Anterior Repositioning Appliance Therapy for TMJ Disorders

0886-9634/2302

089$05.00/0, THEJOURNAL OF

CRANIOMANDIBULAR

PRACTICE,

Copyright © 2005

by CHROMA, Inc.

Manuscript received

June 30, 2004; revised

manuscript received

December 6, 2004; accepted

January 13, 2005

Address for reprint requests:Dr. H. Clifton Simmons III

1916 Hayes Street

Nashville, Tennessee 37203

E-mail: [email protected]

-TMJ

Anterior Repositioning Appliance Therapyfor TMJ Disorders: Specific Symptoms Relievedand Relationship to Disk Status on MRI

H: Clifton Simmons III, D.D.S.; S. Julian Gibbs, D.D.S., Ph.D.

ABSTRACT: Forty-eight (48) consecutive patients seeking treatment in a referral based practice for

complex chronic painful temporomandibular joint (TMJ) disease were enrolled in a prospective study to

assess specific symptom relief from anterior repositioning appliance (ARA) therapy and the relationship

between specific symptom relief and the status of the TMJ disk. Each patient was assessed on 86 symp

toms based upon whether each symptom was present before treatment and absent, better, unchanged

or worse after Maximum Medical Improvement (MMI). The most common symptom was occipital cepha

lalgia (94%). The least common symptom was pain and burning of tongue (8%). A profile of a temporo

mandibular disorder (TMD) patient was developed. The typical TMD patient has cephalalgia, mainly in

the occipital, temporal and frontal region, pain upon chewing food, pain upon opening and closing the

mouth, TMJ pain, pain in the back of the neck and difficulty chewing food. Before treatment, patients with

bilateral displaced disks had more symptoms than those with unilateral displaced disks and the opposite

side normal. After MMI, the maximum benefit (percent of pretreatment symptoms relieved) was found in

patients with normal or recaptured disks. The minimum occurred in patients whose disks did not recap

ture with therapy. ARA therapy improved or eliminated symptoms in all patients in the study.

Dr. H. Clifton Simmons m received his

D.D.S. degree in 1977 from the Universityof Tennessee College of Dentistry. He iscurrently an assiStant clinical professor inthe Department of Dentistry at VanderbiltUniversity School of Medicine and has aprivate practice. Dr. Simmons is aDiplomate of the American Board ofCraniofacial Pain, the American Board ofOrofacial Pain, and the AmericanAcademy of Pain Management. Dr.Simmons is a Fellow of the AmericanCollege of Dentists, the InternationalCollege of Dentists, the AmericanAcademy of Craniofacial Pain, theAcademy of General Dentistry, theTennessee Dental Association and the

Academy of Dentistry International. He iseditor of the Journal of the TennesseeDental Association.

89

This article reports on the continuation of theauthors' research relating to anterior repositioningappliance (ARA) therapy and its effect on patients

with craniofacial pain and temporomandibular disorders(TMD).1,2 Symptom relief has been described in a generalsense by Fricton, et al,3 and Dworkin, et a1.4 The ability torelieve specific symptoms of craniofacial pain in TMDpatients has not been reported. The visual analog scaleS(V AS) is a popular method of evaluating pain. Thepatient is instructed to rate pain on a scale of 0 to 10 withno pain at 0 and the worst pain imaginable at ten points.This method can be customized to address specific symptoms, but it is time-consuming and is thus not typicallyused among research subjects to evaluate more than afew symptoms.

The TMJ Scale6,7 is a proprietary quantitative and qualitative assessment of patient symptoms from TMJ disorders and includes pain evaluation. A few studies havebeen published that used the TMJ Scale to rate symptomimprovement at treatment completion.8,9 Specific symptoms have been tracked but outcomes for specific symptom improvement were not given.

The purposes of the present study were: 1. to determinethe effect of ARA therapy on specific symptoms in TMD

ARA THERAPY FOR TMD SYMPTOM RELIEF SIMMONS AND GIBBS

Table 1Patients Who Did Not Reach

Maximum Medical Improvement*

4/7 grid. Before treatment, the condyles in this study wereconsistently located posterior to the Gelb 4/7 position.The amount of repositioning required to place the condylein the Gelb 4/7 block was determined. The mandible was

repositioned anteriorly by this amount. Cephalometric allycorrected tomograms were repeated on each joint withthe patient biting into the newly constructed appliance toverify that the condyles were repositioned as planned.

