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 Table of Contents  
Year : 2019  |  Volume : 53  |  Issue : 1  |  Page : 21-26

Immediate Complete Anterior Guidance Development (ICAGD) applied to post-orthodontic patients with Temporomandibular Disorders: A single interventional study of 50 cases

1 Prof. and HOD, Orofacial Pain Clinic, Raja Rajeshwari Dental College, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India
2 Chairman, Research, Development, R&D, Bioresearch Associates Inc., Wisconsin, US
3 Researcher, Orofacial Pain Center, Bengaluru, Karnataka, India

Date of Submission02-May-2018
Date of Acceptance11-Oct-2019
Date of Web Publication5-Feb-2019

Correspondence Address:
Dr. Prafulla Thumati
296, Orofacial Pain Center, Katriguppa Main Road, Banashankari 3rd Stage, Rajiv Gandhi University of Health Sciences, Bengaluru - 560 085, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jios.jios_70_18

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Objective: The objective was to test the efficacy of immediate complete anterior guidance development (ICAGD) treatment applied to a select group of postorthodontic temporo-mandibular disorder (TMD) patients with specified myalgic symptoms. Materials and Methods: The symptoms of a carefully selected group of fifty postorthodontic myalgic TMD patients without serious temporomandibular joint disturbances were documented with a 0–10 Visual Analogue Scale, pre and post ICAGD treatment. Bilateral masseter and temporalis muscle activity and relative bite force were measured multiple times before and after treatment. The Mann–Whitney U-test was used to analyze the anamnestic data, and Student's paired t-test was used to analyze all the measured data. Results: Disclusion times were significantly reduced (P = 0.000) as were the posttreatment subjective symptoms (P = 0.0003). The relative force levels clenching in maximum intercuspal position became more equally distributed between the left and right sides after treatment (P < 0.0002), although the total electromyography (EMG) activity during the clenching did not change (P > 0.4940). The left and right lateral excursive EMG activity was significantly reduced after treatment (P < 0.05). Conclusions: The application of ICAGD reduced: (a) the lateral excursive disclusion times, (b) the myalgic reported symptoms, (c) the left–right imbalance of forces during clenching, and (d) the amount of muscular effort during lateral excursions for this group of postorthodontic myalgic TMD patients.

Keywords: Force finishing in orthodontics, immediate complete anterior guidance development, temporomandibular disorder

How to cite this article:
Thumati P, Radke JC, Thumati RP. Immediate Complete Anterior Guidance Development (ICAGD) applied to post-orthodontic patients with Temporomandibular Disorders: A single interventional study of 50 cases. J Indian Orthod Soc 2019;53:21-6

How to cite this URL:
Thumati P, Radke JC, Thumati RP. Immediate Complete Anterior Guidance Development (ICAGD) applied to post-orthodontic patients with Temporomandibular Disorders: A single interventional study of 50 cases. J Indian Orthod Soc [serial online] 2019 [cited 2019 Jun 16];53:21-6. Available from: http://www.jios.in/text.asp?2019/53/1/21/251555

  Introduction Top

For many decades, there has been periodic speculation regarding whether orthodontic treatment might be one of the causes of, or a possible contributing factor to, the development of any one or more of the conditions within the broad category of temporomandibular disorders (TMDs).[1] This question may not be sufficiently resolved to the satisfaction of everyone, but even if it is finally determined to be negative,[2] a follow-up question should be asked whether orthodontic treatment effectively removes any of the risks present before treatment. It has been suggested that about 10% to as high as 25% of juveniles do exhibit some of the most common TMD symptoms.[3],[4],[5] It has also been suggested that the benefits of orthodontic treatment, both physical and psychological, may be fleeting.[6] Since the evidence to date suggests no significant difference in the prevalence of TMD after orthodontic treatment, it is probable that the “average orthodontic treatment” neither increases nor reduces the risk of developing TMD.[7],[8] However, it is certain that many post-orthodontic patients do develop TMD. It is a goal for some that orthodontic treatment should reduce the risk of developing TMD after several years of occlusal treatment.[9],[10]

