the gold standard of diagnosis of tmds consists of patient history , physical evaluation and , in most chronic cases , behavioral or psychological assessments . treatment has been also planned based on symptoms such as dysfunction and/or pain.1,2 in general , the symptoms and/or signs of tmds can be categorized into : extrajoint and/or intrajoint . although there have been some controversies , no concentric condyle position has been still proposed as an implicated factors in development of tmds.38 it has been stated that there has been a relationship between the position of the condyle and displacement of the disk , as well as a relationship between the position of the condyle and tenderness of the tmjs.9 it has been also supposed that superior disc position was found to be statistically significant for centric condylar position.4 it was found that condyles of patients with anterior disc displacement were situated more posterior and superior in the fossa than those in the control group and in the anterior disc displacement group , the posterior condylar displacement was noted to be 2.4 times greater than the superior condylar displacement.3 weinberg mentioned that condylar displacement also contributes to tmds depending on its direction . anterior condylar displacement can initially affect the muscles by inducing over functional response in the proprioseptive system . posterior condylar displacement usually results in an intrajoint response consisting of a disc displacement and clicking.10 the aim of this study was to evaluate the correlation between the condyle position and tenderness of masseter ( mm ) , temporal ( tm ) and posterior cervical muscles ( psm ) , clicking , jaw deviation and deflection , jaw limitation , lateral palpation of tmj and occlusion . in two months , 100 patients applied to oral diagnosis clinic of faculty of dentistry for pain in face and/or jaws . the clinical signs and/or symptoms of 85 persons ( 170 joints ) with tmds fifteen persons have had pain in face and/or jaws caused from different causes such as tooth ache , impacted teeth , lesions in soft tissues , lymphadenitis and sialadenitis . the mean age of subjects was 29 in total , 28 for female patients and 34 for male patients . the clinical signs and symptoms clicking , crepitating , limitation , deviation , deflection , tenderness of masseter , temporal , lateral pyterigoid , medial pyterigoid and posterior cervical muscles , lateral palpation of tmj area , occlusion were recorded by a clinician for each patient according to the okeson.2 in table 1 , the criterion of clinical examination of each sign and symptom were presented . the joints were categorized into four groups : joints without the signs and/or symptoms of tmds ( c ) , intraarticular - articular group ( ia ) ( clicking , deviation , deflection , limitation ( hard - end - feel ) , and tenderness to the lateral palpation of tmj ) , extra - articular group ( ea ) ( tenderness on the mm , lpm , mpm and/or tm ) , complex group ( ia+ea ) ( intra and extra - articular ) according to the clinical signs and symptoms . if the deviation occurred during opening and the jaw than returned to midline before 30 to 35 mm of total opening and if the speed of opening altered the location of the deviation , this condition was accepted as intraarticular deviation . the deviation with muscular origin is commonly large , inconsistent , sweeping movement not associated with the clicking sounds . the deflection with intraarticular origin was differentiated from the deflection with muscular origin by observing the protrusive movement . on the protrusion , if mandible deflected to the side of the involved joint this condition was recorded as intraarticular deflection . in the deflection with muscular origin , the direction of deflection depends on the position of the involved muscle with respect to the joint and deflection was not observed in protrusive movement . the intraarticular limitation ( hard - end - feel ) was differentiated from extraarticular limitation by the mild passive force to lower incisors . when the mouth could not opened wider even if mild force , the limitation was recorded as hard - end - feel . the amount of opening could increase by the mild passive force ; this condition was accepted as myogenous limitation ( soft - end - feel).2 during the patient was opening the mouth , condylar head was localized by the digital palpation and the fingertips of clinician were placed over the lateral aspects of joint . after the fingertips felt the lateral pole of condyle medial force was applied to the joint area . the feels of tenderness or pain at that area , was recorded as the tenderness of lateral palpation . first , the fingers were placed on each zygomatic arch and then were dropped down slightly just anterior to the joint and that area was palpated . subsequently , the fingers were dropped to inferior attachment on the inferior border of the ramus . the middle region was palpated directly above the tmj and superior to the zygomatic arch . lateral and medial pyterigoid muscles were examined by functional manipulation according to okeson.2 in palpating of psm , the examiner s fingers were slipped behind the patient s head . the right hand palpated the right occipital area and the left hand palpated the left occipital area at the origins of muscles . each side was palpated twice within a 5 min interval and subjects were asked to indicate pain or not . the condylar position were determined the narrowest anterior ( a ) and posterior interarticular distance ( p ) on mid - sagittal mris of condyles , in similar way as described in the literature.4 mris of joints were scanned and converted into digital images . images were magnified and the measurements were made on these images as millimeters by computer . most superior part of the glenoid fossa was used for the determination of condyle position . posterior joint space ( pjs ) and anterior joint space ( ajs ) were measured in this area . condyle position was expressed as pjs / ajs ratio and these ratio were transformed into logarithmic base ( base e ) according to the blaschake and blaschake11,12 and pullinger and hollender.13,14 the measurements were repeated in two weeks by same clinician blindly and the reproducibility of measurements was calculated . in figures 1 , 2 and 3 , spearman s correlation was used to investigate the relationship between the condyle