Pregledni lanak/Review

Michigan splint and treatment of

temporomandibular joint
Michiganska udlaga i lijeenje temporomandibularnog zgloba

Tomislav Badel1, Sunana Simoni-Kocijan2*, Vlatka Lajnert2, Nika Duli1, Dijana Zadravec3

1
Department of Removable Prosthodontics,
School of Dental Medicine, University of
Zagreb, Zagreb Abstract. Splints, in a broader sense, include various groups of removable intraoral appliances
which are used in biomechanical treatment approach and they help establish the neuromus-
2
Department of Prosthodontics,
cular functional balance between different parts of the stomatognathic system. The aim of the
Department of Dental Medicine School
paper was to review the literature related to temporomandibular disorder (TMD) treatment
of Medicine, University of Rijeka, Rijeka
with special attention given to clinical importance and the fabrication of the Michigan splint. A
3
Department of Diagnostic and clinical case with a 9-year follow-up is presented within the framework of Michigan splint
Interventional Radiology, Clinical Hospital practical use and an evaluation of TMD treatment success until now. Generally, in TMD trea-
Center Sestre milosrdnice, University of tment, the principle of palliative medicine is preferred, which means treatment, control and
Zagreb, Zagreb alleviating of temporomandibular pain. The principle of non-invasive and reversible methods
of treatment is preferred. The splint achieves a behavioral effect of self-awareness (cognition)
about the position, function and parafunction of the mandible as well as a placebo effect.

Primljeno: 7. 1. 2013.
Key words: magnetic resonance imaging, temporomandibular joint, treatment
Prihvaeno: 12. 4. 2013.

Saetak. Udlage u irem smislu predstavljaju velik broj skupina mobilnih intraoralnih naprava
pomou kojih se provodi biomehanika terapija te uspostavlja neuromuskularna funkcijska
harmonija dijelova stomatognatog sustava. Svrha rada je pregled literature vezan uz lijeenje
temporomandibularnog poremeaja s naglaskom na kliniki znaaj i nain izradbe michigan-
ske udlage. U sklopu praktine primjene michiganske udlage i dosadanje znanstvene evaluac-
ije uspjeha lijeenja TMP-a opisan je kliniki sluaj s 9-godinjim praenjem. Openito, principi
palijativne medicine preporuuju se u lijeenju TMP-a, to podrazumijeva lijeenje i kontrolu
temporomandibularnog bola. Prednost se daje neinvazivnim i reverzibilnim metodama
lijeenja. Udlaga postie bihevioralni uinak samosvjesnosti (kognicije) o poloaju, funkciji i
parafunkciji mandibule, te se postie uinak placeba.

Kljune rijei: lijeenje, magnetska rezonancija, temoromandibularni zglob

Adresa za dopisivanje:
*
Sunana Simoni-Kocijan, dr. dent. med.
Katedra za stomatoloku protetiku
Medicinski fakultet Sveuilita u Rijeci
Kreimirova 40, 51 000 Rijeka
e-mail:
[email protected]