The category of TMD contains at least 30–40 or more discrete diagnosable physical conditions.[11] Some of these conditions are related to dysfunction within the temporomandibular joint (TMJ), such as arthralgias and internal derangements. Others primarily affect the musculature, such as myalgias and muscle spasms, which are very common.[12] Some patients experience more than one condition, but it is common to distinguish between primary myalgic cases and primary arthralgic cases.[13]

Some authors have suggested that patients with TMD muscle disorders are more likely to have pain in other areas of their bodies than non-TMD patients.[14] Patients with pain in their knee, hip, ankle, shoulder, wrist, or elbow, and without TMD muscle disorders may have pain in only one site. Those with TMD muscle disorders must have a minimum of at least two pain sites. That is potentially a biased sample. Some patients with myalgic TMD may concurrently have other diseases, but many do not have systemic conditions. Thus, we hypothesize that the primary etiology of masticatory occluso-muscle dysfunction in the absence of serious TMJ disease or systemic other diseases is related to various malocclusions.[15],[16],[17],[18]


The objective of this study was to evaluate the effects of immediate complete anterior guidance development (ICAGD)[19] treatment method applied to a group of carefully selected post-orthodontic myalgic patients with painful occluso-muscle disorder (OMD) symptoms.

  Materials and Methods Top

A carefully selected group of fifty (17 males and 33 females) postorthodontic patients, all with painful OMD symptoms, referred for ICAGD treatment, were evaluated clinically using Visual Analog Scale (VAS) from 0 (no pain) to 10 (worst possible pain) for self-report of specific myalgic symptoms.

The inclusion criteria were: (1) Previous orthodontic treatment without any symptoms prior to orthodontic treatment (in the last 10 years), (2) myalgic TMD symptoms, (3) seeking treatment for painful muscle symptoms, and (4) a willingness to participate in this study.

The exclusion criteria were: (1) Advanced TMJ disease (diagnosed by imaging methods such as cone beam computed tomography and magnetic resonance imaging), (2) painful internal derangement of the TMJ, (3) closed lock or open lock of the TMJ, and (4) any systemic diseases or poor general health. All patients were fully informed of all procedures and risks of treatment following the guidelines of the World Medical Association declaration of Helsinki as amended in 2013.

Prior to any treatment, all patients consented to have the bilateral electrical activity of their masseter and temporalis muscles recorded (BioEMG III, BioResearch Inc., Milwaukee, WI, USA) [Figure 1] and simultaneously the percentage of force recorded on the left and right sides (Tekscan Inc., South Boston, MA, USA) [Figure 2] and [Figure 3]. Records were made during three successive clenches in the maximum intercuspal position. A second set of simultaneous recordings of left and right lateral excursions were made, while a T-Scan™ III instrument recorded the relative forces and timing of the occlusal contacts. These records included a measurement of the time required to disclude the posterior teeth during the lateral excursions, which is clinically referred to as “disclusion time.” The records also included the amount of muscle activity occurring during the lateral excursions. Thus, simultaneous and synchronized records of the muscle activity, relative forces, and timing were digitized (at 16 bits) and saved for future analysis.
Figure 1: The T-Scan as applied and the placement of the surface electromyography electrodes over the bilateral superficial masseter and anterior temporalis muscles

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Figure 2: The combined T-Scan (top) and BioEMG III (bottom) at the beginning of a left lateral excursion showing hyperactivity in all muscles

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Figure 3: The combined T-Scan (top) and BioEMG III (bottom) at the beginning of a left lateral excursion showing reduced activity in all the four muscles. The left anterior temporalis and right masseter muscles are the most active in producing this movement (as they should be)

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Next, all patients underwent the ICAGD procedure, using T-Scan III instrument to reduce each patient's disclusion time below 0.5 s in right and left lateral excursions with the ultimate objective of reducing the severity of the symptoms. All treatments were performed by the same trained clinician (PT).

After the completion of the ICAGD procedures, the patients self-reported on their posttreatment levels of pain associated with the same specific symptoms previously recorded and using the same scale (0–10 VAS). The simultaneous electromyography (EMG) and T-Scan recordings (clenching three times and left and right lateral excursions) were repeated in an identical manner to the initial recordings.

