I have written a couple of times before about the delivery of orthodontic treatment as part of an interdisciplinary team effort. In July 2009, I expressed my admiration for orthodontists who keep abreast of developments in all areas of dentistry. In October 2010, I pointed out how interdisciplinary care that significantly improves a patient's facial appearance can bestow psychological benefits of enhanced self-esteem and self-efficacy not only on the patient in question, but on the doctor as well. When we raise the overall level of beauty in the world as active team players in these difficult cases, it reinforces my contention that what we do is not only an application of evidence-based clinical science but, at its very essence, an art form.
Although there is no doubt that the correction of a patient's malocclusion and facial appearance through orthodontics alone involves artistry, a number of orthodontists who have been practicing successfully and admirably for many years have told me that after awhile, all cases begin to look alike from a diagnostic standpoint. Having taught orthodontics and watched others teach orthodontics for more than a quarter of a century, I've always been amused at how quickly new graduate students learn the predilections of their senior faculty members--to the point that their own case presentations are generally based more on the senior clinician's idiosyncrasies than on any other diagnostic criteria: "Oh, this one is a case for Dr. So-and-So. He's Tweed. Let's extract the 8s, upper first bicuspids, and lower second bicuspids and use a J-hook headgear. No, wait--my mistake, this is a case for Dr. Such-and-Such; he's nonextraction. Let's apply a Schwarz appliance to the lowers first, a bonded palatal expander next, and correct the Class II with a Herbst." So much for artistic expression.
Complex malocclusions--particularly those seen in adults with mutilated dentitions--defy such broad-based diagnostic algorithms. You don't have to look very closely at these patients to reach the conclusion that each and every one of them is truly unique. Perhaps that explains my own fascination with complex, interdisciplinary cases. They demand not only an extensive knowledge of the evidence- based literature, but a tremendous level of creativity and individual expression from the orthodontist and every other participating specialist.
In this issue of JCO, you will note several examples of such outstanding interdisciplinary teamwork. From Portugal, Drs. Teresa Pinho, Celia Coutinho-Alves, and Manuel Neves present a complex case in which the patient had experienced significant periodontal disease and subsequent tooth migration, along with significant gingival recession that had compromised the crown-root ratios of most of the teeth and exacerbated the unesthetic appearance of the dentition. These authors display a firm grasp of the literature to go with an admirable level of artistry in the resolution of periodontal disease, correction of the malocclusion, and restoration of a functional occlusion with an esthetic outcome. I particularly liked their creative application of composite gingival restorations.
Some of my most challenging interdisciplinary cases have been those that involved physicians as well as various dental practitioners. In this issue, French orthodontists Adrien Marinetti and Jessica Soussan join with maxillofacial surgeon Dominique Deffrennes in describing a patient who had been treated with fixed appliances and elastics as a teenager, but whose mandible had remained Class II, with the lower incisors unacceptably proclined. Even though orthognathic surgery was clearly the best option, the authors' creative and artistic approach to uprighting the lower incisors without extractions resulted not only in an acceptable esthetic outcome, but in a functional occlusion with a full complement of teeth (third molars excluded).
Craniofacial anomalies require every ounce of evidence-based knowledge and artistic creativity we possess. From India, Drs. Karan Nehra, Mohit Sharma, Vineet Sharma, and Ramen Sinha present an extraordinarily complicated case of a 20-year-old male with a huge anterior open bite, microtia, long-face syndrome, and a constellation of malformations that few of us will ever encounter. The well-coordinated efforts of their interdisciplinary team resulted in a remarkable improvement in facial esthetics and occlusal function.
When asked why the graduate program I attended at the Eastman Dental Center of the University of Rochester, New York, included so many craniofacial-anomaly cases--all of them interdisciplinary--our venerable chairman, Dr. Daniel Subtelny, always replied, "You'll learn more about orthodontics from one complex interdisciplinary craniofacial case than you will from any 10 routine cases." The years have borne him out.