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Clicking or Snapping Jaws
T h o len a n d B a lye a t— C lickin g J a w s
I t would seem th at the small dosage of procaine-epinephrine as employed in local anesthetic solutions has no consistent re lation to the variations observed in pulse rate or blood pressure. If this is true, it would appear to follow that the operator employing local anesthetic solutions as used in the practice of dentistry need not fear th at any possible blood pressure or pulse rate changes occurring before, dur ing or after operation are caused by in jection of the anesthetic solutions per se. O n the other hand, the operator should be aw are of the possibility of alarming or serious reactions of the cir
873
culatory system in apprehensive, nervous persons that occur during dental oper ations performed under local anesthe sia. A skilful handling of the patient, minimizing his fear and pain, probably is of more importance in controling these circulatory reactions than the amount of procaine-epinephrine used. If more pro caine is necessary to produce adequate anesthesia, it should be employed without hesitation, because the assurance of a painless procedure is of more importance in preventing circulatory upsets than is the hypothetical toxic effect of an in creased anesthetic dose.
CLICKING OR SNAPPING JAWS By E. F. T H O L E N , M .D ., D .D .S., a n d F. S. B A LY EA T, M .D ., D.D.S., Los A ngeles, Calif.
A R E C E N T review of our cases of clicking temporomandibular joints interested us very much because it seemed a rather frequent complaint and, in many cases, caused much discomfort and annoyance. A search of the literature revealed few articles that shed much light on the subject. T h is may be due to the fact th at the joint is rarely subjected to exploratory operation and to the few recorded postmortem findings of the con dition. A few years ago, one of us (F . S. B.) sent a questionnaire to forty oral surgeons in an endeavor to get their viewpoints. T h e ir opinions and con clusions varied considerably. E T IO L O G Y
T here is a marked difference of opin ions as to the causes of this condition, and it is hard to substantiate any of the theories advanced. T h e answers to the Jour. A.D.A., May, 1934
questionnaire showed that the majority believe traum a to be the chief cause. T h e remainder thought arthritis, nervous habits of grinding the teeth and the pres ence of loose ligaments to be the principal cause. W e failed to find any predispos ing factors, such as age, sex or occupa tion, to have any bearing on the condi tion. O f the direct causes, we found that traum a was perhaps the most important factor. T h e history shows that many of these cases often begin months or years before any one is consulted regarding the case and, as a result, the patients often overlook any possible traum atic factor. T h e common causes are blows on the chin and strain on the joint from having the mouth opened excessively wide or for a prolonged period of time, as in dental operations and in difficult extractions. Biting unsuspectingly on large or hard
874
T h e Jou rn al of the A m erican D e n t a l Association
substances such as fruit pits may cause the condition; also violent sneezing or coughing. W e have had several cases that followed changes in occlusion after the insertion of dental bridges or partial plates and in which cures resulted when the w earing of them was discontinued. In most of the cases which are caused by traum a, we believe the snapping or clicking is due to an abnormal slipping of the cartilage, which has been torn loose or been damaged by some violent action of the pterygoid externus. In most cases, the cartilage is intact and in one piece, but several cases have been re ported where the disk was found to be split into several pieces. REPORT OF CASES
L. R., a white man, aged 24, fell and struck his chin on the edge of a swimming pool. T his caused a fracture of the neck of the right condyloid process and painful click ing in the left joint. T he jaw w as immobilized by interdental w iring of the upper and lower teeth for six weeks. On removal of the ap pliances, it w as found that the clicking had disappeared and the patient had good oc clusion of the teeth, with good jaw action. C. J. B., a middle aged white woman, had all the posterior teeth extracted in January, 1927. T he extractions were difficult. P artial plates were inserted a few months later but were never satisfactory, although many ad justments w ere made. She came in in October, 1927, with a complaint of cracking and dis tress in the left joint of three months’ dura-, tion. On examination, there w as a distinct coarse click on opening and closing the jaw in the left joint. New plates and restriction of jaw action were suggested. In 1931, the patient returned because of an acute dentoalveolar abscess and, on being questioned regarding the clicking, she stated that she had not w orn her plates since her previous visit and that she had no more trouble in the joint. T h is w as verified by examination. F. S. B., in 1930, unknowingly bit on some hard substance. T his w as immediately fol lowed by severe pain in the right temporo m andibular joint, which lasted for several days. T he soreness gradually disappeared, but an audible and palpable clicking fol
lowed, lasting for three months. On restric tion of the jaw action, the clicking entirely disappeared.
