CRANIO®

The Journal of Craniomandibular & Sleep Practice

ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20

Changes in Vertical Tooth Position and Face Height

Related to Long Term Anterior Repositioning Splint
Therapy

Donald T. Brown, Elmer L. Gaudet Jr. & Ceib Phillips

To cite this article: Donald T. Brown, Elmer L. Gaudet Jr. & Ceib Phillips (1994) Changes in
Vertical Tooth Position and Face Height Related to Long Term Anterior Repositioning Splint
Therapy, CRANIO®, 12:1, 19-22, DOI: 10.1080/08869634.1994.11677988

To link to this article: http://dx.doi.org/10.1080/08869634.1994.11677988

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 •rMJ

Changes in Vertical Tooth Position and Face Height

Related to Long Term Anterior Repositioning Splint
Therapy
Donald T. Brown, D.D.S., M.S.; Elmer L. Gaudet Jr., D.D.S., M.S.D.;
Ceib Phillips, M.P.H., Ph.D.

ABSTRACT: This study evaluates whether extended full-time wear of a partial coverage mandibular
anterior repositioning splint (MORA) causes intrusion of posterior teeth and determines the effect on jaw
0886-9634/1201-
position. Sixty-four patients from two private orthodontic practices were studied using cephalometric
0019$03.00/0, THE radiographs to measure vertical change in position of the anterior and posterior teeth and the mandible.
JOURNAL OF The splint wear time ranged from a minimum of one half year to a maximum of 4.8 years, with a mean
CRANIOMANDIBULAR
PRACTICE, of 1.33 years. No significant change was recorded in the distance from the mandibular molar to the
Copyright© 1994 mandibular plane. On average, the maxillary incisor and maxillary molar extruded about 1 mm, while the
by CHROMA, Inc.
Manuscript received
mandibular molar was unchanged and the mandibular incisor intruded about 0.6 mm. Posterior face
June 22, 1993; accepted height increased an average of 1.6 mm, and anterior face height increased an average of 2.7 mms. In
Sept. 3,1993
20% of the patients, intrusion of the mandibular molars of 1 mm or more occurred. In 41 %, extrusion of
Address for reprint requests:
Dr. Donald T. Brown
the maxillary incisors of 1 mm or more was noted. Intrusion of the upper molars or extrusion of the lower
P.O. Box 1735 incisors occurred in only 5% of the patients. The data indicates that only a very small proportion of
Covington, LA 70434-1735
patients having long term splint therapy using the MORA have clinically significant molar intrusion.
Change in mandibular position was expressed in a vertical increase in posterior and anterior face height.
Only very small changes occurred in antero-posterior position.

Introduction

nterior repositioning splints are used in the treat-

A ment of temporomandibular joint dysfunction

Dr. Donald T. Brown received his
D.D.S. degree in 1972from Louisiana
State University School of Dentistry and
his M.S. and Certificate in Orthodontics in
1976 from the University of North
Carolina School of Dentistry. He has been
in private practice as an orthodontist for
17 years in Covington, Louisiana. Dr.
Brown is a member of the American
Dental Association; American Association
of Orthodontists; American Academy of
Head, Neck, Facial Pain and TMJ
Orthopedics; Pierre Fauchard Academy;
and a Dip/ornate of the American
Academy of Pain Management.
(TMD) with reciprocal clicking due to anterior
displacement of the intra-articular disk on closure. In
theory, holding the mandible in a protrusive position will
allow the disk to remain in a normal relationship with the
mandibular condyle and articular eminence. Healing of
stretched or torn disk attachments can result in the recap-
ture of the disk so that displacement no longer occurs.'· 2
In practice, even if successful disk recapture does not
occur, an anterior repositioning splint often results in
reduction of pain and symptoms, helping the patient to
adapt to the disk displacement and regain reasonably
normal function.3
The MORA (mandibular anterior repositioning appli-
ance) is a frequently used partial coverage splint made on
the maxillary or mandibular teeth that has high patient
acceptance because of the relatively unobtrusive design.
When used on the lower arch, it consists of two occlusal
pads of acrylic covering the mandibular premolars and
molars that are tied together with a heavy metal lingual
bar. 4 Although the device is clinically useful in the treat-
ment of TMD, a number of authors have expressed con-
cern about the possibility that long-term wear of the splint
could lead to orthodontic tooth movement, particularly

