TEMPOROMANDIBULAR

JOINT

OCCLUSION

SECTION EDITOR

GEORGE A. ZARB

The role of stress, occlusion, and condyle position in

TM J dysfunction-pain
Lawrence A. Weinberg, D.D.S., M.S.*
New York, N.Y.

n recent years increased attention has been given to

condyle position in the fossae in the hope of broadening
knowledge of the mandibular position in centric relation. The essential factor before contemplating prosthodontic treatment or the treatment of temporomandibular joint (TMJ) dysfunction-pain is the significance of the position of the condyle in the fossae. If it is
not important, then only the relative repeatable
position of centric relation need be used; and any
mandibular deviation due to deflective contacts should
be eliminated. However, if the condyle position in the
fossa is significant, then further questions must be
answered before diagnosis and treatment can begin.
Documented evidence should form the basis for the
treatment plan to follow.
A radiographic technique that is duplicable and
simple should be established in order to be accepted as
a baseline for investigation and documentation. The
anatomic topography of the TMJ radiograph should
be perfectly clear to provide statistical evaluation of the
degree of asymmetry between right and left sides. A
large sampling of TM J and control patients should be
compared to see if there is a correlation between the
condylar position in the fossae and dysfunction symptoms. If a valid correlation is found, then the definition
of centric relation should be modified to identify a
functional or dysfunctional centric relation. Implicit in
any new definition of centric relation that distinguishes
between a healthy (functional) joint and a dysfunctional one would be the need to establish the appropriate
treatment procedures to suit the individual needs of the
patient. This approach is in contradistinction to the
common practice of placing the mandible in the classical most retruded position without regard for the
actual condylar position in the fossae as indicated by
radiographs. This article will document the available
data and the resultant conclusions that can be drawn.
Presented before the Greater New York Academy of Prosthodontics,
New York, N.Y.
*Former Director of the TMJ Service, Department of Dentistry,
Nassau County Medical Center, New York, N.Y.

532

DUPLICABILITY
RADIOGRAPHS

OF LATERAL TMJ

A technique of TMJ radiography was reported by

Pordes in 1920 (frontal view) and the lateral transcranial view by Lindblom2 (1936), Riesner,3 Grewcock,4 Updegrave, and Weinberg.6 Although Zech7
and Freihofer compared various techniques, Frolich9
was the first to attempt to measure and evaluate the
duplicability of TMJ radiographs with the same
technique. He reported that a plus or minus rotation of
the head of 3 degrees in the midsagittal plane had no
influence on the linear dimensions of the radiographs.
In a previous articlelO a statistically valid study reported that the TMJ radiographs of 28 patients were
duplicable within ? 0.2 mm (Fig. 1). The joint spaces
were measured from the superior portion of the fossa
using a measuring system that was statistically valid to
-+O.l mm. It was reported that the .slight
within
variations in head position from one radiograph to
another did not significantly affect image duplicability
(-+ 0.2 mm). However, the angulution of the central
x-ray beam should remain constant.

ASYMMETRY OF THE TMJ AND ITS

EFFECT ON DIAGNOSIS
Much criticism has been directed at the lateral
transcranial TM J radiograph due to the asymmetry
of the condyle and fossa with the assumption that the
resultant radiographs are composite views of an irregular object taken at an angle. No experimental evidence
has been offered to confirm this supposition. To the
contrary a previous article attempted to establish what
is really seen in a lateral TMJ radi0graph.l It
concluded that the lateral TMJ radiograph was actually a cross-sectional view of the lateral third of the
joint. Because the validity of the radiograph is important, the findings will be summarized.
From the frontal view the medial portion of the
condyle is usually more superior than the lateral
surface, producing approximately a lo- to 15-degree
inclination to a liue drawn between the centers of both
condyles (Fig. 2). From the same frontal.view the head

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1128 PAIRS OF TMJ RADIOGRAPHSi

OF PATIENTS

II

MEDIAL SURFACE
MORE SUPERlOR

FRONT VIEW
Fig. 1. Pairs of TMJ radiographs were made a week
apart in 28 patients; posterior, superior, and anterior
joint spaces were duplicable within approximately
20.2 mm.

