Occlusal splint selection is strictly related to the type of disorder. Generally I recommed maxillary stabilization splint to create ideal occlusion, synchronous tooth contact in a centric condyle position and decrease the hypertension of masticatory muscles (muscles relaxation e.g. tension-type headache, bruxism). MAS is suitable for disc displacement and temporomandibular joint compression.

I am a a big believer in occlusal splints ,I have seen during my days as a graduate student in The University of Michigan  the results obtained by two of my most famous professors in Occlusion in the world (Professor major Ash and professor  Sigurd P. Ramfjord both these professors from the University of Michigan were  world renowned and  developers of the famous Michigan Occlusal splint ,and I have seen how  they were able to correct most of the  problems of TMD using occulsal splints .Also they were against  mandibular advancement splints because of the many problems it creates following   that kind of treatment

Prof Galil

I use stabilization with good results. I do not have experience with mandibular advancement splints.

Considering all of the available data, it can be concluded that

the oral stabilization appliance that does not change the

occlusion has sufficient evidence to support its use in the

management of localized myalgia and arthralgia of the

masticatory system.

However, there is no support in the scientific literature for

the use of mandibular repositioning appliances (MORA) in the

management of internal derangement.

Clark GT & Minakuchi H: Oral Appliances In, TMDs An Evidence-Based Approach to

Diagnosis & Treatment. Laskin DM, et al (Eds). Quintessence. Chicago, 2006 pp. 377-390.

I would have to agree with Dr Mercuri current evidence surrounding evidence relating to the management and specifically treatment  of internal derangement is weak at best. 

I think it is vitally important to separate mialgia and Emotional components form an anatomical derangement and therefore the management thereof. We do however utilize Michigan Splints routinely to protect and maintain the occlusion  of cases where we are undertaking occlusion reorganization or just to maintain a stabilized occlusion.    

A maxillary hard acrylic stabilization splint is my choice for specific TMD.

I have used MAS for mild to moderate obstructive sleep apnea (OSA) cases. A reminder that sleep apnea patients bruxers 6 times more than non-sleep apnea patients. Fitting an (undiagnosed) OSA patient with a stabilization splint may worsen this life-threatening condition. Careful screening of TMD cases for underlying OSA is  important for our patients. A fact to ponder.

As it is so often the case in TMD therapy, there are many opinions regarding occlusal appliances. For mandibular advancement splints, there are only two indications: anterior disc displacement and OSAS. Because of the risk of permanent changes in the occlusion caused by this appliance, it should only be used if less harmful devices cannot be applied. Therefore, the stabilization splint is the generally accepted gold standard in TMD therapy. Provided that it is manufactured in the correct way, there will be no harm to worry about. Thus the appliance of first choice in TMD therapy is the stabilization splint. To my knowledge there is no study providing evidence that suggests that the advancement splint is superior to the stabilization splint in any TMD diagnosis, especially not in myofascial pain.

Eberhard, D., Bantleon, H. P. & Steger, W. (2002). The efficacy of anterior repositioning splint therapy studied by magnetic resonance imaging. Eur J Orthod, 24, 343-352.

Schmitter M, Zahran M, Duc JM, Henschel V, Rammelsberg P. Conservative therapy in patients with anterior disc displacement without reduction using 2 common splints: a randomized clinical trial. J Oral Maxillofac Surg. 2005;63:1295-303.

Stabilization splint obviously. The point is : what is a stabilizing splint? We all agree on what it should do, but how can we check if it is working properly? That's why you need mandibular tracking and emg. That's why you need Neuromuscular Dentistry. If you can measure it , it's a FACT, if you can't, it's an OPINION. Cheers.

There is no objective evidence, including a lack of controlled trials, showing any benefit at all for patients with TMD, other than, perhaps, a temporary relief which will not cause any long term improvement.

It may work or it may be one of the persistent myths of dentistry.

The hallmark of neuromuscular dentistry in the use of electronic diagnostic devices in the diagnosis and management of not only oro-facial pain patients, but also for “discovering” problems in asymptomatic patients.

The results obtained from diagnostic testing should have a high probability of affecting either the correctness of the diagnosis, selection of the appropriate treatment, or both. Unfortunately these devices do not.

Gonzalez YM, et al: Technological Devices in the Diagnosis of Temporomandibular Disorders. Oral Maxillofac Surg Clin N Am Jan 2008.