19
CHANGES RELATED TO SPLINT THERAPY
intrusion of the posterior teeth and/or extrusion of the
anterior teeth. 2 • 3 · 5 Winklestern reported three cases
of iatrogenic intrusion of posterior teeth during therapy
with the partial coverage lower MORA appliance, 6 and
Tallents et al. reported that 66 of 68 patients, who had
worn similar splints for six months, required ortho-
dontic or prosthodontic treatment to close a posterior
open bite.? The extent to which this represents intrusion
of posterior teeth, extrusion of anterior teeth or reorgani-
zation within the temporomandibular joint (TMJ) as the
thicker portion of the articular disk is repositioned on top
of the condyle, 8 has not been determined.
Subjects and Methods
Two hundred and fifteen consecutive patients treated
in the private orthodontic practices of the senior authors
did the following: a) wore a MORA device for a mini-
mum of six months; b) had a complete natural dentition;
and c) had no significant medical problems reviewed. Of
these, 86 had initial and final cephalometric radiographs
available. Sixty-four patients were selected for inclusion
(Brown 39 , Gaudet 25 ).
Clinical characteristics of the sample are shown in
Table 1. The 3: I female to male ratio is typical of TMD
treatment groups, as is the wide age range (x=28 years,
MIN=7 years, MAX=61 years). Almost one-third of the
patients were age 18 or younger. Note that the group con-
tained no skeletal Class Ill patients (none with a negative
ANB angle), but included some severe skeletal Class 11
individuals. On average, the sample had a higher ANB
angle and longer anterior face height than population
norms. The initial characteristics of the patients treated in
the two practices were compared using unpaired t-tests.
No significant differences (P>0.09) were recorded in the
initial cephalometric characteristics of the patients treated
in the practices.
The construction of the MORA, a modified Gelb splint
constructed on the mandibular arch, was identical in the
two practices. Acrylic covered the occlusal and lingual
surfaces of the mandibular posterior teeth, from the
canines to the most distal molar bilaterally. There was a
Table 1
Pretreatment Cephalometric Characteristics
(N=64)
Change Standard
Measure Mean Dev. Minimum Maximum
SNA 82.3 3.6 75.6 90.7
SNB 78.6 4.0 70.7 88.5
ANB 4.0 2.3 0.1
10.7
Ant Face Height 121.9 9.4 101.9 146.9
Post Face Height 72.1 8.6 47.9 103.8
20 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
BROWN ET AL.
lingual apron of acrylic anteriorly (metal lingual bar
enclosed in acrylic). The incisal edges of the lower ante-
rior teeth were left uncovered, and the upper incisors did
not contact the splint. Total occlusal contact of the poste-
rior teeth, including canine guidance, was established in
the appliance. All patients had the mandible advanced to
approximately an edge-to-edge incisor relationship, with
a mild anterior open bite created by the minimal thickness
of acrylic required for coverage of the posterior teeth. No
adjunctive treatment involving changes in the occlusion
was delivered during the time the splint was worn. The
patients were instructed to remove the appliance only to
clean it. The average wearing time was 1.3 years with a
range of six months to 4.8 years.
The initial cephalometric radiographs were made in
natural head position with the posterior teeth in centric
occlusion. In the follow-up cephalometric radiographs,
48 (75%) were made during therapy with the splint in
position. Only the 16 follow-up films with the splint out
were used to calculate changes in face height or mandibu-
lar position, thus eliminating any artificial influence on
mandibular position. The demographics of the subset of
16 patients are very similar to the entire sample (3: 1
female/male ratio; mean age = 30; average wearing time
= 1.4). For analysis, the key landmarks (Figure I) were
located and digitized in the university laboratory by an
orthodontist not connected with the study, and statistical
analysis was accomplished using SAS. 9 Paired t-tests
were used to assess whether the mean changes observed
in the dental and facial measures were significantly dif-
ferent than zero.
Results
Mean changes in vertical tooth positions and jaw rela-
tionships are shown in Tables 2 and 3. For maxillary
molars, maxillary incisors and mandibular incisors, the
mean change was small, approximately 1 mm, but statis-
tically significant (Figures 2A, 2B, 2C). The maxillary
teeth extruded, while the mandibular incisors intruded.
Figure 1
Landmarks selected for
digitizing and perpendicular
lines from the sella-nasion
plane and mandibular plane.
Posterior face height was
measured along the perpen-
dicular from the sella to
mandibular plane and ante-
rior face height along the
nasion-pogonion-mandibular
plane. Dental changes were
measured from a perpendicu-
lar intersection to the molar
furcations and incisal tips.
JANUARY 1994, VOL. 12, NO. 1
BROWN ET AL. CHANGES RELATED TO SPLINT THERAPY

