CRANIO®

The Journal of Craniomandibular & Sleep Practice

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Recapture of Temporomandibular Joint Disks

Using Anterior Repositioning Appliances: An MRI
Study

H. Clifton Simmons III D.D.S. & S. Julian Gibbs D.D.S., Ph.D.

To cite this article: H. Clifton Simmons III D.D.S. & S. Julian Gibbs D.D.S., Ph.D. (1995)
Recapture of Temporomandibular Joint Disks Using Anterior Repositioning Appliances: An MRI
Study, CRANIO®, 13:4, 227-237, DOI: 10.1080/08869634.1995.11678073

To link to this article: http://dx.doi.org/10.1080/08869634.1995.11678073

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0886-9634/1304-
227$03.00/0, THE
JOURNAL OF
CRANIOMANDIBULAR
PRACTICE,
Copyright © 1995
by CHROMA, Inc.
Manuscript received
June 17, 1995; revised
manuscript received
Aug. 21, 1995; accepted
Aug. 23, 1995
Address for reprint requests:
Dr. H. Clifton Simmons Ill
1916 Hayes Street
Nashville, Tennessee 37203
.TMJ
Recapture of Temporomandibular Joint Disks Using
Anterior Repositioning Appliances: An MRI Study
H. Clifton Simmons III, D.D.S.; S. Julian Gibbs, D.D.S., Ph.D.
ABSTRACT: Thirty consecutive patients seeking treatment for painful temporomandibular joint (TMJ)
disease were enrolled in a prospective study to assess the relationship between the recapture of dis-
placed disks by anterior repositioning appliances (ARA) and the relief of symptoms. After standard clin-
ical workup including assessment of pain, maxillary and mandibular ARAs were constructed that
repositioned condyles to the Gelb 4!7 position. Magnetic resonance imaging (MRI) was performed
before and immediately after the insertion of ARAs. Initial MRI findings showed 26 joints with reducing
disk displacements in 17 patients, seven partially-reducing joints in four patients, 14 nonreducing joints
in 11 patients, and 13 normal joints in eight patients. Postinsertion MRI showed recapture of disks in 25
of 26 reducing displacements (96%), but no recapture in partially-reducing or nonreducing joints. All but
one of the normal joints remained unchanged. Pain assessment showed significant relief of symptoms
in all three categories. The degree of pain relief was significantly greater in recaptured reducing disks
than the other categories (p < 0.05). ARA therapy provides effective pain relief regardless of disk status,
although a greater degree of relief may be achieved in recaptured reducing internal derangements.
nterior repositioning appliance (ARA) therapy
Dr. H. Clifton Simmons m received his
D.D.S. degree in 1977 from the University
A has been controversial since its earliest use.
Ireland 1 described the use of ARAs in 1951. Gelb
and Gelb2 reported the mandibular orthopedic reposition-
ofTennessee College of Dentistry. He is ing appliance and its success in symptom relief. However,
currently an assistant clinical professor in they did not use the recapture of temporomandibular joint
the Department of Dentistry at Vanderbilt (TMJ) disks as a criterion for success. Success has been
University in Nashville, Tennessee, and
has a private practice. Dr. Simmons is a described as either recapture of displaced disks or symp-
Fellow of the Academy of General tom relief when disks were not recaptured. 3 Manzione et
Dentistry and a Diplomate of the al. 4 found that claims of high percentages of recaptured
American Academy and Board of Head,
Neck and Facial Pain. He currently serves disks have later proven to be less successful than origi-
as President ofTennessee CRAN10 and is nally thought. Katzberg and Westesson 5 state that disk
Editor of the Tennessee Academy of recapture is best achieved when mandibular repositioning
General Dentistry.
is guided by disk visualization with either arthrography
or magnetic resonance imaging (MRI). Nickerson6 stated
there is often a relationship between masticatory muscu-
loskeletal pain and the position of the TMJ disk, and that
the primary focus of treatment of patients with reducing
Dr. S. Julian Gibbs is a professor of anterior displacements should be an attempt to correct
Radiology and Radiological Sciences at that condition. Internal derangement may be associated
Vanderbilt University School of Medicine. with other abnormalities. Schellhas et al.7 found that chil-
Dr. Gibbs is a 1956 graduate of Emory
University School ofDentistry and earned dren with retrognathia and mandibular asymmetry usu-
his Ph.D. in radiation biology at the ally have advanced degrees of TMJ derangement with
University of Rochester in 1969. He is a characteristic skeletal shifts toward the deranged joints.
Diplomate and former President of the
American Board of Oral and Lundh et al. 8 found that recapturing a displaced disk
Maxillofacial Radiology and Fel/ow and effectively eliminates pain and dysfunction in patients in
former President of the American whom a normal relationship between the disk and the
Academy of Oral and Maxillofacial
Radiology. condyle can be established. Anterior repositioning was
deemed superior to either flat plane appliance therapy or
to no treatment. The symptoms returned when the
ARA was removed, suggesting that permanent change in
227
TMJ DISKS AND ARA
the occlusion should be used to achieve long-term symp-
tom relief. In a later study, Lundh and Westesson9 found
