Journal of Oral Rehabilitation 2007 34; 807–813
Short-term efficacy of physical therapy compared to splint
therapy in treatment of arthrogenous TMD
F . I S M A I L * , A . D E M L I N G †, K . H E ß L I N G * , M . F I N K ‡ & M . S T I E S C H - S C H O L Z *
*Department of Prosthetic Dentistry, Hannover Medical School, †Department of Orthodontics, Hannover Medical School and ‡Department of
Physical Medicine and Rehabilitation, Hannover Medical School, Hannover, Germany
SUMMARY A prospective randomized study was car-
ried out to evaluate the efficacy of physical therapy
in addition to splint therapy on treatment outcome
in patients with temporomandibular disorders
(TMD) with respect to objective and subjective
parameters. Twenty-six patients suffering from an
arthrogenic TMD and exhibiting a painfully restric-
ted jaw opening were randomized in two groups.
Thirteen patients were treated solely with Michigan
splint (group I), 13 patients received supplementary
physical therapy (group II). Before treatment a
clinical examination and electronic recording of
jaw movements were performed and subjective
pain level was evaluated by visual analogue scales.
After 3 months of therapy maintenance of improve-
ment was evaluated. Within treatment groups com-
parison of data before and after treatment was
analysed using Wilcoxon test. Groups were com-
pared by Mann–Withney-U test. A P-value < 0.05
was considered significant. Compared with the
Introduction
Arthrogenic temporomandibular disorders (TMD) are
associated with pathologic changes of the condylus-disc
relation, bone remodelling and degenerative changes of
the condyle. These pathologic changes can induce signs
and symptoms of a TMD. Patients suffering from TMD
frequently exhibit pain on palpation in the region of the
temporomandibular joint (TMJ) and the masticatory
muscles, joint sounds like clicking or crepitus and
restricted jaw movements. The aetiology of TMD is
considered to be multifactorial (1). Various factors like
excessive loading on the TMJ as a result of loosing
ª 2007 Blackwell Publishing Ltd
baseline, in both groups mandibular movement
capacity increased significantly after treatment,
whereas subjective pain decreased significantly
(P < 0.05). Active jaw opening increased from
28.6  5.8 to 35.9  4.8 mm in group I and from
30.1  5.4 to 40.8  4.1 mm in group II. After ther-
apy the difference of active jaw opening between
groups was significant (P < 0.05). Physical therapy
also gave a supplementary improvement of protru-
sive mandibular movement capacity during electro-
nic registration and subjective pain level. For none
of these parameters this difference between groups
was significant. Physical therapy seems to have a
positive effect on treatment outcome of patients
with TMD.
KEYWORDS: physical therapy, efficacy, splint, treat-
ment, arthrogenous, temporomandibular disorders
Accepted for publication 25 February 2007
posterior teeth support, parafunctional activity and
rheumatic diseases are discussed to cause TMD (2–5).
As a consequence of the multifactorial pathogenesis,
therapeutic concepts must be interdisciplinary. This
interdisciplinary conservative treatment includes com-
binations of splint-, pharmacological- and physical
therapy as well as psychological approaches. Splint
therapy is performed applying various types of stabil-
ization, repositioning or relaxation splints. For medical
therapy, usually non-steroidal anti-rheumatic drugs
and muscular relaxants are used. In recent studies
improvement of jaw-opening and subjective pain levels
by splint therapy and medical treatment was shown
doi: 10.1111/j.1365-2842.2007.01748.x
808 F . I S M A I L et al.
(6–8). In physical therapy joint mobilization by trac-
tion, detoning exercises and massages of masticatory
muscles are usually used to reduce signs and symptoms
of TMD (9). Prospective studies investigating the effects
of physical therapy on treatment outcome within an
interdisciplinary concept are rare.
Therefore, the purpose of the present study was to
investigate the efficacy of physical treatment in addition
to splint therapy in patients suffering from arthrogen-
ous TMD with a painful restricted jaw movement.
Materials and Methods
Selection of patients
The study was approved by the Ethics Committee of
Hannover Medical School (no. 3747). The study was
undertaken with the understanding and written con-
sent of each subject.
Twenty-six patients who suffered from acute symp-
toms (duration <6 months) of a TMD and who were
treated in the Department of Prosthetic Dentistry of the
Hannover Medical School between 2002 and 2006 for
that reason were included in the present study.
Inclusion criterion was the diagnosis of an arthrogenic
TMD with a limited (<38 mm) and painful jaw opening.
For confirmation of the clinical diagnosis magnetic-
resonance imaging (MRI) examinations were carried
out with closed and open jaw position using proton
density biplanar coronal and sagittal scans and fat
saturated T2 sagittal enhancement (General Electric,
1.5 T, Excite platform, Waùkesha, WI, USA).
Exclusion criteria were the presence of systemic
diseases, especially rheumatic diseases, other types of
treatment of TMD (e.g. prior operative or medical
therapy), therapeutic co-interventions during treat-
ment, signs of psychosomatic illness and insufficient
compliance of patients.
Therapeutic intervention and evaluation of treatment outcome
Before treatment all patients were clinically examined
according to the RDC ⁄ TMD criteria (10).
The patients were divided into two treatment groups
using permuted block randomization with block sizes
of four. In both groups no drop-outs were recorded.
The patients in group I (n = 13) underwent Michigan
splint therapy. The patients in group II (n = 13) were
given physical treatment in addition to the splint. For
ª 2007 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 34; 807–813
each patient, an upper jaw splint was prepared as
described by Ash and Ramfjord (11). The patients were
instructed to wear the splints 24 h a day, excluding
mealtimes.
The physical treatment was based on the guidelines for
manual therapy to mobilize the TMJ (12). To mobilize
the joint, passive traction and translation movements
were carried out in every restricted direction, which were
most craniocaudal, cranioventral or mediolateral. This
mobilizing procedure was accompanied by detoning
exercise of jaw elevator muscles. When the muscle tone
in the jaw elevator was high, the patient was prepared
for the manual therapy with a detoning massage. All
patients were treated for 45 min twice a week (total:
90 min) by the same physical therapist.
All patients were examined and controlled 1, 4, 8 and
12 weeks after the start of treatment by one examiner.
Active and passive maximum jaw opening were taken
as objective criteria to evaluate the mobility of the
lower jaw. In each session measurements were per-
formed three times and data was averaged. In addition,
a subjective pain evaluation was made by the patient
using a visual analogue scale, with ratings between 0
for pain-free and 100 for maximum pain (13). Pain was
differentiated in total pain intensity, pain intensity
during mandibular movement, pain intensity without
mandibular movement and pain intensity after man-
dibular loading.
An electronic registration was performed before
therapeutic intervention and in the last session after
12 weeks using an infrared-based system (String Cond-
ylocomp LR3; Dentron, Hoechberg, Germany). First the
head frame was mounted. Afterwards the transmitter
frame was attached to the mandibular teeth with an
individualized paraocclusal appliance (PalatrayXL; Her-
aeus Kulzer, Hanau, Germany) using hard silicone
(Futar D Occlusion; Kettenbach, Eschenburg, Ger-
many). The sensor boxes were placed in the region of
the left and right TMJ with respect to the marked
arbitrary hinge axis located 12 mm anterior the tragus
and 3 mm under the line tragus-canthus according to
the procedure manual. Recording individual hinge axis
the registration system was adjusted using special String
software (Jaws 2.0; Dentron). Maximum protrusive
mandibular movements under tooth guidance were
recorded three times after initial instruction. Left and
right measurements were averaged, and processed with
the software, allowing the calculation of mandibular
mobility.
 PHYSICAL THERAPY COMPARED TO SPLINT THERAPY IN TMD 809