position and the clinical findings . reliability statistic was used to determine intra - observer concordance of two measurements of condylar position . in two months , 100 patients applied to oral diagnosis clinic of faculty of dentistry for pain in face and/or jaws . the clinical signs and/or symptoms of 85 persons ( 170 joints ) with tmds fifteen persons have had pain in face and/or jaws caused from different causes such as tooth ache , impacted teeth , lesions in soft tissues , lymphadenitis and sialadenitis . the mean age of subjects was 29 in total , 28 for female patients and 34 for male patients . the clinical signs and symptoms clicking , crepitating , limitation , deviation , deflection , tenderness of masseter , temporal , lateral pyterigoid , medial pyterigoid and posterior cervical muscles , lateral palpation of tmj area , occlusion were recorded by a clinician for each patient according to the okeson.2 in table 1 , the criterion of clinical examination of each sign and symptom were presented . the joints were categorized into four groups : joints without the signs and/or symptoms of tmds ( c ) , intraarticular - articular group ( ia ) ( clicking , deviation , deflection , limitation ( hard - end - feel ) , and tenderness to the lateral palpation of tmj ) , extra - articular group ( ea ) ( tenderness on the mm , lpm , mpm and/or tm ) , complex group ( ia+ea ) ( intra and extra - articular ) according to the clinical signs and symptoms . right and left joints and sides were categorized separately in a patient . if the deviation occurred during opening and the jaw than returned to midline before 30 to 35 mm of total opening and if the speed of opening altered the location of the deviation , this condition was accepted as intraarticular deviation . the deviation with muscular origin is commonly large , inconsistent , sweeping movement not associated with the clicking sounds . the deflection with intraarticular origin was differentiated from the deflection with muscular origin by observing the protrusive movement . on the protrusion , if mandible deflected to the side of the involved joint this condition was recorded as intraarticular deflection . in the deflection with muscular origin , the direction of deflection depends on the position of the involved muscle with respect to the joint and deflection was not observed in protrusive movement . the intraarticular limitation ( hard - end - feel ) was differentiated from extraarticular limitation by the mild passive force to lower incisors . when the mouth could not opened wider even if mild force , the limitation was recorded as hard - end - feel . the amount of opening could increase by the mild passive force ; this condition was accepted as myogenous limitation ( soft - end - feel).2 during the patient was opening the mouth , condylar head was localized by the digital palpation and the fingertips of clinician were placed over the lateral aspects of joint . after the fingertips felt the lateral pole of condyle medial force was applied to the joint area . the feels of tenderness or pain at that area , was recorded as the tenderness of lateral palpation . first , the fingers were placed on each zygomatic arch and then were dropped down slightly just anterior to the joint and that area was palpated . subsequently , the fingers were dropped to inferior attachment on the inferior border of the ramus . the middle region was palpated directly above the tmj and superior to the zygomatic arch . lateral and medial pyterigoid muscles were examined by functional manipulation according to okeson.2 in palpating of psm , the examiner s fingers were slipped behind the patient s head . the right hand palpated the right occipital area and the left hand palpated the left occipital area at the origins of muscles . each side was palpated twice within a 5 min interval and subjects were asked to indicate pain or not . the condylar position were determined the narrowest anterior ( a ) and posterior interarticular distance ( p ) on mid - sagittal mris of condyles , in similar way as described in the literature.4 mris of joints were scanned and converted into digital images . images were magnified and the measurements were made on these images as millimeters by computer . most superior part of the glenoid fossa was used for the determination of condyle position . posterior joint space ( pjs ) and anterior joint space ( ajs ) were measured in this area . condyle position was expressed as pjs / ajs ratio and these ratio were transformed into logarithmic base ( base e ) according to the blaschake and blaschake11,12 and pullinger and hollender.13,14 the measurements were repeated in two weeks by same clinician blindly and the reproducibility of measurements was calculated . in figures 1 , 2 and 3 , spearman s correlation was used to investigate the relationship between the condyle position and the clinical findings . the difference between the condyle positions of different groups reliability statistic was used to determine intra - observer concordance of two measurements of condylar position . the frequency and percentage of clinical findings were presented in table 2 . no case with deviation or deflection with muscular origin and crepitating forty and seven sides , ( 34% ) have had only extraarticular symptoms ( tenderness on mm , tm , lpm and mpm ) . in 40 ( 23% ) ( table 2 ) the distribution of 85 patients was presented as number and percentage in table 3 . the distribution of number and percentage of occlusion 127 ( 74.7% ) , 21 ( 12.4% ) , 22 ( 12.9% ) for class 1 , class 2 and class 3 occlusions , respectively . a significant relationship was found between the condyle position and the tenderness of psm ( at 0.05 level , spearman s rho value:0.164 ) , occlusion ( at 0.01 level , spearman s rho value:209 ) . there was no significant difference ( p>.05 ) between the groups in aspect of condyle positions . 