant.
Results
Maximal jaw opening was taken as the criterion for
lower jaw mobility and increased significantly in both
treatment groups (Table 1). At the fourth follow-up,
the average maximal jaw opening in Group I (stabil-
ization splint) was 40Æ93
7Æ49 mm and in Group II
(pivot splint) 40Æ38
4Æ31 mm.
During the total time of treatment, the mean max-
imal protrusion increased in Group I from 4Æ94
1Æ95
to 6Æ71
2Æ67 mm and in group II from 4Æ94
2Æ15 to
6Æ85
2Æ08 mm. However, this difference in the
increase in mobility between the two groups was not
statistically significant (Wilcoxon–Mann–Whitney
U-test, P > 0Æ05).

Table 1. Maximal active jaw opening at the follow-up visits, with the two types of splint. The level of significance of the difference
between the splint groups (Wilcoxon–Mann–Whitney U-test) and of the values before and after treatment (initial visit and last follow-up,
Wilcoxon test) are presented

Stabilization Pivot Mean difference Level of

Visit splint splint (95% CI) significance

Initial visit 32Æ88
7Æ54 32Æ12
7Æ46 0Æ55 ()4Æ61–5Æ71) P ¼ 0Æ741

First follow-up 36Æ59
8Æ24 34Æ12
7Æ75 2Æ47 ()3Æ12–8Æ06) P ¼ 0Æ339
Second follow-up 35Æ53
7Æ30 35Æ28
7Æ54 0Æ25 ()4Æ86–5Æ36) P ¼ 0Æ961
Third follow-up 38Æ67
7Æ20 38Æ13
5Æ56 0Æ54 ()4Æ17–5Æ25) P ¼ 0Æ599
Fourth follow-up 40Æ93
7Æ49 40Æ38
4Æ31 0Æ55 ()4Æ31–5Æ39) P ¼ 0Æ685
Level of significance P ¼ 0Æ046 P ¼ 0Æ014

ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 474–479

 SPLINT THERAPY OF ANTERIOR DISC DISPLACEMENT 477

Table 2. Pain intensity at follow-up visits: measured with the visual analogue scale. The level of significance of the difference between
the splint groups (Wilcoxon–Mann–Whitney U-test) and of the values before and after treatment (initial visit and last follow-up, Wilcoxon
test) are presented

Visit Stabilization splint Pivot splint Mean difference (95% CI) Level of significance

Initial visit 54Æ25
25Æ91 58Æ21
21Æ02 )3Æ96 ()20Æ09–12Æ17) P ¼ 0Æ523

First follow-up 44Æ56
26Æ78 46Æ67
25Æ58 )2Æ11 ()20Æ41–16Æ19) P ¼ 0Æ772
Second follow-up 35Æ25
29Æ19 35Æ32
24Æ84 )0Æ07 ()18Æ64–18Æ51) P ¼ 0Æ987
Third follow-up 28Æ93
28Æ51 31Æ41
29Æ16 )2Æ48 ()22Æ36–19Æ38) P ¼ 0Æ786
Fourth follow-up 23Æ71
26Æ54 18Æ85
22Æ54 4Æ87 ()14Æ61–24Æ34) P ¼ 0Æ430
Level of significance P ¼ 0Æ012 P ¼ 0Æ001

At the fourth follow-up, there was significant reduc-
tion in subjective pain in both groups (Table 2). The
reduction in pain in Group II (39Æ36
22Æ3 on the VAS
scale) was greater than that in Group I (30Æ54
21Æ5),
although the differences were not significant (Wilcoxon–
Mann–Whitney U-test, P > 0Æ05). The corresponding
time courses indicate differences between the groups.
There was a major improvement in the pain score even at
the second follow-up in Group II, although further
improvement was only registered at the fourth follow-
up. The improvements in Group I were evenly distri-
buted over the total time of treatment.
The number of patients with tenderness to palpation
in the muscles or in the TMJ and the number of
patients with deviations in mouth opening all decreased
during therapy (Table 3). Here too there were no
significant differences between the groups.
Side-effects of splint therapy, such as tooth intrusion,
tooth loosening or sensitivity on biting, were not found
in any of the patients.
Discussion
The present study compares the stabilization splint with
the pivot splint in the treatment of patients with disc
displacement of the TMJ. The success of the treatment
Table 3. Number of patients with signs of internal derangement
before and after therapy
Stabilization splint Pivot splint
Initial Fourth Initial
visit follow-up visit
Jaw muscle tenderness 14 5 17
Temporomandibular 9 4 8 2
joint tenderness
Deviation in 14 6 10
mouth opening
was assessed on the basis of the reduction in the leading
symptoms. Maximal jaw opening and maximal protru-
sion were used as objective measures of restrictions in
mobility. The patients’ subjective symptoms were eval-
uated with validated VAS (16). The methods of eval-
uation correspond to those in the current literature
(17–19).
This comparative study employed a stabilization
splint and a special form of the distraction splint, as
the use of both types of splint for the treatment of
anterior disc displacement has been described in the
international literature [6, 18, 20]. It had already been
shown in a previous study that the use of the pivot
splint gives the greatest reduction in symptoms as early
as in the first 8 weeks of treatment (20). For this reason
and to minimize the side-effects from this type of splint,
the pivot splint was abraded after 8 weeks (third
follow-up), which then ensured balanced contacts.
The efficacy of bite guard splints is thought to be due
to several factors. First, all splints cause occlusal
decoupling and this can cause reorientation of estab-
lished neuromuscular reflex mechanisms, leading to
the release of muscular tension and the recovery of
physiological muscular coordination (21, 22). Secondly,
it is discussed in the literature that the mechanical
action of the splint reduces stress on the joint struc-
tures, for example, on the bilaminar zone which has
been compressed by disc displacement. In particular,
this effect has been described when distraction or pivot
splints are used (20). It is assumed in this context that
the occlusion contacts of the pivot splint near the joint
Fourth can activate the posterior temporal sections, causing
follow-up
rotation of the lower jaw, caudal displacement of the
4 condyles and distraction of the joints (12). It follows
that an increase in the mobility of the lower jaw may be
directly because of the reduction in stress on the joint,
7
or because of the reduction in pain resulting from the
decrease in stress.

ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 474–479

478 M . S T I E S C H - S C H O L Z et al.
Apart from these factors, successful treatment with
splints may be influenced by psychological effects, such
as an increase in the cognitive consciousness for oral
habits, a placebo or Hawthorne effect (6, 23) and
spontaneous remission of the symptoms (18, 23).
The results of the present study tend to support the
hypothesis that splints act neuromuscularly and psy-
chologically, as the success of the therapy in our group
of patients was independent of the design of the
occlusal splint component in the two treatment groups
and no significant difference was found between the
groups. Thus, the follow-ups found significant increases
in maximal jaw opening and in maximal protrusion and
there were no significant differences between the
groups in this respect. Pain was evaluated with VAS;
greater reductions were found in Group II (pivot
splints), although the difference was not statistically
significant. Pain in Group II was only reduced in the
first and third months of treatment (first, second and
fourth follow-up), but remained about constant in the
second month (third follow-up), suggesting that this
splint acts by occlusal decoupling, followed by reorien-
tation of neuromuscular reflex mechanisms. What
makes this more plausible is that the occlusal situation
of the patients in Group II was dramatically changed on
two occasions: first, at the start of the therapy, because
of the assembly of the pivot; secondly, after 2 months
(third follow-up), because of reduction of the pivot.
Each of these changes then apparently led to a clear
reduction in pain. The occlusal situation of the stabil-
ization splint was checked at each follow-up and
slightly abraded if necessary, resulting in slow and
even reduction in pain over the whole period of
treatment.
The sample size in the present study was 20 patients
per group. As the results showed very small outcome
differences between the splint groups, it is very
improbable that a larger sample size would lead to
clinically relevant and significant differences between
the groups.
The results of Tsukasa et al. (24) also support the idea
that the occlusal design has only a minor mechanical
effect. These authors investigated the position of the
condyles when grinding the teeth in comparison with
the habitual closed position of the jaws. They found
that the stabilization splint did not cause any caudal
movement of the condyle. The splint with bilateral
pivots caused caudal movement of only 0Æ02 mm,
which was not statistically significant. The significance
ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 474–479
of these results is qualified by the facts that the study
population consisted of healthy volunteers without
craniomandibular dysfunction and the splint was only
worn for short periods. Moncayo et al. (25) carried out
an X-ray study of the position of the condyle with a
pivot splint in comparison with the position without
splint and found bilateral distraction of the condyle, at
any rate, in 30% of the volunteers.
Gray et al. (26) carried out a comparative study of
treatment of patients with craniomandibular dysfunc-
tion with two different types of occlusion splint. Their
results support the idea that the occlusal splint design is
only of minor importance. At the fourth follow-up,
there was no significant difference between the treat-
ment success with a stabilization splint and with an
interceptor, as described by Schulte (27). These results
support the neurological concept described by Türp
et al. (28), according to which the therapeutic activity of
occlusion splints is because of the specific reduction in
stress in painful muscle regions, caused by a change in
the position in the lower jaw. This can then lead to the
secondary effect of stress reduction in articular struc-
tures.
The success rates in the present study are high in
comparison with published values. Thus Linde et al.
(10) treated patients for 6 weeks with a stabilization
splint and found that only 60% of the patients reported
a reduction in the VAS pain scale of at least 50%.
Okeson (29) found that 75% of patients were totally
free of pain two and a half years after treatment with a
reposition splint.
Conclusion
In summary, treatment with either of the two types of
splint was acceptably successful and a significant
reduction in the leading symptoms could be achieved.
The results indicate that the success of the therapy was
less to do with the design of the occlusal splint
component and more to do with the basic decoupling
of established neuromuscular reflex mechanisms and
the consequent reduction in stress on the joints.
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Correspondence: PD Dr Meike Stiesch-Scholz, Department of Pros-
thetic Dentistry, Hannover University Medical School, Carl-Neuberg-
Straße 1, 30625 Hannover, Germany.
E-mail: stiesch.meike@mh-hannover.de