Effect of muscle relaxation splint therapy on the

electromyographic activities of masseter and anterior

temporalis muscles
~enay Canay, a Abdullah Cinda~, b Gtilay Uzun, c Nur Hersek, d and Ye~im Grk~e Kutsal, e
Ankara, Turkey
UNIVERSITY OF HACETTEPE

The purpose of this study was to compare the effectiveness of splint therapy on the electromyographic activity of
masticator'/muscles (anterior temporalis and masseter) before and after the application of a muscle relaxation splint. Electromyog-
raphy recordings from the masseter and anterior temporalis muscles were analyzed quantitatively during maximal biting in the
intercuspal position both before and after treatment without a splint. Fourteen patients whose chief complaint was masticatory
muscle pain were selected for the study. After the initial evaluations muscle relaxation splints were applied, and the patients were
instructed to use the splints for 6 weeks. Surface electromyographic recordings were taken from each patient before the beginning
of clinical therapy and after 6 weeks of wearing the splints. The data obtained were analyzed through paired sample t tests and
Wilcoxon's signed rank tests. The results of the study were as follows: (1) the electromyographic activity of the two muscles during
maximal biting was not markedly changed after the muscle relaxation splint was used; and (2) the changes observed in elec-
tromyographic activity of the involved and noninvolved sides were insignificant as well. (Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1998;85:674-9)

In recent years much attention has been devoted to the

Many types of occlusal appliances have been suggested
use of electromyographic recordings in the diagnosis
for the treatment of temporomandibular joint (TMJ)
and treatment of TMJ disorders. Electromyography
disorders. The two most common such appliances are
(EMG) has been proved to provide excellent informa-
the muscle relaxation splint (MRS) and the anterior
tion on muscle function under research conditions.5,6,11-16
repositioning splint. The MRS, sometimes called a
Many studies have shown that a reliable and
stabilization splint, is used to treat muscle h))peractivity. 1
reproducible relation exists between changes in the
Studies have shown that wearing an MRS can
amplitude of the EMG signal and changes in isometric
decrease the parafunctional activity that often accompa-
muscle tension. 17 The applicability of EMG has
nies periods of stress. 2,3 For muscle splints, the feature
reached beyond the determination of simple muscle
that may be responsible for decreasing muscle activity
function and dysfunction into the areas of orthodontics,
is the alteration of the occlusal condition. A more stable
periodontics, prosthodontics, and oral surgery. 18 EMG
occlusal condition generally decreases muscle activity
is also used as a treatment tool in conjunction with
and eliminates the symptoms. 4-7 It has been demon-
relaxation and biofeedback therapy. 19-22
strated that increases in vertical dimensions can also
Previous studies have shown that both at rest and
decrease muscle activity and symptoms. 8,9 In addition
during submaximal clenching the myoelectrical activity
to these changes, patients who wear occlusal appliances
of the temporalis muscles decreases after insertion of a
become more aware of their functional and pa_rafunc-
stabilization splint. 8,23-26The purpose of this study was
tional behavior; the splint acts as a constant reminder to
to compare, both before and after MRS therapy, the
alter activities that may affect the disorder. As cognitive
EMG activity of the masseter and anterior temporalis
awareness increases, factors that contribute to the
muscles of patients experiencing muscle pain. The
disorder increase also. 5 Besides, as with any treatment,
EMG readings of masseter and anterior temporalis
a placebo effect can result. 10
muscles were recorded at maximum biting force
aAssociate Professor, Faculty of Dentistry, Department of Prostho- without splint to determine quantitatively the effect of
dontics. splint therapy on the myoelectrical activities before and
bAssistant, School of Medicine, Department of Physical Medicine after such therapy. The splint was therefore removed
and Rehabilitation.
CAssistant, Faculty of Dentistry, Department of Prosthodontics.
just before the second EMG readings.
dProfessor, Faculty of Dentistry, Department of Prosthodontics.
eProfessor, School of Medicine, Department of Physical Medicine MATERIAL AND METHODS
and Rehabilitation. This study was performed on 14 patients who had
Received for publication Feb. 26, 1997; returned for revision May facial pain problems; 5 of the patients were male and 9
30, 1997; accepted for publication Jan. 20, 1998.
Copyright © 1998 by Mosby, Inc.
were female. Patient age ranged from 23 to 48 years;
1079-2104/98/$5.00 + 0 7/13/89279 the mean age was 32 years. All patients had natural

674
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Canay et al. 675
Volume 85, Number 6

Table I. Symptoms in patients with muscle pain

Patient no.
Symptom 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Clenching + + + + + +

Grinding + + + +
Pain at rest + + + + + +
Pain with function + + + + + + + + + + + + + +
Trigger Point +
Limitation at opening + + +
Interferences in intercuspal positions + + +
Retruded contact position + + + + + +
= Intercuspal position
Deviation + + + + + + + + +