Fig. 2. Viewed from front, condyles are not parallel to

a line drawn between them. Medial poption of condyles is usually more superior than lateral surface,
forming approximately a lo- to 15-degree angle to
horizontal plane.

must be inclined inferiorly 12 to 15 degrees to obtain

diagnostic radiographs (Figs. 3 and 4). This inferior
inclination of the head compensates for condylar asymmetry, causing the condyle being radiographed to be
aligned perpendicular to the film (Fig. 3).
From the top view each condyle is inclined most
often approximately 10 degrees from a line drawn
between the centers of both condyles (Fig. 5). In order
to avoid other cranial structures, the head must be
inclined anteriorly approximately 9 to 11 degrees from
a perpendicular to the film (Figs. 6 and 7). The condyle
being radiographed is again oriented perpendicular to
the film in this plane and parallel to the x-ray path
(Fig. 6). To summarize, the orientation of the head
(anteriorly and inferiorly), in order to accidentally
avoid other cranial structures, lines up the condyle to
be photographed perpendicular to the film in both
planes.
Signi&eance of the x-ray angulation. Dead soft
wires were placed on the fossa, in the sagittal plane, at
the lateral border position (I), lateral third (II),
medial third (III), and medial border position (IV)
(Fig. 8). A similar wire was attached to the condyle in
the same sagittal plane corresponding to the wire on the
fossa (Fig. 9). Because the condyle is oriented perpendicular to the film, the 75-degree x-ray angulation

required to avoid other cranial structures will always

produce a cross section of the lateral third (Fig. 10).
The lateral two points are superimposed on each other
(Fig. 11, 1 and .Z), while the medial ones (3 and 4) are
projected inferiorly on the film due to the 75-degree
angulation of the central x-ray beam (Fig. 12). This
was confirmed experimentally; the lateral border position wire was seen almost in complete outline of the
image of the condyle and fossa (Figs. 13 and 14). The
same cross-sectional view was produced by the lateral
third wire in tlhe radiograph (Figs. 15 and 16). The
medial third wire was projected inferiorly on the film,
out of the image of the joint space, as was the medial
border position. wire (Figs. 17 to 20). This confirms
that the transcranial radiograph is a cross section of the
lateral third and not a composite z&w (Figs. 14
and 16).
Degree of asymmetry between right and left
sides. A previous article reported that the variation in
the shape of the glenoid fossa and condyle due to the
asymmetry between right and left sides is extremely
small (approximately 0.2 mm) and is not observable
with the naked eye.I2 On this basis the inherent
asymmetry of the TMJ, when the right and left sides
are compared, is clinically insignificant.i2 Seventy control patients and 70 TM J patients were examined, and

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WEINBERG

03

PERPENDICULAR
TO FILM
Figs. 3 and 4. In order to avoid superimposition of other cranial structures, head must
be inclined inferiorly 12 to 15 degrees. Condyle being photographed is aligned
perpendicular to film.

it was found that there was no statistically significant

between the two groups. This is important
because if a valid correlation is observed between
condylar displacement and TM J dysfunction-pain, it
cannot be attributable to any innate asymmetry of the
condyle or fossa shape between right and left sides.
In summary the lateral transcranial TMJ radiograph is an ultradetailed, duplicable, cross-sectional
slice (approximately 4 mm thick) of the lateral third
of the TM J. The image is a tomogram (if we define
it as a slice of a predetermined portion of the
anatomy) since we always get the lateral third.
However, it is not a true tomogram because we cannot

select the plane of the image or narrow the thickness of

the slice.