Table 2
Descriptive Statistics for the Vertical Changes Observed
in the Dental Measures and Intra-arch Facial Measures
(N=64) B.
Change Standard
Measure Mean Dev. Minimum Maximum P value
SNA -0.55 2.10 -7.12 4.70 0.04
Max Molar 1.18 1.48 -2.00 5.10 0.0001
MandMolar -0.03 1.38 -4.30 2.30 0.86
Max Incisor 0.73 1.71 -3.30 3.90 0.001
M and
Incisor -0.61 1.35 -5.60 2.60 0.001 A.
Positive numbers indicate extrusion and negative numbers indicate Figure2
intrusion. A schematic composite of pre- and post-MORA wear illustrating the
changes observed during splint therapy. A. Cranial base superimposi-
tion B. Maxillary superimposition C. Mandibular superimposition.
Table 3 Pre-Treatment Post-Treatment----
Descriptive Statistics for the Changes Observed in the
(5%) had 2 mm or more intrusion. Four of the 64 patients
Facial Measures for Those Patients Whose Follow-Up
(6%) had 1 to 2 mm intrusion of the maxillary molar, but
Radiograph was Taken with the Splint Out
no one had more than 2 mm intrusion. Extrusion of the
(N=l6)
upper molar was considerably more likely than intrusion:
Change Standard
55% of the patients had at least 1 mm extrusion, and six
Measure Mean Dev. Minimum Maximum P value
(9%) had >3 mm extrusion. Extrusion of the mandibular
SNB 0.19 1.25 -1.93 2.34 0.55
ANB -0.49 1.01 -2.53 0.98 0.07
molar occurred with almost exactly the same frequency
Post Face
as intrusion, with 25% of the patients having at least 1
Height 1.58 2.92 -4.20 8.90 0.05
mm extrusion and 3 (5%) having 2 to 3 mm extrusion.
Ant Face Although the mean change was a 1 mm extrusion of
Height 2.73 2.28 -1.00 8.00 0.0002 the maxillary incisors, extrusion of 1 mm or more actu-
ally occurred in only 41% ofthe patients. Six (9%) had 3
mm or more extrusion. Sixteen percent of the patients had
There was no mean change in the vertical position of the some intrusion of the upper incisors. For the mandibular
mandibular molars. A statistically significant increase in incisors, only three patients (5%) had any extrusion,
both anterior and posterior face height was noted in the while almost one-third (28%) of the group had at least 1
patients whose follow-up cephalometric radiograph was mm intrusion, and four (6%) had >3 mm intrusion.
taken with the splint out. All of these patients had a pos- Changes in the vertical position of the teeth are reflected
terior open bite at follow-up. in face height with the teeth in occlusion. Although this
Approximately one third of the sample was less than could be measured in only a limited sub-sample of the
18 at the start of treatment. However, the average changes patients (due to the need to have the splint out for this
reported are not unduly influenced by any potential measurement), consistent increases in face height were
growth effects of the younger patients. The average noted. Seven (44%) of the sub-group had a 2 to 4 mm
changes for those patients 18 or older are within 0.28 mm increase in anterior face height, and three ( 19%) had >4
and .13 degrees of the sample as a whole. No correlations mm increase. Interestingly, there was no change in the
were observed between gender or age at the beginning of antero-posterior position of the mandible, despite the use
treatment and the response to treatment. The vertical of an anterior repositioning splint.
change in the maxillary molars (r=.3) and the mandibular
molars (r=-.28) were the only response measures signifi- Discussion
cantly correlated (p<0.02) with the length of time wear-
ing the splint. But the association explained less than 9% This data indicates that continuous use of a splint with
of the variability in the molar movements. coverage of the posterior teeth and no coverage of the
Mean changes frequently obscure clinically significant incisal edges of anterior teeth, usually does not cause
variation within the sample, and it is important to note clinically significant intrusion of the posterior teeth. It
that there were wide variations in individual responses to appears that there is about a 20% chance of a 1 to 2 mm
the splint therapy. Intrusion of the mandibular molar intrusion of the mandibular molars, and a 5% chance of
occurred in 23% of the patients, but only three patients >2 mm intrusion. Intrusion of maxillary molars is quite

