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• W2002802156 abstract "In this paper, the authors review the rationale and history of mandibular repositioning procedures in relation to temporomandibular disorders (TMDs) as these procedures have evolved over time. A large body of clinical research evidence shows that most TMDs can and should be managed with conservative treatment protocols that do not include any mandibular repositioning procedures. Although this provides a strong clinical argument for avoiding such procedures, very few reports have discussed the biologic reasons for either accepting or rejecting them. This scientific information could provide a basis for determining whether mandibular repositioning procedures can be defended as being medically necessary. This position paper introduces the biologic concept of homeostasis as it applies to this topic. The continuing adaptability of teeth, muscles, and temporomandibular joints throughout life is described in terms of homeostasis, which leads to the conclusion that each person's current temporomandibular joint position is biologically “correct.” Therefore, that position does not need to be changed as part of a TMD treatment protocol. This means that irreversible TMD treatment procedures, such as equilibration, orthodontics, full-mouth reconstruction, and orthognathic surgery, cannot be defended as being medically necessary. In this paper, the authors review the rationale and history of mandibular repositioning procedures in relation to temporomandibular disorders (TMDs) as these procedures have evolved over time. A large body of clinical research evidence shows that most TMDs can and should be managed with conservative treatment protocols that do not include any mandibular repositioning procedures. Although this provides a strong clinical argument for avoiding such procedures, very few reports have discussed the biologic reasons for either accepting or rejecting them. This scientific information could provide a basis for determining whether mandibular repositioning procedures can be defended as being medically necessary. This position paper introduces the biologic concept of homeostasis as it applies to this topic. The continuing adaptability of teeth, muscles, and temporomandibular joints throughout life is described in terms of homeostasis, which leads to the conclusion that each person's current temporomandibular joint position is biologically “correct.” Therefore, that position does not need to be changed as part of a TMD treatment protocol. This means that irreversible TMD treatment procedures, such as equilibration, orthodontics, full-mouth reconstruction, and orthognathic surgery, cannot be defended as being medically necessary. Statement of Clinical RelevanceThis article discusses the controversial topic of managing temporomandibular disorders with mandibular repositioning. The authors argue that both clinical and biologic evidence are sufficient to reject this approach for the treatment of temporomandibular disorders. This article discusses the controversial topic of managing temporomandibular disorders with mandibular repositioning. The authors argue that both clinical and biologic evidence are sufficient to reject this approach for the treatment of temporomandibular disorders. Throughout the twentieth century, the dental profession adopted numerous concepts and clinical procedures involving repositioning of the mandible as part of dental treatments. In the case of dentulous patients, the major reasons offered for the manipulation of the mandible into a proposed ideal maxillomandibular relationship can be grouped into two major categories: (1) to achieve a repeatable mandibular position in cases of comprehensive dental treatment and (2) to prevent or manage temporomandibular disorders (TMDs). It is well accepted that dental procedures, such as full-mouth prosthodontic restorations, orthodontics, or orthognathic surgery, usually involve repositioning of the mandible into a repeatable maxillomandibular position that is different from the original relationship found in the individual patient.1Schuyler C.H. Fundamental principles in the correction of occlusal disharmony, natural and artificial.J Am Dent Assoc. 