Journal of Dentistry, 11, No. 4. 1983, pp.

346-355 Printed in Great Britain

An analysis of temporomandibular joint

sounds*
D. M. Watt, PhD, FDS RCS(Edin)
P. M. McPhee, ASCT
Department of Restorative Dentistry (Prosthodontics) University of Edinburgh

ABSTRACT
Six thousand nine hundred and nineteen temporomandibular joint sounds made by 110 patients in 2200 opening-
and-closing cycles were classified and analysed. On average there were three TMJ sounds in each cycle. Fifty-
nine per cent of the sounds occurred on opening and 4 1 per cent on closing. Only 27 per cent of the sounds were
clicks and 73 per cent were crepitus. The average duration of hard TMJ clicks, excluding background crepitus,
was 1Oms and the average duration of soft clicks was 14 ms. Eighty-six per cent of all the sounds (clicks and
crepitus) were soft and 14 per cent were hard. Ninety-four of the patients were studied more closely: 17 had only
opening clicks, 7 had only closing clicks and 43 had reciprocal sounds; 28 had groups of 20 consecutive sounds,
but in only 5 did they occur in both opening and closing. The significance of these findings is discussed.

CLASSIFICATION
Three years ago a paper was published on temporomandibular joint sounds and a method of
classification was proposed (Watt, 1980). The sounds were placed in near, middle or wide
classes depending on the position of the jaws at the time the sounds occurred. This spatial
classification is more useful than the more common temporal classification (early, middle, late)
for the reasons stated in the legend of Fig. 1. The sounds were divided into two types, clicks and
crepitus, which were then designated hard or soft according to their quality. It was also noted
whether the sounds occurred when the jaws were opening or closing. These divisions of the
sounds generated 24 different classes, which could easily be recorded by placing a tick in the
appropriate box in the table (Fig. 2).

MATERIAL
In the present study the classificationwas used to record and study the variations in type and
position of 69 19 temporomandibular joint sounds made by 110 patients in 2200 opening-and-
closing cycles (Table I). Ninety-four of the patients were studied more closely to try to find
answers to four questions.

METHODS
The sounds were recorded on tape at 38.1 cm/s and played back at 9.5 cm/s through a
Mingograph recorder with a paper speed of 10 cm/s. To assess the position ofthe jaws when the
joint sounds occurred, the Mingograph record, between the separation noise at the start of
opening and the next sound of occlusion of the teeth, was divided into two equal parts, opening
and closing. Each half was then subdivided into three equal parts representing the near, middle
and wide positions in the opening and closing cycles (Fig. 1).
In general clinical practice gnathosonic recording equipment is unnecessary and the position
of the sounds is defined as follows: near sounds occur between the position of occlusion and one

*Presented at the Ammal Conference of the British Society for the Study of Prosthetic Dentistry at Holloway
College, London, March 1983.
 347
Watt and McPhee: Temporomandibular joint sounds

Fig. 1. Gnathosonic records illustrate the method of classifying

temporomandibular joint sounds. In the top trace the ‘early’, ‘middle’ and ‘late’
classification of TMJ sounds has the disadvantage that early opening sounds
occur when the jaws are near each other, but early closing sounds occur when
the jaws are wide apart. For this reason ‘near,’ ‘middle’ and ‘wide’ classes are
preferred. The gnathosonic record between the separation noise (S) and the
occlusal sound (0) is divided equally into opening and closing parts, each of
which is sub-divided into three equal sections: near, middle and wide. In the
upper trace the double opening sound (solid arrows) is classified as ‘middle’
and ‘wide’. In the lower trace the sounds occurring at the borders between near
and middle in opening and closing (open arrows) are both classified as ‘middle’
since their greatest parts lie within the middle sections. The near closing
sounds present no problem of classification.

Name.. . . . . . . . . . . ..I.......... No.. . . . . . . . . . . . .

TEMPOROMANDIBULAR JOINT SOUNDS

I TYPE
HARD I

Fig. 2. Temporomandibular joint sounds are classified by placing a tick in the

appropriate box in the classification table. The ticks together with the number
‘2’ represent a double hard click and hard crepitus. which occur when the jaws
are near each other in the opening cycle.
348 Journal of Dentistry, Vol. 1 1/No. 4

Fig. 3. In clinical practice neartemporomandibularjointsounds occur between

the position of occlusion and one finger’s breadth of jaw opening. Middle
sounds occur between oneand two fingers’breadth and wide sounds between
two and three fingers’ breadth of opening.