d&-rence

534

ADVANTAGES AND DISADVANTAGES

OF TOMOGRAMS
Advantages. If a neoplasm is suspected (extremely
rare), radiographic examination of the medial two
thirds of the TMJ may be necessary. Obviously the
plane of the radiograph can be chosen, which is not
possible with the transcranial radiograph. Evaluation
of a fractured and displaced condyle may be aided by a
tomogram.
Disadvantages. A tomogram does not have compa-

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rable resolution (clarity and contrast) with the transcranial radiograph. The tomogram is therefore not
suitable to define osteoarthritic changes other than in
the most gross contours. More radiation is given to the
patient and expensive, complicated equipment is necessary, which rules it out as an in-office tool. As a result
tomograms are made by nondental personnel and the
jaw position is completely unreliable. Therefore, tomograms cannot be used to determine condylar position in
the fossa with any degree of dependability unless made
by a dentist.

APPROX,, IO*
9

SEMANTIC ARGUMENTS AGAINST

LATERAL TRANSCRANIAL TMJ
RADIOGRAPHS
A comparative study of lateral transcranial radiographs with tomograms by Klein et al.13 revealed
differences in the gross shape of the condyle. However,
less than 6 mm of the superior portion of the condyle is
used in the diagnostic area to determine condylar
position in the fossa (Fig. 21). It is therefore possible to
have marked differences in the gross shape of the
images at the anterior and posterior extremes of the
condyle (Fig. 21, 1 and 2) without affecting the
determination of the condylar position in the fossa (Fig.
21, P and A).
The joint spaces usually diminish proportionately
from the lateral to the medial portions of the TMJ as
measured in the sagittal plane (Figs. 14, 16, 18, and
20). This does not alter the relative condylar position
in the fossa and has no bearing on diagnosis since the
lateral transcranial projection repeatedly captures only
the lateral third of the joint. More rather than less
error can be produced if the tomograms are madd in
different sagittal planes when one side is being compared to the other. In the authors opinion the condylar
position is more reliable with the lateral transcranial
projection because the section is always the same
(lateral third). It remains to be seen if those who
advocate tomography will experimentally produce a
duplicability of + 0.2 mm as shown with lateral
transcranial radiographs in 1970.

CORRELATION BETWEEN CONDYLAR

DISPLACEMENT AND TMJ DYSFUNCTION
In three previous articles totaling over 320 patients,
the incidence of condylar displacement in the TMJ
groups was almost 90%.4-6Conversely the incidence of
condylar concentricity was approximately 6 times
greater in the control groups. A detailed analysis of
condylar position in acute TMJ dysfunction patients,
including a report by Mikhail and Rosen,17can be seen

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TOP VIEW
Fig. 5. From top, condyles are inclined approximately
10 degrees from transverse center line.
in Fig. 22. It is particularly important to note the
extremely high incidence of posterior condylar displacement (53% to 71%), while condylar concentricity
varied from only 4% to 11%. In the control groups the
posterior displacement was one half that found in the
TMJ groups (Fig. 23).
Significance. Because TM J dysfunction-pain is
multicausal and the isolation of variables is not possible
in humans, the continued reporting of the correlation
between condylar displacement and TM j dysfunctionpain should be encouraged by many more researchers.
Bessette et al..,lH correlating the elongation of the
masseteric silent period with TMJ pain, found that
90% of the TMJ patients also had condylar displacement (22 patients). This collection of data14.*supports
the view that the condylar displacement observed in
relation to TM J pain is not a random finding.

NEW DEFINITION

OF CENTRIC RELATION

There is a commonly held assumption that when

centric relation and centric occlusion are harmonious,
the condyles will be oriented properly in the fossae. For
example, in Fig. 24 centric relation and centric occlusion are identical and both condyles are centered in the
fossae (Figs. 2Ei and 26). It is not unusual for a patient
to have harmony between centric relation and centric
occlusion (Fig. 27) and yet have both condyles displaced posteriorly (Figs. 28 and 29). The same occlusion (Fig. 30) could also result in one condyle being

535

WEINBERG

go-II
ANTERIOR INCLINATION

X-RAY
PATH

06

FiLM
Figs. 6 and 7. Head must be inclined anteriorly approximately
9 to 11 degrees to avoid
superimposition
of cranial structures on image of TMJ. Condyle being photographed
is
oriented perpendicular
to film.

