case report
J. Stomat. Occ. Med. (2009) 2: 219–228
DOI 10.1007/s12548-009-0035-7
Printed in Austria
© Springer-Verlag 2009
Long-term follow up of improvements of anterior disc
displacement with reduction using combination therapy:
a case report
K. Sasaguri, S. Kuramae, E. M. Tanaka, S. Sato
Department of Craniofacial Growth & Development Dentistry, Kanagawa Dental College, Yokosuka, Japan
Received August 9, 2009; Accepted September 9, 2009
This article is to review our approach to disc displacement
with reduction case by using combination therapy of modified
functional appliance (mFA) and multibracket appliance
(MBA). This patient was a 17-year-old Japanese female who
was complaining of right-side temporomandibular joint (TMJ)
clicking, pain during mouth opening, and limitation of con-
dylar movement at initial medical examination. We assumed
that the clicking during mouth closing occurred in the man-
dibular position in which the displaced disc returned to
normal position on the condyle, as we called therapeutic
reference position (TRP), and performed mFA therapy, by
which disappearance of clicking and subjective symptoms
were obtained. We stabilized the occlusion by mFA and MBA
setting at TRP and reconstructed occlusion was obtained with
disappearance of all the clinical symptoms passed about 4
years of postretention. Therefore, it is possible that the com-
bination therapy of mFA and MBA of occlusal reconstruction
seems to be an effective treatment for the disc displacement
with reduction cases.
Keywords: Reciprocal clicking, MEAW, therapeutic reference
position, CADIAX, MRI
Introduction
Splint therapy is a widely accepted and used conservative
treatment for patients with temporomandibular joint disor-
ders (TMD). The application of splint is particularly useful for
cases of disc displacement with reduction since the treat-
ment goal is to obtain disc recapture position [1, 11]. How-
ever, the relationship between the disc and condyle becomes
physiologic only when the splint is placed to maintain the
mandibular position. Therefore, it is important to stabilize
permanently the mandibular position, established by the
splint, using prosthetic or orthodontic techniques for recon-
structing functional occlusion [6, 7]. Accordingly, we report a
case in which the patient had typical anterior disc displace-
Correspondence: Kenichi Sasaguri, Department of Craniofacial Growth &
Development Dentistry, Kanagawa Dental College, 82 Inaoka-cho, Yoko-
suka 238-8580, Japan. E-mail: sasaguri@kdcnet.ac.jp
J. Stomat. Occ. Med. Ó Springer-Verlag Long-term follow up of improvements of anterior disc displacement
ment with reduction. We stabilized occlusion by modified
functional appliance (mFA) and performed tooth movement
using orthodontic therapy, setting the mandible at the posi-
tion to be obtained as the treatment goal referred to as
therapeutic reference position (TRP). Reconstructed occlu-
sion was obtained with disappearance of all the clinical
symptoms 4 years posttreatment.
Case report
This patient was referred to our office for treatment of TMD
by a private practitioner in February 1997. At that time, she was
a 17-year-old Japanese female who complained of right side
temporomandibular joint (TMJ) clicking and pain during
mouth opening and closing. After clicking, she was able to
open her mouth wide 30 mm interincisal distance. She had no
abnormal habits, para-function and systemic or psychological
problems. On the study model, there was an over jet of 3 mm,
over bite of 2 mm, Angle class II molar relationship on left side,
midline shift of about 3 mm to the left side and mesial rotation
of both upper lateral incisors (Fig. 1). Several years ago, she
had first noticed clicking and pain at the left TMJ similar to the
right side. At present, she had no symptoms on the left TMJ,
but the symptoms had shifted to the right TMJ. The panoramic
radiograph and TMJ sagittal tomogram showed no abnormal
findings in the hard tissues and both condyles (Fig. 2). How-
ever, the right condyle was slightly shifted postero-inferiorly in
the glenoid fossa (Fig. 2A).
Using computer-aided axiograph (CADIAX Ver. 3.0:
CadiaxÒ Gamma Dental Company, Medizinisch–wis-
senschaftliche Fortbildungs–AG, Hundskehle 21, 3400 Klos-
terneuburg, Austria), the tracing of right condylar movement
was that of a typical disc displacement with reduction and that
of the left side was disc displacement without reduction during
opening and closing (Fig. 3B). Magnetic resonance imaging
(MRI) findings confirmed the diagnosis of the CADIAX data
on both side (Fig. 4).
We have diagnosed the patient as having Angle
class II malocclusion on the left side associated with TMD
type III or internal derangement (ID) of TMJ being type IIIa
4/2009 219
 case report

