LETTERS TO THE EDITOR A concern about facial esthetics To the Editor:
The case report on page 10 of the January issue of the AMERICANJOURNALOF ORTHODONTICSAND DENTOFACIAL ORTHOPEDICSiS something that I must comment on.
At a time when our specialty is being bombarded from all directions for allegedly producing poor facial esthetics, producing temporomandibular joint problems, and not being truly concerned about excellent occlusion, I find this case report a little disturbing. If this is the best that we can offer our patients in esthetics in the late 1980s and early 1990s, then I think we are in big trouble as a dental specialty. The profile relationship in Fig. 19 on page 15 shows an extremely obtuse nasolabial angle of somewhere around 140 °. The patient's face has an absolutely empty appearance that I would not be proud to have as an example of my finest services for other patients in my community to see. I read the case report carefully and noted that originally the treatment plan was to prosthetically replace the maxillary lateral incisors. There was no clear reason given for altering the treatment plan to merely close all the spacing. I think the stage was set for failure when the statement was made on page 12 that "facial profile was within normal limits." I would have to say that, based on this assessment, being 5 feet 4 inches tall and weighing 400 pounds is "within normal limits." If the patient was given the option of orthognathic surgery and rejected it, then that certainly should have been mentioned. If, indeed, it was the judgment of the orthodontist treating this case that the best result would be achieved through orthodontics alone, I strongly disagree. A treatment plan featuring opening of spaces for lateral incisor bridges and orthognathic surgery would have given the best occlusion, function, and facial appearance. In my early years in practice, I would go to all lengths to eliminate the need for any type of prosthodontic treatment. It always seemed a shame to grind virgin teeth to make traditional bridges. With the many options available to us today, including bonded bridges, new ceramic bridges, and single-tooth implants, I think it is inappropriate for us to focus all of our energy on trying to close spaces to eliminate bridges at the expense of facial esthetics. I think it is fine to present this type of case report in our journal, but the write-up should have been completely different. It should have included the fact that this patient either rejected orthognathic surgery, and all of the above compromises had to be made because of that, or it should have talked about the severe lack of facial esthetics that resulted. This case was not treated in the 1970s, and I think the standard of care should be far beyond this in the late 1980s and 1990s. Instead of crying that the general practitioners are taking orthodontic cases away from us, we need to be
teaching the finest and best treatment to our orthodontic residents. The specialist's orthodontic office should be the place where a patient can come for the best facial esthetics and temporomandibular joint health, as well as alignment of the teeth. Teeth can be hidden by the patient but an unesthetic facial appearance cannot. This case only adds fuel to the fire of the general dentists who have been sometimes rightfully shooting bullets at our specialty in the last 10 to 15 years because of our lack of concern for facial esthetics. We are currently using a video imaging system in cases similar to this case report to show patients what their appearance will be after reopening of spaces for proper prosthetic replacement of missing teeth and orthognathic surgical procedures to properly relate the jaws. If those who treated this case would like an analysis with this machine to present to this patient, I would be happy to do that. All they would need to do is send me a full-size profile photograph like the one in Fig. 19, and I would gladly send them a polaroid photograph showing the dramatic difference a different treatment would have afforded this patient. William M. Hang, DDS Rutland, VT.
Reply To the Editor:
I appreciate the opportunity to answer some of the questions that the case report presented in the January issue has generated (AMJ ORTHOD DENTOFAC ORTHOP 1990;97:10-9). Several of the extraoral photographs selected for publication, including Fig. 19, showed the patient in a strained lip posture. However, several examples of the posttreatment soft tissue profile in which the patient demonstrated a relaxed lip posture were also included. Figs. 30 and 31 are more representative of the patient's soft tissue relationship at the end of treatment. In addition, the patient's soft tissue profile from the pretreatment, reanalysis, and postdebanding lateral cephalometric radiographs is demonstrated in Figs. 33, 34, and 35, respectively. Table II shows the soft tissue measurements derived from these radiographs. The nasolabial angle on the pretreatment radiograph (14Y-01M) was 125 °, while the nasolabial angle on the postdebanding radiograph (18Y-03M) was 121 °. (It is noted at the bottom of Table II that radiograph 17Y-10M was not used to measure the soft tissue values because the patient strained her lips while this radiograph was being taken.) The concern over facial esthetics should be reevaluated with this information. The question has also arisen as to why the original treatment plan was altered. The original treatment plan, developed at the Indiana University School of Dentistry, was interrupted when the patient and her family moved from Indianapolis for 1 year. During the patient's 1-year absence, she received orthodontic treatment at her new location. It was during this year that the spaces for the 27A
The case report on page 10 of the January issue of the AMERICANJOURNALOF ORTHODONTICSAND DENTOFACIAL ORTHOPEDICSiS something that I must comment on.
