28A
Am. J. Orthod. Dentofac. Orthop. Januao' 1990
Letters to the editor
Fig. 2.
REFERENCES I. WieslanderL Intensive treatmentofsevcreClass II malocclusions with a headgear-Herbst appliance in the early mixed dentition. AM J OR'ntOD 1984;86:1-13. 2. Pancherz H. Treatment of Class II malocclusions by jumping the bite with the Herbst appliance: a cephalometric investigation. AM J OR'rtlot) 1979;76."423-41. EDITOR'SNOTE:I have had a chance to measure the original headplates used in this study, and my measurements corroborate the study 100%. The important point is that the study covered only 4 months, and one cannot annualize the increments of increase. Actually, in the 4 months after treatment, for the sample, there was little or no mandibular growth. One other point has not been answered--that is, the possible role of the electrical field effect. Intensive research now being done in Sweden, Norway, and Germany shows that cellular enhancement under magnetic force is quite possible, just as it has been demonstrated in orthopedics, with the use of electromagnetic pulses to overcome the problem of nonunion of long bones. The headplates shown in Figs. ! and 2 were taken at the beginning of appliance placement (left), 4 months later on removal (center), and 4 months after treatment (right). Note posttreatment closure of posterior open bite that was created by bonded occlusal magnets. Significant sagittal improvement has occurred.
--T. M. Graber
Debate on orthognathic surge j continues To the Editor: I would like to comment on the letter from Bruce L. Douglas (AM J ORTHOD DENTOFACORTHOP 1989;96:22A23A) concerning orthognathic surgery. It is absolutely incredible to me that Dr. Douglas admits to "not being sufficiently knowledgeable about the reasons for removal of seemingly good, asymptomatic teeth for orthodontic reasons" yet is willing to appear in court as an "expert witness." I would recommend that
Dr. Douglas spend about an hour in the office of a welltrained orthodontist to be educated on this matter before appearing in court again and contributing to the "embarrassing and humiliating" experience that the sued dentist must agonizingly endure. It is an insult to orthodontists when Dr. Douglas goes on to state that "orthodontists do not comprehend how serious, traumatic, and potentially dangerous" orthognathic surgery can be. Is it possible that he does not realize that we are, above all, dentists who happen to specialize in orthodontics? Before becoming orthodontists, many of us had spent many hours engaged in oral surgery procedures. I cannot understand how a surgical procedure could be performed without the complete cooperation or "close harmony" of the orthodontist and surgeon. No matter how positive the orthodontist is that surgery is indicated, no surgery is possible without the complete approval of the surgeon. It would be appalling to discover that there are surgeons who would proceed with surgery with which they strongly disagree simply because it is being recommended by the orthodontist. I agree wholeheartedly with Dr. Douglas in his appropriate description of the facial muscle "memories" and his caveat that evidence is still lacking as to the stability and efficacy of many of the surgical procedures being recommended today. The bones are not inanimate blocks of wood that can be sectioned and placed where the doctors believe they should be. Bone can resorb and readapt and reposition itself, powered by the musculature and other soft tissues. There is no doubt that complications can occur, and I agree with Dr. Douglas that honest, informed consent is of great importance. An understanding of our willingness to chance the complications that can occur is also important to an individual who is willing to serve as an expert witness in "dozens of cases." The need for these surgical procedures arose out of the inability of orthodontic appliances alone to solve the disfiguring real-
Volume 97 Number l
occlusions now recommended to the surgeon. In most
of these cases, the patient must either undergo surgical treatment (with the chance of complications) or suffer a lifetime with the disfigurement. The competent individuals who are now attempting to solve these problems-even though they risk ending up "in the courtroom"-deserve our admiration. Philip Levens, DDS, MS St. Louis, Mo.
Push for "shortcuts" yields inferior results To the Editor:
Remember how nectarines tasted a few years ago? Today the ones found in the market are pulpy, tasteless little balls as hard as a rock. What happened? As far as can be determined, growers, shippers, and merchants feel they can sell the "appearance of a nectarine" in a colorful ball but no real taste or substance. Also, it is said, "The quick-food people sell the sizzle, not the steak!" The same is true today of "orthodontics" as practiced by those in general dentistry. They try to align the upper six anterior teeth and believe that the patient will be happy. Until the public realizes that more must be accomplished with proper treatment, our specialty is in trouble. General dentistry does very little to help. The "bottom-line" is "in" today, and general dentistry ("fullservice dentistry," if you will) has taken over our specialty. If they fail, they say, "We did our best, but now you need a specialist." Qualified orthodontists then try to pick up the pieces, but "orthodontics" gets the bad-mouthing. Reading letters and articles despairing the lack of research workers and teachers in orthodontics in our country, I am hard-pressed to understand how anyone could go into our field, which is beleagured by dentistry as a whole and offers a bleak future as a specialty. I have had prospective dental students and interested high school students talk with me about a career in orthodontics. They want to proceed immediately into our field with no collegiate experience or dental background. They do not understand why a dental education is necessary and are not willing to take the time. The "NOW" generation is upon us. How difficult it must be for orthodontic educators to cope with this attitude. Two years is an absolute minimum for an orthodontic education. And yet there are hundreds of people on the Holiday Inn circuit, the "gurus" of orthodontics for the general practitioner, telling gullible GPs that they too will become "orthodontists" over the weekend. So back to the initial thoughts. Until the public understands the scope of "real orthodontics" and until orth-
Letters to the editor
29A
odontic education is understood and appreciated, our problems will continue. We will have and have had little help from the ADA and general dentistry. H. Brown Otopalik, DDS, SC Northeastern Wisconsin Orthodontic Stttdy Group Fond du Lac, Wis.