Fig. 1: Mounted cast model before treatment

A –Y R L –Y
+2
A +2

2 4 6 8 10 X X 10 8 6 4 2
–2 –2
2 4 6 8 10 X X 10 8 6 4 2

2 2

4 4

6 6

B 8 8

10 10

+Z +Z

B –Y R L +Y

+2 +2

2 4 6 8 10 X X 10 8 6 4 2
–2 –2
2 4 6 8 10 X X 10 8 6 4 2

2 2

4 4
Fig. 2: (A) Lateral tomograms of TMJs before treatment; (B) orthopan-
tomogram before treatment 6 6

8 8
on the right side and type IIIb on left side ID-TMJ, respec- 10 10
tively [9]. +Z
+Z

C –Y R L +Y
Treatment planning +2 +2

From the above findings, this case was diagnosed as reciprocal 2 4 6 8 10 X 10 8 6 4 2

clicking on the right TMJ and closed lock on the left TMJ, –2 –2
2 4 6 8 10 X 10 8 6 4 2
associated with interference because of mesial rotation of both
side maxillary lateral incisors (Fig. 1) when the mandible was 2 2
set forward in TRP position to correct of the TMJ problem with
4 4
disc recapture on the right side (Fig. 3C). As a treatment, the
closed lock treatment of left TMJ for reduction was recom- 6 6

8 8
"
Fig. 3: CADIAX findings before treatment. (A) Protrusion-retrusion; 10 10
(B) opening and closing: , opening click , closing click; (C) opening +Z +Z
and closing from TRP: #, TRP

220 4/2009 Long-term follow up of improvements of anterior disc displacement Ó Springer-Verlag J. Stomat. Occ. Med.
 case report

Fig. 4: MRI findings of TMJs before treatment. R: Right side, L: left side

Fig. 5: Brackets were bonded partially on anterior tooth and first molars with mFA at TRP

J. Stomat. Occ. Med. Ó Springer-Verlag Long-term follow up of improvements of anterior disc displacement 4/2009 221
 case report

A –Y R L +Y Treatment progress
+2 +2
As initial treatment, upper anterior teeth were partially
bracketed with 0.018-inch standard brackets and the initial
2 4 6 8 10 10 8 6 4 2
–2
X X
–2 wire (0.0175 twist flex wire) was set for eliminating inter-
2 4 6 8 10 X X 10 8 6 4 2 ference on account of mesial rotation that functionally
induced the movement of the condylar position backward
2 2 or posterior (Fig. 5A). Furthermore, recapture of the disc
4 4
displacement of the right side TMJ was attempted with
mFA that was made in a mandibular position at TRP by
6 6
clinically using paraffin wax. The patient was instructed to
8 8 place the mFA in her mouth except during mouth cleaning
10
and mastication. About, two month after initial treatment,
10
on palpation of the left side TMJ an opening click was
+Z +Z
clinically felt when almost maximum open (about 40 mm)
B +Y
as well as a closing click at nearby intercuspal position.
–Y R L
Accordingly, the anterior teeth were aligned by using a
+2 +2
utility arch wire (UA) in order to eliminate the interference
2 4 6 8 10 X X 10 8 6 4 2
when positioning the mandible forward at TRP with the
–2 –2 mFA that had been set in the mouth (Fig. 5B). About nine
2 4 6 8 10 X X 10 8 6 4 2 months after starting of the initial treatment, the CADIAX
findings indicated that both side condylar pathways had
2 2 shown typical disc displacement with reduction during
4 4 opening and closing movement (Fig. 6B). Then, the treat-
ment plan was changed as follows:
6 6

