Case report UDC: 616.724-009.7:616.314-089.

5
doi: 10.5633/amm.2023.0312

A 36-YEAR-OLD FEMALE PATIENT TREATED WITH AN OCCLUSAL

SPLINT: A CASE REPORT

Frosina Volcheski1, Jasna Petrovska1, Elena Aleksova Noveska2,

Valdeta Osmani2

This article describes a case of a 36-year-old female patient who sought help due
to long-lasting pain in the temporomandibular joint (TMJ) region. Clinical examination
revealed pain on the left side in the region of TMJ, and pain on opening, chewing, and
palpation. Also, deviation to the right, and clicking on opening were present. A painful
sensation on the left masseter muscle was detected on palpation. The diagnosis was
established according to the functional analysis, clinical examination, and obtained
anamnestic data. The decision was stabilizing occlusal splint to be administered in
combination with exercises, physiotherapy, and symptoms-relieving analgesic treatment
if needed.
This protocol aimed to alleviate the painful symptomatology and enable
relaxation of the muscles of mastication to some degree, before orthodontic treatment.
This would obtain a solid basis for stable orthodontic treatment outcomes.
Based on the case of the presented patient, it can be concluded that
temporomandibular joint disorders (TMJD) can be treated with occlusal splint therapy in
combination with exercises and physiotherapy. Acta Medica Medianae 2023;62(3):81-
87.

Key words: temporomandibular joint (TMJ), temporomandibular disorders

(TMD), stabilization splint therapy, orthodontics

1
University Dental Clinic “St. Pantelejmon”, Skopje, Republic of behaviors are reliant and share overlapping neural
North Macedonia mechanisms. Consequently, TMD (temporo-
2
University “St. Cyril and Methodius”, Faculty of Dentistry,
Skopje, Republic of North Macedonia mandibular disorder) pain due to inflammation
might correspondingly induce emotional
disturbance (1). Of immense importance for our
Contact: Frosina Volcheski
79 3/15 Hristo Tatarchev St., Skopje, Republic of North
practice is accurate diagnosis and treatment
Macedonia planning of our patient’s condition (2, 3, 4, 5).
E-mail: [email protected] As orthodontic practitioners or future
Phone: 0038972257710 orthodontic practitioners, we should consider that
orthodontic treatment is neither the cause nor
cure for TMD, relying on reports of the current
systematic reviews (6, 7).
The proper management will include using
reversible and conservative modalities such as
medications, physical therapy, oral appliances,
and self-care (8, 9).
A thorough clinical interview and physical
Introduction examination to detect TMD signs and symptoms
before the establishment of orthodontic therapy is
Temporomandibular disorders (TMD) are mandatory (5).
relatively present in everyday practice. Patients Unilateral pain present in the TMJ region and
are used to living with that kind of pain, which sensations in the soft tissues around the joint, that
usually is accepted as common and normal. TMJD increases during mandibular movements may
(temporomandibular joint disorders) are often often be symptoms of TMD (2, 3, 5).
misdiagnosed and patients are experiencing As muscles are holding the body in a given
similar mild symptoms for long period, to the point position, this location awareness is primarily
when those symptoms are not tolerable. Chronic relayed to the cortex in order of proprioception.
pain might cause a decrease in quality of life, According to TMJ, there has been an overall
triggering many health concerns for patients and a consensus that the symptoms of TMJ are not
great social burden. Nociceptive and emotional
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A36-year-old female patient treated... Frosina Volcheski et al.

