Clicking is a common occurrence in the jaw joint that does not always occur with pain. It occurs when the posterior ligament of the temporomandibular joint disc, the articular disc, stretches. And the disc migrates anteriorly, disrupting the smooth process of condylar translation. Normal jaw opening relies on a combination of jaw rotation and full anterior translation. When the disc is in its normal anatomical position, it sits on top of the condyle, and the disc travels along with that condyle during the translation component of the movement. Both sides moving equally produces straight jaw opening. If one of the discs has fallen forward, it is going to change the order of muscle activation, and the brain will start to compensate for the disruption of the jaw mechanics. One condyle behind a disc might stay behind while the other one translates forward. Once it clicks back into place, then that's going to change the alignment of the jaw. We may see a deviation or deflection off to the side toward where that disc is restricting it, and then with a click, it may pull it back into that midline alignment once again. So I'm going to demonstrate the disc mechanics using this model. Once again, here's the lateral condyle of the jaw, and this little red component directly above it is representing the articular disc. This is the normal anatomical position. Jaw rotation occurs underneath that disc, so there is no noise because that disc is protecting. In order to translate all the way forward, that disc needs to travel along with it, and then it should settle back into place. But if that disc, like already happened, has started to migrate forward, that might block that condyle from being able to come forward at the right time. And then we will see a deviation or deflection off toward that side. In order to get back into the right position, to get back underneath the disc, you will hear a click or feel a click. Sometimes it's even loud enough to be a snap. And then if it stays forward, you'll hear another click as it falls back off of the disc into its original position. When it's deflecting to the side and then it clicks, you may see it snap back to that midline in order to complete the full opening. And then you may have a click as you close back up again as well. People can get very upset about jaw clicking. But unless there is inflammation or pain, it is not considered a pathological condition. The jaw is designed to adapt to changes. And for many people, clicking will not disrupt their function or cause disruptions in their daily life. There is no reason to treat clicking alone, aside from considering it as a symptom of joint hypermobility and counseling patients to watch their habits to make sure that it doesn't progress. The body will adjust to the condition. And much of the time, it adjusts without difficulty. One of our goals of treatment, if somebody has an anteriorly displaced disc, is to help that posterior ligament to thicken up, almost to form a callus and to form what we call a pseudodisc, where it protects that condyle during opening and closing, almost as if the disc never migrated forward in the first place. We used to think that clicking would progress to cause jaw locking and or arthritis if left untreated. But an observational study published by Dr. Eric Schiffman and colleagues in 2017 demonstrated that after eight years imaging of 789 joints with a disc disorder, showed 76% actually stayed stable with no change in their disc condition. 14% had a progression of disc displacement. But 10% actually reversed and showed improvement. Therefore, the profession has decided that invasive irreversible interventions to treat clicking are not supported and should not be considered as the first line of treatment. That being said, it is important to assess for clicking, especially if you are considering using a mandibular advancement device to treat somebody with sleep apnea. You don't want to exacerbate that clicking. And with the right application of exercises and interventions, assessing whether it's joint versus muscle pain, you can set that patient up for success for them to be able to proceed with oral appliance therapy. So if your patient has clicking and you are considering using oral appliance therapy, you want to first assess for pain, limited range of motion, and jaw movement as discussed in the screening video. If any of those factors are present, the patient could have a flare of their pain once they start using the appliance. And they may benefit from some of the following exercises. So first of all, we're going to say that our patient deflects off to the side. So go ahead and open your jaw, yep, and close. And then push it off to the side, either way there you go, yep, and then close. And then one more time, off to the side. So she might click on there, actually she did click on her right side when she did that. If her jaw is pulled forward, that could exacerbate that problem. So we want to teach her how to open and close her jaw straight without getting that clicking. So first, put your fingers up in front of your ears on both sides, okay, and then I want you to jut your chin forward. This isn't the exercise, but feel how it's moving under your fingertips, yep, and can you feel that click on the right-hand side, yep, as it's going off to the side. Okay, so now we want to take that away. So this time I'm going to have you keep your right hand up in front of your ear, put that tongue on the roof of the mouth, and then place your left hand in front of your chin. Think about opening down and back, good, and then close only in that range where that tongue stays up, and that clicking should go away, because we are not letting it come forward like before. This will balance out those muscles responsible for causing the clicking, and it will straighten out your jaw opening. And I want you to do this five or six times, six times throughout the day, twice in the morning, afternoon, evening, whenever you think about it. Now for jaw stretching, we need to make sure that they are only stretching within their straight range and not allowing that click and deviation to the side to occur. So I do this by combining that tongue up protected opening with our finger, our knuckle stretch. So in order to make sure that we don't irritate that click, we're going to take the exercise you just practiced with your tongue up and feel over your joint there. You're going to drop your jaw open, then take your hand with your one knuckle and slide it in between your teeth. Now you can relax your tongue, add that pressure up, and let your jaw hang. Good. Okay, now take your hand out. We're going to do it to the next level, to a two-fingertip stretch. So feel both sides with your tongue up, drop it open where it doesn't click. Good. Now take your hand with your two fingertips, point it toward yourself. Good. Add that pressure upward. If you get any clicking while you're stretching, back off and go back to the previous level. You can take your hand out and then you're going to hold it for three breaths at each point.

jaw joint clicking

temporomandibular joint

jaw movement

muscle activation

treatment options