Table II. Electromyographic activity of masseter and anterior temporal muscles before and after splint therapy
(gV/sec)
Before splint After splint
Muscle f2 SD X SD t p
Right masseter 283.86 167.61 262.71 130.34 0.53 0.604
Left masseter 249.79 99.95 249.71 96.16 0.00 0.997
Right temporal 358.86 134.55 372.57 126.25 0.72 0.483
Left temporal 305.57 103.44 347.93 127.79 1.33 0.205

dentition, and none was currently undergoing treatment
for any medical problem. Patients were selected on the
basis of the following criteria:
1. Spontaneous facial pain at rest and increased pain
with function.
2. Restriction in mandibular opening; changes in
movement, as evidenced by mandibular deviation;
and changes in normal range of lateral movements.
3. Moderate to severe tenderness to bimanual palpa-
tion at the preauricular region of the elevator
muscles. When two or more painful spots were
present, this factor was recorded as positive.
4. Muscle weakness and fatigue, especially in the
morning.
5. Lack of joint sounds.
6. Onset of symptoms between 8 to 16 weeks before
admission into the study.
Each patient underwent a thorough clinical examina-
tion and was questioned to determine the anamnestic and
clinical dysfunction index. The type of parafunctional
activity was recorded as either clenching or grinding.
Intermittent application of masticatory force in a static
occlusal relationship was recorded as clenching. Fric-
tional excursive movements of opposing teeth were
recorded as grinding. Pain was classified as at rest or
during function (or both). Hypersensitive areas in
muscles that elicit pain during palpation were recorded as
trigger points. An interincisal opening of less than 45 mm
was recorded as limitation at opening. Retruded contact
position (RCP) and maximum intercuspal position (IP)
were identified, and if the occlusion was stable in the
RCR it was recorded as RCP = IP. Contacts that signifi-
cantly altered the intercuspal position were recorded as
occlusal interference in intercuspal position. According
to the data obtained, the main problem was determined to
be muscle disorder (Table I).
Occlusal splint
For each patient a full-coverage maxillary muscle
relaxation splint was made of clear, self-curing acrylic
resin. The base of the occlusal splint was shaped on a
model, and the occlusal surface was prepared from a
layer of autopolymerizing acrylic resin. Before the resin
set, a bilateral manual mandibular manipulation tech-
nique was used to achieve RCR Canine disclusion of
the posterior teeth during eccentric and protrusive
movements was also provided. The height of the
occlusal splint was approximately 1 mm more than the
freeway space, and it was controlled by speech. The
patient was instructed to wear the appliance all day
long--both at night and during the day---except during
eating. The first EMG recordings were made just before
the MRS was adjusted, and the final EMG recordings
676 Canay et al.
Fig. 1. Schematic diagram shows placement of electrodes on
temporal and masseter muscles.
were made after 6 weeks of treatment with the splint.
During the EMG recordings the splints were removed.
Electromyographic technique
For the EMG recordings surface electrodes were placed
bilaterally on the anterior temporalis and masseter
muscles. Bipolar surface electrodes of silver amalgam, 8
mm in diameter and with an inter-electrode distance of 20
mm, were used. Before the electrodes were applied the
skin was thoroughly cleaned with alcohol. Electrode jelly
was applied to the skin, and adhesive strips were used to
secure the electrodes in position. With each subject the
electrodes were placed in a standard position, as shown in
Fig. 1. The EMG equipment was an eight-channel system
(Toennies Multiliner Version 2.0)calibrated to 200 ~V,
with a constant time fixed at 0.35 seconds and an upper
frequency limit of 2000 Hz. The printer frequency was 50
mm/second. The EMG activity was evaluated by
measurement of the maximum height (in ram) of the inte-
grated signal from the baseline, and the absolute value of
the integral was calculated by multiplying the height of
the signal by a calibration factor (200 ~V).
The patient, sitting relaxed and upright in a straight-
backed chair without head support, was instructed to look
forward and asked to make no head or body movements
during the test. Before recordings all patients were care-
fully briefed about the tests to be performed and were
immediately introduced to the EMG equipment.
The EMG activity was registered during maximal
biting in the intercuspal position. The patient was
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
June 1998
instructed to close the jaws in centric occlusion as
forcibly as possible. For both the temporal and the
masseter muscles, measurements of the mean value of
the right and left sides were recorded. The electrical
activity during maximal clenching in the intercuspal
position was recorded during a contraction of approxi-
mately 3 seconds. To avoid muscle fatigue a relaxation
period of 3 minutes was allowed between each maximal
clenching and the next. The average value of the mean
amplitude of maximal activity (in pV/sec) for a period of
1 second was measured on the electromyogram record-
ings. The level of maximal activity in each muscle was
calculated as the average of three such recordings. EMG
readings were made just before the insertion of the splints
and after 6 weeks of treatment with the splints.
Statistical analysis
The differences in the EMG activity of the muscles
before and after MRS therapy were tested by means of
paired sample t tests. Because of a lack of homogeneity
of variance, the data were analyzed by means of
Wilcoxon signed rank tests for comparison of the
involved and noninvolved sides.
RESULTS
Table II shows the mean EMG activity values for
masseter and anterior temporalis muscles before and
after treatment with MRS. At the end of the 6-week