usually in the joint itself, but also in the body’s examination, the mouth opening was 30 mm
neuromuscular system, primary the masseter and (Figure 2 A), which also referred to a problem with
temporalis, medial and lateral pterygoid (10). TMJ. The maximum mouth opening was 35 mm on
Internal derangements of the assisted opening, and opening with mild pressure
temporomandibular joint are defined as a change on the mandible was 40 mm and was painful. It is
in normal anatomic relationships so that the essential to emphasize that a slight deviation to
articular disc is displaced from its position between the right was present during mouth opening.
the head of the condyle and the glenoid fossa. The Lateral excursions noted a symmetrical pattern on
internal derangement can be functional or both sides and were normal, 10 mm, on both
anatomic disturbance between the condyle, the sides (Figure 2 D, E). The amount of protrusion
disc, and the glenoid fossa. A more common was 6 mm (Figure 2 C).
derangement is the joint's functional
(neuromuscular) derangement that often results Dental status
from trauma. Those trauma-initiated
displacements of the articular disc, especially the Clinical examination and anamnesis of the
anterior displacement of the disc due to the spasm patient revealed that the patient had undergone
of the superior head of the lateral pterygoid orthodontic treatment two years before. The upper
muscle, will generally result in symptoms like alveolar arch (Figure 1 A, B, C) presented
clicking, popping, pain, and other functional sufficient alignment on both sides. She reported
problems in the masticatory system (11). that before starting with the orthodontic treatment
The five most common etiologic factors that she had a unilateral crossbite. Even though the
have been the topic of research are the occlusal crossbite was solved back then, it was obvious
condition, trauma, emotional stress, deep pain that the result was obtained only by dental
input, and parafunctional activity such as bruxism inclination and the palatal vault remained high and
and clenching (2). Functional conditions resulting narrow. The patient also reported the same painful
from occlusal interferences are found in clinical sensations 2 years before starting with the
practice usually and regularly. In orthodontic orthodontic treatment but was given an
practice, unilateral crossbite conditions may cause explanation that after the treatment the pain
a functional one-sided shift, which if not treated would diminish. Clinical examination and
on time might be, but not necessarily cause a TMJ panoramic radiographs did not reveal any
problem (12). pathology of the teeth, nor prosthodontic
restoration was present. The overjet was 3 mm,
Case Presentation and the overbite was measured at 2 mm.
Panoramic radiography (Figure 1 D) did not reveal
A 36-year-old female patient came to the any serious joint pathology and since we were not
University Dental Clinique “St. Pantelejmon”, able to make diagnostic conclusions only by
Skopje at the Department of Orthodontics, panoramic radiography, we suggested a cone
complaining of pain in her left side around the TM beam computed tomography (CBCT) of TMJ, which
joint region. The pain was increasing on the mouth unfortunately, due to technical issues, was not
opening. Also, the patient reported that she had performed. According to the overall functional,
already consulted several doctors before coming clinical examination, and available radiographic
to our department and got an explanation that the data, the preliminary diagnosis indicated
condition was not curable and was suggested intracapsular TMJ disorder which included disk
medication treatment only, which reportedly did displacement with reduction, TMJ arthralgia, and
not help. Medical history revealed prior masseter myalgia. Regarding the patient’s report
orthodontic treatment, and the same was of unsuccessful pain management in her previous
performed 2-years before for unilateral crossbite medical history and diagnostic findings, a decision
treatment. Also, she reported existing bad habits was made to administer stabilization occlusal
like holding the phone with her shoulder while splint therapy in combination with counseling and
speaking and chewing gum frequently. avoiding parafunctional activities, physiotherapy
which would include wet moist wraps and self-
Clinical diagnostics massage of the masseter muscle, as well as
exercises for joint distraction.
On palpation, a painful sensation was
present in the left masseter muscle region Treatment plan
approximately near the TMJ, and a painful
sensation while palpating the left TMJ region. A The primary goal, of crucial and utmost
painful sensation on the mouth opening was importance, was the resolution of the pain
present, also the pain was present during problem. Treatment included stabilization splint
mastication. Protrusive and lateral movements fabrication under the guidance of Aqualizer ™. The
were painful as well. A click was present on the Aqualizer™ is a therapeutic and diagnostic tool for
left side on opening. The questionnaire given to TMJ disorders. The Aqualizer™ was placed in the
the patient gave a result of 3 points which patient’s mouth for 30 minutes while sitting on the
indicated a problem with TMJ (2, 4). On clinical dental chair. As a diagnostic tool, this phase also
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exhibited problems with TMJ because while As already noted, the patient mentioned bad
wearing it for a short amount of time, the patient habits like holding the phone on her shoulder
reported mild pain relief (13, 14, 15). while talking, and frequent chewing gums during
The Aqualizer™ is primarily used as a the day, so we suggested immediate habit
prefabricated splint, for relieving acute TMD elimination. Also, we suggested very careful
symptoms (16, 17. However, the always opening movements, especially to avoid sudden
preferable solution is an individually fabricated and excessive opening of the mouth.
splint of hard acrylic material. The splint was Follow-up appointments were on the 1st,
finished and placed on the lower arch, with mild 2nd, and 3rd month, and after six months of
impressions on the occlusal surface of the upper wearing the splint. On the first appointment, the
teeth. In addition to occlusal splint, the treatment patient reported pain diminishing, but the opening
protocol included self-administered exercises and was still not favorable. On the 2nd visit
passive muscle stretching which included exercises improvement in the symptoms was noted and
to open on a straight opening pathway while after 6 months of wearing the splint, the amount
standing in front of the mirror. Also, exercises to of opening improved, from 30 mm to 45 mm,
open and close the mouth while keeping the (Figure 2 B), and also correction of the deviation
tongue up on the palate. The stabilization splint was noted.
was worn during the night.

Figure 1

A. The intraoral photography shows a matching of the upper and lower interincisive line
B. Class I canine relation and molar relation - left side
C. Class I canine and molar relation - right side
D. OPG did not reveal any severe pathology of the joints

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A36-year-old female patient treated... Frosina Volcheski et al.

