CASE REPORT

Diagnostic and treatment protocol for a

patient with temporomandibular disorder
using a stabilization splint and temporary
anchorage devices
Mengyuan Zhao,a Peiqi Wang,b Hongzhe Wang,b Xiaoqing Li,c Ding Bai,b and Ye Tianb
Beijing, and Chengdu, Sichuan, China

Treatment of orthodontic patients with temporomandibular disorder (TMD) is challenging for orthodontists
because of the TMD signs and symptoms and unstable mandible position, which may lead to improper diagnosis
and treatment design. This case report presents a 22-year-old woman with proclined maxillary incisors and TMD.
First, stabilization splint therapy was implemented to eliminate temporomandibular joint pain and to obtain the
stable adapted centric posture. Subsequently, orthodontic treatment was initiated on the basis of a definitive
diagnosis made from the postsplint records. Temporary anchorage devices were used to intrude maxillary mo-
lars and distalize the maxillary dental arch. Favorable soft tissue, skeletal, and dental relationship were accom-
plished after 12 months of comprehensive orthodontic treatment. Functional occlusion was established with
teeth as well as vacuum-formed retainers. Excellent posttreatment stability was maintained after a 20-month
retention. (Am J Orthod Dentofacial Orthop 2021;159:666-81)

T
emporomandibular disorder (TMD) is a compre-
hensive term that encompasses a group of muscu-
loskeletal and neuromuscular conditions that
involve the temporomandibular joint (TMJ), the masti-
catory muscles, and all related tissues.1,2 Although
poorly understood, the etiology of TMD is believed to
be multifactorial, involving factors such as genetic fac-
tors, psychological factors, and anatomic factors. Pain
in the masticatory musculature and TMJ area, limited
a
Institute of Dental Research, and Department of Orthodontics, Beijing Stomato-
logical Hospital, School of Stomatology, Capital Medical University, Beijing,
China.
b
State Key Laboratory of Oral Diseases, and National Clinical Research Center for
Oral Diseases, and Department of Orthodontics and Pediatric Dentistry, West
China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China.
c
State Key Laboratory of Oral Diseases, and National Clinical Research Center for
Oral Diseases, and Department of Oral Anatomy and Physiology, West China Hos-
pital of Stomatology, Sichuan University, Chengdu, Sichuan, China.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Ye Tian, State Key Laboratory of Oral Diseases, and
National Clinical Research Center for Oral Diseases, and Department of Ortho-
dontics and Pediatric Denistry, West China Hospital of Stomatology, Sichuan
University, #14, 3rd Section of Renmin South Road, Chengdu 610041, Sichuan,
China; e-mail, tianye@scu.edu.cn.
Submitted, January 2020; revised and accepted, May 2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.05.015
mouth opening, and clicking or crepitus during jaw
movement are common signs and symptoms of TMDs.1
Despite that the connection among occlusal factors,
condylar position, and TMD remains part of an extensive
discussion, multiple occlusal risk factors have been identi-
fied to be closely associated with TMD, with uncertain
recognition of their cause-and-effect relationship.2 It has
been demonstrated by numerous studies that when the
centric slide, defined as “the movement of the mandible
while in centric relation (CR), from the initial occlusal con-
tact into maximal intercuspal position (MIP),” reaches a
certain value, usually 2 mm, it could be correlated to
TMD.3,4 In addition to the related signs and symptoms, a
large centric slide can also be troubling because the
discrepancy between the 2 positions may interfere with
the proper diagnosis and treatment planning.5
It is widely believed that no aggressive, irreversible
occlusal treatment should be given to patients with
TMD when the disease is in the active stage.1 The therapy
begins with the release of the TMD symptoms, the pause
of condylar resorption, and confirmation of a reliable
mandibular position for occlusal treatment.6
A stabilization splint can provide temporary ideal oc-
clusion to eliminate occlusal factors and reduce
abnormal muscle activity. It is sometimes called a muscle
relaxation appliance because it can effectively reduce
muscle pain.2,7 Furthermore, a stabilization splint allows

