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The correct operation for TMJ disc perforation
J Oral Maxillofac Surg 53:351-352, 1995
ously, the treatment of posterior attachment perforations was not addressed. While the evidence is that most joint perforations occur in the posterior attachment, 1'2disc perforations are not rare in my experience or those of othersY Considering the Pereira et al referenced study2 of 34 fresh human cadaveric TMJ, there were 11 perforations: five posterior attachment perforations, one disc perforation, and five large perforations of the disc and posterior attachment. Therefore, of 11 perforations, six were in the disc and 10 involved the posterior attachment. In another study3 of 15 TMJ perforations in human cadaveric joints, 11 were present in the disc and four were present in the posterior attachment associated with anterior disc displacement. Dr Hall questions preserving the displaced disc, which I treat by anterior surgical release and reduction and lasing of the posterior attachment with the Holmium laser. Obviously a grossly deformed disc would not be preserved and discectomy would be justifiable. His statement that discectomy is "the gold standard" for the treatment of late stage osteoarthritis and internal derangement, with or without perforation, is controversial. The desirability of maintaining a perforated, undeformed disc that still possesses much of its inherent ability to function seems reasonable. Why remove one of the most important TMJ structures before more conservative procedures have failed? The treatment of late stage TMJ disease using the minimally invasive techniques of arthroscopic laser debridement, discoplasty, and abrasion arthroplasty for advanced chondromalacia, described in my article, seems to provide a conservative, biologic approach to the problem. A future article with more patients and a longer follow-up will be forthcoming. The TMJ has a great reparative potential, particularly if the etiologic factors responsible for the degenerative process, predominantly bmxism, are controlled. No surgical procedure will be successful long term without controlling these factors.
TH~ Coed~CX Oe~e,nXlO~ Fo~ T M J Disc PERFORATION
To the Editor--I was puzzled by the analogy between the knee meniscus and the disc used in Dr. Quinn's recent article.~ He uses the current practice of partial meniscectomy of the knee as a rationale for preserving the disc when perforations are present in the temporomandibular joint and suggests that the disc continues to serve useful purposes such as contributing to joint stability and absorbing compressive loads. Perforations, however, almost always occur in the posterior attachment in late-stage disease and are well illustrated in recent publications.24 Thus, it is difficult to see how preservation of the disc will, for example, provide stability to the joint when the disc is both displaced and grossly deformed. If, on the other hand, he is indeed referring to a true perforation of the disc, the possible indication for his technique would be severely limited because of the relative rarity of disc perforation. Based on published outcomes, the gold standard for any operation for late-stage osteoarthrosis and internal derangement, with or without perforation, remains discectomy, s H. DAVID HALL, DMD, MD Nashville, Tennessee
References 1. Quinn JH: Arthroscopic management of temporomandibular joint disc perforationsand associated advanced chondromalacia by discoplasty and abrasion arthroplasty: Preliminary results. J Oral Maxillofac Surg 52:800, 1994 2. Wilkes CH: Internal derangements of the temporomandibular joint: Pathologicalvariations.Arch OtolarlyngolHead Neck Surg 115:469, 1989 3. Pereira FJ, Lundh H, Westesson P: Morphologic changes in the temporomandibularjoint in different age groups. An autopsy investigation. Oral Surg Oral Med Oral Pathol 78:279, 1994 4. Widmalm SE, Westesson P, Kim I, et al: Temporomandibular joint pathosis related to sex, age, and dentition in autopsy material. Oral Surg Oral Med Oral Pathol 78:416, 1994 5. Hall HD: Discussion: Long-term evaluation of discectomy of the temporomandibular joint: J Oral Maxillofac Surg 52:727, 1994
J.H. QUINN, DDS New Orleans, Louisiana
References 1. Wilkes CH: Internal derangements of the temporomandibular joint: Pathological variations.Arch Otolaryngol Head Neck Surg 115:469, 1989 2. Peireira FJ, Lundh H, Westesson P: Morphologic changes in the temporomandibularjoint in different age groups. An autopsy investigation. Oral Surg Oral Med Oral Path 78:279, 1994 3. Helmy ES, Bays RA, Sharawy MM: Histopathological study of human TMJ Perforated disc with emphasis on synovial membrane response. J Oral Maxillofacial Surg 47:1048, 1989
In Reply:--In order to clear up Hall's puzzle, the reason that I chose the analogy between the knee meniscus and the perforated TMJ disc was that a perforated disc anatomically and functionally resembles the G-shaped meniscus which has a large central open area. I also do not understand his confusion about the title of my article, "Arthroscopic Management of TMJ Disc P e r f o r a t i o n s . . . " Obvi-
C h a n g i n g the Democratic Process
To the Editor:--For the past 75 years the democratic process, with no limitation on freedom of speech and other inherited rights, has worked in letting the AAOMS House of Delegates chose our leadership. Therefore, I want to urge the House Committee on Election Reform to proceed with much caution when considering a change in this process for whatever reason, whether it is apparent or not. I honestly feel that the real reasons for election reform in