In our cases, arthritis was the second most im portant etiologic factor. W e be lieve that cases associated w ith arthritis usually have a fine grating or crepitation in contradistinction to the usual coarse single click. T w o of our arthritic cases showed definite joint changes in the roentgenogram. T h e diagnosis in these was based upon the history, the local signs and the finding of arthritic joints elsewhere in the body. R. R., a white man, aged 41, came in in October, 1931, complaining of pain and crepitus of the right tem porom andibular joint and restricted jaw action. About January, 1930, he noticed clicking in the right temporo m andibular joint w ith no pain and from no apparent cause. One y ear later, the clicking disappeared w ith no treatm ent. Progressive soreness in the joint and back of the ear fol lowed, with some limiting of jaw motion, the jaw deviating to the right. T he patient had had no treatm ent except that, three months prior to his coming in, a physician injected the joint area w ith magnesium sul phate, with no relief. T he family history was negative. T he patient had always been in excellent health. Examination revealed that the lower jaw deviated from 6 to 7 mm. to the right and opened 2.5 cm. in the midline. T h ere was a fine crepitus in each temporomandibular joint, but more noticeable on the right. The occlusion w as good. T here w as no dental reconstructive work. Roentgenograms of both temporomandibular joints showed a joint space of 5 mm. on the right as compared to 2.5 mm. on the left and the joint surface of the right condyle was definitely roughened as compared w ith the left. In 1920, C. D. B., a boy, aged 13, came to the office complaining of crepitus in the right joint. A t the age of 11, he had an attack of scarlet fever which was complicated by severe bilateral otitis media. Four or five months after the infection, he could not open his mouth fully and noticed fine crepitus in the right joint. W e did not see him again for ten years. He returned in 1930, complaining of ankylosis of the right temporomandibular
T h o len and B a lyea t— C lickin g J a w s joint. Examination revealed a bony ankylosis of the right joint. A rthroplasty was per formed, with a good result. M rs. J. G., aged 40, came into the office complaining of pain and crepitus in the right joint of five or six months’ duration. From the history, no cause could be found except the fact th at there was some trouble in the knees which she had been told was arthritis by a competent physician. Examination revealed numerous fine g rat ings or crackings in the right joint. T he roentgenograms revealed the right joint space to be 1 mm. narrow er than the left.
875
caused changes in the joint accompanied by snapping. T h e chief symptoms and signs of this condition are snapping, popping, grating or clicking. These vary in character and degree, but, in the majority of cases, there is only a single coarse click or snap on opening the jaw wide. T his is easily felt and is often audible. A certain percent age of the cases have pain and soreness about the joint area or in the area of dis tribution of the auriculotemporal nerve. From the questionnaire, it was found In many of our cases, the patients that 15 per cent believed that arthritis learned th at the pain and soreness was was the sole cause of all cases, 50 per cent aggravated by opening the mouth wide, believed that arthritis was the cause in thereby bringing on a snapping sensation. a small percentage of cases, 10 per cent M any complained of restricted jaw ac believed that arthritis was never the tion, which w as again due to having cause and 25 per cent did not express an learned that wide opening exaggerated opinion. the symptoms. W e thought this was par T h e third factor to be considered un ticularly true in arthritic cases. der etiology is loose ligaments. In some T h e treatm ent of our cases has been of our cases, the condyles were more along conservative lines. In the early prominent on motion than was normal. cases, we advise the patient to use only W e believe w ith W akely1 that, in the soft foods and to rest the jaw