At a time when our specialty is being bombarded from all directions for allegedly producing poor facial esthetics, producing temporomandibular joint problems, and not being truly concerned about excellent occlusion, I find this case report a little disturbing. If this is the best that we can offer our patients in esthetics in the late 1980s and early 1990s, then I think we are in big trouble as a dental specialty. The profile relationship in Fig. 19 on page 15 shows an extremely obtuse nasolabial angle of somewhere around 140 °. The patient's face has an absolutely empty appearance that I would not be proud to have as an example of my finest services for other patients in my community to see. I read the case report carefully and noted that originally the treatment plan was to prosthetically replace the maxillary lateral incisors. There was no clear reason given for altering the treatment plan to merely close all the spacing. I think the stage was set for failure when the statement was made on page 12 that "facial profile was within normal limits." I would have to say that, based on this assessment, being 5 feet 4 inches tall and weighing 400 pounds is "within normal limits." If the patient was given the option of orthognathic surgery and rejected it, then that certainly should have been mentioned. If, indeed, it was the judgment of the orthodontist treating this case that the best result would be achieved through orthodontics alone, I strongly disagree. A treatment plan featuring opening of spaces for lateral incisor bridges and orthognathic surgery would have given the best occlusion, function, and facial appearance. In my early years in practice, I would go to all lengths to eliminate the need for any type of prosthodontic treatment. It always seemed a shame to grind virgin teeth to make traditional bridges. With the many options available to us today, including bonded bridges, new ceramic bridges, and single-tooth implants, I think it is inappropriate for us to focus all of our energy on trying to close spaces to eliminate bridges at the expense of facial esthetics. I think it is fine to present this type of case report in our journal, but the write-up should have been completely different. It should have included the fact that this patient either rejected orthognathic surgery, and all of the above compromises had to be made because of that, or it should have talked about the severe lack of facial esthetics that resulted. This case was not treated in the 1970s, and I think the standard of care should be far beyond this in the late 1980s and 1990s. Instead of crying that the general practitioners are taking orthodontic cases away from us, we need to be
teaching the finest and best treatment to our orthodontic residents. The specialist's orthodontic office should be the place where a patient can come for the best facial esthetics and temporomandibular joint health, as well as alignment of the teeth. Teeth can be hidden by the patient but an unesthetic facial appearance cannot. This case only adds fuel to the fire of the general dentists who have been sometimes rightfully shooting bullets at our specialty in the last 10 to 15 years because of our lack of concern for facial esthetics. We are currently using a video imaging system in cases similar to this case report to show patients what their appearance will be after reopening of spaces for proper prosthetic replacement of missing teeth and orthognathic surgical procedures to properly relate the jaws. If those who treated this case would like an analysis with this machine to present to this patient, I would be happy to do that. All they would need to do is send me a full-size profile photograph like the one in Fig. 19, and I would gladly send them a polaroid photograph showing the dramatic difference a different treatment would have afforded this patient. William M. Hang, DDS Rutland, VT.
Reply To the Editor:
I appreciate the opportunity to answer some of the questions that the case report presented in the January issue has generated (AMJ ORTHOD DENTOFAC ORTHOP 1990;97:10-9). Several of the extraoral photographs selected for publication, including Fig. 19, showed the patient in a strained lip posture. However, several examples of the posttreatment soft tissue profile in which the patient demonstrated a relaxed lip posture were also included. Figs. 30 and 31 are more representative of the patient's soft tissue relationship at the end of treatment. In addition, the patient's soft tissue profile from the pretreatment, reanalysis, and postdebanding lateral cephalometric radiographs is demonstrated in Figs. 33, 34, and 35, respectively. Table II shows the soft tissue measurements derived from these radiographs. The nasolabial angle on the pretreatment radiograph (14Y-01M) was 125 °, while the nasolabial angle on the postdebanding radiograph (18Y-03M) was 121 °. (It is noted at the bottom of Table II that radiograph 17Y-10M was not used to measure the soft tissue values because the patient strained her lips while this radiograph was being taken.) The concern over facial esthetics should be reevaluated with this information. The question has also arisen as to why the original treatment plan was altered. The original treatment plan, developed at the Indiana University School of Dentistry, was interrupted when the patient and her family moved from Indianapolis for 1 year. During the patient's 1-year absence, she received orthodontic treatment at her new location. It was during this year that the spaces for the 27A
