CRANIO®

The Journal of Craniomandibular & Sleep Practice

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The Significance of Posterior Open Bite

After Anterior Repositioning Splint Therapy
for Anteriorly Displaced Disk of the
Temporomandibular Joint

Sadako Kai, Hiroyuki Kai, Osamu Tabata & Hideo Tashiro

To cite this article: Sadako Kai, Hiroyuki Kai, Osamu Tabata & Hideo Tashiro (1993)
The Significance of Posterior Open Bite After Anterior Repositioning Splint Therapy for
Anteriorly Displaced Disk of the Temporomandibular Joint, CRANIO®, 11:2, 146-152, DOI:
10.1080/08869634.1993.11677956

To link to this article: http://dx.doi.org/10.1080/08869634.1993.11677956

Published online: 18 Feb 2016.

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 • CASE REPORTS

THE SIGNIFICANCE OF POSTERIOR OPEN BITE

AFTER ANTERIOR REPOSITIONING SPLINT
THERAPY FOR ANTERIORLY DISPLACED DISK
OF THE TEMPOROMANDIBULAR JOINT
Sadako Kai, D.D.S., D.D.Sc., Hiroyuki Kai, D.D.S.,
Osamu Tabata, D.D.S., Hideo Tashiro, M.D., D.M.Sc.

0886-9634/1102- ABSTRACT: Spontaneous posterior open bite was observed in 15 patients after the application of ante-
Downloaded by [Australian Catholic University] at 15:29 27 September 2017

0146$03.00/0, THE
JOURNAL OF rior repositioning splints in the treatment of anterior1y displaced disk. Recapture of the disk after treat-
CRANIOMANDIBULAR ment was clinically diagnosed in five patients. Arthrography performed on 10 patients with open bite
PRACTICE,
Copyright© 1993 revealed a completely recaptured disk in four patients, an anterior1y displaced disk without reduction in
by CHROMA, Inc. four patients, and an anterior1y displaced disk with reduction in two patients. This suggests that recap-
Manuscript received ture of the disk in the correct position at mouth closing should be a major cause of the posterior open bite
March 3, 1992; revised
manuscript received in patients who have a relatively short duration of locking and successful mandibular manipulation.
August 11, 1992; accepted Although the cause of posterior open bite with the persistently displaced disk is still unclear, an increase
October 9, 1992
in the posterosuperior joint space by the posterior open bite appears to eventually produce favorable
Address for reprint requests:
Dr. Sadako Kai, D.D.S. effects to joints with anterior1y displaced disks.
First Department of
Oral and Maxillofacial Surgery
Faculty of Dentistry

Kyushu University
3-1-1 Maidashi, Higashiku,
Fukuoka, 812 Japan
Dr. Sadako Kai received her D.D.S.
degree from Kyushu University in 1977
and her D.D.Sc. degree from the same
institution in 1982. She has been working
as an oral surgeon and an instructor in
the First Department of Oral and
Maxillofacial Surgery, Faculty of
Dentistry, Kyushu University since 1981,
and has actively treated and researched
TMJ disorders since /987. Dr. Kai has
focused her professional interest on the
relationship between occlusal problems
and TMJ disorders.
T
he recognition of the concept of internal derange-
ments of the temporomandibular joint (TMJ)I. 2
has directed clinical attention toward the spatial
relationship between the disk and the condyle. Thus, the
anterior repositioning splint has recently become a
common therapeutic appliance for internal derangements.
It is generally applied to patients with anteriorly dis-
placed disks with reduction in order to maintain a correct
disk-condylar relationship during all phases of mouth
movement. In patients with closed lock (anterior disk dis-
placement without reduction), it is applied after success-
ful mandibular manipulation. 3 In the course of treatment
with the anterior repositioning splint, we observed 15
patients whose posterior open bite persisted after removal
of the splint. This report describes these cases and dis-
cusses the mechanical causes of the posterior open bite.

Dr. Hiroyuki Kai received his D.D.S.
degree from Kyushu University in 1983.
He has been at First Department of Oral
and Maxillofacial Surgery, Faculty of
Dentistry, Kyushu University since 1983
and has actively treated and researched
oral maxillofacial lesions. Dr. Kai is a
member of the Japanese Society of Oral
Maxillofacial Surgeons and the Japanese
Society ofTMJ.
Case Reports
Case I: A 31-year-old Woman
The patient visited our clinic complaining of limited
mouth opening with pain in the left TMJ and the masseter
muscles. She had reciprocal clicking in the left TMJ for
three months, followed by a sudden limitation of her
mouth opening for 10 days.
At the first visit, maximal interincisal distance was
20 mm and the mandible at mouth opening was remark-