666
Zhao et al
the condyles to sit in their most musculoskeletally stable
position by reproducing functional occlusion.8
In the present case report, we demonstrate the 2-
phase treatment of a female patient with TMD and a
large centric slide. Alleviation of TMD symptoms and
stable, functional occlusion were achieved by stabiliza-
tion splint therapy and subsequent nonsurgical ortho-
dontic treatment.
DIAGNOSIS AND ETIOLOGY
The patient, a 22-year-old woman, had a chief
complaint of maxillary incisor protrusion and jaw pain.
She also mentioned joint noises, limited opening, and
pain in front of the ears on both sides occasionally for
over 3 years. The jaw pain was greater in the morning
and during mastication. She claimed no history of dental
trauma and orthodontic treatment but admitted sleep
bruxism and unilateral mastication.
Clinical examination revealed a convex facial profile,
hyperdivergent mandible, and skeletal Class I relation-
ship (Fig 1). The maxillary dental midline was coincident
with the facial midline, whereas the mandibular midline
was shifted to the right by 1.5 mm. Meanwhile, her chin
point was deviated to the right side.
Intraoral and dental cast examination showed an
Angle Class I molar relationship bilaterally with normal
anterior overbite and overjet (Fig 1). There was mild
crowding in both dental arches with maxillary incisor
procumbency.
The cephalometric analysis (Fig 2) revealed a skeletal
Class I relationship (ANB, 3.5
) with a hyperdivergent
growth pattern (SN-MP, 41.0
). Normal interincisal
angle was obtained by proclined maxillary incisors and
reclined mandibular incisors (U1-L1, 121.1
; U1-SN,
108.2.0
; L1-MP [IMPA], 90.0
). The panoramic radio-
graph showed that all teeth were present except the
maxillary left third molar. There were mild root resorp-
tions of both maxillary central incisors, the crooked
root of maxillary second premolars, and abnormal
condyle shape on the left side.
The TMJ evaluation was performed in accordance with
the diagnostic criteria for TMD guidelines.9 We revealed
bilateral crepitus in her TMJ during mouth opening and
closing. The distance of maximal mouth opening was
41 mm, and excursive and protrusive movements were
longer than 8 mm. Moderate pain in the lateral pole of
TMJ on both sides and anterior aspect of temporalis mus-
cle on the left side was detected with palpation. Mean-
while, the obvious centric slide was discovered by the
bilateral manual manipulation technique, according to
Dawson.8 This indicated a discrepancy of condylar
position between CR and MIP. Cone-beam computed
American Journal of Orthodontics and Dentofacial Orthopedics
667
tomography (CBCT) scans were reconstructed into
3-dimensional images with Dolphin Imaging software
(version 11.8, Dolphin Imaging and Management Solu-
tions, Chatsworth, Calif). The long axis of the condyle
was determined, and the vertical plane bisecting the
long axis was defined as the sagittal section.10 The
CBCT images showed a discontinued cortical layer of
the condylar head on the left side (Fig 2). Magnetic reso-
nance imaging (MRI) of the TMJs demonstrated that on
either side of the TMJ, the posterior band of the disc
was located anterior to the condylar head in the MIP,
with the intermediate zone located between the articular
eminence and the condylar head during maximal mouth
opening (MRI data missed). On the basis of these findings,
the patient was diagnosed with arthralgia at both sides of
the TMJ, degenerative joint disease in both TMJs, local
myalgia in the left temporalis, and anterior disc displace-
ment with reduction of both TMJs.
On the basis of the data, a definitive diagnosis should
be made after the stabilization of the mandibular posi-
tion. The patient was advised to chew on both sides
alternatively. Meanwhile, a full-time maxillary stabiliza-
tion splint was prescribed to the patient to achieve a
musculoskeletally stable position.
After 9 months of stabilization splint therapy, a sta-
ble, comfortable jaw position was determined. No
discomfort was discovered during the load testing. Given
that the patient had bilateral anterior disc displacement
with reduction, this stable completely seated condylar
position was more appropriate to be described as adapt-
ed centric posture rather than CR.8,11 Postsplint records
for definitive diagnosis were taken, including intraoral
photographs, cephalograms, and CBCT scans (Figs 3
and 4). Split casts were mounted on a semiadjustable
articulator and then scanned (Fig 4). Cephalometric
and CBCT superimpositions showed a clockwise rotation
of the mandible and a posterosuperior shift of the con-
dyles (Fig 3). The CBCT image showed an improved
cortical continuity of the left condylar head. Three treat-
ment goals were achieved through stabilization splint
therapy: (1) both condyles were completely seated in a
musculoskeletally stable position, (2) pain in TMJ and
masticatory muscle were eliminated, and (3) no progres-
sive condylar resorption was discovered.
After splint therapy, this patient was diagnosed with
an Angle Class II malocclusion with skeletal Class II base,
deep overjet, anterior open bite, mandibular midline de-
viation, and degenerative joint disease at left TMJ.
TREATMENT OBJECTIVES
The treatment objectives were to (1) align and level
both dental arches, (2) obtain an Angle Class I molar
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668 Zhao et al

Fig 1. Pretreatment facial and intraoral photographs and dental casts.

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Zhao et al 669

Fig 2. Pretreatment radiographs. A, lateral cephalogram; B, panoramic radiograph; C, CBCT image of

both TMJs. R, right TMJ; L, left TMJ.

Fig 3. Postsplint treatment radiographs: A, lateral cephalogram; B, cephalometric superimposition;

C, CBCT image of both TMJs. R, right TMJ; L, left TMJ.

