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A treatment looking for a disease
EDITORIAL J Oral Maxillofac
Surg
45:97. 1987
A Treatment Looking For a Disease eliminating the need for maxillomandibular fixation and thus becomes a selling point for patients requiring orthognathic surgery. However, whether this advantage will outweigh the effect on the joint of the condylar rotation produced by the close approximation of the bony parts, the added chance of inferior alveolar nerve compression, and the lack of ability to compensate for malposition of the proximal fragment still remains to be seen. Even more questionable, at the moment, is the increasing use of multiple miniplates for fixation of midface fractures without evidence of their superiority over less complicated closed procedures. A further example of treatment availability exceeding need lies in the field of temporomandibular joint surgery. The introduction of arthrography was an important step in our understanding of the biomechanics of this joint and has resulted in the subsequent development of surgical procedures that now enable us to help patients that we were unable to help before. However, these operations were not designed for treating every click or pop, regardless of whether there is pain or dysfunction, although they sometimes appear to be used in this manner. Perhaps the most current example of seeking a use for expanding technology is arthroscopy. Before we are certain about what can be seen arthroscopically in terms of normal anatomy and pathology, and without proper training either in routine arthroscopic examination or the more difficult triangulation techniques needed for arthroscope surgery that can only be learned by extensive experience on cadavers, there is a rush to purchase instruments and start working. At present, it seems more logical that arthroscopy, like microsurgery, should be a procedure used only by those who have trained extensively and who perform sufficient procedures to remain technically skilled. These remarks should not be interpreted as advocating a moratorium on clinical exploration. As already noted, this is an essential way for our specialty to progress. Instead, it is a plea for greater patience and better judgment. Technological advancements are necessary, but they should occur in response to a need rather than in a attempt to create one. Patients benefit from the former-what they gain from the latter is questionable.
Oral and maxillofacial surgeons are constantly seeking to improve the care of their patients. This is accomplished in a variety of ways. Some improvements come from extensive basic and clinical research, others through innovative technical advancements, and still others through fortunate serendipitous discoveries. Another common way is by the transfer of knowledge or the application of technology developed in other areas to similar problems involving the oral and maxillofacial region. The latter is perhaps the most expeditious method because it provides an already established basis from which to expand and helps avoid the pitfalls of first exploring an unknown territory. In normal times, the use of new treatments generally develops slowly. A few pioneering individuals attempt the procedure, study their results, perhaps make modifications, and finally are in a position to report their findings and transfer their knowledge to others. Gradually, use of the procedure increases as the indications and contraindications become better understood and there is greater awareness of the possible complications and how to avoid them. Finally, the operation becomes a generally accepted therapeutic modality. Unfortunately, however, these are not normal times. Conflicting socioeconomic factors have simultaneously expanded the cadre of professionals and diminished the demand for services. This has had two effects: first, it has greatly increased competition within the specialty and second, it has produced a lack of busyness. Understandably, the result is a rush to find ways to reverse this situation. The quickest way to solve these problems is the expansion of existing technology. Although this may lead to many innovative applications, it also has the danger of leading to patients being treated with procedures that have not yet been perfected or of unproven procedures being used that ultimately prove to be ineffective. One example has been the extensive use of hydroxylapatite. Although it has proved to be a useful material for augmentation of the atrophic mandible and maxilla, its use as a root substitute to maintain alveolar bone or its placement in alveolar clefts or postsurgical defects has not been as successful. Another treatment modality that is currently gaining rapid popularity is the use of rigid fixation. This technique has the advantage of reducing or
DANIELM. LASKIN 97
Surg
45:97. 1987
A Treatment Looking For a Disease eliminating the need for maxillomandibular fixation and thus becomes a selling point for patients requiring orthognathic surgery. However, whether this advantage will outweigh the effect on the joint of the condylar rotation produced by the close approximation of the bony parts, the added chance of inferior alveolar nerve compression, and the lack of ability to compensate for malposition of the proximal fragment still remains to be seen. Even more questionable, at the moment, is the increasing use of multiple miniplates for fixation of midface fractures without evidence of their superiority over less complicated closed procedures. A further example of treatment availability exceeding need lies in the field of temporomandibular joint surgery. The introduction of arthrography was an important step in our understanding of the biomechanics of this joint and has resulted in the subsequent development of surgical procedures that now enable us to help patients that we were unable to help before. However, these operations were not designed for treating every click or pop, regardless of whether there is pain or dysfunction, although they sometimes appear to be used in this manner. Perhaps the most current example of seeking a use for expanding technology is arthroscopy. Before we are certain about what can be seen arthroscopically in terms of normal anatomy and pathology, and without proper training either in routine arthroscopic examination or the more difficult triangulation techniques needed for arthroscope surgery that can only be learned by extensive experience on cadavers, there is a rush to purchase instruments and start working. At present, it seems more logical that arthroscopy, like microsurgery, should be a procedure used only by those who have trained extensively and who perform sufficient procedures to remain technically skilled. These remarks should not be interpreted as advocating a moratorium on clinical exploration. As already noted, this is an essential way for our specialty to progress. Instead, it is a plea for greater patience and better judgment. Technological advancements are necessary, but they should occur in response to a need rather than in a attempt to create one. Patients benefit from the former-what they gain from the latter is questionable.
Oral and maxillofacial surgeons are constantly seeking to improve the care of their patients. This is accomplished in a variety of ways. Some improvements come from extensive basic and clinical research, others through innovative technical advancements, and still others through fortunate serendipitous discoveries. Another common way is by the transfer of knowledge or the application of technology developed in other areas to similar problems involving the oral and maxillofacial region. The latter is perhaps the most expeditious method because it provides an already established basis from which to expand and helps avoid the pitfalls of first exploring an unknown territory. In normal times, the use of new treatments generally develops slowly. A few pioneering individuals attempt the procedure, study their results, perhaps make modifications, and finally are in a position to report their findings and transfer their knowledge to others. Gradually, use of the procedure increases as the indications and contraindications become better understood and there is greater awareness of the possible complications and how to avoid them. Finally, the operation becomes a generally accepted therapeutic modality. Unfortunately, however, these are not normal times. Conflicting socioeconomic factors have simultaneously expanded the cadre of professionals and diminished the demand for services. This has had two effects: first, it has greatly increased competition within the specialty and second, it has produced a lack of busyness. Understandably, the result is a rush to find ways to reverse this situation. The quickest way to solve these problems is the expansion of existing technology. Although this may lead to many innovative applications, it also has the danger of leading to patients being treated with procedures that have not yet been perfected or of unproven procedures being used that ultimately prove to be ineffective. One example has been the extensive use of hydroxylapatite. Although it has proved to be a useful material for augmentation of the atrophic mandible and maxilla, its use as a root substitute to maintain alveolar bone or its placement in alveolar clefts or postsurgical defects has not been as successful. Another treatment modality that is currently gaining rapid popularity is the use of rigid fixation. This technique has the advantage of reducing or
DANIELM. LASKIN 97