ImagingDisk position immediately before delivery of the ARA

was determined by magnetic resonance imaging (MRI)using a superconducting MR scanner operated at 1.5T(Magnetom, Siemens Corp., Iselin, NJ). According toKatzberg and Westesson,17 MRI is the gold standard forTMJ disk position. Closed-mouth images consisted ofsagittal oblique and coronal oblique Tl-weighted images

Patients

Fifty-eight (58) consecutive patients seeking care in areferral-based practice for complex chronic craniofacialpain and TMD were recruited for the study. Criteria for

inclusion were chronic temporomandibular pain and dysfunction by history and examination, age at least 18years, and informed consent. Exclusion criteria wereinability or unwillingness to undergo magnetic resonanceimaging (MRI) (such as implanted electronic devices,claustrophobia, etc.) and pregnancy. Forty-eight (48)patients completed initial therapy and are reported onhere. Ten withdrew from the study for the reasons shownin Table 1. Six of the ten were doing well but elected tostop treatment for a variety of reasons. The other four terminated before sufficient treatment time to achieve significant symptom reduction. It is extremely unlikely thatthese departures biased the results of the study. Therewere 47 female participants and one male. The mean ageof participants at appliance delivery was 38 years. Theyoungest was 18 and the oldest was 67.

The protocol was approved in advance by the Institutional Review Board of Vanderbilt University. Informedconsent was obtained from each patient before entry intothe study.

patients; 2. to relate these changes to the position of theTMJ disk; and 3. to relate the changes to the disk status atmaximum medical improvement (MMI).

Materials and Methods

Treatment

Maxillary and mandibular anterior repositioning appliances were constructed for each patient. The mandibularappliance was worn whenever the patient was awake,e.g., eating and speaking. The maxillary appliance wasworn whenever the patient was reclined for more than anhour and during sleep. The maxillary appliance had aramp that extended lingual to the mandibular incisors tohold the mandible either open or protruded while thepatient was reclined. The patients were instructed to leaveone appliance in during teeth brushing while brushing theopposing dental arch. One appliance was, therefore, inthe patient's mouth 24 hours a day. There is a consensusin the literature supporting the use of dual appliances onthe same patient in ARA therapy with the wearing schedule described.5,lo.12 The ARA established the treatment

position for the condyles in the fossae as the Gelb 4/7position,I,13 which is its normal position, as published byrecognized authorities.14.16 This position was derived byfirst determining the location of the condyles on cephalometrically corrected tomograms in relation to the Gelb

90 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE APRIL 2005, VOL. 23, NO.2

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SIMMONS AND GIBBS

plus sagittal oblique T2-weighted images. A publishedMRI protocol was used to perform the scans,!8 Closedmouth images were performed with the teeth in centricocclusion. Open-mouth studies were composed of TIweighted sagittal oblique and coronal oblique images.Tl-weighted images used a conventional spin-echosequence, TR=700 ms, TE=12-15 ms, two acquisitions.T2-weighted images were obtained with turbospin-echosequences, effective TR=5 s, TE=90 ms, lO-echo chain,one acquisition. All images used a slice thickness of3 mm with no inters lice gap, matrix of 192x256 and fieldof view of 12xl2 to 14xl4 cm. Each image set was composed of at least seven slices, to include the entire condyleplus adjacent structures. The patient was biting on a stackof tongue blades at a predetermined vertical dimensionwhen the open-mouth scans were performed. Imagingtimes ranged from 3 to 4.5 minutes. The complete examination was performed for each subject in approximately35 minutes. Closed-mouth Tl-weighted images wererepeated immediately after insertion of the mandibularappliance, with the patient closed on the appliance in theprescribed position.

Disk position in relation to the condyle was categorized from MR images for each joint in each position,using a modification of a scheme proposed by Tasaki, eta1.19 as normal (N), anterior (A), anterolateral (AL),anteromedial (AM), medial (M), lateral anterior rotary(LAR, disk rotated anteriorly toward the lateral pole, i.e.,anterior at the medial pole and in normal position at thelateral pole), and medial anterior rotary (MAR, rotatedtoward the medial pole, or anterior at the lateral pole andnormal at the medial pole). No posterior or lateral dislocations were identified in the sample.

Magnetic resonance imaging and evaluation of theresults, especially disk position, were the only procedures in the study that were performed solely for purposes of the study. All other procedures were routinepatient treatment.

Evaluation of SymptomsEach patient was asked how long he/she had been

seeking care for the head, neck and facial pain disorder,for which treatment was now sought. Presence of eachsymptom listed in Table 2, at any time since the pain disorder started, was then determined. The list of specificsymptoms was accumulated by the authors over severalyears from numerous undocumented sources. The symptom list was then reviewed at the first follow-up appointment, three weeks after delivery of appliances and everysix weeks during active treatment. The same evaluationwas done at MMI. Each symptom in the list was evaluated as absent, better, unchanged or worse on average in

ARA THERAPY FOR TMD SYMPTOM RELIEF

the preceding three weeks compared with its presenceand severity before treatment.

This study compares the patients presenting symptomsat a diagnostic appointment to the patient's evaluation atthe MMI visit and categorizes them by disk status pretreatment and disk status at MMI. Each patient had aknown disk status based upon three dimensional MRIevaluation prior to ARA treatment. The improvement insymptoms after MMI was related to disk position aftertreatment.

Twenty patients in this study were given trigger pointinjections as part of their treatment. Ten patients in thisstudy were given iontophoresis as part of their treatment.

Statistical Analysis

Numbers of symptoms per patient vs. disk status beforetreatment and disk recapture after MMI were subjected tochi-square tests for independence and paired t tests.