American Journal of Orthodontics and Dentofacial Orthopedics May 2021  Vol 159  Issue 5
670 Zhao et al

Fig 4. Intraoral photographs and dental casts mounted in the adapted centric posture of postsplint
treatment.

and canine relationship, (3) coordinate dental midlines,
(4) rotate mandible counterclockwise for the improve-
ment of facial esthetics, (5) establish ideal anterior over-
bite and overjet, (6) monitor the condylar position
closely and shorten orthodontic treatment duration, (7)
achieve functional occlusion after orthodontic treat-
ment with and without retainers, and (8) give up unilat-
eral chewing habit.
TREATMENT ALTERNATIVES
Two treatment options were considered for this pa-
tient. The first option was combined orthognathic
surgery and orthodontic treatment. LeFort I osteotomy
for maxilla uplift and bilateral sagittal split ramus os-
teotomy for mandibular advancement and counter-
clockwise rotation were designed. This treatment
option would be favorable for the correction of the skel-
etal discrepancy and improvement of facial and smile es-
thetics. The second option involved camouflage
orthodontic treatment without extraction. The intrusion
of the maxillary posterior teeth by using TADs was de-
signed to achieve counterclockwise rotation of the
mandible. Meanwhile, TADs could also provide direct
anchorage for the distalization of the maxillary dental

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Zhao et al 671

Fig 5. Occlusal adjustment of the stabilization splint to reproduce mutually protected occlusion: A, the
final occlusal surface presents simultaneous centric contact in adapted centric posture and suitable
anterior guidance during protrusive and lateral excursive movements of the mandible; B, centric con-
tact; C, protrusive movement; D, left excursive movement; E, right excursive movement.

arch to alleviate an Angle Class II relationship, excess
anterior overjet, and maxillary incisor procumbency.
Three of the third molars were suggested to be extracted
no matter which treatment was chosen. The patient
refused orthognathic surgery because of concerns of
the surgery-related risks and high treatment costs and
thus decided on the second option.
TREATMENT PROGRESS
To relax the masticatory muscle and locate the mus-
culoskeletally stable position of the condyles, an anterior
deprogramming splint was prescribed to the patient
before the stabilization splint was fabricated. The initial
musculoskeletally stable position was determined by
bilateral manual manipulation technique, and the ante-
rior deprogramming splint provided even contact of
mandibular anterior teeth to the splint and guidance
of protrusive and excursive movements. Because the
posterior disocclusion eliminated the existing occlusal
condition and muscle engrams associated with muscular
protection, it allowed the complete seating of the con-
dyles in their musculoskeletally stable position. After
1 week of splint use, the refined musculoskeletally stable
position was acquired and was double-checked with the
bilateral manipulation technique, which may be more

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672 Zhao et al

predictable and accurate to fabricate the stabilization
splint.12,13 Then, the acrylic resin was added to the
occlusal surface of the splint to fabricate a stabilization
splint on the basis of this jaw relationship. The stabiliza-
tion splint provided a smooth surface for all buccal cusps
or incisal edges of mandibular teeth to contact against
and provided immediate disocclusion of posterior teeth
in all protrusive and excursive jaw movement (Fig 5).
The bite marks on the occlusal surface of the splint
were checked and adjusted after 1 week, 3 weeks, and
every month afterward to ensure a mutually protected
occlusion. With the use of stabilization splint, the jaw
relationship gradually shifted as indicated by the contin-
uous changing of the anterior relationship and bite
marks on the occlusal surface of the splint (Table I). A
2.5 mm increase of anterior overjet and 1 mm decrease
of anterior overbite were detected after 3 months of
treatment and remained stable afterward. Her mandib-
ular dental midline deviation was decreased, as shown
by intraoral photographs (Figs 1 and 4). No discomfort
was discovered in this jaw relationship during the load
testing experiment. The pain of muscle or joint origin
showed gradual improvement and was eliminated after
6 months of splint therapy. The stable, comfortable,
adapted centric posture (final musculoskeletally stable
position) was determined by stabilization splint therapy.
The patient reported that she had quit unilateral masti-
cation. However, the bilateral crepitus remained un-
changed during the whole treatment duration.
Orthodontic treatment began after 9 months of stabi-
lization splint therapy. Our TADs (diameter, 1.6 mm;
length, 10 mm; Ormco Corp, Glendora, Calif) were placed
in the palatal alveolar bone mesially and distally to maxil-
lary first molar bilaterally, and another 4 (diameter,
1.6 mm; length, 8 mm; Ormco Corp) were placed in the
corresponding positions on the buccal side. All third mo-
lars had been extracted before starting the orthodontic
treatment. Subsequently, both arches were bonded with
self-ligating brackets (0.022 3 0.028-in; Masel, Carlsbad,
Calif) and were aligned with sequenced 0.014, 0.016,
0.018, 0.016 3 0.025-in nickel-titanium archwires. After
progressing to 0.018 3 0.025-in nickel-titanium arch-
wire, elastic power chains were placed bilaterally from
buccal to palatal TADs over the occlusal surface of maxil-
lary first molars to create a directly vertical intrusive force.
Two elastic power chains were used on each side and
formed an X shape from the occlusal view. Intrusive
movement of maxillary posterior teeth was evident after
6 months of active treatment, as indicated by the
decreased length of the clinical crown of these teeth
(Fig 6, A). However, the Angle Class II relationship and
large overjet barely changed. This phenomenon was
partially caused by the presence of glass ionomer cement
(3M Unitek, 3M Dental Products, Monrovia, Calif) bite-
blocks on mandibular molars, which were used to protect
buccal tubes of mandibular second molars from bite force.
After 7 months of orthodontic treatment, a
0.018 3 0.025-in stainless steel archwire was used in
the maxillary arch, and then the nickel-titanium closed
coil springs were applied to distalize the whole maxillary
dentition (Fig 6, B). Active molar intrusion lasted for
4 months and was retained with the lighter force for
another 3 months, and maxillary arch retraction lasted
for 3 months and was retained with 0.25 mm ligation
wire until the end of the active orthodontic treatment.
Angle Class I molar relationship and ideal anterior overjet
and overbite were achieved after 10 months of treatment
(Fig 6, C). At this point, no occlusal contact was found be-
tween the mandibular right first premolar and the
opposing teeth. Then, extrusion of the mandibular right
first molar was accomplished in another 2 months to
obtain ideal occlusal contact of all teeth.
The active orthodontic treatment lasted for
12 months. Mandible position was checked again by
bilateral manipulation, and coordination was found be-
tween MIP and adapted centric posture. Selective
grinding was performed to establish functional occlu-
sion before appliances were removed. Then, modified
vacuum-formed retainers were fabricated for both
arches with two 1-mm-thick hard, clear acrylic resin