experimental period the patients who had been treated
with MRS showed an increase in EMG activity during
maximal biting in the intercuspal position in the right and
left temporal muscles and a decrease in such activity in
the right masseter muscle, but there was no change with
respect to the left masseter muscle. When the mean EMG
results for right and left temporal and masseter muscles
were considered, both the pretreatment and posttreatment
results were found to be higher on the right side. In addi-
tion, when the mean data pertaining to the involved and
noninvolved sides were evaluated, 5 of the 14 patients
exhibited bilateral involvement and 9 exhibited unilateral
involvement. After MRS therapy the mean masseter
muscle activity during maximal biting reflected a slight
decrease of the EMG values in the involved side. On the
other hand, the EMG activity in the noninvolved side
exhibited almost the same values (Table III). According
to the Wilcoxon signed rank test, p was 0.678 for the
involved side and 0.594 for the noninvolved side.
In the bilaterally involved patients the EMG activity of
the left and right masseter muscles exhibited a slight
decrease, which was also insignificant (left, p = 0.893;
right, p = 0.500). This was different for the temporal
muscle, where the mean values showed a decrease in the
involved side and an increase in both the noninvolved
side and the bilaterally involved patients (Table IV).
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 85, N u m b e r 6
l a n e Ilk Myoelectrical value of masseter muscle on involved and noninvolved sides (gV sec)
n Before treatment X
Involvedside 9 287.77
Noninvolvedside 9 252.33
Bilateralinvolvement
Left masseter 5 255.2
Right masseter 5 266.8
lable IV. Myoelectrical value of anterior temporal muscle on involved and noninvolved sides (gV sec)
n Before treatment X
Involvedside 9 334.44
Noninvolvedside 9 316.44
Bilateralinvolvement
Left temporal 5 309.2
Right temporal 5 379.6
According to the Wilcoxon signed rank test, p was 0.441
for the involved side and 0.515 for the noninvolved side.
The patients' complaints before and after MRS therapy
are compared in Table V. The main clinical symptoms
were muscle pain and restricted interincisal opening. Of
the 14 patients experiencing pain before splint therapy,
12 reported no pain after therapy; 2 patients still had
muscle pain, especially in the masseter region. In eight
patients interincisal opening had increased; in three
patients there was no change; and the other three patients
showed decreased interincisal opening after therapy. The
paired sample t test did not demonstrate any significant
difference (t = 0.696; p = 0.499).
Before MRS therapy, 8 of the 14 patients in the study had
a deflection; after MRS therapy 5 patients were the same, but
the remaining 3 patients had normal openings of the pathway.
DISCUSSION
During the last decade several theories have been
proposed concerning the causes of dysfunction of the
TMJ. Most authors agree that the etiology is multifacto-
rial and that muscle hyperactivity is one of the main
factors. To understand the underlying neurologic process
of muscle hyperactivity, EMG has been widely used.
A considerable number of reports on clinical observa-
tions of the therapeutic effects of splints are available in
the literature. However, little has been done to quantita-
tively determine whether splint therapy changes
muscular activity and contributes to muscular relaxation.
Available studies do not appear to demonstrate directly
the muscular activity changes during maximal biting
force. Many studies have reported the EMG activities of
the muscles with and without occlusal splints. 4,27-29
There exist many previous studies that measured
EMG activity with splint. In our work we conducted
Canay et al. 677
After treatment J( z p
265.77 0.4146 0.6784
258.11 0.5331 0.5940
240.0 0.1348 0.8927
251.8 0.6742 0.5002
After treatment X z p
288.11 0.7701 0.4413
344.44 0.6516 0.5147
356.2 0.1348 0.8927
416.6 0.6742 0.5002
measurements with no splint, primarily to avoid causing
muscle fatigue through the exercise of two measure-
ments in the same session, and secondarily to prevent
such fatigue from affecting our results.
Lund and Laminate 3° recorded maximum biting
forces and electromyograms of the masseter and
temporal muscles during maximum voluntary isometric
contraction in the region of the premolar teeth on one
side of the jaw with and without local anesthesia. EMG
potentials were reduced after local anesthesia. They
concluded that cortical neurons controlling the excita-
tion of the closing muscles of the jaw would receive
positive feedback from receptors in the periodontal
membrane. Blockage of these receptors would reduce
the biting forces and the integrated EMG potentials
during maximum voluntary isometric contraction.
Furthermore, some recent studies have reported that the
palatal base causes changes in tongue position and in the
discharge of mucosal palatal receptors.31-33These inputs
may play a role in the postural control mechanisms.
In our study we bore in mind the fact that forces
conveyed onto the periodontal membrane were different
depending on the presence or absence of a splint in the
mouth. As the person's biting force would formulate
different muscular activities from a tooth-to-tooth
contact, palatal receptors would be effective on splints;
therefore EMG recordings were made without splint.
In the present study the EMG readings in the masseter
on the affected side declined in comparison with
pretreatment readings. These readings were the same
for both the unilaterally affected and the bilaterally
affected patients (Table III). The posttreatment EMG
activity readings were lower than the pretreatment read-
ings in the temporal muscle in the unilaterally affected
678 Canay et al. ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
June 1998

