J Oral Maxillofac Surg

61:32-34, 2003

Natural Course of Disc Displacement

With Reduction of the
Temporomandibular Joint: Changes in
Clinical Signs and Symptoms
Shuichi Sato, DDS, PhD,* Satoshi Goto, DDS,
Fumiko Nasu, DDS, and Katsutoshi Motegi, MD, DDS, PhD
Purpose:

The goal of this study was to examine the natural course of disc displacement with reduction
in the temporomandibular joint (TMJ).
Patients and Methods: This retrospective study involved 24 patients who had been diagnosed with
disc displacement with reduction of the TMJ, but who had not undergone any treatment. The extent of
maximal mouth opening, protrusion, lateral excursions, noise of the TMJ, pain of the TMJ, and
tenderness of masticatory muscles were recorded monthly for a mean of 25.8 months.
Results: Maximal mouth opening, protrusion, and lateral excursions remained unchanged during
follow-up. TMJ pain decreased by 15.7% (P .05). Clicking decreased by 20.8% (P .05), and
tenderness of masticatory muscles decreased by 33.3% (P .05). Reciprocal clicking remained unchanged in 19 patients (79.2%) and disappeared in 5 patients (23.8%). Four patients (16.7%) in whom
clicking disappeared had a normal mouth opening, but locking developed in 1 patient (4.2%).
Conclusions: In patients with disc displacement with reduction who do not undergo treatment, range
of movement remains unchanged over time. Tenderness of masticatory muscles tended lessen, but
reciprocal clicking and TMJ pain tended to remain. Clicking did not progress to locking in most patients.
2003 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 61:32-34, 2003
Painful disc displacement with reduction in the temporomandibular joint (TMJ) has been treated with
medication, disc-repositioning splints1-5 physical therapy,6,7 and surgery.8-10 However, most studies evaluating the effect of a particular treatment for disc
displacement with reduction have lacked an untreated control group. Although many patients benefit
from these treatments, earlier studies11-13 indicate that
reciprocal clicking does not usually progress to locking. An understanding of the natural history of the

disease seems necessary for evaluating the actual effect of a particular treatment. The purpose of this
study was to clarify the natural course of disc displacement with reduction in the TMJ.

Patients and Methods

This retrospective study involved 24 patients (6
male patients and 18 female patients) ranging in age
from 11 to 43 years, with mean age of 19.3 years.
Between 1993 and 1998, 321 patients were diagnosed
with disc displacement with reduction of the TMJ at
the Department of Oral and Maxillofacial Surgery,
Tohoku University. Of these 321 patients, 24 were
selected for no treatment. They agreed not to undergo
treatment and were observed periodically (usually
monthly) for a mean of 25.8 months (range, 6 to 53
months). Twenty patients were diagnosed with a unilateral condition and 4 with a bilateral condition. The
following inclusion criteria were used: 1) clinical diagnosis of disc displacement with reduction based on
the presence of reciprocal clicking; 2) diagnosis confirmed with arthrography or magnetic resonance imaging (MRI); 3) no active treatment provided; and 4)

Received from the Department of Oral and Maxillofacial Surgery I,

Tohoku University School of Dentistry, Sendai, Japan.
*Lecturer.
Assistant Professor.
Resident.
Professor.
Address correspondence and reprint requests to Dr Sato: Department of Oral and Maxillofacial Surgery I, Tohoku University
School of Dentistry, 4-1 Seiryo-machi, Aoba-ku, Sendai 980-8575,
Japan, e-mail: shuichi@mail.cc.tohoku.ac.jp
2003 American Association of Oral and Maxillofacial Surgeons

0278-2391/03/6101-0006$35.00/0
doi:10.1053/joms.2003.50005

32

33

SATO ET AL

Table 1. CHANGES IN CLINICAL SIGNS AND SYMPTOMS

A range of motion for maximal mouth opening (mm)

Protrusion (mm)
Lateral excursion to the TMJ affected side (mm)
Lateral excursion to the TMJ uaffected side (mm)
Patients with TMJ pain (n [%])
Patients with clicking (n [%])
Patients with tenderness of the masticatory muscles (n [%])

At Initial Visit

At Follow-Up

51.4 6.59*
7.3 2.37*
8.1 2.48*
7.7 2.33*
6 (25.0)
24 (100)
9 (37.5)

52.1 7.79*
8.0 3.41*
9.0 3.45*
8.1 3.32*
2 (8.3)
19 (79.2)
1 (4.2)

*Mean standard deviation.