Alternate inte 7oretation of mandibular osteotomy results To the Editor:
Having read the article by Wenzel et al. (AMd ORTHOD DENTOFAC ORTHOP 1989;96:138-43.), I wish to suggest an alternative interpretation of the data. When the mandible is surgically repositioned, it carries the tongue to an extent which, in these cases, reduces the lumen of the oropharynx. Unfortunately, the dimensions between the posterior border of the tongue and the posterior pharyngeal wall are not given in this report, but I would hazard a guess that they were reduced postoperatively; that has been my experience. Because the axis of rotation in cervical movements is behind the airway, the mechanics of mandible, hyoid, and connective tissues effect a closure on flexion and an opening on extension. '-3 Therefore a likely reason for the change in head posture is that it was compensatory and was a move to restore any loss in the essential oropharyngeal airway patency. It might be interesting to use the same technique on cases in which retrognathic mandibles have been moved forward and see whether the head is lowered. DonaM Timms Royal Preston Hospital Preston, England REFERENCES I. Safar P, Escarra G, Chang F. Upper airway obstruction in the unconscious patient. J App Physiol 1959;14:760-4. 2. Read WR, Roberts RL, Thach BT. Factors influencing regional patency and configuration of the human infant upper airway. J App Physiol 1985;58:635-44. 3. Hellsing E. Cervical angulation and oropharyngeal airway [Poster]. London: EOS Congress, 1988.
Reply To the Editor:
I wish to thank Dr. Timms for his interest in our article (AM J ORTHOD OENTOFAC ORTHOP 1989;96:138-43) and for his alternative interpretation. We have not investigated tongue position relative to the dimensions of the posterior pharynx at this stage, but an ongoing study will, we hope, clarify this essential point. The interrela-
Am. J. Orthod. Dentofac. Orthop. Januao' 1990
Letters to the editor
Fig. 2.
REFERENCES I. WieslanderL Intensive treatmentofsevcreClass II malocclusions with a headgear-Herbst appliance in the early mixed dentition. AM J OR'ntOD 1984;86:1-13. 2. Pancherz H. Treatment of Class II malocclusions by jumping the bite with the Herbst appliance: a cephalometric investigation. AM J OR'rtlot) 1979;76."423-41. EDITOR'SNOTE:I have had a chance to measure the original headplates used in this study, and my measurements corroborate the study 100%. The important point is that the study covered only 4 months, and one cannot annualize the increments of increase. Actually, in the 4 months after treatment, for the sample, there was little or no mandibular growth. One other point has not been answered--that is, the possible role of the electrical field effect. Intensive research now being done in Sweden, Norway, and Germany shows that cellular enhancement under magnetic force is quite possible, just as it has been demonstrated in orthopedics, with the use of electromagnetic pulses to overcome the problem of nonunion of long bones. The headplates shown in Figs. ! and 2 were taken at the beginning of appliance placement (left), 4 months later on removal (center), and 4 months after treatment (right). Note posttreatment closure of posterior open bite that was created by bonded occlusal magnets. Significant sagittal improvement has occurred.
