TMJ Clicking: Understanding the Evidence, Imaging, Causes, Natural Course, and Standard of Care

Clinical Exam: TMJ Clicking

TMJ clicking is identified during a clinical examination by placing a finger lightly over the lateral pole of the joint or by using a stethoscope to listen for a clear, reproducible click as the jaw opens. The jaw may deviate slightly toward the affected side before straightening once the disc reduces. Although the clinical exam reliably detects joint noise, its diagnostic accuracy for confirming disc displacement with reduction is limited. MRI-validated studies report a sensitivity of approximately 44 percent and a specificity of approximately 51 percent, meaning clinical findings alone cannot confirm disc position.

MRI: TMJ Clicking

MRI is the gold standard for diagnosing disc displacement with reduction because it visualizes soft-tissue anatomy directly. In the closed-mouth image, the disc is positioned anterior to the condyle. In the open-mouth image, the disc returns to its normal position on top of the condyle, confirming disc reduction. MRI also identifies features such as joint effusion, adhesions, perforation, and degenerative changes, providing the most complete assessment of TMJ soft-tissue structure and function.

CBCT: TMJ Clicking

CBCT evaluates only the bony structure of the TMJ and cannot visualize the disc. When the disc is displaced anteriorly, the condyle often appears posterior and superior in the glenoid fossa, a finding that may support—but cannot diagnose—disc displacement. CBCT is valuable for ruling out fractures, erosions, osteophytes, ankylosis, and other bony abnormalities that may mimic symptoms or contribute to joint dysfunction. Confirmation of disc position still requires MRI.

Natural History of TMJ Clicking

Most TMJ clicking is stable over time and does not progress to painful or limiting conditions. Long-term MRI studies show that about seventy-six percent of joints with disc displacement with reduction show no structural change. Roughly ten percent demonstrate improvement, and clicking may diminish or resolve. Approximately fourteen percent show structural progression, although symptoms rarely develop. Clinical studies similarly show that about seventy-one percent of clicking remains unchanged and about twenty-nine percent resolves spontaneously. Only about nine percent of patients develop locking, and those individuals typically exhibit baseline pain or increased joint-loading risk factors. Most cases of clicking do not require treatment and do not progress to degeneration.

Causes of TMJ Clicking

TMJ clicking occurs when an anteriorly displaced disc snaps back onto the condyle during jaw opening. Laxity or elongation of the discal ligaments allows the disc to shift forward. When supporting tissues weaken, overload contributes to disc displacement. Microtrauma includes clenching, bruxism, gum chewing, forward-head posture, sleep parafunction, unilateral chewing, and reduced molar support. Macrotrauma includes chin impact, whiplash injury, sports-related blows, and facial trauma. General joint hypermobility and connective-tissue laxity increase susceptibility.

Standard of Care of TMJ Clicking

Painless TMJ clicking does not require treatment. According to AAOP and DC/TMD guidelines, joint noise alone is benign, common, and usually stable over time. Education, reassurance, and reduction of joint load are first-line management strategies. Patients are encouraged to avoid wide opening, gum chewing, hard foods, and daytime clenching. Conservative treatment such as self-care instruction, short-term stabilization splints, or physical therapy is reserved for cases with pain, limited opening, or locking. Irreversible procedures such as occlusal adjustment, orthodontics, or TMJ surgery are not indicated for isolated clicking.

Summary

TMJ clicking occurs when an anteriorly displaced disc reduces during jaw opening. The clinical exam identifies the click, but MRI is required to confirm disc position. CBCT evaluates bone only and cannot diagnose disc displacement. Most cases remain stable or improve, with only a small percentage progressing to locking. Factors such as ligament laxity, microtrauma, macrotrauma, and joint hypermobility contribute to disc displacement. Standard care for painless clicking is reassurance and load reduction, with treatment indicated only when pain, limited opening, or locking develops. Individuals experiencing TMJ clicking are welcome to schedule a comprehensive assessment at Orthodontics Victoria.

Snoring, Mouth Breathing, and Sleep Apnea: Orthodontic Considerations

Snoring and mouth breathing are common signs of sleep-disordered breathing (SDB) or obstructive sleep apnea (OSA), conditions that may affect a child’s behavior, physical growth, and cognitive performance—or contribute to long-term health risks in adults. Our office provides early screening and coordinates care with your physician for referral to a sleep physician or ENT specialist, who may order a sleep study (polysomnography), the gold standard for diagnosis.

