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This study was conducted to compare the final outcome of treatment of anterior disc displacement without reduction (ADDWoR) by using centric and anterior repositioning splints. Twenty patients, (16 females and 4 males) were included in this study with age ranged from 18-35 years, who were suffering from anterior disc displacement without reduction. Selected patients were divided into two equal groups; ten patients each according to the type of the occlusal splint. Group (I): included patients treated with a centric splints. Group(II): included patients treated with anterior repositioning splints. Clinical evaluation was performed before and after 15, 30, 90, and 180 days of splint therapy. Electromyography was done before and after three and six months post-treatment. Data were collected, tabulated, calculated and statistically analyzed. The results of this study showed that there was significant improvement in clinical and electromyographic results with no statistically significant difference between two types of used splints. It could be concluded that splint therapy as a non-invasive technique improved significantly symptoms of ADDWoR, regardless the type of splint used. (1396) Atef M. Hassaneen E.D.J. Vol. 63, No. 2 Clinical Stages of Internal Derangement Of Temporo-Mandibular Joint Internal derangement of the TMJ has been described as a progressive disorder that may be classified into four consecutive clinical stages (5). Stage One which is characterized clinically by clicking as a result of anterior disc displacement with reduction. The clinical hallmark of disc displacement with reduction is limited mouth opening, usually accompanied by deviation of the mandible to the involved side, until a pop or click (reduction) occurs. After the pop, the patient is able to open the mouth fully with a midline position of the mandible (5). Stage Two features are similar to that of stage one, plus additional episodes of limited mouth opening, which can last for various periods. The obstruction may disappear spontaneously or the patient may be able to manipulate the mandible beyond the interference (5). Stage Three : Closed lock (ADDWoR) occurs when clicking disappears but limited opening persists. Patient complains of TMJ pain and chronic limited opening, with the opening usually less than 30 mm. Examination will reveal preauricular tenderness and deviation of the mandible to affected side with opening. In chronic closed lock episodes, if the condition progresses, the condyle may steadily push the disc forward to achieve almost normal ranges of mouth opening, in spite of the presence of a non-reducing disc4). Stage Four : as retrodiscal tissue continues to be stretched and loaded, it becomes subject to thinning and perforation. Anatomic studies have shown that this tissue may remodel before it succumbs, ill-adapted to the functional load, and perforates4 Wilkes’s (6) classification of TMJ disc displacement: TMJ disk displacement has been categorized by Wilkes, using such criteria as severity of displacement and chronicity (Table – 1). TABLE (1) Wilkes’s classification of TMJ disc displacement Stage I Early reducing disk displacement Stage II Late reducing disk displacement Stage III Nonreducing disk displacement: acute/subacute Stage IV Nonreducing disk displacement :Chronic Stage V Nonreducing disk displacement: chronic with osteoarthritis It has been suggested that treatment modalities initially used for those disorders should be reversible and noninvasive (7). Nonsurgical techniques that can decrease unintentional overloading of the masticatory system, eliminate pain, reduce dysfunction, and promote healing are essential in all phases of therapy (7). Surgical intervention for treatment of TMD should only be considered when all conservative treatment modalities have failed after at least 4–6 months. Surgical interventions include arthrocentesis, arthroscopy, and arthrotomy that include disc plication, meniscectomy, arthroplasty, and joint reconstruction is the most invasive surgical technique used to treat TMD (8,9). Nonsurgical Management may include: diet, pharmacotherapy (analgesics, anti-inflammatory medications, anxiolytics, antidepressants, muscle relaxants, local anesthetics), physical therapy and splint therapy(10-18). Conservative nonsurgical therapy should be attempted first and for proper period of time. The most common conservative therapy is the splint that associated with 90% success rate as reported by Clark(19). On other hand the surgical intervention