Table /. Distribution of 6919 temporomandibular joint sounds made by 1 10

patients in 2200 opening-and-closing cycles

Temporomandibolar joint sounds (type)

Position
Soft Hard

Click Crepitus Click Crepitus

Near
Opening 399 1053 41 134
Closing 314 959 24 127
Middle
Opening 443 886 105 151
Closing 117 712 14 93
Wide
Opening 182 535 69 85
Closing 113 275 24 64

linger’s breadth opening of the jaws, middle sounds between one and two lingers’ breadth
opening, and wide sounds between two and three fingers’ breadth opening (Fig. 3).
A stereostethoscope is used to listen to the sounds, which are then recorded in the
classification table. A rubber stamp was made of the table shown in Fig. 2 and for each patient
a series of 20 tables was stamped to correspond to the number of opening-and-closing cycles
studied. Each temporomandibular joint sound that occurred during a cycle was classified by
placing a tick in the appropriate box in the table (Fig. 4). The ticks in all the tables for the series
were then counted and the totals were entered in the appropriate spaces in the final table. A
brief inspection of this table showed which sounds were constant (appearing in every opening-
and-closing cycle in the same place) and which sounds were variable either in position or type.
In the example in Fig. 4 a short series of six cycles is shown. The middle opening and near
closing sounds are typical of reciprocal clicking. It is interesting to note that two opening clicks
 349
Watt and McPhee: Temporomandibular joint sounds

TM J SOUNDS

TOTAL NUMBER of CLICKS CL CREPITUS

Fig. 4. A classification grid is printed with a rubber stamp for each opening-
and-closing cycle. In the example above the sounds occurring in only six cycles
are classified. The bottom table summarizes the series. The middle opening
and near closing clicks are the only ones to occur in every cycle. The near
opening click is missing only in the sixth cycle, when it is replaced by a wide
opening click. The occurrence and position of crepitus is very variable from
cycle to cycle.
350 Journal of Dentistry, Vol. ll/No. 4

A I
MnF.C. 18-6-82 -

Occlusal
1. M.J. sound
1st Closure sound 1

10th Closure i_

20th Closure I,

Mrs F.C. 7-9-82 Occlusal

Sound

1 st. Closure

10th Closure 4

20th Closure

Fig. 5. The temporomandibular joint sounds (arrowed) of this patient changed

in amplitude and position with successive opening and closing cycles. In the
top three traces (made in June) the sounds reduced in amplitude and changed
from wide closing to middle closing by the twentieth cycle. In the record made
about three months later the amplitude was further reduced, but with
successive closures the sound changed position in the opposite direction from
middle to wide. This suggests that the sound is a surface effect related to
changes in muscle activity.

occur in all six cycles, but in the sixth they are at middle and wide positions instead of at near
and middle positions as in the other cycles. All the closing clicks occur in the near position and
the crepitus varies considerably in occurrence and position.
It is difficult to analyse temporomandibular joint sounds because of their variability. They
vary between patients and also between different openings and closings of the jaws in the same
patient and they vary with time. Sometimes the sounds disappear altogether, only to return
later. Fig. 5 shows how the temporomandibularjoint sounds of a patient varied with successive
Wan and McPhee: Temporomandibular joint sounds 351

Tab/e //. Percentage distribution of 6919 temporomandibular joint sounds

between the various classes

Classification Percentage

Near sounds (opening and closing) 44.0

Middle sounds (opening and closing) 36.0 100
Wide sounds (opening and closing) 20.0 I

Clicks (soft and hard) 27.0

100
Crepitus (soft and hard) 73.0 I
Soft sounds (clicks and crepitus) 86.5
100
Hard sounds (clicks and crepitus) 13.5 1
Opening sounds (near, middle and wide) 59.0
100
Closing sounds (near, middle and wide) 41.0

opening-and-closing cycles and also between the visits at which the recordings were made. The
upper three traces show the temporomandibular joint sound on the first, tenth and twentieth
closures of the patient’s jaws recorded in June. It can be seen that the sound reduced in
amplitude and changed its position from middle closing to near closing by the twentieth closure.
A recording made of the same patient three months later shows a further reduction in the
amplitude of the sound and a change in its position in the opposite direction, from near to
middle, by the twentieth closure of the jaws. Altered joint morphology cannot account for these
rapid changes and it seems reasonable to assume that differences in muscle function are chiefly
responsible. The speed of closure of the jaws was constant in this series. It therefore seems
likely that the sounds may have been caused by changes in the relationship of the disc to the
condyle and glenoid fossa brought about by uncoordinated activity of the lateral pterygoid
muscles.