Table I. Progress note of the stabilization splint therapy

Duration Anterior OJ and OB TMD symptoms TMJ Noises CBCT
Pretreatment 5.5 mm; 2.4 mm Moderate pain in TMJ on Bilateral crepitus Discontinued cortical layer
both sides and temporalis of the left condylar head
muscle on left side
1 mo 6.5 mm; 1.9 mm No change No change
3 mo 8.0 mm; 1.4 mm Mild pain in TMJ of left side No change
6 mo 8.0 mm; 1.4 mm No pain in TMJ or masticatory No change
muscle
9 mo 8.0 mm; 1.4 mm No pain in TMJ or masticatory No change Improved cortical continuity
muscle of left condylar head

OJ, Overjet; OB, overbite.

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Zhao et al
Fig 6. Progress of orthodontic treatment: A, intrusion of the maxillary molars with TADs; B, distalization
of the whole maxillary dental arch; C, Angle Class I molar relationship with proper anterior overbite and
overjet.
sheets of material. Autocuring acrylic was added to the
occlusal surface of the maxillary retainer with similar
fabrication procedures of stabilization splint, which pro-
vided even contact of all incisal edges and buccal cusps
to the occlusal surface and eccentric guidance. The pa-
tient was instructed to wear the retainer full time for
1 year and then at night for the next 1 year.
TREATMENT RESULT
A more attractive facial profile, aligned dental arches,
excellent interdigitation, improved condition of TMJ,
and stable mandibular position were achieved through
9-month splint therapy and 20-month comprehensive
orthodontic treatment (Fig 7).
The patient was very satisfied with the improvement
of her facial esthetics (Fig 7). Her chin point deviation
was decreased after treatment. Her proclined maxillary
central incisors were aligned and retracted, leading to
a more appealing lip contour. An ideal Angle Class
I occlusion was achieved, namely, a normal anterior
overbite and overjet, a U-shaped dental arch form, and
a satisfactory alignment. Both maxillary and mandibular
midline was coincident with the facial midline.
The cephalometric analysis and superimposition
showed some interesting changes in this 2-phase treat-
ment (Figs 8 and 9). Comparisons between pretreatment,
postsplint, and posttreatment cephalometric analysis
American Journal of Orthodontics and Dentofacial Orthopedics
673
were shown in Table II. There was a backward and up-
ward movement of the condyles and a slight clockwise
rotation of the mandible after stabilization splint ther-
apy, which resulted in a skeletal Class II relationship
and deep anterior overjet and open bite. However, after
orthodontic treatment, the anteroposterior discrepancy
was alleviated (ANB decreased from 5.4
to 3.1
) by
counterclockwise rotation of the mandible in response
to the maxillary molar intrusion and retraction of maxil-
lary anterior teeth. The vertical growth pattern was also
improved, as indicated by the decrease of SN-MP angle
from 41.9
to 40.0
. The condylar position remained sta-
ble, and only rotation occurred in the mandible. Maxil-
lary incisors were significantly retruded (U1-SN
decreased from 108.3
to 95.3
), and upright mandib-
ular incisors were proclined (LI-MP increased from
90.3
to 97.3
), which led to a more appropriate U1-
L1 angle of 126.6
after treatment.
The posttreatment panoramic radiograph (Fig 8, C)
showed that no further root resorption occurred in the
maxillary central incisors. The crooked root of maxillary
second premolars and abnormal contour of left condyle
remained similar to the pretreatment status.
Throughout the 12-month orthodontic treatment,
there was no recurrence of limited opening or pain in
the joint and masticatory muscle. Meanwhile, MIP was
coordinated with adapted centric posture, and no centric
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674 Zhao et al