Fig. 8. In order to identify cranial structures on film, dead soft wires were attached to
fossa in sagittal plane at lateral border position, I; lateral third, 11; medial third, 111;and
medial border positions, IV.
Fig. 9. Another wire was attached to surface of condyle in same sagittal plane as wire
luted to fossa.
536

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MEDIAL

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X-RAY ANGULATI

FILM

-~-

--\-LATERAL
OUTLINED

03

FILM

FILM

THIRD
ON

TMJ

IMP.GE

Fig. 10. Seventy-five-degree

angulation of central x-ray beam will always produce a
cross section of lateral third of TMJ.
Figs. 11 and 12. Due to vertical orientation of condyle to film and 75-degree angulation
of central beam of x-ray, lateral two points (2 and 2) are superimposed on each other
while wires that are more medial (3 and 4) are projected inferiorly on film.

Figs. 13 and
(Fig. 13) was
Figs. 15 and
condyle and

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14. Cross-sectional image was confirmed when lateral border position wire
recorded in outline on image of condyle and fossa on film (Fig. 14).
16. Lateral third wire also was recorded in outline form on image of
fossa, confirming a cross-sectional view.

DENTISTRY

537

WEINBERG

Figs. 17 and 18. Medial third wire was projected inferiorly

on radiograph
due to
75-degree angulation of central x-ray beam.
Figs. 19 and 20. Medial border position wire was also projected inferiorly on radiograph
by central x-ray beam angulation.

CONDY LAR

CONDYLE
CONDYLEg2

ASYMMETRY

ASYMMETRY DOES
NOT AFFECT

Fig. 21. Tomograms and lateral transcranial radiographs can produce different images
(1 and 2). Only approximately
6 mm of superior condylar surface is used for determining
condylar position in fossa. Differences in extreme outlines of condyles do not affect
evaluation of condylar position in fossae, that is, posterior joint space (PJS) and anterior
joint space (AJS).

538

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[C~N~YLAR DISPLACEMENT: ACUTE TMJ G%jI]

[551

pis-mmq

1631

RETRUDED 171
MIDDLE
I4 /

RETRUDED
MIDDLE

)59/IB
p%J

RETRUDIED f?%j
MIDDLE
I-imJ

ANTERIOR (18
ANTERIOR (24%1 I ANTERIOR
(271
REDUCED JS 7% 1 REDUCED JS 3% 1 REDUCED JS 9 %
6%
MISC.

WEINBERG
JPD JUNE 1979

MIKHAIL & ROSEN

I JPD

OCT

1979

I WEINBERG Bi LAGEG
1 JPD DEC 1980

Fig. 22. Analysis of condylar position in acute TMJ dysfunction is given from several
recent publications. Posterior displacement was found in 53% to 71% of TMJ patients.
displaced posteriorly and the other displaced superiorly (Figs. 31 and 32).19 In summary the condylar
position in the fossae does not necessarily conform
to the occlusal findings. The occlusion should therefore be related to the TMJ radiographs to establish whether centric relation is functional or dysfunctional.

FUNCTIONAL

CENTRIC RELATION

A functional centric relation can exist with or

without a deflective slide, depending on the condylar
position in the fossa. For instance, when centric
relation and centric occlusion are harmonious (Fig. 24)
and the condyles are concentrically located in the fossae
(Figs. 25 and 26), the centric relation is functional. A
functional centric relation can also exist when a
deflective slide is present, providing the occlusal displacement can be correlated with the condylar displacement observed in the radiographs.

