Dr. Solomon has chosen to ignore scientifically sound information in lieu of the misleading rhetoric that pervades the dental literature. Our role as academic dentists is to encourage fellow clinicians to critically evaluate the literature and base the treatment of their patients on the outcomes of sound scientific and clinical trials.
Dr. Solomon claims our statement about the goal of early treatment is incorrect because it does not agree with an introductory statement made in "Space Age Pedodontics: The Use of the Utility Archwire Appliance" (
Brehm W, Carapezza L J. Space age pedodontics: the use of the utility archwire appliance. J Pedod 1987;11[3]:201–29[Medline]
).
This article is a clinical technique report offering no evidence that the procedures described "establish a state of normalcy for further growth and development."
It also makes unsupported claims that the Brehm Straight Wire System "eliminates most headgear, elastics and functionals for Class I corrections, and reduces the extraction of bicuspids and molars." The authors fail to produce even one clinical case demonstrating the ability of their appliance to change the direction and degree of an individual’s growth. Yet, Dr. Solomon, for reasons that confound us, appears to have adopted Dr. Brehm’s theory as gospel and blindly rejects the results of carefully conducted clinical trials.
Throughout his letter, Dr. Solomon claims that the studies we cited cannot be valid measures of early treatment efficacy because to accurately evaluate "true early treatment," one must consider the effect on overjet, molar relationship and jaw relationship.
This is curious because in Tulloch’s article, single- and two-phase treatment groups are compared by their change in overjet, Peer Assessment Rating score (an objective evaluation of occlusion that includes molar relationship) and ANB (
Tulloch JF, Phillips C, Proffit WR. Benefit of early Class II treatment: progress report of a two-phase randomized clinical trial. Am J Orthod Dentofacial Orthop 1998;113[1]:62–72[Medline]
).
Ghafari’s study evaluates treatment effect via change in molar and canine occlusion, overjet and 17 cephalometric measures representing the sagittal and vertical planes (
Ghafari J, Shofer FS, Jacobsson-Hunt U, Markowitz DL, Laster LL. Headgear versus function regulator in the early treatment of Class II, division 1 malocclusion: a randomized clinical trial. Am J Orthod Dentofacial Orthop 1998;113[1]:51–61[Medline]
).
Finally, the article by Keeling and colleagues studies treatment effect by the change in mandibular and maxillary position, apical base change, overjet, molar relationship, and maxillary and mandibular incisor and molar position change (
Keeling SD, Wheeler TT, King GJ, et al. Anteroposterior skeletal and dental changes after early Class II treatment with bionators and headgear. Am J Orthod Dentofacial Orthop 1998;113[1]:40–50[Medline]
).
A frequent justification for early intervention (Phase I) is that it may reduce the severity and complexity of comprehensive treatment with fixed appliances (Phase II), which in turn should lead to less time to complete later treatment. In fact, for some isolated instances, successful Phase I treatment may even preclude the need for later comprehensive therapy. It was in this context that we suggested that a goal of early treatment is "to reduce time and complexity of fixed-appliance therapy."
It is well-documented that most two-phase treatment increases the overall time of treatment. Therefore, in terms of efficiency and cost-effectiveness, it is valid to ask whether the additional time required for two-phase treatment justifies an early phase, especially when it has been shown that the long-term results of many multiphase treatments are no better than a single phase of treatment.
Dr. Solomon’s statement that "reducing treatment time is not a goal of early treatment" is only valid if the additional time required for two-phase treatment results in increased benefits for the patient when compared to single-phase treatment.
Our review of recent literature did not find compelling evidence supporting the claim that every patient treated early could expect significant benefit. Therefore, we think that overall treatment time should be an important cost/risk consideration in early management of a developing malocclusion.
Dr. Solomon states that one of the most profound enigmas of our article is our recommendation on treatment of transverse discrepancies. He may have misread our intent in this section.
We discussed the relative merits of timing the correction of a posterior crossbite according to its skeletal origin. To assume that we were ignoring the issues of transverse interrelationships when managing a Class II skeletal relationship is presumptuous. It is a gross misunderstanding to assume that our discussion precluded this rather obvious consideration for Class II management.
Finally, Dr. Solomon accuses us of making a fallacious conclusion in our summary when we recommended that early treatment is not indicated in many cases and delaying treatment until later in dental development may be advised. He states, "Treating almost all malocclusions to normalcy as early as possible cannot be harmful to the patient."
We can only respond, once again, that we base our recommendations on scientific and clinically based research. We encourage [Dr. Solomon] to review our previous response to a letter to the editor in August JADA and hope that he will develop a more discriminating approach to the timing and protocol of his orthodontic care.