The non-parametric Mann–Whitney U-test was chosen to test the VAS data for significance, comparing the pre-treatment levels with the posttreatment levels. Student's paired t-test was applied to the EMG and T-Scan-measured data to evaluate; (a) the repeatability and (b) to detect any significant changes in the force and muscle activity levels during clenching and excursions after ICAGD treatment.

  Results Top

Analysis of the pre-treatment VAS data using the Mann–Whitney U-test indicated no significant difference between the median symptom levels of the males compared to the females (P = 0.136). However, significant reductions were found in the median symptom levels after treatment for males (P = 0.021), for females (P = 0.0008), and for the entire group (P = 0.0003) [Table 1].
Table 1: Analysis of Visual Analog Scale (0-10) using the Mann-Whitney U-test

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The multiple clench data that recorded the distribution of force between the left and right sides were tested with Student's paired t-test. The means of the absolute values of the difference between the left and right percentages of force were 19.9% (± 21.9) pre-treatment and 8.2% (± 4.3) after treatment (P < 0.0002) [Table 2].
Table 2: A significant difference was found between the absolute percentage difference in the force measured by T-Scan between the left and right sides of the arches during forceful clenching before and after treatments

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On comparing the EMG activity levels between repeated clenches prior to treatment, a significant difference was found between clench 1 and clench 2 and between clench 2 and clench 3 (P < 0.05). However, there were no significant differences between the three EMG clench activities after treatment (P > 0.05). The EMG activity from the three pret-reatment clenches was averaged and then activity of all the four muscles was summed to total the EMG activity. The same procedure was used to calculate the total EMG activity post-treatment. Using Student's paired t-test, no significant difference was found between the pre-treatment and post-treatment total activities (P = 0.499).

The disclusion times from the pre-treatment lateral excursions were compared to the disclusion times after treatment using Student's paired t-test. They were found to be significantly shorter for both the left and right excursions (P < 0.0000). The level of each muscle's activity during right lateral excursions was reduced for all the four muscles (P < 0.05). The same finding of significantly lower muscle activity was also true for left lateral excursions (P < 0.05).

  Discussion Top

Myalgic TMD patients exhibit a variety of painful muscle symptoms. It was not the purpose of this study to evaluate any single symptom, but to evaluate an aggregate of these myalgic symptoms. Consequently, the group median level of subjective pain was calculated for each of the 13 symptoms, both pretreatment and post-treatment. Then, the 13 group medians were compared using the non-parametric Mann–Whitney U-test. Although for each symptom the median resolved to 0, only 4 of the means did, which indicates that the distribution was skewed toward complete resolution with just limited numbers of holdouts.

Difficulty chewing, clenching/grinding, shoulder pain, and tingling sensations in the fingers were the only symptoms that were totally resolved in all patients (all zeros). While the range of VAS scores prior to treatment was from 0 to 10, the range after treatment was reduced to 0–2. The most resistant symptom was temporal headaches with a mean score of 0.46, but in this group, in 34 out of 50 patients (68%), temporal headaches too were completely resolved. These headaches are the most commonly associated symptom with TMD patients.[20]

It is likely that the reduced lateral excursive EMG activity recorded was in part due to the removal of occlusal restrictions to functional movements.[21] It is also probable that the shortened time of contraction requires less work from the muscles, since work = effort × time.[22],[23],[24],[25],[26]

The T-Scan measures only the relative forces, not the absolute forces. However, EMG activity levels are directly proportional to the force levels. By recording the two systems simultaneously, it was possible to verify that there was no significant difference between the mean total contraction levels (and thus the clenching forces) between pretreatment and posttreatment records (P = 0.4940) [Table 3]. Although the levels of contraction, as indicated by the EMG activity levels, were not significantly different pre-treatment and post-treatment, the distribution of forces changed to a more even balance between the left and right sides. This typically results in excessively high forces on some individual teeth being reduced and the low forces on other teeth being increased.[27],[28]
Table 3: Mean, standard deviation, and 95% confidence intervals for the disclusion times and electromyographic activities during lateral excursions

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Some have considered the lack of the ability of T-Scan to measure absolute forces as a limitation.[29],[30],[31],[32] However, the article did show the validity and good reliability of the T-Scan for relative measurements.