DYSFUNCTIONAL

CENTRIC RELATION

A dysfunctional centric relation can also exist with

or without a deflective slide. As seen in Figs. 27 to 32,
the patients exhibited a harmony between centric
relation and centric occlusion. However, the condyles
were retruded (Figs. 28 and 29) or superiorly displaced
(Fig. 32). Often a patient will exhibit an occlusion with
a hit and slide that cannot be correlated with the TM J
radiographs. For instance, in Fig. 33 the patient is
lightly touching a centric relation deflective contact.
Occlusal pressure causes the mandible to slide directly
laterally into centric occlusion with hardly any anterior
component (Fig. 34). In this patient the right condyle

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~~C~N~YLAR DISPLA~~EM~JT: coNfRt)~

MIDDLE

23%

ANTERIOR

3I%

REDUCED JS I 0%

WEINBERG

JPD JUNE 1979

@0up~

I MIDDLE

I ANTERIOR

37%

ASYMMET. ilS 18%

MIKHAIL e( ROSEN

JPD OCT

1979

Fig. 23. In control groups, posterior displacement

was one half that in TMJ groups.
would be expected to be in the middle of the fossa with
the left condyle considerably protruded to facilitate the
right lateral movement. However, the right condyle is
slightly retruded (Fig. 35), while the left condyle is
almost in the middle of the fossa after a 3 mm slide
toward the opposite right side (Fig. 36). The occlusal
displacement cannot be correlated with the condylar
displacement observed in the radiographs; therefore the
centric relation is dysfunctional, requiring completely
different corrective procedures., !

ROLE OF STRESS IN
CRANIOMANDIBULAR

PAIN

Attempts have been made to associate stress and

personality with craniomandibular pain as a primary
etiologic agent to the exclusion of occlusal factors.22~2
Other reports have acknowledged elevated stress in

539

WEINBERG

Fig. 24. There is harmony between centric relation and centric occlusion.
Figs. 25 and 26. Both condyles are in middle of fossae, indicating a functional
relation; posterior joint space CPJS)is equal to anterior joint space CAJSJ.

TM J patients, but the level of stress was not thought to

be significant enough to be a causative agent.24
Stress literature. The larger proportion of women
to men with craniomandibular pain is often cited as
evidence that it is a stress-induced (female) disorder.
However, an exhaustive investigation into the scientific
stress literature previously reported indicated that in
all male vertebrates, from rats to and including
humans, all males are measurably more susceptible to
stress than females. 25 With specific experiments on
humans,, Frankenhaeuserz6 showed that the stress
chemicals (catecholamines and 17-hydroxycorticosteroid) were higher in men than women when comprehension tasks and frustrating problem solving were
given. If craniomandibular pain is directly related to
stress (as a direct causative agent), then more men
should have the disorder than women. Those who
claim that stress is a direct causative agent in craniomandibular pain never address themselves to this fact,
which is accepted in all scientific stress literature.
Evaskus and Laskin2 reported that women with myofascial pain-dysfunction (MPD) had elevated catecholamines, but the men in the control group also had an
elevated catecholamine level that was not explained.
Placebo occlusal adjustment. Placebo occlusal
adjustment was used on 25 MPD patients with
improvement in 64%.2s This is given as scientific
540

centric

proof that occlusion is not involved in MPD. In a

previous report on 138 patients,16 it was found that
58% had bilateral palpable pain, which excludes them
from classification as MPD according to the original
definition of Laskin.29 Of those patients with unilateral
pain 9% had pain in the TM J itself (another exclusion
for MPD by Laskinz9), making a total of 67% of the
sampling. Eleven percent of the total group were
non-TMJ patients or had pain of medical origin. In
other words 22% of the sampling fulfilled the criteria of
MPD. It is invalid reasoning to apply to a whole group
of TMJ patients what seems to work in only 14% of
the entire cross section of craniomandibular pain
patients. Even on that basis, how do Laskin and
Greene propose to treat the other 36% who did not
improve with placebo occlusal adjustment?
Few dentists realize that MPD (as defined by
Laskinz9 its originator) is not synonymous with TMJ
dysfunction-pain. Furthermore, Laskin recognized that
if MPD is not treated early, it can. become secondarily involved with bilateral pain and/or pain in the
TM J itself.29 In the authors view MPD is a good term
if universally understood and applied correctly to early
TMJ patients who may respond to any reasonable
(irreversible) palliative program that treats only muscles. Treatment could include moist heat, soft diet,
limited opening, muscle relaxants, and occlusal splint
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Fig. 27. Centric relation and centric occlusion are identical.

