J Dent Res 77(2): 361-365, February, 1998
Natural Course of Untreated Symptomatic
Temporomandibular Joint Disc Displacement
without Reduction
K. Kurital*, P.-L. Westesson2, H. Yuasa3, M. Toyama3, J. Machidal, and N. Ogil
'The Second Department of Oral and Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori, Chikusaku, Nagoya,
464, Japan; 2Department of Radiology, University of Rochester, New York; and 3Department of Oral and Maxillofacial Radiology, School of
Dentistry, Aichi-Gakuin University; *corresponding author
Abstract. In some patients with disc displacement without
reduction, the symptoms of pain and decreased range of
motion have been observed to resolve spontaneously over
time without treatment. The natural history of this
condition, however, is not well-understood. Thus, to study
the natural course of disc displacement without reduction,
we followed 40 patients without treatment for a period of
2.5 years. The diagnosis was established by history and
physical examination and confirmed with magnetic
resonance (MR) imaging. 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. MR evidence of osteoarthritis and
advanced stages of internal derangement at the initial
evaluation was associated with a poor prognosis. The result
of this prospective cohort study indicated that approxi-
mately 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. This knowledge should be valuable for
the treatment planning and evaluation of prognosis of
patients with non-reducing symptomatic disc displacement.
Key words: temporomandibular joint, disc displacement
without reduction, internal derangement, osteoarthritis,
natural course.
Received August 26, 1996; Last Revision July 23, 1997;
Accepted August 1, 1997
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Introduction
In clinical work, we have observed that some patients with
symptomatic temporomandibular joint (TMJ) disc
displacement without reduction spontaneously improved
over time without treatment. This indicates that disc
displacement without reduction may have a favorable
natural prognosis in some patients. However, the natural
course of this condition is not well-documented (Toller,
1973; Rasmussen, 1983; Nickerson and Boering, 1989; Lundh
et al., 1992), and further knowledge about the natural course
of symptomatic disc displacement without reduction would
be of the utmost value for treatment planning and the
evaluation of prognoses. The purpose of this study was to
document the natural course of untreated symptomatic disc
displacement without reduction over a 2.5-year period.
Subjects
This study was based on 40 patients (38 females and two males)
ranging in age from 13 to 68 years with a mean age of 35 years.
The patients were selected from a consecutive series of 280 new
TMJ patients who were seen in the TMJ/ TMD Clinic in the
Department of Oral and Maxillofacial Surgery at our Institution
during a one-year period. This clinic is the primary referral
center for temporomandibular disorder patients at our
institution, since both conservative and surgical treatments are
offered. There is no other TMJ/TMD Clinic at our institution.
Thus, all TMJ/TMD (temporomandibular disorders) patients at
our institution are referred to this clinic, not just patients with a
need for surgical treatment. The population referred to our
clinic should, therefore, be comparable with what is seen in
TMJ/TMD clinics at other institutions.
We classify the degree of TMJ dysfunction into four
categories-no dysfunction, slight dysfunction, moderate
dysfunction, or severe dysfunction-as described below and in
Table 1. One hundred and seventy-five of the 280 patients had
severe to moderate TMJ dysfunction on one or both sides. The
361
362 Kurita et al.
Table 1. Classification of TMJ dysfunction
Degree of TMJ Maximal Mouth Maximum Value on Any
Dysfunctiona Opening (mm) of Four Visual Analog Scalesb
No . 40 0
Slight 35 - 39 1 - 33
Moderate 30 - 34 34 - 66
Severe < 29 67 - 100
a Degree of TMJ dysfunction was based on the worst value of
maximal mouth opening and any of four visual analog scales.
b Four visual analog scales were used to evaluate pain at rest,
pain with mandibular motion, pain on chewing, and inter-
ference with daily life (Price et al., 1983).
other 105 patients had slight or no dysfunction. The 175 patients
with severe or moderate TMJ dysfunction were referred for
bilateral MR imaging. Fifty-two of the 175 patients had
symptomatic unilateral disc displacement without reduction,
and these 52 patients were requested to participate in the study.