http://hrcak.srce.hr/medicina

112 medicina fluminensis 2013, Vol. 49, No. 2, p. 112-120

 T. Badel, S. Simoni-Kocijan, V. Lajnert et al.: Michigan splint and treatment of temporomandibular joint

INTRODUCTION static and dynamic occlusal variables has not

been explained in the context of etiopathogene-
Temporomandibular disorders (TMDs) have a sis and treatment of TMDs. Although such an ap-
musculoskeletal origin and are part of orofacial proach to TMDs has a strict dental focus, many
pain problematic. As a form of somatic pain in patients (up to 45%) have no indications for any
the stomatognathic system, TMDs imply a disor- kind of dental treatment11,12. On the other hand,
der in the masticatory muscles and/or the tem- the prevalence of temporomandibular pain is rel-
poromandibular joint (TMJ) with accompanying atively low (around 5%) in general population
disturbances (limited mouth opening, noise and/ and it is disproportionate with the serious public
or ear pain) as well as pathologic noise (clicking, health issue of untreated teeth and thereby, with
crepitations) in the joint1-3. non-replaced teeth13-15.
The aim of the paper was to review the literature
related to treatment of TMJ with special atten-
The principle of occlusal therapy is the irreversibility
tion paid to the clinical significance and fabrica-
and non-invasiveness in achieving orthopedic stability
tion of the Michigan splint. A clinical case with a
of TMJ.
9-year follow-up is presented within the frame-
work of Michigan splint practical use and an eval-
uation of TMD treatment success.
MANAGEMENT OF TMDs
TMD DIAGNOSTICS
Etiopathogenesis of TMDs, as well as of other
Diagnostics and differential diagnostics of TMDs painful conditions of the musculoskeletal system
are based on a standardized clinical examination. (such as the public health issue of back pain), has
The Research Diagnostic Criteria (RDC)/TMD di- not been completely explained and the treat-
agnostic system has become standard in scientif- ment methods used are primarily those minimal-
ic studies, wherein the clinical term TMDs has ly invasive or completely noninvasive16,17. Con-
been divided into separate diagnoses4,5. Thus, cepts of etiopathogenesis only included dental
there is a distinction between a muscular disor- causes (neuralgia as a part of Costens syndrome)
der and TMJ disorder: osteoarthritis and anterior but there was also a multifactorial concept and a
disc displacement. However, the generally ac- biopsychosocial concept (apart from the somatic,
cepted terminology does not explain all clinical RDC/TMD includes psychiatric testing of pa-
aspects of temporomandibular pain as the most tients). For this reason, TMDs are defined by a
important clinical sign and symptom of the ill- concept of nonspecific etiology, similarly to other
ness6. musculoskeletal disorders in the body. The con-
Apart from the use of nonspecific clinical proce- cept of nonspecific etiology gains importance
dures (palpation, auscultation, measuring of ac- when it has to be applied on individual patients.
tive and passive mandibular mobility), the impor- In such a case, the personalized approach to den-
tance of orthopedic tests is also growing (manual tal medicine/medicine plays an important role
functional analysis by Bumann and Groot and the idiopathic etiology is often mentioned at
Landeweer). This implies a modern, biomedical this stage of direct contact with the patient18,19.
approach to the illness but also an individual ap- Unknown etiology of TMDs and particularly of
proach to the patient and treatment proce- TMJs does not lessen the importance of radiolog-
dures7-10. ical diagnostics. Apart from the panoramic radio-
Direct occlusal analysis is carried out in everyday graph as a basic document of identification for
practice and it provides data on static contacts each dental patient, there are also noninvasive
between teeth in supportive areas as well as on but rather expensive radiological methods such
dynamic occlusal relations between the teeth a as magnetic resonance imaging (MRI). Although
type of laterotrusal guidance, hyperbalance and it is possible to show osteoarthritis of TMJ on im-
interference contacts. The significance of various ages of classical and computerized tomography,

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 T. Badel, S. Simoni-Kocijan, V. Lajnert et al.: Michigan splint and treatment of temporomandibular joint

MRI has been accepted as the gold standard in freedom in centric in a space of 0.5-1.0 mm on
diagnostics of soft intraarticular structures20,21. the splint plane (Figure 1)30. During occlusal
Since disc displacement is a common finding, movements, the concept of canine guidance is
mostly in younger population of TMD patients, realized by planes of the splint in the canines re-
MRI was accepted as the gold standard but there gion, whereas the interference, hyperbalance
is still no agreement on the gold standard in and balance contacts between other teeth and
TMDs treatment22,23. The psychological factor can splint plane are avoided31.
be evident, even in non-characteristic geriatric Indications for Michigan splint are as follows:
population of TMD patients, and it can contrib- TMDs of arthrogenic and/or myogenic origin,
ute to the general clinical picture as a recurring management of nocturnal bruxism and uncon-
etiological factor24. trolled parafunction during the day, maintaining
Priority is given to noninvasive and reversible of centric relations as a precondition to extensive
treatment methods where the occlusal splint prosthodontic restoration in patients with painful
plays a key role in dental, that is, initial occlusal and stiff masticatory muscles or limited mandibu-
therapy25. The occlusal splint is the most com- lar movements, and as a means of differential di-
mon and efficient treatment procedure of arthro- agnostics of TMDs with respect to other ailments
genic and/or myogenic forms of TMDs and brux- with similar symptoms (orofacial and craniocervi-
ism. The occlusal stability is established by cal pain, tension headache, secondary tinnitus,
specific morphology of the splint which is placed etc.)32,33.
on the teeth alignment of one jaw thus serving as In Michigan splint, centric relation serves as a
an orthopedic means of TMJ stabilization26. therapeutic position which stabilizes the mandi-
The occlusal splint is used as a temporary means ble in occlusal relations, wherein the habitual
of obtaining therapeutic occlusion and as a pre- mandibular position is often identical to the cen-
paratory stage for definite prosthetic treatment27. tric position in the TMJ. Apart from excluding oc-
In treatment with occlusal splints, their biome- clusal interferences, the relaxation of masticatory
chanical concepts of activity, characteristics of muscles is achieved by increasing the occlusal
position and retention have changed and com-
plemented each other. The morphology of the
occlusal splint plane has been tested as well as its
influence on mandibular position and move-
ments and the position and relationship between
the intraarticular structures of TMJ. Depending
on the indications of use and treatment effects of
the occlusal splint, hyperactivity is reduced, that
is, the masticatory muscles are relaxed, the con-
dyle is therapeutically positioned, which means
that it is placed into the centric relation position
with the behavioral effects increasing awareness
about the position, function and parafunction of
the mandible thus achieving placebo effect28,29.

