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Make No Apologies
READERS’ FORUM Make No Apologies I am responding to an article written by Charles Alexander, titled “Open bite, dental alveolar protrusion, Class I malocclusion: A successful treatment result,” which was in the November 1999 issue of The American Journal of Orthodontics and Dentofacial Orthopedics. I would like to congratulate Dr Alexander for an excellently treated case. However, I was bothered by his apology for treating the case using orthodontics. He made a statement, and I quote “[The] surgical treatment alternative would resolve the skeletal problems and produce a profile change that would be superior to the change realized with the nonsurgical orthodontic option.” He also stated that the patient was not willing to commit to a surgical treatment plan, therefore a nonsurgical alternative was chosen. Dr Alexander should not make any apologies. It was a good thing that the patient forced him into treating the case in an orthodontic manner. If he had treated the case with surgery, the patient would have been overtreated, and he would have also allowed the patient to undergo unnecessary risks. If you were to look at posttreatment profiles on occlusion, you would probably agree that most patients would be happier with the results if they could avoid surgery. We should always try to do what is best for the patient and not apologize for your decisions. Roy K. King, PA Jupiter, Fla
Revisiting Root Resorption Rosa Y. Lee, Jon Årtun, and Todd A. Alonzo, in their article “Are dental anomalies risk factors for apical root resorption in orthodontic patients?” (Am J Orthod Dentofacial Orthop 1999; 116:187-95) report a meticulous radiographic study of apical root resorption in a sample of 84 orthodontically treated patients with various dental anomalies and in a control sample without the presence of anomalies. In their discussion, they refer extensively to my article, “Morphological characteristics of dentitions developing excessive root resorption during orthodontic treatment” (Eur J Orthod 1995; 16:25-34), in which I reported a high prevalence of various types of dental anomalies observed on radiographic material from 107 orthodontic patients submitted by 35 orthodontic practitioners according to the criterion that more than one third of at least one root had been resorbed during the orthodontic treatment. Fortunately, such excessive root resorption occurs only rarely during an orthodontist’s career, but, on the other hand, is well remembered. A total of 418 occurrences of one or more of 19 types of dental anomalies were reported, the most prevalent being 64 occurrences of short-root anomaly of incisors. The fact that such a large number of anomalies of tooth formation was observed in my sample suggests that these
extreme types of root resorption are probably not just extreme variants of the common, minor, and clinically insignificant root resorptions that are seen after most orthodontic treatments. Rather, it indicates that such patients are probably at special risk for root resorption, and therefore require a special approach to their orthodontic treatmentplanning to avoid the catastrophic side effects. The problem of detecting these patients has not been solved. The study of Lee et al shows that it is not enough to single out patients with “dental anomalies” in general. In my article, it was concluded that the dental anomaly associations with root resorption can be divided into 3 levels: strong associations are found for invagination, abnormal root shapes, such as short root length, pipette shaped roots, abrupt root deflections, and taurodontism; associations are found for ectopia and agenesis; and possible associations are expected for abnormal patterns of resorption of deciduous teeth. From the data presented in my article, it is seen that an average of about 4 occurrences of dental anomalies were noted in each patient with severe root resorption. The article by Lee et al analyzed only the average amounts of root resorption in their samples. Only 4 cases had more than 2 occurrences of anomalies, the remaining 80 patients thus having only 1 or 2 occurrences each. Neither the occurrence of excessive root resorption, defined as more than one third of the length of at least one root, nor the resorption data for the individual types of tooth anomalies were reported. Obviously, the study of Lee et al analyzed a different problem from that reported in my article. The fact that no differences were observed between the dental anomalies sample and the control sample in the study of Lee et al does not document that patients with a certain pattern of dental anomalies are not at increased risk for excessive root resorption. It only documents that their research project was not adequately designed to test for the risks reported in my article. In a study in which more than 2 dental anomalies (namely, 3) were present in only 4 subjects, it is hardly acceptable to conclude that “...patients with more than one anomaly did not appear to be at increased risk.” The AJO/DO assumes a great responsibility for the possible malpractice committed by practitioners who might be misled to follow the official endorsement that follows from the inclusion of the article by Lee et al in the Continuing Education section of the Journal and, in particular, in the CE Credit test: Learning Objective 1 and Article 1, Question 3: “Which of the dental anomalies examined in this study was a risk factor for apical root resorption?” Inger Kjær, Dr Odont, Dr Med Copenhagen, Denmark