Five patients refused because they wanted to be treated. Two
other patients were excluded because their symptoms had
improved when they came back for a complete enrollment
examination for the study, and they were no longer in the
moderate or severe dysfunctional category. Thus, 45 patients
with disc displacement without reduction, who had moderate
or severe TMJ dysfunction, were enrolled in the study. This
study was approved by the Committee on Human Research in
the Department of Oral and Maxillofacial Surgery at Aichi-
Gakuin University. Informed consent was obtained from all the
participants. No patient incentives were used. Nineteen of the
45 patients were referred to our clinic by general dentists or
physicians, and the remaining 26 came directly to the clinic.
During the 2.5-year follow-up period, four patients
developed symptoms on the contralateral side, which made it
difficult for changes in the symptoms on the original side to be
assessed. These four patients were therefore excluded from the
statistical analysis. One other patient had requested treatment
for symptoms from the other side during the 2.5-year
observation period. Treatment included an occlusal splint and
may have affected the side under investigation, so this patient
was excluded. Thus, the final material for analysis consisted of
40 patients of whom 14 had moderate and 26 had severe TMJ
dysfunction at the initiation of the study
Methods
Clinical evaluation
Physical examination was performed as previously described
(Eriksson and Westesson, 1983). Maximal mouth opening was
measured to the nearest millimeter. Pain at rest, pain with
mandibular motion, as well as pain on chewing were evaluated
by the patient, who placed marks on 100-mm visual analog
scales. Interference with daily life was recorded by the patients
on a 100-mm visual analog scale. The worst rating on any of
these four visual analog scales was used in determining the
degree of TMJ dysfunction as described below and in Table 1.
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J Dent Res 77(2) 1998
Table 2. Changes in TMJ dysfunction over a 2.5-year period
Initial Registration 2.5-year Follow-up
Degree of TMJ Number of Number of Assessment
Dysfunction Patients (%) Patients (%)
No 0 ( 0) 17(42.5) improved
Slight 0 ( 0) 13 (32.5) improved
14 (35) 4 (10) not improved
Moderate
Severe 26 (65) 6 (15)a not improved
Total 40 (100) 40 (100)
a Four patients had required treatment.
Imaging
Bilateral magnetic resonance (MR) images were obtained on a
1.0 Tesla MR Imager with bilateral 10 x 10 cm surface coils (SMF
Shimadzu Corp., Tokyo, Japan). Images were obtained in the
oblique sagittal plane at the closed and opened mouth
positions. The degree of angulation of the imaging plane was
determined on an axial scout image. Time of repetition was
1000 msec, time of echo was 20 msec, slice thickness 4 mm, and
field-of-view 20 cm. Two excitations were used. The scanning
time was 4 min and 28 sec, with a matrix of 256 x 256.
Classification
The intent of the study was to follow each patient's natural
course without intervening treatment. Therefore, all patients
were reassured about the benign nature and favorable
prognosis of their condition. The patients in this study were not
treated. They did not receive physical therapy, behavioral
therapy, splints, or surgery, with the exception of four patients
who requested treatment during the study. We did not control
the use of over-the-counter analgesics. In these four patients, the
symptoms were such that the requested treatment was
reasonable, and the treatment was delivered. All of these four
patients had persistent and severe dysfunction when treatment
was initiated at 2, 4, 15, and 21 months into the study. The
treatment consisted of non-steroid anti-inflammatory drugs,
physical therapy, a bite splint, and arthroscopic surgery,
respectively.
The degree of TMJ dysfunction was classified into four
groups as described in Table 1. Four visual analog scales were
used for assessment of (1) pain at rest, (2) pain with mandibular
motion, (3) pain on chewing, and (4) the interference with daily
life. The highest value on any of these four scales, together with
the amount of limitation of mouth opening, was used to classify
the patient's degree of TMJ dysfunction into: no dysfunction,
slight dysfunction, moderate dysfunction, or severe
dysfunction, as described in Table 1. If the maximum mouth
opening and the visual analog scales resulted in a different
degree of TMJ dysfunction, the most severe classification was
noted. The same classification was used both at the initial and at
the follow-up examinations at 2.5 years. At the end of the 2.5-
year period, the natural course of the condition was classified as
complete resolution, decreased symptoms, or no improvement.
J Dent Res 77(2) 1998 Natural Course of Symptomatic TMJ Disc Displacement
Table 3. Changes in TMJ dysfunction based on original presentation
Initial Degree Degree of TMJ Dysfunction
of TMJ Dysfunction Number of Patients at 2.5-year Follow-up
no
Moderate 14 slight
moderate
severe
subtotal
no
Severe 26 slight
moderate
severe
subtotal
Total 40
a Four patients had required treatment.
