THE EDITOR'S CORNER
The term surgical-orthodontics has been used to describe surgical procedures in conjunction with orthodontic procedures and surgical procedures as a substitute for orthodontic procedures. What is really needed is a diagnostic procedure that will differentiate between the two, a diagnostic procedure that would serve as common ground for both the oral surgeon and the orthodontist.
There are cases for which the only practical solution is orthodontic treatment and there are cases for which the only practical solution is surgical treatment. There are cases that are best treated with a combination of surgical and orthodontic treatment.
Oral surgeons know what they can do and often have little conception of what orthodontists can do. Orthodontists know what they can do and often have little conception of what surgery can accomplish. Oral surgeons do not yet seem to lay much store in cephalometrics. Orthodontists have probably overused cephalometrics. Oral surgeons will undertake a surgical treatment where they think it feasible. Orthodontists will undertake an orthodontic treatment where they think it feasible. If one hundred patients were to see an oral surgeon and an orthodontist independently, the chances are that each specialist would accept a high percentage for his method of treatment. Under these circumstances, the diagnosis may depend upon who sees the patient first. This does not imply that the patient will be mistreated, but it is a situation that requires new information and understanding on the part of the two specialties, and some change in their training and in their interprofessional relations. The public is entitled to a coordinated effort based on mutual understanding of the problems. In dental schools at the graduate and undergraduate levels and in hospital dental departments, somebody should be responsible for seeing that the disciplines in dentistry are tied together and that students and practitioners recognize the need for and implement group effort on behalf of the patient and group understanding of patients problems.
Orthodontists are capable of treating a wide range of abnormalities. The fact that we can most often achieve a satisfactory result on the cases we undertake should not close our minds to the possibility that we rarely entertain, that some of the more marked growth problems might have fared better with a combination of orthodontics and surgery. We treat cases with deficient mandibles and with protrusive maxillae by tooth movement alone, when some of these might be even better results if we were able to recognize when a combination therapy is called for. Rather than tip teeth off base to satisfy centric occlusion, surgery to advance an underdeveloped mandible, in addition to orthodontic treatment, might be superior. A chin implant might be called for more often than we now prescribe. Some maxillary surgery on mid-face protrusion might do more to carry back the prominent maxilla than tooth movement alone. We all recognize the extreme Class III malocclusion as a surgical case. The problem is with the less-than-extreme.
On the surgical side, the confidence of surgeons generally can justify, for them, the treatment by surgery of a less-than-extreme case which would be amenable to orthodontic treatment. This does not imply that all less-than-extreme cases should be treated orthodontically. There should be some consideration of alternative treatment and some option on the part of a patient if the short inconvenience and discomfort of the surgical procedure is a factor when compared to the much longer period of orthodontic treatment. Some individuals cannot physically or psychologically go through with orthodontic treatment; some refuse to; and some adults may find it inconvenient to.
Nevertheless, oral surgeons cannot continue to work in cubits in a millimeter world. They cannot ignore the information that cephalometrics can provide and they cannot continue to make diagnoses prior to orthodontic consultation. We need a coordinated profession and the fact that we don't have one is nowhere more apparent than in surgical-orthodontics.
What to do if you become involved in a surgical-orthodontic case? Stick to your guns. If you are convinced that your diagnosis is correct, do not participate in a treatment program based on another diagnosis. Try your best to advocate your opinion on behalf of the patient, but if you fail to gain concurrence, inform the patient of the lack of agreement and withdraw from the case.
Informing the patient of the facts in the case as you see them is not a betrayal of professional ethics. It was never intended that the interest of the patient be subordinated to concepts of professional manners. Often, the patient needs a friend in your own office, let alone in the midst of a disagreement of professional judgment. Orthodontists need to be informed about surgical procedures and forceful in support of their diagnostic opinion of shared cases.
