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Orthodontic guidelines
576 Readers’ forum
American Journal of Orthodontics and Dentofacial Orthopedics May 2007
can influence dentofacial morphology.” This might be correct; however, in a cross-sectional study, the temporal sequence is uncertain. The results of this study could also support the reverse hypothesis—that abnormal dentofacial morphology precedes the development of TMJ disorders and is a risk factor for their occurrence. In the retrospective cohort study by Flores-Mir et al, the participants were recruited from a previous cross-sectional investigation that found an association between altered facial morphology and TMJ disc status in adolescents. These participants were followed over time, and those with disc abnormalities had reduced maxillary and mandibular facial growth. However, given the results of the previous crosssectional study, it seems likely that, at the beginning of the cohort study, altered facial morphology was already associated with disc status. Under these circumstances, the observed reduction in facial growth could merely reflect initial differences, by disc status, in facial morphology and associated growth potential. (Adjustment by initial facial morphology or presentation of the results stratified by initial facial morphology might clarify this issue.) These potential ambiguities illustrate how difficult it can be to investigate the relationship between facial morphology and TMJ disorders. Randomization of TMJ disorders to persons at risk of developing abnormal facial morphology, or randomization of facial morphology to those at risk of developing TMJ disorders, is not possible. Therefore, we are left with nonrandomized studies and their attendant difficulties with design, analysis, and interpretation.
both our hands and our intelligence. Orthodontics is demanding and, at times, frustrating. We will always seek perfection and will rarely, if ever, achieve it. This was rightly put by Dr James Vaden2 as the “achievable optimum” for cases that are beyond the envelope of discrepancy and to meet realistic goals in terms of cost-benefit analysis. Achievable optimum holds good for treatment of any malocclusion and, especially, for patient satisfaction. Considering the above-mentioned scenario, we believe it will be worthwhile to establish firm orthodontic guidelines, but not before the search and ultimatum of evidence-based solutions to the controversies. Because of the many independent variables involved in orthodontic treatment, it might never be possible to identify evidence-based methods for all orthodontic procedures. But the effort is worthwhile. Tolerance and understanding of conflicting opinions and evidence are mantras for every orthodontist. Today, many old theories and facts are resurging, and new concepts are developing. We have traveled far from Pierre Fauchard’s “bandelette” to today’s skeletal anchorage, and the search will likely continue for some time into the future. Arunachalam Sivakumar Ashima Valiathan Manipal, India
James R. Miller Carmel, Ind
1. Walker L, Levine H, Jucker M. Koch’s postulates and infectious proteins. Acta Neuropathol 2006;112:1-4. 2. Vaden J. Case reports: Achievable optimum. World J Orthod 2002;3:41-9.
Am J Orthod Dentofacial Orthop 2007;131:575-6 0889-5406/$32.00 Copyright © 2007 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.03.012
Am J Orthod Dentofacial Orthop 2007;131:576 0889-5406/$32.00 Copyright © 2007 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.03.004
REFERENCES
Editor’s response Orthodontic guidelines We read with interest Dr Turpin’s comments in the February 2007 editorial regarding the establishment of orthodontic guidelines for the management and correction of malocclusions (The case for treatment guidelines. Am J Orthod Dentofacial Orthop 2007;131:159) and would like to express our opinion regarding this. Malocclusion is never a diseased state. The postulates of Koch1 and the therapeutic procedures for medical problems go hand in hand toward standardized care, as rightly stated by Dr Loren H. Roth. We believe that we, as orthodontists, can hardly plan treatment based solely on the desires of our patient or any standing guidelines. The treatment plan must be organized by the orthodontist and based on what previous studies set out and what the orthodontist’s eye determines is best. Not all orthodontic knowledge is in a book. The conundrum is how one can address all of the prevailing controversies in orthodontic education and practice. There is no “any-almost-always” system in orthodontic theory and practice. No other specialty offers a better opportunity to use
Thank you for taking time to respond to my editorial. Although few members realize it, the American Association of Orthodontists appointed a committee that started working on the development of practice guidelines in 1994; it eventually voted on and passed them in 2001. After reading them, I found these guidelines to be well written and definitely a good starting point. In fact, they could be more appropriately titled practice management guidelines instead of treatment guidelines. The description of what needs to happen as a patient enters a practice, including the gathering of a health history, the appropriate records, and a written diagnosis and treatment plan with alternatives, is excellent. Overall, the guidelines are very broad and all-inclusive when describing proposed categories of treatment. I agree that “it might never be possible to identify evidence-based methods for all orthodontic procedures.” That fact we are well aware of, as more and more systematic searches come up empty. Without doubt, the entire set of AAO guidelines needs to be upgraded, specifically in the areas of the types of records that might be appropriate now— considering new technologies, including cone-beam
American Journal of Orthodontics and Dentofacial Orthopedics May 2007
can influence dentofacial morphology.” This might be correct; however, in a cross-sectional study, the temporal sequence is uncertain. The results of this study could also support the reverse hypothesis—that abnormal dentofacial morphology precedes the development of TMJ disorders and is a risk factor for their occurrence. In the retrospective cohort study by Flores-Mir et al, the participants were recruited from a previous cross-sectional investigation that found an association between altered facial morphology and TMJ disc status in adolescents. These participants were followed over time, and those with disc abnormalities had reduced maxillary and mandibular facial growth. However, given the results of the previous crosssectional study, it seems likely that, at the beginning of the cohort study, altered facial morphology was already associated with disc status. Under these circumstances, the observed reduction in facial growth could merely reflect initial differences, by disc status, in facial morphology and associated growth potential. (Adjustment by initial facial morphology or presentation of the results stratified by initial facial morphology might clarify this issue.) These potential ambiguities illustrate how difficult it can be to investigate the relationship between facial morphology and TMJ disorders. Randomization of TMJ disorders to persons at risk of developing abnormal facial morphology, or randomization of facial morphology to those at risk of developing TMJ disorders, is not possible. Therefore, we are left with nonrandomized studies and their attendant difficulties with design, analysis, and interpretation.