8 8
1. New mFA was prepared for new TRP on both sides TMJ
(Fig. 6C).
10 10 2. Further alignment of the upper anterior tooth and a control
+Z +Z of the vertical dimension of molar regions by up righting
and/or extrusion were carried out as combination therapy
C –Y R L –Y of the new mFA and MBA for keeping a new TRP.
+2 +2 3. Establishment of stable occlusion at the new TRP using
new mFA and MBA.
2 4 6 8 10 X X 10 8 6 4 2
–2 –2 First of all, new mFA was prepared at the new TRP and
2 4 6 8 10 X X 10 8 6 4 2 MBA were set in the whole mouth. After that, the treatment
was continued by the procedure shown in Fig. 16, such as UA,
2 2 Ni-Ti wires, gradual adjustment of resin parts of new mFA,
4 4 multiloop edgewise arch wire (MEAW) and intraoral (up and
down) elastics for vertical and antero-posterior control for
6 6
about 2 years and 2 months (Fig. 7).
8 8 After active treatment, a Hawley’s-type retainer main-
10
tained the occlusion (Fig. 8) during a retention period of
10
2 years.
+Z +Z

Fig. 6: CADIAX findings indicated that the left condyle movement

changes over from closed lock to typical reciprocal clicking. (A) Protru-
sion-retrusion; (B) opening and closing: , opening click , closing click;
(C) opening and closing from new TRP: #, TRP
mended by manipulation or so-called pumping manipulation,
depending on the clinical history [2, 5], but the patient did not
agree.
The treatment was then planned as follows:
1. Correction of mesial rotation of both side maxillary lateral
incisors for eliminating interference at TRP of right side
TMJ (Fig. 3C) using mFA and orthodontic treatment with
partial bracketing.
2. Establishment of stable occlusion by keeping the TRP
of right side TMJ using mFA and MBA.
Treatment results
After a total treatment time of 3 years and 2 months, the
reconstructed occlusion was obtained and all of TMD
symptoms disappeared. Although the treatment time was
longer than a usual nonextraction case, the patient was
satisfied with the treatment outcome. Moreover, the TMD
condition showed an improvement with the present treat-
ment result. The CADIAX findings indicated that the move-
ment of condylar sagittal pathways was very smooth on
opening and closing with no clicking posttreatment
(Fig. 10). Furthermore, from the MRI findings, it was
observed that discs on both sides moved superiorly to
almost a normal position compared with that before start-
ing the treatment (Fig. 11).

222 4/2009 Long-term follow up of improvements of anterior disc displacement Ó Springer-Verlag J. Stomat. Occ. Med.
 case report

Fig. 7: Treatment procedure

Fig. 8: Intraoral photographs. (A) Posttreatment; (B) postretention

About four years after treatment, the case has maintained
acceptable and functional occlusion without any TMD symp-
toms (Figs. 8B, 12, 13). The mandibular position was steadily
kept in the induced position, which indicated that correction of
mesial rotation of both side maxillary lateral incisors and
posterior molar tooth uprighting and/or extrusion were pre-
served in this treatment method, in the cephalometric analysis,
mandibular position indicator (MPI), and superimposition
made on lateral cephalograms (Table 1, Figs. 14, 15). This case
needs to be observed for a long term in the future.