RESULTS
On average there were three temporomandibular joint sounds in each opening-and-closing
cycle. The average duration of 100 hard clicks (excluding background crepitus) was 10mm.
The average duration of 100 soft clicks was 14 ms. The percentage distribution of the 6919
sounds between the different classes is shown in Table II.
The findings did not differ widely from those of a previous study (Watt, 1981) of a smaller
sample of sounds. Thirty-six per cent of the sounds were middle sounds and there were more
than twice as many near sounds as wide sounds. This may have been because some patients
had limitation of movement and could not open their jaws wide enough to produce middle or
wide sounds. Patients who cannot open the mouth wide enough to admit one finger are
classified as having severe limitation of mandibular movement. If only two fingers can be
admitted the limitation is moderate, and slight if opening can admit between two and three
lingers. A jaw opening of three fingers or more is considered to be normal.
The percentage distribution of near, middle and wide clicks was very similar to that of
‘early’, ‘middle’ and ‘late’ clicks in a study by Duxbury (1976), whose figures were 45.1 per
cent early, 32.3 per cent middle, and 22.6 per cent late (on opening).
In the present study 59 per cent of the sounds occurred on opening, but only 4 1 per cent on
closing of the jaws. Soft sounds (‘popping’ clicks or ‘rubbing’ crepitus) were much more
352 Journal of Dentistry, Vol. 1 l/No. 4

Table Ill. Clicks

Distribution of Distribution of
17 patients with 7 patients with
only opening clicks only closing clicks
Position of click of TMJ of TMJ

Near and middle 2 patients -

Near, middle and wide 6 patients 1 patient
Middle and wide 3 patients -
Near and wide 2 patients -

Near only 1 patient 3 patients

Middle only 1 patient 2 patients
Wide only 2 patients 1 patient

common (86.5 per cent) than hard sounds (cracking clicks and grating crepitus) (135 per
cent). The hard sounds were of such a nature that they clearly indicated arthritic change. The
soft sounds were probably caused by surface separation and disc impaction through muscle
incoordination. Clicks were less common (27 per cent) than crepitus (73 per cent). We
attributed clicks to sudden movements of the disc or condyles, and crepitus to synovial fluid
and surface effects.
The temporomandibular joint sounds of 94 of the patients were studied more closely inorder
to find answers to the following questions:

1. Do most of the patients with mid!lle opening clicks have near closing clicks or
crepitus?
The answer was ‘Yes’. Forty-six of the 94 patients had middle opening clicks; of these, 43 also
had near closing sounds (clicks or crepitus). This reciprocal clicking was the commonest
combination of joint sounds in the sample of patients. Although we used the accepted term
‘reciprocal clicking’, it should be noted that the closing sound was often crepitus rather than
clicking. Nine patients had near opening and near closing sounds.

2. Inpatients with opening clicks only, and no closing sounds, do the clicks occur in a
particular pattern of near, middle or wide positions?
Seventeen of the 94 patients had only opening clicks, distributed as shown in Table III. At first
no pattern was evident.

3. Do patients with only closing clicks have a pattern of near, middle or wide
positions?
We found that 7 of the 94 patients had only closing clicks, distributed as shown in Table III. At
first glance this also did not seem to present any pattern, but when we compared the percentage
distribution of sounds occurring in more than one position on opening with those occurring in
more than one position on closing, an interesting difference could be seen (Fig. 6).
It would seem that when sounds are heard only during opening of the jaws they frequently
occur in more than one position, but sounds that occur only on closing usually occupy single
positions. We conclude that in only about a quarter of the sample clicks occurred only on
opening (18 per cent) or only on closing (7.4 per cent), but the small size of the sample makes us
hesitate to draw firm conclusions about their positions at present.
Watt and McPhee: Temporomandibular joint sounds 353

NON- RECIPROCAL TM J
CLICKS
Oat several positions

[7at only one position

1ooqb.3

opening closmg
clicks clicks

Fig. 6. In 77 per cent of the 14 patients with only

opening TMJ clicks, the clicks occurred in more
than one position (e.g. near and middle, or middle
and wide, or near, middle and wide). In only 1 (14
per cent) of the 7 patients with only closing clicks
did the clicks occur in more than 1 position; the
remainder (86 per cent) had clicks in only one
position (near or middle or wide).