MICHIGAN SPLINT CHARACTERISTICS AND

FABRICATION

Relaxation splints are used in treatment of brux-

ism as well as in management of arthrogenic and
myogenic temporomandibular pain. The Michi- Figure 1 Antagonists are supported by working cusps of
gan splint by Ramfjord and Ash is an occlusal bite the posterior teeth on the flat occlusal plane of the
splint (b, buccal; o, oral)
plane stabilization splint with cusped rise and

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 T. Badel, S. Simoni-Kocijan, V. Lajnert et al.: Michigan splint and treatment of temporomandibular joint

vertical dimension by the amount of thickness of

the occlusal part of the splint. Michigan splint is
most often indicated for the maxilla, but esthetic
and phonetic reasons can also indicate its place-
ment on the mandibular teeth.
Splint fabrication is of utmost importance be-
cause it has to be made individually and the den-
tal technician has to be trained in Michigan splint
fabrication. Although the methodology of fabri-
cation is limited, apart from the method of di-
rectly applying the acrylic composite onto the
definitive cast placed into the articulator, the ad-
vantage is given to the indirect method, which
means that the splint is waxed-up first11,31.
Figure 2 Centric relation record obtained from impressions of alu-wax in
The impression of both jaws includes teeth align-
contact position of centric relation
ment and surrounding tissues: the palate, mar-
ginal gingiva and edentulous spaces in the jaw in
cases of partial tooth loss. The limits of the splint sions during polymerization. The use of vacuum-
are drawn on the cast of the maxilla: vestibularly adapted resin sheet wherein the outline of the
across the incisal edges of the anterior teeth (2 splint is then cut off the cast along the vestibular
mm) as well as on the distal teeth in order to and palatal edge is optional. The vacuum-adapt-
achieve splint retention, across the equator of ed acrylic sheet is waxed-up a layer of pink wax
the buccal planes. The palatal border follows the is softened over a flame and manually molded
dental arch with the distance of 18-20 mm. Neu- and immediately adjusted in closing movement
romuscular position of condylar centric relation made in the articulator so that the incisal pin can
is achieved by an anterior jig which is obtained by contact the guide table in the vertical dimension.
dripping aluminum wax onto the registration wax The excess wax is removed and the occlusal
in the upper central incisors region. A definitive plane is modeled. This is followed by waxing of
mandibular position in the contact position of slightly concave planes for canine guidance in
centric relation is obtained by aluminum wax in hard inlay-wax. Finally, occlusal contacts are
the canine and first molars region (Figure 2)11,34. preliminary checked by powder.
After mounting the cast of the maxilla into the ar-
ticulator (it is recommended to use a semi-ad-
justable articulator with a corresponding facial
arch), the incisal articulator pin is placed in the
+2 mm position (registration wax thickness)
prior to mounting of the mandibular cast. This is
followed by checking of the space (about 1-2 mm
between the cusps of posterior teeth) intended
for the splint in order to enable subsequent oc-
clusal adjustment and to compensate for splint
wear.
Prior to modeling of the splint, the custom model
bed should be prepared: blocking out the under-
cuts, interdental regions and deep fissures by us-
ing modeling wax or dental plaster. This helps to
avoid difficulties in applying the splint, which can Figure 3 Vestibular edge (made by putty impression material) of the splint
wax up (blue planes for canine guidance)
be caused by unwanted changes in acrylic dimen-

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 T. Badel, S. Simoni-Kocijan, V. Lajnert et al.: Michigan splint and treatment of temporomandibular joint