that there was no appreciable difference in the clinical
status of two patients with abnormal disk position at
follow-up compared with nine patients with a normal
disk-condyle relationship. This raised the question of
whether correction of disk position was actually a prereq-
uisite for symptom relief. However, Weinberg and
Chastain 10 observed that eccentric position of the condyle
in the fossa- suggestive of disk malposition - was more
common in symptomatic TMJ patients than in normal
subjects.
Katzberg and Westessons in a recent text said that
ARA therapy, followed by permanent alteration of the
occlusion, is effective in relieving symptoms related to
reducing internal derangements. Their results show that
ARA therapy with subsequent occlusal-orthodontic treat-
ment can maintain the condyle-disk relationship, as
shown with MRI, for a long period of time.
There are many variables to control in a study of ARA
therapy. Did patients wear only a mandibular appliance?
Did they have a sleep appliance that held the mandible
forward during reclining? Did they wear the appliance 24
hours a day and not eat in it? Did they wear the appliance
24 hours a day and eat in it?
Most of the studies do not document all variables.
Therefore comparison between studies is difficult.
The purpose of the present study is: (I) to investigate
whether TMJ disks can be recaptured short term and long
term by using anterior repositioning therapy and Phase II
treatments; and (2) to investigate whether TMJ disk
recapture is necessary for symptom relief when using
anterior repositioning therapy in a temporomandibular
disorder.
Materials and Methods
Consecutive patients seeking care for head/neck/facial
pain were recruited for the study. Criteria for inclusion in
the study were: (I) chronic temporomandibular pain and
dysfunction by history and examination, i.e., documented
need for ARA therapy; 2 and (2) informed consent.
Exclusion criteria were: ( 1) inability or unwillingness
to undergo MRI, such as implanted electronic devices,
claustrophobia, etc.; and (2) pregnancy.
Gold standards are those procedures by which research
is measured. These procedures should be as broadly
accepted as possible by the scientific community. The
gold standards used in this study were: (I) MRI for disk
position; (2) TMJ Scale and TMJ Compare™ for objec-
tive pain assessment.
MRI has been a broadly accepted method of determin-
228 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
SIMMONS AND GIBBS
ing disk position of the TMJ. Katzberg and Westesson 11
stated that "the overall best diagnostic modality for a
thorough assessment of internal derangement is a bilat-
eral, multiplanar MRI examination."
MRI was used as a gold standard in this study because
of recent research that found that clinical examination,
including joint sounds, may be unreliable for determining
the position of the disk in patients with signs and symp-
toms of TMJ internal derangement. 12
The TMJ Scale is a quantitative and qualitative
analysis of patient symptoms. • Published studies have
shown the development, validation, determination of
accuracy, and clinical usefulness of the TMJ Scale. 13• 18
Brown and Gaudet, 19 using the TMJ Scale, showed that
TMJ symptoms are improved with ARA therapy, and that
untreated patients were not significantly improved. The
TMJ Compare is a computation of patient symptom
improvement based on a comparison of two different
TMJ Scales.
Each patient's consultation visit was composed of
obtaining the chief complaints in order of importance,
complete trauma history, range of motion, muscle palpa-
tion, review of proposed treatment, financial arrange-
ments, and informed consent. The second or diagnostic
visit was composed of a complete review of all of the
patient's presenting symptoms, radiographic studies,
(typically including cephalometrically-corrected linear
tomography, a panoramic radiograph, A-P Chamberlain-
Townes, P-A skull film, and lateral cephalometric), range
of motion study, muscle, ligament, and tendon palpation,
objective evaluation of pain level using the TMJ Scale,
doppler analysis, and electrovibratography. Records
taken on each patient included orthodontic quality study
models, as well as full face, lateral, and intraoral pho-
tographs. All patient visits during Phase I were audio
taped. Maxillary and mandibular anterior repositioning
appliances were constructed and the bite was positioned
intraorally to the Gelb 417 condylar position. No appli-
ance was altered in any way because of information
derived from MRI studies.
MRI was performed using a superconducting MR
scanner operated at 1.5T. •• Closed-mouth images con-
sisted of sagittal oblique and coronal oblique Tl-weighted
images plus sagittal oblique T2-weighted images. The
imaging protocol in many MR centers is to perform the
closed-mouth studies with the mandible in the rest posi-
tion. In this study, closed-mouth images obtained before
insertion of appliances were performed with the teeth in
centric occlusion. Open mouth studies were composed of
'Pain Resource Center, Durham, North Carolina
"Magnetom SP-4000, Siemens Medical Systems, Iselin. New Jersey
OCTOBER 1995, VOL. 13, NO. 4
SIMMONS AND GIBBS
Tl-weighted sagittal oblique and coronal images.
T !-weighted images used a conventional spin-echo