Fig 7. Posttreatment facial and intraoral photographs and dental casts.

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Zhao et al 675

Fig 8. Posttreatment radiographs: A, lateral cephalogram; B, lateral cephalogram tracing; C, pano-

ramic radiograph; D, CBCT image of both TMJs; E-F, MRI of both TMJs, disc (arrow) at both TMJs
in sagittal view of closed-mouth position (E) and open-mouth position (F). R, right TMJ; L, left TMJ.

slide was present. Favorable anterior and lateral guid-
ance were established during mandibular protrusive
and lateral excursive movements with or without re-
tainers (Fig 10). Posttreatment CBCT images (Fig 8, D)
showed that both condyles were seated centrally in the
glenoid fossae, and cortical continuity of the condylar
heads was improved. However, the crepitus of both
TMJs during jaw movement remained unchanged. MRI
of both TMJs demonstrated anterior disc displacement
with reduction, which was similar to the pretreatment
condition (Fig 8, E and F).
A stable jaw position and occlusion with well-aligned
teeth were maintained after 20 months of retention (Fig
11 and Supplementary Fig 1). The CBCT superimpositions
focusing on condyle movement of pretreatment, postsplint,
posttreatment and after retention were showed in
Supplementary Figure 2. No discomfort or pain in TMJ
and masticatory muscle reoccurred. The cortical layer of

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676 Zhao et al

Fig 9. Cephalometric superimposition of pretreatment, postsplint, and posttreatment: A, cranial base

superimposition; B, maxillary superimposition and mandibular superimposition.

the patient's condyles was thicker and smoother than the
posttreatment period (Fig 12).
DISCUSSION
Accurate diagnosis and treatment plan are the keys to
successful orthodontic treatment, whereas centric slide
can be a big confounding factor that prevents orthodon-
tists from making correct decisions. The mechanisms by
which centric slide leads to TMD development have been
proposed by Roth14 and Dawson.8 They declared that
when a centric slide exists, the inferior lateral pterygoid
contracts nonphysiologically and pull the condyles out
of CR to achieve maximal intercuspation position during
mouth closing. This leads to hyperactivity of elevator
muscles and imbalance between elevator and depressor
muscles, which in turn cause masticatory muscle pain,
articular disc derangement, intracapsular disorder, and
even condylar resorption.
The patient had pain in TMJ and masticatory muscle,
obvious centric slide, and condylar resorption in the first

Table II. Cephalometric measurements at pretreatment, postsplint, and posttreatment

Measurements Norm (mean 6 SD) Pretreatment Postsplint Posttreatment
SNA (
) 83.0 6 3.0 82.2 81.7 80.7
SNB (
) 80.0 6 3.0 79.3 76.6 77.6
ANB (
) 3.0 6 1.0 3.9 5.1 3.1
SN-MP (
) 33.0 6 4.0 41.0 41.9 40.0
MP-FH (
) 28.0 6 4.0 31.9 32.5 30.5
U1-L1 (
) 127.0 6 9.0 121.1 122.3 126.6
U1-SN (
) 105.0 6 6.0 108.2 108.3 95.3
U1-NA (mm) 4.0 6 2.0 10.0 10.1 4.7
U1-NA (
) 21.0 6 6.0 28.1 28.1 15.1
L1-NB (mm) 6.0 6 2.0 4.4 7.1 8.1
L1-NB (
) 28.0 6 6.0 30.5 25.7 35.8
L1-MP (
) 95.0 6 7.0 90.0 90.3 97.3
UL-EP (mm) 2.0 6 2.0 1.0 2.0 0.3
LL-EP (mm) 3.0 6 2.0 2.0 2.0 1.5
Norm, normal values; SD, standard deviation.