The most complicated stage of laboratory fabri- transparent acrylic is used (such as Futura Jet,
cation is replacing the wax by acrylic, which be- Schtz Dental). The stone mould is slowly closed
gins by surrounding the vestibular splint edge in order to squeeze out the excess acrylic mass
with putty impression material. A space for ex- (Figure 4). The cast with splint is then placed into
cess acrylic putty is situated dorsally (Figure 3). a pressure chamber (6 bar and temperature
The wax cast is replicated by dental stone fixator 40C/15min).
which will precisely copy the splint surface. By re- The polymerized splint is not removed from the
moving the hardened stone negative from the casting mould; it is mounted into the articulator
cast, the entire wax is also removed. The cast for preliminary occlusal adjustment to obtain oc-
should then be isolated by a hard, clear resin clusal contacts in centric relations (Figure 5). Af-
sheet as well as the stone mould. The self-curing ter this, the canine guided movements are
checked (Figure 6). The splint is then removed
The Michigan splint increases occlusal vertical dimensi- from the cast and the final polishing is carried
on which has to provide comfort to the patient. out. Occlusion is also additionally adjusted when
the splint is tried in by the patient.

A CLINICAL REPORT

Clicking and pain in the right TMJ appeared 6

months before the 19-year-old female patient
visited our clinic, and at the time of her first visit
she complained about continuous pain in the
joint without clicking. Apart from the preauricu-
lar region, she also felt pain in the right ear. She
rated the pain with 5.6 on the visual-analogue
scale (0 no pain, 10 the strongest pain). She
had difficulties chewing and limited mouth open-
ing (48 mm). Laterotrusal movements were ca-
nine guided, 12 mm to the right and 7 mm to the
left with pain in the right TMJ. The occlusal status
Figure 4 Eliminating of excess acrylic is checked by joining the moulage was Angle class I, vertical overlap was 3 mm, hor-
cast in lateral openings (arrows) izontal was 1.5 mm whereas the incongruity of
the medial line amounted to 3 mm. She did not
undergo any orthodontic treatment or tooth loss,
there were no wear facets and she denied any
bruxist experiences. The clinical examination de-
termined pain and limited mouth opening on ac-
tive movement and under dynamic compression.
The right TMJ was also painful under passive
compression (bilaminar zone). An isometric ex-
amination of the muscles confirmed pain in the
right masseter and temporal muscle. The defini-
tive diagnosis was confirmed by MRI, including
disc displacement without reduction (Figure 7).
She was treated by Michigan splint, which she
wore regularly for three months at night.
Follow-up was carried out by subsequent MRI re-
Figure 5 Even centric contacts between working cusps and incisal edges cording after 3 months with the splint placed in
on the splint plane
the mouth. Clinical check-ups were carried out

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 T. Badel, S. Simoni-Kocijan, V. Lajnert et al.: Michigan splint and treatment of temporomandibular joint

after 6 and 12 months as well as after 5 and 9

years. A follow-up MRI was also performed then.
All the procedures were carried out with the pa-
tients written consent within the scientific study
which was approved by the Ethics Committee of
the School of Dental Medicine, University of Za-
greb.
MRI showed DD without reduction and an osteo-
phyte on the condyle as well as mild sclerosation
of the tuberculum of right TMJ. The condyle was
in the centric position which is shown on Figure 8
whereas it had a therapeutic position posteriorly
within the glenoid fossa on the image with the
splint applied in closed mouth position (Figure 8). Figure 6 Canine guidance in left laterotrusal movement with the splint
The disc was displaced anteriorly in open mouth
position. Regardless of the MRI finding, on check-
ups, the patient had 50-51 mm painless mouth
opening without clicking in the right TMJ. A long-
term follow-up by MRI showed condyle in the
centric position without any pronounced oste-
oarthritic changes. However, the disc had a less
displaced position and there was reduction in
open mouth position because beneficial remode-
ling changes correspond to the state of TMJ dis-
order improvement (Figure 9).

DISCUSSION
a b
The prevalence of pain varies with age (mild pain
was more frequent in younger age), with the Figure 7 MRI of the right TMJ
peak occurring between 41 and 55 years of age. A) in the closed mouth; B) open mouth position
Another issue in the TMD epidemiology is de- Disc displacement without reduction (arrows; 1, condyle; 2 tuberculum)
pendence on the age and gender of the patient.
Manfredini et al.22 differentiated two age peaks
(two peaks of greatest incidence) in TMD pa-
tients (30-35 and 50-55 years) with the female:
male ration 5:1, which partly coincides with pre-
vious knowledge that the greatest prevalence is
in women of reproductive age (that is between
18-45)11, 35. Mobilio et al.13 found clicking as the
most common TMD symptom (33%), whereas
pain was present in 5.1% of subjects from the
general population. Clicking can be a benign
symptom of disc displacement in patients with
dental anomalies in childhood36.
The issue of occlusion in dental medicine has
reached a dogmatic level, which in case of TMD Figure 8 MRI of the right TMJ with the splint applied in closed mouth
patients should not apply, particularly the use of position. Note: condyle was situated in a therapeutic position posteriorly
within the glenoid fossa
irreversible treatment methods as well as plan-

