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J Dent Educ. 69(11): 1242-1250 2005
© 2005 American Dental Education Association
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Evidence-Based Dentistry

Stabilization Splint Therapy for the Treatment of Temporomandibular Myofascial Pain: A Systematic Review

Ziad Al-Ani, B.D.S., M.Sc., Ph.D.; Robin J. Gray, B.D.S., M.D.S., Ph.D., M.F.G.D.P.; Stephen J. Davies, B.D.S., M.D.Sc., D.G.D.P.; Philip Sloan, B.D.S., Ph.D., F.R.C. Path., F.D.S.; Anne-Marie Glenny, B.Sc., M.Med.Sci.

Key words: temporomandibular joint disorders, myofascial pain, systematic review, myofacial pain, stabilization splint, pain dysfunction syndrome

Submitted for publication 08/03/05; accepted 08/22/05


   Abstract
Top
 Abstract
Method
 Results
 Discussion
 References
 
The aim of this review is to establish the effectiveness of stabilization splint (SS) therapy in reducing symptoms in patients with myofascial pain. Searching of electronic databases, handsearching of relevant key journals, and screening of reference lists of included studies were undertaken. There was no language restriction, and unpublished research was sought. The selection criteria were randomized controlled trials comparing splint therapy to either no treatment or another active treatment. Data extraction and validity assessment were carried out independently and in duplicate. Studies were grouped according to treatment type. Twenty potentially relevant Randomized Controlled Trials (RCTs) were identified. Only twelve met the inclusion criteria. There is insufficient evidence either for or against the use of stabilization splint therapy over other active interventions for the treatment of temporomandibular myofascial pain. However, it appears that stabilization splint therapy may be beneficial for reducing pain severity at rest and on palpation and depression when compared to no treatment. The authors suggested the need for well conducted RCTs that pay attention to method of allocation, blind outcome assessment, sample size, and duration of follow-up. Various measures were adopted to assess the outcomes of treatment. Standardization of the methods used to measure outcomes of the treatment of myofascial pain should be established in future RCTs.

Myofascial pain is the most common temporomandibular disorder (TMD). There are many synonyms for this condition including facial arthromylagia, TMJ dysfunction syndrome, myofacial pain dysfunction syndrome, craniomandibular dysfunction, pain dysfunction syndrome (PDS), and myofacial pain dysfunction.1 The etiology of myofascial pain is multifactorial. Consequently, many different therapies, some conservative and reversible, others irreversible, have been advocated for patients with myofascial pain. A number of successful treatment outcomes have been reported, including occlusal splints, physiotherapy, muscle-relaxing appliances, and pharmacological interventions.

There are various types of occlusal splints (bite plates or intraoral appliances of variable designs used in the management of TMD) described in the literature; they have different indications and functions. The stabilization splint (SS), one such type of occlusal splint, is also known as the Tanner appliance, the Fox appliance, the Michigan splint, or the centric relation appliance. The stabilization splint is a hard acrylic splint that provides a temporary and removable ideal occlusion (ideal contact between the teeth for the muscles and the temporomandibular joints).1,2 Providing an ideal occlusion by the use of splint therapy reduces abnormal muscle activity and produces "neuromuscular balance."2 Normally, it is suggested that patients wear the splint only at night. The splint needs to be adjusted (rebalancing of the splint to the new position of the jaw by grinding some of its surface points, since the lower jaw will adopt a new position as a result of wearing the splint) over several visits as the masticatory muscles relax until a consistent jaw relationship is reached. The patients then should be reviewed at regular intervals. After a period of successful splint therapy (normally between two to three months), patients can be weaned off the splint.2

The splint is constructed after taking impressions of the upper and lower dental arches, face bow registration, and recording of centric relation. A face bow is a calliper-like device used to record the spatial relationship of the upper teeth to some anatomic reference point or points and then enable transfer of this relationship to an articulator. It orients the dental cast in the same relationship to the opening axis of the articulator as the teeth relate to the jaw joints in the patient.

