TMJ Surgery A Response to an orthodontic editorial standard of care

Dr Peter Quinn, DMD, MD is past chairman of the Department of Oral And Maxillofacial Surgery at the University of Pennsylvania, Current President of the American Society of Temporomandibular Joint Surgeons  (, and currently is the Chief of the Medical/Surgical staffs at the University of Pennsylvania in Philadelphia. His job is to administratively represent all physicians at HUP. He has developed the total TM joint prosthesis that is referred to elsewhere in this website/blogs that is currently produced by Biomet Corporation, the world’s largest producer of orthopedic prosthetics. This is produced with his permission. His response was sent to the American Journal of Orthodontics relative to what was recently published in their journal. This was referenced in the previous blog on this site.

RE: Guest Editorial/ Managing Patients with Temporomandibular Disorders: A “New Standard of Care”..July, 2010

It was with a sense of great disappointment that many of us read what was purported to be a new “standard of care” for temporomandibular disorders. The American Society of Tempormandibular Joint Surgeons (ASTMJS) is a multidisciplinary organization of clinicians, oral and maxillofacial surgeons, ENT surgeons, oral medicine specialists, orthopedic surgeons and radiologists who, over the past quarter century, have attempted to define a rational approach to a small subset of patients within the broader “TMD” classification that may ultimately need appropriate surgical intervention.

Since Dr. Green , in his paper, said that the “AADR recognizes that temporomandibular disorders encompasses a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joints (TMJs), the masticatory muscles and all associated tissues, “that clearly can be interpreted as an all encompassing diagnosis.” The ASTMJS guidelines for diagnosis and management of disorders involving the temporomandibular joint  (See related musculoskeletal structures concentrates more on internal derangement since we feel that again a small proportion of those patients may ultimately require a surgical approach. We do state (in the ASTMJ Guidelines) that “Non-surgical treatment should be considered for all symptomatic patients with internal derangement or osteoarthritis.” We clearly agree with the statement that the vast majority of patients who have myofascial complaints should have treatment based “:on the use of conservative reversible and evidence based therapeutic modalities.” (AADR Guidelines)

What is concerning is to give the impression that “TMD type pain” should all be managed “within a biopsycho-
social framework”. This would be a kin to saying that all orthopedic disorders should be treated within the same biopsychosocial framework. It is difficult to conceive that the most used , and probably the most complicated joint in the body would not be prone to a disorder that could not be treated with conservative medical care. In the United States alone, there are close to 900,000 hip and knee replacements and I think it would be difficult to find a rheumatologist or orthopedic surgeon who would feel that these all should have been dealt with in a non-operative fashion.

I have had the priviledge of being a member of a multidisciplinary TMJ and Facial Pain Clinic at the University of Pennsylvania for over 20 years. Our operative intervention rane (arthroscopy and or open joint surgery) is less thatn 3% of our patient population. We use the standard Wilkes classification for all patients, and exhaust all conservative therapy before considering any intervention. We clearly recognize that there has been over – use of surgical treatments at time in the past and we are committed to an evidence-based approach to surgical interventions now and in the future. In the last month alone, we had surgical patients with diagnoses that include traumatic osteoarthritis, rheumatoid arthritis, synovial chondromatosis, and a malunited condylar fracture. it is naive, and somewhat irresponsible, for the authors to think that these guidelines will not be used by third party insurers to deny treatment to patients with temporomandibular joint disorders that not amenable to the conservative approach. If one searches the internet using “temporomandibular joint disorders”, the first two websites (WEBMD and Wikipedia) both include references to surgery (arthrocentesis, arthroscopy and open joint surgery) as appropriate when conservative therapy fails or when the initial diagnosis would dictate that approach. If even public websites acknowledge a broader “orthopedic” approach to temporomandibular joint disorders, it would be less confusing for patients if “professional organization” gudelines were as inclusive of all potential treatment modalities.”

Dr. Peter Quinn, DMD, MD, President, American Society of Temporomandibular Joint Surgeons.

University of Pennsylvania, Philadelphia, Pa.

Final comments,  Dr. Kirk……

Many patients who develop “TMJ” that has progressed to severe state report to me that their condition began in adolescence. This website/blog is dedicated to presenting the orthopedic problems found in the jaw joint (TMJ) and relate it to orthopedic conditions that the patients/public are familiar with and have enough common sense to relate to from their own life experiences. For a professional publication of the dental profession to publish a position that puts secondary emphasis on appropriate and timely imaging of patients…particularly patients who could be at an age of vulnerability and in orthodontic treatment and in their growth and development years…..and relates that patients who come to providers with complaints be looked at in generic fashion,….is in this day and time misguided…….Publications in the orthodontic literature have suggested that the incidence of  significant TM joint derangement match those of adults who are managed with “TMJ”….relatively 1 in 10.  Why consider to first manage with a psychosocial model of disease or management when life long consequences can be significant….growth and development impacted, and a joint system that is known to exhibit significant degenerative arthrosis at the extreme end of the spectrum 20 to 30 years earlier than similar degrees of arthrosis in a knee or hip ?

These are the types of patients who are unfortunately created when viewed  as having a  primary muscular disorder, a psychological disorder, or disorder of the fit of their teeth….all the while ignoring a medical/orthopedic model of significant disease in a subset of patients…..progression of disease due to no consideration of dysfunctional orthopedic biomechanics and not delegating imaging of these patients to a secondary level of management.

W. Kirk
Charlotte, NC

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