  Conclusions Top

Within the limitations of this study, it was concluded that for this group of post-orthodontic myalgic TMD patients: (1) the ICAGD procedure significantly reduced the median levels of 13 subjective symptoms, (2) the mean disclusion times during left and right lateral excursions were significantly reduced, (3) rectified mean EMG activity from the masseter and anterior temporalis muscles was significantly less during the left and right lateral excursions post-ICAGD, and (4) the left–right imbalance of force was also significantly reduced while clenching at the same level of EMG activity after treatment. It is desired that from the orthodontic society, a longitudinal study is required, with objective data and without any subjective expressions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Pullinger AG, Monteiro AA. History factors associated with symptoms of temporomandibular disorders. J Oral Rehabil 1988;15:117-24.  Back to cited text no. 1
Kremenak CR, Kinser DD, Melcher TJ, Wright GR, Harrison SD, Ziaja RR, et al. Orthodontics as a risk factor for temporomandibular disorders (TMD). II. Am J Orthod Dentofacial Orthop 1992;101:21-7.  Back to cited text no. 2
Hans MG, Lieberman J, Goldberg J, Rozencweig G, Bellon E. A comparison of clinical examination, history, and magnetic resonance imaging for identifying orthodontic patients with temporomandibular joint disorders. Am J Orthod Dentofacial Orthop 1992;101:54-9.  Back to cited text no. 3
Christidis N, Smedberg E, Hägglund H, Hedenberg-Magnusson B. Patients' experience of care and treatment outcome at the department of clinical oral physiology, dental public service in Stockholm. Swed Dent J 2010;34:43-52.  Back to cited text no. 4
Špalj S, Šlaj M, Athanasiou AE, Žak I, Šimunović M, Šlaj M. Temporomandibular disorders and orthodontic treatment need in orthodontically untreated children and adolescents. Coll Antropol 2015;39:151-8.  Back to cited text no. 5
McGuinness NJ. Orthodontic evolution: An update for the general dental practitioner. Part 2: Psychosocial aspects of orthodontic treatment, stability of treatment, and the TMJ-orthodontic relationship. J IR Dent Assoc 2008;54:128-31.  Back to cited text no. 6
McNamara JA Jr., Seligman DA, Okeson JP. Occlusion, orthodontic treatment, and temporomandibular disorders: A review. J Orofac Pain 1995;9:73-90.  Back to cited text no. 7
Hirsch C. No increased risk of temporomandibular disorders and bruxism in children and adolescents during orthodontic therapy. J Orofac Orthop 2009;70:39-50.  Back to cited text no. 8
Henrikson T, Ekberg EC, Nilner M. Masticatory efficiency and ability in relation to occlusion and mandibular dysfunction in girls. Int J Prosthodont 1998;11:125-32.  Back to cited text no. 9
Mohlin B, al-Saadi E, Andrup L, Ekblom K. Orthodontics in 12-year old children. Demand, treatment motivating factors and treatment decisions. Swed Dent J 2002;26:89-98.  Back to cited text no. 10
Machado LP, Nery Cde G, Leles CR, Nery MB, Okeson JP. The prevalence of clinical diagnostic groups in patients with temporomandibular disorders. Cranio 2009;27:194-9.  Back to cited text no. 11
Lövgren A, Österlund C, Ilgunas A, Lampa E, Hellström F. A high prevalence of TMD is related to somatic awareness and pain intensity among healthy dental students. Acta Odontol Scand 2018;76:387-93.  Back to cited text no. 12
Lobbezoo F, Aarab G, Knibbe W, Koutris M, Warnsinck CJ, Wetselaar P, et al. Painful temporomandibular dysfunctions: Diagnosis and -treatment. Ned Tijdschr Tandheelkd 2016;123:528-32.  Back to cited text no. 13
Bonato LL, Quinelato V, De Felipe Cordeiro PC, De Sousa EB, Tesch R, Casado PL. Association between temporomandibular disorders and pain in other regions of the body. J Oral Rehabil 2017;44:9-15.  Back to cited text no. 14