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Zhao et al 677

Fig 10. Functional occlusion with or without modified clear retainers: A-C, posterior disclusion during
protrusive, left and right excursive movements; D-F, posterior disclusion during protrusive, left and right
excursive movements with modified clear retainers.

visit. Whether condylar resorption was in the active
phase or in the burn-out phase remained unknown,
and therefore aggressive, irreversible occlusal treatment,
such as orthodontic treatment, should be avoided.15 To
eliminate TMD symptoms, find a stable jaw relationship,
and observe changes of condylar resorption, we pre-
scribed anterior deprogramming splint and stabilization
splint to this patient. The anterior deprogramming splint
provided even contact of the mandibular anterior teeth
to the splint and guidance of protrusive and excursive
movement, which can be the best strategy to relax hy-
peractivated masticatory muscles and allow the condyles
to assume their most musculoskeletally stable posi-
tion.2,8 The latest network meta-analysis concluded

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678
Fig 11. Facial and intraoral photographs at the 20-month retention follow-up.
that mini-anterior splints (similar to anterior depro-
gramming splint in mechanism) were the highest-
ranked treatment for myogenous TMDs.16 However,
the long-term use of anterior deprogramming splint
was believed to allow the uncovered teeth to erupt and
then lead to deterioration of hyperdivergent growth
pattern. So, we only prescribed an anterior deprogram-
ming splint to this patient for 1 week (usually 3 weeks).
Through splint therapy, pain in TMJ and masticatory
muscle was relieved, and a stable mandible position
was acquired. Postsplint records showed a clockwise
rotation of the mandible and posterosuperior shift of
the condyles, and no progressive condylar resorption
was present according to the CBCT result. Bilateral crep-
itus and anterior disc displacement with a reduction in
her TMJ persisted throughout the whole treatment pro-
cess. Nevertheless, it has been suggested that no further
treatment was needed for patients with painless clicking
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Zhao et al
TMJs.1 Previous studies revealed that a displaced disc
could not be recaptured to a normal position with stabi-
lization splint therapy, but the use of this splint would
promote the formation of a pseudodisc on the posterior
band of the disc in patients with disc displacement.8,17
The splint therapeutic process provided a reliable way
to identify the stable condylar position and reveal the
true malocclusion, which was the key to design a proper
treatment plan.
To correct these malocclusions, a treatment plan
containing maxillary molar intrusion and distalization
of the whole maxillary dental arch with TADs was
made for the patient. Several studies have confirmed
the effectiveness of TADs in treating open-bite patients
through molar intrusion.18,19 The mandibular plane was
reported to be rotated by more than 3.5
with regard to
absolute molar intrusion with TADs.19,20 Meanwhile,
distalization of the whole dental arch with TADs has
Zhao et al
Fig 12. Radiographs of the 20-month retention follow-up: A, lateral cephalogram; B, panoramic radio-
graph; C, CBCT image of both TMJs.
been widely used to compensate mild to moderate skel-
etal malocclusion in patients with Class I, Class II, and
Class III jaw relationships.21-23 As shown in the
cephalometric superimposition (Fig 9), considerable
maxillary molar intrusion and distalization were
achieved, accompanied by correction of Angle Class II
relationship to Class I relationship. In addition, we ob-
tained an approximately 2
of counterclockwise rotation
of the mandible with solely molar intrusions of the
maxilla. A reduction of the facial height and improve-
ments of esthetics were achieved within 12 months of
orthodontic treatment. The relatively short orthodontic
treatment duration would lessen the risk of recurrence
of TMD symptoms because of unstable occlusal contact
during tooth movement.
Tracing the movement of the condyles throughout
the treatment process is vital for patients with unstable
TMJs. The condylar position indicator is widely used to
determine condylar displacement in 3-dimensions be-
tween CR and MIP.24,25 It can monitor the condylar
movement in an accurate and visualized way during
the stabilization splint treatment process.26 We observed
the condylar movement in serval substitute ways: ante-
rior overjet and overbite, bite mark changes of the splint
during splint therapy, and cephalometric and CBCT su-
perimposition at each treatment stage. The condylar po-
sition can be traced throughout the whole treatment
process regardless of changes in teeth alignment.