1935; 22: 1193-1202Abstract Full Text PDF Google Scholar, 2Greene C.S. Temporomandibular disorders: the evolution of concepts.in: Sarnat B.G. Laskin D.M. The Temporomandibular Joint: A Biologic Basis for Clinical Practice. 4th ed. W.B. Saunders, Philadelphia, PA1992: 298-315Google Scholar However, when mandibular repositioning is performed as a preventive therapy or as a treatment approach in patients with TMDs, the procedure is performed on an assumption that the mandible is not in an ideal maxillomandibular relationship as a result of the existing static or dynamic occlusal relationships. These deviations from the “ideal” are assumed to be the fundamental cause for the development of TMD symptoms and signs.3Dawson P.E. Evaluation, Diagnosis and Treatment of Occlusal Problems.2nd ed. C.V. Mosby, St. Louis, MO1989Google Scholar, 4Thompson J.R. Abnormal function of the stomatognathic system and its orthodontic implications.Am J Orthod. 1962; 48: 758-765Abstract Full Text PDF Scopus (10) Google Scholar, 5Shore N.A. Occlusal Equilibration and Temporomandibular Joint Dysfunction. J.B. Lippincott, Philadelphia, PA1959Google Scholar The general implication has been that dentists should both recognize these deviations and correct them by performing various mandibular repositioning procedures.3Dawson P.E. Evaluation, Diagnosis and Treatment of Occlusal Problems.2nd ed. C.V. Mosby, St. Louis, MO1989Google Scholar, 4Thompson J.R. Abnormal function of the stomatognathic system and its orthodontic implications.Am J Orthod. 1962; 48: 758-765Abstract Full Text PDF Scopus (10) Google Scholar, 5Shore N.A. Occlusal Equilibration and Temporomandibular Joint Dysfunction. J.B. Lippincott, Philadelphia, PA1959Google Scholar, 6Gelb H. Clinical Management of Head, Neck, and TMJ Pain and Dysfunction. J.B. Lippincott, Philadelphia, PA1977Google Scholar, 7Weinberg L.A. Role of condylar position in TMJ pain-dysfunction syndrome.J Prosthet Dent. 1979; 41: 636-643Abstract Full Text PDF PubMed Scopus (99) Google Scholar When discussing the management of TMD cases in terms of malposition of the mandible and the need for its repositioning, the apparent clinical success of a variety of mandibular repositioning procedures is often described in the dental literature.8Sato H.I. Fujii T. Uetani M. Kitamori H. Anterior mandibular repositioning in a patient with temporomandibular disorders: a clinical and tomographic follow-up case report.Cranio. 1997; 15: 84-88Crossref PubMed Scopus (8) Google Scholar, 9Williamson E.H. Rosenzweig B.J. The treatment of temporomandibular disorders through repositioning splint therapy: a follow-up study.Cranio. 1998; 16: 222-225Crossref PubMed Scopus (15) Google Scholar, 10Simmons H.C. Gibbs S.J. Anterior repositioning appliance therapy for TMJ disorders: specific symptoms relieved and relationship to disk status on MRI.J Tenn Dent Assoc. 2009; 89: 22-30PubMed Google Scholar However, even when a rationale for mandibular repositioning is offered, it is, in most cases, not discussed within the framework of medical necessity. This important concept11Gross R. Decisions and Evidence in Medical Practice. Mosby, Inc., St. Louis, MO2001Google Scholar implies that the clinical procedure should be indicated and performed for the following reasons:1.The medical condition (i.e., mandibular malposition) is generally recognized as a valid health problem or a disease.2.The diagnostic tests used to assess whether the patient has this condition are valid with acceptable specificity and sensitivity.3.The patient's condition will get worse unless a specific procedure is done.4.The clinical procedure itself has specificity for addressing the patient's particular problem.5.The procedure is clinically efficacious according to evidence-based criteria (i.e., not just a placebo effect).6.The disease or disorder cannot be resolved by performing a less invasive procedure, thus justifying the invasiveness of the clinical procedure based on its benefit-to-risk ratio. The term “medical necessity” appears often in the medical literature with regard to treating patients with various diseases or disorders. However, it is almost never defined in an operational manner. The authors were unable to find a complete or consistent definition for this term by searching medical dictionaries and PubMed or by using