146
 KAI ET AL
ably deviated toward the left side. Mandibular manipula-
tion after pumping and loading hydraulic pressure into
the upper joint cavity4 of the left TMJ resulted in recap-
ture of the displaced disk with palpable clicking of the
TMJ. The interincisal distance increased to 43 mm and
the bilateral condyles showed symmetrical translation.
The patient wore an anterior repositioning splint to
maintain the mandibular dental arch at an edge-to-edge
incisal position, in order to maintain the recaptured disk in
the correct position for 24 hours, even while eating. Three
days after the manipulation, spontaneous posterior open
bite in the premolar and molar region with intermaxillary
contact on the bilateral second molars was confirmed after
removal of the splint (Figure 1). The mandibular arch was
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located approximately 1.5 mm anterior to its position
before the treatment and was slightly posterior to the posi-
tion produced by the splint. The patient was able to
smoothly open her mouth up to 46 mm without any pain
or deviation of the mandible. Lateral transcranial radio-
graphy showed that the condyle was located centrally in
Figure 1
Posterior open bite of Case I after three days of anterior repositioning
splint therapy. A. The mandibular arch was located about 1.5 mm
anterior to that before treatment. B. There was intermaxillary contact
at the second molars bilaterally.
APRIL 1993, VOL. 11, NO. 2
POSTERIOR OPEN BITE
Figure2
Lateral transcranial radiograms of Case I. A. The left condyle was
located posterosuperiorly in the articular fossa before treatment.
B. The condyle was located centrally in the articular fossa after devel-
opment of the posterior open bite.
the articular fossa after the treatment, whereas it was
located posterosuperiorly before the treatment (Figure 2).
An arthrographic examination performed four weeks
after the manipulation revealed that the disk was superior
to the condyle even after removal of the splint (Figure 3).
After a slight walk back procedure, the splint was replaced
with a pair of silver splints cemented on the occlusal sur-
Figure3
Arthrotomograms of Case I with a posterior open bite shows the
complete recapture of the disk, even after removal of the splint:
A. At mouth closing; B. At mouth opening.
Figure4
Left lateral view of a silver splint cemented on the bicuspid and molar
region to fill the space of the open bite.
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 147
 POSTERIOR OPEN BITE KAI ET AL.

FigureS
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Occlusion after the final prosthetic treatment. The patient was able to
open her mouth smoothly up to 45 mm without pain or deviation of the
mandible.

faces of the posterior mandibular teeth to fill the space of

the open bite (Figure 4). Upon the confirmation of the
suitability of the silver splints, the final prosthodontic
treatment was performed (Figure 5). The patient was
able to open her mouth smoothly up to 45 mm without
pain or deviation of the mandible.

Case 2: A 15-year-old Woman

This patient had intermittent closed locking of the left Figure6

TMJ for six months. At the first visit, she exhibited two Two different occlusions in Case 2 with intermittent closed lock.
A. Occlusion when the patient was able to open her mouth up to 55
different maximal interincisal distances. Upon first open- mm interincisally. A posterior open bite was observed. B. Occlusion
ing her mouth, she experienced the sensation that her jaw when the patient was not able to open her mouth more than 40 mm
was caught and she was not able to open more than 40 interincisally. All teeth were uniformly in contact.(Reprinted with
permission from Sadako Kai: Evaluation of the treatment in young
mm. The second time she was able to open to 55 mm after people with an anteriorly displaced disk of the TMJ. Jap J Oral
an audible clicking sound. When she was able to open her Maxil/ofac Surg 1992; 38:134
mouth sufficiently, her posterior teeth were not in contact
together except at the bilateral second molar regions and
the incisal region (Figure 6A). When she clenched
strongly, the teeth were in uniform contact with an audi-
ble clicking sound (Figure 6B), and then she was unable
to smoothly open her mouth which required mandibular
manipulation.
This patient was treated with an anterior repositioning
splint for one month to stabilize the correct disk-condylar
relationship. The treatment was followed by functional
orthodontic treatment with a bionator, 5 which allowed
passive eruption of the posterior teeth and, thus, closed
the posterior open bite (Figure 7). After the treatment,
she had no signs of a displaced disk and was able to open
her mouth up to 58 mm interincisally.
Figure7
Case 3: A 25-year-old Woman Occlusion after the functional orthodontic treatment with a bionator.
(Reprinted with permission from Sadako Kai: Evaluation of the treat-
ment in young people with an anteriorly displaced disk of the TMJ.
This patient had reciprocal clicking in the right TMJ, Jap J Oral Maxillofac Surg 1992; 38: 134)

