Disc Displacement With Reduction

When a jaw joint problem has been occurring long enough for example either through
chronic tooth clenching/grinding (micro trauma) or from an injury (macrotrauma), often the disc
will become displaced, or positioned forward to the condyle.
When the mouth opens or is moved from side to side, the disc bunches up against the condyle
and gets stretched until it pops, cracks, or clicks and recaptures into its correct position. This
can happen every time the jaw is opened or moved, or only occasionally. It typically is much
worse in the mornings on waking. It can either be very quiet and heard only by the person
themselves, or sometimes it can be loud enough to be heard across the table and by everyone in
the room.
When the teeth bite back together, the disc typically slips off the condyle again and is displaced
until the mouth is opened or the jaw is moved. Often the disc slipping off the condyle when the
teeth come together cannot be felt or heard.
When a jaw joint problem has been present for long enough, or following a fall or sudden
blow to the jaw, often the person is suddenly unable to open their mouth or move their jaw very
far from side to side. Most commonly patients report that their jaw has clicked all my life then
suddenly stopped, or I woke up this morning and my jaw was locked shut. When this occurs,
the disc no longer is able to be recaptured back onto the condyle during normal jaw movements.
It becomes trapped forward of the condyle and bunches up restricting jaw movement and mouth
opening. Often a lot of pain is associated with this condition and urgent correct repositioning and
stabilisation treatment is vital to prevent a long term and chronic problem from developing.





This occurs when the ligaments are stretched more and the disk slips too far out of
position so that it can no longer click back into place. It then acts like a door-jam and blocks
the normal movement of the joint. As the mouth opening is limited it is also called locked jaw
even though typically a person can still open to two-finger widths. When the disk is positioned
forward there is increased load onto the painful and compressible retrodiscal tissues which can
lead to increased TMJ/ear pain, deviated mouth opening, bite changes and osteoarthritis. Acute
jaw locking episodes can usually be unlocked using manual jaw manipulation and oral splints. If
the locking is left untreated then the disk displacement becomes chronic as there are more
permanent anatomic changes within the TMJ. Successful treatment will usually result in
increased mouth opening, decreased pain and increased ability to eat normally. Typically the
clicking will return and not go away. Treatment usually consists of medications, jaw exercises,
manual jaw manipulation, oral appliance therapy and minimally invasive arthroscopy.
Internal derangement of the temporomandibular joint is defined as a disruption within the
internal aspects of the TMJ in which there is a displacement of the disc from its normal
functional relationship with the mandibular condyle and the articular portion of the temporal
bone
1
. The prevalence of TMJ internal derangement has been well documented. Dulcic et al.
examined 96 elderly subjects and verified that the symptoms in internal derangement of the
temporomandibular joint were found in 9.3% or subjects and tissue specific diagnosis were
established in 52.1% or the subjects
2
.
Guler examined patients with known bruxism and was able to correlated via MRI that 64
or 102 joints exhibited evidence of disk displacement
3
. Studies by Farrar show that as much as
25% of the entire population has an internal derangement
4
. Internal derangement can be divided
into four separate stages.
In the first stage of internal derangement clicking begins suddenly and spontaneously or
after an injury. This reciprocal clicking is considered to be pathognomic for the first stage of disc
displacement. The noise is often loud and can sometime be heard by others. The patient may be
aware of an obstructive feeling within the joint during movement until the click occurs. The
mandible frequently deviates toward the affected side until the click occurs and then returns to
the midline. It has been stated that the later the opening click occurs the more advanced the disc
displacement, however this point has been under debate. The fifth World Congress on Pain
determined that "Clinic cases cannot be distinguished from controls on the basis of clinically
detectable joint sounds."
5
This concept is further emphasized by Rohlin and others, who showed
in an arthorgraphic study that anterior displacement with reduction can exist without joint
noises
6
.
The second stage of disc displacement is reciprocal clicking with intermittent locking.
Symptoms include locked jaw and usually, but not always, severe pain over the affected joint.
Patients may describe an obstructive feeling to opening within the joint. Patients may be able to
use manipulation in order to reposition the joint and restore function. In some cases, the jaw may
unlock spontaneously. In most cases, a previous history of joint clicking exists.
The third stage of disc derangement is associated with limited opening and has been
termed closed lock. A limited opening of < 27mm will exists as well as preauricular tenderness
and deviation of the mandible to the affected side with mouth opening and protrusive
movements. Again, the patient will often describe a feeling of fullness or obstruction. 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
disc.
The fourth stage shows continued mandibular function as the stretched posterior
attachment slowly loses its elasticity. The patient begins to regain some of the lost range of
motion. 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 perforates
7
. Although it is often classified as a
characteristic of a separate final stage, hard tissue remodeling probably occurs throughout all
stages.
Many patients undergo the progressive changes that have been previously described.
However, it is still not clear as to whether or not this progression happens in all cases. Numerous
studies show that this progression does not exist. For instance, in a 10 year study performed by
Magnusson et al. 293 subjects with clicking exhibited no progression of clicking into locking
8
.
At the 10 year follow up, only one of the 293 subjects reported intermittent locking
9
. In addition,
the authors state that half the patients who exhibited clicking at age 15 no longer did so at age 20,
and about half of those who did not exhibit clicking at age 15 went on to develop clicking. This
lack of progression of internal derangement from a reducing disc to a non-reducing disc
condition has also been confirmed in studies by Greene and Laskin, Lundh and others.
studies have been performed examining the natural course of anterior disc displacement
without reduction. Sato et al observed 44 patients with anterior disc displacement. At 18 months,
68% of the study population exhibited successful resolution
10
. Although this finding suggests
that the symptoms of an anterior displaced disc without reduction can resolve without
intervention, the authors fail to mention what happened to the disc. It is possible that there was
some stretching and remodeling of the retrodiscal tissues enabling the disc to be displaced more
anteriorly by translating the condyle. These findings are similar to another study performed by
Kurita et al
11
. In their study they examined 40 patients over a period of 2.5 year. After 2.5 years,
43% of the patients were asymptomatic, 33% had decreased symptoms, and 25% of the patients
showed no improvement or had required treatment. The result of this prospective cohort study
indicated that approximately 40% of patients with symptomatic disc displacement without
reduction will be free of symptoms within 2.5 years, one-third will improve, whereas one-quarter
will continue to be symptomatic.
Although studies have accurately shown that internal derangements can be treated
conservatively or simply monitored, there still exists a small proportion of patients that will
require therapy. Internal derangement is normally treated with non-surgical methods initially.
Should these methods prove unsuccessful, they are often followed by surgical methods such as
meniscectomy, disc repositioning procedures and condylotomy. The use of invasive surgical
means has decreased in recent years as the introduction of more conservative surgical procedures
has become more popular. TMJ arthroscopy is an example of minimally invasive surgical
therapy.