A number of clinical studies have specifically evaluated the treatment of myofascial pain by SS therapy, and articles demonstrating clinical success have been published.3–5 When properly adjusted, the SS delivers a good method of providing centric relation occlusion (the position of the jaw relative to the skull when the muscles are at their most relaxed and least strained position), eliminating posterior interferences (any predominant contacts between the back teeth that interfere with or hinder harmonious jaw movement), providing anterior guidance on anterior teeth (the contact between the anterior teeth without any posterior contact during jaw movements), reducing neuromuscular activity, and obtaining stable occlusal relationships with uniform tooth contacts throughout the dental arch.1,2

The objective of this review was to determine the effectiveness of stabilization splint therapy in reducing symptoms in patients with myofascial pain, compared with any control group. The review was undertaken with the Cochrane Oral Health Group; a more detailed version of the review is available on the Cochrane Library (www.Cochrane.org).


   Method
Top
 Abstract
 Method
Results
 Discussion
 References
 
To be included in the review, the identified studies had to meet the following four criteria:

  1. Study Design. Randomized or quasi-randomized controlled trials (RCTs), in which splint therapy is compared concurrently to no treatment, physiotherapy, relaxing appliances, pharmacological interventions, other occlusal appliances, or any other active intervention. Data from conference abstracts were not included in the review.
  2. Types of Participants. All patients with myofascial pain of all degrees of severity were included. A diagnosis of myofascial pain can be made if the patient exhibits more than one of the following signs and/or symptoms in any combination:5
    Studies examining temporomandibular disorders other than those of primarily muscular origin were excluded.
  3. Types of Interventions. Stabilization splint (Tanner appliance, the Fox appliance, the Michigan splint, or the centric relation appliance). Any control group (no treatment, physiotherapy, pharmacological intervention, other occlusal appliances, or any other active intervention).
  4. Types of Outcome Measures. The outcome measures considered were improvement in pain of the temporomandibular joint, improvement in pain of associated mandibular muscles, improvement of the range of movement to a normal range of movement, and, when relevant, disappearance of joint sounds. Depression, dysfunction scores, treatment credibility, and quality of life were also examined. Response to treatment must be assessed subjectively and clinically. Subjective assessment requires patients to have recorded their present overall state at review as being cured, improved, static, or deteriorating. Since discrepancies between subjective and objective assessments have been reported,6 improvement in pain should also be confirmed clinically by palpating the muscles and the joints.

Search Strategy for Identification of Studies
For the identification of studies included or considered for this review, detailed search strategies were developed for each database searched (Cochrane Oral Health Group Trials Register; The Cochrane Central Register of Controlled Trials [CENTRAL], 2003, Issue 2; MEDLINE, 1966 to June 2001; EMBASE, 1966 to June 2001). This search was combined with the Cochrane Sensitive Search Strategy for RCTs.7 The search strategy developed for MEDLINE was revised appropriately for each database to take into account differences in controlled vocabulary and syntax rules.

The search attempted to identify all relevant studies irrespective of language. The reference lists of all relevant trials obtained were checked, along with the reference lists of relevant review articles. In addition, reference lists from prosthetic dentistry textbooks on temporomandibular disorders and splint therapy were also checked. The following journals have been identified as being important to be handsearched for this review for the period 1960 to present: Journal of Prosthetic Dentistry, Acta Odontologica Scandinavica, Journal of the American Dental Association, and Journal of Oral Rehabilitation.

The results of the searches were screened independently and in duplicate by two reviewers (MZA and RG). The full articles of all studies meeting, or potentially meeting, the defined inclusion criteria were obtained for further assessment.

Data Assessment and Synthesis
All potentially relevant articles and reports were assessed independently by two reviewers (MZA and RG) using a previously prepared data extraction form. The two reviewers knew the names of the authors, institutions, journal of publication, and results when applying both the inclusion criteria and during data extraction. After assessment of the studies, the results were compared and discussed until consensus was achieved. Disagreements were handled by discussion and by consulting a third reviewer (PS). Additional information was sought from the authors when necessary. To reduce pre-formed opinions of experts in the area that can bias the assessment of the relevance of articles, one reviewer was not an expert in the area.