Pediatric OSA

In children, untreated OSA has been associated with restless sleep, hyperactivity, poor academic performance, and delayed growth. Risk factors that may contribute to airway restriction include enlarged adenoids (pharyngeal tonsils), lingual tonsils (faucial region), nasal congestion, sinus inflammation, a narrow upper jaw (palate), or a retruded lower jaw.

Orthodontic treatment may include palatal expansion to support nasal airflow and orthopedic guidance of the mandible to promote jaw development. Myofunctional therapy complements these treatments by retraining tongue posture, improving lip seal, and enhancing cervical and masticatory muscle coordination for more efficient breathing and swallowing.

Adult OSA

In adults, untreated OSA is associated with elevated risk of hypertension, cardiovascular disease, type 2 diabetes, and cognitive decline. When CPAP is not tolerated, a sleep physician may prescribe a custom oral appliance. Orthodontic treatment may help align the teeth and jaws to improve appliance fit and effectiveness.

Oral appliances are provided under the direction of a sleep physician. We collaborate with speech-language pathologists and orofacial myofunctional therapists when needed to support airway function and treatment success.

Please contact our office to learn more about airway-focused orthodontic screening and coordinated care for sleep-disordered breathing.

The Hidden Link Between Dental Crowding and Black Triangles: Why Early Orthodontic Treatment Matters

Introduction

Black triangles, also known as open gingival embrasures, are small triangular gaps that appear between teeth near the gumline. These spaces occur when the gum tissue (interdental papilla) does not fully fill the area between adjacent teeth. While they may seem like a minor cosmetic issue, black triangles can contribute to food impaction, difficulty cleaning between teeth, increased plaque buildup, and, in some cases, changes in speech. Contrary to popular belief, black triangles are not caused by braces or aligners. Rather, they often become visible after orthodontic treatment reveals areas where bone or gum tissue did not develop normally due to crowding or spacing. Early orthodontic intervention during growth can help prevent these voids by supporting proper bone formation and tissue health.

Why Do Black Triangles Form?

One of the most important anatomical factors in black triangle formation is the vertical distance between the contact point of two teeth and the crest of the alveolar bone. Research shows that if this distance is less than or equal to 5 millimeters, the gum tissue usually fills the space. However, when the distance exceeds 5 millimeters, the likelihood of full papilla fill drops significantly. At 6 millimeters, papilla presence drops to about 56%, and at 7 millimeters, it drops to only 27% (Tarnow, Magner, & Fletcher, 1992). Tooth shape is another major factor. Teeth that are narrower at the gumline and wider toward the biting surface (triangular-shaped teeth) have smaller contact areas and a longer vertical distance to the bone, increasing the risk of black triangle formation. Additionally, when roots are not properly aligned or are spaced too far apart—particularly after orthodontic treatment—the space between them may be too wide for the gum tissue to bridge.

How Dental Crowding and Spacing Contribute

Both dental crowding and spacing can negatively affect the development of the interdental alveolar bone and the papilla. In the case of crowding, overlapping teeth prevent the normal formation of bone between roots. Once the teeth are aligned, these previously compressed areas are exposed, and the lack of interdental bone becomes visible as a black triangle. In the case of spacing, prolonged gaps between teeth can lead to underdevelopment or flattening of the alveolar bone in the space. Because bone responds to physical forces and adjacent tooth contact, teeth that remain widely spaced for long periods may fail to stimulate normal vertical bone growth between them. Instead of the bone forming a pointed crest, it may remain flat or low. This becomes especially important during growth. If interdental spaces persist in a growing child or adolescent, the opportunity for bone to form in those areas may be lost. Even after orthodontic closure of the spaces later in life, the papilla may not regenerate because the supporting bone is absent or deficient. As a result, black triangles may remain despite excellent alignment (Glickman & Carranza, 2021; Montevecchi et al., 2011).

Additional Risk Factors

Several other factors may increase the risk of black triangle formation: thin or delicate gum tissue (thin periodontal biotype), which is less capable of regenerating or maintaining its shape; periodontal disease, which can destroy bone and lead to tissue loss; natural aging, which results in gum recession and decreased tissue volume; systemic health conditions, such as diabetes or autoimmune diseases, that impair healing and tissue repair; poor oral hygiene or chronic inflammation, which weakens the supporting tissues; and improper flossing techniques, such as snapping or forcing floss, which can damage the gum tissue between teeth.