sequence, TR =700 ms, TE = 15 ms, 2 acquisitions. T2-
weighted images were obtained with turbospin-echo
sequences, effective TR = 5 s, TE = 90 ms, 10-echo
chain, I acquisition. All images used a slice thickness of
3 mm with no interslice gap, matrix of 192 x 256 and
field of view of 12 to 14 em. Each image set was com-
posed of at least seven slices, to include the entire condyle
plus adjacent structures.
The patient was biting on a stack of tongue blades at a
predetermined vertical dimension when the open-mouth
scans were performed. Imaging times ranged from 3 to
4.5 minutes. The complete examination was performed
for each subject in approximately 35 minutes. The patient
was then removed from the MRI scanner and the mandibu-
lar appliance was inserted. The closed-mouth Tl-weighted
images were repeated with the patient biting into the
indentations on the appliance, i.e., with the mandible
repositioned anteriorly.
Five patients had undergone recent MRI examination
of the TMJs at the time of entry into the study. Only
postappliance images were obtained for these patients.
Disk relation to the condyle was categorized for each
joint in each position, using a modification of a scheme
proposed by Tasaki et aJ.2° Disk positions included
normal (N), anterior (A), anterolateral (AL), anterome-
dial (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 the lateral pole),
and medial anterior rotary (MAR, rotated toward the
medial pole, or anterior at the lateral pole and normal at
the medial pole). No posterior or lateral dislocations were
identified in the sample.
Patients were seen every three weeks during Phase I
treatment. At each visit range of motion and muscle pal-
pation studies were done. In addition, at six-week inter-
vals all presenting symptoms were reviewed, asking
specifically whether each presenting symptom had been
the same as before treatment, better than, or absent during
the previous three weeks. Phase I lasted for an average of
nine months (range six to 12 months), composed of three
to five months to achieve maximum symptomatic improve-
ment and three to six months of stabilization, as recom-
mended by the American Dental Association Council on
Dental Care. 21 At the end of Phase I, range of motion
study, muscle palpation, and a complete review of the
patient's presenting symptoms were repeated. One
cephalometrically-corrected tomogram per side was
obtained in the closed (ARA in place) position and one in
the full mouth open or extended position. The interincisal
opening was recorded. The TMJ Scale was repeated and a
OCTOBER 1995, VOL 13, NO. 4
TMJ DISKS AND ARA
TMJ Compare computed to determine the objective symp-
tom improvement after Phase I. The patients were asked
what percent of their presenting symptoms had disap-
peared, using a scale ofO (no improvement) to 100 (com-
plete relief). The patients were asked this same question at
every three-week visit and were asked to sign the subjec-
tive statement of improvement in their symptoms.
Phase II is now underway in most patients in the study,
using either orthodontics, crown and/or bridges, or partial
dentures. MRI will be repeated after its completion. In
this study there were no edentulous patients.
This article addresses only disk position as determined
by MRI, and relief of symptoms as determined subjec-
tively and objectively. Other data collected will be the
subject of future presentations. Statistical analysis of the
data required comparison of multiple groups of subjects.
Because of the well-known possibility of false positive
results from repeated simple comparisons, such as
Student's t test, analysis was performed using analysis of
variance, with widely-accepted commercial software. t
This study was approved in advance by the Institutional
Review Board of Vanderbilt University. Informed con-
sent was obtained from all subjects before they were
entered into the study. The only procedure performed
solely for the purpose of the study was the MRI. All other
procedures were a part of routine patient care.
Results
This article presents results of initial MRI before and
immediately after the insertion of appliances of 60 joints
from 30 patients enrolled in the study. In addition, objec-
tive and subjective evaluations of symptomatic changes
were presented in the 19 patients who had completed
Phase I. There were 28 females and two male participants
in the study.
Cephalometrically-corrected tomograms of the right
and left TMJs are shown in Figure 1 (before treatment)
and Figure 2 (after ARA insertion). The condyles have
been repositioned by the appliance from a posterior supe-
rior position in the fossa. Gelb tracings have been super-
imposed over the post-treatment tomograms (Figure 2)
and the fossa and condyle were traced. The majority of
each condyle is in the 4 and 7 blocks of the grid.
In this patient, both disks were anterolaterally
displaced initially (Table 1) and recaptured by placing
the condyles in the position shown in Figure 2. They
remained recaptured after Phase II treatment was
completed. The TMJs shown in Figures 1 and 2 had
displaced disks with reduction with absolutely no click
'SAS Institute, Cary, North Carolina
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 229
TMJ DISKS AND ARA SIMMONS AND GIBBS