351
ously, the treatment of posterior attachment perforations was not addressed. While the evidence is that most joint perforations occur in the posterior attachment, 1'2disc perforations are not rare in my experience or those of othersY Considering the Pereira et al referenced study2 of 34 fresh human cadaveric TMJ, there were 11 perforations: five posterior attachment perforations, one disc perforation, and five large perforations of the disc and posterior attachment. Therefore, of 11 perforations, six were in the disc and 10 involved the posterior attachment. In another study3 of 15 TMJ perforations in human cadaveric joints, 11 were present in the disc and four were present in the posterior attachment associated with anterior disc displacement. Dr Hall questions preserving the displaced disc, which I treat by anterior surgical release and reduction and lasing of the posterior attachment with the Holmium laser. Obviously a grossly deformed disc would not be preserved and discectomy would be justifiable. His statement that discectomy is "the gold standard" for the treatment of late stage osteoarthritis and internal derangement, with or without perforation, is controversial. The desirability of maintaining a perforated, undeformed disc that still possesses much of its inherent ability to function seems reasonable. Why remove one of the most important TMJ structures before more conservative procedures have failed? The treatment of late stage TMJ disease using the minimally invasive techniques of arthroscopic laser debridement, discoplasty, and abrasion arthroplasty for advanced chondromalacia, described in my article, seems to provide a conservative, biologic approach to the problem. A future article with more patients and a longer follow-up will be forthcoming. The TMJ has a great reparative potential, particularly if the etiologic factors responsible for the degenerative process, predominantly bmxism, are controlled. No surgical procedure will be successful long term without controlling these factors.
TH~ Coed~CX Oe~e,nXlO~ Fo~ T M J Disc PERFORATION
To the Editor--I was puzzled by the analogy between the knee meniscus and the disc used in Dr. Quinn's recent article.~ He uses the current practice of partial meniscectomy of the knee as a rationale for preserving the disc when perforations are present in the temporomandibular joint and suggests that the disc continues to serve useful purposes such as contributing to joint stability and absorbing compressive loads. Perforations, however, almost always occur in the posterior attachment in late-stage disease and are well illustrated in recent publications.24 Thus, it is difficult to see how preservation of the disc will, for example, provide stability to the joint when the disc is both displaced and grossly deformed. If, on the other hand, he is indeed referring to a true perforation of the disc, the possible indication for his technique would be severely limited because of the relative rarity of disc perforation. Based on published outcomes, the gold standard for any operation for late-stage osteoarthrosis and internal derangement, with or without perforation, remains discectomy, s H. DAVID HALL, DMD, MD Nashville, Tennessee
References 1. Quinn JH: Arthroscopic management of temporomandibular joint disc perforationsand associated advanced chondromalacia by discoplasty and abrasion arthroplasty: Preliminary results. J Oral Maxillofac Surg 52:800, 1994 2. Wilkes CH: Internal derangements of the temporomandibular joint: Pathologicalvariations.Arch OtolarlyngolHead Neck Surg 115:469, 1989 3. Pereira FJ, Lundh H, Westesson P: Morphologic changes in the temporomandibularjoint in different age groups. An autopsy investigation. Oral Surg Oral Med Oral Pathol 78:279, 1994 4. Widmalm SE, Westesson P, Kim I, et al: Temporomandibular joint pathosis related to sex, age, and dentition in autopsy material. Oral Surg Oral Med Oral Pathol 78:416, 1994 5. Hall HD: Discussion: Long-term evaluation of discectomy of the temporomandibular joint: J Oral Maxillofac Surg 52:727, 1994
J.H. QUINN, DDS New Orleans, Louisiana
References 1. Wilkes CH: Internal derangements of the temporomandibular joint: Pathological variations.Arch Otolaryngol Head Neck Surg 115:469, 1989 2. Peireira FJ, Lundh H, Westesson P: Morphologic changes in the temporomandibularjoint in different age groups. An autopsy investigation. Oral Surg Oral Med Oral Path 78:279, 1994 3. Helmy ES, Bays RA, Sharawy MM: Histopathological study of human TMJ Perforated disc with emphasis on synovial membrane response. J Oral Maxillofacial Surg 47:1048, 1989
In Reply:--In order to clear up Hall's puzzle, the reason that I chose the analogy between the knee meniscus and the perforated TMJ disc was that a perforated disc anatomically and functionally resembles the G-shaped meniscus which has a large central open area. I also do not understand his confusion about the title of my article, "Arthroscopic Management of TMJ Disc P e r f o r a t i o n s . . . " Obvi-
C h a n g i n g the Democratic Process
To the Editor:--For the past 75 years the democratic process, with no limitation on freedom of speech and other inherited rights, has worked in letting the AAOMS House of Delegates chose our leadership. Therefore, I want to urge the House Committee on Election Reform to proceed with much caution when considering a change in this process for whatever reason, whether it is apparent or not. I honestly feel that the real reasons for election reform in
351