TMJ pain and dysfunction have plagued our profession since Costen, an ENT surgeon, ceded the problem to dentistry. As Dr Charles Greene states, Costen pulled off the best triple play ever-he defined a syndrome in his own unsubstantiated way, got his name placed on it, and then gave it to dentistry to deal with! The plague of TMJ dysfunction has been the profession’s quest for an etiology and ultimately a rational treatment. All are familiar with the historical background of this quest through tooth grinding, use of plastic splints, medications, treatment by psychologists, biofeedback, and on and on. The answer still remains elusive, and this troubles the dental mind. Caries causes teeth to hurt: remove caries, teeth don’t hurt-quick fix. We all remember the way dental schools taught us to be puzzle-solvers rather than problem-solvers. Unfortunately, there is only one solution to a puzzle, but a problem can have more than one solution. We took this same puzzle-solving mindset and tried to solve the TMJ problem and treating the disc became the quick solution. This solution was “confiied” by our sophisticated technology-arthrotomography, CT scans, and MRI, to name a few. Now we had the answer-we could see it! With open arthrotomy and arthroscopy we could not only see it but also touch it, move it, remove it, biopsy it, cut it, and tie it! Those who chose to take the conservative route tried to “recapture” the disc with all kinds of physiologically unproven plastic devices. But, lo and behold, the same technology that legitimized the treatment of the disc and its position betrayed it as well. Suddenly, when results were not what we expected, we found that disc displacement was more common in asymptomatic individuals than we imagined.‘** Cadaver studies also revealed the same situation, but to a much greater extent than would have been expected in a symptomatic population.3*4 Also, asymptomatic patients, when restudied posttreatment using our sophisticated technology, also showed that the disc often was not in a more anteriorly displaced position than in the preoperative symptomatic state.5.6 We now find ourselves cursing the technology on which we built this house of cards and await the next sophisticated advancement to reprove what appears to be a sophism. It was so convenient, so simple, such a quick fix. The puzzle was solved! But is it? The reader who has come this far might be saying, “But patients were reported to have been relieved of TMJ pain and dysfunction when the disc displacement was the focus of treatment. How do you account for that?” If we review most of the prose (literature) that addresses this issue we find a cumulative average 80% to 85% “success” rate. Unfortunately success is a very vague, nonspecific parameter, which is exactly what we find in most of the prose. Many times apples were compared with oranges, but the solution to the puzzle was always treating the disc, with no real science involved in the report on the problem. Also, to some, “success” meant the patient never

ADVANTAGEOFTRADITIONALSEQUENCEFOR THE LE FORT I OSTEOTOMY To ?he Editor:-Dr Vargas-Garcia in his article AlteredSequence Le Fort I Osteotomy (J Oral Maxillofac Surg 48:323, 1990) is correct when he states that radiating vibrations increase during separation of the pterygoid plates from the maxilla when other preliminary bony cuts have been made prior to the separation. These radiating vibrations may contribute to a less precise pterygoid plate fracture. However, he did not mention the primary reason the classic Le Fort I osteotomy technique describes pterygoid separation as the last step. In the event of sudden hemorrhage from the greater palatine, internal maxillary, or other vessels during the pterygoid plate separation, immediate downfracture can be accomplished, with much greater access to the damaged vessels than would be obtained if working with an incompletely osteotomized maxilla. The benefit-risk ratio of the modified sequence osteotomy may not outweigh the benefit-risk ratio of the classic technique in individual cases. DANIEL L. ORR II

Las Vegas, Nevada

TMJ DISC DISPLACEMENT = THE CAUSE OF TMJ DYSFUNCTION AND PAIN: A SOPHISM? To the Editor:-Webster defines a sophism as an argument correct in form but which is actually invalid in content. Is this the case with TMJ disc displacement as the cause of TMJ dysfunction and pain? Since the early 197Os, when the concept of TMJ internal derangement was “rediscovered,” our profession has spent numerous hours and pages in discussion, argument, and prose trying to make this connection. Many of these communications have been subjective, anecdotal, and unsubstantiated testimonials for a technique or a gadget, but have been accepted as the way it is. Why did we as a profession jump on the disc derangement bandwagon? Weren’t we sophisticated enough, skeptical enough, and critical enough? Frustration with these cases, the quick-fur dental school mentality, and too much sophisticated technology all probably had a lot to do with it.

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