Figure 1
Cephalometrically-corrected linear tomograms of right (A) and left (8) TMJs of patient L.E., * 12-18-93, are shown before treatment, closed (centric
occlusion) position. Note that the condyles are posterior and superior in the fossae, which is a common finding.

Figure2
Cephalometrically-corrected linear tomograms of right (A) and left (B) TMJs of patient L.E., * 12-18-93, are shown with the mandibular anterior
repositioning appliance in place. A Gelb tracing has been superimposed over the tomograms and the fossae and the condyles have been traced. The
condyles are located predominately in the 417 blocks of the Gelb grid.

detected on auscultation or palpation. The patient had an
initial interincisal opening of 23 mm. After treatment it
was 53 mm.
MRis obtained before any treatment was initiated in
the closed or centric occlusion position are shown in
Figure 3. The disk is visualized anterior to the condyle on
both sides. Figure 4 shows these joints in the open or
fully extended position (33 mm interincisal distance).
The patient was biting on a group of tongue blades taped
together with surgical tape to make the interincisal open-
ing exact. Notice that the condyle is anterior to the most
inferior point on the eminence, which is the usual crite-
rion for normal opening movement. Both of the disks
reduce in these images. The "bow tie" appearance of the
disk can now be seen between the condyle and the fossa.
Figure 5 shows MRis of these TMJs with the ARA
inserted. The disks are recaptured. Other images show
that the disks were recaptured in both anteroposterior and
mediolateral dimensions. The MRI studies shown in
Figures 3 through 5 were all performed on August 21,
1993. The status of these TMJ s after Phase II was com-
pleted is shown in Figure 6. Both disks remain recap-
tured. The post Phase II MRI study was done on January
14, 1995. Phase II was done with only posterior ortho-
dontics. The patient is no longer wearing an appliance
during waking hours and sleeps in a maxillary ARA
every night.
MRI reports of disk position for the 30 subjects, plus
objective (TMJ Scale Global scores) and subjective
symptom relief at completion of Phase I treatment for 19
of these patients, are shown in Table 1. The patients are
identified by their first and last initials, as well as the

230 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE OCTOBER 1995, VOL. 13, NO. 4
SIMMONS AND GIBBS TMJ DISKS AND ARA