The etiology of sleep bruxism is multifactorial,
including exogenous factors, such as stress, anxiety,
American Journal of Orthodontics and Dentofacial Orthopedics
679
and occlusal interference, as well as endogenous fac-
tors involving neurotransmitters of the basal ganglia.27
No neurologic, psychiatric, or sleep disorder was pre-
sent in documented or self-reported history of this pa-
tient. Okeson28 demonstrated that 80% of subjects had
a significant reduction of nocturnal electromyogram
activity using a hard stabilization splint. Although its
role in the long-term reduction of sleep bruxism re-
mained debatable because of insufficient evidence,29
many short-term studies supported the efficiency of
stabilization splint treatment for sleep bruxism through
its positive effect on temporomandibular symptom and
sleep quality.30,31 The jaw pain in the morning was also
eliminated after 6 months of stabilization splint ther-
apy, which indicated that the sleep bruxism activity
might be reduced. Meanwhile, we prescribed modified
clear retainers to this patient. In addition to the reten-
tion effect, these retainers provided functional occlu-
sion similar to stabilization splint, which would be
beneficial for the reduction of sleep bruxism and mus-
cle hypersensitivity. They could at least protect teeth
from attrition during clenching or grinding, which
cannot be achieved by either fixed lingual retainers or
Hawley's retainer.
CONCLUSIONS
The successful and high-efficient correction of this
patient with TMD with a centric slide depended on pre-
cise orthodontic diagnosis and a rational treatment
design. Stabilization splint therapy provided a reliable
May 2021  Vol 159  Issue 5
680
way to eliminate TMD symptoms and identify the true
mandibular position. TADs performed effectively for
maxillary molar intrusion and maxillary dental arch dis-
talization, which brought the counterclockwise rotation
of the mandible and the consequent improvement of
facial esthetics.
ACKNOWLEDGMENTS
This work was supported by the National Natural Sci-
ence Foundation of China (Grant No. 82071146 and No.
81700929). The authors thank Dr Sai Ma for the help
with 3D reconstruction of CBCT, and also thank Dr
Chenlei Dou for providing some important references.
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2020.05.015.
REFERENCES
1. de Leeuw R, Klasser GD, editors. Orofacial pain: guidelines for
assessment, diagnosis, and management. 6th ed. Batavia: Quintes-
sence Publishing; 2018.
2. Okeson JP. Management of temporomandibular disorders and oc-
clusion-e-book. 8th ed. St Louis: Elsevier Health Sciences; 2019.
3. Song F, He S, Chen S. Temporomandibular disorders with skeletal
open bite treated with stabilization splint and zygomatic miniplate
anchorage: a case report. Angle Orthod 2015;85:335-47.
4. Jim
enez-Silva A, Tobar-Reyes J, Vivanco-Coke S, Past
en-Castro E,
Palomino-Montenegro H. Centric relation-intercuspal position
discrepancy and its relationship with temporomandibular disor-
ders. A systematic review. Acta Odontol Scand 2017;75:463-74.
5. The Academy of Prosthodontics. The glossary of prosthodontic
terms: ninth edition. J Prosthet Dent 2017;117:e1-105.
6. Tanaka E, Detamore MS, Mercuri LG. Degenerative disorders of the
temporomandibular joint: etiology, diagnosis, and treatment. J
Dent Res 2008;87:296-307.
7. Kuzmanovic Pficer J, Dodic S, Lazic V, Trajkovic G, Milic N,
Milicic B. Occlusal stabilization splint for patients with temporo-
mandibular disorders: meta-analysis of short and long term ef-
fects. PLoS One 2017;12:e0171296.
8. Dawson PE. Functional occlusion-e-Book: from TMJ to smile
design. St Louis: Elsevier Health Sciences; 2006.
9. Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G,
Goulet JP, et al. Diagnostic criteria for temporomandibular disor-
ders (DC/TMD) for clinical and research applications: recommen-
dations of the International RDC/TMD Consortium network* and
Orofacial Pain Special Interest Groupy. J Oral Facial Pain Headache
2014;28:6-27.
10. Ikeda K, Kawamura A. Assessment of optimal condylar position
with limited cone-beam computed tomography. Am J Orthod Den-
tofacial Orthop 2009;135:495-501.
11. Dawson PE. New definition for relating occlusion to varying con-
ditions of the temporomandibular joint. J Prosthet Dent 1995;74:
619-27.
May 2021  Vol 159  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Zhao et al
12. McKee JR. Comparing condylar positions achieved through
bimanual manipulation to condylar positions achieved through
masticatory muscle contraction against an anterior depro-
grammer: a pilot study. J Prosthet Dent 2005;94:389-93.
13. Zoidis P, Troulis A, Polyzois G. The use of an anterior depro-
grammer in a removable prosthodontic case: the key to accurate
and predictable centric relation records. Gen Dent 2014;62:60-3.