both our hands and our intelligence. Orthodontics is demanding and, at times, frustrating. We will always seek perfection and will rarely, if ever, achieve it. This was rightly put by Dr James Vaden2 as the “achievable optimum” for cases that are beyond the envelope of discrepancy and to meet realistic goals in terms of cost-benefit analysis. Achievable optimum holds good for treatment of any malocclusion and, especially, for patient satisfaction. Considering the above-mentioned scenario, we believe it will be worthwhile to establish firm orthodontic guidelines, but not before the search and ultimatum of evidence-based solutions to the controversies. Because of the many independent variables involved in orthodontic treatment, it might never be possible to identify evidence-based methods for all orthodontic procedures. But the effort is worthwhile. Tolerance and understanding of conflicting opinions and evidence are mantras for every orthodontist. Today, many old theories and facts are resurging, and new concepts are developing. We have traveled far from Pierre Fauchard’s “bandelette” to today’s skeletal anchorage, and the search will likely continue for some time into the future. Arunachalam Sivakumar Ashima Valiathan Manipal, India
James R. Miller Carmel, Ind
1. Walker L, Levine H, Jucker M. Koch’s postulates and infectious proteins. Acta Neuropathol 2006;112:1-4. 2. Vaden J. Case reports: Achievable optimum. World J Orthod 2002;3:41-9.
Am J Orthod Dentofacial Orthop 2007;131:575-6 0889-5406/$32.00 Copyright © 2007 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.03.012
Am J Orthod Dentofacial Orthop 2007;131:576 0889-5406/$32.00 Copyright © 2007 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.03.004
REFERENCES
Editor’s response Orthodontic guidelines We read with interest Dr Turpin’s comments in the February 2007 editorial regarding the establishment of orthodontic guidelines for the management and correction of malocclusions (The case for treatment guidelines. Am J Orthod Dentofacial Orthop 2007;131:159) and would like to express our opinion regarding this. Malocclusion is never a diseased state. The postulates of Koch1 and the therapeutic procedures for medical problems go hand in hand toward standardized care, as rightly stated by Dr Loren H. Roth. We believe that we, as orthodontists, can hardly plan treatment based solely on the desires of our patient or any standing guidelines. The treatment plan must be organized by the orthodontist and based on what previous studies set out and what the orthodontist’s eye determines is best. Not all orthodontic knowledge is in a book. The conundrum is how one can address all of the prevailing controversies in orthodontic education and practice. There is no “any-almost-always” system in orthodontic theory and practice. No other specialty offers a better opportunity to use
Thank you for taking time to respond to my editorial. Although few members realize it, the American Association of Orthodontists appointed a committee that started working on the development of practice guidelines in 1994; it eventually voted on and passed them in 2001. After reading them, I found these guidelines to be well written and definitely a good starting point. In fact, they could be more appropriately titled practice management guidelines instead of treatment guidelines. The description of what needs to happen as a patient enters a practice, including the gathering of a health history, the appropriate records, and a written diagnosis and treatment plan with alternatives, is excellent. Overall, the guidelines are very broad and all-inclusive when describing proposed categories of treatment. I agree that “it might never be possible to identify evidence-based methods for all orthodontic procedures.” That fact we are well aware of, as more and more systematic searches come up empty. Without doubt, the entire set of AAO guidelines needs to be upgraded, specifically in the areas of the types of records that might be appropriate now— considering new technologies, including cone-beam