10 patients exhibited myofascial pain before therapeu-

Statistical analysis
tic intervention. All patients in group II were females
Power and sample sizes were calculated using nQuery aged 41.7  16.5 years. In 10 of them a disc displace-
Advisor 5.0 (Statistical Solutions, Saùgùs, MA, USA). ment without reduction, in two patients a disc dis-
Before the start of the study maximum active jaw placement with reduction and in one patient an
opening was defined as the main criterion. Power osteoarthrosis was found. In group II eight patients
calculation revealed that a sample size of 13 in each showed myofascial pain before treatment. Comparison
group will have 85% power to detect a difference in of baseline characteristics revealed no significant dif-
means of 5.0 mm assuming that the common standard ferences between groups (Table 1).
deviation is 4.0 mm. Figures 1–4 summarize the improvement of the
Documentation and evaluation of the data was recorded parameters. Analysis of treatment outcome
performed with data processing program SPSS ⁄ PC showed that in both groups all analysed parameters
Version 13.0 for Windows (SPSS Inc., Chicago, IL, improved significantly during treatment compared with
USA). All data was analysed by one blinded researcher. the baseline.
First the means and standard deviations of In group I maximum active jaw opening was
– maximum active jaw opening, 28.6  5.8 mm before therapeutic intervention with
– maximum passive jaw opening, Michigan splint (Figure 1). After 12 weeks of treatment
– maximum protrusive mandibular movement during
electronic registration,
– total pain intensity,
– pain intensity during mandibular movement,
– pain intensity without mandibular movement and
– pain intensity after mandibular loading were deter-
mined. Mann–Whitney-U test was used to compare
baseline characteristics and treatment outcome of the
two groups. In addition categorical variables of the
baseline were compared by use of Fisher’s exact test.
Treatment outcome in both groups compared with the
baseline was analyzed using Wilcoxon test. A P-value
<0.05 was considered statistically significant for all
performed tests.