Table 1
Pretreatment and Post-Treatment Disk Position, Symptoms, and Improvement
Patient ID Disk Position' Symptom Evaluation!
and date of Pretreatment Postinsertion Relief after
appliance Closed O:~en Closed Objective Phase I(%)
insertion R L R L R L Pre-Rx Phase I Objective Subjective
MA N N N N N N 99- 48 86 80
10-16-93
TB AL AL AL N AL N 99+
09-17-94
BB LAR LAR N N N N 99+ 17 94 100
07-09-94
CB AM AM M M M M 99+ 65 77 70
01-08-94
MB LAR LAR N N N N 99+ 9 97 100
04-23-94
- BC N A N A N A 99+ 86 63 100
09-04-93
JD M M M M M M 99+
08-14-94
DO AL AL L L L L 99+
10-15-94
so A A N N N N 99+
01-14-95
SE N N N N N N 99+
09-17-94
LE* AL AL N N N N 99+ 51 86 99
12-18-93
HU
AL AL N AL N AL 99+
10-15-94
JH M M N N N N 99+
12-03-94
CH AM A A A AM A 99+ 82 59 95
04-15-94
RH N N N N N N 99+ 36 84 99
05-07-94
SH A A N N N N 99+
09-17-94
UK
12-17-94 M AM M M M M 99+
DL AL AL N N N N 99+
12-03-94
LM AL AL N N N N 99+ 45 84 100
05-07-94
LP* AL AL N AL N AL 99+ 85 67 82
12-18-93
LP* AM N N N N M 99+ 4 98 98
02-19-94
AR N AL N N N N 99+ 91 57 80
10-01-93
MS AM AM M M M M 91
08-20-94
BS* A A A A A A 78 48 47 95
11-09-93
MS N N N N N N 99+ 94 57 100
04-09-94
RT A A A N A N 99+ 65 76 75
02-26-94
AW N N N N N N 98 36 80 100
10-23-93
BW* A AL N AL A A 99+ 90 54 90
02-26-94
ow MAR A N N N N 99+ 71 86 92
08-21-93
NW A A A A A A 99+ 36 84 60
08-07-93
*These are patients who presented With recent MRI studies of the TMJs at the lime of referral for treatment. These pretreatment Images were not repeated for
the study. • Disk position: N, normal; A, anterior; AL, anterolateral; AM, anteromedial; L,lateral; LAR,lateral anterior rotary; M, medial; MAR, medial
anterior rotary.'"' Objective evaluation of symptoms before and after Phase I treatment was performed with the proprietary instrument (TMJ Scale). Objective
measure of relief from symptoms at end of Phase I was obtained with the compare function (TMJ Compare), which evaluates the difference between two TMJ
Scales. Subjective measure was obtained by asking the patient.

OCTOBER 1995, VOL. 13, NO. 4 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 231
TMJ DISKS AND ARA SIMMONS AND GIBBS

Figure3
Sagittal oblique Tl-weighted MRis of patient D.W., 08-21-93, are shown before any treatment was initiated with the patient biting into centric
occlusion. Note the slight anterior displacement of the disks and the small anterior osteophyte on the condyles: (A) right TMJ; (B) left TMJ.

Figure 4
Sagittal oblique Tl-weighted MRis of patient D.W., 08-21-93, are shown in the open-mouth or extended position before treatment. The interincisal
distance was 33 mm. Note the reduction of anterior displacement bilaterally. The condyle passes the most inferior point on the eminence, a sign of
normal translation: (A) right; (8) left.

date of their initial MRI study after entering the research
project.
Thirteen joints with normal condyle-disk relationships
were identified in eight patients (five bilateral normal and
three with unilateral internal derangements). Joints with
internal derangements that reduced on opening the mouth
numbered 26 in 17 patients (nine bilateral, two unilateral
with opposite side normal, and six unilateral with oppo-
site side nonreducing). Seven joints with two-dimen-
sional dislocations exhibited partial reduction on opening,
e.g. anterolateral disk in closed-mouth images reducing
to lateral in open-mouth views. These partially-reducing
disks were found in four patients, three bilateral and one
with a nonreducing joint on the opposite side. Fourteen
joints with nonreducing internal derangements were
identified in 11 patients, three bilateral, six with reducing
joints on the opposite side, one opposite a normal joint,
and one opposite a partially-reducing joint. The distribu-
tion of reduction on opening the mouth versus disk posi-
tion in closed-mouth views is shown in Figure 7.
Pretreatment objective symptom scores (TMJ Scale)
ranged from 78 to 99+. Only three patients had objective
scores less than 99+. Post Phase I objective scores ranged
from 4 to 94. Five patients had MRI reports of normal
disk position bilaterally, yet had signs and symptoms of a
temporomandibular disorder. There were 15 patients out
of 30 with at least one recapturable disk. Only two of
these patients had normal disk position in the contralat-
eral joint.
The results of objective evaluation (TMJ Compare) of
improvement in symptoms are shown in Table 2. The
greatest improvement (range 84% to 97%, average 89%)