The patients remaining in the moderate or severe TMJ
dysfunctional group at the follow-up were classified as no
improvement. Those who had gone down to slight or no TMJ
dysfunction were classified as improved. The Wilkes staging
system (Wilkes, 1989, 1991) was also used to classify the
patients at the beginning of the study.
Correlation between initial clinical characteristics
and final outcome
To understand what initial characteristics were associated with
a poor vs. a favorable prognosis, we analyzed the outcome
relative to the observations at the initial examination. We used
the following variables in this analysis: maximal mouth
opening, pain at rest, pain with mandibular motion, pain on
chewing, degree of interference with daily life, duration of TMJ
symptoms, duration of locking, age, molar support on the
symptomatic side, molar support on the asymptomatic side,
disc configuration, and osteoarthritic changes on MR images
and Wilkes stage of internal derangement (Wilkes, 1989,1991).
To determine the length of time of locking, we asked all
patients about the initial onset of difficulties in opening their
mouths. The number of months from the onset of difficulties of
mouth opening to the initial examination was regarded as the
duration of locking. Concerning molar support, we counted the
contact between one or several molars as molar support. If there
were no molars that occluded with another molar on the same
side, this was considered as no molar support. Disc
configuration and osteoarthritic changes were diagnosed with
MR imaging, and disc configuration was classified as biconcave
or deformed, according to a previously described criterion
(Tasaki and Westesson, 1993). Osteoarthritic changes were
diagnosed in the presence of erosion and/or osteophyte or
substantial flattening of the condyle or temporal component,
according to the previously described criteria (Tasaki and
Westesson, 1993). Behavioral and psychosocial factors were not
evaluated in this study.
Statistical analysis
The findings were analyzed statistically by means of Student's t
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363
Number of Patients (%) Assessment
5 (36) improved
5 (36) improved
3 (21) not improved
1 ( 7) not improved
14 (100)
12 (46) improved
8 (31) improved
1 ( 4) not improved
5 ( 19)a not improved
26 (100)
test, the Mann-Whitney U-test for comparison of medians, Chi-
square tests for assessing observed frequency in 2 x 2 and 2 x 3
contingency tables, and Fisher's exact probability test
(SAS/STAT). A probability value of less than 0.05 was
considered statistically significant.
Results
At the end of the 2.5-year follow-up period, 17 patients
(42.5%) were asymptomatic, 13 (32.5%) had improved, and
10 (25%) continued to be symptomatic or had requested
treatment. Four additional patients had developed contra-
lateral symptoms. The distribution of the patients according
to the degree of TMJ dysfunction in the beginning and at the
end of study is shown in Table 2. At the initial examination,
65% of the patients had severe dysfunction, and 35% had
moderate. At the end of the study, 15% had severe
dysfunction or had required treatment, 10% had moderate,
33% had slight dysfunction, and 43% had no symptoms.
There was no difference in the outcome when analyzed
with respect to the initial degree of dysfunction (Table 3).
Thus, the patients with moderate dysfunction improved
with the same frequency as those with severe dysfunction at
the initial presentation.
At the initial presentation, 15 patients showed MR
evidence of osteoarthritis of the TMJ, whereas the remaining
25 patients showed no such changes. Of the 15 patients with
osteoarthritic changes, eight (53%) had improved, and seven
(47%) remained unchanged. Of the 25 patients without
evidence of osteoarthritis, 22 (88%) patients improved, and
three (12%) did not improve. This difference was statistically
significant, indicating that those with osteoarthritic changes
had a poorer prognosis than those without such changes.
The stage of internal derangement (Wilkes, 1989, 1991) at the
initial presentation showed a strong correlation to the
outcome. Thus, of those in stage III, 88% improved; of those
in stage IV, 67% improved, whereas only 33% of the patients
in Stage V improved (Table 4). There were no other
statistically significant associations between the outcome
and the initial characteristics.
364 Kurita et al.
Table 4. Natural course over 2.5 years relative to Wilkes Stage
at initial presentationab
Wilkes Stage Improved Not Improved
3 22 (88%) 3 (12%)
4 6 (67%) 3 (33%)
5 2 (33%) 4 (67%)
Total 30 (75%) 10 (25%)
a Number: cases 3 x 2 contingency table.
bx2 = 8.14 (S); p = 0.017; degree of freedom = 2.