Results
In group I, three males and 10 females were included
with an average age of 44.5  14.1 years. In 11
patients, a disc displacement without reduction, in
one patient a disc displacement with reduction and in
one patient an osteoarthrosis was diagnosed. In group I, Fig. 1. Improvement of maximum active jaw opening.

Table 1. Comparison of baseline

Group I Group II Significance
characteristics
Age (years) 44.5  14.1 41  16.5 n.s.
Sex 3m 0m n.s.
10 f 13 f
Active mouth opening 28.6  5.8 mm 30.1  5.4 mm n.s.
Protrusive movement capacity 5.9  2.4 mm 5.8  1.8 mm n.s.
Total pain intensity 42  22 45  20 n.s.
Myofascial pain 10 patients 8 patients n.s.

ª 2007 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 34; 807–813

810 F . I S M A I L et al.
Fig. 2. Improvement of maximum passive jaw opening.
Fig. 3. Improvement of maximum protrusive mandibular move-
ment capacity during electronic jaw recording.
active jaw opening increased to 35.9  4.8 mm (D
7.3  6.2 mm; P < 0.05). Group II exhibited an active
jaw opening of 30.1  5.4 mm before and
40.8  4.1 mm after combined treatment with splint
and physiotherapy (D 10.4  5.4 mm; P < 0.05). Ana-
ª 2007 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 34; 807–813
Fig. 4. Improvement of total pain intensity.
logous results were obtained for the passive jaw
opening (Figure 2), which in group I was
30.5  6.5 mm before and 38.4  4.8 mm after treat-
ment (D 7.9  5.7 mm; P < 0.05). In group II, this
parameter changed from 31.9  5.3 to 42.1  4.7 mm
(D 10.7  5.1 mm; P < 0.05). Comparison of data
between groups revealed that active jaw opening was
significantly higher in group II after treatment
(P < 0.05), whereas the difference between groups
for the passive jaw opening was not statistically
significant.
The analysis of data obtained from electronic regis-
tration (Figure 3) showed, that in group I maximum
protrusive mandibular movement during electronic
registration improved from 5.9  2.4 to 7.4  2.7 mm
(D 1.5  1.5 mm; P < 0.05), whereas in group II this
parameter improved from 5.8  1.8 to 8.3  2.7 mm
(D 2.5  2.6 mm; P < 0.05). The difference between
groups was not statistically significant.
Analysis of subjective pain evaluation in group I gave
an improvement of total pain intensity (D 23  22;
P < 0.05) (Figure 4), pain intensity during mandibular
movement (D 25  22; P < 0.05), pain intensity with-
out mandibular movement (D 8  9; P < 0.05) and
pain intensity after mandibular loading (D 36  25;
 PHYSICAL THERAPY COMPARED TO SPLINT THERAPY IN TMD
P < 0.05). Analogously pain intensity in group II
decreased after treatment (total pain intensity D
28  21; P < 0.05, pain intensity during mandibular
movement D 23  27; P < 0.05 pain intensity without
mandibular movement D 16  17; P < 0.05, pain
intensity after mandibular loading D 49  35;
P < 0.05). For the subjective parameters no significant
differences were found between the two groups.
In group I four patients exhibited myofascial pain
after treatment, whereas in group II two patients
showed myofascial pain after therapeutic intervention.
Discussion
A population-based study showed that the prevalence
of signs of TMD in adults is 50% but that not more than
3% of the adults are subjectively aware of TMJ pain
(14). Only these patients exhibit treatment need.
Evaluating the efficacy of a treatment method, the
examined patients have to be aware of symptoms and
have to exhibit clinical signs of TMD. For this reason, in
the present study, only patients with a painful and
limited jaw opening were included.
The patients were clinically examined and diagnosed
in accordance to the RDC ⁄ TMD criteria of Dworkin and
LeResche. For the most common TMD diagnoses these
criteria demonstrated a sufficiently high reliability (15).
As restricted mandibular movement is often associated
with TMJ diseases that cannot be identified by clinical
examination alone (16), diagnosis was improved and
validated by additionally taken MRI. MRI is considered
to be an accurate method for the assessment of soft and
hard tissues of the TMJ (17), especially in patients with
clinical signs and symptoms of TMD.
Determining the efficacy of a treatment method
objective and subjective parameters have to be consid-
ered. In the present study objective parameters for
mandibular mobility were maximum active and passive
jaw opening. These parameters can be used to deter-
mine improvement of mandibular mobility, because
determination of vertical mandibular motions can be
done with an excellent reliability (18). Furthermore, an
electronic registration was performed to quantify man-
dibular mobility. Although electronic registration for
diagnosis of TMD is questioned in literature (19),
graphic recording remains an accurate method for the
evaluation of mandibular movement capacity (20–22).
Subjective pain evaluation was performed using a