It’s All in the Details I am GC America’s product manager for orthodontic products. I recently read “The air-abrasion technique versus
American Journal of Orthodontics and Dentofacial Orthopedics/April 2000
23A
Revisiting Root Resorption Rosa Y. Lee, Jon Årtun, and Todd A. Alonzo, in their article “Are dental anomalies risk factors for apical root resorption in orthodontic patients?” (Am J Orthod Dentofacial Orthop 1999; 116:187-95) report a meticulous radiographic study of apical root resorption in a sample of 84 orthodontically treated patients with various dental anomalies and in a control sample without the presence of anomalies. In their discussion, they refer extensively to my article, “Morphological characteristics of dentitions developing excessive root resorption during orthodontic treatment” (Eur J Orthod 1995; 16:25-34), in which I reported a high prevalence of various types of dental anomalies observed on radiographic material from 107 orthodontic patients submitted by 35 orthodontic practitioners according to the criterion that more than one third of at least one root had been resorbed during the orthodontic treatment. Fortunately, such excessive root resorption occurs only rarely during an orthodontist’s career, but, on the other hand, is well remembered. A total of 418 occurrences of one or more of 19 types of dental anomalies were reported, the most prevalent being 64 occurrences of short-root anomaly of incisors. The fact that such a large number of anomalies of tooth formation was observed in my sample suggests that these
extreme types of root resorption are probably not just extreme variants of the common, minor, and clinically insignificant root resorptions that are seen after most orthodontic treatments. Rather, it indicates that such patients are probably at special risk for root resorption, and therefore require a special approach to their orthodontic treatmentplanning to avoid the catastrophic side effects. The problem of detecting these patients has not been solved. The study of Lee et al shows that it is not enough to single out patients with “dental anomalies” in general. In my article, it was concluded that the dental anomaly associations with root resorption can be divided into 3 levels: strong associations are found for invagination, abnormal root shapes, such as short root length, pipette shaped roots, abrupt root deflections, and taurodontism; associations are found for ectopia and agenesis; and possible associations are expected for abnormal patterns of resorption of deciduous teeth. From the data presented in my article, it is seen that an average of about 4 occurrences of dental anomalies were noted in each patient with severe root resorption. The article by Lee et al analyzed only the average amounts of root resorption in their samples. Only 4 cases had more than 2 occurrences of anomalies, the remaining 80 patients thus having only 1 or 2 occurrences each. Neither the occurrence of excessive root resorption, defined as more than one third of the length of at least one root, nor the resorption data for the individual types of tooth anomalies were reported. Obviously, the study of Lee et al analyzed a different problem from that reported in my article. The fact that no differences were observed between the dental anomalies sample and the control sample in the study of Lee et al does not document that patients with a certain pattern of dental anomalies are not at increased risk for excessive root resorption. It only documents that their research project was not adequately designed to test for the risks reported in my article. In a study in which more than 2 dental anomalies (namely, 3) were present in only 4 subjects, it is hardly acceptable to conclude that “...patients with more than one anomaly did not appear to be at increased risk.” The AJO/DO assumes a great responsibility for the possible malpractice committed by practitioners who might be misled to follow the official endorsement that follows from the inclusion of the article by Lee et al in the Continuing Education section of the Journal and, in particular, in the CE Credit test: Learning Objective 1 and Article 1, Question 3: “Which of the dental anomalies examined in this study was a risk factor for apical root resorption?” Inger Kjær, Dr Odont, Dr Med Copenhagen, Denmark
It’s All in the Details I am GC America’s product manager for orthodontic products. I recently read “The air-abrasion technique versus
American Journal of Orthodontics and Dentofacial Orthopedics/April 2000
23A