J. Stomat. Occ. Med. Ó Springer-Verlag Long-term follow up of improvements of anterior disc displacement 4/2009 223
 case report

Fig. 9: Lateral tomograms of TMJs. (A) Posttreatment; (B) postretention

Fig. 11: MRI findings of TMJs after treatment. R: Right side TMJ, L: left
side TMJ

A –Y R L +Y A –Y Right Left +Y

+2 2 2
+2

2 4 6 8 10 X X 10 8 6 4 2
2 4 6 8 10 X X 10 8 6 4 2
–2 –2
–2 –2
2 4 6 8 10 X X 10 8 6 4 2 2 4 6 8 10 X X 10 8 6 4 2

2 2 2 2

4 4 4
4

6 6 6
6
8 8
8 8

10 10
10 10
+Z +Z +Z
+Z

B –Y R L +Y B –Y Right Left +Y

+2 +2 2 2

2 4 6 8 10 X X 10 8 6 4 2 10 8 6 4 2
2 4 6 8 10 X X
–2 –2 –2 –2
2 4 6 8 10 X X 10 8 6 4 2 2 4 6 8 10 X X 10 8 6 4 2

2 2 2 2

4 4 4 4

6 6 6 6

8 8 8 8

10 10 10 10

+Z +Z +Z +Z

Fig. 10: CADIAX findings after treatment. (A) Protrusion-retrusion; Fig. 12: CADIAX findings post retention. (A) Protrusion-retrusion;
(B) opening and closing (B) opening and closing

224 4/2009 Long-term follow up of improvements of anterior disc displacement Ó Springer-Verlag J. Stomat. Occ. Med.
 case report

Fig. 13: MRI findings of TMJs postretention. R: Right side TMJ, L: left
side TMJ
Discussion
A splint is the widely accepted and used type of conserva-
tive therapy for patients with TMD, and application of the
splint is particularly useful for disc displacement with
reduction as called reciprocal clicking [1, 11]. Thus, recent-
ly the splint is used as much as possible in combination
with prosthetic or orthodontic treatment for reconstructing
occlusion at guided TRP [6, 7]. However, it is difficult to
simultaneously control upper and lower dentitions three-
dimensionally, using the orthodontic approach together
with splint therapy. Accordingly, this case was managed
with orthodontic treatment combined with mFA prepared
for TRP and gradual adjustment of the resin part during
treatment.
The combination therapy was useful for reciprocal click-
ing cases, especially three-dimensional control of several teeth
can be easily and efficiently carried out through the resin part
of mFA, after selective grinding or combined with orthodontic
techniques and maintaining TRP.
During first examination, the patient had typical recip-
rocal clicking on the right side TMJ accompanied with joint
pain and clicking during mouth opening and closing. On the
left side, there were no symptoms although disc displace-
ment without reduction, as closed lock, based on CADIAX
and MRI findings (Figs. 3, 4). The proper approach to this
case should be the treatment for closed lock of the left side
TMD with manipulation of Farrar’s method or pumping
manipulation [2, 4, 5] at first. However, the patient did not

Tab. 1: Cephalometric analysis

Mean S.D. Pretreatment Posttreatment Retention
(1997–2003) (2000–2004) 4 year (2004–2003)
SNA 82.3 3.4 87 87 87
SKB 78.9 3.4 85 85 85
ANB 3.4 1.7 2 2 2
Ul-FH 111.1 5.5 120 118 117
Ul-SN 104.5 5.5 110 109 108
Facial axis 86.0 3.0 94 93 93
Facial depth 87.8 3.0 95 94 94
Mandibular plane 28.8 5.2 17.5 18 18
LFH 49.0 4.0 41.5 44.5 44.5
Mandibular arc 25.0 4.0 38 41 41
Convexity (mm) 4.0 2.0 1 2 2
Ll-APO (mm) 3.0 1.5 2 3 3.5
Ll-APO (deg) 25.0 5.0 30 29 28
U6-FTV 11.0 3.0 24 24.5 25
E-plane 2.0 1.5 2 0.5 0.5
Occlusal plane 11.4 3.6 5 5 4
ODI 72.0 5.2 69 72 70
APDI 81.0 4.3 88 87 89
CF 153.0 – 157 159 159