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 T. Badel, S. Simoni-Kocijan, V. Lajnert et al.: Michigan splint and treatment of temporomandibular joint

Unlike the above mentioned relaxation splints,

the Michigan splint (occlusal bite plane stabiliza-
tion splint with cuspid rise and freedom in cen-
tric) by Ramfjord and Ash is a splint covering all
the teeth in the jaw, enabling antagonistic con-
tacts on the flat planes according to occlusal con-
cepts of freedom in centric position30,43. The new-
ly developed Relax splint (Unident), introduced
into practice by Nilner et al.44, has proven to be
as effective in treatment of myofascial pain as
the Michigan splint. On the other hand, the pla-
cebo effect of the splint on treatment of TMDs
was proven in control groups of patients who
a b
wore non-occluding hard palatal oral appliance.
Figure 9 A long-term follow-up by MRI showed condyle in the centric Better efficiency of the Michigan splint and of the
position with reducing disc displacement in the right TMJ
resilient splint was not proven in treatment of
A) closed mouth position; B) open mouth position
TMDs45,46.
Within TMDs treatment modalities, physical ther-
ning of possible preventive procedures37. Current
apy has shown efficiency in its unique methods
opinion19 is that TMDs are idiopathic in origin and
as well as in those indicated for other muscu-
the correlation with certain etiologic factors can-
loskeletal disorders. Namely, the basic principle
not be entirely confirmed38. Although MRI is the
of improving the function while removing pain is
gold standard in TMJ diagnostics, there is still no
gold standard in diagnostics of temporomandibu- seen in mobilization exercises wherein the pa-
lar pain39. tient is directly involved. The basic exercises in-
The importance of a correct clinical procedure clude performing physiological and accessory
used to determine centric relation is shown in movements, such as kinesiotherapy by Schulte47.
the case of a patient with myalgia whose splint Physical therapy is an equivalent of the Michigan
positioned the mandible in a non-physiological splint treatment 48. Nonsteroidal anti-inflamma-
bite with shift on the left side28. Ferrario et al.40 tory drugs are a complementary treatment in
noticed that the Michigan splint achieved equilib- acute pain, and apart from peroral use, they can
rium in the action of temporal and masseter pairs also be applied topically49,50.
of muscles and that it also reduced electrical ac- Anterior disc displacement is perceived as a de-
tivity of the muscles. velopment malpositioning disc form which over
An alternative to the traditional splints are those time develops from a reducing to a non-reducing
that not require the contribution of a dental lab- disc form. Also, degenerative bone changes had a
oratory, with the so-called Nociceptive Trigemi- significant relationship with non-reducing disc
nal Inhibition (NTI) being the best known in the displacement51. On the other hand, a two and a
treatment of TMDs and bruxism41. However, it half year follow-up of untreated painful disc dis-
has numerous adverse effects, mostly related to placement without reduction showed that 42.5%
changes in occlusion, as well as less efficiency were asymptomatic52. Apart from removing clini-
compared to the Michigan splint42. NTI covered cal symptoms, the influence of the Michigan
the upper incisors only, just like many relaxation splint was also observed in MRI studies, wherein
splints from the past: the original group of relaxa- not only the clinical success of the treatment but
tion splints was based on muscular relaxation also the ability to recapture the previously ante-
achieved by elevation of occlusal vertical dimen- rior displaced disc was evident in 40% of pa-
sion and by removal of posterior occlusal inter- tients, which proved to be a greater success than
ferences by covering only the anterior teeth the use of anterior repositioning splint53. On the
(Hawley retainer, plate by Sved, anterior jig etc.). other hand, apart from clinical treatment suc-

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 T. Badel, S. Simoni-Kocijan, V. Lajnert et al.: Michigan splint and treatment of temporomandibular joint

cess, MRI analysis did not confirm improvement 12. Badel T, Marotti M, Savi Paviin I, Bai-Kes V. Tem-
poromandibular disorders and occlusion. Acta Clin Cro-
in non-reducing displaced disc54. Hasegawa et al. at 2012;51:419-24.
reported that application of a splint resulted in 13. Mobilio N, Casetta I, Cesnik E, Catapano S. Prevalence
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