Works Cited:
1. Dolwick MF, Katzberg RW, Helms CA. Internal derangements of the
temporomandibular join: fact or fiction? J Prosthet Dent 1983; 49: 415-8.
1. Dulcic N, Panduric J, Kraljevic S, Badel T, Celic P. Frequency o finternal derangement
of the temporomandibular joint inelderlhy individuals. Eur J Med Res 2003 Oct 22;
8(10): 465-71.
1. Guler N, Yatmaz PI, Ataoglu H, Emlik D, Uckan S. Temporomandibular intgernal
derangement: correlation of MRI findings with clinical symptoms of pain and joint
sounds in patients with bruxing behaviour.
1. Farrar WB. Myofascial pain dysfunction syndrome [letter]. J Am Dent Assoc 1981; 102:
10-1.
1. Stohler C. Disk-interference disorders. In: Zarb G, Carlsson G, Sessle B, Mohl N, editors.
Temporomandibular joint and masticatory muscle disorders. Copenhagen: Munksgaard;
1992. p271-6.
1. Rohlin M, Westesson PL, Eriksson L. The correlation of Temporomandibular joint
sounds with joint morphology in fifty-five autopsy specimens. J Oral Maxillofac Surg
1985; 43: 194-200.
1. Heffez L, Blaustein D. Pathologic anatomy of internal derangements. In : Heffez L,
Blaustein D, editors. Arthroscopic atlas of the Temporomandibular joint. Philadelphia:
Lea & Febiger, 1990.
1. Magnusson T, Egermark-Eriksson I, Carlsson GE. Fiver year longitudinal study of signs
and symptoms of mandibular dysfunction in adolescents. J Craniomandib Pract 1986;
4:338-44.
1. Magnusson T, Carlsson GE, Egermark I. Changes in subjective symptoms of
crainiomandibular disorders in children and adolescents during a 10 year period. J
Orofacial Pain 1993; 7:76-82.
1. Sato S, Takahashi K, Kawamura H, Motegi K. The natural course of nonreducing disc
displacement of the temporomandibular joint: changes in condylar mobility and
radiographic alterations at one-year follow-up. Int J Oral Maxillofacial Surg 1998; 27:
p173-7.
1. Kurita K, Westesson PL, Yuasa H, Toyama M, Machida J, Ogi N. Natural course of
untreated symptomatic temporomandibular joint disc displacement without reduction. J
Dent Res. 1998 Feb;77(2):361-5.