various Internet search engines (e.g., Google, Bing, Yahoo). The main source for the above list has been certain insurance company contracts, in which doctors and hospitals are informed about what will or will not be covered. The authors have modified those statements to develop the six-point definition presented here. Mandibular repositioning procedures inevitably result in irreversible changes of the condyle or fossa and the interocclusal relationships that require subsequent extensive prosthodontic, orthodontic, and orthognathic procedures. Therefore, it is important to examine their medical necessity and their clinical validity if they are being recommended as preventive therapy or for active management of TMDs. It is the purpose of this paper to review the available scientific evidence related to these concepts and procedures of permanent mandibular repositioning. Temporomandibular joint (TMJ) and mandibular anatomy and function have long been topics of great interest to dental scientists and clinicians. As new empirical and scientific evidence about these issues became available, different concepts of “ideal” dental occlusion or articulation (static and dynamic relationships of opposing teeth) have been introduced. Similarly, various concepts of “ideal” maxillomandibular skeletal relationships have been proposed over the years, especially with regard to condyle–fossa relationships. Although mandibular movements are incredibly complex, involving TMJs, masticatory muscles, and the occlusal or incisal surfaces of teeth, the endpoint of full closure into maximum intercuspation (MI) is a precise and repeatable position. It is this position that determines exactly where the mandibular condyle will be “seated” in relation to the articular fossa and eminence. Therefore, any modification of tooth relationships (occlusion) affects the position of the condylar head in the TMJ articular fossa. There are several examples of dental conditions that require jaw repositioning as part of the therapeutic protocols. These include various malocclusions that need orthodontic and orthognathic treatments for correction. Also, many patients who have experienced major tooth loss, periodontal disease, and severe tooth wear will need reconstructive dental procedures to establish new occlusal relationships. Several concepts about how to achieve an “ideal” maxillomandibular relationship in those cases have been proposed.1Schuyler C.H. Fundamental principles in the correction of occlusal disharmony, natural and artificial.J Am Dent Assoc. 1935; 22: 1193-1202Abstract Full Text PDF Google Scholar, 12Keshvad A. Winstanley R.B. Comparison of the replicability or routinely used centric relation registration techniques.J Pros. 2003; 12: 90-101Crossref PubMed Scopus (38) Google Scholar Some of the recommended clinical protocols may involve the initial use of an oral interocclusal appliance to “free up” the mandible from its habitual MI position to establish the desired TMJ relationship.13Wassell R.W. Adams N. Kelly P.J. The treatment of temporomandibular disorders with stabilizing splints in general dental practice: one-year follow-up.J Am Dent Assoc. 2006; 137: 1089-1098Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar Independent of the clinical procedure, the goal is to achieve stability, reproducibility, and predictability of treatment success in those clinical cases. However, applying these repositioning concepts in preventing or treating TMDs requires a separate analysis of cause and effect. The premise that the etiology of these disorders is improper occlusal and maxillomandibular relationships goes back almost a century. That belief led to various dental procedures to prevent and treat TMDs by using the concept of an “ideal” jaw relationship. The first authors who wrote about this subject in the 1920s and 1930s14Monson G.S. Impaired function as a result of a closed bite.Nat Dent Assoc J. 1921; 8: 833-839Abstract Full Text PDF Google Scholar, 15Goodfriend D.J. Symptomology and treatment of abnormalities of the mandibular articulation (normal) (Part I).Dent Cos. 1933; 75: 844-852Google Scholar, 16Goodfriend D.J. Symptomology and treatment of abnormalities of the mandibular articulation (normal) (Part II).Dent Cos. 1933; 75: 947-957Google Scholar, 17Goodfriend D.J. Symptomology and treatment of abnormalities of the mandibular articulation (normal) (Part III).Dent Cos. 1933; 75: 1106-1111Google Scholar attributed ear symptoms and facial pain to the decrease of vertical dimension of occlusion, but it remained for Costen (1934),18Costen J.B. A syndrome of ear and sinus symptoms depend upon disturbed function of the temporomandibular joint.Ann Oral Rhinol Laryngol. 