Figs. 28 and 29. When both condyles are displaced posteriorly (posterior joint space,
P/S, reduced), it indicates a dvsfunctional centric relation. AJS = Anterior joint space.
AM = Auditory meatus.

therapy. A barometer to evaluate the prognosis would

be revealed in the history of the trigger mechanism
combined with information from the TM J radiographs
as related to the occlusion. Twenty-six percent of the
138 patients treatedt6 were initiated by stress while
24% were initiated by occlusal changes. In the latter
group it would be expected that MPD advances into
TM J dysfunction-pain syndrome. If the symptomatic
side has a dysfunctional centric relation (displaced
condyle or lack of correlation between the occlusion
and condylar position in the fossa), then the prognosis
is more grave. Anterior condylar displacement is usually more favorable to treat than posterior condylar
displacement because the displacement is in the direction of normal movement. The longer the patient has
the symptoms, even for as little as 6 to 8 weeks, the
more he or she will resist easy treatment. It should be
emphasized that not all patients start with MPD and
progress into TMJ dysfunction-pain if untreated. For
instance 76% of the patients had subjective pain in the
TMJ region at the first visit,16 which would immediately indicate secondary involvement or what is
termed TM J dysfunction-pain syndrome.
NEUROMUSCULAR
CRANIOMANDIBULAR

ROLE IN
PAIN

Muscle length. The myotatic stretch reflex is a

two-neuron reflex arc the function of which is to give
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proprioceptive information to the central nervous system concerning position and movement.30*31Both the
position of the mandible and maintenance of the
interocclusal space are controlled by the proprioceptivt
function of masticatory muscles.32When the interacclusal space is obliterated for an extended period of time,
the teeth tend to be intruded into the sockets, reestablishing the original vertical dimension of ocelusion.33
Ramfjord and Blankenship34 have shown irrefutable
evidence on monkeys in which the original vertical
dimension of oicclusion was almost reestablished within
36 months.
Vertical dimension and electromyqpq&ic
f~buscle activity. Paradoxically, a decrease in myographic
activity has been reported by several researchers when
the vertical dimension is increased slightly beyond the
interocclusal space.35-37This apparent conflict (intrusion of teeth is caused by increased muscle activity
rather than reduced muscle activity) is produced by the
fact that no long-term studies have been done to
determine the optimum length of time an increase in
vertical dimension can be used before the initial
decreasein myographic activity reverses itself and tooth
intrusion begins.
Proprioception
and occlusal poaoitid
sense.
Thilander38 demonstrated a loss of mandibular occlusal
positional sensory perception (patient could not find
habitual occlusion) when the TM Js were injected with
541

WEINBERG

Fig. 30. Centric relation and centric occlusion are identical.

Figs. 31 and 32. Right condyle is displaced posteriorly (reduced posterior joint space,
PJS) (Fig. 31), while left condyle is displaced superiorly with osteoarthritic changes
evident (Fig. 32). AJS = Anterior joint space. PJS = Posterior joint space. AM = Auditory
meatus.