Each study included was quality assessed independently by two reviewers (MZA and RG). In the case of discrepancies, the authors were contacted for details of randomization where necessary.

Three main quality criteria were assessed: 1) randomization and allocation concealment; 2) blind outcome assessment—participants and investigators cannot be blinded to splint therapy; however, it is feasible to blind the outcome assessor and all included studies were assessed for blinding of the outcome assessment; and 3) completeness of the follow-up.

Uncertainty about methodology employed during the quality assessment phase was resolved by contacting the authors when necessary.

The significance of discrepancies in the estimates of treatment effects from the different trials was assessed by inspection of a graphical display and by means of Cochrane’s test for heterogeneity. The Cochrane Oral Health Group’s statistical guidelines were followed and relative risk (RR) values calculated along with 95 percent confidence intervals (CI) for binary data. Weighted mean difference (WMD) was used for continuous data. Meta-analysis was to be undertaken using a random effects model in the absence of clinical and statistical heterogeneity.

Data were analyzed using Review Manager program and the main results of the studies presented separately for pain (TMJ, muscles and jaw movements), movement of the jaw (deviation in mouth-opening, range of mouth opening, lateral movements), TMJ clicking, depression level, Helkimo dysfunction score (an index for anamnestic and clinical dysfunction and occlusal state), treatment credibility, and quality of life. If data allowed, a sensitivity analysis had to be conducted to see how the quality of the studies affects the findings.


   Results
Top
 Abstract
 Method
 Results
Discussion
 References
 
Twenty RCTs were identified as being potentially relevant. All were published in English. Eight trials were excluded due to use of splint therapy other than stabilization splint or due to the participants’ not meeting the criteria for myofascial pain.8–15 Twelve RCTs fulfilled the inclusion criteria. Details are presented in Table 1Go. Apart from one study with vague descriptions of the splint used,16 all other studies provided some information about splint construction and adjustment to centric relation. Comparison groups included acupuncture,16,17 bite-plates,18 biofeedback,19,20 visual feedback,21 non-occluding splints,22–24 relaxation/hypnorelaxation,25,26 jaw exercises,27 and minimal/no treatment.17,20,22,25


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  		Table 1. Characteristics of included studies
 
The study participants consisted of patients who had been referred for treatment for myofascial pain to a special clinic. In two studies,22,24 patients were recruited through announcements published in a local journal. The number of participants ranged from twenty18,21 to eighty patients.20 The number of patients per study group was twenty or less in four studies. Five studies gave detailed criteria for inclusion and/or exclusion of patients in the study.17,20,22–24 Information about previous TMD treatment was reported in only one study.17

The number of follow-up visits was standardized in both the study and control treatments in all studies included. However, the period of treatment/ follow-up varied from four to twelve weeks across included studies.

The type of outcomes measures varied between the studies (Table 1Go). Pain was measured using a Visual Analogue Scale (VAS)17,22,25 and the Pain Severity Scale (PSS), Muscle Palpation Index (PPI),20 and a pain diary.24 Two studies reported number of patients reporting pain on movement of mandible or pain on retrusion of the mandible.16,22 Other outcomes measured included electromyographic analyses,18 quality of life,22 clinical dysfunction scores,17,19,27 depression,20 range of jaw movement, sound, locking, and deviation in opening of mouth.16,21,25

The methodological quality of included studies is as follows: randomization and concealment procedures—one of the included studies reported on the method used to generate the randomization sequence or allocation concealment; blind outcome assessment—blind outcome assessment was clearly stated in only two trials;22,25 and drop-outs—drop-outs were reported in six studies,7 none of which undertook a full intention to treat analysis.2,18,20,22–24