Results

This research presents results of tracking 86 specificsymptoms on 48 patients. The patients were asked if theynow have or have had any of the 86 symptoms duringtheir time of pain prior to beginning treatment. The symptoms that they responded to by a yes were then assessed atsubsequent visits to determine if the symptom was thesame as before treatment, better than before treatment,absent or worse.

Table 2 lists the 86 symptoms surveyed for each of 48patients before starting ARA therapy. The number ofpatients with each symptom is shown. Before treatmentthe average patient had 54±4 symptoms (mean±95%C.I.). Patients with bilateral displaced disks had moresymptoms (56±5) than those with bilateral normal or unilaterally displaced, opposite side normal (47±1O). Thedifference was statistically significant ()e=12.3, df=l,p<O.OOI). Conversely, the average symptom was presentin 30±2 patients.

At MMI, patients had a weighted average of 11±2.8symptoms. Symptoms at MMI were weighted as absent,0; improved, 0.5; unchanged, 1; and worse, 2. The average symptom was present in 6±1.3 patients. This decrease was statistically significant (X2 = 2153, df=l,p<O.OOO1). The weighted average improvement in numberof symptoms per patient at MMI was 80±5%. Overall, ofthe 2,570 symptoms noted as present before treatment,1,699 (66%) were absent, 737 (29%) improved, 108 (4%)unchanged, and 26 (1 %) worse after MMI. Thus, 95%of pretreatment symptoms were absent or improvedafter MMI.

APRIL 2005, VOL. 23, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 91


Table 2

Symptoms Surveyed in 48 PatientsPre-Treatment Symptoms VS. Symptoms After Maximum Medical Improvement

(Number of Patients/% of Total)

Symptom Pretreatment AfterMMISame

BetterAbsentWorseR

LRLRLRLRL

Cephalalgia - frontal

41/8540/831/22/515/3714/3525/6124/600/00/0

Cephalalgia - temporal

44/9244/920/00/020/4517/3924/5527/610/00/0

Cephalalgia - parietal

28/5826/540/00/08/296/2320/7120/770/00/0

Cephalalgia - occipital

46/9644/921/2"1/2"14/3014/3231/6729/660/00/0

Cephalalgia - mastoid

37/7736/750/00/013/3511/3124/6525/680/00/0

Cephalalgia - vertex

25/520/06/2419/760/0

Retroorbital pain

40/8335/731/3 I 0/012/3011/3127/6824/690/00/0

Photophobia

39/812/513/3324/620/0

Loss of equilibrium

31/651/311/3519/610/0

Vertigo

38/792/58/2127/711/3b

Otalgia

41/8536/752/52/610/248/2229/7126/720/00/0Tinnitus

32/6632/662/61/310/3110/3120/6321/660/00/0Fullness/stuffiness - ear

40/8337/774/13/812/306/1624/6028/760/00/0Itchiness - ear

31/6530/631/32/712/398/2718/5820/670/00/0

Preauricular pain

28/5830/630/00/08/293/1020/7127/900/00/0

lMJpain

42/8843/900/01/216/3910/2326/6332/740/00/0

Maxillary sinus pain

38/7935/733/83/919/5015/4316/4217/490/00/0

Frontal sinus pain

35/7335/733/93/910/2910/2920/5720/572/62/6

Sinus drainage

38/793/918/4714/373/8Pain in cheek

37/7736/750/00/010/276/1727/7330/830/00/0Numbness - side of face

10/219/190/00/03/301/117/708/890/00/0Pain in mandible

35/7334/710/01/38/234/1227/7729/850/00/0

Popping in lMJ - opening

33/6937/771/34/115/157/1927/8226/700/00/0

Popping in lMJ - closing

25/5229/601/43/103/126/2121/8420/690/00/0Visual disturbances

30/632/79/3019/630/0Paresthesia - arm

19/4018/380/00/05/263/1713/6813/721/52/11Paresthesia - hand

19/4019/400/00/04/213/1614/7414/741/52/11

Paresthesia - fingers

16/3318/380/00/02/135/2813/8112/671/61/6

Crepitus - lMJ

25/5225/521/41/45/204/1619/7620/800/00/0

Limited opening

36/752/610/2824/670/0

Jaw deviates upon opening

27/568/170/00/05/19 I 2/2521/78 I 6/750/00/0Inability to move iaw

16/33 I 18/381/61/65/31 I 4/2210/63 I 13/720/00/0

Mouth locks open

6/130/01/175/830/0Mouth locks shut

18/380/00/018/1000/0

Maxillary odontalgia

25/521/45/2019/760/0

Mandibular odontalgia

23/482/93/1318/780/0

Pain or burning - tongue

4/84/80/00/01/251/253/753/750/00/0Metallic taste

22/461/52/919/860/0Painful mastication

45/941/211/2433/730/0

Difficulty chewing

41/850/014/3427/660/0

Dysphagia

22/460/04/1818/820/0

Constant clearing of throat

30/631/39/3019/631/3Constant sore throat

17/350/02/1215/880/0

Foreign object in throat

22/460/03/1419/860/0

Table 2 cont'd next page

92 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE APRIL 2005, VOL. 23, NO. 2

