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Staging of maxillary and mandibular osteotomies
LETTERS TO THE EDITOR EFFECTS OF CONDYLAR IMMOBILIZATION
To the Editor:-1 feel that the authors of the article “The Effects of Immobilization on the Primate Temporomandibular Joint: A Histologic and Histochemical Study” (J Oral Maxillofac Surg 40:3, 1982) took considerable liberty in suggesting that “in older individuals or those with already existing degenerative changes, it is possible that (replacement cartilage) may not occur.” Sicher,’ in his textbook of oral anatomy, describes the difference between the mandibular cartilage and the articular cartilage of tubular bones as follows:
regularities, including osteophyte formation, is a basic diagnostic sign of the disease. To us, this suggests that at some point degenerative changes in the condylar cartilage may become irreversible. On this basis, it seems a reasonable hypothesis that condylar cartilage previously insulted by osteoarthritis, particularly in an olger individual in whom all regenerative processes are slowed, should react less favorably to immobilization than that which is not so affected. On the other hand, because this is as yet only a hypothesis, we suggested it only as “possible.”
Since the condylar cartilage of the mandible is cov-
DAVID BLAUSTEIN,DDS, PHD Chicago, Illinois
ered by a thick layer of dense connective tissue it cannot be compared with an articular cartilage of tubular bones or to an epiphyseal plate, even though growth of the mandible does occur in the condyle by proliferation of the cartilage and its gradual replacement by bone just as in the cartilages of tubular bones. The covering of connective tissue enables the cartilage to increase in thickness not only by interstitial, but also by appositional growth, whereas the cartilages of long bones, both articular and epiphyseal, thicken by interstitial growth only. The hyaline cartilage in the head of the mandible, therefore, holds a unique position and differs widely from that of other cartilaginous growth centers in its reaction to certain pathologic conditions.
References 1. Hochman LS, Laskin DM: Repair of surgical defects in the articular surface of the rabbit mandibular condyle. Oral Surg Oral Med Oral Path01 19534, 1%5 2. Blackwood HJJ: Pathology of the temporomandibular joint. J Am Dent Assoc 79: 118, 1969 STAGING
OSTEOTOMIES
To the Editor:-This letter relates to the article by Dr. Timothy Turvey, “Simultaneous Mobilization of the Maxilla and Mandible: Surgical Technique and Results” (J Oral Maxillofac Surg 40:96, 1982). In Dr. Turvey’s introduction he states that we advocate staging total maxillary and mandibular osteotomies (Gross BD, James RB: The surgical sequence of combined total maxillary and mandibular osteotomies. J Oral Surg 36513, 1978). In that article we stated that consideration be given to staging the procedures and that the final decision is dependent on the experience of the surgeon. The patients presented in that article were treated in 1975. Our article was the first to direct attention to the workup of patients requiring combined procedures, the many problems involved with this type of surgery, the sequencing of the surgery, and the use of a transitional splint. These ideas are restated by Dr. Turvey but without reference to our article. Since the publication of our article, we have done hundreds of total maxillary and mandibular osteotomies. From experience we now generally advocate a one-stage procedure, although each patient is evaluated and considered individually. It is of interest that in two of Dr. Turvey’s patients, one-stage total maxillary and mandibular osteotomies had to be aborted and a two-stage procedure performed. Therefore, as we stated, consideration should be given to staging this type of surgery.
I feel that the investigation was well done and documented; however, to blatantly make a statement which is not proven by prior experimentation, and which is actually refuted by this very study, shows a lack of open-mindedness. I believe the study should have included different age groups and comparisons, and/or differences could have been pointed out and a proper conclusion extrapolated from these results. LEONARDWEISS, DDS, MS
Freehold, New Jersey
References 1. SicherH: Oral Anatomy,C. V. Mosby Company, 2nd Edition, 1952, page 113.
