On Ortho101 we were discussing our obligations to patients and my reticence to extract teeth on patients to achieve a Class I canine “just because that’s the way it’s supposed to be”. In that context I got this question from a resident:
“So Ben, what is your objective for treating a case?  If you are not concerned with attaining a Class I canine relationship which almost always correlates with coupled incisors, then what are you trying to achieve?  Do you have any real objective basis for a finished case?  If it is only about leveling and aligning, then what separates your treatment from that rendered by a GP?”
I do love when I get these kinds of questions. It reminds me of me when I was in school. In a profession like dentistry and a specialty like orthodontics it is so difficult to understand the depth and scope of all the variables involved in any given case until you have significant experience. But the irony is that you can’t get the experience without treating cases – and we treat those early cases as we have learned to do in school, read in the texts and literature, and in a way that we believe correct despite our lack of experience! Many orthodontists never change from their initial philosophy but some learn from doing an realize that the entire scope of orthodontic diagnostics, treatment planning and treatment is not contained in the literature and could never be. Given all that, I responded to the resident thus:
“My objective is to get the best possible result for each patient within the boundaries of what is possible and what is pragmatic and what I would do for my own child based on the thousands of cases I’ve treated. You guys think very one dimensionally. You can’t help it. It’s all you know. I do so love when you speak like this and feel that you have implacable backing because your texts and precious literature say so. What you don’t understand is that applying a single standard and a single goal to all your patients and calling it ideal because someone told you that’s how it is is just plain silly. I don’t expect you to understand this. I’ve written quite a bit about it and explained it as well as I can but orthodontics is experienced based no matter how much we try to act like there’s any solid science behind what we do. Let’s talk again in 20 years if I live that long…  But you and most orthodontists and residents will likely still feel the same then because you love the certainty of tradition and consensus even though no one could answer the simple question I asked about WHY a class I is better than a class II with anything other than “because”. Go back and find that poll and give a good reason and then we can talk more.
Which sounds more like a professional who has a deep understanding of their trade – someone who blindly chases an “objective basis” for finishing all cases because they read it in a book or someone who uses what he was taught in residency as a baseline to learn how to treat in the real world and get the best possible results for each individual in any given set of circumstances? Any idiot can blindly point to their attempt to achieve a Class I canine as an excuse for herodontics, amputation and cases that go years overtime – just like the ones that choke every residency program in the country.”
The choice to me is simple. Are we dogs blindly fetching the stick our masters cast for us no matter the distance or the brambles and mud and filth we run through in our pursuit? If so, then there truly is no difference between us and PCDs doing ortho. Think. Look. Feel. Empathize. Understand what your patients want and what they are willing to do to get there and what you can deliver on their terms. To do otherwise is dogmatic and unrealistic given the death of the Paternal Model.
Not to mention we are much more like hair stylists than real doctors as we admit ourselves.

12 thoughts on “Interesting Question From a Resident

  1. Ben .. I couldn’t agree more …“My objective is to get the best possible result for each patient within the boundaries of what is possible and what is pragmatic and what I would do for my own child”.

    1. Thanks. I know the vast majority of orthodontist have great judgement. I just want to encourage them to use it even when an especially when it doesn’t align with the Angle Dogma.

      1. Judgement for ones patients is central to any medical practice. The problem arises when other doctors look at patients and tell them their treating doctor doesn’t know what they’re doing. We shoot our collective profession in the foot when we speak negatively to patients about other doctors treatment.

    1. I love a class I occlusion with midlines centered on the face and on each other and perfect overjet and overbite as much as anyone but it’s just not always possible.

  2. I think I’m fundamentally on the same page as you, but it just feels like we’re creating this idea of “the dogmatic orthodontist” who considers nothing other than the canine classification. Does this person really exist?

    When you ask me if I aim for Class I canines my answer is: Of course…unless I’m doing something else. I don’t think that makes me dogmatic. In 90+% of cases you and I both probably shoot for and achieve Class I canines, not because of a textbook, but because it really is the best treatment. Esthetics, function, and stability is the dogma I received and they served me well when I graduated. Add patient (and parent) satisfaction/happiness at the front of that list and you get a pretty good recipe. Maybe I’m naive, but I think most orthodontists see themselves as pragmatic and their goals flexible based on the situation. I like what you said in your objectives including treating as you would your own child. I find myself actually verbalizing that language to patients and I think they find it very comforting to know that what I’m recommending is what I really think is the best option.

    As for your question as to why Class I is better than Class II, I just tend to have more relapse of overbite and general difficulty in retention in those cases with excess overjet, i.e. more Class II.

    1. I think we are on the same page. I’m glad you threw in the bit about why Class I is better.. that is exactly the kind of answer I got from everyone else. Unfortunately what you feel and see and think is not proof and if we are going to base the “evidence” on what we see clinically then that means the most experienced should be the ones to say what is what… and I’ve got a ton of experience! Maybe someone will figure out how to test the Class I Class II question but until they do talking about what we think, feel, have seen, etc is not proof. And if there is not proof then it is arbitrary. And if it’s arbitrary then it’s not smart to amputate and torture people for 3-4 years in the pursuit of an arbitrary end point.
      All that being said, I like a Class I, midlines on to the facial midline and to each other, min OJ and OB, “ideally” finished case as much as any orthodontist and I try to get it every time. The reality is that it’s just not possible in some cases and in some cases it’s not advisable to go after it. This is why we need to use our judgement and experience instead of blindly following the Angle Dogma. I know it feels weird but that’s just because we are creatures of habit who have done it this way for 100 years

  3. What’s your view and rationale for extracting 3rd molars vis a vis orthodontic treatment?

    1. If the 3rd molars will be a problem later in life then I’m all for removing them.

  4. Rest assured—if you dont recommend serious consideration of removal of third molars and some relapse occurs—guess who will get blamed for not discussing this issue?I know all the technical pros and cons but ,sometimes ,real life takes precedence.
    Same principle operating for MD,s that Rx antibiotics for pediatric ear infections when Cochrane level studies state categorically that this is not advisable.
    Bend or break with the wind !

    1. Are you suggesting that the wisdom teeth cause crowding? Or that people assume it and General dentists believe it so we will get blamed regardless? Because I have always felt anecdotally that late mandibular growth caused an adaptation of the lower anteriors to crowd and gets mistakenly correlated with wisdom tooth impaction.

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