1934; 43: 1-15Crossref Scopus (344) Google Scholar an otolaryngologist, to place this concept in the spotlight. According to his theory of TMD etiology, which was not based on any specific research conducted by him or his colleagues, the decreased vertical dimension of occlusion leads to distalization of the condylar head within the TMJ. He attributed 11 painful as well as nonpainful otologic and facial symptoms to condylar pressure on the retrocondylar tissues of the posterior glenoid fossa. To reposition the condyles, he proposed a treatment approach that included opening the habitual vertical dimension of occlusion using an overlay dental prosthesis, covering posterior teeth only. Interestingly, this concept emerged again many years later with the introduction of the mandibular orthopedic repositioning appliance (MORA) as a phase I treatment for TMDs.19Gelb M.L. Gelb H. Gelb appliance: mandibular orthopedic repositioning therapy.Cranio Clin Int. 1991; 1: 81-98PubMed Google Scholar, 20Simmons H.C. Orthodontic finishing after TMJ disk manipulation and recapture.Int J Orthod Milwaukee. 2002; 13: 7-12PubMed Google Scholar A significant side effect of this treatment approach was intrusion of posterior teeth, which resulted in a bilateral posterior open bite. Advocates of this approach recommended crowning all posterior teeth, the extrusion of posterior teeth with the use of orthodontic methods, or long-term overlay wear as the phase II component of this treatment protocol.20Simmons H.C. Orthodontic finishing after TMJ disk manipulation and recapture.Int J Orthod Milwaukee. 2002; 13: 7-12PubMed Google Scholar Costen's anatomic concept was later rejected by Sicher,21Sicher H. Temporomandibular articulation and mandibular overclosure.J Am Dent Assoc. 1948; 36: 131-139Abstract Full Text PDF PubMed Scopus (67) Google Scholar Zimmerman,22Zimmerman A.A. Evaluation of Costen's syndrome from an anatomic point of view.in: Sarnat B.G. The Temporomandibular Joint. Charles C Thomas, Springfield, IL1951: 82-110Google Scholar and Christiansen et al,23Christiansen E.L. Thompson J.R. Zimmerman G. et al.Computed tomography of condylar and articular disk positions within the temporomandibular joint.Oral Surg Oral Med Oral Pathol. 1987; 64: 757-767Abstract Full Text PDF PubMed Scopus (20) Google Scholar who demonstrated that the proposed condylar pressure could not have occurred in vivo, given the normal morphology and physiology of the posterior aspect of the human TMJ. Other authors24Tradowski M. Dworkin J.B. Determination of the physiologic equilibrium point of the mandible by electronic means.J Pros Dent. 1982; 48: 89-98Abstract Full Text PDF PubMed Scopus (9) Google Scholar have discussed the decrease of the vertical dimension of occlusion in terms of loss of molar support. They claim that the loss of molars results in secondary osteoarthritis because of the increase of TMJ loading. However, their studies were done on skulls and autopsy specimens, so the changes observed might well have been the result of remodeling and adaptation. In addition, aging as a confounding factor was not taken into consideration, despite the fact that both tooth loss and secondary osteoarthritis increase with age. Epidemiologic studies of general populations found no evidence of an increased risk for TMDs or even of any tendency for more signs or symptoms of TMD in individuals with shortened dental arches.25Lundeen T.F. Scruggs R.R. McKinney M.W. Daniel S.J. Levitt S.R. TMJ symptomology among denture patients.J Cranio Disord. 1990; 4: 40-46PubMed Google Scholar, 26Witter D.J. De Haan A.F.J. Kayser A.F. Van Rossum G.M. A 6-year follow-up study of oral function in shortened dental arches. Part II, Craniomandibular dysfunction and oral comfort.J Oral Rehab. 