[Orthodontics founded on "proof" or therapeutic decision making based on the literature]

[The search for balance in the therapeutic decision-making process: the example of Class II malocclusion treatments in children and adolescents]

INTRODUCTION

Therapeutic decision-making is essentially the key to our clinical practice, and its most medical feature. The history of orthodontics is studded with multiple intellectual debates and stand-offs between conflicting treatment philosophies, the authors of which all aspire to a balance guaranteeing optimal treatment for their patients. Among the wealth of published data, which items should we select to ensure balanced treatment decisions in our daily practice and how can we remain serene in the face of the uncertainty and loneliness engendered by therapeutic decision-making process?

MATERIALS AND METHODS

Evidence-based orthodontics is an aid to clinical decisionmaking. Its main features are illustrated by four clinical cases describing the treatment of class II malocclusions in children and adolescents.

RESULTS

A search for the best pre-evaluated data on two-step treatments shows that : (1) a significant reduction in the prevalence of incisive trauma is observed in children when an increased overjet is corrected by an initial treatment phase, compared to single-stage treatments conducted in early adolescence; (2) the long-term impact of the first treatment phase on the amount of mandibular growth is at best weak and clinically insignificant.

DISCUSSION

The evidence-based approach, particularly when performed in user mode, enables us to reach more balanced clinical decisions. However, the article points out the key role of the clinician and the double risk of reducing the evidence-based approach to a mere standard of care - which it is not - and the subordination of treatment management to the strict clinical application of data in the literature.

[Methodology for clinical research in Orthodontics, the assets of the beOrtho website]

The rules applying to the "evidence-based" methodology strongly influenced the clinical research in orthodontics. However, the implementation of clinical studies requires rigour, important statistical and methodological knowledge, as well as a reliable environment in order to compile and store the data obtained from research. We developed the project "beOrtho.com" (based on orthodontic evidence) in order to fill up the gap between our desire to drive clinical research and the necessity of methodological rigour in the exploitation of its results. BeOrtho website was created to answer the issue of sample recruitment, data compilation and storage, while providing help for the methodological design of clinical studies. It allows the development and monitoring of clinical studies, as well as the creation of databases. On the other hand, we designed an evaluation grid for clinical studies which helps developing systematic reviews. In order to illustrate our point, we tested a research protocol evaluating the interest of the mandibular advancement in the framework of Class II treatment.

[Very early treatment, early treatment or just watchful waiting? Thoughts based on the follow-up treatment of class III with vertical excess]

The debate concerning the optimal timing for beginning treatment of maxillo-facial dysmorphia is far from over. The possible choices are very early treatment in the primary dentition, early treatment only during a period of time when the mixed dentition is stable or waiting until complete adult dentition is present, at the end of, or close to the end of, the growth period. Opting for early treatment is problematic because it is difficult to make a very early diagnosis (and sometimes impossible to make when there are no strong developmental signs for dysmorphia present), long-term prognosis can always be inaccurate, patients may not yet be psychologically mature enough, there is insufficient anchorage available, ultimately a two-stage treatment is required and hence a longer process, the feeling that this is "experimental therapy", that, in case of failure, leads to disappointment and a loss of confidence. Opting for later treatment reassures both orthodontist and patient; however, these delayed treatments might represent a lost opportunity for some patients who must a priori undergo more extractions and additional surgical procedures. The presentation of a case of hyperdivergent class III occlusion, where the orthodontist hesitates to treat at various stages of growth, and finally ends up performing a late surgical treatment, illustrates quite well the problem we face in choosing a timeframe for treatment.