should be considered only for those cannot respond to nonsurgical therapy due to high potential complication and unpredictable result of the surgery (19). Also the splint may be used to reposition the jaw in attempt to recapture the disc (18,20). COMPARISON BETWEEN TWO TYPES OF OCCLUSAL SPLINTS FOR TREATMENT (1397) Splints refer to various appliances such as; bite plates bite planes, occlusal appliances, and others. Collectively they are usually acrylic devices that snap on to the dentition and disocclude the jaws (17,18). Centric splints are commonly used for treatment of masticatory dysfunction, TMJ pain, clicking and limitation of motion. It is constructed in centric relation position and may either cover maxillary or mandibular teeth (21). Okeson et al (22), evaluated 33 patients with TMJ pain for one month with centric splint, 85% showed decrease in pain score, maximum interincisal opening was improved. Eberhard D et al (23), investigated the efficacy of anterior repositioning splint using MRI. They mentioned that post insertion MRI showed no recapture of the disc in subjects with ADDWoR, while disc recapture was observed in 15 out of 18 subjects with ADDWR. Stiesch-Scholz M et al (24), compared pivot splint against centric splint in treatment of (ADDWoR), they concluded that both types of splints provided effective therapy in patients with (ADDWoR) without significant difference. Lous (25) published the results in study of 60 clicking patients treated with pivots. The splints supplemented with vertical pull headgear attached to chin strap. The average treatment lasted 3-4weeks with follow up 3 months. 72% of the patients had elimination of symptoms. 17% had improvement but reoccurring symptom episodes. Because of limited occlusal contact with this splint there is a possibility of change in tooth position. Harkins and Marteney (26) tested soft splints in half of a sample of 84 patient who TMJ dysfunction. The other half served as control the splints were worn full time for 10-20 days. 10 of the patient stopped clicking, 64% had less clicking, 7% increased, and 19% had no change. Myalgia did not change in 26% of patients. Minor occlusion changes were noted in67%. There was no change in control. In a study that compared the outcome of treatment of TMD by Nociceptive Trigeminal Inhibition– tension suppression system (NTI–tss) splints and stabilization splints the investigator reported that there was no significant differences were noted between the two splints (27). Carlsson and Mgnusson(28) mentioned that from a neurophysiologic point of view, thick appliance is more effective than thin one, but for comfort reason it should be as thin as possible. Elelectromyography (EMG) is a method to study the electrical activity of the muscle, to detect and characterize disease processes affecting the motor units(29), and to provide a guide to prognosis. EMG evaluations of the masticatory muscles constitute important resource to help the differential diagnosis and supply substantial surveying and management of suggested therapy (30). PATIENTS AND METHODS The present study was conducted on twenty patients of both sexes suffering from anterior disc displacement without reduction of TMJ confirmed by clinical and radiographic examination with no congenital malformation and no previous surgical treatment in TMJ. They were 16 females and 4 males with mean age 26.5 (range, 18-35 years). They were selected from outpatient clinic of Oral and Maxillofacial Surgery Department, Faculty of Dental Medicine, Al-Azhar University. Grouping of patients: patients were divided into two equal groups, 10 patients each. Group 1 included patients treated by maxillary centric splint (Fig.4a), while group 2 included patients treated by maxillary anterior repositioning splint (ARS) (Fig. 4b). (1398) Atef M. Hassaneen E.D.J. Vol. 63, No. 2 All patients were submitted to the following procedures: I-Clinical examination 1-Assessment of TMJ pain The maximal range of mouth opening between the incisal edges of the upper and lower incisors was measured and recorded as MMO. Lateral and protrusive ranges of motion were also measured. Pain was assessed using the visual analogue scale. The patients marked the level of their pain on a 0-10 scale, with 0 representing no pain and 10 representing maximum pain (31). The TMJ was palpated bilaterally by index finger. The degree of the pain was recorded at each observation and given score value, 0 = No pain, 1 = Mild pain,

COMPARISON BETWEEN TWO TYPES OF OCCLUSAL SPLINTS FOR TREATMENT OF ANTERIOR DISC DISPLACEMENT OF TMJ