Stabilization Splint (SS) vs. Minimal/No Treatment
Pain.
In the study by Turk et al.,20 SS was compared to a waiting list control group. A statistically significant lower pain score, using the PPI, was shown in the SS patients with a WMD –3.20 (95% CI: –4.81, –1.59). Similarly, using PSS, a statistically significant difference in pain scores was found in favor of the SS group with a WMD –1.40 (95% CI: –2.19, –0.61). A statistically significant difference was also seen when SS was compared to a minimal treatment group25 in terms of change in present pain (WMD –23.53; 95% CI: –29.41, –17.65) and pain on palpation (WMD –0.77; 95% CI: –0.90, –0.64) measured using a VAS. However, no statistically significant difference was shown when SS was compared to a passive control group in terms of the number of patients showing an improvement in intensity of pain at rest.22

Johansson et al. compared SS with acupuncture and a no intervention control group.17 Both of the treatment groups showed a statistically significant improvement in pain post-treatment compared to the non-intervention group (p<0.01).

Depression.
A statistically significant difference was shown between the same groups in terms of depression level evaluated by the Centre for Epidemiologic Studies-Depression (CED-S) (WMD –3.90; 95% CI: –6.29, –1.52) but not the Profile of Mood States (POMS) index (WMD –3.90; 95% CI: –7.74, –0.06).20

Stabilization Splint (SS) vs. Non-Occluding Splints
Pain.
No statistically significant difference in palpation score or pain diary score was seen, however, when SS was compared with a non-occluding splint.24 The number of painful muscles on palpation in the SS group in one study did not differ significantly from the number in the palatal splint group after six weeks of treatment.23 One trial investigated improvement in unpleasantness and intensity of pain at rest and showed no statistically significant difference between the two groups with an RR 0.75 (95% CI: 0.41, 1.37) and RR 1.44 (95% CI: 0.81, 2.58) for the improvement in the unpleasantness and intensity of pain respectively.22

Movement.
There was no statistically significant difference in the increase in maximal opening (mm) between groups receiving SS or a non-occluding splint (WMD 1.45; 95% CI: –1.47, 4.37).24

Overall Improvement.
There was no statistically significant difference in the number of participants reporting an overall improvement of symptoms between groups receiving SS or a non-occluding splint (RR 1.13; 95% CI: 0.79, 1.61).24 Similarly, in another study that compared SS to a non-occluding splint, no statistically significant improvement was found for any of the functional outcomes measured (swallowing, chewing, yawning, drinking, etc.).23

Quality of Life.
In the study by Dao et al., quality of life was examined in terms of improvement in sleep, efficiency at work, social activities, feeling depressed, feeling anxious, and poor appetite.22 A statistically significant difference in favor of SS therapy was shown for efficiency at work (RR 0.12; 95% CI: 0.02, 0.90). However, a statistically significant difference in favor of bite plates was shown when examining participants’ social activities and feelings of depression (RR 1.88; 95% CI: 1.07, 3.27 and RR 2.00; 95% CI: 1.07, 3.75 respectively). No other statistically different differences were shown.

Stabilization Splint (SS) vs. Acupuncture
Pain.
One study reported the number of patients with pain on palpation three months after treatment.16 There was no statistically significant difference between the two groups with a relative risk (RR) of 0.63 (95% CI: 0.24, 1.65) for the pain on palpation of the right side and RR 2.00 (95% CI: 0.19, 20.67) for pain on palpation of the left side. Similarly, no statistically significant difference was shown for pain on retrusion of the mandible (RR 0.60; 95% CI: 0.16, 2.25) or jaw opening (RR 0.86; 95% CI: 0.34, 2.19).

One study assessed change in severity of pain, described by a subjective symptom score (SDS).17 No statistically significant difference was found in the SDS when comparing the SS and acupuncture groups with RR 1.50 (95% CI: 0.29, 7.73), although both groups showed a statistically significant decrease in SDS and VAS scores after treatment.

Movement.
Raustia and Pohjola16 showed a statistically significant difference with regard to deviation to the right side in mouth-opening movement after treatment in the SS group when compared with the acupuncture group with an RR 0.55 (95% CI: 0.35, 0.84). Interestingly, the analysis showed no significant difference between these two groups in terms of deviation to the left side in the mouth-opening movement after treatment with RR 5.00 (95% CI: 0.63, 39.79).