1994; 21: 353-366Crossref PubMed Scopus (108) Google Scholar Vertical mandibular malposition concepts were soon followed by various concepts of “ideal” horizontal maxillomandibular relationships.27Ramfjord S.P. Dysfunctional temporomandibular joint and muscle pain.J Pros Dent. 1961; 11: 353-374Abstract Full Text PDF Scopus (138) Google Scholar Throughout the twentieth century, one of the proposed ideal jaw relationships has been centric relation (CR), based entirely on how the mandibular condyle is anatomically related to the articular fossa. The most recent version of the Glossary of Prosthodontic Terms defines CR as the position of the condyle, with the intermediate zone of the articular disk interposed between the articular eminence and the condylar head when it is in its most superoanterior position within the glenoid fossa.28The Academy of Prosthodontics. Glossary of prosthodontic terms, 8th ed.J Pros Dent. 2005; 94: 1-95Abstract Full Text PDF Google Scholar According to this ideal (which has been redefined several times in the prosthodontic literature), the maximum intercuspation (MI) of teeth should coincide with the initial point of occlusal contact (CO) when the mandible is in CR. Any MI that is different from CO results in a change in the ideal condylar position. Mandibular displacement from CR can occur in any direction, depending on the occlusal contact of the “interfering” cusps, but is most often anterior. According to clinicians who consider CR to be the true anatomic ideal, even a small discrepancy between MI and CO may result in an uncoordinated activity of both the superior and inferior lateral pterygoid muscles acting as antagonists to the activated elevator muscles. If this uncoordinated activity of the masticatory muscles persists, it may lead to chronic myofascial pain.29Dawson P.E. New definition for relating occlusion to varying conditions of the temporomandibular joint.J Pros Dent. 1996; 74: 619-627Abstract Full Text PDF Scopus (75) Google Scholar Interestingly, the orthodontic community came up with a quite different concept of mandibular displacement, in which the mandible was displaced posteriorly by a deep anterior overbite in some patients (the “trapped mandible”).30Thompson J.R. Concepts regarding function of the stomatognathic system.J Am Dent Assoc. 1954; 48: 626-637Abstract Full Text PDF PubMed Scopus (30) Google Scholar, 31Fraga M.R. Rodrigues A.F. Ribeiro L.C. Campos M.J. Vitral R.W. Anteroposterior condylar position: a comparative study between patients with normal occlusion and patients with Class I, Class II Division 1, and Class III malocclusions.Med Sci Monit. 2013; 29: 903-907Google Scholar The concepts of occlusal dysharmonies causing mandibular malposition became even more popular as investigators proposed variations on the theme of increased muscular effort for coping with occlusal interferences.27Ramfjord S.P. Dysfunctional temporomandibular joint and muscle pain.J Pros Dent. 1961; 11: 353-374Abstract Full Text PDF Scopus (138) Google Scholar, 32Sheikholeslam A. Riise C. Influence of experimental interfering occlusal contacts on the activity of the anterior temporal and masseter muscles during submaximal and maximal bite in the intercuspal position.J Oral Rehabil. 1983; 10: 207-214Crossref PubMed Scopus (52) Google Scholar Early research utilizing electromyography (EMG) seemed to show muscular hyperactivity leading to jaw muscle fatigue and pain.33Perry H.T. Muscular changes associated with temporomandibular joint dysfunction.J Am Dent Assoc. 1957; 54: 644-653Abstract Full Text PDF Scopus (48) Google Scholar, 34Jarabak J.R. An electromyographic analysis of muscular and temporomandibular joint disturbances due to imbalances in occlusion.Angle Orthod. 1956; 26: 170-190Google Scholar, 35Laskin D.M. Etiology of the pain-dysfunction syndrome.J Am Dent Assoc. 1969; 79: 147-153Abstract Full Text PDF PubMed Scopus (513) Google Scholar, 36Ash M.M. Current concepts in etiology, diagnosis and treatment of TMJ and muscle dysfunction.J Oral Rehab. 