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A most significant survival factor in orthodontics turned up in a conversation that I had with Bob Schulhof of Rocky Mountain Data Systems (See page 776). Most orthodontists probably have not paid much attention to the economic effect of extraction versus nonextraction. A good deal of the time in the past the same decision should have been made even if some weight had been given to whether an extraction decision would be refused and the patient either not have orthodontic treatment or find treatment elsewhere in the orthodontic or GP community.

It is necessary to reexamine the extraction-nonextraction decision in light of new knowledge in orthodontic diagnosis and treatment to be sure that we are not reflexly making the same extraction decision on outmoded diagnostic and treatment premises and driving patients away from orthodontic offices either before, by our reputation as extractionists, or after the case is presented.

Orthodontics has been progressing at an unprecedented rate and we have capabilities in the areas of diagnosis and treatment which must be taken advantage of simply because it is a better way and just incidentally because it may result in retrieving a group of patients whose prejudice against extraction may occasionally have been justified in light of newer knowledge, but perhaps was not achievable at the level of diagnosis and treatment which existed at that time.

Our specialty has grown up in phases. We have gone through a phase in which we were appliance-oriented. In relation to extraction-nonextraction, we had appliances and appliance techniques which required extraction a great deal of the time, as well as appliances which were not designed to handle closure of extraction spaces very well. Frequently, the appliance and treatment technique would have a strong influence on the extraction-nonextraction decision.

Great sophistication has been achieved in appliance mechanics. In understanding, in treatment technique, and in hardware, we have mastered appliances to a point where we are better able to achieve the precise tooth movements that we may want. Some orthodontists are superior and can achieve excellent control with any appliance. The rest of us should consider whether appliances are not available which may increase our control capabilities and, in doing so, throw more cases into a nonextraction category and, in doing that, not only preserve teeth, but be practice building at the same time.

In diagnosis, we have gone through a phase in which we were depending on a few cephalometric measurements to set up rigid criteria for extraction, and are advancing to a high level of sophistication in diagnosis and treatment planning. An obvious example in connection with the extraction-nonextraction decision is that we have learned to compromise with the IMPA in deference to chin development and the appearance of the face. Valuable though it may have been, the Tweed triangle should pass into history, at least as the sole cephalometric input into orthodontic diagnosis.

We are in the age of the computer. We are talking about being able to separate the majority of our patients who are likely to behave in a predictable manner, from those who may not and, at least for that majority, to be able to separate the effects of growth and the effects of treatment, to approach diagnosis of the average patient with a much clearer visualization of the arrangement of his parts and of the rearrangement that will occur through growth and can occur through treatment. As we continue to refine our understanding, we may throw more of those at either end of the majority into the middle.

Computerization may complicate our lives, but it has the potential to give us a much more sophisticated understanding of our work and it may avoid some extractions. The computer can juggle more factors than a human with a pencil is likely to, and it can give nonextraction the edge more often than other methods of analysis by narrowing the borderline.

No matter how satisfied one may be with his treatment results, complacency about it may be his worst enemy, if he does not investigate thoroughly whether the newer diagnostic methods and treatment systems will permit him to provide a service that is superior to his present effort in terms of control, efficiency, effectiveness, and in terms of a more finely tuned extraction-nonextraction decision.



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