Pain-nape 43/9041/852/511218/4216/3922/5123/561/21/2

Inability to turn head

22/4722/471/52/97/327/3213/5912/541/51/5Stiff neck

39/8135/732/52/515/3812/3421/5420/571/31/3

Cervical crepitus

27/562/79/3316/590/0

Shoulder pain34/71 I 31/653/92/616/74 I 12/3915/44 I 17/550/00/0

Pain - opening or closing

43/900/011/2632/740/0Backache

36/754/1114/3918/500/0

Nausea - occasionally

33/691/35/1524/73319"

Nausea - frequently

5/111/201/203/600/0

Clenching! grinding - day

34/715/1512/3517/500/0

Clenching! grinding - night

35/735/1417/4913/370/0

Awakening - jaws clenched

34/716/189/2619/560/0

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aneck injurybnot related

Cpregnant

The six most common pretreatment symptoms for thispatient population and the percentage of the patients withthis symptom were:

1. Cephalalgia - occipital area (94%)2. Painful to chew food (94%)

3. Cephalalgia - temporal area (92%)4. Pain upon opening or closing mouth (90%)5. TMJ pain (89%)6. Pain in back of neck (88%)The three least common symptoms were:1. Pain or burning side of tongue (8 %)2. Nausea - frequently (11 %)3. Mouth locks open (13%)Table 3 and Figures 1 and 2 show disk status versus

symptoms pretreatment versus symptoms after MMI. Asshown in Figure 1, there were considerable variations inboth the pretreatment frequency and posttreatment frequency of specific symptoms. The overall weighted frequency after MMI was significantly less than thepretreatment frequency (X2=1345, df=l, p<O.OOOl). InFigure 2, symptoms were reordered in decreasing orderof frequency before treatment. Because the number ofpatients in each disk-status group differed, frequenciesare shown as percentages of patients in each group. Sincethere was only one patient with one normal and one diskthat did not recapture, that patient was included in thegroup having one disk that recaptured and one that didnot. Thus, patients were divided into five categoriesbased on pretreatment disk status (Table 4, Figure 3)and whether or not the disk was recaptured by ARA therapy. Frequency of symptoms before treatment, weightedfrequency at MMI, and improvement (as percentage ofpretreatment symptoms) were significantly differentamong the five categories (Table 4). In each group, the

APRIL 2005, VOL. 23, NO. 2


frequency of symptoms before treatment and weightedfrequency at MMI were significantly different (Table 5).No patients with nomeducing disks before treatment hadtheir disks recaptured by treatment. Only five patientshad reducing disks that were not recaptured by treatment.That is, disk reduction on opening the mouth before treatment was tantamount to disk recapture by ARA therapy,while nomeducing disks before treatment predicted failure of recapture. Pretreatment symptom frequencies canbe grouped as 47-48% in patients with at least one normaldisk and 54-58% in patients with bilateral disk abnormalities. Similarly, there were two groupings of patients bysymptom improvement: 81-87% in patients with bothdisks either normal or recapturing, and 76% in patientswith at least one disk that did not recapture. The overallrange of symptom frequencies was 20-82 (23-95%).

These data also demonstrate that a normal disk position on MRI does not indicate absence of a temporomandibular disorder. Seven patients with bilateral andfive with unilateral normal disks achieved significantalleviation of symptoms with ARA therapy.

Discussion

Patients with craniofacial pain and temporomandibulardisorders report a variety of symptoms. These samesymptoms are also described by patients who have beendiagnosed with other painful disorders of the head andneck region. This study shows that most of the symptomstracked improved with ARA therapy. These resultsshould provide a basis for investigating the utility ofevaluating specific symptoms, especially in combinationwith disk status on MRI, in the differential diagnosis offacial pain. Table 6 lists specific symptoms found most

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 93


commonly (>85%)in these patients. TMJ disease shouldbe highly placed in the differential diagnosis of patientspresenting with these symptoms. Table 7 lists those specific symptoms found least commonly «20%) in thesepatients. Other sources of pain should be strongly consid-

SIMMONS AND GIBBS

ered in the differential diagnosis of patients presentingwith only these symptoms.

Symptom groups (Table 2) have been established toallow ease in evaluating the results of this study:

Cephalalgia group: Occipital headache occurred in

Table 3

Disk Status at MMI VS. Symptoms Pretreatment and Symptoms at MMI

RightLeftNumber ofNumber ofNumber ofNumber ofNumber ofPatient

DiskDiskSymptomsSymptomsSymptomsSymptomsSymptomsStatus

StatusPre-Same Post-Better Post-Absent Post-Worse Post-treatment

MMI(%)MMI(%)MMI(%)MMI(%)M.A. 10-16-93

NN46 010(22%)3678% 0S.B. 10-04-95

NAlWR 471(2%)04391% 3(sinus)(6% )C.B. 03-25-95

AlWRAlWOR3101652%1548% 0V.B.01-28-95

NN43 0716%3684% 0T.B. 03-01-94

AlWORMARlWOR440818%3682% 0L.B. 09-02-95

AlWORAJWR5902339%3661% 0B.B. 07-09-94

LARIWRLARIWR670067100%) 0CB. 01-08-94

AMlWORAMlWOR60013(22%)4778% 0T.B. 08-05-95

A.LIWORAMlWOR64021(33%)4367% 0A.B. 02-09-95

AlWRAlWOR4828(58%)11(23%)919%0M.B. 04-23-94

MAWWRMARJWR775(6%)07192% 1(1%)B.C. 09-04-93

NAlWOR 471(2%)2145%2553% 0V.C. 05-05-95

AJWRAMIWR5001428%36'72% 0J.D. 08-14-94

MlWORMlWOR766(8%)3749% 2128% 12(neck)(16%)D.D. 01-28-95

MAWWRMARlWR760912%6788%0D.D. 10-15-94

A.LIWORA.LIWOR6506(9%)5991% 0J.D. 02-10-95

NM!WR413(7%)26(63%)12 29%0S.D. 01-14-95

AlWRAlWR330033100% 0S.E.09-17-94

NN80 012(15%6885% 0L.E. 12-18-93

A.LIWRA.LIWR5408(15%4685%0B.H.02-19-94

A.LIWORA.LIWOR6204877% 1423%0CH. 04-15-94

AMlWORAlWOR599(15%)2746% 2339% 0N.H. 01-14-95

AlWORAlWOR6803146% 3754% 0RH.05-07-94

NN579(16%)12%)4782% 0S.H. 09-17-94

AlWRAlWR6216(26%)1931%) 2743% 0J.J. 09-23-95

AlWORAlWOR513(6%)48%)3976% 5(lIremant)(1 0%)Q.J. 09-16-95

M!WRM!WR7504864%) 2736% 0D.K. 12-17-94

MlWORAMlWOR46049%)4189% 1(premant)(2%)D.L. 12-03-94

A.LIWRA.LIWR388(21%)1129%) 1950%0C.M.07-01-95

AlWRAlWOR44012%)4398% 0A.M. 08-14-93

NMARJWR2000201000/.) 0L.M.05-07-94

AlWRA.LIWR6201016%5284% 0D.M.02-24-95

MlWORMlWOR5603359% 2341% 0K.N.08-24-96

AlWORAlWR828(10%)4049% 3340% 1(premant)(1 % )J.N. 11-04-95

AlWORAlWOR7103549% 3651% 0L.P. 12-18-93

A.LIWRALIWOR4402352% 2148% 0D.P. 01-28-95

AlWORAlWR6009(15%)5185% 0L.P.02-19-94

AMIWRN572(4%)11(19%)4477% 0A.R. 10-01-93

NALIWR 6903246%)3754% 0c.R. 03-14-94

NN24 0833%)1667% 0M.S. 08-20-94

AMlWORAMlWOR31013%)3097% 0M.S. 04-09-94

NN612(3%)3151%)2643% 2(3%)R.T. 02-26-94

AlWORAlWR57029(51%)2849% 0A.W.I0-23-93

NN25 0025(100%) 0B.W.02-26-94

AlWORALIWOR331(3%)1339%) 1958% 0D.W.08-21-93

MAR!WRAlWR4901122%) 3878% 0B.W.09-16-95

AlWORAlWR541(2%)59%)4889% 0N.W.08-07-93

AlWORAlWOR455(11%)2556%) 1533% 0

N - Normal, A - Anterior, M - Medial, AM - Anteromedial, AL - Anterolateral, MARMedial Anterior Rotary, LAR - Lateral Anterior Rotary, WR - With Recapture (not to beconfused with reduction), WOR - Without Recapture (not to be confused with reduction)


SIMMONS AND GIBBS ARA THERAPY FOR TMD SYMPTOM RELIEF

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Figure 1Frequency of specific symptoms before treatment and

weighted frequency of thesame symptoms at maximum medical improvement.Symptoms are numberedsequentially as listed inTable 2. Those symptomslisted bilaterally in Table 2are assigned separate numbers for each side. Symptoms at MMI were weightedas absent, 0; improved, 0.5;unchanged, I; and worse, 2.ARA therapy produced astatistically significantdecrease in the frequency ofthese symptoms (X2 = 1345,df= I, p<O.OOOl).

Symptom number

95% of the patients. Headaches after MMI were unchangedin 1% of the patients, better in 33% of the patients and

eliminated in 66% of this patientpopulation. No patient's headaches were made worse.