as much older snapping cases, there is a relaxa as possible. W e make a careful study of tion and stretching pf the articular cap the occlusion, and if we find that this sule, ligaments and possibly muscles has been changed by recent dental work, which tend tow ard a vicious circle. W e we advise correction. If the condition doubt that looseness of the ligaments is causes much annoyance, we apply ortho the cause of this condition, but believe dontia bands w ith lugs to the bicuspids rather th at they result from traum a or and first molars and direct the patient to an effusion in the joint. apply rubber bands to the lugs and there In answer to the questionnaire, one by restrict the jaw action. In tw o cases oral surgeon stated his belief that loose in which the symptoms were especially ligaments was the sole cause in all cases; annoying, we preceded the use of ortho 40 per cent believed that loose ligaments dontia bands by w iring the teeth in oc were seen in old cases and associated w ith clusion. As an aid to the foregoing treat other loose periarticular structures, and ment, we advise the application of dia 35 per cent did not express an opinion; thermy to the joints. while 15 per cent thought that a few cases If arthritis is the cause, all foci of in were caused by looseness of the ligaments. fection should be removed and general W e have seen no case in which a gen measures used to improve the health. eral disease such as syphilis or tuberculosis Local treatm ent to the joint, such as 1. Wakeley, C. P. G .: Lancet, 2:543-545 potassium iodide ionization and deep heat, may be helpful. (Sept. 14) 1929.
876
T h e Jo u rn a l of the A m erican D e n t a l Association
In new cases w ith sudden onset and pain or partial dislocation a symptom, Pringle2 and also W akeley advise at tem pting to replace the cartilage. T h e method used is to apply continued pres sure behind the condyle w ith the mouth open for several minutes, then -slowly close the mouth. Several attempts may be necessary. Annandale,8 in 1887, advised suturing the cartilage to its proper position. T h is method never gained adherents and has been abandoned in favor of excision of the cartilage. In 1918, Blake4 emphasized the difficulties of operating on this joint. W e fully agree w ith him and believe that the joint should not be opened until all conservative methods have been tried. Excision of the cartilage has been done with reported good results by A shhurst,6 Ivy, W akeley1 and Sir H olburt W aring.0 2. Pringle, J. H .: Brit. J. Surg., 6:385 (Jan.) 1919. 3. A nnandale, Thom as: Lancet, Feb. 26, 1887, p. 411. 4. Blake, J. B .: Ann. Surg., 68:141 (Aug.) 1918. 5. Ashhurst, A. P. C.: Ann. Surg., 73:712 (June) 1921. 6. W aring, H olburt: Proc. Roy. Soc. Med., May, 1930, p. 940.
T h e last two mentioned report that a transient paralysis of some branches of the facial nerve occurred, which cleared up spontaneously. In cases in which rest of the part and building up of the patient does not give relief, G. M . Dorrance advises the pro duction of traum atic arthritis. T his he does by irritating the surface of the con dyle w ith a sharp instrument. T h e ob ject is to more or less fix the disk and contract the joint. CONCLUSIONS
1. W e believe that the majority of these cases are due to trauma. 2. A rthritis is the cause in a small per centage of cases. 3. T h e symptoms are mainly due to displacement or pathologic changes in the interarticular disk. 4. T h e treatm ent should be conserva tive, preventive measures, restriction of jaw action and diathermy being used. If this does not give relief, operative procedures should be tried. 5. T h e operation of choice is the re moval of the disk. 1136 W est Sixth Street.
ESSENTIAL FACTORS IN TH E TR IAL BASE AND TH E TRIAL DENTURE* By V IC T O R H . SEARS, D .D .S., N ew Y ork City
H E trial base is entirely suitable for trial only if it possesses the same character of surface, the same adap tation, the same border extension and the
T
*Read a t the Seventy-Fifth Annual Session of the American Dental Association in con junction w ith the Chicago Centennial Dental Congress, Aug. 10, 1933.
