THE READERS' CORNER

Topics are adult vs. child treatment and use of headgear.

1. In your practice, how is adult orthodontic treatment different from child orthodontic treatment in terms of:

a. Length of treatment? The majority of the readers felt that adult treatment took longer than child treatment--commonly an extra six months. About a third said that their treatment times were similar, with the increased difficulty of adult treatment offset by improved cooperation.

b. Treatment plans? Although they agreed almost unanimously that adult therapy was much more likely to involve surgery, the respondents were divided equally regarding the need for extractions. One group reported trying to minimize extractions, particularly in the lower arch, using procedures such as air-rotor stripping. The other group felt that extractions, usually of upper first bicuspids, were often needed because of the lack of growth potential. Both groups recognized that adult treatment requires more compromises. They were equally likely to use more ceramic brackets, particularly on upper anterior teeth, than in children.

c. Retention? More than 80 percent of the clinicians used longer periods of retention with their adult patients. The term ''indefinite retention" was mentioned frequently. The most common appliances were a maxillary Hawley retainer, worn at night, and a mandibular bonded cuspid-to-cuspid retainer.

d. Privacy? A little more than two-thirds of the respondents said they had no separate treatment area for their adult patients.

e. Appointment scheduling? Some readers reported mixing adults in with adolescents, while others tried to schedule adults at specific times--midmorning, for instance--when children were less likely to be in the office.

f. Staffing? Without exception, the orthodontists said they used the same staff members for both adult and adolescent patients. Some made an effort, however, to schedule an adult patient with the same staff member whenever possible.

g. Fees? More than 85 percent of the practices charged more for adults than for children. Twenty percent and $500-600 were the figures most commonly mentioned as the increased amounts.

Specific comments included:

"I use the open bay for both adult and child treatment. Adults are encouraged to come in the midmorning, thus avoiding the after-school rush."

"We have had no negative feedback, to my knowledge, on integrating adults and adolescents together in our practice. In fact, some adults like it--it makes them feel younger!"

"We use a 'semiprivate' area for the adults (two chairs located off the main bay)."

"I do enjoy treating adults, but they definitely require more explanation, caution, care, and time."

"Because many adult patients require periodontal therapy and restorative care as well as potential surgical phases of treatment, the amount of time spent in consultation with other health-care professionals and coordination of efforts dictate longer treatment planning and I justify higher fees."

2. In what cases or phases of treatment do you use headgear alone?

The clinicians were divided equally between those who did and those who did not use headgear alone. Maxillary skeletal protrusion, space loss due to early loss of upper primary second molars, and the need to distalize upper first molars were the three most commonly cited reasons for using headgear alone.

In what cases do you use headgear in combination with fixed appliances? removable appliances?

More than three-quarters of the respondents used headgear in conjunction with fixed appliances, principally to produce an orthopedic change in a Class II malocclusion. Many clinicians also employed headgear to enhance molar anchorage during closure of extraction sites.

Only about a third of the clinicians reported using headgear in conjunction with removable appliances. A headgear was often combined with an activator or bionator to improve the skeletal correction and vertical control.

Do you select a certain headgear for a certain tooth movement, or do you generally use the same headgear?

Most respondents said they varied the type of headgear, based mainly on the patient's expected direction of growth. Cervical headgears were by far the most common (80 percent), with high-pull headgears used in cases of open-bite tendency.

Do you modify the facebow to influence tooth movement?

More than 90 percent of the orthodontists replied that they modified the facebows. Both the length and the angulation of the outer arms were frequently adjusted to control molar eruption and to direct the line of force through the center of resistance of the teeth.

Do you believe there are any unfavorable effects from use of cervical headgear?

The extrusion of maxillary molars and subsequent opening of the mandibular plane angle was almost universally mentioned as the principal side effect of cervical headgear. Some clinicians said they took advantage of this effect to benefit certain deep-bite cases.

How do you control mesial-in rotation of molars when using headgear?

Some respondents preferred to use archwires or transpalatal arches to derotate molars before placing a headgear. Many said their appliance prescriptions included 1st-order bends to alleviate this problem. Others said they would gradually bend in the distal end of the inner bow as the headgear took effect.

How do you control intermolar width when using headgear?

Keeping the inner bow expanded was by far the most common response, although some clinicians reported using transpalatal arches.

Can you achieve a unilateral effect with headgear?

More than 80 percent of the respondents felt they could achieve a unilateral effect. Virtually all used a longer outer bow on the side where the greater distalization was required, and they concurrently expanded the arch to prevent molar crossbite.