Jussila P, Krooks L, Näpänkangas R, Päkkilä J, Lähdesmäki R, Pirttiniemi P, et al. The role of occlusion in temporomandibular disorders (TMD) in the northern Finland birth cohort. Cranio 2018:1-7. doi: 10.1080/08869634.2018.1537088. [Epub ahead of print].  Back to cited text no. 15
Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6:301-55.  Back to cited text no. 16
Laskin DM. Etiology of the pain-dysfunction syndrome. J Am Dent Assoc 1969;79:147-53.  Back to cited text no. 17
Costa YM, Porporatti AL, Stuginski-Barbosa J, Bonjardim LR, Conti PC. Additional effect of occlusal splints on the improvement of psychological aspects in temporomandibular disorder subjects: A randomized controlled trial. Arch Oral Biol 2015;60:738-44.  Back to cited text no. 18
Kerstein RB, Wright NR. Electromyographic and computer analyses of patients suffering from chronic myofascial pain-dysfunction syndrome: Before and after treatment with immediate complete anterior guidance development. J Prosthet Dent 1991;66:677-86.  Back to cited text no. 19
Di Paolo C, D'Urso A, Papi P, Di Sabato F, Rosella D, Pompa G, et al. Temporomandibular disorders and headache: A retrospective analysis of 1198 patients. Pain Res Manag 2017;2017:3203027.  Back to cited text no. 20
Kerstein RB, Radke J. Average chewing pattern improvements following disclusion time reduction. Cranio 2017;35:135-51.  Back to cited text no. 21
Kerstein RB, Radke J. Masseter and temporalis excursive hyperactivity decreased by measured anterior guidance development. Cranio 2012;30:243-54.  Back to cited text no. 22
Thumati P, Manwani R, Mahantshetty M. The effect of reduced disclusion time in the treatment of myofascial pain dysfunction syndrome using immediate complete anterior guidance development protocol monitored by digital analysis of occlusion. Cranio 2014;32:289-99.  Back to cited text no. 23
Thumati P. The influence of immediate complete anterior guidance development technique on subjective symptoms in myofascial pain patients: Verified using digital analysis of occlusion (Tek-scan) for analysing occlusion: A 3 years clinical observation. J Indian Prosthodont Soc 2015;15:218-23.  Back to cited text no. 24
[PUBMED]  [Full text]  
Thumati P, Thumati RP. The effect of disocclusion time-reduction therapy to treat chronic myofascial pain: A single group interventional study with 3 year follow-up of 100 cases. J Indian Prosthodont Soc 2016;16:234-41.  Back to cited text no. 25
Thumati P. Digital analysis of occlusion using T-Scan III in orthodontics. J Indian Orthod Soc 2016;50:196-201.  Back to cited text no. 26
  [Full text]  
Maness WL, Podoloff R. Distribution of occlusal contacts in maximum intercuspation. J Prosthet Dent 1989;62:238-42.  Back to cited text no. 27
Reza Moini M, Neff PA. Reproducibility of occlusal contacts utilizing a computerized instrument. Quintessence Int 1991;22:357-60.  Back to cited text no. 28
Cerna M, Ferreira R, Zaror C, Navarro P, Sandoval P. Validity and reliability of the T-scan(®) III for measuring force under laboratory conditions. J Oral Rehabil 2015;42:544-51.  Back to cited text no. 29
Cerna M, Ferreira R, Zaror C, Navarro P, Sandoval P.In vitro evaluation of T-Scan® III through study of the Sensels™. Cranio 2015;33:299-305.  Back to cited text no. 30
Kuiken TA, Lowery MM, Stoykov NS. The effect of subcutaneous fat on myoelectric signal amplitude and cross-talk. Prosthet Orthot Int 2003;27:48-54.  Back to cited text no. 31
Cram JR, Steger JC. EMG scanning in the diagnosis of chronic pain. Biofeedback Self Regul 1983;8:229-41.  Back to cited text no. 32


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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