148 APRIL 1993, VOL 11, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
 KAI ET AL.
followed by a sudden restriction of mouth opening for
two weeks. At the first visit, the maximal interincisal dist-
ance on mouth opening was 22 mm, and the mandible
was remarkably deviated to the right. Examination along
with her history showed anterior disk displacement with-
out reduction of the right TMJ.
Mandibular manipulation was performed to recapture
the right disk. With an audible clicking sound, the maxi-
mal interincisal distance increased up to 42 mm and the
mandibular deviation disappeared. We had the patient
maintain the mandibular protrusive occlusion by wearing
an anterior repositioning splint at all times.
At the second visit, bilateral posterior open bite was
observed and the mandibular arch was located 2.5 mm
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anterior to its position before treatment (Figure 8). The
patient complained of continuous pain in the right TMJ,
the mandible deviated to the right on mouth opening, and
there was reduction of maximal interincisal distance to
36 mm. Subsequent continuous use of the splint produced
no improvement in these conditions. Bilateral arthro-
graphic examination seven weeks after the mandibular
manipulation revealed an anteriorly displaced disk with-
out reduction of the affected joint (Figure 9).
Since several attempts of manipulation failed to recap-
ture the disk, a flat occlusal splint was applied to maintain
the open bite space. Lateral transcranial radiography with
the mouth closed, splint in place, revealed adequate
condylar position in the articular fossa, and several adjust-
ments of the splint were performed. Further treatments
with the splint and the subsequent prosthodontic treat-
ments for six months resulted in resolution of the limited
mouth opening and pain in the TMJ and masticatory mus-
cles. She was able to open her mouth up to 45 mm without
pain, although crepitation of the TMJ was palpated.
Table 1 shows 15 patients with posterior open bite
Figure 8
Posterior open bite with the anterior repositioning splint in Case 3. The
mandibular arch was located 2.5 mm anterior in comparison with that
before treatment.
APRIL 1993, VOL. 11, NO. 2
POSTERIOR OPEN BITE
Figure9
Arthrotomogram of Case 3 performed seven weeks after the
mandibular manipulation with a posterior open bite shows the
anteriorly displaced disk without reduction: A. At mouth closing;
B. At mouth opening.
after anterior repositioning splint therapy. Before treat-
ment, 12 patients were diagnosed as having anterior disk
displacements without reduction. Only two of them
received an arthrographic examination before the treat-
ment. The clinical diagnoses, however, for the remaining
10 patients were reliable because they had histories of
previous clicking that disappeared immediately after a
sudden onset of limitation of mouth opening, and they
showed continuous deviated mouth opening to the symp-
tomatic side. In these 12 patients, the duration of the lock-
ing appeared to be short, ranging from three days to two
months. The mandibular manipulation produced a click-
ing sound and a subsequent remarkable increase in the
maximal interincisal distance without deviation of the
mandible upon mouth opening, indicating the successful
recapture of the disk.
Two patients were diagnosed as having anterior disk
displacements with reduction. Their obvious reciprocal
clicking on mouth movement disappeared by mandibular
protrusive repositioning. The remaining patient had
apparent symptoms of intermittent closed lock (Case 2).
An arthrographic examination after development of
the open bite was performed in 10 patients. Four patients
showed complete recapture of the disks, even after
removal of the splints. Four patients still had anteriorly
displaced disks without reduction, and they had no
improvement in clinical symptoms. In addition, the other
two patients had anteriorly displaced disks with reduc-
tion, although one of them showed partial recapture of the
disk at its medial position.
In the five patients without arthrographic examination
after the treatment, recapture of the disk was apparently
observed from such clinical findings as no deviation of
the mandible or clicking, symmetrical anterior translation
of the condyles, relief of pain in the TMJ and/or mastica-
tory muscles, and a sharp increase in the maximal interin-
cisal distance. It took little time to confmn the posterior
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 149
 POSTERIOR OPEN BITE KAI ET AL.