APRil 2005, Val. 23, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

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Figure 2Frequency of specific symptoms before treatment and

weighted frequency at maximum medical improvement,by disk status before treatment. Symptoms arereordered in decreasing orderof pretreatment frequency inall patients. Weights forsymptom frequencies at MMIas in Figure 1. Symptomfrequencies before treatmentwere significantly differentamong the five disk-statusgroups (X2=13.6, df= 4,p<O.OI). There were similarsignificant differences amongthese groups at maximummedical improvement(X2=31.2, df= 4, p<O.OOOI).Disk status groups: N-N,bilateral normal; N-WR,unilateral normal and unilat

eral displaced with recapture;WR-WR, bilateral displacedwith recapture; WR-WOR,unilateral displaced with andunilateral displaced withoutrecapture; WaR-WaR,bilateral displaced withoutrecapture.

95


Retroorbital pain group: Retroorbital pain after MMIwas unchanged in 1% of the patients, better in 30% of thepatients and eliminated in 68% of the patients. Travelland Simons20 stated that eye pain is most often referredfrom the sternocleidomastoid muscle. The relief in

retroorbital pain by using ARA therapy suggests theinvolvement of the relationship between the arthrokineticreflex from the TMJ and the neck musculature.

Loss of equilibrium and vertigo group: Balance problems after MMI were unchanged

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Figure 3Relief of specific symptomsat maximum medical

improvement, as a percentageof symptoms present pretreatment. Weights for symptomfrequencies at MMI as inFigure 1. Disk status groupsas in Figure 2. Numerousspecific symptoms were completely relieved (100% ) inseveral disk-status groups,but only one in all patients(mouth locked closed, presentin 18 patients). The appearance of worse symptoms atMMI in the N-WR group wasthe result of one patient withsinusitis. See Figure 1 forsymptom numbering.


SIMMONS AND GIBBS ARA THERAPY FOR TMD SYMPTOM RELIEF

in 4% of the patients, better in 34% of the patients, andeliminated in 62% of the patients. No balance problemswere made worse.

Ear symptoms group: Otalgia, tinnitus, fullness andstuffiness in ears and itchiness in ears can be combined to

form an ear symptom profile. Earache is a common complaint of TMD patients and occurred 85% of the time. Earsymptoms after MMI were the same in 5% of the patients,better in 27.5 % of the patients, and eliminated in 67 % ofthe patients. No ear symptoms were made worse.

Preauricular pain occurred in 60% of the patients.Preauricular pain after MMI was unchanged in no patients,better in 13% and absent in 87% ofthe patients.

TMJ pain group: Of the 43 patients reporting TMJ painpretreatment, 29 (67%) reported complete relief, 13(30%) reported improvement, and one (2%) reported nochange at MMI. That is, TMJ pain was improved or elim-

inated in 42 of the 43 patients.Sinus symptoms group: Some symptoms were tracked

to enable the clinician to discriminate between a non

temporomandibular disorder, such as sinus drainage, anda temporomandibular disorder. Sinus symptoms afterMMI were the same in 9% of the patients, better in 40%of the patients, and eliminated in 48% of the patients. Nopatient had worse maxillary sinus pain after MMI. Sixpercent of the patients had worse frontal sinus pain and8% of the patients had worse sinus drainage after MMI.

Popping in TMJ group: TMJ popping was unchangedin 7% of the patients, better in 17% of the patients, andeliminated in 76% of the patients. No patient's TMJ popping was made worse.

Paresthesia in arms, hands and fingers group: Paresthesia in the arms, hands and fingers can be grouped toget a symptom profile. Paresthesia was the same in nopatients, better in 20%, absent in 73% and worse in 7%.Paresthesia in the arms, hands and fingers can be frommultiple causes. Nerve entrapment in muscle in spasm



can cause paresthesia, and relieving an arthrokineticreflex explains the positive response from ARA therapy.There is no known factor associated with ARA therapythat could contribute to the worsening of 7% of thepatients' paresthesia in the arms, hands and fingers.

Pain on opening or closing mouth was unchanged inno patients, better in 26%, absent in 74% and worse in0%.

Mouthlocking shut was eliminated in 100% of thepatients in this study.

Teeth pain group: Teeth pain after MMI was the samein 6% of the patients, better in 16% and absent in 77%.None of the patients reported worse teeth pain. Thesepatients were wearing a mandibular appliance on theirteeth during their waking hours and a maxillary applianceon their teeth during sleep. One can conclude that wearing an appliance does not cause teeth pain. Also, it is wellknown that many patients have occult teeth pain fromdental causes that is not related to their craniofacial painorTMD.

Pain and difficulty chewing/oDd group: Pain and difficulty chewing food after MMI were the same in 1% of thepatients, better in 29%, absent in 70%. None of thepatients reported worse pain or difficulty chewing food.Those who had never worn an appliance felt that theycould possibly not eat in the appliance. The results of thisstudy clearly show that this patient population had noproblem eating in their mandibular appliance.

Throat symptoms group: Dysphagia, constant clearingof the throat, feeling of constant sore throat and feeling offoreign object in the throat can be combined to get athroat symptom profile. When these were combined andaveraged, throat symptoms were reported by 48% of thepatients. Of the four categories that are lumped together,only one patient reported that throat symptoms remainedthe same at MMI. Nineteen percent (19%) said that theirthroat symptoms were better at MMI. Eighty percent(80%) said their throat symptoms were absent at MMI.Only one patient said that his/her throat symptoms wereworse after treatment.