a local anesthetic. As stated by Kawamura39: Whenever the condyle moves, sensory information is transmitted from the joint capsule to some of the trigeminal
motor neurones that innervate the jaw muscles. Others have emphasized the importance of the joint capsule
innervation (branches of the posterior deep temporal
and masseteric nerves)38-4and the pressoreceptors in
the periodontal membrane and oral mucosa.42s43
Thus,
positional sensory perception and occlusal stimuli are
finely monitored by proprioceptive reflexes from the
joints, muscles, periodontal membranes, and oral
mucosa.
Effect of occlusal disharmonies on the neuromuscular system. Overstimulation of the neuromuscular
system can result in muscle spasm. For example, in the
recent report of 138 patients with craniomandibular
pain, 54% were aware of clenching at the first interview visit.16 The cuspal relationships produce a constant stream of proprioceptive stimuli to position the
mandible correctly to avoid trauma and as a guide to
normal chewing movements and swallowing. When the
patients occlusion is uncomfortable, consciously or
unconsciously (exaggerated state of proprioceptive
stimulation), there is a tendency to clench. In addition,
if the occlusion produces condylar displacement, there
is a further increase in noxious proprioceptor input

542

into the neuromuscular system from the joints themselves.

Behavioral effect of stress on the neuromuscular
system. As stated previously, stress is not a direct
causative agent in craniomandibular pain.25 However,
stress can induce exaggerated temporal and masseteric
muscle response44;and in combination with the stressrelieving habit of clenching, the neuromuscular system
can be overwhelmed. For example, Christensen45 produced experimental TMJ pain by having dental students clench for 30 minutes. Of the patients previously
reported, 26% revealed that stress triggered the onset of
symptoms. I6 In summary, in most craniomandibular
pain patients, stress plays an important indirect role (to
a greater or lesser extent, depending on the individual
patient) that usually acts through clenching to overstimulate the proprioceptive system and/or through
condylar displacement.
EFFECT OF CONDYLAR
IN CRANIOMANDIBULAR

DISPLACEMENT
PAIN

Every joint has an optimum functional range of

movement beyond which intrajoint trauma will occur.
Anterior condylar displacement is less serious, usually
because the displacement is in the direction of normal
movement. Posterior condylar displacement by its very

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Fig. 33. Patient is maintaining centric relation position with posterior deflective
contact.
Fig. 34. Mandible slides directly into right lateral position with no anterior shift when
occlusal pressure is applied.
Figs. 35 and 36. Right condyle exhibited posterior displacement (reduced posterior joint
space, PJS),although degree of lateral movement should center condyle in fossa (Fig. 35).
Left condyle is observed to be almost in middle of fossa (slight posterior displacement)
(Fig. 36) when it should be displaced anteriorZy to permit lateral mandibular shift to
opposite side. This demonstrates a dysfunctional centric relation since occlusal displacement cannot be correlated with condylar displacement observed in TMJ radiographs.
A1.S= Anterior joint space. PI.5 = Posterior joint space. AM = Auditory meatus.
nature is dysfunctional and more difficult to treat.20,2
It represents posterior hyperextension
and most
often results in a disk derangement because the condyle
cannot maintain the normal disk-condyle relationship
as it is displaced posteriorly. There simply is not room
for the posterior thick portion of the disk and the
condyle in the posterior joint space of the fossa. This is
not anterior disk displacement, as the disk may remain
in its normal anatomic position. However, it is anterior relative to the posterior displaced condyle. As
soon as the condyle moves forward, there is a (reciprocal) click as the condyle moves back into its proper
relationship with the disk. On complete closure to the
intercuspal position, there is another (reciprocal)
click as the condyle moves beyond the posterior lip of
the disk.
Anterior disk dislocation. Anterior dislocation
occurs when the disk is unable to assume its normal
relationship with the condyle, even in protrusive movements. There should be an absence of reciprocal
clicking. According to Farrar46 only 5% of posterior

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displaced condyles, with confirmed anterior dislocated disks, require surgical procedures. The anterior
dislocated disk should be confirmed by arthrography.*
It is importam to point out that in both anterior
displaced and ainterior dislocated disks the etiology is
the posterior condylar displacement caused by the
occlusion. The exception would be the traumatically
induced disk displacement, which is subject to manipulative reduction as described by Farrar.4,
The effect of condylar displacement on the neuromuscular system. Posterior condylar displacement
produces a noxious stimulus to the proprioceptive
system because it is out of the normal range of motion
within the joim. The normal attachment apparatus of
the disk to the condyle is stretched or torn to permit this
separation. There is the possibility of pressure atrophy
on some of the synovial cells located in the posterior
portion of the joint that provide nourishment and
lubrication to the joint parts.
Many TM J patients acquire a pathologic swallowing pattern to prevent the posterior displacement of the