0 value represents real concentricity and + values and  values represent anterior and posterior positions respectively . according to this finding in table 4 , the frequency and percentage of the condyle positions were presented for each group . tomography or magnetic resonance imagings ( mri ) use to display tmj structures and their pathologies . signs and symptoms such as clicking , deviation , deflection or limitation of tmds are fairly definitive for treatment planning . in tmds , the purpose of treatment is the elimination or minimization of dysfunctions such as limitation , intermittent locking and extraarticular or intraarticular pain.1,2 existing treatment approaches are generally sufficient to elimination of signs and symptoms . for this reason , we classified the patients according to the clinical findings in this study . however , in cases that resist to conventional treatments , proper imaging modalities should be necessary . several papers pointed out that the relationships between the disc position and condyle position.3 there has been limited information about the relationship between the clinical signs or symptoms and the condyle position . it was stated that there has been a relationship between the position of the condyle and displacement of the disk , as well as a relationship between the position of the condyle and tenderness of the tmjs.9 no significant relationship was found between the tenderness on lateral palpation and condyle position in this study . tenderness on masseter , temporal , lateral pyterigoid and medial pytreigoid muscles are the most common signs of tmds but the sensitivity of psm is considered as an accompanying feature.15 it was stated that tmd was seen in connection with a marked forward inclination of the upper cervical spine and an increased cranio cervical angulations.16 the asymmetric activation of jaw and neck muscles was interpreted as a compensatory strategy to achieve stability for the mandibular and cervical systems during masticatory function.17 it was also found that severe tmd showed a tendency to cervical spine hyperlordosis prevalence.18 in a systematic review which assessed the evidence concerning the association between head and cervical posture and tmd , it has been concluded that the association between intraarticular and muscular tmd and head and cervical posture is still unclear , and better controlled studies with comprehensive tmd diagnoses , greater sample sizes , and objective posture evaluation are necessary.2 cervical posture and/or head position can be important etiological factors in development of muscular or articular tmds . therefore , the treatment strategy of tmds may be directed to improve the inclination of upper cervical spine and cranio cervical angulations or vice versa , condyle position may change the activation of neck muscles . anterior condylar displacement can initially affect the muscles by inducing over functional response in the proprioseptive system . posterior condylar displacement usually results in an intra - joint response consisting of a disc displacement and clicking . no significant difference was found between the groups in aspect of condyle position in this study . furthermore , there were no relationships between the intrajoint signs and posterior condyle position or extrajoint findings and anterior condyle position . contrary to the opinions of weinberg , we found that a significant relationship between the posterior condyle position and the tenderness of psm which is extraarticular finding . in addition , no significant difference was found between the groups in aspect of condyle position in this study . according to table 4 , only two cases with concentric condyle position and condyle position of 99% of total cases located in posterior or anterior position in glenoid fossa in this study . according to this finding , it can be concluded that condyle position is not main etiological factor in development of tmds . furthermore , the position of condyle in glenoid fossa can be different in normal persons . this finding is in accordance with the literature.68 however , it may effective together with other possible etiological factors synergistically . in the unilateral extra and intraarticular cases which have not other possible etiological factors ; furthermore , whether the condyle position varies with the age and gender should be examined to confirm its effect on the development of tmds . this finding is accordance with the literature.19 however , there were several studies were reported that no relationship between these parameters.5,20,21 in this study , the number and percentage of class 1 ( 127 , 74.7% ) occlusion was significantly higher than the others ( 21 , 12.4% and 22 , 12.9% ) . the number of occlusion types in each group must be equal and large sample should be evaluated to obtain reliable results within the limitation of this study , the inclination of the upper cervical spine and craniocervical angulations can cause the signs and symptoms of tmd and condyle position is not main cause of tmds alone but it may be effective together with other possible etiological factors synergistically .
objectives : to investigate the relationship between different clinical findings and condyle position.methods:tenderness on masseter ( mm ) , temporal ( tm ) , lateral pyterigoid ( lpm ) , medial pyterigoid ( mpm ) and posterior cervical ( psm ) muscles , limitation , deviation and deflection in opening of mouth , clicking , crepitating , tenderness on lateral palpation of temporomandibular joint ( tmj ) area for each side of 85 patients were evaluated . 
 each side of patients was categorized into the clinical findings : no sign and/or symptom of temporomandibular dysfunctions ( tmds ) , only extraarticular findings and only intraarticular findings , extra and intraarticular findings . 
 condyle positions of 170 tmjs were determined the narrowest anterior ( a ) and posterior interarticular distance ( p ) on mid - sagittal mris of condyles and expressed as p / a ratio and these ratio were transformed into logarithmic base e. spearman s correlation was used to investigate the relationship between the condyle position and the clinical findings . 
 the difference between the condyle positions of different groups was tested by t test . 
 reliability statistic was used to determine intra - observer concordance of two measurements of condylar position.results:a significant relationship was found between the condyle position and tenderness of psm . 
 there was no significant difference between the groups in aspect of the condyle position . 
 occlusion and condyle position correlated with significantly.conclusions:the inclination of the upper cervical spine and craniocervical angulations can cause the signs and symptoms of tmd and condyle position is not main cause of tmds alone but it may be effective together with other possible etiological factors synergistically .