Neck and shoulder group: Pain in right and left back ofneck, inability to turn head to right and left, stiff neckright and left, cervical crepitus upon movement of head,right and left shoulder pain can be grouped to form a neckand shoulder profile. Of the nine categories lumpedtogether, neck and shoulder symptoms after MMI werethe same in 5% of the patients, better in 36% of thepatients and eliminated in 56% of the patients. Patients'neck and shoulder symptoms were worse 3% of the time.This probably indicates that neck and shoulder pain canbe either referred from the TMJ apparatus or can be independent from the TMJ apparatus.

SIMMONS AND GIBBS

Nausea group: There were only five patients who hadnausea frequently. There were 33 patients who hadnausea occasionally. Only one patient in each nausea typereported that their symptoms stayed the same. AfterMMI, 18% of the patients in the nausea group werebetter, and symptoms were eliminated in 66% of thepatients. Three patients' occasional nausea worsenedafter MMI, but they were all pregnant.

Clenching and/or grinding teeth group: The clenchingand grinding teeth group after MMI were the same in16% of the patients, better in 37% of the patients andabsent in 48% of the patients. None of the patients clenching or grinding were worse after MMI.

Symptoms that were not very common in this patientpopulation were pain or burning right (8%) and left (8%)side of tongue, nausea frequently (11%) and mouth locking open (13%).

Four patients believed that 100% of their symptomshad been relieved by ARA therapy. Each of these patientshad a different status of disk position.

It should be noted that all categories of TMJ disk statuswere included in this study of ARA therapy. According torecent research by Paesani, et al.,21 TMJ authorities canaccurately diagnose the status of the TMJ disk only 43%of the time from clinical exam and history. Most clinicians treating TMD today use clinical exam and history toassess the status of the disk in their patients and do nothave MRI data. Therefore, most clinicians do not trulyknow the status of their patients' disks. Ribeiro, et al.22found that patients who have symptoms of TMD havedisk displacement 86% of the time. Katzberg, et ap3found that patients who have symptoms of TMD havedisk displacement 77% of the time. Patients in this studyhad disk displacement 79% of the time according to MRI.ARA therapy for TMD is appropriate because it is effective in recapture of disks when they are recapturable andprovides symptom relief when the disk is not recapturable.1 ARA therapy is also effective in symptom reliefin joints with a normal disk status on MRI with symptomsofTMD.

There seems to be relief from symptoms of temporomandibular disorder from the orthopedic effect of recapturing the TMJ disk to a more normal relationship orrepositioning the condyle to a more normal position in thefossa. Gelb and Gelbll have stated that ARA can relieve

symptoms without disk recapture. This orthopedic effectis predictable to a high degree of certainty and should bea part of treatment of temporomandibular disorderpatients. This seems to be the most effective treatment toreverse the arthrokinetic reflex pain described by Isberg,et al.24 and Bertolucci25 in muscles, ligaments and tendonsassociated with joint injuries. Pharmacotherapeutics,


SIMMONS AND GIBBS

physical therapy, biofeedback therapy and flat planeappliance therapy are supportive therapy and do notaccomplish these same goals. Treatment of the temporomandibular disorder patient may require all of thesemodalities, but as seen in this study, the orthopedic effectof anterior repositioning appliances can achieve highlevels of MMI without other modalities in many patients.

The results of this study cannot be translated to anyother type of appliance or splint therapy other than thatwhich is described in this study. These results may not beachieved from other treatment protocols.

Conclusions

Anterior repositioning appliance therapy for temporomandibular disorders provides significant relief for mostsymptoms tracked in this study, for most patients.Presence of many of the nine most frequent symptoms(Table 6) suggests that TMJ disease should be stronglyconsidered in the differential diagnosis of facial pain.Conversely, presence of only the least frequent symptoms (Table 7) should guide the differential diagnosisaway from TMD. The typical TMD patient has headaches,mainly in the occipital, temporal and frontal region, earache, TMJ pain, pain and difficulty chewing food, backof neck pain, and pain on opening and closing the mouth.Since headache is the top complaint of TMD patients,health care providers should include TMD in their differential diagnosis of headache patients.

After MMI, patients with both disks either normal orrecaptured showed the greatest symptomatic improvement (81-87%). Patients with at least one disk that did notrecapture showed less improvement (76%). This agreeswith previous reports showing that ARA therapy relievesmore symptoms in patients with disks that are recapturedthan those that do not. Overall, ARA therapy resulted ineither absence or improvement of 95% of symptoms present before treatment.

References

1. Simmons HC, Gibbs SJ: Recapture of temporomandibular joint disks usinganterior repositioning appliances: an MRI study. J Craniomandib Proct1995; 13:227-237.

2. Simmons HC, Gibbs SJ: Initial TMJ disk recapture with anterior reposition-ing appliances and relation to dental history. J Craniomandib Praci 1997;15:281-295.