We compared the case notes of six randomly selected patients with only middle opening
sounds with the case notes of the seven patients who had closing clicks only. There were no
obvious clinical characteristics that were not common to both groups. None suffered acute pain
and in both groups the main complaint was a dull ache. All of the patients were relieved of their
symptoms after one or two appointments and in this limited sample it seemed that the treatment
of clicks occurring only on opening or only on closing presented few problems.

4. How many patients had sounds occurring at the same positions in all 20 opening-and-
closing cycles?
Only 28 (30 per cent) ofthe 94 patients had groups of 20 consecutive sounds. In the majority of
these the 20 sounds occurred in only one position (near, middle or wide), but 5 patients with
crepitus had 20 sounds occurring in more than one position, distributed as shown in
Table IV.
354 Journal of Dentistry, Vol. 1 l/No. 4

Table IV Crepitus

Patients
Position and type of sounds ho.)

Near and middle opening crepitus 2

Near, middle and wide opening
crepitus 2
Near closing crepitus and near
opening crepitus 1

DISCUSSION
In the group of 28 patients with groups of 20 consecutive sounds, the occurrence of sounds in
every cycle seemed to suggest a permanent change in joint morphology, but if that was the case
we might have expected to see the same number of closing sounds as opening sounds. This was
not found, except in the one patient with near opening and near closing crepitus. Most of the
sounds occurred in the opening cycle. The presence of 20 consecutive opening sounds and the
absence of 20 consecutive closing sounds might be explained by wedging of the anterior band of
the disc between the eminentia articularis and the condyle on opening. The sounds produced by
the sudden stopping of the condyle when wedging occurred would be accompanied by trauma
that would cause reflex contraction of the lateral pterygoid muscle. This would release the
‘wedge’ by pulling the disc forward and allow the jaw to open further. On closing, with the disc
in the anterior position, no impaction would occur and the closing cycle would be silent. The
observatrion by McNamara (1973) that in Mucaca muhttu the upper head of the lateral
pterygoid contracts on closing would, if applicable to man, further ensure that no wedging
occurred in that part of the cycle.
The findings of our study call into question the current hypothesis that reciprocal clicking is
caused by the condyle lying behind the disc and jumping onto it on opening of the jaws and then
jumping off the disc on closure. We do not doubt that the condyle can sometimes lie behind the
disc following severe trauma, but it seems unlikely that this could occur in the absence of such
trauma. As there were more opening sounds than closing sounds, some other hypothesis is
necessary and should be sought.
From our study we were able to identify four groups of patients according to the types and
positions of their temporomandibular joint clicks:
1. Forty-three patients who had ‘reciprocal clicking’ with middle opening clicks and near
closing clicks or crepitus. This was the largest group.
2. Nine patients who had near opening and near closing sounds which were either clicks or
crepitus.
3. Seventeen patients who had opening clicks only.
4. Seven patients who had closing clicks only.
The remaining patients had a large variety of TMJ sounds occurring in different positions. It
will be necessary to analyse a larger sample of patients to determine if there are other
identifiable groups.
Only 30 per cent of the 94 patients had 20 consecutive sounds in the same positions during
the opening or closing of the jaws. In the majority of these the sounds occurred in only one
position.
Watt and McPhee: Temporomandibular joint sounds 355

By means ofthe classification we are beginning to detect patterns ofjoint sounds. The system
readily lends itself to computer analysis and it is hoped that groups of sounds can be matched
with groups of symptoms in the future to give us a better understanding of this complex
subject.

REFERENCES
Duxbury J. T. (1976) Studies of Mandibular Movement and Temporomandibular Joint Sounds.
MSc thesis, University of Manchester.
McNamara J. A. (1973) The independent functions ofthe two heads of the lateral pterygoid muscle.
Am. J. Anat. 138, 197.
Watt D. M. (1980) Temporomandibular joint sounds. J. Dent. 8, 119.
Watt D. M. (1981) Gnathosonic Diagnosis and Occlusal Dynamics. New York, Praeger
Publishers.