Discussion
This study of the natural course of symptomatic disc
displacement without reduction showed a great variation of
symptomatology at the end of the 2.5-year study. The results
indicate that approximately 40% of the patients will be
spontaneously asymptomatic, one-third will have decreased
symptoms, and approximately one-quarter will not show
any improvement.
The Wilkes classification (Wilkes, 1989, 1991), which is
based on both clinical and radiographic observation, seems
to be the best predictor of the outcome. Thus, 67% of the
patients in Wilkes' stage V showed no improvement,
whereas 88% of those patients in Wilkes' stage III improved
during the follow-up period. This implies that the
combination of clinical and radiographic observations is the
best way to determine the prognosis. Other single
observations at the initial presentation, as outlined in Table
4, did not seem to be of strong value in the determination of
the prognosis. The presence of osteoarthritic changes on MR
images at the initial presentation was also found to be
associated with a poor outcome. The presence of
radiographic changes is a part of Wilkes' classification, and
this observation indicates that those with a more advanced
stage have a poorer prognosis. No reliability studies of the
Wilkes staging system for internal derangement have been
published.
An earlier report on the one-year natural course of disc
displacement without reduction (Lundh et al., 1992) reported
28% pain-free, 36% improved, and 36% unchanged at one-
year follow-up. These earlier observations are in accordance
with the findings of this study, and indicate that most of the
improvement will occur during the first year. This should be
valuable information for those planning treatment of these
patients.
We were in constant contact with the patients during the
2.5-year study period to ensure that they did not receive
treatment from other clinics. Interim follow-ups were also
performed over the 2.5-year period. The results of these
interim follow-ups were not included in the results, because
the time interval could not be standardized during the study
period. Some patients were followed closer than others, and
the overall goal of the study was to see what happens to this
condition over a relatively long period of time.
The study was based on the observations of 40 patients.
We think that the observations are fairly representative of
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J Dent Res 77(2) 1998
those patients presenting with moderate to severe TMJ pain
and dysfunctions due to disc displacement without
reduction. All patients at our institution with this symptom
Total complex were seen in our department during this study. We
used MR imaging to examine all patients who had moderate
25 (100%) to severe dysfunction, since past experience has indicated
9 (100%) that a clinical diagnosis is not accurate for determining the
6 (100%) status of the joint (Paesani et al., 1992). Only patients with
40 (100%) unilateral symptoms were included in this study, because
we believed that it was easier to evaluate the alterations of
symptoms if only one side was involved. Four patients
developed symptoms in the contralateral joint during the
study. We excluded these patients from statistical analysis
because we consider contralateral joint symptoms to be of a
different origin than the symptoms from the initially
symptomatic joint. This, however, does not exclude the
possibility that there might be a common etiology, and it is
also possible that the disease in the initially symptomatic
joint may have led to problems in the contralateral joint. If
the four patients who developed symptoms in the
contralateral joint had been included in the analysis, 15 out
of 45 patients (33%) would have been classified as not
improved instead of 10 out of 40 (25%).
The statistical analysis of the predictors of outcome based
on the initial variables did not reveal any single variable to
be the strong prognostic indicator. This may be the result of
too small a sample size. However, none of the variables,
other than degenerative changes on MR imaging, was close
to a statistical significance, It seemed that a combination of
variables such as those included in the Wilkes staging
system was necessary if any predictor of clinical value was
to identified. Even if one or several parameters turned out to
be of some prognostic value in the material of 50 or 100
patients, this would be of relatively limited value in the
individual patient if statistical significance could not be
shown on a group of 40. For this reason, we think that the
Wilkes staging system is the most practical way of
predicting outcome at this time.
In conclusion, this study has shown that about three-
quarters of patients with moderate to severe TMJ
dysfunction-associated disc displacement without reduction
will improve without treatment over a 2.5-year period.
About 25% will not improve and will probably need
treatment. The classification according to Wilkes indicates
that those patients with stage V have a worse prognosis than
those with stages IV and III. This indicates that Wilkes'
classification should be a valuable tool for the evaluation of
prognosis.
Acknowledgment
This study was financially supported by the Department of
Oral and Maxillofacial Surgery, Aichi-Gakuin University.
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