232 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE OCTOBER 1995, VOL. 13, NO. 4
SIMMONS AND GIBBS TMJ DISKS AND ARA

FigureS
Sagittal oblique TI-weighted MRis of patient D.W., 08-21-93, are shown after insertion of the mandibular anterior repositioning appliance: (A) right;
(B) left. The disks are recaptured bilaterally. Note the slight anterior and inferior repositioning of the condyle.

Figure6
Sagittal oblique Tl-weighted MRis of patient D.W., 08-21-93, are shown in the centric occlusion position after Phase II was completed. Both disks
remain recaptured even though Phase II allowed a slight posterior repositioning of the condyle, as compared to immediate post-treatment results:
(A) right TMJ; (B) left TMJ.

was found in the bilateral recapturable disk group. The
least improvement was the bilateral nonrecapturable disk
category with a low of 47% and a high of 84% improve-
ment, giving an average improvement of 65%.
Table 3 reports on the subjective assessment of
improvement in symptoms at the completion of Phase I
treatment. Four patients with bilateral normal disk posi-
tion with symptoms showed a low of 80% and a high of
I 00% improvement. This gives an average improvement
for this category of 95%. There were two patients with
unilateral normal and unilateral recapturable disks.
Improvement ranged from 80% to 98%, with an average
of 89%. The greatest improvement, again, was seen in the
bilateral recapturable disk group of five patients. The
lowest improvement reported was 93% and the highest
was I 00% for an average improvement of 98% for this
category. Again, the least improvement was seen in the
bilateral nonrecapturable disk category, with a low of
60%, a high of 95%, and an average of 82%.
Nonreducing and partially-reducing joints were pooled
since the disk in partially-reducing joints does remain
displaced on opening the mouth. The classification of
disk position with ARA in place was essentially unchanged
from that in pretreatment open-mouth views in 58 of the
60 joints (Figure 8). The disk in one joint that reduced on
opening was not recaptured by the appliance, and one
disk that was normal before treatment was medially dis-
placed afterwards.
Pain assessment was performed per patient, not per
joint. No attempt was made to correlate symptoms to
specific joints, such as left versus right in a patient with
unilateral internal derangement. Instead, patients were

OCTOBER 1995, VOL. 13, NO. 4 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 233
 TMJ DISKS AND ARA SIMMONS AND GIBBS