Do you use headgear for anterior retraction?

About 60 percent said they did not use headgear for anterior retraction; of those who did, two-thirds used a Kloehn inner bow as anchorage during space closure, and the others attached J-hooks directly to the archwire or brackets.

What is your best motivational tool for gaining patient cooperation?

Fervent prayer was mentioned, with tongue only partially in cheek, by several respondents. Other common suggestions included making the patient understand and take ownership of the problem; explaining the consequences of poor cooperation, such as extractions; and treating the patient as a mature person, giving the patient rather than the parents the responsibility for treatment success.

How do you insure patient safety when prescribing headgear?

Nearly all of those responding said they used breakaway headgear. Most of the clinicians also stressed the importance of carefully instructing patients and parents to use headgear properly and to avoid wearing it during athletics or other physical activities.

Comments included:

"Sometimes we need to place appliances just to rotate the molars before headgear can be initiated."

"Our best motivational tool is to make the patient understand the reason and need for the headgear--making the patient understand that treatment will take much longer without it and that as a last resort, if poor patient cooperation extends treatment excessively, additional fees will be added on. This motivates the parents to motivate the patient."

"The 'Bart Simpsons' of the '90s are so undisciplined that the orthodontist must find and use 'doctor-controlled' mechanotherapy."

"In order to motivate patients, I give them a vision of the treatment goal. I remain positive and praise them whenever possible."

"Motivating patients comes down to understanding what the patient wants as an end result, then shaping your appliance rationale to support the benefit. They have to motivate themselves with our thoughtful support."

JCO wishes to thank the following contributors to this month's column:

Dr. Lloyd K. Adkins, Richwood, WV

Dr. Joseph M. Arcidi, Concord, MA

Dr. Robert A. Arnold, Watertown, SD

Dr. Paul O. Austin, Pensacola, FL

Drs. Michael Baron and Edward G. Steinlauf, Branford, CT

Dr. William J. Bauer, Springfield, MO

Dr. Anton J. Bisbas, San Diego, CA

Dr. Eugene Brain, Renton, WA

Dr. D. Gregory Brooks, Dunn, NC

Dr. Saul M. Burk, Gaithersburg, MD

Dr. David R. Carden, Jacksonville Beach, FL

Dr. William H. Craig, Wilmington, NC

Dr. James M. Danko, Worcester, MA

Drs. Philip Doster and Oliver Willham, Des Moines, IA

Dr. A. Joseph Ecker, Camarillo, CA

Dr. Daniel B. Farber, Rockville, MD

Dr. Guy A. Favaloro, LaPlace, LA

Dr. Alvaro A. Figueroa, Woodridge, IL

Dr. Michael J. Foy, Colorado Springs, CO

Dr. Robert E. French, Laguna Beach, CA

Dr. Mark Geller, Plano, TX

Dr. Kenneth R. Greenbaum, Salem, OR

Dr. Ronald G. Hieber, Reynoldsburg, OH

Dr. Townsend V. Holt, Florence, SC

Dr. Gary O. Inman, Elizabethtown, kY

Dr. Ralph L. Jensen, Paoli, PA

Dr. Gerald Jacobson, Cherry Hill, NJ

Dr. S. Meredith Johnson, Jeffersonville, IN

Dr. John T. Krull, Indianapolis, IN

Dr. Leo Lane, Petaluma, CA

Dr. David E. Massignan, Bay City, MI

Dr. Thomas J. Melcher, Louisville, CO

Dr. Deborah F. Novak, High Point, NC

Dr. Jan A. Olenginski, Wilkes-Barre, PA

Dr. Barrett J. Parker, Alameda, CA

Dr. John S. Phelps, Carbondale, IL

Dr. George F. Pinsak, Monroe, NC

Dr. J. Scott Pinkard, Marquette, MI

Dr. Robert S. Portenga, Traverse City, MI

Dr. William W. Robinson, Sherman, TX

Dr. Steven L. Shcer, Westport, CT

Dr. Stephen Searcy, Lafayette, LA

Dr. Hugh C. Sobottka, Seattle, WA

Dr. Albert M. Stush, Lewisburg, PA

Dr. Wayne D. Summers, Lincoln, NE

Drs. Edwin S. Sved and Neil O. Lawner, East Brunswick, NJ

Dr. Steven H. Tinsworth, Bradenton, FL

Dr. William L. Wright, Jackson, MI