3. Fricton JR, Kroening R, Haley D, Siegert R: Myofascial pain syndrome of thehead and neck: a review of clinical characteristics of 164 patients. OralSurg Oral Med Oral Patho11985; 60(6):615-623.


4. Dworkin SF, Huggins KH, LeResche L, et al: Epidemiology of signs andsymptoms in temporomandibular disorders: clinical signs in cases and controls. JADA 1990; 120(3):273-281.

5. Kaplan AS, Assael LA: Temporomandibular disorders diagnosis and treat-ment. Philadelphia: W.B. Saunders Co. 1991.

6. Lundeen 1F, Levitt SR, McKinney MW: Discriminative ability of the TMJScale: age and gender differences. J Prosthet Dent 1986; 56:84-92.

7. Lundeen TF, Levitt SR, McKinney MW: Clinical application of the TMJScale. J Craniomandib Pract 1988; 6:339-345.

8. Brown DT, Gaudet EL Jr: Outcome measurement for treated and untreated

TMD patients using the TMJ Scale. J Craniomandib Proct 1994; 12(4):216222.

9. Gaudet EL Jr, Brown DT: Temporomandibular disorder treatment outcomes:first report of a large-scale prospective clinical study. J CraniomandibPract 2000; 18(1):9-22.

10. Bledsoe WS Jr: Selection, application and management of Phase I orthotics.Intraoral orthotics. Cranio Clinics Int Bledsoe WS Jr., eds. Baltimore:Williams & Wilkins, 1991.

II. Ge1b ML, Gelb H: Gelb Appliance: mandibular orthopedic repositioningtherapy. In: Bledsoe WS Jf. ed. Intraoral orthotics. Cranio Clinics IntBaltimore: Williams & Wilkins, 1991:81-98.

12. Pertes RA, Gross SG: Clinical management of temporomandibular disordersand orofacial pain. Lombard, IL: Quintessence Books, 1995.

13. Gelb H: Clinical management of head, neck and TMJ pain and dysfunction.2nd ed. Philadelphia: W.B. Saunders Co., 1985.

14. Katzberg RW, Westesson P-L: Diagnosis of the temporomandibular joint.Phi1adelphia:W.B. Saunders Co., 1993.

15. Okeson JP: Management of temporomandibular disorders and occlusion. 5th

ed. Chicago: Mosby, Inc., 2003. ,16. Netter PH: Atlas of human anatomy. Summit, NJ: Ciba-Geigy Corp., 1990.17. Katzberg RW, Westesson P-L: Selection of imaging modalities for patients

presenting with symptoms of intemal derangement. Cranio Clin Int 1991;1:127-132.

18. Gibbs SJ, Simmons HC III: A protocol for magnetic resonance imaging of thetemporomandibular joint. J Craniomandib Pract 1998; 16:236-241.

19. Tasaki MM, Westesson P-L, Isberg AM, et al.: Classification and prevalenceof temporomandibular joint displacement in patients and asymptomaticvolunteers. Am J Orthod Dentofac Orthop 1996: 109.

20. Travel! JG, Simons DG: Myofascial pain and dysfunction. The trigger pointmanual. Baltimore: Williams and Wilkins,1983.

21. Paesani D, Westesson P-L, Hatala MP, et al.: Accuracy of clinical diagnosisfor TMJ internal derangements and arthrosis. Oral Surg Oral Med OralPath 1992; 73:360-363.

22. Ribeiro RF, Tallents RH, Katzberg RW, Murphy WC, Moss ME, MagalhaesAC, Tavano 0: The prevalence of disk displacement in symptomatic andasymptomatic volunteers aged 6 to 25 years.J Orofac Pain 1997; 11(1):3747.

23. Katzberg RW, Westesson P-L, Tallents RH, Drake CM: Anatomic disordersof the temporomandibular joint disc in asymptomatic subjects. J OralMaxillofac Surg 1996; 54(2): 147-153.

24. Isberg A, Widmalm SE, Ivarrson R: Clinical, radiographic and electromyo-graphic study of patients with internal derangements of the temporomandibular joint. Am J Orthodont 1985; 88:453-460.

25. Berto1ucci 1.: The trilogy of the "triad of 0'Donoghue" in the knee and itsanalogy to the TMJ derangement. J Craniomandib Pract 1990; 8(3):268.

Dr. S. Julian Gibbs is a Professor of Radiology and RadiologicalSciences, Emeritus, at Vanderbilt University School of Medicine.Dr. Gibbs is a 1956 graduate of Emory University School of Dentistryand earned his Ph.D. in radiation biology at the University of Rochesterin 1969. He is a Diplomate andformer President of the American Boardof Oral and Maxillofacial Radiology, Fellow andformer President of theAmerican Academy of Oral and Maxillofacial Radiology, Fellow of theTennessee Dental Association, Life Member of the American DentalAssociation and member of numerous scientific and professional societies in dentistry and radiology. He has authored or coauthored morethan 150 articles, chapters, abstracts, and presentations in the scientificand professional literature.


Anterior Repositioning Appliance Therapy for TMJ Disorders

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