Figure 2

A. Opening pattern with a slight deviation to the right before splint therapy measured 30mm,
B. Opening pattern after 6 months of treatment with the splint measured 45 mm,
C. Protrusive movement before the treatment and after the treatment remained the same at 6mm,
D. Lateral movement to the left before treatment was 10 mm and remained the same after treatment,
E.Lateral movement to the right was 10mm and remained the same after treatment

Discussion categories: Internal derangements and inflam-

matory joint disorders (2, 10, 11).
Functional irregularities of the temporo- The mandibular condyle displays a different
mandibular joints are undoubtedly the chief morphological variation in different groups and
patient problem detected during examination for individuals due to developmental variations and
masticatory dysfunction. The cause for this is due constant condylar remodeling. The articular
to the high incidence of signs, and not necessarily eminence inclination also varies in individuals,
symptoms (2, 3, 10). The focus of such an which determines the movement and degree of
evaluation is to determine whether the patient has rotation of condyles in the glenoid fossa. The
a TMD or not. Many of the signs such as joint radiographic joint space is a radiolucent area
sounds or deviated opening are not painful, and between the mandibular condyle and the temporal
therefore the patient may not pursue treatment. bone (18). The condylar position is determined by
These TMJ disorders generally fall into two broad this relative dimension of the radiographic joint

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spaces between the glenoid fossa and the need to be rehabilitated first for the prevention of
mandibular condyle (8, 18). condylar asymmetry (19).
Clinicians should be vigilant in diagnosing
TMD in patients who present with pain located in Conclusion
the TMJ area. A multidisciplinary approach is
successful for the management of TMD. Initial We reported a 36-year-old female patient
treatment goals should focus on resolving pain with TMJ problems with a 6-month follow-up.
and dysfunction. Occlusal splints are used to Based on the case of the presented patient, it can
alleviate or prevent degenerative forces placed on be concluded that TMJ disorders can be treated
the TMJ, articular disk, and dentition (5, 8, 9). with conservative and occlusal splint therapy. The
We presented an adult patient with severe clinician aims to identify the symptoms, relieve the
pain in her left TMJ region. The patient did not pain to help the patient have a normal life, and
report trauma in the TMJ region. She reported a cease the progression of the TMJ problems.
unilateral crossbite problem which had been According to the case progression, it was
orthodontically treated 2 years before. The reason concluded that conservative treatment in
this woman had TMD problems was pretty much combination with counseling, exercises in
related to the unstable occlusion in this case. She combination with occlusal splint therapy, should
also reported pain in the TMJ region before be the first-choice therapy for TMD, due to their
orthodontic treatment but was told that after the low risk of side effects. Regarding using occlusal
treatment she would feel pain relief. Unilateral splint therapy as a treatment modality, it should
crossbite might, but not necessarily be the reason be highlighted that we can use it but not abuse it.
for TMD. Usually, the problem that arises in However, further research should be exhibited for
unilateral crossbite cases is with the muscles that
more accurate conclusions to be established

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A36-year-old female patient treated... Frosina Volcheski et al.

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Prikaz slučaja UDC: 616.724-009.7:616.314-089.5

DOI: 10.5633/amm.2023.0312

TRIDESETŠESTOGODIŠNJA BOLESNICA TRETIRANA

OKLUZALNIM SPLINTOM: PRIKAZ SLUČAJA

Frosina Volčeski1, Jasna Petrovska1, Elena Aleksova Noveska2,

Valdeta Osmani2

1
Univerzitetska stomatološka klinika „Sv. Pantelejmon”, Skoplje, Republika Severna Makedonija
2
Univerzitet „Sv. Kiril i Metodij”, Stomatološki fakultet, Skoplje, Republika Severna Makedonija

Kontakt: Frosina Volčeski

Ulica Hristo Tatarčev 79 3/15 Skoplje,
Republika Severna Makedonija
E-mail: [email protected]
Telefon: 0038972257710

Ovaj članak opisuje slučaj tridesetšestogodišnje bolesnice koja je zatražila

pomoć zbog dugotrajnog bola u predelu temporomandibularnog zgloba (TMZ).
Kliničkim pregledom otkriven je bol na levoj strani u predelu TMZ i bol pri otvaranju,
žvakanju i palpaciji; primećena je devijacija udesno, kao i klikćući zvuk pri otvaranju.
Palpacijom je otkriven bolni osećaj na levom mastikatornom mišiću. Dijagnoza je
bila utvrđena na osnovu funkcionalne analize, kliničkog pregleda i anamnestičkih
podataka. Doneta je odluka da se tretman započne ordiniranjem stabilizacionog
okluzalnog splinta u kombinaciji sa vežbama, fizioterapijom i analgetičkim tretmanom
za ublažavanje simptoma, po potrebi.
Ovaj protokol imao je za cilj da ublaži bolnu simptomatologiju i omogući
opuštanje mastikatornih mišića u određenoj meri, pre ortodontskog lečenja, kako bi se
dobila solidna osnova za stabilni ishod ortodontskog lečenja.
Na osnovu slučaja prikazanog bolesnika može se zaključiti da se poremećaji
temporomandibularnog zgloba (TMZ) mogu lečiti terapijom okluzalnim splintom u
kombinaciji sa vežbama i fizioterapijom. Acta Medica Medianae 2023;62(3):81-87.

Ključne reči: temporomandibularni zglob, temporomandibularni poremećaji,

stabilizacioni splint, ortodoncija

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(CC BY 4.0) Licence".

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