543

WEINBERG

condyles during swallowing. The tongue is placed

between the teeth to avoid the posterior condylar
displacement that would occur with occlusal contact.
Many TMJ patients, particularly with posterior condylar displacement, have unobserved pathologic swallowing patterns without necessarily demonstrating the
typical anterior open occlusion.
Anterior condylar displacement in TMJ patients
occurs approximately half as often as posterior displacement (27% to 53X). Its effect on the neuromuscular system is primarily muscular in the early stages
as finely coordinated muscle action is necessary to
position the mandible in the acquired centric occlusion.
Joint damage can be avoided if treated early by occlusal
adjustment procedures that will reposition the mandible posteriorly.48 Long-term anterior or posterior condylar displacement can result in pathologic remodeling. 20,48-50
Chronic capsulitis can occur with long-term
trismus and muscle spasm.
The relationship of condyle position to treatment
procedures. Only 18% to 27% of patients with acute
craniomandibular pain have anterior condylar displacement, and 4% to 11% have condylar concentriciMPD patients are most often found within these
ty. 15-17
groups since the dysfvnction is primarily muscular,
whereas posterior and superior condylar displacement
have intrajoint involvement, which is the result of the
condylar displacement. This differentiation is important to establish appropriate treatment because palliative procedures are most effective when there is no
intrajoint involvement. In posterior and superior condylar displacement, the treatment of preference is to
unlock the occlusion by selective occlusal adjustment,
and sometimes by condylar repositioning.20, 21F6r longterm anterior condylar displacement, the deflective
occlusal contacts should be eliminated.48 In these
patients palliative treatment procedures are adjunctive
in nature and in themselves usually will not achieve
complete remission of symptoms. Lateral transcranial
TM J radiographs are necessary to establish the differential diagnosis and treatment procedures.

A correlation was reported between condylar position in the fossa and TMJ dysfunction in over 320
patients, This observation suggests that a new definition of centric relation is indicated, a definition that
differentiates whether it is functional or dysfunctional.
The criterion is the correlation between the occlusal
findings and the condylar position in the fossa as
recorded by the lateral TMJ radiographs (when the
teeth are in maximum occlusion).
Stress response was found to be greater in males than
in females (in all vertebrates, including humans); therefore stress cannot be a direct cause of craniomandibular
pain since more women have the disorder. It was concluded that stress is an indirect contributing factor that
usually works through the medium of clenching. The
role of the neuromuscular mechanism in craniomandibular pain was discussed. Proprioception reflex activity
forms the basis for muscle length, mandibular positional sense,as well as masticatory function. Occlusal disharmonies increase noxious input to the neuromuscular
system, as well as stress-induced clenching, causing increasedmuscle activity and spasm-pain.
Condylar displacement also contributes to TMJ
dysfunction-pain, depending on its direction. Anterior
condylar displacement can initially affect the muscles
by inducing overfunctional response in the proprioceptive system. Posterior condylar displacement usually
results in an intrajoint response consisting of a disk
derangement, reciprocal clicking, possible anterior disk
dislocation, possible pathologic swallowing pattern,
and noxious stimulation to the proprioceptive system.
These factors contribute to subsequent trismus, muscle
spasm and pain, and long-term pathologic remodeling
of the joint. A detailed history is necessary to evaluate
the role of stress. The physical occlusal findings are
correlated with the condylar displacement observed in
the TMJ radiographs to diagnose and plan corrective
treatment.
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Kqmn/
wyurtlc 10
DR. LAWRENCE A. WEINBERG
57 w. 57rH ST.
hEw YCJKK, NY 10019

545