Significant differences between initial visit and follow-up (P .05).

monthly follow-up data were available for at least 6

months.
The extent of maximal mouth opening, protrusion,
lateral excursion to the affected and unaffected sides,
noise in the TMJ, pain in the TMJ, and tenderness of
masticatory muscles were thoroughly documented at
the initial visit and at monthly follow-up. The interincisal distance at active full mouth opening was measured in millimeters as the range of motion for maximal mouth opening. Clicking and crepitus of the TMJ
and tenderness of the TMJ and masticatory muscles
were evaluated by palpation. Spontaneous pain of the
TMJ during maximal mouth opening and mastication
were also evaluated. Whether reciprocal clicking progressed to locking during the follow-up period was
recorded. Locking was clinically defined as a history
of clicking followed by limitation of opening ability
without clicking, and protrusion and lateral excursions without clicking.
Paired t tests were used to analyze differences in
the range of motion for maximal mouth opening,
protrusion, and lateral excursion to the affected and
unaffected sides between patients at the initial visit
and at follow-up. Fishers exact test was used to assess
changes in the noise and TMJ pain and changes in
tenderness of masticatory muscles if the observed
frequencies in 2 2 contingency tables differed from
those expected. Significance was set at P values less
than .05.

Results
In the 24 patients followed up for a mean 25.8
months, maximal mouth opening, protrusion, and
lateral excursions to the affected and unaffected sides
remained unchanged. TMJ pain was present in 6 patients (25.0%) at the initial visit. It decreased to 2
patients (8.3%, P .05). The number of patients with
reciprocal clicking decreased from 24 (100%) to 19
(79.2%, P .05) (Table 1). The number of patients
with tenderness of masticatory muscles decreased
from 9 to 1 (P .05) (Table 1). Reciprocal clicking

remained unchanged in 19 patients (79.2%) and disappeared in 5 patients (23.8%) (Table 1). In 4 patients
(16.7%), clicking disappeared without reduced mouth
opening a mean of 9.3 months (range, 1 to 17
months) after the initial visit. In 1 patient (4.2%),
clicking disappeared with reduced mouth opening 3
months after the initial visit (Table 2).

Discussion
This study showed that, in patients with disc displacement with reduction who did not undergo treatment, range of mandibular movement remains unchanged over time. Masticatory muscle tenderness
tends to lessen, but reciprocal clicking and TMJ pain
tend to remain. Clicking does not progress to locking
in most patients. Several studies followed the course
of TMJ clicking with or without interventions.11-13
Lundh et al11 followed up 23 untreated patients with
reciprocal clicking for 52 weeks. The authors observed that reciprocal clicking disappeared in 2 patients without reduced mouth opening after 6 weeks,
and locking developed in 1 patient after 17 weeks.
However, reciprocal clicking remained unchanged in
the other patients. The authors also observed that the
frequency of masticatory muscle tenderness increased during 52 weeks.
Koenoenen et al12 examined the variation of reported and recorded TMJ clicking in 128 young adults
longitudinally over 9 years. They found that reported
and recorded TMJ clicking increased with age, varying from 11% to 31% and from 11% to 34%, respectively, and that no patients developed locking. Our

Table 2. PATIENTS IN WHOM CLICKING

PROGRESSED TO LOCKING DURING FOLLOW-UP

Progression to Locking

Patients (n [%])

Yes
No

1 (4.2)
23 (95.8)

34
results were consistent with those of these studies
that clicking does not usually progress to locking in
patients with reciprocal clicking who do not undergo
treatment. However, our results did not agree with
those of Lundh et al regarding masticatory muscle
tenderness changes. The present study showed that
masticatory muscle tenderness tends lessen in such
patients, although Lundh et al11 found that the frequency of masticatory muscle tenderness increases. It
is known that several factors such as age, gender,
angle of the posterior slope of the eminence, and
degenerative changes of the condyle influenece clinical outcome in patients with temporomandibular disorders.14,15 We suggest that changes in masticatory
muscle tenderness in our patients might be different
from those in patients in Lundh et als study11 because
of the different distribution of these factors in patients
between the 2 studies.
We cannot say why reciprocal clicking disappeared
without locking in 4 patients, because these patients
did not agree to undergo MRI after the clicking disappeared. In such patients, disc displacement with
reduction might convert to disc displacement without
reduction, but without occasion locking. Conversely,
disc position might be normalized.
When treatment for internal derangement is initiated, reduction of pain is an essential goal. In this
study, only 25% of patients exhibited pain when they
agreed to forego treatment. The most significant outcome in this group may be the maintenance of function and diminution of clicking. However, whether
cessation of clicking should be a treatment goal is
controversial.

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