Why Early Orthodontic Treatment Helps

Orthodontic care during childhood or adolescence offers significant advantages in supporting healthy gum and bone development. When teeth are aligned early, root positions can be guided to remain close together and parallel. This allows the bone to develop fully between them and keeps the vertical contact-to-bone distance within a healthy range. Early treatment also reduces the need for extensive tooth movement later, which can otherwise damage or compromise the surrounding tissues. Spacing, in particular, should be addressed early. If left untreated during the growth period, the bone may remain flat or underdeveloped. Once the opportunity for vertical bone maturation is missed, even ideal alignment may not result in full papilla regeneration. Additionally, younger patients tend to have healthier, more regenerative soft tissues. When orthodontic alignment occurs during growth, the body is more capable of adapting and forming stable bone and papillae that prevent black triangles.

What Can Be Done If Black Triangles Are Already Present?

By the Dentist: Clinical and Restorative Solutions

Interproximal Reduction (IPR) involves reshaping enamel between teeth to broaden contact areas and reduce embrasure height. Orthodontic root parallelism corrects diverging root positions that contribute to wide interproximal gaps. Composite bonding reshapes teeth with tooth-colored material to bring contact points closer to the bone. Porcelain veneers offer high-esthetic solutions by modifying tooth shape and contact levels. Papilla reconstruction surgery involves grafting tissue or using microsurgical techniques to rebuild lost papilla. Injectable hyaluronic acid fillers provide a temporary, non-surgical method to enhance papilla volume in select cases, though results may require retreatment and are technique-sensitive.

By the Patient: Home Care and Prevention

Excellent oral hygiene is essential to prevent further bone and tissue loss. Gentle use of interdental brushes or soft picks stimulates the papilla without trauma. Improper flossing should be avoided to protect delicate tissue. Managing systemic conditions such as diabetes can enhance healing and tissue integrity. Quitting smoking improves blood flow and reduces risk of periodontal breakdown. Finally, early orthodontic evaluation and space management in children can prevent black triangle formation later in life.

Conclusion

Black triangles are not a complication caused by braces. They are a consequence of underlying anatomical, developmental, and periodontal conditions that may be exposed during or after orthodontic alignment. Both crowding and spacing can interfere with normal bone formation between teeth. Spacing left untreated during growth may result in permanent flattening of the interdental alveolar crest, leading to an increased vertical distance between the contact point and bone and a reduced likelihood of papilla regeneration. Early orthodontic treatment supports healthy root alignment, promotes full interproximal bone development, and helps prevent these spaces from ever forming. If black triangles do appear, a range of dental and periodontal solutions are available. Combined with excellent home care, these strategies can restore both function and esthetics while preserving long-term periodontal health.

References

De-la-Rosa-Gay, C., Gay-Escoda, C., & Velasco-Ortega, E. (2018). Black triangles: Etiology and treatment options. International Orthodontics, 16(3), 529–539. https://doi.org/10.1016/j.ortho.2018.05.001

Glickman, I., & Carranza, F. A. (2021). Carranza’s Clinical Periodontology (13th ed.). Elsevier.

Jung, J. S., Park, H. Y., Kim, S. K., & Kang, K. H. (2024). The occurrence and risk factors of black triangles after orthodontic treatment. Journal of Clinical Periodontology, 51(1), 44–54. https://doi.org/10.5051/jpis.210155

Kurth, J. R., & Kokich, V. G. (2001). Open gingival embrasures after orthodontic treatment in adults. American Journal of Orthodontics and Dentofacial Orthopedics, 120(2), 116–123. https://doi.org/10.1067/mod.2001.115867

Lee, D. W., Kim, C. K., Park, K. H., & Moon, I. S. (2011). Gingival papilla reconstruction using injectable hyaluronic acid gel: A pilot study. Journal of Esthetic and Restorative Dentistry, 23(4), 244–252. https://doi.org/10.1111/j.1708-8240.2011.00446.x

Montevecchi, M., Zaffe, D., & Checchi, L. (2011). Interproximal papilla height: Relationship between clinical parameters and anatomical variables. The Open Dentistry Journal, 5, 126–132. https://doi.org/10.2174/1874210601105010126

Pugliese, M., Farronato, G., Gassino, G., et al. (2019). Prevention of gingival black triangle formation with early orthodontic treatment in crowded teeth. American Journal of Orthodontics and Dentofacial Orthopedics, 156(3), 351–359.e1. https://doi.org/10.1016/j.ajodo.2019.01.018

Roccuzzo, M., Bunino, M., Dalmasso, P., & Layton, D. (2018). Papilla height in relation to the distance between bone crest and contact point in adjacent implants. Clinical Oral Implants Research, 29(6), 546–552. https://doi.org/10.1111/clr.13116

Tarnow, D. P., Magner, A. W., & Fletcher, P. (1992). The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. Journal of Periodontology, 63(12), 995–996. https://doi.org/10.1902/jop.1992.63.12.995