LETTERS TO THE EDITOR

Muscle contraction and disk displacement

To the editor:
Loughner et al. 1 (Oral Surg Oral Med Oral Pathol
Oral Radiol 1996;82:139-44) embrace the concept
that disk displacement of the temporomandibular
joint is the result of contraction of muscles attached
to the disk. The appeal of this concept is that it is easy
to imagine anterior displacement of the disk by contraction of the lateral pterygoid muscle. A weakness
of the concept is there is no evidence that muscles attached to the disk actually cause displacement.
Another problem is there are no muscle attachments
to the disk that could explain the occasional pure medial or lateral displacement. Our observation that the
disk often moves posteriorly and superiorly toward a
reduced position when joint space is increased by the
extra-articular operation of modified condylotomy, is
also difficult to reconcile with the muscle contraction
theory. We recently proposed a different hypothesis
for disk displacement 2 that tries to account for what
is now known about joint anatomy and disk behavior
with internal derangement and osteoarthrosis. This
hypothesis suggests that the disk is mechanically
maintained in a displaced position because of loss of
joint space as a result of growth of subchondral bone
and thickening of the posterior band of the disk. Associated changes in surface contour appear to cause
the disk to act like a wedge. Several observations
support the hypothesis. Loss of joint space, especially
in the lateral part of the glenoid fossa, and thickening
of the disk are commonly seen during arthrotomy and
also have been reported with arthroscopy. 3 Another
common observation during arthrotomy for repositioning of the disk is that loading the condyle after the
disk is reduced frequently results in displacement of
the disk again, similar to a watermelon seed being
displaced under pressure between opposed fingertips.
The concept of a disk acting like a wedge also
explains how medial and lateral displacements can
occur. It seems time to abandon the concept that
muscles attached to the disk play a role in disk displacement and to develop hypotheses that better fit
current observations.

H. David Hall, DMD, MD

Vanderbilt University School of Medicine
Nashville, Tennessee 37232
REFERENCES
1. Loughner BA, Gremillion HA, Larkin LH, Mahan PE, Watson RE. Muscle attachment to the lateral aspect of the artic-

ular disk of human temporomandibular joint. Oral Surg Oral

Med Oral Pathol Oral Radiol Endod 1996;82:139-44.
2. Werther JR, Hall HD, Gibbs SJ. Disk position before and after modified condylotomy in 80 symptomatic temporomandibular joints. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1995;79:668-79.
3. Moses JJ. Lateral impingement syndrome and endaural surgical technique. Oral Maxillofac Surg Clin North Am
1989;1:165-83.

In reply:
We agree with Dr. Hall that there is no proof that
muscles attached to the temporomandibular joint disk
cause disk displacement. To date no definitive mechanism(s) have been identified that explain this commonly seen phenomenon. We disagree with the
statement "there are no muscles attachments to the
disk that could explain the occasional pure medial or
lateral displacement." On the one hand, as cited in
our article, Myers 1 has described fibers of the deep
masseter muscle that attach to the anterior-lateral
corner of the disk. Pure lateral displacement has been
reported to be extremely rare. Our study 2 failed to
identify deep masseter muscle attachment in any of
the specimens. On the other hand, we observed in all
specimens that the most superior fibers of the superior belly of the lateral pterygoid muscle attach to the
anterior-medial margin of the disk, especially the inferior surface of the anterior margin. At wide openi n g with the condyles translated approximately 12
m m forward the angulation of the lateral pterygoid
fibers would approximate a 75 degree angle to the
midsagittal plane. The pull of these muscle fibers in
a medial direction at wide opening could serve to
medially displace the disk.
The concept that the disk moves back onto the
condyle in the modified condylotomy procedure may
be erroneous. It is plausible that the condyle moves
forward to relocate into the concavity of the normally
shaped disk. We have observed the development of an
anterior open bite after a modified condylotomy as the
condyle/disk assembly moved into a more superior
position in the glenoid fossae after removal of intermaxillary fixation. Furthermore, the idea that the disk
relocates after modified condylotomy in no way explains the mechanism of discal displacement. Dr.
Hall's hypothesis regarding the mechanical mechanisms serving to maintain the displaced position of
the disk is certainly plausible. Alteration in the morphology of the disk, once displaced, has been recognized for many years. However, it does not explain
the initial cause of displacement. It is important to
differentiate between initial displacement of the disk