To the Editor:-We are surprised by the extreme reaction evoked by the rather innocuous statement in our paper. We agree with Sicher than not only does the anatomic difference between the articular surface of the mandibular condyle and that of a long bone affect their growth potential, but also it has an effect upon their ability to repair themselves following injury. This has been shown experimentally.’ Moreover, Blackwood has demonstrated that 40% of the mandibular condyles he examined at autopsy showed histologic and histochemical evidence of degenerative arthritis. Additionally, it should be noted that radiologic evidence of condylar ir-
OF MAXILLARY AND MANDIBULAR
RANDAL B. JAMES, DDS Denver. Colorado BOBD. GROSS, DDS, MS Shreveport, Louisiana
327
To the Editor:-1 feel that the authors of the article “The Effects of Immobilization on the Primate Temporomandibular Joint: A Histologic and Histochemical Study” (J Oral Maxillofac Surg 40:3, 1982) took considerable liberty in suggesting that “in older individuals or those with already existing degenerative changes, it is possible that (replacement cartilage) may not occur.” Sicher,’ in his textbook of oral anatomy, describes the difference between the mandibular cartilage and the articular cartilage of tubular bones as follows:
regularities, including osteophyte formation, is a basic diagnostic sign of the disease. To us, this suggests that at some point degenerative changes in the condylar cartilage may become irreversible. On this basis, it seems a reasonable hypothesis that condylar cartilage previously insulted by osteoarthritis, particularly in an olger individual in whom all regenerative processes are slowed, should react less favorably to immobilization than that which is not so affected. On the other hand, because this is as yet only a hypothesis, we suggested it only as “possible.”
Since the condylar cartilage of the mandible is cov-
DAVID BLAUSTEIN,DDS, PHD Chicago, Illinois
ered by a thick layer of dense connective tissue it cannot be compared with an articular cartilage of tubular bones or to an epiphyseal plate, even though growth of the mandible does occur in the condyle by proliferation of the cartilage and its gradual replacement by bone just as in the cartilages of tubular bones. The covering of connective tissue enables the cartilage to increase in thickness not only by interstitial, but also by appositional growth, whereas the cartilages of long bones, both articular and epiphyseal, thicken by interstitial growth only. The hyaline cartilage in the head of the mandible, therefore, holds a unique position and differs widely from that of other cartilaginous growth centers in its reaction to certain pathologic conditions.
References 1. Hochman LS, Laskin DM: Repair of surgical defects in the articular surface of the rabbit mandibular condyle. Oral Surg Oral Med Oral Path01 19534, 1%5 2. Blackwood HJJ: Pathology of the temporomandibular joint. J Am Dent Assoc 79: 118, 1969 STAGING
OSTEOTOMIES
To the Editor:-This letter relates to the article by Dr. Timothy Turvey, “Simultaneous Mobilization of the Maxilla and Mandible: Surgical Technique and Results” (J Oral Maxillofac Surg 40:96, 1982). In Dr. Turvey’s introduction he states that we advocate staging total maxillary and mandibular osteotomies (Gross BD, James RB: The surgical sequence of combined total maxillary and mandibular osteotomies. J Oral Surg 36513, 1978). In that article we stated that consideration be given to staging the procedures and that the final decision is dependent on the experience of the surgeon. The patients presented in that article were treated in 1975. Our article was the first to direct attention to the workup of patients requiring combined procedures, the many problems involved with this type of surgery, the sequencing of the surgery, and the use of a transitional splint. These ideas are restated by Dr. Turvey but without reference to our article. Since the publication of our article, we have done hundreds of total maxillary and mandibular osteotomies. From experience we now generally advocate a one-stage procedure, although each patient is evaluated and considered individually. It is of interest that in two of Dr. Turvey’s patients, one-stage total maxillary and mandibular osteotomies had to be aborted and a two-stage procedure performed. Therefore, as we stated, consideration should be given to staging this type of surgery.
I feel that the investigation was well done and documented; however, to blatantly make a statement which is not proven by prior experimentation, and which is actually refuted by this very study, shows a lack of open-mindedness. I believe the study should have included different age groups and comparisons, and/or differences could have been pointed out and a proper conclusion extrapolated from these results. LEONARDWEISS, DDS, MS
Freehold, New Jersey
References 1. SicherH: Oral Anatomy,C. V. Mosby Company, 2nd Edition, 1952, page 113.
To the Editor:-We are surprised by the extreme reaction evoked by the rather innocuous statement in our paper. We agree with Sicher than not only does the anatomic difference between the articular surface of the mandibular condyle and that of a long bone affect their growth potential, but also it has an effect upon their ability to repair themselves following injury. This has been shown experimentally.’ Moreover, Blackwood has demonstrated that 40% of the mandibular condyles he examined at autopsy showed histologic and histochemical evidence of degenerative arthritis. Additionally, it should be noted that radiologic evidence of condylar ir-
OF MAXILLARY AND MANDIBULAR
RANDAL B. JAMES, DDS Denver. Colorado BOBD. GROSS, DDS, MS Shreveport, Louisiana
327