Jour. A.D.A., May, 1934
same buccal and labial thickness as the proposed denture base. These are qual ities that are generally recognized by careful prosthetists. In addition, there is another which may be incorporated, the quality of transparency. T here are two reasons that a trial base should be transparent: th at any imper
I t would seem th at the small dosage of procaine-epinephrine as employed in local anesthetic solutions has no consistent re lation to the variations observed in pulse rate or blood pressure. If this is true, it would appear to follow that the operator employing local anesthetic solutions as used in the practice of dentistry need not fear th at any possible blood pressure or pulse rate changes occurring before, dur ing or after operation are caused by in jection of the anesthetic solutions per se. O n the other hand, the operator should be aw are of the possibility of alarming or serious reactions of the cir
873
culatory system in apprehensive, nervous persons that occur during dental oper ations performed under local anesthe sia. A skilful handling of the patient, minimizing his fear and pain, probably is of more importance in controling these circulatory reactions than the amount of procaine-epinephrine used. If more pro caine is necessary to produce adequate anesthesia, it should be employed without hesitation, because the assurance of a painless procedure is of more importance in preventing circulatory upsets than is the hypothetical toxic effect of an in creased anesthetic dose.
CLICKING OR SNAPPING JAWS By E. F. T H O L E N , M .D ., D .D .S., a n d F. S. B A LY EA T, M .D ., D.D.S., Los A ngeles, Calif.
A R E C E N T review of our cases of clicking temporomandibular joints interested us very much because it seemed a rather frequent complaint and, in many cases, caused much discomfort and annoyance. A search of the literature revealed few articles that shed much light on the subject. T h is may be due to the fact th at the joint is rarely subjected to exploratory operation and to the few recorded postmortem findings of the con dition. A few years ago, one of us (F . S. B.) sent a questionnaire to forty oral surgeons in an endeavor to get their viewpoints. T h e ir opinions and con clusions varied considerably. E T IO L O G Y
T here is a marked difference of opin ions as to the causes of this condition, and it is hard to substantiate any of the theories advanced. T h e answers to the Jour. A.D.A., May, 1934
questionnaire showed that the majority believe traum a to be the chief cause. T h e remainder thought arthritis, nervous habits of grinding the teeth and the pres ence of loose ligaments to be the principal cause. W e failed to find any predispos ing factors, such as age, sex or occupa tion, to have any bearing on the condi tion. O f the direct causes, we found that traum a was perhaps the most important factor. T h e history shows that many of these cases often begin months or years before any one is consulted regarding the case and, as a result, the patients often overlook any possible traum atic factor. T h e common causes are blows on the chin and strain on the joint from having the mouth opened excessively wide or for a prolonged period of time, as in dental operations and in difficult extractions. Biting unsuspectingly on large or hard
874
T h e Jou rn al of the A m erican D e n t a l Association
substances such as fruit pits may cause the condition; also violent sneezing or coughing. W e have had several cases that followed changes in occlusion after the insertion of dental bridges or partial plates and in which cures resulted when the w earing of them was discontinued. In most of the cases which are caused by traum a, we believe the snapping or clicking is due to an abnormal slipping of the cartilage, which has been torn loose or been damaged by some violent action of the pterygoid externus. In most cases, the cartilage is intact and in one piece, but several cases have been re ported where the disk was found to be split into several pieces. REPORT OF CASES
L. R., a white man, aged 24, fell and struck his chin on the edge of a swimming pool. T his caused a fracture of the neck of the right condyloid process and painful click ing in the left joint. T he jaw w as immobilized by interdental w iring of the upper and lower teeth for six weeks. On removal of the ap pliances, it w as found that the clicking had disappeared and the patient had good oc clusion of the teeth, with good jaw action. C. J. B., a middle aged white woman, had all the posterior teeth extracted in January, 1927. T he extractions were difficult. P artial plates were inserted a few months later but were never satisfactory, although many ad justments w ere made. She came in in October, 1927, with a complaint of cracking and dis tress in the left joint of three months’ dura-, tion. On examination, there w as a distinct coarse click on opening and closing the jaw in the left joint. New plates and restriction of jaw action were suggested. In 1931, the patient returned because of an acute dentoalveolar abscess and, on being questioned regarding the clicking, she stated that she had not w orn her plates since her previous visit and that she had no more trouble in the joint. T h is w as verified by examination. F. S. B., in 1930, unknowingly bit on some hard substance. T his w as immediately fol lowed by severe pain in the right temporo m andibular joint, which lasted for several days. T he soreness gradually disappeared, but an audible and palpable clicking fol
lowed, lasting for three months. On restric tion of the jaw action, the clicking entirely disappeared.