There was no statistically significant difference between groups with regard to range of lateral movements (to the right WMD 0.80; 95% CI: –0.43, 2.03; to the left WMD 0.40; 95% CI: –0.86, 1.66) or range of mouth opening (WMD 2.60; 95% CI: –0.86, 6.06).

Clicking.
The same study compared the TMJ clicking in the SS and acupuncture groups.16 No statistically significant benefit was found. The RR for TMJ clicking on the right side was 1.00 (95% CI: 0.56, 1.78) and that for the TMJ clicking on the left side was 0.58 (95% CI: 0.28, 1.23).

Dysfunction Score.
Johansson et al.17 assessed the clinical signs by means of the Helkimo clinical dysfuction score. Both the SS and acupuncture groups showed a statistically significant decrease in dysfunction score (p<0.01) although no between-group differences were found.

Stabilization Splint (SS) vs. Biteplates
In the trial by Dahlstrom et al.,18 no statistically significant difference was found in the number of patients showing a high Helkimo dysfunction score in SS and bite plates groups with an RR 0.68 (95% CI: 0.20, 2.23) at final examination (after six weeks of appliance treatment).

Stabilization Splint (SS) vs. Feedback
Pain.
One trial20 investigated reduction in pain severity level using PSS. A comparison between biofeedback/stress management (BF/SM) and SS was undertaken. The results of this trial showed that SS patients had lower pain scores for PSS. However, the difference between the two groups was not statistically significant (WMD 0.30; 95% CI: –0.48, 1.08). Similarly, no statistically significant difference was found between SS and BF/SM for the reduction in muscle severity as evaluated by the Palpation Pain Index (PPI) (WMD 0.90; 95% CI: –0.26, 2.06).

Depression.
In the same study by Turk et al.,20 a statistically significant benefit in BF/SM group was found, when compared with the SS group, in depression level evaluated by CES-D index with a WMD 5.50 (95% CI: 1.49, 9.51). Evaluation of depression using the POMS index also showed a statistically significant difference between the SS and BF/SM groups with a WMD 6.50 (95% CI: 2.12, 10.88).

Treatment Credibility.
No statistically significant difference was reported in the study by Turk et al.20 regarding the increase in treatment credibility between SS and BF/SM with a WMD –0.10 (95% CI: –0.69, 0.49).

Dysfunction Score.
One trial,19 comparing SS and biofeedback, presented data for clinical signs of dysfunction according to the Helkimo index D1. No statistically significant difference was shown with regard to the number of patients achieving a decrease in the dysfunction score, RR 1.11 (95% CI: 0.64, 1.92). Subjective rating of symptoms using a five-point scale showed a statistically significant reduction in both groups, with a median change in score from three to one in both groups. However, the difference between groups was not statistically significant.

Movement.
In the study by Monteiro and Clark,21 both the SS and visual feedback groups showed statistically significant decrease in their lateral mandibular movement scores (p<0.01). However, data were unavailable for analysis. The authors gave no details of the data obtained.

Stabilization Splint (SS) vs. Jaw Exercises
Magnusson and Syren27 found improvements in all outcomes measured (mandibular mobility, TMJ function, TMJ pain, muscle pain, pain on movement, clinical dysfunction, and anamnestic dysfunction) for both groups at both three-month and six-month assessment. A follow-up questionnaire one to four years after the first clinical assessment showed a lasting treatment effect in most patients, although many patients continued to perform their jaw exercises or wear their occlusal splint. No statistically significant differences were observed between the groups at any time point.

Stabilization Splint (SS) vs. Relaxation
Pain.
Two trials compared SS with relaxation.25,26 Both studies assessed reduction in pain and changes in the maximal mouth opening. Okeson et al.26 showed a statistically significant reduction in pain on palpation in favor of SS; however, this was not supported by the Winocur trial.25 Significant statistical heterogeneity was found between the two trials for reduction of pain on palpation (p<0.01; I2=98.3%); it was therefore felt inappropriate to pool the data.