1986; 13: 1-20Crossref PubMed Scopus (64) Google Scholar, 37Wood W.W. A review of masticatory muscle function.J Pros Dent. 1987; 57: 222-232Abstract Full Text PDF PubMed Scopus (47) Google Scholar, 38Liu Z.J. Wang H.Y. Pu W.Y. A comparative electromyographic study of the lateral pterygoid muscle and arthrography in patients with temporomandibular joint disturbance syndrome sounds.J Pros Dent. 1989; 69: 229-233Google Scholar, 39Okeson J.P. Occlusal and functional disorders of the masticatory system.Dent Clin North Am. 1995; 39: 285-300PubMed Google Scholar However, subsequent studies showed that there was no consistent correlation between higher EMG activity and muscular pain.40Mohl N.D. Lund J.P. Widmer C.G. McCall W.D. Devices for the diagnosis and treatment of temporomandibular disorders. Part II: Electromyography and sonography.J Pros Dent. 1990; 63: 332-336Abstract Full Text PDF PubMed Scopus (79) Google Scholar, 41Lund J.P. Widmer C.G. Evaluation of the use of surface electromyography in the diagnosis, documentation, and treatment of dental patients.J Cranio Dis Fac Oral Pain. 1989; 3: 125-137PubMed Google Scholar, 42Christensen L.V. Rassouli N.M. Experimental occlusal interferences. Part I. A review.J Oral Rehab. 1995; 22: 515-520Crossref PubMed Scopus (45) Google Scholar Presuming that nocturnal bruxism was initiated by such occlusal interferences, the phenomena of occlusal “disharmony,” bruxism, and myofascial pain became inextricably linked.43Ramfjord S.P. Ash M.M. Occlusion.3rd ed. W.B. Saunders, Philadelphia, PA1983Google Scholar Not surprisingly, the treatments recommended for bruxism and myofascial pain involved changing the morphology of the interfering teeth and improving jaw relationships by means of equilibration, restorative treatment, and orthodontics.44Williamson E.H. Sheffield L.W. The non-surgical treatment of internal derangement of the temporomandibular joint. A survey of 300 cases.Fac Orthoped Temporomandib Arthrolo. 1985; 2: 18-21PubMed Google Scholar, 45Thompson J.R. Temporomandibular disorders: diagnosis and treatment.in: Sarnat B.G. The Temporormandibular Joint. 2nd ed. Charles C Thomas, Springfield, IL1964: 146-184Google Scholar Common to all these concepts is that it is the occlusal relationship that has disrupted the ideal maxillomandibular (or TMJ) relationship. A direct approach for assessing mandibular horizontal position is based on the evaluation of sagittal TMJ radiographs, using specific anatomic parameters to fulfill the requirements of the “ideal” condyle–fossa relationship. Gerber46Gerber A. Kefergelenk und Zahnokklusion.Dtsch Zahnartzl Z. 1971; 26: 119-141PubMed Google Scholar and Weinberg,47Weinberg L.A. Posterior unilateral condylar displacement: its diagnosis and treatment.J Prosthet Dent. 1977; 37: 559-569Abstract Full Text PDF PubMed Scopus (25) Google Scholar for example, were advocating that the condylar heads, as seen on sagittal radiographs, should be centrally located within the TM joints, whereas Gelb48Gelb M. Clinical Management of Head, Neck and TMJ Pain and Dysfunction.2nd ed. W.B. Saunders Co., Philadelphia, PA1985Google Scholar proposed a more anterior position of the condylar head. However, these concepts were rejected later as several researchers showed that “displaced” condyles are commonly present in nonsymptomatic patients.49Blaschke D. Blaschke T. Normal TMJ bone relationships in centric occlusion.J Dent Res. 1981; 60: 98-104Crossref PubMed Scopus (86) Google Scholar, 50Pullinger A.G. Hollender L. Solberg W.K. Petersson A. A tomographic study of mandibular condyle position in an asymptomatic population.J Pros Dent. 1985; 53: 706-713Abstract Full Text PDF PubMed Scopus (144) Google Scholar Therefore, the position of the condylar head relative to the glenoid fossa, as it appears on the radiograph, is usually of little clinical importance. With the introduction of arthrography and magnetic resonance imaging in the 1970s and 1980s, it became possible to visualize the TMJ disk during mandibular function. As a result, the treatment focus shifted from myofascial pain and condylar displacements to TMJ disk derangements. Another concept of an ideal mandibular relationship that has lately gained attention is neuromuscular dentistry. Neuromuscular dentists advocate that the optimal position of the mandible can be determined and should be registered with the aid of various muscle stimulators, jaw trackers, and EMG devices.51Sheikholeslam A. Moller E. Lous I. Postural and maximum activity in elevators of mandible before and after treatment of functional disorders.Scand J Dent Res. 1982; 90: 37-46PubMed Google Scholar, 