------------------
and the subjective response of each patient (Figure 10).
16 Objective estimates of relief were 86 ± 14% for subjects
~ Reducing
14
~ Partially reducing
with internal derangements that recaptured on appliance
~12 ill!lllll Nonreducing insertion, 77 ± 14% in subjects with normal disk relation-
..c ships, and 66 ± 13% in those with nonrecapturable disks .
E 10
:::l
c Subjective responses were 96 ± 7%, 95 ± 10%, and
~a
83 ± 14%, respectively. Analysis of variance indicated a
E6
·a
..., significant difference in the degree of relief from the
objective assessment between the three classifications (p
< 0.05). No significant differences were noted between
the subjective estimates of pain relief. The subjective
N A AL AM M LAR MAR
estimates were consistently greater (average 15%) than
Disk Position objective assessments. No statistical comparison of
Figure 7
the two methods was done, since it is not clear what the
The status of reduction of disk position in open-mouth views classified difference (if any) means.
by pretreatment disk position in closed-mouth images is shown. Of the
60 joints studied, 13 had normal disk relationships, 26 had reducing
internal derangements, and 21 had nonreducing internal derangements.
Discussion
See the text or footnote in Table I for an explanation of symbols for
direction of disk dislocation. It is obvious, even without statistical analysis, that
displaced disks that reduce on opening the mouth can
be recaptured by anterior repositioning appliances. These
classified according to the most advanced internal results confirm, extend, and further document those
derangement in either joint. That is, a patient with one of several other investigators who have used ARAs
side normal and a reducing displacement on the opposite successfully in the treatment of TMJ pain. 8•9 Similar
side was called a reducing displacement. A patient with a results have been recently reported by a surgical tech-
reducing joint on one side and a nonreducing displace- nique, condylotomy, that achieves condylar repositioning
ment on the other side was called nonreducing. to an anterior and inferior relationship in the fossa. 22
Pretreatment symptom evaluation using the objective Long-term stability of the recapture, however, remains to
instrument found no significant differences in pain score be demonstrated.
between the three classes, 99 ± 0 (mean ± standard devi- There are several unique features of the current study
ation) in recapturing joints, 99 ± 1 in normals, and 96 ± 7 that are worthy of comment. First, a concerted effort has
in subjects with nonrecapturing joints (Figure 9). been made to document every significant step in proce-
However, post-treatment scores (41 ± 32, 54± 28, and 70 dure and method of evaluation, and to present the details
± 20, respectively) were significantly different from the in this report. ARA therapy is technique sensitive. For
pretreatment scores in each class (p < 0.05). example, patients were specifically instructed to bite in
Estimation of relief from symptoms as a result of treat- centric occlusion while pretreatment closed-mouth imag-
ment used both the comparison function (TMJ Compare) ing was performed. Otherwise, position of the mandible

Table 2
Objective Improvement in Symptoms
End of Phase I
Disk Status Improvement(%)
(number of subjects) Low High Average
Bilateral normal with symptoms (4) 57 86 77
Unilateral normal with unilateral
57 98 78
recaptured (2)
Unilateral normal with unilateral
63
nonrecaptured (I)
Bilateral recaptured ( 5) 84 97 89
Unilateral recaptured with unilateral
67 76 72
nonrecaptured (2)
Bilateral nonrecaptured (5) 47 84 65

234 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE OCTOBER 1995, VOL. 13, NO. 4
SIMMONS AND GIBBS TMJ DISKS AND ARA

Table 3
Subjective Improvement in Symptoms
End of Phase I
Disk Status Improvement(%)
(number of subjects) Low High Average
Bilateral normal with symptoms (4) 80 100 95
Unilateral normal with unilateral
80 98 89
recaptured (2)
Unilateral normal with unilateral
100
nonrecaptured ( I )
Bilateral recaptured (5) 93 100 98
Unilateral recaptured with unilateral
75 98 87
nonrecaptured (2)
Bilateral nonrecaptured (5) 60 95 82

and its influence on condyle-disk-fossa relationships
would have been unspecified and perhaps irreproducible.
In patients with displaced disks pretreatment, man-
dibular condyles were commonly positioned posteriorly
and superiorly in the fossae. Post-treatment images found
condyles in the Gelb 4/7 position, with disks in normal
relationship to condyles. A number of recognized author-
ities have published illustrations labeled as normal
condyle-disk-fossa relationships, which coincide with the
Gelb 4/7 position. 5• 23-25 It is important to point out that the
physiologic normal position is not the most posterior and
superior position of the condyle in the fossa, as stated by
older dogma.
It seems clear that imaging studies that unequivocally
establish disk position are necessary for those patients
whose treatment will be influenced by such disk position.
MRI studies are now regarded as the gold standard for
this purpose. If an MRI study is to be performed, it must
meet current standards for thoroughness. A complete
examination must be bilateral, including both sagittal
oblique and coronal oblique images, with at least one set
obtained with T2 weighting. These images must be
obtained with the mouth closed in centric occlusion,
rather than rest position. Additional images must be
obtained with the mouth open beyond the point of any
joint click. It may be that accurate prognosis as to relief of
symptoms will best be achieved by using both pretreat-
ment and post-treatment MRis.
There were five patients in the consecutive series seen
in this study that had symptoms of temporomandibular
disorder and normal disk position bilaterally on three-
dimensional MRI study. All of these patients had a TMJ
Scale Global score in excess of 98. All of these patients
had significant symptoms of temporomandibular disor-
der. Most of these patients had temporomandibular click-
ing that was either palpable and/or auscultatable.