In our cases, arthritis was the second most im portant etiologic factor. W e be lieve that cases associated w ith arthritis usually have a fine grating or crepitation in contradistinction to the usual coarse single click. T w o of our arthritic cases showed definite joint changes in the roentgenogram. T h e diagnosis in these was based upon the history, the local signs and the finding of arthritic joints elsewhere in the body. R. R., a white man, aged 41, came in in October, 1931, complaining of pain and crepitus of the right tem porom andibular joint and restricted jaw action. About January, 1930, he noticed clicking in the right temporo m andibular joint w ith no pain and from no apparent cause. One y ear later, the clicking disappeared w ith no treatm ent. Progressive soreness in the joint and back of the ear fol lowed, with some limiting of jaw motion, the jaw deviating to the right. T he patient had had no treatm ent except that, three months prior to his coming in, a physician injected the joint area w ith magnesium sul phate, with no relief. T he family history was negative. T he patient had always been in excellent health. Examination revealed that the lower jaw deviated from 6 to 7 mm. to the right and opened 2.5 cm. in the midline. T h ere was a fine crepitus in each temporomandibular joint, but more noticeable on the right. The occlusion w as good. T here w as no dental reconstructive work. Roentgenograms of both temporomandibular joints showed a joint space of 5 mm. on the right as compared to 2.5 mm. on the left and the joint surface of the right condyle was definitely roughened as compared w ith the left. In 1920, C. D. B., a boy, aged 13, came to the office complaining of crepitus in the right joint. A t the age of 11, he had an attack of scarlet fever which was complicated by severe bilateral otitis media. Four or five months after the infection, he could not open his mouth fully and noticed fine crepitus in the right joint. W e did not see him again for ten years. He returned in 1930, complaining of ankylosis of the right temporomandibular
T h o len and B a lyea t— C lickin g J a w s joint. Examination revealed a bony ankylosis of the right joint. A rthroplasty was per formed, with a good result. M rs. J. G., aged 40, came into the office complaining of pain and crepitus in the right joint of five or six months’ duration. From the history, no cause could be found except the fact th at there was some trouble in the knees which she had been told was arthritis by a competent physician. Examination revealed numerous fine g rat ings or crackings in the right joint. T he roentgenograms revealed the right joint space to be 1 mm. narrow er than the left.
875
caused changes in the joint accompanied by snapping. T h e chief symptoms and signs of this condition are snapping, popping, grating or clicking. These vary in character and degree, but, in the majority of cases, there is only a single coarse click or snap on opening the jaw wide. T his is easily felt and is often audible. A certain percent age of the cases have pain and soreness about the joint area or in the area of dis tribution of the auriculotemporal nerve. From the questionnaire, it was found In many of our cases, the patients that 15 per cent believed that arthritis learned th at the pain and soreness was was the sole cause of all cases, 50 per cent aggravated by opening the mouth wide, believed that arthritis was the cause in thereby bringing on a snapping sensation. a small percentage of cases, 10 per cent M any complained of restricted jaw ac believed that arthritis was never the tion, which w as again due to having cause and 25 per cent did not express an learned that wide opening exaggerated opinion. the symptoms. W e thought this was par T h e third factor to be considered un ticularly true in arthritic cases. der etiology is loose ligaments. In some T h e treatm ent of our cases has been of our cases, the condyles were more along conservative lines. In the early prominent on motion than was normal. cases, we advise the patient to use only W e believe w ith W akely1 that, in the soft foods and to rest the jaw as much older snapping cases, there is a relaxa as possible. W e make a careful study of tion and stretching pf the articular cap the occlusion, and if we find that