--T. M. Graber
Debate on orthognathic surge j continues To the Editor: I would like to comment on the letter from Bruce L. Douglas (AM J ORTHOD DENTOFACORTHOP 1989;96:22A23A) concerning orthognathic surgery. It is absolutely incredible to me that Dr. Douglas admits to "not being sufficiently knowledgeable about the reasons for removal of seemingly good, asymptomatic teeth for orthodontic reasons" yet is willing to appear in court as an "expert witness." I would recommend that
Dr. Douglas spend about an hour in the office of a welltrained orthodontist to be educated on this matter before appearing in court again and contributing to the "embarrassing and humiliating" experience that the sued dentist must agonizingly endure. It is an insult to orthodontists when Dr. Douglas goes on to state that "orthodontists do not comprehend how serious, traumatic, and potentially dangerous" orthognathic surgery can be. Is it possible that he does not realize that we are, above all, dentists who happen to specialize in orthodontics? Before becoming orthodontists, many of us had spent many hours engaged in oral surgery procedures. I cannot understand how a surgical procedure could be performed without the complete cooperation or "close harmony" of the orthodontist and surgeon. No matter how positive the orthodontist is that surgery is indicated, no surgery is possible without the complete approval of the surgeon. It would be appalling to discover that there are surgeons who would proceed with surgery with which they strongly disagree simply because it is being recommended by the orthodontist. I agree wholeheartedly with Dr. Douglas in his appropriate description of the facial muscle "memories" and his caveat that evidence is still lacking as to the stability and efficacy of many of the surgical procedures being recommended today. The bones are not inanimate blocks of wood that can be sectioned and placed where the doctors believe they should be. Bone can resorb and readapt and reposition itself, powered by the musculature and other soft tissues. There is no doubt that complications can occur, and I agree with Dr. Douglas that honest, informed consent is of great importance. An understanding of our willingness to chance the complications that can occur is also important to an individual who is willing to serve as an expert witness in "dozens of cases." The need for these surgical procedures arose out of the inability of orthodontic appliances alone to solve the disfiguring real-
Volume 97 Number l
occlusions now recommended to the surgeon. In most
of these cases, the patient must either undergo surgical treatment (with the chance of complications) or suffer a lifetime with the disfigurement. The competent individuals who are now attempting to solve these problems-even though they risk ending up "in the courtroom"-deserve our admiration. Philip Levens, DDS, MS St. Louis, Mo.
Push for "shortcuts" yields inferior results To the Editor:
Remember how nectarines tasted a few years ago? Today the ones found in the market are pulpy, tasteless little balls as hard as a rock. What happened? As far as can be determined, growers, shippers, and merchants feel they can sell the "appearance of a nectarine" in a colorful ball but no real taste or substance. Also, it is said, "The quick-food people sell the sizzle, not the steak!" The same is true today of "orthodontics" as practiced by those in general dentistry. They try to align the upper six anterior teeth and believe that the patient will be happy. Until the public realizes that more must be accomplished with proper treatment, our specialty is in trouble. General dentistry does very little to help. The "bottom-line" is "in" today, and general dentistry ("fullservice dentistry," if you will) has taken over our specialty. If they fail, they say, "We did our best, but now you need a specialist." Qualified orthodontists then try to pick up the pieces, but "orthodontics" gets the bad-mouthing. Reading letters and articles despairing the lack of research workers and teachers in orthodontics in our country, I am hard-pressed to understand how anyone could go into our field, which is beleagured by dentistry as a whole and offers a bleak future as a specialty. I have had prospective dental students and interested high school students talk with me about a career in orthodontics. They want to proceed immediately into our field with no collegiate experience or dental background. They do not understand why a dental education is necessary and are not willing to take the time. The "NOW" generation is upon us. How difficult it must be for orthodontic educators to cope with this attitude. Two years is an absolute minimum for an orthodontic education. And yet there are hundreds of people on the Holiday Inn circuit, the "gurus" of orthodontics for the general practitioner, telling gullible GPs that they too will become "orthodontists" over the weekend. So back to the initial thoughts. Until the public understands the scope of "real orthodontics" and until orth-
Letters to the editor
29A
odontic education is understood and appreciated, our problems will continue. We will have and have had little help from the ADA and general dentistry. H. Brown Otopalik, DDS, SC Northeastern Wisconsin Orthodontic Stttdy Group Fond du Lac, Wis.
Alternate inte 7oretation of mandibular osteotomy results To the Editor:
Having read the article by Wenzel et al. (AMd ORTHOD DENTOFAC ORTHOP 1989;96:138-43.), I wish to suggest an alternative interpretation of the data. When the mandible is surgically repositioned, it carries the tongue to an extent which, in these cases, reduces the lumen of the oropharynx. Unfortunately, the dimensions between the posterior border of the tongue and the posterior pharyngeal wall are not given in this report, but I would hazard a guess that they were reduced postoperatively; that has been my experience. Because the axis of rotation in cervical movements is behind the airway, the mechanics of mandible, hyoid, and connective tissues effect a closure on flexion and an opening on extension. '-3 Therefore a likely reason for the change in head posture is that it was compensatory and was a move to restore any loss in the essential oropharyngeal airway patency. It might be interesting to use the same technique on cases in which retrognathic mandibles have been moved forward and see whether the head is lowered. DonaM Timms Royal Preston Hospital Preston, England REFERENCES I. Safar P, Escarra G, Chang F. Upper airway obstruction in the unconscious patient. J App Physiol 1959;14:760-4. 2. Read WR, Roberts RL, Thach BT. Factors influencing regional patency and configuration of the human infant upper airway. J App Physiol 1985;58:635-44. 3. Hellsing E. Cervical angulation and oropharyngeal airway [Poster]. London: EOS Congress, 1988.
Reply To the Editor:
I wish to thank Dr. Timms for his interest in our article (AM J ORTHOD OENTOFAC ORTHOP 1989;96:138-43) and for his alternative interpretation. We have not investigated tongue position relative to the dimensions of the posterior pharynx at this stage, but an ongoing study will, we hope, clarify this essential point. The interrela-