Table V, Comparison of symptoms before and after treatment

Muscle pain
Interincisal Masseter Temporal
opening (mm) Deflection Before After Befo~ After
Subject Before After Before After Right Left Right Left Right Left Right Left
l 38 40 + +
2 53 54 + + + + +
3 40 42 + + + + + +
4 49 51 + +
5 46 50 + + + + +
6 43 45 + + + + + +
7 48 53 + + + + + +
8 45 45 + + + +
9 44 42 + + + +
10 57 52 + + + +
11 55 55 + +
12 45 45 +
13 50 55 +
14 59 52 + + + +

patients. However, a rise was observed in bilaterally
affected patients (Table IV).
Because temporal muscle is fan-shaped, its fibers pull
in different directions. Blanksma and Van Eijden34 have
reported that alteration in activity relative to bite force
was generally the smallest in the anterior region of the
muscle. In our study the EMG muscular activities were
measured in the anterior region of the temporal muscle;
for this reason, no proportionate change in EMG activity
was observed in the temporalis muscle after treatment.
When the mean EMG muscular activities on the right
and left sides were compared, the EMG activities on the
right side were found to be higher. However, this differ-
ence was statistically insignificant. This is true for both
the temporal and the masseter muscles with regard to
both pretreatment and posttreatment (Table III).
The comparison of the differences between the right
and left sides for both pretreatment and posttreatment
and for both the masseter and temporal muscles was
made with a Student t test; the results displayed
insignificance for both the right and left sides (right, t =
0.12 andp = 0.904; left, t = 1.03 andp = 0.155).
With the occlusal splint inserted, it is reasonable
because of the new occlusal scheme to expect a change
in the neuromuscular problem stemming from peri-
odontal receptors. On the other hand, the TMJ receptor
could also be involved, on account of the rotation of the
condyle on variation of the vertical dimension caused
by the occlusal splint insertion.
Previous studies have reported the clinical importance
of the vertical height of the occlusal splints33,35-37;
furthermore, the thickness of an appliance may be crit-
ical for its effectiveness. In our study the increase in the
vertical dimension caused by the splint during therapy
varied between 1 and 2 mm with respect to the natural
occlusal vertical dimension.
Some studies showed that occlusal splints with canine
guidance reduce radically the contractile activities
recorded from the masseter and anterior temporalis
muscles during teeth grinding and mastication. 38-4°
Williamson and Lundquist 41 had also concluded that
only when posterior disclusion is obtained by an appro-
priate anterior guidance can the electromyographic
activity of the elevating muscles be reduced.
Hersek et al.42 observed in their study the effect of ante-
rior repositioning splint therapy on the masticatory
muscle activity of patients, particularly those with disk
displacement with reduction problems, and concluded
that splint therapy did not cause any significant modifica-
tion of the EMG activity. Our study follows the same line.
The purpose of this study was to investigate the effec-
tiveness of splint therapy in patients with muscle pain.
Many studies have failed to adequately define their
patient populations, incorporating both patients with
extracapsular and patients with intracapsular problems.
In contrast, we selected a patient population with
muscle problems and then evaluated our results on the
basis of objective criteria. It is known that the splint
causes changes in muscular activity while it is in the
mouth; our objective was to investigate whether there
would be a permanent change in the muscular activity
as a result of treatment. It was found that in comparison
with the pretreatment findings, the appliance did not
cause any significant modification of EMG activity in
the aforementioned muscles after splint therapy. As a
result of our experiment, even though a significant
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 85, Number 6
change in EMG activity could not be demonstrated we
found that the symptoms associated with the complaints,
especially pain, were markedly decreased after the therapy.
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Reprint requests:
~enay Canay, DDS, MS, PhD
Ba~gi~ sokak 17/10
Kocatepe 06660, Ankara
Turkey