14. Roth RH. Functional occlusion for the orthodontist. J Clin Orthod
1981;15:32-40: 44-51 contd.
15. Kalladka M, Quek S, Heir G, Eliav E, Mupparapu M, Viswanath A.
Temporomandibular joint osteoarthritis: diagnosis and long-term
conservative management: a topic review. J Indian Prosthodont
Soc 2014;14:6-15.
16. Al-Moraissi EA, Farea R, Qasem KA, Al-Wadeai MS, Al-Sabahi ME,
Al-Iryani GM. Effectiveness of occlusal splint therapy in the
management of temporomandibular disorders: network meta-
analysis of randomized controlled trials. Int J Oral Maxillofac
Surg 2020;49:1042-56.
17. Lee GH, Park JH, Lee SM, Moon DN. Orthodontic treatment proto-
cols for patients with idiopathic condylar resorption. J Clin Pediatr
Dent 2019;43:292-303.
18. Kuroda S, Sugawara Y, Tamamura N, Takano-Yamamoto T. Ante-
rior open bite with temporomandibular disorder treated with tita-
nium screw anchorage: evaluation of morphological and
functional improvement. Am J Orthod Dentofacial Orthop 2007;
131:550-60.
19. Kato C, Ono T. Anterior open bite due to temporomandibular joint
osteoarthrosis with muscle dysfunction treated with temporary
anchorage devices. Am J Orthod Dentofacial Orthop 2018;154:
848-59.
20. Kuroda S, Katayama A, Takano-Yamamoto T. Severe anterior
open-bite case treated using titanium screw anchorage. Angle Or-
thod 2004;74:558-67.
21. Chen G, Teng F, Xu TM. Distalization of the maxillary and mandib-
ular dentitions with miniscrew anchorage in a patient with moder-
ate Class I bimaxillary dentoalveolar protrusion. Am J Orthod
Dentofacial Orthop 2016;149:401-10.
22. Kuroda S, Hichijo N, Sato M, Mino A, Tamamura N, Iwata M,
et al. Long-term stability of maxillary group distalization with
interradicular miniscrews in a patient with a Class II Division 2
malocclusion. Am J Orthod Dentofacial Orthop 2016;149:
912-22.
23. Jing Y, Han X, Guo Y, Li J, Bai D. Nonsurgical correction of a Class
III malocclusion in an adult by miniscrew-assisted mandibular
dentition distalization. Am J Orthod Dentofacial Orthop 2013;
143:877-87.
24. Ciavarella D, Parziale V, Mastrovincenzo M, Palazzo A,
Sabatucci A, Suriano MM, et al. Condylar position indicator
and T-scan system II in clinical evaluation of temporomandib-
ular intracapsular disease. J Craniomaxillofac Surg 2012;40:
449-55.
25. Weffort SY, de Fantini SM. Condylar displacement between centric
relation and maximum intercuspation in symptomatic and asymp-
tomatic individuals. Angle Orthod 2010;80:835-42.
26. Ikeda K. TMJ 1st Orthodontics: concepts, mechanics, and stability.
Tokyo, Japan: TOPNOTCH KIKAKU Ltd; 2014.
27. Trindade M, Orestes-Cardoso S, de Siqueira TC. Interdisciplinary
treatment of bruxism with an occlusal splint and cognitive behav-
ioral therapy. Gen Dent 2015;63:e1-4.
Zhao et al
28. Okeson JP. The effects of hard and soft occlusal splints on
nocturnal bruxism. J Am Dent Assoc 1987;114:788-91.
29. Jokubauskas L, Baltrusaityt_e A, Pileicikien_e G. Oral appliances for
managing sleep bruxism in adults: a systematic review from 2007
to 2017. J Oral Rehabil 2018;45:81-95.
30. Rosar JV, Barbosa TS, Dias IOV, Kobayashi FY, Costa YM,
Gavi~ao MBD, et al. Effect of interocclusal appliance on bite force,
American Journal of Orthodontics and Dentofacial Orthopedics
681
sleep quality, salivary cortisol levels and signs and symptoms of
temporomandibular dysfunction in adults with sleep bruxism.
Arch Oral Biol 2017;82:62-70.
31. Tuna SH, Celik OE, Ozturk O, Golpinar M, Aktas A, Balcioglu HA,
et al. The effects of stabilization splint treatment on the volume
of masseter muscle in sleep bruxism patients. Cranio 2018;36:
286-93.
May 2021  Vol 159  Issue 5
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SUPPLEMENTARY DATA

Supplementary Fig 1. Cephalometric superimposition

of posttreatment and 20-month retention.

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Zhao et al 681.e2

Supplementary Fig 2. CBCT superimposition of pretreatment, postsplint, posttreatment, and after

retention. The superimposition was made on the basis of the temporal bone, sphenoid bone, and zygo-
matic bone with Dolphin Imaging software (version 11.8, Dolphin Imaging and Management Solutions,
Chatsworth, Calif). A and B, Superimposed images of pretreatment (white in coronal, sagittal, and axial
slices; brown in 3D reconstruction image) and postsplint (Cambridge blue); C and D, superimposed im-
ages of postsplint (white in coronal, sagittal, and axial slices; brown in 3D reconstruction image) and
posttreatment (green); E and F, superimposed images of posttreatment (white in coronal, sagittal
and axial slices; brown in 3D reconstruction image) and 20-month of retention (pink). 3D, 3-
dimensional; R, right TMJ; L, left TMJ.

American Journal of Orthodontics and Dentofacial Orthopedics May 2021  Vol 159  Issue 5