J. Stomat. Occ. Med. Ó Springer-Verlag Long-term follow up of improvements of anterior disc displacement 4/2009 225
 case report

A want treatment of the left side TMD because she did not have
B months after initial treatment, surprisingly enough, most of
C
Fig. 14: Mandibular position indicator (MPI) analysis. RP: Reference
position [11, 12], ICP: intercuspal position. (A) Before treatment;
(B) posttreatment; (C) postretention
any subjective symptoms, although presence of a closed lock
had been explained to her. Inevitably, only the right side
TMD was approached with combination therapy of mFA for
maintaining TRP and orthodontic treatment for correcting
the medial rotation of both maxillary lateral incisors in order
to decrease the clicking and pain (Fig. 5). The lateral incisors
had to be corrected in order to eliminate the interference
caused by TRP while pushing forward the mandible accom-
panied with more contact on anterior teeth. About two
the patient’s symptoms on the right TMJ had been reduced,
but clicking become obvious on the left TMJ at late opening
and closing. It appeared as typical reciprocal clicking
(Fig. 6B), on palpation. Initial stages of disk displacement
without reduction are generally accompanied by severe pain
and limited mouth opening. However, the patient’s left TMJ
had almost no symptom. It is assumed that the case had a
comparatively long history of nonreducing. Generally, pump-
ing manipulation is carried out for this type of TMD, however,
this case could be managed with alignment of upper anterior
tooth and TRP could be maintained by combination therapy
without surgical approach. It is one of the possibilities that
elimination of interference, changing the occlusal contacts
and mandibular repositioning for maintaining TRP had a
favorable effect on nonreducing TMJ through the neuromus-
cular system as it was evidenced by the superimposition of
tracings and CADIAX tracings during the evolution of the
case. Further clinical and basic investigations in this area are
required.
We could not quantify the morphological changes of the
both condyles with the MRI images because of the difference
between the orientation of pretreatment, posttreatment, and
postretention imagery (Figs. 4, 11, 13). It is disappointing

A-2

A-3
A-1

B-2

B-1 B-3
Pre-treatment
Post-treatment
Post-retention

Fig. 15: Superimposition of cephalometric tracings. (A) Before treatment (solid line) and posttreatment (dotted line); (B) before treatment (solid line)
and postretention (dotted line)

226 4/2009 Long-term follow up of improvements of anterior disc displacement Ó Springer-Verlag J. Stomat. Occ. Med.
 case report

A that no distinct morphological changes such as double

contour or other evidence of bone remodeling [6, 12] were
observed on either condyle heads, thus making it difficult to
compare the findings before treatment with those of post-
treatment and postretention on lateral tomogram (Figs. 2, 9).
However, the induced mandible position was obviously
maintained after treatment and postretention (Fig. 15). Ac-
tually, mandibular position indicator (MPI) findings indicat-
ed that the RP-ICP difference decreased in 4 years
posttreatment (Fig. 14B, C). It could be speculated that the
anterior position of the mandible might be maintained for
achieving a normal disc-condyle-fossa relationship and/or
skeletal adaptation.
B Eberhard et al. [3] reported that the possibility for disc
recapture depends on the disc-condyle position and configu-
ration, the integrity of the posterior attachment, the degree of
degenerative changes of intra-articular structure, and the
efficacy of anterior repositioning splint therapy. It is interest-
ing to note that in the present case the initial conditions were
obviously different, with typical reciprocal clicking on the right
side and closed lock on the left side (Fig. 3). Actually, there was
difference in the effect of treatment on condylar movement
during protrusion and retrusion and opening and closing, as
shown on CADIAX findings (Figs. 10, 12). The right-side
condylar pathway was almost normal as reported by Slavicek
[8, 10], nevertheless, the opposite side showed more transla-
tional movement than the right side in the beginning of
C movement, which we called change character, after treatment
and postretention (Figs. 10, 12). The different treatment
results on condylar movements might be explained by the
different conditions of degenerative change of the temporo-
mandibular structures, such as morphological change of
condyles and articular discs and the level of loosening of the
joint ligaments. Hereafter, the prognosis of this case will be
carefully observed.
In conclusion, the therapeutic effect of combination
technique was investigated after treatment and postretention
using CADIAX and MRI. The reconstructed occlusion was
obtained with disappearance of all symptoms. With the aid of
CADIAX, it was found that the clicking point of condylar
D movement had disappeared during opening and closing.
Furthermore, the discs of TMJ had changed from anterior
position with reduction to a retrosuperior position on the
condyle as shown on MRI findings. It is suggested that com-
bination therapy was effective for disk displacement with
reduction. Furthermore, long-term monitoring of the condi-
tion of the TMJ and occlusal stability of this patient is
necessary.