Table 1
Fifteen patients with posterior open bite
after anterior repositioning splint therapy
before treatment after development of posterior open bite
case age sex duration until postenor
diagnosis* duration of maximal interincisal diagnosis* maximal interincisal open bite was posterior
locking distance (mm) distance (mm) confirmed (days) contact
I 31 F AD 10 days 20 Nt 46 7 +
2 15 F AD(intermittent) - 40 N 58 +
3 25 F AD 14 days 22 ADt 36 10 +
4 26 F ADR 45 Nt 45 I
5 24 M AD 3 days 28 Nt 55 0 +
6 30 F ADR 43 Nt 43 30 +
7 16 F ADt 10 days 30 ADRt 46 7 +
8 21 F AD 8 days 29 ADRt 51 8 +
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9 47 F ADt 2 months 25 ADt 41 0 +

10 25 F AD 10 days 25 ADt 43 25 +
II 61 F AD 5 days 33 ADt 32 17 +
12 23 F AD 10 days 27 N 44 2 +
13 43 F AD 3 days 30 N 50 21
14 37 F AD 17 days 30 N 48 10
15 II F AD I month 29 N 54 0 +
*AD: anterior disk displacement without reduction.
ADR: anterior disk displacement with reduction.
N: normal disk-condylar relationship.
t arthrographically diagnosed.

open bite after the manipulation, ranging from immedi-
ately after the manipulation to 30 days after. However,
the exact time of onset of the open bite was unclear in the
majority of patients. While open bite was bilaterally
observed in some cases, all of the cases had the unilateral
displaced disk.
Discussion
loose organized connective tissue which is not designed
for loading. The posterior attachment is compressed
between the condyle and the fossa when the disk is dis-
placed anteriorly. If the disk is recaptured correctly, the
posterior band is at the 12 o'clock position of the condyle
at mouth closing. This change results in increased joint
space dimension between the condyle and the fossa,
especially in the posterosuperior portion of the joint. In

The anterior repositioning splint used in this study was

applied to the maxillary arch and had a lingual ramp at its
anterior portion to guide the anterior mandibular teeth recapture of the disk
anteriorly (Figure 10). This splint maintains the disks in
the correct position by positioning the condyles forward,
if effectively applied.6- 8
Farrar and McCarty 2 defined internal derangement of
the TMJ as anterior displacement of the disk associated
with posterosuperior displacement of the condyle when
the teeth are closed in occlusion. Apart from the condylar
position within the fossa before treatment, there must
necessarily be spatial changes in the condyle if the disk
has been recaptured completely. Since the patients in this
study had a relatively short duration of locking, ranging protrusive position
ramp
from three days to two months, the disk is thought to have of the mandible
maintained its original shape, as shown in the arthroto-
mogram, (i.e. the posterior band of the disk was thicker Figure 10
The anterior repositioning splint has a lingual ramp at its anterior
than the other parts of the disk). portion to keep the mandibular arch in the forward position and to
On the other hand, the posterior attachment consists of maintain the disk in the recaptured position.