visual analogue scale. This method appears to be valid
ª 2007 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 34; 807–813
811
in determination of subjective pain improvement (23).
In the present study, 23 women and only three men
fulfilled criteria of inclusion. This difference between
the sexes can be explained by the higher prevalence of
TMD in female persons (24, 25).
Patients in both groups revealed a significant
improvement of objective and subjective parameters
during treatment. In literature improvement of these
parameters during splint therapy was found (6, 16, 26).
An early begin of splint therapy was supposed to
improve treatment outcome (27). As all patients
revealed acute symptoms of TMD and therapeutic
intervention was not prolonged, the improvement of
mandibular mobility and pain level in both groups can
be explained by the cited findings. The reduction of
pain intensity might also be the consequence of a
regression or spontaneous remission of acute symp-
toms.
Comparison of groups showed a significantly higher
active jaw opening after physical therapy. The smallest
detectable change in active mouth opening can be
reduced from 9 to 6 mm by performing multiple
measurements. Therefore, data of vertical mandibular
movement capacity was obtained three times per
session (28). With an average maximum active jaw
opening of 35.9 mm in group I after treatment with
Michigan splint only, jaw opening has to be considered
as restricted. This aspect has to be regarded carefully, as
one of the main goals in treatment of TMD is the
restoration of a physiological mandibular movement,
which was not achieved in group I.
A tendency of further improvement after physical
therapy was recognizable for passive jaw opening,
maximum protrusive mandibular movement capacity
registered by electronic recording and for total pain
intensity, but no significant differences between groups
were found for these parameters. In literature, the
efficacy of physical therapy in treatment of patients
with TMD remains controversial. In a study of Stiesch-
Scholz et al. comparison of medical and physical therapy
in combination with splint therapy in patients with disc
displacement without reduction showed no significant
influence of physiotherapy on treatment outcome (8).
These findings were explained by the application of
various treatment methods from different not calibrated
physiotherapists. Other researchers also found no
additional benefit of physiotherapy during treatment
of patients with anterior disc displacement without
reduction (29).
812 F . I S M A I L et al.
In contrast another study showed that manual
physical therapy, therapeutic exercises and patient
education improved jaw opening and pain level in
patients with anterior disc displacement without reduc-
tion (30). Further studies showed the efficacy of
exercise therapy and physiotherapy in patients with
myofascial pain, internal derangements and cervical
spine dysfunction (31–35). In patients with anterior
disc displacement with reduction the application of
therapeutic exercises significantly reduced joint clicking
(36). Even in long-term outcome of TMD an effective
treatment of osteoarthrosis using exercise therapy was
reported (37). Comparison of the cited studies is
difficult, as different criteria of inclusion were used,
researchers and physiotherapists were not calibrated
and various methods of physical therapy were applied.
In the present study, an approach to determine the
clinical outcome of physical therapy in a randomized
clinical trial was performed. Although clinical exam-
ination was performed by one dentist and physical
therapy was applied by only one physiotherapist, only
for one parameter significant differences were found
between groups. As a tendency of further improvement
of all subjective and objective parameters was recog-
nizable, the lack of significance in some parameters
might be due to the relatively low number of included
patients.
With respect to the results of the present study and
regarding findings in literature, efficacy of physical
therapy seems to be depending on various factors.
These factors could be the used physiotherapeutic
methods as well as the subgroup of TMD. Furthermore,
duration of sings and symptoms and pain level could
play a role. To evaluate the influence of these factors
prospective multicenter studies with calibrated
researchers have to be performed with high sample
sizes to show differences between groups. In these
future studies comparison of single matched treatments
should be carried out to determine relative effects and
mechanisms of treatment.
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Correspondence: Fadi Ismail, Department of Prosthetic Dentistry,
Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover,
Germany.
E-mail: Ismail.Fadi@mh-hannover.de