52Jankelson B. Neuromuscular aspects of occlusion. Effects of occlusal position on the physiology and dysfunction of the mandibular musculature.Dent Clin North Am. 1979; 23: 157-168PubMed Google Scholar In their view, the activated muscles of mastication determine the initial point of occlusal contact that represents the repeatable and the most physiologic mandibular position. Since these “ideal” neuromuscular jaw positions are always clinically different (usually anterior) from the habitual occlusal position (MI) of most patients, treatment of this occlusal discrepancy requires invasive and nonreversible dental procedures.53Jankelson R.R. Adib F. Literature review of scientific studies supporting the efficacy of surface electromyography, low frequency TENS, and mandibular tracking for diagnosis and treatment of TMD.Myotronics. 1995; Google Scholar, 54Cooper B.C. The role of bioelectronic instrumentation in the documentation and management of temporomandibular disorders.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997; 83: 91-100Abstract Full Text PDF PubMed Scopus (48) Google Scholar, 55Cooper B.C. Kleinberg I. Establishment of a temporomandibular physiologic state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients.Cranio. 2008; 26: 104-117PubMed Google Scholar However, the advocates of this concept have failed to prove the validity of their assertions that such complex clinical procedures are either necessary or successful for the treatment of TMDs.56Klasser G.D. Okeson J.P. The clinical usefulness of surface electromyography in the diagnosis and treatment of temporomandibular disorders.J Am Dent Assoc. 2006; 137: 763-771Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, 57Manfredini D. Cocilovo F. Favero L. Ferronato G. Tonello S. Guarda-Nardini S. Surface electromyography of jaw muscles and kinesiographic recordings: diagnostic accuracy for myofascial pain.J Oral Rehab. 2011; 38: 791-799Crossref PubMed Scopus (86) Google Scholar Many of the mandibular repositioning procedures described above involve the use of an oral appliance both to relieve symptoms and to help in establishing a “proper” jaw relationship.1Schuyler C.H. Fundamental principles in the correction of occlusal disharmony, natural and artificial.J Am Dent Assoc. 1935; 22: 1193-1202Abstract Full Text PDF Google Scholar, 13Wassell R.W. Adams N. Kelly P.J. The treatment of temporomandibular disorders with stabilizing splints in general dental practice: one-year follow-up.J Am Dent Assoc. 2006; 137: 1089-1098Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar Several different designs of interocclusal appliances have been developed and used according to various theories of how they might work. The term “occlusal splint” is an indicator that such appliances were believed to be primarily directed at the dental occlusion. According to Ramfjord and Ash,58Ramfjord S.P. Ash M.M. Reflections on the Michigan splint.J Oral Rehab. 1994; 21: 491-500Crossref PubMed Scopus (73) Google Scholar the most commonly used maxillary oral appliance (the stabilization splint or Michigan splint) could be utilized to:1.Establish differential diagnosis for patients with TMD2.Treat TMD symptoms (TMJ and muscle pain)3.Relax muscles to establish optimal condylar position before definitive occlusal therapy4.Treat patients with tension headaches5.Temporarily disclude teeth for orthodontic purposes6.Stabilize teeth after orthodontic treatment7.Protect teeth against damage from severe bruxism8.Stabilize mobile maxillary teeth and prevent eruption of mandibular teeth An oral appliance that is placed between the dental arches alters the afferent proprioceptive feedback; this process is described by some clinicians as “deprogramming” the mandibular muscles.59Jayne D. A deprogrammer for occlusal analysis and simplified accurate case mounting.J Cosm Dent. 2006; 21: 96-102Google Scholar Clinicians who believe that “occlusal disharmonies” cause TMDs, including improper maxillomandibular vertical and horizontal relationships, see the" @default.
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• W2002802156 title "Treating temporomandibular disorders with permanent mandibular repositioning: is it medically necessary?" @default.
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