150 APRIL 1993, VOL. 11, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
 KAI ET AL.
other words, replacement of the posterior attachment
with the posterior band should reposition the mandible
anteroinferiorly.
There has been no report of posterior open bite after
surgical correction of disk position (disk plication
surgery). On the other hand, the postoperative arthro-
graphy or magnetic resonance imaging (MRI) shows fre-
quent recurrence of anteriorly displaced disk after
plication surgery. 9· 10 It seems that the recurrence depends
on insufficiency in the joint space to maintain the recap-
tured disk in the correct position. Thus, the necessity of
occlusal rehabilitation is suggested.
Most patients did not recognize the onset of the poste-
rior open bite because we instructed them to not attempt to
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place the posterior teeth in contact after the removal of the
splint. However, it is believed that the open bite occurred
immediately after complete recapture of the disk in such
cases. This conjecture was evidently demonstrated in
Case 2 (a 15-year-old woman who had intermittent closed
lock with two different occlusions). Accordingly, a poste-
rior open bite is definitely not an undesirable side effect of
splint therapy, but shows the occlusal disorders which
causes the disk to slip from the condyle.
Lundh et al. 11 stated that a favorable effect of the ante-
rior repositioning splint is short duration. The majority of
patients reported pain and clicking and demonstrated ten-
derness following removal of the splint after six weeks of
treatment. More permanent devices were needed to stabi-
lize the mandible in an anterior position, thereby main-
taining the recaptured disk in a normal relation to the
condyle. Generally, the tedious walk back procedure 12· 13
requires much time to select a position as far posteriorly
as possible without displacing the disk anteriorly. The
presence of the posterior open bite shortens the procedure
because occlusion with an open bite closely represents
the final anteroposterior position of the mandible after the
occlusion is restored.
A correct disk-condylar relationship failed to be main-
tained in patients with anteriorly displaced disks after the
occurrence of posterior open bite. However, the open bite
does not appear to be an undesirable condition, because it
increases the joint space; especially in the postero-
superior portion, where the stretched posterior attach-
ment tissue exists under excessive loading from occlusal
forces. Increased joint space may be favorable to prevent
destructive changes of the disk and posterior attachment.
We followed the course of symptoms in 35 patients
with persistent anteriorly displaced disks which failed to
be ultimately recaptured by mandibular manipulation. 14
These patients received conservative therapy with flat
occlusal splints in order to: (a) eliminate hyperactivity of
the masticatory muscles, and (b) achieve sufficient joint
APRIL 1993, VOL 11, NO. 2
POSTERIOR OPEN BITE
space in which the posterior attachment tissue might
functionally adapt to the altered intracupsular conditions.
Excellent results were obtained in 94% of the patients
concerning the range of maximal mouth opening and pain
in the TMJ and masticatory muscles: excluding the fact
that crepitation gradually occurred during the treatment.
The development of an open bite may depend on the
duration of splint wear. This is because a posterior open
bite frequently occurred in patients with anteriorly dis-
placed disks without reduction before treatment, who had
to wear the splint at all times to stay unlocked and to
avoid recurrent locking. The explanation for this may be
that the continuous anterior position of the condyle may
surpass the volumetric expanding capacity of the poste-
rior disk attachment, 15 and the deficit so created increases
the volume of joint fluid in the upper joint cavity. There
is also a possibility that long-standing application of the
splint decreases or eliminates hyperactivity or hyper-
tonicity of the elevator muscles, such as the masseter or
temporal muscles resuspending the mandible beneath the
cranial base, thereby causing the posterior open bite.
These alterations may even enhance the degree of open
bite in patients with completely recaptured disks and
occurrence of open bite in the contralateral side.
The possibility that the open bite was due to intrusion
of the posterior teeth was excluded in this study by com-
paring the models before and after treatment, and because
the patients had such a short duration of splint therapy
until the presence of a posterior open bite was confirmed.
Additionally, when the occlusion with posterior open
bite had one or more intermaxillary contacts in the molar
region, the stability appeared to be obtained more easily
than when occlusion without contacts resulted. The sta-
bility resulting from this posterior contact may influence
development of the posterior open bite on the contralat-
eral side in which the disk has not been displaced. Indeed,
most of the patients had unilateral or bilateral contacts at
the second molar. It goes without saying that these con-
tacts should not be equilibrated, as their removal may
induce recurrent displacement of the disk or pain due to
loss of the occlusal stability they provide.
Conclusion
This study indicates that complete recapture of an ante-
riorly displaced disk changes the maxillomandibular rela-
tionship between the jaws, resulting in a posterior open
bite in patients with a short duration of locking. This
change shows the occlusal compensations causing or
contributing to the displacement of the disk. The occlu-
sion change occasionally occurs when the disk is not
recaptured because the maxillomandibular relationship
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 151
 POSTERIOR OPEN BITE
has been made more normal. Clinicians should pay atten-
tion to this resulting change in occlusion and symptoms
of TMJ disorder in the course of treatment with the ante-
rior repositioning splint in order to select the most
suitable mandibular position (maxillomandibular
relationship).
Acknowledgements
The authors wish to thank Dr. Y. Yamasaki. Department of
Pediatric Dentistry, Faculty of Dentistry, Kyushu University, for
performing the orthodontic treatment in Case 2. The authors also
acknowledge Dr. S. Nakashima, Second Department of Prosthetic
Dentistry, Faculty of Dentistry, Kyushu University, for performing
the final prosthetic treatment in Case I.
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Dr. Osamu Tabata recei1•ed his D.D.S. degree from Kyushu University
in 198/. He has been an instructor in the Department of Oral and
Maxillofacial Radiology. Faculty of Dentistry. Kyushu University since
/98/. He is a member of the Japanese Society of Oral Maxillofacial
Radiology and the Japanese Society ofTMJ. Dr. Tabata has focused his
professional interest on TMJ disorders.
Dr. Hideo Tashiro graduated from the Medical Faculty of Kyushu
University in 1955. He then recei1•ed training in general surgery. neuro-
surgery. dentistry. and oral maxillofacial surgery at Kyushu University.
plastic surgery at Tokyo Metropolitan Police Hospital, and oral and
maxillofacial surgery at Dusseldorf University, Germany. Dr. Tashiro
was a professor and chairman of the Department of Oral and Maxillo-
facial Surgery, Faculty of Dentistry at Kyushu University in 1974 and
served as the Director of the University Dental Hospital from /979 to
1982. From 1985 to /989, he was the Dean of the Dental Faculty at
Kyushu University. Dr. Tashiro sen•ed as President of the Japan Society
of Head and Neck Cancer in 1977, the Japanese Stomatological Society
in 1986, and the Japanese Cleft Palate Association in /988.
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE