Veristic reporting

logical to believe that less leadership is evident now in academic orthodontics? This should not belittle the valiant efforts made in certain departments, but the majority are not doing very much or what they are doing is less publishable, marketable, or presentable. The next issue to address is that of manpower and of internal structure under which our teaching units operate. It has already been pointed out that we no longer can uniformly say “departments of orthodontics,” because many schools have changed or plan to change this teaching unit into a section, a division, a program, or a similar lower-designation unit. This restructuring and renaming process does not seem to affect all disciplines equally; orthodontics appears to be on top of the hit list. it does not take a high degree of eloquence to convince the reader that the loss of departmental designation generally means the loss of its autonomy and the loss of prestige, and even higher financial and fiscal dependability. Let us consider briefly the question of academic manpower within teaching units. First, who wants to teach, and why? Sure, there are genuinely interested persons with the talent to be teachers, but they rightly expect to be justly compensated for their work and effort. It is disheartening to report that newly graduating orthodontists entering private practice frequently command incomes higher than full-time orthodontic faculty members with years of experience. In many places, and for many years, this problem was handled by hiring graduates of foreign dental schools, who generally could not obtain an unrestricted license to practice orthodontics. This important, albeit somewhat unfair, avenue of securing faculty members is drying up as more and more states do not allow appointments of clinical faculty without “proper” credentials. In addition, it is common for a junior faculty member to stay in a department for a relatively short period of time. After a year or two, he or she often resigns for one or more of the following reasons: financial discrepancy between the faculty salary and practice income; workload put upon the faculty, especially in units where there are vacancies or shortages of faculty members; increasing pressures from a school’s tenure and promotion committees; and, finally, the currently high ievel of insecurity about the future of many dental schools (i.e., closing of the dental schools at Georgetown, Oral Roberts, Emory: Fairleigh Dickinson, Washington University, etc,). All these factors directly affect the department head, who is frequently the only senior faculty member in the unit. There is also the increasing expectation of ABO certification which in the past has been made difficult to achieve in an academic setting. The practice opportunities are often very limited, mainly because of time constraints. One other factor making the life of the head of an orthodontic unit difficult is the proverbial incompatibility with the school’s administration. It is really hard to know why dental school deans and heads of orthodontic units do not work well together. Have you checked recently how many dental school deans are orthodontists?

It is hard to understand why more ~~~odo~tist§ are not recognized for their achievements and administrative abilities, and named deans. Another peril for our aging o~hodontic leaders is a possibility of job burnout. Those who have been at the helm of a department for many years, and who have not been adequately supported, recognized and compensated, are likely to seek a way out. Two options are clearly available: one is the switch to a private practice; the other, a relatively new alternative, is early retirement. A significant number of weathered orthodontic educators have been taken out of education by either mechanism. Where is the solution? Indeed, where is this small segment of our higher education heading? Quo vadis? I can offer no easy answers, for it will take a great deal of careful planning and determined action on the part of orthodontists (and that will have to include both the private and the academic sectors) and the dental schools’ administrators alike. Salaries and other forms of compensation will have to be carefully reevaluated because discrepancies have to be eliminated. recognition in nonmaterial, nonmonetary forms is in order. Perhaps some tooting of our own horn may be needed. The alarming fact must come into clear focus and receive immediate attention: orthodontic educators, particularly department heads, are an endangered species. Let us awake those empowered to take some action before it is too late. A concerned orthodontic department head

Veristic reporting To the Editor:

I am often inspired by the case reports that are published in the AMERICAN JOURNAL OF ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS, by both the quality of the results and the polish of the treatment records. f-lowever, the case presented in the April 1989 issue ~Q~hodontic Treatment of a Patient Born With a Severe Right Unilateral Cleft Lip and Palate”) appeared deficient in a number of areas. The management of a patient with a cleft palate is invariably an educating experience for both the clinician and the observer; the treatment objectives are demanding and the limitations frustrating. The clinician is also presented with a number of compromising options of retaining unfavorable teeth or moving teeth into unfavorable locations. The case in question is no exception and should be cited for some of the controversies it presents. Briefly, I would like to address the following points. 1. Anterior esthetics is a key consideration, but no mention is made of why the upper midline was maintained to the left, opting for prosthetic replacement at the graft site. This vital aspect of the treatment was barely referred to after the brief note in the statement of the problem. This option has also resulted in an edge-to-

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A m . .I. Qrihod. Dent&-. Orrhop. September 1989

Letters to the editor

edge relationship on the left side, once again without any reference in the text. 2. An extraoral “smiling” photograph should be mandatory in such cases, regardless of the absence of a corresponding pretreatment photograph. The intraoral photographs by themselves are quite deceptive, although the aberrant midlines and occlusion do hint that a mismatch does exist. 3. One can only conjecture that some concern existed over the movement of the upper right central incisor into the graft, with the possible sequelae of root resorption or perhaps just resorption of the graft itself. If that were the case, then it would have been a most pertinent point worthy of mention. Furthermore, subjecting the patient to a permanent prosthesis in favor of just permanent retention needs justification. Finally, the perceived disadvantages of upper arch space closure may well have been outlined for completeness. aving treated a number of similar patients, I can well appreciate the dilemmas posed. The above points are not to be taken as criticism of the treatment result: rather they serve to highlight the apparent “glossing over” of some rather apposite aspects of the presenting malocclusion. After all, “cases” should be “reported” in a veristic manner if we are to benefit or learn from them. John Mamutil, BDS Westmead, Australia

To the Editor:

I write to express great concern to the orthodontists of the United States about a set of circumstances that has evolved over time in the professional relationship between orthodontists and oral and maxillofacial surgeons. I believe that orthodontists, in effect, tend to make surgical judgments too frequently without adequate consultation with surgeons. That fact has led large numbers of both types of specialists into unnecessary litigation. In this context, there are two specific types of problems that need public expression, The first has to do with orthodontists deciding that certain teeth should be extracted and then sending the patients to oral surgeons to have the procedures done; the second has to do with the manner in which patients are being told that orthognathic surgery is necessary as a corollary to their orthodontic treatment. In both of these situations, surgeons may find themselves in the compromised position of having to abdicate their decision-making roles, even though it remains the surgeon’s primary legal responsibility to do the surgery. I have now been an expert witness in a number of cases in which removal of deciduous teeth, first pre-

molars, and third molars was recommended by orthodontists or general dentists. Surgeons removed the teeth that were designated for removal, only, in a number of instances, to have to answer to a iawyer or a jury for having done so simply because the referring dentist said that the teeth should be extracted. I am not sufficiently knowledgeable about the reasons for removal of seemingly good, asymptomatic teeth for orthodontic reasons, but I have become convinced over many years of practice, that a significantly larger number of such teeth are removed than need be. This is especially true, I am convinced, in the case of unerupted third molars, since the after effects of such surgery often raise the legitimate question of whether the end justified the means! This decision, incidentally, is often made by the surgeon, without consultation with the prior treating orthodontist. Relating to the same subject is the undisclosed incidence of postoperative sequelae of all types, iflclud~ng TMJ disorders (both transient and permanent) that can occur from third molar surgery and o~hognathic procedures. It is both embarrassing and humiliating when an orthodontist and an oral surgeon have to answer to a lawyer for the development of such symptoms when the original surgery may well have been unwarranted or unnecessary! The orthognathic surgery matter is one of monumental seriousness! I am absolutely convinced that there are far too many such procedures done, with the initial impetus coming from the “innocent” mouths of orthodontists! Orthodontists often do not comprehend how serious, traumatic, and potentially dangerous such surgery is. Many orthodontists have never been in an operating room or seen such patients shortly after such surgery has been performed. They, albeit u~i~te~tional~y, tend to leave the patient and his/her parents with the impression that the surgery is simply part of the tr and “no big deal” when, in fact, it is a “very big deal”! Also, in too many orthognathic surgery cases the patient is left with permanent injuries and, in a select number of cases, treatment fails to accomplish the intended objectives. No one yet knows the true incidence of serious TMJtype postoperative problems that evolve from orthognathic surgery (or even from third molar surgery)? The incidence of relapse, being reported more and more frequently in the literature, is still a mystery. Every orthodontist knows that facial muscles have “memories” and that after surgery those muscles often are not ative” in leaving bone in the same place in w surgeon puts it during surgery! Orthodontic-related oral surgery should be pern formed only when the orthodontist and the oral work in close harmony with each other. As the d S and treatment plan should be shared between the two, so should the responsibility for doing the surgery. While much orthognathic treatment is being handled in this way today, more orthodontists should accompany their patients to the operating room to watch the surgery being