120 Pre-treatment
25 110
100
i20 90
.c 80
E
.s 15
I!! 70
~ 60
~ 50
~ 10 40
30
5 20
10
0 0
Normal Reducing Nonreducing Recapture Nonrecapture Normal
Internal Derangement Disk Status
FigureS Figure 9
Immediate recapture of disks by anterior repositioning appliances is Objective evaluation of symptoms before treatment and at completion
shown. Twelve of 13 normal joints were unchanged by the insertion of of Phase I are shown. Error bars denote standard deviations. The
the appliance. One became slightly medially displaced. Twenty-five of decrease in pain score in each class after treatment was statistically
26 reducing disks were recaptured, while nonreducing disks remained significant (p < 0.05).
unchanged.

OCTOBER 1995, VOL 13, NO. 4 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 235
TMJ DISKS AND ARA
Objective
110
I!!
8
en 50
40
30
20
10
0 Anterior repositioning appliances successfully recap-
Recapture Nonrecapture Normal
Disk Status
Figure 10
The estimation of relief of pain at the conclusion of Phase I of treat-
ment is shown, objective and subjective, scale of 0 (no relief) to I 00
(complete relief). Error bars denote standard deviations. The difference
between categories was statistically significant (p < 0.05) on objective
assessment, but not on subjective assessment.
An MRI study is a snapshot in time. A patient can have
clicking in the TMJs one day and not the next. It is possi-
ble that internal derangements may be temporally unsta-
ble, as well. One hypothesis for explaining the sounds
from these MRI-normal joints could be disk shudder,
possibly resulting from stretching of ligaments, with the
sound arising from disk vibration as the condyle trans-
lates. One patient (A.R. 10-01-93) had an MRI study
showing the right disk anteriorly displaced with reduction
and the left disk anteriorly displaced without reduction.
The MRI study just prior to her appliance insertion 15
months later showed the right disk normal and the left
disk anteriorly displaced with reduction. MRI studies
may differ with time in some patients.
There were 25 patients with at least one TMJ showing
internal derangement. Only three of these had unilateral
disk displacement, with the other side normal. Of 11
patients with at least one joint that had a nonreducing
disk, there was only one normal joint. This strongly sug-
gests that if a patient has a displaced disk on one side then
the other side is probably not normal.
The earliest click recaptured was 4 mm and the latest
click recaptured was 43 mm. Late opening clicks were
routinely recaptured. These results challenge the near-
universal opinion that only early opening clicks are
recapturable. Symptomatic relief occurred to a high
degree in all subjects, demonstrating the effectiveness of
anterior repositioning appliances at providing patient
comfort. These results indicate that the appliances are
effective, as Gelb and Gelb 2 claimed, even without the
recapture of displaced disks. However, the degree of
relief was greater in subjects whose disks were displaced
236 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
SIMMONS AND GIBBS
and recaptured. Even from the small sample available to
date, these results were statistically significant.
Given the information achieved in this study, if some-
one has a TMJ Scale Global score of 99+ and they have
an MRI study that shows that both disks are displaced and
reduce upon opening, then the expected reduction in the
patient's presenting symptoms using the technique in this
study is between 89% and 100%.
Conclusions
ture displaced disks that reduce on opening the mouth,
even late-reducing displaced disks (up to 43 mm interin-
cisal distance). ARA therapy also provides effective
relief for patients with painful TMJ disease. However,
correlation between these two results is far from perfect.
Three classes of pretreatment disk positions were included
in this study: normal, reducing displacement, and nonre-
ducing displacement. All patients in all three classes had
severe symptoms of TMJ disease. That is, MRI report of
normal disk position does not necessarily indicate absence
of temporomandibular disorder. Disk position was
changed by treatment in only one class, reducing dis-
placement. This change was accomplished by placing the
condyle in the Gelb 417 position in the fossa, based on
information from cephalometrically-corrected tomo-
grams alone. MRI studies were not required for condylar
repositioning for disk recapture.
Symptomatic relief was significant in all three classes,
but greatest in patients with reducing displacements. It
must be concluded that disk recapture is an important
factor - but not the only factor - in providing patients
with relief from painful TMJ disease. Follow-up studies
of these patients are still in progress. The issue of long-
term retention of disk recapture and its relationship to
patient symptoms will be the subject of a future report.
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