Conflict of interest
The authors declare no conflict of interest.
Fig. 16: The illustrations indicated the treatment concepts of disc
displacement with reduction using mFA and multibracket appliance.
(A) Anterior tooth advancement for eliminating interference by UA to-
gether with mFA at TRP; (B) leveling by MBA together with mFA;
(C) lateral parts without second molars were made upright and/or Acknowledgements
extruded by MEAW and short class III elastics together with mFA as
gradually adjustment of resin parts for space making; (D) detailing for This work was performed at Kanagawa Dental College, Re-
interdigitations including vertical control of second molars search Institute of Occlusion Medicine, and supported by a
grant-in-aid for open research from the Ministry of Education,
Culture, Sports, Science, and Technology, Japan.

J. Stomat. Occ. Med. Ó Springer-Verlag Long-term follow up of improvements of anterior disc displacement 4/2009 227
 case report
References
[1] Clark GT. Treatment of jaw clicking with temporomandibular
repositioning: analysis of 25 cases. J Craniomandib Pract
1984;2:263–70.
[2] Dimitroulis G, et al. Temporomandibular joint arthrocentesis and
lavage for treatment of closed lock: a follow-up study. Br J Oral
Maxillofac Surg 1995;33:23–6.
[3] Eberhard D, et al. The efficacy of anterior repositioning splint therapy
studied by magnetic resonance imaging. Eur J Orthod 2002;24:343–52.
[4] Farrar WB. Characteristics of the condylar path in internal
derangements of the TMJ. J Prosthet Dent 1978;39:319–23.
[5] Jagger RG. Mandibular manipulation of anterior disk displacement
without reduction. J Oral Rehabil 1991;12:497–500.
[6] Lundh H, et al. Long-term follow-up after occlusal treatment to
correct abnormal temporomandibular joint disk position. Oral
Surg Oral Med Oral Pathol 1989;67:2–10.
228 4/2009 Long-term follow up of improvements of anterior disc displacement
[7] Mimura H, et al. A patient with temporomandibular joint disorders.
Angle Orthod 1996;66:21–6.
[8] Piehslinger E, et al. Reproducibility of the condylar reference
position. J Orofac Pain 1993;7:68–75.
[9] Shibuya Y, et al. A clinical study of temporomandibular joint
disorders: an analysis based on the Japanese subtype
classification. Kobe J Med Sci 2007;53:63–70.
[10] Slavicek R. Clinical and instrumental function analysis for diagnosis
and treatment planning. Part 5. Axiograpy. J Clin Orthod 1988;
22:656–67.
[11] Tallents RH, et al. Use of protrusive splint therapy in anterior disk
displacement of the temporomandibular joint: a 1- to 3-year follow
up. J Prosthet Dent 1990;63:336–41.
[12] Westesson P-L, et al. Temporomandibular joint disk displacement:
Arthrographic and tomographic follow-up after 6 months’ treatment
with disk-repositioning onlay. Oral Surg Oral Med Oral Pathol
1988;66:271–8.
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