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Hammers, Nails, and Misdiagnosis

The 20th-century psychologist Abraham Harold Maslow is remembered as both the father of contemporary humanistic psychology and the developer of the famous "Hierarchy of Needs", which is almost a catechism to every undergraduate psychology major. But when I think of Maslow, what usually come to my mind are his keenly insightful aphorisms. For instance, whenever I become discouraged about one or another aspect of life, a Maslow quotation, "The good society is one in which virtue pays", seems to bring some sanity to an uncomfortable situation.

Such a situation arose recently, when I was called onto review a paper dealing with treatment of relapsed maxillary incisor crowding in an adult female. The authors, while impeccably credentialed and unquestionably meticulous in their measurements of tooth movement and their scientific technique, missed the entire point of the case. It would never have relapsed if it had been treated appropriately to begin with--and darned if the authors did not repeat the same diagnostic mistake all over again. Sure enough, one of Maslow's quotes went right to the heart of the matter: "If the only tool you have is a hammer, you tend to see every problem as a nail." The authors of this paper seemed to have only one tool at their disposal, and that was straightening teeth. Because of their narrow diagnostic mindset, they couldn't see that the case would have been treated better with some judicious restorative dentistry and conservative cosmetic bonding.

Any prudent and caring clinician wants to please the patient, and the patient's chief complaint is certainly at the top of our diagnostic problem list. If the main problem in the patient's mind is "crooked teeth", the simple solution is to straighten them in the easiest and cheapest way possible. If that can be done without braces, so much the better. All too often, though, orthodontists--and other practitioners as well--allow patients' wishes to skew their better judgment. Our professional training and experience should allow us to point out that, for example, extractions may be necessary, or that while the teeth could be made straight by a simple removable appliance, the resulting tooth positions might be unstable and prone to relapse.

The case in question was just such a patient. She presented with a high-angle, Class I crowded dentition, with crowded and flared upper and lower incisors. It was a typical example of what Tweed referred to as a bimaxillary protrusion. If the original treatment had involved extraction of four first bicuspids and some judicious use of headgear, this retreatment would never have been necessary. Unfortunately, in the minds of those who diagnosed the case after the relapse of crowding, the simple expedient of tooth straightening was in order. Their only tool was a hammer, so the problem became a nail. They elected to retreat to the occlusion that was improperly treated in the first place. To comply with the patient's wishes, the authors did not suggest extractions and relied on an inexpensive, but inappropriate, removable appliance. In this case, if the patient did not want extractions and braces, the best orthodontic treatment would have been referral to a cosmetic dentist. Not all malocclusions should be handled by orthodontics.

The authors of this paper used some impressive high-tech gadgets to record individual tooth positions in three dimensions as the case progressed. They kept enviable records. But they still missed the forest for the trees; they treated a relapsed high-angle, Class I bimaxillary protrusive case back to a high-angle, Class I bimaxillary protrusive case with straight teeth. It' sdoomed.

Any orthodontist worth his or her salt knows that there are many more subtle nuances to malocclusions than just crooked teeth. The authors of this case report were well educated and certainly well intended--they wanted to do what they could to make their patient happy. That involved simply giving the patient straight teeth again, without considering the long-term implications. Another of Maslow's quotes came to mind: "People are not evil, they are schlemiels."



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