Stabilization Splint can minimize hiperactivity on patients with parafunctional activities and also is useful to protect teeth to not worn out.That's for sure! Mio facial pain, muscle disorders, tensio-type headaches and disc displacement are in general caused by multiple etiologic factors and can not be treated  only by a single device.  Mandibular/Maxillary advancement splint may be indicated as a treatment option only in anterior disc deslocation with reduction. If did not succeed artroscopic surgery can be considered, if one think it is mandatory to have the disc on its proper position. If the patient has no paint  or impaired funcional activities, no tratment is necessary. Most patients in their elderly have a remodeling process and syntoms go way. 

I note with interest that none of the responses favouring splint cite any evidence. 

Because there is no scientific evidence at all. Sometimes it work like a placebo!

i prefer to start with bite rasing appliance i use aqua splint , till the acute symptoms subside , then I shift to advancement splint

Regards

I.Kassem,BDs,MSc,FDS RCS

I will repeat:

Considering all of the available data, it can be concluded that

the oral stabilization appliance that does not change the

occlusion has sufficient evidence to support its use in the

management of localized myalgia and arthralgia of the

masticatory system.

However, there is no support in the scientific literature for

the use of mandibular repositioning appliances (MORA) in the

management of internal derangement.

Clark GT & Minakuchi H: Oral Appliances In, TMDs An Evidence-Based Approach to

Diagnosis & Treatment. Laskin DM, et al (Eds). Quintessence. Chicago, 2006 pp. 377-390.

Fricton et al. conclude in their meta-analysis that "hard stabilization appliances when adjusted properly have good evidence of modest efficacy in the treatment of TMJD pain when compared to non-occluding appliances and no treatment and are, at least, equally effective in reducing TMJD pain when compared to physical and behavioral therapies and pharmacological and acupuncture treatments. Other types of appliances, including soft stabilization appliances, anterior positioning appliances, and anterior bite appliances, have some RCT evidence that they are effec- tive in reducing TMJD pain.

The primary indication for anterior positioning appliance therapy is TMJ disc displacement with reduction that is associated with painful clicking and/or intermittent locking. When this appliance is worn 24 hours per day for a prolonged period, it may cause a permanent anterior mandibular position and a posterior open bite. Thus, anterior positioning appliances are usually recommended to be worn part-time while sleeping."

1. Fricton J, Look J. Systematic Review and Meta-analysis of Randomized Controlled Trials Evaluating Intraoral Orthopedic Appliances for Temporomandibular Disorders. J Orofac Pain. 2010;24(3):237–54.

UP to Raphael and Marbach "people with widespread pain are less likely to benefit from an appliance. Patients with TMJD may also have a number of comorbid conditions, such as fibromyal- gia, neuropathic pain, migraine, depression, anety, bruxism, xerostomia, and other contributing factors that increase the risk for treatment failure.2 Single treatment strategies such as an appliance can also fail due to long-standing maladaptive behav- iors, attitudes, and lifestyles that accompany a chronic condition. For these reasons, clinicians need to determine the level of complexity and extent of comorbid conditions in each patient prior to treatment and match the complexity of the patient to the complexity of the treatment strategy. Patients with recent pain onset, limited treatment history, no comorbid conditions, and few behav- ioral and psychosocial contributing factors are sim- pler to manage by a single clinician with single treatments. Patients with comorbid conditions, per- sistent pain longer than 6 months, behavioral and psychosocial problems, frequent use of health-care services or medication, and lifestyle disturbances such as sleep and work interference are more com- plex to manage and require a multimodal treatment strategy with an interdisciplinary team. Thus, appliances can be considered as part of a

broader rehabilitation treatment program to encourage healing, normal function, and restoration of normal activities. In many TMJD cases, the use of other interventions such as self-care, exercise, physical therapy, and pharmacological treatments can improve the condition and preclude the need for an appliance. "

Fricton J, Look J. Systematic Review and Meta-analysis of Randomized Controlled Trials Evaluating Intraoral Orthopedic Appliances for Temporomandibular Disorders. J Orofac Pain. 2010;24(3):237–54.

Raphael KG, Marbach JJ. Widespread pain and the effectiveness of oral splints in myofascial face pain. J Am Dent Assoc. 2001 Mar 1;132(3):305–16.

Considering all of the available data, it can be concluded that the oral stabilization appliance that does not change the occlusion has sufficient evidence to support its use in the management of localized myalgia and arthralgia of the masticatory system.

However, there is no support in the scientific literature for the use of mandibular repositioning appliances (MORA) in the management of internal derangement.

Clark GT & Minakuchi H: Oral Appliances In, TMDs An Evidence-Based Approach to Diagnosis & Treatment. Laskin DM, et al (Eds). Quintessence. Chicago, 2006 pp. 377-390.

We did a literature review and have published a working copy on the research gate platform. Okeson  pointed out that permanent occlusal therapy should not be completed in the forward therapeutic position. He concludes that the main purpose of the anterior positioning appliance is to promote adaptation of the retrodiscal tissues. Once this adaptation has occurred, the condyle should be returned to the muscoskelettaly stable (MS) position by gradually modifying and eliminating the splint. Therefore following successful anterior positioning therapy and stabilization appliance therapy, the condyle should be in the MS position. The treatment goals of permanent occlusal therapy are to establish orthopedic stability.

I compliment Dr Kritzler for an extensive review. I also  would like to know  whether with the growing stress in life, do u come across young children with TMD symptoms and what do you recommend for them  

Stabilization.

There is no support in the scientific literature for the use of mandibular repositioning appliances (MORA) in the management of internal derangement.

Clark GT & Minakuchi H: Oral Appliances In, TMDs An Evidence-Based Approach to Diagnosis & Treatment. Laskin DM, et al (Eds). Quintessence. Chicago, 2006 pp. 377-390.

May not be Mandibular Repositioning Appliances as such but there is much evidence in the literature which addresses "repositioning the mandible". when malocclusion is addressed properly at the young age using an appliance which facilitates the proper TMjoint relationship with the disc & ligaments,MOM. This itself explains T/T of TMJ disorders. But grownups TMJ, I don't think anything else other than new occlusal stability followed by appliance therapy, would "Reposition the TMJ" truly.

• I agree with above researcher...because experience teaches us that mandibular repositioning , sometimes in hybrid appliances too, given at a young age, do lead to improvement in TMD symptoms but in this evidence based world, anecdotal references sadly do not show warrant mandibular repositioning appliances for management of internal derangement

Hello dr. Priyanka Kapoor;

I have to differ with some of my colleagues who approve of the mandibular repositioning appliance (MORA ) .I am a student of two the well-known worldwide professors in the field of Tempromandibuar joint disorders these ae professor Sigurd Ramfjord and professor Major Mackinlay Ash both are professors of periodontics and TMJ and occlusion dept. These two professors were my professors at the University of Michigan ,School of Dentistry ,Ann arbor, USA.

Let me say first that I agree with Dr. Louis G Mercuri Who wrote (see above ) There is no support in the scientific literature for the use of mandibular repositioning appliances (MORA) in the management of internal derangement. To confirm this I can tell you that I have seen during my days at the university of Michigan as a graduate student in periodontics many cases of patients with MORA appliances coming to Dr. Ash to be treated by Michigan splint and he was very successful in that treatment.

I have included here two interesting papers on Michigan splint one by professor Ash and the other is a recent one by Dr badel.

Drs. Ash and Ramjford also have many books two are listed below .Just for the record there are many many articles written about Michigan splint and its advantages see pub med.

So here are some references which might help any one interested in Michigan splint and its design.

sincerely

Dr.K.A.Galil.Professor of Dentistry DDS.,D.Oral & Maxillofacial Surgery ,PH.D,FAGD.,FADI.,Cert. Periodontist(Royal College of Dental Surgeons of Ont ) Departments of Periodontics ,Orthodontics and Clinical Anatomy Schulich School Of Medicine and Dentistry. University of Western Ontario London,Ontario.

Visit us at

WWW.drgalil.ca

Occlusion Hardcover – 1966

by Sigurd & M. Ash, Jr. Ramfjord (Author)

Occlusion Hardcover – 1966

by Sigurd & M. Ash, Jr. Ramfjord (Author)

stabilization splint has a success rate in night bruxism

TMD are multifactorial disorders. It is best to perform the management of TMD in a team approach and TMD specialist, facial pain specialist, orthodontist, prosthodontist (in older individuals), can work together in collaboration. For most cases, minimal intervention (less) is better.

Case report-based or experience-based dentistry may be convenient, but is inadequate when better data are available. Evidence that a simple splint is effective and an MORA not needed is available. Therefor keep it simple or prove the benefit in an adequate scientific study.

Huang IY, Wu JH, Kao YH, Chen CM, Chen CM, Yang YH. Splint therapy for disc displacement with reduction of the temporomandibular joint. part I: modified mandibular splint therapy. Kaohsiung J Med Sci. 2011;27:323-329.

MRI-based determination of occlusal splint thickness for temporomandibular joint disk derangement: A randomized controlled clinical trial

My evidance based study published in OOOOO journal in 2018

Hegab splint / Hard full arch upper stablization splint with ball clasps 4 mm vertical thickness in cases of DDR and 6 mm vertical thickness in cases of DDNR is so effective with disk recapture in both types of disk displacement as shown in the MRI pre and post treatment