JANUARY 1994, VOL. 12, NO. 1 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 21

CHANGES RELATED TO SPLINT THERAPY
unlikely, with only about a 6% chance of any intrusion.
Extrusion of incisors is considerably more likely, but
this also is far from a consistent occurrence. Forty-one
percent of the patients showed extrusion of the maxillary
incisors, and only 5% had extrusion of mandibular
incisors. This difference presumably is related to the
splint design, which did include coverage of the lingual
surface of the lower incisors, although the incisal edges
were not capped.
The relationship between force against the teeth and
intrusive or extrusive movements is complex and not well
understood. From experiments with animal teeth, it
appears that light sustained forces of very small magni-
tudes can lead to intrusion, if the force is maintained for
25% or more of the time. 10• 11 Although biting force may
play a role in controlling human eruption, it seems likely
that light forces of long duration are most effective in
producing vertical tooth movements in humans. 12 From
clinical studies with human patients, it appears that intru-
sion of posterior teeth is difficult to produce, but most
likely to occur when a posterior splint, that is worn most
of the time, opens the patient well beyond the freeway
space and includes active elements (springs or magnets)
to produce an intrusive force. 13 It therefore appears likely
that for most patients in this study, the posterior opening
was not great enough to produce enough intrusive load-
ing of the posterior teeth to lead to intrusion. The data is
not extensive enough to allow absolute certainty, but does
indicate that the more the patient must be opened to bring
the incisors to edge-to-edge contact, the greater the
chance that posterior intrusion might be produced.
It appears that the clinical observation of increased
vertical space between the posterior teeth after splint
wear does not necessarily indicate that the teeth were
intruded. Instead, it most likely confirms a change in ver-
tical mandibular posture. A rapid increase in interdental
space as described by Ash, 2 who reported that a posterior
open bite could develop in as little as two weeks when a
splint was worn continuously, almost certainly is the
result of a change in mandibular posture. This is consis-
tent with Lundh's report that lowering of the mandible is
the dominant movement associated with mandibular
repositioning in an effort to promote recapture of a dis-
placed disk. 8
The patients did not show a forward movement of the
mandible after treatment. Previous work with functional
appliances (of which the MORA can be considered a
variant) has shown that growth of the mandible in adults
is not achieved by posturing the mandible forward, 14 so
net growth was not expected. The change in posture
brought the mandible downward, and presumably this
masked any small anteriorrepositioning that also occurred.
In conclusion, although intrusion of posterior teeth can
occur when an anterior repositioning splint is worn for
22 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
BROWN ET AL.
prolonged periods, this happens in only about 20% of the
patients and is small in magnitude. Extrusion of maxillary
incisors, also small in magnitude, occurs in about 40% of
the patients. Much of the change in dental relationships,
therefore, represents a change in mandibular posture.
Acknowledgements
