We thank Dr Doshi for his comments about our case report. His questions concerning diagnosis, treatment planning, and results allow us to discuss many topics.
Our clinical protocol when a patient has TMD as part of his or her chief complaint is to explain that we cannot ensure that orthodontic treatment will either treat or worsen the preexisting problem. We now use the recent Point/Counterpoint article in the January 2011 issue of the AJO-DO (Slavicek R. Relationship between occlusion and temporomandibular disorders: implications for the gnathologist [Point/Counterpoint]. Am J Orthod Dentofacial Orthop 2011;139:10-5; and Greene CS. Relationship between occlusion and temporomandibular disorders: implications for the orthodontist [Point/Counterpoint]. Am J Orthod Dentofacial Orthop 2011;139:11-6.) to show patients that there are still controversies about this matter. In our case report, we explained to the patient that her anterior crossbite could be the cause of her TMD symptoms. As we stated, we could have investigated further using radiographs and magnetic resonance imaging scans, but the patient considered that these examinations were too expensive and decided to begin orthodontic treatment without them.
The purposes of the anterior biteplane were to reduce the overbite for facilitating crossbite correction and to permit correct placement of the anterior maxillary brackets. It was placed over the anterior mandibular teeth.
The aligning wires did correct the anterior crossbite, but, as the incisors, canines, and premolars were proclined, generalized diastemas were created. This is why the open-coil springs were necessary. What Dr Doshi called “molar distalization” was actually molar uprighting. As the initial records show, the second and third molars were inclined mesially.
We do not agree with Dr Doshi’s suggestion of using Class III elastics for correcting the patient’s malocclusion. For making this option possible, we would have had to bond the mandibular teeth, and this could have harmed the mandibular incisor position in the thin mandibular symphysis, which is clearly shown in the lateral cephalogram and tracing.
Dr Doshi’s observation about the maxillary third molar having no antagonist tooth is only true on the right side, as shown in the intraoral and dental cast photographs. This fact was explained to the patient and to the prosthodontist. The patient is aware that this molar might have to be extracted in the future, but she considered it a minor side effect of her successful treatment. This molar is observed in the patient’s regular follow-up examinations.
Once again, we appreciate Dr Doshi’s careful reading and comments about our article.