this sule, ligaments and possibly muscles has been changed by recent dental work, which tend tow ard a vicious circle. W e we advise correction. If the condition doubt that looseness of the ligaments is causes much annoyance, we apply ortho the cause of this condition, but believe dontia bands w ith lugs to the bicuspids rather th at they result from traum a or and first molars and direct the patient to an effusion in the joint. apply rubber bands to the lugs and there In answer to the questionnaire, one by restrict the jaw action. In tw o cases oral surgeon stated his belief that loose in which the symptoms were especially ligaments was the sole cause in all cases; annoying, we preceded the use of ortho 40 per cent believed that loose ligaments dontia bands by w iring the teeth in oc were seen in old cases and associated w ith clusion. As an aid to the foregoing treat other loose periarticular structures, and ment, we advise the application of dia 35 per cent did not express an opinion; thermy to the joints. while 15 per cent thought that a few cases If arthritis is the cause, all foci of in were caused by looseness of the ligaments. fection should be removed and general W e have seen no case in which a gen measures used to improve the health. eral disease such as syphilis or tuberculosis Local treatm ent to the joint, such as 1. Wakeley, C. P. G .: Lancet, 2:543-545 potassium iodide ionization and deep heat, may be helpful. (Sept. 14) 1929.
876
T h e Jo u rn a l of the A m erican D e n t a l Association
In new cases w ith sudden onset and pain or partial dislocation a symptom, Pringle2 and also W akeley advise at tem pting to replace the cartilage. T h e method used is to apply continued pres sure behind the condyle w ith the mouth open for several minutes, then -slowly close the mouth. Several attempts may be necessary. Annandale,8 in 1887, advised suturing the cartilage to its proper position. T h is method never gained adherents and has been abandoned in favor of excision of the cartilage. In 1918, Blake4 emphasized the difficulties of operating on this joint. W e fully agree w ith him and believe that the joint should not be opened until all conservative methods have been tried. Excision of the cartilage has been done with reported good results by A shhurst,6 Ivy, W akeley1 and Sir H olburt W aring.0 2. Pringle, J. H .: Brit. J. Surg., 6:385 (Jan.) 1919. 3. A nnandale, Thom as: Lancet, Feb. 26, 1887, p. 411. 4. Blake, J. B .: Ann. Surg., 68:141 (Aug.) 1918. 5. Ashhurst, A. P. C.: Ann. Surg., 73:712 (June) 1921. 6. W aring, H olburt: Proc. Roy. Soc. Med., May, 1930, p. 940.
T h e last two mentioned report that a transient paralysis of some branches of the facial nerve occurred, which cleared up spontaneously. In cases in which rest of the part and building up of the patient does not give relief, G. M . Dorrance advises the pro duction of traum atic arthritis. T his he does by irritating the surface of the con dyle w ith a sharp instrument. T h e ob ject is to more or less fix the disk and contract the joint. CONCLUSIONS
1. W e believe that the majority of these cases are due to trauma. 2. A rthritis is the cause in a small per centage of cases. 3. T h e symptoms are mainly due to displacement or pathologic changes in the interarticular disk. 4. T h e treatm ent should be conserva tive, preventive measures, restriction of jaw action and diathermy being used. If this does not give relief, operative procedures should be tried. 5. T h e operation of choice is the re moval of the disk. 1136 W est Sixth Street.
ESSENTIAL FACTORS IN TH E TR IAL BASE AND TH E TRIAL DENTURE* By V IC T O R H . SEARS, D .D .S., N ew Y ork City
H E trial base is entirely suitable for trial only if it possesses the same character of surface, the same adap tation, the same border extension and the
T
*Read a t the Seventy-Fifth Annual Session of the American Dental Association in con junction w ith the Chicago Centennial Dental Congress, Aug. 10, 1933.
Jour. A.D.A., May, 1934
same buccal and labial thickness as the proposed denture base. These are qual ities that are generally recognized by careful prosthetists. In addition, there is another which may be incorporated, the quality of transparency. T here are two reasons that a trial base should be transparent: th at any imper