We thank Dr. Linda Simon for digitizing the sample radi-
ographs, Dr. Olga Keith and Ms. Debora Price for assistance with
illustrations and Ms. Lisa Himber and Dr. William Proffit for assis-
tance in preparing the manuscript.
References
I. Gelb H: Clinical Management of Head. Neck and TMJ Pain and Dysfunction.
Philadelphia: W.B. Saunders, 1985
2. Ash MM: Cunent concepts in the etiology, diagnosis and treatment of TMJ
and muscle dysfunction. J Oral Rehabi/1986; 13:1-20
3. Okeson JP: Management of Temporomandibular Disorders and Occlusion.
St. Louis: C. V. Mosby, 1989
4. Pertes RA: Updating the mandibular orthopedic repositioning appliance
(MORA). J Craniomandib Pract 1987; 5:351-356
5. Clark GT: A critical evaluation of orthopedic interocclusal appliance therapy:
design, theory, and overall effectiveness. JAm Dent Assoc 1984; 108:359-
364
6. Winkelstem S: Three cases of iatrogenic intrusion of the posterior teeth
during mandibular repositioning therapy. J Craniomandib Pract 1988;
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7. Tallents RH, Katzberg R W, Macher DJ, Roberts CA: Use of protrusive splint
therapy in anterior disc displacement of the temporomandibular joint: a 1-
to 3-year follow-up. J Prosthet Dent 1990; 63:336-341
8. Lundh H: Correction of temporomandibular joint disk displacement by
occlusal therapy. Swed Dent J 1987, Suppl; 51:1-159
9. SAS Institute Inc.: SAS Procedures Guide, Version 6, 3rd Ed. Cary, North
Carolina: SAS Institute Inc., 1990
10. Steedle JR, Proffit WR, Fields HW: The effects of continuous axially directed
intrusive loads on the erupting rabbit mandibular incisor. Arch Oral Bioi
1983; 28:1,149-1,153
11. Proffit WR, Sellers KT: The effect of intermittent forces on eruption of the
rabbit incisor. J Dent Res 1986; 65:118-122
12. Steedle JR, Proffit WR: The pattern and control of eruptive tooth movements.
Am J Orthod 1985; 87:56-66
13. Barbre RE, Sinclair PM: A cephalometric evaluation of anterior openbite cor-
rection with the magnetic active vertical corrector. Angle Orthod 1991;
61:93-102
14. McNamara JA: Dentofacial adaptations in adult patients following functional
regulator therapy. Am J Orthod 1984; 85:57-71
Dr. ElmerL. GaudetJr. received his D. D. S. degree in 1962from
Loyola University School of Dentistry in New Orleans, Louisiana. He
completed a year rotating dental internship in the U.S. Air Force in 1963.
Dr. Gaudet received his M.S. and Certificate in Orthodontics in 1968
from Fairleigh Dickinson School of Dentistry in Teaneck, New Jersey
and has practiced orthodontics exclusively for 25 years in Natchez.
Mississippi. He is a member of the American Association of
Orthodontists; American Equilibration Society; American Dental
Association; American Academy of Head, Neck, Facial Pain and TMJ
Orthopedics; and a Dip/ornate of the American Academy of Pain
Management.
Dr. Ceib Phillips received her Ph.D. in anatomy from the University of
Wisconsin and an M.P.H. in biostatistics from the University of North
Carolina. After a three-year post-doctoral fellowship in orthodontics at
the University of Washington, she joined the faculty at the University of
North Carolina where she is currently a research associate professor.
Dr. Phi/lips is the statistical liaison between the School of Dentistry and
the Biometrics Consulting Laboratory. She is also the research coordina-
tor and statistician for several research contracts and N1H grants.
JANUARY 1994, VOL. 12, NO. 1