Movement.
Similarly, for changes in maximal mouth opening, significant heterogeneity was found between the two studies both for active/comfortable opening (p<0.01; I2=92.9%) and assisted/painful opening (p<0.01; I2=94%). Again, it was felt inappropriate to pool the data from the trials. Okeson et al.26 found a statistically significant difference in favor of SS, but these results were not supported by Winocur et al.25


   Discussion
Top
 Abstract
 Method
 Results
 Discussion
References
 
Myofascial pain is the most common temporomandibular disorder (TMD) and the aetiology is multifactorial. Consequently, many different therapies, some conservative and reversible, others irreversible, have been advocated for patient with myofascial pain. A number of successful treatment outcomes have been reported.3–5 Various types of occlusal splints described in the literature have different indications and functions. The stabilization splint (SS) is one such type of occlusal splint. The stabilization splint is a hard acrylic splint that provides a temporary and removable ideal occlusion. Providing an occlusion by the use of splint therapy reduces abnormal muscle activity and produces "neuromuscular balance."

Our systematic review of the literature showed that there is only weak evidence to suggest that SS therapy may be beneficial in comparison to minimal or no treatment in terms of pain as measured using the PPI, PSS, VAS, and CED-S. However, there was no evidence of a statistically significant difference in the effectiveness of stabilization splint therapy in reducing symptoms in patients with myofascial pain when compared with other conventional treatments such as acupuncture, biteplates, and biofeedback. In general, the comparisons were based on a small number of patients with no standardization of the outcomes measured. Little attention was given to the randomization process and concealment of allocation in the included studies, increasing the risk of selection bias. Given the subjective nature of the outcome assessment in this area, blind outcome assessment is imperative to reduce bias within the RCTs. Only two of the included studies stated that blind outcome assessment was used.22,25

On the basis of our results, we conclude that there is insufficient evidence either for or against the use of stabilization splint therapy over other active interventions for the treatment of temporomandibular myofascial pain. However, it appears that stabilization splint therapy may be beneficial for reducing pain severity at rest and on palpation and depression when compared to no treatment.

Well-conducted RCTs are needed to clarify the effectiveness of stabilization splint therapy for patients with myofascial pain. Trials should pay attention to the generation of the randomization sequence, method of allocation, blind outcome assessment, sample size, and duration of follow-up. Clear inclusion/exclusion criteria may help identify whether or not the patients entering a study had myofascial pain or a different diagnosis of temporomandibular disorder. A standardization of the outcomes used to assess the treatment of myofascial pain should be established in the RCTs. The Cochrane version of this systematic review will be updated periodically to include any newly emerging, relevant RCTs.


   Acknowledgments
 
The reviewers would like to thank members of the Cochrane Oral Health Group for their support, particularly Professor Helen Worthington (coordinating editor and statistician), Emma Tavender (review group coordinator), and Sylvia Bickley (trials search coordinator).


   Footnotes
 
Dr. Al-Ani is Clinical Lecturer in Restorative Dentistry, School of Dentistry; Dr. Gray is an Honorary Fellow in Dental Medicine and Surgery, School of Dentistry; Prof. Davies is a Lecturer in Dental Practice, School of Dentistry; Prof. Sloan is a Professor of Experimental Oral Pathology, School of Dentistry; and Ms. Glenny is a Lecturer in Evidence-Based Oral Health Care, Cochrane Oral Health Group, MANDEC, School of Dentistry—all at the University of Manchester, UK. Direct correspondence and requests for reprints to Dr. Ziad Al-Ani, TMD Unit, School of Dentistry, University of Manchester, Higher Cambridge Street, Manchester, UK M15 6FH; 44-0-161-275-6717 or 6788 phone; 44-0-161-275-6797 fax; ziad.al-ani{at}manchester.ac.uk.


   REFERENCES
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 Abstract
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 Results
 Discussion
 References
 

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P. C. R. Conti, C. N. dos Santos, E. M. Kogawa, A. C. d. C. F. Conti, and C. d. R. P. de Araujo
The treatment of painful temporomandibular joint clicking with oral splints: A randomized clinical trial.
J Am Dent Assoc, August 1, 2006; 137(8): 1108 - 1114.
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